An Assessment of the Problem with Implications for Prevention and Treatment

by MICRONESIAN SEMINAR
Pohnpei, FSM
March, 1997

Even drugs introduced from abroad have been circumscribed by a set of cultural parameters that can be missed by Western social workers. Tuba (fermented sap of the coconut palm), which reached many of the islands of Micronesia by the end of the last century and is still in common use today, has been fully assimilated into the life of outer island dwellers in Yap. The circle of tuba drinkers that gathers at the end of a typical day on one of these islands includes almost all the adult males on the island. This drinking circle is more than a form of male relaxation; it is something of a bonding ritual that offers men the opportunity to do community planning and sometimes air their problems.

Other forms of alcohol such as beer and liquor, like almost everything else adopted from the West, serve certain positive functions in these island societies and are bounded by cultural conventions, even if none of this is immediately apparent to the foreign eye. Typically in Micronesian societies men drink and women do not. Young men often drink with a reckless abandon that older and presumably wiser men are expected to eschew. Certain kinds of drunken behavior are shrugged off as "normal," while other, more offensive and destructive actions call for retribution.

We must, therefore, beware of regarding drugs as simply a counter cultural phenomenon, for they are in fact very much a part of today's culture in the Pacific. Drug use is not simply a dark marginal corner of society, a cultural vacuum, into which certain individuals have been pushed by the anomie that often accompanies rapid modernization. Still less can it be explained as a reaction to colonial oppression. Drug use may be a refuge, but it is a culturally sanctioned refuge with a logic and guidelines recognized by the society.

To view drug use as a cultural rather than counter cultural phenomenon in this way is not to deny that drug use unleashes social problems. The pathways of Micronesian societies, like those of other places, are littered with the wrecks of lives ruined by drugs. Anyone who has watched the line of women and children streaming from their houses with mats under their arms on a payday Friday afternoon to spend the night in the boonies is aware of the apprehension that drinking causes for the more vulnerable members of the family. The smashed cars and the weekend trauma cases in the emergency room are further testimony to the damage that drugs can wreak.

This report assumes that drug use must be understood in its sociocultural context before successful strategies can be devised for controlling drug use. Unless we understand the reasons Micronesians use drugs, the situational contexts of this use, and the array of social controls available in these island cultures, our attempts to provide treatment will be fruitless. The decision to sniff gas, to smoke marijuana, to drink case after case of beer, or even to snort coke or smoke "ice" may be an individual choice, but it is conditioned by the social environment and the cultural norms of the community. Micronesians, like other Pacific islanders, are social animals to a much greater degree than Westerners. The drugs on which they rely are almost always enjoyed with others rather than alone, take their meaning from their cultural milieu and are subject to the same prohibitions and sanctions of the island society. Those who will attempt to find effective ways of addressing the drug problem ignore this fact at their own peril.

Purpose of this Report

The Center for Substance Abuse Treatment (CSAT) has undertaken an initiative with states, along with territories and the Freely Associated States in the Pacific, to assess the demand and need for substance abuse treatment services at the state and sub-state levels. CSAT contracted this study, as it has studies in other regions, in order to assess the magnitude of the alcohol/drug problem in Federated States of Micronesia (FSM). Employing sound methodology, this study was to establish prevalence rates for substance abuse and identify the areas and populations in greatest need of treatment services. The supposition was that carefully established rates alone would provide adequate baseline data for planning and funding purposes inasmuch as the relevance of treatment methods need not be questioned. The underlying question that CSAT studies sought to answer was how much expansion in treatment facilities would be necessary to accommodate all potential users.

This study does not share the assumption that drug and alcohol abusers in the Pacific Islands will respond to the treatment methods commonly employed in the US. Because of this, the thrust of this present study may differ from similar studies conducted in the states. The author feels that it is essential to review the sociocultural context of alcohol and drug abuse, along with the meaning that the use of these drugs has for Micronesians, even if this leads to what some would consider a disproportionate emphasis on qualitative rather than quantitative data.

Likewise, this study will attempt to review the various types of treatment approaches currently being used by agencies operating in FSM. While not intended as an evaluation of these agencies, the last chapter in this report will point to approaches that might be more effective in an island society.

Given the small size of the island communities being studied, that data generated by this study may be handled more simply than is usually the case in a survey of this type. We have attempted to highlight the most significant correlations between drug use and social status markers. We also present projections on the size of the drug-using populations-projections that we feel can be made with a good level of confidence. These projections together with the profiles that have been derived from the survey data, when used with the information on the social context of drug use that this study attempts to provide, should furnish a useful basis for working out treatment strategies.

At bottom, however, the purpose of the study remains the same as others authorized and funded by CSAT-that is, to establish substance abuse prevalence rates for FSM, which, viewed against the distinctive cultural features of the area, can be converted into comprehensive estimates of service need and demand that can be used for planning, program management and policy making.

Accordingly, the goals of this study are:

• To assess the absolute level of alcohol/drug abuse treatment need in the four states by providing solid prevalence rates for the total population and the different age-sex cohorts.
• To provide a sound assessment of the sociocultural factors peculiar to Micronesian societies, including the functions that alcohol and drugs serve, the social context in which they are used, and the meanings they have for Micronesians.
• To inventory the agencies, private and public, and the kinds of prevention and treatment programs they offer.
• To suggest what the most effective and culturally appropriate approaches in providing treatment and support for drug and alcohol abusers.

There are two other goals endorsed by CSAT that must be addressed: training in the collection and use of data, and networking among non-governmental organizations (NGOs). Both are important goals but could not be met, for various reasons, as this report was being prepared. Our hope is that the process that follows the production of this report will offer an opportunity to meet these additional goals. We anticipate using this report as a teaching tool for representatives of government substance abuse offices and heads of NGOs to help them develop a facility in using and gathering data of the kind presented here. The public presentation of this data to these same representatives will provide an opportunity to do the networking among various agencies envisioned by those who funded this project.

Scope of this Study

The study covers the Federated States of Micronesia, a newly independent nation that is bound to the US by the terms of a document known as the Compact of Free Association. The nation acquired full self-government in October 1986. At the end of World War II, the four major island groups comprising the FSM were joined with Palau, the Marshalls and the Northern Marianas in a UN trusteeship administered by the United States. For sixty years before the US assumed authority over the islands, these islands had been subject to the colonial administration of three other countries.

The Federated States of Micronesia is a nation of small islands, with the largest, Pohnpei, having an area of about 100 square miles. The total population of the country, according to a 1994 census, is 105,506. The FSM has four states-Yap, Chuuk, Pohnpei and Kosrae-with pronounced language and cultural differences between them. Moreover, each of the states except Kosrae contains more than one ethnic subgroup. For this study representative sampling was done in each of the four states. The populations of the states in 1994 were: Chuuk 53,319; Pohnpei 33,692, Kosrae 7,317; and Yap 11,178.

Although the principal focus of this study is on alcohol, since it is far more widely used than any of the others and is generally thought to be the most damaging, the study also includes marijuana, inhalants and "hard drugs." This last term is used to embrace illegal drugs other than marijuana taken for non-medicinal purposes (that is, cocaine, heroin, amphetamines, and hallucinogens). The study does not include tobacco, nor two widely used locally grown substances-namely, sakau (sometimes known as kava) and betelnut. These last items were excluded from the survey because of the fear that the study would lose its principal focus on that narrow range of drugs whose use can be said to contribute to social problems (as distinguished from health problems) in Micronesia.

Contracting Agency

Micronesian Seminar, a non-profit pastoral-research institute sponsored by the Society of Jesus in Micronesia, was contracted by the Center for Substance Abuse Treatment to undertake this needs assessment for drug and alcohol abuse treatment in the Federated States of Micronesia. The Micronesian Seminar, which is incorporated under the laws of FSM, has a long history of social research in Micronesia and is widely known in this part of the Pacific and beyond. In 1985-1986, under contract with the Justice Improvement Commission, the Micronesian Seminar directed a regional-wide study of child abuse and neglect. In 1988 it conducted a two-year survey of schizophrenia and other psychoses in the FSM, Palau and the Marshalls. For twenty years the Seminar has been researching the high incidence of suicide in Micronesia, work that has issued in several published papers on the subject.

The director of the Micronesian Seminar, Fr. Francis X. Hezel, was the project director. He was responsible for drawing up the work plan, analysis of all data, and writing the final report. He was assisted by James Mormad, an FSM citizen who had worked for years at the private Jesuit high school in Chuuk and later in the FSM National Government. His major responsibility was conducting the survey and collecting the data.

In keeping with the directive allowing each state to determine the appropriate methodology in gathering information for establishing prevalence rates, we have elected not to adopt the conventional methods used in most CSAT-funded surveys-that is, personal interviews, conducted face-to-face or via telephone, with a sample of the population. Instead, for this study we have employed an indirect approach that makes use of key informants to obtain information on an entire community.

The methodology we have chosen is, admittedly, more problematic, and the epidemiological data may be challenged as little better than "second-hand" or "mere hearsay" and the prevalence rates derived from the data regarded as corrupted. There is an obvious appeal in personal interviews done with a well-designed instrument: they are neat, simple to administer and can generate good figures.

Even so, we believe that the problems with the direct interview method in Micronesia outweigh its advantages. In many Pacific societies, personal interviews on life problem areas are not culturally appropriate and often yield information that is not reliable. Micronesians dislike talking about their own problems or those of other members of their family to outsiders. Whatever promises may be made, anonymity is impossible and confidentiality extremely rare in small island societies. In past surveys that have dealt with culturally sensitive subjects (eg, child abuse, suicide), we have had reason to suspect the reliability of information derived in direct interviews, or even with the individual's family. In these studies we have found it preferable to rely on information supplied by others in the community outside the immediate family. Hence, we have adopted the same data collection procedures for this report that we have successfully employed in other studies in Micronesia.

Another difference in approach is the way in which subjects were chosen. Rather than using random selection, as many epidemiological surveys do, we opted to survey everyone-men, women and children-in several preselected communities from each state. The communities were chosen with an eye to providing a good representation of the various ethnic groups, religious backgrounds, and stages of relative acculturation as measured by position on the rural-urban residence scale. Each community selected contained between 200 and 400 persons, including children. All members of each household were screened for any alcohol and drug users, past or present, and individual forms were completed for all of those with a history of alcohol or drug use. The questionnaire form in the interviews was adapted from the core instrument prepared by the National Technical Center for Substance Abuse Needs Assessment (NTC). (The survey interview forms can be found in Appendix 3 of this report.)

Our preference for a community survey approach rather than random sampling is grounded in the social realities of a Pacific society. The community survey yields a picture of the behavioral patterns of a social group rather than an individual isolate. In a place like Micronesia, with its enormous stress on social interaction and communal norms of behavior, we are likely to derive information that will better help us understand the etiology of the drinking and drug problem in the lives of individuals and suggest more effective forms of prevention and treatment.

The coded individual data were entered in the computer and a check was made against the 1994 census for FSM to verify that the data represented at least 5 percent of the total population and that the distribution of the persons surveyed corresponded to the breakdown of the general population by state, gender, age-cohort, residence and ethnicity. Where there appeared to be significant over- or under-representation in any of these categories, adjustments were made to compensate for the differences before calculating prevalence rates and making projections on treatment.

All general population figures used for comparative purposes in this study were taken from the 1994 FSM census and used without adjustment for population growth. Since the census, taken in September 1994, preceded the start of our survey (May 1996) by less than 20 months, the increased accuracy of the population data did not seem proportional to the effort involved in making such adjustments. This is all the more true since yearly population growth has declined substantially everywhere in the FSM, as the recent census indicates.

The survey instrument allowed us to generate two types of prevalence rates: lifetime prevalence and point prevalence within the last 12 months. The current prevalence rate is by far the more important and more reliable of the two, and it is this that will be presented in the tables. Where there is no indication to the contrary, the reader can assume that the twelve-month point prevalence rate is referred to in all figures. Where significant findings appear, lifetime prevalence rates will be given as well.

Selection of Representative Communities

The communities to be surveyed were chosen so as to provide a good balance of ethnicity, religion, and position on the scale of distance from modernization. The selection process aimed at picking a broad geographical range within a state. Hence, we attempted to select some communities that contained large pockets of off-islanders and an ethnic mix, and others that were made up almost exclusively of the ethnic majority; some strongly Protestant communities and others that were predominantly Catholic; some in or close to the main town, others at a considerable distance from the town and its amenities. We attempted to make this selection with an eye to the composition of the population of the state, but without adopting rigorous statistical norms.

Each community constituted a village or, if the village was too large to be surveyed in its entirety, an identifiable section of a village. (The ideal community size was established at between 200 and 400 persons of all age groups.) All households within this area were interviewed to avoid any hidden bias that might be at work in random selection.

The total number of communities surveyed was proportionate to the size of the state population; they totaled three in Kosrae, five in Yap, seven in Pohnpei, and nine in Chuuk. The ideal total state sample sizes, at 5 percent of the population, would have been: Chuuk 2,650; Pohnpei 1,770; Yap 560; and Kosrae 370.

In fact, the survey samples in all the states exceeded these numbers. The actual sample size for each state was: Pohnpei 2,284; Kosrae 450; Chuuk 2,857; Yap 952 (Tables showing the breakdown of the state samples for each age group and sex are found in Appendix 4. The comparative breakdown of the general population and the survey sample into age groups and sex by percentage is also included in the appendix.)

The communities sampled in each state and the sample size for each are given below. Additional background on the communities and their characteristics can be found in Appendix 2.

Pohnpei: Enipein (369), Saladek (428), Sokehs (302), Ohmine (382), Mesihsou (264), Palipowe (293), Mokil (246)

Kosrae: Lelu (212), Utwa (125), Malem (113)

Chuuk: Kuchua (293), Seletiw (351), Sapuk (323), Tunnuk (316), Sopou (294), Sapore (318), Nomwin (307), Nama (354), Foup (301)

Yap: Maa/Thol (213), Ngolog (214), Kanifay (216), Falalop (150), Mogmog (159)

Sample Stratification

The interview data for each state were checked against the population figures for that state from the FSM census of 1994 to ensure that the data represented a 5 percent sample. The interview data were then cross-checked by sex, age, ethnicity, and position on the urban-rural scale to determine whether it was representative of the percentage of the state population as presented in the FSM census. Where the data for sex and age was under-representative or over-representative, it was weighted accordingly in calculating any projections for the general population.

The study excluded all children below the age of 10. It was decided to make the cut-off point 10 rather than 15 since we believed that in using the latter age we would run the risk of eliminating boys and girls in their young teens who might be inhaling gas and glue. The results of the survey not only supported this belief but indicated that some of those in their early teens use alcohol as well.

The age matrix used in our tables has been adapted from the standard US matrix so as to conform better to the life-cycle of the Micronesian societies studied. The age cohorts used here are: 10-14, 15-19, 20-29, 30-44, 45-64, and 65+. A breakdown into five-year age cohorts in the teens is helpful since during these years many young islanders begin using drugs and alcohol. On the other hand, the age of 18 is not a significant boundary marker for Micronesians as it is for Americans. In many cases the most intense period of alcohol and drug use comes during the 20s. The next 15 years of life, between the ages of about 30 and 44, mark young adulthood and are a transitional time for many male islanders. Often a heavy drug user or drinker will modify his intake or cease altogether as he approaches the age of responsible maturity. By the age of 45 or so, a man is expected to attain full maturity and exercise control over the impulses that may have dominated his life as a young man.

The numerically significant ethnic groups in the states of FSM are these: Yapese, Yapese Outer Islander, Chuukese, Chuukese Western Island, Mortlockese, Pohnpeian, Pingelapese, Mokilese, Nukuoroan, Kapingamarangi, Kosraean, American, Chinese, and Filipino. Not all are identified in the results of the survey, either because the sample size was too small to be reliable or because those surveyed were not always identified by their ethnic origins. Many Mortlockese surveyed on Pohnpei, for instance, were identified as "Pohnpeian" rather than "Mortlockese" even if both parents had been born in the Mortlocks.

The urban-rural spectrum can be roughly divided into three categories: town dwellers, village dwellers, and inhabitants of the outer atolls. Town dwellers are those who live in or near the port towns, the commercial centers that enjoy a relatively modern living standard not found elsewhere. The village dwellers are those who reside in the rural areas of the high islands, often at some distance from the town. Local food is eaten there and little wage employment is to be found. Finally, the coral atolls, which often lie hundreds of miles away from the state capitals, have the simplest life-style and the fewest amenities of modern life. Their contacts with the population centers are tenuous and infrequent.

Interview Methods

The field investigator, a Micronesian with long work experience in the FSM National Government, selected between two to four persons to serve as key informants for each community. In one or two cases, the informants were expatriates with an intimate knowledge of the community, but usually they were Micronesians residing in the community who were familiar enough with the families to possess detailed information on all the members of the households and were willing to do so on the guarantee that they and the information they furnished would be held strictly in confidence. Church ministers and older persons with a high position in the community were excluded in favor of younger adults who might be more knowledgeable about the behavior of that segment of the population engaged in drug use. An attempt was made to include at least one female informant to ensure adequate coverage of women in the community.

Working with the field investigator, the informants completed a sheet on each household listing all the members of the household, their age and sex, their religion and ethnicity. Next to each name the informants indicated whether that person had ever used drugs in his/her life. This preliminary survey of the community served as a screen to identify individuals about whom more detailed information was to be collected.

Once the household survey forms were finished, an individual interview sheet was completed for any individual known to have been using alcohol or drugs at any time. In addition to basic biodata-sex, age, marital status, educational background, occupational status, and travel abroad-the sheet recorded detailed information on the type of drugs used, the frequency and extent of use, the seriousness of the problem, and the kind of treatment sought, if any. The interview protocol used was a heavily modified and abbreviated form of the core instrument designed by NTC.

It should be noted that the names were retained on these interview sheets, as well as in the computer files, so that any additional information that might be found from additional sources such as court records, police files, and case reports, might be added to the individual's record. We felt that names were necessary if we were ever to compile some "thick data" on individual users that might help us determine key factors that put persons at risk for substance abuse problems. Once the data collection was completed, however, the names were deleted from the files to maintain confidentiality.

Although we were confident that a key informant methodology was far more suited to Micronesia than direct interviews, the reliability of third-person interview data remained a serious question. As a check on the reliability of our data, therefore, we conducted direct personal interviews with a small sample (10-12 persons) from each community. These persons were a convenience sample, but selected to include a male and female from each of the major age cohorts employed in this study. This yielded about 200 direct interviews throughout the four states. A random preliminary check was then made to determine the extent of discrepancies between the direct interviews and the third-person interviews. In this preliminary comparison of the interview results for ten persons, the correspondence of the data was strikingly close. There were no discrepancies at all in the reports on the type of drugs used and surprisingly little on the amount consumed; the greatest variation appeared in the reported frequency of drug use, with the third-person interview reporting a lower frequency than the direct personal interview.

Another check of the different interview sheets was made of 20 more persons after all the data were entered in the computer, but this check produced results very close to the first one. Given the positive results of these informal checks, we decided against doing a more careful tally of the discrepancies on the grounds that they were not significant enough to justify the time and trouble. The close correspondence seen in these reliability checks confirmed our judgment that sound data could be gathered by a key informant study in communities that are as small and closely knit as the ones that we were studying in Micronesia.

Data Processing and Analysis

As the interviews in each community were completed, they were checked for completeness and consistency by the field investigator. When this was done, the survey results were entered on the computer in a dBASE IV file, with a field for each of the questions asked. A computer record was established for all individuals surveyed, even those who had no history of drug use of any kind, so that statistical tables could be more easily generated.

When all the computer entries for a state were completed, the computer entries were checked for keying errors through the use of the EpiInfo 6 statistical frequency function. When any errors were corrected in the dBASE IV file and the record numbers for each community were checked against the original interview forms, we began generating tables on the use of each drug. Tables showing age-sex distribution of current drug users were first generated, and then tables indicating the frequency and amount of the drug consumed.

After the tables were reviewed, the decision was made as to what correlations should be examined. Numbers and percentages for such correlations were generated from the dBase IV file, but further statistical operations to determine the confidence level and p-value were performed through the EpiInfo 6 program. These were used in the tables and narrative only to the degree that was deemed appropriate.

Projections of total current drug users on the island were made on the basis of the sex-age breakdowns of the survey data, since age and sex correlated more strongly with drug use than any other factors. Each age-sex group of persons surveyed was compared with the same group in the general population to derive the percentage of the sample before projections were made for the users in this category.

Collection of Other Data

Despite the reporting requirements that are built into most US federal program grants, data collection and maintenance remains uneven in the FSM. This hampered us in our attempt to gather data on social indicators of alcohol and drug abuse. Figures on alcohol imports by quantity and type were not available; only figures on the dollar amount of imports could be obtained. Deaths due to alcohol-related illness, accidents, homicide and suicide were recorded by the state departments of health services, but the criteria used in determining these deaths seems to have varied from state to state. In the initial data obtained from Chuuk, for example, the list of alcohol-related diseases was longer and the number of deaths in each category much larger than one would project. Moreover, the number of suicides recorded by the states was fewer in almost every case than the number generated by the author from the data-base he has maintained on suicide cases for the past twenty years.

In the end, we used whatever reliable data we could get on social indicators of drug and alcohol abuse. Where possible, we attempted to get figures for the past five years. Social indicators for which reasonably good data was found are: yearly alcohol imports by dollar value; per capita yearly expenditures on alcohol; alcohol-related deaths (as recorded by the hospitals); arrests for alcohol-related crimes as a percentage of total arrests; suicides occurring while under the influence of alcohol or drugs as percentage of total suicides.

History of Alcohol Use

Alcohol is clearly a Western contribution to Micronesia. Before the first intensive European and American contact with the islands in the mid-nineteenth century, Micronesians possessed no knowledge of fermentation or distillation. Even tuba, the coconut toddy made from the fermented sap of the blossom of the tree which is widely used today in the coral atolls, appears to have been a late arrival. Alcohol was introduced to all parts of Micronesia by whalers and copra traders in the last century and drinking soon became an important male recreational pastime in many places.

From the beginning of the twentieth century, the colonial powers that ruled Micronesia imposed a prohibition on all alcoholic beverages for island people, although the rigor with which the ban was enforced varied at times. This policy was continued by the American administration after World War II until 1959, when the US rescinded the ban in response to a growing reaction among Micronesians against the discriminatory liquor policy of former years. The public sale of beer was permitted in that year, and a year later distilled beverages were also sold (Mahoney 1973:12).

The liberalization of liquor laws, as it happened, occurred at the beginning of a period of intense social change in Micronesia. After years of slow-paced development, the US reversed direction and greatly increased funding for the islands, a move that led to more and higher paying jobs for Micronesians, a much larger disposal income for the average islander, and growing concentration of the population in the district centers. In other words, there was more money with which to purchase beer and liquor and more people in town to enjoy these pleasures (Hezel 1981:4).

The predictable consequence of all this was a fair amount of drunkenness and mayhem. Young men, the main consumers of alcohol, would often gather in small groups in the bush or in bars to spend much of the weekend in marathon drinking bouts. In nearly all the towns in Micronesia biweekly payday weekends became a dreaded event, as young men raced around the roads in crowded pickups or whooped and cursed as they staggered home, challenging all passersby. Not all drinking ended in brawling and belligerence, but intemperate use of alcohol was generally regarded as the greatest single curse in Micronesia. Police statistics showed time and again that over 90 percent of all arrests were related to alcohol: "for illegal possession and consumption of alcohol; or while under the influence of alcohol disturbing the peace, assault and battery, and vandalism; and burglary and larceny to get alcohol or money to purchase alcoholic beverages" (TTPI 1976:24-5).

Meanwhile, community groups and political authorities made one attempt after another to stem the flood of alcohol and check the anti-social behavior it was causing. Drinking permits were issued in some of states in an effort to control sales, bars were closed and only package stores were allowed to sell alcohol, higher taxes were imposed, and municipalities voted to go dry in desperation. The best known example of the new prohibition occurred in Chuuk in January 1978, when Weno, the government center and capital of Chuuk, passed a law forbidding the sale and consumption of all alcoholic beverages.

Cultural Background

Alcohol is almost never drunk alone in Micronesia. Drinking is a social activity, one that has taken on cultural meanings and is performed in certain cultural contexts.

Alcohol use throughout Micronesia has long been identified as an activity in which principally, though not exclusively, young males engage. In a Chuukese village he studied in 1976, Marshall (1979:67) found that drinking was nearly universal among the young men living there: 50 of the 57 males between the ages of 18-35 drank at least occasionally. As many anthropologists who have worked in Micronesia have observed, young people were traditionally granted an extended period of "play time," a time of freedom and experimentation that lasted until their thirties. This period of lengthened adolescence was permitted to the young while they were still apprentices and did not yet enjoy "decision-making responsibilities either at home or in the community" (Mahoney 1973:6).

As much as parents and older members of the community may counsel against drinking and bemoan its disruptive effects in the home and village, they fully expect that young men will drink regardless, since they see drinking as an almost inevitable part of growing up. It is widely regarded as something of a rite of passage into adulthood. Like youthful love affairs, drinking is seen as a necessary evil concomitant with the long period of freedom and self-expression that constitute Micronesian "adolescence" (Hezel 1981:9). Abandonment to the pleasures of drinking slips easily into the cultural niche that Micronesian societies had long ago carved out for the young before they were expected to behave as mature adults.

Mahoney noted that in an earlier age males in that age category would have been young warriors. Marshall argues, in the same vein, that drunk young Chuukese males are even today "weekend warriors" who substitute for more traditional battle the adventure of the romping through town on the lookout for trouble. One need not accept this paradigm totally to appreciate that the use of alcohol by youth in Micronesian societies serves very real functions, whatever social damage it may cause at times.

First, it provides youth with the opportunity to express themselves much more freely despite the restrictions on self-expression that the cultures impose on all persons, especially the young. Young males who have been drinking frequently give vent to emotions that it would not otherwise be proper for them to express. Most young Micronesians, if asked, would put it another way; they would say that drinking "gives them the courage" to do or say things that they could not do or say if sober. This self-expression may take different forms: making a complaint against older family member, talking freely with an attractive girl they have been watching shyly from a distance, or even provoking a fight with someone against whom they have held a long grudge.

Second, drinking gains recognition for young people, who are ordinarily relegated to the back of the meeting house, given menial tasks to perform at public functions, and told by and large to keep out of the way and say as little as possible. Micronesian cultures, with the premium they place on age, do not afford youth a high social status. On the one hand, as we have seen, their mischief is lightly dismissed as what may be expected from the young; but, on the other hand, relatively little attention is paid to their desires or opinions (Hezel 1981:17-18). A son returning home drunk will be the center of attention in his family at least for a few hours, and perhaps even pampered by them until he sleeps off the alcohol.

Third, drinking is an escape from routine and a brief exciting interlude in what could otherwise be a rather monotonous life. Drinking is seen as something of an adventure, especially when it is done on the sly and against the express wishes of family and community. The thrill is compounded by the element of risk that surrounds many drinking escapades; one never knows when the party will erupt into violence or end with the arrest of all the revelers.

One of the most important points to be noted about alcohol use in Micronesia is that the act of drinking redefines the person culturally; the drinker now stands in a special category and is no longer regarded as entirely accountable for his acts. To sit with an open can of beer in front of one is to declare a "cultural time-out." It affords a young man (or an old one) freedom from some of the cloying cultural demands that shape one's life in a small island society. In this view, alcohol use is not so much a symptom of personal maladjustment or social malaise as it is a strategy employed by young people for obtaining the freedom and the hearing that they might otherwise not get.

As Marshall puts it in Weekend Warriors:

To become drunk in Truk is to put on a culturally sanctioned mask of temporary insanity. While insane/drunk one can express physical and verbal aggression that would bring strong disapproval were one normal/sober... Trukese believe that when one ingests an alcoholic beverage in whatever amount and of whatever sort, he is drunk and no longer entirely responsible for his words or deeds. Consumption of alcohol allows for an altered state of conscience in which one can get away with behaviors not normally permitted. (Marshall 1979: 53)

In this work Marshall develops the notion of a "cultural time out"-ie, a temporary exemption from the strong cultural demands for conformity-which he borrows from MacAndrew and Edgerton (1969). This notion requires modification, however, since Micronesians are not given entirely free scope to do and say whatever they wish to whomever they wish, at least not without risking unpleasant consequences.

Marshall (1979:134) also notes that the belief that most alcohol abusers are unemployed high school dropouts is a myth. Many are, in fact, wage-earners. Marshall finds no difference between employed and unemployed with respect to frequency of drinking, incidence of problem drinking, and the aftermath of the drinking.

All this is not intended to suggest that older Micronesian adults never engage in drinking. Drinking patterns, however, seem to change substantially as the person moves into his 30s. In Chuuk and Kosrae it is expected that young men will decrease the frequency and amount they drink as they make their transition into adulthood and eventually stop altogether. In Pohnpei adults usually seem to give up drinking alcohol in favor of Pohnpeian sakau, although they may have a beer or two after an evening of sakau drinking. In Yap there appears to be a larger number of youth who continue drinking well into adulthood, even into relatively old age. What we might call "adult drinking"-as distinguished from youth drinking-is a phenomenon that has never received the attention it deserves.

Social Indicators

Amount Spent on Alcohol

Table 2.1: Alcohol Imports (Wholesale $ Value)

Table 2.1 presents figures showing the official government figures for expenditures on imported alcoholic products. These figures, however, include only those distilled and fermented beverages that were registered with the customs office, not alcoholic beverages brought in for private consumption or those that were never routed through customs officials. Moreover, these figures take no account of fermented yeast and tuba, which are commonly drunk in some islands, especially in Chuuk and the outer islands of Yap.

As Table 2.1 shows, between 1972 and 1977 expenditures on alcohol doubled, from $480,000 to over $1,000,000. By 1984 the value of imported alcoholic beverages doubled again, to $2,035,000-although no adjustments for inflation have been made in these figures. Thereafter, the import value of alcohol in FSM has generally remained at a plateau of between $2 million and $4 million a year. The average import value during this period was $2,837,000 per year. Any dollar increase during the years between 1984 and 1994 was in effect nullified because of the 47 percent rise in the FSM inflation index over the same period.

During the early 1970s, alcohol accounted for 7 percent of the total private sector imports in Micronesia. By the mid-1980s it had dropped to just above 6 percent of all such imports, and ten years later it had fallen to about 2.5 percent. If these government figures are reliable, it appears that the increase in alcohol use has not only tapered off but possibly even fallen during the last decade.

Yap, one of the least populous states, has always shown a much higher average consumption than any other part of FSM despite the fact that almost 40 percent of its people live in the remote outer islands where imported alcohol is largely unavailable. Yap's yearly per capita expenditure on alcohol in 1972 and 1977, the only two years during the 70s for which we have figures, was several times higher than either Chuuk's or Pohnpei's (there are no figures for Kosrae since it was still administered as a part of Pohnpei at that time). Yap's figures showed no appreciable increase during the most recent ten years. In 1994 its per capita expenditures on alcohol ($63) were still over twice Kosrae's ($28) and half again higher than Pohnpei's ($42); the Yap figure was many times higher than Chuuk's, although the government figure for the latter is probably under-reported.

Kosrae shows a rather high per capita expenditure in view of the fact that it is a strongly Protestant island with rigorous beliefs about the evils of drinking. Even so, its annual per capita figures for several recent years are higher than that of Pohnpei, the FSM capital and an island regarded as much more cosmopolitan than Kosrae because of its mixed population and high percentage of non-Micronesians.

Chuuk shows the lowest figures of all the states in per capita expenditures on alcohol; its figures between 1984 and 1994 are roughly half of Pohnpei's and Kosrae's. Since 1978, most of the municipalities in Chuuk, including the main island of Weno, have been legally "dry." Although the law permits the importation of alcohol into the state, one may drink legally only in one or two small islands in the state. Yet, even before the prohibition measure was passed in 1978, drinking was not regarded as acceptable from either a cultural or religious point of view. Although the churches in Chuuk were not as vehemently anti-alcohol as the church in Kosrae, drinking was generally regarded as an activity that, even if not necessarily evil in itself, often had lamentable effects. Alcohol use has never been incorporated into community or family celebrations in Chuuk as it has in Yap and Pohnpei.

Per Capita Consumption of Alcohol

Information on quantity of alcohol imports is not publicized in FSM. The only information we have on yearly imports must be calculated from tax revenue records. Since we know the revenue generated from import taxes on beer, wine and spirits and the tax rates on each type of beverage, we can infer the amount of each type of alcohol imported that year. Based on these calculations, the annual per capita consumption in liters of absolute alcohol for 1974 was

Yap 4.4
Chuuk 1.8
Pohnpei & Kosrae 1.5

Per capita consumption in 1974 for all parts of what would later become FSM was 2.0 liters of pure alcohol.

We may compare this with figures for 1992, based on similar calculations by Marshall (FSM&WHO 1993:Table 13). The per capita consumption in FSM during that year was 70 bottles of beer, seven one-and-a-half oz shots of whiskey, and 3 oz of wine (about half an ordinary wine glass). This translates to 1.4 liters of pure alcohol for every man, woman and child in FSM. It should be noted that the 1992 per capita consumption figure shows a significant drop from the 1974 figure.

The per capita figures for the states differ greatly from one place to another, with some showing a considerable increase or decrease from the 1974 figures cited above. The breakdown of 1992 per capita consumption by states is:

Yap 5.3
Kosrae 2.5
Pohnpei 1.2
Chuuk 0.5

By way of comparison, the per capita consumption during 1983 in Palau was 5.7; Japan's was 6.2, New Zealand's 8.2, and Australia's 9.7 (WHO 1987:2). Other figures can be derived for some of the Pacific Island nations, although they are for more recent years and are based on beer consumption only. Fiji's per capita beer consumption for 1982 was recorded at 1.5; American Samoa's for 1983 was 4.0; and Tonga's for 1991 was 1.5 (FSM&WHO 1993:27).

Alcohol-Related Deaths

Common causes of death by illness usually associated with alcohol abuse include cirrhosis, gastritis and hepatitis. In addition, many motor vehicle accidents and other kinds of accidental deaths, as well as homicides and suicides can be attributed to alcohol use.

Table 2.3 shows the number of alcohol-related deaths for each state in the FSM during the years 1991-1995, as recorded in hospital death certificates. The number of such deaths has increased in Pohnpei and Kosrae as well as for FSM as a whole. During this five-year period, the percentage of alcohol-related deaths over all deaths in FSM has risen from 3.5 percent to 5.9 percent, as Table 2.3 shows.

Hospital Admissions

No reliable information could be obtained on the number of hospital admissions for alcohol-related injuries or illnesses. Such information as was available seemed incomplete, with some states reporting mainly on motor vehicle accidents that occurred when the driver was intoxicated and others on alcohol-induced psychosis or drug dependency. The figures that can be obtained for Yap, Kosrae and Pohnpei indicate that about one percent of the total hospital admissions in 1995 were for conditions directly attributable to alcohol or other drugs. The hospital records on Pohnpei show that 0.8% of all admissions in that year were alcohol-related. Yap had a 0.9% rate, and Kosrae a rate of 1.7%.

Suicides

Since the early 1970s suicide has been a serious problem in FSM, claiming over 30 lives annually in recent years. The high suicide rate in FSM over the past 20 years has often been attributed to the drunken state that the young man is in when he takes his life. The author of this report, who has researched suicide for 20 over years and has an extensive data-base with records of nearly all victims since 1965, has discovered that nearly half of the suicides occur when the victim is inebriated (Hezel 1989:45).

Table 2.4 shows the ratio of suicides in which the victim had been drinking before his death to the total number of suicides for the year. The table shows data for the years 1991-1996, state by state. For FSM as a whole during this six-year period, 81 of 182 suicides occurred when the victim was intoxicated. Thus, 45% of all suicides were occasioned by alcohol use.

Everywhere in FSM alcohol-related crimes account for the vast majority of arrests. For twenty years official reports have estimated that 90% of all arrests were connected to alcohol: either because they were committed by persons while intoxicated (as in most cases of aggravated assault, homicide, disorderly conduct, DUI, etc) or because they were motivated by the desire to obtain money for drinking (as with many the crimes of theft, breaking and entering, and larceny).

Arrest data for recent years obtained from the state departments of public safety are incomplete and cannot easily be tabulated for comparison between states. Nonetheless, Table 2.5 shows the number of arrests for alcohol-related crimes in each state for various years throughout the past six-year period.

Only Yap and Kosrae provided the data on total number of arrests necessary to determine the relative role that alcohol plays in crime. Kosrae's records for August 1995-July 1996 indicate that 82% of the arrests (180/220) were alcohol-related.

The statistics for Yap during the five-year period 1991-1995 show a comparable percentage of alcohol-related crimes: 73% in 1991, 82% in 1992, 80% in 1993, 85% in 1994, and 87% in 1995. While the growing percentage of crimes in Yap attributed to alcohol may be significant, it may just be a function of the improved record-keeping that has been occasioned by requirements for US federal funds targeted at substance abuse control.

There is no doubt that alcohol contributes greatly to the crime rate in every part of the FSM. If the figures cited here are an accurate measure of that contribution, 80%-85% of the arrests are for crimes that were committed by persons under the influence of alcohol-or other drugs, in a small percentage of these cases. Although the frequently quoted axiom that alcohol is responsible for 90% of the criminal acts in Micronesia may be slightly overstated, it is certainly not much of an exaggeration, especially when allowance is made for the motivation of thefts that may not be officially connected to alcohol.

The only state for which we have data on juvenile arrests is Yap. The figures for 1995 in Yap show 61 arrests of juveniles (under 18 years of age) during the year, but the offenses were so minor that 55 of these could be handled outside the court system. They included illegal consumption of alcoholic beverages (24), curfew violation (4), and disturbing the peace (15).

We have little information on the jail population in the states other than for Yap. Of the 16 men who constituted the prison population in mid-October 1996, ten are reported to have been jailed for crimes committed when they were under the influence of alcohol. These prisoners were charged for crimes such as sexual assault, homicide, and assault with a deadly weapon. We may assume that the profile of the prison population in Yap is not dissimilar to what can be found in other states.

Survey Data on Alcohol

General Prevalence Rate by Sex

The 12-month prevalence rate of alcohol use in the FSM is 32%, as indicated in Table 2.6. Because of the wide variance from state to state and an even greater difference along the sex divide, this general prevalence rate itself is of limited usefulness.

The survey data reveals, unsurprisingly, a marked difference in the use of alcohol by sex. As we have noted in the section on cultural background, drinking has always been regarded as a predominantly activity, and in some places exclusively so. The rate of alcohol use among males is six times as great as the rate among females. About 55% of all males over the age of 15 drink alcoholic beverages, while only 9% of the women above this age drink. While confirming the observation that drinking is generally a male prerogative, the data also indicate the degree to which Micronesia is beginning to depart from that norm as women start taking to drink.

The comparative rate differs from one state to another. The male prevalence rates in Yap (63%) and Pohnpei (61%) are considerably higher than in Kosrae (35%), where alcohol use is strongly discouraged by the church. Chuuk's male prevalence rate of 50% stands midway between Kosrae and the other two states.

Female rates in the states vary much more widely than male. In Kosrae and Chuuk, where the male rates are comparatively low, the female rates of 1% are the lowest in FSM. The ratio of male to female drinkers in Kosrae is 29:1, while in Chuuk it is 46:1. The low female rates of alcohol use in these two places are indicative of the strong cultural prohibition on female drinking that persists even today. In Yap, on the other hand, where the gap between the prevalence rate of males and females is lowest, at 63% and 27% respectively, the ratio of male to female drinkers is only 2.4:1. Pohnpei, with a female rate of 14%, holds a middle position; the male rate is a little over four times the female rate.

Comparison with Past Studies

The prevalence rates computed from this survey are not out of line with earlier studies of young Micronesian drinkers. In a survey of 275 students at the three campuses of the College of Micronesia, Jeanne Edman (1980) found that over 70% of the males and 12% of all females used alcohol at least occasionally. Employing a convenience sample and written questionnaire methodology, she reported a rate for Pohnpeian students that is consistent with the findings of this survey. Her figures-72% for males and 23% for females-are comparable with the prevalence rates found among the 20-29 age cohort for Pohnpei in this survey: 73% for males and 15% for females.

In a 1985 survey of the general population of Chuuk (sample size=1000), Mac Marshall found a prevalence rate of 43% for males and 0.6% for females (Marshall 1991:339). This compares favorably with the rates discovered for Chuukese aged 15 and over in this survey: 50% for males and 1% for females.

The alcohol use data from the "Behavioral Risk Factor Assessment among Youth of the FSM,"

a written questionnaire answered by over 6,000 school children aged 12-18, or one-third of all in this age group, is difficult to use for comparative purposes. The age-grouping does not coincide with most groupings, including those used in this survey, and the results are not broken down by sex. The total 30-day prevalence rate for those in the 12-18 age cohort is given as 35% (Reed 1993). This seems to be unusually high, especially for an age group where the rate of alcohol use was found to be rather low in this present survey; the Pohnpei rate for the entire 10-19 age cohort was only 15%. As we shall see in a later chapter, figures from the same survey on other types of drug use also seem inflated.

General characteristics

Age. Everywhere in FSM prevalence rates for alcohol correlate strongly with age as well as with sex. Table 2 indicates that the highest rate for each of the states is found in the 30-44 age group. The rates in this group are even higher than the rates for the 20-29 cohort in all states, the period in which drinking is generally thought to pose the greatest social problem. While one might have expected that young drinkers would have begun to slow down in their 30s and early 40s, the survey indicates that male drinking peaks during the 30s, a period of young adulthood that still offers males the freedom to associate with their peers and carry on adolescence-like activities. Drinking rates fall significantly in later adulthood, as reflected in the drop among those in the 45-64 age group in all states but Yap.

The onset of drinking varies considerably by state, as Table 2.7 shows. Pohnpei data reveal a small number (4.3%) beginning to drink during their early teens (10-14), with a much larger percentage (27.6%) than the national average drinking during their late teens (15-19). Chuuk has a very small number drinking in their early teens, which grows into a rate (15%) half the size of Pohnpei's by the late teens. Yap and Kosrae figures do not show any evidence of drinking in the 10-14 age group, and Kosrae shows none in the 15-19 age cohort. Yap's rate in the late teens, however, is already substantial, with one out of every six in this age group using alcohol.

Although alcohol use declines in the later age groups, this decline too varies considerably from state to state. Chuuk, Kosrae and Pohnpei show a drop in prevalence rate for the 45-64 age group and an even sharper fall off among those over the age of 65. On the other hand, Yap's rate remains remarkably high in the 45-64 age group, almost as high as for the 30-44 age group, and the decline in drinking among those over 65 is more modest than for the other states.

Marital status. Marital status does not correlate well with alcohol use, as Table 2.6 indicates. The prevalence rate for single persons (30%) is lower than the rate for those who are married (37%), but even this weak correlation shows little substance when examined more closely. When a comparison is made of marital status within a more circumscribed age group (20-44), there is very little difference in the rates, as is illustrated on Table 2.8. The rates of alcohol use among the married and unmarried are so close for Yap and Pohnpei as to be virtually indistinguishable. Chuuk and Kosrae show a slightly higher rate of alcohol use among the married, but the difference does not appear to be significant. For Micronesians marriage is not as significant a milestone in life, indicating that one is ready to "settle down" and act responsibly, as it seems to be for Americans.

Employment. The figures on employment status in Table 2.6 show a rate for those with salary employment (55%) that is double the rate of the unemployed (26%). It is difficult to explain this difference except insofar as salaried employees have access to the money with which to purchase alcoholic beverages.

Educational status. The low rate of alcohol use for students (15%) is due in part to their relatively young age; most have not yet reached the age groups in which the highest levels of drinking occur. Nonetheless, a strong correlation between alcohol use and educational status is to be found in the data, as may be seen in Table 2.9. When the age is narrowed to the 10-19 group, the difference in rate of alcohol use between in-school and out-of-school youth is striking. The prevalence rate among those not in school is many times higher than for students-three times higher on Pohnpei, five times higher in Chuuk, and ten times higher in Yap.

Ethnicity. The ethnicity figures for non-Micronesian groups are too small to admit of meaningful comparison with Micronesians. A mere handful of Asians, Americans, and other Pacific islanders showed up in the survey data.

When the state populations are broken down along ethnic lines, few strong differences seem to emerge from the survey data. In Pohnpei, Ngatikese (38%) and Kosraeans (32%) have higher alcohol rates than ethnic Pohnpeians (27%), but Mokilese (19%) have the lowest rate of any major ethnic group. In Yap, ethnic Yapese and Outer Islanders, who possess very different cultural traditions, show only a negligible difference in alcohol use rates for those 15 and above; the former had a rate of 25% and the later a rate of 28%.

Residence. Residence, too, seems to have little effect in establishing drinking behavior, as the figures on residence in Table 2.6 suggest. Town dwellers, who have access to retail stores, wage employment and a modern lifestyle, were found to have a prevalence rate of 29%. Despite their relatively advanced status on the continuum of westernization, they show a slightly lower rate of alcohol use than those who live in the less developed rural villages (33%) or in the far more traditional remote coral atolls (32%). This finding may be a surprise for those who regard alcohol abuse as one of the legacies of modernization, or at least as an accurate yardstick with which to measure the degree of westernization in a society.

In Yap State, the community with the highest (birth to death) prevalence rate (31%) is Falalop, an island in Ulithi Atoll, while Mogmog, another island in the same atoll, has a rate (24%) that is comparable to any on the main island of Yap. In Kosrae the highest rate (20%) was recorded in Malem, one of the outlying villages, while the more central communities of Lelu and Utwa showed much lower rates of alcohol use: 7% and 13% respectively. In Chuuk the two outer islands surveyed show very different rates: Nama had one of the highest rates of any community in Chuuk (26%), while Nomwin had one of the lowest (12%). In Pohnpei, two rural communities close to one another provided an especially striking contrast with respect to drinking. One of them, Saladak, had the highest rate on Pohnpei at 33%; the other, Mesihsou, registered the lowest by far at 8%.

Breakdown by states

Pohnpei. As in all the states, the male prevalence is much higher than the female rate, with over four times as many males using alcohol as females. The percentage of males drinking in the peak years of alcohol use (20-44) is comparable with the rates in Yap for these same age groups and much higher than in the other two states. Roughly three-quarters of all males between the ages of 20 and 44 drink, and about one of every five women in the same age group uses alcohol. The survey indicates a younger onset of drinking in Pohnpei than in other states; a few begin in their early teens and a considerable number take up drinking in their later teens-almost half of the males in the 15-19 age cohort are using alcohol. As significant as the drop in the percentage of those drinking in the later age groups is the fall in average consumption, as we shall see later in this chapter. Older Pohnpeian drinkers seem to prefer sakau, the traditional island beverage, capping an evening of sakau drinking with one or two beer chasers. Those who continue to use alcohol in their later years seem to move from binge drinking to a more moderate style of social drinking.

Kosrae. Female drinking is very rare, as the survey figures indicate. Only one of every 30 drinkers in the state is a woman. Male drinking is less common than in other states; the male rate for the peak age group (30-44) is a little over 50%. In addition, drinking begins later than in other states (there is not a single instance of teenage drinking in the survey data) and is concentrated between the ages of 20 and 64, with rates falling off sharply after 65. In Kosrae, however, there is no replacement drug for alcohol such as sakau on Pohnpei. The data confirm the widely held view of Kosrae as a controlled society, notwithstanding the fact that half of the males drink during their early adult years.

Chuuk. As in Kosrae, women rarely drink in Chuuk. They account for only one drinker in 47, the survey indicates. The prevalence rate among Chuukese males grows steadily through the 20s, reaching its apex during the 30-44 age group when two-thirds of the men use alcohol with some regularity. Although the rates fall sharply afterwards, it is significant that nearly half (45%) of the males continue to drink in the 45-64 age range. Alcohol use is no longer merely the amusement for the young that it was once considered to be, but is becoming an activity in which older adults enthusiastically take part. The data on consumption and frequency, as we shall see, suggest that Chuukese males drink more often and greater quantities of alcohol in their earlier years than their counterparts in other states, but slow down considerably or stop drinking later in life.

Yap. Female drinking is much more common than it is in other states; almost 30% of all those using alcohol in Yap are women. The female prevalence rate in Yap for those aged 15+ is nearly double the female rate in Pohnpei, the state with the next highest female drinking rate. The prevalence rate for the 10-14 age cohort was nil and that for the 15-19 age group (17%), although relatively high by comparison with the same age group in other states, is low when set alongside the Yap rates for the following age cohorts. To judge from the survey figures, Yapese seem to delay drinking until the late teens or early 20s, but once they start they do not stop. Both the male and female rates show a negligible decrease in the 45-64 years, and even after the age of 65 the decline is moderate. Throughout the major part of the adult life span, ages 20-64, the prevalence rate is uniformly high, with three-quarters of the males drinking and about one of every three females.

Frequency and Amount Consumed

The frequency of drinking is generally rather low throughout FSM, as Table 2.10 shows. The great majority of those who use alcohol-61% in Chuuk, 73% in Yap, 76% in Pohnpei, 93% in Kosrae-do so no more than once or twice a week. Only about 11% of the FSM population drink daily. Just one of every three male drinkers and one of every six female drinkers uses alcohol every day or every other day.

Although the frequency of drinking is moderate by US standards, the reported amount consumed is prodigious. If we take at face value the figures from the survey, the average number of drinks consumed per day of drinking in FSM would be 13. According to the computations from survey data, the average Pohnpeian has 9.3 drinks per sitting, the Kosraean 9.2, the Yapese 11.9, and Chuukese 15.9 (see Table 2.11). One-quarter of all drinkers in Pohnpei and Yap and one-sixth of the drinkers on Kosrae were reported as having 13 or more drinks each drinking session ⁽¹⁾.

A large number of young men were said to finish off a case of beer (24 cans) whenever they drank, and several were reported to be able to consume two cases alone. The most astonishing feats were attributed to Yapese men, whose per capita consumption was significantly higher than that of any other state. While these estimates of daily alcohol consumption need not be accepted uncritically, it would be a mistake to dismiss them out of hand as gross exaggerations. While engaged in conducting the survey, the field investigator witnessed a Yapese man finish three cases of beer by himself in the course of a 12-hour drinking bout. This accomplishment entailed the consumption of 72 12-oz cans of beer, the equivalent of almost a quart and a half (43 fluid oz) of pure alcohol.

When we look at the consumption data more closely, we find that it falls into five different patterns:

1. having a drink or two at a sitting, often as a social gesture or, on Pohnpei, after finishing sakau in the evening;
2. taking slightly more, perhaps three or four drinks, on a typical day;
3. finishing a six-pack of beer in a moderate drinking session;
4. drinking about two six-packs, or the equivalent of twelve drinks, often on a minor binge;
5. finishing a good part of a case of beer (24 cans), or less frequently a bottle of whiskey (20 drinks), usually as part of an all-day or all-evening session.

Since these categories seem to serve as common benchmarks for consumption in the eyes of Micronesian informants, we have adopted them in our tables as a rough measure of alcohol consumption. While they may serve as reasonably accurate indicators of the relative heaviness of the subject's drinking, the figures on the number of drinks consumed in a day should not be taken too literally. For that reason we have ordinarily used the categories described above rather than the tabulated averages.to measure alcohol consumption.

Table 2.11 presents a view of the average alcohol consumption as organized into the patterns discussed above. Kosrae's consumption is more moderate than any of the other states, for nearly 40% finish the equivalent of a six-pack (5-7 drinks) in a typical drinking session. Pohnpei shows a peak (21%) at the same consumption level, but survey figures indicate another, even higher rise (24%) at the 13+ level. The greatest number of Yap drinkers (30%) consume 8-12 drinks in an outing, thus drinking at one level higher than Kosrae and Pohnpei drinkers. The Chuuk figures show a very high percentage of the drinking population (58%) consuming alcohol at the highest level--13 or more drinks in a day--and a large percentage (24%) having 8-12 drinks a day.

Even when allowances are made for exaggeration, the number of what might be called "binge drinkers"-those who have five or more drinks on a day-represents a high percentage of the total alcohol drinking population in FSM. Over four-fifths of the males and one-half of the females were said to be drinking more than five drinks per sitting and so qualifying as "binge drinkers" by standard US norms. The percentage of "binge" drinkers is even higher among males in Yap (86%) and Kosrae (78%). As might be expected, the percentage begins dropping with increasing age-beginning in the 20s for females and in the 30s for males-and continues falling through the upper age groups.

Drinking Patterns in States

Some further differences should be noted in the drinking patterns in various states.

Kosrae. When the amount consumed is plotted against frequency of drinking, it is evident that the heaviest drinkers in Kosrae are those few who drink most frequently. The four young men sampled on Kosrae who used alcohol daily or nearly every day were reported as consuming over 15 drinks at a sitting; by contrast, those who indulged in alcohol less regularly reportedly consumed an average of less than 10 drinks at a sitting. This suggests a small segment of very heavy alcohol users, possibly alcoholics, and a larger number of more moderate "social drinkers."

Yap. In Yap, as in Kosrae, average consumption per session varies directly with the frequency of drinking. The average reported consumption for those who drank daily was 21 drinks per session, but that number decreased for those who used alcohol less frequently. Those who drank 3-4 times a week reportedly averaged 16 drinks, those drinking 1-2 times each week had 11 drinks, those taking alcohol 1-3 times a month 10 drinks, and those drinking less than once a month were reported to have 7 drinks per sitting. This pattern seems to hold true for females as well as for males. Overall, the consumption pattern in Yap is similar to that on Kosrae, although Yapese drink much more heavily than Kosraeans. The table plotting frequency against consumption suggests that a significant number of Yapese, male and female-about one-quarter of the drinkers in the survey sample-are engaged in heavy addictive drinking, while many more engage in more moderate and less frequent drinking episodes that would be labeled "binges" by our definition.

One other anomaly for Yap should be noted, even if the supporting data are not shown in tabular form. When the drinking population is broken down by age groups, we find that the average daily consumption in Yap does not drop as sharply for the older age groups as it does in other states. Rather, it remains nearly as high for the 45-64 and 65+ groups (with 28% and 22% respectively in the heaviest daily consumption range) as for the 30-44 age group (33%). Thus, the drinking population in Yap appears to be drinking almost as much in late middle age and beyond as in youth. This would tend to confirm the suspicion that the incidence of alcoholism in Yap is higher than in other states.

Pohnpei. The correlation between frequency of drinking and amount consumed is not as direct in Pohnpei. The highest per sitting consumption is registered for those who drink 3-4 times a week and those who drink 1-3 times a month. (Check consumption rate for those who drink 3-4 times week--seems to be discrepancies) The heaviest alcohol consumption was found among the younger drinkers, and consumption dropped sharply for the older age cohorts. The data do not reveal the same degree of protracted heavy drinking in Pohnpei that can be found in Yap. What might be called "social drinking"-including the practice of using beer as a chaser after drinking sakau in the evening- seems very common, especially in later years.

Chuuk. Chuuk shows a higher frequency of drinking than the other states, with 39% of all drinkers consuming alcohol every day or two. Its average consumption per drinking day is also much greater than the other states; nearly 60% of the drinking population consume 13 or more drinks at each drinking session. The drinking is heaviest in the 20-29 and 30-44 age groups, but dips considerably for the next age cohorts. Although a sizeable number of males are still drinking in the older age groups, most of the drinking population seem to be seasonal drinkers, drinking heavily during youth and moderating their intake or stopping altogether as they get older.

Problem Drinkers

Definition. In this survey we have made no attempt to identify alcoholics as such, inasmuch as the diagnostic criteria offered in DSM III-R and DSM IV remain elusive and resistant to quantitative measurement. Clinical alcoholism is notoriously difficult to define, and in the end seems to be confirmable only after lengthy examination of an individual's life history. Instead, for this survey we have attempted to establish behavioral norms to identify "problem drinkers." The criteria for the category that we use to designate "problem drinkers" fall under two headings: 1) quantity and frequency of alcohol use; and 2) behavioral problems associated with drinking.

Under the first heading, we established as a norm for quantity and frequency:

• consumption of five or more drinks twice a month or more often; or
• having two or more drinks nearly every day; or
• going on a binge (defined as a drinking spree lasting more than one day) at some time during the month previous to the survey.

Under the second heading, one of the following conditions must be verified:

• the person must have undergone treatment for alcohol abuse in the past; or
• he must have experienced at least one serious problem (eg, domestic violence, fighting, absenteeism from work or school, arrest while drunk) as a consequence of alcohol use; or
• he must be judged by community informants to have a "serious problem" or to be an outright "alcoholic."

One of the conditions under the first heading and one under the second heading had to be verified for a subject to be classified as a "problem drinker." Repeated testing of this algorithm proved that it was a satisfactory device for screening drinkers who appear to be having serious problems with alcohol.

In order to determine how many are at serious risk for clinical alcoholism, we had to screen for young problem drinkers, who may share many of the behavioral problems of over-use with alcoholics but could be going through the protracted young male drinking period almost mandated by Micronesian cultures. To do this, we have identified "possible alcoholics" as all those "problem drinkers" who are 40 years of age and above.

Survey results. Problem drinkers appear to be very numerous in the FSM. More than half of the drinking population surveyed-58% of the males and 27% of the females-fit the description of "problem drinkers," as the term was used in this survey. These percentages appear to be uniform throughout the nation.

As Table 2.13 indicates, over 35% of the entire FSM male population over the age of 15 may be called problem drinkers. Except for Kosrae, with a low male rate of about 21%, the individual states show little variation from this figure. Predictably, the female rate for FSM is very low at less than 3%, with Yap (7%) and Pohnpei (4%) showing the highest rates among the states.

Overall, one of every five people in the general population (15 years and older) is a problem drinker. Table 2.14, which indicates the estimated number of problem drinkers, shows that there are over 11,000 problem drinkers in FSM at present. Almost half of them are in Chuuk, inasmuch as the breakdown of problem drinkers by state follows that of the general population rather closely.

The quantity of alcohol consumed by those designated as "problem drinkers" in this survey was unusually high, even when measured against the high levels of consumption recorded for the average drinker. The average daily consumption recorded for problem drinkers was 15 drinks at a session, compared with 12 for the average FSM drinker. Frequent binge drinking, usually several times a month, was much more characteristic of the problem drinkers than daily drinking episodes. Only 15% of all problem drinkers drank daily, but they averaged 19 binges a year, or nearly two a month. A person who drank a six-pack a day was seldom designated a problem drinker by informants by virtue of the quantity and frequency of his drinking because he was thought to be able to impose limits on his intake of alcohol, even if these limits exceeded what peoples in other countries might normally regard as an acceptable level of consumption. This was especially the case where no significant behavioral problems were noted in his dealings with his family or community.

Problem drinkers, then, were distinguished from "heavy drinkers" in this survey through the addition of a separate set of criteria, as was noted in the comments on the definition of problem drinkers. In many cases, informants identified problem drinkers as "having a serious drinking problem," and in some instances flatly labeled individuals as "alcoholics." Underlying these judgments, however, was a solid behavioral norm. In virtually every instance, the person designated as a problem drinker was known to have experienced problems related to his drinking: alcohol-related illness, repeated absenteeism, public fighting when drunk, arrests for offenses committed when intoxicated, domestic violence or other serious family problems. Most of those identified as problem drinkers in the survey had experienced more than one of these problems.

These problem drinkers, whether or not they can be termed alcoholics as such, represent an astonishingly large percentage of the FSM population. They represent the portion of the drinking population who need assistance and they are the potential clientel of alcohol treatment services.

Treatment

Survey data on the number of those who have sought treatment, the type of treatment they tried, and the degree of success they experienced with the treatment is very thin. This is one of the shortcomings of the key informant approach that was used in the present survey. The interview files show treatment information on only 59 persons: 16 from Pohnpei, 12 from Kosrae, 24 from Chuuk and seven from Yap. All of these 59 people are still currently drinking, it should be noted. There are undoubtedly others who were treated successfully for their alcohol problem, but they were not picked up in the survey.

The types of treatment sought were of various types. Four participated in Alcoholics Anonymous meetings while overseas. Ten received treatment in the hospital either in the form of substance abuse counseling or medication. The rest mention involvement in village or family activities (such as vigorous work on the land), participation in youth organizations, or increased involvement in church activities and counseling from church leaders. It may be noteworthy that the largest number (19) mentioned church as the place where they sought help. Church and community organizations are normally where people afflicted with alcohol or drug problems turn for help.

Epilogue: Comparative Measures of Alcohol Consumption

Using the survey data on frequency and alcohol consumption at a sitting, whatever its limitations, we may calculate the per capita yearly consumption in each of the states and total amount of alcohol consumed in a year. Such calculations may also serve as a check on the reliability of the reported data regarding the quantity of alcohol consumed, one of the most questionable parts of the entire survey.

If we accept the survey consumption figures as reported, we find that the annual per capita consumption of pure alcohol falls within reasonable limits. The annual per capita amount of absolute alcohol drunk, as measured in liters, is:>

Yap 4.5
Pohnpei 3.4
Chuuk 4.5
Kosrae 1.0

When compared with the figures for 1974 and 1992 shown on page 19, these figures show decreases in consumption levels for Kosrae and Yap and increases for Chuuk and Pohnpei. The greatest difference is in Chuuk, where the per capita consumption appears to have soared from 0.5 to 4.5 liters. We must remember, however, that the figures for 1974 and 1992 were derived from records giving the quantity of imported alcohol. Such records, even if they accurately reflect the amount of alcohol purchased from abroad, understate the quantity of alcohol consumed since they do not take account of the tuba, yeast or other fermented beverages produced locally.

To translate these quantities into a more familiar measure, the average person (child as well as adult) on Pohnpei drinks the equivalent of 190 drinks, or nearly eight cases of beer a year. For Yap and Chuuk the figure is 255 drinks, or ten and a half cases, while for Kosrae it is 57 drinks, or two and a half cases a year. The amount of alcohol consumed yearly in FSM is the equivalent of almost one million cases of beer.