Epidemiology, Etiology, and Motivation of Alcohol ...

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Epidemiology, Etiology, and Motivation of Alcohol Misuse Among Australian Aboriginal and Torres Strait Islanders of the Northern Territory: A Descriptive Review a

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Ramya Ramamoorthi , Rama Jayaraj , Leonard Notaras & Mahiban c

Thomas a

School of Psychological and Clinical Sciences, Charles Darwin University, Darwin, Northern Territory, Australia

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National Critical Care and Trauma Response Centre, Royal Darwin Hospital, Darwin, Northern Territory, Australia c

Department of Head and Neck Surgery, Royal Darwin Hospital, Darwin, Northern Territory, Australia Published online: 28 Jan 2015.

To cite this article: Ramya Ramamoorthi, Rama Jayaraj, Leonard Notaras & Mahiban Thomas (2015): Epidemiology, Etiology, and Motivation of Alcohol Misuse Among Australian Aboriginal and Torres Strait Islanders of the Northern Territory: A Descriptive Review, Journal of Ethnicity in Substance Abuse, DOI: 10.1080/15332640.2014.958642 To link to this article: http://dx.doi.org/10.1080/15332640.2014.958642

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Epidemiology, Etiology, and Motivation of Alcohol Misuse Among Australian Aboriginal and Torres Strait Islanders of the Northern Territory: A Descriptive Review RAMYA RAMAMOORTHI and RAMA JAYARAJ School of Psychological and Clinical Sciences, Charles Darwin University, Darwin, Northern Territory, Australia

LEONARD NOTARAS National Critical Care and Trauma Response Centre, Royal Darwin Hospital, Darwin, Northern Territory, Australia

MAHIBAN THOMAS Department of Head and Neck Surgery, Royal Darwin Hospital, Darwin, Northern Territory, Australia

The per capita alcohol consumption of the Northern Territory, Australia, is second highest in the world, estimated 15.1 liters of pure alcohol per year. Alcohol abuse is a major public health concern among Aboriginal and Torres Strait Islander people in Australia. The Aboriginal and Torres Strait Islanders in the Northern Territory consume approximately 16.9 liters of pure alcohol per year. This descriptive review is based on current published and grey literature in the context of high risk alcohol use, with a special focus on the epidemiological, etiological, and social factors, to predict alcohol misuse among the Australian Aboriginal and Torres Strait Islanders in Northern Territory. The methodology involved a descriptive search on PubMed, Northern Territory government reports, health databases, and Web sites with an emphasis on the etiology and Note: Australian Aboriginal and Torres Strait Islanders are currently termed as Indigenous people. Financial support provided by the National Critical Care and Trauma Response Centre, Royal Darwin Hospital, Darwin. Address correspondence to Rama Jayaraj, School of Psychology and Clinical Sciences, Charles Darwin University, Yellow 2.2.14, Ellengowen Drive, Casuarina, NT 0909, Australia. E-mail: [email protected] 1


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R. Ramamoorthi et al.

epidemiology of high-risk alcohol consumption among the Australian Aboriginal and Torres Strait Islanders of the Northern Territory. This review has its own limitations because it does not rely on systematic review methodologies. However, it presents real data on the motives for binge drinking and alcohol-related violent assaults of this vulnerable population. Alcohol abuse and alcohol-related harms are considerably high among the rural and remote communities where additional research is needed. High-risk alcohol misuse within Australian Aboriginal and Torres Strait Islanders communities often leads to a series of physical and social consequences. This review highlights the need for culturally appropriate intervention approaches focusing on alcohol misuse among the Aboriginal and Torres Strait Islanders population of the Northern Territory. KEYWORDS high-risk alcohol consumption, Australian Indigenous people, Northern Territory, etiology of alcohol misuse

INTRODUCTION High-risk alcohol consumption among the Indigenous people is widespread. Indigenous communities frequently face the harmful consequences of high-risk alcohol consumption (Saggers & Gray, 1998). As per the Health and Welfare of Australia’s Aboriginal and Torres Strait Islander People’s report, high risk alcohol consumption was estimated based on the largest quantity of alcohol consumed in a single day during a fortnight (Australian Bureau of Statistics [ABS], 2013). Indigenous alcohol abuse is also highly prevalent in Australia (ABS, 2010; Chikritzhs, Heale, & Webb, 2000; Chikritzhs & Pascal, 2004), New Zealand (‘‘About Indigenous People,’’ 2007; National Drug Strategy, 2001), and Canada (ABS, 2013). Alcohol abuse was noted to be highest among Native American or Alaska Natives in the 12 to 17 years age group in 2000–2003 (Library Index, n.d.). Australian Indigenous people comprise 32% of the total Northern Territory (an Australian Territory in the centre and the central northern regions of the continent; ABS, 2012) population (Department of Families, 2011). Australian Indigenous people in the rural and remote communities of the Northern Territory are currently facing serious social and health issues due to high-risk alcohol consumption and alcohol-related violence. The aim is to outline briefly the epidemiology and etiology of high-risk alcohol consumption among the Australian Aboriginal and Torres Strait Islanders in the Northern Territory.

ALCOHOL CONSUMPTION AMONG THE INDIGENOUS POPULATION Indigenous Australians constitute 2.5% of Australia’s population (Department of Families, 2011). However, in 2008, 17% of Australian Indigenous people


Epidemiology, Aetiology and Motivation of Alcohol Misuse

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aged 15 years and older reported drinking at high-risk levels in the past 12 months, representing no significant change from 2002 (at 15%) (Australian Institute of Health and Welfare, 2011). In the Northern Territory, each person older than age 14 years consumes 1.5 times the national average, estimated to be an average of 15.1 liters of pure alcohol per year (Chikritzhs & Pascal, 2004). The Northern Territory Indigenous Australians consumption in 2004-2005 is estimated to be 16.9 liters of pure alcohol per year (South Australian Centre for Economic Studies, 2009). The proportion of alcohol consumption among the Indigenous adults was 50% in 2008, comprised of 63% of Indigenous men and 36% of Indigenous women who had consumed alcohol in 2007 (National Aboriginal and Torres Strait Islander Social Survey, 2008). ETIOLOGY High-risk drinking among the Indigenous people is motivated for the following reasons (‘‘Aboriginal alcohol consumption,’’ n.d.; Kominka, 2011): 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Breakdown of customary practices and social control mechanisms; Traditional Indigenous rules on the alcohol consumption; Indigenous group identity; Culturally introduced sharing ethos; A lack of processes for reducing tension; Poverty; Homelessness; Overcrowding; Unemployment; Payday binge and Mining royalty

BREAKDOWN OF CUSTOMARY PRACTICES AND SOCIAL CONTROL MECHANISMS Social control mechanisms among the rural and remote Indigenous communities are informal in the sense that leaders do not inherit power and they are not all powerful nor do they dictate to the clan (Berndt & Berndt, 1985). The Indigenous leaders are simply elders of the community and traditionally control each Indigenous community in the Northern Territory. In the past, the Indigenous control mechanism was maintained through the infusion of religious ideology and purely exerted by elders of the Indigenous community thorough uniting all community members together in their ceremonial activities. In due course, the increasing numbers of disgruntled young Indigenous people are likely to challenge their elders for various reasons.


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In addition, the Australian Federal Government policy proposed a notion of individuality that deteriorates customary control enforced by elders among the Indigenous people in the rural and remote communities (Australian Law Reform Commission, n.d.). Currently, these customary practices and social control mechanism have been wrecked by the fragmentation of Indigenous community groups and migration of community members from rural and remote areas to urban. Currently, the major concerns of the community elders in the many Indigenous communities are high-risk alcohol misuse and alcohol-related violence. The Northern Territory government reports highlighted that 52% of family violent incidents were alcohol related and 3449 alcohol-related domestic violence offences were reported to the police in 2010 (Alcohol Policing Strategy 2010-2012, 2010; Northern Territory Quarterly Crime & Justice Statistics Issue 32 to 30 June 2010-12-06, 2010). TRADITIONAL INDIGENOUS RULES ON THE ALCOHOL CONSUMPTION All Indigenous customary rules are primarily considered as laws. These laws do not distinguish between Holy matters and social behaviors (Debelle, 1997). Breaching sacred law or committing incest or murder are generally considered as public wrongs, whereas private wrongs consist of homicide and adultery. The Indigenous community elders used to take effective actions against public wrongs; however, victims usually decided the suitable punishment for private wrongs. Alcohol abuse is an introduced problem to the Indigenous communities and is not generally controlled by Indigenous customary laws, which may seem to be regarded as desirable by Indigenous themselves (‘‘Per capita alcohol consumption. . .,’’ 1997). INDIGENOUS GROUP IDENTITY High individual group fragmentation in the rural and remote Indigenous communities is associated with appropriate social and ideological underpinning. Indigenous group identity is frequently related to the index of alcohol misuse. Indigenous group identity stands for the last link to a social network, especially on the rejected urban fringes of society. Excessive drinking behavior is often noticed among these Indigenous fringe groups in the rural and remote Indigenous communities (Larsen, 1980). CULTURALLY INTRODUCED SHARING ETHOS Sharing ethos is considered as a deep routed need for survival among the Australian Indigenous society. Sharing is the most important ethos of the Indigenous culture. It is considered as the nature of Indigenous kinship obligations and a desire for social harmony. Food, weapons, or land were shared in the past, whereas money is now shared more than anything among the


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Indigenous community members. Communal gambling and alcohol drinking are also major occasions for sharing money among the Indigenous people. Particularly, drinking is considered juncture for leisure and excitement among the Indigenous people in the rural and remote communities (Sackett, 1988).


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LACK OF PROCESSES FOR REDUCING TENSION

Problem drinking may often tend to be associated with an onset of symptoms related to social phobia. Indigenous people may fear of mingling at a non-Indigenous social gathering where there may be many unfamiliar people. Indigenous people may use alcohol as a primary means of coping with fear and anxiety, but there is no valid research study to examine stress associated with socializing. One theory of why this occurs is the tension reduction hypothesis. This theory suggests that alcohol is used as a self-medicating method to reduce stress and anxiety (Ankrom, 2009). The initial effects of alcohol may reduce tension or inhibitions. This may could help to explain the reasons for Indigenous binge drinking (‘‘Alcohol use background information,’’ 2013). POVERTY The intricate links between poverty and binge drinking are clearly illustrated by the issues of access to employment, education, health costs, and access to housing. These links create a cycle of poverty that may further worsen the living conditions of Indigenous people by binge drinking. It also degrades their quality of life in the remote Australian Indigenous communities to a point where fundamental needs like housing and food are often compromised (‘‘The Links Between Alcohol . . . ’’, 2003). The Northern Territory (NT) alcohol and other drug agencies are able to provide considerable assistance and support to Indigenous families and individuals in rural and remote communities, but their limited resources cannot meet the high level of need in the community. The isolation from urban areas and poverty of Indigenous people along with binge drinking deter the support provided by those agencies (Australian Institute of Health and Welfare, 2003). HOMELESSNESS Higher rates of homelessness and unemployment among the NT Indigenous communities can result in high rates of alcohol-related harm (Australian Institute of Health and Welfare, 2003). The Indigenous kinfolk’s obligation is to provide help to one another in a time of need. This kith and kin obligation acts to shape the structure of the Indigenous response to the need for housing, leading to overcrowding, high alcohol abuse, violence, and


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the experience of homelessness (Birdsall-Jones, Corunna, Turner, Smart, & Shaw, 2010). The shared home may become the place for community member’s gatherings, which result in heavy drinking and alcohol-related fights. This violent act associated binge drinking may lead to physical and sexual abuse of women or children in the shared household of Indigenous communities (‘‘Homelessness and Indigenous Australians,’’ 2014). Primary cause of homelessness among the NT Indigenous Australians is the family violence. According to the Australian Government’s Aboriginal Land Rights Act, large areas of the Northern Territory Indigenous lands have been returned to groups of the Northern Territory traditional owners in 1976 without identifying individuals and providing individual property rights (Hughes & Hughes, 2012). The Northern Territory Indigenous groups ‘‘own’’ those land communally, but they are strictly restricted to secure title over their own land for constructing a private house or private business premises. As a result, Indigenous people were not allowed to build houses on their own land (Hughes & Hughes, 2012). However, they are allowed to lease those lands to mining companies. In the Northern Territory, 63% of Indigenous people represent homeless service users (‘‘Homelessness and Indigenous Australians,’’ 2014). OVERCROWDING Overcrowding in housing is a major public health problem in the Northern Territory. In rural and remote communities, 17 people can share a 3-bedroom house in the Northern Territory (‘‘About Indigenous People’’, 2007). Indigenous people are six times more likely to live in overcrowded household than non-Indigenous Australians (‘‘Homelessness and Indigenous Australians,’’ 2014). Overcrowding in the rural and remote communities is often associated with shortage of housing in the Northern Territory. In addition, housing prices are very high and not affordable in the Northern Territory. Overcrowding is often considered one of the major causes of hidden homelessness among Indigenous communities (‘‘Homelessness and Indigenous Australians,’’ 2014). Many Indigenous people from rural and remote communities have to travel to urban health centers to access basic services. In this circumstance, they may temporarily stay with their families and relatives in an overcrowded house or in public places (‘‘Homelessness and Indigenous Australians,’’ 2014). Children often are at risk from visitors with alcohol misuse and overcrowded conditions that may disrupt their education. In response to these circumstances, children may leave home and return when circumstances improve. However, if the home continues to operate as a venue for alcohol and=or drug abuse, these circumstances may drive the children away permanently and they end up in staying in shelters (Birdsall-Jones et al., 2010).


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UNEMPLOYMENT The Indigenous unemployment rate is approximately three times higher than that of non-Indigenous people in Australia (‘‘About Indigenous People,’’ 2007). Indigenous people also often rely on government-funded unemployment work programs, such as the Community Employment Development Program (‘‘About Indigenous People,’’ 2007). Labor force participation rates for Indigenous people decrease with remoteness, with a 57% participation rate in major cities compared with a 46% participation rate in very remote areas (ABS, 2006b). Nationally, 54% of all Indigenous peoples aged 15 to 64 years were participating in the labor force in 2001. This figure increased to 57% in 2006 (ABS, 2006a). The unemployment rate of Aboriginal and Torres Strait people in 2009 was 18%, which is more than three times the rate than non-Indigenous Australians. The major proportion of Aboriginal employees were at lower salary levels was 63% (Korff, 2014), which is often based on their qualification level and experience. This figure indicates that they were not actively engaged in the labor market for reasons that included high alcohol abuse, illness, disability, or a lack of market opportunities. PAYDAY BINGE Indigenous people often drink in groups; however, the focus is not enjoying each other’s company and getting drunk rather than socializing like their non-Indigenous counterpart. Indigenous drinkers commonly migrate from the rural and remote communities, where access to alcohol is restricted, to Darwin and Alice Springs to engage in binge drinking activity with family members and friends (Jayaraj, Thomas, Thomson, et al., 2012). Binge drinking among the Indigenous population is often funded by government Centrelink allowances. These paydays commonly occur every other Thursday and have always been the binge drinking days for Indigenous people in the Northern Territory (National Drug Strategy, 2001). Due to the effect of this payday bingeing, the Indigenous people often live without money for the remainder of the payment period, relying on ‘‘humbugging’’ (i.e., demanding money from) others to survive financially. MINING ROYALTY Mining monies for leasing their Indigenous lands have become a major source of income, supplementing government grants for services and social security payments for Indigenous people in a few remote communities. The Aboriginals Benefit Account received $155 million in royalties and had more than $400 million deposited in Australian banks in 2010–2011 (Department of Families, 2011). The Indigenous economy was based on sharing, and Indigenous people generally do little financial planning. As a result of these

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two factors, there is no relationship established between future royalty payments and Indigenous financial security in the future. Alcohol was the major preoccupation of a large group of Indigenous people in those communities. Mining impacted alcohol misuse among Indigenous people in several ways: the availability of royalty revenues, greater power to purchase alcohol and vehicles, opening of new liquor outlets, and the lethal combination of alcohol and vehicles (Wilson, 1997).


ALCOHOL-RELATED VIOLENT ASSAULTS The primary cause of alcohol-related injury for hospital admission in the Northern Territory in 1991–2001 was violence (You & Guthridge, 2005), estimated to be 38% of the total injury admissions for Indigenous people. Alcohol-related violence involves large numbers of young adults in pubs and clubs in the two major cities of Northern Territory—Darwin and Alice Springs—on weekend nights. The close family members and friends of Indigenous people involved in binge drinking are highly prone for violent assaults (Jayaraj, Thomas, Thomson, et al., 2012). In the Northern Territory, the proportion of alcohol-related assaults are 60% (Northern Territory Quarterly Crime and Justice Statistics, 2010). An intoxicated husband or another family member is often responsible for the violent assaults against women in the rural and remote Northern Territory communities. The Indigenous people in the remote communities migrate to Darwin and Alice Springs in the Northern Territory and they often stay in the bushes, relative’s homes, parks, or narrow pathways. These places are the primary sites of the Indigenous assaults in the Northern Territory urban area. Alcohol-related violent assaults among the Indigenous population leads to high incidences of facial trauma patients at Royal Darwin Hospital (Jayaraj, Thomas, Kavanagh, et al., 2012; Jayaraj et al., 2013; Nagel, Jayaraj, Ah Kit, Thompson, & Spencer, 2010).

CONCLUSION Alcohol is the biggest public health issue among the Northern Territory Australian Indigenous population. The negative consequences of high-risk drinking among Indigenous people are clearly reflected as a high alcohol-related mortality and morbidity in the Northern Territory. Cultural isolation and the challenges to implementing and evaluating culturally appropriate intervention are often coupled with funding need. This need has contributed to the proliferation of hospital-based intervention programs that are currently unacknowledged. These requirements fulfill the objectives of the Australian Government closing the gap by utilizing culturally appropriate screening tools to identify those at risk, the study of the population of


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those with recurrent alcohol incidences in an attempt to identify those maximally at risk after an initial injury.


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