Prior to World War II, diabetes was virtually unknown among the Native American population. After 1940 diabetes became "epidemic" among many tribes.

Today, diabetes is a vicious 21st-century Indian killer. National statistics show that Indians are hit four times harder than the general population.

Among Pima Indians in southern Arizona, 50 percent of persons over 35 years of age have diabetes. In some tribes in Oklahoma more than 40 percent of persons 60-64 years old have the disease. In all, about 60,000 of the 2.2 million American Indians/Alaska Natives who receive health care from Indian Health Care facilities throughout the nation are known to have diabetes.

Every American history student knows that American Indians had no immunity to simple childhood diseases, such as measles, that came with European explorers and wiped out entire villages and nations of native peoples. But why, in the last half century, has diabetes taken such a deadly toll among today's native peoples?

Mark Butterbrodt, a tall lanky Harvard-educated physician teaching pediatrics at the University of Minnesota, asked himself that question and decided to try out some theories.

Of Norwegian descent, Butterbrodt grew up in the northeast corner of South Dakota, next door to the Sisseton-Wahpeton reservation, in an era when the chasm that separated the native and non-native populations of border towns was even more pronounced than it is today. (As recently as 1999, the U.S. Commission on Civil Rights held public hearings on race relations in Rapid City, S.D. and emphatically reported racism there to be rampant.)

"It was through the wisdom and character of one man, Vine Deloria Sr., that I traversed that chasm as an adolescent," says Butterbrodt. Deloria, an Episcopal priest, was a member of the proud Sioux family of priests and poets, authors and advocates that has spanned three generations of distinction in a land often teeming with malevolence.

"Beyond my genuine respect for the inner character and spirituality of Indian people, my lifelong connection with them has been bolstered by the Episcopal Church, the Lakota/Dakota (Sioux) language and the wonderful old Lakota Hymnal," he says.

"My family had been Episcopalian for three generations before I was born," Butterbrodt adds. His great-grandfather, a Norwegian immigrant, had left the Lutheran Church to become Episcopalian "because the latter was much less strait-laced about the temperance movement." Butterbrodt's father, a pharmacist, was a linguist who spoke excellent Dakota and young Mark mastered the language early in life.

Historically, the Episcopal Church played a major role in the lives of the Sisseton-Wahpeton band. Driven out of Minnesota in 1863, the impoverished band would likely have starved to death had it not been for Bishop Henry Whipple, who relentlessly badgered the U.S. Congress for financial assistance (which the bishop, himself, administered). Large numbers of the band converted or at least supplemented their traditional religious ethos with Episcopalian Christianity.

Butterbrodt recalls long summer evenings spent on the lawn of St. John's Church at the rural hamlet of Brown's Valley listening intently to the legendary "Father Vine," a renowned storyteller. Attending the annual Niobrara Convocations, a gathering of Episcopalian Indians from across South Dakota, remains an endearing memory.

After graduating from a small South Dakota high school, Butterbrodt did his undergraduate work at Harvard. "I was Harvard's 'token hick,'" he says. He returned to his native state for medical studies and finished his medical degree at the University of Minnesota.

He was recruited to come back home to do his "pay-back" stint, to pay off expenses of medical school. His assignment with the Indian Health Service (IHS) was on the Yankton Sioux reservation, in the southern part of the state. "I did not start out with some sort of mission-driven, noble notion about being the good white doctor serving impoverished native peoples," he muses. "In fact, I was strongly drawn to academic medicine and figured when my 'pay-back' stint was taken care of, I'd return to the University of Minnesota."

Such was not the case. He would not return to Minneapolis until after seven years and several assignments on various Sioux reservations and facilities. It was in Rapid City in 1984 that his tie with Sioux people was further strengthened. He was working at Sioux Sanitarium in Rapid City and became close friends with several Pine Ridge people. Among those Lakota friends were John and Flossie Bear Robe, who lost a son about Mark's age in an automobile accident. The Bear Robes informed him they were taking him to replace their son. "It was no formal adoption," he said, "but I have since felt very much a part of their family."

Butterbrodt became a part of the congregation at St. Matthew's, the predominantly Indian church in Rapid City. Here he became quite proficient in singing from the Lakota Hymnal -- after serious coaching from Christine Prairie Chicken and Marie Rogers and other elders. It was the Lakota Hymnal, in fact, that became a powerful icon to him at a moment in his life when he was testing professional options. He had to make a decision whether to accept an offer to enter private practice, accept a fellowship for doctoral work at University of Minnesota or remain with IHS. While visiting a friend in Los Angeles, he visited a museum and stumbled on to an Indian exhibit. His attention quickly focused on a worn old Lakota Hymnal with a beaded cover. The Hymnal was open to hymn 167 -- "Guide Us, Oh Thou Great Jehovah." Legend says this was the favorite hymn of Philip J. Deloria, the priest-father of Vine Deloria, Sr. and grandfather of the renowned author, Vine Deloria, Jr. The hymn, according to legend, had figured largely in the proud young chieftain's conversion to Christianity.

Butterbrodt chose to remain focused on Indians. As he did so, the reality of the toll of diabetes on his patients began to occupy his mind.

He returned to Minneapolis with a Bush Foundation fellowship for coursework at the University of Minnesota. A professor spoke of the theory surrounding the "thrifty gene." This not-proven theory suggests that hunter-gatherer peoples were able to effectively store fat. The fat was then used during periods of famine. "People who make a rapid transition from nomadic or physically demanding lives to a more sedentary, inactive lifestyle with a steady food supply, appear to be more susceptible to obesity and diabetes," says Butterbrodt.

"Before the second World War, Indians were certainly more involved in physical labor," says Butterbrodt. "Rural women had few household conveniences. Simply to put a meal together required physical labor -- from gardening to gathering. Men were often day laborers, ranchers or farmers. All the children had chores requiring far more physical activity than watching TV."

Such observations led Butterbrodt to believe diabetes could be preventable among native people with a consistent and conscientious effort to revert to a pre-war lifestyle of food consumption and physical activity. "If we could get involved early with children, could we prevent diabetes altogether?" he pondered.

He wrote a proposal and the American Academy of Pediatrics gave him a $5,000 start-up grant. He departed a comfortable urban life in Minneapolis and set out for the Pine Ridge Reservation, located 90 miles from the nearest Office Depot or Target store. The reservation, home of the Oglala Sioux (or Lakota) Indians, is centered in Shannon County, the poorest county of the U.S. and, except for Haiti, has the shortest life expectancy of the western hemisphere.

Pine Ridge Reservation is noted for contentiousness, clique conflict and bitter memories. It was on this desolate reservation that the appalling massacre of Wounded Knee, in which 369 Sioux Indians were mercilessly slaughtered, occurred in 1890. And it was here, in 1973, that fierce inter-tribal conflict surfaced with the 71-day occupation of Wounded Knee.

"I came to Pine Ridge in 1995, fully expecting to get the program launched and return to Minneapolis in about three months," says the sandy-haired Butterbrodt. He is now entering his sixth year at work on the reservation.

The lynchpin of the project to illustrate how diabetes could be prevented was to screen children for risk of diabetes and to go into homes with training on nutrition and exercise.

From the onset, Butterbrodt sought to encourage and enable community ownership of the diabetes project. To achieve acceptance, he drew from all aspects of his background -- his knowledge of the language and respect for the character of Sioux people and his involvement in the Episcopal Church that once had 38 churches, chapels and mission stations on Pine Ridge.

Within a month he had a community board for the clinic. Acceptance for both the project and for him personally was promptly forthcoming. Staff soon included Darleen Bear Killer as coordinator and Mike He Crow as Community Health Representative. Pine Ridge people have been trained to do screening; Lakota-speaking people are trained to make home visits.

Also an aspect of the diabetes prevention program was a vigilant blending of traditional healing practices with western medicine. Spokespersons for the program soon included persons such as the Oglala elder, Rick Two Dogs, whose grandfather knew Crazy Horse. Two Dogs was trained by elders and is connected by spiritual practices to the use of herbs and ceremonies to achieve traditional healing.

Butterbrodt's staff included a certified diabetes educator and nutritionist who urged communities to provide nutritious school lunches and physical education in school curricula. Families were taught how to use "commodity foods" effectively.

Before long, kindergarteners were walking a mile a day and grandmothers were pumping iron at the school gym (after program staff was able to get schools to stay open after school hours for community use of facilities).

Every schoolchild on the Pine Ridge Reservation -- 4,000 in all -- has been screened. The project has identified 500 at highest risk. More than 800 home visits have been made to teach nutrition practices.

"A primary result of the project has been to educate families that diabetes is preventable, not inevitable," Butterbrodt says. "A secondary result is that we have demonstrated that positive lifestyles can change and improve longevity even in settings where there are so many obstacles to a healthy lifestyle."

The diabetes prevention project now funded by IHS employs 30 tribal members. Butterbrodt has "kicked back" and, while serving as unpaid medical adviser for the project, is working full-time with IHS and raising his adopted 14-year-old son, an Ojibwa from Red Lake Reservation of Minnesota.

Owanah Anderson, who lives in Wichita Falls, Tex., is of the Choctaw nation of Oklahoma. She is a member of the Episcopal Church Publishing Company board of directors (ECPC owns The Witness).

See also the Book Review