|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
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.
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.
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.
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.
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.
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.
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.
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.
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.
|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.
|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%).
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.
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.
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.
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.
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.
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.
|out of school|
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.
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.
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.
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.
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.
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.
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.
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.
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).
Marijuana use is more common among young men in their 20s than in any other age group, as Table 3.2 indicates. A few boys begin in their early teens, with the rate rising slightly in the late teens (15-19) before peaking in the 20s. The rate descends sharply in the 30-44 age group, after which no use is recorded in the older age groups. This pattern of marijuana use by age in the Marshalls closely resembles follows that of the FSM except that use of the drug in the latter does not cease entirely in the older age cohorts.
As Table 3.1 indicates, marijuana use among single persons (2%) is higher than among married persons (1%). One possible explanation for this finding is that unmarried persons tend to be younger, and it is among the young that marijuana use is concentrated. Table 3.3, which corrects for any age bias by narrowing the age range to 20-44, confirms the correlation between marijuana use and single marital status. As the table shows, the rate of marijuana use among single persons aged 20-44, at 2.1%, is somewhat higher than that for married persons (1.5%). The difference in use rate by marital status is even more pronounced among women: 1.4% of single women use marijuana by comparison with 0.3% of the married.
(Percentage of sample)
The rate of use among those without salaried employment is slightly higher than for those who have a paying job. The figures are not statistically significant, the more so in view of the very small numbers. A recent survey in the FSM showing a reversal of the correlation, with the use rate of employed males double that of those without jobs, should caution against exaggerating the significance of unemployment in occasioning drug use (Micronesian Seminar 1977).
The rate of marijuana use among students, aged 15+, is presented as 0.3% in Table 3.1, but this rate was based on a single user. Table 3.4 draws on the school-age population, aged 10-19, to provide a sharper contrast between the drug use of in-school and out-of-school youth. The rate among out-of-school persons is many times higher than the use rate of those who are attending school. This finding, which tallies with a similar conclusion from the FSM drug/alcohol survey, establishes that marijuana use, like alcohol use, is strongly correlated with educational status among the young.
|Out of school|
The survey sample showed very little marijuana use in non-Marshallese ethnic communities, as Table 3.1 indicates. There was none found among Asian or other Pacific islanders, and only one person among US/Australian citizens living in the Marshalls. Perhaps the only significant finding here is that the prevalence rates discussed in this chapter have not been distorted because of heavy use by other ethnic groups, for marijuana users in the Marshalls are almost entirely ethnic Marshallese.
Not surprisingly, the population centers of Majuro and Ebeye show higher rates than the outer islands. The male rates (15+) for Majuro and Ebeye are 2.4% and 2.3% respectively, while the male rate for the other atolls is 0.7%. Marijuana use, then, seems to be a relatively rare occurrence in the outer atolls of the Marshalls. Of course, in any comparison by residence, as in other comparisons made here, the small number of marijuana users is bound to cast doubts on the statistical significance of the findings.
The concordance of marijuana use with alcohol use is complete in the Marshalls: 100% of marijuana users (N=25) also drink alcohol. This again confirms the hypothesis long maintained by social scientists and social workers that drug use in Micronesia is additive rather than substitutive.
Table 3.5, showing the frequency of marijuana consumption, indicates that none of the current users are reported to smoke more than once or twice a week, with almost half smoking only an average of twice a month and another 24% smoking less than once a month. This is in strong contrast to findings in the FSM, where nearly half the drug users smoke daily. Those women who use the drug in the Marshalls tend to smoke more frequently than males, it appears, for 80% smoke once or twice a week.
Table 3.6 shows that males smoked a little less than an average of 2 joints on any day that they smoked, while females smoked an average of 2.2 joints. The average number of marijuana cigarettes smoked per day by the population using this drug was about 2. This is fewer than the average smoked daily in any of the states of the FSM, where the daily consumption ranged from 2.3 to 4.2. Hence, not only is marijuana is smoked less frequently than in the FSM, but fewer joints per sitting are consumed.
When the frequency data are computed against the average number of marijuana cigarettes smoked daily, it appears that the average Marshallese marijuana user smokes an average of 65 joints a year. This compares favorably with the FSM, where the average user smokes between 355 and 860 marijuana cigarettes yearly, depending on the state (Micronesian Seminar 1997:48).
Total Estimated Marijuana Use
When the survey sample is adjusted for age and sex to correct for over- or under-representation of any age-sex cohort, we may project the number of current marijuana users in the Republic of the Marshalls. As shown in Table 3.7 below, the estimated number of users at the time of the survey is 390, with 75 females among them.
Based on the number of projected users and the average number of joints smoked in a year, residents of the Marshalls consume about 25,000 marijuana cigarettes annually. To put this in another perspective, this quantity would be the equivalent of a four-day supply for the marijuana smokers in Chuuk State.
Although one recent report on the Marshalls mentioned "some anecdotal stories about widespread gasoline-sniffing among children," including the tale of a death due to gas sniffing, the use of inhalants in the Marshalls has been generally unremarked upon in the drug literature in Micronesia (Wood 1991:56).
The use of inhalants, although not especially common, is sometimes regarded as the first rung on the drug ladder for Micronesians. Young boys throughout the region are thought to begin sniffing in their early teens but usually stop well before they reach the age of 20, often moving on to marijuana smoking and then alcohol. An added cause of concern is the health risks that inhalant abuse poses. These range from lead poisoning to brain damage and possible higher incidence of mental disorders (Marshall et al. 1994:26-28). Despite the dangers they present, the use of inhalants has not received much attention-"in part because the substances that are abused by sniffers are legal, easily obtainable, and normally not viewed as drugs" (Marshall et al. 1994:24).
Inhaling is one of the rare types of drug use that is done outside of a social context. Unlike drinking and even smoking marijuana, drugs around which social rituals have developed, the use of inhalants is usually a solitary activity. Young boys will normally go off by themselves, sometimes with one other friend, to sniff gas or glue in some out-of-the-way place where they are unlikely to be disturbed by adults. Even if the boy goes with a friend, almost no social interaction takes place while the two are sniffing.
Survey Data on Inhalants
The survey data showed only 15 people currently using inhalants. Although this may reflect the current rates in the Marshalls, the reader should be cautioned that sniffing may be under-reported in this survey despite the vigilance of the field investigator inasmuch as inhalant use is harder to detect than other types of drug use. Sniffing, as was explained above, tends to be a "hidden vice;" boys characteristically sneak off and sniff the substance alone and out of sight of others. In a survey like this that employs key informants, the practice may go unobserved.
The data also reveal that the pattern commonly ascribed to inhalant use in the islands, however well it may apply to FSM, does not hold true in the Marshall Islands. The differences are such that we must postulate an altogether distinct use pattern for the drug.
Current Prevalence Rate by Sex and Age
All 15 of the current users recorded in the survey were males. Inhalant use, then, follows the familiar sex-linked pattern in which males use drugs and females generally abstain.
All except two of the 15 current users of inhalants recorded in the survey are from Ebeye; the other two live in Majuro. There are no instances of inhalant use found on the other, less developed atolls.
While the rate of inhalant use is not high, as Table 4.1 indicates, it is of interest that the highest rates are found in the 20-29 and 30-44 age groups, which show current use rates of 2.3% and 2.0% respectively. This is very different from the pattern in FSM, where the highest rates of inhalant use are registered for boys in their teens and the rate falls away to almost zero by the age of 20. It appears that in the Marshalls gasoline and glue sniffing are addictions of older males rather than merely a passing early stage in the drug cycle, as is true in Chuuk and Pohnpei of FSM. To put it another way, Marshallese inhale ten years later than Chuukese and Pohnpeians.
It may be noted that the overall rate of current use among Marshallese males over the age of ten (1.2%) is twice the general male rate for Chuuk (0.7%), the state with the highest rate in FSM.
Frequency of Use
Table 4.2, which shows the frequency of inhalant use, indicates that most of those sniffing gas or glue do so several times a week. Over half the users (54%) for whom we have data on frequency are reported to use these inhalants every day or every other day. This high frequency of usage contrasts with the distribution that was recorded for FSM, where most users resorted to the drug a few times a month and none more than once or twice a week (Micronesian Seminar 1997:57). This striking difference in the frequency pattern in the Marshalls would seem to confirm our finding that those who sniff in the Marshalls are older males who have become addicted to the use of inhalants.
Estimated Number of Users
Use of inhalants, as we have seen in Table 4.1, is confined to males. Using the survey data to generate the number of males currently using inhalants in the Marshalls, we may estimate their number to be about 260. A breakdown by age group is shown in Table 4.3.
"Hard drugs," as it is used here, is a catch-all term to include amphetamines, heroin, cocaine, hallucinogens, and all other illegal substances with the exception of marijuana. It does not include barbiturates or tranquillizers, since there is nothing to suggest that these are used, or even known to be tempting, in FSM.
Despite the well-publicized drug problems in Palau, Guam and the Commonwealth of the Northern Marianas to the far west, the Marshall Islands like FSM have usually been perceived as having escaped the serious drug problems of their neighbors. Now and then one might read of an isolated incident involving drugs, as when bricks of a white substance well wrapped in plastic washed up the shores of an island in the Marshalls a few years ago. The substance proved to be cocaine, which was thought to have been dumped by a Chinese ship carrying illegal immigrants that had experienced engine problems and was about to be seized by authorities. Periodically officials on Kwajalein would become nervous about charges, whether true or merely alleged, of outbreaks of drug use on the military base. Occasionally there were also rumors of cocaine use among some of the more well-to-do members of Majuro society. Yet, even with these periodic alarms, there was never anything to suggest that anything approaching a drug epidemic was taking place in the republic. There still is not.
Survey Data on Hard Drugs
The survey data showed three persons currently using hard drugs, one male and two females. All are between the ages of 20 and 30. All three are residing on Majuro and are said to be using cocaine and heroin.
The lifetime users reported in the survey were six: the three current users and three Marshallese males in their 20s living on Ebeye. The three young men from Ebeye all used cocaine at one time but all have now given up the habit. In confirmation of the assertion that drug use in Micronesia is additive rather than substitutional, all six lifetime users are currently using alcohol and marijuana. All but one of the six are Marshallese.
The survey data on these lifetime users indicates that their drug habit originated, for the most part, outside the Marshall Islands. Four of the six users (including the non-Marshallese) had lived abroad for a period that ranged between two and ten years; the other two lifetime users, although they had not traveled abroad, shared households with other drug users.
Although it is risky to project the number of hard drug users in the Marshalls on the basis of such small numbers, the survey data may provide a rough indication of the magnitude of the hard drug problem today. Based on the three current users found in the survey sample, we may project an estimated 50 persons-the equivalent of 0.1% of the population-using hard drugs in the Marshalls today. Twice that number may have used hard drugs at one time or another in their life.
Hard drugs must always be considered a real threat, especially in view of the well-publicized problems drug use is causing in other Micronesian societies, but this type of drug use is not widespread in the Marshalls at this time. Hence, drug prevention policy might ignore hard drugs for the present to focus instead on alcohol.
Culturally Appropriate Intervention
The question of what type of intervention should be attempted is a critical one. We ought not assume that Micronesia needs more of the same kind of prevention and treatment strategies in the future. Models of intervention adopted from Western societies have often been adopted uncritically in the past. While these should not be a priori dismissed out of hand, they should be carefully evaluated for their effectiveness.
Needless to say, any strategy for intervention that is to succeed must be culturally appropriate. It must take account of island values, the social reasons for the use of alcohol and other drugs, and the mechanisms of social control within the island society. It must not assume that these values or social levers are the same as those in the US and so can be used accordingly.
Some Western-style programs, such as those modeled on the Outward Bound Program, appear to have had some success over the years, especially when counselors follow up on those who have taken the three-week program with regular personal interviews and counseling sessions. The same might be said for "Big Brother" type programs that have been established in some places. As important as the initial program itself is the relationship that often develops between the individual youth and the counselor. The bonding element appears to be decisive in these programs, although even successful bonding does not guarantee equal success in leading youth to moderation or sobriety.
One of the most successful innovations in the Marshalls has been "Youth to Youth," a program that has set out to use young people to speak to their peers about the dangers of alcohol and drug abuse as well as on other health-related issues. The program does this primarily through a program of skits, songs and dances that is presented time and again in halls crowded with youth. The program not only speaks to young people in a format that they find compelling, but is dedicated to training a cadre of youth leaders who will be able to carry on this work in various communities and on many different atolls. Although the program does little direct one-on-one work, it could be an excellent model for prevention programs in the region.
On the other hand, many programs that have proven effective in the US have not worked in Micronesia. The most notable example is Alcoholics Anonymous, which was first brought to the islands by well-intentioned Peace Corps volunteers in the 1970s and was periodically reintroduced by expatriates since. These experiments "inevitably fail when the novelty wears off or when the initiator leaves the island" (DuPertuis 1988:20). AA has had little lasting impact on the islands for reasons that DuPertuis and other commentators have easily discerned. Anonymity in a tightly-knit island society is impossible, and islanders know that they can expect to meet people in their support group on an almost daily basis outside of the meetings. Furthermore, Micronesian males are not given to sharing with others the intimate details of their lives, to say nothing of the serious personal problems and reverses that drinking has caused them.
AA does offer its members a small support community, but this type of a community can only seem artificial to Micronesians, embedded as they are in vital, functioning communities. The same can be said of the religious dimension of AA, with its appeal to a "Higher Power." This notion represents the blandest type of deism compared to the doctrinal richness of the "salvation" that Christian churches offer their members. In summary, AA is asking its members to pretend that they are in a large, anonymous society and tell their life story to others who probably could add spicy details of their own to the narrative. Members are to do this in the embrace of an artificial community and they are expected to draw inspiration from a general concept that is only vaguely related to their real-life church teachings. Given these liabilities, it is no wonder that AA has proven unsuccessful in the islands.
Programs modeled on AA have had some success in American Samoa, according to Whitney (NDa:15-17). When the program is modified to do away with the sharing of life history and the emphasis on individual failings, and when it takes on enough of the local cultural features to serve as a comfortable support group for islanders, the program can be effective. Even then, however, by Whitney's own description, it takes on many of the characteristics of a church revival group.
The tendency of foreigners to fall back on AA-type programs as a form of treatment for alcohol abuse is like their recourse to the "hot-line" approach when planning intervention strategies for suicide attempts and spouse abuse. Whatever success this might have in the US, the assumption that an islander will pick up a phone and pour out his heart to an unknown person at the other end of the line is simply unwarranted.
The Role of Church Groups
Drug use in the Marshalls, as we have attempted to show earlier, is governed by cultural norms that are inimical to pleas for moderation. Drinking and drug use is normally a social event in which participants are expected to comply with the wishes of all the others who join the circle. The prevalent attitude toward consumption, as researchers in the Pacific have repeatedly observed, is to finish off everything that is provided, the goal being that "one should continue until the effect is felt as fully as possible" (Larson 1987:222; see also Whitney NDb:95). In view of these cultural norms, abstinence is generally recognized as a more effective strategy than moderation.
Micronesians may rue the effects of their drinking or drug episode afterwards, but they do not regard the episode as the effect of an ineluctable compulsion. The disease model of alcoholism is not widely accepted in the islands, since people believe they can control the use of alcohol, and the use of other drugs, with willpower. Alcoholism-as-sin is more in line with the Marshallese worldview than alcoholism-as-disease.
Over the years, the most successful abstinence-type programs in Micronesia have been church-run. The major denominations have their own anti-alcohol and drug programs, as do most of the smaller sects. Assembly of God and the Congregational Church, among others, run revival-type programs for youth that seek to inspire and motivate them to turn from drugs and drinking. While these church programs have their own distinctive features, they share some common traits that seem to be necessary conditions for effective abstinence programs in the islands.
A look at typical Catholic youth group in another part of Micronesia may illustrate some of these features. Young men join the group when they kneel before the altar to make their promise to abstain from alcohol or drugs, or possibly other things, for a specified period of time. Most young men pledge for three to six months, often renewing their pledge at the end of this period, but some pledge for longer and occasionally a person swears off for life. Frequently a rather large number of young men from the same village take the pledge together. They then join the village chapter of the association, which meets frequently, sometimes even nightly, to sing church songs, listen to pious talks, and socialize with others who have sworn off alcohol. On one Sunday each month, the village members join with those from other villages after church services to celebrate an island-wide meeting that offers singing (sometimes competitive singing between village groups), speeches on the religious meaning of what the youth are doing, and food.
Protestant youth groups may differ in some details, but they all include the same essential elements: companionship with select other youth from their actual community, a meaning to their abstinence ("sacrifice" in the case of the Catholic group described above) derived from a familiar religious belief system and surrounded by religious symbols, and regular support sessions from the group to keep motivation at a high level.
It is conceivable that such a group could be replicated in village communities but without being affiliated with a church. Even lacking the religious symbolism, such a youth group might command a sizeable membership and be able to promote abstinence from alcoholic beverages. Yet, one wonders whether such a group would be as successful as many of the religious youth groups, and why the creation of a new group would be necessary in the first place. To establish parallel secular structures in the local communities for the control of drug and alcohol abuse is not only costly but usually less effective than relying on what already exists. Yet, this is what government-funded drug and alcohol abuse programs have sometimes attempted to do.
One can only agree with DuPertuis when she writes:
The churches remain the only institutions which take a stand against alcohol. At the state-wide level, the denominational churches offer the possibility of disseminating information to and exchanging ideas from the local communities. And on the community level, they offer the possibility of active, effective public community-level social control. While the sectarian positions on alcohol are now fixed and seem viable enough for the small numbers who adhere to them, the denominations are trying to readjust their abstinence style toward a realistic yet effective policy in the control of alcohol problems. (1988:22)
In his article, "Strategies for Alcoholism Counseling in Hawai'i," Scott Whitney (NDb:104-105) sees two pathways to recovery for Hawaiian males who abuse alcohol: "the Vow" and "reaffiliation." By "the Vow" he means a decision not to drink again, often made in a religious context. As we have seen above, the churches in Micronesia offer drinkers a meaningful framework within which to make such a vow or pledge, and most of these same churches operate what can be called support programs to maintain motivation and provide a helpful social surrounding.
By "reaffiliation" Whitney means the change of allegiance from one's drinking buddies to a sober group. In Micronesia it is expected that this will happen naturally as one ages and gradually ascends into a new and more respected status in the community. Social pressure builds on the male during his 30s to give up the joys of adolescence, among them heavy drinking, to concentrate on his obligations toward his family and community. Hence, reaffiliation is the natural conclusion to an early stage in the life cycle of islanders. Or so the process has worked in the past, at least, when the young adult was eventually reintegrated into his community after giving up his excesses.
But reaffiliation can occur earlier, as when at-risk youth bond with counselors or other older role-models. To the extent that they are able to continue their positive relationship with these older persons, they may continue to avoid excess drinking and other drug use. It should be understood, however, that the factor that tips the balance is the relationship itself rather than any skills competence the youth may have acquired in the course of the program. Relationships rather than achievements continue to define the self in Micronesia.
This is not to say that there is no place for individual counseling services at treatment centers. A number of young people with drug problems have received good advice and warm encouragement from the staff at these centers, but the latter can only point them toward one of the paths about which Whitney writes. Whether the clients are youth or older adults, they must be encouraged to make a fundamental decision (or "vow") with regard to the problem drug and they must be directed toward a support group that can sustain them ("reaffiliation"). Hence, the paths of effective treatment lead back to local institutions, especially the churches.
If prevention strategies are aimed at keeping youth from drinking and other drug use, then they have had mixed results, for almost half of all males in the 20-29 age bracket today drink, and a great many of them drink heavily. Curricular units in the schools on the harmful effects of drug and alcohol abuse appear to be having only a marginal impact on the decision that young people make as to whether to use drugs or not. Recreational facilities like village basketball courts undoubtedly offer young people alternatives to evening drinking and so may have reduced the quantity of alcohol consumed, but it is unlikely that these have caused many youth to eschew drinking and drug use altogether. Even church-sponsored abstinence groups command relatively few adherents, although these groups have the effect of driving drinking underground. Programs of this sort, although they can make drinking slightly less acceptable, seem to have a minimal impact in reducing the number of young drinkers. This is not surprising since, as we have seen, males are more or less expected to engage in drinking during their youth.
Drinking and drug use in Micronesia is not the product of an individual choice; it is the consequence of a set of cultural expectations that encompass young and old alike. To put the matter simply, Micronesians are taught from an early age how important it is to conform to social expectations, and the expectations are that young males will drink. Moreover, they are expected to drink heavily, because people are expected to enjoy everything with abandon.
Prevention strategies, therefore, can take two basic approaches. They can attempt to influence young persons to swim against the tide and foreswear the use of all drugs, or they can work to change the direction of the tide-that is, popular expectations. The latter is not as sisyphean as it might seem, when we recall similar reversals that have been effected in recent years. Smoking was banned on all flights and in all government offices by a nation in which nearly half the population smokes. Over-water outhouses, which were once used nearly everywhere, were eliminated practically overnight in one state of the FSM following a cholera outbreak in the early 1980s. It would seem that we might have reason to hope for a similar turn-about in expectations regarding drinking and drug use.
To bring about a change of public attitude toward drinking, the public must be helped to look at itself and catch a reflection of the consequences drinking and drug use are having on the society. It is not enough to view only the health issues or the loss of life. The type of cost-benefit analysis islanders must have if they are to be roused to public action includes an honest look at the social gains as well. In other words, the problem of alcohol use cannot be adequately explored unless the benefits of alcohol as a release from stress and an aid in coping with anger are addressed. This kind of public education program must be targeted at adults in the community, since it is they who establish the community norms.
The Role of Government Agencies
There is an important role for government agencies, especially the Division of Mental Health and Substance Abuse, but this role is in need of redefinition. Thanks to the substantial SAMHSA block-grant funds that the Republic of the Marshalls has received over the past five or six years, the national offices have expanded, hiring new employees and often attempting to set up an outreach program in remote islands and villages. Much of this expansion seems to have been unplanned and new programs conducted without proper evaluation.
As government substance abuse offices have grown and developed their own outreach programs, they can easily run the risk of neglecting to network with other institutions-churches and other NGOs. The degree of interaction between agencies, government and private, may be worse now than in an earlier age, because government agencies and private organizations have come to look on one another as competitors for US block-grant funds.
The role of government agencies should be reexamined and redefined. The government office would do well to abandon outreach programs of their own and to rely instead on local private, even religious, institutions. Their primary focus should be on prevention rather than treatment. The role of these government agencies might include these items:
A Summary of Basic Strategies
In view of the social realities in Micronesia and the nature of the alcohol/drug problem described in this survey, the following general strategies are proposed.
In keeping with these recommended strategies, the following funding priorities for locally generated and US federal funds are proposed.
Appendix 2 COMMUNITIES SURVEYED
Majuro This atoll is the capital of the Republic of the Marshalls and the business center of the nation. Its estimated population of 26,600 comprises nearly half of the entire population of the Marshalls. It has an airfield that handles traffic from the South Pacific as well as the Continental Air Micronesia flights linking the Marshalls with Guam, Hawaii and the Federated States of Micronesia. Majuro also has a state-of-the-art government building, a modern telecommunications system, and dozens of hotels including the five-star Outrigger Hotel constructed in 1995. The town area of the island is very densely settled, although houses in the more outlying sections of the atoll are much more spread out. Very little food is produced in the atoll; almost all of the foodstuff consumed is imported and sold at modern grocery stores. Prices for commodities are outrageously high due to a new sales tax that the government has imposed on most items. There are no less than five high schools and numerous elementary schools on the island. Discos are also numerous and well attended by high school and college age youth. Marijuana use is common on the atoll.
Ebeye Ebeye is a single small island on the Kwajalein reef in the Ralik (western) chain of the Marshalls. It is located a mile or two north of the main island, which houses the US missile testing and radar development base with its exclusively American population of about 5,000. Ebeye has for years been the "dormitory" for the Marshallese work force employed on Kwajalein. Roughly one-tenth of a square mile in area, Ebeye is home for 12,000 Marshallese. The island is crowded and until recently was a squalid place that sometimes went by the name of the "Slum of the Pacific." In recent years fund shave gone into cleanup and infrastructure development so that the island now has reliable power and water, improved sanitation, and even sidewalks. Moreover, a causeway has been built connecting Ebeye with three or four other islets to the north in an effort to relieve the population congestion. Ebeye has no fewer than five high schools, all but one private, and at least as many elementary schools. Yet, the many out-of-school youth lounge on the western side of their houses in the morning, shifting to the opposite side as the sun changes position in the afternoon. The population supports itself by taking work on the base at Kwajalein for US minimum pay, but the store prices on Ebeye are extraordinarily high. Evenings feature bingo games for women and beer parties for men.
Arno Arno Lagoon, in the southern Ratak (eastern) chain, is only 12 miles east of Majuro. Its population in 1988 was about 1600. As in nearly every part of the Marshalls, the population is overwhelmingly Protestant. The lifestyle on the island is semi-traditional, with much local food eaten, although less fishing is done there than in most other atolls. The atoll has a law prohibiting the use of alcoholic beverages. There are 14 elementary schools on different islets in the atoll. The municipal government is headed by a mayor and 16 councilmen.
Mili Like Arno and Majuro, Mili is located in the southern part of the eastern archipelago in the Marshalls. Its 1988 population was recorded at 850. Most are Congregationalist. Local foods form the greater part of the diet and fish is abundant in the waters of the lagoon. As in most other atolls, there are no salaried jobs apart from those in the elementary schools of the atoll. There are plans being made to develop a tourist industry on the island and so stronger transportation links with Majuro have been forged. In addition to the government ship that services the island every two months, there is a weekly flight from Majuro on Air Marshall Islands. Perhaps due to these links, liquor is being smuggled into the island and yeast is consumed there regularly.
Jaluit Jaluit, once the headquarters of the Marshalls during pre-war colonial days, has now reverted to the status of an outer atoll. Jaluit is located in the center of the Ralik (western) chain of the Marshalls. The atoll had a population of 1700, as recorded in the 1988 census, with 670 living on the main island of Jabwor. Jabwor has a public high school serving the region and a Catholic elementary school as well as a public elementary school. Although the atoll is chiefly Protestant, the Catholic presence is stronger here than in almost any other part of the Marshalls. A government ship visits the island monthly and an Air Marshall Islands flight arrives weekly. Bingo games are common among women, especially on weekends, while men engage in some drinking.
Appendix 3 SURVEY INSTRUMENTS
1) HOUSEHOLD SURVEY RECORD SHEET
State ________________ Village ____________________ House # ___
Total number living in household: ________
Head of household:
Name_______________________________ Sex____ Age _________
Name_______________________________ Sex____ Age _________
Name_______________________________ Sex____ Age _________
Name_______________________________ Sex____ Age _________
Name_______________________________ Sex____ Age _________
Name_______________________________ Sex____ Age _________
Name_______________________________ Sex____ Age _________
Name_______________________________ Sex____ Age _________
Name_______________________________ Sex____ Age _________
Name_______________________________ Sex____ Age _________
Name_______________________________ Sex____ Age _________
Name_______________________________ Sex____ Age _________
2) INDIVIDUAL USER RECORD SHEET
State ________________ Village ____________________ House # ___
Name_______________________________ Sex: M F Age _________
Marital Status: Single Married Divorced Widowed
Wage Employment: No Yes If yes, where? ______________________
Education: Last grade completed in school __________
Student at present? No Yes If yes, where? ___________________
Travel abroad (6 months or more)? No Yes If yes, how long?
Drugs used: Alc Mar Coc Her Other ________________
Gas/glue Sniffing? Y N
Frequency in last year:
___3-4 days a week
___1-2 days a week
___1-3 days a month
___less than once a month
Amount consumed in last year: avg number of drinks in one day_____
More than 5 drinks in one day? Y N
Frequency during last month:
___3-4 days a week
___1-2 days a week
___1-3 days a month
___less than once a month
Amount consumed in last month: avg number of drinks in one day_____
Binges lasting more than one day? Y N
Neglect of his responsibilities? Y N
How many binges in the last year? ______
When did last binge occur? ____________
Problems related to drinking? Y N
___ illness or injury
___ missed work or duties
___ arrested for alcohol-related offenses
___ fighting while drunk
___ beating wife or children
___ other family problems
___ mental problems
Treatment for alcohol abuse sought? Y N
Serious drinking problem? Y N
Alcoholic? Y N
Smoked marijuana more than 2 times in the last year? Y N
Frequency of marijuana smoking:
___3-4 days a week
___1-2 days a week
___1-3 days a month
___less than once a month
Amount consumed: avg number of joints smoked in one day _____
Use of marijuana now? Y N
Problems related to use of marijuana ____________________________
What drugs used? _______________________________________
Use of these drugs now? Y N
Sniffing now? Y N
How often? _______________
3) INDIVIDUAL USER INTERVIEW INSTRUMENT
1) In the last year, has the person had something to drink
___ almost every day
___ 3-4 days a week
___ 1-2 days a week
___ 1-3 days a month
___ less than once a month
2) On days when he drank, about how many drinks on average would he have?
___ drinks in one day
3) Has he had more than 5 drinks in a day at any time during the last year?
4) During the last month, has he had at least one drink?
How many days did he drink?
On days when he drank, how many drinks did he take on average?
5) Has he ever gone on binges where he has kept drinking for a couple of days or more without sobering up?
Did he neglect some of his usual responsibilities at those times?
About how many times has this happened in the last year?
When was the last time this happened?
6) Has he ever had problems related to his drinking?
Has he ever been admitted to the hospital or treated in the hospital or dispensary or at home for alcohol-related illness or injury?
Has he ever missed work or neglected his other responsibilities due to his drinking?
Has he ever been arrested for alcohol-related offenses?
Has he been involved in fights with others while he was drunk?
Has he beaten his wife or children or other relatives when drunk?
Has he experienced other problems with his family--for instance, arguments with family members, his wife threatening to leave him or actually doing so because of his drinking?
Has he shown any signs of mental problems--for instance, talking to himself, hallucinations, hearing voices, avoiding other people, or unpredictable behavior?
8) Has he ever sought treatment for alcohol abuse in any kind of anti-alcohol program (AA, church programs, private counseling, etc)?
9) Does he, in your judgment, have a serious drinking problem?
10) Is he addicted to drinking?
1) Has he used marijuana more than 2 times in the past year?
2) How frequently did he smoke marijuana?
How many days a month?
How many joints on days that he smoked marijuana?
3) Does he still use marijuana now?
4) Has he experienced any problems in connection with his use of this drug?
1) Has he ever used other, stronger drugs than alcohol and marijuana?
hallucinogens: PCP, LSD
cocaine: coke, crack
heroin or other opiates (Codeine, morphine, Demerol)
amphetamines: speed, ice, "uppers", Benzedrine
2) What kind of drugs has he used?
3) Does he still use these drugs?
1) Has he sniffed gas, glue, or any other inhalant during the last year?
2) How frequently has he done so?
Appendix 4 TREATMENT AND PREVENTION AGENCIES
Majuro Substance Abuse and Mental Health Program. This official government agency serves Majuro and the outer islands of the Marshalls. Kwajalein Atoll has its own semi-autonomous branch operating on Ebeye. The office is under the supervision of the Division of Human Services, headed by Glorina Harris, which falls under the Department of Health and Environment. Nine persons work in this office. There are two individuals responsible for alcohol/substance abuse and mental health, both of whom report to Glorina. These two people are employed to care for alcohol/substance abuse. They do some counseling of those who seek help, follow up on the continuing cases of alcohol abuse, and run public awareness programs, especially in connection with the schools.
Ebeye Substance Abuse and Mental Health Program. This office operates on Ebeye and performs the same functions that the Majuro office provides. The Ebeye office is attached to the Division of Human Services in Majuro and has two employees. Rose Bobo heads the office. The office staff follows up on cases of mental illness and alcohol abuse. In the line of alcohol prevention, the staff occasionally makes radio programs for broadcast. They usually make about four programs a year. They reported handling 38 alcohol abuse cases during 1995. They have also targeted employees with drinking problems and hope to work in cooperation with employers in setting up mandatory counseling services for employees with a high absentee record due to drinking. This program has not yet become effective, however. The yearly budget for this office is $46,000, with the money coming from the US SAMHSA block grant funds.
Youth to Youth. This is an NGO founded by the late Darlene Keju as part of the Division of Population of the Department of Health Services. It became independent of the government about 1990 and now receives funds from private organizations and foundations as well as government funds. The Department of Health in the Marshalls provides $12,000 funding for the position of program director, but the rest of the funding comes from private organizations. The total yearly funding is about $300,000. Donors includes international church organizations, WHO and other health organizations, and regional associations and foreign governments. The director of "Youth to Youth" is Marita Edwin, a Pohnpeian. There are 12 full-time employees in the program.
The program is aimed at educating the youth of the Marshalls on alcohol and drug awareness as well as sexually transmitted diseases and other youth problems. The program presents to youth in local communities shows featuring songs, dances and skits that have an educational message. The performances it stages are lively and well attended. At the same time, the program seeks to train a cadre of youth peer educators who can bring these shows to further communities and carry on other forms of community education. The program conducts several week-long training sessions each year, many of which are held on remote atolls. The program promotes public health and assists community in carrying out practical projects such as the construction of youth centers.
Alcoholics Anonymous. This is a small private program run by Jerry Nii, a Hawaiian married to a Marshallese. It has been in operation under his direction for 14 years. The program began with a few Americans but has expanded to included some Marshallese. There are two meetings a week, about an hour long, that are held at the Land Grant office of the College of the Marshall Islands and are attended by about 3-5 persons. The format of the meetings is similar to that of AA chapters around the world. A total of about 20 persons are involved in the program to some extent. The program does not require funding.
Church Groups. The various churches--Congregational, Assembly of God, Catholic--have youth groups that offer young people a range of activities. The aim of most of these programs is to engage the young so that they will not drink, smoke and get in trouble.
1996 "Drugs in Micronesia." THE MICRONESIAN COUNSELOR. Series 2, Number 1. April.
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1980 "Alcohol and Marijuana Use Among Micronesian College Students." Unpublished paper. Community College of Micronesia, Pohnpei.
1986 "Prevention and Treatment of Mental and Neurological Disorders, Alcohol and Drug Abuse." Suva, Fiji, World Health Organization.
FSM&WHO [Federated States of Micronesia and World Health Organization]
1993 "FSM/WHO Joint Conference on Alcohol and Drug-Related Problems in Micronesia Report: 9-13 August 1993." Palikir, Pohnpei, FSM: FSM National Government.
Hezel, Francis X.
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Larson, Bruce R.
1987 "Marijuana in Truk." Chapter 9 in Lamont Lindstrom, ed. DRUGS IN WESTERN PACIFIC SOCIETIES. New York: University Press of America. 219-30.
MacAndrew, C. & R.B. Edgerton
1969 DRUNKEN COMPORTMENT: A SOCIAL EXPLANATION. Chicago: Aldine Publishing Co.
Mahoney, Francis B.
1973 "Social and Cultural Factors Relating to the Cause and Control of Alcohol Abuse Among Micronesian Youth." Prepared for the government of the TTPI under Contract: TT 174-8. James R. Leonard Associates, Inc. 80.
1979 WEEKEND WARRIORS: ALCOHOL IN A MICRONESIAN CULTURE. Explorations in World Ethnology. Palo Alto: Mayfield Publishing Co. 170.
1987 "'Young Men's Work': Alcohol Use in the Contemporary Pacific." In Robillard & Marsella, eds. CONTEMPORARY ISSUES IN MENTAL HEALTH RESEARCH IN THE PACIFIC ISLANDS. Honolulu: Social Science-Research Institute. 72-93.
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Marshall, Mac, Rocky Sexton, Lee Insko
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Oneisom, Innocente I.
1991 "Marijuana in Chuuk." MICRONESIAN COUNSELOR. Series 1, No. 3 (June). Micronesian Seminar, Pohnpei.
RMI [Republic of the Marshall Islands]
1988 CENSUS OF POPULATION AND HOUSING. Majuro, Marshalls, Office of Planning & Statistics.
1995 MARSHALL ISLANDS STATISTICAL ABSTRACT 1995. Majuro, Marshall, Office of Planning & Statistics.
Rubinstein, Donald H.
1980 "Social Aspects of Juvenile Delinquency in Micronesia." Conference Report for the Micronesian Seminar and Justice Improvement Commission. Agana, Guam: Micronesian Area Research Center
TTPI [Trust Territory of the Pacific Islands]
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TTPI [Trust Territory of the Pacific Islands] Department of Health Services
1976 "Supplement to 1975 Alcohol and Drug Abuse Plan of the Trust Territory of the Pacific Islands." Saipan. 36.
1976 "1976 Update for the State Alcoholism Plan for the TTPI. Saipan. 16.
Whitney, Scott & Fuala'au Hanipale
NDa "Feeling Strong: Themes in Samoan Drinking and Recovery." Unpublished paper. 26.
NDb "Getting Sober Local Style: Strategies for Alcoholism Counseling in Hawaii." ALCOHOLISM TREATMENT QUARTERLY. (??) 87-107.
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1987 "Report: Regional Working Group on Community-Based Approach to Alcohol-Related Problems, Yokohama City, Japan, 1-7 July 1987." Manila: WHO. 30.