Arleen Marcia Tuchman—

Like African Americans, Native Americans did not suffer from diabetes. At least, that was the nearly universal belief in the first decades of the twentieth century. Not that they were healthy. Tuberculosis was ravaging their communities. Trachoma, enteritis, and other infectious diseases were rampant as well. But diabetes, cancer, and cardiovascular ailments—the so-called diseases of civilization—seemed to rarely claim a victim. Trying to make sense of this disease pattern, professional and popular writers alike drew on widespread tropes of “primitive” and “civilized.” According to these narratives, Native Americans, as a so-called primitive people, continued to die of infectious diseases that flourished in unhygienic homes and communities, spread by individuals ignorant of modern hygienic codes of behavior. These were the dirty diseases of “savages.” As far as the “clean” diseases of the “civilized” were concerned, Native peoples appeared to be immune.

These claims persisted until the middle of the century, when diabetes rates among Native Americans seemed to be rising, in some cases even surpassing those of whites. Yet few argued that Native peoples had finally become civilized. Instead, these increasing rates were attributed to their being biologically unequipped, as “primitive” peoples, to adapt to the challenges of civilization.

How was it possible to read both low rates of diabetes in the early twentieth century and high rates of diabetes decades later as evidence of the primitiveness of Native Americans? What assumptions, arguments, and explanations worked to sustain an image of Native peoples as primitive, even as one of the markers of that alleged primitiveness shifted from immunity to diabetes to an unusually high susceptibility to the very same disease? The answer to these questions rests in the confluence of a number of developments, including the tendency to lump together tribes with different genetic ancestries into a single racial category, “Native Americans” or “American Indians”; the perception of Native peoples as an ideal laboratory for studying disease; the emergence of human genetics as a legitimate and highly revered scientific endeavor; and a reluctance by researchers and government officials to engage seriously with the direct health consequences of federal policies, which had been systematically decimating Native American lands, cultures, and communities for over a century.

None of this addresses the question of whether diabetes rates did, in fact, start out low among Native peoples, only to escalate rapidly as the century progressed. And while it is likely that diabetes rates did follow this pattern with some tribes, the paucity of reliable data, coupled with the ambiguity surrounding the category “Native American,” provide ample reason to doubt diabetes’s absence from Native populations in the early twentieth century. After all, for which of the thousands of Native American tribes might this have been true? As Kim Tallbear, an Indigenous Studies scholar, has pointed out, before contact with Europeans, “Native Americans” did not exist. Instead, there were thousands of small groups, each with its own language, history, and cultural traditions. European settlers erased these differences and placed all indigenous populations under one heading as part of their colonialist ventures, which then allowed them to rank different “races” in a hierarchy from least to most “civilized” and, thereby, to justify the forced removal of “primitive” peoples from their lands and homes.

Such clear demarcations were never, however, stable. Intragroup differences—whether cultural, linguistic, geographic, historical, or genetic—consistently pushed against the totalizing nature of a single category. This was evident in political disputes between Native populations; the persistence of distinctive cultural traditions and rituals; and in noticeably different mortality and morbidity rates. In the diabetes literature, medical researchers certainly struggled throughout the century to make sense of differential rates between tribes, especially as unusually high rates of the disease were found among the Akimel O’odham (Pima), Cherokee, and several other Native populations in the decades following World War II. Nevertheless, despite comparatively low rates among a number of other tribes, including the Athapascan Indians, Eskimos, and Dineh (Navajo), professional and popular writers alike continued to claim that whites and Native Americans had different experiences of the disease. Ideas of racial difference in general, and the alleged primitivity of Native Americans in particular, proved difficult to let go.

This remained the case after World War II, despite attempts by physical anthropologists and population geneticists to change how race was understood. Wanting to distance themselves from their eugenic past, they declared their intent to replace fixed racial typologies with the idea of race as a population defined by “the frequencies of some gene or genes.” In theory, this meant that an individual, or community of individuals, might belong to different “races” depending on the trait being studied. In practice, fixed typologies, and the racial hierarchies they represented, proved difficult to avoid. Ideas about “primitive” and “advanced” societies would continue to influence medical narratives about diabetes and indigenous societies for decades to come.

No theory revealed this influence more clearly than the thrifty gene hypothesis. First proposed by the geneticist James Neel in 1962, it offered an evolutionary explanation for how a deleterious trait—a diabetic genotype—might have attained a high frequency in the human gene pool. Why, Neel wondered, did natural selection not result in a lower frequency of this trait? Building on recent work that explained how the sickle cell trait conferred some protection against malaria, Neel suggested that a “thrifty genotype” might have helped early humans as they lived through repeated cycles of feast and famine by increasing the efficiency with which they stored fat when food was plentiful—and thus helping these “efficient” fat storers to survive and reproduce. According to this theory, when food became consistently available, this ability to store fat efficiently became a liability.

What often goes unnoticed is that Neel did not offer his hypothesis as a way of explaining high rates of diabetes among Native Americans; in fact, he did not even mention them in his 1962 article. Instead, he was trying to understand the near universal distribution of diabetes. That is why he referred to “the first 99 per cent or more of man’s life on earth, while he existed as a hunter and gatherer.” For Neel, “man” referred to all the peoples of the world. Yet Neel’s hypothesis, which he first proposed in 1962 to explain the origin of diabetes in early humans, had by the late 1970s acquired the status of a highly plausible explanation, occasionally referred to as a theory, about why Native Americans had some of the highest rates of diabetes not only in the United States, but also in the world. Indeed, the idea of a close link between thrifty genes and indigenous peoples has persisted until today, despite Neel’s abandonment of his own theory before his death in 1999, and despite the lack of any concrete evidence. A belief in racial difference keeps it alive.

The history of Native Americans and diabetes provides additional evidence of the deep entrenchment of ideas of race in professional and popular writings on disease. It also opens a window onto one of the first sites where diabetes underwent a gradual transformation from a disease of “civilized humanity” to one that most afflicted those who lacked “culture.” Poverty, primitivity, and ignorance, not wealth, civilization, and education, became its defining traits.

From Diabetes by Arleen Marcia Tuchman. Published by Yale University Press in 2020. Reproduced with permission.

Arleen Marcia Tuchman is professor of history at Vanderbilt University specializing in the cultural history of medicine. She is the author of Science, Medicine, and the State in Germany and Science Has No Sex: The Life of Marie Zakrzewska, M.D.

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