ACKNOWLEDGEMENTS. Blair, Dr. D. Nagaraja, Director, NIMHANS, Bangalore, Dr. Sasikeran, Director, NIN, Hyderabad, Dr. GNV Brahmam,

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1 ACKNOWLEDGEMENTS Alcohol consumption: prevalence and pattern in Andaman and Nicobar Islands, a collaborative project of RMRC, Port Blair, NIMHANS, Bangalore, and ActionAid, International India is funded entirely by ActionAid, International India. We acknowledge their support. We are thankful to Dr. P. Vijayachari, Director, RMRC, Port Blair, Dr. S. C. Sehgal, former Director, RMRC, Port Blair, Dr. D. Nagaraja, Director, NIMHANS, Bangalore, Dr. Sasikeran, Director, NIN, Hyderabad, Dr. GNV Brahmam, Deputy Director (SG), NIN, Hyderabad, and Dr. Vishnuvardhan Rao, Assistant Director, NIN, Hyderabad, and Harjeeth Singh the team leader of Action Aid, International India in A&N Islands for their help in successful completion of this project. We acknowledge the support of Directorate of Social Welfare, A&N Administration in general and the enthusiastic involvement of Mr. Mohammed Habib, the then Director of Directorate of Social Welfare, Andaman and Nicobar Administration in developing this project. We acknowledge the extensive co-operation extended by the Tribal Council Car Nicobar in particular and the countless tribal volunteers in general. We acknowledge the active involvement of the office bearers and field staff of ActionAid, International India in general and Mr.Mihir Mohanty, Ms.Monica singh, Mr.Neeraj, Ms. Anupama, Mr. Sajeev, and Ms.Sheetal in particular. We acknowledge the help of many known and unknown for their direct and indirect help during the entire project. Dr. Sathya Prakash.M Dr. Vivek Benegal Dr. Balakrishna. N Dr. A. P. Sugunan Dr. K. Thennarasu Dr. D. Pandian RMRC, Port Blair NIMHANS, Bangalore NIN, Hyderabad

2 Alcohol, tobacco and other substance abuse affects a disproportionately large section of people in India. The National Household Survey of Drug Use in the country (Ray, 2004), the only systematic effort to document the nation-wide prevalence of drug use in India, recorded alcohol use in the past year in about 21% of adult males. Prevalence among adult women has consistently been generally estimated at less than 5% (Benegal et al, 2005; Isaac, 1998). Significantly higher use has been recorded among tribal, rural and lower socio-economic urban sections (Ray & Sharma, 1994). However, the relatively low prevalence of alcohol use (compared to other cultures) is offset by the alarming signature pattern of alcohol use in India, i.e. heavy drinking, typically more than five standard drinks on a typical occasions (Benegal et al, 2003; Gaunekar et al, 2004; Mohan et al, 2001). Repeated observations have documented that more than 50% of all drinkers satisfy criteria for hazardous drinking. Under-socialized, solitary drinking of mainly spirits, drinking to intoxication and expectancies of drinkrelated disinhibition and violence add to the hazardous patterns (Gupta et al, 2003; Saxena, 1999). The impact of a health problem should not be gauged merely by its prevalence but by the burden and social cost that it wreaks on society. Alcohol misuse wreaks a high social cost. In addition to the health costs, there are indirect costs linked to a wide variety of social costs - family disruption, marital disharmony, impact on development of children, deprivation of the family, absenteeism and industrial loss, crime and violence, etc.( Benegal et al, 2007). The social cost attributable to alcohol use, extrapolated to the entire country was estimated at Rs 244 billion for the year Studies have strongly linked alcohol misuse to poverty. Alcohol related health care costs can result in catastrophic impoverishment among alcohol using households including severe adverse consequences like debt entrapment and distresses selling of assets (Bonu et al, 2005). With a steadily increasing per capita consumption and given the patterns of drinking prevalent (Benegal, 2005) beverage alcohol will increasingly add to the burden of disease in India. The consequences of alcohol have not however been comprehensively documented in India. The available evidence is from individual studies in isolated areas based on the specific interests of researchers. The wide socioeconomic and cultural variations within the country make it highly unlikely that assessments made in one part of the country, will accurately measure the situation in another part of India. Andaman and Nicobar Islands an archipelago in Bay of Bengal: brief back ground: Andaman and Nicobar Islands is a union territory an archipelago of more than 500 islands and islets located at longitude of 92 to 94 degree east and latitude of 6 to 14 degree north in the Bay of Bengal 1200 km away from main land India. But only 38 islands are inhabited. Total area of Andaman and Nicobar Islands is 8249 Sq.Km. It has 3 districts and 7 tehsils. According to 2001 census the population of the archipelago is The sex ratio is 1000:846. It is home for six aboriginal tribes among which the Nicobarese constitute the largest group and their population is more

3 than They live in Nicobar group of islands in the south. The combined population of other five aboriginal tribes doesn t exceed Andaman and Nicobar Islands is unique in the sense that people of different ethnic and linguistic background live here. The north and middle Andaman are inhabited predominantly by Bengalis either settlers who are rehabilitated by Govt. of India under settlement schemes or non-settlers who came in search of better livelihood. Rural South Andaman is constituted by people of different linguistic communities like Bengalis, Tamilians, Malyalis etc. belonging to settlers,non-settlers and pre-42 strata. Urban Port Blair is also a mixture of people from various ethnic and linguistic back ground. However the significant proportion is constituted by government employees. The islands of south Andaman like Neil, Havelock, and Hut Bay (Little Andaman) are inhabited predominantly by Bengalis who are rehabilitated there under different settlement schemes by Govt. of India. Nicobar group of islands is home for Nicobarese an aboriginal tribe. However, in Campbell bay there is a Sikh settlement. There are more than tribal people from present day Jharkand and Chattisgad who were either bought or later came on their own as labourers are living in the archipelago and they are dispersed throughout the island from Diglipur in the north to Campbellbay in the south.

4 Sales (in crores of Rupees) Alcohol misuse in the Andaman and Nicobar Islands - rationale for the study: There is no reliable data on the consumption of alcohol in Andaman and Nicobar Islands and problems related to alcohol misuse. However, there has been a significant increase in the sale of alcohol between 2005 and The revenue from alcohol sales increased from Rs lakhs in January 2005 to Rs lakhs in January The corresponding increase in February during the same period was 78 lakhs and in March it was 35 lakhs (Andaman and Nicobar Islands Integrated Development Corporation Ltd Performance review for the year ). Alcohol sales in Andaman: % 10.20% 3.64% 19.66% 16.8% Years Sales It is also observed by the experts in G.B.Pant Hospital, that consultations for alcohol related problems are on the increase. However, there are no available estimates of the magnitude of the problem. There is also general consensus among social workers and psychologists that the natural and manmade disasters consequent to the earthquake and the subsequent tsunami that devastated these islands in 2004 have precipitated various psycho-social problems including alcoholism. A large number of people lost near relatives, lost their assets and means of livelihood, were displaced from their homes and their homelands and a large proportion have had to face the daunting prospect of dealing with the loss of their entire way of life. It is well known that alcohol and other substance use tends to worsen in persons who face the emotional consequences of disasters. There is a strongly held belief that there has been an alarming increase in alcohol consumption with subsequent problems. This has among other things

5 severely impaired initiatives to enhance the developmental and economic parameters of the people in this region. However, this remains an untested proposition. It is necessary to validate this assumption and, if true, there is an urgent need to institute appropriate intervention measures for prevention and control of the problem. Baseline data on the extent of the problem is therefore necessary. The current study was planned to estimate the prevalence and examine the patterns of alcohol consumption in the archipelago and its consequences on public health. In the context of the wide ranging impact of the tsunami, it was also planned to study the psychological well being of the people and its effects if any on alcohol misuse. Data on tobacco misuse was also collected. Aims and Objectives: Aims: To conduct an epidemiological study of alcohol consumption and its consequences in Andaman and Nicobar Islands. Specific objectives: (i) To estimate the prevalence and patterns of alcohol and tobacco consumption and its public health consequences among the population of Andaman and Nicobar Islands. (ii) To study the residual psychological consequences of the tsunami and explore its effects on alcohol misuse Method: The current study is a collaborative project of Action Aid International India, the Regional Medical Research Centre (ICMR, Port Blair) and the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore. Study Design: A cross sectional population based survey was undertaken to assess the prevalence and pattern of alcohol consumption among the population of Andaman and Nicobar Islands. Sample size and sampling strategy: Since there is no earlier data to guide the estimation of the required sampling frame, the study made assumptions based on previous studies conducted in the Indian mainland. The National Household

6 Survey of Drug Use in the country (Ray et al, 2004), the only systematic effort to document the nationwide prevalence of drug use in India, recorded alcohol use in the past year in only 21.4% of adult males. Assuming a prevalence of 20% and absolute precision of 2% the required sample size is Keeping in mind the diversities in geographic, social, cultural, and economic factors existing in the islands of Andaman and Nicobar Islands the study determined to focus on the five prominent social groups which characterize the population of these islands, namely: 1] the indigenous peoples of the archipelago - Nicobarese tribes people, 2] the re-settled tribal populations from Jharkhand region (known locally as the Ranchi tribals), 3] people from the mainland who had settled in the islands before 1942, 4] later settlers and 5] non-settlers people from the mainland temporarily living in the islands due to business and employment considerations. Hence the minimum sample size was fixed to 1600 x5=8000. Households were considered as sampling units. Accounting for the possible design effect because of using households rather than individuals as sampling units and allowing for non-compliance, a total sample size of 18,000 was fixed. Although the idea was to select sufficiently large sample of people to estimate the prevalence of alcohol consumption with the required precision in each stratum, a stratified sampling strategy was not used because of the absence of stratum-wise sampling frame. It was decided to select the study subjects at random without stratification and then to check that adequate number of subjects from each stratum was included in the sample. A multistage random sampling was followed. In the first stage required numbers of villages are chosen at random sampling and in the second stage households in the village were chosen by following the same sampling method. In Car Nicobar all 300 tuhets were enlisted and the tuhets were chosen randomly and all the members aged 14 and above were interviewed. This procedure is followed until the required sample size is met. Subjects: Persons aged 14 and above residing in Andaman and Nicobar Islands. Investigations: The interviews were conducted using a two-stage process. First, eligible households were identified, using the census enumeration data and the sampling schema outlined above. After obtaining informed consent from the head of the family or other responsible family member the interview instruments were administered. All the instruments had been reliably translated into Hindi (using the standard translation-back-translation methodology).

7 Instruments 1. A Family Questionnaire which collected composite data about the family (number of members, demographics, illness profile, alcohol and tobacco use status) from any reliable adult member belonging to the family. From the list of family members, individual subjects were randomly selected to be interviewed on the Individual Subject Questionnaire. 2. An Individual Questionnaire The questionnaire used was a modified version of an instrument which has been used successfully in several multi-country epidemiological studies of the World Health Organisation. The questionnaire has been used previously in India (Benegal et al, 2005) for a multi-country epidemiological study on the effects of gender and culture on alcohol misuse. The instrument was simplified for the present study, to focus on alcohol and tobacco use parameters. Additionally, several modules were added, to specifically study the emotional status of the population and the persisting impact of the tsunami, if at all. The modules comprised A. Socio-demographic details of the individual B. Checklist of known illnesses the individual has suffered in the past year which has required formal medical consultation. C. General Health Questionnaire (GHQ 12): to assess the mental health status of the individual. Despite its title GHQ is designed to assess mental health, not general health. It is a measure of current mental health (Goldberg, ) extensively used in different settings and different cultures. It has been extensively used in epidemiological studies in India. Developed for use as a screening instrument in community settings, primary care, and medical out-patients, it focuses on breaks in normal functioning, rather than lifelong traits and concerns itself with two major classes of phenomenon a] inability to carry out one s normal healthy functions and b] appearance of new phenomena of a distressing nature. Originally developed as a 60-item instrument, it has a range of shortened versions of the questionnaire including 12 item GHQ-12. The scale asks whether the respondent has experienced a particular symptom or behaviour recently. Each item is rated on a four-point scale (less than usual, no more than usual, rather more than usual, or much more than usual); and when using the GHQ-12 it gives a total score of 36. GHQ is a good measure of psychological well being in the population. The sensitivity and specificity of the 12-item General Health Questionnaire among persons of Indian origin has been shown to be high and it can be

8 employed as a screening instrument to identify individuals with psychiatric morbidity in the Indian population (Jacob et al, 1997). D. Trauma Screening Questionnaire (to screen for presence Post Traumatic Stress Disorder): This self report questionnaire designed for trauma victims in general, consists of 10 items. Of these, five are re-experiencing items and five are arousal items taken from the PTSD Symptom Scale. A useful threshold is to ask whether symptoms have occurred at least twice in the past week (Brewin et al, 2002). When the cut-off is set to require the endorsement of at least six reexperiencing or arousal items in any combination, the overall efficiency of the screening instrument has been found equivalent to that obtained from a comparison of diagnoses yielded by the two most highly regarded interview assessments currently available for PTSD: the Structured Clinical Interview for DSM-IV (SCID; First et al, 1996) PTSD module and the Clinician- Administered PTSD Scale (CAPS I; Blake et al, 1995). Subjects having a score of 6 and above were considered to be suffering from PTSD. E. Fagerström Test for Nicotine Dependence (FTND). It is a six item questionnaire to assess the pattern and severity of Tobacco use. We used items from both the versions for smoking (Heatherton et al., 1991) and smokeless tobacco use (Ebbert et al, 2006). This is a set of 6 questions having a maximum score of 10 which categorises the consumers of tobacco into various grades of dependence [0-3 = Low; 4-6= Medium; 7-10= High] F. Alcohol Use Disorders Identification Test (AUDIT) The AUDIT is a simple ten-question test developed by the World Health Organization to determine if a person's alcohol consumption may be harmful. The test was designed to be used internationally, and was validated in a study using patients from six countries. Questions 1-3 deal with alcohol consumption, 4-6 relate to alcohol dependence and 7-10 consider alcohol related problems. A score of 8 or more in men (7 in women) indicates a strong likelihood of hazardous or harmful alcohol consumption. A score of 13 or more is suggestive of alcohol related harm. The interviews were carried out by 30 trained field workers, under the supervision of one of the investigators from the RMRC. The data collected was cross checked every week and test-retest and inter-

9 rater reliability exercises were carried out by conducting repeat interviews in randomly selected individuals in each sampling zone. The collected data was entered into computers using custom soft ware by trained data entry operators. Data cleaning was done once weekly. The data was analysed by using the Statistical Package for Social Studies version Ethical issues: The study proposal was presented to Institutional Ethics Committee and prior approval was obtained. The interview was carried out in private with the informed consent and strict confidentiality was maintained. Time frame: The project was conceived and preparatory work started in June In November 2006 the training was imparted to field staff. In December 2006 pre-testing of the questionnaire and standardisation of field staff in interview technique was carried out. From January 2007 to December 2007 the field survey was carried out through out Andaman and Nicobar Islands. The data was entered simultaneously and analysis of the data was over by October Man power: Thirty trained and standardised field staff carried the survey and the Principal Investigator and qualified psychologist and Social Workers from ActionAid International, India monitored the survey and through out the survey a quality check was maintained. Training and standardisation: A training session in interview technique was conducted by a team consisting of Psychiatrist, Psychiatric Social Worker, and Epidemiologists from RMRC Port Blair, NIMHANS, Bangalore, and ActionAid International, India to all field staff. For one month pre-testing and standardisation was carried out prior to the start of survey.

10 Training in progress A view of participants

11 RESULTS A. Demographics Table 1a: General demographic characteristics of the sample by gender (%) Characteristics Total n (%) Male Female (100) Age-Mean (SD) 35.2 (15.0) 36.2 (15.36) 34.3 (14.5) Area North & Middle Andaman 3621 (20.1) South Andaman Rural 6933 (38.5) South Andaman Islands 2909 (16.1) Urban Port Blair 2040 (11.3) Car Nicobar 1870 (10.4) Campbell Bay 645 (3.6) Population groups (100) Settler 6131 (34) Non-settler 7511 (41.7) Ranchi 2028 (11.3) Nicobarese 1891 (10.5) Pre (2.5) Table 1b: Socioeconomic characteristics of the sample by gender (%) Characteristics Total n (%) Male Female Education None 3687 (20.5) < 8 years 4003 (22.2) years (57.3) Religion (100) Hindu (64.1) Christian 5298 (29.4) Muslim 1163 (6.5) Sikh 13 (0.1) Marital status Married/ Living with partner (63.7) Widowed/divorced/separated 1030 (6.1) Never married 5438 (30.2) Monthly Income (Rs.)- Mean (SD) ( ) (2795.6) 384.0( ) Employment Govt. Employee 2167 (12) Non-Govt. Employee 3080 (17.1) Self employed 1912 (10.6) Non-paid (Volunteer) 142 (0.8) Student 2629 (14.6) Housewife 5924 (32.9) Retired 442 (2.5) Unemployed (able to work) 1339 (7.4) Unemployed (unable to work) 380 (2.1)

12 Table 1c: Distribution of age, education, income and occupation across different population subgroups Male Female Nicobar Ranchi Pre42 Settler Non settlers Total pop Nicobar Ranchi Pre42 Settler Non settlers Age % 41.7% 35.6% 40.6% 42.6% 40.6% 36.2% 45.2% 38.8% 45.1% 47.0% 44.7% % 25.1% 30.7% 30.5% 29.4% 29.3% 34.2% 30.1% 29.3% 29.7% 31.4% 30.9% >= % 33.2% 33.8% 29.0% 27.9% 30.0% 29.6% 24.7% 31.9% 25.2% 21.7% 24.4% Education Illiterate 23.8% 20.8% 8.9% 9.4% 17.8% 15.7% 31.8% 28.6% 18.1% 19.9% 27.8% 25.4% <8yrs 26.6% 23.1% 12.9% 25.2% 20.3% 22.7% 22.8% 16.6% 15.1% 24.4% 21.0% 21.7% >=8yrs 49.6% 56.1% 78.2% 65.4% 61.9% 61.7% 45.4% 54.8% 66.8% 55.7% 51.2% 52.8% Income None 43.5% 21.2% 23.6% 29.7% 26.0% 28.3% 93.9% 86.4% 87.9% 89.1% 89.5% 89.5% < % 30.0% 15.1% 29.9% 25.1% 27.5% 2.2% 8.0% 2.2% 5.7% 5.1% 5.2% >= % 48.8% 61.3% 40.4% 48.9% 44.2% 3.9% 5.6% 9.9% 5.2% 5.4% 5.3% Occupation Govt. Employee 9.9% 25.6% 39.6% 17.0% 22.5% 20.2% 3.1% 3.4% 8.6% 3.3% 3.8% 3.6% Non-Govt. Employee 3.4% 41.8% 25.3% 27.7% 35.1% 30.2% 1.2% 7.0% 2.6% 4.1% 3.2% 3.7% Self employed 46.8% 3.7% 1.3% 25.9% 13.5% 19.4% 2.2%.9%.4% 1.5% 1.7% 1.6% Total pop Non-paid (Volunteer) 4.6% 1.1% 1.5%.6% 1.3%.6%.6%.4%.2%.1%.3% Student 10.6% 11.6% 14.7% 13.8% 16.4% 14.4% 9.4% 15.1% 15.5% 13.2% 17.6% 14.8% Housewife 2.9%.7%.4% 1.1%.6% 1.0% 67.8% 59.3% 62.1% 69.7% 63.6% 65.6% Retired 3.8% 7.5% 11.1% 2.7% 3.7% 4.0%.1% 1.8%.9%.6% 1.1%.9% Unemployed (able to work) Unemployed (unable to work) 12.2% 6.7% 5.3% 6.7% 6.2% 7.0% 14.5% 11.1% 7.8% 5.3% 7.4% 7.9% 5.8% 1.3% 2.2% 3.5% 1.5% 2.6% 1.2%.7% 1.7% 2.1% 1.6% 1.6%

13 Table1d: Distribution of health status: physical and emotional Male Non settler s Total pop Female Non settler s Nicobar Ranchi Pre4 2 Settler Nicoba r Ranchi Pre42 Settler Any High BP Diabetes Chd Disc prob Headache Stroke Deafness Blindness Ulcer Skin dis Cancer Accidents Suicide Others Emotional GHQ>9 Anxiety Insomnia Total pop Higher prevalence of reported significant illness (having required formal medical consultation or hospitalisation) in the Nicobarese and Ranchi tribal groups, among both men and women. Non-settlers had the least prevalence of significant physical illness in the past year. The most common conditions reported were complaints related to high blood pressure and discproblems. Self reported emotional/psychological symptoms were high in all groups more than 50% of both men and women among all groups scored above a cutoff of 9 on the General Health Questionnaire which assesses the mental health status of the individual Table 1e: Prevalence of loss due to tsunami- assets and life Male Non settler s Total pop Female Non settler s Nicob ar Ranchi Pre42 Settler Nicoba r Ranchi Pre42 Settler Loss - assets Loss-life % 1.4% % Compensation received Total pop Loss of assets were highest in Nicobarese followed by pre-1942 settlers (which islands) Loss of lives highest among Nicobarese Greater proportion of the Nicobarese had received compensation

14 B. Alcohol use Around 35% of the male adult population and 6% of the female population reported having drunk an alcoholic beverage at least once in the past twelve months. The prevalence of alcohol use (ever used in past 12 months) was highest in the Nicobarese followed by Ranchi tribals among both males and females. The other groups had similar prevalence rates to those observed in the mainland. There is a strong male preponderance with regard to prevalence of alcohol use. Table2a : Prevalence of alcohol use in the population Nicobarese Ranchi Pre42 Settler Nonsettlers Total pop Male 68.5% 61.0% 17.8% 20.5% 32.6% 34.7% Female 34.4% 10.5%.4%.7% 2.3% 6.3% Alcohol consumption varies significantly with age. As the age advances severity of alcohol consumption increases (p<0.001). The prevalence of drinking is highest in the years age group Table 2b: Severity of drinking pattern: variation with age Abstainer Infreq_light Freq_light infreq_heavy freq_heavy %.7%.2%.1%.3% % 5.4% 5.0%.6% 1.3% % 10.3% 11.8%.7% 3.5% >= % 11.0% 14.5% 1.0% 4.7% Similarly, alcohol use varies negatively with education. Persons with formal education of 8 years and more had the highest rates of abstainers while illiterate persons had the highest rates of use (p<0.001) Table 2c: Severity of drinking pattern: variation with educational status Abstainer Infreq_light Freq_light infreq_heavy freq_heavy Illiterate 70.9% 11.2% 12.4% 1.0% 4.4% <8yrs 75.4% 9.0% 11.2%.7% 3.6% >=8yrs 83.8% 6.4% 7.3%.5% 1.9% However, alcohol consumption appears to have a positive relationship with monthly income (p<0.001); and employment (p<0.001). Table 2d: Severity of drinking pattern: variation with personal income per month Abstainer Infreq_light Freq_light infreq_heavy freq_heavy No Income 91.6% 4.5% 2.7%.4%.8% < % 12.6% 15.5%.9% 5.1% >= % 13.2% 20.3% 1.2% 6.0% -- Table 2e: Severity of drinking pattern: variation with occupation Abstainer Infreq_light Freq_light infreq_heavy freq_heavy Govt.Empl. 61.5% 12.0% 19.9%.8% 5.8% Non-Govt.Emp. 60.6% 14.1% 18.9% 1.0% 5.4% Self Emp 63.3% 12.3% 17.3% 1.7% 5.4% Non-paid 58.5% 14.1% 19.7% 1.4% 6.3% Student 98.2% 1.1%.3%.2%.2% Housewife 92.2% 4.9% 2.0%.2%.7% Retired 61.5% 11.5% 18.1% 1.6% 7.2% Un-Emp(able to work) 86.9% 6.6% 4.0%.9% 1.6% Un Emp.(Unable to work) 83.2% 7.1% 7.4%.5% 1.8% The prevalence and severity of alcohol consumption also varies with geographical regions. The highest prevalence of alcohol consumption was observed in Campbell Bay followed by Car Nicobar.

15 Table 2f: Severity of drinking pattern: variation with geographical region Abstainer Infreq_light Freq_light infreq_heavy freq_heavy North M Andaman 78.4% 7.6% 7.8% 1.3% 5.0% Rural Port Blair 84.7% 4.7% 8.5%.1% 1.9% South Andaman = 90.6% 3.3% 4.6%.1% 1.4% UrbanPort Blair 83.1% 8.5% 7.8%.0%.5% Car Nicobar 50.2% 23.9% 16.6% 3.3% 6.0% Campbell Bay 47.0% 18.6% 29.3%.2% 5.0% Alcohol consumption is highest among Sikhs (very small sample size), followed by Christians, Hindus, and Muslims (p<0.001) Table 2g: Severity of drinking pattern: variation with religious affiliation Abstainer Infreq_light Freq_light infreq_heavy freq_heavy Hindu 84.7% 5.7% 7.4%.3% 1.9% Christian 63.6% 14.5% 14.9% 1.7% 5.2% Muslim 96.8% 1.2% 1.5%.1%.3% Sikh 61.5% 7.7% 15.4%.0% 15.4% Frequent-heavy drinking was much greater among the pre 1942 settlers and the more recent settlers (both men and women) Table 3a: Beverage of first preference Nicobarese Ranchi Pre42 Settler Nonsettlers Male Toddy 87.3 Handia Jungli Beer IMFL Whisky Brandy Rum Gin Vodka Female Toddy Handia Jungli Beer IMFL Whisky Brandy Rum Gin Vodka Nicobarese and Ranchi tribals drink predominantly low alcohol containing traditional beverages Others drink spirits (IMFL or illicitly distilled jungle)

16 Availability / Source Table 3b: Patterns: Source of beverage Nicobarese Ranchi Pre42 Settler Nonsettlers Male Make it in the community/ home 89.0% 53.1% 7.5% 10.2% 24.5% Buy in the shop/restaurant etc 8.8% 41.2% 80% 84.2% 64.8% Buy from local illicit manufacturer 1.4% 5.7% 12.5% 4.8% 10.5% Female Make it in the community/ home 98.4% 89.3% 20.0% 70.0% Buy in the shop/restaurant etc 1.0% 7.8% 100% 50.0% 21.5% Buy from local illicit manufacturer.6% % 8.5% High prevalence of home brewed beverages in the Nicobarese and Ranchi tribals Table 3c: Patterns: Commonest drinking location Nicobarese Ranchi Pre42 Settler Nonsettlers Male In a pub, bar or arrack shop 4.3% 11.7% 27.5% 30.2% 31.4% In the country liquor serving place 4.3% 6.2% 12.5% 10.7% 10.7% At the counter of the liquor shop.5% 1.0% 3.8% 3.2% At parties or at friends houses 15.5% 26.1% 15.0% 24.3% 20.7% At home 61.8% 27.4% 17.5% 17.7% 21.7% At clubs, restaurants.5%.8% 1.3% 2.2% On the street or lonely places.2%.2%.5%.2% At social gatherings, weddings, 10.8% 6.7% 2.5% 3.9% 1.5% religious festivals Others.3% 7.0% 10.0% 1.4% 4.6% Female In a pub, bar or arrack shop 1.4% 2.0% 1.2% In the country liquor serving place.6% 4.0% 1.2% At the counter of the liquor shop.3% At parties or at friends houses 3.1% 15.9% 10.0% 13.4% At home 79.6% 68.4% 100.0% 80.0% 81.6% At clubs, restaurants On the street or lonely places.3% 5.0% At social gatherings, weddings, 14.5% 6.9% 5.0% 1.2% religious festivals Others.3% 3.0% 1.2% Table 3d: Patterns - Commonest drinking situation Nicobarese Ranchi Pre42 Settler Nonsettlers Male Festivals, marriages, parties 32.8% 28.1% 30.0% 24.8% 24.1% Returning home from work 11.6% 10.9% 17.5% 11.6% 21.8% Relaxing at home 27.5% 7% 7.6% 6.6% Going out with friends 20.2% 24.2% 20.0% 37% 31.6% Weekends 1.2% 4.7% 3.8% 4.9% Evenings (almost every day) 6.2% 18% 22.5% 13% 5.1%

17 Others.3% 7.5% 10.0% 2.7% 6.2% Female Festivals, marriages, parties 50.3% 22.5% 38.9% 28.0% Returning home from work 2.8% 2.0% 5.6% 2.4% Relaxing at home 39.1% 40.2% 38.9% 32.9% Going out with friends.6% 5.9% 5.6% 3.7% Weekends 2% 5.0% 100.0% 7.3% Evenings (almost every day) 5% 20.6% 11.2% 14.6% Others.3% 4.9% 9.8% Table 3e: Patterns - Drinking companions Female Male Nicobarese Ranchi Pre42 Settler Nonsettler Total male friends & family members 10.9% 39.8%.0% 50.0% 18.3% 18.6% male and female friends 55.6% 38.8% 100.0% 15.0% 52.4% 48.4% on my own [including alone in 31.0% 9.7%.0% 30.0% 12.2% 26.7% a bar] Other 2.5% 11.7%.0% 5.0% 17.1% 6.4% male friends and acquaintances 68.0% 74.4% 72.5% 77.9% 75.5% 74.7% male and female friends 9.3% 3.9%.0%.9% 1.5% 3.3% on my own [including alone in 21.9% 10.8% 22.5% 16.9% 12.7% 15.0% a bar] Other.7% 11.0% 5.0% 2.8% 10.3% 7.1% Table 3f: Reasons for drinking Female Male To enhance positive hedonic tone 16.9% 28.7% To relieve negative mood states 83.1% 71.3% Pearson Chi square=32, df 1; p< Table 3g: Patterns - Who drinks in the family? Nicobarese Ranchi Pre42 Settler Nonsettler Total Female No one else 10.6% 6.5%.0% 22.2% 17.7% 11.3% My brother(s), 18.2% 21.5%.0% 22.2% 26.5% 21.8% son(s) Father / uncle(s)/ 9.2% 21.7%.0% 27.8% 2.6% 9.9% grandfather(s) Spouse 58.6% 48.9% 100.0% 27.8% 51.9% 55.6% Other 3.4% 1.4%.0%.0% 1.3% 1.4% Male No one else 23.7% 35.7% 62.5% 58.8% 58.9% 47.8%

18 My brother(s), 35.1% 21.3% 7.5% 13.9% 16.5% 20.2% son(s) Father / uncle(s)/ 20.9% 32.3% 27.5% 24.2% 20.9% 23.9% grandfather(s) Spouse 5.7% 5.1%.0%.8%.6% 2.3% Other 14.7% 6.8% 2.5% 2.4% 3.2% 5.8% Table 3g: Patterns - Age at onset of alcohol use Nicobarese Ranchi Pre42 Settler Nonsettlers Total population Male (initiation) 23.8 (8) 19.6 (4.8) 22.4 (4) 21.9 (5.8) 19.6 (4.5) 20.9 (5.9) Male (Regular drinking) 25.3 (8.9) 21.8 (5.7) 25.1 (6.2) 24.3 (6.3) 21.3 (5.4) 22.8 (6.7) Female (initiation) 25.4 (8.4) 23.5 (5.6) (4.4) 21.1 (6. 3) 24.3 (7.7) Female (Regular drinking) 27.4 (8.8) 26.4 (6.3) (7.4) 22.4 (7.6) 26.3 (8.3) Fairly late age at initiation and regular drinking in Nicobarese and Ranchi tribals counterintuitive. General age at initiation and regular use later than in the mainland. Table 3h: Drinking pattern and chronological age Abstainer Infreq_light Freq_light infreq_heavy freq_heavy Total (N) %.7%.2%.1%.3% % 5.4% 5.0%.6% 1.3% % 10.3% 11.8%.7% 3.5% 5414 >= % 11.0% 14.5% 1.0% 4.7% 4898 Table 4a: Frequency of drinking Nicobarese Ranchi Pre42 Setler Nonsettler Total Female Monthly or less 77.7% 52.4% 100.0% 30.0% 40.2% 66.0% 2 4 times a month 8.1% 34.0%.0% 40.0% 40.2% 18.6% 2 3 times a week 4.7% 7.8%.0% 20.0% 18.3% 7.8% 4 or more times a week 9.5% 5.8%.0% 10.0% 1.2% 7.6% Male Monthly or less 40.0% 38.3% 32.5% 35.4% 37.2% 37.5% 2 4 times a month 28.2% 41.5% 25.0% 37.6% 43.4% 38.8% 2 3 times a week 14.8% 10.0% 15.0% 14.0% 12.2% 12.6% 4 or more times a week 17.0% 10.2% 27.5% 12.9% 7.2% 11.0% Table4b : Quantity no. of standard drinks on typical occasion Female Nicobarese Ranchi Pre42 Setler Nonsettler Total 1 or % 51.5% 100.0% 60.0% 61.0% 72.9% 3 or 4 9.5% 26.2%.0% 15.0% 23.2% 14.7% 5 or 6 3.9% 12.6%.0% 25.0% 14.6% 7.8% 7 to 9 1.4% 5.8%.0%.0% 1.2% 2.1% 10 or more 2.8% 3.9%.0%.0%.0% 2.5% Male

19 1 or % 45.9% 47.5% 47.6% 52.4% 49.9% 3 or % 35.2% 35.0% 34.3% 34.1% 32.4% 5 or % 13.3% 5.0% 12.0% 12.2% 12.6% 7 to 9 2.4% 3.8%.0% 1.3%.7% 1.7% 10 or more 8.9% 1.9% 12.5% 4.9%.6% 3.4% Table 4c : Pattern of alcohol use (among drinkers) Nicobarese Ranchi Pre42 Settler Nonsettlers Total population Male Infrequent-light 32.0% 34.0% 30.0% 33.5% 36.3% 34.4% Frequent-light 43.0% 47.1% 52.5% 48.3% 50.2% 47.9% Infrequent-heavy 8.1% 4.4% 2.5% 1.9%.9% 3.1% Frequent-heavy 17.0% 14.6% 15.0% 16.2% 12.6% 14.6% Female Infrequent-light 73.5% 45.6% 100.0% 25.0% 40.2% 61.9% Frequent-light 18.4% 32.0%.0% 6.9% 24.8% 25.7% Infrequent-heavy 4.2% 6.8%.0% 5.0%.0% 4.1% Frequent-heavy 3.9% 15.5%.0% 20.0% 15.9% 8.3% Frequent = 2 3 times a week or more; Heavy = Five or 6 drinks on drinking occasion or more Table 4d: Pattern of alcohol use: frequency of heavy drinking among all drinkers Total population Nicobarese Ranchi Pre42 Settler Nonsettlers Male Never 50.2% 16.3% 25.0% 38.7% 46.7% 39.3% Monthly or less 20.3% 39.6% 25.0% 26.5% 30.7% 29.7% 2 4 times a month 2 3 times a week 4 or more times a week 18.2% 19.6% 10.0% 12.4% 12.1% 14.8% 5.7% 4.1% 12.5% 7.1% 5.0% 5.4% 5.7% 20.5% 27.5% 15.3% 5.5% 10.8% Female Never 76.8% 25.2%.0% 40.0% 54.9% 62.8% Monthly or less 16.2% 33.0% 100.0% 15.0% 26.8% 20.9% 2 4 times a month 2 3 times a week 4 or more times a week 4.5% 11.7%.0% 10.0% 11.0% 6.9% 1.1% 2.9%.0% 10.0% 4.9% 2.3% 1.4% 27.2%.0% 25.0% 2.4% 7.1% Table 4e: Prevalence of hazardous drinking among drinkers Nicobarese Ranchi Pre42 Settler Nonsettlers Total population

20 Male 35.7% 61.7% 47.5% 47.4% 39.5% 44.9% Female 8.1% 56.3%.0% 55.0% 35.4% 22.5% Table 4f: Problems in alcohol users Physical problems score GHQ12 PTSD Male User.80(1.5) 9 (3.4) 1.05 (1.98) Non-user.48(1.2) 8.98 (3.8) 1.1 (1.65) T, df 11, , , 9128 p < Female User 1.2(1.6) 9.9 (3.7) 2.5 (3.4) Non-user.69(1.4) 9 (3.7) 1.8 (2.1) T, df 7.7, , , 8886 p < < < Table 4g: Problems to self because of own drinking (among drinkers) Nicobarese Ranchi Pre42 Settler Nonsettler Total Female 0None 99.7% 32.0% 100.0% 65.0% 74.4% 82.7% 1physical health [Accidents/ medical problems].3% 5.0%.0%.0% 1.2 % 1.3% home life [trouble with wife / trouble with parents / children].0% 11.0%.0%.0% 3.7% 2.5% 3work.0% 9.0%.0%.0% 3.7% 2.1% 4Money problems.0% 42.0%.0% 35.0% 17.1% 9.9% 9Others.0% 4.0%.0%.0% 6.1% 1.6% Male 0None 96.7% 54.9% 59.0% 65.0% 78.2% 74.0% 1physical health [Accidents/ medical problems] 1.2% 5.0% 2.6% 3.0% 2.4% 3.8% home life [trouble with wife / trouble with parents / children].2% 4.0% 2.6% 2.9% 3.1% 2.6% 3work 1.2% 4.4%.0% 3.3% 2.6% 2.8% 4Money problems.5% 29.2% 35.9% 25.0% 12.6% 16.4% 9Other.2% 2.5%.0%.8% 1.3% 1.2% Table 4h: Harm due to others drinking (total population) Nicobarese Ranchi Pre42 Settler Nonsettler Total Female 0 None 96.9% 58.5% 73.7% 79.1% 82.4% 80.1% 1 insulted, or disturbed 1.8% 13.0% 16.8% 8.7% 9.9% 9.0% 2 physically assaulted, beaten up/.5% 4.0%.4% 1.5% 1.5% 1.5% sexually assaulted 3 Family problems.6% 22.2% 7.8% 9.3% 4.5% 8.4%

21 4 Accidents.1%.5%.4% 1.0%.9%.4% 9 Others.1% 1.8%.9%.4%.8%.6% Male 0 None 96.9% 59.6% 71.1% 78.0% 82.9% 79.6% 1 insulted, or disturbed 2.4% 13.6% 17.8% 9.7% 9.5% 9.5% 2 physically assaulted, beaten up/.5% 2.9% 1.3% 1.5%.8% 1.3% sexually assaulted 3 Family problems.2% 19.8% 8.0% 8.5% 4.3% 7.2% 4 Accidents 1.9% 1.8% 1.7% 1.2% 1.4% 9 Others 2.2%.6% 1.2% 1.0% Table 5a: Prevalence of current PTSD :Trauma Screening Questionnaire (TSQ) Nicobarese Ranchi Pre42 Settler Nonsettlers Total population (TSQ score > 4) Male 18.9% 10.7% 15.6% 5.6% 7.1% 8.3% Female 35.3% 18% 25.9% 11% 16.8% 17.3% (TSQ score > 6) Male 12.2% 4.8% 2.7% 1.3% 2.9% 3.4% Female 24.3% 6.6% 5.6% 2.9% 4.6% 6.6% Table 5b: drinking more than before the tsunami (subjective assessment in drinkers) Nicobarese Ranchi Pre42 Settler Nonsettlers Total population Male No Yes, a little more Yes, much more Female No Yes, a little more Yes, much more Table 5c: Factors influencing increase in drinking after tsunami Drinking More after tsunami (%) Temporary shelter Yes 76.3 No 23.7 Loss of assets Yes 75.6 No 24.4 Loss of life

22 Yes 76.3 No 23.7 Compensation received Yes 77.1 No 22.9 Table 6a: Prevalence of smokers or smokeless tobacco users Nicobarese Ranchi Pre42 Settler Nonsettlers Total population Male 87.9% 76.8% 52.9% 60.9% 59.3% 64.5% Female 80.9% 28.5% 20.7% 35.2% 19.4% 33.0% Table 6b: Prevalence of Tobacco use (General population) Nicobarese Ranchi Pre42 Setler Nonsettler Total Female Nil 19.1% 71.5% 79.3% 64.7% 80.6% 66.9% Chewing 73.9% 28.2% 20.3% 34.0% 18.6% 31.4% Smoking 2.7%.4%.2%.5% Both 4.3%.3%.4%.9%.6% 1.1% Male Nil 12.1% 23.2% 47.1% 39.1% 40.5% 35.5% Chewing 61.4% 73.9% 42.2% 45.3% 45.9% 50.2% Smoking 9.2%.5% 1.8% 3.3% 2.0% 2.9% Both 17.3% 2.5% 8.9% 12.4% 11.7% 11.3% Table 6c: Prevalence of Tobacco Use among drinkers Setler Nonsettler Ranchi Nicobarese Pre42 Total Female Not at all 20.0% 20.7% 13.6% 2.0% 7.4% chew 70.0% 78.0% 86.4% 87.4% 100.0% 85.3% smoking 5.0% 2.2% 1.6% Both 5.0% 1.2% 8.4% 5.7% Male Not at all 7.6% 9.3% 5.5% 3.4% 10.0% 7.1% chew 65.7% 70.4% 90.9% 63.9% 60.0% 72.3% smoking 3.5% 2.0%.3% 9.5% 5.0% 3.3% Both 23.3% 18.4% 3.3% 23.2% 25.0% 17.3% Female Table 7a: Substance use and medical problems nil alcohol tobacco both Well 75.5% 45.2% 50.4% 43.1% Ill 24.5% 54.8% 49.6% 56.9% Male Well 81.9% 64.4% 71.1% 64.3%

23 Ill 18.1% 35.6% 28.9% 35.7% Table 7b: Substance Use and Well being ghq12>=9 nil alcohol tobacco both Female 53.6% 64.3% 57.0% 60.7% Male 54.4% 64.4% 54.4% 53.7% Table 7c: PTSD & Substance Use ptsd >=6 nil alcohol tobacco both Female 5.1% 2.4% 7.2% 20.7% Male 3.7% 8.0% 1.9% 4.3% Table8a: Distribution of types of intervention required among drinkers Risk Zone AUDIT Score Intervention All drinkers Nicobarese Ranchi Pre42 Settler Nonsettler Male Alcohol Education 64.3% 38.3% 52.5% 52.6% 60.5% 55.1% Simple Advice 27.5% 27.7% 22.5% 26.6% 26.3% 26.8% Simple Advice + Brief Counselling; Continued Monitoring 4.0% 10.6% 7.5% 4.1% 5.9% 6.2% Referral to Specialist for Diagnostic 4.3% 23.3% 17.5% 16.7% 7.2% 12.0% Evaluation and Treatment Female Alcohol Education 91.9% 43.7% 100.0% 45.0% 64.6% 77.5% Simple Advice 7.0% 20.4%.0% 20.0% 22.0% 12.1% Simple Advice + Brief Counselling; Continued Monitoring Referral to Specialist for Diagnostic Evaluation and Treatment.8% 5.8%.0% 5.0% 8.5% 3.0%.3% 30.1%.0% 30.0% 4.9% 7.4% Table 8b: Proportion of population requiring intervention Risk Zone AUDIT Score Intervention Percentage of population Male Alcohol Education Simple Advice Simple Advice + Brief Counselling; Continued Monitoring 2.1

24 Referral to Specialist for Diagnostic Evaluation and Treatment 4.2 Female Alcohol Education Simple Advice Simple Advice + Brief Counselling; Continued Monitoring Referral to Specialist for Diagnostic Evaluation and Treatment.5

25 Discussion How many people use Alcohol in the population? Alcohol use Around thirty-five percent of the male population and over six per cent of the female population were current drinkers, i.e. they had had an alcoholic beverage at least once in the past 12 months. The prevalence of drinking observed in the Andaman and Nicobar islands is therefore higher than the average national estimates, which have reported around 21% of all adult males (Ray et al, 2004) and less than 5% of adult females (Benegal et al, 2005; Isaac, 1998). The most recent data from the National Family Health Survey-3 (NFHS-3; ) found that almost one-third of men in India drink alcohol, compared with only two percent of women.

26 Variations across different population groups? However, these aggregate figures conceal a wide variation in the rates observed among the different population groups studied. The prevalence of alcohol use (ever used in past 12 months) was highest in Nicobarese (almost seventy percent among adult males and around thirty five percent among adult females) followed by Ranchi tribals (around 60% and over 10% respectively). The other groups (pre 1942 settlers, recent settlers and temporary residents) have similar prevalence to rates observed in the mainland. Significantly higher use than the average national levels has also been consistently recorded before, in mainland India, among tribal, rural and lower socio-economic urban sections (Ray & Sharma, 1994). Especially among tribal populations this is linked to the traditional home-brewing practices and the time honoured use of low-strength alcoholic beverages as a part of accepted dietary practice. What are the preferred beverages? This traditional pattern of alcohol use is very evident in the Andaman and Nicobar islands. The overwhelming proportion of the beverages drunk (beverage of first preference) among the Nicobar and the Ranchi tribal groups continues to be toddy and handia respectively. This is especially true for female users. Among the male settler and the temporary resident population spirits (IMFL) are very clearly the beverage of choice. Illicit or jungli spirits are the next most popular beverage, especially among the long-time settlers. Beer (factory made) is clearly not a very popular drink. This is a pattern which has been observed throughout India. Despite growing trends in beer use, India is clearly, still not a beerpreferring nation, especially in rural areas or among the lower economic sections. In the Andaman & Nicobar Islands this is even more so. Preferred alcoholic beverage Among Males Among Females

27 While in the rest of the country, IMFL and illicit spirits constitute the most popular beverage segments (Benegal, 2005), here the overall consumption is largely concentrated in the home-made (or illicit) brewed segment. In the male settlers, however, IMFL is the most common drink. Among women, handia seems to be the most popular drink. Traditional alcoholic beverages Among the Nicobarese, the source of alcoholic beverages, still is exclusively from home-brewing (or more correctly community brewing). However, it needs to be noted that a small proportion are accessing alcoholic beverages from non-traditional sources namely retail liquor outlets. This may reflect an ongoing change in drinking mores. The Ranchi tribal women, likewise, rely mainly on home-brew sources. The men on the other hand are almost evenly divided between home/ community made brew and beverages sold from commercial retail outlets. Strangely, a large proportion of female non-settlers or temporary residents also rely on home-brewing. This could be attributed to the fact that the region houses a large number of temporary residents displaced from other parts of India and south Asia, who have imbibed the local drinking customs. Traditional alcoholic beverages Toddy (tādi)being collected from the cut ends of the flowering spathe of the palm tree Handia traditional rice beer Toddy (tādi) is brewed using methods which have not changed much over the ages, from the natural fermentation of the sap from the cut ends of the flowering spathe of the palm tree. This is a beverage which is traditionally found all over India and indeed south Asia. However, in much of mainland India, it has been banned by state governments and supplanted by cheap higher alcohol containing spirits, on the risible pretext that it is more hygienic and healthy. About 12% of Nicobarese men report spirits (Indian Made Foreign Liquors IMFL) and distilled illicit or jungli spirits as their

28 beverage of first choice. This naturally leads one to question whether such a shift in drinking practices is taking place. There is anecdotal evidence of Nicobarese tribes people being supplied IMFL at inflated prices by unscrupulous traders in islands where IMFL trade was previously proscribed. Apparently, an unforeseen impact of the tsunami in 2004 was the temporary displacement of these indigenous populations to relief camps to Port Blair and other towns, unprecedented contact with urban populations and of course it s drinking mores. Reportedly, significant proportions of the subsequent financial compensation were misdirected towards buying alcohol. Handia, similarly is traditional rice beer (alcohol concentration varies from 5-8% v/v) which is traditionally made and consumed in the Chotanagpur plateau, especially in the Munda and Santhal tribes. Handia, is also a popular drink among the tribals of Keonjhar, Mayurbhanja, Sundargarh, Deogarh, Sambalpur, Balangir, Dhenkanal and Angul Districts of Orissa and also in other states like Bihar, Jharkhand and West Bengal. It is also found among Nicobarese The Nicobarese tribespeople are the original inhabitants of the Nicobar group of Islands. Even though they are known in the same generic name each tribe live in separate Islands and speak separate languages. They share many cultural and social rituals among them. Tuhet is the extended household of the Nicobarese, and it plays very important roles in controlling their social and trading activities of its members. As the Nicobarese are mainly fishermen, herders, horticulturalists and sailors, they frequently have to cross the straits between the Islands for trading purposes. For the purpose of transporting goods across the sea, special type of boats, by name canoes are used for this purpose. These canoes are made by of digging out the bark of a single wood By the ardent work of the government agencies the Nicobarese have been imparted with some formal education. This has enabled them to acquire some types of jobs like Police, Shipping related works, clerks etc There are five Primitive Tribal Groups who have been identified in the Andaman & Nicobar Islands. They are i) Great Andamanese of Strait Island ii) Onges of Little Andaman iii) Jarawas of South and Middle Andaman (iv) Sentinelese of Sentinel Islands.and v) Shompens of Great Nicobar. However, their numbers are small and most of them are very difficult to reach. Pre-42: Pre-1942 settlers of Andaman and Nicobar Islands comprise of local borns, the Bhatus or Bantus, the moplahs, and the Karens. Ranchis There are over 65,000 Ranchis, accounting for over 13% of the population of the Andaman and Nicobar archipelago. During the British rule, people from the Chhota Nagpur tribal belt were brought to work here as forest labourers. They included people from the Oraon, Kharia and Munda tribes who collected here from Jharkhand, Chhattisgarh, Bihar, Orissa, West Bengal and Madhya Pradesh. In the Andamans they are called Ranchis, after the city that was their recruiting centre. While these communities are recognised as Scheduled Tribes in their regions of origin, in Andaman and Nicobar islands they are seen simply as a homogenous group of migrants. Introduced in 1918 under the British government's island development scheme, Ranchis' continued to be brought to the islands after India's independence as labourers to clear jungle areas for settlements. Evicted from the forests in 2002 following a Supreme Court ruling, Ranchis now own no land and rely on irregular labour jobs for survival. While, the Scheduled Tribes have fixed quota' benefits for education, employment and other social security guaranteed under the Indian Constitution. In the absence of tribal status and living in remote inaccessible areas, the Ranchis remain outside the fold. The Andaman and Nicobar Islands have a high concentration of tribal groups living in the forest covered areas which make up 87% of the island. The Great Andamanese, Onge, Jarawa, Sentinelese, Shompen and Nicobarese people are recognized as indigenous tribes and have been receiving benefits under various government's schemes while the migrants' on the other hand face a double edged sword. Locals see them as outsiders and government refuses to recognise them as distinctive and vulnerable groups. With labour work increasingly insecure, health and education of the community also suffers. Settlers In 1960s and 1970s 330 families of ex-servicemen from all over India were settled in Great Nicobar Island. They were given land and agricultural inputs. By sheer hard work, they have been able to convert the are into prosperous plantation area. In Katchal Island under Indo-Sri Lankan agreement 48 families of plantation Tamils were given jobs in 1970s in the rubber plantation area, which is now under Forest and Plantation Development Corporation. The significant chunk of settler population belongs to Bengali linguistic community and they were rehabilitated by Govt. of India under various rehabilitation schemes from 1950s to 1970s. Their population exceeds Non-settlers or temporary residents Non-settlers don t belong to any of this group. They may be Govt. servants, people who came here in search of better prospects. Many of them who are living in the Island for more than 10 years possess islander card. Their population also exceeds the tribals in Bangladesh and Nepal. Handia use occupies a pivotal role in the tribal community, socially, culturally and economically. Accepted as a most sacred drink in the Munda and Santhal tribes, its use is imbued with religious uses and customs. Handia is offered to local deities and in ancestor rituals and is very commonly offered during marriages, birth anniversaries and festivals.

29 The Ranchi tribals in the Andaman and Nicobar islands who have been displaced from the Jharkhand region appear to have supplanted their traditional alcohol use practices to their current settlements. However, almost a third of the male users appear to have shifted to IMFL and jungle spirits. The traditional extended joint family structure of the Nicobarese tribe s people and their relative isolation in the Nicobar Islands may have had a hand in protecting them from the civilizational influences of the liquor trade! The Ranchi tribal who live more cheek by jowl with urban society and have also suffered fragmentation of their traditional community support systems have perhaps not been able to resist these influences. Gender differences There is a strong male preponderance in the prevalence of alcohol use. This is a phenomenon which has been observed in the rest of the country. However, in the Andaman & Nicobar Islands there appears to be a higher proportion of female users. This effect is mainly contributed to by female users within the Nicobarese (about a third of the female population) and the Ranchi tribal (eleven percent). This is much higher than average rates in the mainland which are generally less than 5%. However these rates are comparable to those that are found in certain areas e.g. North East India The choice of drink among women especially in the settler and temporary resident populations is distinct from their men, being distinguished by the much greater use of handia. This can perhaps be attributed to the fact that 0.2 Prevalence of alcohol use among adult women Source: NFHS-2, handia being a home-brew can perhaps be easier to access and less likely to attract attention. In a culture where drinking carries stigma especially women s drinking, women are much less likely to go out in public and buy IMFL from officially maintained retail outlets Influences on drinking drinking companions Women drinkers appear to have more of solitary drinking than male drinkers and also appear to drink in mixed company more than the men. Solitary drinking in females has been linked to the stigma attached to women s drinking. This means that women find it necessary to hide their drinking. This has been observed earlier in other parts of India (Benegal et al, 2005). Males appear to drink predominantly in the company of other males.

30 Influences on drinking who else drinks? A much larger proportion of drinking females report is having drinking spouses (56%) and to a lesser extent, drinking male members from their family of origin (fathers and brothers) than do drinking males. This observation is a validation of earlier findings (Benegal et al, 2005), where it was noted that most alcohol-using women were strongly influenced by significant males in the family (especially spouses and to a lesser extent fathers and brothers) in initiation and patterns of drinking. Drinking males on the other hand report that almost 45% had drinking male first degree relatives and a negligible proportion of drinking spouses. Male drinking is known to be more susceptible to genetic susceptibilities, which are suspected to be transmitted along the male line of descent (Cloninger et al, 1981). Drinking situations The commonest drinking situation for Nicobarese males and females was drinking while relaxing at home (30 and 50% respectively). This speaks of greater normalisation of drinking among this group. There is also a high degree of fiesta drinking at festivals and occasions. This is also reflected in the fact that drinking in the home situation was the most common drinking location. The settlers and temporary residents tended to drink outside the home at pubs and bars. Nicobarese Toddy drinkers

31 Patterns of alcohol use Quantity and frequency of typical use It is assumed that societies which have traditionally sanctioned patterns of alcohol use, often labelled as wet societies are more relaxed in their attitudes to alcohol use and the pattern is one of frequent, light drinking with relatively low incidence of alcohol related problems. So it was to be expected that use in the Nicobarese and even the Ranchi tribal would be frequent but light and that the settlers and especially the temporary residents would display the typical pattern of dry societies infrequent heavy or frequent heavy use, which is the dominant pattern in the rest of India. As it stands, there is not a great variation in the quantity and frequency of heavy drinking, especially frequent-heavy drinking across male drinkers across the different population groups. Around 15% of the male drinkers reported frequent heavy drinking. Quantity drunk on a typical occasion Typical quantites of standard drinks (1 unit=12 gm. Ethanol) drunk on a typical drinking occasion Males appear to drink an average of 4 standard drinks and females 3 drinks (one drink equivalent to 30 ml. of spirits) on a typical drinking occasion. As usual, there is a variation between population groups. Nicobarese and the pre42 settler men drink the largest amounts on typical occasions (4 drinks) followed by the Ranchi, settler and non-settler men. They also report the highest prevalence of persons drinking in the heavy drinking category. Among women, the Ranchi women, average 4 drinks per typical drinking occasion with the rest at around 3 drinks. The Ranchi women and the Nicobarese women have the highest prevalence of the heaviest drinkers (more than 10 drinks). There does not appear to be much of a difference between the amounts drunk on a typical occasion, between men and women. This seems to follow the trend elsewhere in India. Women have a much lower prevalence of drinking. But when they do drink, their consumption on a typical drinking occasion is similar to that of the men (Benegal et al, 2003). This as has been observed earlier, is a departure from global trends. This has an important bearing on alcohol related pathology. Women users suffer equivalent physical health consequences to males at lower quantities and frequencies. Women are also prone to more rapid progression of alcohol-related health problems: the

32 telescoping of alcohol-related physical consequences in women alcohol users (Redgrave, 2003; Greenfield, 2002). The typical quantities of ethanol consumption reported are surprisingly lower than the typical consumption on mainland India (Benegal et al, 2005). This is probably due to the as yet, low preference for spirits. The predominant beverages in use in the islands are low alcohol content homebrewed beers like toddy and handia. Typical frequency of consumption The average number of drinking days is around eighty days in a year for males and around 60 days for females. Typical frequency of use of alcoholic beverages Again this is about 140 days/year for pre-42 settler males, more than 100 days a year for Nicobarese men, 90 days/year for settlers, 80 days for Ranchi tribals and around 70 days for the other males. Among women, the settler women have the highest frequency (90 days), followed by the nonsettler, Ranchi and Nicobarese tribal women (about 60 days). The difference between male and female drinking appears to be in the frequency of drinking. Males drank more frequently than women. This is in keeping with the trend observed in the rest of the country. Quantity x Frequency The QF value is a product of the number of drinks consumed on a typical drinking occasion and the number of drinking occasions/year for an individual. This measure provides an approximate measure of the total annual consumption. The mean amount drunk per year was around 5 litres of absolute alcohol /drinker / year for males and 3 litres of absolute alcohol /drinker / year for females. This approximates to the consumption of 16 bottles and 9 bottles of 750 ml. whisky/year by each male drinker and female drinker respectively. While the consumption is lower than observed for males in the rest of India, this is certainly much higher than the consumption recorded in females from the Indian mainland. Per capita consumption The per capita consumption was 1.5 litres of alcohol per year for each adult member of the population of the Andaman and Nicobar islands. This is slightly lower than the 2 litres per capita consumption measure obtained from mainland India.

33 strata Heavy use Still, the Nicobarese men (and the non-settler men) had the least frequency of heavy drinking (drinking six drinks or more on a typical drinking occasion) whereas the pre1942 settlers and the Ranchi tribals had the highest frequencies of heavy use. Among women drinkers the pre 1942 settlers along with the Nicobarese and the non-settlers had the least frequency of heavy drinking. The Ranchi tribal women had high frequencies of heavy use similar to their men. Hazardous drinking Hazardous drinking is consumption at a level or in such a pattern that increases an individual s risk of physical or psychological consequences. Physical consequences of hazardous drinking could include injuries caused by impaired judgment after drinking alcohol while psychological effects could relate to mood disturbance, which may affect personal or social interactions. Hazardous and heavy drinking are more or less synonymous terms and are often used interchangeably.. 45% of the male drinkers and almost a quarter of female users had a pattern of hazardous use. However, again there appears to be a wide variation among different population groups. The Nicobarese male drinkers had lower rates of hazardous drinking (36%), followed by non-settlers (40%), around 50% among settlers (old and recent) and reaching high rates of over 60% among Ranchi tribal drinkers. Similarly, the Nicobar women drinkers had very low rates of hazardous drinking (less than 10%) while the Ranchi women scored almost as high as the men. The Pre 1942 settler women had very low rates in contrast to their men who seemed to be drinking at heavy levels and also had significant rates of hazardous drinking. Fem ale Male Nonsettler Setler Pre42 48 Ranchi Nicobarese Bars show % of Cases > 0.00 % Hazardous drink ing % Hazardous drink ing This observation might seem incongruous at first, since the Nicobarese men and women seem to have the highest quantity x frequency of drinking. However, scrutiny of the individual items on the AUDIT, reveals some interesting findings in this group. There is comparatively lower prevalence of a] heavy drinking of 6 or more drinks, b] loss of control over drinking (inability to stop once one starts drinking), c]

34 drinking affecting ability to carry out normal duties/responsibilities, d] early morning drinking (signs of dependence), e] guilt or remorse over drinking, f] criticism by others, g] injuries or h] blackouts. This finding separates the Nicobarese pattern of drinking from the rest and points to a retention of wet society patterns of drinking. So there is a lot more of festive and convivial drinking, more in shared social situations less of solitary drinking. This is not so for another tribal group, which also has a tradition of convivial and culturally accepted drinking, at least in their place of origin. They have the highest prevalence of hazardous drinking (more than 60% of all drinkers, whether male or female). They have a higher prevalence of the items that the Nicobarese score less on. This is perhaps a consequence of the state of anomy (a state or condition of individuals or society characterized by an absence or breakdown of social and legal norms and values, as in the case of an uprooted people) that they appear to exist in. Merton (1938), in his anomie theory, argued that in society, there are conditions of disequilibria, disorder, social disorganisation, lack of social integration and lack of normative consensus. Alcoholism becomes a conditio-precedent in anomic societies. Alcoholism thrives where there is no neighbourhood cohesion, where there is moral decay, family breakups and above all, where all social instruments that enhance the social fabric of society are dismantled.

35 sixormore cant stop salience injuries morn drink guilt anyconcern forgot Endorsement of items on AUDIT across different population groups [From Left to Right Settlers, Non-settlers, Ranchi, Nicobarese, Pre-42] Female Male Female Male Female Male Female Male A1-frequency Setler Ranchi Pre42 Nonsettler Nicobarese strata Setler Ranchi Pre42 Nonsettler Nicobarese strata Typical Frequency [0-4] First drink in the morning [0-4] Female Male 2 Setler Nonsettler Ranchi Female Nicobarese Pre42 Setler Nonsettler Ranchi Pre42 Nicobarese Male 1.0 Qtty-no. ofdrinks Setler Ranchi Pre42 Setler Ranchi Pre42 Pre42 Set ler Nonsett ler Nicobarese Pre42 Nonsettler Set ler Nonsett ler Ranchi Nicobarese Ranchi Nicobarese strata Typical quantity [0-4] strata Guilt or remorse [0-4] Nonsettler Nicobarese Female Male Female Male Setler Ranchi Pre42 Setler Nonsettler Nicobarese strata Frequency of heavy drinking [0-4] Nonsettler Ranchi Nicobarese strata Pre42 Setler Ranchi Pre42 Setler Ranchi Pre42 Nonsettler Nicobarese Nonsettler Nicobarese Unable to remember what happened the night before Female Male 0.6 Female Male Setler Ranchi Pre42 Setler Setler Ranchi Pre42 Setler Ranchi Pre42 Nonsettler Nicobarese Nonsettler Nicobarese Nonsettler Nicobarese Not able to stop once started [0-4] Injured self or others [0-4] Female Male Female 3 Nonsettler Ranchi Pre42 Nicobarese Male Setler Ranchi Pre42 Setler Ranchi Pre42 Setler Ranchi Pre42 Setler Ranchi Pre42 Nonsettler Nicobarese Nonsettler Nicobarese Nonsettler Nicobarese Nonsettler Nicobarese Failed to do what was normally expected [0-4] Others expressed concern about drinking [0-4]

36 Impact of alcohol misuse Medical problems Alcohol drinkers (men and women) have significantly higher self-reports of medical illness in the past year[table 4c ]. This is a logical corollary to the finding of high rates of hazardous use among drinkers. Medical problems in the general population Medical problems are fairly high in the population. Around a third of the population reported that they had medical problems requiring formal help-seeking in the past year. They are the highest among the Nicobarese men and women (50%) and the Ranchi tribal. Almost a third of the problems in the Nicobarese were attributed to the category marked others which consisted mainly of infectious disorders. Emotional problems Above 55% of the entire population appeared to be suffering from emotional/psychological problems. This is also reflected in the considerably high number of suicide cases reported in the archipelago. It was 137, 126, 126, 106, 136, 136, and 153 for the year 2000, 2001, 2002, 2003, 2004, 2005, and 2006 respectively. This suffering was uniform across all social groups. Perhaps ubiquitous impact of the recent tsunami-earthquake which affected the islands and which spared no one has deteriorated the emotional health of the population to the worse. The worrying aspect of these figures is that the emotional sequelae of the tragedy appear strong even after so many years have passed. It can be attributed to the fact that the trauma was so intense and the loss so great. But it also points fingers at the efficacy of the remedial help that the population received. There appears to be still an urgent need to provide solutions for the psychological well-being of the population of the islands Emotional problems: Differences between drinkers and non-drinkers While there are no significant differences in emotional problems between male drinkers and nondrinkers, female drinkers have significantly greater scores on the General Health Questionnaire and the

37 Trauma Screening Questionnaire, suggesting that they have greater emotional problems than female non-drinkers. Interestingly, this is a finding which has been seen in the rest of India, where women drinkers appear to have more emotional problems. Indeed the most important reason for drinking in women is to relieve negative mood states, while in men the most important reason attributed is drinking in order to increase hedonic state. In the current study, the respondents reported similar attributions for drinking. Compared to male drinkers, a significantly larger proportion of female drinkers reported that they drank to relieve negative mood states. Conversely, a significantly larger proportion of male drinkers (compared to female drinkers) were drinking to enhance their positive hedonic tone. However, in the total sample as a whole, drinking to relieve negative mood states was higher than the other reason as the major attribution for drinking. Harm due to drinking Problems faced due to other s alcohol misuse About 20% of both males and females in the total population (drinkers and non-drinkers) reported that they had suffered aggression; accidental injuries, violent assault or a family problem due to other s drinking. Alcohol misuse has been clearly associated with violence especially intimate partner violence. This includes domestic, intellectual, emotional, physical, sexual and economic violence. The Bangalore study (Gururaj et al, 2006) on alcohol impact documented that about

38 ten percent of alcohol users reportedly abused other members of the family. The extent of emotional abuse and physical abuse was nearly 2 to 4 times higher among alcohol users. Deaths attributable to alcohol related domestic violence range between 12 to 33%. Regular consumption of alcohol by the husband / partner has been noted to be a significant risk factor for life time physical interpersonal violence and psychological violence against women in India (Jeyseelan et al, 2004). Wives of substance users have a greater risk of attempting suicide and the risk can be attributed to spousal abuse (Gururaj et al 2004a), loss of quality time spent by the family members, disturbed relationship with relatives, financial problems, and lack of emotional support and love (Ponnudorai et al 2001). Several psychosocial problems, cognitive disabilities, behavioral problems and scholastic disadvantages have been observed in children of alcoholics. National Sample Survey data suggests that alcohol use in the family impacts children not being immunized, having acute respiratory tract infection or being malnourished with increased risk of infant mortality was significant even after controlling for other socioeconomic and demographic characteristics (Bonu et al, 2004). The increasing crime rates in the Indian society have been partly attributed to the growing consumption of alcohol in recent years. The cost associated with enforcement, judiciary, and property disputes, and marital discord has been acknowledged but not clearly documented (Gururaj et al, 2005). Interestingly, the experience of such alcohol related harm due to other s drinking was the least (around 3% in both men and women) in the Nicobarese, maximum among the Ranchi tribals (around 40%) with the settlers and non-settlers reporting intermediate rates from 20%-30%. Harm due to one s own drinking Similarly, the rates of self reported harm due to one s own drinking [physical health & injuries, family and emotional problems, work and money problems] was least among the Nicobarese (3% in men and less than 1% in women drinkers), maximum in the Ranchi tribals (45% of male drinkers and almost 70% of female drinkers). The male pre 1942 settlers also reported high rates of about 60%, the women none. The rates for the general population of male and female drinkers were 26% and 17% respectively. Alcohol has been shown to be causally related to more than 60 different medical conditions (Rehm et al 2003). Alcohol consumption is estimated to cause 1.8 million deaths per year (3.2% of all deaths) and to be responsible for 4.0% of the disability-adjusted life years lost per year worldwide (Rodgers et al 2004). Recent studies among alcohol users, elsewhere in India, have documented that they experience more negative health events, more injuries and increasing psychosocial problems during their life course, than non-users. A large epidemiological study of alcohol use in the community, from southern India, observed that alcohol users suffered significant health problems nearly two and a half times more than non users. They also sought health care services more often, both emergency and routine services (Gururaj et al, 2006). Alcohol-related problems account for over a fifth of hospital admissions and they have a higher incidence of mortality, hospitalization and disabilities due to injuries (Sri et al, 1997, Benegal et al, 2001). Studies, especially from wet cultures often cite the J shaped curve effect of alcohol use on health, with moderate alcohol consumption providing some health benefits, but with health problems rising sharply with increasing consumption. Such a distinction has not been possible in India, as most alcohol use,

39 when it happens at all, is marked by high levels of hazardous drinking. Consequently, the findings from India have not been able to really focus on the so-called benefits of moderate drinking. In this study, the drinking pattern of the Nicobarese men and women, which may (in comparison with the other groups) be described as comparatively benign (or less hazardous) and the aggregate consumption approaching that of moderate drinking. The health problems attributable to alcohol abuse as well as harm to others are comparatively low in this group. Contrast this with the hazardous drinking in the Ranchi tribal group and the correspondingly high rates of pathology in this group.

40 Drinking across lifetime Prevalence of alcohol use across the lifespan In both males and females the prevalence of drinking, the frequency and quantity drunk on typical occasions increases with increasing age. The prevalence of drinking is highest in the population above 45 years, as is the prevalence of frequent, heavy drinking. Drinking, as has been observed in other studies throughout India, is a privilege of age. This is contrary to reports from Europe and America which observe that there is a spurt of drinking in late adolescence and young adults, with rates tending to decrease with age. This has been an important protective factor in the past as alcohol and other substance use in childhood and adolescence, causes severe and longlasting consequences on the as yet immature brain, resulting in more severe and early alcohol related problems. But as we can see from the following paragraphs, this too shall change. Age at initiation and severity of drinking The earlier the age at initiation of drinking, the higher are the rates of consumption. A potentially powerful predictor of progression to alcohol-related harm is age at first use. Evidence from around the world, suggests that the earlier the age at which young people take their first drink of alcohol, the greater the risk of abusive consumption and the development of serious problems, including alcohol disorders. In the United States, Grant and Dawson s analysis of the National Longitudinal Alcohol Epidemiological Survey found that over 40% of all individuals who reported drinking alcohol before the age of 14 became alcohol dependent, four times the rate (10%) observed for those who first reported drinking at ages 20 and older (Grant & Dawson, 1997). This predictive influence of the age at starting to drink is highly significant. It is also a strong pointer for public health interventions in the community. To reduce the impact of alcohol related problems, it would be prudent to work with young people to delay the age at starting to drink. Simulations done in India

41 have demonstrated that implementing a nationwide legal drinking age of 21 years in India, can achieve about per cent of the alcohol consumption reducing effects of prohibition (Mahal, 2000). It is instructive to note that the age at onset of drinking is the least among Nicobarese men and women (the average age being 24 years and 25 years respectively). The Ranchi tribal men and the Non-settler men have the earliest ages at initiation (19.6 years). The other groups generally appear to start after the age of 21 years. Reduction in age at initiation across successive birth cohorts The other trend which is observable in this data is the consistent decrease in the age at initiation of alcohol use in successive birth cohorts. Figure illustrates this effect. Younger people in the drinking population reported younger ages at initiation of drinking than older people. Previous studies in the Indian population have revealed a secular downward trend in the ages at initiation. This finding is consistent with data from previous studies from India that found very strong cohort effects, with an accelerated onset of regular use of alcohol in younger birth cohorts (Benegal et al., 2005; 2003).

42 Female Male Age - Initiation of drinking Birth cohort Birth cohort These two observations when coupled together are a cause for worry. With decreasing ages of starting to drink in successive birth cohorts, the prevalence of drinking and heavy problem drinking is likely to rise. This has major negative implications for the burden on health attributable to alcohol misuse. In addition, there are clear portends that the benign traditional pattern of drinking of the past, is rapidly undergoing change, in these islands. As noted above, there is a significant proportion of Nicobarese men who appear to have shifted to IMFL spirits and whose drinking patterns are beginning to assume more hazardous/harmful proportions. The drinking among the Ranchi tribal is also increasingly far removed from the convivial, festive drinking of their cultural past.

43 Tobacco Use The prevalence of tobacco use is high in the islands. About 65% of the male adult population and a third of the female adult population use tobacco products (smoking and smokeless forms). This is certainly higher than the aggregate national figures for prevalence of tobacco use. The most recent data from the National Family Health Survey-3 (NFHS-3; ) found that the prevalence of any tobacco use among men (15-49 years) was 57 % and 11 % among women. Onethird of men smoke cigarettes or bidis, and 37 percent use paan (betel quid), paan masala, gutkha, or other chewing tobaccos. By contrast, only 1 percent of women smoke cigarettes or bidis, and 8 percent chew paan, paan masala, gutkha, or other tobacco products. The prevalence of tobacco use is very high among the Nicobarese, with 80% of the women and near 90% of the men using some kind of tobacco product. The Ranchi men also have a near 75% prevalence of tobacco use. This again, is probably influenced, at least in the Nicobarese by their age old traditions of smoking. The data obtained from the islands appears to suggest that smoking is relatively low and the major demand is for smokeless tobacco. In recent times there is a growing realisation about the health dangers of smoking. Unfortunately, the same cannot be said of the public understanding of the dangers of chewing tobacco, which are considerable Female Male Severity of tobacco dependence 5% of both male and female adults had high nicotine dependence and almost 40% in the medium dependence category. This has immediate implications for the health of the people of these islands and the preliminary evidence we have gathered, suggests the need for further studies. Fagerstrom score Setler Ranchi Pre42 Nonsettler Nicobarese Setler Ranchi Pre42 Nonsettler Nicobarese

44 Tobacco use in alcohol users Very significantly, alcohol users had much higher prevalence of any tobacco use than did non-drinkers. This effect of alcohol use is most prominent among women alcohol users, where smokeless tobacco use is almost thrice the rates prevalent in abstainers. Male alcohol users have 2.5 times greater usage of tobacco than non-users. Alcohol consumption and tobacco use are closely linked behaviors. Thus, not only are people who drink alcohol more likely to smoke (and vice versa) but also people who drink larger amounts of alcohol tend to smoke more cigarettes. Smokers are far more likely to consume alcohol than are nonsmokers, and smokers who are dependent on nicotine have a 2.7 times greater risk of becoming alcohol dependent than nonsmokers (Breslau 1995). Treatment outcomes for patients addicted to both alcohol and nicotine are generally worse than for people addicted to only one drug, and many treatment providers do not promote smoking cessation during alcoholism treatment. Recent findings suggest, however, that concurrent treatment for both addictions may improve treatment outcomes.

45 Impact of the tsunami on the sampled population Persisting effects of the tsunami Although this survey was conducted almost four years after the tsunami struck the islands and the mainland of India, the emotional impact of the tsunami was so severe that the people of the Andaman and Nicobar islands still report persisting emotional problems. Post traumatic stress disorder [PTSD] develops in some people after exposure to a severe traumatic event. The DSM-IV diagnosis of PTSD consists of symptoms in three clusters: 1) re-experiencing symptoms, including intrusive recollections of the trauma that are triggered by exposure to cues symbolizing the trauma; 2) avoidance symptoms, which involve diminished participation in activities and avoidance of thoughts, people, places, and memories associated with the trauma; and 3) arousal symptoms, which include difficulty sleeping, irritability, difficulty concentrating, hyper-vigilance, and exaggerated startle response. The Trauma Screening Questionnaire was used to screen for the presence of presumptive Post- Traumatic Disorder. Using a cutoff of four on the Trauma Screening Questionnaire, which is a screening instrument for Post traumatic stress disorder almost 10% of the male population and a little less than 20% of the female population surveyed, qualified for active post-traumatic stress disorder. Using a stricter criteria (cutoff of six) the prevalence of emotional difficulties was around four and seven percent of males and females respectively. Naturally, the impact was the most among the Nicobarese and the Pre 42 settlers in Campbell island, the worst hit by the tsunami. It must be mentioned that the instrument used is a screener and not a diagnostic instrument, and therefor not a confirmation of PTSD diagnoses in these persons. However, we recommend that simple screening tests like this, will likely improve the detection rate of persons requiring attention in the primary care population, who can then be referred to trained interventionists or to a psychiatric specialist. Studies on survivors of other disasters elsewhere, like the 9/11 destruction of the twin towers in New York, have revealed that elevated rates of posttraumatic stress disorder in the general population follow terrorist attacks but soon normalize, whereas directly exposed populations have higher rates and more persistent symptoms. An increased risk of persistence of posttraumatic stress disorder is associated with direct exposure, geographical proximity, female sex, low income, poor education, poor social supports and prior psychotropic drug use, and high-level media reporting of events (for vulnerable individuals)( Laugharne et al, 2007). Unemployment and exposure to adverse work conditions, particularly high levels of perceived work stress, may also be important determinants of the persistence of posttraumatic stress after a disaster (Nandi et al, 2004). Delayed PTSD cases (more than 2 years) were more likely to have been belonging to disadvantaged social groups, to have experienced more negative life events, and to have had a decline in self-esteem (Adams and Boscarino, 2006). The persistence of PTSD in a large proportion of the affected population has to be understood then, in connection to the persisting changes in habitation, occupation and the old (traditional) way of life which has afflicted people in the islands, especially the tribal populations.

46 Impact of the tsunami on drinking patterns 11.4% of male drinkers and almost 10% of female drinkers reported that they were persistently drinking more after the tsunami [Table 5b]. This increase appeared to be more among the Nicobarese, the Ranchi tribal and to a lesser extent, the settler populations. The factors which appeared to influence this increased use were a] the experience of loss of lives of close relatives; b] loss of assets; c] having been forced to live for extended periods in temporary shelters. Another factor which appeared to influence this increased use was a positive relationship with receiving compensation. As observed in Tamil Nadu (Manickam et al, 2006), a large proportion of the compensation payments appear to have been diverted to buying alcohol. In Tamil Nadu after the tsunami of 2004, seven per cent of families spent the entire tsunami relief money on alcohol, while nearly two thirds (65%) spent varying proportions between 1 to 100%. On an average, while Rs 15 was being spent daily by men on alcohol before the tsunami it declined to Rs 12 immediately after tsunami and increased to Rs 21 during the disbursement of relief money. Alcohol misuse thus strongly impacts the economics of disaster and relief. Substance use disorders, particularly abuse of and dependence on central nervous system (CNS) depressants, are common in patients with posttraumatic stress disorder (PTSD). Among men with PTSD, alcohol abuse or dependence is the most common co-occurring disorder, followed by depression, other anxiety disorders, conduct disorder, and nonalcohol substance abuse or dependence. Among women with PTSD, rates of comorbid depression and other anxiety disorders are highest, followed by alcohol abuse and dependence (Kessler et al, 1995). Surprisingly, in the current study, co-morbid alcohol misuse and PTSD was higher in females than in males [Table 7c]. One major theory of the relationship between PTSD and substance use is that use of drugs or alcohol is motivated by desires to escape or alleviate the distressing symptoms of PTSD. Substance use problems have been found to be more likely to follow the development of PTSD, suggesting that there is something about having PTSD that may increase risk for substance use problems. Another likely explanation, given that chronic substance use can lead to higher levels of arousal and anxiety as well as to sensitization of neurobiological stress systems, is that alcohol & substance abuse may result in a higher level of vulnerability to development of PTSD after exposure to trauma (Jacobsen et al, 2001). The current data appears to provide support for the latter hypothesis, since the increase in alcohol consumption was seen in people who had already been previously drinking. Cases of persons who started drinking in response to the tsunami were extremely rare in the population sampled. The high rate of co-occurrence between PTSD and substance use should prompt public health providers and researchers to try and better understand this relationship so that treatments can be targeted more effectively. Earlier studies have found a reciprocal relationship between the two. Specifically, as PTSD symptoms get worse, people reported that their drug use increased as well. Conversely, as their PTSD symptoms got better, their drug use also decreased.

47 Thus a direct recommendation from this study would be to plan and deliver combined interventions for alcohol tobacco and other misuse and for emotional problems (anxiety, depression, PTSD) in a broadbased manner to the population of these islands. Proportion of male and female population requiring intervention The numbers involved are too large to be dealt with by instituting tertiary treatment facilities for treatment of alcohol dependence and severe alcohol related problems only. Proportion of population requiring intervention The Alcohol Use Disorders Identification Test [AUDIT], was developed by the World Health Organization (WHO) as a simple method of screening for excessive drinking and to assist in brief assessment. It can also help to provide a framework for intervention to help risky drinkers reduce or cease alcohol consumption and thereby avoid the harmful consequences of their drinking. Four levels of risk can be derived from the scores. Zone I refers to low risk drinking or abstinence. The second level, Zone II, consists of alcohol use in excess of low-risk guidelines, and is generally indicated when the AUDIT score is between 8 and 15. A brief intervention using simple advice and patient education materials is the most appropriate course of action for these patients. The third level, Zone III, is suggested by AUDIT scores in the range of 16 to 19. Harmful and hazardous drinking can be managed by a combination of simple advice, brief counseling and continued monitoring, with further diagnostic evaluation indicated if the patient fails to respond or is suspected of possible alcohol dependence. The fourth risk level is suggested by AUDIT scores in excess of 20. These patients should be referred to a specialist for diagnostic evaluation and possible treatment for alcohol dependence. If these services are not available, these patients can be managed in primary care, especially when mutual help organizations are able to provide community-based support. Using a stepped-care approach, patients can be managed first at the