Diabetes among the Pima: Stories of Survival (review)

Even as health care providers focus increasing attention on the social, cultural, and environmental contexts of type-2 diabetes, the disease continues to grow at alarming rates in the United States and around the world. Carolyn Smith-Morris's Diabetes among the Pima: Stories of Survival clearly demonstrates the ways in which an ethnographic approach can offer key insights into the limits of the current efforts to fight this growing epidemic. Based on nearly ten years of fieldwork with the Pima Indians of the Gila River, this book is an ambitious, thoughtful ethnographic work exploring the causes and consequences of what she identifies as a "conflict in worldview" between the Pima and the clinicians working to prevent, diagnose, and treat diabetes within this population (p. 5). The research presented in this book focuses primarily on Pima perspectives on the disease, particularly the perceptions of Pima women. By collecting and representing Pima women's accounts of diabetes as they both experience it and understand it in their own individual lives, Smith-Morris makes visible the conflicts taking place in health education efforts and points to potential avenues for combating the disease in the future.

Smith-Morris dedicates a large portion of her book to explaining the limits of current biomedical attempts to prevent and treat the disease among the Pima. For example, she describes the pragmatic concerns affecting the everyday lives of the women with whom she works, including the desert heat, unemployment, the inaccessibility of healthy foods, and the lack of transportation—all of which shape the unique "mind-set" and "body-set" governing how Pima women approach diabetes. (The concept of mind-set in the book is grounded in David L. Kozak's notion of surrender in his work on diabetes among the Pima, while the idea of body-set is based on Pierre Bourdieu's idea of habitus.) Smith-Morris also discusses several common obstacles to treatment that women identify in their interviews, including long waits at the doctor's office and concerns about confidentiality, as well as Pima perceptions of their own personal competency and the cultural ignorance of their health providers. What she identifies as the "conflict of worldview" becomes most clear in chapter 6 ("Two Hands Shaking"), where she uses the metaphor of two hands shaking to highlight the differing expectations Pima women and medical professionals bring to medical interactions, and in chapter 12 ("Collective Identity, Loner Disease"), where she explores some of the cultural and ideological reasons for rejecting biomedical care.

While Smith-Morris's study focuses on Pima women's perspectives, she also includes the views of individual clinicians working with these women at Gila River, taking care to warn her readers against ignoring the difference between the actual working clinicians and biomedical hegemony. She describes problems stemming from the idea of "patient compliance," but her larger argument is not that these clinicians should stop what they are doing; rather, she argues that the "clinical setting must be decentered as the primary site for diabetes education and prevention" (p. 93). Pima culture should be seen not as separate from health education efforts but as intrinsically a part of them, and work in diabetes prevention should be integrated into the daily lives of the Pima through community-based approaches.

Smith-Morris is not the first researcher to use illness narratives to access people's experiences of diabetes, but her focus on Pima women and prenatal diabetes or gestational diabetes mellitus (GDM) offers a unique entry point into the study of the disease among the Pima in general. As she explains her rationale for this focus, she points to research indicating that GDM increases the risk of both mothers and babies getting diabetes later in life, claiming that "combating GDM effectively is the linchpin of a coherent strategy against Pima diabetes in all its manifestations" (p. 26). When she is talking about women's diabetes, then, she says she is in fact "talking about...