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Diseases of Affluence

Diseases of Affluence

Everywhere Western ideas touch down, people get fatter. Urbanization is literally making us sick.

RECENTLY I WORKED as an internist-intensivist at the Canadian Combat Surgical Hospital in Kandahar. Most of our casualties were Afghans: National Army soldiers, National Police and civilians caught in crossfire. They were diminutive men, almost always less than a hundred and forty pounds. I cannot comment on the body masses of the Taliban—they were never brought to us. But they are not likely larger than those of the soldiers and the police. And because, in war, soldiers are fed first—prospering right up to the moment they are pierced—the civilians were even thinner.

For someone used to the life and the pathologies of the rich and settled, much about practicing medicine in Afghanistan felt unfamiliar. One of the striking differences was the way gunshot victims’ abdomens looked in CT scans. Back home, I was used to seeing organs stand out with some prominence from the abdominal fat. In fact, in Canadians, the state of the kidneys can be partly assessed by the degree of inflammation in the perinephric fat that envelops them. It’s the same with the pancreas, and the liver often looks like it belonged to a French goose fattened for foie gras. Indeed, the idea of “normal” in a Canadian body proceeds from the assumption that it might be normal to spend one’s days tied to a grain spout, beak pried open, being filled with cracked corn.

Not the Afghans. The surgeons, in fact, often commented on how the abdominal contents spilled out once the abdominal wall was opened; every loop of bowel immediately visible, unobscured by mesenteric fat, which, in Canadians, would cling to every organ like yellow oily cake. Excessive fattiness is precisely why, when caring for the critically ill in North America, glucose levels are tightly controlled with insulin—a procedure necessary even for those not thought to be diabetic. Stressed by the infection, or the operation that has brought us to the intensive care unit, our sugar levels rise, paralyzing our white blood cells and nourishing the bacteria chewing upon them. But it was never necessary to give the Afghans insulin, no matter how shattered they were.

Among North American adults, 40 percent of us maintain normal glucose levels only by secreting larger than normal quantities of insulin from our pancreas. So we wander in and out of our family doctors’ offices and, if some blood work is done, we are reassured that our glucose levels are normal, that we don’t have diabetes. Mostly, they are and mostly, we don’t. But our bodies are not normal. The Afghans’ bodies are normal. We are so commonly ill we take it to be normal.

Here is our normal: 40 percent of North American adults have metabolic syndrome. The syndrome is caused by being fat, even at levels North Americans would not recognize as abnormal. Obesity prompts the receptors that insulin acts upon to become numb to its effects. As we grow fatter, and insulin resistance proceeds, higher and higher levels of insulin are necessary to get the sugar out of the blood. Eventually, overt diabetes may supervene, as it has for 8 percent of North American adults, a tenfold increase since the turn of the last century. But even prior to the development of diabetes, metabolic syndrome insidiously eats away at the bodies of those it affects.

Metabolic syndrome’s elevated insulin level is why we order a second Whopper; getting fatter, cruelly, stimulates our appetite. It is also why high blood pressure is more common among Westerners, too, and why our cholesterol panels are more alarming. Ultimately and especially, it is why heart attacks are almost unknown among traditional peoples like the Pashtun, while half of us will spend our last minutes with the impression that a large kitchen appliance is sitting on our chests.

Afghans die through causes that are widely considered avoidable—war being chief among those, but also tuberculosis, complications of childbirth, measles, meningococcus and polio. This fact is revealed conclusively by the life expectancy in Afghanistan, the lowest in the world: thirty-nine. Westerners are made ill by diseases the Afghans avoid—even among the very elderly, traditional peoples do not suffer cardiovascular disease—while the Afghans perish from diseases we are too rich to tolerate.

It might satisfy certain notions about comeuppance, but there is as yet no scientific reason behind wealth’s relationship with obesity and cardiovascular disease. To start with, it is the poorest Westerners—indigenous peoples, African-Americans, Hispanics—who are the most overweight and most likely to be diabetic. Within any population, the poor always bear the brunt of that population’s most characteristic and lethal pathologies. Much in epidemiology is mysterious, but this is constant.

Around the world, as traditional peoples and societies have been absorbed into the global monoculture, the prevalence of diabetes has exploded. Since 2001, premature death from obesity has exceeded death from malnutrition. The milestone was reached at almost the same time as another: for the first time in history, the number of urbanites exceeds the number of rural dwellers. Canada is an example. For all its magnificent and extensive wilderness, 87 percent of the population lives in a community with at least ten thousand neighbours. Afghans are at the other end: less than 12 percent live in cities. No lattes, no internet, no phone, no pool. And no XXXL elastic stretch pants. After wealth and death rates, the biggest difference between Afghanistan and Canada—and the hallmark of the world’s creeping homogeneity—is urbanization.

A THOUSAND MILES WEST of the Galapagos, the Marquesan islands of Hiva Oa and Tahuata can be said to demonstrate, albeit on a smaller scale, the Canada-Afghanistan spectrum. The six hundred residents of Tahuata pursue a life strikingly similar to that of the traditional Marquesans, who warred with the French ferociously in the late nineteenth century until, cut down by disease—their number reduced from a hundred thousand to a little over a thousand—they were conquered and colonized. Today the Tahuatians grow taro and sweet potato. They fish the cool Eastern Pacific for tuna and mahi mahi. They consider the urbanized Hiva Oa, looming on the northern horizon, a kind of co-opted culture. On Tahuata, the chief remains the principal civil authority; on Hiva Oa, the gendarmes settle disputes and enforce civility. Indeed, the kepi of the French Foreign Legion is ever-present in the thatched-roof watering holes of Hiva Oa’s Atuona beach.

Tahuatians regard themselves as different from the people of Hiva Oa and thus they appear. The boys are elaborately tattooed in the age-old  manner (the Marquesan word is tatu—which, with tabu, is one of its few loanwords to English). The young are lean and supple from hours spent working on the sea, or from tending the taro. Hiva Oa’s bodies resemble those of North Americans as much as you might suppose from the similarity in diet. Fried cornmeal snacks and canned luncheon meat line the shelves of the Épicerie Gaugin. In the aforementioned thatched roof bars, grilled hotdogs are consumed by the plateful by young Frenchmen far from Bordeaux and Avignon. And they are joined in their bingeing by the jiggly young men and women of Hiva Oa, all of whom, it seems, own a motorcycle for the two mile commute from one end of town to the other.

During my last visit, I docked my sailboat in Atuona, finished my inclearance at the gendarmerie, and went to a bar with my friend. Drinking beside the French soldiers were men and women from the other sailboats anchored in the harbour. The sailors were pink, obnoxious and puffed up, impressed with their own resilience and seamanship. These small vessel voyagers espouse a single idea: self-sufficiency. Open ocean voyaging provides the purest test of that quality. Eric, a fiftysomething single-hander—a term with more than strictly nautical implications—told a story about a woman he met in Ecuador. He tried to talk her into joining him. “Thank God she didn’t,” he concluded. “I was becalmed for three weeks between the Galapagos and here. She would have gone cra-zee.”

Although the men in the grassy bar were no compelling advertisement for self-sufficiency, the ideal possesses a potent allure for urbanites. We all want to be steadfast, uncomplaining, resourceful. But five thousand years ago, cities were founded on the principle of specialization: I’ll grow the barley, you beat the bronze. Everything about the pull of the city proceeds from this idea. The fewer practical skills one needs to cultivate, the more one can experiment with pursuits one holds dear. You can already see the effects of this thinking taking hold among the people of Hiva Oa, who can devote themselves to their internet access thanks to food-laden freighters from Papeete.

But limiting our competence to our profession, and perhaps a consuming hobby or two, renders a large part of the world bewildering—and few things incline someone more powerfully to immobility. Immobile bewilderment, accompanied by a beer fridge and the phone number of Pizza Pizza, is the picture of emasculated despair. So men like Eric put to sea. Or subscribe to survivalist magazines. Or learn to bow hunt. Or install photovoltaic panels on their roofs. It sounds preposterous—because it is. You might even call it another disease of affluence.

I left the bar and walked back to the harbour, where I telephoned my parents to tell them I had arrived safely. As I have at the beginning of nearly every ocean passage I’ve made, I invited my father to join me. I explained how my friend, Kevin, was flying home and told them I would single-hand to Raiatea, near Bora-Bora, where there is a boatyard I could store the Sea Mouse over cyclone season. I told my dad how the stembolt anchoring the bowplate and forestays had broken, again. “We were lucky,” I added. “Just like eight years ago, it broke the day after a big blow.”

“I thought you were going to reinforce it,” he said.

“That’s the first thing I’m going to get your advice on, when you come down here,” I told him.

“Okay,” he laughed. “Well, one of these times I just might.”

My father is a study in real self-sufficiency. A farm boy from outside Grand Prairie, he has worked as a mechanical engineer designing swathers and combine headers most of his life. He can do anything: weld, work a metal lathe, build a house or a canoe, lay concrete and bricks, cut tile and fell trees. The first time I got back from the sea, I showed him the fitting around the troublesome bolt and he rolled his eyes. “Anyone could tell just by looking at it that it would concentrate the load…”

To my delight, my father actually flew to Hiva Oa. I picked him up at the airport and, on our drive back to Atuona harbor, we talked about diabetes among the Pacific Islanders. I told him that the world’s highest prevalence was in Nauru, west of Samoa. Essentially one huge guano deposit, the island has been strip-mined until every vestige of the traditional fishing and taro economy vanished beneath seacans full of Spam, pornography, beer and television sets. Fifty percent of adults have frank diabetes. Among the oldest, an incredible 78 percent. This in a people who, prior to World War II, were lithe fishermen and farmers among whom the disease was unknown. Rule number one: don’t sell your island out from underneath your own feet.

The same process is underway across the Pacific, where the most acculturated islands have the highest rates of obesity, metabolic syndrome and diabetes. In 2001 I worked in Saipan, which is American soil in the Northern Marianas. The indigenous Chamorro, numbering just over sixty-two thousand, were in an awful state. The dialysis population, all of whose kidneys had failed due to diabetes, was growing at 18 percent per year—doubling every three and half years. The miracle of compound interest would have half the population on dialysis within a generation or two. (The other half, presumably, would find thriving careers as nephrologists.) These are the same people Spaniards described as swimming through the ocean like seals to meet their ships, climbing aboard glistening and smiling. Here, and in narratives by other European Pacific explorers, we see a people defined by their incredible capacity for movement—in this instance, through the sea.

The Polynesians were the first to explore this ocean, using great sailing canoes in an explosion of discovery beginning about fifteen hundred years ago. After settling in Fiji for several millennia, the Polynesians’ eastward expansion through the Pacific happened over the course of a few long lifetimes—and unknowable numbers of failed attempts. They settled the Marquesas, Hawaii, Tahiti, the Cooks, Easter Island and New Zealand. There was a regular trade route, as well, between the Marquesas and Hawaii, a three-thousand-mile distance—this was five hundred years before the Europeans would attempt the 1,700-mile passage to America. Finding Hawaii in the first place was a task many magnitudes more difficult than sailing from Europe and running into something hard. Collectively, it was the greatest feat of ocean exploration ever undertaken, and was done without compasses, paper charts or metal fastenings. All to windward.

The only boats here now are long Korean and Japanese liners, all after tuna. Streaked with rust, and searching incessantly for the dwindling stocks of marketable fish, these vessels avoid encounters with anyone else, and for the most part we only glimpse them on the horizon, headed away.

My father and I rowed out to the Sea Mouse in the stillness off Atuona Bay. I watched him survey my thirty-five-year-old vessel, and I winced a little at the various amateurish wiring jobs and repairs he noted. Together we examined the chart of French Polynesia. Eight days, we figured. The next morning at dawn we awoke, started her engine and pulled up the anchors. We found more wind than we had expected and soon we were surging forward on a broad reach, closing with the Tuomotos to port. Low pressure systems rolled through, dragging squalls with them.

CHURCHILL, MANITOBA sits as a boundary point between three cultures: the Cree of the boreal forest, the Dene of the taiga along the tree line, and the Inuit. The Northern Medical Unit of the University of Manitoba serves each of these communities. Of the three, the Cree are the most acculturated. Norway House, a Cree reserve, sits at the top of Lake Winnipeg, population ten thousand. Forty percent of adults have type two diabetes. Kids as young as nine have “adult onset”—obesity-related, type two diabetes. Twenty-two-year-olds are on dialysis. It is like nothing a southern Canadian could imagine. Urban liberals think that residential schools, smallpox and tuberculosis are shameful matters of history, but the worst of the disasters to befall the Cree is unfolding right now.

In Norway House, traditional food makes up a tiny part of the diet. There used to be a commercial fishery in Lake Winnipeg. It has collapsed. A few of the families still hunt moose in the autumn, but ten thousand people require much more food than the forest possesses, and mostly what the people here eat are Cheez Doodles and Pepsi. They are among the least expensive foodstuffs available. Milk is three dollars a litre. Bread, two dollars a loaf. Anything perishable is flown in and carries its air freight in the price. The pop and the chips are trucked in over the ice on winter roads and last all year. It is precisely the same circumstance that prevails on Hiva Oa, Nauru and Saipan.

The Dene, who acculturated after the Cree and before the Inuit, are a little less severely affected, but the numbers are still terrible. Lac Brochet sees diabetes rates of 15 percent, still three times that in the south, and climbing steadily. The Inuit, until recently, seemed immune to this process. In 1995, a population prevalence study showed only 0.3 percent of Inuit adults to have type two diabetes. But now, predictably, that number is rising precipitously.

One animal in particular helped slow the process for the Inuit: caribou. In the winter of 1994, I went to watch Eric Anautalik on a caribou hunt near Baker Lake, in what is now Nunavut. In the extreme cold, I rode in the qomatik behind the snowmobile. We were among the tuktu before I knew they were even close. When Eric shut off his engine, the caribou calmed visibly. The herd, which had parted to allow our entry, began to coalesce again, the animals nearest to us lifting their heads from the snow briefly before resuming their foraging. Eric unwrapped his rifle, a .222 Remington, and fed shells into its magazine. A very fat doe approached us. When she was fifty yards away, Eric worked the bolt and inserted a round into the chamber. He lifted the rifle to his shoulder and fired.

With the report of the rifle, the whole herd rippled in a succession of stutter steps, drawing away from the snowmobile ten, even twenty feet, before stopping to resume grazing. It seemed astonishing that they hadn’t all scattered into the early afternoon twilight. For a moment, it appeared that Eric had missed. Then it became clear he had not.

The doe began hopping. She jumped back and forth between her forelegs and hind legs like a rodeo pony. She began coughing, hacking out a red plume that settled on the snow around her. Her forelegs buckled first and she lay down on the snow and then stopped moving.

Erik ran over to her. It is not possible to eviscerate a frozen carcass, so he moved very quickly, shedding his mittens as he cut her open from the throat to her hindquarters. When he pulled out the offal, a cloud of steam arose from the abdominal cavity. He tore the hide away from the body and breathed heavily as he stood and turned the body over. Erik cut away the legs beneath the knees and quartered the doe. As he was finishing, the crystals of frozen blood on the meat extended. The rind of ice surrounding each quarter made a grinding sound as his knife cut through. He stood panting over the meat, and then he tied it down on the qomatik.

Caribou are plentiful. This time of year, they provide the only colour and relief on the tundra: small dots of brown moving slowly against an otherwise relentlessly white background. Were the Inuit to turn their backs on these animals, they would be left with only the distractions of the Kablunauks: satellite televisions, movies, WWE wrestling, committees and professional sports teams. Diabetes is not the problem it is further south—yet—but everyone understands the direction things are going.

The children, in particular, are fatter every year. There is a school bus in Rankin Inlet now, for this community a mile across with no roads in or out. In December and January, when the days are so short and weather particularly severe, hardly anyone hunts. And though the caribou and char remain favoured foods, people are losing their taste for the more challenging flavours of seal and walrus and whale. The old men are appalled. The women, when they want to be particularly biting about their men, complain that “he doesn’t even own a gun anymore.”

The Thule Inuit culture burst out of Northern Alaska about the same time the Polynesians began their great voyages, around 900 CE, when the Medieval Warm Period began. With the warming, sea mammal populations in the Arctic exploded and the Thule, who had developed a sophisticated technology for hunting them, including the kayak and the toggle-headed harpoon, prospered. They spread eastward, displacing and absorbing the Dorset people who preceded them.

The Inuit arrived in Greenland about the same time as the Norse. When the Little Ice Age began, around 1350, and the Greenland Norse perished, the Inuit endured. The whale populations fell, and the Inuit retreated from the most northerly coasts of Greenland and Ellesmere Island, but they survived. The Norse needed summer to pasture their cattle, and every day they lost to the longer winter was catastrophic. For the Inuit, however, it just meant more days out on the floe edge, waiting for seals to surface to their air holes. Imagine a self-sufficiency like that.

THE POLYNESIANS, and especially the most acculturated among them—the Hawaiians—are attempting to recapture the most magnificent part of what they have lost: their voyaging tradition. In 1986, oceangoing canoes were built for the first time in one and a half centuries by a community of neotraditionalists in Hawaii. The effort extended beyond merely attempting to fashion sailing canoes that resembled those in the lithographs; the whole art of Polynesian navigation, which was the real miracle of those voyages, is being resuscitated.

The Polynesians did not have lodestones with which to make compasses, and their navigation system does not emphasize the stars, but the sea itself. The different wave patterns are studied and observed, as many, improbably, as fourteen simultaneously. The sophistication of the navigation is best appreciated in the bathtub. Set up a small wave train at one end of the tub by wiggling your finger. Now wiggle your finger at another end of the tub. Observe the interaction between the two sets of waves. Add a third system with another finger and try to discern each of the three wave patterns. This is already becoming formidably complex. Add a fourth, and a fifth. Keep going.

Navigating by wave train alone, the waves were best felt with the testicles; the navigator on each canoe had a special cabin he hunkered in. The idea, however, of making sense out of an interference pattern involving more than three or four wave systems is mind-boggling. The mathematical complexity of a fourteen-source interference pattern would appear more than can be held by any human brain. Or scrotum. And yet the historical record is clear about the existence of trading routes between Hiva Oa and Hawaii.

Thirteen years ago, in the course of my first South Pacific passage, I was in Rarotonga when the voyaging vakas arrived from Tahiti, a thousand miles to the east.  After making landfall the Rarotongans seemed as energized as they were proud. The sailors off the canoes strutted around the island like Stanley Cup winners come home to rural Saskatchewan. Extensively and traditionally tattooed, they bulged and rippled as they sat in the cafes and told stories of their month at sea.

I couldn’t take my eyes off them. My own acquaintance with the ocean presupposed the possession of a GPS and an engine. I could not even understand how they had gotten their unpowered craft through the pass in the reef. Were I to find myself engineless, through lack of fuel or maintenance proficiency, my response would be to head for a harbour without a fringing reef. Be that Vancouver Island or Hiva Oa, it would mean a pretty long hike.

ONE OF THE COMMON PITFALLS for clinicians who treat type two diabetes occurs when they prescribe metformin to young women. Metformin decreases insulin resistance, which helps reduce blood sugar. Insulin resistance is also what causes infertility in women with polycystic ovary syndrome, as well as type two diabetes. Often, women thought to be infertile become pregnant after taking metformin. Sometimes, of course, this delights them, but sometimes it does not. Contraception does not normally seem like one of the things diabetes doctors need to emphasize. But obesity commonly underlies infertility in women, just as it also causes the growth of facial hair. And, in men, the growth of breast tissue. Adipose tissue secretes estrogens and insulin resistance increases levels of androgens. Diabetes is overwhelmingly the most common cause of male impotence in the developed world. Men and women are designed to move, and when we do not, our immobility reduces us in every respect.

THE OLDEST of the bowhead whales in the Arctic Ocean have lived for two hundred years. We know this because when they are killed and examined today, we find ivory harpoon heads lodged in their skin. The implication is that they were large enough to be hunted prior to the arrival of the Hudson Bay Company and its steel harpoon heads in the 1830s. Isotopic analysis of the whales’ eyes confirms the point: these whales were calves during the Napoleonic Wars. They are certainly the longest-lived mammals on the planet. Indeed, they may be the longest-lived complex animals of any sort.

The Canadian Inuit, with motives similar to those prompting the revival of the Polynesian voyaging tradition, have resurrected the Bowhead whale fishery. In 1998, the Inuit took a whale in Repulse Bay. That hunt was a catastrophe. A magnificent cow was killed, shot a hundred times by men with deer rifles, who ignored the plan to use a whaling gun. She sunk and was lost. Three days later she floated to the surface. She was pulled ashore, and part of her was cut up for muktuk, but mostly she just rotted. The shame in the community afterwards was thick.

In 2006, there was another hunt. This time the Inuit used a large calibre Norwegian exploding bullet to kill the whale. They pulled it back to town efficiently and distributed its muktuk throughout the Canadian Arctic. Everyone was very proud. In 1807, when the whale might have been a calf, the Ottoman Empire had another 111 years to live—that is, half this animal’s lifespan.

In Inuit mythos, the Thule people were preceded by men of enormous strength, the Tuniit, who built rock houses, stacking enormous boulders one upon the other. These stories might evoke a historical memory of the Dorset people, who were supplanted by the Thule Inuit in the course of their expansion, and who lived in cold stone homes and skin tents instead of the igloo. The descriptions in these tales emphasize the power and endurance of the vanished Tuniit, and there is a melancholy to the tales, grief for these legendary, better people.  Every generation sees itself as a decadent, diminished version of its predecessors. What is different is the extent to which we actually are.

See the rest of Issue 35 (Spring 2010).

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