摘要：Objectives. I examined community risk factors that explained variation in suicide rates among young rural Alaska Native men, evaluating the effectiveness of local alcohol control as a public health policy to reduce this population’s historically high vulnerability. Methods. I compiled suicide data, alcohol control status, and community-level social, cultural, and economic characteristics for Alaska Native men aged 15 to 34 years in 178 small Alaska communities from 1980 to 2007. Poisson regression equations explained variation in suicide rates as a function of endogenous alcohol control and community characteristics. Results. Suicide rates were higher in communities prohibiting alcohol importation under state law, but the effect was not significant after controlling for other community characteristics. More remote communities, those with fewer non-Natives, and those with evidence of cultural divides had higher suicide risks. Communities with higher incomes, more married couples, and traditional elders had lower risks. Conclusions. Alcohol control is ineffective in preventing suicide among Alaska Natives; suicide instead appears related to particular complex community characteristics that are either protective or increase risk. Communities have limited means to pursue economic and cultural development strategies that might offer more protection. Indigenous residents of Alaska (Alaska Natives) die by suicide at a rate nearly 4 times the US average and the average for all American Indians and Alaska Natives (AI/ANs). 1–3 An astonishing 7% of Alaska respondents to a 2003 international household survey of Arctic Indigenous people indicated that they had seriously contemplated suicide within the past year. 4 Studies have shown that alcohol is directly or indirectly involved in most of these deaths. 5–9 Although Alaska Natives have encountered alcohol for well over a century, the high suicide risk is an entrenched but comparatively recent phenomenon affecting only the past 2 generations. 9,10 Figure 1 shows that crude suicide rates for this group rose rapidly in the decade after Alaska achieved statehood in 1959. The 3-year moving average rate peaked at more than 50 per 100 000 in the early 1980s, before declining to a level of about 40 per 100 000 during the past decade. The dip in suicide rates in the late 1970s likely represents faulty data rather than a real departure from the secular trend. 11 Open in a separate window FIGURE 1— Crude suicide death rates of Alaska Natives: Alaska, 1950–2007. Source. Alaska Division of Vital Statistics, unpublished data on deaths by cause. Population estimated from US Census data. An emerging new pattern of risk drove the increase in suicide rates in the 1960s. Higher suicide rates among young men led the rise in suicide as a whole. 9,12,13 More recently, another important pattern of differential risk emerged as more Alaska Natives moved to the state’s growing urban areas in search of jobs. Suicide rates among Alaska Native residents remaining in small rural communities are more than twice as high as those among Native residents of urban areas and vary greatly among communities even in the same region (Alaska Bureau of Vital Statistics, unpublished data). 13 In fact, suicide rates may have declined since the peak in the 1980s ( Figure 1 ) only because the lower risk population of urban-dwelling Alaska Natives has grown relative to the more vulnerable rural population. The large disparities among populations with similar ethnicity and histories suggest that the elevated suicide risk is not simply an unfortunate side effect of rapid social change but may be influenced directly by contemporary living conditions. The association between Alaska statehood and rising Native suicide rates may not be entirely coincidental. The early statehood period included a number of critical cultural, political, and economic transitions for Alaska Natives. These changes included state takeover of rural governance from the federal government, the discovery of oil—first in the Cook Inlet region and later at Prudhoe Bay—that brought many new residents as well as new wealth to the state, and the settlement of land claims in the Alaska Native Claims Settlement Act. Despite Alaska’s overall rapid economic growth since statehood, about 10% of the state’s population continues to live in small, rural, predominantly Alaska Native communities. Characteristics of these communities generally include lack of road connection to urban centers, a weak cash economy limited to natural resource extraction and government, and continued strong subsistence hunting and fishing traditions. 14–16 The natural question, then, is do certain indicators of living conditions in these communities correlate with persistent high suicide rates for Native residents? If so, which indicators appear to increase risk, and which offer some protection? Given the widely recognized role of alcohol abuse in many of these suicides, an important research question is whether the availability of alcohol affects the risk in this population. One potentially significant change associated with the state government assuming jurisdiction over rural Alaska from the federal Bureau of Indian Affairs related directly to alcohol availability. Before statehood, the bureau, in administering Native affairs, had generally recognized village council authority to prescribe rules for local communities, including prohibition of alcohol importation, regardless of territorial statutes. After statehood, village councils found they could no longer enforce rules that kept alcohol out of their communities because the state constitution included a strong individual right to privacy and there were no state laws against alcohol importation. 17 The state refused to recognize that tribal legal authority existed in Alaska beyond 1 small congressionally designated Indian reservation on Annette Island, a view affirmed by the US Supreme Court in 1998. 18 Although larger incorporated communities in Alaska had long-standing rights to control alcohol sales within their boundaries, most rural villages were unincorporated and had no rights under state law. Amid a rising tide of violence blamed on alcohol and in response to repeated requests from rural communities, 19 the Alaska legislature passed a series of laws beginning in 1980 permitting unincorporated communities to control alcohol via a local referendum. Options included no local restrictions, prohibiting sale but allowing importation, prohibiting sale and importation, and allowing sale only by a community-operated or licensed outlet. A 1986 amendment added an option to prohibit alcohol possession, enacted to facilitate enforcement. 20 By 1999, more than 100 small communities had used the local option law to control alcohol sales or importation. 21 Alaska’s local option law has been credited with reducing injury morbidity and mortality and improving public safety. 22–24 However, its effect on suicide remains unclear. 24 I examined the role of community alcohol control as a public health policy in mitigating or exacerbating suicide risks among rural Alaska Natives. I sought to identify community-level risk factors that explain observed variation in suicide risks among communities and may confound the effects of alcohol control. Rigorous testing of the effects of alcohol control and other community factors on suicide risks requires overcoming several significant methodological challenges. Communities changed their alcohol status in different years. Some reversed course, and others changed their status several times. 21 Populations of rural Alaska communities are small—generally less than 1000 persons—and have experienced substantial demographic change during the 3 decades since the local option became available. The percentage of the rural population that is Alaska Native is changing, and demographic change has reduced the population percentages of the age cohorts most at risk. The standard practice of age-adjusting death rates, however, could lead to inaccurate measurements for small populations measured only once every 10 years. Given the large gender disparity in suicide rates and observed gender differences in out-migration, 25–27 adjusting only by age could miss potential effects of gender ratio differences associated with varying migration rates. Because alcohol control status on average correlates with time, demographic change could produce spurious correlations between alcohol status and suicides, even in studies using the community as its own control. 24 Alcohol availability represents only 1 of potentially many community risk factors for suicide. Local option regulation is not externally imposed or a random event; rather, it is a community choice that requires substantial local organizing effort, including collection of signatures on a petition from a large percentage of registered voters before a referendum may be held. 21 Alcohol control is therefore an endogenous policy change. If some of the same factors that affect suicide risks at the community level also affect the likelihood that a community decides to adopt a strong alcohol control measure, then failing to address the endogenous nature of the local alcohol policy could produce biased results. 28 In this study, I adopted strategies to address all these important methodological challenges as I tested associations among alcohol control status, other specific observable community characteristics, and suicide risks.
