SACATON, Ariz. -- He shakes the rattle in rhythmic pulses and sings a melodic Tohono O'odham prayer song, asking the creator to hear the group and to have mercy and forgiveness.
''Sialim Tago Jiosh E-Tonalic O-Himetha.''
Those who know the song join in quietly.
About 10 people sit in a circle around Gerard Kisto, a traditional practitioner who leads various American Indian healing ceremonies, including the free weekly talking circle at the Hu Hu Kam Memorial Hospital for those afflicted with diabetes.
The talking circle is one of several ways the tribe and hospital are seeking solutions to the high rate of diabetes on the Gila River Indian Reservation, 40 miles southeast of Phoenix.
By offering traditional American Indian practices in combination with Western medical treatment, the hospital staff hopes diabetes sufferers will be more willing to educate themselves about the disease and seek treatment.
''The hospital can provide medicine to balance them, but the traditional practices can help balance them spiritually and emotionally,'' said Dr. Don Warne, a family physician who helped develop the diabetes support group.
Nine percent of American Indians have diagnosed diabetes, according to a division of the National Institutes of Health. On the Gila River Indian Reservation, where the population comprises two tribes, the Pima and the Maricopa, the rate of diabetes is much higher; among Pimas, 50 percent of the population has diabetes, the NIH reports.
Warne, who is Lakota, said the hospital's talking circle is based on traditional American Indian talking groups and is a place where communication is encouraged and supported in a respectful atmosphere.
''In modern medicine, we're focused on issues of confidentiality,'' Warne said. ''That's important, but they start to feel isolated within their disease. We wanted to create a forum for people who wanted to talk about it.''
Before the ceremony begins, the group meets with a doctor from the hospital who discusses medical information about diabetes.
Kisto then begins the talking circle by unrolling a hand-woven square rug and setting up an ''altar'' on the floor. He lays out a wooden rattle, drum sticks, a tobacco pouch, an eagle bone whistle and an eagle feather.
He cannot burn sage or other purifying herbs as he normally would in other traditional ceremonies because this one is inside a hospital building with fire alarms and Western building codes.
Kisto does what he can to compensate, turning off the fluorescent lights to create an intimate, comforting and safe atmosphere. At the end of his opening blessing, he picks up the eagle feather and hands it to the person on his left.
He reminds the group to speak from their hearts.
''Whenever you're holding the eagle feather, you're truthful in the words that you talk,'' Kisto said. ''We as native people regard this bird as being so sacred because ... it flies so high to the creator and carries a lot of wisdom. It can tell if you're being honest or not.''
Participants take turns holding the feather and talking about their struggle with diabetes -- how difficult it is to stay away from sugar and carbohydrates at a child's birthday party, their pride in improving exercise habits or sharing worries about a family member or friend with diabetes.
They understand that what is said stays within the group.
''Generally Native Americans ... turn inward. So consequently, they're more quiet,'' said Leonard Fairbanks, a Choctaw who lives in Chandler and participates in the group.
Other members of the talking circle decline to talk outside the circle to maintain their privacy.
Diabetes sufferers do not produce or properly use insulin, a hormone that converts sugar, starches and other food into energy. The unused sugar in the bloodstream is corrosive and can cause complications including kidney failure, blindness, nerve damage and a loss of circulation that can lead to amputations. Among American Indians, amputation rates are three to four times higher than the general population, according to the American Diabetes Association.
Scientists believe Pimas -- who long ago relied on farming, hunting and fishing for food -- are now predisposed to developing diabetes because of high-fat diets and a genetic tendency to retain fat, once helpful in times of famine.
The hospital provides free treatment of basic services -- physicals and eye exams, for instance -- to anyone enrolled in a federally recognized tribe. It is working to provide a variety of services other than strictly medical to help those struggling with diabetes. A $1 million wellness center opened in April with exercise equipment, yoga and tai chi classes, and free transportation to the center.
''The tribe is really taking an active role in trying to prevent diabetes among its community members,'' said Dr. Sheila Tann, former director of the Diabetes Education Center at the reservation. ''The solutions need to come from within and the tribe is working very hard to do that.''
Only about 10 people regularly participate in the hospital's diabetes talking circle. Doctors hope that as word of the program spreads, that number will grow.
''Diabetes doesn't affect people just physically. It also affects them emotionally, spiritually and mentally,'' Warne said. ''When they come to me, they come with anger, depression and spiritual concerns, asking 'Why would the creator let this happen?'''
Without addressing those spiritual questions, Warne said many patients won't take their medication.
''It's the traditional interventions that are needed to provide balance.''
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