In 1943, the Missouri River flooded repeatedly. As author Paul VanDevelder describes in his book, Coyote Warrior, the havoc this wreaked on Iowa and Nebraska caused the director of the Army Corps of Engineers for the region to roar to his subordinates: ‘I want to control the Missouri!’ ”

Eventually, the bureaucrat got his wish. The Garrison Dam was constructed, creating a lake that covered every inch of the North Dakota farmland tilled by the people of the Mandan, Hidatsa and Arikara nations. What happened next, as told by Indian Country Today, dramatically illustrates the health effects of decisions made about the built environment.

Prior to the dam being built, there was not a single known case of diabetes on the Fort Berthold Indian Reservation where these tribes lived. Obesity was virtually non-existent and few Indians received government food assistance. Fewer than 20 years later, there were 200 reported cases. By 2009, more than 14 percent of the people using the health system on the reservation had diabetes–double the national average.

The line between a healthy community and an unhealthy one traces directly back to the building of the dam. No longer able to farm, the people on the reservation were forced to take low-paying jobs, relocate or go hungry. By 1956, unemployment hovered around 80 percent on the reservation and there were real concerns about starvation.

To head this off, the government started sending commodity foods–unhealthy ones. A General Accounting Office investigation on Fort Berthold and three other reservations in the 1990s found that “often the only vegetable available is canned green beans, the only fruit available is canned pineapple, and the only meat available is canned luncheon meat” adding that during the last week of each month, some families subsisted solely on macaroni, rice and cornmeal.

Those few reservation residents who could afford fresh food often had a hard time finding it because the closest grocery store was at least 10 miles away.

While the story of Fort Berthold is dramatic, it is not unique. In 1940, only 21 cases of diabetes were identified among the Akimel O’odham or Pima people, a tribal community Arizona. Then ranchers moved in, cities grew up and water from the Gila River was diverted away from irrigating Native crops, disrupting a traditional food system. Today the Pima of the United States have among the highest diabetes prevalence rates of any known ethnic group.

Since the 1980s, federal health officials have been trying to tackle the problem of diabetes in Native communities, with limited success.

Many of the programs focus on diet and exercise—offering residents regular workout classes or building community gardens. In 2008, the Centers for Disease Control and Prevention launched a traditional foods program that attempted to integrate culture into diabetes education and outreach, working with communities to reclaim their food heritage and clearing barriers that kept that heritage out of reach.

These are positive steps but some in Native communities say far more is needed and that too many attempts to reduce diabetes among Native Americans boil down to little more than lectures that blame the victims.

To reduce diabetes in Native American communities, these advocates say, will require a fundamental overhaul of the life of the world in which these communities exist. Diabetes is an outgrowth of racism, and poverty, of a fatalistic hopelessness that is not mitigated by diet and exercise.

A true diabetes strategy that works over the long term, they believe, would include restoring water rights and otherwise strengthening self-determination and self-sufficiency through changes in tribal laws, programs and policies – some of which are directly connected to food and nutrition and some of which are aimed at countering the sense of “futurelessness” that girds and bolsters the crisis.