Health, wealth and wisdom

Rita Romo treats a lot of wounds. In fact, in the course of a day’s work, that’s often the main thing she does.

Romo is a community health nurse at the Pyramid Lake Tribal Health Clinic, and she deals especially with foot and leg wounds, trying to hold off infections so her patients don’t end up needing amputations or, worse yet, dying from sepsis. The patients she treats—Paiute (Numu in their native language) on the Pyramid Lake Indian Reservation—almost all have problems with healing wounds, so even small cuts can have dire consequences. And the underlying cause is type 2 diabetes, which disrupts healing because high blood sugar levels damage blood vessels and nerves and impair the function of white blood cells.

Jeff Davis, a physician assistant at the clinic and, for the time being, the de facto director of medicine, said that educating people about diabetes prevention and treatment has had a big impact on the reservation. Even so, he guessed that some 30 to 40 percent of the Paiute on the reservation have type 2 diabetes.

Before the 1950s, relatively few Americans, native or otherwise, had the disease, but these days one often hears about a national “diabetes epidemic.” So, what has happened at Pyramid Lake is part of a larger phenomenon. However, diabetes prevalence for the whole country is “only” about 9 percent, far below the level among the Pyramid Lake Paiute.

According to Davis, who is white, and Romo, who is half-Paiute and half-Mexican, it’s not just that diabetes is especially common on the reservation, but also that many people have serious complications from the disease. For patients whose blood sugar levels get out of hand, it becomes a sickness of the entire body.

“The peripheral neuropathies, the pain in the legs, the amputations, the blindness, the visual problems, the heart disease, everything really stems from the diabetes,” Davis said.

In 2006, public health experts at Harvard identified eight U.S. sub-populations, categorized by race and place, and showing great differences in life expectancy. They ranged from “Asians” (excluding Pacific Islanders) with life expectancies of about 82 years for males and 87 years for females to “high-risk urban blacks,” with life expectancies of about 67 years for males and 75 years for females. As the researchers pointed out, life expectancy at the bottom end was at the level of low-income countries such as Nicaragua and Lebanon, while at the top end it was higher than that of any country.

The eight sub-populations were labeled “America 1” through “America 8,” in order of highest to lowest life expectancy. At number 5 were “Native Americans living in the West, excluding the West Coast.” Most of these were Indians living on or near reservations, including the Pyramid Lake Paiute. This “America 5” group had life expectancies just under 70 years for males and about 75 years for females, much closer to the low end of the scale than to the top. America 5 also had a high rate of death from diabetes.

The message that comes through loud and clear from this “Eight Americas” study is that, within the U.S., there are huge disparities in overall health. And these health differences are tied to race and socioeconomic circumstances.

Genetic myths

Three or four days a week, Ed Nasewytewa works out in the gym at the Reno-Sparks Tribal Health Center on Kuenzli Street. He does an hour of cardio work first, and then hits the weights. Sometimes he boxes. At 56, he cuts a distinctive figure, with a mix of gray and black hair pulled back in a ponytail, and a barrel body that makes his metal prosthetic lower legs look even spindlier than they are.

Nasewytewa was born in Arizona, worked as an IT specialist in California for many years and moved to the Reno area in 2016. He was diagnosed with type 2 diabetes in 1998, lost his left lower leg to the disease in 2012 and lost his right lower leg five years later. His brother and sister also have diabetes, and both his mother and father died from diabetes-related complications. He’s been working out at the health center for about a year now, and has lost weight, gained strength, and built up his endurance. His blood sugar is pretty much under control, although there are times when it spikes.

The Reno-Sparks Indian Colony is unusual in that it is home to members of three different tribes—Washoe, Paiute and Shoshone. Nasewytewa isn’t part of any of those groups, though. His ancestry is in the Desert Southwest. He’s part Hopi and part Pima.

A Pima Indian with a severe history of diabetes. For anyone familiar with diabetes research that phrase will get some brain neurons firing. The Pima, specifically those living on the Gila River Reservation in Arizona, were one of the first tribes recognized as having an unusually high prevalence of diabetes. In the 1950s, the disease was already much more common in the Pima than in the overall U.S. population, and today the tribe has one of the highest rates of diabetes anywhere in the world.

Many medical experts viewed the rate of diabetes among the Pima as so anomalously high that it couldn’t possibly be due only to poor diet or other lifestyle influences. The Pima, the thought went, must be inherently susceptible to type 2 diabetes; they must be genetically predisposed to develop the disease. The experts especially applied to the Pima the “thrifty genotype” hypothesis, the notion that because of a long history of famines, certain populations possessed genetic alleles for efficiently storing fat. This was fine if you were actually experiencing frequent food shortages, but in the here-and-now, with a constant surplus of food, that “thrifty genotype” translated to obesity. And obesity led to diabetes.

It sounds like a reasonable explanation, but it doesn’t hold up. For one thing, the idea that the Pima experienced especially frequent food shortages is debatable. More importantly, nobody has been able to find the supposed “thrifty genes” in the Pima. Genetic alleles that increase the risk of diabetes do exist, but they do not seem to be more common in the Pima or other Native Americans than in Europeans.

Davis and Romo, in talking about diabetes among the Pyramid Lake Paiute, were much more on the mark about why the disease is so prevalent among reservation Indians. Type 2 diabetes is strongly tied to living habits, especially lack of exercise and a diet that includes lots of sugar and other refined carbohydrates, and those were the sorts of things Davis and Romo brought up.

They pointed to sedentary modern habits. They talked about the unhealthy, non-perishable food provided by the government in the form of so-called “commodities”—powdered potatoes, sugary peanut butter, heavily-salted ham, and so forth. They noted that, from the tribal seat in Nixon, one has to drive at least 19 miles to get to a grocery store, and that there are people on the reservation who don’t have a car or can’t afford the gas to make the trip. They mentioned the simple lack of money to purchase healthy food.

“You can buy a lot of beans and macaroni and cheese, but if you’re buying fresh vegetables and fruit, it doesn’t go as far, and you have to make it go,” said Davis. “You have to make that dollar last.”

In other words, it’s about money and access to resources, especially access to healthy food. It’s about living habits constrained by circumstances, which, in turn, have been dictated by history. It’s not about genes.

The tiny Pacific island of Nauru, part of Micronesia, has one of the highest rates of type 2 diabetes in the world, with over 40 percent of the population afflicted. As at Pyramid Lake, amputations, blindness and kidney disease—all tied to diabetes—are unusually common on Nauru. Other Pacific Islanders also are suffering from especially high rates of the disease, as are indigenous Australians.

Medical experts have often used the “thrifty genotype” or other genetic explanations to account for the high rates of diabetes in these indigenous peoples. For instance, one group of researchers has argued that adoption of Western lifestyles, while important, cannot explain “the prevalence [of diabetes] above and beyond that of the dominant or “Westernized” society.” In other words, the high rates have to be tied to genetic susceptibility, because these populations could not have become more Western than the dominant society itself.

This is not a logical argument. It does not recognize that indigenous people in the modern world often experience unhealthy Western habits—for instance, lack of exercise and diets overloaded with processed carbs—in an exaggerated form. It is possible to be more Western than the West.

It seems telling that the genetic susceptibility argument for a high rate of diabetes also has been applied to blacks, Asians and Hispanics. And in the late 1800s and early 1900s a similar argument was made for Jews.

In all these cases, supporting genetic evidence has been weak or non-existent.

Death by the numbers

At the Nevada Department of Health and Human Services in Carson City, a statistician from something called the Office of Analytics will, as if by magic, pull up data on “all-cause mortality,” the rate of death by any cause, sort of the inverse of good health. This person will also—implausibly quickly by bureaucratic standards—divide the data up by race and ethnicity. And they will make sure the results are adjusted for age, so that the numbers for different groups can be directly compared.

The results, depicted in the graph, are illuminating (even if a bit messy because of small numbers). Just as the situation at Pyramid Lake fits into the big picture of diabetes on Indian reservations and beyond, so the “all-cause mortality” for Washoe County is a microcosm of racial and ethnic distinctions for the whole country.

Some of what comes out of the graph echoes the “Eight Americas” study. For instance, blacks have the highest mortality rate, Asians have a low rate, and whites are in between. The fact that Native Americans in Washoe County have a mortality rate similar to or even lower than whites might seem to go against the “Eight Americas,” but most Native Americans in the county are urban, and those Indians tend to be healthier than the reservation Indians of America 5.

Maybe the most striking result is the low mortality for Hispanics, lower even than the rate for Asians (although the two probably are not statistically different). This is surprising, because Hispanics as a group are relatively poor, and poverty usually means bad health. But, as it turns out, the county numbers here are in line with national data. In fact, the relatively good health of Hispanics despite often being poor has been observed so often that it has been dubbed “the Hispanic Paradox.”

Nobody knows for sure why Asians and Hispanics are doing markedly better than other racial/ethnic groups, but, as with most health differences among populations, the immediate explanation is probably living habits. For both groups, diet is often given as a possible reason. Hispanics also tend to have especially strong ties to family and community, and those connections might be important; various studies show that positive social networks translate not just to better mental health, but to improved physical health as well.

The county mortality figures might give the impression that non-Hispanic whites, some 63 percent of the population, are actually a disadvantaged group. But the reality is that only some whites are disadvantaged.

A few years ago, University of Nevada, Reno researchers Wei Yang and John Packham put together data that give some insight into this issue. They took Washoe County health statistics for the years 2008-2010 and divided them up, not by race or ethnicity, but by place, specifically, by zipcode areas.

From this dataset, one can pull out a rather stark comparison: zipcode 89519 versus zipcode 89433. 89519 is Caughlin Ranch, one of the wealthiest areas in Washoe County, and 89433 is Sun Valley, one of the poorest; the per capita income of 89519 is more than three times that of 89433. Both areas are majority non-Hispanic white, although Caughlin Ranch is more heavily white than Sun Valley.

Yang and Packham included rates—age-adjusted—for three kinds of hospitalizations, and for all three there were huge differences between the two areas, with Sun Valley always having the higher rate. For heart attacks, the figure for Sun Valley was 2.3 times higher than for Caughlin Ranch, for asthma, 2.9 times higher, and for chronic obstructive pulmonary disease (COPD) a whopping 6 times higher. It’s as if these two places, both mostly white and fewer than 10 miles apart, are in different countries.

This is just one comparison, obviously, but similar connections between wealth and health have been reported over and over, whether comparing countries, counties or neighborhoods. Contemplating such results, John Packham, who is now associate dean for the Office of Statewide Initiatives at UNR, said that health problems related to social class, regardless of race, haven’t gotten the attention they deserve. Poor whites, poor blacks, poor Native Americans—they all tend to fare badly when it comes to health, and for many of the same reasons, such as poor education and lack of access to healthy food. The message is that, whatever gave rise to socioeconomic inequalities, diminishing them will help erase the massive health differences in our society.

Still, it would be hard to argue that race and racism are not part of the puzzle. For instance, the relatively poor health of Native Americans on reservations is linked to poverty, but that poverty is itself tied to a long history of racial oppression, from genocide to the theft of land and water to cultural erasure at Indian boarding schools. Along the same lines, how can black poverty and health be separated from slavery, segregation, unnecessary incarceration?

The widening gap

In the U.S., health disparities among groups have gone up over the past several decades, as indicated by the “Eight Americas” study and others. The gap has especially widened between the poor and the middle class; for health, the fuzzy border between haves and have-nots is not between wealthy elites and the rest, but instead is much further down the ladder.

Jeff Davis, the physician assistant at the Pyramid Lake Tribal Health Clinic, said something that suggests why this gap has widened. Davis had gone on a “paleo diet” and lost 25 pounds, and was talking about how his circumstances had allowed him to do this. “I can afford to go to the grocery store three times a week,” he said. “I can afford to buy the groceries that are the right groceries for me. I can afford to join the gym. And that’s huge right there.”

The implication is that middle-class folks like Davis, even if they’re not medical professionals, tend to have both information about living healthily and the wherewithal to translate that knowledge into action. The information and the ability to do something with it have gotten better, and so overall health has improved, despite persistent problems. Those in disadvantaged circumstances, whether connected to race or not, are more likely to lack the information or the wherewithal or both. And, too, poverty often means living with high stress, which also affects health.

If such things are at the core of widening health disparities, as they seem to be, then it is not obvious how to close the gap. John Packham said education is a key, because it leads to higher income, and he particularly mentioned raising Nevada’s high school graduation rate to 90 percent. No doubt that would have a positive impact. But one wonders if, ultimately, a societal shift is needed. Perhaps what is required is an overall movement toward greater equality, something fundamental, something seismic.