Family Income Supplements and Development of Psychiatric and Substance Use Disorders Among an American Indian Population

To the Editor: Dr Costello and colleagues¹ studied the association of income supplements from casino revenues with adult psychiatric and substance use disorders in the Eastern Band of Cherokee Indians (EBCI) community. The authors concluded that “ . . . there are environmental interventions that can have long-term benefits, even after the intervention is over.” Commensurate with the study's findings, the authors mentioned the possibility of income supplements being provided to poor families as an intervention to reduce delinquent behaviors, including drug problems. As important as increased income is to people living in poverty, there are some important contextual points to the Cherokee experience that need to be raised to better inform any such intervention efforts.

First, Indian gaming revenues are not welfare payments. Some Indian people see them as a positive expression of tribal sovereignty, and thus they enhance individual and tribal self-image. Second, tribal communities make all of the decisions related to the use of gaming revenues. It is exceptional for a community with high poverty rates to have access to significant recurring resources, let alone the power to allocate them based on local needs and priorities. Third, although the EBCI has made the choice to distribute half of its gaming revenues to individual tribal members, not mentioned in the study by Costello et al is that the other half goes to tribal services, including behavioral health, drug abuse prevention, health care, education, and social services.² It is likely that the study participants benefitted from these investments made at the collective level just as they did from those given to individuals and families.

The result has been an apparent increase in Cherokee of something the study was not designed to evaluate but which has been shown to have significant effects on both behavioral and physical health: collective efficacy, which is often defined as social cohesion and the willingness of community members to help each other when needed.^{3 - 5} We suggest that the increased resources so desperately needed in poor communities should be targeted in ways that strengthen the social fabric and enhance community self-determination. And, as the study by Costello et al suggests, this needs to happen early in the lives of low-income youths to have the most positive effect on their life trajectories.