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A . 5 5 ””"fipi ‘ 5'L1'IJX' Aq. g .5~.,.. pp. .~ v.51 ... r . . - . mum-- ..w r-rmc-rr- wififi.’.¥§.g&1¥=~= H. 5......L 1-51. 5. 5.5-5 "mm-AI 3.343.: ;..-5 1-5-1-r ' '.’.IJ‘-‘\‘§{‘—' S 1293 This is to certify that the thesis entitled NATIVE AMERICAN WOMEN'S PERSPECTIVES ON ALCOHOL ABUSE AND FETAL ALCOHOL SYNDROME: A COMPARISON ON— AND OFF- RESERVATION IN MICHIGAN presented by GAIL BURKE has been accepted towards fulfillment of the requirements for LILLdegee in Whig Major professor Date W1 0—7639 MS U ix an Affirmative Action/Equal Opportunity Inrtitution PLACE IN RETURN BOX to remove this checkout from your record. TO AVOID FINES return on or before date due. DATE DUE DATE DUE DATE DUE MSU Is An Affirmative Action/Equal Opportunity Institution c:\cIrc\dateduerpm3-p.1 NATIVE AMERICAN WOMEN’S PERSPECTIVES ON ALCOHOL ABUSE AND FETAL ALCOHOL SYNDROME: A COMPARISON ON — AND OFF- RESERVATION IN MICHIGAN By Gail Burke A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF ARTS Department of Anthropology 1992 ABSTRACT NATIVE AMERICAN WOMEN’S PERSPECTIVES ON ALCOHOL ABUSE AND FETAL ALCOHOL SYNDROME: A COMPARISON ON— AND OFF—RESERVATION IN MICHIGAN By Gail Burke Native American women appear to be at high risk for having children afflicted with Fetal Alcohol Syndrome. Fetal Alcohol Syndrome is a constellation of physiological and neurological abnormalities caused by alcohol use during pregnancy. This research seeks the perspective of Native American women of child-bearing age on alcohol abuse among women and Fetal Alcohol Syndrome. The first objective is to determine their level of knowledge about the effects of alcohol during pregnancy and whether this knowledge differs among on- and off-reservation women. The second objective is to establish two points from the emic perspective; first, the reasons that women abuse alcohol during pregnancy and second, women's perceptions about the meaning of Fetal Alcohol Syndrome to their culture. This research represents initial work on Fetal Alcohol Syndrome among Native Americans in Michigan. The method of investigation included interviewing women of child-bearing age both on— and off-reservation. The two on-reservation groups include the Bay Mills Tribal community in Brimley and the Saginaw Chippewa reservation in Mt. Pleasant. Both are Ojibway tribal communities. The off—reservation research was conducted in an urban setting, in the city of Detroit. A total of 24 women were interviewed. According to the research findings, there is a high level of awareness of the effects of alcohol during pregnancy among both on-and off— reservation women. On-reservation women are more knowledgeable about Fetal Alcohol Syndrome. In their explanations for women's alcohol abuse, the predominant theme which emerged was that of abusive drinking as a culturally patterned behavior. They also cited stressful conditions in their lives, including poverty, lack of educational opportunity, and discrimination. Another important finding of this research is the insider's perspective that Native American spiritual teachings and practises can be of great value to women who are addicted to alcohol. Copyright by GAIL BURKE 1 9 9 2 Dedicated to the Anishnabe women who heal and teach the ways ACKNOWLEDGEMENTS I would like to acknowledge the members of my Guidance committee for their counsel on all phases of this research study. Special thanks to Dr. Loudell Snow, who chaired my committee, for her invaluable guidance in working with minority women on a sensitive health topic; to Dr. Charles Cleland, for sharing his extensive knowledge about Indians of the Great Lakes, to Dr. Robert McKinley for posing questions about the meaning of Fetal Alcohol Syndrome. I would also like to thank Dr. Joseph Chartkoff, chairman of the Department of Anthropology, for his encouragement and interest in this research. I am grateful to the Saginaw Chippewa Tribe and the Bay Mills Indian community and their Tribal Councils for entrusting me with the mission to learn more about Fetal Alcohol Syndrome. It is my sincere hope that the recommendations which were developed as a result of this research will benefit their ongoing prevention work. I extend my appreciation to health directors Audrey Falcon of the Saginaw Chippewa Tribe, Laurel Keenan of the Bay Mills Indian Community, and Lucy Harrison of the Detroit American Indian Health Center. I am grateful to the members of their staff who welcomed me into the health clinics. I would also like to thank Chet Eagleman of the Michigan Department of Public Health and Char Hewitt, Health Director of the Inter Tribal Council. vi 7“!" During the course of this research I learned a great deal from many Indian people whom I met in health conferences, women’s spiritual gatherings, and classes. I would especially like to thank my friend, Wilma Henry, for her support and interest in this research, as well as Margaret Toulouse and Lillian McGregor who enabled me to experience some of the traditional ways. I have been deeply touched by their vision, wisdom, and courage. My deepest gratitude is extended to the women who participated in this research. I am indebted to them for their generosity and honesty, and for helping me to better understand the meaning of Fetal Alcohol Syndrome. Their insights form the essence of this work. To these women I say Migwetch. Finally I would like to express my appreciation to my family, my parents and brother, Adam, as well as my friends for their ongoing support. A special thank you to my son, Patrick, who inspired me with his dedication to writing, and to Michael, who has accompanied me on this path and whose heart is also in this work. vii TABLE OF CONTENTS I. INTRODUCTION 1 II. HISTORY OF ALCOHOL USE AMONG INDIANS 7 OF THE GREAT LAKES III. THEORETICAL EXPLANATIONS FOR INDIAN ALCOHOL USE 1 5 IV. NATIVE AMERICAN HEALTH 2 6 V. FETAL ALCOHOL SYNDROME 3 8 VI. FIELD WORK 5 1 VII. RESEARCH FINDINGS 5 9 VIII. CONCLUSIONS 7 4 APPENDIX A: CONSENT FORM 8 7 APPENDIX B: QUESTIONNAIRE 8 8 APPENDD( C: RESEARCH RESULTS 9 2 REFERENCES 128 Viii CHAPTER I INTRODUCTION Today alcohol is taking its greatest toll among the youngest members of the Indian nations; an increasing number of Native American babies are born with serious birth defects caused by their mother’s drinking during pregnancy. Fetal Alcohol Syndrome, a constellation of physiological and neurological abnormalities, leaves an individual permanently damaged, greatly diminished in capacities, and dependent upon family and tribal community. Native American women appear to be at high risk for having children afflicted with Fetal Alcohol Syndrome. Many tribal leaders express concern about the viability of the Indian people given the increasing number of children born with birth defects. They discuss Fetal Alcohol Syndrome within the context of their survival. Fetal Alcohol Syndrome is of profound significance to both individuals and the entire Native American culture and, as such, is an important topic for anthropological inquiry. An analysis of Fetal Alcohol Syndrome among Native Americans must take into account the large body of theoretical work on Native American alcohol abuse. The diverse theoretical literature can be broadly categorized into sociocultural and biological perspectives. According to the sociocultural perspective, the specific pattern of Indian alcohol use reflects other aspects of Native American culture, 1 2 such as attitudes, norms and meanings. One important position which reflects this perspective explains Native American alcohol abuse as a response to the devastating losses and cultural disruption they experienced with the coming of the Europeans to the Americas. According to this viewpoint alcohol abuse continues to this day as a means of coping with the stress and anxiety of poverty, transition in their own culture, lack of economic and educational opportunity and discrimination. Another position holds that the particular character of drinking in Native American culture is an expression of Indianness and is related to cultural identity. According to this position, drinking has some positive aspects for Indian people, such as promoting group solidarity. In contrast to these theoretical positions, the biological perspective holds that the Indian is constitutionally prone to alcohol intolerance. This research has focused on differences between Native Americans and Caucasians in alcohol—metabolizing enzymes. A serious omission from the theoretical literature is the emic or insider's perspective. Little work has been done with Indian people to elicit their explanations for the alcohol abuse which causes them so much suffering. The literature does not address what alcohol abuse means to the Indian people, nor how they perceive its impact on their culture. Another significant omission from the theoretical literature is that it does not adequately address the alcohol abuse of Indian women. It indicates that the alcohol consumption of young Native American women has increased, and that Indian women pay a high price for their 3 alcohol consumption in terms of morbidity and early death, and having their children taken from them. However, it does little to describe or analyze drinking by Native American women within a cultural context. There has been no research to learn how they would explain the abusive drinking of women during pregnancy, nor what the agonizing phenomenon of Fetal Alcohol Syndrome means to them as Indian women. This knowledge is essential to further our understanding of the abusive drinking which has become more prominent among women in Indian culture. From the anthropological perspective, a number of questions are raised which analyze this phenomenon within a broader framework of cultural values, belief systems, and meanings: Has Native American women’s experience with alcohol changed over the centuries since its introduction? How has woman’s role been transformed in Native American culture and has this transformation contributed to problem drinking? How does this dysfunctional behavior pattern articulate with broader Native American cultural values and behaviors? How do the traditional Native American spiritual beliefs and teachings relate to the phenomenon of women and alcohol use? And, most importantly, what would drive a young woman to such desperate behavior that she risks her well-being and that of her child, especially if she is aware of the teratogenic effects of alcohol? This research seeks the perspective of Native American women of childbearing age, a group characterized as high-risk for bearing children afflicted with Fetal Alcohol Syndrome. The first objective is to determine their level of knowledge about the effects of alcohol 4 during pregnancy and whether this knowledge differs among on- and off-reservation women. The second objective is to establish two points from the emic pespective; first, the reasons that women abuse alcohol during pregnancy and second, women's perceptions about the meaning of Fetal Alcohol Syndrome to their culture. Specifically, does Fetal Alcohol Syndrome represent a problem for the woman and her child, or for the entire Indian culture? One hypothesis of this research is that there are differences in the level of knowledge about Fetal Alcohol Syndrome among on- and off- reservation women. Women on-reservation have more access to health care and are likely to receive more Fetal Alcohol Syndrome prevention messages in their tribal communities. Therefore, they are likely to be more knowledgeable about the effects of alcohol use during pregnancy. A second hypothesis is that reservation women would tend to see the problem of Fetal Alcohol Syndrome in terms of its impact on the entire culture rather than just the woman and her child. They live in a closed community and are more likely to be aware of the alcohol-damaged child in their midst. The urban women, on the other hand, live in a dispersed setting and are not as likely to interact with other Indian people on a regular basis. This research represents initial work on Fetal Alcohol Syndrome among Native Americans in Michigan. The method of investigation included interviewing women of child-bearing age both on— and off-reservation in Michigan. The two on-reservation groups include the Bay Mills Tribal community in Brimley and the Saginaw Chippewa reservation in Mt. 5 Pleasant. Both are Ojibway tribal communities. The Bay Mills Tribal community is a traditional Indian community; there is a high Indian population in the region. The Saginaw Chippewa reservation is a less traditional community and Native Americans represent a small part of the larger population. The off—reservation research was conducted in an urban setting, in the city of Detroit. These Native American women represent many different Indian groups from around the country. All of the interviews took place at Native American health clinics; the women were either coming in for a prenatal exam, or physical exam for themselves or their children. With social science research in general many tribal councils are reluctant to offer their members as research 'subjects". In undertaking this research there was uncertainty whether tribal communities would authorize it, and whether individual women would be willing to discuss this sensitive topic. There was awareness that the women with the most to say are the hardest to reach. More than likely they would not be coming to clinic for a prenatal exam; they would be at home, away from the scrutiny of the medical community and silent to a researcher interested in their insights on alcohol abuse. But the research was pursued because of the potential value of insights gathered in the course of talking with women. These insights could contribute to the ongoing prevention efforts of tribal communities in Michigan. In fact, Indian women did participate; they talked openly about the alcohol problems Native American women experience; some talked about their 6 own problems with alcohol. They said they participated in order to help other Indian women with similar problems. The following chapters present background information which contributes to an understanding of Fetal Alcohol Syndrome among Native Americans. The analysis begins with the historical background of alcohol use among Native Americans of the Great Lakes. This is followed by an overview of the various theoretical perspectives which have been put forth to explain Indian problems with alcohol. The next section addresses the health status of Native American women; poor health is a principle risk factor for bearing an alcohol-impaired child. This is followed by a section which presents current information about Fetal Alcohol Syndrome and findings for some tribal groups in the United States. The central part of this report are the research findings which represent the valuable perspectives of the 24 Native American women who participated in this research. CHAPTER II HISTORY OF ALCOHOL USE AMONG INDIANS OF THE GREAT LAKES Native Americans' historical experience with alcohol is an important factor in the analysis of contemporary alcohol problems. This section will consider the introduction of alcohol to the Indians of the Great Lakes and the pattern of alcohol use which developed. Alcohol use by Native American women within the historical context will also be considered. According to the cross—cultural and historical literature, alcohol has been an integral part of most cultures of the world for at least the last 5000 years (Lucia, 1963). The experience of most Indian people of North America is unique. With few exceptions, alcohol was not a part of their cultures before contact with European explorers. Why this was the case is not known. There were natural grains and cultivated plants for fermentation. The native people sought out altered states of consciousness, to better contact the spirit world. They achieved these states through such means as fasting and meditation. Driver points out that narcotics and stimulants were common in the New World before 1492, but were much more prevalent in the southern continent than the northern. The pre-contact people of what is now 8 meso— and South America produced a variety of home-brewed alcoholic beverages. In Mexico the Indians had 40 distinct alcoholic beverages (Driver, 1969). The principle narcotics and stimulants used in aboriginal North America were tobacco, peyote and Jimsonweed in the southwest. Probably all were used as medicines. The absence of alcohol north of Mexico in the pre-contact period has significance in Native Americans' subsequent experience with alcohol. Alcohol was not part of the Native American culture; it had no assigned meaning shared by the people, no role in ritual and social life. The native inhabitants of North America had no physiological or metabolic experience with ethanol. Most people of the world produce and consume their own fermented beverages, usually of a lower alcohol content than the rums and brandies introduced to the Indians by the Europeans. Another factor of historical significance is that the Indian people had to look outside their own culture for models of drinking behaviors. There are many historical accounts of Europeans' introduction of alcohol to the people of the Great Lakes area early after contact (MacAndrew and Edgerton,l969; Heath, 1983). The Europeans who came to this continent were competing among themselves for territory and resources; toward this end they sought to forge military alliances with various Indian groups. They offered alcohol initially as a gift, to win and maintain the loyalty of the native people. Once the European traders and trappers discovered that the Indians seemed unable to resist alcohol, that it interfered with their judgment and decision-making 9 during trade, alcohol became an integral part of every trade operation (Heath, 1983). Most scholars of American Indians and alcohol refer to a history of exloitation in trade and treaty. MacAndrew and Edgerton suggest that the villain in this history is the trader who realized that, if he created a desire for alcohol, it would be insatiable. They record that "every conceivable form of deceit and coercion was employed in forcing liquor upon the Indians." (1969: 113). They report that some Indians were unwilling to use it at first, but the white traders persisted in offering it to them. Important information about early Native American alcohol use can be gained from the fur traders' journals. Waddell has analyzed the journal of 19th century Northwest Company fur trader, Francois Malhiot, who traded among the Chippewa (Ojibway) of the Lac du Flambeau region of Wisconsin. From Malhiot's journal we learn that distribution of alcohol and heavy drinking bouts were episodic, not an ongoing feature of the Indians' everyday life during this period. Malhiot talks about the vital role the natives played in providing food for him and his men, specifically wild rice, corn, meat, grease and sugar. Though there is mention of Indian drinking bouts, the Chippewa spent most of their time at work fishing, hunting and trapping, not drinking. Distribution of rum coincided with the peak time of food plenty. Little rum was distributed from November through January when bands were dispersed and food difficult to obtain. The Chippewa were busy trapping during this period. . % miglfl’ t‘.",lit:gnu£. "u, “Um!” MI flat-2%: ' ’ 10 According to Malhiot's ledgers, he distributed l4 kegs of West Indies double-strength rum to the Chippewa during the period July 25. 1804 to May, 1805. He talks about the strength of the alcohol, specifically that it was 88%—90% or more pure alcohol. Traders, including Malhiot, typically mixed it with water so that the average mix was 30% alcohol; this is still quite potent, especially for a people who had no previous experience with lower alcohol-content beverages. Malhiot‘s journal recounts problems among the intoxicated Indians. “We had a great deal of trouble last night owing to the liquor. They quarreled among themselves; we quarreled with them and almost came to blows...They made many apologies in the morning, saying that such a thing never happened to them, that they were too drunk-the usual excuses of such black dogs!” (Waddell,1985: 254). Malhiot clearly disdained the behavior of the Indians while intoxicated. Waddell hypothesizes that Malhiot offered them the alcohol, as a businessman, for the following reasons: to obtain provisions for winter; to quiet restless Indians and to keep the peace; to persuade the Chippewa to drink at their lodges; to encourage natives to trap; and to acknowledge the authority of band leaders by leaving to them the responsibility for distributing rum and regulating behavior at their lodges. (Waddellz261). The journal also mentions the abusive drinking of the other European men at the trading post. He writes that his own vogaeurs got very drunk on 29 September and that, “through fear, this intimidated the natives to stop drinking.”(Waddell: 259). Waddell and others have mentioned ..~:s :::-..«-:r. all.“ a.“ {“5“ :«M 11 that Indian culture lacked role models for drinking behavior and say the Indians patterned this behavior on the trappers, traders, and soldiers, who themselves were given to excess while intoxicated. Malhiot's journal also recounts the behavior on the part of the Indians in these liquor transactions, noting that they played an active role in securing it for themselves, coming to the trading post and demanding rum, begging for it or waiting restlessly. Thus, though they were unquestionably taken advantage of by the traders in many of these transactions, they were not passive; they exercised their own independent action in securing liquor for themselves. Other historical accounts by the fur traders describe the behaviors which took place during the drinking bouts. John Long was a fur trader with the Northwest Fur Company, going out to Mackinac in the spring of 1777 and then to the Lake Superior district. His journal, kept over a period of two years, contains many passages about giving rum to the Indians with whom he traded. In these passages he describes the staggering level of violence which occurred during the drinking bouts; these bouts typically lasted for days. “The women, who are on all occasions slaves to their husbands, were ordered to make up bark huts which they completed in about an hour, and everything was got in order for merriment. The rum being taken from my house was carried to their wigwam and they began to drink. The frolic lasted four days and nights, and notwithstanding all our precaution (securing their guns, knives, and tomahawks) two boys were killed and six men wounded by three Indian women. One of the chiefs was also murdered, which reduced me to the necessity of giving several articles to bury with him, to complete the usual ceremony of their l2 interment. These frolics are very prejudicial to all parties, and put the trader to a considerable expense, which nevertheless he cannot with safety refuse. On the fifth day they were all sober, and expressed great sorrow for their conduct, lamenting bitterly the loss of their friends.”(Long: 74). Another passage reveals his treatment of one of the elder Indian women. “When the feast was over I took two of the Indians to my house and gave them two kegs of rum and ten carrots of tobacco with other articles, for which they gave me all their peltry. Then they began to frolic, which continued three days and nights. The only accident which happened was to a little child, whose back was broken by the mother. When they had rested a day after intoxication I supplied them with plenty of ammunition for their winter's hunt and they departed perfectly satisfied with their reception. I cannot help relating the method I was obliged to adopt to quiet an old Indian woman who was more troublesome than the rest, and continually importuned me for liquor. I infused forty drops of the tincture of cantharides and the same quantity of laudanum into a glass of rum, and when she came to me soliciting very earnestly for the strong water, I gave her the dose which was prepared for her. She drank it without hesitation, and being already much intoxicated, it made her stagger. But this did not satisfy her and she still asked for more. I then repeated the dose, which she also drank and then fell on the floor. I ordered my Canadian to carry her out of the house and lay her carefully near her own wigwam, where she remained twelve hours in a deep sleep, to my entire satisfaction. I have always found laudanum extremely useful. In general it may be considered an essential article in the commerce with Indians, as it proves the only method of overcoming their intoxicated senses, and making the life of a trader more tolerable by putting a stop to their impertinence.” (Long: 142). The historical literature documents an appalling level of violence which characterized these sporadic drinking bouts. The colonial newspapers wrote about the acts of hostility toward white settlers by intoxicated Indians and the so—called "firewater myths" began, portraying Indians as totally unable to resist alcohol and completely. 13 out of control when intoxicated. Primarily because of reaction of the dominant society against Indian excess while intoxicated, Indian drinking became prohibited by federal legislation in 1832. There is record of concern on the part of some Indian leaders as well. By 1802, Chief Little Turtle of the Miami was so fearful of the deleterious effects of alcohol on his people that he asked President Thomas Jefferson to enact prohibition. Federal prohibition was not repealed until 1953 at which time tribal councils were empowered to decide to retain local option prohibition on reservations. More than two—thirds have done so. (Fuller, 1975). A salient question for this research regards the historical experience of Native American women with alcohol. As some of the above passages reveal, the early historical accounts of Indian drinking bouts refer to the intoxication of Indian women. There is some documentation that their violent behavior parallels that of the men. From his study of Malhiot's journal and Chippewa culture overall, Waddell concludes that among the Chippewa who traded with Malhiot, women or children may have been drinking but it is unlikely (highly so in the case of children) because drinking likely involved status associations among adult men. He argues that an estimate for personal alcohol consumption based on adult males alone is closest to the facts of Chippewa drinking. By and large the literature on Native American alcohol abuse focuses on males, making it impossible to know with certainty how the use of alcohol by Native American women changed over the centuries. The historical records document abusive drinking by some women early on. 14 The early pattern of abusive drinking by some women may have shifted to sobriety, and drinking may have become almost exclusively a male activity. Native American women may have taken up a more moderate level of drinking. Perhaps it is not the case that more Native American women are drinking in the contemporary period, but rather that they are drinking more excessively. One ninety—two year old female elder from the Garden River Reserve in Canada said the women on her reserve drank some alcohol when she was a young woman, but it was a minimal amount; the drinking never reached the extreme, self-destructive level practised by many young women today. The role of women has changed in Native American culture; their contemporary use of alcohol may well reflect these changes. CHAPTER IH THEORETICAL EXPLANATIONS FOR INDIAN ALCOHOL USE The theoretical explanations for Native American alcohol abuse are many and diverse. In a recent critique, Mail (1984) counted more than 450 studies in support of 60 different theoretical explanations for abusive drinking among Indians. The theoretical explanations for Native American alcohol abuse, which can be broadly categorized into sociocultural and biological explanatory models, will be considered in this section. A significant shortcoming of the theoretical literature is that it does not address the emic or insiders' perspective on Native American alcohol abuse. Little work has been done with Native Americans to learn how they explain the alcohol abuse which has become such an integral and damaging part of their culture. In addition, though the literature refers to an increase in abusive drinking by women, there is minimal analysis of this phenomenon within the cultural context. These are important topics for anthropological inquiry which formed a primary focus of this research. The specific focus of this research was to elicit the perspective of Native American women on the reasons many women abuse alcohol, as well as the meaning of Fetal Alcohol Syndrome to their culture. 15 16 An important point should be made early in the theoretical discussion. We should be cautious to avoid theoretical generalizations about "Indian drinking" as though it has uniform cultural expression or meaning among all Indian tribal groups. There is tremendous variation in every aspect of Indian drinking, from intertribal drinking rates and patterns, to attitudes and values about drinking, to the meaning of alcohol. It can be reasonably stated, however, that heavy drinking, characterized by episodic binge drinking, is widespread among some North American tribal groups. The most relevant question for anthropological inquiry is whether Indian alcohol abuse is rooted in social structure and is similar to that of any disadvantaged class, or if there are culturally-based differences and explanations for Native American alcohol abuse. It is important to consider whether certain cultural beliefs and attitudes may be a factor in this pattern of alcohol abuse. This research was especially interested in the phenomenon of cultural changes which may have an impact on the drinking patterns of Native American women. Sociocultural Perspectives Some of the theoretical literature analyzes the early use of alcohol by Native Americans and its ultimate integration into Indian culture. The previous section presented the historical perspective on the introduction of alcohol to Native Americans and established that alcohol became an integral commodity in trade and diplomacy. The 17 historical record documents that deceit and manipulation were common on the part of many traders and government agents in their dealings with Native Americans. A key point remains, however, that the Indians were not powerless; though they had lost much of their freedom, they were still autonomous in their decision—making relating to personal alcohol consumption. One could ask what function alcohol served for them during this period. Some theorists look within the culture and explain the initial appeal and use of alcohol historically as an extension of the quest for the mind-altering state which characterized much of the traditional Native American spiritual experience. Carpenter describes the initial use of alcohol by the Iroquois as an integral part of the dream quest and vision quest (Carpenter, 1959). Alcohol enabled the Indian to get out of himself and better communicate with the spirit world. According to this view, once the mind-altering properties of alcohol were discovered, alcohol was used to bring about this altered state more rapidly than fasting or meditation. An important point is made in some of the theoretical literature; namely, that at some time the function of alcohol shifted. First a means of attaining a valued spiritual state, alcohol in time became a way of coping with stress and expressing anger due to the invasion of the Europeans. No one can say with certainty whether this is the correct transformation. For some individuals alcohol may still be used as a substitute for the Vision Quest. But the idea of change is a valid one. The American Indian people today are different from those who 18 first received the white man's brandy. Just as most other aspects of Native American culture have changed, so has the role of alcohol. Much of the sociocultural explanation for contemporary Indian alcohol abuse explains it as a response to cultural disruption and loss. What these theorists are saying is that alcohol abuse results directly from what the Indian people have experienced, both in historical and contemporary times. This work reflects the theoretical perspective of Horton's cross-cultural study of alcohol in the 1940's; he hypothesized that the primary function of alcohol in most societies is the reduction of anxiety (Heath, 1983:380). This theory has become very influential today. According to this view alcohol is a release mechanism, which serves to reduce the anxiety and liberate the aggression of the Indian people who were decimated and depressed, as individuals and as a people. This particular explanation for Indian alcohol abuse makes a great deal of sense in that it accounts for both the historical and contemporary problems with alcohol. Inherent in this analysis is the notion of continuity in the stress the Indian people experienced, from centuries ago when their lands were taken and their lifestyle changed to today's conditions of limited educational and employment opportunity, and prejudice from members of the dominant society. Individual theorists highlight different factors in explaining conflicts which may lead to substance abuse. Miller (1986) blames upheaval of Indian culture, coupled with paternalistic attitudes of the United 19 States government, for creating a continuous situation of extreme stress for Indians which may be a contributing factor to substance abuse. Dozier (1964) explains alcohol abuse in terms of a general condition of great deprivation among Indians. He says this condition may be attributed to wars, cultural invasion, military subordination, loss of land and placement in reservations. He also hypothesizes that transformation in cultural roles might have been a primary factor in Native American alcohol abuse. He suggests that the most severely affected in terms of cultural changes were the warring and hunting tribes and that the required transition from the role of male hunter to agriculturalist was degrading. He concludes that perhaps the greatest blow was federal wardship; in the early days this meant a direct dependence on the government for food and clothing through the ration system. A large body of theoretical work discusses Indian alcohol abuse in terms of stress, acculturation and role confusion. According to this View, Native Americans have managed to maintain their own culture, ’9 but they must also interact with the “dominant society. Some theorists discuss the dynamic of a “dominant-subordinate” relationship (Heath) which may create a condition of conflict and stress for Native American people, in terms of discordant values and attitudes. In the analysis of Native American problems with alcohol, Jilek refers to "anomic depression which develops in reaction to alienation from aboriginal culture under westernizing influences; it 20 derives from relative deprivation, the negative discrepancy between a minority groups' legitimate expectations and its actual situation in a larger society; cultural confusion, the weakening of norms in members of a cultural group. unable to integrate the contrasting values of their own with those of a different culture." (Jilek,l981:l6l). Within the overall sociocultural literature there is another explanatory model for Indian drinking. This view differs from those just described in that its focus is the positive aspects of drinking in Indian culture. A number of theorists have written about ways in which drinking fits well with other aspects of Indian culture and reinforces social solidarity (Heath, 1983; Lurie, 1964). One of the proponents of this latter theoretical view calls Indian drinking the world's "longest ongoing protest demonstration" and an expression of Indianness (Lurie,1964). Lurie challenges the supposition that Indian drinking is caused by loss of cultural identity and low self- esteem, prejudice and exploitation, and that Indian people drink to escape into an idealized past. She refers to stereotyping and images about other minority groups, such as violence among Blacks during the civil rights riots of the 1960's. She says these images are internalized by the people who gain strength from them. While such stereotypes work against minority people among members of the dominant society, she argues they are a powerful weapon to the in-group. Lurie hypothesizes that Indian people understand the value of the negative 21 stereotype as a form of communication and protest demonstration to register opposition. According to another theoretical explanation for alcohol use, the function of drinking among Indians is that it serves as a “time out”ceremony. This theory holds that Indians are not held liable for crimes or acts of violence committed during intoxication. According to this perspective, many Native American people believe that during the altered states of the dream or of intoxication, an individual hears from the spirits about things he should do. Any action committed in this state may be excused because the individual is in another world. MacAndrew and Edgerton (1963) draw on the historical records which document countless incidents of brutality committed during intoxication, and no negative sanction by the community afterward. Contemporary accounts suggest that in some instances drunken Indians are not held responsible for their actions while intoxicated. There is community tolerance and lack of negative social sanction. In his study of the Standing Rock Sioux, Whittaker found few negative social sanctions against alcohol abuse. He also notes a "striking absence of guilt about excessive drinking and drunkenness." (Whittaker, 1979:145). The theoretical literature contains minimal description or analysis of alcohol abuse by Native American women. An exception is Weibel- Orlando's 1988 study of drinking patterns among several tribal groups which found male—to—female differences clearly defined. Across all tribal groups studied, (save for the Sioux) women drink substantially 22 less than their male cohorts. Weibel—Orlando attributes this pattern of alcohol abuse among Sioux women to socioeconomic factors. She mentions specifically there is little opportunity for gainful employment, their children are either in school or being cared for by grandparents, various kinds of financial assistanCe is available with which to buy alcohol, and the young Sioux women have ample time for partying whenever funds became available. The drinking party has become their principle form of recreation. Though she describes these lifestyle factors specifically in terms of Sioux women, in fact they would apply to Native American women of many other tribal groups. They would certainly be similar to the experience of Native American women on- and off-reservation in Michigan. Biological Perspectives The second principle category of theoretical explanation for Indian alcohol abuse is the biological. There is a great deal of literature which holds that Indian are genetically vulnerable to problems with alcohol. The idea of Indian alcohol problems as being biologically determined is the basis of much medical research; it is also the basis of the so-called “firewater myths”which began soon after liquor was introduced to the Indians. Leland (I976) tells us that these myths regard Indians as being constitutionally prone to develop inordinate cravings for liquor and to lose control over their behavior while drinking. She also refers to a "reverse—firewater hypothesis" which holds that true alcohol addiction, 23 or alcoholism, is rare among Indians. Though heavy drinking is universally reported, she says there are few reported cases of true alcoholism or addictive drinking. Her own work refutes the basis that Indians are constitutionally prone to develop inordinate cravings for liquor; she neither confirms nor denies that alcohol addiction occurs less frequently. A significant conclusion of her research is that alcoholism and alcohol addiction are poorly defined concepts. It is difficult to conceive of alcoholism as a disease valid cross-culturally because behaviors are an important part of the diagnostic criteria and they may, and in fact do, vary cross culturally. For example, solitary drinking is one of the hallmark behaviors of the alcoholic in this society, but in Indian society heavy drinking rarely occurs in private. Drinking is a group affair, among a network of friends or family members. Leland's work is important in calling attention to the pervasive mythology about Indian alcohol use which is grounded within the biological context. The genetic research conducted in the last two decades suggests that Indians, along with other people of Mongoloid origin, have a genetic intolerance for alcohol. The genetic basis for alcohol problems is postulated to be a deficiency in one or two liver enzymes involved in alcohol metabolism, alcohol dehydrogenase and acetaldehyde dehydrogenase. These enzymes are involved in the breakdown of alcohol in the body. 24 Much of the experimental research has involved giving research subjects ethanol and then looking for certain physiological indicators of alcohol intolerance. such as facial flushing and increased heart rate. Wolff‘s (1973) study of American Indians, Japanese, Koreans and Taiwanese found the incidence and intensity of flushing to oral alcohol was significantly higher among them in comparison to Caucasian groups. The hallmark research which supports a genetic basis for Indian alcohol problems is that of Fenna (1973), frequently cited by those who support a bio-genetic basis for Indian alcohol problems. Fenna's study of 65 Indians found they required significant amounts of alcohol to achieve intoxicating blood levels, but that they metabolize alcohol slower than whites. Other studies have found results which contradict . Fenna’s. Reed's 1978 study of Caucasian, Chinese and Ojibway found the Ojibway had significantly higher rates of ethanol metabolism. Reed argues that the variation among races in alcohol metabolism is no different from such variation within racial groups. Bennion's 1985 study of 30 American Indians from one tribe and 30 whites found no significant difference in alcohol metabolism. Clearly the findings on this topic are by no means conclusive. Many researchers (Dozier,1988; Lurie, 1986) vehemently refute a biological explanation for Indian sensitivity to alcohol. Fisher (1987283) says that the "drunken Indian" stereotype is a quintessential example of racist thinking. The United States Indian Health Service agrees; in its 1977 Task Force on Alcoholism, it concurred there is no 25 valid evidence that Indians differ in any way from others in physiological or constitutional response to alcohol. With regard to the biological perspective, the research findings are far from conclusive. Unfortunately the biological explanation has been accepted as the ultimate explanation by many Indian people. Believing it is one's genetic destiny to have alcohol problems can lead to resignation; it certainly makes the work of prevention much more of a challenge. CHAPTERIV NATIVE AMERICAN HEALTH Studies on alcohol consumption during pregnancy suggest that alcohol appears to be a necessary, but not sufficient, condition for Fetal Alcohol Syndrome (Sokol, 1986). Not all women who drink heavily during pregnancy will bear an alcohol-damaged child. There seem to be other risk factors in addition to alcohol consumption which play a role in the etiology of Fetal Alcohol Syndrome. Investigators have identified high mean maternal age, low socioeconomic class, and poor health status as additional risk factors. The overall health of a pregnant woman is one of the primary determinants of birth outcome in general (Cephalo and Moos, 1988), and especially so if the woman is a heavy alcohol user. In this analysis of Fetal Alcohol Syndrome among Indian people, the general health status of Native American women of child—bearing age must be considered a critical variable. It therefore makes sense to consider some of the specific health problems which Native American women are likely to experience, and to consider these health issues within the cultural context. It is important to analyze changes which have occurred in Native American culture that have an impact upon women's health. It is also necessary to ask what specific obstacles to 26 27 optimal health are experienced by Native American women on— and off— reservation in Michigan. The Indian Health Service has reported dramatic health improvements among Indians since 1955. The infant and maternal mortality rate, and deaths related to infectious diseases have all decreased. There has been an 81% decrease in the infant death rate; a 91% decrease in the maternal mortality rate; an 80% decrease in pneumonia and influenza, and a 96% decrease in tuberculosis. (Jackson,l986). Chronic disease has replaced infectious disease as the predominant health concern for Native Americans; in general, lifestyle factors, including diet, lack of exercise, use of alcohol and cigarettes, contribute to more than half of all deaths from chronic disease. (Centers for Disease Control,1980). One of the primary factors linked to health problems of Native Americans today is the change in diet. Before the coming of Europeans to the Americas, the indigenous people sustained themselves through farming, hunting, fishing and gathering. Good nutrition of the indigenous people in the pre~contact period has been suggested as one of the factors which promoted their health. After losing their land and being forced to live on reservations, they had to give up traditional sources of subsistence. The type of government rations typically offered to the Native people were a radical departure from their traditional diet; ration items included bacon, lard, flour, navy beans, baking powder. The high amount of starch and calories in the diet contributed to obesity 28 and other health problems. This change in diet continues to exert a major adverse effect on health status. Ritenbaugh would characterize this major change in the Native 99 American diet in terms of “foodways. Foodways are behaviors that affect what people eat, such as food preparation and rules for distribution (Ritenbaugh, 1978). Change in foodways is one of the most significant changes made by a people who are acculturating. In the Great Lakes region the indigenous people had provided their food through corn farming, fishing, and the hunting of game animals including moose, deer, beaver, muskrat and rabbit. Meat and fish were smoked and dried. Berries such as blueberries and strawberries were gathered and dried and were a major source of Vitamins A and C. Wild rice was an important part of the diet and the culture for some Great Lakes Indians. The quest for food was an important part of the people's livelihood and linked to all other aspects of the culture. There was a high level of physical activity required for people who had to secure their own food from the water and land. This high level of daily physical activity contrasts with the sedentary lifestyle on reservations today. Sedentary lifestyle is considered a significant health risk factor for Native Americans. On the Grassy Narrows, Ontario Ojibway reserve, excess calorie intake from alcohol and from fats has led to a number of diseases that were 29 either absent or very rare among Indian people in the past, including gall bladder disease. They are also now more prone to certain cancers, particularly of the colon and lower gut (Shkilnyk.l985). Messer (1989) indicates that many Native American women purchase food for their families with very limited means, with Women, Infants, and Children (WIC) coupons and food stamps. Low income persons by necessity must select foods of lowest costs, longest shelf life, most ability to stretch other foods. She refers to other studies (Calloway and Gibbs,l976) of women's food choices on reservations which have concluded that inadequate nutrition levels were a result, not of lack of nutrition knowledge, but of lack of money. These nutrition studies indicate that in the United States the greatest incidence of obesity is found among minority women of low socioeconomic status. Obesity is a serious health problem which puts an individual at risk for a number of chronic diseases. Among studies of Eskimo, Cree, Ojibway, Seminole and Pima, the high incidence of obesity has developed over the past 40-50 years accompanied by an increased incidence of obesity—related disease, including hypertension and diabetes. Diabetes is a very serious health problem for Native Americans. As recently as 1955 the Indian Health Service data showed there were no significant differences between Indians and whites in the rate at which diabetes was assigned as a cause of death. By 1967 diabetes-related deaths in Indians were 2.3 times as high as whites. (U of M, The 30 Chippewa Health Study: Final Report, 1978). The Chippewa Health Study also revealed a high prevalence of diabetes for this tribe. For females, 27 and 36 percent of those 45—64 and 65—80 years old, respectively, reported having been told by a physician that they had diabetes. Diabetes is often accompanied by vascular disease. Researchers working among Indians of the Southwestern United States have documented that acute myocardial infarction was observed significantly more often during 1975-78 (75/100,000 among Indians over age 30 years) than in 1957-66 (35/100,000). Of special relevance in this health analysis of Native American women is the fact that the rise of acute myocardial infarction was greater for women than for men; in fact the rate more than tripled between 1957 and 1975 (Sievers and Fisher,l979). Contributing factors may be increasing rates of obesity, diabetes, and hypertension and rapidly changing lifestyle on- and off—reservation. With regard to the health status of Indian people in Michigan, the percentage of deaths from accidents, chronic liver disease and cirrhosis, suicide and diabetes were higher among Native Americans in Michigan (1984-86) than for all Michiganders in 1985. The first three causes of death may be directly or indirectly related to alcohol abuse, which the Michigan Indian Health Report of the Director's Indian Health Task Force of 1985 concluded is one of the most critical health problems among American Indians. 31 Research has been done to assess health risk factors among some tribal groups in Michigan, including the population of the Saginaw Chippewa reservation (Sobeck, 1990). The research found that almost half of the tribal members smoked cigarettes and over one-quarter were considered heavy drinkers. Almost two—thirds of tribal members reported that they experienced stress in their lives; half reported that they experience stressful episodes frequently. Younger tribal members reported more stress in their lives and less time to relax to reduce stress. The report recommended that stress reduction may be an important component of a community program. It also found male tribal members were more satisfied with their weight and physical fitness than female tribal members. Changes in the traditional culture and way of life have placed Native American women at greater risk for a number of chronic diseases. With the change in her diet and high level of fat intake, she is prone to obesity and related diseases such as diabetes. The Native American woman's activity patterns have also changed; the contemporary lifestyle for most women both on- and off-reservation is sedentary with minimal physical activity or exercise. In earlier times the Native American woman was an active producer of food and goods for the household, working the trap lines or planting and harvesting. With reservation life, she is now a passive consumer. Most Native American women on the reservation have very little to do. There is high unemployment among Native American people in general and this is certainly the case for women. Most of the women interviewed in this research were not employed outside the home. A few, however, were 32 involved in important work in their tribal communities, such as counseling other women with alcohol problems. Several women (both on- and off—reservation) said that women drink because there is little else to do during the day but watch soap operas and have a few beers. Alcohol consumption is a primary health risk factor for many Native American women. Alcohol consumption exacerbates the problem of poor nutrition, adding extra calories and little nutritional value. Heavy alcohol use can lead to malnutrition, which is an especially serious problem if a woman is pregnant. Native American women are particularly at risk to the damaging effects of alcohol. According to the federal Office of Substance Abuse Prevention (1985), the rate of cirrhosis among Native American women is 37 times the rate for white women. Research has found that in general women are more damaged by alcohol than men in terms of complications of cirrhosis (Camberwell Council on Alcoholism, 1980). Women exhibit more physical illness in association with alcoholism. Cirrhosis develops in women after a shorter period of alcoholism and lower daily consumption of alcohol. According to the Camberwell Council on Alcoholism, in comparison with men, women less than 45 years age have more severe liver damage. Over 55 years there is not as great a difference. Women of childbearing years are therefore more vulnerable to the toxic effects of alcohol. This finding is especially relevant in this analysis of Native American women. With the Native American population the heaviest 33 drinking takes place during the childbearing years; therefore, many women in this age group are likely to have some degree of liver damage. Chronic alcohol consumption can result in numerous health problems and damage to bodily organs. Abel's analyses of the case studies of 122 women who had given birth to a child with Fetal Alcohol Syndrome documented that they experienced a number of serious health problems (1990). Liver disorders, including cirrhosis and fatty liver, were most common. These women also suffered from kidney disorders, iron deficiency anemia, and gastrointestinal disorders. Another critical factor in this health analysis is a woman's access to the health care system. Barriers to health care may be geographic, economic, or cultural. According to the Report of the Director's Indian Health Task Force (1985) access to health care is a problem for Native Americans in Michigan. One of the reasons cited is that many resource providers mistakenly assume that Indians are solely the responsibility of the Indian Health Service, whereas the Indian Health Service's Kincheloe Health Center and Indian Health Service-supported tribal health centers provide health services to only one-sixth of the Michigan Indian population. The Detroit Indian Health Center is also Indian Health Service funded, with limited resources unable to accomodate the needs of Michigan's urban Indian population. The report cites the following access problems: an insufficient number of trained Indian health professionals; discrimination or cultural insensitivity by non-Indian providers; inadequate Indian outreach; and lack of knowledge and sensitivity toward Indians by State and local health department staff. 34 On both the Saginaw Chippewa reservation and Bay Mills Tribal Community women have access to primary health care for themselves and their children at the tribal health clinics. Both of these clinics offer a wide array of coordinated services and employ a significant percentage of Indian staff persons. However, a very signficant point is that prenatal care is not provided at either of these clinics. The women are able to come in for a pregnancy test; if it is positive, they are referred to one of the obstetrical practises in the city. The staff at both clinics recognize this as a problem. Failure to receive early, ongoing prenatal care is considered to be a primary risk factor for poor birth outcomes in general, including low birth weight. With early and regular prenatal examinations, potential problems can be detected. In the prenatal setting a woman can receive education about the effect of her drinking on the fetus; she can be encouraged to abstain or modify her alcohol and tobacco intake. One of the main findings of Abel's (1990) study of mothers of Fetal Alcohol Syndrome children is that a significant percentage of them do not attend prenatal clinics. The staff of both clinics are hopeful that in time they will be able to provide this service to women at the reservation clinic, and offer prenatal care in a more wholistic, culturally sensitive manner. The nurse practitioner at the Bay Mills Clinic (a Native American woman) 35 hopes to begin a women's circle for pregnant women which will highlight some of the traditional Chippewa teachings about women. The director of the Saginaw Chippewa clinic has been negotiating with the obstetrians in the city who provide prenatal care to the reservation residents. Many of the Saginaw Chippewa women who are their obstetrical patients have private health insurance coverage, which is provided through employment at the casino on the reservation. The majority of the women who participated in this research are Medicaid recipients. One of the Women said that when she was pregnant last time no private obstetricans in her Upper Peninsula community would take her as a patient because she is a Medicaid recipient. She had to hitchhike twenty miles to Sault Ste. Marie to get prenatal care, and because of this inconvenience missed several of her appointments. Another woman who participated in the research said her insurance did not cover prenatal care visits, so she did not receive any health care until she went to the emergency room for delivery of her child; at that point she was advised that she had toxemia and might die. The Detroit Indian Health Center is the only one of the three clinics which provides prenatal care. One of the nurses explained that much of their work involves ongoing counseling of their prenatal clients about alcohol use throughout the pregnancy. She said she realizes that a number of the pregnant women continue to use alcohol, but they keep talking with them and encouraging them to come in for prenatal care and to quit or at least cut down on their drinking. There is a great deal of education and outreach on substance abuse prevention provided by 36 the Center. Substance abuse counselors have their offices on the ground floor of the building. For a few of the interviews conducted for this research, women went first to the substance abuse counselor, then to the obstetrician, then to the interview. The geographic barrier to health care is a much greater problem for Indian people in a dispersed urban setting. To address this problem, the Detroit American Indian Health Center has a van which provides transportation for those women who can't get there on their own. Another barrier to health care is lack of sensitivity by non-Indian health care providers. One of the nurse practitioners mentioned that some Native American women feel uncomfortable with non-Indian doctors, especially in the context of prenatal health care. One of the Native American women who participated in this research described how difficult it had been for her to see a male, non-Indian doctor in Detroit for acute headaches she was experiencing. At the start of the physical exam, the doctor asked her to remove her clothes. She said she was from a very traditional Indian community (Baraga) and had been raised with the notion of a woman's modesty. It caused her a great deal of anguish to comply with the doctor's request. She said she cried a lot in his office and finally complied. After the exam and tests, she learned she was pregnant. She was fortunate in that her doctor went to the library and got several books on Native American culture. He told her she was the first Native American patient he'd had. w «a at Bath mini-i" . . .. - 'x. .‘3' 37 Overall health status was not the primary focus of this research. But a number of women volunteered information about their health status during the course of the interviews, referring to kidney problems, ulcers, migraine headaches, previous problem pregnancies, numerous miscarriages, diabetes and overweight. They also talked about mental health problems, specifically depression and anxiety. These health problems can compromise a woman's overall health status which, in combination with poor nutrition, low level of physical activity and heavy alcohol consumption, put her at greater risk of bearing an alcohol-impaired child. CHAPTERV FETAL ALCOHOL SYNDROME Native American anthropologist Michael Dorris brought Fetal Alcohol Syndrome to’the attention of the general public in 1989 with his book, The Broken Cord. In the book he chronicles life with his Lakota Sioux son whom he adopted in 1971. Soon after adoption, the child began to experience seizures and fevers and ongoing learning disorders. Fetal Alcohol Syndrome had not been identified as a specific pattern of malformation and disability at that time. When a pediatrician first asked Dorris about Adam's biological mother, he wondered, “How could her behavior years ago be related to this attack(Dorris, 1989)?”. Later he says, “It was not until the following summer. when Adam was five years old, that I began to have an inkling that my real adversary was the lingering ghost of Adam's biological mother, already dead in 1973 of acute alcohol poisoning (Dorris, I989 )..” She had ingested denatured alcohol, antifreeze. On September 25, 1991, the Saginaw Chippewa tribal community held its eighth annual Alcohol Awareness Day on the reservation. One brochure being distributed bore the headline: Drinking is not Indian. There were several workshops held during the day; including one on suicide and one on Fetal Alcohol Syndrome. The workshops were to be followed by a tribute and feast in honor of Arnold and Margaret Sawmick, the tribal chief and his wife who were killed in an auto 38 39 accident that summer. To encourage people to attend the workshops, there was no charge for the meal for anyone who attended two sessions. The presentor of the Fetal Alcohol Syndrome workshop was Bruce Hinman, tribal substance abuse coordinator. He used the Dorris book as his reference. Behind him on an easel was a drawing of a pregnant Indian woman in traditional dress, with a glass of alcohol raised high, teepee in the background. The headline read, “Every third child born to us is poisoned by alchol and the blood of our race dwindles to extinction. Fetal Alcohol Syndrome. Stop it before one more child is lost.” The audience was comprised of a number of elders, a few women who are substance abuse professionals, and a few women of child- bearing age. Bruce explained later that the workshop had been well-publicized. In his presentation, he talked about the diagnostic features of Fetal Alcohol Syndrome. A few people asked questions: Does alcohol produce a genetic change in the next generation? Will better nutrition help reduce the alcohol damage? In speaking about recommendations he said, “As a tribe, we know the solutions formed in Lansing and Washington don't solve our problem. When this community finds a solution, we'll achieve that which we desire.” In talking about the damage inflicted upon the fetus, he asked, “When do the rights of one stop and the rights of the other begin? Neglect is a crime. In Florida they punished a woman who used cocaine during pregnancy but that won't happen at the tribal level. These are lifelong disabilities we need to look at. We could have a whole generation of people brain-damaged. It's scary as hell.” Afterwards he explained that in this particular tribal community a 40 woman's drinking problem is often looked at as less serious than a man's. “People don't think alcohol hurts their kids in this community, or think they'll get addicted. It's an accepted social practise. It's a real 99 dangen After the workshops ended many people came for the feast. One of the youth workers brought and cooked fresh Whitefish from Lake Superior which was served with corn soup, fry bread and sweet potatoes. One of the local women said she recently moved back to the reserve from Canada, with her four daughters. She said she used to be a heavy drinker; now she does beadwork instead. At this gathering a minister said he plans to start a discussion group on Fetal Alcohol Syndrome. He too is using the book, The Broken Cord. In the book there are several black-and-white photos of newborns with full—blown Fetal Alcohol Syndrome. He said he recently showed these pictures to friends back on his home reservation in Minnesota. In looking at these babies with the characteristic facial dysmorphology of Fetal Alcohol Syndrome, they replied: “Aren't they cute? They sure look Indian!” This remark deeply disturbed him; it indicated to him that the damage of alcohol is so pervasive among Indian people that they just take it for granted. Within the last twenty years, the medical community has officially recognized a constellation of birth defects caused by a woman‘s drinking alcohol during pregnancy. Fetal Alcohol Syndrome is now the leading known cause of mental retardation in the United States, 41 surpassing Down's syndrome and spina bifida. (Streissguth,l99l). Of the three, it is the only birth defect that is preventable. Many writers on the topic of Fetal Alcohol Syndrome suggest that the deleterious effects of alcohol on a developing fetus were recognized by the ancients, and cite Biblical admonitions such as the following: From the Book of Judges (13:7): “Behold now, thou art barren but thou shalt conceive and bear a son. Now therefore,l pray thee, drink not wine nor strong drink.” Other researchers (Abel, 1990) suggest that these quotes were taken out of their original context, and that awareness of the prenatal effects of alcohol did not occur until the gin epidemic of London in the 1700's. Gin was cheap and readily available and women of child-bearing age were drinking alcohol to the same degree as males; the number of miscarriages, stillbirths, and birth defects soared. By mid-19th century the influence of drinking on pregnancy outcome began to receive critical attention. Probably the landmark investigation of the effects of alcohol during pregnancy was conducted in an 1899 study by Dr. William Sullivan. Sullivan conducted his observations on the offspring of 120 alcoholic women who were in Liverpool prison. He studied their 600 children and found the stillbirth and mortality rate was 212 times higher than the general population (Streissguth and Martin, 1983). . ." .5 , Ikz.“ 5'- ._:-__. 531.9-.__n-_'.. ..__-. . “haik- flqmadlmm '4“ W m we! in!"- - 'z - - 'imlm‘tl‘" $11! l- 13in: :i.:.:’3 34' 42 Some relatively modern references, however, disregard the role of alcohol during pregnancy. A classic work on alcoholism in the 1950's (Jellinek and Haggard) said there is no basis to support the harmful effects of alcohol use during pregnancy. This basic reference work was accepted as a standard and informed the judgment of countless obstetricians who suggested to their patients that the moderate use of beer or wine is recommended for general relaxation. By the late 1950's a French medical thesis was published on the subject of prenatal influences of alcohol. In 1968 Lemoire conducted a study which found that 25% of the children of alcoholics had the unusual facial features associated with Fetal Alcohol Syndrome in addition to low birth weight. In 1973 the constellation of symptoms was assigned the name Fetal Alcohol Syndrome by Drs. David Smith and Kevin Jones of the University of Washington in Seattle. A syndrome is a collection of symptoms that regularly co—exist; there is rarely a single diagnostic feature and no specific biochemical, chromosomal, or pathological test to determine its presence. There are many syndromes known in medicine, including Down's, Melnick-Needles, Noonan, and Cornelia de Lange. In most cases the syndrome is given the name of the investigator who "discovered" it. The name means little except to the medical community and to the individuals who suffer the syndrome. An exception was made in the case of the Fetal Alcohol Syndrome, because the investigators wanted to ensure that the name clearly reflects the nature of the disorder, so that knowledge would be 43 more widespread in the health community and among the general public (Abel, 1990). Alcohol is classified as a human teratogen (from the Greek "terrato", and "genen", "to make monsters"). A teratogen is a chemical agent that in certain doses can cause birth defects. When a pregnant woman drinks alcohol, it crosses the placenta and enters the fetal circulatory system. Newborn infants metabolize alcohol at half the adult rate, which means it takes twice as long for the newbom's blood to clear of alcohol. Newborns whose mothers have been drinking alcohol undergo withdrawal and experience abdominal distension, convulsions, and cyanosis. In all likelihood, the number of embryos with Fetal Alcohol Syndrome is much greater than the number of children with Fetal Alcohol Syndrome because of spontaneous abortion of abnormal embryos.The range of adverse effects depends most likely on dose, total amount of alcohol, pattern of drug use, and period of cell differentiation at exposure (Abel, 1990). The four principal features which must be present before a child is diagnosed as having Fetal Alcohol Syndrome include the following: prenatal and/or postnatal growth retardation, facial dysmorphology, central nervous system impairment, and history of maternal drinking (Abel, I990; Streissguth,l983). There are a cluster of major and minor anomalies associated with it. The main facial phenotype characteristic of Fetal Alcohol Syndrome includes short palpebral fissures (horizontal length of eye), long midface relative to normal nasal length, flat long philtrum, thin upper lip and flat midface. Organ pathologies include 44 cardiac anomalies (ventricular and septal defects), liver, urogenital,and genital anomalies. Skeletal defects of limb and joint are often reported. Immunological function is compromised; Fetal Alcohol Syndrome patients have fewer lymphocytes, which makes them more prone to infections such as bacterial meningitis, pneumonia, and recurrent otitis media. Fetal Alcohol Syndrome children have significantly higher susceptibility to serious illness during the first two years of life. Damage to the developing fetal brain is one of the main features of Fetal Alcohol Syndrome. The brain is one of the first organs to be developed and one of the last to be completed and is consequently at risk for a long period during gestation. Central nervous system involvement is one of the principle effects of maternal drinking; it results in mental retardation and seizures. Streissguth and colleagues at the University of Washington in Seattle recently completed the first systematic follow~up study of the long— term progression of the disorder into adulthood (Streissguth et a1, 1991). Their work helped to answer some of the questions surrounding Fetal Alcohol Syndrome, such as whether it is a permanent, lifelong disability. In Streissguth's study, individuals ranged in age from 12 to 40 years. The average IQ was 63, just into the mentally retarded range. The range of IQ scores varied widely, from 20 (severely retarded) to 105 (normal). In school placement only 6% were in regular classes without 45 help; 28% were in self-contained special education; 15% were not in school or work; and 9% were in sheltered workshops. Arithmetic deficits were the most characteristic academic disability. Failure to consider consequences of actions, lack of appropriate initiative, and unresponsiveness to subtle social cues were characteristic of those Fetal Alcohol Syndrome patients who technically were not retarded. 62% had a significant level of maladaptive behavior, including poor concentration, stubborness and sullenness. Individuals studied by Streissguth came from extremely unstable home environments. Many of their mothers were chronic alcoholics. One compelling finding of the Streissguth study was that, of those for whom accurate records could be obtained, 69% of the biological mothers were known to be dead. Many died of alcohol—related illness, others from alcohol—related causes such as suicide, homicide, falls and auto accidents. Nearly one-third of the patients had not been raised by their biological mothers and had been given up for adoption at birth or abandoned in the hospital. The conclusion of this major research study is that children who are diagnosed with Fetal Alcohol Syndrome will not get better with time. The "natural history" of Fetal Alcohol Syndrome can be traced to adulthood. There are lifelong adjustment problems and major psychosocial problems. Short stature and microcephaly appear to be the most prominent growth deficiencies. Developmental and cognitive J'I-‘iillbinI '. tit: 46 handicaps persist into adult life. None of the adults were independent in terms of housing and income. Streissguth says that few of these individuals were diagnosed with Fetal Alcohol Syndrome at birth and that, if they had been, it might have led to appropriate early intervention and possibly reduced some of the secondary psychopathology. Not all alcoholic women who become pregnant will bear children damaged by alcohol.This places more burden on the medical community to determine dose/response ratios and to learn more about possible protective factors. Sokol (1986) identified 204 pregnant women out of 12,000 as abusive drinkers. Only 2.5% of those 204 gave birth to children with Fetal Alcohol Syndrome. When all alcohol—related birth defects were considered, only 50% had adverse outcomes. Some factors in addition to chronic alcohol intake render some women more at risk. Later born children of alcoholics are at much greater risk of anomalies and Fetal Alcohol Syndrome. One study of 7 children born to an alcoholic woman in Germany who drank regularly from age 17 found that the first two children were normal, the third had psychomotor problems, the fourth and fifth had cardiac disorders, the fifth also was mentally retarded, the sixth died shortly after birth due to brain hemorrhage, and the seventh had full-blown Fetal Alcohol Syndrome (Streissguth, 1983). The overall health of a pregnant woman is an important variable in the outcome of any pregnancy,especially if she is consuming alcohol during . III-Jae? ,. m 13 ,..... -H- l. 4. J" I' "11' ’1 . "i I". 'l.‘ a” ": I :flfl 'i-‘fl'i" I A Mimi :'. l"- 47 the pregnancy. Alcohol consumption is associated with numerous adverse effects in bodily organs, especially the liver. Fetal Alcohol Syndrome is commonly associated with consumption of large amounts of alcohol over a long period. Women who give birth to Fetal Alcohol Syndrome children tend to have other alcohol—related illnesses, the most prevalent being cirrhosis of the liver. Another important factor in determining risk is the maternal drinking pattern. Jones' 1984 study of consumption levels found that chronic rather than binge drinking is more damaging. Infants born to chronic heavy drinkers had increased incidence of spontaneous abortion, decreased birth weight and Fetal Alcohol Syndrome. In this study high risk was determined to be 10 drinks per day. Most studies point to a much lower level of alcohol consumption in identifying women who are at risk, such as 2 drinks per day. Amount of alcohol and specific drinking pattern are still being investigated. It is difficult to diagnose many children who are damaged by alcohol at birth, because central nervous system damage might not appear until several years after birth. Estimates at birth are very conservative. The overall rate in the United States is 1.9 perlOOO live births. Most identified cases in the United States come from areas where the majority of mothers are Black or Indian and have low socioeconomic status. The overall rate among them is 2.6 per 1000 births (Streissguth et a1, 1991). . :'., ‘33..” , - I”, I . ”I'l'.’ - I! w ‘ 'nqtlfi'i". -_‘.._.- 'I m . . _ - .5“! i“ lg“ _ . -1_ . .. ‘Ilgi' I}... . . - ' II .. is" 'f‘m'ik‘f” I .' 339*“ a!" = 48 The incidence rate of Fetal Alcohol Syndrome among American Indian tribal groups varies significantly. The highest rates have been found among women of the Apache and Ute tribes in the southwest United States and Canadian Indians in British Columbia. Minimal prevalence rates in the southwest United States range from one in 97 to one in 750 live births. The highest reported prevalence is one child in eight in a Canadian Indian village. (Streissguth, 1991). Among other Indian tribes studied incidence was considerably lower (May et al 1983). Some researchers suggest that differences might be due to cultural drinking patterns. To consider the impact of drinking patterns on birth outcome, May conducted a study of Native Americans living on 26 reservations in the southwest United States (1988). The reservations studied were in New Mexico, Colorado, Utah, and Arizona. Subjects included Navajo, Pueblo and Plains culture tribes. Of the 243 children evaluated in this study, 31.3% had Fetal Alcohol Syndrome, and 16% had Fetal Alcohol Effect. The incidence of Fetal Alcohol Syndrome was highly variable from one cultural group to another, from a low of 1.3 per 1000 live births among the Pueblo Indians to a high of 10.3 per 1000 among Plains Indians. The rate of 1.3 per 1000 live births among the Pueblo Indians is comparable to that found in Seattle, Sweden and France. May points out that all of these tribal groups are in transition; all have low education and limited economic development. Plains tribes have consistently higher death rates from alcohol-related accidents and /. 49 suicide. According to his cultural analysis, female Indian adolescents usually experiment with alcohol; in their twenties. societal rules are enforced. Among Plains groups more variation in drinking behavior is allowed. Among the Navajo and Pueblo, a woman's drinking is much less tolerated. This research found that the rate of mothers who produced a Fetal Alcohol Syndrome child was 6.1 per 1000 women of childbearing age. These women led highly disruptive lives, often isolated from their families and tribal community. One unanticipated finding of this research was the frequent occurrence of two or more alcohol—damaged children born to one mother. With these women they found social maladjustment, high risk lifestyle, and high mean maternal age (29.7). In 23% of the cases the mother was dead from alcohol-related illness or trauma. While May and other researchers favor the cultural explanation for difference in rates, he suggests it could also be due to innate biological differences among groups, either a liability for prenatal alcohol damage or difference in metabolism of ethanol. There could possibly be an environmental co—factor, or a difference in ingredients in various alcoholic beverages. According to May's studies, there is no evidence for a genetic component in Fetal Alcohol Syndrome; type and severity of its manifestations are identical in Indian and non—Indian children. He concludes there has been an increase in Fetal Alcohol Syndrome over the past 15 years among Indian tribes of the Southwest United States. 50 Native American women appear to be at high risk for having children afflicted with Fetal Alcohol Syndrome. This could be due to a combination of the following factors. The general population is a young one and childbearing begins early and is extended into later years, resulting in a fertility rate which is over twice the national average. This, coupled with a very severe degree of alcohol abuse in some women, and a pattern of binge drinking, may be predisposing factors. The possibility remains that some metabolic difference in the handling of alcohol in truly alcoholic Indian women may put their babies in increased peril (Aase, 1981). CHAPTER VI FIELD WORK The state of Michigan has been home to the tribes collectively known as the Three Fires (Ojibway, Potawatami and Odawa) for centuries. At this time there are seven federally recognized Tribal groups within the state, as well as other non-recognized communities. Two of the Michigan Indian communities which participated in this research are federally recognized tribes, the Bay Mills Indian Community and the Saginaw Chippewa Tribe. The off-reservation research was conducted at the Detroit American Indian Health Center in the Detroit. The Bay Mills Indian community is located in Brimley, approximately 30 miles west of the city of Sault Ste. Marie in the Upper Peninsula. The reservation has a land area of 3.5 square miles; tribal land holdings run parallel along the shores of Lake Superior. There are approximately 750 enrolled tribal members living within the service area of the reservation and throughout Chippewa county. The median age of the tribal population is 20.2 years. Fishing is the primary economic activity for this community, and employs at least 65% of the work force. The unemployment rate varies from 32% to as much as 45% with the variable factor being the seasonal commercial fishing. Other tribal members are employed by tribal government or tribal enterprises such as the casino. 51 52 The Tribal Health Center provides a full range of services including primary health care and dental services. There is a full—time female physician at the health center, Dr. Sherman, a pediatrician. She is of Black and Native American heritage and recently moved to the Upper Peninsula from Detroit. She and her teenage daughter do not live on— reservation but in Kinchloe, about twenty miles away. There are about 934 registered patients in the Bay Mills Indian community. The clinic operates with funds provided by the Indian Health Service and the Michigan Department of Public Health. Disease prevention and health promotion are priorities for the Bay Mills Tribal Health Center. Community health programs at the reservation consist of mental health, social services, substance abuse and health education. The second reservation in this research project is the Saginaw Chippewa reservation in Mt. Pleasant. The Saginaw Chippewa Tribe is federally recognized and traces its roots to three bands of Chippewa (or Ojibway) that once inhabited most of the northeastern and southeastern portions of the lower pensinsula of Michigan. Their traditional name is the Anishnabe, which means the “original people”. The Tribal community has a population of about 407, with a reservation-wide population of 866. The Indian labor force population is about 270, with 230 presently employed, many of them in the casino on the reservation. The unemployment rate is 8.5%. Tribal membership totals about 2,089. 53 One of the forty—eight tribally operated programs is an outpatient health clinic, the Nimkee Memorial Health Clinic. It opened in 1979, and in 1990 a new facility was constructed. It has grown to 4900 patient visits in 1990. The clinic is financed through a contract between the Indian Health Service and the Tribe. Additional funds are provided by the State of Michigan Department of Public Health, Department of Mental Health, Office of Substance Abuse Services, the American Heart Association, and the Inter-Tribal Council of Michigan. The Saginaw Chippewa Indian Tribe also provides funding for numerous projects, including the new tribal health facility. The medical clinic is comprised of a Family Nurse Practitioner, contractual physician coverage (a group of nine internists and pediatricians from the Davis clinic in Mt. Pleasant who come to the clinic twice a week), two licensed practical nurses, a contractual licensed pharmacist and laboratory service. The Tribe is currently advertising to hire a physician to work full-time at the Health Center. The director said she expects it will take a year to find someone. One of their goals is to be able to provide prenatal care on the reservation. The stated philosophy of the clinic is to provide "primary health care on the Isabella Reservation, highly individualized to meet the personal and cultural needs of each client or situation, and provided by qualified personnel in a caring, quality, and cost conscious manner." Clinic priorities include physical fitness, health promotion and disease prevention. Major focus areas include diabetes patient care, HIV 't II. .‘_ r', .. .. .. in! mane m timid u-‘iu _ all mam loam-- ..- n Mun-14' '. - :.- ;-i-_. :tE'T new «I 54 counseling and testing, Healthy Heart Project, maternal and child health programs, and the special needs of tribal youth and the elderly. Research with women off—reservation took place at the Detroit American Indian Health Center on Livernois Avenue in Detroit. Detroit has the highest Indian census in the state. Clients are members of the three Indian tribes of Michigan. In addition, there are clients who have come to Detroit from other regions of the country, and represent Indian tribes from throughout the United States. The Center has been in existence since 1986. It is supported by the Indian Health Service and also Michigan Department of Public Health funds. In 1990 the Center provided 15,000 units of service, or patient visits. The Center provides a full range of primary health care services, including prenatal care, provided by a physician who is affiliated with Hutzel Hospital in Detroit. Women go to Hutzel Hospital for their deliveries. Getting permission from the tribal communities to conduct this research varied in the three settings. With the Saginaw Chippewa community, I initially submitted a letter to the Chief, Ron Falcon. I was asked to submit a research proposal which would be read by the Tribal Council. Subsequent to this request, I was also asked to submit a resume and two letters of reference. The assistant to the tribal health director who called me explained that the community is somewhat reluctant to allow research projects because of previous experiences they have had. She explained they have participated in a number of studies. The investigators always promise they will provide the community with the findings of the research, but in fact seldom do. 55 Thus, the tribal council is reluctant to have community members volunteer as research subjects, when they may well receive nothing in return. I had had some previous contact with this community. In the fall of 1990 I had attended the opening ceremony of the Nimkee Memorial Wellness Center on the reservation. I had been asked to read a proclamation of tribute from then—Governor James Blanchard. I had also attended that fall's Substance Abuse Awareness Day and community feast. The two letters I submitted were from a Native American colleague at the Michigan Department of Public Health with whom I have worked on several projects and from a woman friend who is a member of the tribal community and a counselor at the high school. Shortly after submitting my letters of recommendation I attended the annual powwow on the reservation where I was introduced to the tribal health director, Audrey Falcon. The tribal council approved the research proposal at their next meeting. The experience with the Bay Mills Indian Community in Brimley was different. I had had no previous contact with this community. I initially contacted the Indian Health Service representative in the Upper Peninsula, Char Hewitt, whom I had met at several health conferences downstate. Char told me to contact the director of the Tribal Health Center, Laurel Keenan, directly. Laurel approved the research during the course of our telephone conversation. She told me she was empowered by the Tribal Council to authorize health-related research. 56 To conduct research at the Detroit American Indian Health Center, I contacted the director, Lucy Harrison. and told her I was referred to her by my colleague in the Michigan Department of Public Health, Chet Eagleman. I explained the intent of the research project. Lucy told me she is very interested in developing prevention and intervention programs for women who abuse alcohol during pregnancy. She added that the Center for Addictions at Wayne State University is doing research on maternal addictions and Fetal Alcohol Syndrome, but that it is limited to Black women at this point. Lucy authorized the research during our conversation. My field experience at the three settings varied. At Bay Mills I spent several days in Brimley. I conducted interviews each day at the Health Center. I was given a staff person's office who was on vacation; this office was adjacent to the examining rooms. The nurses had previously explained the research to a number of women and gotten their permission to participate. The women came in for their appointment with the doctor or nurse practitioner, and then the nurse brought them in to my office for the interview. With a few of the women, their young children accompanied them for the interview. If the nurses were not busy with a patient, and there was no one in my office, they would come in and ask about the research and my findings. One in particular asked that I send her a copy of the findings directly. During my stay in the community I was able to attend the annual health fair, held outdoors on one beautiful August day on the shores of Lake Superior. Tables were set up with literature on diabetes, AIDS, and nutrition. 57 Blood pressure tests were being conducted. An elder was there serving wild rice and venison. To conduct interviews at the Isabella Reservation in Mt. Pleasant I commuted on several weekdays. I was given an office of a staff person who was on extended sick leave. As with the Bay Mills community, the nurses at the health center had previously contacted a number of women to explain the research and determine their interest in participating. They brought these women in to see me after the women had their visit with the physician. For my interviews at the Detroit American Indian Health Center I commuted several days. Here too I was given an office and the nurses brought in the women who had agreed to participate. Twenty-four women were interviewed, including 12 women on- reservation and 12 off-reservation. The criteria for women to be included in the research sample are that they are Native American and of child-bearing age. About one—third of the sample of 24 women were pregnant. The women ranged in age from 15—41. All of the interviews were conducted at a health clinic when they came in for their scheduled prenatal or other health appointment. They were asked if they would be willing to participate in this research by one of the clinic nurses, during a previous visit to the clinic. -I‘.’- . .'f',__ __ _ m: - - . . ”an m. .r- M “W .. 9 BM” uh - - . . _ up "5'." __._ '— “I | . .. '.’: , -IJI . i' . _ - -' _ .I‘J.t “of. :'" 3. I . .13." w 58 The research questionnaire (see Appendix B) was divided into three sets of questions: traditional health practises; cultural proscriptions and prescriptions about pregnancy; and knowledge about the effects of alcohol use during pregnancy. Traditional health practises and pregnancy questions were placed at the beginning of the questionnaire since they are less threatening than questions about alcohol use. There were no questions about personal alcohol use in the research questionnaire. Appendix C contains the results of the research in data and narrative form. CHAPTER VII RESEARCH FINDINGS The objective of the first part of this research was to determine Native American women's level of knowledge about the effects of alcohol during pregnancy and about Fetal Alcohol Syndrome.The research findings indicate that the Native American women who participated in this research have a fairly high level of awareness that alcohol use during pregnancy causes major problems for the developing fetus. Much of the information they reported about Fetal Alcohol Syndrome is technically correct. The research found that all the women in the on-reservation group and all but two in the off-reservation group have heard that drinking alcohol when you are pregnant can harm the fetus. When asked to report what they had been told about alcohol use during pregnancy, all on-reservation women reported they had heard about adverse effects to the fetus, in terms of interrupting development and causing birth defects. The off-reservation women also reported problems, in terms of birth defects and “making the baby drunk.” Two of them, however, reported having been told nothing. We cannot conclude that all Native American women in Michigan are as knowledgeable about the adverse effects of alcohol as these 59 60 women; nonetheless, this research finding is a positive one which indicates that prevention messages are effective in raising awareness. In addition to learning about women's level of knowledge regarding alcohol use during pregnancy, the research questioned their belief in the prevention messages. The mechanisms involved in Fetal Alcohol Syndrome are still not completely understood by the medical community. The typical prevention message emphasizes no alcohol during pregnancy. Yet the majority of alcoholic women do not have alcohol-damaged children. At this time it is not known what protects some women who drink heavily. One can assume that some Native American women have observed a female relative or friend drink heavily during her pregnancy and bear a perfectly normal child. This fortunate outcome runs contrary to the warning from the health care provider who tells her to give up a substance which she uses to reduce stress or boredom; the credibility and motivation of the health care provider could be seriously questioned. The research found, however, that both groups of women report that they believe the warnings about alcohol use during pregnancy. In fact, several mentioned that they have seen children with birth defects on the reservation and they explain the child's problem in terms of the mother's alcohol use during pregnancy. With regard to knowledge about Fetal Alcohol Syndrome, more women on—reservation (90%) had heard of it and could explain what it means than off—reservation women (75%). Most of the on 61 reservation women explained Fetal Alcohol Syndrome in terms of physical and mental disabilities, or in terms of problem behaviors. They showed a more in—depth understanding of some of the effects of alcohol use during pregnancy. No one person responded with all of the diagnostic criteria, but in general their answers accurately covered the range of diagnostic criteria. An interesting point of comparison is that nearly half of the off- reservation women reported that Fetal Alcohol Syndrome means a baby is born addicted to alcohol. This is technically correct; babies in utero do become addicted to alcohol when their mothers drink heavily during the pregnancy. They go through withdrawal after delivery and may experience abdominal distension, convulsions and apnea. But Fetal Alcohol Syndrome is much more than this. This answer ignores the host of specific physiological and neurological problems experienced by the fetus; it does not indicate that the alcohol has resulted in permanent damage to the brain or other organs. It suggests rather than the fetus is an alcoholic like his mother. As one woman explained, such a child would be much more likely to become an alcoholic later in his life, “having one addiction already.” This may be a common understanding of Fetal Alcohol Syndrome. More of the on—reservation women were knowledgeable about the morphological characteristics of a Fetal Alcohol Syndrome child. For example, they reported differences in head size, smaller body size, facial abnormalities, anomalies of the eyes. The off 62 reservation women on the other hand primarily responded in terms of problem behavior. There was nothing specific about physical characteristics, other than “His physical appearance is different.” One said you'd know he has Fetal Alcohol Syndrome because he'd also have Cerebral Palsy or Down‘s Syndrome. Participants were asked whether the alcohol-induced damage to the fetus is permanent. A greater percentage of on—reservation women (75%) knew that the symptoms of Fetal Alcohol Syndrome last a lifetime, as compared to the off-reservation women (50%). Both groups of women were equally knowledgeable that there is no safe period during pregnancy to drink alcohol, which is an important finding. The majority of women both on— and off—reservation women said the first trimester is the most harmful time to drink alcohol. They explained that this is the period when most of the organs are developing. Several of the women pointed out that many women do not know they are pregnant during the first trimester and continue to drink alcohol. This point which the women raised is precisely one of the more problematic and challenging aspects of Fetal Alcohol Syndrome prevention. Women were also asked if there were a safe amount of alcohol to drink during pregnancy. Seventy-five percent of the on—reservation women said there is not, compared to half of the off-reservation women. In both cases, those who said there is a safe amount indicated very low amounts of alcohol, such as one beer a month. 63 Participants were asked about the effect of different drinking styles on birth outcome, specifically chronic or binge drinking. Binging, which is considered the typical pattern of Indian drinking. refers to continuous heavy drinking by a group of individuals until the money or the liquor is gone. Women from both groups said binge drinking is most harmful because “It floods the baby with poison.” Half of the on-reservation women said both chronic and binge drinking are equally harmful, and the majority of off-reservation women said binging is more harmful. A related question asked about the cumulative impact of drinking over the course of several pregnancies. A woman may drink heavil; during her first pregnancy and her child is not damaged by alcohol; however, if she keeps drinking, her later-bom children are more likely to have birth defects or Fetal Alcohol Syndrome. The result Of this research show that all the women in both groups said that a woman drinks during her first pregnancy and bears a healthy chi there is no guarantee that her next child will be all right if she Continues to drink. Many of the women talked about the woman bei lucky the first time. One question asked about the synergistic effects of alcohol with Other health risks which affect pregnancy. Overall the level of awareness was very high in both groups of women. Both groups 01 Women consider smoking, poor nutrition, caffeine, stress and missing prenatal appointments as harmful to a pregnancy. Sevent; fi . . ve percent of the on—reservatron women said they had heard that i I rat-Jill HIP}. “IVE”?! i‘.‘"-' not! arm-'4‘- Jr .' _-. M-Iu'ai‘ M8 ‘0" _ .‘E' t l I;.-:.‘:- :‘i gfi‘ -. .-.'I-:._ .. g . ' 1'0 ”A“ 64 quitting or cutting down on alcohol consumption at any time pregnancy increases a woman‘s chances of having a healthy I compared to half of the off—reservation women. More on—res women said hard liquor and beer have the same effect on the Compared to the majority of off—reservation women who saic liquor is most harmful. One very important factor in any healing system, whether it' offered by a physician or a shaman, is the belief that a persor the healer. This belief is one of the factors which determine compliance with the treatment regimen. One question asked participants whom they would be most willing to listen to w comes to information about alcohol use during pregnancy. On reservation women said they would be most willing to listen advice from an elder, whereas off-reservation women said t1 Would be most likely to listen to a doctor. The conclusion based on the research findings is that both or off— reservation women are fairly knowledgeable about the 0f alcohol use during pregnancy and Fetal Alcohol Syndrome particular. The on-reservation women are more knowledgeal: which supports one of the research hypotheses. The Second part of the research focused on the the emic per about alcohol abuse and asked women whether or not they ci a maj or problem which affects the entire culture. This line . i - . . . . nqull‘y was rmtrated by asking the women to define an alcol 65 "problem." Women on—reservation talked about alcohol affectin relationships, and physical trauma. An interesting difference it off-reservation women was the significant number who quantii an alcohol problem, in terms of the frequency with which alcol dl‘ink, for example; “They're drunk every day.” Alcohol abuse by pregnant women is considered a very serious problem by the medical and public health community. From the perspective of Medical Anthropology, it was important to learn Indian women perceive the same phenomenon. The research reSI found a difference between on— and off-reservation women. All the on-reservation women said it is a problem, compared to 7 o 12 off-reservation women. One on-reservation woman said it's problem for Indian women everywhere, and that many women ar losing their children because of alcohol problems. In referring t Bay Mills community, one women estimated that over 50% of th Women have a serious drinking problem. The women who participated in the research offered a number ( explanations for alcohol abuse by Native American women. The Primary response from both on- and off—reservation women is alcohol abuse is part of the culture. They explain that women d becauSe they grow up with it. —“Thel‘e's partying at home all the time. How's a woman to quit She goes home and her grandma's drinkin' and her aunties, and a hOuSe full of drunk people and the first thing they do is offer beer? ’9 66 ._“If a woman can't quit and her husband don't either, and her at come over with a 'jumbo' she just can't ever give it up.” ,”You learn that drinkin' behavior. You don't learn coping skills; way of life. Young children think it's condoned. It's natural for 1 —“It's the way they were brought up. Families did it together. ’I whole families of drunk men and women. They're taught about dx‘inkin'. When Indian people get together, there's always alcoho ——“It's 'cause of the parents. How they grew up. You know, monke see, monkey do. It's part of life among a lot of them. You have to really strong to resist. I have. You have to disown them to chang your life. I lost all respect for my parents. They have 18 kids. T Start drinkin and let anybody in the house to drink, someone ma} raped or beat up. I tell them I'm different from them. I'm strong —“Peers accept it, the more drunk you get the better people thin yo u - ” Another woman talked about the tribal community's response tc abusive drinking. —“The attitude around here's gotta change. We have to support \ mOre throughout pregnancy. A girl who drinks when she is pregr iS not looked down upon. This should be discouraged but it's not. dOn't think they recognize drinking as a contributing factor to a Child's disability. Must be the woman and the community is in denial 3, One Very young woman, 15 years old and eight months pregnant. it's hard to quit because then you feel different and left out. “1 depends on your friends,” she explained. She said she quit drin w . hen she found out she was pregnant, at about five months rntc 67 pregnancy. She is well acquainted with the adverse effects of alcohol during pregnancy. Her two—year old brother has Fetal Alci Syndrome. “With my last brother it caused all kinds of problems. just can't see right and he wears real thick glasses and he ain't it fully two years old and he can't walk. They say he ain't ever gonn: able to walk. But he pushes and he crawls. He's pushing his walke now, so he's gonna be able to walk. His legs ain't strong enough. V know it's the case ‘cause she was drinkin; and doin' drugs. That h. to be. He could've been worser. He was already premature.” Other women reported that problems of low self—esteem and depression, loneliness, and limited economic opportunity caused alcohol problems. —“Fimancial problems, problems in the home; emotional problems brought on by lack of money to buy groceries. Problems in the hor stem from financial problems, not having this or that. Having to SEFUggle from day to day, not being able to get things for your kit —“I think it's how they feel about themselves, cause I worked wit lOt of them when I was back home (Baraga). And that's what I see Self—respect and no self—esteem, you know, just how they think I th€>Illselves, how they look at themselves. I think a lot of it is th: are depressed in the kinds of homes they live in. I mean it's like homes they have for them are not in good shape or they're left he With their kids and no one visits them. And when they have the ti to go out and have fun, that's the way they'll choose to do it.” 68 —“They drink because of how good it makes them feel. People are told alcohol is bad and it will get them into trouble, but they know makes them feel good, and they perceive this message is a lie. It's pain killer, an anesthetic. You know, someone might say, 'So what 1' it's ten degrees below zero and I don't have any wood?’ and just laugh.” ——“Abuse by your spouse, hardships, being on welfare.” Another question asked if alcohol use by pregnant women is a majr crisis facing American Indian people today, as popular medicine pox‘trays it. All of the on—reservation women said it is, compared t 75 % of the off-reservation women. One woman, pregnant with her seventh child, explained it in these words: —“It's as bad as they say. It's worse, cause I don't think a lot of Women on reservations they don't talk about it. You know, if a nurs Comes to their house and asks them I don’t think they're truthful With them. I mean I know how bad it is cause I'm related to all those people. I grew up with them. I mean I can sit here and say, 'I don't know how they can do that' and you know sometimes it gets mad \vhen I see 'em, but I did the same thing myself, and now I try think, what was I thinkin' then?” ”“It is a crisis. A lot of girls drink and they don't care. They don't see it as a problem. It sure affects how they take care of their kit _“It Sure is a major crisis. Alcohol is like crack for Indian people. And no one has tolerance for crack. It takes a long time to build up tolerance. Indian people may build up a tolerance to alcohol but it W111 take a long time. The Mediterranean people have used alcohol 69 centuries and have built up a tolerance. The weak ones were eliminated. Maybe this will happen to us.” In this research women were asked about the impact of Fetal Alcohol Syndrome on Indian culture. Most of the women on— reservation said it's a problem for the entire Indian culture, compared to about 75% of the off-reservation women. One wor talked about Fetal Alcohol Syndrome in terms of "hurting our 1: hel’itage." Other women offered the following comments. —“ The rest of the community has to deal with it, and feels bad it, and sees it keep on happening.” -“We're concerned about extinction. A woman who abuses alcol when she is pregnant can't bring a baby to full term. Indian pec have married so much with other races. We need to get rid of alcohol, spouse abuse, child molestations and teach good value you don't have to drink to be Indian.” —“It affects our entire population. These kids are our leaders C the line; this will affect our people. Fetal Alcohol Syndrome pi will be our leaders. How will they run this tribe?” The research sought women's input about what should be done NatiVe American women who abuse alcohol. This input was especially meaningful in that some of the women identified thetnsfitlves as former alcohol abusers and acknowledged they I drunk alcohol during their previous pregnancies. Most of the or reservEition women recommended support groups, someone to I to . the home to be With her, and more support from the commu 70 One talked about alcohol abuse in terms of an illness which ne constant surveillance. Twenty—five percent of the on—reserva women said they should be offered the traditional teachings. r“It would have helped me to have someone then to come in to home and be there.” _— “They need to have a program with more Indian women with t same problem. You need to know you're not the only one, other you hide behind the bottle.” —“There's a whole lot of denial here about the cause of disabi If a woman who's been drinking has a baby with disabilities, Vt should say to her, 'Did you ever consider that this happened be you were drinking when you were pregnant with this child'?”. In comparision, of the 12 off-reservation women, five talked support groups. Four said these women can't be helped until th make up their minds to quit. -“Women won't give it up. If they're pregnant, they deny there': PI‘Oblem til it's too late. They won't give it up til they get to b elders. Then they die after being sick about two years. They dc Want to quit til they realize the damage; they're sick with dis or they've lost a child.” AnOther area of interest of this research is the application of traditi()nal Indian teachings and practises in helping women Vl alcohol problems. Women were asked about their participation tr ' - . . . . adltl()nal practises. The on—reservatlon women part1c1pate 71 significantly more in sweat lodge, women's circle, talking to tribal elders, pipe ceremonies, medicine wheel, and consulting a medicine man. An interesting finding is that nine out of 12 women in both groups consider spirituality a necessary part of a healthy pregnancy. The meaning of spirituality differed between on— and off-reservation women. On—reservation women talked about spirituality in terms of traditional beliefs, and having respect for the unborn child's spirit, whereas off—reservation women referred to a good emotional state. Two on-reservation women explained the spiritual perspective in this way: —“Women are capable of giving life. We have a sacred lodge within ourselves. Being pregnant is a sacred thing.” -“For the Anishnabe people pregnancy is a special time, a time of restriction and protection. The woman's spirit is very strong during this time. Mother Earth was pregnant with, and gave birth, to all the spirits. Women are considered special. They are closer to Mother Earth. Mother Earth favors women.” Half of the on-reservation women identified traditional practises which would be useful to women who want to give up alcohol, as opposed to only two of the off—reservation women. Some of them mentioned the experiences of specific individuals in the community who were able to give up alcohol when they went back to the traditional ways. Others mentioned their own experiences. 72 —“I went back to the traditional way ten years ago and I heard from the very beginning to give up drugs and alcohol.” Another woman said there are traditional Indian values which have to do with alcohol use during pregnancy. -“They say when you drink when you're pregnant, it has something to do with your baby's spirit. It won't be as strong as it should be. All the values come in line when you're pregnant, like respect your body. If you're pregnant, respect that baby, though you don't know who they are yet. They say the Creator has given you that child to take care of, even though that child is never actually yours, he's given it to you to take care of while he's here. They say those babies, even though they're inside, they know what's going on. They know if you're feeling crabby or in a good mood or if you don't want to be pregnant. They even get jealous I hear. I heard that one time about this couple, they lost their babies and they went to see a medicine man about it. That medicine man told them they were too involved in each other and they didn't think about that baby so that baby went back to the spirit world.” Women were asked about traditional ceremonies which might be helpful to women with alcohol problems. They mentioned the healing lodge and women's talking circle, and summer and fall traditional ceremonies. -“The sweat lodge and the traditional teachings and goin' to a medicine man to learn about the Indian ways. All them things helped me give up alcohol last time I was pregnant.” -“If you plan to follow the red road, do all your ceremonies and everything, then you cannot associate with drugs, alcohol, smoking. 73 Then they understand more about who they are and where they're coming from and what they're giving up when they drink alcohol. They're basically giving up their right to be Indian because you have to realize when you're pregnant that, if you have children, they are special things and you're hurting them by drinking. If you understand the importance of being Indian and continuing on everything, you can't do drinking. ” CHAPTER VIII CONCLUSIONS Though all Indian people suffer in some way from the effects of alcohol, Native American women pay the highest price. They have a high rate of cirrhosis of the liver and other alcohol—related illnesses. Many have their children taken from them because of their problem drinking. Some women continue their heavy drinking during pregnancy and give birth to children with birth defects. Others die young from toxic alcohol poisoning. Given the devastating toll of alcohol, and their awareness of the damage it causes, why do Native American women continue to abuse alcohol? What would drive a woman to so completely destroy herself, and risk the well-being of the child she carries? These are the fundamental questions which were posed in this research, and for which the insider's perspective was sought. The Native American women who participated in this research offered valuable insights on this troubling phenomenon. Overall they painted a picture of the life of a young Native American woman, a portrait which is striking in its lack of opportunity and lack of hope. At a very young age, she is confronted by alcohol and drug abuse among her peers and more than likely feels pressure to join them and be part of a partying group. She is likely to marry early, not likely to advance her education. With her educational career limited, job and 74 75 economic opportunities are limited as well. In her life on the reservation there is little for her to do. Her male partner probably drinks. She is surrounded by the episodic "partying" or binge drinking of friends and relatives. In many cases there is dysfunctional behavior in the family and she is a victim of physical and emotional abuse. If she takes up the pattern of partying and binge drinking as a young woman, it is harder for her to quit when she learns she is pregnant. In many cases she doesn't, not for the sake of her baby or her own life. In their explanations for women's alcohol abuse, the predominant theme which emerged was that of abusive drinking as a culturally—patterned behavior. Most women mentioned that alcohol abuse is part of the Indian way of life, for women as well as for men. They say it is what children experience as adult behavior as they are growing up. Drinking represents having a good time with other Indian people, participating in the social life of the tribal community, being part of a group. Women talked about whole families who drink and party together, as well as groups of friends. They explained that it is very hard to resist this way of life, to be different. They spoke of pressure from friends or family to drink, even if you're pregnant. Women also talked about the influence of their male partners; if he is out partying and having a good time, she wants to be there as well. As these women confirmed, alcohol abuse has become an integral part of lifestyle and cultural identify for many Indian people. Many consider it an integral part of being Indian. Given that a particular pattern of abusive drinking has become part of the culture, the so-called "binge 76 drinking", it is important to consider how the tribal community or group responds to this phenomenon. Certainly there is concern on the part of tribal communities. Since the days of Chief Little Turtle of the Miami, tribal leaders have expressed concern about the devastating effect of alcohol among their people. Consequently, alcohol is prohibited on many reservations, and at tribal events such as powwows. Tribal communities offer substance abuse services, support groups and preach prevention. With the rise in the number of cases of Fetal Alcohol Syndrome, tribal communities are cognizant that they confront a more insidious problem related to abusive drinking. They recognize that the the alcohol-impaired individual will be permanently disabled and dependent on family and tribal community. Already burdened by unmet economic needs, the tribal community's anticipated costs of caring for these impaired individuals could be staggering. In addition, the community will have to accomodate the needs of developmentally disabled individuals, in terms of special education and appropriate employment or other activity. It is easy to understand why so many tribal communities are vigorous in their Fetal Alcohol Syndrome prevention outreach, sponsoring seminars to educate women about the teratogenic effects of alcohol. Without any doubt most tribal communities are working hard to educate women about the damage which alcohol can cause. And, judging from the level of awareness of the women in this research, they have been successful. But an important question remains about the cultural perceptions and attitudes about women's drinking and how these may 77 contribute to the problem. Though it is officially discouraged, women report that, in practise, there is little attention paid to women's drinking. They say women's alcohol abuse is not considered as serious as that of men. There is little to discourage women from continuing to drink during pregnancy. There is little negative sanction, nor encouragement when she is able go give up "partying." Women reported it is very common to see pregnant women in the bars drinking. Others talked about the community being in denial and conclude the community does not make a connection between a woman's alcohol abuse and the damage to her child. Clearly there is a real conflict if, on the one hand, the tribal community is preaching Fetal Alcohol Syndrome prevention but, on the other hand, drinking is still a vital aspect of the cultural experience for many Native American people. The next most significant reason cited for women's problems with alcohol revolve around conditions of poverty, lack of education and economic opportunity. Women talked about stressful conditions in their lives, which include living in substandard housing, not being able to buy things for their children, having no job, no car, little education, minimal opportunity in general. These are conditions which generate stress and hopelessness. Many Indian women recognize this pattern of poverty and limited opportunity as their most likely fate. It is easy to understand the origin of despair, given such conditions. A number of women said that low self-esteem plays a major role in a woman's alcohol addiction. They explained that many women have low self-esteem because they are poor and don't have jobs. Others , _ mink-if! IF. _ , ., Iii I I WWI? " Siam-a- Want-hr." t - o ... 78 mentioned that a person's sense of well—being and self—esteem are injured by the prejudice of the dominant society. Several women talked about the discrimination they have experienced their whole lives, and the unfairness of the stereotypes about "drunken Indians". Other women talked about traumatic incidents in their lives, "things which have happened to hurt them inside." Within the sanctuary of the sweat lodge, one woman sought healing for her addiction to alcohol, which had rendered her unable to care for her two young children. She explained that sexual abuse she suffered as a child led her to abusive drinking and other destructive behaviors. Two periods of hospitalization in a treatment center hadn't helped her and she now sought the healing traditions of her culture. Spouse abuse has become more widespread in Indian communities and should be considered an important determining factor in a woman's alcohol use. In discussing Indian alcohol abuse a number of women referred to the belief that Indian people are genetically prone to drinking problems, saying, "It's in our genes." They indicated that they as Indians are much more susceptible to alcohol abuse than the general population. They have accepted the biological determinist model which says Indians are genetically unable to metabolize alcohol effectively. On some level they have bought into the "firewater myths" which posit that Indians are constitutionally unable to resist liquor. Acceptance of this kind of thinking makes the work of prevention a formidable challenge. It becomes more difficult to resist abusive drinking patterns if one 79 believes it is her genetic destiny, that alcohol abuse is part of the package of being Indian. One of the central factors which should be considered in a cultural explanation of alcohol abuse is the transformation in roles of Native American women. Coming of age, into womanhood, no longer entails rites of passage: the dreaming, the move to the women's lodge. In earlier times, before reservation life was imposed on them, Indian women held clear—cut roles and responsibilities in their communities. They lived industrious lives, providing food, shelter, and clothing for their families. With reservation life, this role changed; today women complain of little to do. Watching soap operas and partying have become typical ways of passing time. Certainly this is not the fate of all Native American women. The tribal community encourages its young women to acquire the professional skills of medicine or law with which to come back to help their people. And some women achieve this. But there is a price to pay. Some women refer to the stress of having to live in two worlds, with sets of values and expectations that are not congruent. The contemporary Native American woman may live on the reservation, but she is probably very far from the knowledge of many of her traditions. The traditional beliefs about women had invested her with power. Her role as child-bearer, favored by Mother Earth, was an honored and valued role. Pregnancy was a sacred time, a time of protection and restriction. With the loss of these beliefs has come a 8O radical departure from the traditional time of protection. Pregnancy is no different than the rest of her life-cycle in which she resorts to use of mind—altering substances to reduce anxiety or to relieve boredom. It is interesting to note that many women report that women are often able to give up alcohol when they get to be grandmothers, in their early 40's. This may be due to the respect still accorded the role of elder, and the importance of the grandmother's role in Native American culture, as one who imparts knowledge to her grandchildren. Another important finding from this research is the insiders' perspective that the traditional Native American spiritual teachings and practises can be of great value to women who are addicted to alcohol. They say there are traditional teachings and values that have to do with a woman's power and her special role, particularly during pregnancy. They explain that the traditional people are there to offer support and healing, through the sweat lodge and other ceremonies. Several women told about people in their community who were healed of their alcohol addiction by going back to the "red road." This finding reinforces the benefit of incorporating traditional values and stories into health education literature. An example of this is the diabetes education brochure developed by the Sault Ste. Marie tribe of Ojibway Indians which includes a story about Nanabozhoo, a well—known figure to all Ojibway people, a central figure in many of their legends. In addition, the numerous posters on Fetal Alcohol Syndrome, on display in many tribal communities, depict women in traditional garb and talk about her sacred role as child—bearer. 81 The traditional ceremonies are of course easier to incorporate within the reservation tribal community than in the urban setting, where in fact most Indian people live today. On the reservation people can come together easily for a women's circle, healing lodge or powwow. This is clearly not the case in a large metropolitan area. However, the director of the American Indian Health Center in Detroit is integrating the spiritual side of Indian tradition into their health programs by bringing in a medicine man and planning a woman's fall ceremony and woman's circle for mothers of alcohol—damaged children. Her focus is women's empowerment through the traditional ways. Certainly not all Native American women are traditional in their beliefs and practises. Some may have heard the stories and teachings from grandparents and reject them, for a variety of reasons. There may be others, however, who have grown up far from traditional teachers. Several of the women who participated in this research reported they are now very involved in the traditional way and that their involvement has only been in the last five to ten years. Before that time, they were living elsewhere, down state or in another part of the country. There were no traditional teachers for them to learn from. When they moved back to a more traditional community, they found elders and teachers and the traditional ways very much alive. It is their opinion that if women had the opportunity to learn, or re-leam, some of the traditional teachings, they would come to accept them. As with alcohol abuse in general, preventing Fetal Alcohol Syndrome is a very complex and challenging issue. There is no single explanation 82 for the problem, nor single prevention strategy. Prevention and outreach strategies will differ in some respects on— and off— reservation. And even among on—reservation Indians, each tribal community will need to develop its own prevention programs, reflecting the particular characterisitics and alcohol problems of that community. There are a number of general recommendations which can be formulated, however. The first is that prevention is critical to reach young Indian people before abusive drinking patterns are established. This work involves educating them about the history of alcohol among Indians and the physiology of addiction so they will not grow up believing that abusive drinking is part of their destiny as Indians. Prevention should focus as well on alternative coping skills and meaningful alternatives to drinking. They need to be offered something in place of alcohol. Traditional practises represent one viable alternative, in the form of activities like dancing, beadwork, learning the Anishnabe language. It goes without saying that offering viable educational and employment opportunities is a powerful prevention strategy which would help remove one barrier to hope. The second critical area is that of intervention with women who are at highest risk. These are the women who are known to be alcohol abusers, especially if they already have a child with Fetal Alcohol Syndrome. They are the ones very likely to continue their drinking and give birth to another alcohol—damaged child. These women are the most alienated, despairing, and least likely to access the health care system 83 for prenatal care or substance abuse counseling. One can only speculate what grief and guilt they are likely to bear, knowing their drinking contributed to their child's disability. It is critical that these women receive the medical and mental health care they urgently need, as well as all the support services the community can manage. Another recommendation is resurgence of the traditional women's talking circle or some other form of women's support group. The aim is to provide women an alternative means of being together and supporting one another other than the drinking group. In this setting they have a chance to share their personal experiences and learn they are not alone in the struggle. Other Native American women can serve as role models in these circles; women who have been successful in their own communities, who have contributed to the well—being of their people. There are many women who have lived with abuse and the addiction of their families, who suffered their own addiction, and overcame it. Some of these women are now pipe carriers and sweat lodge leaders. They have a wealth of knowledge to share. It is important for them to tell other women how they were finally able to overcome the power of alcohol. The goal is to empower women with knowledge so they are better able to take responsibility for their health and their lives. Ultimately the work of prevention must be borne by the entire tribal community, not just the medical and substance abuse sectors. The community should acknowledge the severity of the problem of women's alcohol abuse, highlighting Fetal Alcohol Syndrome. There needs to be 84 consistency between prevention messages and the actual practise of discouraging alcohol abuse. Women need to receive encouragement from the community to give up "partying" and be offered support in the form of treatment and other services. There are a circle of Indian people working on the challenge of Fetal Alcohol Syndrome in their communities, networking across the nation. Their work focuses on raising awareness about Fetal Alcohol Syndrome on the part of all members of the community and training them in ways of offering support to women with alcohol abuse problems. An important focus of this research was to learn what Fetal Alcohol Syndrome represents to Indian people. As acknowledged by the women who participated in this research, the tragedy of Fetal Alcohol Syndrome falls upon the entire Indian culture, as well as the individual woman and her child. Today alcohol is taking its greatest toll on the Indian people's most valuable resource and hope for the future, their children. It is not possible to predict at this time how great the toll of alcohol will be to the future generations of Native Americans. One cannot say if Fetal Alcohol Syndrome will become epidemic in tribal communities, if there will be an ever-increasing number of permanently handicapped children. There is consensus that an increasing number of young women are drinking alcohol; therefore, it seems likely that this horrendous problem will only get worse. Native American anthropologist Michael Dorris expressed the concern about Fetal Alcohol Syndrome in this way: “I thought of generations of 85 Indians, of ancestors, who had managed to survive into the twentieth century despite invasions and plague and government policies aimed at cultural genocide. Would our story end with alcohol?” Many Indian people fear that it will. They look upon alcohol as a curse of incredible proportion, which wreaks havoc among the Indian people. They fear the Indian people are as powerless to resist alcohol today as they were 500 years ago unable to resist this gift of the white man. It is undeniable that many Indian people remain powerless, enslaved to alcohol. The dysfunctional drinking behavior pattern of many Indian women represents extreme helplessness and desperation. Fetal Alcohol Syndrome represents the most poignant suffering. Fetal Alcohol Syndrome reflects the life story of the woman who gives birth to an alcohol-damaged child; in some ways it reflects the story of the Indian people, a story of struggle and injustice. Fetal Alcohol Syndrome mirrors the deeper problems of a society which was nearly vanquished. It reflects current conditions of poverty and despair. Ultimately it speaks of loss. Potential leaders will be lost to the Indian nations. Gifts of vision and talent, be they in the artistic, political, or healing realm, will be denied to the Indian people. Fetal Alcohol Syndrome is a tragic loss of human potential. These children will be accepted by the tribal community. They will leave their mark on this earth in some unique way, but they will have lives which are limited and they will be frustrated. This research sought to learn what Fetal Alcohol Syndrome means to Indian people; one woman expressed it with APPENDICES APPENDIX A CONSENT FORM Thank you for participating in this research project. The purpose of this research is to learn more about Indian women’s understanding of the effects of alcohol during pregnancy. Indian women of child-bearing age will be interviewed both on- and off-reservation in Michigan. With the feedback from the women who are interviewed, we can develop better prenatal educational material to help Indian women have healthier pregnancies and reduce the number of alcohol—related birth defects. As a participant in this research, you will be interviewed once, at the prenatal clinic, when you come for your regular prenatal visit. The interview will last approximately 30 minutes. Participation in this project is voluntary. You may choose not to participate at all. You may refuse to answer certain questions. You may discontinue the interview at any point; if you decide to discontinue this interview, it will not affect your receiving prenatal care. All findings will be treated with strict confidence and you as a participant will be anonymous; your name will never be used. If, at any time after the interview you have questions, you can call Gail Burke at 517—337—7690. Signature________________________; ________________________ Date 87 APPENDIX B QUESTIONNAIRE Traditional Health Practises 1. Do you participate in sweat lodge ceremonies? 2. Do you participate in a woman’s circle? 3. Do you talk to tribal elders? 4. Do you participate in pipe ceremonies or tobacco burning ceremonies? 5. Do you participate in healing which involves the Medicine Wheel? 6. Do you participate in any traditional practises that you believe prevent illness? 7. Do you consult a medicine man or woman? 8. (If yes) What was the treatment you received? 9. Do you fast? 10. What home remedies have you used during your pregnancy? 11. Is spirituality a necessary part of a healthy pregnancy? 12. Are there traditional Indian values which discourage alcohol use, especially during pregnancy? 13. Which traditional health practises do you think might be useful to women who want to give up alcohol? 88 89 Pregnancy 1. Have you ever heard about things a woman should not do when she is pregnant? 2. Or things she should do when she is pregnant that she usually doesn’t do? 3. Who told you about these things? 4. Have you ever heard of any things a pregnant woman should not eat? 5. Have you heard of any things a pregnant woman should not drink? 6. Have any other women shared their babies’ birth stories with you? 7. Have you ever heard that it’s possible for a pregnant woman to “mark” her baby? 8.How much control do you think a woman has in terms of having a healthy baby and how much is controlled by fate? 9. Have you ever heard any stories having to do with pregnancy and childbirth? 10. What should be done to help women have healthier pregnancies? Knowledge About Effects of Alcohol During Pregnancy 1. Many people believe that drinking alcohol when you are pregnant can harm the fetus. Have you ever heard this? 2. Do you think this is true? 3. What were you told about drinking alcohol during pregnancy? 4. Who have you heard this from? 5. Have you ever heard about drinking during pregnancy from: your doctor____;nurse___;mother___;aunt___;sister___;grandmother___; girlfriend____;husband___;boyfriend__;community health representative__;Urban Indian health center___;Indian outreach worker___;other___ 6. Have you seen warning labels about alcohol use during pregnancy on beer, wine, and liquor bottles? 90 7. Have you seen posters and brochures about drinking during pregnancy? 8. Have you heard about the effects of drinking during pregnancy from any of the following:TV____;Indian workshops__;word of mouth__? 9. Have you ever heard of Fetal Alcohol Syndrome? 10. What do you think it means? 11. How can one tell if a child has been affected by his or her mother’s drinking alcohol while pregnant? 12. Do the symptoms of Fetal Alcohol Syndrome last a lifetime, or will the child get better as he/she gets older? 13. Is there any period during pregnancy when it’s safe to drink alcohol? 14. If a woman drinks when she is pregnant, would it be more harmful during the first three months of the pregnancy, the second three months, or the final three months? 15. Is there a safe amount of alcohol to drink during pregnancy? 16. (If yes) How many beers a day would this be? Number of glasses of wine? Number of wine coolers? Number of drinks of hard liquor, like gin or whiskey? 17. What do you think would be moe harmful-moderate drinking (2 drinks a day during pregnancy) or heavy alcohol intake for short periods, spree or binge drinking? 18. Some women drink during their first pregnancy and their children are fine. If they drink in a later pregnancy, will their other babies be fine too? 19. Do you think a young woman or an older woman is at greater risk of bearing a child damaged by alcohol? 20. Do you think drinking alcohol during pregnancy can cause more harm if a woman: smokes_;has poor nutrition_;consumes a lot of caffeine, in Coke or coffee_;is under a lot of stress_;misses her prenatal appointments____? 21. Does drinking hard liquor cause more damage to the fetus than beer, wine, and wine coolers? 22. Did you know that if a woman quits or cuts down on her drinking at any time during pregnancy, it increases her chances of having a healthy baby? 23. Do most women you know drink more, or less, or the same amount of alcohol when they are pregnant? 24. Would you be more likely to listen to advice about alcohol use during pregnancy if it came from an elder__; a girlfriend___;a public health nurse__;a doct0r__;anybody else____? 25.How would you define an alcohol problem? 91 26. Is alcohol abuse a major problem for Indian women in your community? 27.What do you think causes some women to abuse alcohol? 28.Popular medicine views alcohol use by pregnant women as a major crisis facing American Indian people today. Are they exaggerting, or is it a major crisis? If no, why not? 29. Is it a problem for just the woman, her child and family, or for the entire Indian culture? 30.What should be done to heop women who want to give up alcohol? APPENDIX C RESEARCH RESULTS 1. Traditional Health Practises Do you participate in sweat lodge ceremonies? On reservation: _5 yes _7 no Off-reservation: _1 yes _11 no Do you participate in a woman's circle? On-reservation:__5 yes _7 no Off-reservation: _1 yes _1 1 no Do you talk to tribal elders? On-reservation: _9_yes _3 no Off-reservation: _3_yes _9 no Do you participate in pipe or tobacco burning ceremonies? On-reservation: _7 yes _5 no Off—reservation: _3_yes _9_no Do you participate in healing which involves the Medicine Wheel? On—reservation: _8_yes _4_no Off-reservation: _0__yes _12____no Do you participate in any traditional practises which you believe help to prevent illness? On-reservation: 6_yes 6 no 92 93 Off—reservation: _1 _yes 1 l_no 7. Do you consult a medicine man or medicine woman? 8. On-reservation: 6_yes 6_no Off-reservation: _l_yes l 1_no (If yes) What was the treatment you received? On-reservation: Lproblem pregnancy; 1 TB; 3__asthma Off-reservation: _1_ first menstrual period 9. Do you fast? On—reservation: _5 yes 7 no Off-reservation: _2_yes _10__no 10. Have you used home remedies during pregnancy or illness? 11. 12. On-reservation: 6_y es 6_no Off-reservation: _l_yes __11_no Is spirituality a necessary part of a healthy pregnancy? On-reservation: _9_yes _3_no Off-reservation: _9_yes _3_no Are there traditional Indian values which discourage alcohol use, especially during pregnancy? On-reservation: _7__yes ____2__no _3_don't know Off—reservation: __6_yes _5 no _l_don't know 94 13. Which traditional health practises do you think might be useful to women who want to give up alcohol? Orr-reservation: 6 identified the following traditional practises: sweat lodges and traditional ceremonies; women's circle; participating in spirituality which encompasses everything; drawing upon the Creator; 6 responded they didn't know of any. Off—reservation: 2 identified following the traditional way; 1Q responded they didn't know of any. II. Pregnancy 1. Have you ever heard about things a woman should not do when she is pregnant? On-reservation: 7 yes 5 no Off—resevation: _1 l__yes 1 no 2. Or things she should do when she is pregnant that she usually doesn't do? On-reservation: _4_yes _8_no Off-reservation: _9_yes _3 no 3. Who told you about these things? On-reservation: 3_ elders; 3_ traditional teachers; 1 doctor Off-reservation: 7 mother; 2 aunt; 1 doctor; 1 common knowledge 4. Have you ever heard of any things a pregnant woman should not eat? On-reservation: _2 yes _10_no Off—reservation: _9_yes _3 no 5. Have you ever heard of any things a pregnant woman should not drink? 95 On-reservation: 9__yes _3_no Off-reservation: __l 1_yes _1 no 6. Have any other women shared their babies' birth stories with you? On-reservation: _l 1_yes __1 no Off-reservation: _10_yes 2_no 7. Have you ever heard it's possible for a pregnant woman to "mark" her baby? On-reservation: _8_yes _4_no Off-reservation: _5_yes _7_no 8. How much control do you think a woman has in terms of having a healthy baby; how much is controlled by fate? On—reservation: 9 woman has greatest amount of control, 75—80%; 1 half and half; 2 fate plays a very big role. Off—reservation: 7 woman has complete control; 4 woman has most of the control; 1 50/50. 9. Have you ever heard any stories having to do with pregnancy and childbirth? On-reservation: _2_yes _10_no Off—reservation: _7_yes _5 no 10. What should be done to help women have healthier pregnancies? On-reservation: 12 respondents provided the following: 3 more education; 1 stress the positives instead of the negatives which frighten women; 2 make sure they're taken care of by a good doctor; 2 prenatal care should be more available for poor women; 1 take smoking, alcohol, drugs off market;l should be encouraged not to party when pregnant and then congratulated; l prenatal education programs should be a requirement; 1community attitude of denial must change. Off-reservation: 12 respondents provided the following: 4 more education; 3 better health care, better doctors; l emotional support from women who have kids; 4 nothing will help. 96 Knowledge about effects of alcohol during pregnancy 1. Many people believe that drinking alcohol when you are pregnant can harm the fetus. Have you ever heard this? On—reservation: _12 yes 0 no Off—reservation: _12_yes _0_no 2. Do you think this is true? On-reservation: _10 yes _0_no _2_only if you drink a whole lot all the time. Off-reservation: _12_yes 0_no 3. What were you told about drinking alcohol during pregnancy? On-reservation: l interrupts baby's development; 3 can lead to defects; 4 baby gets drunk; 1 suffocates fetus; 2 it's not good for baby; 1 if you abstain, baby has a better chance. Off—reservation: 1 alcohol deforms the face; 2 makes baby drunk; 2 affects brain; 2 baby will be slow to develop; 3 birth defects; I told about FAS; 2 told nothing. 4. Have you ever heard about drinking alcohol during pregnancy from: on—reservation off-reservation your doctor: 6 7 nurse 5 8 mother 4 10 sister 3 8 aunt 2 5 grandmother 6 5 girlfriend 2 8 husband 1 6 boyfriend I 2 community health representative 7 3 97 Urban Indian Health 0 7 Center Indian outreach 0 2 other 3 (reading) 5. Have you seen warning labels about alcohol use during pregnancy on beer, wine, and liquor bottles? On—reservation: _6___yes _6 no Off—reservation: _8 yes _4 no 6. Have you seen posters and brochures about drinking during pregnancy? On-reservation: _10 yes _2_no Off-reservation: _12_yes _0_no 7. Have you heard about the effects of drinking during pregnancy from any of the following: TV, Indian workshops, word of mouth? On—reservation: _10_TV; _9_Indian workshops; _12 word of mouth. Off—reservation: _10_TV; _l_Indian workshops; _9_word of mouth. 8. Have you ever heard of Fetal Alcohol Syndrome? On-reservation: _11 yes O_no _l_not sure Off-reservation: 8_yes 4__no 9. What do you think it means? On-reservation: _2_it's connected with physical and mental disabilities; _l_child is developmentally behind; _l_slower in head to learn things; _l_damage to a child during pregnancy; _l_they don't think right; _2_retarded; _2_problem behavior. Off—reservation: _5_baby born addicted to alcohol; _3_birth defect; _3_brain damage; 1_don't know the effects. 10. How can one tell if a child has been affected by his or her mother's drinking alcohol while pregnant? On-reservation: _l_head is smaller; 1_how they speak; _l_they're shorter if they're from a family of tall people;_1_they appear slow; _l_only in extreme cases you can tell by behavior, could be jittery, 98 hyperactive, sluggish, despondent; _l_big head, small body; _2_slanted eyes; _l_eyes wide apart; _l_physically different; _l_face like with Downe's; _l_facial abnormalities. Off-reservation: _l_if he has Cerebral palsy or downe's syndrome; _3_physical appearance is different; _6__problem behavior; _2_don't know. 11. Do the symptoms of Fetal Alcohol Syndrome last a lifetime or will the child get better as he/she gets older? On-reservation: _9_lifetime _3_child can get better Off-reservation: _6 lifetime _6__child can get better 12. Is there any period during pregnancy when it is safe to drink alcohol? On-reservation: _0_yes _12_no Off-reservation: _0_yes 12 no 13. If a woman drinks when she is pregnant, would it be more harmful during the first three months of the pregnancy, the second three months, or the final three months? On-reservation: _6_lst; _0_2nd; _0_3rd; _l_lst and 3rd;_l_lst and 2nd; _4_all three. Off-reservation: _5_lst; _0_2nd; _3_3rd; _2_lst and 3rd; ___1st and 2nd; _2_all three. 14. Is there a safe amount of alcohol to drink during pregnancy? On-reservation: _3_yes ___9_no Off-reservation: _4__ yes _8_no 15. (If yes) How many beers a day would this be? Number of glasses of wine? Number of wine coolers? Number of drinks of hard liquor, like gin or whiskey? On~reservation2 ___2_ 1 can of beer monthly; _l_as long as you don't get drunk. Off-reservation: _l_l glass of wine weekly; _l_a very limited amount; _l_as long as it's not daily. 16. What do you think would be more harmful——moderate drinking (2 ddrinks a day throughout the pregnancy) or heavy alcohol intake for short periods, spree or binge drinking? 99 On-reservation: _2_chronic _4_binge _6_both are equally harmful Off—reservation: _4___chronic _5_binge _3_both equally harmful 17. Some women drink during their first pregnancy and their children are fine. If they continue to drink in a later pregnancy, will their other babies be fine too? On-reservation: _3_yes _4_no _5_there's no way to know Off-resersvation: _0_ yes _11_no _l_no way to know 18. Do you think a young woman or an older woman is at greater risk of bearing a child damaged by alcohol? On-reservation: _2_young _2_older _8_same Off-reservation: _3_young _4_older _5 same 19. Do you think drinking alcohol during pregnancy can cause more harm if a woman: on-reservation off—reservation smokes 11 yes; 1 no 9 yes; 3 no has poor nutrition 12 yes 11 yes; 1 no consumes a lot of caffeine 10 yes; 2 no 9 yes; 3 no under lot of stress 10 yes; 2 no 12 yes misses prenatal appointments 7 yes; 5 no 12 yes 20. Does drinking hard liquor cause more damage to the fetus than beer, wine, and wine coolers? On-reservation: _5_yes _0_no _7_same effect Off-reservation: _7_ yes _2_no _3_depends on volume 21. Did you know that if a woman quits or cuts down on her drinking at any time during pregnancy, it increases her chances of having a healthy baby? On—reservation: _8_yes _4_no Off—reservation: _6_yes _6_no 22. Do most women you know drink more, or less, or the same amount of alcohol when they are pregnant? In at??? D ‘51.“? film - 3.4.131»; 2;": ---_-.t_. -. =-v ='. ., 100 On—reservation: _l_more _3_less _4_same _3_little less _l_if she's drinking, she doesn't stop because she's pregnant. Off-reservation: _3_more _5_less _4_same 23. Would you be more likely to listen to advice about alcohol use during pregnancy if it came from an elder, a girlfriend, a public health nurse, a doctor, anybody else? On—reservation: _7_elder; _girlfriend; __nurse; _3_doctor; _anybody else; _2_all the same. Off-reservation: __elder; __girlfriend; _l_nurse; _6_doctor; _anybody else; _5_all the same. 24. How would you define an alcohol "problem"? On-reservation: _2_when it affects their life and others; _2_when you don't think about anyone but yourself; _l_when you start to get into trouble; _2_when it affects them physically and financially; _4_when they want to drink all the time and can't stop; _l_when they crave it Off-reservation: _5_when they're drunk every day; _4_they 're into denial about having a problem; _3_their behavior changes. 25. Is alcohol abuse a major problem for Indian women in your community? On-reservation: _12_yes _0_no Off—reservation: _7__yes _5_no 26. What do you think causes some women to abuse alcohol? On-reservation: _5_how they're brought up; whole family drinks; _l_something happened to hurt them inside; _l_peer pressure; _l_financial problems; _l_stress in relationships; _l_spouse abuse; _l_dpressed, wants to go out and have fun; _l_no self-respect. Off—reservation: _3_whole family drinks; _l_how good it makes them feel; _4_to help deal with problems; _l_low self-esteem; _2_1ack of job, education; _l_you need something. 101 27. Popular medicine views alcohol use by pregnant women as a major crisis facing American Indian people today. Are they exaggerating, or is it a major crisis? On—reservation: _12 yes _0_no Off—reservation: _9_yes _3_no 28. Is it a problem for just the woman, her child and family, or for the entire Indian culture? On-reservation: _2_woman and family _8_entire culture __2_both Off—reservation: _4_woman and family _5_entire culture _3_both 29. What should be done to help women who want to give up alcohol? On—reservation: _l_women's support groups geared toward Native American women. _l_really up to the woman herself to quit _l_support person, 24 hours a day _l_need other activities for her _l_more education about what alcohol does to them and dto family _2_offer traditional teachings, spiritual help _l_educate children more; they're at greater risk of becoming alcoholic _l_someone to come to home and be there _l_introduce them to Indian ways _l_must be more support from community _l_treat it as an illness which needs constant surveillance. Off-reservation: _4_they've got to do it themselves; can't help them til they make up their minds _3_offer support programs like AA _5_provide support groups. Results in Narrative Traditional Health Practises 1. Of the five on-reservation women who responded that they participate in sweat lodge ceremonies, all are from the Bay Mills community. They described their participation in sweat lodges as a regular event. One of the women I interviewed talked about the nature of the sweat lodge. "We call it a healing lodge. Sweat lodge is actually a corruption of the name by the white man. When it was first given to 102 the Anishnabe people, it was given to the men. The women didn't need it. They have their own built-in sweat lodge once a month with their moon time for purification. Now women participate in the lodges and they should go to be healed." Of the 12 off-reservation women, only one had ever participated in a sweat lodge. 2. Of the five on-reservation women who answered that they have participated in a woman's circle, all are from the Bay Mills community. Of the 12 off-reservation women, only one had ever participated in a woman's circle, and this was at her first "moon time," her first menstrual period. 3. Nine out of 12 on—reservation women said they talk to tribal elders about health, family and personal matters. Of the twelve off- reservation women, three talked to tribal elders. One of them added, "There aren't too many of them around here to talk to as often as I'd like." 4. Seven of the on-reservation women said they regularly participate in pipe ceremonies or tobacco burning ceremonies. Three of the off- reservation women participate in pipe ceremonies; one added she also burns sage and sweet grass. 5. Eight of the on—reservation women said they participate in healing which involves the Medicine Wheel; none of the women in the off- reservation group had this experience. 6. Six on—reservation women participate in traditional practises which they believe help to prevent illness . These include the healing lodge and traditional summer and fall feasts. One off—reservation woman said she participated in traditional practises to prevent illness. She said her mother is an herbalist and gives her lots of herbal remedies, more often for treatment rather than prevention. 7. Five of the on—reservation women said they consulted a medicine man or medicine woman. One said she'd never had reason to, but would if the occasion arose. One woman said she'd never had any success with healing by regular doctors. "But I've been cured by traditional healers." Fifteen years ago she had problems with her lungs and the white doctors couldn't find anything. Then she went to a medicine man who diagnosed her condition as tuberculosis and cured her in one and a half months. One year ago she had to get a chest X-ray for her job, and the doctor said that the scarring on her lungs indicated she must have 103 had TB years ago. Only one off—reservation woman said she'd consulted a medicine man, during her first moon time. Another off—reservation woman added, "My aunt, who works at the center as a substance abuse counselor, travels all around Minnesota and Canada visiting at pow wows and meeting medicine people and she says they have a lot of power." 8. The women reported they had consulted a medicine man for TB, asthma, and first menstrual period. One woman from the Bay Mills tribal community was eight months pregnant with her sixth child when we talked; she had experienced three previous miscarriages. She said she had wanted to consult her medicine man during this pregnancy. "Yeah, I was supposed to let him know next time I was pregnant, cause I always had problems. And I couldn't even get hold of him or he was never in the area. He is from Minnesota." One 16 year old said she had consulted a medicine man to help her with her alcohol problems. With regard to the treatment they received, one said the medicine man placed an eagle bone whistle over her. Another woman said she could not talk about the treatment she received. 9. Five on-reservation women said that they fast, at least occasionally, for purification and spiritual reasons. Two off— reservation women said they have fasted. One of them said she fasts "when someone else close to you is fasting. You support them in their fast." 10. Six of the on-reservation women said they have used home remedies, either during a pregnanCy or for other health reasons. They said they used native medicines and herbs, either from the medicine man or woman, herbalist, or grandmother. One example cited was red willow bark for sore throats. One off-reservation woman (whose mother is an herbalist) reported using home remedies. She said she uses her mom's medicines for mosquito bites and burns. 11. Nine on-reservation women said they believe spirituality is a necessary part of a healthy pregnancy. (Of these nine on-reservation women, seven were from the Bay Mills tribal community. ) One woman, pregnant with her sixth child, said, "I'd say for me it would have to be how you feel about yourself from day to day. I kind of think that like if I don't feel good then I have to make myself think I'm going to be OK. Not just sit there and say 'I ain't gonna make it. I ain't gonna make it." Another woman said, "Traditional people believe the woman's spiritual purpose is to give life. The sweat lodge was given to men to purify and 104 cleanse themselves. Women can go in to them now, but they didn't long ago. Women didn't need to because they have their own built—in cleansing once a month when they're on their "moon time". Women are capable of giving life; it is the role of the female to reproduce. We have a sacred lodge within ourselves. Being pregnant is a sacred thing." Another woman said, "Spirituality helps keep you balanced. There are so many physical and emotional changes when you are pregnant, you need to find the balance." Another said, "This has to do with our belief about Mother Earth. Mother Earth was pregnant with, and gave birth to, all the spirits. Women are considered special. They are closer to Mother Earth. Mother Earth favors women. That's why in some tribes after girls had their menstruals she took what was soiled giving back to Mother Earth and thanking her for making her a child bearer." Another said, "Spirituality is important but I don't think of spirituality in the traditional Indian way. They don't believe in God, but idols. Your spiritual self should be in tune with God for everything to work out. If you love Jesus in your heart, everything will be OK." Nine off- reservation women also thought spirituality was a necessary part of a healthy pregnancy. Their comments to this question included: "Yes, she shouldnt' have stress ." "A woman should have a lot of support to feel good when she's pregnant." "If she's calm when she's pregnant, the baby will be calm before and after he's born." "It depends on who the person 18." 12. Seven on—reservation women said there are traditional Indian values which discourage alcohol use during pregnancy; two said there weren't; and three said they didn't know. "I went back to the traditional way ten years ago and I heard from the very beginning to give up drugs and alcohol." "Indian people honor their children and consider them sacred and special." Another mentioned respect for an unborn child's spirit. One added, "With alcohol, you will not be balanced. " Another added, "Here on our reservation a lot of men and women gave up alcohol when they came to accept the traditional teachings." One woman said, "Alcohol was never part of the Indian way. The spirit of alcohol was honored traditionally. But it's not to be abused." Another woman added, "Traditional Indian values discourage alcohol use before and during pregnancy. During pregnancy, a woman is continuing life and this is precious. She's continuing the Indian nation. You should follow the Red Road and all the traditional ceremonies during all parts of your lifetime." One woman said, "The traditional teachings would say to a woman to watch what she eats, drinks, looks at when she's pregnant. It doesn't mean that a woman who keeps on drinking has no values, but she's ill and can't quit.“ "They say when you 105 drink when you're pregnant it has something to do with your baby's spirit. It won't be as strong as it should be. I think they bring that on real strong about drinking and drugs cause they know that stuff is what takes Indian people futher away from their traditional values. All the values come in line when you're pregnant, like respect your body. If you're pregnant, respect that baby, though you don't know who they are yet. They say the Creator has given you that child to take care of, even though that child is never actually yours he's given it to you to take care of while he's here. They say those babies, even though they're inside, they know what's going on. They know if you're feeling crabby or in a good mood or if you don't want to be pregnant. They even get jealous I hear. I heard that one time about this couple, they lost their babies and they went to see a medicine man about it. That medicine man told them they were too involved in each other and they didn't think about that baby so that baby went back to the spirit world. You have to have a lot of respect for yourself. " With the off-reservation women, six said there are traditional values which discourage alcohol use, five said no, and one didn't know. "I think there are. If they're part of a drum, they can't be near that drum if they're drunk or on drugs." "Indians just don't believe in alcohol. There's a common understanding about not using alcohol." "Yes, for a healthy baby, it starts when they're inside. You've gotta take care of yourself especially when you're pregnant." "Yes, if you're spiritual, you don't need chemicals." "Everyone discourages alcohol use during pregnancy but especially Indians because of our history of drinking so much. I'm sure other races have drinking problems too, but ours has been so bad that we're more aware." ”If they wanna drink, they're gonna drink." 13. Six on—reservation women identified traditional practises which they thought might be helpful to women who want to give up alcohol . "Definitely the healing lodge and ceremonies like the fall and summer traditional ceremonies and women's talking circle." "I quit when I was pregnant last time. I drank before that every time I was pregnant. The first month I'd be real drunk. Then I'd quit for a while. My mom would say, 'Oh, you'll start drinkin' again, just wait and see.’ I didn't. I quit three years ago. I never went to counselors but to tribal elders." "The way we believe is that participating in spirituality encompasses everything. It's a wholistic way of looking at life, not just like religion is one separate part of life in white society." "Drawing upon the Creator." "The sweat lodge and the traditional teachings and goin' to a medicine man to learn about the Indian ways. All them things helped me give up alcohol last time I was pregnant." "All the ‘_IL.- - 106 traditional practises, like the sweat lodge and ceremonies will help. Indian healing is real different from biomedicine. Biomedicine don't include spiritual. We believe all life has a spirit. Germs or bad spirits are the origin of illness. To treat a person we believe you have to drive the spirits out. Biomedicine only treats symptoms. There's a real arrogance of this which eliminates older culture's sources of wisdom. They bypass the earth and use synthetic medicines. We think of depression as opening up the door for all other spirits which can make a person sick." One woman added, "If you plan to follow the red road, do all your ceremonies and everything, then you cannot associate with drugs, alcohol, smoking. Then they understand more about who they are and where they're coming from and what they're giving up when they drink alcohol. They're basically giving up their right to be Indian because you have to realize when you're pregnant that if you have children they are special things and you're hurting them by drinking. If you understand the importance of being Indian and continuing on everything you can't do drinking." "You'll see a lot of people, men and women, who gave up alcohol through Native American traditional ways. My mother never practised the traditional way, and I never knew who to turn to. Then when I moved back up here it was like all of a sudden here were people I could learn from. Even when I was young, the traditional way was something I more or less leaned to." Ten on—reservation women said they did not know which traditional health practises might be useful to women who want to give up alcohol. The two other women said , "She should join a woman's circle." "What you feel for the child's health makes a difference; you have to use common sense". Pregnancy 1. Seven on—reservation women said they had heard about things a woman should not do when she is pregnant. One woman from the Bay Mills tribal community said, "For the Anishnabe people, pregnancy is a special time, a time of restriction and protection. The woman's spirit is very strong during this time and she should not participate in some ceremonies. For example, she shouldn't go into the sweat lodge during this time. This area was settled by the Jesuit missionaries and a lot of Indian people became Catholic. But we differ fundamentally. The Anishnabe people believe that all beings have spirits and can suffer. There are some things a woman should not do when she's pregnant. She shouldn't look at deformities or at car accidents. No hunting, killing or l' I i I 107 gutting animals. The animal has a strong spirit and may take the baby with him. Don't go to funerals; the spirit of the deceased is departing around this time and might take the spirit of the baby along with him." "You can't look at an ugly person. " "A woman can't go into the sweat lodge during this time." "Her husband or male partner can't wear feathers around the birth of the child because the baby might turn into a bird and fly away." "A pregnant woman who is travelling should not look at a dead animal killed along the side of the road. That animal's spirit is real powerful." "She should not look at anyone who is bleeding or hurt as this will affect her child." One woman added, "Never step over someone else if you are pregnant (or menstruating). " Other women cited other kinds of proscriptions such as not lifting one's hands over one's head, swimming in lakes, or hanging clothes , riding horses or snowmobile and no swimming because the pressure of the water will exert too much pressure on the fetus and might induce labor. One woman, 40 years old and mother of nine, said she was told not to "lift heavy pails, or hang clothes or pick apples...this could bring on a miscarriage. And don't do no fighting. That helps you lose the baby." Eleven of the off—reservation women answered that she had heard of something. Their comments included: "Don't get scared cause if you get scared the baby will be marked in some way." "Don’t take hot baths. It can fry the baby's brain." "The pressure of water on your abdomen isn't good so you're not supposed to swim. Don't go into the sun. You shouldn't be around a microwave." "You're not supposed to go to funerals, but I'm not sure why. My aunt died and my mom said she'd rather that I not go cause I was pregnant." Another said her mother-in- law told her when she was pregnant with her twins nine years ago that she couldn't go out during the eclipse. "She's from Mexico; they believe a lot of the same things Indians do about not doing this or that when you're pregnant. I don't believe them, but I humor her." ”Don't lift too much or get too much exertion." 2. Four on—reservation women said they had heard about things a pregnant woman should do that she usually doesn't do. "If she wants a boy, she should eat choice meats, sleep with a spear, and pray to the spirits. If she wants a girl, she should make clothing for a girl. She should wear a charm, like a whittled arrow, on her abdomen to protect the baby against evil spirits. " "She should eat in a more healthy way and get more rest. " "She should do everything right for the baby." Nine off—reservation women said they had heard of things a pregnant woman should do. These included: "She should keep pure thoughts." 1' Jan." -' =3; 108 "Watch what she's eating to feed the baby well." "She should go to the doctor's all the time." "She should rest a lot and not get upset." 3. Three on-reservation women said they had learned about these things from elders; three had learned them from traditional teachers; and one learned them from a doctor. With the off—reservation women, seven had learned about these things from their mother; two from an aunt; one from a doctor, and one said, "It's common knowledge." 4. Two on-reservation women said they had heard of things a pregnant woman should not eat. One woman said that, according to the traditional teachings, " No rabbit or turtle to eat. You're not supposed to eat fish with teeth, such as trout. It has something to do with clotting of blood, I think. Whitefish , however, is good for you to eat." Another mentioned , "Birds, animal with wings. And the father should not eat burnt meat when his wife is pregnant." Nine off-reservation women said they had heard of things a pregnant woman should not eat. Responses included: "Raw rare meat, uncooked meat, and any non—food items, you know like dirt and cigarette butts ....some people really lose it." "Nutrasweet." "Spicy foods." "Some kinds of fish from the lake". The youngest woman in the off-reservation sample, who is 15 years old and pregnant, responded, "Candy." 5. Nine on—reservation women said they had heard of things a pregnant woman should not drink. They all responded, "alcohol." One answered "Firewater, but some medicine men might make a brew for a strong baby." For the off-reservation women, eleven responded that a pregnant woman should not drink alcohol. 6. Eleven of the on-reservation women said other women had shared their babies birth stories with them; one of the youngest in the sample, age 16, said she hadn't heard any of these stories "yet." One talked about women traditionally giving birth attended by other women, in a squatting position, in a birthing lodge, and that the lying down position which women have to assume in hospitals is against gravity and counter-productive. Ten of the off—reservation women said other women had shared their babies' birth stories with them. One said her friend showed her pictures her husband had taken during the delivery. Another said, "That's all we talk about." 7. Eight of the on-reservation women said they had heard it's possible for a pregnant women to "mark" her baby. One woman said, "You shouldn't look at dead animals when you travel and see them along the 109 side of the road because the dead animal's spirit might overpower the baby." "You shouldn't experience anything that would frighten you or that was traumatic." Another woman shared her own experience. "I had been told by my mother that you shouldn't look at bloody or upsetting things when you're pregnant. One day when I was pregnant with my son...this was nineteen years ago...I was home alone and heard a little child outside crying. A little girl had fallen off the back of a truck onto the road in front of my house. The back of her head was bleeding. I remembered what I had been told about looking at bloody things, but there was no one else there to help, so I had to. I went to take care of the little girl who had a gash on the back of her head. When my son was born, he had big red marks on the back of his head in the very spot where the little girl had been cut. " Another woman said, "The food you crave when you are pregnant can mark the baby. I've seen babies with marks on their faces that look just like strawberries." "How you feel when you're pregnant can mark the baby. When I was pregnant the first time I was restless and moody, my little boy is like that now. My second pregnancy I was happy and my new baby is happier." Five of the off-reservation women have heard it's possible for a pregnant woman to "mark" her baby. One woman said" My grandmother told me that when she was pregnant she was chopping wood and she almost cut off her husband's toe. Her baby was born with two toes missing. Also my aunt saw a rat when she was pregnant, and was startled and put her hand on her chest in fright; the baby was born with the imprint of a rat on his chest. " Others responded : "If you are nervous during your pregnancy, your baby will be nervous." "Bad thoughts can harm the baby. You have to have positive mind when you're pregnant." 8. Nine of the on—reservation women said the women has the greatest amount of control in having a healthy baby, rather than fate. Two said fate plays a very big role, and one said it's about half and half. Responses included the following: "It depends on her how healthy her baby is." "The baby's health is controlled by the mother; fate is how the baby thinks." "A woman has quite a bit of control. People are responsible for themselves and can put themselves at risk. It begins with the person. The Creator will help spiritually, but people must take control." Another answered "The woman has 50% of the control. The spirits have their own way. If they favor you, the baby will be healthy. Mother Earth gives us power." Another woman assigned a different percentage "Only 10% is controlled by fate." Two felt that a woman has between 75% and 80% control. One said she wasn't sure. "You just try 110 to do what's right. I sure knew more with my later kids". And the last answered that "A lot of control is under a woman's power. On the list, fate is below. But, you never know, you could get in a car accident or fall." With the off-reservation women, seven said the woman has total control; four said she has most of the control, and one said it's 50/50. Responses included the following: "She's got 100% control over the health of her child." "You have all the control by using your brain." "She has all the control; it depends on what she cats and how she takes care of yourself...you know, smoking hurts the baby." "A woman has a lot to do with it unless it's hereditary." "I believe in fate. What will happen will happen. A pregnant woman has options to do anything in her power to have a healthy baby. There are too many free clinics and the WIC program not to give your baby a good start. But there are some strange diseases; and that is fate." "She has a lot of control, 70%." "It's 50/50, depends on what health she is in, how she takes care of herself. There are some things out of your control." "80% is a womans' control, the rest is genetics." 9. Two on-reservation women said they had heard stories about pregnancy and childbirth. One woman, aged 28, who had four children living with her, had her first child when she was 14. "During that first pregnancy when I was 14 years old my mother told me Indian women should not scream while they give birth. That made me angry and it sure wasn't possible for me". Another woman said she had heard a story about pregnancy and childbirth. "You're not supposed to have a mirror in the crib." When I asked, she wasn't sure why. Seven of the off- reservation women said they had heard stories about pregnancy and childbirth. Responses included: "Yeah sure, from my mom; she had 18 kids.""Mostly stories about pain." "I've heard it's a positive feeling, beautiful, when the baby is being born." "If you're carrying low, its' a boy; if you carry high, it's a girl." "Mostly about going through labor. I did it the natural way without any drugs, now I have beautiful memories of it." 10. On-reservation women expressed the following ideas about helping women have healthier pregnancies. "Prenatal care should be more available for poor women. In my last pregnancy, I was livin' in Escanaba , 30 miles away, and I had to hitchhike to Bay Mills ‘cause no doctor was takin' Medicaid patients there. That was real hard for me to do and I didn't get to come for as many visits as I should have." Another answered emphatically "Tobacco , alcohol, and drugs should be taken off the market!" Another talked about helping women eat healthier and get 111 more exercise, like walking to get strength. This young woman , age 15, said that ,"When my time comes, I'll use the birthing lodge and squatting. If you use the old ways, they're probably better. They had more healthy babies then, they were stronger. They had wholesome foods. Babies had a better chance to make it." Several women said that women should be encouraged to get into prenatal care earlier; two said they didn't go ‘til their sixth or seventh month. "For my first one I was told medical insurance wouldn't cover doctor visits. When I went to the hospital to deliver I was told I had toxemia and a 20% chance of living." "There should be more education about taking care of yourself during pregnancy and what affects a baby. Young girls should be better eduated in school; they should start at a young age--fourth or fifth grade. " Another said "It's up to a woman how well it comes. We should make sure they're taken care of, and have the right doctor. There are some things a woman shouldn't do, like jogging. A woman knows her limits." "More positive things should be presented, like how you are being blessed with a baby. Now women hear just the negatives; they are afraid of too many things when they're pregnant. If fate gives you a baby which is less than perfect, it shouldn't be the mother's fault. She should take a look at the gift of the baby, it's spiritual. " "There should be more education. When I was pregnant a number of years ago there was very little education. Now there's lots. Now we know an aspirin can affect her and travelling in a car is most dangerous the first part of the pregnancy. We didn't know about FAS then, that a baby would get drunk too. There could also be long-term disabilities related to the father's alcohol use that we don't know about yet." "Encourage them more to not drink and get high at parties when they are pregnant. Tell them congratulations for not drinking." "Give them better health care and tell them what to do and what not to do when they're pregnant. They should learn about that at a younger age. Younger people, at 17 or 18 don't know much and they're the ones havin' the babies." "Educate themselves more about what goes into them affects their babies. Have more programs and sessions. Make it more of a requirement for pregnant girls. There are quite a few Indian women in the community who are not educated about keeping themselves healthy and their child's welfare. It's not stressed as much as it ought to be." One emphatically said ,"The attitude around here's gotta change. We have to support women more throughout pregnancy. A girl who drinks when she is pregnant is not looked down upon. This should be discouraged, but it's not. I don't think they recognize drinking as a contributing factor to a child's disability. Must be the woman and the community is in denial. A child can have a number of different disabilities, and I think they write off FAS or FAE around here as due to something else entirely and 112 label it differently." Comments from the off-reservation women included following: "Get them into prenatal care earlier”; "Get them the best health care available; go to their home, to check if there are problems"; "You've got to give them something to take care of their emotions, like they need to Visit with other pregnant women who've had children." "Give them proper education from day one." "Get knowledge to them." "People who've already had kids should inform them more about what to do, what not to do." "It's all up to them. You can't force them to do nothin’." "Nobody can do much. Maybe you should give them cash, like $100, to quit drinkin' for the sake of the child and come in for their visits." "You can't make their minds up for them to get help." Knowledge about effects of alcohol during pregnancy 1. All 12 on—reservation respondents said they had heard that alcohol can harm the fetus. Several women said they had not been told anything about alcohol use by their doctors in their first pregnancies and they'd only learned about this in the last two-five years. All 12 off- reservation women said they had heard alcohol can harm the fetus. 2. All of the on-reservation woman said they believe this information is true. One added , "I've seen children with major problems on our reservation. I didn't understand what was the matter til I learned they had Fetal Alcohol Syndrome." "Yes, I believe it, ‘cause I've seen it. You can see the side effects; they're smaller and a grade behind in school. Their moms drank ‘til at least six months into the pregnancy." However, two qualified their yes response with "If you drink a whole lot." "If you drink on a regular basis almost all time. One can of beer every three weeks is not as harmful as every day." Twelve of the off— reservation women believe this is true. One young woman, 15 years old and five months pregnant, said, "Yeah, I do, in a way, but uh Indian people don't think so, cause I know like my aunt and my mom were drunk all through their pregnancy and it never affected my brothers and me. But in my belief I think it will affect my baby." 3. On-reservation women provided the following responses to the question about what they had been told about alcohol use during pregnancy: "I had my first daughter when I was 14 years old; I had no information then, and none with my second child who was born in Oklahome. When I was pregnant four years ago, I learned alcohol and 113 smoking affects the baby. The baby gets intoxicated. This is bad for the baby." Another said, " I was just told not to drink by white doctors. Medicine men also tell us not to drink alcohol. They can give you medicines to drink to minimize labor and help after birth." Another said "It could affect the baby, or do something to it like change the birth weight. At different times you drink it could affect different things." A young woman said her mother had shown her photos of babies with FAS, and warned her not to drink or her baby would look like that. She also warned her that she was "real vulnerable to alcohol because my great grandfather was an alcoholic. " Several said that, if you drank during pregnancy, whatever is developing that day will be affected. Another said "I heard it passes the placenta and suffocates the fetus." A few said it interrupts development. "Alcohol abuse is 100% preventable. If you abstain, your child will have a better chance." "Your baby can have an abnormal defect." The off-reservation women provided the following responses: From the 15 year old young woman: "I just figured, I seen my mom do it while she was pregnant and I didn't want to do it. With my last brother it caused all kinds of problems...he just can't see right and he wears real thick glasses and he ain't even fully two years old and he can't walk...they say he ain't ever gonna be able to walk. But he pushes and he crawls. He's pushing his walker now, so he's gonna be able to walk. His legs ain't strong enough. We know it's the case cause she was drinkin' and doin' drugs. That had to be..He could've been worser..he was already premature. He's the only one came out like that." "If alcohol has such long term effects on an adult, what can it do to a growing baby? The baby doesn't need a depressant, but something to speed up its growth and not alter his mind before he's even born." "When you drink it affects the baby's brain. If you drink in the early stages, it can lead to deformities and lots of problems with the heart and limbs." "You can harm his development; I stopped drinkin’ with the last three kids ." (She has nine). "Not a good thing to do, can cause defects; he'll be born with alcohol syndrome." "In early stages, it can affect the brain, nerves and early development." "Alcohol can harm the baby and give all kinds of terrible birth defects. Whatever goes into you goes into the baby. " "Could deform the baby's face and makes the baby as drunk as you." 4. On—reservation women said they had heard about drinking alcohol during pregnancy from a number of sources. These included: community health representative (7); doctor and grandmother (6); nurse (5); mother (4); sister (3); aunt and girlfriend (2); and boyfriend and husband (2). One woman mentioned that her boyfriend encouraged her 114 to drink while she was pregnant and said, "It ain't gonna hurt you." Three said they learned about this from reading. Off-reservation women reported the following: Mother(10); nurse , girlfriend, and sister (8); Urban Indian Health Center and doctor (7); husband (6); aunt and grandmother (5); community health representative (3); Indian outreach worker and boyfriend (2). "My mom is German, not Indian. My mom kept stressing about alcohol use cause my Dad is alcoholic and my Grandfather too and it runs in the family. " "I already knew before any doctor told me about it. Everyone in my family drinks and I could see what it does to them and figured it would do worse to a baby. It ruined their lives, so I figured it would hurt the baby." 5. Six on-reservation women said they had seen warning labels about alcohol use during pregnancy on beer, wine, and liquor bottles. Of those who answered “no” to this question, two said they do not drink alcohol at all and that's why they hadn't seen the warning labels. Eight off- reservation women said they had seen warning labels on alcohol bottles. 6. Ten on—reservation women said they had seen posters about drinking during pregnancy. (Posters on FAS were prominently displayed at the Bay Mills Health Center and at the Nimkee Memorial Wellness Center. In the bingo hall on the Mt. Pleasant reservation, which is located across from the Nimkee Memorial Wellness Center, posters on FAS were displayed in the women's rest room.) Twelve off—reservation women said they had seen posters about drinking during pregnancy. FAS posters were on display at the Detroit American Indian Health Center. 7. Ten on—reservation women said they had heard about effects of drinking during pregnancy from TV. "They have commercials about babies bein' born drunk." Nine said they learned about it from Indian health workshops; and 12 said they learned about it by "word of mouth". Of the off—reservation women, ten said they had heard about drinking during pregnancy from TV; one from an Indian health workshop; and nine by word of mouth. 8. Eleven on—reservation women said they had heard of Fetal Alcohol Syndrome. One woman responded that she wasn't sure what it was. Eight off-reservation answered they had heard of Fetal Alcohol Syndrome, and four answered “no.” 9. The on-reservation women provided the following responses to the question about what FAS means: "The kid is developmentally behind." 115 "It affects the baby's growth and how they think." "Effects of alcohol on growing fetus." "Retardation of brain cells. Alcohol lews the growth and the baby doesn't develop. It's pretty close to being retarded." “It's connected with mental and physical disabilities. If women knew about the effects of alcohol, 80% would quit, the other 20% couldn't because they're addicted.” "Baby becomes addicted to alcohol." "Damage to a child during pregnancy." "Children born with a defect or learning disorder from parents' drinkin'." "I've seen a lot of kids that look like they have it. They just look different. It's a preventable birth defect." "A child has a low birth weight. He's slow in developing and slower in the head to learn things." "When you're pregnant and you drink, the child has certain characteristics." "Fetal Alcohol Syndrome is when the baby ain't well developed; he's retarded and smaller and his eyes are different." "It's behaviour child has from mother's drinking alcohol. I don't know, maybe the child may pick things up slower than if mother hadn't been drinkin'.". The off—reservation women provided the following responses: "If you drink while pregnant the child can have physical and mental problems." "A baby born addicted to alcohol." "If an adult can be a victim of alcoholism, it‘s a shame for a baby to come out as an alcoholic without a chance to learn about themselves." "If you drink the baby can be damaged for life. If a woman drinks when she's pregnant, she doesn't care for the life inside her. It's like killing him." 10. The on-reservation women said you could tell if a child was affected by his mother's drinking by the following: "Sometimes you can tell by how they think and speak. They might be short even if they're from a family of tall people. Their head is smaller." "This friend of mine that drank whiskey when she was pregnant, you can tell in her kids that she had while she was drinkin' they have problems in school. It don't show in the features of their faces or anything but that's what I think." "His facial features are a little like Down's; he might be slow". "Some babies look Mongoloid." "You can tell when you look at him; he has slanted eyes. He's also slow learning." "There's a distance between his eyes, also you can tell from behavior patterns, like hyperactivity. Might do things and not realize consequences, has a short attention span." "Facial abnormalities. mental retardation, slow learning." "They say such a child has a big head and a small body. The eyes are wide apart." One woman said, "Sure you can tell in extreme cases. You can tell by his behavior..it depends on the child's personality. He could be hyperactive, jittery, sluggish, or despondent." "He's physically different. I think his eyes are spread far apart." "You can look at him. He looks a little different, talks different. He looks Chinese." One 116 woman mentioned that there are certain ways you can tell for sure, like facial abnormalities and mental retardation if the mother drank a lot during pregnancy. She said, "There might be a whole lot of other things caused by alcohol we just don't know about yet, you know, like agoraphobia. We don't really know what causes that, or a lot of other illnesses for that matter. Medical science doesn't know a lot yet. What's going on in development will be affected when the woman drinks, be it brain cells or whatever. It can be visible or mild. The child is affected , even if it's not as severe. Either way, he won't function at capacity." With the off-reservation women, two reported they did not know how one could tell if a child was affected by his mother's drinking. The others reported the following: "It acts distant, doesn't want to play. They are retarded." "I don't know if they can find out while the baby's still in the mother. A doctor would see telltale signs, you wouldn't know FAS by looking at him. It could affect his learning." "They are in the hospital longer; something is wrong." "Smaller head, eyes further apart,nose is flat, thin upper lip, ears stick out." "With a newborn, you can tell if they're alert. If they're older, it depends on reaction and what their behavior is like; there's an alteration in their behavior." ”Not all are afffected by the mother's drinkin’, but you can tell if it had Cerebral Palsy or Down's syndrome or somethin’ like that." "Facial deformities." "After it's born? They're slow; they can't learn to cope." ”Smaller head, eyes further apart, nose is flat, affects how they function in life, the way they think." 11. Nine on-reservation women said the symptoms of Fetal Alchol Syndrome lasted a lifetime. One of these nine women explained, "These problems would be with the child during his lifetime but they may not be as prominent as he gets older. It kinda depends on the person, I guess. It may even become much more of a problem." Another said, "The kid is mentally impaired a lifetime. If air's cut off, you never get it back." Of the three women who said the child might get better, comments included: "Sometimes they might get better; other times not. It's easier for him to become an alcoholic himself because he's got one previous addiction already." Another woman said, "It could be worked on, you could work with him more closely and help him understand." And a third woman said, " Maybe some healing people can get some cells to work." Six off-reservation women said the symptoms of FAS last a lifetime. Comments included the following: "It's permanent. They just have to learn to cope." "It can last a lifetime, but if she works with the child everyday, it helps somewhat. But why would she work so hard and care then if she didn't care when she was pregnant with the baby?" One woman said, "It depends if he's affected physically or not. If it's only 117 mild and it's mental with time he could get help." "It's 50/50; it depends on how strong he is... like my little brother. The doctors said he'd never walk cause his legs are too weak but now he's in his walker and I know he'll be walkin soon." "It depends on severity or if they receive treatment." 12. All 12 of the on—reservation women said there is no period during pregnancy when it is safe to drink alcohol. One said, "Whatever's goin' on in development will be affected, brain cells or whatever. The effects would be visible or mild. Either way the child is affected. It may not be as severe, but he won't function at capacity." All 12 of the off-reservation women said there is no period during pregnancy when it's safe to drink alcohol. 13. Six on-reservation women said drinking during the 1st trimester is most harmful; one said the 1st and 3rd are equally harmful; one said the 1st and 2nd; and four said all three. Some of the comments included, "In the first three months, everything in the baby is growing more." "The first three months are harmful because the fetus is forming." "First three...the chromosomes are getting together." "The first trimester the organs are forming; the third the baby needs to grow. The last is pretty harmful because the baby is getting ready to be born." "The first three months because most of the baby is forming...the heart is forming, the organs, bones, legs, everything." Five off- reservation women said the lst trimester would be most harmful; three said the third; two said the lst and 3rd: two said all three. The 15 year old said, "I really didn't know, cause when I was pregnant I didn't know. I was drinkin' just a little bit, no big thing, it really didn't matter, but at that time if you realize the baby was just developing the heart, it was wrong I guess. I say it's more safer somewhere after you're pregnant cause the lungs develop at the end. I just didn't know." One added, "It's real hard cause a lot of time you don't even know you're pregnant during that time and you keep drinking. I didn‘t know til about five months." One woman said, "Really all nine are important. If you want a baby, the least you can do is wait nine months ." 14. Nine on—reservation women said there is no "safe" amount of alcohol to drink during pregnancy. The other three responded in terms of very moderate alcohol use: "If you're going out to dinner, a glass of wine low on alcohol volume wouldn't hurt. But you should avoid it the first three months." One woman said "Some won't hurt but don't get drunk." Another woman said, "Some may say one beer. But you've got to count the total number of beers throughout the whole pregnancy." And 118 one said "Maybe a can of beer monthly would be OK." Then she laughed as she added, "But what's the sense of drinkin' though,if it's only one beer a month?" Eight off—reservation women said there is no safe amount of alcohol to drink during pregnancy. "I heard it's OK to drink moderately." "A very limited amount is OK, not everyday use. I just got married and had champagne at my wedding and I think that’s OK." One woman was very emphatic, "Even one drink can cause FAS." 15. When asked to identify a "safe" amount of alcohol, two on- reservation women said a can of beer monthly, and one said "as long as you don't get drunk." With the off-reservation women, one said one glass of wine weekly, one said " a very limited amount,” and one said, "as long as it's not daily." 16. Six on-reservation women thought chronic and binge drinking were equally harmful; four thought binge drinking was most harmful; and two thought chronic drinking was most harmful. Some of the comments included: "Binging is bad for the kidneys. I had bad kidneys during my first two pregnancies and was pretty sick. " "I don't know; you're taking a chance with both." "If you drink everyday, like chronic drinking, you build up a need for alcohol and so does the baby. But if you binge, a large amount is hitting the baby at one time which is very harmful." With off—reservation women five thought binge drinking was most harmful; four thought chronic drinking was most harmful; and three said they are equally harmful. "Binge does a lot of damage. It floods the baby with alcohol. It takes longer for a baby to metabolize the alcohol." "Binge, cause taking more at one time really hurts the fetus." "It's putting lots of poison in at one time." "Weekend binging is most harmful. Whatever you feel the baby will also feel. If you feel so messed up, so will your baby. " "With chronic, it's a constant amount and the fetus gets used to the alcohol. It becomes alcohol addicted." "Both are as bad. Whatever she drinks, the baby is taking it in." "Anything is bad; why take the chance?" 17. Eight on-reservation women said there's no way to know if a woman will have a healthy baby if she continues to drink in a later pregnancy; four said she would not have a healthy baby. Some of the comments of the on-reservation women include: "I know somebody that drank like that. And she said 'I drank just as much as you and see, nothin' happened to my baby.’ She was just lucky the first time. The next one might not be so lucky." Another woman said, " There's no way to reassure a healthy pregnancy unless the woman abstains from alcohol completely." Eleven off-reservation women said there's no way 119 to know if a woman will have a healthy baby if she continues to drink in a later pregnancy. One woman said, "My girlfriend drank a lot of beer everyday when she was pregnant. Her baby was OK, he was even walking at eight months and at two years old he was talking in sentences. But he's real skinny. I don't think you can be that lucky twice. You shouldn't take chances; it's not a card game." Several responded "They got lucky!" "You can't tell. Everyone is different." "It's bound to show up even if she got lucky the first time. My friend is 39 years old and got pregnant for the first time. It's hard enough at her age, now she's drinkin’. I don't know where her head's at." 18. Eight of the on—reservation women said young women and older women are at equal risk of bearing a child damaged by alcohol; two said an older woman because "they have more complications anyway." Two said younger women are at greater risk: "They really like the taste of alcohol and how it makes you feel and they keep drinkin’." and "Younger ones because their bodies aren't as developed." Five of the off- reservation women said young women and older women are at equal risk of bearing a child damaged by alcohol; four said an older woman is at greater risk; and three said younger women. "She's still developing. Her body is not ready". "They don't know as much when they're young." "It can go either way. It may be harder for the older one to give it up cause she likes the taste too much." 19. In this question about risk factors during pregnancy, which act in synergistically with alcohol, 11 on-reservation women thought smoking would cause more harm, 12 thought poor nutrition, ten said caffeine, ten said stress,and seven said missing prenatal appointments. One woman, who is mother of nine children, said that with her first kids she never went to doctors til at least the seventh month and everything was OK. With the off—reservation women, nine thought smoking would cause more harm, 11 said poor nutrition, nine said caffeine, 12 said stress, and 12 said missing prenatal appointments. Some of the comments having to do with stress include: "Way you feel has a lot to do with the baby." "It makes the baby feel sad inside." And with regard to prenatal appointments: "You need to go there to see if his heartbeat is OK." 20. Seven on-reservation women said drinking hard liquor has the same effect on the fetus as beer or wine, and five said hard liquor is more harmful. "Whiskey, because it's the highest concentration of alcohol. But Nyquil has a lot of booze too. It's 40% alcohol, 80 proof. Nyquil can be as damaging. We have to look at all influences." "It's all the same." 120 "Alcohol is alcohol whatever the disguise it's in." "Definitely hard liquor. It's stronger, it burns more, even if you're not pregnant." Seven off-reservation women said hard liquor is more damaging; two said it is not; and three said it depends on volume. 21. Eight on-reservation women said they had heard that quitting or cutting down at any point could improve the chances of having a healthy baby. Six off-reservation women said they had heard this. 22. Four on—reservation women said most women they know drink the same amount of alcohol when they are pregnant; three said they drink a little less; three said less; one said more; and one woman said," If she's drinking, she doesn't stop because she's pregnant." Some of the comments included the following: "They curtail it; they're more cautious when they find out they're pregnant. There's more awareness now." "They drink less because they know it's not safe." "A little less. They worry about the baby being affected, being drunk." One woman said, "If she is drinking, she doesn't stop when she's pregnant. If she's abstaining, it's all the time. " "They drink more. Every year the problem gets worse...even if they are pregnant. I mean alcohol is a problem that gets worse, it don't get better." One woman said , "Seems like the younger ones are drinking at least at much, goin’ to bars in groups and drinking even when they're showing. " Another woman said, "My friend drank during her first four months of pregnancy and didn't tell none of us she was pregnant so she could keep drinkin' the same amount." With the off-reservation women, five answered that most people quit or cut down; four said they drink the same amount; and three said they drink more. The fifteen year old young woman said, "I'd say a little bit less. They drink a little less. We drink ‘til we're ready to go to sleep or ‘til we get sick and throw up. It really all accounts on your friends. If you see them do it, you're gonna do it too so you won't feel left out when you're pregnant. When I didn't know I was pregnant I was drinkin' less. I was drowsy and wanted to go to sleep and eat all the time. I'd drink once in a while and finally I gave it up when I went to the doctor's and found out I was pregnant. Girls should be shown pictures about how a baby is damaged. You know, I've been to school before and I go to school and I hear my friends. We don't listen. We don't care. We just say, so what if we drink anyway, it's our life." "My girlfriends are all about the ages 18 to 25, the biggest drinkers, 90% of them got pregnant. Now most of them have quit for the sake of the baby. " "Some of them drink more when they find out they're pregnant. They have bad feelings about bein' pregnant." "In my personal experience, 98% continue to drink. They don't care." "The majority stop 121 drinking except one of my aunts who is a big drinker. The doctor limited her drinking, to every other day. Her baby was small, less than six pounds." "They drink a little bit less. It's hard to quit completely, because then you feel different and left out." "They drink less because of concern about the fetus." "One girlfriend continued to drink some. Most others don't drink; they quit for the baby." 23. Seven on-reservation women said they would be most likely to listen to advice about alcohol use during pregnancy if it came from an elder; two said from a doctor; two said from any source; and one said, "I'm not sure who I'd trust more." One woman said, "They're all close to you. They all want to help you." Another said, "It doesn't matter to me. I'm willing to listen and give them a chance." With the off- reservation women, six said they would be more likely to listen to a doctor; 5 said it would be all the same; and one said from a nurse. 24. The on-reservation defined an alcohol "problem" with the following responses: "She might do it only once a year but totally lose control. Heavy drinking is considered social. We have more blackouts. There's a difference in our metabolism; we have a propensity for the disease of alcoholism. Oriental livers release a substance like antabuse. There's an enzyme involved. Alcohol goes straight to our brains and causes euphoria." "When they just want to drink". "When you can't stop yourself. You have to have a drink. You go to any extent to get it." "When you don't think about no one else but yourself." "When they feel they have to have it; they crave it within themselves." "They use it daily; need it. Have mood swings." "When their choices revolve around alcohol and it affects their life and others around them." "When you can't stop yourself, and you'll go to any extent to get it." "When they need it constantly, even one drink a day." "When you start to get into trouble and you won't admit to financial and legal problems." "When they can't control it. If it would bother you if you couldn't have any beers for two weeks." "When it affects any part of their life negatively, like financially using money for rent or bills to buy alcohol, and then physically they might damage their liver." "When they want to drink all the time." The off- reservation women responded with the following answers: "Cutting down on work, violence, abuse, not admitting there's a problem." "If you couldn't quit." "When they take the baby's diaper money and buy beer and are smashed and snockered all day." "Drinking three times a week or every day." "If they're never sober; they can't admit they're drunk." "If they drink a couple times a week, by their behavior while drinking or a personality change. If they see beer, they get happy. They can't stop after one or two drinks. three or four days a week is 16 times a month, 122 times 12 months a year. That's a lot of alcohol." "If they're drinking everyday or binging. It stops them from finding other ways to cope." "If they don't know when to stop. Being drunk everyday, early in the morning when they wake up." 25. Twelve on-reservation women said alcohol abuse is a major problem for Indian women in their community. One woman said, "It's a major problem for Indians everywhere. A lot of women are losing their kids because of alcohol problems." One added, "Over 50% of the women here have a serious drinking problem." When the off-reservation women were asked if alcohol abuse is a major problem for Indian women in their community, seven said it is. "I used to volunteer here to drive the van to pick up ladies who didn't have a car to come in for their prenatal visit. Last one I went to get, it was 9:00 in the morning; she was already too drunk to get in the van to come here." Of those who said it isn't a problem, one said she rarely saw other Indian women except when she came to the clinic. Another said "I'm not too sure around here. But I go back to the reservation in Wisconsin in the summer and it's real bad there and white people come to the reserve and see the whole tribe drunk; they think all those drunk Indians; it's not fair." Another woman said, "It may be but it's not just a problem for Indian women. I don't like when they do that...you know, blame all Indian people just cause some do it. That's wrong." 26. The on-reservation women provided the following explanations for alcohol abuse by women: "A lot is from what they see as children growin' up. No one is watchin' out for the kids. Adults are drinkin‘ all the time. They're livin' with it. Everyone's sittin' around laughin' and partyin'. There's a lot more group drinkin' and visitin', not home by themselves drinkin, but partyin' in groups." This woman (who had her four-year old child with her) then said, "I still go out to party but I don't want my kids see me doin' this so I send them to their Dad's place when I do." (From a woman who told me she had drunk heavily in her earlier pregnancies but had quit three years ago): "I think it's how they feel about themselves, ‘cause I worked with a lot of them when I was back home. And that's what I see, no self respect and no self-esteem, you know, just how they think of themselves, how they look at themselves. I think a lot of it is they are depressed in the kinds of home they live in. I mean it's like the homes that they have for them are not in good shape or they're left home all day with their kids and no one visits them. And when they have the time to go out and have fun, that's the way they'll choose to have it." "It's a pain killer, an 123 anesthetic. You know, someone might say 'So what if it's ten degrees below zero and I don't have wood?’ and just laugh." "The way they were brought up. Families did it together. Some people get married and move away. But there's whole families of drunk men and women." "There is not one answer; it's on an individual basis." "Abuse by spouse, hardships...being on welfare and being taught about drinking." "Sometimes how they're brought up, how their parents acted and drank, then peer pressure. What's happened to hurt them inside." "They learn it; see it as part of life. When people get together, there's always alcohol." "How they feel about themselves. Lots of pressure from being single parents. Lack of self—respect, no self—esteem. How they look at themselves." "Peers accept it, the more drunk you get the better you are. The more you drink the better people think of you." "You grow up with it. You don't see any other life." The next question asked them why some women abuse alcohol. "It has to do with the family they grew up in and the stress in their relationships." Another said, "Financial problems, problems in the home; it's a circle..emotional problems are brought on by lack of money to buy groceries. Problems in the home stem from financial problems, not having this or that. Having to struggle from day to day, not being able to get things for your kids." "She's probably depressed and wants to go out and have fun, and she gets mad for an excuse to have fun. The kids get on her nerves. Her husband is out somewhere drinkin' too." Responses from the off- reservation women include the following: "Seeing friends drink or you just feel like it and like you can run your own life. It's when you ain't got nothin else. You need it." "Parents, how they grew up...you know 'monkey see, monkey do'. It's part of life among a lot of them. You have to be really strong to resist. I have. You have to disown them to change your life. I lost all respect for my parents. They have 18 kids. I'm not close to my brothers and sisters. I'm still mad at my parents. They start drinkin' and let anybody in the house to drink, someone may get raped or beat up. I tell them I'm different from them. I'm strong." "The men in their lives drink and they want to be with him. Their moms did a lot of drinkin’ too." "Lifestyle, pressures, if parents drink too and all your family and they keep a lot of liquor around." "It's not just a family problem. People enjoy the altering feeling of what alcohol will do." "No support, no job, no education, a poor home." "Her huband drinks; so does the whole family. They do it to solve their problems." "Low self— esteem; they need to escape from that and the stress." 27. Twelve on—reservation women said alcohol use by pregnant women is a major crisis facing American Indian people today. "It's as bad as they say. It's worse, ‘cause I don't think a lot of women on reservations 124 they don't talk about it. You know if a nurse comes to their house and asks them I don't think they're truthful with them. I mean 1 know how bad it is ‘cause I'm related to all those people. I grew up with them. I mean I can sit here and say 'I don't know how they can do that' and you know sometimes it gets me mad when I see 'em but I did the same thing myself, and now I try to think, what was I thinkin' then?" "It's a crisis because it's affecting our future generations of kids. They have learning and behavior problems." "Small pox and TB were introduced to the Indian people on purpose. All this AIDS spreading sounds like germ warfare against black people to me. Alcohol was a tool of genocide introduced to the Indians by the white man." "It sure is a major crisis. Alcohol is like crack for the Indian people. And no one has tolerance for crack. It takes a long time to build up a tolerance. The Eskimos coming down died from the cold. Indian people may build up tolerance to alcohol but it will take a long time. The Mediterranean people have used alcohol for centuries and have built up a tolerance. The weak ones were eliminated. Maybe this will happen to us.” "It is a crisis. A lot of girls drink and they don't care. They don't see it as a problem. It sure affects how they take care of their kids." "It's as bad as they say. On the reservation they don't talk much about it, just the social workers do." "We're concerned about extinction. A woman who abuses alcohol when she is pregnant can't bring a baby to full term. Indian people have married so much with other races; the Indian population is down to about 1% of the US. population. We need to get rid of alcohol, spouse abuse, child molestations and teach good values....Like you don't have to drink to be Indian. You know an Indian man today has a life expectancy of 45 years?" "It's not just getting to be a problem; it's been one for years. Just like heart disease and cirrhosis; there's a lot of denial of illness, and alcoholism is an illness." "Alcohol affects a person and the family and the family's choices. You learn that drinkin' behavior. You don't learn coping skills; it's a way of life. Young children think it's condoned; it's natural for kids." "It is a crisis becauses alcoholism is genetic. We must stop this cycle. We don't want a bunch of FAS kids with no chance at all. It's not just Indians who have this either!" Another woman said, "It's a major problem especially among the younger kids." One woman said that, while there is a crisis, "There's a whole lot of other problems. White people see a few Indians drink and they generalize to all of us." "It affects our entire population. These kids are our leaders down the line, this will affect our people. FAS and FAE people will be our leaders. How will they run this tribe? A person I work with is 30 years old now, he's incompetent; I know the history of the family and all the drinking; I'm sure he must have FAE; his level of understanding is real slow." "A lot of young girls drink and they don't 125 seem to care what happens to their child. They don't see it as a problem." Nine off-reservation women said drinking by pregnant women was a crisis for the Indian people. Comments included the following: "It's a crisis because no one takes it serious enough." "Yes, because it's hereditary, you're raised with it, it's all you know. Goes on from generation to generation." "It‘s a crisis because a lot of women who are drinking and they get pregnant, they deny they have a problem til it's too late. They don't want to to give it up . They won't give it up ‘til they get to be elders. Then they die after being sick for about two years. They don't want to quit ‘til they realize the damage; they're sick with disease or they've lost a child." ”Yes it is a crisis. There's a lot of it out there, and even one case is a big problem." "They're exaggerating, it just goes back to the blaming of Indian people for drinking." 28. Eight on-reservation women said alcohol abuse by pregnant women is a problem for the entire culture; two said it is a problem for just the woman and her family; and two said it is for both. Following are some of the comments from the on—reservation women: "For the entire culture because that child will grow up. They're our future." "We all have to deal with it. Too much can ruin something." "That child is damaged. He'll have a very difficult time functioning in the world, the way the world is...to get a job. Alcohol syndrome babies are slow. I've seen kids with it and that child suffers." "It hurts our Indian heritage." "The whole commuity is involved." "Another life is lost and opportunity to teach the ways." "In a way, both. The mother wil feel guilty for doing this to her child. Indians will accept the child, and treat it like a normal kid, but have to take care of him his whole life." "It affects the entire culture; there are more women with alcoholism disease in Indian country. There's no more stigmatization for the female who abuses alcohol." "The children are the future of our people." "Different people in the tribe will have to help that individual damaged by alcohol." Two thought it was a problem for only the mother and child. "The mother will have to give it more attention. She'll have a hard time with this kid." With the off-reservation women, five said it is a problem for the entire culture; four said it is for the woman and her family, and three said for both. Their responses included the following: "For her and her baby. She's the one who'll have to take care of him his whole life." Another said "It's harder for her; she has to live with what she did. She can't blame it on other people. It gives all Indians a bad reputation; it's not fair." "It's a problem for all Indian people. If a woman can't quit and her husband don't either, and her aunties come over with a 'jumbo' she just can't ever give it up. " "It's a 126 problem for everyone. I don't want my kid goin' to school with someone who's got problems 'cause of his mom's drinkin' and he'll disrupt the whole class." "It's a problem for all of us. Leads to bad stereotypes of Indian women. You can go to a pow wow and see lots of women with cans of beer in their hand. A lot of people are turned of ." "It's a problem for both. Rest of the community has to deal with it and feels bad about it....and sees it keep on happening." " It's a problem for everyone, not just the Indian culture. There's so much discrimination but everybody, all races, have to live together. Everyone is affected. Everyone should be more aware." "It shows problems for the whole culture. We're all a group of people and should take responsibility for each other and our culture." "The culture is affected because it prevents them from making it. They have to make it in the United States; it prevents them from having a good life." 29. On—reservation women offered the following recommendations about what should be done to help women who want to give up alcohol. One woman said she had drunk heavily during her earlier pregnancies and then quit in her last one. "It would have helped me to have someone then to come in to the home and be there." "They should see some of the elders and traditional people who offer teachings to get help spiritually." "Offer them more support services, other choices and better lifestyle." "They have to have a program with more women with the same problem. You need to know you're not the only one, otherwise you hide behind the bottle. It was really depressing when I was pregnant last time. I started bleeding second day after I learned I was pregnant. I was hospitalized. I changed my routine of partying and going to bars. My girlfriends all continued to drink. This depressed me cause I quit drinking and had the most problems." "They should be introduced to Indian ways. They're curious and will learn. Then at least they're offered support." "Need better treatment options. Who's going to take care of their kids?" "Chance of becoming alcoholic is high for Indian children; it's genetic. If they have alcoholic parents, they are at great risk of being alcoholic themselves. They need to be better educated." "Must be a lot of support from the community." ”A woman comes back from treatment to the same environment. She may be a single parent; coming back to same economic conditions; she don't have a car." "It should be treated like an illness, like diabetes, but it's not. It needs constant surveillance. It's an illness, but it's talked about like a bad thing, like 'you'll get into trouble.'It's really kind of like a lie then. You're told bad things about alcohol, but it just feels so good. It's a contradiction, scare tactics, and people don't believe it." "They need a support person, 24 hours a day, maybe one or two support people if 127 they're from a drinking family. There's partying at home all the time . How's a woman to quit if she goes home and her grandma's drinkin, and her aunties, and there's a house full of drunk people and the first thing they do is offer her a beer? It's real hard to go for a walk and not drink for a while. You can let your baby know you love him by not drinking. " She also added that women should probably be confronted about their drinking. "There's a whole lot of denial here about the cause of disabilities. If a woman who's been drinking has a baby with disabilities, we should say to her ,'Did you ever consider that this happened because you were drinking when you were pregnant with this child?‘ " "Needs to be more substance abuse get-togethers; the young ones have no one to talk to about this. Parents don't talk to them. They just want to have fun." "There should be more women's support groups geared toward Native American women. It would help to know you're not the only one going through this in your life. It would help to relate to someone else." One young women said she tried to get her friends with young kids out of their houses. "I ask them to go to the park to play with our kids. They need to find other ways to cope." Off-reservation women offered the following recommendations: "There is a need in the beginning to know how to feel good about ourselves." "There should be more support groups for women so they can get together and discuss their problems with other Indian people. That way we feel more comfortable discussing things. Also one—on-one counseling is good." "They should have someone to talk to; there should be groups, but on the other hand, some won't attend. Maybe they don't want everyone to know about the alcohol problem." "They need group therapy, getting off drugs." "They've got to go through it themselves." "Put them in a program and show them what will happen to a baby if you drink. Tell them if you drink so much, it makes you look older." "Make them feel it’s OK to educate themselves as much as possible. Indian culture has a history of drinking so now they're more aware." REFERENCES Aase, Jon M 1981 The Fetal Alcohol Syndrome in American Indians: A High Risk Group. Neurobehavioral Toxicology and Teratologyz3:153—156. Abel, Ernest L. 1990 Fetal Alcohol Syndrome. Oradelleedical Economics Company, Inc. Akutsu, Phillip, D.,S. Sue,N. Zan, and CY. Nakamura 1989 Ethnic Differences in Alcohol Consumption Among Asians and Caucasians in the US: An Investigation of Cultural and Physiological Factors. Journal of Studies on Alcohol 50: 261-267. Allen, Paula Gunn 1986 The Sacred Hoop. Boston: Beacon Press. Bennion, Lynn J. and T.K. Li 1985 "Alcohol Metabolism in American Indians and Whites." Ne England Journal of Medicine 294: 9-13. Camberwell Council on Alcoholism 1980 Women and Alcohol. London: Tavistock Publications. Carpenter, ES. 1959 "Alcohol in the Iroquois Dream Quest". American Journal of Psychiatry. 116:148. Cefalo, Robert C. and Merry—K. Moos 1988 Preconceptional Health Promotion Aspen Publications, Inc. 128 129 Centers for Disease Control 1980 Ten Leading Causes of Death in the United States. Washington, DC US. Government Printing Office Clifton, James, George Cornell, James McClurken 1986 People of the Three Fires: The Ottawa, Potawatomi and Ojibway of Michigan. The Michigan Indian Press. Cohen, Fay G.,R.D. Walker, and S. Stanley 1981 "The Role of Anthropology in Interdisciplinary Reseach on Indian Alcoholism and Treatment Outcome." Journal of Studies on Alcohol 42: 836-845. Crosby, Alfred W. 1972 The Columbian Exchange. Biological and Cultural Consgjuences of 1492. Westport: Greenwood Publishing Company. Dorris, Michael 1985 The Broken Cord Harper and Row Publishers,Inc. Dozier, Edward 1964 "Problem Drinking Among American Indians: The Role of Sociocultural Deprivation." Pacific Historical Review 40: 72-87. Driver, Harold 1969 Indians of North America. University of Chicago Press. 2nd edition, revised. Fenna,D., L. Mix, O.Schaeffer,J.A. Gilbert 1971 Ethanol Metabolism in Various Racial Groups. Canadian Medical Association Journal 105: 472—475. Fisher, AD. 1987 "Alcoholism and Race: the misapplication of both concepts to North American Indians." Canadian Review of Sociology and Anthropology 24:80-97. Foster, George M. 1978 Medical Anthropology. Berkeley:University of California. 130 Fuller, LL. 1975 Alcoholic Beverage Control: Should the remaining reserva— tions repeal prohibition under 18 U.S.C. 1161? American Indian Law Review.3:429. Goedde, H.W., D.P. Agarwal, S. harada, F. Rothhammer, F.D.Whittaker 1986 Aldehyde Dehydrogenase Polymorphism in North American, South American, and Mexican Indian Populations. American Journal of Human Genetics 38: 395-399. Goedde, H.W., D. Agarwal, S. harada, D. Meier-Takman, D. Ruofu, U. Bienzle, A. Kruger, and L. Hussein 1983 Population Genetic Studies on Aldehyde Dehydrogenase Isozyme Deficiency and Alcohol Sensitivity. American Journal of Human Genetics 35:769-772. Goedde, H.W., S. Harada, And D.P. Agarwal 1979 Racial Differences in alcohol Sensitivity: A New Hypothesis. Human Genetics 51:331—334. Goedde, H.W., F. Rothhammer, H.G. Benkman, and P. Bogdanski 1984 Ecogenetic Studies in Atacemeno Indians. Human Genetics 67:343-346. Grollig, Francis X.,S.J. 1976 Medical Anthropology. The Hague :Mouton Publishers . Harada, Shoji,S. Misawa, D. Agarwal, and H. Werner Goedder 1980 Liver Alcohol Dehydrogenase and Aldehyde Dehydrogenase in the Japanese: Isozyme Variation and Its Possible Role In alcohol Intoxication. American Journal of Human Genetics 32:8-15. Heath, Dwight B. 1983 "Alcohol Use Among North American Indians. A Cross- Cultural Survey of Patterns and Problems" In Research Advances in Alcohol and Drug Problems, vol. 7:343-396. Reginald Smart and Frederick Glaser, eds. Horton,D. 1943 The Functions of Alcohol in Primitive Society: A Cross— Cultural Study. uarterl ournal of Studies of Alcohol 4:199. 1 3 1 Hungry Wolf, Beverly 1982 The Ways of My Grandmothers William Morrow and Company Ikuta, Tohru, A. Shibuya, and A. Yoshida 1988 Direct Determination of Usual (Caucasian-Type) and Atypical (Oriental—type) Alleles of the Class I Human Alcohol Dehydrogenase-2 Locus. Biochemical Genetics 26:519-525. Jackson, M.Yvonne 1986 "Nutrition in American Indian Health: Past, Present, and Future." Journal of the American Diabetic Association 86: 1561—1565. Jilek, Wolfgang 1981 Anornic Depression, Alcoholis and a Culture—Congenial Indian Response. Journal of Studies on Alcohol. No.9, 159- 170. Jones, Kenneth and David Smith 1973 Recognition of the Fetal Alcohol Syndrome in Early Infancy. Lancet: November 3, 1973. Kissin, Benjamin and Henri Beglieter 1983 The Pathogenesis of Alcoholism. Biological Factors. Plenum Press. Knowler, William C., David Pettit, Peter H. Bennett, Robert Williams 1983 "Diabetes Mellitus in the Pima Indians: Genetic and Evolutionary Considerations." American Journal of Physical Anthropology 62:107-114. Lamarine, Roland 1988 "Alcohol Abuse Among Native Americans" Journal of Community Health, 13: 143-155. Lamarine, Roland 1989 "The Dilemma of Native American Health." Health Education 12: 15-18. 132 Leland, Joy 1976 Firewater Myths. New Brunswick: Rutgers Center of Alcohol Studies Lewis, Ronald G. 1982 "Alcoholism and the Native American: A Review of the Literature."Alcohol and Health Monograph 4. Special Population Issues. Rockville: National Institute on Alcohol Abuse and Alcoholism. Lewontin, Richard 1984 "Adaptation". In: Conceptual Issues in Evolutionag Biology. C. Sober, ed. MIT. Long, John 1922 John Long's Voyages and Travels in the Years 1768-1788 The Lakeside Press, Chicago. Lucia, Salvatore 1963 Alcohol and Civilization. New YorkchGraw-Hill Book Company. Lurie, Nancy Ostereich 1964 "The World's Oldest Ongoing Protest Demonstration: North American Drinking Patterns." Pacific Historical Review 35: 311-333. MacAndrew, Craig and Robert B. Edgerton 1969 Drunken Comportment: A Social Explanation Chicago: Aldine Publishing Company. Mail, PD, and DR. McDonald 1980 Tulapai to Tokay: A Bibliography of Alcohol Use and Abuse among Native Americans of North America. New Haven: HRAF Press. May, Philip A., Karen Hymbaugh, Jon M. Aase and Jonathon Samet 1988 "Epidemiology of FAS among Indians of the Southwest" Social Biology 30:374—387. 133 May , Philip A., and Karen Hymbaugh 1989 "A Macro-Level FAS Prevention Program for Native Americans and Alaska Natives" Journal of Studies on Alcohol 50:508—518. May, Philip A. 1989 "Alcohol Abuse and Alcoholism Among American Indians: An Overview." in Alcoholism in Minorig Populations, Thomas Watts and Roosevelt Wright, eds.Springfield: Charles C. Thomas, Publisher. Messer, Ellen 1989 "Methods of Studying Determinants of Food Intake." In Research Methods in Nutritional Anthropology. Gretl H. Pelto, Pertti J. Pelto and Ellen Messer,eds. Tokyo: United Nations University. Michigan Department of Public Health 1988 Minority Health in Michigan: Closing the Gap Miller, Paris 1986 Effective Substance Abuse Counseling Among Specific Population Groups. Office of Substance Abuse Services, Michigan Department of Public Health. Office of Substance Abuse Prevention 1985 Alcohol and Native Americans. Oswalt, Wendell H. 1966 This Land Was Theirs. John Wiley and Sons, Inc. Pittman, David J. and Charles Snyder, editors. 1962 Socieg, Culture and Drinking Patterns. John Wiley and Sons, Inc. Reed, T.E. 1978 Racial Comparisons of Alcohol Metabolism Alcoholism 2:83. Ritenbaugh, Cheryl 1978 "Human Foodways: A window on Nutrition". In Anthropology and Health. E. Bauwens, ed.,pp.lll-120. St. Louis: Mosby. 134 Rothschild, Henry R. 1981 Biocultural Aspects of Disease. Academic Press Inc. Sievers, Maurice, MD. and Jeffrey R. Fisher, MD. 1979 "Increasing Rate of Acute Myocardial Infarction in Southwestern American Indians." Arizona Medicine 36: 738—742. Shkilnyk, Anastasia M. 1985 A Poison Stronger Than Love- Destruction of an Ojibway Communigz. New Haven and London: Yale University Press. Smart, Reginald, Frederick Glaser, Yedy Israel, Harold Kalant, Robert Popham, and Wolfgang Schmidt 1983 Research Advances in Alcohol and Drug Problems. Plenum Press. Sobeck, Joanne L. 1990 Lifestyle and Behavioral Risk Factors of Health: A Final Report on a Mail Survey Conducted for the Saginaw Chippewa Tribe. Detroit: Addiction Research Institute, Wayne State University. Sokol, R.J.,J. Marier, S.I.Miller, S. Debanne, C. Emhart, J. Kuzma 1986 "Significant determinants of susceptibility to alcohol teratogenicity." Annals of the New York Academy of Sciences 477:87-102. Stimmel, Barry MD. 1984 Cultural and Sociological Aspects of Alcoholism and Substance Abuse. New York: Haworth Press . Streissguth, Ann, John M. Aase, Sterling Clarren, Sandra Randels, Robin LaDue, and David Smith 1991 "Fetal Alcohol Syndrome in Adolescents and Adults" Journal of the American Medical Association 265: 1961—1967. 135 Streissguth, Ann and J.C. Martin 1983 "Prenatal Effects of Alcohol Abuse in Humans and Laboratory Animals." In The Pathogenesis of Alcoholism, 7:539—589. B. Kissin & H. Begleiter, eds. Teufel, Nicolette and Darma L. Dufour 1990 "Patterns of Food Use and Nutrient Intake of Obese and Non-obese Hualapai Women of Arizona." Journal of the American Dietetic Association 90:1229-1235. United States Indian Health Service, Task Force on Alcoholism 1977 Alcoholism: A High Priorigz Health Problem. Washington: Public Health Service Publication 77-1001. University of Michigan 1978 The Chippewa Health Study: Final Report Vogel, Virgil J. 1972 American Indian Medicine. University of Oklahoma Press. Waddell, Jack O. Malhiot's Journal: An Ethnohistoric Assessment of Chippewa Alcohol Behavior in the Early Nineteenth Century Ethnohistog 32(3):246—268. Wallace, Douglas C., K. Garrison. and WC. Knowles 1985 Dramatic Founder Effects in AmerIndian Mitochondrial DNAs. American Journal of Physical Anthropology 68: 149-155. Watts, Thomas D. and Roosevelt Wright, Jr. 1989 Alcoholism in Minority Populations. Springfield: Charles C.Thomas, Publisher. Weibel-Orlando 1990 "American Indians and Prohibition: effect or affect? Views from the Reservation and the City". Contemporary Drug Problems, summer 1990. 136 West, Kelly, MD. 1974 Diabetes in American Indians and Other Native Populations of the New World. Diabetes, 23:841-855. Westermeyer, Joseph MD. 1974 "The Drunken Indian: Myths and Realities." Psychiatric Annals 4:29-36. Whittaker, James O. 1979 "Alcohol Use and the American Indian: Some Sociocultural Lessons About the Nature of Alcohol." British Journal of Alcohol and Alcoholism 14: 140-142. Wolff, Peter 1972 Ethnic Differences in Alcohol Sensitivity. Science 125:449—450. Wolff, Peter 1973 Vasomotor Sensitivity to alcohol in Diverse Mongoloid Populations. American Journal of Human Genetics 25: 193-199. ‘7 "T" 777.”. ,Y’letlznlwst—r.r~.a. . . ' ‘ ’ ‘ : amt-awn. ll>\:—-. 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