This is the fifth post in the Perennial Problems series exploring the intersections of environmental history and histories of health
First Nations people in Canada face a heavy burden of Type 2 diabetes mellitus, being five times more likely to die of the disease compared to the Canadian population. It is also a disease in which significant complications (blindness, amputations, kidney failure, and premature mortality, among others) extract a terrible price from the individual, their family, and their community. While researchers may focus attention on the current burden, particularly as they work with First Nations communities that are profoundly challenged, it is critical that we understand that this epidemic is a recent development and, more importantly, that it was not inevitable. Rather, the current patterns of diabetes reflect “the intergenerational impacts of ongoing colonial policy and resultant social, political, economic and cultural inequities.” Diabetes is a direct and on-going by-product of colonialism.
An elder from northern Manitoba – living in a community which has coped with some of the highest rates of diabetes in the country – informs us that this epidemic is rooted in recent cultural and lifestyle changes which has led to new, foreign afflictions, stating that, “It is today that these sicknesses have developed, diabetes, cancer, hypertension and heart disease. […] These are all the diseases that were given to us when we started to become white men. And when we were Anishiniin we did not have these sicknesses.” 
In 2000 I began a journey to help me understand the roots of the epidemic in Island Lake, in northeastern Manitoba. I did so with the hope that this historical perspective would help to shed light on an avoidable health crisis, and would temper what I considered to be a preoccupation among some with searching for inherent weakness in Indigenous communities with respect to current health challenges, including at the genetic level. Elsewhere I have written on the value of contextualizing contemporary First Nations health through understanding the history of cultural change, whether voluntary or enforced. Indeed, this approach has underpinned much of my research career. Dr. Judy Bartlett has identified the need to understand historic and ongoing cultural change and the role of colonization as a means of guiding the present battle to improve Indigenous health. In short, we must know the past in order to improve the future. With this in mind I offer some thoughts on the roots of this current diabetes crisis.
In 2000, my mentor, Dr. Kue Young, and his partners concluded that the emerging diabetes epidemic among First Nations people in Canada was a function of “rapid sociocultural changes experienced in the past several decades” though with some genetic component. Just how many decades this epidemic had been growing is unclear. From a historical perspective, proving the absence of something is no easy task. Absent a detailed longitudinal medical record, as there is for the Pima of the American Southwest beginning in the 1960s, we are left with scattered surviving records, that were, more often than not, not intended for the purpose.
Still, evidence suggests that the epidemic is of recent origin. For example, a diabetes survey carried out in the 1930s in Saskatchewan found no confirmable cases among 1,500 First Nations people, while Inspector W. Murison of Indian Affairs claimed that he “ha[d] never heard of a case of diabetes in a pure-blooded Indian.” A study that I and my colleagues conducted based on residential schools in Saskatchewan and Manitoba found that children entering the schools between the 1930s and 1950s overwhelmingly had normal BMI values; obesity is one predisposing factor for diabetes. In contrast, a retrospective study of diabetes prevalence in Saskatchewan found increasing rates in First Nations people as early as 1980, with higher rates than among non-First Nations people. Likewise, by the late 1970s First Nations people in Manitoba experienced almost three times the rate of hospital admissions for diabetes as the province as a whole.
For this research I distinguished between primary risk factors, those with a direct impact on the health of people regardless of era, and historical factors, those specific to the era under study that influence the primary factors. Although there are many primary risk factors for diabetes at the individual level, some, such as age and history of heart disease, matter less in this context. Others, such as high birthweight and gestational diabetes, could be relevant at the population level, however they are generally lacking in terms of accessible historical data. I also set aside the role played by genetic makeup in order to focus on changes to the cultural, social, and economic environments, although evidence suggests that interplay exists between genetic characteristics and environmental factors. Instead, I explored three key factors, including overweight, sedentary lifestyle, and stress, which can play out at individual, population, or intergenerational scales.
I identified several historical factors that contributed to the rise of diabetes in Island Lake. These were specific to the research context but played out in similar ways across the north, often with local variations. One major contributing factor was a shift in diet from healthy bush foods that matched traditional activities and energy expenditures, to one dominated by non-local (southern) foods that exacerbated an increasingly sedentary lifestyle. One community member noted that in his youth “Food was plentiful. There was no junk food. No booze and very little tobacco. People hardly got sick living off the land. They were healthy and husky, the way we see animals today who still live off the land.” Starting in the 1940s, observers commented on the changing diet in northern First Nations communities, and occasionally described the health effects of increased contact and poor-quality and calorie-dense foods. For instance, a nutritional study of northern Manitoba in 1946 linked greater use of store-bought foods to declining health in some communities. For the people of Island Lake this change came later; nevertheless by 1976 “new foods,” especially those full of sugar including candy and soft drinks, became common and led, initially, to a decline in the oral health of the children.Soon after it would be joined by diabetes.
As much as any other single factor, the emergence of the residential school system helped to drive this epidemic. Its role in changing (and damaging) First Nations communities through the children was multifaceted, and its repercussions have transcended generations. For some children the schools served as their first exposure to non-traditional foods, acting as a gateway to permanent dietary change. For many, poor quality foods may have contributed to nutritional ailments, later poor health and, perhaps, even subsequent eating disorders. Away from their communities, children were unable to receive instruction from family members, and for some this undoubtedly led to a failure to master traditional hunting skills. Schools exposed many to mental, physical, or sexual abuse, which, at the very least, resulted in chronic stress. These stress effects have not always been resolved over the lifetime of the student, and intergenerational impacts of residential school attendance are well-documented, contributing to present-day health disparities in First Nations communities. Finally, the food environments, particularly with respect to nutritional and caloric deficiencies, had long-term impacts on their health, and may have included stunting, which can contribute to subsequent diabetes. For female students these food environments may also have increased their chances of later giving birth to high-birthweight babies who would, in turn, be more prone to diabetes in their lifetime.
Another crucial factor was the transformation of local economies in the north, fueled by growing resource development in the region. By the 1930s the fur trade, a longstanding source of employment opportunities as well as an outlet for the exchange of traditional products, had fallen into decline. Towards the end of the Second World War new jobs emerged based on securing northern resources for the war effort. Employment in construction, guiding, and resource extraction, provided income that encouraged First Nations families to abandon the hunt in favour of more secure livelihoods. This accelerated as capital flooded the north. As traditional economies were replaced by wage labour, a new source of income emerged in the form of transfer payments, provided by the federal and provincial governments as a hedge against poverty and starvation. The result of this transformation in terms of its long-term effects on diabetes was twofold. First, localized jobs encouraged families to adopt a sedentary lifestyle and led in some cases to the emergence of permanent villages. In turn this decreased activity levels (and the required daily caloric intake) and provided more frequent opportunities to purchase non-local foods. At the same time, the presence of a cash economy based on wage labour and transfer payments brought novel foods into the north, including those that were rich in carbohydrates (especially sugars), as these foods often appealed to youthful palates.
Transport innovations helped create an environment that was conducive to change. By the 1930s the Hudson’s Bay Company began bringing in bulk foods at reduced prices to northern Manitoba via winter tractors in response to the availability of treaty monies and increased demand. A similar pattern of increased non-local foods played out with each new form of transport in the region, eventually leading to a situation in which bulk non-perishable foods of dubious nutritional quality were brought in via semi-trucks travelling the temporary winter roads. Outboard motors and snowmobiles simplified travel into the bush, replacing canoes and dogsleds, leading to decreased exercise and energy expenditure. Later, airplanes were used to transport hunters to and from traplines. In some communities seasonal patterns of movement were rewritten and only men went for shorter periods, while their families remained behind in permanent villages. In these cases, the aged, children, and women became sedentary even as they were exposed to growing amounts of poor-quality foods .
Underlying all these changes was the influence of both the state and, increasingly, the church. Following the war both actors encouraged, or in some cases, demanded, the abandonment of hunting and seasonal migrations. This was to be replaced by life in permanent villages that provided greater opportunity for control, and to carry out missionary work. Mandatory attendance in the schools, and even enforced dietary change, played a direct role in setting the stage for the coming epidemic, and by opening up the north to development, government reinforced new economic patterns that would further facilitate it.
The interplay between these factors can be seen in the diagram below. Historical factors intertwined during the twentieth century as, for example, new forms of transportation in combination with a decline in the fur trade, opened the north to industrial development, new foods, the wage economy, and, eventually, higher levels of both obesity and sedentary life. These historical patterns played out, with variation, across parts of the provincial and territorial north during the period following the Second World War. This research offers landmarks from which we can better understand the present diabetes epidemic.
These factors form only part of the story, however, as they must be contextualized within a colonial framework. Understanding the origins of the diabetes epidemic requires a consideration of the role of power and control in the context of changing disease environments among northern peoples. Every factor identified in my study was influenced or determined by government, its agents, or its policies. In this respect the current diabetes epidemic in First Nations communities is man-made, a product of historical contingency and poorly reasoned policy, and was far from inevitable.
 Walker, J. D., et al. (2020). “Diabetes Prevalence, Incidence and Mortality in First Nations and Other People in Ontario, 1995-2014: a Population-Based Study Using Linked Administrative Data.” Canadian Medical Association Journal 192(6): E128-E135, p. E128.
 Interview conducted with St. Theresa Point First Nation in 2004.
 Hackett, F. J. P. (2005). “From Past to Present: Understanding First Nations Health Patterns in a Historical Context.” Canadian Journal of Public Health 96 (Supplement 1): S17-S21.
 Bartlett, J. “Involuntary Cultural Change, Stress Phenomenon and Aboriginal Health Status (Editorial).” Canadian Journal of Public Health 94, no. 3 (2003): 165-66.
 Young, T. K., et al. (2000). “Type 2 Diabetes Mellitus in Canada’s First Nations: Status of an Epidemic in Progress.” Canadian Medical Association Journal 163 (5): 561-566.
 Chase, L. A. (1937). “The Trend of Diabetes in Saskatchewan 1905 to 1934.” Canadian Medical Association Journal 36: 366-369.
 Hackett, F. J., et al. (2016). “Anthropometric Indices of First Nations Children and Youth on First Entry to Manitoba/Saskatchewan Residential Schools-1919 to 1953.” Int J Circumpolar Health 75: 30734. Dyck, R., et al. (2010). “Epidemiology of diabetes mellitus among First Nations and non-First Nations adults.” Canadian Medical Association Journal 182(3): 249-256.
 Stevens, H. (1982). A Review of Changes in the Living Conditions of the Registered Indian Population of Manitoba during the 1970’s. Winnipeg, Social Planning Council of Winnipeg.
 Memoirs of Esias Beardy, Garden Hill (Island Lake First Nations, Manitoba), manuscript provided by the late Ted Wilson.
 Moore, P. E., et al. (1946). “Medical Survey of Nutrition among the Northern Manitoba Bush Indians.” Canadian Medical Association Journal 54: 4 -13.
 Lindsay, A. M. (1976). The History of the Northeast District of Manitoba, manuscript textbook prepared for the Island Lake school board and provided by the late Ted Wilson.
 Bombay, A., et al. (2014). “The Intergenerational Effects of Indian Residential Schools: Implications for the Concept of Historical Trauma.” Transcultural Psychiatry 51 (3): 320-338.
 Mosby, I. and T. Galloway (2017). “”Hunger was Never Absent”: How Residential School Diets Shaped Current Patterns of Diabetes among Indigenous Peoples in Canada.” Canadian Medical Association Journal 189(32): E1043-E1045.
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