(\.,rp )MNH/ICP / ADA/002
ENGLISH ONLY
REPORT WORKSHOP ON ALCOHOL AND DRUG-RELATED PROBLEMS IN MICRONESIA
CONVENED BY THE REGIONAL OFFICE FOR THE WESTERN PACIFIC OF THE WORLD HEALTH ORGANIZATIO~
KOROR, PALAU
I
5 - 9 JUNE 1989
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!. . f1 C1 1939 Not for sale Printed and distributed by the
Regional Office for the Western Pacific of the World Health Organization Manila, Philippines August 1989
NOTE
The views expressed in this report are those of the participants in the Workshop on Alcohol and Drug-Related Problems in Micronesia and do not necessarily reflect the policies of the World Health Organization.
This report has been prepared by the Regional Office for the Western Pacific of the World Health Organization for governments of Member States in the Region and for the participants in the Workshop on Alcohol and Drug-Related Problems in Micronesia held in Koror, Palau, from 5 to 9 June 1989.
CONTENTS
1. 2. 3.
INTRODUCTION .........•••.••....... , . • . . . . • . . . . . • . • . • . . • . • . • • • OBJECTI VES OF THE MEETI NG ••••.••••••••••••••••••••••••.•••••• SUMMARY OF COUNTRY PROFILES.................................. 3.1 High-risk groups....................................... Substances abused .•.•••.••..••••••••••...••.......•••••
1 2 2 3 4
3.2 3.3 3.4 4.
Changi ng en vi ronmen ts ••••••••••••.••••••••••••••••••••• Encouraging trends •.•••••••••••••••••••••••••••••••••••
4 4 5 5 6 8 9
INTERNATIONAL AND REGIONAL ACTIVITIES ••••••••••••••.••••••••• 4 •1 4.2 4.3 4.4 WHO •••••• ,. •.•.••••••••••••••.••••••••••••••••• " • • • • • • • • The role of the South Pacific Commission ••••••••••••••• United States Public Health Service •••••••••••••••••••• Alcoholic Liquor Advisory Council Report ••••••••••....•
5. 6.
FI'ELD VISITS................................................. SUMMARY OF SMALL GROUP DISCUSSIONS ••••••••..•••..••••••••••••
10 11
6.1 6.2 6.3 6.4 6.5
Prevention.............................................. Treatment and rehabilitation........................... Culture, religion and other social factors ••••••••••••• Development of national programmes..................... International and regional activities ••••••••••••••••.•
11 14 14 16 17
7.
CONCLUSIONS AND RECOMNENDATIONS ANNEXES ANNEX 1 -
., ............................ .
18
LIST OF PARTICIPANTS, TEMPORARY ADVISER, CONSULTANT, OBSERVERS AND SECRETARIAT ..•.•••••••••••••••••••.•••••••••• AGENDA. • • • • • • • • • . • • • • • • • • • • • • • • • • • • . • • • • • • • . • • .. • •
23 29
ANNEX 2 -
ANNEX 3 -
SUMMARY OF COUNTRY PROFILES •••••••••••••••••••••.
31
1.
INTRODUCTION
The Workshop on Alcohol and Drug-~elated Problems in Micronesia was held at the Grace Hotel, Koror, Palau, from 5 to 9 June 1989. This was the first workshop on alcohol and drug-related problems organized by the World Health Organization in Micronesia. Dr N. Shinfuku, Regional Adviser in Mental Health and Drug Dependence, opened the meeting on behalf of Dr S.T. Han, Regional Director of the Regional Office for the Western Pacific of the World Health Organization. In his opening speech, the Regional Director expressed his sincere gratitude to the Government of the Republic of Palau for agreeing to host the workshop. His Excellency the President, Mr Ngiratkel Etpison, honoured the opening ceremony through his attendance and welcomed the participants representing the host country. The workshop was attended by eleven participants from six countries or areas of the Region, namely, Guam, Republic of the Marshall Islands, Federated States of Micronesia, Nauru, Commonwealth of the Northern Mariana Islands and Republic of Palau. One consultant, Dr Robert B. Fisher, United States of America and one temporary adviser, Mr Keith Evans, New Zealand provided support in the preparation and conduct of the meeting. Dr K. Zimmern, Office of the Secretary, Human Resources, Federated States of Micronesia; Mr Michael Davis, Programme Consultant, United States Public Health Service of Region IX; and Mr David B. Rosario, Health Education Specialist, South Pacific Commission, attended the workshop as observers representing their organizations. A list of participants, temporary adviser, consultant, observers and secretariat is given in Annex 1. Dr Anthony Polloi, Chief, Public Health/Mental Health, Republic of Palau, acted as Chairman, Ms Rosa Palacios, Commonwealth of the Northern Mariana Islands, Vice-Chairman. Mr Robert Borger, Guam, and Ms Glorina Harris, Republic of the Marshall Islands, contributed as Rapporteurs of the workshop.
- 2 2. OBJECTIVES OF THE MEETING
The specific objectives of the workshop were: (1)
to assess the nature and trend of alcohol and drug-related problems in Micronesian countries and areas; to review eXisting national health policies and programmes for the prevention and control of these problems; to formulate guidelines to develop more effective national health policies and programmes for the prevention and control of alcohol and drug-related problems; and to discuss possible collaborative activities between countries and areas in Micronesia for the prevention and control of alcohol and drug-related problems.
(2) (3)
(4)
3.
SUMMARY OF COUNTRY PROFILES
The representative(s) of each country presented reports on the nature and level of alcohol and drug-related problems within their communities. Where possible, data were produced to help support the need for resource allocations to be increased. Each participant described the trend of the increasing availability of alcohol, tobacco, marijuana and certain other drugs, with an increase in the prevalence of the problems associated with consumption. This section of the report will examine the common themes running through each of the presentations made. It became clear at an early stage that similar patterns of alcohol and drug abuse exist right across Micronesia. Also, it is clear that there is a tremendous degree of enthusiasm and energy on the part of health, legal, police and social agencies to tackle the problems. This section will be written under the following headings: 3.1 High-risk groups
Those individuals who are most likely to develop problems, and the nature of the problems they face. 3.2 Substances abused A breakdown of the types of drugs used across Micronesia.
- 3 3.3 Changing environments
The ways in which changes occurring within the Micronesian environment are affecting the problems. 3.4 Encouraging trends
Those positive things that are happening and their need to be reinforced and supported. Public health approach: It is worth noting at this point that it was agreed that the public health perspective was a useful way to approach the issue of alcohol and drug abuse. This involves examining the issue from the perspectives of the host (consumer), agents (alcohol/drug) and the environment (situational variables). This will present a clearer picture as to the scope and nature of the problems faced, so that comprehensive programmes may be developed to address them.
3.1
High-risk groups
It is clear from all participants that the males in Micronesia are at the highest risk for developing alcohol and drug-related problems. While women are beginning to show up in the statistics of alcohol and drug-related problems, they are usually considerably outnumbered by men. It was agreed that young men aged 15-35 appear to be most at risk. These are the people injuring themselves and others, taking up the time of the emergency services, causing family and social disruption. They have poor health status. They indulge in violent behaviour, damage property and create social discord. This group of men has a high accident rate. They use their money to purchase alcohol and/or drugs and tend not to spend it on essentials such as food and clothing. They perform poorly at work and neglect their social and personal responsibilities. They are said to be poorly nourished. Suicide rates are high amongst this group. These men usually have a poor self-image and lack the se1fdetermination to solve their problems without alcohol and other drugs. These men are a priority and they require a large amount of support and human resources that are often simply not available. 3.2 Substances abused
By far the most commonly used and abused drug in Micronesia is alcohol, in the form of beer. However, there is also a rapid rise in the use of other forms of alcohol and certain other drugs.
Imported beer continues to increase, now augmented by the importation of hard liquor in the form of high alcohol content rum, whiskey, vodka, etc. It is noted that young people tend to drink hard
- 4 -
liquor to get "high" and beer to maintain the "high". Wine coolers are increasingly popular particularly amongst the young. These products tend to be aimed also at young women who are seen as a growing market. Tobacco use is a major problem that many mentioned alongside alcohol, although this workshop will generally not focus on tobacco use. Marijuana use fluctuates but continues to be popular across Micronesia. Hard drug use (e.g. heroin) appears to be dropping off at this time, although trafficking in hard drugs clearly still occurs in the various jurisdictions. Some solvent abuse is occuring also. Kava and Betel nut problems were also mentioned as issues of some concern. 3.3 Changing environments
It is clear that within Micronesia, there tends to be a permissive attitude towards alcohol use and abuse. There is stronger disapproval of the use of other drugs. It is felt that the environments generally encourage experimentation. The laws that exist tend not to be observed strictly enough, either by the law enforcement agencies, the suppliers, or the family. It is agreed that given the small size of the communities, it is sometimes very difficult to take a personal stand as the person you are accusing is very likely a member of your family or clan. The availability of alcohol is encouraged as profit is the main concern, with public health a distant second. The increasing promotion of alcohol by distributors, including advertising aimed at the young and women, is seen as a particular problem. High unemployment, poor educational attainment and cultural constraints are seen as significant environmental variables which contribute towards the increasing number of alcohol and drug users. Insufficient awareness by Government of the substantial costs incurred by alcohol and other drugs continues to be a problem across Hicronesia. 3.4 Encouraging trends
It is clear that increasing numbers of Micronesians are prepared to express concern and commit themselves to doing something to reduce the misery inflicted by alcohol and drug abuse. Health care workers, justice and police personnel, educators, churches, women's groups, youth organizations and other NGOs are at the forefront of moves to place alcohol and drug issues high on the national political agenda. People are increasingly prepared to put public health pressure on opinion formers and leaders to consider the health implications of these products. New initiatives by young people who show their concern are particularly welcome. As the generation most at risk they have most to lose if things do not change and most to gain if they do change.
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Ivomen are at the forefront of action to reduce problems. As mothers, as wives and as respected community leaders, they should be encouraged to continue their strong efforts to influence community attitudes and standards. The mobilization of all parents on behalf of the generations yet to come is vitally important also. The group felt that there were many positive developments. The meeting was proof of the commitment. The need to support each other in the future was seen as of critical importance.
4.
INTERNATIONAL AND REGIONAL ACTIVITIES
4.1
WHO
Since its inception in 1946, WHO has been actively involved with programmes related to mental health as mandated by its famous definition of health which says "Health is the state of physical, mental and social well-being and not merely the lack of disease or infirmity". In the Western Pacific Region where WHO collaborates with 24-member states, the programmes for the prevention and control of alcohol-related problems started only in 1980. The Regional Working Group on AlcoholRelated Problems held in Tokyo in 1980 defined the scope of the WHO Alcohol Programme which is wide enough to include various public health and social consequences of alcohol abuse such as drunk driving, violence, accidents, and family disruption as well as alcoholism. Technical discussions on Alcohol-Related Problems held at the World Health Assembly in Geneva in 1982 drew the attention of Member States to the magnitude and the seriousness of alcohol problems within both the developed and developing worlds. Based on the resolution adopted at the Regional Committee in Manila in 1982, that "Alcohol as a major public health problem", a series of activities were undertaken to reduce the emerging alcohol problems in the Region. The main thrust of the regional alcohol programme has been to collaborate with Member States to formulate and strengthen comprehensive national policy and programmes for the prevention and control of alcohol related problems. The Regional Office organized three successful workshops on alcohol in Manila in 1983, Auckland in 1984 and Yokohama in 1987. In addition, WHO has collaborated with the South Pacific Commission to organize the SPC/WHO Joint Pacific Conference on Alcohol-Related Problems in Noumea, New Caledonia in 1985.
- 6 These regional level activities stimulated activities at the country level and many Member States organized national workshops to reduce alcohol problems, e.g. in Papua New Guinea and Fiji. WHO's activities on alcohol abuse cover the organization of training programmes such as workshops, the recruitment of short-term consultants and the provision of educational materials. In the countries/areas of Micronesia, a series of consultancy services were provided during 1982 to 1989, e.g. Dr D. Hawk to Guam in 1983, Dr T. Hemi to the Republic of Palau in 1984, Dr R. Fisher to the Marshall Islands in 1986, Mr K. Evans to the Republic of Palau in 1987, Dr R. Fisher to the Federated States of Micronesia and to the Northern Mariana Islands in 1988 and Dr L. Wilson to the Northern Hariana Islands in 1989. These consultancy services have greatly influenced the promotion of national programmes for the prevention and control of alcohol and drug abuse. The programmes related to the prevention of drug abuse have stimulated a series of activities, mainly in Malaysia, the Philippines and Singapore where there are long and continuous histories of heroin abuse. However, the upsurge of heroin addiction in the Republic of Palau in 1987 drew the attention of international organizations to the need to develop effective prevention programmes for drug abuse in Micronesia. 4.2 The role of the South Pacific Commission
The South Pacific Commission is an international development agency established in 1947 which is made up of 22 Pacific island countries and five metropolitan countries. All contribute to the financial support of the Commission and determine its overall policies. The SPC is dedicated to improving the health of Pacific islanders, through prevention and primary health care on a community level, using a multi-sectoral approach. SPC provides expertise in the following health areas, which form the essential components of primary health care: health education nutrition environmental health, including water supply and sanitation disease surveillance and control oral health
- 7 The SPC health programmes respond to official requests from the 22 island Member countries to assist governments in strengthening their health and development programmes. The abuse of alcohol is a worldwide problem. It has also become a matter of growing concern in all Pacific Island countries, especially since most of them gained independence in the past few decades. Alcohol is no longer the drink of a few privileged people. Unfortunately, not everybody has learned to handle it. Alco~ol is a cause of much strife and misery, leading to crime and the break-up of otherwise happy families, to name only a couple of problems. It is true that alcohol has never played a significant historical role in the customs and traditional life of Pacific islands. However the impact of foreign cultural values, the imitation of Western lifestyles and the exposure to advertising through the mass media have made alcohol drinking a very popular and widespread pastime for increasing numbers of island people. "ALCOHOL or UFE", a slide tape show was produced with the primary objectives of helping people, particularly the young, learn that alcohol is a drug and that its abuse has disastrous mental, physical and social effects. The programme is divided into three parts: (1) (2) (3) can: (a) (b) (c) (d) collect alcohol and drug-related statistics and assist governments in improving their routine data collection; assist member countries in conducting surveys relating to drug and alcohol abuse; assist in developing the alcohol and drug component of health education curricula for primary and secondary schools; assist in designing and producing alcohol and drug education materials (video tapes, print materials, etc.) for regional use or specific use by a country; and What is alcohol and how does it affect the body? What are the problems caused by alcohol? What can we do against the abuse of alcohol? In the area of alcohol and drug control, the SPC Health Section
- 8 -
(e)
organize training courses in alcohol and drug education and control (e.g. SPC biennial regional training course on drug identification and concealment methods). United States Public Health Service
4.3
The United States related Pacific Jurisdictions include American Samoa, the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, Guam, the Republic of the Marshall Islands and the Republic of Palau. The United States Public Health Service recognizes that alcohol and drug abuse is a major problem in these Pacific Jurisdictions and is involved through various programmes. It provides federal grant funds, mental health personnel and technical assistance to help the Pacific Jurisdictions deal with alcohol and drug abuse. Federal Grant Programmes The Alcohol, Drug Abuse, and Mental Health Services Administration of the Public Health Service provides grants to each Pacific Jurisdiction so that they may develop and implement comprehensive community-based alcohol, drug abuse and mental health services. The United States Public Health Service, San Francisco Regional Office, administers a special initiative grant programme which has funded several substance abuse and mental health projects. Grants have been awarded to train mental health counsellors and to develop and implement culturally-sensitive alcohol and drug abuse programmes. Mental health personnel There are 35 National Health Service Corps assignees in the Pacific Jurisdictions. Of the 35 assignees, two psychiatrists are stationed in Guam and one clinical psychologist is assigned to the Federated States of Micronesia. The United States Public Health Service, through the National Health Service Corps, is assisting the Commonwealth of the Northern Mariana Islands and the Republic of Palau in the recruitment of psychiatrists. Technical Assistance The United States Public Health Service San Francisco Regional Office provides mental health experts and consultants to those Pacific Jurisdictions requesting technical assistance. Technical assistance may involve assistance in setting up a billing and collection system, training mental health workers and reviewing the appropriateness of medications used to treat alcohol and drug abuse patients. Fighting alcohol and drug abuse requires a comprehensive approach. The United States Public Health Service is committed to assisting the United States-related Pacific Jurisdictions in improving their alcohol and drug abuse services.
- 9 4.4 Alcoholic Liquor Advisory Council Report
The Alcoholic Liquor Advisory Council (ALAC) is a statutory body with responsibility to encourage moderate drinking in New Zealand and reduce the costs of alcohol misuse. ALAe receives its income from a levy on all alcohol sold in New Zealand, (including imported alcohol). In 1989-1990, this will bring nearly $NZ6 million into ALAe. ALAC spends its money on treatment, health promotion, research, industry programmes and Maori programmes. ALAC believes that health promotion is the secret to reducing problems. The ALAe health promotion approach includes: school education advertising consumer education community development professional education political information networking ALAe is convinced, following research done throughout the world, that reducing alcohol consumption in New Zealand will lead to a drop in problems over time. ALAe monitors alcohol consumption and problems year by year. Public attitudes are tested and detailed research is undertaken on the nature of alcohol-related problems and their reduction in New Zealand. Special emphasis is placed on the development of culturally sensitive programmes for the indigenous Maori population of New Zealand. ALAe is determined that it will approach matters related to its tasks in a bi-cultural manner. ALAC accepts the need to apply resources to solve Maori alcohol-related problems in a way acceptable to the Maori people. ALAe funds three Maori resource units which cover treatment and health promotion programmes prepared specifically for Maori. Research undertaken on Maori drinking problems is carried out by Maori researchers - using traditional Maori methods of information gathering. A major initiative over the past two to three years has been the development of a programme designed by specialists in the Maori
• - 10 -
community to address heavy drinking among young Maori men and women. The programme, called Kua Makana, is based on a theme of music, and uses traditional song writing and actions to convey a powerful message which says "A little but not too much". ALAC works alongside policy makers to help them appreciate that alcohol is a health issue not a moral issue. ALAC believes that a comprehensive programme of education, early identification, treatment and appropriate laws which are respected and enforced are the key to successfully reducing the unacceptably high problem rate. There is mounting public interest in New Zealand for setting up an alcohol/tobacco/drug council. This council might receive money from a special tax on tobacco in addition to the existing tax on alcohol which funds ALAC. ALAC supports networking in the Pacific and will do all it can (given its resources) to work collaboratively.
5.
FIELD VISITS
As in the other Micronesian centres, alcohol use is exerting a major impact on the people of Palau.
On the Tuesday afternoon of the workshop week, the participants and staff of the Workshop on Alcohol and Drug-Related Problems in Micronesia visited the national McDonald Memorial Hospital, Palau Museum and the jail. Participants and staff were able to observe some of the facilities available at the hospital for treating patients suffering from alcohol or drug-related problems. In an extensive tour of the hospital, participants visited the psychiatric ward and public health section. Ninety per cent of the young male population in jail were said to be there because of alcohol-related problems such as stealing, fighting and Committing other crimes. Palau and its people are being pulled into a "westernized" world at a far more rapid rate than that which their cultural values are able to absorb, resulting in a social lag. Many of the valuable things observed in the museum are no longer seen in daily life, or have less value or use for the people than in the past. The undermining of traditional cultural values, and the effect of this in such matters as the abuse of alcohol and drugs, and loss of traditional control mechanisms, were constantly referred to by participants.
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6.
SUMMARY OF SHALL GROUP DISCUSSIONS
6.1
Prevention
The small group discussion on prevention began by determining a suitable definition of prevention in the context of alcohol and drug abuse. It was agreed that five prevention encompasses those activities which are aimed at stopping the development of particular alcohol and other drug problems. Prevention might be Primary as in School Education programmes, Secondary, as in early identification of problem drinkers or Tertiary, as in preventing relapse for alcohol and/or drug abusers. For the purpose of this group work, it was decided that primary prevention was to be the focus. It was agreed that five primary prevention areas were most relevant to the population of Hicronesia: (1) (2) (3) (4) (5) (1) Children and young people Family Community Awareness Professional Education Legal Children and young people The following strategies were suggested: (a) Education Comprehensive school education as part of the curricula for all children. (b) Support Many children and young people who now do not use alcohol or other drugs, or who want to give them up must be supported. (c) Role models Proper role models are very important to young people. (-1)
Values training Additional training in the important values involved in indigenous cultures is felt to be necessary for young people.
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(e)
Recreational choices A lack of good recreational alternatives is considered to be contributing to the increasing sense of boredom among the young, and an attendant increase in problems with alcohol and other drugs. Youth centres and related activities are recommended.
(2)
Family
The role of the family is crucial to helping resolve alcohol and drug problems. The following areas need serious attention. (a) Support Many parents want to teach their children how to deal appropriately with alcohol and other drugs. However, they lack support within their communities. (b) Education As well as being supportive, parents should take the opportunity to also give their children education on alcohol and other drug abuse. (c) Values Parents may benefit frOID "values training" in order to put their past, present and future into perspective. Traditional values are being adversely affected by modern trends. These issues need to be addressed. Also the role of both parents in child-rearing needs to be clear. (3) Community awareness
Lack of knowledge about alcohol and other drug problems at the community level makes it difficult for community members to alter current attitudes and behaviour.
(a)
PTA training Parent and Teacher Association (PTA) training programmes, along with training for other community groups, is seen as of real value.
(b)
Health promotion Raising awareness via health promotion techniques is supported.
(c)
Networking The development of networks of concerned persons is seen to be a most appropriate way to ensure effective grassroots action.
- 13 Cd) Video programmes Videos are popular throughout Micronesia. Using this technology to carry positive messages to the community in a culturally appropriate way would be an innovative addition to current techniques. (e) Political activities Social impact statements are encouraged for all proposed legislation that might have an adverse effect on the social environment. (f) Committee on alcohol/drugs A Central Committee on alcohol and drugs needs to be initiated in each jurisdiction to offer advice to policy makers on all alcohol and other drug related problems. The existence of these groups will show the community how seriously concerned the government is at the state of current alcohol and other drug problems. (4) Professional education
The training of key professional groups in Micronesia is considered to be essential. Much of the effectiveness of good prevention work rests with these people: (a) (b) (c) Cd) (e) (f) (5)
teachers health workers police officers church leaders politiciruls/policy makers. probation officers
Legal
A comprehensive alcohol and other drug education programme needs a legal component. Control over the availability, marketing, sale and supply of drugs is necessary if we are to combat the increase in alcohol and other drug abuse. (a) Import controls Control of the amount of alcohol coming into Micronesia states appears currently to be based on demand alone and not considered from a public health perspective. This should not continue.
- 14 (b) Special stores Alcohol should be sold in premises designated for the sale of alcohol only (e.g. national liquor stores). 6.2 Treatment and rehabilitation
The discussion group summarized the various treatment and rehabilitation programmes currently available in Micronesia for people with drug and/or alcohol problems. Individual and group counselling is available but is done under the title of mental health services. Most Micronesians think of alcohol and other drug addiction as a mental illness. There are no public inpatient treatment services available. In Palau, Guam, the Commonwealth of the Northern Mariana Islands and the Harshalls detoxification is available but not often done because of lack of medical supervision: Alcoholics Anonymous (AA) support groups are active only in Guam; they have experienced little success to date on the other islands. Recently, there have been efforts to involve family members in treatment and to expand educational efforts concerning substance abuse treatment into the community. The group looked at legal issues in developing prevention and treatment policies. A major concern is the fact that intoxication is sometimes used as an excuse for unlawful behaviour. It is important to make strict alcohol importation laws and to limit the availability of intOXicating beverages. There is a need for better communication between the courts and the treatment planners. Public schools could test students to make sure they are familiar with the risks of using alcohol and drugs. Culturally relevant treatment modalities need to be developed for Micronesians. Hospital staff need training to help diagnose alcoholism and other drug addiction so as to make timely referrals to treatment services. Suggestions from this group concerning the development of treatment/rehabilitation programmes for alcohol and other drug abusers are as follows: (1) (2) (3) (4) 6.3 the establishment of a substance abuse training centre within Micronesia; training programmes for social workers and nurses; standardized data collection systems; and. the provison of a drug/alcohol treatment representative on each island to help in coordination. Culture. religion and other social factors
Basically all domestic religions have guidelines governing the consumption of alcohol. These guidelines. expressed or implied, are pursued in the interest of morality.
- 15 -
The use of alcohol does not necessarily mean its abuse. For example some religions use wine in their religious ceremonies. It is important that people also considers the symbolic nature of some alcohol use, rather than considering use of alcohol as necessarily an abuse. It is important that leaders, traditional or elected in high positions do not abuse their authority by publicly selling illegal drugs, thus setting a bad example for the community which looks to them for guidance and leadership. Even though the Micronesian tradition says a High Chief will be removed from his position if he does something to harm his people, this custom is not enforced. Cigarette smoking by children as young as nine years of age is often observed. These marijuana and/or tobacco cigarettes are reported to have been given to children as pay for chores, by adults. Before World War II, Micronesians were not permitted to drink alcohol; drinking increased as economic conditions in the islands began to improve rapidly during the 1960s, and has now reached epidemic proportions with the greatest problems among the young. Alcohol is a commodity with potentials serious health and social consequences, and its availability should not be seen simply from a financial standpoint. The church/spiritual leaders can playa role in assisting those who wish to stay sober. Risk factors: It is suggested that the attitude of many young male Micronesians is to "drink to get drunk". The traditional culture and value systems are at times in conflict with western influences. It is suggested this may influence alcohol and other drug abuse. Tourism, unemployment, gambling and a generation gap between young and old are considered to have an impact on abuse rates. Suggestions arising from the discussions included: (1) (2) (3) (4) (5) Reevaluate the culture: Lu;guages. Reduce the importation of alcohol. Conduct needs-assessments to gather data. Use existing groups to support alcohol/drug abuse reduction programmes. what makes us Micronesian? Use the Micronesian
':;'_:o'-t school-based culture classes.
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(6) (7) (8) (9) 6.4
Introduce peer-group youth counselling. Educate young people to understand the dangers of alcohol and other drug abuse. Heighten self-esteem. Introduce pre-parenting anti-abuse programmes. Encourage church groups to remain active in counselling troubled people. Development of national programmes
Small group discussions were held on the topic of the development of national programmes for the prevention and treatment/rehabilitation of alcohol and drug-related problems. The following suggestions were made: (a) Setting up of "task forces" or "commissions" to oversee the implementation of alcohol and drug programmes within the individual jurisdictions. This body would have official status and monitor programme implementation and effectiveness. The development of national policies on alcohol and drug dependence would be the responsibility of this national body. Linkages with relevant community groups e.g. health, police, education and church organizations would be encouraged. This national body could do much to raise awareness in the community, and it should have a substantial training function. Advice to governments, policy makers and community leaders might also form a significant focus of attention for this body. (b) A national needs assessment should be undertaken to highlight the nature and type of problems associated with alcohol and other drug abuse. This assessment should include a review of the amount of alcohol and other drugs available, and the problems associated with this availability. This assessment will need regular updating to accurately reflect changing trends. (c) The need for a national coordinator for alcohol and drug issues was supported. This person might be placed in the health system, and could have authority (mandated if necessary) to coordinate activities across all sectors public and private. It is noted by participants that many government departments and individuals are involved with alcohol and drug issues, and such coordination could avoid wasteful duplication. (d) The need for mandatory school education on alcohol and drugs to be instituted at all levels within the education system was emphasized. (e) A special tax on alcohol should be introduced (as in New Zealand) which should be exclusivelY used for alcohol and drug problems.
- 17 (f) The value of a biennial conference on alcohol and drugs for Micronesia was discussed and supported. (g) Some controls on the importation of alcoholic beverages is felt to be necessary as a means of controlling alcohol consumption and related problems.
(h) Prohibiting the consumption of alcoholic beverages and tobacco in all government buildings is seen as a very important statement from government. (i) Early intervention and screening programmes for at risk groups are supported. The counselling of pregnant women to avoid alcohol and tobacco is particularly important. (j) Men's groups should be renewed with encouragement for the traditional values of fasting and discussion. (k) Radio and video/T.V. segments should be developed and used to widely disseminate health information. (1) The provision of a half-way house facility, as an alternative to jail, is felt to be of importance for young offenders. (m) The introduction of local Alcoholics Anonymous Chapters with a socio-cultural orientation is supported. en) Support for working closely with local community organizations is felt to be of great value as local groups usually know best what is happening in their own areas.
(0) Rehabilitation programmes such as Palau's "Rock Islands" scheme are encouraged. (p) Mandatory counselling programmes for all government employees with alcohol/drug problems are supported. (q) Data collection is felt to be crucial to measure the size of the problem(s), future trends, and the effectiveness of prevention, treatment and rehabilitation efforts. 6.5 IGternational and regional activities
Alcohol and other drug abuse is increasingly a world problem, with dimensions that are similar in many countries. The erosion of national boundaries, because of communication and transportation advances, has contributed to an international drug culture; this culture reflects both the commonness of demand from country to country, and the international cooperation of traffickers. Health officials must increase their cooperative efforts in developing international health approaches to the prevention of drug abuse where pOSSible, and the effective identification, treatment, and rehabilitation of those persons already abusing drugs.
- 18 A regional centre has been proposed for Micronesia that might serve as a resource for environmentally appropriate educational materials and research into effective prevention and treatment approaches. International agencies such as the World Health Organization and South Pacific Commission, the Colombo Plan and, for some jurisdictions, the United States Agency for International Development (AID), could well serve both as advisors and as contributors of necessary resources.
7.
CONCLUSIONS AND RECOMMENDATIONS
Conclusions A positive feature of the workshop was that it enabled participants to appreciate the similarity and size of the problems they were having to tackle in preventing and controlling drug and alcohol abuse. Concern was also expressed over the effects abuse was having on both children and adults, and the undermining of traditional values and customs. There are also marked differences in culture, language and the extent of the problems, often requiring different approaches in the various countries. There was a recognition by the participants that certain problems might benefit from intercountry solutions. To some extent the problems and constraints are not dissimilar to those reported in earlier workshops. Allowing for some local differences, the problems are seen as: (1) There is a growing problem with drug and alcohol abuse, affecting but not restricted to, children and youth. Alcohol was overwhelmingly the most important substance being abused although hard drugs were recognized individually as serious. A decision was made that tobacco addiction, although tobacco was clearly an abused substance, was a sufficiently important problem that it would have distracted from the consideration of alcohol and other hard drug abuse. Betel nut chewing and kaya drinking were not seen as problems as serious as alcohol and hard drug abuse. Problems related to alcohol abuse included: the undermining of traditional culture and values health, work, and financial problems domestic and family disruptions traffic and other accidents
(2)
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(3) (4) (5)
It was generally agreed that while appropriate legislation was often in place, enforcement was inadequate. It was agreed that there was insufficient commitment to prevention, treatment and rehabilitation. Pressures to consume alcohol from manufacturers, tourists and advertising were seen as a majol.- constraint. The point was made that health should be more important to a society than profits. There is a lack of sound information and data on which to form the basis for policy decisions.
(6)
It was felt important that member countries develop national policies and programmes. Six jurisdictions reported on the current status of this suggestion. Commonwealth of the Northern Mariana Islands has a task force to make special recommendations to the Governor and there has been strong enforcement of drunken driving laws. However, teenagers still appear to have easy access to alcohol. The Federated States of Micronesia are about to instigate a Mental Health and Substance Abuse Council with two representatives from each State as well as those from local government. The Marshall Islands are, at present, working more informally on substance abuse problems through local government. Guam policy is essentially that of the federal policy of the United States although, depending on funding, local initiatives are undertaken. Information on an Employee Assistance Programme (EAP) is available in the form of educational packages which Guam has offered to make available to other Micronesian jurisdictions. Nauru has no national alcohol and drug abuse policy or programme at present. The Republic of Palau formed a national Committee on Mental Health Issues in May of this year, which includes alcohol and other drug abuse. Recommendations Recommendations that came out of the workshop may be divided into suggestions reflecting issues of reducing supply, reducing demand, treatment/rehabilitation, and general issues. 8.1 (a) (b) (c) Cd) To reduce supply, it was suggested that: Existing legislation should be consistently enforced. Alcohol (and tobacco) products brought into the country should be taxed, hence increasing the price of consumption (See 8.2.i). Customs vigilance should be increased. Countries should limit the amount of alcohol that can be imported.
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(e)
Countries should enforce existing legislation, especially concerning the availability and the sale of alcohol and cigarettes to minors. Work places and schools should be drug-free. To reduce demand, it was suggested that: Some of the revenue from taxes should be allocated to prevention and treatment activities for drug and alcohol abuse. Countries should introduce or strengthen mandatory alcohol and other drug, (including tobacco) prevention awareness at all levels of the education systems (Kindergarten to year 12). A curriculum for years 7, 8, 9 is about to be tested in Palau, which should cover all years by 1993. Aspects of traditional culture should be included in such curricula. Countries should emphasize traditional cultural values and control systems perhaps through men's and women's groups which would reduce the demand and accessibility of alcohol and other drugs. Countries should use existing organizational structures (e.g. women's groups, youth groups, community organizations) to raise awareness of related problems and hence reduce demand. EffectiVe mass media materials should be designed. There should be mandatory counselling programmes for all government employees. The screening of teachers should be increased to ensure that they are suitable role-models for children. Treatment/rehabilitation issues included: Use of peer-group counselling. Involvement of families, traditional and church groups in rehabilitation. Increased detection of (particularly young) people using drugs. The provision of a "halfway" house for young offenders, the parents of whom would be required to undergo counselling. A multi-layered prevention/treatment/rehabilitation model should be considered, ranging from the halfway house, to youth schemes such as the Rock Islands programme (where youth stay to receive training, clean up the islands, receive health education, etc.), to hospital aid work in the Mental Health Department, and jail.
(f) 8.2 (a) (b)
(c)
(d)
(e) (f)
8.3 (a) (b) (c) (d) (e)
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(f)
The development of a culturally appropriate and sensitive, "Alcoholics Anonymous" group in the Island States. Better cooperation between the legal systems and the treatment/rehabilitation systems.
(g)
8.4 General issues included overall policy issues such as: (a)
A needs assessment for the development of policy should be required for each country. A National Committee/Commission should be developed to be supplemented by local task forces; or, for some programmes a national coordinator should coordinate eXisting resources. Data collection and surveillance systems on alcohol and drug consumption, and alcohol-related conditions, including violence should be improved or established. A data collection form should be standardized within Micronesia, as consistent with each country's needs. A recently published WHO Assessment Form is available. Alcohol and other drug addiction, and drug and alcohol-related diseases should be notifiable conditions. National policies on drug and alcohol abuse should be developed. There should be increased coordination between the various Micronesian programmes. A Micronesian Alcohol and Drug Abuse Prevention and Control Training Centre and a clearing house should be set up. Both high and low risk persons should be identified for potential alcohol and drug abuse problems. A biennial or follow up conference on Alcohol and Drug Abuse Prevention and Control should be organized. A major focus might be a follow-up of the suggestions in this workshop.
(b)
(c)
(d) (e) (f)
(g) (h)
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ANNEX 1
LIST OF PARTICIPANTS, TEMPORARY ADVISER, CONSULTANT, OBSERVERS AND SECRETARIAT
GUAM
Mr Robert Borger Supervisor Drug and Alcohol Drug Branch Department of Mental Health and Substance Abuse Tamuning
Ms Marilyn L. Wingfield Acting Director Department of Mental Health and Substance Abuse Tamuning REPUBLIC OF THE MARSHALL ISLANDS Ms Glorina Harris Mental Health Coordinator Ministry of Health Services Majuro
Ms Rose Bobo Mental Health Social Work Community Health Center Ministry of Health Services Ebeye FEDERATED STATES OF MICRONESIA Mr McGarry Miguel Mental Health Aide (Educator) Pohnpei State Health Services Pohnpei Ms Julie R. Yoruw Psychiatric School Worker Colonia REPUBLIC OF NAURU Mr Diegob Bill Medical Officer Nauru General Hospital Nauru Mr Lorenzo LG. Iriarte Administrator Public Health Division Commonwealth Health Center Saipan
-COMMONWEALTH OF THE NORTHERN MARIANA ISLANDS
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Annex 1
Ms Rosa Palacios Public Health Educator Public Health Division Commonwealth Health Center Saipan REPUBLIC OF PALAU
Dr Anthony Polloi Chief, Public Health/Mental Health Medical Director, Community Health Center Bureau of Health Services Koror Mrs Francisca B. Blailes Public Health Nurse Supervisor Acting Chief Nurse Bureau of Health Services Koror
TEMPORARY ADVISER
Mr Keith Evans Executive Director Alcoholic Liquor Advisor Council National Insurance House Wellington, New Zealand
CONSULTANT
Dr Robert B. Fisher Consultant Psychiatrist Drug Abuse Programme Seattle, Washington
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Annex 1
OBSERVERS
KOLONIA, POHNPEI
Dr A.W. Zimmern Office of Secretary, Human Resources Department of Human Resources Government of Micronesia Kolonia, Pohnpei Mr Michael Davis Program Consultant U.S. Public Health Service Office of Pacific Operations Region IX, San Francisco California Mr David B. Rosario Health Education Specialist South Pacific Commission Noumea Cedex New Caledonia Dr Masao Kumangai Director Bureau of Health Services Koror Mr Dwight Keptot Representative Evangelical Church Koror
UNITED STATES PUBLIC HEALTH SERVICE
SOUTH PACIFIC COMMISSION
-LOCAL OBSERVERS
--
Mr John C. Thing Law Enforcement Officer Drug Enforcement Task Force Bureau of Public Safety Koror -
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Annex 1
Ms Deborah Rebeluud Drug Free School and Community Curriculum Research:r and Writer Bureau cf Education Koror Ms Julita Tellei Health Policy Consultant House of Delegate Olbiil Era Kelulau (National Congress) Koror
Mr Tobias Marbou Youth Coordinator Koror State Government Koror Ms Josepha Tiobech Acting Mental Health Coordinator Bureau of Health Services Koror Ms Regina Mesebeluu Coordinator Drug-Free School and Community Action Bureau of Education Koror
Mr Palik, Heinrich Instructor of Police Science Micronesia Occupational College Koror
Mr Dominic Sasao Substance Abuse Coordinator Palau Community Action Agency Koror
Mr Steven Sachalraimul P.O. Box 82 Koror
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Annex 1
Mr Wendell Chock School of Public Health Health Services Administration and Planning University of Hawaii at Manoa Honolulu Hawaii
SECRETARIAT
Dr N. Shinfuku (Operational Officer) Regional Adviser in Mental Health and Drug Dependence WHO Regional Office for the Western Pacific Manila Dr I. Darnton-Hill Medical Officer for Noncommunicable Diseases (Short-term Professional) c/o WHO Representative Suva
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ANNEX 2
AGENDA
1. 2. 3. 4. 5. 6.
Opening ceremony Introduction to the workshop Presentation of country profiles Summary discussions on country profiles Field visits Development of national health policies and programmes on alcohol and drug abuse. 6.1 6.2 6.3 Presentation of introductory paper Small group discussions Summary of discussions
7.
International and regional cooperation 7.1 7.2 7.3 Presentation of introductory paper Small group discussions Summary of discussions
8. 9. O.
Suggestions for future actions Review of the draft report Closing ceremony
-
31 -
ANNEX 3
SUMMARY OF COUNTRY PROFILES
5.1
Commonwealth of the Northern Mariana Islands
Nature and trend of alcohol and drug-related problems in the CNMI All agencies such as: ABC Board, Division of Youth Services, Commonwealth Health Center, Criminal Justice Planning Agency, Department of Public Safety, Catholic Social Services and the Public School System have recognized an increase in alcohol and drug abuse problems in CNMI which has led to a dramatic rise in mental health and social problems, such as suicide, pregnancies, spouse and child abuse, incest, homicide and violence. The reasons for this increase in alcohol and drug abuse are varied: The CNMI is experiencing rapid changes in its socioeconomic growth. The impetus for the rapid development seems to be the CNMI's emergence as a major tourist center for Japanese tourists. Because of the expanding tourist market, the construction industry (particularly in hotel construction) have seen the need for importation of alien labour. CNMI has noted, consequent to this influx of tourists and alien workers, an increase in drug and alcohol abuse. These new arrivals, and the extensive leasehold land sales, have contributed to an increase in the destruction of traditional customs and the breakup of family relationships. The CNMI Government has a state plan and has come out with a report noting the health and social difficulties associated with alcohol and drug abuse, and has made important recommendations to the government. However, the considerable early momentum has slowed greatly in the last six months. We need to improve and update the plan. In addition, psychiatric care has not been sufficient to meet the needs of persons with alcohol and drug abuse problems.
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Annex 3
We do not have any collaborative activities with other areas in Micronesia but maybe with the help of our Director, we can join forces with Guam on the regional prevention of alcohol and drug abuse. I would also hope that additional meetings with regional health bodies such as the South Pacific Commission and the World Health Organization could be arranged so that we could continue to learn from each other better ways of ridding our islands of this noxious disease. 5.2 Federated States of Micronesia
There are four states in F.S.H.: Pohnpei, Yap, Truk and Kosrae. All are included in a national alcohol, drug abuse, and mental health programme. 5.2.1 Yap State
Traditionally, Yap has had a complex, but successful culture with a caste system, namely the chief ranks, the middle ranks and the low ranks. In essence, they take care of each other and are loyal to each other. It is only now that there is such a mixture of culture and westernization that some people have come to abuse this system. Nature and trend of alcohol and drug-related problems Today, drinking alcohol, especially Budweiser, has found its way into the Yapese customs and traditions. Whenever there is a traditional celebration of some sort, Budweiser and vodka are most likely to play an important role instead of the customary coconut or other traditional drinks. Alcohol has become the focus of traditional functions and celebrations. Alcohol abuse plays a vital role in the lives of everyone in Yap today. It is not a problem among only the young people as many have been led to believe. Rather, it is a problem that exists in most families. It is not uncommon to see fathers, mothers, and children drinking. The devastating effects that alcohol abuse has on a family is reflected in children who are abused and/or neglected, women sleeping in the bushes during weekends, unemployed parents or adolescents who come in contact with the law. Alcoholism is indeed a family disease. Yap could provide many examples. A family with alcoholic parents is more likely to have young children with drinking problems who are on their way to becoming alcoholics too.
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Annex 3
A significant finding from a November 1988 survey, was the attempt to find out the amount of alcohol consumed in one hour amongst subjects who have an idea of the level of intoxication. All age groups reported consuming more than one can of beer (,;an - 12 oz. of any kind of beer) in one hour, and also from what I have observed, the drinking lifestyle on Yap may have come to be "drink to get drunk" instead of "social drinking". (Social drinking meaning, having a few sips of alcohol which would not allow intoxication). A resolution has just been passed by the Yap State Legislature. Although this resolution may not reflect the grassroots of the alcoholism problem on Yap, as it talks mainly about the youth, it is bringing collaboration between departments together towards this effort. This is an important beginning. 5.2.2 Pohnpei State
Nature and trend of alcohol and drug-related problems Pohnpei State, including five (5) outer islands, had been known to the outside world for many, many years. Lately, we have become very greedy customers of outside brewers and tobacco producers. More men and women in Pohnpei State are starting to be involved heavily with these drugs, and particularly more and more of our young people are starting to use and abuse these available drugs, even the young kids in elementary schools. In Pohnpei, these drugs, e.g. alcohol and marijuana, can be obtained by young people any time they want as they are freely available. Over 90% of the stores in Kolonia sell alcoholic beverages. Leading alcohol and drug-related problems in Pohnpei are as follows: (a) accidents all types; (b) conflict in families; (c) disturbing the peace; Cd) assault and battery: (e) trespassing; and (f) suicide. Policies and programmes for their prevention and control Pohnpei State has several policies regarding alcohol beverages which are published in a state code and cover the following topics: (a) drinking age: (b) place for drinking: (c) licensure, taxation, importation and sales of alcohol beverages; (d) prohibition of drinking during elections.
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Annex 3
We have several programmes responsible for the prevention of alcohol and drug problems in Pohnpei i.e. the State of Pohnpei Alcohol, Drug Abuse and Mental Health Programme (ADAMH) which is operated under the Department of Health Services, and the National Alcohol, Drug Abuse and Mental Health Programme, in the D~partment of Human Resources. One Pohnpei ADAMH staff member is now in a three-month substance abuse training programme in a United States university. Pamphlets in English have been distributed to elementary school and high school students in Pohnpei. The Pohnpei Counsel Against Substance Abuse Organization (CASA) was created by the concerned citizens who really care about the increasing problem of substance abuse in Pohnpei, to maintain substance abuse prevention. The Pohnpei Catholic Media Center provides radio programmes sometimes on substance abuse for the general public. It also provides other related radio programmes regarding problems created when people start abusing substances. The Pohnpei State Alcohol, Drug Abuse and Mental Health Programme has always been glad to cooperate and collaborate with those interested in substance abuse prevention. Particular needs we have are (1) establishing a data collection system; (2) establishing Island A.A. programmes; (3) training programmes. We welcome assistance through appropriate channels of those colleagues who share our goals. 5.3 Guam
The misuse of alcohol and drugs is a major health and social problem in Guam. The increase in the number of referrals being made for treatment, the court, hospital and private physicians would demonstrate that the problem is getting worse. Estimates made from the number of people seeking treatment indicate that alcohol is by far and away the most abused drug, followed by marijuana. The pattern of drinking in Guam makes it almost exclusively a social affair. Village "fiestas" are popular weekend activities where unlimited supplies of alcoholic beverages (mostly beer) are customarily served. Heavy drinking and some degree of permissiveness and tolerance of drunkenness are observed during these occasions. In general, drinking in Guam can be described as moderate to heavy sporadic social drinking. Most people feel that individuals suffering from drug and/or alcohol addiction can best be handled by the family without professional intervention. People seem to feel that drinking is part of the Chamorro culture and should be accepted. These attitudes pose a barrier in the treatment of substance abuse problems by encouraging enabling behaviours by family members and lengthening the time before a person enters treatment.
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Annex 3
The substance abuse prevention message is very evident as seen and listened to on Guam radio and television stations. Public service announcements produced locally and on the mainland receive a good deal of our time. Guam's only daily newspaper prints current listings of support groups, treatment programmes and prevention seminars taking place in the island. It is realized that in Guam, alcohol and illicit drugs will never be completely eliminated. The nature of the problem demands that a coordinated effort be made by all sectors of the government working toward our common goal. Particular attention needs to be paid to the influencing of local politicians in gaining their support of legislation which helps reduce problems associated with drug and alcohol abuse. In the past, Guam has tried to adapt U.S. Drug and Alcohol policies to fit its particular local problems. There is now a trend to look toward our Micronesian neighbours, especially the ~NMI, as a source of new programme initiatives. 5.4 Republic of Nauru
No major surveyor study on alcohol and drug related problems has ever been undertaken in Nauru. However, from clinical experience, the major drug of abuse is, without doubt, alcohol. Drug (other than alcohol) related problems beside hyper-sensitivity is practically nonexistent. A very brief report on alcohol related mortality was included in the Nauru Mortality Report by Taylor and Thoma in 1983 (SPC Noumea, New Caledonia, April 1983). It was estimated at that time, that about 50% of the total male population over the age of 16 years and about 15% of females of the same age grouping, were taking alcohol in large quantities. These numbers have increased since that time. The disease patterns related to alcohol mainly involve the liver, pancreas and the heart. Excessive alcohol is not the only cause of cirrhosis of the liver, but the cases recorded suggest a major contribution. Similarly, those cases with fatal and non-fatal pancreatitis are also associated with excessive drinking, and two fatal cases of cardio-myopathy are also known as heavy-drinkers. Death from alcohol poisoning. accidental drowning, falling from heights are also recorded as being alcohol related. Alcohol related morbidity and mortality from motor vehicle accidents and injuries is well documented. The major cause of death in Nauru during the five-year period (19761981) were traffic accidents and injuries associated with drunkendriving. Alcohol abuse has been associated with the disruption of homes and the break up of marriages, and other social problems.
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Annex 3
Since 1982, the numbers of motor vehicles accidents associated with drunken driving has decreased by 8% and that could be attributed to a change of peoples' attitude. Before Nauru became independent in 1968, drinking of intoxicating liquor was prohibited for the natives. This law was lifted about a year later and people immediately began taking alcohol excessively to a loss of functioning, perhaps as a response to this new "opportunity". Because of cheap prices and ease of access at any liquor supply in Nauru, more and more people are learning to drink. Drinking liquor by the women was almost taboo pre-independence day, but it is no longer regarded so. Recommendations for control and preventive measures for alcohol related problems has been submitted to the Government and are still awaiting consideration. The legal drinking age, for males is 18 years, and for females, 21. Violations of this law might be more aggressively pursued than they are currently. Devices for monitoring vehicle speeding and "breatha1yser units" are available but are not currently in use. The possible use of these valuable devices as prevention instruments, should be reviewed. The use of safety crash helmets, the use of safety belts, and limiting or the import of motor vehicles to those smaller than 90 cc, should also be considered. Public and school education on both alcohol and drugs and their associated problems, has not been implemented on a large scale, and the use of this potentially valuable prevention resource is encouraged. I am looking forward to this golden opportunity to attend this workshop, and particularly the suggestions that will come from it, so that innocent people in my country may, in the long run, have their health improved. 5.5 Republic of Palau
Palau is struggling with licit and illicit drugs. Palau lists licit drugs as alcohol and tobacco products and illicit drugs as marijuana, heroin and the rest of the "hard" drugs. Palau has experienced the introduction of heroin and marijuana but feels it can to some extent handle the problem because it is illegal. Palau is frustrated about alcohol and tobacco control because it is legal to import and to sell them. Palau finds that because the substances have been legal for sometime, the use and abuse finds its roots into the social and political fabric and so that when the time comes for regulating it, the process would be equivalent of destroying the political and social system in existence.
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Annex 3
A variety of studies have shown that the longer the alcohol and drug problem is left unsolved, the greater the problem and so the Palauan society finds itself committing a suicide, so to speak. Police records in the area of arrests, driving under the influence of alcohol and drinking in public places have shown an increase over 40% across the board. Social indices have shown increased percentages in problems relating to violence against children, wives, others, properties and self. Medical indices have shown that there are more medical problems coming to the emergency room relative to alcohol and drugs, or a combination of both, than more biologically caused problems. Pathology records indicate that alcohol is a major factor in the causes of death in a good percentage of the deceased. Business records show that every year, the importation of alcohol escalates by leaps and bounds. The raids on marijuana farms according to the police reports show that the more they raided, the more they plant. It is a known fact that law enforcement is inadequate, the laws have a lot of loopholes, and the sentencing is lenient. It is also a known fact that youth emulate the elders and that in Palau, youth see parents drink freely, and that legislators, policemen, doctors, teachers and businessmen drink heavily. !ltaybe, to be somebody in the society is to drink alcohol". Palau has not yet found a way to influence the decision makers to act in a more positive manner, in finding ways to reduce the problems relative to alcohol and drug abuse. 5.6 Republic of the Marshall Islands
Alcohol usage in the Marshall Islands The users and abusers of alcohol are primarily the male population aged 14 years and up. The number of those who are true "social drinkers" and can control their use of alcohol is heavily outweighed by those who actively and chronically abuse alcohol. This is becoming increasingly obvious from the upward spiraling rates in motor vehicle accidents and increasing social problems, i.e. broken families, abused and neglected children and spouses, poor work performance of employees, and breakdown in the extended family and Marshallese customs. The impact of alcohol abuse extends to the physical and mental health and social, cultural and economic stability of the Marshall Islands.
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Annex 3
In 1983, the Government tax office records showed that over 1.8 million dollars was spent to import alcohol in just one year. To put this into perspective, this amount nearly equalled one half of the total health budget for the entire country and nearly equalled the total amount spent on medical referrals in the same year. The Republic of the Marshall Islands is striving to establish its independence and self-sufficiency. Continued acceptance and tolerance of alcohol abuse will prevent the Marsha11ese from reaching their goal. There is not yet an official government policy on alcohol abuse. The Board of the Ministry of Health Services has submitted a Cabinet Paper for consideration and approval of the following: (a) (b) (c) acceptance of a national resolution recognizing the problem of alcohol abuse in the Marshalls. establishment of a National Alcohol Abuse Prevention Coordinating Committee, under the Chief Secretary's Office, directing all government ministries to establish alcohol abuse prevention and control programmes.
The Health Services have been actively working with other government agencies in confronting this problem. The Ministry should also look to other neighbouring islands for help and support. Coordination and communication, sharing of technical assistance and consultants, participating in workshops and conferences, and the sharing of educational materials will help to lessen the problems.