Alcohol and Drug Use in the FSM
by Francis X. Hezel, S.J. MicSem Articles | Alcohol and Drugs

An Assessment of the Problem with Implications for Prevention and Treatment

by MICRONESIAN SEMINAR
Pohnpei, FSM
March, 1997


Preface: A CULTURAL CAUTION

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 (Yap and Palau) and kava in the Eastern Carolines (Pohnpei and Kosrae).

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

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

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

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

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

INTRODUCTION

Purpose of this Report

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

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

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

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

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

Accordingly, the goals of this study are:

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

Scope of this Study

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

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

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

Contracting Agency

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

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


Chapter 1: RESEARCH METHODOLOGY

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 we have employed an indirect approach that makes use of key informants to obtain information on an entire community.

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

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

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

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

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

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

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

Selection of Representative Communities

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

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

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

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

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

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

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

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

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

Sample Stratification

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

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

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

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

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

Interview Methods

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

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

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

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

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

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

Data Processing and Analysis

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

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

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

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

Collection of Other Data

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

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


Chapter 2: ALCOHOL

The Cultural Context

History of Alcohol Use

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

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

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

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

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

Cultural Background

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

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

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

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

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

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

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

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

As Marshall puts it in Weekend Warriors:

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

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

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

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

Social Indicators

Amount Spent on Alcohol

Table 2.1: Alcohol Imports (Wholesale $ Value)


Year
Yap
Chuuk
Pohnpei
Kosrae
Total FSM
1972 135,331 270,083 74,804 N/Aa 480,218
1977 431,886 343,282b 262,282 N/Aa 1,037,450
1984 584,308 315,010 957,356 178,888 2,035,582
1985 538,293 627,097 807,578 215,390 2,188,358
1986 571,898 384,401 791,666 220,057 1,968,022
1987 563,232 582,584 688,136 185,953 2,019,905
1988 626,488 782,838 2,767,637 244,964 4,421,919
1989 638,946 844,088 1,048,440 243,321 2,774,715
1990 961,836 912,463 1,735,374 299,112 3,908,785
1991 788,453 994,086 1,296,711 294,519 3,373,769
1992 768,433 717,960 1,330,528 448,831 3,265,752
1993 783,261 538,722 1,078,473 273,848 2,674,305
1994 706,887 242,801 1,420,675 204,484 2,574,847

Notes: a Kosrae data included with Pohnpei for 1972 & 1977.
b The 1977 figure for Chuuk is given as $441,605 from Millay (1987:175).
Sources: 1972 data taken from Mahoney (1973:19); 1977 figures from
TT Bulletin of Statistics
, 1:2 (1978:18); later figures from
FSM Trade Bulletin Nos. 1-8.


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

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

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


Table 2. 2: Per Capita Yearly Expenditures on Alcohol (US$)

Year
Yap
Chuuk
Pohnpei
Kosrae
1972 18.18 8.98 4.38 N/A
1977 55.61 9.47 11.64 N/A
1984 64.07 7.46 36.14 28.64
1985 57.42 14.46 28.17 33.52
1986 59.39 8.64 27.08 33.31
1987 55.55 12.77 23.11 27.83
1988 60.74 16.75 91.17 36.24
1989 60.91 17.63 33.9 35.6
1990 90.17 18.64 55.13 43.16
1991 72.72 19.87 40.47 41.91
1992 69.74 14.04 40.81 63.01
1993 69.97 10.32 32.52 37.93
1994 63.24 4.55 42.17 27.95

Alcohol consumption rates vary widely from state to state, as Table 2.2 indicates. This table shows the yearly per capita expenditures on alcoholic beverages for each state. It should be borne in mind, however, that since Tables 2.1 & 2.2 are based on wholesale import costs, the retail value of the alcohol consumed-the sum that people actually spend on imported alcohol-would run at least 50% higher than the figures given here.

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

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

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

Per Capita Consumption of Alcohol

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

Yap 4.4
Chuuk 1.8
Pohnpei & Kosrae 1.5

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

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

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

Yap 5.3
Kosrae 2.5
Pohnpei 1.2
Chuuk 0.5

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

Alcohol-Related Deaths

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

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


Table 2.3: Alcohol-Related Deaths, 1991-1995
Cause of Death 1991 1992 1993 1994 1995
Pohnpei:
Cirrhosis 3 4 4 2 2
Homicide 0 2 1 2 2
Suicide 0 4 4 5 7
Gastritis 0 0 0 1 1
Total 3 10 9 10 12
Kosrae:
Suicide 1 1 0 0 1
Hepatitis 0 0 1 0 0
Drowning 0 0 0 1 0
MVA 0 0 0 1 0
Liver disease 0 0 0 0 1
Total 1 1 1 2 2
Yap:
Cirrhosis
1
0
0
0
1
Homicide
1
0
0
0
1
Suicide
1
0
6
1
0
Gastritis
0
0
0
1
0
MVA
1
0
2
0
0
Drowning
0
0
0
1
1
Total
4
0
8
3
3
Chuuk:
Suicide
4
5
4
1
5
Homicide
2
1
1
5
1
Drowning
1
1
0
0
0
Hepatitis
0
1
1
0
2
Total
7
8
6
6
8
FSM TOTAL
15
19
24
21
25
as % of all deaths
3.5%
4.7%
4.9%
4.3%
5.9%

Hospital Admissions

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

Suicides

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

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


Table 2.4: Alcohol-Related Suicides, 1991-1996
(ratio of alcohol-related suicides to all suicides)

State
1991
1992
1993
1994
1995
1996
Pohnpei
3 / 7
1 / 4
4 / 6
4 / 7
6 / 11
3 / 7
Kosrae
1 / 2
1 / 1
1 / 1
0 / 0
1 / 1
0 / 0
Chuuk
11 / 20
13 / 23
6 / 12
0 / 8
8 / 21
11 / 26
Yap
1 / 4
0 / 1
3 / 11
0 / 1
2 / 5
1 / 3
Total FSM
16 / 33
15 / 29
14 / 30
4 / 16
17 / 38
15 / 36

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


Table 2.5: Alcohol-Related Arrests
State
1991
1992
1993
1994
1995
1996
Pohnpei
685
443
Kosrae
180*
Yap
2,367
2,256
2,138
1,856
1,623
Chuuk
212
286
311
391
375

Note: Kosrae data is from August 1995 to July 1996


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

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

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

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

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

Survey Data on Alcohol

General Prevalence Rate by Sex

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

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

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

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


Table 2.6: Users of Alcohol Within Past 12 Months (15 + yrs):General Characteristics
(Number and percentage of sample)

Males
Females
Total
N
%
N
%
N
%
FSM
1223
54.9
195
9.1
1418
32.4
Pohnpei
477
61.4
108
14.4
585
38.2
Kosrae
52
34.9
2
1.2
54
17.3
Chuuk
520
50.5
10
1.1
530
27.0
Yap
174
63.1
75
26.7
249
44.6
Marital Status
single
490
47.9
62
7.3
552
29.6
married
694
62.9
119
10.8
813
36.9
divorced
26
70.3
8
17.8
34
41.5
widowed
11
28.9
6
4.9
17
10.5
Employment Status
salary job
512
70.0
56
18.6
568
55.0
unemployed
710
48.6
139
7.8
849
26.0
student
95
29.2
10
2.8
105
15.3
Ethnicity
Micronesian
1213
54.9
190
9.0
1403
32.4
Asian
2
37.5
1
20.0
3
37.5
US/Australian
6
60.0
4
50.0
10
55.5
Other Pacific
2
66.6
0
0
2
66.6
Residence
town
187
48.1
46
11.2
233
29.2
village
759
55.3
99
7.8
858
32.5
outer-islands
208
53.1
46
11.8
255
32.3

Comparison with Past Studies

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

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

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

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

General characteristics

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

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


Table 2.7: Users of Alcohol Within Past 12 Months by Age Group
(Percentage of sample)


<10
10-14
15-19
20-29
30-44
45-64
65+

Total 15 +

FSM
Males
0
2.6
32.4
63.0
69.5
50.7
21.8
54.9
Females
0
0.8
5.5
8.1
14.6
7.6
4.4
9.1
Total
0
1.8
19.0
36.7
43.0
28.7
13.6
32.4
Pohnpei
Males
0
6.4
44.4
73.4
76.1
48.6
18.4
61.4
Females
0
2.1
9.9
14.6
20.5
12.5
2.6
14.4
Total
0
4.3
27.6
46.0
47.3
30.5
10.4
38.3
Kosrae
Males
0
0
0
37.0
54.5
42.3
7.1
35.1
Females
0
0
0
0
3.0
3.8
0
1.2
Total
0
0
0
16.2
32.5
23.1
4.5
17.6
Chuuk
Males
0
1.7
27.9
56.6
65.6
45.4
22.2
50.5
Females
0
0
1.1
1.1
2.0
0
0
1.1
Total
0
0.9
14.9
30.9
36.8
21.6
11.9
27.0
Yap
Males
0
0
22.2
75.3
75.9
75.9
46.2
63.1
Females
0
0
11.1
23.3
36.8
34.1
25.0
26.7
Total
0
0
16.7
47.8
55.5
54.5
36.0
44.6

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

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


Table 2.8: Current Users of Alcohol (aged 20-44) by Marital Status
(Percentage of sample)


Males
Females
Total
N
%
N
%
N
%
FSM
single
338
59.2
37
9.2
375
38.5
married
507
72.6
95
12.3
602
41.2
Pohnpei
single
111
75.5
19
17.9
130
51.4
married
216
76.6
55
18.0
271
46.1
Kosrae
single
15
36.6
0
0
15
19.5
married
25
53.2
1
1.8
26
25.2
Chuuk
single
176
52.7
4
1.8
180
32.4
married
194
70.8
4
1.4
198
35.7
Yap
single
36
73.5
14
35.0
50
56.2
married
72
75.8
35
30.7
107
51.2

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

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


Table 2.9: Current Users of Alcohol (aged 10-19) by Educational Status

Males
Females
Total
N
%
N
%
N
%
FSM
in-school
55
10.6
11
2.1
66
6.3
out of school
100
42.7
16
9.6
116
28.9
Pohnpei
in-school
29
18.8
7
4.3
36
11.3
out of school
56
56.0
12
13.8
68
36.4
Kosrae
in-school
0
0
0
0
0
0
out of school
0
0
0
0
0
0
Chuuk
in-school
21
8.4
1
0.4
22
4.3
out of school
37
31.1
1
1.5
38
20.3
Yap
in-school
5
4.4
3
2.9
8
3.7
out of school
7
46.7
3
25.0
10
37.0

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

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

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

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

Breakdown by states

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

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

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

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

Frequency and Amount Consumed

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


Table 2.10: Frequency of Alcohol Use for Current Drinkers
(Percentage, with rows totaling 100%)


Daily

3-4 times wk

1-2 times wk
1-3 times mo

less than
monthly

FSM
Males
11
21
26
24
18
Females
7
8
23
26
35
Total
11
19
26
24
20
Pohnpei
Males
15
11
24
28
22
Females
10
4
26
23
37
Total
14
10
24
27
25
Kosrae
Males
6
2
45
17
30
Females
0
0
0
0
100
Total
5
2
44
16
33
Chuuk
Males
6
33
27
22
12
Females
0
20
20
60
0
Total
6
33
27
22
12
Yap
Males
18
15
22
26
20
Females
3
12
20
28
36
Total
13
14
21
27
25

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

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

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

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

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

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

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


Table 2.11: Usual Number of Drinks Consumed at a Sitting by Current Alcohol Users
(Percentage with rows totaling 100%)

1-2
3-4
5-7
8-12
13 +
(Avg)
FSM
Males
10
8
18
23
39
13
Females
31
17
20
13
15
8
Total
13
9
19
22
36
12
Pohnpei
Males
24
11
21
19
26
10
Females
48
9
22
9
13
6
Total
28
11
21
19
24
9
Kosrae
Males
6
15
38
25
15
9
Females
0
50
50
0
0
5
Total
6
17
39
24
15
9
Chuuk
Males
1
3
13
24
59
16
Females
0
0 20
50
30
13
Total
1
30
14
24
58
16
Yap
Males
2
12
23
35
27
13
Females
16
32
19
16
17
9
Total
6
18
22
30
24
12

Drinking Patterns in States

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

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

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

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

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


Table 2.12: Usual Number of Drinks per Day Consumed by Frequency
(Avg. number of drinks)

Daily
3-4 times wk
1-2 times wk
1-3 times mo
> 1 mo
Total
FSM
Males
14
15
12
14
10
13
Females
6
15
7
9
5
8
Total
13
15
11
13
9
12
Pohnpei
Males
9
11
9
13
8
10
Females
5
11
8
9
4
6
Total
8
11
8
13
7
9
Kosrae
Males
14
20
10
9
9
9
Females
0
0
0
0
0
0
Total
14
20
10
9
9
9
Chuuk
Males
18
17
15
16
14
16
Females
0
20
9
11
0
13
Total
18
17
15
16
14
16
Yap
Males
21
16
13
11
9
13
Females
15
16
9
9
6
9
Total
21
16
11
10
8
12

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

Problem Drinkers

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

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

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

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

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

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


Table 2.13: "Problem Drinkers" (15+ yrs)
(Number and percentage of total sample)

Males
Females
Total
N
%
N
%
N
%
Total FSM
793
35.6
55
2.6
848
19.4
Pohnpei
272
35.0
30
4.0
302
19.3
Kosrae
31
20.8
0
0
31
9.9
Chuuk
387
37.6
5
0.5
392
20.0
Yap
103
37.6
20
7.1
123
22.2

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

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


Table 2.14: Estimated Numbers of Drinkers and Problem Drinkers

Drinkers
Problem Drinkers
Male
Female
Total
Male
Female
Total
FSM
16,290
2,525
18,815

10,607

701
11,308
Pohnpei
6,146
1,408
7,554

3,474

371
3,845
Kosrae
797
33
830

480

0
480
Chuuk
7,287
160
7,447

5,437

80
5,517
Yap
2,060
924
2,984

1,216

250
1,466

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

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

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

Treatment

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

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

Epilogue: Comparative Measures of Alcohol Consumption

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

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

Yap 4.5
Pohnpei 3.4
Chuuk 4.5
Kosrae 1.0

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

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


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.


Chapter 3: MARIJUANA

The Cultural Context

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 of the states 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).

In the absence of any specific information about the other states, we may presume that the spread of marijuana use in Yap and Pohnpei followed similar lines. Wood (1991:46) relates that police in Pohnpei seized over 2,000 marijuana plants with a total street value of over $1 million in a single year (1988). This figure serves to indicate how widespread marijuana use there was at the time. Kosrae seems to have been slow in developing a local marijuana industry, thanks to strong church sanctions against the drug, but marijuana is reportedly now grown for local consumption in one part of the island.

Cultural Background

Marijuana, like other drugs, is used socially in Micronesia. What Larson reported witnessing in Chuuk during the early 1980s would seem to be equally applicable to other states:

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 FSM (15+ years), as seen in Table 3.1, is 8.1%.

A comparison of male and female prevalence rates reveals that marijuana use is even more gender-linked than alcohol use. The rate for FSM males is 15.1%, while the female rate is only 0.8%. The data indicate that marijuana use, which follows the pattern of other drug use in that it was sanctioned for males but not females, does not yet show even the slightly broader gender distribution that alcohol has gained.


Table 3.1: Persons who Smoked Marijuana within Past 12 Months (15 + yrs): General Characteristics
(Number of current users and percentage of sample)

Males
Females
Total
N
%
N
%
N
%
FSM
337
15.1
16
0.8
353
8.1
Pohnpei
118
15.3
13
1.8
131
8.9
Kosrae
23
15.4
0
0
23
7.4
Chuuk
177
17.2
2
0.2
179
9.1
Yap
19
6.9
1
0.4
20
3.6
Marital Status
single
202
19.8
9
1.1
211
11.3
married
126
11.4
5
0.5
131
6.0
divorced
9
24.3
2
4.4
11
13.4
widowed
0
0
0
0
0
0
Employment Status
salary job
92
30.6
2
0.3
94
9.1
unemployed
245
16.8
14
0.8
259
8.0
student
37
11.4
3
0.8
40
5.8
Ethnicity
Micronesian
334
15.1
16
0.8
350
8.1
Asian
0
0
0
0
0
0
US/Australian
0
0
0
0
0
0
Other Pacific
2
6.7
0
0
2
6.7
Residence
town
50
12.9
9
2.2
59
7.4
village
263
19.2
7
0.6
270
10.2
outer-islands
24
6.1
0
0
24
3.0


Table 3.2: Persons who Used Marijuana within Past 12 Months by Age Group
(As percentage of sample)
<10
10-14
15-19
20-29
30-44
45-64
65+

Total (15 +)

FSM
Males
0
1.9
14.4
22.4
16.8
3.3
1.0
15.1
Females
0
0.3
0.9
1.0
1.0
0
0
0.8
Total
0
1.1
7.7
12.1
9.2
1.6
0.5
8.1
Pohnpei
Males
0
2.1
11.6
19.2
20.4
7.2
0
15.3
Females
0
0.7
1.2
2.8
2.2
0
0
1.8
Total
0
1.4
6.6
11.6
11.0
3.6
0
8.9
Kosrae
Males
0
0
0
15.6
32.6
3.8
7.1
15.4
Females
0
0
0
0
0
0
0
0
Total
0
0
0
6.7
18.4
1.9
4.5
7.4
Chuuk
Males
0
2.9
19.8
27.1
15.6
1.7
0
17.2
Females
0
0
1.1
0
0
0
0
0.2
Total
0
1.6
10.7
14.6
8.6
0.8
0
9.1
Yap
Males
0
0
9.3
15.4
4.5
0
0
6.9
Females
0
0
0
0
1.1
0
0
0.4
Total
0
0
4.6
7.2
2.7
0
0
3.6

The prevalence rates discovered in this study were lower than the rates reported from previous surveys. In her 1980 survey of Micronesian college students on Pohnpei, Palau and Saipan, Edman (1980) found that 34% of all students interviewed were using marijuana, at least on an occasional basis. Her survey offered no breakdown by sex and no information on quantity or frequency of use.

The survey of FSM school children undertaken by the FSM Substance Abuse and Mental Health Office in 1993 recorded a 30-day prevalence rate of 20% for boys and girls aged 12-18 with no breakdown by sex (Reed 1993). This is much higher than the 7.7% rate that we found for the 15-19 age group in FSM, the closest comparable cohort (see Table 3.2). Even the male 15-19 rate for Chuuk, the state in which the highest rates were found in this survey, is slightly below the figure reported by the 1993 survey.

Marshall's 1985 survey of the Chuuk population shows a current use rate of 26% among males and 0.6% for females over the age of 15 (Marshall 1991:339). The figures for the over-15 Chuuk population in this present survey are considerably lower than Marshall's: 17.2% for males and 0.2% for females.

General Characteristics

Age. Marijuana tends to be a younger man's drug, even more so than alcohol, as Table 3.2 shows in its breakdown of prevalence for different age groups. FSM rates by age form a pyramid with its apex in the 20-29 age group where the general rate rises to 12.1%. According to the survey data, a very small percentage of the 10-14 age group begin using marijuana, but the number of users grows greatly during the late teens and peaks during the 20s. The rate falls off for the 30-44 age group and drops even more sharply for the 45-64 age cohort. All the states show the same pattern except for Kosrae, where marijuana use peaks in the 30-44 age cohort and is generally greater among the older age groups than is the case in other states.

Marital Status. As Table 3.1 indicates, single persons (11%) show a significantly higher percentage of marijuana use than married persons (6%). This may be due to the fact that marijuana use, much more than alcohol use, tends to be concentrated among the young, many of whom are still unmarried. The higher rates among single persons are verified in Table 3.3, which corrects for any age bias by examining only those within the relatively young age range of 20-44. The use rate for the unmarried within this age range is 15%, well above the 8% recorded for married persons. The difference in rates between the single and the married is significant in every state but Kosrae, as Table 3.3 shows.


Table 3.3: Current Users of Marijuana (aged 20-44) by Marital Status
(Percentage of sample)
Males
Females
Total
N
%
N
%
N
%
FSM
single
138
24.2
5
1.2
143
14.7
married
113
16.2
5
0.7
118
8.1
Pohnpei
single
36
24.5
5
4.7
41
16.2
married
49
17.4
4
1.3
53
9.0
Kosrae
single
9
22
0
0
9
11.7
married
11
24
0
0
11
10.8
Chuuk
single
86
25.7
0
0
86
15.5
married
47
17.2
0
0
47
8.5
Yap
single
7
14.3
0
0
7
7.9
married
6
6.1
1
0.9
7
3.3

Employment. The current use rate among males with wage employment (31%) is nearly double the rate among the unemployed (17%), although for female users the gap is reversed. There is very little difference between the rates of employed and unemployed for both sexes, however.

Educational Status. The rate of marijuana use among students (15+ yrs), as shown in Table 3.1, is about 6%. This is lower than the 8% rate for the general population. Table 3.4, which focuses on comparative marijuana use rates among the school-age population, 10-19, offers a sharper look at the contrast between the drug use of in-school and out-of-school youth. Marijuana use, like alcohol use, is strongly correlated with educational status. The prevalence rate for out-of-school youth in that age group is 11.5%, nearly four times the rate of marijuana use among those who are still in school. Everywhere in FSM the rate of those not in school is three or four times higher than that of students.


Table 3.4: Current Users of Marijuana (aged 10-19) by Educational Status

Males
Females
Total
N
%
N
%
N
%
FSM
in-school
28
5.4
3
0.6
31
2.9
out of school
44
18.8
2
1.2
46
11.5
Pohnpei
in-school
6
3.9
2
1.2
8
2.5
out of school
17
17.0
1
1.2
18
9.6
Kosrae
in-school
0
0
0
0
0
0
out of school
0
0
0
0
0
0
Chuuk
in-school
19
7.6
1
0.4
20
3.9
out of school
25
21.0
1
1.5
26
14.0
Yap
in-school
3
2.7
0
0
3
1.4
out of school
2
13.3
0
0
2
7.4

Ethnicity. The survey sample showed very little marijuana use among non-Micronesian ethnic communities in FSM. Two Pacific islanders from outside FSM were the only other users found. In Pohnpei, the breakdown for marijuana use along ethnic lines paralleled what has been noted for alcohol use. Ngatikese (28%) and Kosraeans (12%) had much higher rates than ethnic Pohnpeians (8%), while Mokilese (6%) showed a lower rate. In Yap, however, where Yapese and Outer Islanders show very similar alcohol use rates, a far different picture emerges for marijuana use. While ethnic Yapese had a rate of over 3%, none of the Outer Islanders in the survey sample were current users of marijuana.

Residence. The highest marijuana use rate was found in rural villages, where the general prevalence rate was over 10% and the male rate was 19%. By comparison, the towns had an overall rate of 7% and a male rate of 13%. The lowest rates were recorded in the outer islands, which registered a general rate of 3% and a male rate of 6%. That the outer islands, where marijuana can not be grown nor easily imported, should have a low use rate is not surprising. One might expect that the towns would show a higher rate than they do in this survey, however. Yet, rural villages seem to be where most of the locally grown marijuana is cultivated just as they offer the seclusion that many young smokers seek.

Other drugs. Marijuana use is closely correlated with alcohol use everywhere in the FSM. Marshall (1991:252-253) cites Oneisom (1991) and Larson (1987) in support of his own findings that drug use in Micronesia is additive rather than substitutive. This assertion is confirmed by our survey, which found that 94% of all current marijuana users (339 of 362 identified in the survey) also drank alcohol.


Breakdown by states

Pohnpei. The overall rate of marijuana use is comparable with the rates for the other states in FSM. The female rate on Pohnpei is higher than anywhere else in FSM; Pohnpei is the only state with a female rate of higher than 1%. Although Pohnpei generally follows the FSM pattern for use rates by age groupings, the base of the curve is much broader than in other places. The male rate for the 30-44 age group actually exceeds the rate for the 20-29 group on Pohnpei, and the use rate among the 45-64 group is higher than anywhere else in FSM.

Kosrae. The very young in Kosrae apparently do not use marijuana, just as they do not drink alcohol. Marijuana use begins later, with the 20-29 age group, and reaches a high of 32.6% for the 30-44 group. Kosrae is the only state in which marijuana use is recorded for the 65+ age group. No female users were found in the survey, in keeping with the reputation of the state for exercising strong controls over the behavior of its women.

Chuuk. This state shows the highest use rate in the nation. Marijuana use, like alcohol use, is more tightly clustered by age group in Chuuk than it is in other states. Use rates ascend sharply during the late teens, rise to a high in the 20-29 age group, and then fall off quickly for the 30-44 group. Chuukese society seems to sanction pecadillos like drinking and smoking marijuana during younger years, but this behavior seems to be less acceptable during the years of supposed maturity.

Yap. At 3.6% the overall marijuana use rate inYap is significantly lower than that of the other states and less than half the national use rate of 8.1%. The low rate for Yap is especially surprising in view of the high alcohol rate there, especially among women and older persons. The survey data show that marijuana use appears to be confined to the young adult age groups (15-44) and then disappears entirely. Perhaps the widespread use of betelnut, a stimulant, makes marijuana less desirable. In contrast with relatively high female alcohol use rates, Yap shows a very low rate of female marijuana use (0.4%) that is half the national rate for women.

Consumption Patterns

Table 3.5, which shows the frequency of marijuana consumption by current users, indicates that half of the males (who comprise 95% of all users) smoke daily. Chuuk has the largest percentage of daily male smokers (56%), followed by Pohnpei (48%). The percentage of daily smokers in Kosrae and Yap is only half as great (26%), with most of the male users in these two states smoking a few times a week. Chuuk, the state with the highest frequency of use, shows that almost three-quarters (73%) of all marijuana smokers there use the drug every day or every other day.

Females were more occasional users than men. As Table 3.5 indicates, only slightly more than one-third of all women using the drug smoked several times a week, while most smoked much less frequently.

This survey indicates that Chuuk reports high consumption levels to match its high frequency levels, for nearly two-thirds of Chuukese marijuana users (63%) smoke four or more cigarettes a day (see Table 3.6). The average number of joints smoked a day in Chuuk over the past 12 months was 4.2, compared with the FSM-wide average of 3.5 daily. This differs markedly from the consumption pattern recorded for Pohnpei and Yap, where 75% of all users smoked 1-3 marijuana cigarettes on any day that they used marijuana. The average daily number of marijuana cigarettes smoked in Pohnpei and Yap were 2.8 and 2.3 respectively. Kosrae showed a higher level of consumption than Pohnpei and Yap, but lower than Chuuk; 74% of its users smoked 2-4 cigarettes a day with an average of 3.1 daily.

When the frequency data from the survey are computed against the average daily usage reported, we can easily derive the total amount of marijuana consumed in a year and the amount consumed by the average marijuana user in the same period of time. This latter figure may be a better index of the relative usage in each state. Using frequency and consumption data from the survey, then, we calculated the average number of marijuana cigarettes that a user smokes in a year as follows:

Pohnpei 505
Chuuk 860
Kosrae 460
Yap 355

Chuuk, which has a slightly higher prevalence rate than the FSM average, has a much higher yearly consumption rate per user than the other states. At the other end of the scale is Yap, which also shows a prevalence rate considerably lower than the other states.


Table 3.5: Frequency of Marijuana Consumption by Current Users
(Percentage, with rows totaling 100%)

Daily
3-4 times wk
1-2 times wk
1-3 times mo

less than monthly

FSM
Males
50.0
16.5
16.5
13.0
3.8
Females
17.7
17.6
23.5
23.5
17.6
Total
48.1
16.6
16.9
13.5
4.4
Pohnpei
Males
47.9
10.7
26.4
10.0
3.3
Females
14.3
14.3
28.6
21.4
21.4
Total
44.0
11.1
26.7
11.1
5.2
Kosrae
Males
26.1
26.1
39.1
8.7
0
Females
0
0
0
0
0
Total
26.1
26.1
39.1
8.7
0
Chuuk
Males
56.0
17.0
7.1
15.4
4.4
Females
50.0
0
0
50.0
0
Total
56.0
16.8
7.1
15.8
4.3
Yap
Males
26.3
36.8
15.8
15.8
5.3
Females
0
100
0
0
0
Total
25.0
40.0
15.0
15.0
5.0



Table 3.6: Usual Number of Marijuana Cigarettes Consumed per Day and Average Cigarettes Smoked Daily
(Percentage, with rows totaling 100%; daily average of marijuana cigarettes smoked in last column)

1
2
3
4
5
6 +

(Daily Avg)

FSM
Males
17
25
11
12
17
17
3.6
Females
65
18
6
12
0
0
1.7
Total
19
24
11
12
16
17
3.5
Pohnpei
Males
27
35
11
8
8
9
2.9
Females
79
7
7
7
0
0
1.4
Total
33
32
10
8
7
8
2.8
Kosrae
Males
9
30
22
22
17
0
3.1
Females
0
0
0
0
0
0
0
Total
9
30
22
22
17
0
3.1
Chuuk
Males
10
18
9
15
21
27
4.2
Females
0
50
0
50
0
0
3.0
Total
10
18
9
15
21
27
4.2
Yap
Males
26
21
26
0
26
0
2.3
Females
0
100
0
0
0
0
2.0
Total
25
25
25
0
25
0
2.3

Note: Average is based on marijuana cigarettes smoked only on those days that marijuana was used.


If the consumption figures reported in the survey are taken at face value, the 353 current marijuana users in FSM smoked approximately 250,000 marijuana cigarettes during the past year. By using the figures on total current marijuana users in the FSM general population (Table 3.7), we can estimate the amount of marijuana smoked last year throughout the nation-860,000 cigarettes in Pohnpei, 175,000 in Kosrae, 2,200,000 in Chuuk, and 120,000 in Yap. Of the total estimated 3,350,000 marijuana cigarettes smoked during the year in FSM, two-thirds were smoked in Chuuk.

Total Estimated Marijuana Use

When the survey sample is adjusted for age to yield a representative sample, the number of current marijuana smokers can be estimated. For the entire nation the number of marijuana users can be estimated at just below 5,000, as Table 3.7 shows; only about 200 of these are female, all the rest are males. More than half of them are from Chuuk State; the smaller states of Yap and Kosrae have only about 330 each.


Table 3.7: Estimated Number of Current Marijuana Users

Male
Female
Total
FSM
4731
217
4948
Pohnpei
1529
175
1704
Kosrae
338
0
338
Chuuk
2543
31
2574
Yap
321
11
332

Lifetime Prevalence

Lifetime prevalence data, which was sought for all types of drugs, was found to be much more robust for marijuana than for alcohol use. A comparison of lifetime use of marijuana with current use is presented in Table 3.8, which shows a significant difference between the two in some of the states. This is not remarkable of itself, for users of marijuana often outgrow the habit, as we have seen in our discussion of the prevalence rates for the various age groups. Hence, the difference between lifetime and current rates for older age groups might simply indicate that a certain number of individuals who had been regular marijuana smokers in their 20s dropped the habit in their later years.

Of greater interest, however, is the difference between lifetime and current use recorded for the lower age groups in some states, a difference that is especially large in Pohnpei and Yap. This difference implies that some of those who had been smokers just a few years earlier gave up marijuana. One user out of 15 from the FSM 15-19 age group, representing 7% of the total, dropped marijuana, and ten percent of the lifetime users from the next age group (20-29) quit smoking. The decline of 28% in the 30-44 age group, although much greater than the younger groups, could be attributed to the fact that people who used marijuana when they were younger simply gave it up as they matured.


Table 3.8: Current & Lifetime Users of Marijuana, by Select Age Group,
with Number and Percentage of Those Who Have Given Up Marijuana

15-19
20-29
30-44
45-64
FSM
lifetime users
83
187
158
20
current users
68
159
113
12
difference
15
28
45
8
diff as % of lifetime users
18.1%
15.0%
28.5%
40%
Pohnpei
lifetime users
34
70
77
13
current users
22
53
48
8
difference
12
17
29
5
diff as % of lifetime users
35.3%
24.3%
37.7%
38.5%
Kosrae
lifetime users
0
9
14
1
current users
0
7
14
1
difference
0
2
0
0
diff as % of lifetime users
0%
22.2%
0%
0%
Chuuk
lifetime users
44
94
57
5
current users
41
89
46
3
difference
3
5
11
2
diff as % of lifetime users
6.8%
5.3%
19.3%
40%
Yap
lifetime users
5
14
10
1
current users
5
10
5
0
difference
0
4
5
1
diff as % of lifetime users
0%
28.6%
50%
100%

Survey data on the younger age groups, particularly from Pohnpei, suggest that a number of young marijuana users are choosing to give up the habit while they are still well within the ordinary age range for smoking. The figures from Pohnpei show that one-third (33%) of the lifetime users in the 15-19 male cohort (30) were not smoking marijuana over the past year. The drop in use is also significant in the two next older age cohorts. Only 53 of 70 of the lifetime users in the 20-29 cohort have smoked in the last year; thus, 25% appear to have stopped smoking. Of the 77 lifetime users in the 30-44 cohort, 29 have dropped the drug. This age cohort shows a 38% fall off in the use of marijuana.

The conclusion may be drawn that dropping the drug does not simply occur as a function of age, with young people outgrowing the use of marijuana, for a significant number of males drop marijuana at an age when they still might be expected to smoke the drug. This is a finding that has a great bearing on treatment strategies, since it would seem that an appreciable number of young people give up the drug without recourse to formal treatment. Reasons for this are not clear from the survey, but other informal interviews and reports suggest that some of the young smokers do not like the effects that the drug has on them, especially the paranoia and social withdrawal that many young people speak of. If so, those who have voluntarily given up marijuana might be prompted to share their experiences with at-risk youth or actual users in an educational campaign to decrease the use of the drug.


Chapter 4: INHALANTS

The Cultural Context

The use of inhalants does not seem to be very widespread in the FSM and there are very few references to it in the drug literature on Micronesia.

The practice seems to be more common in Chuuk than in other places, although there is evidence from the present survey that it was also carried on to some extent in Pohnpei. During his 25 years in Chuuk, the author occasionally heard stories of young boys sniffing gas or paint thinner to produce a "high." Marshall (1991:351) writes that "during the summer of 1985, on Moen (Weno), I was told of boys as young as nine or 10 sniffing gasoline." Some of the heaviest users seem to have suffered brain damage as a result of their excesses, if one is believe the stories that are told of them. Not infrequently, one would encounter an elementary school drop-out who exhibited strange or even deviant behavior that was attributed to gas sniffing. Rubinstein (1980:10) tells of a troubled young man in his early twenties who had begun sniffing gasoline before the age of 12 and who might have suffered brain damage as a result.

Glue sniffing is another form of inhalant use seen in Chuuk and Pohnpei. During his fieldwork in Chuuk during the early 1980s, Larson (1987:229) noticed that glue sniffing was becoming more popular among young adolescents in Chuuk. Other expatriates on Pohnpei have made similar remarks. One young Peace Corps teacher in a rural village on Pohnpei noted that Crazy Glue was sold in nearly all the village stores and that he has had to take tubes away from his students at times.

The use of inhalants, although not very widespread, is the first rung on the drug ladder for some Micronesians. Young boys may begin sniffing in their early teens but usually stop well before they reach the age of 20, usually moving on to marijuana smoking and then alcohol. An added cause of concern is the well documented 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 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 will not be disturbed by adults. Even if the boy goes with a friend, almost no social interaction at all takes place while the two are sniffing.

Survey Data on Inhalants

The survey data showed inhalant use only on Pohnpei and Chuuk; no indication of use was found on Kosrae or Yap. Even when informants in these two states were asked to double-check the survey forms for inhalant use, they could come up with no instances of gas or glue sniffing.

The survey found only 12 people currently using inhalants, 10 from Chuuk and two from Pohnpei.

The number of those who once used inhalants but have not done so during the year prior to the survey was considerably larger than the number of current users. Nine people from Pohnpei and 72 from Chuuk were reported to have sniffed gas or some other substance at some time in their life.

A caution is in order here. Sniffing may be underreported in this survey, despite the vigilance of the field investigator in insuring that informants carefully record all cases of this in their data sheets, because of the limitations of this type of survey and the atypical nature of this kind of drug use. Sniffing, far more than any other type of drug use in FSM, is a "hidden vice;" boys characteristically sneak off and sniff the substance alone and out of sight of others. This and the fact that it is normally practiced for a limited time, in late childhood or early adolescence, before it is dropped (and often forgotten) make it much more difficult to detect in a key informant survey such as this.

Current Prevalence Rate by Sex and Age

Of the 12 current inhalant users reported in the survey, all but one were males. Hence, the familiar sex-linked pattern of drug use found for alcohol and marijuana, with males using drugs and females generally abstaining, is also seen here. This pattern is confirmed in the survey data on lifetime prevalence that will be presented below.

Use of inhalants is tightly circumscribed with respect to age, with the great majority of the users (83%) falling in the 10-19 age cohort.

Data for Chuuk, the only state recording a significant number of current users, shows a prevalence rate of 2.9% for males aged 10-14, and 1.5% for males aged 15-19. The male prevalence rate for the combined age groups is 2.2%

The figures for inhalant use recorded in this survey are low in comparison with those derived from other drug surveys. In a 1985 survey conducted of 852 students at the 4th to 12th grade levels-that is, between the ages of 10 and 20-in several schools on Weno, Chuuk, 9.9% of the total sample claimed that they had sniffed gas or some other substance at some time in their life (Marshall et al. 1994). Unfortunately, the study offered no breakdown by sex. The results of this survey are similar to one conducted on Saipan of junior and senior high school students in 1987; 9% of those surveyed had used inhalants (Lord 1987). Oneisom (1991) reports that 5% of the 121 persons he interviewed in a convenience sample in Chuuk in 1985 claimed to have tried

sniffing at least once. It should be noted, however, that all of the above studies measured the lifetime prevalence rather than the point prevalence rate of inhalant use.


Table 4.1: Current Users of Inhalants by Sex and Age

10-14
15-19
20-29
30-44
Total (10 +)
N
%
N
%
N
%
N
%
N
%
Pohnpei
Males
0
0
1
0.6
0
0
1
0.6
2
0.2
Females
0
0
0
0
0
0
0
0
0
0
Total
0
0
1
0.3
0
0
1
0.3
2
0.1
Chuuk
Males
5
2.9
3
1.5
1
0.3
0
0
9
0.7
Females
0
0
1
0.5
0
0
0
0
1
0.1
Total
5
1.6
4
1.0
1
0.2
0
0
10
0.4

Table 4.2: Lifetime Users of Inhalants by Sex and Age

10-14
15-19
20-29
30-44
45-64
Total(10 +)
N
%
N
%
N
%
N
%
N
%
N
%
Pohnpei
Males
0
0
2
1.2
0
0
6
2.8
1
0.9
9
1.0
Females
0
0
0
0
0
0
0
0
0
0
0
0
Total
0
0
2
0.6
0
0
6
1.4
1
0.4
9
0.5
Chuuk
Males
6
3.5
15
7.6
18
5.5
25
8.5
6
3.4
70
5.8
Females
0
0
1
0.5
0
0
0
0
1
0.5
2
0.2
Total
6
1.9
16
4.2
18
2.9
25
4.6
7
1.9
72
3.1

Lifetime Prevalence Rates

The lifetime prevalence rates recorded in the survey may offer a more accurate measure of the extent of inhalant use in Pohnpei and Chuuk. The lifetime prevalence rates in Pohnpei for males of select age groups run from about 1% to nearly 3%, as Table 4.2 indicates. Those in Chuuk, which are much higher, range between 3% and nearly 9% for males. The lifetime prevalence rate for males, 10 years of age and older, in Pohnpei is 1%, while for Chuuk it is nearly 6%. The figure for Chuuk at least is comparable with other surveys done there during the 1980s.

Frequency of Use

As Table 4.3 shows, inhalants are not used as frequently as alcohol and marijuana. Most current users (73%) sniff one or twice a month or less frequently; only three users, or 27% of the sample, are reported to be sniffing as often as once a week.


Table 4.3: Frequency of Inhalant Use by Current Users

Daily
3-4 wk
1-2 wk
1-3 mo
>1 mo
Total
Males
0
0
2
5
3
10
Females
0
0
1
0
0
1
Total
0
0
3
5
3
11


Note: All current users, from Pohnpei and Chuuk, are included in this table.


Other Observations

Inhalant use would appear to be a real problem in Chuuk alone of all the states. Informants from Kosrae and Yap say that gas sniffing is a rare occurrence in these places. The absence of inhalant data in our survey on these places confirms this contention. Observers on Pohnpei report that in the past use of inhalants was probably greater than it is now. They explain the decrease as due to more pastimes for young boys on the island with the construction of basketball courts and the development of other recreational outlets. There is another, more ominous explanation that some offer for the decrease on Pohnpei-the tendency of boys to use alcohol at an increasingly younger age. The relatively high percentage of Pohnpeian drinkers among the 10-14 and 15-19 age groups noted in this survey would seem to support that explanation.


Chapter 5: HARD DRUGS

Background

"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 barbituates or tranquillizers, since there is nothing to suggest that these are used, or even known, in FSM.

Despite the well-publicized drug problems in Palau to the west and in Guam and the Commonwealth of the Northern Marianas in the north, FSM has always been perceived as having escaped the serious drug problems of its neighbors. From time to time one hears reports of an individual using a strange "white powder" or even injecting with needles, but these have always been isolated instances and the individuals in question have either been non-Micronesian visitors or Micronesian young men who have recently returned home after years of living abroad. There is nothing to suggest that these rumored drug users have been responsible for spreading the habit to others in their community. On the contrary, the speed with which such reports die out would seem to indicate that these individual users have either dropped their habit or left for another part of the world where they can procure drugs more easily and practice their drug habit in privacy-something that is not afforded them in Micronesian communities. Until recently there has been no report of any regular supply line for hard drugs from outside.

The only indication of a serious "hard drug" problem in FSM stems from a questionnaire administered in 1992 to over 6,000 FSM students between the ages of 12 and 18. The self-reported prevalence of drugs in this age group was surprisingly and perhaps improbably high: over 2% claimed to be using cocaine, 6% reported using injectible drugs, and nearly 5% said that they were taking steroids (Reed 1993).

Survey Data on Hard Drugs

The present survey picked up only one current user of hard drugs. He is a male living in Pohnpei, although not an ethnic Pohnpeian nor even Micronesian, who is reported to be using cocaine and heroin.

The lifetime users reported in the survey were three: two residents of Pohnpei (including the current user) and a young man from Chuuk. All three are males, one in his late teens and the other two in their mid-30s. All three once used heroin, with the two older persons using cocaine as well. In keeping with the finding that drug use in Micronesia is additive rather than substitutional, all three are also currently using alcohol and marijuana.

If such a slender data base may be used to project the current number of lifetime users in Pohnpei and Chuuk, there may be 15 males in Chuuk and 25 in Pohnpei who have used hard drugs at some time in their life. No users, current or lifetime, were picked up in either Kosrae or Yap.

While the survey data may accurately represent the scale of the problem in Pohnpei and Chuuk, and perhaps even in Kosrae with its strict community controls, there is some anecdotal evidence that the survey falls short of accurately representing the scope of the drug problem in Yap. A young man who died a violent death last year was found in the autopsy to have traces of "ice" in his system. Although informants would not identify anyone as a confirmed user of hard drugs, some suspect that several young men in Yap are currently using "ice." Estimates on the number of users range from four to "between 10 and 20." Yap, situated as it is between Palau and Guam, is the most natural gateway for hard drugs into FSM.

Even though the introduction of hard drugs into other parts of FSM must always be considered a real danger, this does not seem to have happened yet. Hence, drug prevention policy ought to ignore hard drugs for the time being and focus instead on alcohol and marijuana.


Chapter 6: PREVENTION AND TREATMENT

Review of Findings

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 such as "Second Chance" in Yap. 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.

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 no lasting impact on the islands, and probably never will, 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 not surprising that AA has had very limited success 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 Micronesia, 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 Micronesians' worldview than alcoholism-as-disease.

Over the years, some of the most successful abstinence-type programs in Micronesia have been church-run. The major denominations, Catholic and Protestant, have their own anti-alcohol and drug programs, as do most of the smaller sects. 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 the "Mwichen Asor," a Catholic group in Chuuk, 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 "Mwichen Asor," 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 mass 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 Mwichen Asor) 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 we sometimes have attempted to do in Micronesia.

DuPertuis may overstate the matter when she maintains that the churches are "the only institutions which take a stand against alcohol," but it is difficult to take exception to the rest of what she writes:

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 in a program like "Second Chance" in Yap. 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 targeted at the youth to keep them from drinking and other drug use, then they have met with utter failure, since the vast majority of 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 but a relatively few adherents, although they 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 used nearly everywhere in the state, were eliminated practically overnight in Chuuk 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 that exists in every state, but this role is in need of some redefinition. Thanks to the substantial SAMHSA block-grant funds that have poured into FSM over the past five or six years, the state offices have greatly expanded, hiring new employees and broadening the services that they offer the public. This expansion has been rapid and state programs have not always been as carefully designed as they might have been. Some states have hired on new personnel in an effort to set up an outreach program in remote islands and villages on the premise that their offices should attempt to reach into the very bowels of the communities.

As government substance abuse offices have grown and developed their own outreach programs, they are tempted to establish programs that parallel those of community organizations rather than complement them. Instead of calling on the local private organizations for help in implementing their substance abuse programs, the states sometimes devote their energies to maintaining their own programs. Hence, the state and church groups run the risk of becoming competitors at the grassroots level rather than partners. Serious thought should be given to cutting back the size of government offices in most states, if for no other reason than that this would oblige them to develop partnerships with local community and church groups at the village level.

The role of government agencies might well be reexamined. While the states should be encouraged to continue the direct treatment work that they now do from their offices, they should be relieved of the burden of having to provide outreach into distant communities. At the same time, they will have to expand their links with private groups to ensure that these communities are served. Notwithstanding the treatment the state offices do, their primary focus should probably be on prevention rather than treatment.

The role of 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.