CHAPTER 6: Prevention and Treatment

• In the Marshalls, as in the rest of Micronesia, drug use is additive rather than substitutional. Hence, those who use marijuana or other drugs are also regular users of alcohol.
• As a rule, drug use follows gender lines, with males using drugs and females generally abstaining.
• The use of "hard drugs" is not yet a major problem, but bears watching. An estimated 50 persons in the Marshalls currently use hard drugs in the form of cocaine and heroin.
• Inhalants (gas and glue sniffing) are a serious problem, although mainly restricted to Ebeye. Those who sniff gas or glue, numbering perhaps 260, are largely older males in their 20s and 30s who are seemingly addicted to inhalants and engage in sniffing several times a week.
• Marijuana is currently used by about 400 people, mainly young males on Ebeye and Majuro. Nonetheless, it is used more sparingly and by fewer persons than in FSM and probably in other island entities in the region. At present, it does not seem to be one of the bigger drug problems in the Marshalls.
• Alcohol appears to be the greatest drug problem in the Marshalls. One-third of all men over the age of 15 drink, and alcohol use seems to have increased among older age groups (45+).
• Binge drinking is a common practice in the Marshalls, in keeping with island styles of consumption. The average daily consumption of alcohol, as reported in the survey, is the equivalent of about nine cans of beer.
• There are currently an estimated 2,600 problem drinkers in the Marshalls. About one out of every six adult males can be designated problem drinkers inasmuch as they drink heavily and manifest behavioral problems related to their drinking.

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)

Treatment Strategies

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.

Prevention Strategies

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:

• Public education. The government office should gather or prepare materials needed for public education on drug and alcohol use, locally-oriented materials as well as standard items from abroad. They should make this available to other institutions that may want to include a module on drugs/alcohol in their programs, whether the form of the education program is a radio program, a state fair, a community celebration, or school class.



• Networking with community organizations. The staff of the government Substance Abuse Center should be a resource to be tapped by other community organizations when they need help in addressing these concerns. The staff should be prepared to assist them in planning for presentations, radio spots, workshops, and summer programs. They should also coordinate meetings between the various institutions, government and NGO, attempting to prevent drug and alcohol abuse.



• Referral treatment work. The government office could handle particularly difficult individual cases, especially those referred to the agency. It might also be able to help those in town who might lack other affiliations from which they could seek help. Treatment work with individuals should take up a rather small fraction of the agency's time, since most treatment would ideally be done by NGOs.



• Training. The government staff should run training programs, if only for a day or two at a time, for local church pastors, youth organization leaders, and key persons in the communities who may be called upon to deal with drug and alcohol problems. This is one of the most important services that the government staff can provide.



• Data keeping. The staff should maintain records on more than just their own caseload. They should keep statistics on drug prevalence rates as indicated in all studies of their state; social indicators of drug/alcohol abuse (eg, trauma cases related to alcohol use, arrests and convictions, mortality rates for alcohol-related diseases); and other relevant data.

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.

• The question of which culturally appropriate forms of intervention are most effective should be reopened and seriously addressed. One should not assume that those forms of intervention that have proven successful in the US will be as effective in Micronesia.



• Every effort should be made to make use of existing grassroots community institutions, especially the churches, in designing intervention strategies. This is cheaper and more effective than expanding government agencies so that they can provide their own outreach.



• Treatment strategies that can be successfully employed with young drinkers and drug users are limited. Abstinence movements would appear to be more effective than summons to moderation. In any case, a community support group is imperative for the reformed drug user, even if this means changing his circle of friends.



• Government agencies should redefine their role. Their most important potential contribution would seem to lie in the area of prevention rather than treatment. Accordingly, they should see their role chiefly as promoting public education efforts, networking with other agencies, and training those in the communities who are in a position to do primary-level intervention.



• The most important focus of overall efforts now is prevention of future drug and alcohol abuse. More effective public education should be a priority. This should be aimed at adults, not just those entering adolescence and the at-risk age-group, since adults will determine the expectations placed on the young and the sanctions to be imposed.

Funding Priorities

In keeping with these recommended strategies, the following funding priorities for locally generated and US federal funds are proposed.

• A smaller but effective office should be maintained to coordinate national efforts and monitor programs.
• Program funds should be set aside for the training of local community leaders.
• Program funds should be put into public education efforts. These should rarely be stand-alone programs, but activities tied in with community events or other workshops.
• State meetings of those whose principal work is substance abuse should be held once or twice a year, as well as opportunities for networking with other states on occasion. Funds should be used for sending NGO representatives as well as state agency employees.
• Resource persons should be brought in occasionally to evaluate the programs and/or assist in the training of state agency staff.