The Bridges of McKinley County: Building Rural Recovery Coalitions

Raymond Daw, M.A.
Executive Director
Na'Nizhoozhi Center, Inc.
Gallup, New Mexico

Herb Mosher, M.A., M. Ph.
Rehoboth McKinley Christian Hospital
Gallup, New Mexico

The purpose of this paper is briefly to describe the response of a small group of people in rural Northwest New Mexico to an epidemic of alcohol and other drug abuse problems.

A County Under the Influence

McKinley County is located in the northwest region of New Mexico not far from the point where the Four Corners of Arizona, New Mexico, Colorado, and Utah touch each other. With a population of about 61,000, McKinley County covers an area larger than the combined States of Connecticut and Rhode Island. Population density ranges from 4 to 14 persons per square mile. The county contains approximately 43,000 Native Americans who are members of the Navajo Nation or the Pueblos of Zuni, Laguna, or Acoma. Standards of living range from upper middle class households with two incomes and three cars to a large number of dwellings without indoor plumbing, where 50 percent of the families earn less than $10,000 per year.

Gallup is the only incorporated municipality in McKinley County. As a major trading center for Indian jewelry, art, rugs, and other crafts, Gallup attracts more than 100,000 people on weekends. Since alcoholic beverages are illegal in the Navajo Nation and Zuni Pueblo, Gallup has more than 60 restaurants, bars, and retail outlets that dispense wine, beer, and other forms of alcohol. As a result of Gallup's proximity to Interstate 40 and the Santa Fe Railroad, illegal drugs are readily available. McKinley County is especially vulnerable to a high incidence of alcohol-related problems, including driving while intoxicated (DWI), because of the combination of easy access to alcohol and other drugs, long travel distances, poor roads, limited medical services, a young population, and a long history of alcohol abuse.

NIAAA's U.S. Epidemiological County Problem Indicators found McKinley County had the highest composite index (910) of alcohol-related problems of all 3,106 counties surveyed from 1975 to 1985. During this period, death rates from cirrhosis of the liver in McKinley County were 3 times higher than the national average; alcohol-related traffic accidents were 7 times higher; and chronic alcoholism rates were 19 times higher than national averages.

From 1987 to 1993, a total of 255 persons died in McKinley County motor vehicle crashes. Of this total, 188 fatal crashes, or 74 percent of the deaths, were alcohol related. According to the New Mexico Traffic Safety Bureau, McKinley County ranked first among the State's 33 counties for alcohol-related crashes on a per-capita basis. During this same period, McKinley County ranked among the top five counties in America for per-capita DWI fatalities.

From 1973 to 1992, the Gallup Police Department operated a protective custody system that picked up public inebriates and put them in the local jail. Gallup protective custody logs record an average of 32,000 protective custody pickups per year for public intoxication in a city of only 22,000 residents. The magnitude of the problem attracted regional and national media attention. In the fall of 1988, the Albuquerque Tribune conducted a 3-month investigative report. In the following months, the region's problems were the subject of lengthy feature stories produced by ABC's 20/20, NBC's Today show, and PBS' MacNeil/Lehrer Newshour.

March of Hope—Journey for Jovita

In the summer of 1988, the chief executive officer of Rehoboth McKinley Christian Hospital (RMCH), Dave Conejo, invited a small group of health care professionals and concerned citizens to meet informally about the hospital's commitment to the community. From these sessions came a core group of people who were committed to changing the situation in McKinley County. Dr. Tom Carmany, the hospital's Chief of Pathology, urged the group to look at Gallup through the hospital's mission statement, which says that RMCH will provide "a Christian-based health care system which is responsive to all peoples." Dr. Carmany asked core group members, "How long are you willing to step over the bodies?"

With the assistance of Gallup's mayor, Ed Munoz, the core group began meeting with elected officials, tribal leaders, schools, parents, health providers, and even representatives of the liquor industry. Initially, many people discouraged the coalition from trying to change the status quo. The Speaker of the New Mexico House of Representatives said, "You are not going to change things in Gallup, and the legislature has no money for you."

Several members of the community coalition met with Tim Gallagher, editor of the Albuquerque Tribune. Mr. Gallagher was aware of the epidemic in Gallup and wanted to "put a human face on it." The Tribune assigned a team of investigative reporters who produced an exhaustive six-part series, "A Town Under the Influence." The series provoked outrage, statewide attention, and a national award for the paper.

In January of 1989, Robbie Christie drove his pickup truck head-on into a van. He had been drinking all afternoon and had a blood alcohol count (BAC) of .35. The crash killed Mr. Christie and four members of a Navajo family, including a 3-month-old baby. The death of little Jovita Vega electrified the community coalition. Within 4 weeks, the March of Hope: Journey for Jovita left Gallup with several dozen walkers. Ten days later, more than 2,000 marchers converged on the State Capital in Santa Fe to present Governor Gary Carruthers with a reform package.

We Can Make a Difference

The March of Hope enabled the local community coalition to bridge the gap between what was historically perceived by State leaders as a local "Gallup Indian problem" and the more global concerns of regional and State lawmakers regarding the health and safety of all citizens. The coalition convinced many New Mexicans that after a century of suffering and indifference, a core group of leaders surrounded by a large group of supporters were going to stick together to end the epidemic of alcohol and other drug abuse.

The precise moment when both sides crossed the new bridge of understanding was captured in a picture of two women hugging each other before the entire New Mexico State Legislature. Mrs. Christie was the wife of the dead DWI driver whose fatal crash killed four people. Mrs. Vega was the mother of Jovita Vega, the tiny infant killed in the DWI crash along with her uncle, aunt, and niece. After their separate presentations to State lawmakers, Mrs. Vega and Mrs. Christie joined hands and embraced before State legislators. The bridge that spanned their shared grief helped move State lawmakers to enact the following measures.

1. A local option referendum to allow McKinley County to close all of its drive-up liquor windows. After vigorous opposition from the powerful State liquor lobby, this measure passed and was enacted in McKinley County by a vote of 3 to 1.
2. A local option referendum to allow McKinley County to impose a 5 percent local liquor excise tax. This tax measure was approved by more than a 4-to-1 vote and now generates approximately $675,000 per year for local prevention, treatment, and education programs within the county.
3. A seed money grant of $300,000 to design a facility to replace the inhumane "drunk tank" of the Gallup Jail. These monies were augmented by a Federal allocation of $1.2 million per year for program operation. Na'Nizhoozhi Center, also referred to as the Gallup Alcohol Crisis Center, developed out of concern about the inhumane conditions under which public inebriates were being detained.

The Navajo Nation, Zuni Pueblo, city of Gallup, and McKinley County formed a planning committee to coordinate efforts to obtain construction and operational funding for a facility that would replace the "drunk tank." Treatment providers, primary care providers, and law enforcement agencies were engaged to assist in design of the facility. Meanwhile, the Congressional delegation from New Mexico was able to obtain Federal funding for the proposed center's operational costs.

The city of Gallup passed a municipal bond that made possible the construction of the facility. Not long thereafter, voters in McKinley County passed a 5 percent excise tax on alcohol sales. A portion of these funds is being used to retire the bond within 10 years. In 1992, the 5 percent liquor excise tax was up for renewal and was overwhelmingly passed by 70 percent of the voters.

During September 1992, the Planning Committee for the Gallup Alcohol Crisis Center reorganized into Na'Nizhoozhi Center, Inc. (NCI). The four governmental entities are represented on the board of directors, which has a total of 11 members. A local private health care provider, Rehoboth McKinley Christian

Health Care Services (RMCHCS) was approached to assist the board in implementation and management of the project. Rehoboth McKinley Christian Health (RMCH) Care Services and the Na'Nizhoozhi Center board collaborated in all aspects of project implementation. RMCH had established networks with substance abuse, mental health, and primary care providers in the region's continuum of care network, which easily accommodated NCI and its clients.

On January 1, 1994, the board of directors took full control of the project and hired an executive director to manage Na'Nizhoozhi Center. The Navajo Nation and Indian Health Services have assumed monitoring and technical assistance roles. In return, NCI has provided training opportunities for regional providers in conjunction with RMCH.

The facility embodies in its name the spirit of harmony that brought about the original community coalition. The word "na'nizhoozhi" is the Navajo term for "bridge." It is also the traditional Navajo way of referring to the city of Gallup. These activities have greatly enhanced service delivery within the region.

4. The State legislature also passed a statute banning open containers of alcoholic beverages. This statute paved the way for DWI reform, which has included tougher penalties, mandatory screening, and a lower BAC for presumed intoxication.

Miles To Go Before We Sleep

For the first time in more than a century, the different ethnic and economic groups are expanding the McKinley County coalition to include partners from the entire Navajo Reservation, eastern Arizona, most of New Mexico, and four pueblos. Subsequently, we have formed a Regional Continuum of Care (see figure 1) that includes assessment, medical intervention, residential treatment, halfway house programs, and a variety of community-based outpatient recovery support systems.

Admissions to protective custody here dropped from an average of 32,000 admissions per year to 19,000 admissions in the past 12 months. We can also identify the substance abuse cycle (shown in figure 2); sources of admissions by client residence; BAC ranges (figure 3); age groups (figure 4); and community of origin.

The New Mexico Alcohol Issues Consortium has adopted McKinley County's policies for statewide replication. Last year, the combined coalition's efforts resulted in DWI reforms that:

• Mandate screening
• Lower blood alcohol levels
• Impose mandatory jail sentences for repeat offenders
• Increase annual DWI funds by approximately $10 million per year

A portion of this funding was recently approved for McKinley County to add a DWI screening and assessment unit for Magistrate Court and to establish an Intensive Outpatient Rehabilitation (IOR) Program for DWI offenders in McKinley County.

In 1992, the enhanced coalition received a Robert Wood Johnson Foundation grant of $3.2 million to establish a Fighting Back Program. Northwest New Mexico was the only rural Fighting Back initiative funded by the Foundation. Program components include intercultural treatment strategies; specialized services for Native American women at risk of having children with fetal alcohol syndrome (FAS) or fetal alcohol effects (FAE); and a campaign to reduce demand for solvents, inhalants, and "Ocean" (hairspray and water). The Fighting Back Program has also initiated the region's only computerized management information system (MIS) and case management system.

The expanded coalition has enabled the Pueblo of Zuni to establish prevention and treatment services through a partnership between local Zuni agencies, the Center for Substance Abuse Prevention (CSAP), and the Indian Health Service (IHS). The expanded coalition has also worked with the Navajo Nation to obtain a 5-year grant from the Center for Substance Abuse Treatment (CSAT) that is designed to improve access to treatment services at the local level throughout the Navajo Reservation.

Recommendations

In order to continue building bridges, the regional coalition has asked Na'Nizhoozhi Center to formulate specific recommendations that include all interested parties. The following recommendations address the alcohol and other drug issues that face our future:

1. Strengthen and enforce alcohol prohibition policies, or
2. Develop and enforce strict legalization policies.
3. Develop a voucher system of disbursing entitlements: food stamps, general assistance, and social security. This would decrease abuse of financial payments and ensure compliance with the purpose of entitlement programs.
4. Set aside alcohol-related court fines to fund construction and staffing of residential facilities for intervention and treatment of, for example, bootlegging, public intoxication, and DWI.
   1. Have 1-week inpatient programs for infrequent public intoxication offenders.
   2. These 1-week programs would be funded by offenders and partially staffed by bootleggers.
5. Require 90-day intensive outpatient treatment for all first-time DWI offenders.
   1. The 90-day program for first-time DWI offenders may be funded by DWI fines levied.
   2. For repeat offenders, require 30-day residential treatment.
6. Require bootleggers to go through 30-day residential treatment at their own cost and to perform community service at substance abuse treatment programs.
7. Strengthen veterans' substance abuse programs to include intervention for posttraumatic stress and family therapy (not counseling). Establish intensive family outpatient programs at each agency for veterans and dependents.
8. Establish facilities like NCI for predetoxification at each major Navajo community for screening, assessment, referral, and tracking of chronic alcoholics.

Substance abuse programs receiving tribal funds would be required:

1. To have affiliation agreements in place with all providing programs in the agency. Tribal evaluation of programs would monitor the programs' compliance with those agreements and, for continued funding, would also monitor the effectiveness of implementation.
2. To participate in the monthly utilization meetings in each agency area. This participation would be included in the programs' monthly reports to health boards and agency councils. This would ensure:
   • Case management collaboration, by indicating who receives services where, and allowing each individual client to be tracked throughout the entire service delivery system.
   • Treatment outcome evaluation, by assessing the changes that occur in clients throughout treatment in the regional continuum of care after their referral from NCI.
   • Quality assurance collaboration, by monitoring compliance with performance standards in the delivery services.
   • Needs and resource assessment, by describing the utilization of existing resources and identifying gaps in the service delivery system.
3. To have family intervention through collaboration with substance abuse program staff. Staff would contact family members of clients at NCI and set up intervention and family treatment plans in order to provide education, assistance, and support in dealing with alcoholism, co-dependency, and other issues.
4. To provide aftercare services/relapse prevention. These would offer structured services for clients who are completing rehabilitation, subsequent to their referral to residential treatment from NCI and their return to their home communities.
5. To offer day treatment (outpatient), after clients' transport from NCI to agency offices. Groups of identified clients would be accepted at each agency and provided with prevention and treatment modalities.
6. To assist in transportation of clients from NCI to the client's residence or agency offices for immediate intervention and placement in an appropriate treatment component.
7. To provide intake and assessment services for clients from the relevant agency catchment area, either on arrival at agency offices from NCI, or immediately after arrival.
8. To rotate substance abuse staff through NCI for supervised clinical internships for durations greater than 5 days, to learn more directly the physical, mental, social, and spiritual effects of alcohol.
9. To provide or coordinate agency training with the area organizations on a regular basis to develop more relevant training for area providers.
10. To provide effective clinical supervision (not administrative supervision) including:
    • An emphasis on supervisor-counselor interaction on a 1-to-1 basis.
    • 1-week internships at area residential programs for clinical supervision methods and procedures.
    • A reduction in administrative workload for clinical supervisors; administrative functions belong with administrators.
11. To establish pay rates that encourage hiring and retention of experienced and qualified counselors. Current pay rates are not adequate, except in Federal programs.

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