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A Dam Brings a Flood of Diabetes to Three Tribes

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Herbert Wilson arrived on Fort Berthold Indian Reservation in North Dakota in 1954. A Vermont-bred 33-year-old, fresh from Harvard with a tour as a bombardier in World War II and a stint in the Coast Guard, Wilson arrived in the tiny town of Elbowoods to serve as the sole doctor for three tribes that had spent the years since white colonization the same way they had spent the preceding centuries—raising corn, beans and squash in the fertile floodplain of the Missouri River. “Very few people were overweight,” recalled Dr. Wilson. “There was no welfare, no commodity food, and did I mention there was no diabetes?”

But even as Wilson and his wife unloaded their four small children and cat from their 1946 Hudson sedan, the disease that has become the scourge of Native American health was on its way. It was coming in the form of water—the recently constructed Garrison Dam was destined to flood that town and seven other Native communities strung along a 30-mile stretch of the Missouri River, which meant the resident Mandan, Hidatsa and Arikara people had to move to high, barren ground, processed food and a five-decade descent into obesity, hypertension, kidney disease and diabetes. Ironically, the flood would drown the only hospital the reservation has ever had.

As dramatic as it is, their story differs from that of other tribes only in the details. Native Americans in the United States have become 2.2 times more likely to develop diabetes than non-Hispanic whites. And they have all gotten there in pretty much the same way—they lost their land, became sedentary, consumed cheap and unhealthy food, and received worse health care than any other group of people in the country. On Fort Berthold, where health needs are poorly met by a leaky network of clinics, a new $20 million clinic will open later this year, but it will take a lot more than that to turn the tide of a health crisis inundating this and other reservations.

Relations between the U.S. government and the people of Fort Berthold began with a chord of pure harmony. The Mandan lived in villages with the Hidatsa, in lodges walled thick against raiders. “If the Sioux were having a slow day they’d ride up to the villages and plunder and steal horses and kill people,” said Marilyn Hudson, the tribes’ ad hoc historian and the granddaughter of Mandan Chief Cherry Necklace.

“We grew large gardens,” she said. “We had a very organized society which was similar to the white European societies. There were systems of law and order, food distribution.… I think it made the people here more compatible with Europeans because they were farmers.”

When the Indian Wars began in the second half of the 1800s, the Mandan and Hidatsa—along with the Arikara, with whom they allied in 1862—signed on as government scouts. They came to be known as the Three Affiliated Tribes and did not have to move to a distant reservation. Rather, the Fort Berthold Indian Reservation was established more or less on their homeland. Amid a bucolic patchwork of riverside willows, cottonwoods and fields, the people ran small farms, sent their children to school, attended church and took pride in their high level of enlistment in the United States’ armed forces. Women and children cultivated beans, potatoes, carrots and beets, storing them for winter. They canned tomatoes and ate lettuce as it grew in the summer. The men used horse-drawn planters to sow corn and cut hay, which they pitched by hand into hayracks. The families also tended cows, pigs and chickens. “Almost everything grown in the garden was consumed by us and our livestock,” remembered Hudson, 74. “The only thing we bought from the store was sugar, coffee, salt.”

And then, in the mid 1940s, the U.S. government decided it needed a dam.

Of all the variable things in creation,” wrote the editor of the Sioux City Register in 1863, “the most uncertain are the actions of juries, the state of a woman’s mind, and the condition of the Missouri River.” In 1943, the restive Missouri had jumped its banks three times, inundating Iowa and Nebraska and angering precisely the wrong person—Colonel Lewis Pick, the short-fused director of the regional office of the Army Corps of Engineers. “As the floodwaters rose in the streets outside his offices, Pick jumped up on a desk and bellowed at his subordinates: ‘I want to control the Missouri!’?” wrote Paul VanDevelder in Coyote Warrior, a history of the Garrison Dam and its effect on the tribes.

President Franklin Roosevelt ordered Pick and the Bureau of Reclamation to hammer out a plan. They called for a series of dams on the Upper Missouri—at its center, the 200-mile-long Lake Sakakawea, which would flood 436 of Fort Berthold’s 531 homes, as well as every square foot of the enviable farmland tilled by the people of the Mandan, Hidatsa and Arikara nations.

The Indians fought back. But as the news from the government the tribes had trusted for nearly 150 years went from bad to worse, the people of Fort Berthold were stunned, then angry. When now-General Pick appeared at an Elbowoods hearing in 1946, a rancher with a third-grade education and a full-feathered war bonnet named Thomas Spotted Wolf stood up and stuck his finger into the general’s face. “You have come to destroy us!” he shouted, according to his grandson, Jim Bear. “If you look around in our town, we build schools, churches.… We’re becoming civilized! We’re becoming acculturated! Isn’t that what you white people wanted us to do? So we’re doing that! And now you’ll flood our homeland?”

The next year, tribal councilman Mark Mahto told the House Appropriations Committee: “The quickest and most merciful way to exterminate the three tribes is by mass execution, like they did to the Jews in Germany,” recounted VanDevelder in his book, “Everything will be lost if Garrison is built. We will lose our homes, our communities, our economy, our resources.”
But these arguments were no match for the government’s determination to tame the Missouri and spare any ill effects being visited upon its constituent white farmers—who owned less than 10 percent of the land lost to the series of dams the Pick-Sloan Flood Control Act of 1944 installed above Yankton, South Dakota. The rest was all Indian land.

Out of options, the tribes accepted the government’s offer of $5 million in exchange for their homeland. At the signing ceremony on May 20, 1948, in Washington, D.C., the bureaucrats were straight-faced. The suit-clad tribal chairman, George Gillette, stood just to the right of Interior Secretary Julius Krug, crying into his hand.

The Elbowoods Bureau of Indian Affairs (BIA) officers moved their base of operations to the rolling, mostly treeless prairie, to the aptly named hamlet of New Town. Dr. Wilson set up shop on Main Street. Today, North Dakota’s longest bridge stretches nearly a mile across the white-capped water of Lake Sakakawea toward Four Bears Village and an 18-year-old casino—one reason reservation unemployment has dropped from an estimated 80 percent after the flood to about 30 percent today. Fort Berthold is on much firmer economic ground than many other High Plains reservations, although not nearly on par with the rest of North Dakota, which has the country’s lowest unemployment rate, at 3.3 percent. A rich oil field was recently discovered under the reservation, and oil rigs dot the landscape like oversized praying mantises. This has generated much-needed revenue for the tribe, supplemented by the casino and a 1993 settlement for dam-caused damages that provides $8 million to $9 million annually to community programs. Still, for years people have complained that the federal government never made good on its promise to replace the flooded hospital at Elbowoods. And although the oil boom has brought money, it has also brought an increase in traffic deaths, social tension and environmental concerns so profound that some wonder if the reservation will be habitable in 20 years.

But that’s getting ahead of the story.

“Men are supposed to be the stronger sex, but I don’t think that’s really true,” said Hudson. “When I start thinking about Elbowoods, it seems like it’s the women who were the survivors.”

As the floodwaters covered his house, Thomas Spotted Wolf, who had stood up so angrily to General Pick, sat on a piece of driftwood. “He found a stick and was singing a song, and he had tears coming down,” said his grandson, Jim Bear. “I didn’t have to ask him what was wrong.… After that, my grandfather just went downhill. He didn’t have anything to live for any more.”

“Our neighbor to the north, Judge Wolf, would hold court right in his house,” said Hudson. “Everyone respected him—he was very adamant that ‘I love this land I will not leave this land.’ And he didn’t leave. He died. I’m thinking he wasn’t any more than in his 50s.”

After pouring his life into fighting the dam, Hudson’s own father died just a month short of his 58th birthday. Like many others, he left behind a wife who outlived him by decades.

“The lake forced us into a cash economy,” said Leo Cummings, the tribal administrator of employment training. “A lot of people lost their lives in downtown New Town, lost their self-esteem, and drank themselves to death.”

Some found low-paying desk positions for the government or service jobs, some took the bus to distant cities like Los Angeles or Chicago as part of the 1956 Indian Relocation Program, but unemployment hovered at around 80 percent, according to Mark Fox, who is now the director of the tribal tax department. The people were so poor that a 1964 BIA investigation reported that starvation was a real possibility on Fort Berthold. But with the hard work of subsistence farming behind them, the Three Tribes became more and more sedentary. About 40 percent of them started receiving commodity foods from the U.S. Department of Agriculture. In 1970, less than 20 years after the creation of Lake Sakakawea, an IHS doctor named James Brosseau found 200 cases of diabetes on Fort Berthold. He was surprised and dismayed. “There were probably a lot more that were undiagnosed,” he said.

Brosseau found similar outbreaks in other reservations on the Northern Plains, reminding him of the smallpox epidemic that

wiped out whole settlements of Indians in the early 1800s. “Diabetes is going to devastate the tribes,” he says he realized. “It’s going to be a long, painful death, not a quick one.” He added, “I’m even more concerned now. It hasn’t improved. Rates have gotten worse.”

To address the problem, Congress established the Indian Health Service (IHS) Division of Diabetes in 1979. “By the late 1980s and 1990s, diabetes was a well-known epidemic among American Indians,” says Charlene Avery, director of the IHS Office of Clinical and Preventive Services.

In 2008, the obesity rate among 18- to 74-year-olds on Fort Berthold was a little more than 60 percent; 2009 figures show that 13.14 percent of the people using the health system on Fort Berthold had diabetes, roughly twice the state average of 6.5 percent. Diabetes risk increases with age, and of people over the age of 35 on Fort Berthold (which has 4,556 resident American Indians, according to the 2010 census), about 41 percent appear to be diabetic.

The symptoms of diabetes include weakness, impaired circulation and thirstiness. Its complications can lead to loss of vision or limbs, and kidney failure, which can be treated with dialysis. Almost all of the diabetes cases on Fort Berthold and beyond are Type 2, which usually develops in overweight adults who become resistant to their own insulin, which controls blood sugar. Type 1 diabetes—an autoimmune disease that typically begins in childhood—has stayed stable at about five percent nationwide, according to Brosseau.

Type 2 diabetes can be prevented or managed with regular activity and a low-fat diet with plenty of fruits and vegetables. “People don’t get as much exercise as they used to,” says Jared Eagle, 28, who grew up with a diabetic grandmother, grandfather and uncle and is the fitness director for the Fort Berthold diabetes program. “They don’t ride bikes. Video games are huge. They do them at home, and there’s an arcade at the casino. Kids get rides just down the block. Things like that really show.”

Dialysis patients—95 percent of whom have diabetes on Forth Berthold—have tripled in the past eight years, according to Stella Berquist, the chief executive officer of the Fort Berthold Minne-Tohe Health Center. Fourteen people are on the waiting list for the life-saving treatment. “We have 10 dialysis patients at a time, two shifts a day,” says Berquist. The tribe transports the extra patients off the reservation to Minot and beyond.

Set against the bleak statistical landscape of American Indian health, the diabetes upsurge on Fort Berthold isn’t unique, severe or even surprising. Nationwide, 16.3 percent of American Indians and Alaska Natives are diagnosed with diabetes and are three times more likely to die of diabetes than non-Indians. Researchers opened their eyes to the phenomenon back in 1963, when a group of them traveled to the Pima reservation in Arizona looking for data on rheumatoid arthritis and stumbled upon an “extremely high rate of diabetes,” according to the National Institute of Diabetes and Digestive and Kidney Diseases website. So they returned to study that instead.

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The Pima Indians thrived for centuries on corn, beans and squash they raised on the banks of the Gila River. They also gathered a huge variety of wild plants, and trapped game and birds. In the 1860s, they grew enough wheat that they could sell—5 million pounds to the U.S. government for the Civil War effort, according to Gregory McNamee, author of Gila: The Life and Death of an American River. A few years after that, white farmers upstream, especially the Mormon colony at Safford, diverted their water supply so much that by 1872 the Pima couldn’t feed themselves. The tribe appealed to the farmers without success, and then went to D.C., to talk to President Ulysses S. Grant. He suggested that the Pima move to Oklahoma. They declined.

In 1900, there was perhaps one recorded case of diabetes among the Pima. In the 1920s and 1930s, the Gila was altered by more dams and diversions to funnel water into growing cities like Phoenix, and the Pima’s already depleted farming enterprises shrank further. And the people got fat. Really fat. They are, in fact, among the fattest people in the world.

The southern remnants of the Pima tribe live south of the Mexican border in the Sierra Madre, where they raise corn, beans and potatoes. They are slim; their diabetes rate is unremarkable.

In the 1930s, there were only five known diabetics among 25,000 hospital admissions at the Sage Memorial Hospital in Ganado, Arizona, on the Navajo Nation. By 1988, The Western Journal of Medicine declared, “The Navajo and most other Indian tribes are now experiencing a pandemic of Type 2 diabetes, related to diet and lifestyle changes, probably in the setting of a genetic predisposition.”

Dams can help set diabetes epidemics in motion, but dozens of other tribes—along with the rapidly fattening non-Indian population of the U.S.—have shown they’re not required.

Back in the 1950s, it wasn’t that unusual for a tribe to report no diabetes among its members, according to Avery, “Other tribes similarly had few documented cases,” she reported. She added that diabetes has always been present among American Indians, but in much smaller numbers than today. The disease was apparent in the population by 1965, the IHS started a diabetes program in 1979, and “by the late 1980s and 1990s, diabetes was a well known epidemic among American Indians.”

Every ethnic group in the United States is becoming fatter and more prone to diabetes, but why are American Indians leading the charge? One theory points to a “thrifty gene”—a tendency to easily put on weight among those who spend generations in cycles of feast and famine. This worked in their favor when they lived hand to mouth, but when they became sedentary and had a steady supply of calories, they became prone to obesity and diabetes.

Diabetes has a correlation with poverty—poor people eat unhealthy food—and roughly one-third of Native Americans live below the poverty level. But the federal policies toward Native Americans have also played a huge role in their worsening health. Take the USDA Commodity Programs that for decades supplied low-income Native Americans with surplus food. Take frybread: “People think frybread is a traditional food,” said Donald Warne, a Lakota with a medical degree from Stanford, a master’s in public health from Harvard and a long history of working on Native American health issues on the Northern Plains. “The origin of frybread is the tribes trying to do the best that they can with commodity food—flour, shortening. Frybread is a USDA commodity traditional food.”

The roots of the commodity food programs reach back to the late 19th century, when displaced tribes received rations—beef on the hoof, salt pork, biscuit mix—from the government. Its next iteration arose in the 1930s, when the government bought surplus crops from distressed farmers and distributed them among people of all races who needed food. Finally, it was folded into the Food Stamp Act of 1977.

On Fort Berthold, perhaps 40 percent of the people were on the program during the decades after flood, according to Wilson. “There was a lot of slurring against the commodities—all the fat they got.” Commodity canned meat was crowned with a white fat cap and “looked like they scraped it off the floor,” and the fruit was “loaded with sugar,” according to Charles “Red” Gates, who runs the commodity food program at another North Dakota reservation—Standing Rock. He started his job in the early 1980s and successfully agitated to improve food quality while there and during a stint as a regional vice president of the National Association of Food Distribution Programs on Indian Reservations.

At a 1990 field hearing of the U.S. House of Representative’s Select Committee on Hunger at the Standing Rock Sioux tribal

headquarters in Fort Yates, North Dakota, cans of commodity meat were opened, prompting two attendees to run outside and throw up. Congressman Tony Hall of Ohio proclaimed, “I wouldn’t feed this to my dog!” A General Accounting Office investigation on Fort Berthold and three other reservations found that “often the only vegetable available is canned green beans, the only fruit available is canned pineapple, and the only meat available is canned luncheon meat,” adding that during the last week of each month, some families subsisted solely on macaroni, rice and cornmeal, although the high starch content of those foods was believed to be “a major contributor to the prevalence of obesity on the reservation.”

Gates’s home reservation hosted a pilot project for the inclusion of fresh fruits and vegetables in a reservation commodity food program. This happened in 1993—14 years after the IHS had launched its first diabetes program, and right when diabetes had developed into a “well known epidemic among American Indians.” These days, commodity food includes healthful fare like whole-grain rotini pasta, low-fat milk, seasonal avocados, nectarines and frozen bison. But on Standing Rock, Fort Berthold and beyond, younger people who qualify for commodities are trickling away from the program and signing up for food stamps, so they can buy convenience foods like chips and soda.

Gates argues with them about their food choices, but reports, “They say, ‘We don’t have time to cook.’

“I say, ‘Make time! You’ve got a family!’ I can see it in my grandchildren. They’ll have something from Taco John’s, or they’ll have a soda.”

About 600 people receive commodity food on the Fort Berthold reservation these days, according to Lionel Chase, the acting director of the commodities program. This is only about nine percent of the population. The construction of a casino in 1993 created 300 jobs, and an oil boom that started three years ago has brought more employment—along with mounting quality-of-life woes—to the reservation. Chase sees the same phenomenon Gates does on Standing Rock—qualifying families opting for food stamps over commodities. The commodity warehouse in New Town is stocked with healthy food, but in the hall sat a woman talking into her cell phone: “I’ll make dinner,” she said to whoever was on the other end of the line. “Hot dogs and chips.”

The IHS is the agency left holding the food basket in this crisis. Its mission is “to raise the physical, mental, social and spiritual health of American Indians and Alaska Natives to the highest level,” but it relies on a funding source that is hardly reliable—the U.S. Congress. “We meet about 57 percent of the need, based on the current budget,” says Michael Mahsetky, director of the IHS Congressional and Legislative Affairs Staff.

In 2010, the IHS spent $2,741 per user on medical care ($3,348 when construction costs are factored in). In comparison, recent figures reveal that the federal government pays about $5,841 per Medicaid enrollee, $7,154 per veteran, and $4,412 per federal prisoner. There’s a long-standing joke that if a Native American is going to get sick, he or she’d better get sick before June, because the IHS runs out of its annual funding by summer. The IHS runs the medical facilities on some reservations, but all of the tribes in Alaska and about half of the rest of the nation’s reservations have become independent in recent years, using IHS funds to run their own clinics. Fort Berthold did this three years ago. Since then, it has received $18 million in services from the IHS, but has had to supplement that with an equal amount from tribal coffers. “We’re not supposed to pay,” says Tribal Chairman Tex G. Hall. “The U.S. government has a trust responsibility, a treaty obligation. I tell them, ‘If you don’t want to live up to that, you give back our land.’?”

Most diabetes treatment is done at the Minne-Tohe Health Center in Four Bears Village, a cobbled-together 10,000-square-foot compound across the street from the casino. It opened its doors some 40 years ago, replacing a series of leased facilities in New Town. Although it is the flagship facility of the five clinics on the reservation (the others are small, regional clinics visited by medical staff a couple times a week), it has few fans. Hours are short, and waits are long.

Two different IHS diabetes programs—one pushed by former Democratic senator Byron Dorgan, the other by former Republican representative Newt Gingrich—pour about $850,000 a year into diabetes-prevention and -treatment efforts on Fort Berthold. Dialysis is covered by Medicare. The two IHS diabetes programs on the reservation “significantly improve clinical intervention and prevention,” says Arne Sorenson, diabetes director at the Minne-Tohe clinic. “We’re losing the fight in terms of obesity and weight gain, but in spite of that we’re ameliorating the quality of life for people who have diabetes.” He’s optimistic that by continuing to treat full-blown diabetics with medications that lower lipids and glucose, plus spreading the word about diet and exercise among the young, they can turn the tide against the disease. “If you’re not an optimist in this field, you’re gone,” he says. Still, due to budget constraints, “we don’t even get close to meeting 100 percent of our need.”

Warne puts it more bluntly: “Every time there’s a budget shortfall for the IHS, Indians die. The analogy I like to use is that it’s like a car that is filled halfway with gas and it’s supposed to get from point A to point B. And it runs out of gas halfway. And you get mad at the road, get mad at the car, get mad at the driver and everyone else except for the people who were supposed to fill the car with gas! In this case, it’s Congress who is responsible, and every time Congress fails to appropriate enough money for the IHS, it’s legislated genocide.”

The IHS was funded at $4.05 billion for fiscal year 2010. A budget-slashing Congress pleasantly surprised some onlookers by increasing the agency’s fiscal 2011 funding to $4.07 billion. President Obama has put in a budget request for $4.6 billion for fiscal 2012, an increase of $571.4 million, or 14 percent, over the fiscal 2010 funding level.

Barack Obama isn’t the only supporter Native Americans have in D.C. Among the politicians who stepped up was Dorgan, who represented North Dakota in Congress for 30 years—first in the House and then in the Senate—before retiring in January 2011. His father worked as a horse wrangler on Fort Berthold before the flood. The elder Dorgan “always respected the Indian culture,” says his son. “He impressed upon me that our country had not lived up to the treaties and promises made to the American Indians.” This contributed to one of the single threads of good luck strung between the tribes and D.C., since the construction of the Garrison Dam. Along with the rest of the North Dakota congressional delegation—Democratic Senator Kent Conrad and Democratic Representative Earl Pomeroy, (who lost his seat this past November)—Dorgan spent years listening to the Fort Berthold people air frustrations about health care, exacerbated by the IHS’s reported mention of a $99 million, full-fledged hospital, a vision that glimmered beckoningly before vanishing into thin air. (The IHS would not comment on this.) Dorgan, however, remembers the $99 million estimate with a sigh: “Typical of IHS estimates, it had no connection to reality,” he says. “The IHS can’t meet current needs, far less get on with new buildings.”

The delegation started working to get a new health facility which, while it wouldn’t deliver a full-service hospital to Fort Berthold, would improve on what they had. Building on Tribal Chairman Hall’s testimony that “the promise to replace the lost infrastructure, particularly the hospital, has not been kept,” Conrad sponsored a bill in 2003 that authorized $20 million for a new clinic. Dorgan then found money in the budget of the Army Corps of Engineers, the agency that built the Garrison Dam more than half a century ago. “I decided that it was the Corps’s responsibility to build the hospital,” says Dorgan, who then headed the Senate Appropriations subcommittee that funded it. “They promised they’d replace [the original Elbowoods hospital] and never did it.” The money was designated in appropriations bills in 2008 and 2009.

The $20 million clinic—called Elbowoods Memorial Health Center—is under construction just outside New Town and slated to open in August. It will be four times the size of Minne-Tohe. Instead of the current six exam rooms, two doctors and four physician’s assistants, Elbowoods will have 13 exam rooms, four doctors, four or five physician’s assistants and a fully equipped mammogram room. It will also have two EKG rooms, a minor-procedure room and an audiology room. The reservation currently has 90 medical staff spread between Minne Tohe and four satellite clinics. That number is projected to go to 157, including a nurse at each field clinic.

The clinic is designed to someday be expanded into a hospital, which would likely be funded by the tribe. Project Director James Foote is proud of the design—a “river wall” near the entrance emulates the banks of the Missouri, and the entryway is a rotunda, reminiscent of the earthen lodges in which ancestors sheltered themselves for centuries. The dialysis unit will stay at Minne-Tohe, and that waiting list won’t go away; some patients will still have to travel for the procedure. There will be no overnight stays at Elbowoods, and no acute care.

Chairman Hall is fully aware that a $99 million facility would have had “a new kidney dialysis unit, a helipad, telepharm, telemed, an ER and 10 to 15 hospital beds.” He ticked off those “losses” with regret. “It was going to have berths for births. There hasn’t been a birth in a clinic on Fort Berthold since 1953. That’s just sad.”

Still, “it’s a much nicer facility than they have now,” says Dorgan. “Is it everything they want? No! But it’ll move substantially in the direction of good health care.” He adds, “I think the displacement [caused by the dam] had a lot to do with health consequences and diabetes. I’ve watched over decades now the promise of adequate health care to Native Americans not be fulfilled by the federal government.”

This story was originally published in the May 16, 2011, issue of High Country News. Lisa Jones wrote this story while participating in the California Endowment Health Journalism Fellowships, a program of USC's Annenberg School for Communication & Journalism. Jones is the author of Broken: A Love Story, the tale of her friendship with quadriplegic Northern Arapaho horse gentler and traditional healer, Stanford Addison.