Six rapid assessments of alcohol and other substance use in populations displaced by conflict

Kenya

Kakuma Refugee camp is found in the arid north-western part of Kenya near Kakuma town. At the time of the assessment there were approximately 100,000 mainly Turkana people in Kakuma town, and close to 100,000 refugees in Kakuma Refugee Camp. The camp was established in 1992 to house Sudanese refugees; at the time of the assessment there were refugees from 9 countries-the Sudan (80%) and Somalia (13%), and smaller numbers from Ethiopia, Uganda, Rwanda, Burundi, the Democratic Republic of the Congo, Eritrea, and Namibia. A large programme of repatriation to Sudan was underway. Access to health, HIV and other services for the refugee population was satisfactory; there was also an alternative income generating programme available for women sex workers and alcohol brewers offering micro-credit initiatives for small businesses such as catering services, hairdressing, small foods and soft drink kiosks, peanut butter production, and tailoring.

Alcohol production and use was widespread. Fermented cereal-based busaa and the stronger distilled changa'a were both popular. In addition, khat (legal) and (clandestine, illegal) cannabis use was reported. Other substances included petrol or organic solvent inhalation. Injection drug use was not considered a significant public health problem: injecting of pharmaceuticals (mainly benzodiazepines) was thought to be uncommon, and heroin or cocaine thought to be rare if not completely absent in the camp and the local community.

Alcohol was seen as useful to "kill time" as well as being important for enjoyment and socialisation. Alcohol production and sale (whether or not associated with sex work by women) was an important source of income in the camp and in the local community. A number of problems were reported, however. The distilled product was illegal and producers subject to intermittent police raids. Violence, particularly gender-based violence, was perceived to be linked to alcohol use. Other perceived problems included mental health concerns, family disruption, and diversion of scarce household resources.

Local community members felt that distilled alcohol brewing had increased because food rations (maize and sorghum) provided a good source of raw materials from which to produce the drinks, either by the refugees themselves or by the surrounding community: "We buy the food rations from the Equatoria, Nuer, Dinka, Acholi from Uganda. The Ugandans produce the best chang'aa [distilled alcohol]. The communities that do not produce are the Congolese, Ethiopians and Somalis" (Man during focus group with local Turkana community group leaders).

For one participant, alcohol production and use changed over time under the influence of different (external) groups, and now particularly under the influence of refugees: "During the European time, many clubs existed where people sold and drank busaa....People later improved on the technology of brewing by distilling busaa to changa'a. The brewers are local people, mostly women who produce both busaa and changa'a. ... When the refugees came, they (particularly the Sudanese) brought their own technology and further improvised on the brewing of the local drinks." (Man, senior local community member).

Limited alternative livelihoods, particularly for women, promoted production of alcohol: "I brew because I want my children to survive. When my customers buy my brew and buy my body, even if I die, my children will inherit my brewing business." (Woman brewer/sex worker during a group discussion in Kakuma Town).

(Sub)-cultural norms surfaced as important in promoting or inhibiting alcohol use. For example, for young people, use of alcohol was associated with their identity. "To be a nigger, you've got to take alcohol and cigarettes" explained one male student during a focus group. On the other hand, alcohol use among unmarried southern Sudanese men and women is not accepted, and thought to be exceedingly uncommon.

Liberia

2003 marked the end of 14 years of civil war that resulted in the death of approximately 250,000 people, accompanied by the near total destruction of infrastructure, and the beginning of the return of some 340,000 refugees and 500,000 IDPs. At the time of the assessment (2006) access to health, HIV and education services around the country were limited, fragmented, and supported largely by international non-governmental organisations (NGOs). The population experienced breakdown in water and sanitation systems, widespread food insecurity, unemployment and limited livelihood options. Seventy six percent of the population lived below the poverty line of US$1 per day, with 52% living on less than US$0.50 per day. Out of a total population of around 3.5 million, unemployment was almost one million people, over 80% of the labour force. Between a third and a half of the country's population lived in the capital Monrovia, where security was seen as better. Furthermore, economic opportunities were greater than in rural areas where there is little culture of growing cash crops outside the decimated plantation economy. In the capital city there was an active informal sector consisting mainly of small subsistence enterprise, for example food stalls, petty trading in dry goods, used clothing and domestically consumed agricultural products like beans, sugar cane, palm oil and vegetables.

Alcohol and cannabis were considered easily available, relatively cheap and widely consumed by men and women of all ages, with an important role in socialisation and relaxation. Distilled cane juice liquor was cheap (around US$0.5 to 0.20 for a shot glass) and consumed in bars or at street stalls. In addition locally produced palm wine is popular, available for around US$0.80 a litre bottle. Locally produced commercial spirits such as 'Godfather' whiskey, 'Bye Bye' tonic wine and 'Superman' dry gin were readily available. Beer was another higher status drink, as one respondent told us: "beer is drunk like water, assuming that people can afford it".

Cannabis was typically smoked in a rolled or cigarette for around US$0.10 (Liberian $5.00) for one 'wrap' or 'parcel', enough to get 2-3 people intoxicated. It was also cooked in soup and brewed as a tea as an intoxicant and as an appetite stimulant. Cannabis was often (and sometimes confusingly) referred to as 'opium'. It was seen as an important cash crop for some counties. In Voinjama, the use of herbal cannabis has become such a problem among young people that one high school had banned children from wearing dark glasses, used to mask the red eyes typical of cannabis intoxication. Ex-combatants and their friends are typically perceived as the main sellers and users of cannabis. One young person, however, claimed that cannabis use was common among many young people aged 12-25, not just ex-combatants. For him, all young people had been affected by the war, either through combat, loss of home and family or social dislocation, and had started cannabis use to be brave and strong to fight or just to meet their everyday difficulties. According to him "now they take it to stop the bad dreams."

The benzodiazepine, diazepam, known as 'ten-ten' 'five-five' and 'bubbles' was purchased without prescription from some pharmacies and reportedly used during the civil war by combatants and other young people affiliated to fighting forces to make them 'fearless' and 'brave'. It was relatively cheap at US$0.10 or less for one 5 mg tablet. Several sex workers interviewed reported that it is used in bars as a 'date rape' drug, with men slipping the substance into the drink of women without their knowledge or consent. Other men allegedly use it "to be brave and for courage in order to commit robbery."

Different forms of cocaine were also available, as well as heroin, although high prices may prevent more popular use of these substances. A cocaine and cannabis smoking mix called a 'dugee' appeared to be more common (perhaps because it is cheaper at around US$5.00) and was reported to be typically consumed by inhaling using the 'chasing the dragon' method. No respondents reported injecting drugs, although injection drug use was reported second hand in returned refugees.

Substance use was believed by many respondents to be problematic because it promoted health problems and violence, particularly gender-based violence. An urban fear of substances and crime-associated with ex-combatants-pervaded Monrovia. One respondent explained: "Each area has its own ghetto where people who are of criminal nature, who take drugs, who do things unlawfully, they get together and stay in these areas."

Endemic poverty and unemployment, ongoing insecurity, police corruption, gender and other structural inequalities were all considered to promote problem substance use. In addition, combat and displacement experiences may promote use "to dull their fears and anxieties and to commit heinous atrocities" explained one respondent. There were no specific substance use treatment services. Access to general health, HIV and education services-which may minimise problems resulting from substance use-was limited.

Uganda

At the time of the assessment (2006), 20 years of civil war in northern Uganda had displaced more than 2 million people into more than 100 IDP camps. Most of the displaced were still living in the 112 long standing over-crowded 'mother camps' in which access to health care and other services was limited. As part of the government's decongestion policy, some 350 smaller 'decongestion camps' or 'transit settlements' were established in 2005 as the first step towards return to ancestral lands; less than half of the displaced population had moved out due partly to lack of peace agreement and services in the new camps. Reluctance to move may be particularly pronounced among those requiring assistance (including alcohol dependent people) and younger people now unfamiliar with more traditional rural lifestyles.

Access to health care and other services in these camps was limited. Alcohol was readily available, its use widespread and considered an important public health and social problem. In addition, some cannabis use was reported, although its use was hidden due to threat of punishment and it was seen as a less important problem than alcohol from the community perspective.

As elsewhere, alcohol was used for recreation and pleasure. Respondents associated a number of problems with alcohol use, including unsafe sex, health problems (such as TB, lack of adherence to HIV treatment, mental health problems, and possibly suicide), dependence, and interpersonal and gender-based violence. Household financial problems, resulting from indebtedness and trading family rations and other goods for alcohol, left families short of food and children hungry.

In the context of limited livelihood options, alcohol brewing was considered an important source of income for many women. As one woman explained during a focus group with women brewers: "we prefer to brew alcohol, it is our culture and easier than other work, we have no strength for other work, we can brew at home, and there is always a good demand." Sometimes income generating was a collective activity. Another camp resident continues:" I am ... part of a group of 7 women who all distil arege as a full-time job. We help each other in turn to brew. This is called kalulu, communal reciprocal labour. The name of our group is called pii aye kwo, meaning 'water of life'. I would like another form of work if possible, but there is nothing else available here".

Many respondents, both men and women, drew causal links between dispossession and alcohol use. Dispossession promoted alienation, idleness and loss of traditional gender roles among men. As a result, since alcohol was readily available and its use culturally accessible for men, alcohol use was increasing among men. "Men have nothing to do, now many even choose not to work in the fields, they have too much time on their hands. Their other responsibilities have been eliminated by camp life and they have become idle." explained one woman camp resident. As a result, cultural norms were changing, as one woman explained: "now there are no rules for drinking alcohol". In turn, this promoted disrespect towards male clan elders and leaders. As one youth said, "how can I respect these older men when I see them becoming drunk and falling down in the dirt." The net effect of these adverse consequences may be a disruption to community cohesion, possibly inhibiting community recovery capacity.

Iran

For more than 20 years Iran has hosted refugees fleeing neighbouring Afghanistan-mainly Hazara, Tajik and Uzbek ethnic groups as well as some groups of Pashtun ethnicity, both Shiite and Sunni Muslim adherents. At the time of the assessment, there were close to one million registered Afghan refugees living in urban, semi-urban and rural areas of Iran, of whom only around 26,000 live in camps. There were an estimated further one million undocumented Afghans. Refugees are permitted access to basic education and health care on the same basis as Iranian citizens. Service utilisation by Afghans was thought to be low due to a combination of barriers such as poverty, lack of awareness, and perceived discrimination, as well as fear of being identified by authorities. Iran is an important transit route for opiate trafficking: an estimated 40% of Afghanistan's opium production passes through Iranian territory, some of which is absorbed locally [79].

Opiates were believed to be readily available and their use widespread among Afghan refugees, although illicit and not always socially and culturally acceptable. The main substance used was opium (inhaled using the 'chasing the dragon' method), consistent with pre-displacement patterns of use. Patterns of use were changing. Use among young people and women was increasing. Newer opiates were becoming more popular, such as heroin, Iranian "crack" and crystal (highly concentrated forms of heroin), and there was some transition to injection. Nevertheless, respondents perceived opiate as less prevalent among the Afghan refugee population than the host population. Alcohol use was believed to be relatively rare, partly due to religious proscription and greater cost than other substances. Cannabis use (in the form of hashish) was considered common particularly among young people. Additionally, there was some amphetamine use reported among young people.

A number of benefits to opiate use were reported: pain relief, pleasure and socialisation. Problems cited included criminal activity to support substance use habits, involvement in dealer gangs, fights and robberies. Behaviours risky for HIV, STI and BBV transmission were reported, including sharing of injecting equipment, unprotected sex, and exchange of sex by women for substances. At the household level, family disruption and divorce, gender-based violence (such as fights around diversion of household resources for substance purchase by males, early marriage of girls either for money or as escape from stressful environment), family poverty and malnutrition, and health and mental health problems of users and family members.

Whereas tight non-substance using social networks among Afghan refugees were considered partially protective against problem substance use, respondents believed that a number of factors might promote substance use and related problems. Examples included: feelings of loss, distress, pain and suffering; curiosity, boredom, influence of social networks, and expectations of enjoyment (particularly young people); ready availability of opiates; involvement in sales networks and limited alternative income; lack of other recreational activities. Young male garbage pickers (13-17 years of age) were seen as particularly vulnerable to substance use and related harms. As a result cultural norms were changing among the displaced community, influenced by local patterns of use among surrounding populations, social marginalisation and economic exclusion of Afghans. Although there are a number of health, HIV, and substance use treatment services in Iran, lack of awareness, stigma, misinformation, fear of being reported, perceived discrimination, cost, and concerns about confidentiality limited utilisation of these existing services by Afghans.

Pakistan

At the time of the assessment (2007), Pakistan was home to approximately 3 million Afghans, less than half of whom were living in UNHCR-supported long-term refugee camps (called 'refugee villages') along the border; the remaining were dispersed both in urban and rural settings, and not in receipt of support from UNHCR. A major repatriation exercise was underway, with the eventual aim of closure of the refugee settlements. As a result, health and other services were being scaled down. From 2001 nearly 3 million Afghans had returned as part of the UNHCR-supported facilitated voluntary return programme. At the time of the assessment numbers were dwindling due to continued insecurity and lack of shelter in Afghanistan. Unregistered Afghans were considered illegal and subject to involuntary deportation.

The main substance classes used were opiates (mainly opium), cannabis (hashish) and tranquilisers (benzodiazepines). Opium was used by men and women; it was mainly smoked or sometimes eaten or drunk in the form of tea. Hashish was seen as used by men whereas tranquilisers were used by women. Alcohol use was seen as uncommon and mostly home-brewed from sugar-cane or grapes and used by young people. Although each refugee 'village' context was distinct, substance use patterns were characterised as a continuation or exaggeration of pre-displacement use modified under the influence of patterns of availability and village livelihood options. The urban displaced were perceived to be particularly influenced by local patterns of use. For example, in urban but not rural areas substances were sometimes injected, reflecting the substance use patterns of the host population. Respondents believed however that the estimated prevalence of injecting among Afghan displaced was still low. A range of problems were believed to be linked with opium including dependence (although this was felt to be rare), financial impacts, incarceration and child neglect. Injection drug use was linked to HIV and other blood borne virus transmission as well as abscesses. Gender-based violence was associated with shortage of money for substances including hashish and opium: one third of the women interviewed said that they knew someone who had a serious problem with hashish and gave accounts of domestic violence associated with its use.

Respondents believed that limited skills, education and employment opportunities promoted substance use. Women balancing livelihood and childcare responsibilities described giving opium to children to keep them quiet; this culturally acceptable practice was considered traditional and widespread. Religious norms proscribing substance use, especially alcohol, were seen as potentially important in preventing greater problem substance use. Some substance users had access to specialist substance use services in urban areas, although utilisation rates were thought to be lower than the local population; no specialist services were available in the villages.

Thailand

Refugees fleeing more than 50 years of civil war in Myanmar have been living in Thailand since the early 1970s. There are approximately 150,000 refugees (both registered and unregistered) living in 9 camps along the Thai-Myanmar border, in addition to several million undocumented and documented migrant workers. A programme of third country resettlement, mainly to the USA, was underway. Access to primary health care and education was considered good; in addition there is abstinence based residential substance use treatment programme in the camps. Health indicators (mortality rates and malnutrition) are comparable to the host population, whereas on the other side of the border in eastern Myanmar these remain high.

Alcohol was the most important substance-related public health and social concern. It was cheap and readily available, particularly an illicitly produced and sold home-brewed distilled rice liquor. A number of other substances were mentioned including ya ba (tablet form of methamphetamine and caffeine), diazepam, cough syrup, and opiates (mainly a smoking form of opium), as well as cannabis. Inhalant use of glues by young people in Mae La and Ban Mai Na Soi was reported. Use of all these substances was considered less prominent than alcohol.

Most adult men were believed to drink alcohol: alcohol use was described as a culturally acceptable and appropriate response to the stressors of displacement for men. As elsewhere, enjoyment and socialising were seen as important benefits of alcohol use. In addition to negative health effects (which many participants thought were made worse by the addition of adulterants), dependence, high risk sexual behaviour (associated with in- and out-of camp mobility), family and neighbourhood disruption, and gender-based violence were perceived to be linked to alcohol use.

Restricted movement, education, and employment opportunities were seen to drive a sense of hopelessness and idleness among men. Coupled with ready availability and social acceptability of alcohol drinking, this was believed to result in high levels of alcohol use particularly among men. Cultural norms were thought to be changing with increased use among young people and women. One man explains: "Young people have no hope, no work, no further study and no future. They have three choices, they can leave the camp and look for work, they can lead a traditional life which means they will have lots of babies, or they can drink alcohol." As in Uganda, dispossession was an important element, as one resident of Ban Ma Nai Soi explained "we have lost our traditions, our property, our belongings and our country. Here we have a restricted limited life so we drink."