Preface and Introduction:

In Western societies drug use is usually looked upon as an indication of deviance to a greater or less degree, depending on the type of drug. Pacific societies, however, have a long tradition of drug use fully incorporated into the culture and surrounded, in some cases, by an elaborate etiquette. The two outstanding examples are betelnut in the Western Carolines and kava in the Eastern Carolines.

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.

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:

To assess the absolute level of alcohol/drug abuse treatment need by providing solid prevalence rates for the total population and the different age-sex cohorts. To provide a sound assessment of the sociocultural factors peculiar to Marshallese societies, including the functions that alcohol and drugs serve, the social context in which they are used, and the meanings they have for Marshallese. To inventory the agencies, private and public, and the kinds of prevention and treatment programs they offer. To suggest what the most effective and culturally appropriate approaches in providing treatment and support for drug and alcohol abusers. There are two other goals endorsed by CSAT that must be addressed: training in the collection and use of data, and networking among non-governmental organizations (NGOs). As important as these goals are, they could not, for various reasons, be met during the preparation of this report. Our hope is that the process that follows the production of this report will offer an opportunity to meet these additional goals. We anticipate using this report as a teaching tool for representatives of government substance abuse offices and heads of NGOs to help them develop facility in using and gathering data of the kind presented here. The public presentation of this data to these same representatives will provide an opportunity to do the networking among various agencies envisioned by those who funded this project.

Scope of this Study

The study covers the Republic of the Marshall Islands, a newly independent nation that is bound to the US by the terms of a document known as the Compact of Free Association. The Marshalls, which was annexed by Germany in 1885 and seized by Japan at the outbreak of World War I, passed into the hands of the United States at the end of the Second World War. Together with the Carolines and the Marianas, the Marshalls was part of a UN trusteeship administered by the US for about 40 years. The Marshalls acquired full self-government in October 1986.

The Republic of the Marshall Islands is a nation of small coral atolls and isolated islands. The 34 atolls and islands are divided into two parallel chains running north-south: Ratak in the east and Ralik in the west. The total land area is 70 square miles and the highest point in the archipelago is at an elevation of 10 meters. The population of the Marshalls in 1988, as recorded in the last census, was 43,380 (RMI 1988). The projected population in 1995, according to the Marshall Islands Statistical Abstract of that year, was 55,575 (RMI 1995). This figure, which corresponds closely to the author's personal population figure for 1997, has been used as a base population figure in this study. The age-sex breakdown given in the above source has been accepted and used here.

Although the principal focus of this study is on alcohol, since it is far more widely used than any of the others and is generally thought to be the most damaging, the study also includes marijuana, inhalants and "hard drugs." This last term is used to embrace illegal drugs other than marijuana taken for non-medicinal purposes (that is, cocaine, heroin, amphetamines, and hallucinogens). The study does not include tobacco, nor two widely used locally grown substances-namely, sakau (sometimes known as kava) and betelnut.

Contracting Agency

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

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