For a country, the considerations are different. A country, unlike a community, is not easy to 'mobilise' to address alcohol problems. But there already are agencies empowered to deal with the whole country, which can therefore take the initiative to reduce a nation's alcohol problems. Government ministries are examples. Things that such agencies can do, to reduce alcohol problems in a country, are well recognized. Strong evidence of effectiveness is available for certain national alcohol policies. The limiting factor at national level is not so much the lack of knowledge about what works. It is more the relative lack of power of the agencies responsible for or interested in reducing alcohol problems.
Concerned national agencies are often not able to bring about the changes that they know will reduce alcohol problems. The opposing pressures are strong enough in many countries to prevent the best measures being implemented. Strategy at national level must then focus mostly on how to proceed in the face of this mismatch: the discrepancy in power between those who want policies that will reduce alcohol problems compared to those whose priority is to increase profits from the trade in alcohol.
At global level too, useful actions can be proposed. But there are different problems to overcome. The global arena is nebulous, and this creates one set of problems. The relative dominance of the global alcohol trade creates another. Where global stratagems clash with the interests of giant commercial enterprises, progress can be slow. Global sentiment to overcome financial interests is difficult to mobilize, given the absence of a means or forum for its expression. Nor are there agencies, akin to a government ministry for a nation, interests right now. A global strategy must explore avenues of promise within these realities. At the same time it must address the absence of credible agency. Regionally, at what we may call a kind of ‘sub-global' level, broader progress is still feasible – such as has been achieved in Europe. Regions are clearly less amorphous than the globe.
Different strategies are obviously needed in addressing the varied priority needs and other considerations in each domain.
Community strategy
The issue for communities is what they should do. There is little opportunity in community action for deliberate and considered action. People move when they are moved by a perceived need. The very nature of community awakening calls for an immediate response. To sit around, debating the best course to take, does not satisfy the spirit of action. Community strategy must deal with the difficulty of channeling enthusiasm in the best directions, without killing it in the process.
Communities should be engaged in analyzing what to do before they are stimulated to action – not the most popular course. But people do need first to examine how they propose to set about things. Addressing the determinants of alcohol problems in their community is a good route to follow. An obvious determinant of heavier use and problems is the easy availability of alcohol. Most community initiatives therefore focus on reducing availability, without really having given it much thought. But success in this venture can usually be achieved only by mustering power, and is therefore dependent on local conditions. There are other determinants of problematic alcohol use that are less exhausting to deal with. Addressing these other determinants requires a little more sophistication than simply closing alcohol outlets. The sophistication required resides in every community, but may be suppressed by zealots.
The determinants that a community should address are few. One of these is the attractiveness of the image of alcohol. Communities can readily recognize, when appropriately guided, the things that they say, do and think, which serve to add glamour, pleasure and positive symbolic meanings to ethyl alcohol and the act of consuming it. An enlightened community can learn to remove this added embellishment, which impact on its alcohol use.
A further example of a determinant is acceptance of so-called misbehaviour after alcohol use. Violence, aggression and abuse are, in some communities, accepted of the intoxicated. Such tacit social approval, for transgressing norms of decency when intoxicated, can be reversed. Remarkable changes in alleged chemically induced aggression then result. The community benefits from the establishment of norms of decency even for the “ drunk”. Improving our ways of relating to each others is part of development. Proposed community action must make a change in the foregoing and other suggested determinants. Examples of other desired changes are: counteracting the influence that promote increased alcohol consumption; reducing unfair privileges attached to alcohol use; ensuring that everybody recognizes the real harm from alcohol; and encouraging, as appropriate, quitting of reduction of use. All of these help in creating a milieu where problem alcohol use and population consumption decline.
Community action must include monitoring its own progress in bringing about these desired changes. Depending on progress, the ongoing action has to be modified. When communities reduce their alcohol problems through such a process, they are able to understand what led to progress. This allows them to teach others. Successful community action grounded on explicit principles allows others to learn. Success by communities should be more than a locality-specific idiosyncrasy. When a theoretical model underlying success is recognized, increasingly robust strategies can be worked out.
Country strategy
Successful policies that a country can adopt are already known. The big question in national strategy in how to get known useful policies implemented. A further question, perhaps not addressed actively enough, is what new measures may surpass those that we already know to be effective. The policies that are known to reduce alcohol problems are conventionally unpopular – increasing alcohol taxes, restricting availability and controlling its promotion, as examples. Good national strategy includes addressing the roots of this seeming public unpopularity.
Informed public opinion should be able to influence those who make the important decisions. Bringing true public opinion to bear on policymakers is not easy. Huge public support for policies that reduce alcohol problems can still be prevented from being felt. Even the opposite can be made to appear the reality. Creating public opinion is far easier than making it count with decision-makes. The latter is the more important strategic issue.
Counteracting the influences that inhibit desired policies should then be a major part of national strategy. Sometimes just one honest politician is enough, and any that emerge should opportunistically.
WHY IS A RESPONSE NEEDED?
(The nature and extent of alcohol-related harm)
Even a school child can mention many of the gross harms that alcohol causes. Medical professionals and social scientists can give longer lists. These lists often obscure the reality because they are only lists. Including figures or numbers quantifying the harm makes the message more telling. Figures facilitate the comparison of alcohol-related harm with other harms. But figures are always open to dispute and doubt.
A figure does not mean much in the absence of the human stories behind it. Let us say twenty thousand people in given country die of alcohol-related causes every year. The interest that this information arouses is likely not to be different if the figures were instead the relative importance of such large figures. They tend not to be real.
Comparing the deaths from alcohol with those from some other cause is more likely to arouse concern- for example if the number of people who died of AIDS in the same year was five hundred. Even so, the response to alcohol is hardly in keeping with the scale of harm. A sudden or violent death of just one person may be capable of arousing much greater indignation and action than a monthly toll a few thousand alcohol deaths.
A brief account of different kinds of alcohol-related harm is given here. The quantification of these is problematic, and has to be attempted as relevant to each setting-whether a small community or a large country. There are many kinds of harm, apart from these, that communities can be guided to recognize. Some alcohol related harms are nowadays obscured by dressing them up as benefits. Examples are given further on in this chapter, under the section titled ‘Countervailing benefits'. How communities can be guided to recognize them is spelt out in detail in the chapter on community action
Death, disease and disability
Higher death rates from injuries, violence, poisoning, cirrhosis, haemorrhagic stroke, pancreatitis, cancers of the oral cavity, pharynx, larynx, oesophagus, liver and breast and, in some cultures, suicide are associated with alcohol consumption (WHO 1999). An estimated net loss of 770,000 lives is attributed to alcohol (WHO 1999), even after making deduction for a presumed prevention of cardiovascular deaths.
Many deaths to which alcohol contributes are not officially added to the tally. Over 800,000 people were reported to have killed themselves in the year 2000 (WHO 2000). Alcohol dependence is associated with suicide. But the proportion to which it can be causally linked is indeterminable. So these deaths do not figure in our calculation.
Because alcohol kills and disables at a relatively young age its impact on Disability Adjusted Life Years (DALYs) is relatively much higher than that of other major causes of premature deaths (Murray and Lopez 1996). The component of alcohol-related deaths varies much from country to country, based on the per capita consumption and particular patterns of use(Edwards et al 1994). The relevant figures will therefore need to be worked out by each individual country.
An argument is strongly put about that alcohol problems of this nature are seen only among ‘problem drinkers'. Interventions, it is argued, should only be directed at vulnerable users. But this is not on acceptable approach, ad harm is generally strongly influenced by a population's level of alcohol use. The idea of vulnerability is not of much practical use, or validity, if the vulnerable can only be identified after they die or experience serious problems.
Harm to others
Harm to the individual user is nearly always the focus in discussions on the negative effects of alcohol. We tend to forget the harm to people from other people's use, especially where alcohol problems are portrayed as being the result of an individual's genetic or other predisposition. Harm to others is rarely on the agenda.
Alcohol leads to harm for users, as we all know. It harms, through the intoxicated, those who aren't – and this damage we forget to include in our reckoning. Victims of alcohol related accidents are not only the intoxicated. A huge number of victims, abused by people who are intoxicated, do not get counted either. What we often count on the plus side of alcohol, alleged ‘disinhibition ‘and related fun, is what allows victimization of the weak by those who are drunk. Moat victims of alcohol's damaging side are probably children and, in many cultures, women. Their suffering is camouflaged by the overall mood of fun, or freedom from stifling norms, created around intoxication. Thus the victimization, ironically enough, is put down on the credits side by alcohol users.
The World Health Organization in a report on violence (WHO 2002) says that over 500,000 people were killed in a preceding year in acts of interpersonal violence. The culture surrounding intoxication, in many countries, is one that allows or encourages aggression and violence. The victims are, of course, not considered part of the alcohol problem. Alcohol often plays a major part, as well, in what is called collective violence.
In the study of the contribution to the Global Burden of Disease, alcohol is said to account for about four percent (Room et al 2003). This comes close to that of tobacco and high blood pressure. As the report itself point out, the alcohol computation takes into account only the harm to the individual alcohol users. Harm to others through the individual who has used alcohol should also be counted.
Dependence and related harm
Dependence is classified as a disorder in the International Classification of Diseases (ICD 10-WHO 1992) and so is included under the previous heading. But dependence is worth recalling separately, as it is often driving force that keeps some people tied to a pattern of long standing harmful use.
Mental and behavioural disorder
Several disorders of this category are listed in the ICD (WHO 1992). The list includes acute intoxication, withdrawal states with or without delirium, psychosis and amnesic syndrome. Other recognized complications brain damage, morbid jealousy and alcoholic hallucinosis.
Family, social and economic problems
These are well recognized and probably unnecessary to list out here. The indirect impact of alcohol on family and community wellbeing is probably most importantly through the economic impact. In the poorest families, especially, the money spent on alcohol is rather a large proportion of the family's earnings. This is often underestimated (Baklien and Samarasinghe 2003).
A second issue that is often unnoticed is the injustice that alcohol permits to be inflicted on the most powerless members of society. People who have consumed alcohol are, in nearly all societies nowadays, allowed to break rules and transgress norms. This was not the case in the diversity of cultures that prevailed in the world (McAndrew and Edgerton 1969) before it became a ‘global village'. Those permitted to break the rules and victimize others ‘under the influence of alcohol' are nearly always the more powerful. So alcohol provides ‘cover' for the strong to victimize the weak. A husband is more often allowed to get away with abusing his wife if he is known to have consumed alcohol. The wife who is victimized too tends to feel less upset if the husband abused her after taking alcohol, rather than without a ‘reason' for violence.
Drink driving
There are specific interventions that have reduced road deaths resulting from alcohol use. They serve as good examples of a class of interventions that on reducing harm from alcohol without necessarily trying to reduce population consumption. This approach is probably saving lives and has the express support of the alcohol trade. As a responsible trade it would do well to support progressively lowering the permitted levels of blood alcohol in drivers of motor vehicles.
Countervailing benefits
Harm from alcohol is not the only determinant of whether we need to do something about alcohol use. Benefits ascribed to it should also be tallied. Most people would list among the benefits, pleasure and conviviality produced by alcohol. Economic activity and employment generation are other benefits emphasized. And from the health angle, there is the lower mortality associated with light to moderate consumption of alcohol, in some population groups.
These should be examined critically to see how much of a benefit they indeed are. And what services critical scrutiny should be included in the equation, when working out the optimal response to alcohol related harm.
Economic benefits
Alcohol producers make money. The benefit from this is no different to that from any other trade. The alcohol trade creates jobs, for instance. So our appraisal should examine the extent of job losses if proposed action led to a fall in alcohol use. We may then discover that more jobs would be created in other sectors if alcohol expenses fell. No jobs would be created if money saved from alcohol expenditure disappeared into thin air – an unlikely event, fortunately. Jobs generated for a given quantum of consumer spending are probably less in the case of alcohol than for most other commodities. Tobacco is the only likely exception. In the employment generation equation, alcohol expenditure counts as a loser. As a passing observation on the employment front, we must note that alcohol use leads to lost productivity of people working in other trades too.
The alcohol trade pays a good deal in taxes, and governments gain. Increasing a population's alcohol consumption does not lead to a net gain because of the countervailing losses. But increasing alcohol taxes is good for government revenue. All tax increases are generally unpopular but increasing alcohol tax is less unpopular than increasing other taxes. Extraordinary energy has to be sent by the legal alcohol producers to ensure that governments do not use this resource maximally. For governments, increasing alcohol taxes is a winner, even in pure revenue-generation terms. There are other gains, because consumption declines when taxes rise. The flip side is that a significant part of the increased revenue may come from those less able to afford it.
Pleasure and fun
People commonly behave after consuming alcohol in ways that they would not quite approve in someone who hasn't consumed. They put away their shyness, and sometimes their restraint, after drinking alcohol. This is its great benefit, especially to the insecure. Whether the ability to perform better socially is due to the chemical effect of alcohol or its social attributes is irrelevant. Pleasure too is associated with drinking occasions. Again, whether this is mostly due to expectation, conditioning through numerous instances of use in happy circumstances, or alcohol biochemistry is of no great consequence.
When people learn in whatever way to rely on alcohol to relax, enjoy, or to perform socially, they lose out. This comes about from the gradual association of alcohol use with the mood that they want to achieve. After a time alcohol becomes a necessary condition for achieving that particular mood. A person who learns to associate alcohol with being carefree or vivacious at a party soon begins to associate the mood with alcohol use.
Initially such persons need only the glass of alcohol in their hand to ‘switch on' the particular mood or manner. Some progress, after a time, to needing the feeling of at least slight intoxication as the cue to turn on the desired effect. The disadvantage is that they then become slightly less capable of experiencing the particular feeling in the absence of alcohol. Learning to rely on alcohol for desired moods or ways of behaving gradually restricts the person's range of enjoyable situations. Only alcohol occasions are experienced or interpreted as enjoyable, or relaxing. When people reach this stage of reliance on alcohol, the pleasure they get life is in reality restricted or reduced.
A person's potential wellbeing is greater as the range of experiences, situations and activities that bring joy, relaxation or other positive feelings, is wider. Alcohol is generally perceived as an agent that increases ‘pleasure' and is in a way promoted as such too (Peele and Grant 1999). Careful scrutiny will help users decide whether alcohol, in the name of increasing pleasure, in reality restricts it for them.
Whether alcohol gradually restricts users' repertoire, and gives pleasure only to those who have allowed it so to restrict them, deserves examination. If this is found to be the case, we must conclude that alcohol use results in a net loss in pleasure gained from life.
There is yet another proviso that should be attached to accounts of alleged pleasure from alcohol. Wellbeing that is said to be experienced during drinking sessions is derived in good part from the permission to be free. ‘It does not matter now, you're drunk', is particularly a boon for the strait-laced. And that's all to the good. Other important beneficiaries are people living in highly restrictive societies. Even brief time out from too rigid norms of propriety is better than none.
But wellbeing that is achieved simply by exploiting opportunities to transgress ordinary social norms has its costs. Social rules and norms serve to protect the weak from victimization by the strong . In situations where alcohol provides time out from usual social rules, the weak are more at risk.
Improved wellbeing for the alcohol user should not be bought at the cost of
impaired wellbeing for the non-user, or for the weaker alcohol user.
In the wellbeing equation, the ‘enjoyment' of the user may be put down on the credit side. But the debit side, where wellbeing is purchased at the cost of other' ill being, is too readily ignored. Those at the butt end of the more dominant alcohol user's fun are usually woman, children, the powerless and the disadvantaged.
On two counts then the alleged pleasure from alcohol use doesn't appear too attractive. Firstly, we found that even the users who perceive genuinely improved subjective wellbeing when intoxicated get it at the cost of restricting their repertoire of fun and relaxation. Secondly, we note the negative consequences on others of the more dominant users' fun.
Health benefits
Undoubted and significant association between lower mortality and the consumption of 10 grams or less of alcohol a day, compared to no alcohol consumption, is found in several studies (Babor et al 2003). This finding applies not to the human population in general but only to people over 45 years old living in affluent countries.
Many medical bodies have endorsed and conclusion that this finding reflects a benefit resulting from alcohol use. This endorsement may not as yet be justified. Examining a different, and purely hypothetical, association will help explain why. Let's imagine that, compared to abstinence, alcohol use in small amounts was associated with a higher mortality of a magnitude similar to the lower mortality now found. And let's say that at higher levels of consumption, the increased mortality rates leveled out.
How easy would it have been, had there been this increased mortality of the same magnitude, then to convince the world that such moderate alcohol use was damaging to health? Even had there been a directly linear relationship, causality would have been hard to establish, in the absence of other criteria being satisfied. We don't have as yet even a convincing dose-response relationship, to support the claimed protective effect on the heart. But we readily accept that the first limb of a ‘J-shaped' curve is causally related to alcohol use in small doses. For instance, the few who abstain from alcohol in the countries where the studies have been done are likely to be different from the rest of the population in many important ways.
Whether the medical establishment has too readily jumped to causal conclusions, based on a population association, is moot. Compare the struggle to establish tobacco use as a cause of cancers or cardiovascular disease. Had the association been similar to the ‘health benefit' associated with small amounts of alcohol use, would the medical profession have got past first base in attributing causality? The relatively small effect and many plausible confounding variables wouldn't have stood up to critical industry scrutiny. The medical establishment may not have been willing even to take up the case. The degree of rigour demanded by industry in proof of causality in the case of harmful consequences should not be laid aside when attributing alleged beneficial impact. The idea that alcohol is good for the heart, quantity unspecified, is widespread. If rigorous enough evidence were available of this, there still remains the problem of making public of private recommendations to drink for health. When, at some future date, the criteria for causality are rigorously satisfied, recommendations on alcohol consumption have nonetheless to be cautiously made. Pronouncement made to individuals can have opposite or paradoxical results on societies. Most authorities are conscious of the harm that can result from going public with a message appropriate for a selected group of individuals at special risk. Although this is known well enough, it is not adequately respected in practice.
Another problem remains, and this one is not at all respected enough. Namely, that recommendations made to individuals in private consultations have public repercussions. A statement to an individual patient about benefit from alcohol, should such recommendations be possible to make with responsibility, must necessarily be made with an eye on the rest of society. A population may shift towards taking more alcohol than it does now, even if some members are individually encouraged, privately, to drink for their health. The level of a population's alcohol consumption is a strong determinant of the extent of alcohol problems in that population. When alcohol can be medically recommended to selected individuals, there still is debate needed on harmful population shifts that could result, before doctors make that recommendation. When recommendations can legitimately be made to individuals, they have to be conveyed in a way that will not carry potential for increasing population harm.
The time has not yet come for cheap generic medicinal alcohol to be sold through pharmacies or drug stores, even to protect the hearts of older people in Western countries. When it does, the rest of the alcohol products in the market may suddenly lose their glamour. And population consumption may well begin to decline. That too would count as a paradox.
Ways to Reduce Harm
Based on our understanding of how alcohol-related problems are generated and maintained, we can workout the objectives that
Should guide our responses, especially at community level, Theses can be summarized as follows.
These objectives can confidently be recommended. They are not just logically desired end-points, but supported by evidence as well.
To achieve these results, our communities have to start moving in a particular direction. There are underlying community-wide changes that could encourage achievement of many of these results. These cross cutting milieu changes have to be worked out logically and then put to the test in real life.
The challenge is to unearth underlying factors or determinants that we can usefully address, which in turn can bring about the impacts listed.
If a certain mood is created in our community it could, for instance, delay the onset or initiation of use ,reduce heavy alcohol sue as well as achieve other desired impacts. We may guess that reducing the attractiveness of alcohol will contribute to achieving many of the desired results. A reduction in social privileges attached to alcohol use is similarly likely to help. There are other likely contributors too. So our strategic action should try to address such underlying factors leading to the impacts that we want.
The community as a whole has to shift in a particular direction. The factors that will lead to delayed initiation, reduced aggregate consumption and so on, apply to the communities can strive to achieve, for a start, could be as follows:
In attempts to reduce alcohol-related harm, the role that individual communities can play is not greatly emphasized. But communities do have a major role. The preceding paragraph listed changes that a community should strive to achieve. Communities, more than policymakers, are effective in achieving the changes listed. Some are of course difficult to achieve. But responses to reduce alcohol- related problems should not be left to ‘policymakers' alone. Issues such as availability are within a community's scope too.
How each of these can be translated into action is later described in detail. A few guidelines and theory issues are dealt with here. Each issue is taken up for discussion separately. But they can be implemented concurrently.
The list is not a particular order of importance. Nor is it a recommended sequence for implementation. So each community can address the issues that it sees as priority.
Reducing the attractiveness of the image of alcohol
How young people see alcohol and alcohol use influences their interest in trying it out. It also influences how they interpret their own alcohol experience, when they start to use it. Young persons expecting to feel good, or light-headed, or free of inhibitions, are likely to experience exactly strongly programmed to interpret their initial alcohol experiences as pure pleasure.
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