| Alcohol and Drug Use in the Republic of the Marshall Islands | |
| MicSem Articles | social problems | |
An Assessment of the Problem with Implications for Prevention and Treatment
Prepared by
Micronesian Seminar
Pohnpei, FSM
June, 1997
Even drugs introduced from abroad have been circumscribed by a set of cultural parameters that can be missed by Western social workers. Coconut toddy, the fermented sap of the coconut palm, which reached many of the islands of Micronesia by the end of the last century, was once commonly used in the Marshalls and is still drunk today in the outer island dwellers in Yap. The circle of 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 to assess the demand and need for substance abuse treatment services at the state and sub-state levels. (US territories and Freely Associated States in the Pacific were made eligible in the funding legislation.) CSAT contracted this study, as it has studies in other regions, in order to assess the magnitude of the alcohol/drug problem in the Republic of the Marshall Islands (RMI). 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 fundamental 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 Marshallese, 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 RMI. 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 population being studied, the 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.
The fundamental purpose of the study remains the same as others authorized and funded by CSAT-that is, to establish substance abuse prevalence rates for the Marshalls, which, viewed against the distinctive cultural features of the area, can be converted into comprehensive estimates of service need and demand that might be used for planning, program management and policy making.
Accordingly, the goals of this study are:
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). As important as these goals are, they could not, for various reasons, be met during the preparation of this report. 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 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 Republic of the Marshall Islands, a newly independent nation that is bound to the US by the terms of a document known as the Compact of Free Association. The Marshalls, which was annexed by Germany in 1885 and seized by Japan at the outbreak of World War I, passed into the hands of the United States at the end of the Second World War. Together with the Carolines and the Marianas, the Marshalls was part of a UN trusteeship administered by the US for about 40 years. The Marshalls acquired full self-government in October 1986.
The Republic of the Marshall Islands is a nation of small coral atolls and isolated islands. The 34 atolls and islands are divided into two parallel chains running north-south: Ratak in the east and Ralik in the west. The total land area is 70 square miles and the highest point in the archipelago is at an elevation of 10 meters. The population of the Marshalls in 1988, as recorded in the last census, was 43,380 (RMI 1988). The projected population in 1995, according to the Marshall Islands Statistical Abstract of that year, was 55,575 (RMI 1995). This figure, which corresponds closely to the author's personal population figure for 1997, has been used as a base population figure in this study. The age-sex breakdown given in the above source has been accepted and used here.
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.
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 Republic of the Marshall Islands. 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.
General Research Design
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, as also for the one done on the Federated States of Micronesia, 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 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 sub-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 the Marshalls, 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 projected population for 1995 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 derived from the projected population figures for 1995 as found in the Marshall Islands Statistical Abstract for 1995. The figure given for 1995--55,575--is higher than this author's projected figure of 52,688 for two reasons: it takes no account of emigration, which has become statistically significant within the last nine years, and it has probably inflated the rate of population increase inasmuch as it uses the same 4.2 percent figure that was measured between 1980 and 1988. The government's projected population figure may fail to recognize the drop in fertility rates, while using annual growth rate figures that could have been inflated because of the undercount in the 1980 census. The author estimated the population of the Marshalls in 1997 to be 55,288. For convenience's sake, it seemed wise to use the figures for the age-sex breakdown from the official Marshall Islands projections for 1995 as provided in the Marshall Islands Abstract for 1995.
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.
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.
According to the 1988 census, roughly two-thirds of the population of the Marshalls lived in the two urban centers of Majuro and Ebeye, with the remaining third distributed among the outer islands and atolls of the republic. In addition, Majuro's population was nearly twice the size of Ebeye's at that time. In this survey the sample size was set to conform to these ratios.
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.
Sample Stratification
The interview data were checked against the population figures 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 Marshallese 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 Marshallese 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 urban-rural spectrum can be divided into two categories: town dwellers (ie, in Ebeye or Majuro) and inhabitants of the outer atolls. Town dwellers are those who live in or near the port towns of Majuro and Ebeye, the commercial centers that enjoy a relatively modern living standard not found elsewhere. The coral atolls, which often lie hundreds of miles away from the towns, 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. The informants were Marshallese 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 the Marshalls 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. 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.
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 Marshalls. 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, and figures on the dollar amount of imports into the Marshalls could be obtained for only a few years. 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 may have varied from one hospital to another. 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: alcohol-related deaths (as recorded by the hospitals); arrests for alcohol-related crimes as a percentage of total arrests; and 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 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. 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 experimented with in an effort to control sales, higher taxes were imposed, and municipalities voted to go dry in desperation.
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 most places young men are expected to decrease the frequency and amount they drink as they make their transition into adulthood and eventually stop altogether. Yet, a larger number of youth continue drinking well into adulthood, even into relatively old age. "Adult drinking"-as distinguished from youth drinking- has never received the attention it deserves.
Social Indicators
Amount Spent on Alcohol
Data on the quantity of alcohol consumed in the Marshalls each year are not to be found. The figures on the dollar amount spent on imported alcohol, although partial and dated, give us some indication of the level of alcohol consumption there. Table 2.1 offers the data for three years, the only ones for which this information is available.
Sources: 1972 data taken from Mahoney (1973:19); 1977 figures from TT Bulletin of Statistics, 1:2(1978:18); 1982 figures from WHO (1985:56).
In the absence of reliable information for more recent years, we can only suggest that if alcohol importation in the Marshalls has shown the same increase as on Pohnpei, which spent about as much on alcohol as the Marshalls did in the early 1980s, it would be importing about $1.5 million worth of alcohol by 1995.
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 2.2 shows the number of alcohol-related deaths in the Marshalls during the years 1991-1995, as recorded in hospital death certificates. The table also gives the total number of deaths during each of these years and the percentage represented by alcohol-related deaths.
| All Deaths | ||||||
| Alcohol Related | ||||||
| % Alcohol-Related |
Hospital Admissions
In a presentation at a 1985 conference of the South Pacific Commission and the World Health Organization, representatives from the Marshall Islands reported that "drunk driving was a major cause of the increase in traffic accidents on Majuro, and was directly related to a growing number of fatalities; that a significant portion of the annual medical referral budget was spent on cases resulting directly from alcohol abuse; and that there was an increasing number of admissions to the ER for injuries suffered from alcohol-related beatings and fights" (Wood 1991:56).
Despite these assertions, no reliable information could be obtained on the number of hospital admissions for alcohol-related injuries or illnesses for years prior to 1995. For 1995 the hospitals on Ebeye and Majuro reported a total of 23 admissions for conditions related to the use of alcohol. In 1996, the hospitals reported 67 such admissions. Because the information on total admissions during these years is not available, we it is impossible to indicate the percentage represented by the figures for 1995 and 1996.
Suicides
Since the late 1960s suicide has been a serious problem in the Marshalls, claiming between 10 and 20 lives annually in recent years. The high suicide rate in the Marshalls, as in the Federated States of Micronesia, 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 well over half of the suicides in the Marshalls occur when the victim is inebriated.
Table 2.3 shows the ratio of suicides in which the victim had been drinking before his death to the total number of suicides for the year for the period 1991-1995. For this entire five-year period, 38 of 56 suicides of Marshallese occurred when the victim was intoxicated. Hence, 68% of all suicides were occasioned by alcohol use.
| All Suicides | ||||||
| Alcohol Related Suicides | ||||||
| % Alcohol-Related Suicides |
Source: Micronesian Seminar suicide database
Arrests for Alcohol-related Crimes
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 are presented in Table 2.4. The table shows the number of arrests for alcohol-related crimes throughout the five-year period 1991-1995. The data indicate that only in one year (1994) was the ratio of alcohol-related crimes to total arrests significantly short of 90 percent.
| All Arrest | ||||||
| Alcohol Related Arrests | ||||||
| % Alcohol-Related Arrests |
Survey Data on Alcohol
General Prevalence Rate by Sex
The 12-month prevalence rate of alcohol use in the Marshalls for all those aged 15 years and older is 19%, as indicated in Table 2.5. As might be expected, there is a marked difference in the use of alcohol by sex, with the male rate much higher than female. Throughout most of the Pacific, as anthropologists and social researchers have affirmed repeatedly, drinking is regarded as a male activity. The male rate is 34% and the female rate is about 5%. The ratio of male to female users of alcohol is nearly 8:1.
The general prevalence rate for the Marshalls at 19% is markedly lower than for the FSM (32%), as recorded in a recent survey conducted there (Micronesian Seminar 1997). The male rate for alcohol use in the Marshalls at 34% is much lower than the corresponding rate for the FSM (55%), and it is well below that of every state in FSM, even Kosrae's (35%). The female use rate for the Marshalls, while significantly higher than that of Kosrae and Chuuk, is just half the female rate for the whole of FSM (9%).
| Total Population | ||||||
| Marital Status | ||||||
| Single | ||||||
| Married | ||||||
| Employment Status | ||||||
| Salary job | ||||||
| Unemployed | ||||||
| Student | ||||||
| Ethnicity | ||||||
| Marshallese | ||||||
| Other Micronesian | ||||||
| Asian | ||||||
| US | ||||||
| Residence | ||||||
| Majuro | ||||||
| Ebeye | ||||||
| Outer-atolls | ||||||
Comparison with Past Studies
The only previous survey of alcohol use among Marshallese with which the author is familiar is contained in a broader study of alcohol and marijuana use at the three campuses of what was then the College of Micronesia. This 1980 survey, conducted by Jeanne Edman, included 35 Marshallese college students. She found that 77% of the Marshallese males and 40% of the females used alcohol. These numbers can be compared with her finding that 70% of all male college students in her survey and 12% of all the female students drank. While the survey methodology was not rigorous nor the figures robust, it is interesting to observe that in Edman's study a higher percentage of Marshallese than other Micronesians used alcohol. This survey has reached the opposite conclusion.
General Characteristics
Age.
The prevalence rates by age cohort given in Table 2.6 show that the use of alcohol by males and females is greatest
among the 20-29 age group, in which 41% of the males and 6% of the females drink. The rate rises slightly in the 30-44
age group, but declines in the 45-64 cohort as young drinkers begin to mature and moderate their drinking. Yet, the rate for
this older age group is higher than one who is familiar with the literature on alcohol use in Micronesia might have expected.
Only in the 65+ age group do we find that the alcohol use rate has dropped off sharply-so sharply, in fact, that it falls to
zero. By contrast, we find that in FSM, where use rates among older age groups remain higher than in the Marshalls, a
residual core of drinkers continues using alcohol even after the age of 65.
|
Total (15+) | ||||||||
| Males | ||||||||
| Females | ||||||||
| Total |
For a small fraction of alcohol users drinking begins in the early teens; the 10-14 age group shows a 3% prevalence rate for males and a much lower one (0.3%) for females. By the late teens (15-19), nearly 20% of the males drink, with 3% of the females also using alcohol. While the prevalence rate for the 10-14 age group is higher than in FSM, the male and female rates for the 15-19 cohort are rather modest by Pacific standards and stand well below the FSM figures of 32% and 6% respectively.
Marital Status.
Table 2.5 shows no significant correlation between marital status and alcohol use in the Marshalls.
Married males show a higher rate of alcohol use than single males, but the reverse is true for females. The use rates for
both sexes show very little difference between married and unmarried persons. Table 2.7 allows us a closer look at the
correlation between alcohol use and marital status within a more circumscribed age group (20-44), one in which the
prevalence rate of drinking is relatively high. Here we find that although the rate for single women (7%) is higher than for
married women (5%), there is very little difference in the male rates for single (40%) and married (42%). Marital status
does not appear to be a good predictor for alcohol use, therefore-perhaps because marriage is not as significant a marker for
Marshallese as for Westerners of readiness to settle down and act responsibly.
| Single | ||||||
| Married | ||||||
Employment.
The alcohol use rate for those with a salary job (34%) is more than double the rate for the "unemployed"
(13%)-that is, those without wage employment-as may be seen in Table 2.5. There are various possible explanations for
this difference: the tendency of the unemployed to be clustered at the lower and higher end of the age spectrum where
drinking rates are not as high as in the 20-29 and 30-45 age cohorts; the lack of access to ready cash with which to purchase
alcohol; the clustering of the unemployed in outer atolls where drinking is less common. Whatever weight may be given to
these different explanations, it is at least apparent that alcohol use does not correlate with lack of wage employment, as may
be the case in some other parts of the world.
Educational Status.
The low rate of alcohol use for students (10%), as seen in Table 2.5, may be explained by their
relatively young age; most have not yet reached the age groups in which the highest levels of drinking occur. Table 2.8,
however, which measures alcohol use among a narrower and younger age group (10-19), offers evidence for a strong
correlation between alcohol use and educational status. The rate for out-of-school males (26%) is four times as high as that
of in-school boys (8%), and the rate for girls who are out-of-school.(3%) is twice as high as for those still attending school
(1.4%). The difference in rates for both sexes combined is three times as great.
| in-school | ||||||
| out of school | ||||||
Ethnicity.
The paucity of subjects surveyed from non-Marshallese ethnic groups forbids meaningful comparisons between
them and Marshallese. Even so, the survey data is presented here as possibly indicative of broad trends, even if the rates
must be suspect. The alcohol use rate among other Micronesians, for instance, is seen in Table 2.5 to be much higher than
that for Marshallese, as is the prevalence rate for Americans. Even Asians show a slightly higher rate of alcohol use than
Marshallese.
Residence.
The overall alcohol use rate on Ebeye (26%) is the highest in the Marshalls, although Majuro's rate (22%) is
not very far behind. Both islands offer a relatively advanced economy, modern facilities and a lifestyle that is a goulash of
Western and island tradition. As one might expect, the other, less developed atolls show a much lower rate of alcohol use
(11%). The most striking difference is in female rates; the rates for Ebeye and Majuro are in the order of 5-7%, whereas
that of the other atolls is less than 1%.
Frequency and Amount Consumed
Frequency. As Table 2.9 clearly indicates, very few of the Marshallese who use alcohol do so on a daily basis and not many more drink three or four times a week. Only slightly more than 20% of the drinking population indulge more than once or twice a week, and over 40% drink a couple of times a month or less. The survey data indicate that alcohol users in the Marshalls drink even less frequently than in FSM.
| Males | ||||||
| Females | ||||||
| Total |
Amount Consumed. If the frequency of drinking is modest by US standards, the amount consumed per sitting is exceptional-at least by the same US norms. Over 70% of Marshallese drinkers are said to consume five or more drinks (1) at a regular sitting, and 12% reportedly consume more than two six-packs of beer in an average outing, as may be seen in Table 2.10. The average number of drinks taken by an alcohol user on a drinking day is 8.7, with men drinking half again as much as women.
When we look at the consumption data more closely, we find that it falls into five different patterns:
Since these categories seem to serve as common benchmarks for consumption in the eyes of Micronesian informants, we have adopted them in our tables here 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 are rough estimates and should not be taken too literally. For that reason we prefer to use the categories described above rather than simply the tabulated averages to measure alcohol consumption.
| Males | ||||||
| Females | ||||||
| Total |
Even with due allowance 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 drinking population in the Marshalls. Over 75% of the male drinkers and about 43% of the female qualify as "binge drinkers" by standard US norms. In view of the drinking style commonly practiced in Micronesia, the term "binge drinker" is a misleading designation for such persons; they would probably be regarded as moderate drinkers by local standards.
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:
Under the second heading, one of the following conditions must be verified:
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.
Those who might be termed "problem drinkers" represent a relatively large percentage of the drinking
population surveyed-about 48% of the males and 29% of the females.
As Table 2.11 indicates, about 9% of the entire adult population of the Marshalls may be called problem drinkers. Predictably, there is a huge difference along gender lines: 16% of all males over 15 years of age, and 1% of all females. The percentage of problem drinkers is highest on Ebeye (15%) and lowest in the outer atolls (3%).
Although these figures might appear disturbingly high, a comparison with similar figures from a survey in the FSM may serve to put them in perspective. The prevalence of problem drinkers in the Marshalls is just about half the rate measured in FSM, where 36% of all adult males, 3% of all females, and 20% of the total population were classified as problem drinkers.
| Marshalls | ||||||
| Ebeye | ||||||
| Majuro | ||||||
| Outer atolls | ||||||
The estimated size of the drinking population and the number of problem drinkers in the Marshalls are shown in Table 2.12. These problem drinkers, whether they may properly be called alcoholics or not, represent the portion of the drinking population who most need assistance. They, more than any others, are the potential clientele of treatment services.
| Marshalls | ||||||
| Ebeye | ||||||
| Majuro | ||||||
| Outer atolls | ||||||
1. In this survey we used the commonly accepted equivalents as our measure for a "drink"-that is, a 12-oz can of beer, a 1.5-oz shot glass of
whiskey (with 20 drinks to a fifth of liquor), or a 6-oz glass of wine. Each of these contains approximately 0.6 oz of pure alcohol.
History of Marijuana Use
Marijuana was introduced into Micronesia during the late 1960s, most likely by Peace Corps volunteers. The early history of the drug in one Micronesian island is outlined by a local author:
It is said that marijuana was first introduced to Chuuk by a foreigner who resided on Nama Island toward the end of the 1960s. The person is reported to have had in his possession some marijuana seeds which he sowed and which later grew into healthy plants. By the early 1970s there was a small amount of marijuana filtering into Chuuk. The substance was bought in by students from Palau, Yap and Saipan who were attending school in Chuuk. As early as 1973 marijuana seeds were brought in from Saipan by a sailor on one of the cargo ships. They were planted on one of the lagoon islands and grew to be extremely healthy plants. It was not until the late 1970s that marijuana invaded the islands in large quantity. With much improved means of communication and transportation, and the increased number of Chuukese leaving the islands for school, marijuana found new and effective means of entering the area. (Oneisom 1991:2)
Smoking marijuana caught on among Chuukese in the middle 1970s when large numbers of college students returned, bringing back the drug to share with their friends (Larson 1987:219). During the late 1970s the habit spread rapidly among young males. By the early 1980s marijuana was being widely grown in Chuuk, as in Yap and Pohnpei. Cultivation of the crop was often a family project, with even older women contributing to the business and demonstrating a surprising knowledge of cultivation techniques. According to a survey of marijuana dealers conducted by Oneisom in 1985, dealers admitted to making about $100 in an average week. Police files show that during the five years between 1979 and 1984 $105,000 worth of marijuana was confiscated in police raids. This presumably represented but a small percentage of the total value of the marijuana produced during these years (Oneisom 1991).
We may assume, in the absence of any information to the contrary, that marijuana use in the Marshalls began around 1970 and rapidly became popular among island youth during the following decade. Yet, it never appears to have become as widely used there as on the high islands of FSM and in Palau, probably because the plant could not be easily cultivated in the coraline soil of the Marshalls. Any marijuana that was smoked had to be imported, and importation was expensive and became increasingly risky as customs surveillance was tightened.
A police raid made on Pohnpei in 1988 resulted in the seizure of 2,000 marijuana plants with a street value of over $1 million (Wood 1991:46). Such extensive cultivation would have been impossible in the Marshalls.
Cultural Background
Marijuana, like other drugs, is used socially in Micronesia. What Larson reported witnessing in Chuuk during the early 1980s would seem to be equally applicable to other parts of Micronesia.
Generally marijuana is smoked by groups of young men, about fifteen to twenty years of age, who gather in a secluded place. Though less common, groups of young women may also smoke regularly. A men's house is an ideal smoking place, but normal residences are also used if few people are around. After dark, smokers may sit circled in a yard or along the shore. Little ceremony surrounds the smoking event itself. Those who smoke together are usually relatives or close friends. Smoking may take place at any time of the day or night although most users prefer to smoke shortly after dark, about six o'clock, and finish later in the evening, about nine o'clock. Daytime smoking is usually of shorter duration and lasts no longer than an hour. Once a joint is lit, each smoker inhales deeply and holds the smoke in as long as possible while passing the joint on to the next person. No stigma is attached to anyone who refuses to smoke. Casual conversation may occur, but the passing of the joint commands the attention of those smoking....
The number of joints smoked during any one session varies considerably. One factor determining the number of joints smoked is the reliability of the source of marijuana. If smokers are accustomed to a daily supply of pot, they tend to smoke less in one sitting. If their supply is more sporadic, they tend to smoke whatever they acquire at once. Smokers' life experience is another factor determining the amount of pot smoked. Those who have never smoked outside Truk (Chuuk) tend to smoke more in one sitting and are less likely to save marijuana for the future. This style of smoking reflects Trukese attitudes toward consumption generally. Whether the activity is eating, drinking, smoking, making love, etc., the ideal is that one should continue until the effect is felt as fully as possible. The purpose of eating and drinking (nonintoxicants) is to feel full. The purpose of drinking intoxicants is to get drunk. With marijuana, the more one smokes, the higher one can get. Hence, the goal is to smoke as many joints as possible at one time. (Larson 1987:221-222)
Survey Data on Marijuana
General Prevalence Rate by Sex
The 12-month prevalence rate of marijuana use for the general population of the Marshall Islands (15+ years), as presented in Table 3.1, is 1.3%.
The marijuana prevalence rates, like those of other drugs, are strongly gender-linked. The male rate (15+ years) is 2.1%, while the female rate is 0.5%. Hence, the male rate is almost four times greater than the female rate.
Although the female prevalence rate for marijuana in the Marshalls (0.5%) is comparable to that in the FSM (0.8%), there is a wide disparity in the male rates in the two countries. The male rate for the Marshalls is much lower than that found in the FSM in the course of a similar survey (Micronesian Seminar 1997); the male rate of 2.1% for the Marshalls is just one-seventh of the FSM male rate (15.1%). The Marshalls rates, as derived from the data for this survey, are well below the rates registered in earlier studies of the FSM or some of its states. They are much lower still than the figures from a study that Jeanne Edman completed in 1980 indicating that 34% of all college students in FSM, the Marshalls and Palau smoked marijuana (Edman 1980).
| Total Population | ||||||
| Marital Status | ||||||
| single | ||||||
| married | ||||||
| Employment Status | ||||||
| salary job | ||||||
| unemployed | ||||||
| student | ||||||
| Ethnicity | ||||||
| Marshallese | ||||||
| Other Micronesian | ||||||
| Asian | ||||||
| US | ||||||
| Residence | ||||||
| Majuro | ||||||