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In the Academy Award-nominated film Killers of the Flower Moon, lead actress Lily Gladstone assumed the role of Osage-tribe resident Molly Burkhart, a woman who suffered from diabetes. 

Throughout the movie set in the 1920s, Molly injected herself with insulin to manage her condition. Her husband, played by Leonardo DiCaprio, helps administer the critical medicine.

This narrative arc of the film is noteworthy as it represents the grounded reality that many Indigenous communities faced as diabetes became a chronic disease. 

Today, Indigenous peoples are three times more likely to be diagnosed with the disease than their non-Hispanic, white counterparts, according to data from the Centers for Disease Control and Prevention. 

Diabetes is a difficult public health challenge for the nation, one which has prompted the federal government and Big Pharma companies to work together on solutions.

In recent years, the introduction of innovative GLP-1 drugs and $35 price caps on insulin products have taken aim at the treatment and access problems surrounding diabetes.

Still, the persistently high rates of both type 1 and 2 diabetes as well as racial health disparities are indicators of lingering gaps in care for Indigenous communities.

Spero Manson, PhD, has studied diabetes with Indigenous communities for over 15 years as the director of the Centers for American Indian and Alaskan Native Health. 

He noted that even in communities that generally have access to diabetes treatments, they typically lag behind when it comes to accessing new medical innovations. 

Medical marketing is a way to bridge that gap, inform providers and get key medicines to patients. However, there are hardly any diabetes campaigns that actively center Indigenous voices or directly market initiatives to these underrepresented patient populations. 

That’s not to say avenues to reach communities don’t exist. 

Researchers who study diabetes rates among Indigenous populations say there are a few worthwhile channels for pharmaceutical companies and medical marketers to promote effective diabetes treatments to target HCPs and patients. 

Plus, reaching out to communities can lead to new business opportunities for drugmakers. 

“You rarely see Big Pharma in this space,” said Manson. “But there are so many opportunities for both parties.” 

A chronic health problem

Throughout modern history, Indigenous communities have dealt with consistently higher rates of diabetes among all U.S. racial and ethnic groups.

Data from the Indian Health Service (IHS) — the federal healthcare agency that provides services to Indigenous peoples — indicates that the average rate of diabetes among these communities sits at around 13% to 15%. This is nearly double the average rate of diabetes among non-Hispanic whites at 7.5%. 

Additionally, a study published in 2023 by researchers at UCI Public Health found that type 2 diabetes is the most persistent form of diabetes amongst Indigenous groups — with 98.06% of the studied population diagnosed with the disease. 

Type 1 diabetes persists at higher rates among children, but after the age of 10, type 2 diabetes becomes the most prevalent form of the disease. 

Research suggests that socio-economic and lifestyle factors are at the root of consistently high diabetes rates. 

Obesity is a primary contributor to diabetes, with data from the National Institutes of Health finding that 48% of Indigenous adults over the age of 18 are obese. 

Additionally, Indigenous communities have lower socio-economic conditions compared to other ethnic groups, including higher rates of poverty and unemployment as well as lower per capita income. 

This can adversely impact their quality of life and lead to the early onset of diseases like diabetes and cancer. 

“There are so many factors,” said Luohua Jiang, MD, professor of epidemiology and biostatistics at UCI, and one of the primary authors of the type 2 diabetes study. 

However, she added that early intervention coupled with lifestyle changes can make a difference.

Intervention initiatives such as culturally-designed community group programs that educate populations on eating and living well have been linked with better patient outcomes for those with diabetes. 

While these treatment options are available, Manson noted that one of the biggest challenges when implementing the programs is getting consistent attendance.

“A lot of diabetes patients also have other coexisting disorders like depression, which makes it more difficult for them to access treatment consistently,” he said. 

Indigenous people have also been linked to having persistent rates of mental health disorders, with NIH data suggesting that more than two-thirds of Indigenous people deal with some form of mental health challenge. 

Where is Big Pharma?

While there are more community programs designed and led by tribal communities than ever before, Manson also noted that Big Pharma companies are rarely, if ever, involved in the development of these programs. 

If they wanted to get involved with these public health groups to extend specific programs to Indigenous communities, there are some important considerations to keep in mind. 

“Indigenous peoples largely operate in close-knit communities,” Manson said. “If groups want to be successful at implementing these programs, they need to center interventions around social and cultural approaches.”

He added that in order to increase patient participation, it may be useful to identify one or two community leaders within the area, as they usually encourage the larger community to participate in programs. 

Some successful programs Manson has been involved in designing include those that engage all genders in the household and center lifestyle interventions around traditional Indigenous diets. 

The access problem

Another area that needs improvement in order to boost patient outcomes is access to treatments. 

While the IHS provides basic diabetes treatments, research has suggested that the underfunded service doesn’t always provide access to the newest or most innovative products on the market. 

“Even though they provide free access to healthcare and free medicines for IHS enrollees, they have limited resources,” Manson said. 

Marketing new treatments to communities is a way to bridge the gap, but it needs to be done right. 

“Building trust is the number one barrier for companies when working with [these] communities,” Jiang said. “If communities don’t feel providers can be trusted, they are less likely to engage.”

Much like conducting research, she noted that drugmakers can achieve this by having an Indigenous point person to facilitate programming or marketing efforts. 

Beyond that, she advised companies to cultivate stronger relationships with these historically marginalized communities. 

Manson also mentioned that there are a few channels companies can use to increase their marketing efforts towards Indigenous communities. 

Firstly, companies can collaborate with the IHS, which reaches all 574 federally recognized tribes across the country. 

For example, the IHS’ Division of Diabetes Treatment and Prevention works with tribal leaders to implement disease-focused programming and educate communities on their care options. 

Companies could also collaborate with the National Indian Health Board, which has a similar extensive reach and works on providing resources and educational materials. 

The National Council of Urban Indian Health is another avenue to reach targeted populations, especially since the council disseminates information to urban and tribal-based communities alike. 

Beyond outreach and marketing efforts, companies can also work to develop specific products for communities. 

One of the key issues facing Indigenous patients living in rural areas is not being able to store insulin in a refrigerated area for use given their spotty access to electricity. 

Share the land

Though outreach may appear to benefit communities, establishing proper relationships with Indigenous communities can also benefit pharma companies in the long-term. 

For example, Allegran collaborated with the St. Regis Mohawk Tribe in 2017.

The drugmaker was able to secure and shield patents for new products, while the tribe was able to invoke tribal immunity before the Patent Trial and Appeal Board. 

In the end, the tribe received $13.75 million upfront as well as royalties for up to $15 million each year until the expiration of the patents. 

This practice, sometimes referred to as “profit-sharing,” benefits both parties and provides pharma companies with a business case for prioritizing Indigenous populations beyond their clinical obligations. 

Another recent instance of this was when Variant Bio, a small Seattle-based biotech, announced a collaboration with Indigenous populations in New Zealand to collect genetic information for further drug development and research. 

Manson said more tribal groups are interested in profit-sharing practices with drugmakers, which offers a potential win-win situation for both parties.

“This engagement benefits companies and also gives tribal groups additional self-governance,” he said.