The Real History Behind Diabetes’ Pivotal Role in Killers of the Flower Moon

Diabetes features prominently in Killers of the Flower Moon, Martin Scorsese’s adaptation of David Grann’s 2017 book about the murders of members of the Osage Nation in 1920s Oklahoma. Mollie Burkhart, played by Lily Gladstone in the film, has diabetes, like many others in the tribe. The condition plays a pivotal part in the story: In the film, Osage people are said to commonly die before the age of 50, often from a “wasting disease” vaguely associated with diabetes, which itself is attributed to the consumption of “the white man’s food.” Mollie’s condition means that her husband, Ernest (Leonardo DiCaprio), assumes care for her, with Mollie’s regular injections of insulin creating an opening for corrupt doctors—working in cahoots with white settlers conspiring against the Osage—to slip in additional doses of what may be poison.

Mollie’s diabetes locates her squarely in her time and place, and in the history of Native people living on reservations in the United States in the 20^th century. Native people today are almost three times as likely to be diagnosed with diabetes as non-Hispanic white Americans. (Rates are similarly disproportionate for Indigenous people around the world.)

I asked Margaret Pollak, an anthropologist and researcher who studies diabetes in urban Native communities, to talk about diabetes in American Indigenous life in the 20^th century, and explain how Mollie’s illness fits into this long history. Our conversation has been edited and condensed for clarity.

Rebecca Onion: Killers of the Flower Moon happens to take place right at a turning point in the history of diabetes. What did people know about it before then, and how did this revolution in treatment come about? 

Margaret Pollak: Up until the 20^th century, diabetes was a fatal disease for those who developed it, even though the disease had been well-recognized as long as 3,500 years ago. It was really around the 19^th century where we started to see scientists discovering the basis of diabetes and gaining an understanding of what causes it, which ultimately led to its treatment.

In the 19^th century, two French scientists were working with a dog, and they discovered that when they removed the pancreas of the dog, that dog ended up displaying what looked like diabetes symptoms. That was where we made the first association of diabetes with the pancreas, which is an organ that produces insulin. In the late 19^th to early 20^th century, a number of scientists worked out that there’s this hormone produced by the body, insulin, and that it seemed like a disruption in its production would lead to someone developing diabetes.

It’s from that history and background that we see scientists aim towards finding a way to reintroduce insulin into diabetic patients. We see that happen in 1921 with Frederick Grant Banting and John James Rickard Macleod, along with their student assistants Charles Herbert Best and James Bertram Collip. Together, that team successfully found a way to extract insulin for use in lowering the blood glucose of a person with diabetes.

At that point, the insulin was literally extracted from another animal, right? 

Yes, in the early years the treatment of diabetes was with insulin extracted from pigs and cattle. Today, however, it’s synthesized.

Mollie Burkhart, who’s the heroine of the movie, is diagnosed with diabetes, or, as the doctor James Shoun calls it in court testimony quoted in David Grann’s book, “sugar diabetes.” She’s described as having suffered from it already for a while in the early 1920s. Did doctors at the time know how to diagnose this? 

Yes—way back in the second century, in Greece, Aretaeus of Cappadocia wrote the first extant work on diabetes that included the full description of what its symptoms looked like. Those symptoms are polyuria, or frequent urination, and excessive thirst, or polydipsia. And so, that would be likely the way in which a patient would’ve been diagnosed at that time.

In your book, you describe the heavy burden of diabetes in Native communities as being more of an identifiable phenomenon by the mid-20^th century. How did this start showing up, and how did it evolve? 

In Indigenous American populations, it seems that diabetes was incredibly rare prior to the 1940s. The first recorded case that I found is from 1902, where an Akimel O’odham woman— Akimel O’odham are sometimes more popularly referred to as Pima—was treated by a doctor for diabetes. The next reported case comes out of Elliott P. Joslin’s work: It’s an interesting article from 1940 where he is curious about the rates of diabetes in the whole U.S. population, and so he goes out and does fieldwork, and in the midst of this fieldwork comes across a Navajo man who has diabetes. There’s other work that’s been done by Kelly M. West and Dennis Wiedman, who have looked at archival records from military medical doctors who served on reservations. In each of those cases, they do not see reports of diabetes in those populations prior to the 1939–1940 time period. Those would’ve been physicians who would be aware of those symptoms of polyuria and polydipsia being indicative of diabetes.

So it looks like diabetes was rare in Indigenous American populations prior to the 1940s, but we start to see cases rise in the 20 or 30 years that follow. There’s been a longitudinal study with the Akimel O’odham population, where a group of scientists have tracked rates of diabetes and its increase over time. That’s a population that probably has the highest rate of diabetes in U.S. Indigenous American populations. It’s really in that period, from the mid-20^th century up until the 1980s and ’90s, where you really see this sharp incline in rates of diabetes there.

Back in the midcentury time period, the leading causes of death for Indigenous people were communicable diseases, so they were worried more about things like tuberculosis. But it’s over that period of a couple of decades where we see a number of chronic conditions take the place of those more communicable diseases and causes of death. By the 1990s, diabetes had become the fourth leading cause of death among Indigenous Americans, and it remains today the fourth leading cause of death behind heart disease, cancer, and unintentional injury in accidents.

Today, Natives continue to have the highest rates of diabetes in the U.S. when compared with other ethnic and racial groups in the United States. But rates of diabetes do vary from tribe to tribe—as I mentioned earlier, the Akimel O’odham have very high rates within their community: among adults 18 and up, 33.5 percent. And then some Alaskan Native nations have lower rates, like 5.5 percent. It varies a lot.

What are some theories that explain this disproportionate impact? In the movie, there’s a throwaway line: Oh, a lot of Osage have it because of the “white man’s food.” What are the theories, and is any one of them provably true? 

We don’t actually know precisely what causes diabetes, so I wouldn’t want to say that any one thing is the reason. But I think, looking at the research, you could very strongly argue that colonialism is to blame for the current diabetes epidemic faced by Indigenous Americans, as well as a number of other health concerns that Indigenous communities are facing today.

A lot of the research and studies out there tend to see diabetes as being a biocultural condition: something that you might be biologically or genetically predisposed to developing that is triggered by life conditions—the type of diet that you eat, the type of exercise that you get. And for diabetes in Indigenous Americans, we see a huge shift in the type of diet and lifestyle that they were able to live in the post-reservation period.

If you think of the Indigenous communities that were relocated through the reservation system, they oftentimes struggled in their new location. The environment that they moved to would not have been the same environment that their ancestors had traditionally worked in and lived in. We see, in the history of Indigenous communities who relocated to reservations, that there were struggles with securing adequate food. This led to the United States federal government opening a food rationing program at the turn of the 20^th century, that later shifted to a commodity food program by the 1950s.

The foods that came in through both the food rationing program and the commodity food programs included things that were high in refined carbohydrates—things like white sugar, white flour, fruits that were canned in syrup, foods that were also high in fat, lard, and shortening. In a study of that earlier rationing program, one scholar described that people would get meat that had often gone rancid by the time it reached the reservation. That later transitioned to canned meats with the commodity food program in the 1950s. Later on, there was also the inclusion of high-fat foods like processed cheese and peanut butter, and foods that were really high in sodium, like canned vegetables.

This foods from federal programs replaced traditional diets that were not only composed of things like lean meats and complex carbohydrates, but that were also diets that based on more strenuous activities and exercise.

There are a number of theories out there in terms of genetic or biological factors that predispose Native people to developing diabetes that is then triggered by life conditions. Some of those include James V. Neel’s 1962 theory of the thrifty genotype. That’s the hypothesis that, over evolutionary history, a “thrifty genotype” allowed the human body to, during times of feast, store excess fat in the adipose tissue, so that during periods of famine, your body could survive and feed off of that fat. Neel’s hypothesis argues that now that we’re in an era of processed food supply, we no longer have those periods of famine, and so we just continually build up fat in the adipose tissue, and it leads to things like obesity and diabetes.

There are a number of scientific critiques of this idea. A lot of social scientists also argue against using that type of argument, because it tends to shift the blame towards, in this case, Indigenous Americans—as in, Well, it’s their genetics—when, in reality, it’s this forced removal and relocation to reservations where Indigenous Americans can no longer live off of traditional food systems and practices that has really been the cause of the diabetes epidemic today.

In your work, you interview Native people about diabetes. What are they saying about why there’s so much more diabetes among Indigenous people? 

A lot of it aligns with what we’re talking about. Certainly, I had a number of people in interviews say it was a white man’s disease. I had this really great statement from an Apache-Sioux woman who described diabetes as being caused by the white flour, the white sugar, and all of these white things that she then associated with white folks coming in.

A lot of people in the community that I worked with described diabetes as being caused by colonialism and the introduction of new lifestyles and diets. Others also associate it with things like high rates of poverty in the community. They described it as being passed down through behaviors and habits as well, so learning this idea of “eating when you can,” where if you’re at an event and there’s a lot of food, you go back and get seconds.

People also talked about stress being a factor in causing it. I think science today seems to support that, that stress can lead to increased rates of cortisol, which can then lead to insulin resistance. They also mentioned substance abuse as possibly being a portion of it, but that was much less commonly cited as a cause. They also relate it to it being passed down through families: Oh, well, my mom had it and I have it, too, and so do my siblings.