Dr. Ann Bullock, a member of the Minnesota Chippewa Tribe, is an energetic and ambitious physician. She is reticent when it comes to talking about herself, but turn the spotlight on diabetes in the Native population—a topic about which she’s incredibly passionate—and it’s hard to get her to stop talking. A family physician who has been employed by the Indian Health Service (IHS) since 1990, Dr. Bullock practices today at the Eastern Band of Cherokee Indians (EBCI) in Cherokee, North Carolina, just as she has for the past 21 years. In 2009, she became the clinical consultant for the Indian Health Service Division of Diabetes Treatment and Prevention. She speaks regularly across the country on diabetes-related issues, including the connection between stress and early-life adverse experiences as well as diabetes risk. She’s excited about the nationwide roll-out of a new program designed to address that connection.
Grants recently awarded and administered by the Administration for Children and Families (ACF)—of which EBCI is a recipient—support 5-year cooperative agreements to plan for and implement high-quality, evidence-based home visiting programs in at-risk Tribal communities. Home visiting services provided under these grants are meant to improve child and family outcomes focusing on areas such as prenatal, maternal and infant health, child health and development, parenting skills, school readiness and family socio-economic status. The services also help to reduce incidence of child abuse and neglect, injuries, crime and domestic violence. Dr. Bullock is delighted that EBCI received a grant under this program and is optimistic about the positive changes the home visits are expected to make for patients with—or predisposed to—diabetes.
Speaking at the Tribal Maternal, Infant, and Early Childhood Home Visiting Program Grantee Kickoff Meeting and Tribal Early Learning Communities Consortium in Washington, D.C. in January of 2011, Dr. Bullock discussed how these grant program activities, including home visits and the relationships formed during those visits over time, may help reduce the poor nutrition, stress and trauma that predispose a child to an elevated risk of subsequent problems in physical and mental health, including diabetes. As she describes it, understanding the complicated event path that leads from poor nutrition, stress and trauma in a person’s environment to an exponential increase in diabetes over multiple generations, begins with an understanding of the relationship between environment and genes, or—using the scientific term—epigenetics.
Broadly defined, epigenetics is the study of changes produced in gene expression caused by mechanisms other than changes in the underlying DNA sequence. It sounds technical, but it is much easier to understand when Dr. Bullock explains it.
“Genes have a way of being turned on and off. And as research has recently proven, they turn on and off based on events that occur in a person’s environment. So let’s say that a new mother has grown up with poor nutrition, and has poor nutrition while she’s pregnant. Some of those genetic on-off switches are turned on or off in a way that puts the newborn at risk for later becoming overweight or obese, which increases risk of diabetes. The problem is compounded by the fact that these diabetes-promoting attributes are passed on from one generation to the next: the at-risk child grows up and becomes pregnant and, if she also suffers from poor nutrition and other related stressors, some of those same attributes are passed on epigenetically to her new baby. This all contributes to the explosion of diabetes in American Indian and Alaska Native people over the past 50 or 60 years.”
To reverse the trend, we must reverse those epigenetic switches. And to do that, Dr. Bullock says, “We change the environment. Home visitation with pregnant women and new mothers and the home visitor-family relationships that emerge, will change the environment,” she explains. “Home visitors offer education and access to additional resources that help expectant and new mothers take culturally appropriate steps to improve their own and their children’s nutrition, reduce stress in the home and community and minimize the potential for trauma.”
Dr. Bullock calls this a major advancement in the understanding of genetic influence on diabetes. “American Indian and Alaska Native people no longer have to feel they are genetically out of control over whether they will become diabetic or not. We do have some control, sometimes a great deal of control, over our environment. And that completely reverses the outdated ‘bad genes’ theories that essentially leave many Native American individuals feeling as if they are helpless in the face of this disease,” she says.
These recent revelations are starting to create a pretty dramatic change in the way the whole medical community is working to reverse the explosion of diabetes in Native populations. But Dr. Bullock wouldn’t be the avid supporter of diabetes treatment and prevention at EBCI if it wasn’t for a dramatic event that took place very early in her career.
A member of the Minnesota Chippewa Tribe, Dr. Bullock, like many people with a sense of mission and the desire to change lives, first considered international health as her focus. During a medical school rotation in South Africa, one little girl changed the course of Dr. Bullock’s life and career. Dr. Bullock describes the life-changing event: “I was doing a medical school rotation in South Africa when a young girl came in for treatment. Her family’s hut had burned down and several family members died. She had developed hysterical paralysis, but I couldn’t talk to her about all of this because I couldn’t speak her tribal language. I realized then that I wanted to work among my own people, in a place where I could communicate with my patients.” The physician who returned home would instead become one of the most knowledgeable, visionary and passionate people we have in the fight to stem the growth of diabetes among American Indian and Alaska Native people in this country. And, in a positively ironic way, it turns out that talking with patients — particularly through in-home visits made possible by grants such as the one EBCI recently received — can truly make a difference in how we go about preventing diabetes: now and in future generations.
Dr. Bullock is still interested in life-changing events, but it seems she would prefer those events be related to the prevention and treatment of diabetes and—in stark contrast to her early aspirations—close to home. “If I could spend the rest of my life right here, I’d be blessed.”