Set against the bleak statistical landscape of Native American health, the upsurge in body weight and diabetes on Fort Berthold isn't unique, severe or even surprising. Nationwide, 16.3 percent of Native Americans are diagnosed with diabetes. Researchers first 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 NIDDK returned to study diabetes instead.
In 1900, there was perhaps one recorded case of diabetes among the Pima. In the 1920s and '30s, the Gila River sprouted dams and diversions to funnel water into growing cities like Phoenix. Without that water, the Pimas' diet -- for 2,000 years based on irrigated corn, beans and squash, as well as game and a huge variety of wild plants -- changed radically. Its fat content increased from 15 to as high as 40 percent. And the Pima got fat. Really fat. They are, in fact, among the fattest people in the world. Researchers theorized that there was a "thrifty gene" at work -- a tendency to put on weight easily that is often seen in populations that evolved amid feast and famine. This gene worked in their favor when they lived from hand-to-mouth, but once they became sedentary and ate processed fatty foods, they became prone to obesity and diabetes. In 2002, one-half of adult Pima Indians had the disease, according to the NIDDK.
Meanwhile, the Southern remnants of the Pima Tribe raise corn, beans and potatoes in the Sierra Madre south of the Mexican border. They are slim, their diabetes rate unremarkable.
In the 1930s, there were only five known diabetics among 25,000 hospital admissions at the Sage Memorial Hospital in Ganado, Ariz., 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."
There are other factors at work besides the "thrifty gene" and lifestyle changes. Diabetes rates correlate with poverty -- poor people eat unhealthy diets -- and roughly one-third of Native Americans live below the poverty level. Federal policies have also played a part, particularly the USDA commodities program, which for decades supplied low-income Native Americans with surplus food.
"People think fry bread is a traditional food," says Donald Warne, a Lakota with a medical degree from Stanford, a public health degree from Harvard and a long history of working on Native American health issues. "The origin of fry bread is the tribes trying to do the best that they can with commodity food -- flour, shortening."
On Fort Berthold, perhaps 40 percent of the people were on the commodity food program during the decades after the flood, according to Dr. Wilson, now a spry 90-year-old living in Bismarck with his wife of 66 years. Commodity canned meat was crowned with a white fat cap and "looked like they scraped it off the floor," while the canned fruit was "loaded with sugar," according to Charles "Red" Gates, who runs the commodity food program on the Standing Rock Indian Reservation, which straddles the border between North and South Dakota.
Gates recalls a 1990 hearing on Standing Rock, where 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," and a Government Accountability Office investigation was launched on Fort Berthold and three other reservations. It 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 the month, some families subsisted solely on macaroni, rice and cornmeal. The high starch content was believed to be "a major contributor to the prevalence of obesity on the reservation."
In 1993, Standing Rock hosted a pilot project to include fresh fruits and vegetables in the commodity food program -- 14 years after the IHS had launched its first diabetes program. These days, commodity food includes healthful fare, like whole-grain pasta, low-fat milk, avocados, nectarines and frozen bison. But low-income Native Americans can choose between commodities and food stamps, and on Standing Rock, Fort Berthold and beyond, younger people are trickling away from the former and signing up for the latter so they can buy convenience foods like chips and soda. Gates argues with them about their food choices. "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."
Just over 10 percent of Fort Berthold's population -- some 600 people -- now receive commodity food, according to Lionel Chase, the reservation's acting director of the commodities program. Chase sees the same phenomenon Gates does on Standing Rock: Qualifying families opt for food stamps over commodities. The commodity warehouse in New Town is stocked with healthy food, but in the hall a woman speaks into her cellphone: "I'll make dinner," she says. "Hot dogs and cheese and chips."
The Indian Health Service is the agency left holding the 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 on medical care per user ($3,348 when construction costs are factored in). In comparison, recent figures reveal that the federal government spends about $5,841 per Medicaid enrollee, $7,154 per veteran, and $4,412 per federal prisoner. There's a longstanding joke that if a Native American is going to get sick, they'd better get sick before June, because the IHS runs out of its annual funding by summer.
The IHS operates 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 and are now 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 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.' "
Dialysis and most other diabetes treatment happens at the Minne-Tohe clinic 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 Sen. Byron Dorgan, D, the other by former Republican Rep. Newt Gingrich -- pour a total of about $850,000 per 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 Diabetes Director Arne Sorenson, who, like some other enrolled tribal members, has a streak of Scandinavian blood. "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 hopeful 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."
Donald Warne puts it more sharply: "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. Last month, a budget-slashing Congress pleasantly surprised some onlookers by increasing the agency's FY 2011 funding to $4.07 billion. President Obama has put in a budget request for $4.6 billion for FY 2012, an increase of $571.4 million, or 14 percent, over the FY 2010 funding level.