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Alcoholism in Zuni New Mexico
PREVENTlVE
MEDICINE
6, 152- 166 (1977)
Alcoholism
in Zuni New Mexico1~2 LEONARD NELSON~
Harvard
Medical
School, Boston,
Massachusetts
02115
An investigation into the etiology and medical and social consequences of alcoholism among Zuni Indians in New Mexico revealed that 10% or twice the national average of the adolescent and adult population were abusive users of alcohol. A community-based rehabilitation program is proposed, involving the creation of a comprehensive Alcohol Center, closely associated with a local Public Health Service hospital. The Center would be staffed by full- and part-time members including project director, social worker, Indian medicine man, clergy, physicians, nurses, and community health representatives. Rehabilitation would be attempted through cultural understanding, vocational and occupational therapy, family therapy, education, research, better cooperation on the part of local police, a community tax to help pay for recreational facilities, better use of local resource people, and more effective use of the media.
I. THE ALCOHOLISM
PROBLEM
In the United States today, alcohol is the most abused drug. It has been estimated that approximately 5% of the adult population manifest the behaviors of alcohol abuse. The most visible victims of alcoholism are inhabitants of skid rows across the United States. Yet they represent only 3 to 5% of the alcoholic population (1). The majority of the alcoholic individuals are in the working and homemaking population. Alcohol plays a major role in half the highway fatalities, an estimated 28,000 lives a year, in our country. It drains the economy of approximately $15 billion a year. Of this total, $10 billion is attributable to lost work time in business, industry, civilian government, and the military; $2 billion is spent for health and welfare services provided to alcoholic persons and their families; and property damage, medical expenses, and other overhead costs account for another $3 billion or more (1). Alcoholism is a complex illness and has divergent orientations among its investigators. Thus, it seems unlikely that any definition will ever be endorsed completely by everyone interested in the subject. Nevertheless, there has been enough agreement among myself and the Zuni people to support the accuracy of the following broad definition published by the AMA. “Alcoholism is an illness characterized by preoccupation with alcohol and loss of control over its consumption such as to lead usually to intoxication if drinking is begun, by chronicity; by progression, and by tendency toward relapse. It is typically associated with physi’ First Prize winning paper in the 1st Annual Preventive Medicine Student Competition. * This paper is based on a research project funded by Harvard Medical School and the United States Public Health Service, July and August 1975, and was submitted while the author was a fourth-year medical student. ’ Present address: 175 Freeman Street, Brookline, Massachusetts 02146. Presently a surgical intern of the Harvard Surgical Service, New England Deaconess Hospital, Boston, Massachusetts. 152 Copyright All rights
@ 1977 by Academic Press, Inc. of reproduction in any form reserved.
ISSN 0091-7435
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cal disability and impaired emotional, occupational and/or social adjustments as a direct consequence of persistent and excessive use of alcohol.” Thus, alcoholism is regarded as a type of drug dependence of pathological extent and pattern, which, ordinarily, seriously interferes with the patient’s total state of health and adaptation to his environment. As the illness progresses, the alcoholic’s preoccupation with alcohol leads him to organize and structure his life around drinking. He very often overextends himself to obtain, insure, and perhaps conceal his supply. When I first arrived in Zuni and observed the majority of inpatients afflicted by alcohol-related illnesses, including several 20-25year-old patients dying of cirrhosis, I was stunned. I soon learned that approximately 10% or twice the national average of the adolescent and adult population were abusive users of alcohol (3). Almost every household within the Zuni community was affected by alcoholism. A recent study to which I will refer in detail shortly, shows that among Zunis, cirrhosis is the leading cause of death, while it ranks fourth among the Indian population nationally and ranks eighth among non-Indians. Another fact that deviates from the national statistics is that the age group suffering the highest rate is the 20-29-year-old group; that is 20 years younger than the national average (3). By formulating an initial general impression of the severity of the alcoholism problem in Zuni, I decided to make an intense investigation into the medical and social consequences of alcoholism and what possible etiology and modifying factors existed. My mode of investigation was in three basic areas: (i) to communicate with all available resource people to acquire knowledge about alcoholism and obtain assistance in stating my intentions to help combat this serious problem actively; (ii) to visit as many homes as possible in order to view the problem myself and to construct a good rapport with the patients; and (iii) to study the statistical data carefully in order to acquire a more concrete notion of exactly what the priorities of my study should be. My basic philosophy which I attempted to communicate through my encounters with the resource people of Zuni and my patients was as follows: (a) I would never impose my own values in dealing with the problem of alcoholism. Instead, I would learn as thoroughly as possible the cultural, religious, and social practices of the Zunis and then work closely with others within the realm of Zuni values; (b) any new ideas or programs to be instituted in Zuni would involve long periods of uncertainty, and change would be a slow process; and (c) dealing with alcoholics can be a very frustrating experience at times, and yet, one must continue to overcome the many obstacles involved. I had hoped at the commencement of my study that I would eventually be able to suggest specific means of dealing with the alcoholism problem in Zuni. Medical
Complications
The Zuni Indian Reservation has an Indian population estimated at 6,350, with 49.1% males and 50.9% females. It is an extremely young population, with 65.1% under 25 years of age. A study of the mortality statistics by Dr. Vondervagen at Zuni, covering a 54-week period from mid-December 1972 through December 1973, revealed several startling results. During this time period, there were 57 Zuni deaths (see Table 1). Of the 43 male deaths, 30, or 70%, were alcohol related (3).
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TABLE 1 MORTALITY
STATISTICS
COVERING A PERIOD FROM MID-DECEMBER WEEKS) AT ZUNI, NEW MEXICO
Female
43 14
Total
57
Male
1973 (54
Deaths related to alcohol (%) (No.1
Deaths (No.)
1972 TO DECEMBER
m 75 25
70 29
30 4
The major causes of death among the Zunis are shown in Table 2. A review of those deaths that are alcohol-related is shown in Table 3. Thirty-four of the fifty-seven deaths in the Zuni population, or 60% of all deaths, were associated with alcohol, shown by age in Table 4. It is apparent from this table that alcohol contributes significantly to the mortality of the young people in Zuni. In summary, 7 of 16 cirrhotics are below the age of 30 years; 12 of 18 accidents are below the age of 30 years. Therefore, 19 alcohol-related deaths out of 34, or S6%, are younger than 30 years old. Finally, it may be of interest to compare cirrhosis and auto accident mortality with other groups, as shown in Table 5. The Zunis have greater than ten times the annual average and greater than three times the national average for auto accident fatalities. Although the numbers reported are small and the data are for a short period of time, I think the fact remains that alcohol is a major factor in mortality, especially among the young Zuni Indians. Social Complications Alcohol provides vastly different functions within diverse societies, cultures, and ethnic and religious groups. Attitudes concerning its use range from extreme permissiveness to absolute abstinence. However, abstainers can always be found when permissiveness is the practice, and, conversely, drinking does not disappear when abstinence reigns. The purposes for which alcohol is used are many. The standards of acceptability applied to the manner or pattern of drinking vary according to age, sex, cultural TABLE 2 MAJOR CAUSES OF DEATH
Cause 1. 2. 3. 4. 5. 6. 7. 8. 9.
Cirrhosis Natural causes Auto accident Suicide Undetermined Drowning Carcinoma Foul play All other
AMONG
ZUNI,
DECEMBER
1972-DECEMBER
Number 16 12 10 4 4 3 3 3 2
1973
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TABLE 3 ALCOHOL-RELATED
DEATHS
AMONG
ZUNI,
DECEMBER
19i%DEcEMBER
1973
Cause
Number
Percent of total
Cirrhosis Auto accident Foul play Suicide All other
16 10 3 3 2
28 18 5 5 4
Total
34
60
TABLE 4 DEATHS
ASSOCIATED
WITH
ALCOHOL,
BY AGE,
DECEMBER
Cirrhosis Group
(No.1
O-9 years 10-19 years 20-29 years 30-39 years 4049 years SO-59years 60-69 years 70-79 years 80+ years Total
1973
Accident, violence (No.1 m
m
0 0 7 3 3 2 0 1 0 16
1!?72-DECEMBER
1 4 7 2 2 2 0 0 0 18
0 0 44 18.5 18.5 12.5 0 6 0 100
5.5 22 39 11 11 11 0 0 0 100
TABLE 5 COMPARISON
OF CIRRHOSIS
AND AUTO
ACCIDENT
MORTALITY
IN ZUNI
WITH
Cirrhosis mortality/lOO,OOOpopulation Nationala Navajo” Apache Hopia Zuni
19.9 13.2-17.2 40.0 104.0 300.0
1964 (Depending on population base) 1%0’s 1%5-1%7 1973, 1 year (population base 5,300)
Auto accident mortality/lOO,OO0 population Zuni National a See Ref. (2).
187.5 56.0
OTHER
GROUPS
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background, social class, and particular circumstances. Thus, sociological factors have a marked influence upon the use of alcohol and are important considerations in the etiology and development of alcoholism, as well as in the treatment of alcoholic patients. It is impossible to isolate the attitudes, purposes, and standards associated with the use of alcohol in any sociological context from the total structure of the social organization. To appreciate their full significance, they must be examined in relationship to preceding historical events and existing conditions, as well as to a multiplicity of other sociocultural variables. The sociological consequences of alcoholism are seldom appreciated or even made comprehensible by the recitation of statistical data. However, there is no doubt that there has been a significant sociological impact of alcoholism on the Zunis. When viewed in terms of the tragedy, suffering, and indeed the waste of life which the illness has brought its victims and their families in Zuni, even the most callous observer would be affected. There is a legend among the Zunis handed down from many generations that was related to me by the tribal historian. This legend stated that the Zunis should be concerned about the white man because he brings the brown water that will make all who drink it crazy. After making an intensive sociological inquiry into the effects of alcoholism among the Zuni people, I understood that the “brown water” had indeed instigated significant sociological consequences in Zuni. One of my first home visits was to a Zuni male paraplegic, who had been injured as the result of an auto accident the year before while intoxicated. Even after this near-fatal alcohol-related auto accident, he continued to drink. During the 2 weeks prior to my visit, he had fallen out of bed twice while drinking. When I asked him why he still indulged, he replied, “The doctor told me that my legs are dead but my insides are fine, and that it was all right to continue drinking.” He refused to admit that it was alcohol that caused his serious accident. Instead, he attributed his fate to the inadequate lighting on the roads. His wife had begun heavy drinking following his accident, and the visit also indicated that their children were being neglected. A middle-aged Zuni woman came to the Emergency Room with a 2-cm-deep scalp laceration sustained from being kicked in the head by her alcoholic husband. She was in tears as she related her suffering during the past several years due to her husband’s alcoholism. Not only had she been physically abused on several occasions, but the mental anguish caused by her assuming both roles, mother and father, to shelter her children from their intoxicated father was now conquering her. When I queried her as to why she withstood this mental and physical cruelty for the past several years, she replied, “There are times when my husband is not drinking and, during these times, he is a good man and a warm father. I have not left him because I keep believing that soon he will stop drinking.” One of the nurses at the Zuni hospital came to see me in order to seek help for her husband who had a serious drinking problem. She told me, “I have cried every night for the past 8 years because my husband, who is an alcoholic, is slowly killing himself. Every night he awakens in fear, screaming, and every morning he vomits and shakes. I thought that my children would be as disgusted as I am with
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his drinking, but now my B-year-old son has started drinking heavily himself. Alcohol has destroyed my marriage and everything I love.” Having an alcoholic in a Zuni family, as the preceding quotes illustrate, is bound to cause emotional problems, no matter how positive the marriage may be. Too often I have made home visits to the alcoholic only to find an environment filled with sadness, suffering, and loneliness. The children in this environment have emotional problems resulting from the anxiety over their parents’ drinking. They are too often deprived of what they need most, a responsible, responsive, and predictable parent upon whom they can always depend. Mrs. Kessler, one of the teachers at Zuni High School, had her class write about alcoholism in Zuni, and I quote one of her student’s comments. “Drinking is a problem in Zuni, yet the Zuni people do not realize it. All they care about is getting drunk. Drinking has changed life in Zuni in a whole lot of ways. There’s much more drinking now than there was 10 years ago. I remember when there weren’t many beer cans lying around in Zuni. Now Zuni looks like a beer can dump. Don’t they care anymore? It looks like the whole village is going crazy. People killing each other, homes broken, families fighting. All this is caused by alcoholism.” II. CAUSES AND MODIFYING
FACTORS
Repeated attempts to attribute alcoholism to a single cause have been consistently unsuccessful, although many factors have been suspected and studied. Several hypotheses have enjoyed enthusiastic but brief acceptance before collapsing under the weight of new evidence. Others have been molded carefully, modified, and expanded, gradually adding to our fund of knowledge. Interwoven throughout have been the threads of mysticism and morality, characteristically contributing nothing to total understanding, but persisting nevertheless. The main objective of my study was an attempt to discover the specific causes and modifying factors that have made alcoholism a major health problem in Zuni. Many of the causes and modifying factors peculiar to the Zunis, I learned, were interrelated and are described as follows. Causes A. The “witched” alcoholic. Many Zunis believe that while intoxicated they are “possessed” by the witches and, thus, not responsible for their actions. This is well expressed by Levy and Kunitz (2): “Thus it was that the Indian came to see that changes-for-the-worse were to be expected during drunkedness, for at such times the drunkedness was temporarily inhabited by an evil supernatural agent. And from this, the Indian reached the entirely reasonable conclusion that since he was thus ‘possessed,’ his actions when drunk were not his own and he was not responsible for them.” Many of the Zunis who believe that they are “possessed” while inebriated are the same people who attribute any alcohol-related illnesses to their being witched rather than to alcohol itself. Therefore, if they become very ill, they will seek the medicine man in Zuni in lieu of obtaining medical help at the Public Health Service (PHS) hospital. B. The jewelry business. Zuni has seen vast economic and social changes during
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recent years, primarily resulting from the increase in the silver and turquoise jewelry market. It is estimated that 90% of all Zuni familes are involved in the production of jewelry (3). Family income has increased rapidly; in 1969, the estimated per capita income was $585 per annum, as compared with a 1974per capita figure of $1,200 per annum. This has provided the Zuni families with greater buying power and thus, a higher standard of living. During the past 10 years in Zuni, as the jewelry business has flourished, so has the drinking problem. After the typical jewelry-producing family acquires its color television and pick-up truck, the family has no conception of what to do with the remainder of this sudden and expanding wealth. The life-style created by jewelry production is very conducive to drinking as well; long hours of sitting and working on jewelry prevail, and individuals working on the jewelry structure their own working hours as they see fit. In conjunction with several other causes enumerated below, the jewelry business has brought with it conflicting ramifications of new luxuries and the evils and destruction of alcoholism. C. The new male role in Zuni. With the flourishing jewelry business replacing agriculture, hunting, and raising sheep as the primary modes of existence, the Zuni male has lost much financial responsibility within the family structure. It was not too long ago that the Zuni man was the main breadwinner, working long hours to provide and care for his family financially. Yet, the jewelry business allows the woman to assume equal, if not greater, responsibility in supporting the family. The male could leave for indefinite periods of time, and the woman would continue to produce her jewelry without lack of security. Therefore, the male Zuni’s new role of decreased responsibility, causing a lack of self-esteem combined with increased leisure and limited recreational facilities (to be discussed below), often results in alcohol manifesting itself as the center of his existence. It provides an escape from his inferior social position and is misused as a form of recreation. D. The family role in relation to the alcoholic member. Many families within different ethnic groups to whom I have been exposed both as a medical student and in my personal life tend to ostracize an alcoholic family member. He is often looked down upon, divorced from many family functions, and becomes isolated, receiving little, if any, family support or care. However, among the Zuni families, the alcoholic is not usually rejected, although there may be variable persuasion tactics attempted to help the drinking problem. Because the Zuni community is closely intertwined, if a family under extreme circumstances should reject the alcoholic, that individual can usually find a new home reasonably quickly. Most Zuni families with alcoholic members will rarely seek professional help but, instead, usually accept and care for these individuals themselves. Thus, the alcoholic in Zuni usually has a home with relatives to care for him or her, is accepted in the family circle, and receives minimal encouragement to alleviate his drinking problem. Therefore, many of the negative traits of the alcoholic in Zuni are reinforced within the family circle. E. Lack of recreation. There are very few established forms of recreation in Zuni. Therefore, with increasing available wealth in recent years (the jewelry business) and little to spend this money on for immediate entertainment, many Zunis resort to alcohol as a form of recreation.
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More than half of the alcoholics in F. “Beer drinkers are not really alcoholics.” Zuni are heavy beer drinkers. Many of these beer drinkers do not view beer as an alcoholic beverage on the same level as wine or hard liquor. Rather, they consider it to be a mild alcoholic beverage. Thus, many of the families of these indulgers and the drinkers themselves, even with prevailing medical, social, and psychological complications of alcoholism, will often deny the association of beer drinking and its ramifications. G. Lack of exposure to other life-styles. The Zunis are very homebound people who rarely leave the reservation. For instance, when on vacation from a specific job on the reservation, Zunis will usually spend the time at home producing their jewelry as opposed to traveling from the reservation. Therefore, many Zunis have little exposure to life in other parts of the country. Due to a lack of perspective on the part of the Zunis, I acquired the impression that many Zunis rationalized their drinking habits by the statement, “Everybody drinks, and if the Anglos can do it, then we should be allowed to drink as well.” Modifying Factors A. The police force. The police force comprised of Zunis, many of whom drank
themselves, was a negative influence in dealing with the problem of alcoholism. Their conception of the complexities of alcoholism was very poor, as illustrated by a statement from the Police Commissioner in a telephone conversation. “The alcoholics are sick people, and the only way to deal with them is to put them away in one of the Rehab Centers in order to do anything for them.” Besides the lack of understanding of the alcoholic, the police force did not handle the alcoholic in an appropriate manner. There were many mornings that I would see a 20- to 25year old drinker who was detained by the police at 2:00 or 3:00 AM for disorderly conduct or drunken driving and was, upon arrest, brutally assaulted by the police. Many times, these people would come to see me at the hospital with lacerations they sustained 5-6 hr earlier but were imprisoned through the night. By the time they were seen for treatment, their lacerations had become infected and could not be sutured. The husband of one of the nurses had a Polaroid camera and photographed a 20-year-old alcoholic being arrested by the police. The following morning he went to the jail with the developed picture to see this prisoner only to find him barefoot, lying in the mud with several lacerations and bruises, all sustained from police brutality. Many of these patients possess a deep hatred for the police. They stated to me that police brutality caused many to drink in greater excess in rebellion against the police force. By law, the Zuni reservation was not permitted to have liquor on the premises, although, in reality, this was not practiced. Considering the serious problem with alcohol-related auto accidents, one would expect the police would have a wellorganized, thorough, and consistent roadblock program to detect and prevent liquor from being smuggled into Zuni. However, their roadblocks were inconsistent, minimal, and thus inadequate. B. The bars selling to those under 18 years old. There are two bars off the
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reservation but within a 25min radius from Zuni where many Zunis purchase alcohol, one in Arizona and one in New Mexico. Both of these bars have, at times, been accused of selling alcoholic beverages to Zunis under the legal drinking age, thus perpetuating alcohol abuse among young Zunis. C. Lack oj’a coordinated program and poor use oj’resource people in Zuni. In making my sociological inquiry into the problem of alcohol abuse in Zuni, the lack of a coordinated program to deal successfully with this problem quickly became obvious. Although the Alcoholism Program, PHS, Social Service, and the religious groups were attempting to deal with the problem as best they could, the magnitude of alcoholism in Zuni made separate institutions ineffectual in solving the basic problems. Many of the practicing alcoholics and former users do not seek or accept help from the present alcoholism program because: (a) Zunis do not like to be “visible” within their community. Since the alcoholism program is located within the confines of Zuni, they will not patronize this for fear of detection. (b) Many Zunis reject fellow members who lend aid with personal problems because they feel that their personal life will later be openly displayed. (c) Zunis do not like to disclose their “secrets” because of the interwoven society structure. Once again, they fear notoriety throughout the village. These factors have prevented any success in beginning an Alcoholics Anonymous (AA) program in Zuni. Finally, there are several potential resource people working for the tribe who have nebulous job descriptions. The CHRs (Community Health Representatives), who have become glorified chauffeurs, have not been utilized with respect to their many talents. Several resource people in the learning center also could be utilized more effectively considering the severity of alcoholism in Zuni. III. TREATMENT
OF THE PROBLEM
The treatment and rehabilitation of the alcoholic patient frequently declines as soon as he or she leaves the hospital or physician’s office. Regardless of how helpful and genuinely therapeutic a regime may be, the patient’s practical view maintains that the professional time devoted to his improvement represents only a small fraction of his total life. At the moment the patient returns to his community, he finds himself face-to-face with the very real issues of where he will go, what he will do, and what he can expect from his environment. If he is forced to find his way alone, and especially if he must return to the exact situation which conquered him before, the likelihood is that he will be unable to withstand much stress before again resorting to alcohol. Perhaps part of the physician’s past reluctance to treat alcohol-dependent patients has been a direct result of his uncertainty about etiology and his frustrations associated with treatment. The failure to identify specific causes and the associated frustrations may have led him to feel there was little rationale behind many recommended therapeutic procedures. If this is true to a large extent, it is unfortunate. In spite of the mixture of fact, theory, fantasy, and misinformation surrounding the subject, enough is known about the pathogenesis and sociological consequences of alcoholism to be of genuine use to the physician and to all related resource people and to ultimately benefit the patient.
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It is worthwhile to reemphasize that in the case of many alcoholics, by the time they are first seen by a physician, many of the stabilizing sociological factors in their lives will have been damaged or destroyed. Also, it is important to remember that the persons affected directly and indirectly by the patient’s illness are likely to need help. Thus, true remedial treatment requires the combined efforts of many persons in the total rehabilitation of the patient and his family. This can be accomplished only as a comprehensive team endeavor in which all community resources are mobilized and utilized to their fullest potential. Realizing the severity of the alcoholism problem in Zuni, several members of the community, including Dan Ukestine and the rest of the counselors at the Alcoholism Program, Marcella Wolf, a social worker at Zuni, and I, thought of possible ways of increasing the care for the vast number of alcoholics and their suffering families. Since the PHS is moving in January 1976 into the newly constructed hospital and is relinquishing the present hospital building to the tribe, we thought one mode of improving the total care of the alcoholic was to convert the present hospital into a comprehensive Alcoholic Center. We realized this would be an extensive undertaking involving hard work, utmost dedication, and, at times, frustrations. Realizing the complex problem of alcoholism, if we could initiate a program in Zuni in which many cooperative disciplines pool their resources, then at least, this would be a concrete beginning. With this proposal, we went to Governor Laselute who offered his full support and, through the Tribal Council, agreed to donate the hospital building for our proposed Alcoholic Center. Our next step, presently being developed, is the writing of an extensive proposal for submission to various foundations for financial assistance. Below, in outline form, is the basic philosophy and organization of the proposed Alcoholic Center, one which will combine many resource people in dealing with the complexities of the problem of alcoholism. The Guiding Philosophy of the Treatment Program (i) Alcoholism is a respectable, treatable illness. (ii) Through medical, psychological, social, and spiritual assistance, the alcoholic can be helped to stop drinking and resume a “normal” life without substituting other injurious practices. (iii) The alcoholic patient can be reeducated to improve his ability to communicate and to adapt in a changing environment. (iv) The alcoholic patient must be encouraged to rebuild and maintain the dignity and self-respect forfeited by the long-continued use of alcohol. (v) The alcoholic patient must be encouraged to express, understand, and deal with his emotions. (vi) Part of the rehabilitation of the alcoholic lies in helping the family, through education on alcoholism and by offering assistance with their needs. Organization of the Health Center A. Staff. The staffing of the center will be composed of both full- and part-time members as follows. The staff will have primary responsibility for the care of both in- and outpatients. Each staff member will have his or her own patients. There will be daily rounds on
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Full-time I. Dan Ukestine (Alcoholism Program Director) 2. Two-four members of present Alcoholism Program 3. Social worker 4. Medicine man
Part-time 1. PHS M.D. 2. Nurse (RN, LPN, and/ or nurse’s aid) 3. Father Melton (Volunteer) (headmaster of local parochial school) 4. Zuni volunteer 5. Community Health Representative
all inpatients so every staff member will know each patient individually. There will be biweekly case review meetings in which patients will be discussed among all staff members. In this way, each member with his or her own background and qualifications will be able to offer constructive criticism, help, and alternatives. Each member will engage in individual therapy with his patients. He will concentrate simultaneous efforts on developing a therapeutic relationship through a sympathetic attitude, demonstrating interest, and acceptance without communicating condonation. There will be an attempt to provide the patient with a sense of protection while at the same time encouraging gradual and progressive independence. Once the relationship has acquired a firm foundation and the patient feels secure in it, he can be guided carefully toward the recognition and acceptance of his problems and then to greater personal responsibilities in dealing with them. Group therapy with alcoholics often proves a much more effective treatment modality than individual therapy. Perhaps one reason for this is that problems in interpersonal relationships plaguing the alcohol-dependent person frequently can be recognized and dealt with more readily in a group situation. The group allows for a nonthreatening environment where the individual gains support as he finds out that others have similar experiences and problems. However, as I stated in the section on causes and modifying factors of alcoholism in Zuni, the Zunis do not open up in group situations readily. Therefore, group therapy in the new Health Center must be done initially on an experimental basis, often in conjunction with other activities (to be described later). Follow-up care, once the patient leaves the Health Center, is a vitally important function of the staff members. The alcoholic patient needs continued support during his readjustment period back into the community, for, without it, he will often revert quickly to his old habits. Follow-up care will aid the patients in meeting the problems that arise from daily living as well as provide a means of developing suitable methods of coping with them. Thus, this is a unique feature of the proposed Health Center in comparison to the present Alcoholic Center now being utilized. At the present centers in Wyoming and New Mexico (Albuquerque), there is no provision for follow-up care. Thus, once the alcoholic is discharged, he has little positive reinforcement in readjusting to his life. B. PHS associalion. Another unique feature of the Health Center will be its close association with the new PHS hospital, both on geographical location and as
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a unified team approach to treating the alcoholic. One of the PHS doctors will be a part-time staff member having the responsibility described in Section A. The physician’s participation in the Health Center in dealing with the many ramifications of alcoholism can be as extensive as he elects. He is able to serve directly in such important matters as providing consultation, assisting in program planning, and, of course, treating patients. Knowledge of the multifaceted problems associated with the illness will certainly place him in a unique position from which he can be a guiding force in increasing the Center’s effectiveness and helping it become a part of community-wide programs. The negative attitudes toward the alcoholic usually permeate all levels of our social organization. However, the physician can do a great deal to foster a better understanding, both among fellow professionals and the general public, of the nature of the illness and the problems of the patient. There will be basically three types of admission to the health center, as follows: (i) When a patient is seen at the new PHS hospital with alcohol-related symptoms serious enough to require hospitalization, the staff members of the Health Center will immediately be notified on admission. They will then closely follow the patient’s stay in the hospital. Once the patient is able, he will be admitted to the Health Center. Thus, the patient is admitted to the Health Center under the guidance of those who are familiar with his case. The process of admission to the Health Center from the PHS hospital will be an organized and effective method of helping the alcoholic deal with the many complexities of his problem. (ii) When a patient is seen at the new PHS hospital with alcohol-related symptoms not serious enough to require hospitalization, the staff members will immediately be notified as well. Together, they will discuss with the patient the possibility of admission to the Health Center for rehabilitation. If the patient voluntarily admits himself to the Health Center, he will continue to be followed medically by the PHS doctors. Thus, the close association of the PHS staff and the staff members of the Health Center will foster better overall care for the alcoholic. (iii) An alcoholic who is not medically ill may voluntarily admit himself to the Health Center for rehabilitation. On admission, the PHS staff will be notified immediately in order to facilitate close medical follow-up on this patient. Again, a close association between the PHS staff and that of the Health Center will make the treatment of the alcoholic effective. This third type of admission will probably not prevail initially. First, it is necessary that people are made fully aware of its benefits. C. The cultural aspect of the Health Center. As I stated earlier, under Causes, many alcoholics believe that, while they are inebriated, they are “possessed.” Therefore, any alcohol-related illness will be attributed to the “witches,” and they will approach the medicine man before seeking the help of a medical doctor. Thus, another unique feature of the Health Center will be the presence of a fulltime medicine man on the staff. Not only will he be able to care for those “possessed” alcoholics, but he will offer a different perspective in caring for the complexities of the alcoholic in general. D. Vocational and occupational therapy. Part of the rehabilitation of the alcoholic is providing him with constructive, worthwhile projects to occupy his time. These will include the standard arts and crafts and also vocational training. By
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offering an opportunity for accomplishment through vocational therapy, the patient gains the feelings of self-respect and self-reliance. Many alcoholics in the past refused to go to the available rehabilitation centers because, during the time spent there, they would not be able to support their families. Therefore, with this in mind, part of the vocational therapy would be the availability of making jewelry, dolls, pottery, etc. This would serve several important functions, as follows: (i) Those alcoholics who are admitted to the Health Center can continue with their financial responsibilities as part of their rehabilitation. (ii) The making of jewelry and other crafts can be done in an environment in which those taking part are working next to each other. Thus, there will be a friendly, warm atmosphere which will serve as a subtle form of group therapy. (iii) While the patients are actively involved in vocational therapy, members of their family can assist them. Therefore, as the alcoholic is in the process of recovering, he will have the continued support of his family. E. Family service. One cannot hope to rehabilitate the alcoholic and then send him back to his old environment without interplay with his family. The needs of each alcoholic’s family may differ. Some families will need to be educated about alcoholism; others will need intensive psychological support in recovering from the social consequences of alcoholism. One of the prime responsibilities of the full-time social worker will be to organize an efficient and productive Family Service Department with active participation from other staff members. F. Education. An extensive educational program organized by the staff members utilizing all available resource people will be instituted. The program will be aimed at the following: (i) professional and in-service training education; (ii) community and specific public education; (iii) formal and informal school education; (iv) information and referral. The process of educating the different institutions will involve continuous lectures by the professional staff, former alcoholics, and all other available personnel. There will also be small group discussions with the utilization of audiovisual instrumentation. This will create a climate of acceptance conducive to the development of a network of therapeutic, rehabilitative education, and preventive services in dealing with the complexities of alcoholism. G. Facilities for research. Remarkable progress has occurred in identifying the metabolic course of alcohol through the body. However, much knowledge is still lacking on the complex biochemical and physiological interactions between alcohol and our bodies. Even fewer studies have been performed on the psychological and social treatment methods for alcoholics. Despite these limitations, the evaluation of community alcoholism centers reveals that when a serious effort is made to meet the needs of alcoholics and when these efforts are available and accessible to them, then many patients will respond and improve. Alcoholism has caused significant morbidity and mortality in Zuni. Facilities should also be set up for research into the biomedical consequences of alcohol. This should be organized in conjunction with other institutions such as IHS, NIH, and NIAAA. The Negative Influence of the Police In order to reverse the attitudes of the police concerning the alcoholic, they
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need to be educated about the many complexities of alcoholism. They must be taught that alcoholism is a serious illness and that brutality is not a method of treatment. Only after the police possess a deeper understanding of alcoholism will they attempt to change their almost inhumane dealings with the alcoholics in Zuni. Thus, the professional staff and all available resource people must teach the police, through lecture and discussion groups with the aid of movies, what alcoholism is, in the “broadest sense.” Also, a better organized and effective roadblock system must be instituted in Zuni in order to reduce the number of fatal auto accidents due to alcohol. There should be a coordinated program with the police from Gallup and Ranag so the responsibility for safer highways is shared effectively. A Community Tax As was illustrated earlier, the standard of living in Zuni has increased substantially during the past 10 years. As the wealth in Zuni has increased, so has the problem of drinking increased proportionately. Diseases seldom have a single cause; epidemics often do. Whether the jewelry business, with its increased wealth and conclusive life-style, is the leading cause of the increased drinking problem in Zuni is a matter of debate. However, it is a significant contributing factor to the overall alcoholism problem. Since approximately 90% of Zunis make jewelry, some of them making $1,000 to $2,000 a week, tax free, there is a huge amount of money available. It has been proposed by several Zunis that a community tax be instituted. Since Zunis pay only Federal tax and none of their profit from their jewelry business is taxed, this would not present any hardships. It could be a progressive tax so that the people would pay taxes according to their earnings. The collected tax would benefit the tribe for use in constructing recreational facilities in Zuni. All money would be allocated in a public fashion for the good of Zuni. Therefore, by taxing the people, several functions would be accomplished: (i) There would be funds available for recreational facilities desperately needed in Zuni. (ii) The Zunis would be taught to be more responsible in spending their money. (iii) The Zunis would be provided with better community spirit, as the taxed money would be directly returned to the village for beneficial and constructive purposes. Better Use of Resource People As stated earlier, there are several potential resource personnel working for the tribe who have nebulous job descriptions. These people, including the CHRs and members of the learning center, could be utilized more effectively in the community and in the new Health Center to deal better with the complexities of alcoholism. They could be involved in showing films in school and in the Health Center on alcoholism. They should be further educated about alcoholism and motivated to use their talents in a constructive and meaningful manner. More Effective Uses of the Media The Zunis have a poor exposure to other life-styles in the United States. Many are also not fully aware of the severity of alcoholism in Zuni, in terms of morbidity
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and mortality. Therefore, better use of the media can serve several basic functions: (i) An educational device to teach the people about the complexities of alcoholism. (ii) Make the Zunis more aware of the problem of alcoholism in the United States and specifically in Zuni. (iii) Expose the two local bars for illegally selling alcoholic beverages to minors. Alcoholics are treatable patients. Their illness is a chronic disorder with a tendency toward relapse. Therefore, alcoholism should be approached in much the same manner as other chronic relapsing medical conditions. The aim of treatment should be viewed more as one of control than of cure. Although abstinence is a primary objective of any program, additional considerations may be better guides to evaluating the success of a treatment program. Among these considerations are improved social and occupational adjustments. Therefore, a positive aspect of a treatment program should be to assist the alcoholic in learning to deal more effectively with his life problems, without alcohol as a crutch. In the process, the patient will learn to adapt to his environment in a reasonable, mature manner. One existing cause of the use of alcohol in Zuni, which is basic to its culture, is the lost financial responsibility of the male. With the present structure of the Zuni society, it is difficult to know how to handle this problem best. Perhaps my successors in Zuni will find the solution. As I pursued my study in Zuni, I was overcome by several emotions: a feeling of sympathy in seeing many suffering people because of alcoholism; a feeling of bewilderment because so little was being done for the leading cause of death; and, finally, a desire to initiate an effective means c,f making Zuni a healthier place in which to live. I only hope that those who iollow me in Zuni will realize that although a unified approach to the alcoholic will invariably run into countless barriers, hard work, dedication, and an awareness of the Zuni culture will eventually help them overcome their obstacles, REFERENCES I. “First Special Report to the U.S. Congress on Alcohol and Health,” Preface, p. vi. National Institute on Alcohol Abuse and Alcoholism, DHEW Pub]. No. (HSM) 72-9099,U.S. Government Printing Ofice, Washington, D.C., December 1971. 2. Levy, G. E., and Kunitz, S. J. Indian drinking: Navajo practices and Anglo-American theories, in “Proceedings of the First Annual Alcoholism Conference of the National Institute of Alcohol Abuse and Alcoholism,” p. 68. John Wiley, New York, 1974. 3. Vondervagen, mimeo report, 1974.
MEDICINE
6, 152- 166 (1977)
Alcoholism
in Zuni New Mexico1~2 LEONARD NELSON~
Harvard
Medical
School, Boston,
Massachusetts
02115
An investigation into the etiology and medical and social consequences of alcoholism among Zuni Indians in New Mexico revealed that 10% or twice the national average of the adolescent and adult population were abusive users of alcohol. A community-based rehabilitation program is proposed, involving the creation of a comprehensive Alcohol Center, closely associated with a local Public Health Service hospital. The Center would be staffed by full- and part-time members including project director, social worker, Indian medicine man, clergy, physicians, nurses, and community health representatives. Rehabilitation would be attempted through cultural understanding, vocational and occupational therapy, family therapy, education, research, better cooperation on the part of local police, a community tax to help pay for recreational facilities, better use of local resource people, and more effective use of the media.
I. THE ALCOHOLISM
PROBLEM
In the United States today, alcohol is the most abused drug. It has been estimated that approximately 5% of the adult population manifest the behaviors of alcohol abuse. The most visible victims of alcoholism are inhabitants of skid rows across the United States. Yet they represent only 3 to 5% of the alcoholic population (1). The majority of the alcoholic individuals are in the working and homemaking population. Alcohol plays a major role in half the highway fatalities, an estimated 28,000 lives a year, in our country. It drains the economy of approximately $15 billion a year. Of this total, $10 billion is attributable to lost work time in business, industry, civilian government, and the military; $2 billion is spent for health and welfare services provided to alcoholic persons and their families; and property damage, medical expenses, and other overhead costs account for another $3 billion or more (1). Alcoholism is a complex illness and has divergent orientations among its investigators. Thus, it seems unlikely that any definition will ever be endorsed completely by everyone interested in the subject. Nevertheless, there has been enough agreement among myself and the Zuni people to support the accuracy of the following broad definition published by the AMA. “Alcoholism is an illness characterized by preoccupation with alcohol and loss of control over its consumption such as to lead usually to intoxication if drinking is begun, by chronicity; by progression, and by tendency toward relapse. It is typically associated with physi’ First Prize winning paper in the 1st Annual Preventive Medicine Student Competition. * This paper is based on a research project funded by Harvard Medical School and the United States Public Health Service, July and August 1975, and was submitted while the author was a fourth-year medical student. ’ Present address: 175 Freeman Street, Brookline, Massachusetts 02146. Presently a surgical intern of the Harvard Surgical Service, New England Deaconess Hospital, Boston, Massachusetts. 152 Copyright All rights
@ 1977 by Academic Press, Inc. of reproduction in any form reserved.
ISSN 0091-7435
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cal disability and impaired emotional, occupational and/or social adjustments as a direct consequence of persistent and excessive use of alcohol.” Thus, alcoholism is regarded as a type of drug dependence of pathological extent and pattern, which, ordinarily, seriously interferes with the patient’s total state of health and adaptation to his environment. As the illness progresses, the alcoholic’s preoccupation with alcohol leads him to organize and structure his life around drinking. He very often overextends himself to obtain, insure, and perhaps conceal his supply. When I first arrived in Zuni and observed the majority of inpatients afflicted by alcohol-related illnesses, including several 20-25year-old patients dying of cirrhosis, I was stunned. I soon learned that approximately 10% or twice the national average of the adolescent and adult population were abusive users of alcohol (3). Almost every household within the Zuni community was affected by alcoholism. A recent study to which I will refer in detail shortly, shows that among Zunis, cirrhosis is the leading cause of death, while it ranks fourth among the Indian population nationally and ranks eighth among non-Indians. Another fact that deviates from the national statistics is that the age group suffering the highest rate is the 20-29-year-old group; that is 20 years younger than the national average (3). By formulating an initial general impression of the severity of the alcoholism problem in Zuni, I decided to make an intense investigation into the medical and social consequences of alcoholism and what possible etiology and modifying factors existed. My mode of investigation was in three basic areas: (i) to communicate with all available resource people to acquire knowledge about alcoholism and obtain assistance in stating my intentions to help combat this serious problem actively; (ii) to visit as many homes as possible in order to view the problem myself and to construct a good rapport with the patients; and (iii) to study the statistical data carefully in order to acquire a more concrete notion of exactly what the priorities of my study should be. My basic philosophy which I attempted to communicate through my encounters with the resource people of Zuni and my patients was as follows: (a) I would never impose my own values in dealing with the problem of alcoholism. Instead, I would learn as thoroughly as possible the cultural, religious, and social practices of the Zunis and then work closely with others within the realm of Zuni values; (b) any new ideas or programs to be instituted in Zuni would involve long periods of uncertainty, and change would be a slow process; and (c) dealing with alcoholics can be a very frustrating experience at times, and yet, one must continue to overcome the many obstacles involved. I had hoped at the commencement of my study that I would eventually be able to suggest specific means of dealing with the alcoholism problem in Zuni. Medical
Complications
The Zuni Indian Reservation has an Indian population estimated at 6,350, with 49.1% males and 50.9% females. It is an extremely young population, with 65.1% under 25 years of age. A study of the mortality statistics by Dr. Vondervagen at Zuni, covering a 54-week period from mid-December 1972 through December 1973, revealed several startling results. During this time period, there were 57 Zuni deaths (see Table 1). Of the 43 male deaths, 30, or 70%, were alcohol related (3).
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TABLE 1 MORTALITY
STATISTICS
COVERING A PERIOD FROM MID-DECEMBER WEEKS) AT ZUNI, NEW MEXICO
Female
43 14
Total
57
Male
1973 (54
Deaths related to alcohol (%) (No.1
Deaths (No.)
1972 TO DECEMBER
m 75 25
70 29
30 4
The major causes of death among the Zunis are shown in Table 2. A review of those deaths that are alcohol-related is shown in Table 3. Thirty-four of the fifty-seven deaths in the Zuni population, or 60% of all deaths, were associated with alcohol, shown by age in Table 4. It is apparent from this table that alcohol contributes significantly to the mortality of the young people in Zuni. In summary, 7 of 16 cirrhotics are below the age of 30 years; 12 of 18 accidents are below the age of 30 years. Therefore, 19 alcohol-related deaths out of 34, or S6%, are younger than 30 years old. Finally, it may be of interest to compare cirrhosis and auto accident mortality with other groups, as shown in Table 5. The Zunis have greater than ten times the annual average and greater than three times the national average for auto accident fatalities. Although the numbers reported are small and the data are for a short period of time, I think the fact remains that alcohol is a major factor in mortality, especially among the young Zuni Indians. Social Complications Alcohol provides vastly different functions within diverse societies, cultures, and ethnic and religious groups. Attitudes concerning its use range from extreme permissiveness to absolute abstinence. However, abstainers can always be found when permissiveness is the practice, and, conversely, drinking does not disappear when abstinence reigns. The purposes for which alcohol is used are many. The standards of acceptability applied to the manner or pattern of drinking vary according to age, sex, cultural TABLE 2 MAJOR CAUSES OF DEATH
Cause 1. 2. 3. 4. 5. 6. 7. 8. 9.
Cirrhosis Natural causes Auto accident Suicide Undetermined Drowning Carcinoma Foul play All other
AMONG
ZUNI,
DECEMBER
1972-DECEMBER
Number 16 12 10 4 4 3 3 3 2
1973
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NEW MEXICO
TABLE 3 ALCOHOL-RELATED
DEATHS
AMONG
ZUNI,
DECEMBER
19i%DEcEMBER
1973
Cause
Number
Percent of total
Cirrhosis Auto accident Foul play Suicide All other
16 10 3 3 2
28 18 5 5 4
Total
34
60
TABLE 4 DEATHS
ASSOCIATED
WITH
ALCOHOL,
BY AGE,
DECEMBER
Cirrhosis Group
(No.1
O-9 years 10-19 years 20-29 years 30-39 years 4049 years SO-59years 60-69 years 70-79 years 80+ years Total
1973
Accident, violence (No.1 m
m
0 0 7 3 3 2 0 1 0 16
1!?72-DECEMBER
1 4 7 2 2 2 0 0 0 18
0 0 44 18.5 18.5 12.5 0 6 0 100
5.5 22 39 11 11 11 0 0 0 100
TABLE 5 COMPARISON
OF CIRRHOSIS
AND AUTO
ACCIDENT
MORTALITY
IN ZUNI
WITH
Cirrhosis mortality/lOO,OOOpopulation Nationala Navajo” Apache Hopia Zuni
19.9 13.2-17.2 40.0 104.0 300.0
1964 (Depending on population base) 1%0’s 1%5-1%7 1973, 1 year (population base 5,300)
Auto accident mortality/lOO,OO0 population Zuni National a See Ref. (2).
187.5 56.0
OTHER
GROUPS
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background, social class, and particular circumstances. Thus, sociological factors have a marked influence upon the use of alcohol and are important considerations in the etiology and development of alcoholism, as well as in the treatment of alcoholic patients. It is impossible to isolate the attitudes, purposes, and standards associated with the use of alcohol in any sociological context from the total structure of the social organization. To appreciate their full significance, they must be examined in relationship to preceding historical events and existing conditions, as well as to a multiplicity of other sociocultural variables. The sociological consequences of alcoholism are seldom appreciated or even made comprehensible by the recitation of statistical data. However, there is no doubt that there has been a significant sociological impact of alcoholism on the Zunis. When viewed in terms of the tragedy, suffering, and indeed the waste of life which the illness has brought its victims and their families in Zuni, even the most callous observer would be affected. There is a legend among the Zunis handed down from many generations that was related to me by the tribal historian. This legend stated that the Zunis should be concerned about the white man because he brings the brown water that will make all who drink it crazy. After making an intensive sociological inquiry into the effects of alcoholism among the Zuni people, I understood that the “brown water” had indeed instigated significant sociological consequences in Zuni. One of my first home visits was to a Zuni male paraplegic, who had been injured as the result of an auto accident the year before while intoxicated. Even after this near-fatal alcohol-related auto accident, he continued to drink. During the 2 weeks prior to my visit, he had fallen out of bed twice while drinking. When I asked him why he still indulged, he replied, “The doctor told me that my legs are dead but my insides are fine, and that it was all right to continue drinking.” He refused to admit that it was alcohol that caused his serious accident. Instead, he attributed his fate to the inadequate lighting on the roads. His wife had begun heavy drinking following his accident, and the visit also indicated that their children were being neglected. A middle-aged Zuni woman came to the Emergency Room with a 2-cm-deep scalp laceration sustained from being kicked in the head by her alcoholic husband. She was in tears as she related her suffering during the past several years due to her husband’s alcoholism. Not only had she been physically abused on several occasions, but the mental anguish caused by her assuming both roles, mother and father, to shelter her children from their intoxicated father was now conquering her. When I queried her as to why she withstood this mental and physical cruelty for the past several years, she replied, “There are times when my husband is not drinking and, during these times, he is a good man and a warm father. I have not left him because I keep believing that soon he will stop drinking.” One of the nurses at the Zuni hospital came to see me in order to seek help for her husband who had a serious drinking problem. She told me, “I have cried every night for the past 8 years because my husband, who is an alcoholic, is slowly killing himself. Every night he awakens in fear, screaming, and every morning he vomits and shakes. I thought that my children would be as disgusted as I am with
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his drinking, but now my B-year-old son has started drinking heavily himself. Alcohol has destroyed my marriage and everything I love.” Having an alcoholic in a Zuni family, as the preceding quotes illustrate, is bound to cause emotional problems, no matter how positive the marriage may be. Too often I have made home visits to the alcoholic only to find an environment filled with sadness, suffering, and loneliness. The children in this environment have emotional problems resulting from the anxiety over their parents’ drinking. They are too often deprived of what they need most, a responsible, responsive, and predictable parent upon whom they can always depend. Mrs. Kessler, one of the teachers at Zuni High School, had her class write about alcoholism in Zuni, and I quote one of her student’s comments. “Drinking is a problem in Zuni, yet the Zuni people do not realize it. All they care about is getting drunk. Drinking has changed life in Zuni in a whole lot of ways. There’s much more drinking now than there was 10 years ago. I remember when there weren’t many beer cans lying around in Zuni. Now Zuni looks like a beer can dump. Don’t they care anymore? It looks like the whole village is going crazy. People killing each other, homes broken, families fighting. All this is caused by alcoholism.” II. CAUSES AND MODIFYING
FACTORS
Repeated attempts to attribute alcoholism to a single cause have been consistently unsuccessful, although many factors have been suspected and studied. Several hypotheses have enjoyed enthusiastic but brief acceptance before collapsing under the weight of new evidence. Others have been molded carefully, modified, and expanded, gradually adding to our fund of knowledge. Interwoven throughout have been the threads of mysticism and morality, characteristically contributing nothing to total understanding, but persisting nevertheless. The main objective of my study was an attempt to discover the specific causes and modifying factors that have made alcoholism a major health problem in Zuni. Many of the causes and modifying factors peculiar to the Zunis, I learned, were interrelated and are described as follows. Causes A. The “witched” alcoholic. Many Zunis believe that while intoxicated they are “possessed” by the witches and, thus, not responsible for their actions. This is well expressed by Levy and Kunitz (2): “Thus it was that the Indian came to see that changes-for-the-worse were to be expected during drunkedness, for at such times the drunkedness was temporarily inhabited by an evil supernatural agent. And from this, the Indian reached the entirely reasonable conclusion that since he was thus ‘possessed,’ his actions when drunk were not his own and he was not responsible for them.” Many of the Zunis who believe that they are “possessed” while inebriated are the same people who attribute any alcohol-related illnesses to their being witched rather than to alcohol itself. Therefore, if they become very ill, they will seek the medicine man in Zuni in lieu of obtaining medical help at the Public Health Service (PHS) hospital. B. The jewelry business. Zuni has seen vast economic and social changes during
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recent years, primarily resulting from the increase in the silver and turquoise jewelry market. It is estimated that 90% of all Zuni familes are involved in the production of jewelry (3). Family income has increased rapidly; in 1969, the estimated per capita income was $585 per annum, as compared with a 1974per capita figure of $1,200 per annum. This has provided the Zuni families with greater buying power and thus, a higher standard of living. During the past 10 years in Zuni, as the jewelry business has flourished, so has the drinking problem. After the typical jewelry-producing family acquires its color television and pick-up truck, the family has no conception of what to do with the remainder of this sudden and expanding wealth. The life-style created by jewelry production is very conducive to drinking as well; long hours of sitting and working on jewelry prevail, and individuals working on the jewelry structure their own working hours as they see fit. In conjunction with several other causes enumerated below, the jewelry business has brought with it conflicting ramifications of new luxuries and the evils and destruction of alcoholism. C. The new male role in Zuni. With the flourishing jewelry business replacing agriculture, hunting, and raising sheep as the primary modes of existence, the Zuni male has lost much financial responsibility within the family structure. It was not too long ago that the Zuni man was the main breadwinner, working long hours to provide and care for his family financially. Yet, the jewelry business allows the woman to assume equal, if not greater, responsibility in supporting the family. The male could leave for indefinite periods of time, and the woman would continue to produce her jewelry without lack of security. Therefore, the male Zuni’s new role of decreased responsibility, causing a lack of self-esteem combined with increased leisure and limited recreational facilities (to be discussed below), often results in alcohol manifesting itself as the center of his existence. It provides an escape from his inferior social position and is misused as a form of recreation. D. The family role in relation to the alcoholic member. Many families within different ethnic groups to whom I have been exposed both as a medical student and in my personal life tend to ostracize an alcoholic family member. He is often looked down upon, divorced from many family functions, and becomes isolated, receiving little, if any, family support or care. However, among the Zuni families, the alcoholic is not usually rejected, although there may be variable persuasion tactics attempted to help the drinking problem. Because the Zuni community is closely intertwined, if a family under extreme circumstances should reject the alcoholic, that individual can usually find a new home reasonably quickly. Most Zuni families with alcoholic members will rarely seek professional help but, instead, usually accept and care for these individuals themselves. Thus, the alcoholic in Zuni usually has a home with relatives to care for him or her, is accepted in the family circle, and receives minimal encouragement to alleviate his drinking problem. Therefore, many of the negative traits of the alcoholic in Zuni are reinforced within the family circle. E. Lack of recreation. There are very few established forms of recreation in Zuni. Therefore, with increasing available wealth in recent years (the jewelry business) and little to spend this money on for immediate entertainment, many Zunis resort to alcohol as a form of recreation.
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More than half of the alcoholics in F. “Beer drinkers are not really alcoholics.” Zuni are heavy beer drinkers. Many of these beer drinkers do not view beer as an alcoholic beverage on the same level as wine or hard liquor. Rather, they consider it to be a mild alcoholic beverage. Thus, many of the families of these indulgers and the drinkers themselves, even with prevailing medical, social, and psychological complications of alcoholism, will often deny the association of beer drinking and its ramifications. G. Lack of exposure to other life-styles. The Zunis are very homebound people who rarely leave the reservation. For instance, when on vacation from a specific job on the reservation, Zunis will usually spend the time at home producing their jewelry as opposed to traveling from the reservation. Therefore, many Zunis have little exposure to life in other parts of the country. Due to a lack of perspective on the part of the Zunis, I acquired the impression that many Zunis rationalized their drinking habits by the statement, “Everybody drinks, and if the Anglos can do it, then we should be allowed to drink as well.” Modifying Factors A. The police force. The police force comprised of Zunis, many of whom drank
themselves, was a negative influence in dealing with the problem of alcoholism. Their conception of the complexities of alcoholism was very poor, as illustrated by a statement from the Police Commissioner in a telephone conversation. “The alcoholics are sick people, and the only way to deal with them is to put them away in one of the Rehab Centers in order to do anything for them.” Besides the lack of understanding of the alcoholic, the police force did not handle the alcoholic in an appropriate manner. There were many mornings that I would see a 20- to 25year old drinker who was detained by the police at 2:00 or 3:00 AM for disorderly conduct or drunken driving and was, upon arrest, brutally assaulted by the police. Many times, these people would come to see me at the hospital with lacerations they sustained 5-6 hr earlier but were imprisoned through the night. By the time they were seen for treatment, their lacerations had become infected and could not be sutured. The husband of one of the nurses had a Polaroid camera and photographed a 20-year-old alcoholic being arrested by the police. The following morning he went to the jail with the developed picture to see this prisoner only to find him barefoot, lying in the mud with several lacerations and bruises, all sustained from police brutality. Many of these patients possess a deep hatred for the police. They stated to me that police brutality caused many to drink in greater excess in rebellion against the police force. By law, the Zuni reservation was not permitted to have liquor on the premises, although, in reality, this was not practiced. Considering the serious problem with alcohol-related auto accidents, one would expect the police would have a wellorganized, thorough, and consistent roadblock program to detect and prevent liquor from being smuggled into Zuni. However, their roadblocks were inconsistent, minimal, and thus inadequate. B. The bars selling to those under 18 years old. There are two bars off the
160
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reservation but within a 25min radius from Zuni where many Zunis purchase alcohol, one in Arizona and one in New Mexico. Both of these bars have, at times, been accused of selling alcoholic beverages to Zunis under the legal drinking age, thus perpetuating alcohol abuse among young Zunis. C. Lack oj’a coordinated program and poor use oj’resource people in Zuni. In making my sociological inquiry into the problem of alcohol abuse in Zuni, the lack of a coordinated program to deal successfully with this problem quickly became obvious. Although the Alcoholism Program, PHS, Social Service, and the religious groups were attempting to deal with the problem as best they could, the magnitude of alcoholism in Zuni made separate institutions ineffectual in solving the basic problems. Many of the practicing alcoholics and former users do not seek or accept help from the present alcoholism program because: (a) Zunis do not like to be “visible” within their community. Since the alcoholism program is located within the confines of Zuni, they will not patronize this for fear of detection. (b) Many Zunis reject fellow members who lend aid with personal problems because they feel that their personal life will later be openly displayed. (c) Zunis do not like to disclose their “secrets” because of the interwoven society structure. Once again, they fear notoriety throughout the village. These factors have prevented any success in beginning an Alcoholics Anonymous (AA) program in Zuni. Finally, there are several potential resource people working for the tribe who have nebulous job descriptions. The CHRs (Community Health Representatives), who have become glorified chauffeurs, have not been utilized with respect to their many talents. Several resource people in the learning center also could be utilized more effectively considering the severity of alcoholism in Zuni. III. TREATMENT
OF THE PROBLEM
The treatment and rehabilitation of the alcoholic patient frequently declines as soon as he or she leaves the hospital or physician’s office. Regardless of how helpful and genuinely therapeutic a regime may be, the patient’s practical view maintains that the professional time devoted to his improvement represents only a small fraction of his total life. At the moment the patient returns to his community, he finds himself face-to-face with the very real issues of where he will go, what he will do, and what he can expect from his environment. If he is forced to find his way alone, and especially if he must return to the exact situation which conquered him before, the likelihood is that he will be unable to withstand much stress before again resorting to alcohol. Perhaps part of the physician’s past reluctance to treat alcohol-dependent patients has been a direct result of his uncertainty about etiology and his frustrations associated with treatment. The failure to identify specific causes and the associated frustrations may have led him to feel there was little rationale behind many recommended therapeutic procedures. If this is true to a large extent, it is unfortunate. In spite of the mixture of fact, theory, fantasy, and misinformation surrounding the subject, enough is known about the pathogenesis and sociological consequences of alcoholism to be of genuine use to the physician and to all related resource people and to ultimately benefit the patient.
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It is worthwhile to reemphasize that in the case of many alcoholics, by the time they are first seen by a physician, many of the stabilizing sociological factors in their lives will have been damaged or destroyed. Also, it is important to remember that the persons affected directly and indirectly by the patient’s illness are likely to need help. Thus, true remedial treatment requires the combined efforts of many persons in the total rehabilitation of the patient and his family. This can be accomplished only as a comprehensive team endeavor in which all community resources are mobilized and utilized to their fullest potential. Realizing the severity of the alcoholism problem in Zuni, several members of the community, including Dan Ukestine and the rest of the counselors at the Alcoholism Program, Marcella Wolf, a social worker at Zuni, and I, thought of possible ways of increasing the care for the vast number of alcoholics and their suffering families. Since the PHS is moving in January 1976 into the newly constructed hospital and is relinquishing the present hospital building to the tribe, we thought one mode of improving the total care of the alcoholic was to convert the present hospital into a comprehensive Alcoholic Center. We realized this would be an extensive undertaking involving hard work, utmost dedication, and, at times, frustrations. Realizing the complex problem of alcoholism, if we could initiate a program in Zuni in which many cooperative disciplines pool their resources, then at least, this would be a concrete beginning. With this proposal, we went to Governor Laselute who offered his full support and, through the Tribal Council, agreed to donate the hospital building for our proposed Alcoholic Center. Our next step, presently being developed, is the writing of an extensive proposal for submission to various foundations for financial assistance. Below, in outline form, is the basic philosophy and organization of the proposed Alcoholic Center, one which will combine many resource people in dealing with the complexities of the problem of alcoholism. The Guiding Philosophy of the Treatment Program (i) Alcoholism is a respectable, treatable illness. (ii) Through medical, psychological, social, and spiritual assistance, the alcoholic can be helped to stop drinking and resume a “normal” life without substituting other injurious practices. (iii) The alcoholic patient can be reeducated to improve his ability to communicate and to adapt in a changing environment. (iv) The alcoholic patient must be encouraged to rebuild and maintain the dignity and self-respect forfeited by the long-continued use of alcohol. (v) The alcoholic patient must be encouraged to express, understand, and deal with his emotions. (vi) Part of the rehabilitation of the alcoholic lies in helping the family, through education on alcoholism and by offering assistance with their needs. Organization of the Health Center A. Staff. The staffing of the center will be composed of both full- and part-time members as follows. The staff will have primary responsibility for the care of both in- and outpatients. Each staff member will have his or her own patients. There will be daily rounds on
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Full-time I. Dan Ukestine (Alcoholism Program Director) 2. Two-four members of present Alcoholism Program 3. Social worker 4. Medicine man
Part-time 1. PHS M.D. 2. Nurse (RN, LPN, and/ or nurse’s aid) 3. Father Melton (Volunteer) (headmaster of local parochial school) 4. Zuni volunteer 5. Community Health Representative
all inpatients so every staff member will know each patient individually. There will be biweekly case review meetings in which patients will be discussed among all staff members. In this way, each member with his or her own background and qualifications will be able to offer constructive criticism, help, and alternatives. Each member will engage in individual therapy with his patients. He will concentrate simultaneous efforts on developing a therapeutic relationship through a sympathetic attitude, demonstrating interest, and acceptance without communicating condonation. There will be an attempt to provide the patient with a sense of protection while at the same time encouraging gradual and progressive independence. Once the relationship has acquired a firm foundation and the patient feels secure in it, he can be guided carefully toward the recognition and acceptance of his problems and then to greater personal responsibilities in dealing with them. Group therapy with alcoholics often proves a much more effective treatment modality than individual therapy. Perhaps one reason for this is that problems in interpersonal relationships plaguing the alcohol-dependent person frequently can be recognized and dealt with more readily in a group situation. The group allows for a nonthreatening environment where the individual gains support as he finds out that others have similar experiences and problems. However, as I stated in the section on causes and modifying factors of alcoholism in Zuni, the Zunis do not open up in group situations readily. Therefore, group therapy in the new Health Center must be done initially on an experimental basis, often in conjunction with other activities (to be described later). Follow-up care, once the patient leaves the Health Center, is a vitally important function of the staff members. The alcoholic patient needs continued support during his readjustment period back into the community, for, without it, he will often revert quickly to his old habits. Follow-up care will aid the patients in meeting the problems that arise from daily living as well as provide a means of developing suitable methods of coping with them. Thus, this is a unique feature of the proposed Health Center in comparison to the present Alcoholic Center now being utilized. At the present centers in Wyoming and New Mexico (Albuquerque), there is no provision for follow-up care. Thus, once the alcoholic is discharged, he has little positive reinforcement in readjusting to his life. B. PHS associalion. Another unique feature of the Health Center will be its close association with the new PHS hospital, both on geographical location and as
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a unified team approach to treating the alcoholic. One of the PHS doctors will be a part-time staff member having the responsibility described in Section A. The physician’s participation in the Health Center in dealing with the many ramifications of alcoholism can be as extensive as he elects. He is able to serve directly in such important matters as providing consultation, assisting in program planning, and, of course, treating patients. Knowledge of the multifaceted problems associated with the illness will certainly place him in a unique position from which he can be a guiding force in increasing the Center’s effectiveness and helping it become a part of community-wide programs. The negative attitudes toward the alcoholic usually permeate all levels of our social organization. However, the physician can do a great deal to foster a better understanding, both among fellow professionals and the general public, of the nature of the illness and the problems of the patient. There will be basically three types of admission to the health center, as follows: (i) When a patient is seen at the new PHS hospital with alcohol-related symptoms serious enough to require hospitalization, the staff members of the Health Center will immediately be notified on admission. They will then closely follow the patient’s stay in the hospital. Once the patient is able, he will be admitted to the Health Center. Thus, the patient is admitted to the Health Center under the guidance of those who are familiar with his case. The process of admission to the Health Center from the PHS hospital will be an organized and effective method of helping the alcoholic deal with the many complexities of his problem. (ii) When a patient is seen at the new PHS hospital with alcohol-related symptoms not serious enough to require hospitalization, the staff members will immediately be notified as well. Together, they will discuss with the patient the possibility of admission to the Health Center for rehabilitation. If the patient voluntarily admits himself to the Health Center, he will continue to be followed medically by the PHS doctors. Thus, the close association of the PHS staff and the staff members of the Health Center will foster better overall care for the alcoholic. (iii) An alcoholic who is not medically ill may voluntarily admit himself to the Health Center for rehabilitation. On admission, the PHS staff will be notified immediately in order to facilitate close medical follow-up on this patient. Again, a close association between the PHS staff and that of the Health Center will make the treatment of the alcoholic effective. This third type of admission will probably not prevail initially. First, it is necessary that people are made fully aware of its benefits. C. The cultural aspect of the Health Center. As I stated earlier, under Causes, many alcoholics believe that, while they are inebriated, they are “possessed.” Therefore, any alcohol-related illness will be attributed to the “witches,” and they will approach the medicine man before seeking the help of a medical doctor. Thus, another unique feature of the Health Center will be the presence of a fulltime medicine man on the staff. Not only will he be able to care for those “possessed” alcoholics, but he will offer a different perspective in caring for the complexities of the alcoholic in general. D. Vocational and occupational therapy. Part of the rehabilitation of the alcoholic is providing him with constructive, worthwhile projects to occupy his time. These will include the standard arts and crafts and also vocational training. By
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offering an opportunity for accomplishment through vocational therapy, the patient gains the feelings of self-respect and self-reliance. Many alcoholics in the past refused to go to the available rehabilitation centers because, during the time spent there, they would not be able to support their families. Therefore, with this in mind, part of the vocational therapy would be the availability of making jewelry, dolls, pottery, etc. This would serve several important functions, as follows: (i) Those alcoholics who are admitted to the Health Center can continue with their financial responsibilities as part of their rehabilitation. (ii) The making of jewelry and other crafts can be done in an environment in which those taking part are working next to each other. Thus, there will be a friendly, warm atmosphere which will serve as a subtle form of group therapy. (iii) While the patients are actively involved in vocational therapy, members of their family can assist them. Therefore, as the alcoholic is in the process of recovering, he will have the continued support of his family. E. Family service. One cannot hope to rehabilitate the alcoholic and then send him back to his old environment without interplay with his family. The needs of each alcoholic’s family may differ. Some families will need to be educated about alcoholism; others will need intensive psychological support in recovering from the social consequences of alcoholism. One of the prime responsibilities of the full-time social worker will be to organize an efficient and productive Family Service Department with active participation from other staff members. F. Education. An extensive educational program organized by the staff members utilizing all available resource people will be instituted. The program will be aimed at the following: (i) professional and in-service training education; (ii) community and specific public education; (iii) formal and informal school education; (iv) information and referral. The process of educating the different institutions will involve continuous lectures by the professional staff, former alcoholics, and all other available personnel. There will also be small group discussions with the utilization of audiovisual instrumentation. This will create a climate of acceptance conducive to the development of a network of therapeutic, rehabilitative education, and preventive services in dealing with the complexities of alcoholism. G. Facilities for research. Remarkable progress has occurred in identifying the metabolic course of alcohol through the body. However, much knowledge is still lacking on the complex biochemical and physiological interactions between alcohol and our bodies. Even fewer studies have been performed on the psychological and social treatment methods for alcoholics. Despite these limitations, the evaluation of community alcoholism centers reveals that when a serious effort is made to meet the needs of alcoholics and when these efforts are available and accessible to them, then many patients will respond and improve. Alcoholism has caused significant morbidity and mortality in Zuni. Facilities should also be set up for research into the biomedical consequences of alcohol. This should be organized in conjunction with other institutions such as IHS, NIH, and NIAAA. The Negative Influence of the Police In order to reverse the attitudes of the police concerning the alcoholic, they
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need to be educated about the many complexities of alcoholism. They must be taught that alcoholism is a serious illness and that brutality is not a method of treatment. Only after the police possess a deeper understanding of alcoholism will they attempt to change their almost inhumane dealings with the alcoholics in Zuni. Thus, the professional staff and all available resource people must teach the police, through lecture and discussion groups with the aid of movies, what alcoholism is, in the “broadest sense.” Also, a better organized and effective roadblock system must be instituted in Zuni in order to reduce the number of fatal auto accidents due to alcohol. There should be a coordinated program with the police from Gallup and Ranag so the responsibility for safer highways is shared effectively. A Community Tax As was illustrated earlier, the standard of living in Zuni has increased substantially during the past 10 years. As the wealth in Zuni has increased, so has the problem of drinking increased proportionately. Diseases seldom have a single cause; epidemics often do. Whether the jewelry business, with its increased wealth and conclusive life-style, is the leading cause of the increased drinking problem in Zuni is a matter of debate. However, it is a significant contributing factor to the overall alcoholism problem. Since approximately 90% of Zunis make jewelry, some of them making $1,000 to $2,000 a week, tax free, there is a huge amount of money available. It has been proposed by several Zunis that a community tax be instituted. Since Zunis pay only Federal tax and none of their profit from their jewelry business is taxed, this would not present any hardships. It could be a progressive tax so that the people would pay taxes according to their earnings. The collected tax would benefit the tribe for use in constructing recreational facilities in Zuni. All money would be allocated in a public fashion for the good of Zuni. Therefore, by taxing the people, several functions would be accomplished: (i) There would be funds available for recreational facilities desperately needed in Zuni. (ii) The Zunis would be taught to be more responsible in spending their money. (iii) The Zunis would be provided with better community spirit, as the taxed money would be directly returned to the village for beneficial and constructive purposes. Better Use of Resource People As stated earlier, there are several potential resource personnel working for the tribe who have nebulous job descriptions. These people, including the CHRs and members of the learning center, could be utilized more effectively in the community and in the new Health Center to deal better with the complexities of alcoholism. They could be involved in showing films in school and in the Health Center on alcoholism. They should be further educated about alcoholism and motivated to use their talents in a constructive and meaningful manner. More Effective Uses of the Media The Zunis have a poor exposure to other life-styles in the United States. Many are also not fully aware of the severity of alcoholism in Zuni, in terms of morbidity
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and mortality. Therefore, better use of the media can serve several basic functions: (i) An educational device to teach the people about the complexities of alcoholism. (ii) Make the Zunis more aware of the problem of alcoholism in the United States and specifically in Zuni. (iii) Expose the two local bars for illegally selling alcoholic beverages to minors. Alcoholics are treatable patients. Their illness is a chronic disorder with a tendency toward relapse. Therefore, alcoholism should be approached in much the same manner as other chronic relapsing medical conditions. The aim of treatment should be viewed more as one of control than of cure. Although abstinence is a primary objective of any program, additional considerations may be better guides to evaluating the success of a treatment program. Among these considerations are improved social and occupational adjustments. Therefore, a positive aspect of a treatment program should be to assist the alcoholic in learning to deal more effectively with his life problems, without alcohol as a crutch. In the process, the patient will learn to adapt to his environment in a reasonable, mature manner. One existing cause of the use of alcohol in Zuni, which is basic to its culture, is the lost financial responsibility of the male. With the present structure of the Zuni society, it is difficult to know how to handle this problem best. Perhaps my successors in Zuni will find the solution. As I pursued my study in Zuni, I was overcome by several emotions: a feeling of sympathy in seeing many suffering people because of alcoholism; a feeling of bewilderment because so little was being done for the leading cause of death; and, finally, a desire to initiate an effective means c,f making Zuni a healthier place in which to live. I only hope that those who iollow me in Zuni will realize that although a unified approach to the alcoholic will invariably run into countless barriers, hard work, dedication, and an awareness of the Zuni culture will eventually help them overcome their obstacles, REFERENCES I. “First Special Report to the U.S. Congress on Alcohol and Health,” Preface, p. vi. National Institute on Alcohol Abuse and Alcoholism, DHEW Pub]. No. (HSM) 72-9099,U.S. Government Printing Ofice, Washington, D.C., December 1971. 2. Levy, G. E., and Kunitz, S. J. Indian drinking: Navajo practices and Anglo-American theories, in “Proceedings of the First Annual Alcoholism Conference of the National Institute of Alcohol Abuse and Alcoholism,” p. 68. John Wiley, New York, 1974. 3. Vondervagen, mimeo report, 1974.