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Smoking the pipe of peace
Wakley Prize Essay
Smoking the pipe of peace Farrah Jasmine Mateen Lancet 2007; 370: 2170–71 Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA (F J Mateen MD) Correspondence to: Farrah Jasmine Mateen, Department of Neurology, 200–1st Street SW, Rochester, MN, USA 55905 [email protected]
“[The tribes] have perfect confidence in the skill of their own physicians, until the disease has made one slaughter in their tribe, and then, having seen white men amongst them protected by [the vaccination], they are disposed to receive it, before which they cannot believe that so minute a puncture in the arm is going to protect them from so fatal a disease; and as they see white men so earnestly urging it, they decide that it must be some new mode or trick of pale faces, by which they are to gain some new advantage over them, and they stubbornly and successfully resist it.” Extinction of the Mandans by smallpox, George Catlin (circa 1832–39)1
Wanuskewin was constructed 15 kilometres off highway 11, on the journey north to the settlement of Prince Albert, Saskatchewan. Saskatchewan might be a barely pronounceable name for a province, but it is in fact five times the area of England. Its capital was named in the Aboriginal Cree tongue, meaning “pile of bones”, after the large heaped carcasses of bison that remained after the bountiful ancient hunt. Blinded by its furry head and heedless of its path, the bison barrelled over cliffs, spurred on by Aboriginal hunters. When it fell helplessly to its death, every part of the bison’s flesh was put to use for the health and wellbeing of the Cree people. There were just bones left over. Piles o’ bones. Today, the province lies void of this slaughtered wild beast. The rivers that once carved the plateaus into high crags now embrace only tiny hills, like nipples, teasing an everlasting flat prairie. There is grass, then snow and the tracks of the jackrabbit. And in the middle of what some would call nowhere, our nowhere, sits Wanuskewin, a metal Aboriginal interpretative centre, in the icy, frigid north. Yes, I know there is global warming, but we, in the north, still feel cold. Robert Highway, his anglicised name, was yet another Cree with diabetes on the vascular surgery service where I was an eager medical student. Robert had been the one to invite me to Wanuskewin. In fact, he had invited our whole team of physicians and nurses, but I found myself on Highway 11 alone. “You take your expensive pills, doctor, and give ‘em to someone else,” Robert had scolded me, forcefully, banging his fist on the plastic hospital tray. “I feel fine. Why would I want to come back to this place?” The health-care team had, admittedly, run out of persuasive arguments long ago. The obvious answer, to us, was to point to his rotting, toeless, and plum-coloured limb. The diabetic foot—painless, disabling, gross. When I unwrapped it, I nearly vomited, but Robert’s retinopathy had made his injury unapparent to him. He was a poor surgical candidate. He had hobbled around for a while and stalled his arrival to the hospital, finding work, 2170
escorting a few American hunters to kill grizzlies in the Canadian Shield. At some point, far too soon, his coronaries had clogged up. Soda and potato chips are cheaper than milk and vegetables in northern Saskatchewan. Beer is more accessible and more popular than health care. And if you were counting on clean drinking water on his reservation, you would need to wait until yet another fast-talking, slow-moving politician lost a political appointment in Ottawa. Robert hadn’t thought much about the difficulty of trapping game up north without a leg, and he, like so many others, had started to collect government support. I suspect that the doctors, none of whom were Aboriginal, knew that some of their tax dollars eventually made their way to the Cree people, but were not helping them very much. But the doctors were busy and Robert was just another example—no longer a fisherman by winter, a collector of muskrat by spring, or a carpenter in summer and fall. At home, he began watching television and drinking, we smelled, too much. Robert’s problem, you see, was not necessarily his health, but something deeper. The paleface would call it illiteracy, alcoholism, even ignorance, poor integration, lack of acculturation, and dropping out of school. But it was none of these things. Robert was an intelligent man. Although he did not speak the Queen’s English, he was a good communicator. For his knowledge of oral history, he was revered by his family members, his community, and the Cree nation. He spoke plainly and simply. “Take your pills back. I feel fine.” “There was total darkness for a great time over the whole of the earth; the Choctaw doctors or mystery-men looked out for daylight for a long time, until at last they despaired of ever seeing it, and the whole nation were very unhappy. At last a light was discovered in the North, and there was great rejoicing, until it was found to be great mountains of water rolling on, which destroyed them all, except a few families who had expected it…” Attributed to Hatchockucknee, or Snapping Turtle (circa 1832–39)1
Diabetes. Not smallpox or war, not even guns, arrowheads, or violent waters, but instead, a silent enemy now lurks among the Cree. But how can you believe in silent enemies when everything you know to be true is heard and spoken? “Diabetes, you see, is like the wind,” I attempted. “You may not hear it or see it, but you know it is always there. You see what it does after it has finished and run away without you.” “Oh yeah?” He scratched the stubble on his chin. “My wife, she has diabetes too. My daughter—she is eight. She has it now. I have given this to her. Come. Talk to them.” The team of surgeons had politely agreed and www.thelancet.com Vol 370 December 22/29, 2007
Wakley Prize Essay
welcomed any referrals. Others on the team had merely smiled, pretending not to have been invited to Wanuskewin or to his reserve, places where most non-Aboriginal people have never been. To understand this awkwardness, you must know that Aboriginal people occupy a curious place in Canada and throughout the world. Unlike most minorities, they hold, or at least once held, special claim to the land we now feast on with our schools, dollar stores, skyscrapers, and fast-food chains. Unlike most of the world’s vulnerable populations, they tend to live in countries of extreme wealth. The health of the Canadian Aboriginal population is ranked more than 50 places behind that of Canada as a whole. Aboriginal people die sooner. They are less likely to survive when they are born. Their diseases are more likely to be preventable. Their mothers are more often children. More often born with the effects of alcohol, they are more likely to die of accidental injury and violent crimes. Sexual assault is more frequent towards Aboriginals, and ultimately, Aboriginals are more likely to kill themselves. To continue this litany, Aboriginals are less likely to graduate from high school. More than half don’t see a diploma—even in this rich, developed country. Despite programmes, committees, and dollars to combat the situation, Aboriginals are less likely to acquire a college education, and, therefore to become doctors or nurses. Three-quarters of all youth encounters with the criminal justice system in Saskatchewan involve Aboriginals. Diabetes, then, seems to be an afterthought. And, surprisingly, there is every reason to believe that Aboriginal people were healthier than European settlers only a few hundred years ago. Some of the oldest remaining treasures of the Cree are not gold and jewels, but medicine wheels, carefully placed into the half-frozen ground. If you look carefully, you can still see them— maybe even find one in your backyard. “Thank you for visiting, but your land, from the beginning, was known to us, the First Nations.” But what starts first at the beginning can end up last. The Aboriginal story tells us that money alone does not lead to health. I am no medicine woman though. My hard-core medical training has driven me away from anything that doesn’t come in a pill or patch. I secretly see most alternative therapies as namby-pamby guarantees of expensive urine. My general ignorant reluctance to understand alternative therapies doesn’t serve my Aboriginal patients well. So I drove down Highway 11 to Wanuskewin. What did I have to tell the Cree about diabetes? Despite my training, not too much. I gave an information session on blood sugar, insulin, and the importance of diet and
www.thelancet.com Vol 370 December 22/29, 2007
exercise. I tried to speak clearly and leave room for questions, but the talk was just mediocre. I felt I had failed when Robert Highway came back, only weeks later, with a below-knee amputation and crutches. Noticing my naïve dismay, Robert put his crutches aside. “Aboriginal people are not a fallen people. They are strong and mighty. For it is told that wherever a history is woven of many threads, the First Nations represent the brightest colours. Yes, there is blame and fear and misunderstanding. There is a romanticisation about the old way of life and anger about the newer ways. But Aboriginal people are survivors. We walk a new path.” “You,” Robert said. “Come here with us now.” There was a peace pipe ceremony and I tried to excuse myself, but my attempt at refusal was insensitive. I looked for the door, but couldn’t find a decent reason to exit through it. We sat there, scattered, with our legs crossed, as some would say, Indian style. “Me?” I asked. “I never smoke.” Robert might have told me to shut up, but instead, he just nodded emphatically. And so, when my turn came, I took the pipe, relishing the aroma of sweet grasses and spiritual tobaccos. I swallowed a cough, and tiny ghostlike whiffs of air escaped my lips towards the glass ceiling of the room. All around me there was a Cree song, originating somewhere deep in the throat—half guttural cry and half proclamation. It was the prayer of our ancestors. There was a rhythm to the song, and the women carried it, as they must have done for many millennia. I had failed to give a useful talk on diabetes—a subject very comfortable to me. I still ponder the strangeness of this moment, in a place to which I was invited but did not belong. I imagine it was akin to the shock of fresh rain to the ancient hunter in the long, dry prairie heat or maybe the stare of the modern city dweller at Saskatchewan’s winter sky, full of stars without smog. Finally, I looked up at Chief Highway—obese, diabetic, blind, hypertensive—pounding the caribou-skinned drum trimmed with eagle feathers. I too revered him. The bison head, now just a bony old rock, sat at the centre of our makeshift circle. All around me were the aromas of sweat and sweet grass. Chicory, rose petals, jute, and scented waters. Beads, insulin, potato chips, braids, quills, crutches, beer, grizzly claws, and leathers. Pendants with stones. You don’t even know us, he seemed to chant. But you could. Reference 1 Catlin, G. Letters and notes on the manners, customs, and conditions of North American Indians written during eight years’ travel (1832–9) amongst the wildest tribes of Indians in North America, vol 2. Toronto, Canada: Dover Publications, 1973: 258, 127.
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Smoking the pipe of peace Farrah Jasmine Mateen Lancet 2007; 370: 2170–71 Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA (F J Mateen MD) Correspondence to: Farrah Jasmine Mateen, Department of Neurology, 200–1st Street SW, Rochester, MN, USA 55905 [email protected]
“[The tribes] have perfect confidence in the skill of their own physicians, until the disease has made one slaughter in their tribe, and then, having seen white men amongst them protected by [the vaccination], they are disposed to receive it, before which they cannot believe that so minute a puncture in the arm is going to protect them from so fatal a disease; and as they see white men so earnestly urging it, they decide that it must be some new mode or trick of pale faces, by which they are to gain some new advantage over them, and they stubbornly and successfully resist it.” Extinction of the Mandans by smallpox, George Catlin (circa 1832–39)1
Wanuskewin was constructed 15 kilometres off highway 11, on the journey north to the settlement of Prince Albert, Saskatchewan. Saskatchewan might be a barely pronounceable name for a province, but it is in fact five times the area of England. Its capital was named in the Aboriginal Cree tongue, meaning “pile of bones”, after the large heaped carcasses of bison that remained after the bountiful ancient hunt. Blinded by its furry head and heedless of its path, the bison barrelled over cliffs, spurred on by Aboriginal hunters. When it fell helplessly to its death, every part of the bison’s flesh was put to use for the health and wellbeing of the Cree people. There were just bones left over. Piles o’ bones. Today, the province lies void of this slaughtered wild beast. The rivers that once carved the plateaus into high crags now embrace only tiny hills, like nipples, teasing an everlasting flat prairie. There is grass, then snow and the tracks of the jackrabbit. And in the middle of what some would call nowhere, our nowhere, sits Wanuskewin, a metal Aboriginal interpretative centre, in the icy, frigid north. Yes, I know there is global warming, but we, in the north, still feel cold. Robert Highway, his anglicised name, was yet another Cree with diabetes on the vascular surgery service where I was an eager medical student. Robert had been the one to invite me to Wanuskewin. In fact, he had invited our whole team of physicians and nurses, but I found myself on Highway 11 alone. “You take your expensive pills, doctor, and give ‘em to someone else,” Robert had scolded me, forcefully, banging his fist on the plastic hospital tray. “I feel fine. Why would I want to come back to this place?” The health-care team had, admittedly, run out of persuasive arguments long ago. The obvious answer, to us, was to point to his rotting, toeless, and plum-coloured limb. The diabetic foot—painless, disabling, gross. When I unwrapped it, I nearly vomited, but Robert’s retinopathy had made his injury unapparent to him. He was a poor surgical candidate. He had hobbled around for a while and stalled his arrival to the hospital, finding work, 2170
escorting a few American hunters to kill grizzlies in the Canadian Shield. At some point, far too soon, his coronaries had clogged up. Soda and potato chips are cheaper than milk and vegetables in northern Saskatchewan. Beer is more accessible and more popular than health care. And if you were counting on clean drinking water on his reservation, you would need to wait until yet another fast-talking, slow-moving politician lost a political appointment in Ottawa. Robert hadn’t thought much about the difficulty of trapping game up north without a leg, and he, like so many others, had started to collect government support. I suspect that the doctors, none of whom were Aboriginal, knew that some of their tax dollars eventually made their way to the Cree people, but were not helping them very much. But the doctors were busy and Robert was just another example—no longer a fisherman by winter, a collector of muskrat by spring, or a carpenter in summer and fall. At home, he began watching television and drinking, we smelled, too much. Robert’s problem, you see, was not necessarily his health, but something deeper. The paleface would call it illiteracy, alcoholism, even ignorance, poor integration, lack of acculturation, and dropping out of school. But it was none of these things. Robert was an intelligent man. Although he did not speak the Queen’s English, he was a good communicator. For his knowledge of oral history, he was revered by his family members, his community, and the Cree nation. He spoke plainly and simply. “Take your pills back. I feel fine.” “There was total darkness for a great time over the whole of the earth; the Choctaw doctors or mystery-men looked out for daylight for a long time, until at last they despaired of ever seeing it, and the whole nation were very unhappy. At last a light was discovered in the North, and there was great rejoicing, until it was found to be great mountains of water rolling on, which destroyed them all, except a few families who had expected it…” Attributed to Hatchockucknee, or Snapping Turtle (circa 1832–39)1
Diabetes. Not smallpox or war, not even guns, arrowheads, or violent waters, but instead, a silent enemy now lurks among the Cree. But how can you believe in silent enemies when everything you know to be true is heard and spoken? “Diabetes, you see, is like the wind,” I attempted. “You may not hear it or see it, but you know it is always there. You see what it does after it has finished and run away without you.” “Oh yeah?” He scratched the stubble on his chin. “My wife, she has diabetes too. My daughter—she is eight. She has it now. I have given this to her. Come. Talk to them.” The team of surgeons had politely agreed and www.thelancet.com Vol 370 December 22/29, 2007
Wakley Prize Essay
welcomed any referrals. Others on the team had merely smiled, pretending not to have been invited to Wanuskewin or to his reserve, places where most non-Aboriginal people have never been. To understand this awkwardness, you must know that Aboriginal people occupy a curious place in Canada and throughout the world. Unlike most minorities, they hold, or at least once held, special claim to the land we now feast on with our schools, dollar stores, skyscrapers, and fast-food chains. Unlike most of the world’s vulnerable populations, they tend to live in countries of extreme wealth. The health of the Canadian Aboriginal population is ranked more than 50 places behind that of Canada as a whole. Aboriginal people die sooner. They are less likely to survive when they are born. Their diseases are more likely to be preventable. Their mothers are more often children. More often born with the effects of alcohol, they are more likely to die of accidental injury and violent crimes. Sexual assault is more frequent towards Aboriginals, and ultimately, Aboriginals are more likely to kill themselves. To continue this litany, Aboriginals are less likely to graduate from high school. More than half don’t see a diploma—even in this rich, developed country. Despite programmes, committees, and dollars to combat the situation, Aboriginals are less likely to acquire a college education, and, therefore to become doctors or nurses. Three-quarters of all youth encounters with the criminal justice system in Saskatchewan involve Aboriginals. Diabetes, then, seems to be an afterthought. And, surprisingly, there is every reason to believe that Aboriginal people were healthier than European settlers only a few hundred years ago. Some of the oldest remaining treasures of the Cree are not gold and jewels, but medicine wheels, carefully placed into the half-frozen ground. If you look carefully, you can still see them— maybe even find one in your backyard. “Thank you for visiting, but your land, from the beginning, was known to us, the First Nations.” But what starts first at the beginning can end up last. The Aboriginal story tells us that money alone does not lead to health. I am no medicine woman though. My hard-core medical training has driven me away from anything that doesn’t come in a pill or patch. I secretly see most alternative therapies as namby-pamby guarantees of expensive urine. My general ignorant reluctance to understand alternative therapies doesn’t serve my Aboriginal patients well. So I drove down Highway 11 to Wanuskewin. What did I have to tell the Cree about diabetes? Despite my training, not too much. I gave an information session on blood sugar, insulin, and the importance of diet and
www.thelancet.com Vol 370 December 22/29, 2007
exercise. I tried to speak clearly and leave room for questions, but the talk was just mediocre. I felt I had failed when Robert Highway came back, only weeks later, with a below-knee amputation and crutches. Noticing my naïve dismay, Robert put his crutches aside. “Aboriginal people are not a fallen people. They are strong and mighty. For it is told that wherever a history is woven of many threads, the First Nations represent the brightest colours. Yes, there is blame and fear and misunderstanding. There is a romanticisation about the old way of life and anger about the newer ways. But Aboriginal people are survivors. We walk a new path.” “You,” Robert said. “Come here with us now.” There was a peace pipe ceremony and I tried to excuse myself, but my attempt at refusal was insensitive. I looked for the door, but couldn’t find a decent reason to exit through it. We sat there, scattered, with our legs crossed, as some would say, Indian style. “Me?” I asked. “I never smoke.” Robert might have told me to shut up, but instead, he just nodded emphatically. And so, when my turn came, I took the pipe, relishing the aroma of sweet grasses and spiritual tobaccos. I swallowed a cough, and tiny ghostlike whiffs of air escaped my lips towards the glass ceiling of the room. All around me there was a Cree song, originating somewhere deep in the throat—half guttural cry and half proclamation. It was the prayer of our ancestors. There was a rhythm to the song, and the women carried it, as they must have done for many millennia. I had failed to give a useful talk on diabetes—a subject very comfortable to me. I still ponder the strangeness of this moment, in a place to which I was invited but did not belong. I imagine it was akin to the shock of fresh rain to the ancient hunter in the long, dry prairie heat or maybe the stare of the modern city dweller at Saskatchewan’s winter sky, full of stars without smog. Finally, I looked up at Chief Highway—obese, diabetic, blind, hypertensive—pounding the caribou-skinned drum trimmed with eagle feathers. I too revered him. The bison head, now just a bony old rock, sat at the centre of our makeshift circle. All around me were the aromas of sweat and sweet grass. Chicory, rose petals, jute, and scented waters. Beads, insulin, potato chips, braids, quills, crutches, beer, grizzly claws, and leathers. Pendants with stones. You don’t even know us, he seemed to chant. But you could. Reference 1 Catlin, G. Letters and notes on the manners, customs, and conditions of North American Indians written during eight years’ travel (1832–9) amongst the wildest tribes of Indians in North America, vol 2. Toronto, Canada: Dover Publications, 1973: 258, 127.
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