The River People

It wasn't the land that was alien. The tall saguaro cacti and the distant desert mountains looked exactly as they did in my neighborhood, except for the discarded liquor bottles that seemed to lie everywhere. Abundant trash is but one sign of a culture in decline. The Pima are the least healthy population in North America and suffer from the highest rate of diabetes in the world. The National Institutes of Health estimates that at least 60 percent of the Pima-some 7,000 people-are diabetic. Obesity is found in life-threatening proportions. It's not uncommon to see 75-pound children in kindergarten, or for adults to top 300 pounds. Health problems related to diabetes-blindness, the loss of limbs, liver and kidney disease-are so severe that some Pimas fear for the very survival of their tribe. Not surprisingly, in a community where jobs are few and problems many, alcohol and drug abuse are rampant, affecting, in one way or another, every member of the reservation.

It wasn't always like this for the Pima-which isn't even their proper name. They call themselves A'a'tam a'kimult, or River People, and they have lived in the Sonora Desert on the banks of the Gila for at least 2,000 years. The word Pima is a corruption of pimate, meaning, "I don't understand," which was probably this people's response to the questions of the Spanish soldiers who explored the Southwest in the 16th century. Even into the 20th century the Pima hunted and fished, raised corn, beans, squash and cotton. Many Anglo settlers passing through the Gila River watershed remarked on the generosity of the Pima and on the beauty of their children. One American soldier, saved from starvation by the tribe in 1846, wrote, "They are a noble race."

But one terrible day in 1928, the river that had sustained the Pima for generations beyond memory suddenly stopped flowing through their land, its water diverted upstream by the Coolidge Dam. The Pimas' days of hunting and farming were largely over, and their days of dependency and disease were about to begin. Instead of tilling their fields, they lined up for government handouts of bread, cheese and bologna.

With the damming of the Gila the Pima became mostly sedentary. But the inactivity of modern life has had a more devastating effect on them than on other ethnic groups, creating unusually high rates of death due to obesity and diabetes. In the 1960s, researchers at the National Institutes of Health began a decades-long study of the Pima, which continues today. Scientists now theorize that the Pima possess a "thrifty" gene, a legacy of their hunger-gatherer past that is proving fatal today. This gene, researchers believe, allows the Pima to easily store fat-an advantage for their ancestors who needed to survive lean times in the harsh Sonora Desert but a crippling liability in a fast-food culture.

Much of my therapeutic work with the Pima consisted of trying to help patients struggling with substance abuse, the effects of disease, depression and weight control. One of the first things I learned on the job was that some of my own unquestioned assumptions about how to work with patients would need to change. Even something as seemingly straightforward as setting a time for a session taught me much about the Pima-and about myself.

I remember my first appointment with a man I'll call Mr. Whitecloud. He was scheduled to see me at 2 o'clock for a typical 50-minute session. He was late. As the minutes passed, my patience waned. "Doesn't he know I'm an important person," I thought, fuming? Finally, at about 2:30 p.m. he showed up. But instead of coming into my office, he stopped in the waiting room to chat with a relative for another 10 minutes. I asked him if there had been some misunderstanding about the time.

"No," he said.

"Well, you only have 20 minutes left, now," I said. I was lying; I didn't have a 3 o'clock appointment, but I wanted to teach him something about the value of punctuality.