A Syndemic Analysis of Alcohol Use and Sexual Risk Behavior Among Tourism Employees in Sosúa, Dominican Republic

Abstract

The Dominican Republic has high rates of HIV infection and alcohol consumption. Unfortunately, little research has been focused on the broader sources of the synergy between these two health outcomes. We draw on syndemic theory to argue that alcohol consumption and sexual risk behavior are best analyzed within the context of culture and economy in Caribbean tourism spaces, which produce a synergy between apparently independent outcomes. We sampled 32 men and women working in the tourism industry at alcohol-serving establishments in Sosúa, Dominican Republic. Interviewees described alcohol consumption as an implicit requirement of tourism work, tourism industry business practices that foster alcohol consumption, and an intertwining relationship between alcohol and sexual commerce. The need to establish relationships with tourists, combined with the overconsumption of alcohol, contributed to a perceived loss of sexual control, which participants felt could impede condom use. Interventions should incorporate knowledge of the social context of tourism areas to mitigate the contextual factors that contribute to HIV infection and alcohol consumption among locals.

The Caribbean region has the second highest rate of HIV in the world following sub-Saharan Africa, with a regional HIV prevalence of 1.6% (Joint United Nations Program on HIV/AIDS [UNAIDS], 2007a). Among Caribbean countries, the Dominican Republic has one of the highest rates, with an adult HIV prevalence of 1.1% (UNAIDS, 2007b). Several factors contribute to a higher risk for HIV transmission in Caribbean tourism areas, which we have described elsewhere as “ecologies of heightened vulnerability” to HIV (Padilla, Guilamo-Ramos, Bouris, & Matiz-Reyes, 2010, p. 70). Findings from numerous studies in the region indicate that individuals who work in tourism industries or engage in transactional sex with tourists report higher rates of sexual risk behaviors. In the Dominican Republic, researchers in studies among men who have sex with men (De Moya & García, 1998; Padilla, 2007; Ruiz & Vásquez, 1993; Vásquez & De Moya, 1990), female sex workers (Centro de Estudios Sociales y Demográficos, 1996; De Moya, Garcia, Fadul, & Herold, 1992; Kerrigan et al., 2003; Kerrigan, Moreno, Rosario, & Sweat, 2001), and hotel and resort employees (Centro para la Promoción y Solidaridad Humana, 1997; Forsythe, Hasbún, & Butler de Lister, 1998) have reported high rates of sexual contact and sexual risk behaviors with foreigners among Dominicans.

Studies of tourist behavior revealed significantly higher levels of HIV/STI-related risk behaviors during vacation than in communities of origin (Clift & Forrest, 1999). In particular, tourists reported that they were more likely to engage in sexual activity (Pritchard & Morgan, 1996), less likely to consistently use condoms (Bellis, Hughes, Thomson, & Bennett, 2004), and more likely to have sexual intercourse with more than one partner (Bellis et al.) while they were on vacation. Ethnographic and public health studies among sex workers in the Caribbean also suggest that sexual vulnerability is heightened in cases in which intimacy and regular visiting relationships are established between tourists and locals, because condom use rates precipitously decline as more intimate relationships are established (Kerrigan et al., 2003; Kerrigan et al., 2006; Kerrigan et al., 2001; Padilla et al., 2010). The convergence of these findings strongly supports the need for greater research aimed at identifying the specific contextual features of Caribbean tourism areas that contribute to risk for HIV and other sexually transmitted infection, and to develop initiatives to ameliorate these factors.

Although some global studies have documented an increased risk of HIV through sexual behavior associated with alcohol and drug use in tourism environments (Sivaram et al., 2008), much of the available global health literature approaches substance use and sexual risk practices as separate phenomena, rather than as practices linked to the larger social and material environments in which people live and work. This fosters the notion that each of these health outcomes involves distinct behavioral pathways to be addressed through separately targeted interventions, rather than examining the social and contextual factors that might produce aggregate vulnerabilities across a range of health outcomes. Here, we argue that although the behavioral focus of most health research permits the measurement of alcohol and sexual risk practices, the exclusive focus on specific health outcomes compromises the ability to understand the social and ecological conditions that might precede or function as antecedents to both of these practices. This is consistent with recent contributions to Qualitative Health Research that have similarly argued for contextual approaches to HIV risk and drug-using behaviors (Adams & Neville, 2009; Goncalves de Moura, van der Meer Sanchez, & Noto, 2010).

We explored the ways that alcohol consumption, illicit drug use, and sexual practices are intertwined within the tourism environments in which a growing proportion of Caribbean populations live and work. Through in-depth interviews with tourism industry employees in Sosúa, Dominican Republic, we elicited narrative descriptions of the social environments and situations that circulate around alcohol consumption, illicit drug use, and sexual encounters. The goal was to develop a contextual understanding of how these practices are integrated into the daily lives and interactions of tourism industry employees in a popular Caribbean tourism zone. By focusing on participants’ descriptions of the social contexts in which alcohol consumption and sex occur, we sought to examine these practices not as behaviors, but as deeply embedded social practices that are linked to broader relations of gender, sexuality, and economy.

The growth of the tourism industry in the Dominican Republic is typical of the growth of the industry throughout the Caribbean. In 2007, 3,398,374 tourists entered the country, a third of whom were from the United States, 17% from Canada, 6% from Germany, 4% from Italy, 29% from other European countries, and 11% from other nations (Caribbean Tourism Organization, 2009). For 2009, the World Travel and Tourism Council estimated that 546,000 Dominicans (13.8% of the employed population) were engaged in tourism work, and the industry accounted for 15.9% of gross domestic product (World Travel and Tourism Council, 2009). Although many studies have been focused on the health effects of tourism, most emphasized the effects on tourists themselves, rather than the workers who engaged in tourism labor (Apostolopoulos, Sonmez, & Yu, 2002; Bellis et al., 2004; Clift & Forrest, 1999; Pritchard & Morgan, 1996).

Although not often discussed in detail in studies of HIV in the Caribbean, alcohol and illicit drug consumption are escalating rapidly and closely track the development of the tourism industry. In the Dominican Republic, the amount of alcohol consumed per adult per year increased from 1.18 L in 1961 to 6.11 L in 2001, reaching a peak of 7.71 L per person in 2000 (World Health Organization, 2004). Much of this increase can be attributed to the growth of transnational alcohol companies that have marketed and invested heavily in major Caribbean tourist destinations (Parry, 2000). Expanding the supply and availability of alcohol in the Caribbean has often been viewed as an important way to support the tourism industry (Room & Jernigan, 2000). Globally, studies consistently document an increased risk of HIV through risky sexual behavior associated with alcohol use and alcohol venues (Fritz et al., 2002; Kalichman, Simbayi, Vermaak, Jooste, & Cain, 2008; Sivaram et al., 2008), and indicate that individuals employed in the tourism and sex industries are particularly vulnerable to alcohol and substance abuse (Ao, Sam, Masenga, Seage, & Kapiga, 2006; Kapiga et al., 2002; Mallory & Stern, 2000). Moreover, alcohol venues in the Dominican Republic are closely linked to transactional sex environments, or the exchange of sex for money or resources. Alcohol-serving businesses, such as bars, nightclubs, and discos, often operate as formal or informal sex establishments where waitresses or dancers working on the premises can also exchange sex for money with patrons (Centro de Orientación e Investigación Integral, 2000). An illustration of this is the emergence of the “liquor store” and the centro cervecero (beer center) as sites where local sex workers and clients gather to drink and arrange commercial sexual encounters (Jerez et al., 2003). In sum, the evidence from a variety of studies demonstrates that the social and economic logic of tourism areas produces a synergy among alcohol, illicit drugs, and sex within the basic fabric of daily life.

Illicit drug use has been increasing throughout the Caribbean, although research is limited. Studies in the Dominican Republic indicate that the illicit drug epidemic is primarily oriented toward the use of powder cocaine, crack cocaine, heroin, and marijuana, with smaller rates of ecstasy and inhalant use (Deren, Shedlin, & Caceres, 2000; Dormitzer et al., 2004; Inciardi, Syvertsen, & Surratt, 2005; Jutkowitz, Eu, Leavy, Pagan, Kunhart, & Valleyron, 1992). One of the largest studies on substance use in the region compared ratios of “exposure opportunity” to “actual use” of substance use (including alcohol) among adolescents across seven Latin American countries (Guatemala, Panama, Costa Rica, Nicaragua, Honduras, El Salvador, and the Dominican Republic; Dormitzer et al., 2004). The 2,023 Dominican adolescents sampled (median age = 15.9) were significantly more likely than those from any other country to report actual use of illicit drugs following exposure opportunities for alcohol, crack cocaine, ecstasy, and heroin. Although research on the factors contributing to the illicit drug epidemic in the Caribbean is underdeveloped, one recent region-wide analysis of drug crime statistics noted that “islands that have experienced either acceleration or high levels of [drug-related] criminality tend to be both highly tourism penetrated and major destinations for narcotraffic: Bahamas, Dominican Republic, Jamaica, Puerto Rico, and the US Virgin Islands” (McElroy, 2006, p. 89). The most significant factor linked to illicit drug crimes was visitor density, suggesting that the tourism industry strongly shapes drug use (McElroy).

Our conceptual approach to alcohol use, illicit drug use, and HIV risk practices is informed by recent medical anthropological theories of syndemics as they apply to marginalized populations in the United States. Inspired by the groundbreaking work of Merrill Singer and colleagues (Singer & Clair, 2003; Singer et al., 2006), and subsequently elaborated by the Centers for Disease Control (Milstein, 2008), syndemic theory centers on the idea that economic, demographic, and social factors produce constellations of epidemics in populations that are multiply marginalized. In such syndemics, vulnerability to one health risk exacerbates or magnifies vulnerabilities to others, as in the case of HIV risk and illicit drug use, which has been described in a range of studies (Kurtz, 2008; Van Tieu & Koblin, 2009; Walkup et al., 2008). Aiming to move beyond disease-specific or single-issue approaches to research and prevention, Singer and colleagues developed syndemic theory to explain the very low overall health profile of poor, drug-using Puerto Ricans in the northeast United States. Subsequently, syndemic theory has been applied to a range of other marginalized communities, such as refugees (Edberg, Cleary, & Vyas, 2011), sex workers (Romero-Daza, Weeks, & Singer, 2003), and gay and bisexual men (Stall, Friedman, & Catania, 2008). Recent research on syndemics indicates that the social and economic environments of urban spaces produce syndemic situations for poor and socially marginalized populations, in which the overall health profile, rather than separate disease risks, is severely compromised.

Here we adapt the context-specific perspective of syndemic theory to examine qualitatively how poor, marginalized persons who work in the Dominican tourism sector describe the intermingling of alcohol use, illicit drug use, and sexual practices in Sosúa, a tourism town on the north coast of the Dominican Republic known for its resorts, beaches, and commercial sex economy. Anthropologist Denise Brennan has described Sosúa as a “sexscape,” a transnational social space dominated by both fantasies and practices of exotic sexual transactions that traverses global boundaries (Brennan, 2004). Tourism areas can produce distinct sexual cultures within the same country—a phenomenon that Hirsch and colleagues (2007) recently described as “sexual geographies.” Ethnographic work in the region documents that Dominicans often perceive tourism areas such as Sosúa as entirely distinct global spaces where different ideas, values, practices, and economies of gender and sexuality are enacted (Padilla, 2007; Padilla et al., 2010)

Tourism areas also require growing numbers of tourism workers to circulate continuously in and out of these environments. Research on male tourism migrants on the southern coast of the Dominican Republic has shown that the vast majority of these men are internal migrants who relocated to the tourism area for work (Padilla, 2007), a finding that has parallels in other studies in the Caribbean (Kempadoo, 1999). For internal migrants, this regular crossing over into globalized spaces with distinct practices of gender, sexuality, and economy can have implications for their overall health and well-being. We argue that with growing employment in the tourism industry, tourism workers in the Dominican Republic and in other tourism-dependent nations are increasingly exposed to social and economic environments that center on the consumption of alcohol, illicit drugs, and sexual intimacy with the informal tourism economy. This synergy potentially leads to contextual influences on behavior that can contribute to syndemic conditions. In nations such as the Dominican Republic, where tourism composes a significant proportion of all sources of labor and where tourism zones are absorbing vast populations of unemployed and underemployed labor migrants, we believe that more holistic research informed by syndemic theory is critical for understanding health vulnerabilities of the working population as a whole.

We suggest that alcohol, illicit drug use, and transactional sex are normative and necessary parts of the social and economic landscape in Sosúa, in part because of the function of these activities as means for establishing and maintaining valued social and material exchanges with tourists. In the context of the tourism-based economy of Sosúa, many businesses and informal employees view the sale of alcohol and/or illicit drugs as a precursor to the establishment of sexual or economic relationships with tourists, which provide a large source of both formal and informal sector profits. As a means of facilitating such transactions and increasing profits for both individual tourism entrepreneurs and tourism businesses, our participants described business strategies aimed to foster overconsumption of alcohol by both tourists and locals. The use of both alcohol and illicit drugs was often viewed by workers as inextricably linked to the transactional sex economy, because each facilitated and reinforced the other. Alcohol and illicit drug use were understood as occupational requirements, even as they were perceived as potentially dangerous vicios (vices). Furthermore, participants described the need to manage their emotional connections to tourists to avoid “getting crazy,” or losing control over their feelings and sexual behavior, which they believed could lead to dangerous or risky sexual practices with tourists. Even though alcohol and substance use were seen as necessary, they also compromised participants’ ability to maintain affective and sexual control, leading to sexual situations which participants viewed as treacherous. Finally, we end by discussing the implications of these findings for syndemic theory as applied to the situations and social contexts encountered by the growing population of Caribbean tourism workers.

Methods and Research Design

Population

Sosúa, the primary site for this research, is a small town of approximately 45,000 located in the Puerto Plata province on the north coast of the Dominican Republic. With its thriving tourism economy, Sosúa is characterized by a dense cluster of alcohol-serving venues (e.g., bars, discos, brothels, liquor stores, hotels, and casinos), a high concentration of formal and informal sites for transactional sex, and a diverse population of permanent local residents, expatriates primarily from North America and Europe, and both Dominican and foreign tourists (Brennan, 2004). Many local residents, as well as migrants from other parts of the country, work within the tourism sector and are employed by the various restaurants, shops, bars, and hotels in the area. Additionally, many are employed informally within the tourism economy as, for example, sex workers (formal or informal), vendors, artisans, waiters/waitresses, hotel employees, and taxi or motorcycle drivers.

Recruitment Strategy and Sample Characteristics

We conducted ethnographic observations in alcohol-serving venues in Sosúa and semistructured interviews with 32 adults (both men and women) between the ages of 18 and 50 years. By design, interviewees were required to be current alcohol consumers, although we did not encounter any potential participants who did not report current alcohol use. Because of our original research interest in the influence of social context and environment on sexual practices and alcohol use, we employed a theoretical sampling approach (Strauss & Corbin, 1998). In theoretical sampling, the researcher aims to intentionally maximize the diversity of perspectives on a set of issues of interest by systematically recruiting participants theorized to represent the widest possible range of perspectives on these issues, while keeping the sample small enough to conduct in-depth qualitative analysis across cases (Miles & Huberman, 1994). The method is designed to balance the richness of a small number of in-depth narratives with a systematic means of ensuring wide variation in the voices and perspectives included in the study. In this way, it balances a relatively small sample with an emphasis on high participant diversity, increasing the breadth of representation in the qualitative sample. The method requires researchers to define participant characteristics that can be used relatively easily in the field to recruit equal proportions of participants from different subject positions (Corbin & Strauss, 2008).

Because our conceptual framework focused on the ways that the social context of Sosúa shapes alcohol use, illicit drug use, and sexual risk practices among tourism industry employees, we defined four criteria by which to selectively recruit participants using theoretical sampling. The sampling framework was aimed to maximize participant diversity in four characteristics: type of venue in which the participant was encountered (local vs. tourist); type of tourism employment (formal vs. informal); sex (male vs. female); and self-reported history of transactional sex. We used a sampling matrix to track our sampling in the field and to continuously adjust our recruitment to achieve maximal sample diversity along these theoretical criteria. Aiming to recruit a minimum of two participants per cell in our 16-cell theoretical sampling matrix, our goal was to conduct in-depth interviews with a diversified theoretical sample of 32 tourism industry employees.

Recruitment of semistructured interview participants unfolded in the course of conducting ethnographic observations in alcohol venues. We conducted ethnographic observations between February and August, 2009, in three neighborhoods of Sosúa: El Batey, Los Charamicos, and Sosúa Abajo. El Batey is the neighborhood with the greatest tourism presence, including many businesses catering largely to foreign tourists but which also attract large numbers of locals seeking entertainment, informal sexual exchanges with foreigners, or other work opportunities. Los Charamicos, adjacent to El Batey, is primarily composed of local Dominican residents, many of whom are employed in service work in El Batey, and contains several well-known puntos (drug sites) known for drug trafficking. Sosúa Abajo is a lower-class barrio located farthest from the dense tourism area of El Batey, and has fewer alcohol-serving venues than either of the other two neighborhoods. To determine the overall spatial organization of alcohol venues in the area, we began the ethnographic observations by conducting a complete walking survey of all alcohol-serving businesses in each neighborhood, and mapping their location on a city map. This led to a detailed map of 134 alcohol venues. Then, team members—including Dominican research assistants originally from Sosúa and very familiar with all neighborhoods—identified a list of sites in each neighborhood at which to conduct more detailed observational visits.

During observational visits to the alcohol venues, team members interacted informally with clients and employees while observing the environment and social context. Because of our focus on context, we felt it was critical to familiarize ourselves with the realities of social interaction in Sosúa. The project team incorporated distinct subject positions, including two North American men of Hispanic descent, two Dominican men, and two Dominican women. We believe the range of perspectives and experiences on our team and our group discussions of observations deepened our understanding of the larger social climate in Sosúa, and also improved the quality of our formal semistructured interviews. The process of participant recruitment began naturally as a consequence of informal interaction during observations in the venues, consistent with the methodological approach of ethnography. We were cautious about the ethical dimensions of the research and the potentially vulnerable position of employees, and thus avoided formally approaching potential participants if we felt it created suspicion or concern from managers, supervisors, or the authorities. Thus, participants were not immediately approached about participation in the interviews, but rather casual conversations and interactions preceded formal recruitment. For example, in the course of observations, the researchers played pool with local men, played dominoes outside establishments, and spoke extensively with bartenders, waiters/waitresses, security personnel, and clients in each venue. Local team members who were very familiar with the environment provided important input to determine the least-invasive means and moments for approaching individuals for formal recruitment. If an individual encountered in the venue appeared to satisfy our sampling requirements, we found an appropriate moment to talk briefly in a private setting outside the venue. On many occasions, this occurred when the individual took a break from his or her work and then advised us he or she was available to speak. Once outside the venue, we explained the research in detail. If the individual expressed interest in participating, a brief verbal screening was conducted to determine whether he or she met the participation criteria. As our observational sessions and recruitment approach proceeded, we used the sampling matrix described above to track the types of participants we were recruiting.

For individuals who were eligible and interested in participating, an interview time was arranged, a contact card with the appointment site and details was provided, and the person was asked to provide a phone number for a reminder call. Through this strategy, research staff recruited the target sample of 32 from 12 alcohol-serving establishments in Sosúa and one outdoor venue (the beach) that was composed of a cluster of alcohol-serving stands. Following informed consent, each participant was interviewed twice during a period of approximately 2 months, with each interview lasting approximately 1.5 hours (3 hours total per person). The first interview focused on family history, work history, migration stories, and relational context. The second interview focused more specifically on transactional sex, relationships with tourists, sexual practices, alcohol/drug use, and perspectives on condom use and HIV/AIDS. We conducted two separate interviews per participant for two primary reasons. First, this broadened the range of topics we could feasibly cover, allowing us to gather more in-depth information on the context of the participants’ lives and to cover a wide range of topical domains. Second, conducting two interviews allowed time for the gradual development of familiarity and rapport, which was especially critical for the more sensitive questions. The most sensitive issues—regarding sexuality, sexual risk behaviors, and alcohol/ drug use—were discussed in the second interview as a means of reducing any apprehension participants might have felt about discussing such experiences during the initial research interaction, and to broach these subjects more gradually after building a certain level of trust between the interviewer and interviewee. Our team’s training in preparation for the interviews also included extensive discussion of techniques for broaching sensitive topics during qualitative interviews, incorporated feedback from local team members on culturally appropriate ways of approaching these issues, and provided opportunities for role playing. We believe that all of these procedures allowed us to approach these topics with the greatest sensitivity and to mitigate many of the problems associated with discussing sensitive issues in interviews. At the end of each interview, participants were given a $10 incentive for their time.

A brief sociodemographic questionnaire was applied to each interview participant following the first interview. Of the 32 participants, 7 (22%) were currently married, 26 (81%) had children, and 22 (69%) had migrated to Sosúa from other parts of the Dominican Republic or Haiti. Their average age was 31 years, ranging from 21 to 59. Seventy-two percent were single, 22% were married, 6% were divorced, and 81% had children; 53% reported a primary school education or less, and only 19% had completed high school.

All semistructured interviews were recorded on digital audio recorders and later transcribed for analysis. Because of the large body of text to be analyzed, en vivo coding and analytic summaries were conducted with each interview. En vivo coding involves the use of short restatements of emerging themes, emphasizing the words and phrases provided by participants themselves (Corbin & Strauss, 2008). Analytic summaries consisted of 1-page overviews of the key findings or emerging themes in each participant’s narrative. Based on these procedures, a provisional codebook was then created, including definitions of codes and subcodes, criteria for inclusion and exclusion, and brief examples of narratives that would be appropriate for each code. Research staff received coding training using the ATLAS.ti computer software program (ATLAS.ti, 2006) and the codebook. A small subset of the interviews was then coded by project staff to ensure viability of the codebook and consistency between coders, followed by team discussion and reflection. Following this process, modifications were made to the codebook and all interviews were then recoded by one of six coders.

Following coding, data were analyzed by examining the range of responses associated with particular themes of analytic interest, to obtain information about the tendencies in experiences and perceptions across the sample. This type of “vertical” analysis decontextualizes segments of textual data associated with themes of interest by removing them for the larger transcript for focused analysis, permitting a closer examination of code-specific responses across the sample. Second, in conjunction with the continual writing of analytic memos and the use of the analytic summaries, subtle variations in perspective among individual participants were situated within the larger context of meaning, experience, and behavior of each person. This “horizontal analysis” allowed us to recontextualize narratives within the larger context of a person’s life, to develop explanations for variations in experience across the sample.

Results

“If Alcohol Doesn’t Sell, There is No Life”: The Business of Alcohol Use in Sosúa

With the high number and concentration of alcohol- serving establishments in the area of Sosúa, it is perhaps not surprising that many participants described drinking as their primary form of entertainment. Indeed, nearly all participants mentioned the consumption of alcohol when asked an open-ended, unprimed question about what they enjoyed doing for recreation. We began the second interview session with a very open-ended question—What do you like to do for fun?—to avoid directly framing the discussion around alcohol use and to explore how participants interpreted having fun. Nearly universally, responses were either direct references to alcohol consumption—such as, “I go drinking with my friends”—or were references to visiting alcohol-serving establishments—such as, “I go to Discoteca [Discotheque] X in El Batey.” Even when participants described having fun as going to specific locations or businesses rather than alcohol consumption per se, follow-up questions about what activities they enjoyed engaging in within these sites very commonly produced descriptions of alcohol consumption or illicit drug use, without direct questioning about these activities from the interviewers. Although this might reflect a cultural script associating “fun” with alcohol, it also reflects the pervasive and ubiquitous presence of alcohol within the lives of all Sosúans. Jonathon,¹ a 35-year-old man who reported working in a wide range of informal jobs within the tourism sector—including teaching Spanish classes, selling illicit drugs, having romantic or sexual relationships with foreign women in exchange for gifts, and brokering sexual exchanges between tourists and locals—noted that, “Here, we live alcohol. Here it is difficult to find a person who doesn’t drink, to say, ‘I do not drink alcohol.’ Very difficult. I know one person who drinks rarely, but he still drinks.”

This perception of the pervasiveness of drinking was attributed largely to the influence of tourism, because the industry depends on what José, a 33-year-old security guard, described as the “vice of drinking and the vice of drugs.” Binge drinking by tourists was described as having a profound impact on alcohol and illicit drug use among local residents, and especially those employed by businesses catering to foreigners. These environments normalized excessive drinking and made it nearly impossible to conceive of a life without alcohol, particularly in interactions or exchanges with tourists or in tourism businesses. Thus, even though alcohol was associated with “fun,” participants also mentioned the consequences of excessive alcohol consumption, which were often described with morally laden terms such as vicio (vice).

Drinking while working in the tourism industry was a common practice. Marcos, a 38-year-old man who worked renting chairs and umbrellas on the beach, observed that alcohol functioned as a way to maintain the ambiente (atmosphere): “You’re not obligated to drink … but the majority easily drink alcohol to create the atmosphere.” “Atmosphere” was composed of rest, relaxation, and the kind of abandon that was facilitated by alcohol. Whereas Marcos stressed that his job did not obligate him to drink, other participants felt explicit pressure to drink as a part of their job in the tourism industry. David, a 31-year-old man who described himself as a “hustler” working informally in promotions within the tourist sector, noted, “The Dominican Republic is a party … there are times when I try not to drink. But at times, it is impossible for me … at times it’s customary that I have to drink.” Drinking with potential clients allowed David to foster friendships and trust, enabling him to successfully offer services, which included serving as an intermediary in the sale of sex and drugs, to tourists in Sosúa.

Alcohol was also described by participants as an essential part of the economic stability of businesses in Sosúa, and of the local economy as a whole. Many expressed the belief that alcohol was, in the words of one participant, “life” itself, because the economic vitality of the city and the hope for a better future depended so fundamentally on the sale of alcohol. Julio, the 39-year-old manager of a local bar located strategically along the main coastal highway, observed that “if alcohol doesn’t sell, there is no life. … We say there is no life, there is no future, no money.” Although this equation of alcohol with life is perhaps not surprising for a bar manager, it describes a more general tendency to view alcohol consumption as a basic and fundamental component of all social and economic transactions in Sosúa.

Margarita, a 32-year-old bar employee reporting a history of transactional sex, described a tension between the perceived imperative to consume alcohol in the course of her work and her responsibilities as a single mother with young children. Although Margarita admitted to drinking beer regularly in tourism areas, she also insisted repeatedly during the interview, “I do not like alcohol; I do not like anything to do with alcohol.” She explained the apparent contradiction between her distaste for alcohol and her regular consumption as follows:

I live with my children, I’m a mother and father at once. I cannot get home drunk. But they [tourists] always offer me drinks. I drink if they offer it to me. But I cannot buy drinks. I do not have resources to buy beer, because I have a newborn baby. And my daughter. I do not want to get drunk. I sometimes drink out of necessity, but not because I want to.

Margarita’s narrative was similar to those a number of the women participants, who expressed gendered reasons to avoid alcohol, such as obligations to family and children, but who also described the necessity to consume alcohol routinely in the course of their work. Here, she expressed this tension in the notion of drinking “out of necessity,” making reference to the ways that drinking is integrated into the material and interpersonal exchanges that structure tourism labor, leading to the perceived imperative to consume. Women had to balance this necessity against other gendered obligations, such as being a responsible mother and provider to children.

This imperative was reinforced by business owners and managers who employed various techniques to encourage alcohol sales, which were described in detail by participants. Many establishments offered regular drink specials, such as discounts or promotional boletos (free drink tickets), providing incentives for clients to buy more alcohol or to patronize the establishment on a particular night. Angelia, a 33-year-old unemployed woman who reported a history of sex work, also noted that some businesses offered employees an incentive system such that “if they sell more, they earn more.” When David, the self-described hustler mentioned above, brought tourists to local businesses, he was often rewarded with free drinks from the manager. This incentive system encouraged both greater rewards for the employees as well as increasing alcohol consumption among both tourists and locals. Through such commissions and informal rewards, businesses perpetuated as well as responded to a pervasive demand for alcohol that was such a defining feature of Sosúa. In turn, this climate of consumption contributed to a major theme that emerged throughout the interviews: the inseparable relationship between sexuality (and particularly transactional sex) and the consumption of alcohol.

Alcohol and Sex as Intertwined in Sosúa

Participants consistently articulated a kind of conflation or persistent association between alcohol and sex, such that one almost necessarily implied the other. One illustration of this is the fact that several participants described the presence of chicas (young women, often used in Sosúa to refer to sex workers) as a prerequisite for the sale of alcohol in Sosúa. Essentially, no alcohol-serving venue was perceived as viable if it did not offer women’s sexuality as a primary component of the alcohol-consumption experience. Miguel, a 44-year-old man employed by a bar catering to tourists, observed that venue owners often sought ways to attract women to the business as a means of drawing in more young men, both Dominican and foreign, who were perceived as the lucrative clients. In local businesses with “good chicas,” he said, “there always are people.” As such, women were framed as prized erotic commodities; they were basic capital needed to generate greater profits from alcohol sales. At the club where José worked the late shift, the owner “requires the [female] bartender to be sexy and always to be dancing with tourists … because it motivates them to spend their money. … [It allows] his business to sell more.”

Recognizing the function of women as a stimulus to alcohol sales, a number of establishments offered entrada gratis, or free entry, to young Dominican women, under the assumption that they would positively influence the sale of alcohol. Many of these young women were known or presumed to be sex workers, but often were not formally employed by these businesses. Rather, their presence created a kind of consumptive synergy: young women obtained opportunities for informally negotiated transactional encounters with tourists, and the businesses used their presence to attract clients to boost alcohol sales. Participants were therefore quite clear in their narratives that the value of women within Sosúa was inextricably linked to the value of alcohol as a commodity, because sexuality, alcohol, and illicit drugs were mutually reinforcing and often “consumed” together.

Participants expressed the perception that Sosúa was a town that sold vicios, a commodity that was the central reason that tourists come from far-away countries to experience this small Caribbean town. A number of participants expressed an awareness that tourists come to Sosúa in search of vicios, including excessive drinking and drug use, even though they rarely do so in their home countries. Cristina, a 21-year-old working as a waitress in a local bar with primarily foreign clientele, described one particular customer as a “good person,” and then added that “in his country he doesn’t drink alcohol. Meanwhile, he comes here and even his passport goes crazy when he is in the Dominican Republic.” Maria, a 24-year-old woman working as a salaried waitress within the tourist area of El Batey, similarly explained that this behavior was acceptable and tolerated while on vacation in Sosúa because of the benefits of such decadence for the local tourism economy:

So they [the tourists] come to this country to have fun; what they cannot do in their country they do here. But also, the contribution that they make is really good for the country because we depend completely on tourism.

Maria’s final remark, which reframes tourists’ hedonistic behavior as beneficial, reflects a pattern in the interviews. Despite recognition of problematic behaviors among tourists, such as excessive alcohol consumption and drug use, few participants characterized the tourism industry as negative or in need of reform. Instead, they focused on the need to accept such excesses because of the country’s utter dependence on the industry. It might be that participants themselves relied so heavily on interaction with tourists for their own livelihoods that it was impossible to envision an alternative reality.

Participant narratives also demonstrated the conceptual linkage between alcohol, illicit drugs, and sex in the linguistic associations between these activities. Often, alcohol, drugs, and sex were all mentioned in a list of vices that were believed to drive the tourism industry in Sosúa. For example, Josefina, a 23-year-old woman who described herself as unemployed but occasionally engaged in transactional sex with foreign men, commented that tourists “come to have a good time, they come to look for whores, to drink—to drink a lot.” Similarly, 35-year-old Jonathon, who supported himself through various informal jobs within the tourism industry, noted that tourists in Sosúa

come for prostitutes and for drugs. Do not tell me that tourists come here to go surfing or come to snorkel, because it’s not true. The tourist that comes here comes to have sex with their women, to snort their cocaine.

Sex, like alcohol consumption, was described as another tourist behavior that was absolutely central to maintaining the industry. Like alcohol, participants emphasized the economic importance of sexual exchanges with tourists for the vitality of the entire industry, because the value of Dominican bodies to tourists was one of the primary resources that guaranteed tourist arrivals. Josefina, 23, who occasionally engaged in transactional sex with gringos (a local term used to refer to foreigners, especially those from North America), for example, was clear that sex work was essential for the flow of dollars to the Dominican Republic. Indeed, echoing the statements made about alcohol described above, she observed that “without whores, there is no life”:

[Tourism is] very good, very important for this country. It brings a lot of money here … and the whores are good. . . . The people talk [badly] about the whores, but the whores make the gringos spend money. They like the whores to go to the dance clubs because without whores, there is no life. Without whores, there are no gringos. The gringo goes where the women go. You see the dance club over there. The drinks are free for the women who enter, because if the women go, the [gringos] go.

Josefina described a script of sex and alcohol in Sosúa that was articulated by a number of participants: Tourism is vital for the life of Sosúa; the consumption of vicios (sex, drugs, and alcohol) is what tourists most desire and what motivates their travel; cueros (translated here as “whores” because of the term’s derogatory connotations) provide the erotic services that maintain the demand for such vices, and are therefore “good,” indeed essential, for Sosúa’s survival. This script emphasizes the inseparability of these vicios, because it is their synergistic relationship to one another that creates the particular social environment of Sosúa. This is evident in the organization of tourism businesses. Participants described alcohol venues functioning as informal brothels, and some having habitaciones (rooms) on site for sexual exchanges, a trend noted in previous studies (Centro de Orientación e Investigación Integral, 2000; Jerez et al., 2003). Furthermore, participants noted that in many alcohol-serving establishments in Sosúa, staff employed as bartenders, waitresses, and security personnel often served double roles as sex workers or as intermediaries between clientele and sex workers. In essence, alcohol venues were not viewed only as places to purchase drinks; they also offered the joint commodities of eroticism and sex. In José’s words,

There are two things that they’re selling: drinks and women. So the guy who has his bar sells the drinks and the women. It’s also the same when consuming alcohol: [the tourist] pays for his drink and takes along his woman. That is, that you do both things at the same time.

“Getting Crazy” and Sexual Risk in Sosúa

As described previously, the literature on tourism and health behaviors has tended to focus on tourists’ uncharacteristic or distinct behaviors as they travel to new environments with different normative systems and controls. In the context of HIV/AIDS, this is hypothesized to be associated with higher rates of tourist-reported risk behaviors (unprotected sex, alcohol/drug use), but few studies have documented the effects of tourism environments on local tourism employees. In this study, participants were well aware of the potentially harmful consequences of escapism in tourism areas, which they often described as particularly dangerous because of the overwhelming presence of illicit drugs and alcohol. In addition to the close linkage between alcohol and sex work, described above, participants understood tourism areas as especially dangerous in the context of HIV/ AIDS. Many participants described decreased inhibitions and poor or atypical behaviors in sexual situations in Sosúa, which could result in ceding control in sexual situations. Laura, a 32-year-old bar employee who “goes out with clients” for money, emphasized in her interview that she was very cautious about drinking when she met clients: “If you get drunk, what’s going to happen is that you’re going to get crazy and anything could happen to you. And this life is very dangerous.” In Laura’s case, “this life” refers implicitly to sex work, which is often referred to indirectly in the Dominican context, but which pervades nearly every aspect of life in Sosúa. Alcohol and illicit drugs were understood by participants to facilitate “getting crazy,” which was often described as a temporary loss of control that ultimately contributed to danger. Like Laura, Cristina, a 30-year-old waitress, noted that after drinking, many women in Sosúa “do not know what they’re doing. They do not know who they are going with, and who they are sleeping with.” Because the entire tourism environment fostered abandon and participation in vices, the addition of alcohol and illicit drugs reduced personal control over one’s sexuality. For Laura and Cristina, the perceived danger of contact with tourists was therefore associated with the temporary suspension of normative controls on behavior that have been described for tourism areas in general, but which were exaggerated by the alcohol and substance use that typically accompanies tourist activities.

The idea of “getting crazy” in Laura’s narrative is similar to that of other interviewees, who expressed similar notions of losing control over sexuality, and explicitly linked this phenomenon to unsafe sex. Sara, a 22-year-old woman working in a local billiard hall, noted the connection between alcohol consumption and condom use with tourists:

[Some tourists] do not want to use a condom … because of the environment, the drink, the women. . . . When they have their rum in their head, their vice [implying drugs], all they want is sex, but they do not want to be careful. . . . They do not want to take care of themselves.

In Sara’s narrative, it is evident that getting crazy and losing control are inherent aspects of the industry, and lack of condom use in sexual situations is simply one component of this larger pattern. Cecilia, a 23-year-old self-identified sex worker, described in her interview that even though she always tried to be careful in her work—which for her involved avoiding alcohol and illicit drugs—the social environment of Sosúa was dangerous for many of her peers, because “sometimes, when they go with a man they do things under the influence [of alcohol], you know, that they shouldn’t do. Then the day after they rethink what they have done.” Cecilia also described an association between alcohol consumption and the false trust that it can generate, leading to dangerous choices with a relatively unknown partner: “There are people that when they are going to have sex, they do not protect themselves, because of the alcohol and trust, and that’s why you cannot trust anyone.”

Here, Cecilia connected the idea of “getting crazy” with a related notion, that is, the development of intimacy with clients and the resulting dangers that this intimacy could provoke, particularly in decisions regarding condom use. As the literature on Dominican sex work has described (Brennan, 2004; Cabezas, 2009; Padilla, 2007), much of Sosúa’s commercial sex industry depends on the development of intimacy and romance between tourists and locals, a phenomenon that has been described as “romance tourism” (Pruitt & Lafont, 1995). The concept is useful in that it draws attention to the fact that much of what is being transacted in tourism environments such as Sosúa is intimacy, affection, and love, rather than sex, per se (Brennan, 2004). It is clear that such intimate relationships were valued among many of our participants, and indeed, many of the histories of transactional sex described by participants did not involve one-time or direct sex-for-money exchanges, but rather intimate relationships or friendships with tourists.

Rosa, a 28-year-old unemployed woman, explained that at the time of the interview she had foreign “boyfriends” with whom she had sexual relationships, but that “they are not clients, but for love. . . . They give me money and I do it with love.” Nevertheless, some participants described affection or love as somewhat strategic; that is, they also noted the utility of affection as a means to obtain material support. Luis, a 34-year-old man working in security in the tourism area, was in a long-term relationship with a Dominican woman, but also described pursuing an extended relationship with a Canadian woman. When asked why he endangered his long-term relationship by developing additional connections with foreigners, he described this as a financial decision: “If you do not have a good economic position, when you find a partner that is economically viable, then you have their benefits.” For him, establishing an affectionate relationship was more explicitly a means to an end—a chance for gaining some economic stability.

At the same time that intimate connections with tourists were valued, these relationships were sometimes complicated to manage, and some participants again described “getting crazy” as the loss of control over one’s emotional relationship with tourists. The ability to appropriately manage emotional feelings with tourists was thus something that was valued among participants, because it allowed them to effectively manage needed relationships to privileged foreigners while also avoiding the loss of control that might lead to negative consequences or disappointments. Maricela, a 23-year-old woman who had had foreign “boyfriends” in the past, noted the fleeting nature of these relationships: “They give you lots of love, but after three months, they forget about you. . . . One day they no longer call you, they do not write.” Speaking of her ex-boyfriend, a tourist from Canada, Angelina noted that he “was a good person, responsible, and because I never had help like that from a man, with him I felt safe. . . . He helped me a lot, he respected me, because times were different, not like now.” Angelina’s comment implies that tourists at the time of interview were less likely to help and protect Dominican girlfriends than in the past, suggesting a need for caution in establishing such relationships. In fact, Clara, a 34-year-old bartender and sex worker, proudly noted that, with the exception of one American tourist, she had “never loved a client,” referring critically to this previous relationship as “crazy.”

These cases demonstrate that even though tourism areas like Sosúa encourage the establishment of intimate or romantic relationships between tourists and locals, they can be challenging to manage emotionally and interpersonally, and require a measure of control to avoid certain dangers or doing something “crazy.” One such danger is engaging in behaviors that can lead to HIV/AIDS. Miguel, a 44-year-old man working informally in a tourist establishment, explained the need to maintain control over one’s feelings:

There are a lot of young, pretty girls, and you see them and you fall in love. And so when you take a drink, and you do not know her, there are many women who have HIV, so [then] you’re left infected. Because you are partially drunk and so is she.

Here, Miguel connected the emotional attribute of “being in love” to the decision to engage in risky sexual behaviors, suggesting that alcohol can influence one’s ability to exercise both emotional control (“you see them and you fall in love”) as well as sexual control (risky sexual behaviors). “There are times,” David, the 31-year old self-described hustler, said, that “the women fall in love with the gringos and it is not like a job … there is pleasure, trust, they open up to that person,” putting them at risk to have sex with these tourists “without any protection.” Sosúa was understood by participants as a space in which the ability to maintain protective controls on one’s emotional and behavioral decisions is compromised, and the presence of vices (alcohol and illicit drugs) exacerbates this tendency.

Discussion

Although the literature on research in the Caribbean documents high rates of sexually risky practices, alcohol consumption, and illicit drug use, these phenomena have been generally understood within a behavioral or issue-specific framework. The goal of syndemic theory is to reconfigure these frameworks to focus on the broader societal and material context that drives the accumulation of negative health effects, particularly in marginalized or disadvantaged populations. Based on the regional social science literature and our own analysis, we believe that tourism industry employees in areas such as Sosúa constitute a vulnerable population often facing syndemic conditions that have rarely been addressed by public health initiatives or public policy, which has primarily centered on educational and behavioral prevention approaches aimed at targeting separate health outcomes. Such approaches do not address the broader social and economic conditions of life and work in Caribbean tourism areas, where a growing population of workers converges as they cope with dwindling options for productive activity. With our qualitative research on the social context of alcohol, illicit drugs, and sexual practices in Sosúa, we aimed to understand how a diverse sample of tourism industry employees described their own social and economic environments, and the influence of these environments on their daily lives and practices. This allowed us to examine whether the theoretical assumptions of syndemic theory are reflected in first-person narratives of the tourism workers themselves, and if so, the specific forms they take.

Our analysis revealed several findings consistent with syndemic theory. In Sosúa, the consumption of alcohol and illicit drugs is described by local tourism workers as basic elements of the social and economic climate of Sosúa, and central to tourist practices and desires. Indeed, without these vices, many participants believed there would be no life, because tourists are primarily drawn to Sosúa precisely because of their ability to temporarily, and with a certain degree of abandon, engage in behaviors that are not typical back home. Tourism workers perceived tourists to behave quite differently in Sosúa than they do in their home countries, where they were regarded as morally upstanding, in contrast to their “crazy” behavior in Sosúa. The participants were often compelled by this general social climate of abandon—which we refer to as touristic escapism—to engage in what they perceived to be crazy practices, partly as a consequence of their desire to establish friendships and intimacy with tourists. Business practices contributed to a social atmosphere in which alcohol, drugs, and sex were readily available and were marketed and consumed as a suite of tourist services, not as separate or independent commodities. This economic rationality combined with the escapist climate of Sosúa functioned to diminish their perception of control over alcohol consumption and sex. For example, although participants described the desire to maintain some control over alcohol use as a protective strategy and a parental responsibility, they also noted the necessity of drinking with tourists as a means of establishing intimate social and sexual relationships. In Margarita’s words, “I drink out of necessity, not because I want to.” Tourism businesses in Sosúa participated actively in generating this sense of obligatory alcohol consumption. Businesses that our participants frequented as part of their work were not only places to purchase alcohol and illicit drugs, but also sites that functioned to link alcohol consumption to eroticism through specific marketing practices. Many bars and discos, for example, provided free drink tickets to young women as a means of supporting alcohol consumption and attracting clients seeking good chicas, or rewarded local promoters and staff with free drinks. Thus, the marketing of Dominican sexuality was functionally inseparable from the sale and consumption of alcohol; conversely, the sale and use of alcohol provided an essential means of establishing and fostering erotic and sexual transactions.

This synergistic relationship created particular challenges for tourism employees as they navigated the potential dangers of Sosúa. Individually, both sex work and alcohol played a role in the sexual vulnerabilities of tourism employees in Sosúa; nevertheless, it was the synergy between alcohol/drugs and transactional sex that likely contributed most to sexual scenarios that could transmit HIV or other sexually transmitted infections. A number of participants in this study noted that alcohol contributes to getting “crazy,” or losing control over one’s sexuality and compromising one’s ability, capacity, or desire to use condoms. Our results and the regional literature suggest that this can be more common among those who engage in transactional sex but either do not self-identify as sex workers or perceive these sexual encounters as a component of an intimate or romantic relationship. In the cases of such transacted intimacy, the desire or the need to establish intimacy—and the consumption of alcohol and illicit drugs as a means to achieving intimacy—created a situation in which self-protective strategies were less likely to be used. HIV interventions do not generally address such experiences of transacted intimacy, because they do not fit within the normative frames of public health, particularly the emphasis on interventions targeting formalized sex workers. Although prevention efforts targeting sex workers are a critical component of public health efforts, they do not capture the range of informally transacted intimate exchanges that our participants described, or that predominate in the Caribbean social science literature.

Approaches to health promotion among Caribbean tourism workers such as those we interviewed in Sosúa should incorporate a broader understanding of the social and economic conditions workers face in the course of their daily lives. As a growing population of tourism workers migrates to tourism zones, health programs and policies should aim to guarantee safer working conditions and acknowledge the syndemic potential of these areas for tourism workers. This involves moving beyond traditional approaches to intervention that separately target health outcomes such as HIV, alcoholism, and drug use. Instead, health-promotion efforts should be focused on the design and implementation of new policies and safer work protections aimed at providing the social and economic conditions for achieving health and well-being among tourism workers more generally.

Following the premises of syndemic theory, and informed by our qualitative findings, we conclude that there are at least three domains in which programs and policies should be focused. First, policy advocacy should be focused on providing greater guarantees for the occupational health of tourism workers, with particular emphasis on ameliorating the synergistic relationships among alcohol, illicit drugs, and transactional sex. This will involve incorporating the perspectives and challenges faced by workers themselves into appropriate initiatives, such as their perceived necessity to consume alcohol as a requirement of tourism work, or the perceived loss of control in intimate encounters with tourists. Interventions with this population should avoid the partitioning and targeting of separate health behaviors, and instead develop industry standards, programs, and protections based on the multiple and intersecting challenges to health and well-being faced by tourism workers. Second, health-promotion initiatives in tourism areas should foster collaboration across the public and private sectors to generate awareness and dialogue about the multiple health vulnerabilities faced by tourism workers, and develop joint policies to ameliorate them. Business owners and managers are likely to be well aware of the synergies between alcohol consumption, drug use, and transactional sex, and are critical partners in ensuring safer environments for employees based on workers’ expressed needs. Because our research demonstrates that local tourism workers in Sosúa are already concerned about the dangers of losing control or “getting crazy,” for example, it is likely they would be responsive to work-based programs and opportunities for dialogue that would provide strategies and resources for avoiding such dangers in the course of their work. Finally, programs for sexual health promotion, which to date have largely avoided the tourism industry, should be mandated and overseen by the state as a basic occupational health protection for all tourism industry employees. Such programs should not seek to target a formalized or stereotyped category of sex workers, but rather address the pervasive presence of transacted intimacy, alcohol consumption, and substance use throughout tourism areas, and incorporate broader HIV-prevention resources that are integrated into occupational health programs. The fundamental goal of such programs should be to openly acknowledge the lived realities of transactional sex, and its frequent combination with alcohol and drug use, and then provide the skills and resources for reducing sexual health vulnerabilities. It would be critical for such programs to avoid the stigmatization or penalization of these practices, which would only serve to marginalize tourism workers and prevent positive changes in the conditions they encounter.

Biographies

Mark B. Padilla, PhD, MPH, is an assistant professor in the Department of Health Behavior and Health Education and an adjunct assistant professor in the Department of Anthropology at the University of Michigan in Ann Arbor, Michigan, USA.

Vincent Guilamo-Ramos, PhD, LCSW, is a professor in the Silver School of Social Work at New York University in New York, New York, USA.

Ramona Godbole, MHS, is a graduate student at Johns Hopkins University in Baltimore, Maryland, USA.