Rural Women's Recovery Program and Women's Outreach . . .Serving Rural Appalachian Women and Families in Ohio

Tanya Tatum
Coordinator of Women's Programs
Health Recovery Systems, Inc.
Athens, Ohio

The Nation's attention on health care problems is at a record high. We have been inundated with numerous versions of plans to improve our health care system. The Clinton plan, the Cooper bill, the Chafee bill, and the Mitchell bill were all submitted to Congress for consideration during the 1994 congressional session. Of the four health care plans mentioned, only the Clinton plan specified provision of substance abuse services. There appears to be a pervasive sense that substance abuse problems are law enforcement problems—not health care problems. Federal drug policy places a priority on law enforcement and interdiction rather than on treatment services. Consequently, Federal funding has followed along those same lines.

Even though we don't like to think about it, substance abuse is our Nation's number one health problem. A recent California cost effectiveness study estimated that victims of crime committed by drug abusers cost $1.3 billion in medical costs, damaged or stolen property, and lost work. The sum of $440 million was spent on health care for these California drug abusers. This study covered a 12-month period and was conducted on a random sample of 145,515 persons enrolled in treatment services. To ignore the role addiction plays within the context of and debate over health care reform is illogical and self-defeating.

In rural areas, many residents are anxiously awaiting the outcome of health care reform. "When are we going to see more doctors and clinics?" "Will there be a doctor in town who takes a Medicaid card?" "Will I still have to wait 3 months for an appointment?" "How far away is that treatment program?" Typically small, remote, and with relatively small populations, rural areas are often neglected in the creating of national political agendas or plans for reform and change. Rural areas are usually handled as the exception to the rule in the development of strategies, regulations, and programs designed to meet the needs of large urban and wealthier suburban populations. The problems of substance abuse affect all segments of society, but prey most heavily on the disadvantaged. These populations—minorities and the poor—have the fewest resources to deal with problems of substance abuse. They have the least access to services, both financial and physical; have the greatest incidence of impairment, disability, and death; and usually end up in our criminal justice and child welfare systems.

Background: Appalachia Today

Appalachia today is a region of contrasts: tradition versus progress, stability versus growth, regional markets versus international markets, agriculture versus industry, and family versus the individual. Appalachia is often synonymous with poverty. The Federal Government identifies the region as a geographic area defined by economic conditions. This definition clearly leaves out the identifiable and distinct cultural aspects that influence to a large degree the success or failure of efforts to improve the region. In truth, much of Appalachia today remains a poverty-stricken, economically depressed, and underserved area. Former president Lyndon B. Johnson's War on Poverty in the 1960s helped, but it merely addressed the symptoms and neglected the source of regional socioeconomic problems.

However, in spite of the extreme regional poverty, there is a wealth of culture, human strength, and a spirit of perseverance. These are the very strengths we relied on to develop programs to address the needs of substance abusing women and their families in Ohio's Appalachia.

While we deal with the same problems faced by many substance abuse providers serving women—extreme poverty, lack of transportation, lack of child care, inability to pay for services, family violence, and low self-esteem—there are additional barriers found in Appalachia. These cultural barriers include a mistrust of outsiders, fear of the "system," the conscious exclusion of specific groups in a bureaucracy, a tradition of self-sufficiency and taking care of one's own, and geographic and social isolation. Additional obstacles to successful programming are providers who fear hostility or rejection from the service population or who have preconceived perceptions of clients, and providers who are reluctant to change service delivery models to be more responsive to the needs of the client population.

We found that the key to delivering effective programs is to gain acceptance from the community and client population. To do this, we had to listen to individuals and then identify and build on the personal and collective strengths of individuals and of the communities to be served. Rural Women's Recovery Program (RWRP) and Women's Outreach are two programs designed to address the gender-specific and cultural needs of substance abusing rural Appalachian women and their families. The work of these programs plays an important role in helping to provide opportunities for health and hope for many in Southeast Ohio.

Methods

Rural Women's Recovery Program

The first consideration in developing this program was to identify community needs. This was begun during the process of creating an application for funding. Upon notification of award of funding from the State of Ohio, we set about formalizing the clinical and program parameters for the residential treatment program, RWRP. (Women's Outreach was not started for another year.) Every effort was made to find out what social and health services were currently available within the community. We contacted the following programs:

• The WIC program for client referrals and nutrition education
• Planned Parenthood for assistance with prenatal care and family planning services
• Local school boards to assist with tutoring and GED programs
• Ohio State Cooperative Extension Service to assist with life skills education for clients
• Department of Human Services for information about public assistance programs available to clients
• The local mental health agency for making referrals and to assist with staff training
• The Area Health Education Center for resource materials
• A domestic violence shelter for making client referrals and staff training
• The homeless shelter for emergency housing
• Many other agencies and organizations

While none of the agencies has large operating budgets or excess staff, all were willing to share information and resources and generally were willing to help out. A cooperative spirit exists in the area. We help our own to provide for our own.

After amassing a wealth of information and offers to assist, we developed the new program. Because the agency had been providing residential treatment services for substance abusing adolescents for 10 years, we were able to work with an experienced administrative and senior clinical staff to develop this program. The new program was designed to have a rural orientation that would acknowledge the multiple and often conflicting roles that women have. The program would also utilize available outside resources. The goal was to interrupt the process of active addiction, to give the clients new coping skills and develop their personal resources, and to reinvest them in their families and communities whenever possible.

Providing Appropriate Staff and Facilities

The first task was to develop staff capable of using a rural approach to deliver services. This does not mean unprofessional or inadequate. It means placing a focus on the individual person, acknowledging and supporting identified personal strengths, and refraining from imposing on clients our own personal and sometimes middle-class or urban-oriented values and measures of success. Many women in the program speak of success as being able to return home to care for their family (aging parents, children, and partners). Success does not always entail completing college and getting a good job. Every effort is made to hire local individuals to staff the facility; such staff help create a sense of safety for clients and provide honest and believable role models.

The program itself is housed in a log home located outside the city limits, but within the county on a high ridge on a gravel road. You have to know where you are going to get there. There were many challenges in turning a four-bedroom home into a treatment facility, but they were worth it in the sense of peace and safety the house created. The building was very reassuring to family members bringing clients into the home. Children of clients were also reassured to see that Mom wasn't going to jail or back to the hospital (psychiatric or medical). As much as clients were ready to come in, yet not wanting to be there, the appearance of the building helped to relieve some of the early distress of being in treatment. RWRP is not a facility with tile floors, stainless steel fixtures, and communal showers. It is a home in a country setting that provides clients with the physical security they need to do the hard work asked of them.

Providing Staff Training

Once the staff were hired and the building secured, staff were required to attend a week-long training program. The training program included the following sessions:

• Delivering treatment services with a feminist perspective
• Respect and knowledge of Appalachian culture, health, and safety issues
• An overview of the program schedule, house rules, and teamwork
• How the clients get here—admissions from initial phone call to intake
• Program collaboration with other community services
• Provider self-care
• Documentation and billing

Ongoing staff training addresses issues of women's treatment and works to develop the cultural competence of the staff, as well as stay abreast of innovative clinical techniques.

Special attention is given to medical and psychological services for the program. We found out very quickly that current literature was right in stating that women, prior to coming into treatment, have typically progressed much farther than men in their addiction. For us this meant many physical and medical complaints. In addition to a full-time nurse, we contracted with a physician to deliver primary care services and to attend weekly treatment team meetings. The agency psychologist provides immeasurable assistance in evaluating clients on admission and in providing needed psychological services.

The physical upkeep, daily housekeeping tasks, and meals are handled by both staff and clients. We created a chore list to eliminate arguments over whose turn it is to take out the trash. Staff are expected to work alongside of clients. This provides clients with specific responsibilities for household operations; staff help clients learn how to complete chores that they are no longer able to perform.

For many clients, helping to make up the grocery list for the house is a terrifying prospect, not to speak of actually doing the shopping. Client chores are seen as a key part of the program. It makes the clients responsible for and respectful of their own living space, renews or teaches homemaking skills, enables clients to establish supportive relationships with other women, and provides them with a sense of accomplishment, no matter how small the task. The physical environment is used to help establish community norms for social interactions and client behaviors.

Women's Outreach

The Women's Outreach program was first funded in 1990. This program began as a client-finding mechanism for the residential program. This was not found to be very effective with the single position we were able to fund. There were also many obstacles presented by the community's lack of awareness about women's need to seek treatment services. During the second year of funding, the program was redesigned to respond to the unmet need for gender- and culture-specific prevention, community education, and intervention services in three rural Appalachian counties. The program focused on reducing the consequences of maternal alcohol and other drug use and on reducing the incidence of fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE). A variety of strategies were developed to accomplish program goals and objectives. These activities include:

• Client education groups for women awaiting admission to treatment services
• Screening, education, and referral for public assistance recipients
• Networking and specific project collaborations with other providers of services to women (such as WIC, Planned Parenthood, and Children's Services)
• One-time educational presentations to community social and civic groups
• Staff training programs and technical assistance for other social service agencies
• Community awareness projects (county fairs, community festivals, parades, and local campaigns, i.e., Red Ribbon campaigns for AIDS awareness)
• Special programs for communities outside county seats (very rural and isolated communities)
• A public information campaign

The basic tenets of program planning are the same as for RWRP.

• Chemical dependency affects women differently from men.
• The program must be responsive and accessible to rural clients.
• The program should view women positively.
• Clients have the right of self-determination.
• The program needs to provide healthy, acceptable, and believable role models.
• The program needs to acknowledge the complexity of clients' lives: children, partners, income level, housing situation, education, employment or lack of it, and values and traditions.

Content Area

Women's Health and Poverty

The health care crisis for women is staggering, and the relationship between poverty and health status is inextricably intertwined. Poverty increases the chance of poorer health status. Lower income leads to increased health risks, and increased health risks lead to lower life expectancy and high rates of chronic disease, including alcoholism and other drug addiction. Preventable hospitalizations (bacterial pneumonia, cellulitis, kidney/urinary infections, dehydration, gastroenteritis, asthma, COPD, congestive heart failure, angina, and diabetes) among poor adults is two to four times as high as for high-income adults (Codman Research Group). Poor women are three times as likely to have problems obtaining prenatal care, and close to 30percent fewer poor women obtain prenatal care during their first trimester as compared to non-poor women (Center for Health Economics Research 1988).

The substance abuse-domestic violence connection and the substance abuse-HIV connection are well documented. In 1984, Wilsnack reported that more than 50percent of all domestic violence and 40 to 74 percent of child abuse cases are related to alcohol and other drug use. She also reported that more than 70 percent of female addicts/alcoholics report a history of sexual abuse. In the State of Ohio, women now make up 8 percent of all reported AIDS cases (Ohio AIDS Surveillance Section 1993).

Alcohol and drug use during pregnancy severely compromises both maternal and fetal health. Robin LaDue, an expert on fetal alcohol syndrome, refers to alcohol as the only known teratogenic agent (cancer-causing agent) in the United States with its own lobby in Washington, D.C. Fetal alcohol syndrome attributed to maternal alcohol use is an entirely preventable condition.

In the four rural counties that served as the initial client referral base, 41 percent of women ages 18 and older are on public assistance, and 27 percent of the total population lives in poverty. Regional poverty, an inadequate number of primary care providers, and poor health-seeking and wellness behaviors among residents (rural adults are less likely to engage in preventive behaviors, according to Bushey) all contribute to the overall poor health status, especially among women. Adverse living conditions, poor education, and poverty are associated with higher rates of alcoholism and other drug addiction (DHHS 1990). Poor health, lack of access to primary care services, and the multiple drug use often seen in women (women have a tendency to use multiple drugs and alcohol, along with use of over-the-counter and prescription drugs) have a cumulative effect on the progression of addiction in women.

Barriers to Treatment for Appalachian Women

Many barriers exist in the region that inhibit and prevent women from obtaining needed services. Women, who constitute a significant portion of the medically indigent, lack the financial resources to pay for care. The lack of child care, lack of available treatment slots, lack of transportation, and discrimination are major hurdles for women anywhere to overcome before they can obtain substance abuse services. Individuals in rural areas must cross additional hurdles that are not typically present in urban and suburban areas, such as not having telephones to ease their access to service. Intrinsic sociocultural obstacles also keep rural women from obtaining care. These obstacles include differences in lifestyle, language, education, values, and beliefs.

Traditional Appalachian values of family solidarity, self-reliance, and pride have held families together in the face of overwhelming problems, yet these same characteristics pose problems for service providers who are promoting healthy lifestyle changes. Cultural beliefs that influence one's view of life, health, illness, and death were very important factors in designing the programs. The "what will be-will be" attitude and a fatalistic perception of how one's life unfolds have a critical impact on a client's health behavior. They also affect our ability to offer acceptable and effective intervention and treatment strategies.

Lastly, there are institutional barriers to be overcome. For residents of Southeastern Ohio, these include a reluctance to go into town (i.e., the county seats) for services, rude and indifferent receptionists, the stigmatization of low-income persons, a general fear of medical and other service providers, long clinic waits, and long waiting lists due to a limited number of providers (all but one of the counties are designated as Health Profession Shortage Areas). Providers must address the need to successfully overcome rural isolationist attitudes, a general lack of trust in institutions, and the need to ensure that agency and program communications overcome barriers of geographic isolation, readability, and cultural differences.

Overview of the Service Area

The target service area for the Rural Women's Recovery Program and Women's Outreach consists of Athens, Hocking, Vinton, and Meigs counties, which make up a portion of the federally recognized region called Appalachia in Ohio. The counties are identified as primarily rural, with a predominantly white population, and with several small Native American communities. The racial minority and ethnic population in the counties can generally be identified as students, faculty, or staff at Ohio University and Hocking College located in Athens County. Minority representation in the area accounts for approximately 3 percent of the total population.

Appalachia is an area plagued with a chronically depressed economy, geographic isolation, and extreme poverty. The heart of regional problems lies in the fact that, historically, businesses were primarily extraction industries (coal, oil, timber) that made little or no significant investment in local communities. When these industries disappeared, small towns and villages were left with no jobs, development, or infrastructure (transportation, water, waste, and sewage). With the global economy of today, there is little call for development in an area that lacks a trained workforce and the political and physical infrastructure to support technology-dependent economic growth.

Limited economic development, high unemployment, and high poverty rates typify the region. The State unemployment rate is 7.7 percent, and unemployment figures in the target counties range from 6.4 to 10.6 percent (Ohio Bureau of Employment Services 1992). Women in this geographic region are not adequately represented in the workforce; many stay at home to raise families or are grossly underemployed. The more traditional the community, the more limited are the employment opportunities for women. The pink collar jobs (service industries that include housekeepers, beauticians, waitresses, and child care providers) and the part-time positions that may be available rarely offer healthcare benefits. For women with children, the choice may be either to accept low wages without adequate healthcare or to remain unemployed and on public assistance with assured medical coverage for themselves and their children. In spite of welfare reform efforts, there remains little incentive to stay employed without adequate healthcare benefits.

The extreme poverty of the region is perhaps the most distressing problem. In the State of Ohio, 15 percent of families live below the Federal poverty level. The poverty rate in Athens County—32 percent—is the highest in the State (Council for Economic Opportunities in Greater Cleveland 1993). Unfortunately, extreme poverty is not the exception in Appalachia, but the rule. The poverty rate is 27 percent in Vinton County, 17 percent in Hocking County, and 28 percent in Meigs County.

In a region that values tradition, the wife in a husband-wife household is especially vulnerable to poverty when the single wage earner loses his job (Tickamyer 1976). Single women holding families together are often the least capable of providing economic security. Across Ohio there are 19.8 percent more female than male heads of households with children. In the target area, the rate of female heads of households with children runs from 23.4 to 36.8 percent, as compared with single men running households with children (1990 U.S. Census data). The most important segments of our population—women with children—are at greatest risk to the dangers of alcohol, nicotine, and other drugs and the related problems of birth defects, mental impairment, incarceration, accidents, violence, physical disability, and death. The daily struggle for survival in Appalachia is clearly visible as alcohol and other drug use become a common way to escape from the harsh realities of living.

Financial and Political Support

Economically speaking, a sparse population limits the number and array of services that can be offered in a given region. The per capita costs of providing special services often make them prohibitive to implement. Yet cost in and of itself does not diminish the need for those kinds of services by the people who live in a rural area.
—Angilene Bushey 1993

Bushey's statement represents the primary problem in providing health care services in most rural areas—money. The State of Ohio, through the Ohio Department of Alcohol and Drug Addiction Services, has made an outstanding effort to address the need for substance abuse services for women and to address the disparity of available services in rural areas of the State. Federal block grant funds designated for women's services have been held separately from the general pool of block grant money.

States have several options for fund distribution. Ohio has chosen to maintain the integrity of the Federal set-aside monies for women's programming and has offered a competitive grant program. This funding mechanism has promoted the development and implementation of specialized programs that specifically address the prevention and treatment needs of women and of women with children.

In addition to State support, the Alcohol, Drug Abuse and Mental Health Service Boards in Athens, Hocking, Vinton, and Gallia, Jackson, and Meigs (agencies legally responsible for oversight of State funding for alcohol and other drug treatment programs) have provided financial, political, and administrative support. Efforts on behalf of these political bodies to recognize the unique needs of rural areas and to secure adequate funding for programs have been invaluable to the success of the Rural Women's Recovery Program and Women's Outreach.

Service Delivery Model

The medical model approaches drug treatment primarily from a physical impairment perspective. While this is important, the model does not recognize the complex and multifaceted lives of women. A sociological model of treatment acknowledges the physical aspect, but also looks at substance abuse from within the context of personal economics and power—or the lack of power. The sociological model demands that one examine and respond to the social and cultural influences and pressures of clients. It was from this model that the treatment and outreach programs were designed. The programs allow women clients to examine how substance abuse is different for them and enable the women to deal with the double standards that exist in many treatment programs, child service agencies, and law enforcement. The program staff and clients need to acknowledge the stigma attached to substance abusing women.

The residential program is committed to assist indigent and low-income women. An 800 number and telephone intakes permit ease of access. Length of stay is typically 90 days, but this is determined by the treatment team for each individual client. Services provided to clients include:

• Individual and group counseling
• Life skills
• Personal health presentations
• Recreation
• Case management
• Parenting
• GED assistance
• Art therapy
• Psychotherapy
• Communication skills
• Conflict resolution
• Special topic presentations and discussion groups (such as incest/rape survivor, eating disorders, pregnancy, HIV, and co-dependency)

The primary counselor helps the client to ferret out her priorities for treatment. Dependency issues are a big item in almost all client treatment plans. Our goal is to help the client believe in her own strengths, in her capacity to care for herself, and to support her taking responsibility for her own recovery and for her life. Group and didactic presentations look at the many competing issues of substance abusing women. We try to help clients recognize that everyone is not a Suzy Homemaker or a June Cleaver, and then help to reestablish a sober mom back into a family unit. Issues around sexuality and intimacy are always addressed. While there are relatively conservative views of sex in the area, sex and relationships are clearly relapse issues for most of our clients. Clients are given the freedom to discuss sex and intimacy openly to get accurate information and honest feedback.

Case managers have the task of helping clients to reconstruct their outside worlds. This includes working on financial counseling, obtaining public assistance, obtaining a primary care physician, securing safe and affordable housing, working with other family members, and child care concerns. All clients being discharged help to create their discharge and aftercare plans. Clients are expected to follow up with outpatient counseling or to comply with other referrals made upon discharge. A monthly alumnae meeting allows former clients to return to the house to share insights with current clients. This meeting also serves to introduce current clients to potential sponsors.

The program has a strong Twelve-Step focus and provides transportation to meetings. Not all women's substance abuse programs and providers feel that traditional Twelve-Step groups are responsive to the needs of women. However, we are committed to help the clients establish as many sober support systems as possible in their home communities. Alcoholics Anonymous is usually the only nonprofessional group available in our rural counties. Cultural strengths and traditional values are also tapped to re-create healthy responses for clients, including:

• Religion—this is a feelings disease with a spiritual base
• Self-reliance—this involves learning how to care for one's self
• Family system—this involves learning how one can create healthy families

In both the residential and outreach programs, activities and plans are examined to ensure that services are acceptable to clients. Maintaining client confidentiality and anonymity in a small town is difficult, but a priority. Women's Outreach operates with a small community, neighborhood, and person-to-person approach. Taking programs to communities instead of expecting people to come to your office goes far in overcoming client reluctance to deal with bureaucracies and "the government." This approach also helps staff learn to relate to residents and clients within the context of their environments, to actually see what their day-to-day realities are. A provider may decide not to see a client because of body odor, but the case quickly takes on another dimension when you understand that person has no running water or electricity.

The reality of living in rural Appalachia is that many people face a day-to-day struggle for basic needs. This reality forms the foundation for our ongoing program development in the Rural Women's Recovery Program and in Women's Outreach.

Findings

A typical client at Rural Women's Recovery Program is 30 years old, divorced or separated, has two minor children, is extremely low-income (50 percent report no source of income—including public assistance—prior to treatment), and has no marketable or vocational skills. Fifty percent of clients have had children removed from the home by child welfare agencies, 99 percent report a history of incest or sexual abuse, 56 percent have an eating disorder, 35 percent have been diagnosed with chronic depression and have been prescribed medication, 50 percent have been prescribed psychotropic medication, 74 percent report alcohol as their drug of choice, and 26 percent report cocaine as their drug of choice.

It is believed that attention to the following areas is what makes these two programs successful:

• The program is psychologically accessible; efforts have been made to eliminate or reduce barriers of perception.
• The program is financially accessible.
• The program is culturally acceptable, with culturally appropriate interventions that address barriers to access.
• The program is based on a holistic approach to health and to self-care directed by client-driven treatment goals.
• Staff exhibit a willingness to learn from clients.
• The program provides both structured and informal programming.
• The community has been incorporated into various aspects of the programs (for example, through a community beautification planting project and recycling efforts).
• Local staff is hired whenever possible.
• Communities are allowed to decide what outreach services they need and what they feel will work for them.
• Community spirit is fostered, as well as a sense of purpose aimed at addressing substance abuse concerns.

Early program outcome evaluations conducted in 1991 document that, at 6 months after treatment, 64 percent of clients were abstinent and 90 percent reported being satisfied with the program. Of clients completing the program, 91 percent reported they were regularly attending counseling sessions or attending self-help groups. After treatment, there was an increase in outpatient health care visits (this was a desirable outcome) and a decrease in emergency hospitalizations. At 6 months after discharge, program completers also reported fewer arrests than did clients not completing the program. Since opening in January 1990, Rural Women's Recovery Program has had 136 client admissions. Women's Outreach has reached more than 9,198 residents, providing education, substance abuse screenings, and referrals.

Conclusions

Rural Women's Recovery Program and Women's Outreach are two programs that address the substance abuse needs of women and families in rural Appalachian communities. Obtaining funding, political, and administrative support from the State and local Alcohol and Drug Abuse and Mental Health Boards allowed us to develop a residential program and a prevention/education outreach program built on the personal and collective strengths of Appalachia. The spirit of the community is evidenced by support from other agencies and programs. Other providers in the State of Ohio who serve women have also shared their trials, tribulations, and successes to help each new program along the way. While Appalachians are not officially recognized as a minority population, our programs are designed to address the specific cultural needs of this population. Substance abuse treatment, prevention, and education really do work.

In 1994, the residential program was expanded to provide space for up to 11 women. The house includes three family units, so mothers of young children may bring their children into treatment with them. We hope to have an even greater impact on entire family systems. Recovery is not a process one does alone. The more positive influence we can have on the family unit, the greater the client's chance of maintaining sobriety.

The outreach program has seven elements for successful programming.

• Lay a foundation for trust; become involved in the community.
• Identify key community leaders; plan activities around community- identified needs.
• Start with what you have; start small.
• Provide programming even when a lot of people don't show up.
• Understand that flexibility and persistence are essential.
• Develop participant and community volunteers.
• Value your key resource—human capital.

"Culture is what a people does, says, lives, dies, and celebrates."
—Deanna Tribe

Recommendations

• There is a need for additional and more secure funding streams for substance abuse programs. In addition, we must be willing to provide sufficient funds to develop new programs and to sustain adequate funding levels.
• Program providers need to find more ways of disseminating information about interventions and programs that are successful. Many of us in rural areas administer, manage, and sometimes see clients in our programs. Finding the time to present or write articles about what we do is often a luxury that we do not have.
• Rural substance abuse providers need to provide assistance to all other programs that are attempting to serve other rural populations.
• The Federal Government should rethink how it defines minority groups. Consideration should be given to raising the status of low-income and rural populations, particularly Appalachians.

References

Bushey, A., ed. Proceedings from the National Rural Health Association Conference. 1993

Center for Health Economics Research. 1988 National Maternal and Infant Health Survey.

Codman Research Group, Ambulatory Care Access Project. New York: United Hospital Fund of New York.

Department of Health and Human Services. Alcohol and Health Seventh Special Report to Congress. 1990.

Back to Top