Wine hath drowned more men than the sea. —Thomas Fuller
Drunkenness is nothing but voluntary madness. —Seneca
There have been several instances when even mild efforts by health authorities to warn about serious health impacts of alcohol were resisted by alcohol lobbyists who also tried to spread disinformation with regard to supposed health benefits of alcohol. A recent example is of the criticism faced by the Ireland government which has enacted a law which requires all alcoholic products to prominently mention that their consumption is directly linked to liver disease and cancer. However this law has been welcomed by several top experts who have also criticized earlier efforts of lobbyists to promote mild drinking and red wine drinking as being good for health despite this being not at all grounded in science. Keeping in view such persistent efforts by lobbyists , results of important scientific research, various surveys and estimates regarding alcohol use are presented here.
The per capita per year pure alcohol consumption at the world level increased from 5.5 litres in 2005 to 6.4 litres in 2016 and is projected to increase again from 2016 to 2025. Keeping in view the population rise, one can imagine what a big increase in quantity of alcohol production and consumption is taking place at world level, resulting in environmental adverse impact too. However the world level increase rate is lower than the faster rate of growth of liquor consumption in India. The world level increase is driven above all by the rising trend in two highly populated countries, India and china. The rate of increase is higher in India than in China.
In India the per capita per year pure alcohol consumption increased from 2.4 litres in 2005 to 5.7 litres in 2016, a more than double increase in roughly a decade. This is projected to increase to about 8 litres in 2025 when for the first time since records are available the average consumption in India at 8 litres is projected to be higher than the world average of 7 litres.
According to the WHO Status report, in 2016, the harmful use of alcohol resulted in some 3 million deaths (5.3% of all deaths) worldwide and 132.6 million disability-adjusted life years (DALYs) – i.e. 5.1% of all DALYs in that year. Mortality resulting from alcohol consumption is higher than that caused by diseases such as tuberculosis, HIV/AIDS and diabetes. Among men in 2016, an estimated 2.3 million deaths and 106.5 million DALYs were attributable to the consumption of alcohol. Women experienced 0.7 million deaths and 26.1 million DALYs attributable to alcohol consumption.
This report tells us that in 2016, of all deaths attributable to alcohol consumption worldwide, 28.7% were due to injuries, 21.3% due to digestive diseases, 19% due to cardiovascular diseases, 12.9% due to infectious diseases and 12.6% due to cancers. About 49% of alcohol attributable DALYs are due to non-communicable and mental health conditions, and about 40% are due to injuries.
13.5% of all deaths among those who are 20–29 years of age are attributed to alcohol.
Explaining the situation further this report tells us that the health and social harms from drinking alcohol occur through three main interrelated mechanisms: 1) the toxic effects of alcohol on diverse organs and tissues in the consumer’s body (resulting, for instance, in liver disease, heart disease or cancer); 2) development of alcohol dependence whereby the drinker’s self-control over his or her drinking is impaired, often involving alcohol-induced mental disorders such as depression or psychoses; and 3) through intoxication – the psychoactive effects of alcohol in the hours after drinking
According to research works consulted for preparing this status report alcohol consumption has been shown to increase the risk of HIV/AIDS by increasing the risk of transmission (resulting from an increased risk of unprotected sex ) and by increasing the risk of infection and subsequent mortality from tuberculosis and lower respiratory infections by suppressing a wide range of immune responses via multiple biological pathways, particularly in people who engage in heavy episodic drinking or who chronically consume large amounts of alcohol .
The harmful use of alcohol is associated both with an increased risk of acquiring HIV infection and with negative effects on people living with HIV/AIDS in terms of treatment outcomes, morbidity and mortality.
Further the WHO status report informs us that alcohol consumption has a synergistic effect with viral hepatitis in the progression of liver disease. In addition, alcohol is a well-known causal factor for non-infectious liver diseases, including hepatitis and liver cirrhosis, and the latter is associated with high mortality.
Coming to cancer this report says that there is an established causal link between alcohol use and cancer development in the oropharynx, larynx, esophagus, liver, colon, rectum and the female breast. The risks are generally higher for females than males. Even moderate alcohol intake, corresponding to daily consumption of no more than 25 grams of pure alcohol, has been shown to increase the risk of developing female breast cancer.
This report informs us that the causal relationship of alcohol consumption and liver diseases is well established, and alcohol has been shown to have an ability to cause hepatocellular damage through ethanol metabolism-associated mechanisms and malnutrition. Alcohol use is one of the most frequent causes of liver disease; alcohol-involved subtypes of liver disease include alcoholic hepatitis, steatosis, steatohepatitis, fibrosis and cirrhosis. Acute alcoholic hepatitis and liver cirrhosis are associated with high mortality (which can reach 50% in acute alcohol hepatitis), and the median survival time of patients with advanced liver cirrhosis can be as low as 1–2 years.
Giving an example from China this report mentions the Beijing 302 Hospital which is a large hospital treating patients from most parts of China, including over 40 000 patients per year with liver disease. Those treated for liver disease at the hospital are thus reflective of trends in liver disease in China. In the period 2002–2013, the distribution of types of liver disease changed at the hospital, with the proportion of alcoholic liver disease (ALD) more than doubling . Throughout this period, most of the patients with ALD (about 98%) were male. A study reporting this remarked that “the number of patients with ALD is rising at an alarming rate in China”.
The WHO report refers to expansive literature which shows that alcohol intoxication can increase dysphoria, cognitive dysfunction, impulsivity and intensity of suicidal ideation. People have approximately seven times increased risk for a suicide attempt soon after drinking alcohol, and this risk further increases to 37 times after heavy use of alcohol. The alcohol-attributable fraction for suicide was estimated to be as high as 18% It is also known that the presence of AUDs (Alcohol Use Disorders) at least doubles the risk of having depression .
This report points out that the potential effects of alcohol include impairment in attention, cognition and dexterity (which are important for such activities as driving a car); aggressive impulses and loss of behavioral control (important for criminal violence); and alcohol poisoning (which can be fatal).
Further this report tells us that alcohol poisoning is a consequence of drinking large amounts of alcohol in a short period of time. Drinking too much in a short period of time can affect breathing, heart rate, body temperature and gag reflex and may result in a coma and death. In comparisons with other psychoactive substances, alcohol is among the most lethal in terms of how close the amounts used for psychoactive effects are to the median amount that is lethal. While poisoning clusters from contaminated alcohol often receive global press coverage, poisoning with ordinary beverage alcohol – usually in concentrated form such as distilled beverages – is an everyday reality in many societies, although it is often under-recorded in health statistics.
The harmful use of alcohol is a component cause of more than 200 diseases and injury conditions, the most notable being alcohol dependence, liver cirrhosis, cancers and injuries, the latest causal relationships established are those between alcohol consumption and incidence of infectious diseases such as tuberculosis and HIV/AIDs.
However, the alcohol industry and its lobbyists have worked overtime to ensure that the massive adverse impacts of alcohol consumption are not reported adequately and properly so that people do not become aware about the full dimensions of these tragic impacts. A recent study led by scientists at the London School of Hygiene and Tropical Medicine and Sweden’s Karolinska Institute has concluded that the alcohol industry “uses denial, distortion and distraction to mislead people about the risks of developing cancer from drinking, often employing similar tactics to those of the tobacco industry." However, the WHO says that drinking alcohol is a well established risk factor for a range of cancers including tumors of the mouth, liver, breast, colon and bowel, and the risk of cancer rises with the level of alcohol consumed.
Earlier also heavy drinking was linked to damage to brain, adverse impact of memory and dementia, but recent findings by researchers of Oxford University and University College London (published in British Medical Journal) has found that this damage is possible also at much lower alcohol consumption. This is also confirmed by another study involving 1300 women in the USA. Brain damage is likely to be higher in the case of binge drinking, particularly binge drinking involving adolescents.
Although the highly adverse impacts of alcohol consumption are very well-known, the alcohol industry has been trying for quite some time to somehow spread the myth that moderate levels are not a problem.
However an extensive study based on 195 countries which was published in the prestigious medical journal The Lancet (August 2018) concluded clearly that not even one drink a day is safe.
Max Griswold, lead author for a group of over 500 experts said, “There is no safe level of alcohol,” “Overall, the health risks associated with alcohol rose in line with the amount consumed each day."
Compared to abstinence, just one drink a day can lead to 1,00,000 additional deaths each year.
In the 15-49 age-group, alcohol is responsible for over 12% of deaths among all.
Deaths in this age-group is generally believed to cause more distress in households.
Considering 24 health problems, this study found that five drinks a day can raise severe health consequences by 37%. In Romania male drinkers average 8 drinks a day, while in Portugal and Ukraine they average 7 drinks a day.
Regarding non-fatal accidents, this encyclopedia tells us that alcohol is involved in 23 to 30 per cent of these accidents. In the case of fatal fire and burn accidents, alcohol was found to have a role in 46 per cent of such accidents.
Dame Sally Davies, Chief Medical Officer of Britain, overcame a lot of resistance from liquor industry lobbyists to radically change two decade old guidelines which had understated health risks of liquor while also either implicitly conceding or at least not adequately refuting imaginary claims of some health benefits (for example in the context of red wine) spread by lobbyists and sellers of liquor.
The new guidelines came in the wake of growing concern over reported 500 per cent increase in deaths from liver disease among working age people in Britain since the 1970s. Another serious concern came with growing evidence of higher risks of a range of cancers associated with liquor, including red wine.
The evidence regarding the closer link between liquor and a range of cancers was supported by a new review from the Committee on Carcinogenicity in Britain.
The development of the new guidelines was chaired by Prof. Mark Petticrew, Prof. of Public Health Evaluation at the London School of Hygiene and Tropical Medicine and by Prof. Sally Macintyre, Prof. Emeritus at the University of Glasgow.
The new guidelines on liquor consumption released on 8 January 2016 by the Chief Medical Officer to replace nearly two decade old guidelines warned that drinking any level of alcohol increases the risk of a range of cancers. The guidelines also make it clear that no level of alcohol is safe for drinking in pregnancy.
These guidelines inform that drinking regularly over time can lead to a wide range of illnesses including cancers, strokes, heart diseases, liver diseases, and damage to the brain and nervous system.
On the other hand, these guidelines also make it clear that there is no justification for drinking for health reasons.
In fact the highly exaggerated and mostly imaginary health benefits cited to justify increased consumption of red wine had led to increased chances of addiction among a different category of drinkers who had been careful regarding hard liquors like whisky, vodka and rum but had become careless regarding consumption of red wine and fortified wines due to the false myths spread regarding their lower risks and higher benefits of red wine.
The alcohol content of red wines and fortified wines is between 10 to 22 per cent for various brands. This is three or more times higher than the alcohol content of beer which ranges between 2 to 10 per cent. Despite this red wine was promoted as a low- risk liquor and at times this was promoted as a health drink which benefits heart.
Later even some of those who claimed such benefits had to admit that these could be more easily obtained from some raw grapes and berries and from some types of exercise and there was no need at all to accept the various risks of alcohol consumption to get these benefits.
However as the myth about benefits and low risk had been spread widely, a significantly large number of people started drinking red wine as a matter of almost daily habit after returning from work. It was against this background that a huge increase in liver disease deaths among working age people caused a lot of concern.
At this stage health professionals and activists started warning about this. Duncan Selbie, head of an organization Public Health, England presented in his calculation of health impacts that one glass of red wine is the equivalent of three shots of vodka. This was widely reported.
Around the same time some objections were also voiced by environmentalists regarding excessive use of agro-chemicals and water by the wine industry and also regarding its high GHG emissions. The Economist reported that 960 litre of water are required to make available one litre of wine. To produce 274 million hectoliters of wine in a year the amount of water needed can be well imagined. About 19 million acres have to be devoted to grow the essential raw material for the wine industry. Hence a lot of precious land and water are taken away from producing staple food at a time when food security is increasingly threatened.
All these factors taken together can lead to a better comprehension of the real costs of the liquor industry. As we in India are painfully aware, the costs of high liquor consumption in terms of road accidents and other accidents, ruin of health, economic loss, domestic violence, sexual violence and other violent crime are very high. Despite the availability of shocking facts and figures on all these aspects, this issue does not get the attention it deserves among elites.
However people particularly women at many places are fighting to reduce the consumption and sale of liquor in various ways. Efforts such as the issue of new guidelines in Britain are a big help for creating conditions in which the voices of these struggles can be heard.
According to the American Psychological Association, “Alcohol use and alcoholism can worsen existing conditions such as depression and induce new problems such as serious memory loss, depression or anxiety.”
According to NIH, USA, “Alcohol abuse may lead to suicidality through disinhibition, impulsiveness and impaired judgment but it may also be used as a means to ease the distress associated with an act of suicide.”
Researchers who compared alcoholics with non-drinkers found suicide tendencies in the former to be 60 times or more. Research by Razvodovsky in Russia revealed that suicides decreased in areas where vodka consumption was restricted.
According to a widely cited paper on ‘alcohol and sexual assaults’ by Antonia Abbey, Tina Zawacki and others of the National Institute of Alcohol Abuse and Alcoholism (USA), “ at least one half of all violent crimes involved alcohol consumption by the perpetrator, the victim or both. Sexual violence fits this pattern. Thus across disparate population studies, researchers consistently have found that approximately one half of all sexual assaults are committed by men who have been drinking alcohol. Depending on the sample studied and the measure used, the estimates for alcohol use among perpetrators have ranged from 34 to 74 percent. Similarly, approximately one third of all sexual assault victims report that they were drinking alcohol at the time of assault with estimates ranging from 30 to 39 per cent. However, these researchers also point out that while a woman’s alcohol consumption may place her at increased risk of sexual assault, she is in no way responsible for the assault. The researchers rightly say that the perpetrators remain legally and morally responsible for their behavior.
However, it also needs to be pointed out that while the data about alcohol consumption by perpetrators is relevant to almost all situations, the data about alcohol consumption by victims may not be relevant to those social contexts such as several parts of India where alcohol consumption by women is very low.
In a widely quoted paper Martin and Hummer argued that many fraternities create a social environment in which social coercion is normalized because women are perceived as commodities available to meet men’s sexual needs. Alcohol is used to encourage reluctant women to have sex. One fraternity man quoted in this paper said, “We provide them with ‘hunch punch’ and things go wild. We get them drunk and most of the guys end up with one”. He describes his plan to get one ‘prim and proper sorority girl’ get drunk by spiking her punch.
According to another paper by Antonia Abbey, “the peer norms for most fraternity parties are to drink heavily to act in an uninhibited manner and to engage in casual sex”.
According to a recent report from the National Task Force on College Drinking (USA), 1400 college students die each year in alcohol related accidents, 5, 000,00 are injured and there are 70, 000 victims of alcohol related sexual assault or date rape.
A study by Testa and Livingston mentioned women’s narrative description of incapacitated rape which indicates that many were unconscious and found out later that they were raped, or else were only dimly aware of what was happening and so were unable to stop the assailant.
It is widely recognized that alcohol has extremely serious adverse health impacts. However, what is not so widely realized is that women are more vulnerable to many sided health hazards of alcohol. According to the WHO , “there is evidence that women may be more vulnerable to alcohol-related harm from a given level of alcohol use or a particular drinking pattern. The vulnerability of females to alcohol-related harm is a major public health concern because alcohol use among women has been increasing steadily in line with economic development and changing gender roles and because it can have severe health and social consequences for newborns…. For health outcomes such as cancers, gastrointestinal diseases or cardiovascular diseases, the same level of consumption leads to more pronounced outcomes for women.”
The vulnerability of women may be explained by a wide range of factors. For example, women typically have lower body weight, smaller liver capacity to metabolize alcohol, and a higher proportion of body fat, which together contribute to women achieving higher blood alcohol concentrations than men for the same amount of alcohol intake. Women are also affected by interpersonal violence and risky sexual behavior as a result of the drinking problems and drinking behavior of male partners. Moreover, alcohol use has been shown to be a risk factor for breast cancer. Also many societies hold more negative attitudes towards women’s drinking alcohol than men’s drinking, which, depending on the cultural context, may increase women’s vulnerability to social harm. Finally, women who drink during pregnancy may increase the risk of fetal alcohol spectrum disorder (FASD), and other preventable health conditions in their newborns.
The WHO Status Report on Alcohol and Health 2018 has clearly stated that alcohol use during pregnancy has been established as a risk factor for adverse pregnancy outcomes, including stillbirth, spontaneous abortion, premature birth, intrauterine growth retardation and low birth weight, and can result in a range of lifelong conditions known as fetal alcohol spectrum disorders (FASD).
As pointed out in this WHO Report, FASD is an umbrella term which includes fetal alcohol syndrome (FAS), partial fetal alcohol syndrome (pFAS), alcohol-related neuro-developmental disorder (ARND) and, depending on the diagnostic and classification system, alcohol-related birth defects (ARBD) . FASD is characterized by central nervous system damage and its manifestations include physical, mental and behavioral features and learning disabilities with possible lifelong implications.
Presenting a review of the available research on this issue the WHO status report states -- A systematic review and meta-analysis by Popova and colleagues estimated that the global prevalence of alcohol use during pregnancy in the general population amounts to 9.8%. In addition, Lange and colleagues observed, at the country level, that binge drinking during pregnancy ranged from 0.2% to 13.9% ( Note—health risks from binge drinking can be much higher than from normal drinking ). Drinking during pregnancy resulted in an estimated prevalence of FAS in the general population of 14.6 per 10 000 people and a prevalence of FASD of 77.3 per 10 000 people . The prevalence of FAS and FASD varies by WHO region, with the prevalence being highest in the Region of the Americas (AMR) and the European Region (EUR) . Additionally, a recent systematic review and meta-analysis by Popova and colleagues found that 428 conditions co-occurred with FASD. Some of the most common health problems are congenital malformations, chromosomal abnormalities, prenatal and postnatal growth delays, intellectual disability, behavioral disorders, speech and language difficulties, visual and audiological impairments, cardiac deformities and urogenital problems.
In some cultures women have been protected from alcohol consumption by strong traditional values. Imagine the public health and social disaster that could result if alcohol consumption by women in India reaches the level of the USA. Yet, promoting alcohol consumption among women as a sign and symbol of liberating modern trends is widely practiced in India and the alcohol industry puts in a lot of effort and money to promote this view. Some recent Bollywood movies which promoted this view in a big way were widely praised by big media as a liberating trend. Such perceptions should be corrected before it is too late.
The Independent newspaper quoted a regular practitioner of drunkorexia saying, “all alcohol contains loads of empty calories, yet we are also expected to be slim. I and others I know do as many shots of vodka as we can so we get drunk on the least amount of calories and make bloating less likely. “
The Independent also quoted a study which revealed that a surprisingly high per cent of female under graduates exhibit drunkorexic tendencies.
According to the Eating Disorder Center of Denver, of the participating college- aged females in an adjunct research study, about 75 per cent met the criteria for alcohol abuse.
In a study in Australia involving women aged between 18 to 29 years, who were enrolled in university, 79 per cent of participants demonstrated engaging in characterized drunkorexia behavior.
Drinking on an empty stomach makes it possible for ethanol to reach the blood system at a faster pace and to raise a person’s blood alcohol content at a high risk speed. This can increase the chances of alcohol related brain damage. In addition, drunkorexia also increases the possibility of black outs, alcohol poisoning, injury and illness. These harmful impacts are more likely in the case of women compared to men as women are generally less capable of metabolizing alcohol than men.
In some cases drunkorexia also involves self induced vomiting soon after the consumption of alcohol.
Further this report says that results of school surveys indicate that in many countries of the Americas, Europe and Western Pacific alcohol use starts before the age of 15 years and prevalence of alcohol use among 15-year-old students can be in the range of 50–70% with remarkably small differences between boys and girls.
Summarizing the result of several studies this report tells us that alcohol use in adolescents is associated with alterations in verbal learning, visual–spatial processing, memory and attention as well as with deficits in development and integrity of grey and white matter of the central nervous system . These neuro-cognitive alterations by adolescents’ alcohol use seem to be related to behavioral, emotional, social and academic problems in later life, the report adds.
Some problems are also passed on to children and youths from alcoholic parents, particularly father. Parental drinking and poor parent–adolescent relationship quality are among the factors related to adolescent alcohol use, this report says quoting several researchers.
As this report points out, there is a consistent and large amount of evidence demonstrating the positive association between parental and offspring drinking. Parental alcohol problems were associated significantly with a higher likelihood of frequent emotional symptoms, depression, low self-esteem and loneliness among both boys and girls. In addition, parental heavy drinking and alcohol problems were shown to be associated with worsening outcomes in children, including educational outcomes, drug use, conduct problems and criminality. Parental alcohol use disorders (AUDs) are associated with a higher risk of their children developing depression in adulthood.
According to the WHO, alcohol consumption in adolescents, especially binge drinking, negatively affects school performance, increases participation in crime and leads to risky sexual behavior. The WHO quotes growing scientific evidence that has demonstrated the special harmful effects of alcohol consumption prior to adulthood on brain; mental, cognitive and social functioning of youth and increased likelihood of adult alcohol dependence and alcohol related problems among those who drink before physiological maturity.
The World Report on Violence and Health ( WRVH) says, especially in the context of youth violence, that drunkenness is an important immediate situational factor that can precipitate violence. In a Swedish study on youth-violence, about three-quarters of violent offenders and around half the victims of violence were intoxicated at the time of the incident.
Several surveys indicate high and rapidly increasing consumption of alcohol amongst youth. What is particularly worrying is high consumption at a very tender age which is likely to be very harmful for brain and also lead to much higher risk of alcohol dependence in later years. For example, in UK binge drinking thrice or more a month is reported among 33 per cent of adolescents in the 15-16 age groups. Binge drinking levels affecting between 25 to 40 per cent of youth are quite common now.
Coming now to the situation in India the WHO status Report on Alcohol and Health has said that India has emerged as a country which is recording some of the highest increase in liquor consumption in the entire world. Although it is not specifically mentioned in this report to what extent this increase in liquor consumption has also led to an increase among students and youth there is a lot of sporadic evidence from many parts of India which indicates that the increase of alcohol among youths in India may be even higher than the overall trend of increase in liquor consumption in the country.
In many parts of the country which this writer visited to write about anti-liquor movements, it was generally seen that women were taking the lead in these movements and their biggest grievance was that their adolescent children are also falling prey to the liquor habit due to the overall increasing trend of liquor consumption and the location of liquor vends within the village.
Heavy episodic drinking, often called binge drinking, is generally regarded as a more risky form of liquor consumption. The WHO Status Report defines this as the consumption of at least 60 grams or more of pure alcohol on at least one occasion in the past 30 days. In India in the 15-19 age group 12.6 per cent of adolescents had indulged in this ( 21.1 per cent of males and 3.6 per cent of females).
Clearly there are several very worrying aspects of these trends and we need to wake up these problems and carry out special campaigns among youth and students before it is too late.
In a 4-year study conducted in New Zealand crime rates in situations of high and low availability of alcohol were compared. This study revealed that crime rates fell significantly for 2 years in areas of reduced alcohol availability.
According to a report prepared by the National Council on Alcoholism and Drug Dependence, USA (NCADD), alcohol and drugs are implicated in estimated 80 per cent of offences leading to incarceration in the USA such as domestic violence, driving while intoxicated, property offences, drug offences and public ordered offences. Alcohol is a factor in 40 per cent of all violent crimes and according to the department of justice, 37 per cent of about 2 million convicted offenders currently in jail report that they were drinking at the time of the event. Alcohol, more than any illegal drug, was found to be closely associated with violent crimes including murder, rape, assault, child and spousal abuse. About 3 million violent crimes occurred each year in the USA in which victims perceived the offenders to have been drinking and statistics related to alcohol use by violent offenders show that about half of all homicides and assaults are committed when the offender, victim or both have drinking.
This report by NCADD points out that alcohol is often a factor in violence where the attacker and the victim know each other. Two thirds of victim who were attacked by an intimate (including a current or formal spouse, boyfriend or girlfriend) reported that alcohol had been involved.
More than 1 million are arrested for driving while intoxicated in a year in the USA. Drinking and drugged driving is the number one cause of death, injury and disability of young people under the age of 21.
(i) 367 persons were killed
(ii) 13,660 persons were hospitalized
(iii) Special care had to be arranged for 19,443 children
(iv) 25,481 family members were attacked
(v) 44,852 strangers were attacked
(vi) 73 per cent persons were affected in some way or the other to a lesser or greater extent
Beyond causing harm to the drinker, alcohol intoxication is often the main mechanism of harm to others from drinking.
Studies of drinking by the offender and by the victim in homicides have chiefly been in societies where drinking to intoxication is common. Meta-analyses of these studies have found that 48% both of victims and of perpetrators had been drinking when the homicide occurred, and that 37% of the offenders and 33–35% of the victims had drunk enough to be intoxicate.
i) Estimate for the European Union, Year 2003 - 125 billion euros
ii) Estimate for UK, Year 2009 – 21 billion pounds
iii) Estimate for USA, Year 2006 – 233 billion dollars
iv) Estimate for South Africa, Year 2009 – 300 billion Rand (10-12 per cent of GNP)
While this data about financial implications of social costs is very disturbing, at the same time it needs to be emphasized that violence leading to loss of life and disruption of close relationships caused by alcohol can never be fully calculated in money terms; it goes beyond that.
Another cause of concern is the increasing consumption of liquor by women in several countries despite the fact that alcohol has some special health risks for women. For example, fetal alcohol syndrome and fetal alcohol effects, preventable causes of mental retardation may result from alcohol consumption during pregnancy.
It is in this context that the demands for curbs on increasing liquor sale and consumption have been raised by several anti-liquor movements in various parts of India, particularly rural India. These include social movements with a larger agenda which have also felt the need for resisting liquor related problems and also very specific anti-liquor movements focusing mainly or only on this issue. Women have played the most important role in most of these movements and have brought a strong sense of urgency and passion into these movements. One important specific demand of several of these movements has been to remove the liquor vend or shop from their village so that easy availability of liquor within the village or very near to the village can be checked.
While most governments have paid lip sympathy to anti liquor sentiments, in reality they have been happy to collect massive revenue from sale of liquor. In addition several politicians have close links with liquor mafias and some of them have themselves entered liquor production and trade. Despite all this, several governments have been forced to respond to growing public sentiments against liquor, particularly in the context of women voters. They have responded to the anti-liquor sentiments of people particularly women in various ways. Prohibition has been in existence in Gujarat and parts of North-East India and was more recently introduced in Bihar. Other state governments have agreed at times to removing liquor vends if certain conditions such as opposition by more than 50 per cent local population are satisfied and proved. Others have withdrawn specific vends following opposition.
On the whole, however, the massive, many-sided damage caused by alcohol has been increasing. However one ray of hope is provided by the fact that where sustained efforts by people’s movements are made there alcohol consumption comes down significantly and this reduction is sustained for a long time. One example is the anti-liquor effort associated with the Chattisgarh movement of iron ore miners led by Shankar Guha Niyogi where several thousand miners gave up liquor motivated by women as well as by wider trade union loyalty and commitment. The big lesson here is that sustained public campaigns and community efforts are necessary for sustainable reduction of alcohol consumption and other substance abuse. Merely government action cannot succeed in a significant and sustainable way even if it is well-intentioned, this has to be supplemented by a sustained, continuing public campaign against liquor and other intoxicants and various forms of substance abuse. This should involve various respected members of community who have credibility. This campaign should have strong links with schools and colleges so that a strong anti-liquor message can be imparted in friendly and interesting ways at an early age and can be included in the curriculum.
Thus a combination of suitable, well-thought government policies suited to local conditions and sustained, broad-based public campaigns with women and respected community leaders playing an important role can together succeed in reducing liquor consumption and all the associated problems to a considerable extent.
What exact form this policy takes will depend on diverse conditions of various societies. What is perhaps common to all societies is that there should be a well- informed sustained campaign against many- sided adverse impacts of alcohol. Such campaigns should be adequately supported by governments. All containers of alcoholic drinks should carry strong warnings of health and social adverse impacts. Efforts to present alcohol in attractive settings should be discouraged in various ways. There should be a ban on not just direct but also indirect advertisements of alcoholic drinks.
More specifically in conditions of rural India there should be clear policy that no liquor vends or shop can be opened in a village where 50 per cent or more people sign a petition against it. At the same time there should be very strong action against illegal or secretive sale points of liquor.
Similar decisions can be taken for urban localities keeping in view their specific conditions.
The government policy should cease to see liquor as a source of obtaining more and more revenue. Instead looking at the wider, much higher adverse impacts of liquor the government should make available resources for strong action to minimize the consumption of liquor as well as for efforts of de-addiction and rehabilitation.
The government should try to take the active participation of people, particularly women, in many sided efforts to curb liquor consumption. Once such widespread public participation is ensured, using legal efforts to curb liquor consumption in various ways will also be more successful.
First a leading newspaper Dainik Jagran reported that apples as well as other highly nutritious fruits in the state will be diverted on a large scale for production of wine and the existing processing facilities of a public sector unit will be made available to a private company for taking this new wine to many parts of country. Then on May 1, 2018 another news appeared in another leading newspaper Navbharat Times that along with fruits special Kangra Tea Leaves will be used to prepare tea wine with alcohol content of 12 per cent ( much higher than beer) . A government science lab is being used to prepare this and a private company has been contracted to sell this as tea wine on a large scale. The government will also be earning from this deal.
It is very worrying that even such a staple drink as tea which is consumed by an overwhelming majority of people in the country is being imitated to prepare an alcoholic drink based on tea leaves with a high alcohol content and at the same time fruits are being diverted for the production of this wine, at a time when children from poor families in this apple-producing state find it very difficult to eat apples.
It is likely that soon there will be a drive by unlicensed shops to sell these new forms of liquor, as can already by seen as some general merchants and fruit juice shops are seen selling fruit wine. What is even worse is that high alcohol content drink or liquor is being promoted for health benefits, a trend which has already been exposed for all its falsehood, deceit and pressures of liquor lobby in the context of red wine.
It is now well known that the completely false promotion of red wine as a healthy drink led to massive damage to health and a huge increase in liver disease as well as other serious health problems. The same tragedy will be repeated in India on an even larger scale when fruit wine and tea wine are promoted for their false health benefits while covering up the conspiracy of the liquor lobby in taking liquor to more and more people.
Hence this dangerous trend and the distorted thinking behind it should be checked as early as possible.
The recently released World Status Report on Alcohol and Health 2018 prepared by the WHO has also argued along similar lines. This report says—“ At the international level, the broad scope and magnitude of health and social problems caused by the harmful use of alcohol require coordinated and concerted actions by different parts of the United Nations system and regional intergovernmental organizations in the context of the 2030 Agenda for Sustainable Development.”
The Status Report has pointed out that neither alcohol nor tobacco was included in the modern international drug control treaties when they were adopted during 1961–1988. With development and ratification of the Framework Convention on Tobacco Control (FCTC) in response to the globalization of the tobacco epidemic, now “alcohol remains the only psychoactive and dependence-producing substance with significant global impact on population health that is not controlled at the international level by legally-binding regulatory frameworks.” Hence clearly strong international action to check alcohol consumption is overdue.
The latest WHO status further draws attention to the fact that as a consumer product and trade item, alcohol comes under the jurisdiction of international trade treaties and the international trade system, which have focused on maximizing the freedom of international trade and investment and thereby minimizing “technical barriers to trade and other alcohol control measures” that national or local governments may impose. While there are “public health” exceptions in the treaties, the WHO report points out, these are interpreted narrowly, so that a provision in the interest of public health is not accepted if an alternative measure can be put forward as an option, whether or not the measure would be effective.
Hence the WHO Status Report on Alcohol and Health states very clearly, “Given the increasing encroachment of international trade and investment on the ability of national and sub-national governments to control their alcohol markets, and the increasingly consolidated global alcohol producers, a strong public health case for considering the negotiation of a Framework Convention on Alcohol Control, or alternatively for including alcohol within other international control systems has been repeatedly presented and discussed by public health entities, experts and advocates.”
This report quotes studies to make the point that alcoholic beverage production has become increasingly concentrated and globalized in recent decades, particularly in beer and spirits, but increasingly also in wine. An additional adverse factor from the point of view of health impacts is that very significant proportions of the commercial alcohol market are consumed in heavy drinking occasions meaning the “central interests of alcoholic beverage producers are inherently at odds with the public health interest.”
This report points out that significant influence of alcohol industries on political decisions which affect them has been documented at national and sub-national levels. In some countries with substantial alcohol production and trade, this influence extends to the international level, both through national delegations in international organizations and negotiations, and through national, regional and global alliances within and across industries What is more, this report states, this interference was reported on several levels, including industry presence during legislative meetings as well as challenges to the legal basis of existing alcohol policies.
Despite this troubling evidence the WHO report regrets that there is no public health-oriented international agreement on alcohol to counter the strong influence of the producers through the international trade institutions and agreements.
On the contrary, the status report tells us, general trends towards deregulation in recent decades have often resulted in the weakening of alcohol controls – to the benefit of economic interests but “at the expense of public health and welfare.”
Keeping in view all these adverse factors this report asserts that substantial added resources are needed to provide leadership at the international level to pursue the public health agendas for alcohol in the face of the strong presence of the global industry at the international policy level.
This report refers to studies which tell us that alcohol producers may also influence public health and welfare perspectives in research .A glaring example given in the status report is that a study of potential health benefits of light drinking (one drink per day) versus abstention, with alcohol industry multinationals and alliances as the main sources of the US$ 100 million funding, was discontinued after a government review group concluded that the interactions of the study’s investigators “and the alcohol industry ‘appear to have intentionally biased the framing of the scientific premise of the study’ in the direction of focusing on possible benefits of alcohol” . This is by no means an isolated example. The status report informs us that such efforts to bias research and public health policies to accommodate industry’s interests, often with as little record of the influence as possible, can also be found in other countries and situations.
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Bharat Dogra is a journalist who has been involved with several social movements and initiatives. His work has been recognized in the form of several prestigious awards. He has travelled to several places of anti-liquor movements to report on them. His recent books include A Day in 2071, Planet in Peril, Protecting Earth for Children and Man over Machine
1. Highly Adverse Health Impacts
There is more evidence than ever before of very serious health risks from alcohol but despite this the overall trend in the world from 2005 to 2025 is of a significant rise in liquor consumption. This is the overall conclusion of the World Status report on Alcohol 2018 prepared by the WHO and released in September 2018.The per capita per year pure alcohol consumption at the world level increased from 5.5 litres in 2005 to 6.4 litres in 2016 and is projected to increase again from 2016 to 2025. Keeping in view the population rise, one can imagine what a big increase in quantity of alcohol production and consumption is taking place at world level, resulting in environmental adverse impact too. However the world level increase rate is lower than the faster rate of growth of liquor consumption in India. The world level increase is driven above all by the rising trend in two highly populated countries, India and china. The rate of increase is higher in India than in China.
In India the per capita per year pure alcohol consumption increased from 2.4 litres in 2005 to 5.7 litres in 2016, a more than double increase in roughly a decade. This is projected to increase to about 8 litres in 2025 when for the first time since records are available the average consumption in India at 8 litres is projected to be higher than the world average of 7 litres.
According to the WHO Status report, in 2016, the harmful use of alcohol resulted in some 3 million deaths (5.3% of all deaths) worldwide and 132.6 million disability-adjusted life years (DALYs) – i.e. 5.1% of all DALYs in that year. Mortality resulting from alcohol consumption is higher than that caused by diseases such as tuberculosis, HIV/AIDS and diabetes. Among men in 2016, an estimated 2.3 million deaths and 106.5 million DALYs were attributable to the consumption of alcohol. Women experienced 0.7 million deaths and 26.1 million DALYs attributable to alcohol consumption.
This report tells us that in 2016, of all deaths attributable to alcohol consumption worldwide, 28.7% were due to injuries, 21.3% due to digestive diseases, 19% due to cardiovascular diseases, 12.9% due to infectious diseases and 12.6% due to cancers. About 49% of alcohol attributable DALYs are due to non-communicable and mental health conditions, and about 40% are due to injuries.
13.5% of all deaths among those who are 20–29 years of age are attributed to alcohol.
Explaining the situation further this report tells us that the health and social harms from drinking alcohol occur through three main interrelated mechanisms: 1) the toxic effects of alcohol on diverse organs and tissues in the consumer’s body (resulting, for instance, in liver disease, heart disease or cancer); 2) development of alcohol dependence whereby the drinker’s self-control over his or her drinking is impaired, often involving alcohol-induced mental disorders such as depression or psychoses; and 3) through intoxication – the psychoactive effects of alcohol in the hours after drinking
According to research works consulted for preparing this status report alcohol consumption has been shown to increase the risk of HIV/AIDS by increasing the risk of transmission (resulting from an increased risk of unprotected sex ) and by increasing the risk of infection and subsequent mortality from tuberculosis and lower respiratory infections by suppressing a wide range of immune responses via multiple biological pathways, particularly in people who engage in heavy episodic drinking or who chronically consume large amounts of alcohol .
The harmful use of alcohol is associated both with an increased risk of acquiring HIV infection and with negative effects on people living with HIV/AIDS in terms of treatment outcomes, morbidity and mortality.
Further the WHO status report informs us that alcohol consumption has a synergistic effect with viral hepatitis in the progression of liver disease. In addition, alcohol is a well-known causal factor for non-infectious liver diseases, including hepatitis and liver cirrhosis, and the latter is associated with high mortality.
Coming to cancer this report says that there is an established causal link between alcohol use and cancer development in the oropharynx, larynx, esophagus, liver, colon, rectum and the female breast. The risks are generally higher for females than males. Even moderate alcohol intake, corresponding to daily consumption of no more than 25 grams of pure alcohol, has been shown to increase the risk of developing female breast cancer.
This report informs us that the causal relationship of alcohol consumption and liver diseases is well established, and alcohol has been shown to have an ability to cause hepatocellular damage through ethanol metabolism-associated mechanisms and malnutrition. Alcohol use is one of the most frequent causes of liver disease; alcohol-involved subtypes of liver disease include alcoholic hepatitis, steatosis, steatohepatitis, fibrosis and cirrhosis. Acute alcoholic hepatitis and liver cirrhosis are associated with high mortality (which can reach 50% in acute alcohol hepatitis), and the median survival time of patients with advanced liver cirrhosis can be as low as 1–2 years.
Giving an example from China this report mentions the Beijing 302 Hospital which is a large hospital treating patients from most parts of China, including over 40 000 patients per year with liver disease. Those treated for liver disease at the hospital are thus reflective of trends in liver disease in China. In the period 2002–2013, the distribution of types of liver disease changed at the hospital, with the proportion of alcoholic liver disease (ALD) more than doubling . Throughout this period, most of the patients with ALD (about 98%) were male. A study reporting this remarked that “the number of patients with ALD is rising at an alarming rate in China”.
The WHO report refers to expansive literature which shows that alcohol intoxication can increase dysphoria, cognitive dysfunction, impulsivity and intensity of suicidal ideation. People have approximately seven times increased risk for a suicide attempt soon after drinking alcohol, and this risk further increases to 37 times after heavy use of alcohol. The alcohol-attributable fraction for suicide was estimated to be as high as 18% It is also known that the presence of AUDs (Alcohol Use Disorders) at least doubles the risk of having depression .
This report points out that the potential effects of alcohol include impairment in attention, cognition and dexterity (which are important for such activities as driving a car); aggressive impulses and loss of behavioral control (important for criminal violence); and alcohol poisoning (which can be fatal).
Further this report tells us that alcohol poisoning is a consequence of drinking large amounts of alcohol in a short period of time. Drinking too much in a short period of time can affect breathing, heart rate, body temperature and gag reflex and may result in a coma and death. In comparisons with other psychoactive substances, alcohol is among the most lethal in terms of how close the amounts used for psychoactive effects are to the median amount that is lethal. While poisoning clusters from contaminated alcohol often receive global press coverage, poisoning with ordinary beverage alcohol – usually in concentrated form such as distilled beverages – is an everyday reality in many societies, although it is often under-recorded in health statistics.
The harmful use of alcohol is a component cause of more than 200 diseases and injury conditions, the most notable being alcohol dependence, liver cirrhosis, cancers and injuries, the latest causal relationships established are those between alcohol consumption and incidence of infectious diseases such as tuberculosis and HIV/AIDs.
However, the alcohol industry and its lobbyists have worked overtime to ensure that the massive adverse impacts of alcohol consumption are not reported adequately and properly so that people do not become aware about the full dimensions of these tragic impacts. A recent study led by scientists at the London School of Hygiene and Tropical Medicine and Sweden’s Karolinska Institute has concluded that the alcohol industry “uses denial, distortion and distraction to mislead people about the risks of developing cancer from drinking, often employing similar tactics to those of the tobacco industry." However, the WHO says that drinking alcohol is a well established risk factor for a range of cancers including tumors of the mouth, liver, breast, colon and bowel, and the risk of cancer rises with the level of alcohol consumed.
Earlier also heavy drinking was linked to damage to brain, adverse impact of memory and dementia, but recent findings by researchers of Oxford University and University College London (published in British Medical Journal) has found that this damage is possible also at much lower alcohol consumption. This is also confirmed by another study involving 1300 women in the USA. Brain damage is likely to be higher in the case of binge drinking, particularly binge drinking involving adolescents.
Although the highly adverse impacts of alcohol consumption are very well-known, the alcohol industry has been trying for quite some time to somehow spread the myth that moderate levels are not a problem.
However an extensive study based on 195 countries which was published in the prestigious medical journal The Lancet (August 2018) concluded clearly that not even one drink a day is safe.
Max Griswold, lead author for a group of over 500 experts said, “There is no safe level of alcohol,” “Overall, the health risks associated with alcohol rose in line with the amount consumed each day."
Compared to abstinence, just one drink a day can lead to 1,00,000 additional deaths each year.
In the 15-49 age-group, alcohol is responsible for over 12% of deaths among all.
Deaths in this age-group is generally believed to cause more distress in households.
Considering 24 health problems, this study found that five drinks a day can raise severe health consequences by 37%. In Romania male drinkers average 8 drinks a day, while in Portugal and Ukraine they average 7 drinks a day.
2. Accidents
According to the Encyclopedia of Drugs, Alcohol and Addictive Behavior, alcohol has been found to have a role in 44 per cent of fatal road accidents.Regarding non-fatal accidents, this encyclopedia tells us that alcohol is involved in 23 to 30 per cent of these accidents. In the case of fatal fire and burn accidents, alcohol was found to have a role in 46 per cent of such accidents.
3. New Guidelines Highlight More Serious Health Impacts
Some time after these were issued by a determined woman medical official with the support of senior cancer experts, new British guidelines on liquor are being seen as a big help by campaigners against the many-sided risks of alcoholic drinks not just in Britain but in other countries as well.Dame Sally Davies, Chief Medical Officer of Britain, overcame a lot of resistance from liquor industry lobbyists to radically change two decade old guidelines which had understated health risks of liquor while also either implicitly conceding or at least not adequately refuting imaginary claims of some health benefits (for example in the context of red wine) spread by lobbyists and sellers of liquor.
The new guidelines came in the wake of growing concern over reported 500 per cent increase in deaths from liver disease among working age people in Britain since the 1970s. Another serious concern came with growing evidence of higher risks of a range of cancers associated with liquor, including red wine.
The evidence regarding the closer link between liquor and a range of cancers was supported by a new review from the Committee on Carcinogenicity in Britain.
The development of the new guidelines was chaired by Prof. Mark Petticrew, Prof. of Public Health Evaluation at the London School of Hygiene and Tropical Medicine and by Prof. Sally Macintyre, Prof. Emeritus at the University of Glasgow.
The new guidelines on liquor consumption released on 8 January 2016 by the Chief Medical Officer to replace nearly two decade old guidelines warned that drinking any level of alcohol increases the risk of a range of cancers. The guidelines also make it clear that no level of alcohol is safe for drinking in pregnancy.
These guidelines inform that drinking regularly over time can lead to a wide range of illnesses including cancers, strokes, heart diseases, liver diseases, and damage to the brain and nervous system.
On the other hand, these guidelines also make it clear that there is no justification for drinking for health reasons.
In fact the highly exaggerated and mostly imaginary health benefits cited to justify increased consumption of red wine had led to increased chances of addiction among a different category of drinkers who had been careful regarding hard liquors like whisky, vodka and rum but had become careless regarding consumption of red wine and fortified wines due to the false myths spread regarding their lower risks and higher benefits of red wine.
The alcohol content of red wines and fortified wines is between 10 to 22 per cent for various brands. This is three or more times higher than the alcohol content of beer which ranges between 2 to 10 per cent. Despite this red wine was promoted as a low- risk liquor and at times this was promoted as a health drink which benefits heart.
Later even some of those who claimed such benefits had to admit that these could be more easily obtained from some raw grapes and berries and from some types of exercise and there was no need at all to accept the various risks of alcohol consumption to get these benefits.
However as the myth about benefits and low risk had been spread widely, a significantly large number of people started drinking red wine as a matter of almost daily habit after returning from work. It was against this background that a huge increase in liver disease deaths among working age people caused a lot of concern.
At this stage health professionals and activists started warning about this. Duncan Selbie, head of an organization Public Health, England presented in his calculation of health impacts that one glass of red wine is the equivalent of three shots of vodka. This was widely reported.
Around the same time some objections were also voiced by environmentalists regarding excessive use of agro-chemicals and water by the wine industry and also regarding its high GHG emissions. The Economist reported that 960 litre of water are required to make available one litre of wine. To produce 274 million hectoliters of wine in a year the amount of water needed can be well imagined. About 19 million acres have to be devoted to grow the essential raw material for the wine industry. Hence a lot of precious land and water are taken away from producing staple food at a time when food security is increasingly threatened.
All these factors taken together can lead to a better comprehension of the real costs of the liquor industry. As we in India are painfully aware, the costs of high liquor consumption in terms of road accidents and other accidents, ruin of health, economic loss, domestic violence, sexual violence and other violent crime are very high. Despite the availability of shocking facts and figures on all these aspects, this issue does not get the attention it deserves among elites.
However people particularly women at many places are fighting to reduce the consumption and sale of liquor in various ways. Efforts such as the issue of new guidelines in Britain are a big help for creating conditions in which the voices of these struggles can be heard.
4. Depression and Suicide
The World Report on Violence and Health (WRVH) says that alcohol abuse may also be an important factor in depression. More ominously the WRVH report says that alcohol and drug abuse also play an important role in suicide. In the USA, at least one quarter of all suicides are reported to involve alcohol abuse.According to the American Psychological Association, “Alcohol use and alcoholism can worsen existing conditions such as depression and induce new problems such as serious memory loss, depression or anxiety.”
According to NIH, USA, “Alcohol abuse may lead to suicidality through disinhibition, impulsiveness and impaired judgment but it may also be used as a means to ease the distress associated with an act of suicide.”
Researchers who compared alcoholics with non-drinkers found suicide tendencies in the former to be 60 times or more. Research by Razvodovsky in Russia revealed that suicides decreased in areas where vodka consumption was restricted.
5. Domestic Violence
According to the WRVH which examined a lot of the available studies on domestic violence, "the evidence is that women who live with heavy drinkers run a far greater risk of physical partner violence, and that men who have been drinking inflict more serious violence at the time of an assault," More specifically this report mentions a survey in Canada which revealed that women who lived with heavy drinkers were five times more likely to be assaulted by their partners than those who lived with non-drinkers.6. Sexual Violence
The WRVH says that both from the perspective of the assaulter and the victim, alcohol and drug consumption increases the risk of sexual violence, including rape. In the context of the victim this report says that consuming alcohol or drugs makes it more difficult for women to protect themselves "by interpreting and effectively acting on warning signs." In the context of the assaulter this report says that alcohol has been shown to play a disinhibiting role in certain types of sexual assault.According to a widely cited paper on ‘alcohol and sexual assaults’ by Antonia Abbey, Tina Zawacki and others of the National Institute of Alcohol Abuse and Alcoholism (USA), “ at least one half of all violent crimes involved alcohol consumption by the perpetrator, the victim or both. Sexual violence fits this pattern. Thus across disparate population studies, researchers consistently have found that approximately one half of all sexual assaults are committed by men who have been drinking alcohol. Depending on the sample studied and the measure used, the estimates for alcohol use among perpetrators have ranged from 34 to 74 percent. Similarly, approximately one third of all sexual assault victims report that they were drinking alcohol at the time of assault with estimates ranging from 30 to 39 per cent. However, these researchers also point out that while a woman’s alcohol consumption may place her at increased risk of sexual assault, she is in no way responsible for the assault. The researchers rightly say that the perpetrators remain legally and morally responsible for their behavior.
However, it also needs to be pointed out that while the data about alcohol consumption by perpetrators is relevant to almost all situations, the data about alcohol consumption by victims may not be relevant to those social contexts such as several parts of India where alcohol consumption by women is very low.
In a widely quoted paper Martin and Hummer argued that many fraternities create a social environment in which social coercion is normalized because women are perceived as commodities available to meet men’s sexual needs. Alcohol is used to encourage reluctant women to have sex. One fraternity man quoted in this paper said, “We provide them with ‘hunch punch’ and things go wild. We get them drunk and most of the guys end up with one”. He describes his plan to get one ‘prim and proper sorority girl’ get drunk by spiking her punch.
According to another paper by Antonia Abbey, “the peer norms for most fraternity parties are to drink heavily to act in an uninhibited manner and to engage in casual sex”.
According to a recent report from the National Task Force on College Drinking (USA), 1400 college students die each year in alcohol related accidents, 5, 000,00 are injured and there are 70, 000 victims of alcohol related sexual assault or date rape.
A study by Testa and Livingston mentioned women’s narrative description of incapacitated rape which indicates that many were unconscious and found out later that they were raped, or else were only dimly aware of what was happening and so were unable to stop the assailant.
7. Special Vulnerability of Women
New research has not only confirmed special vulnerability of women to alcohol but in addition the high risks to babies in case of consumption of alcohol during pregnancy are more widely recognized now. The latest Status Report on Alcohol and Health released by the WHO very recently in September 2018 has thrown important light on several important aspects of these issues.It is widely recognized that alcohol has extremely serious adverse health impacts. However, what is not so widely realized is that women are more vulnerable to many sided health hazards of alcohol. According to the WHO , “there is evidence that women may be more vulnerable to alcohol-related harm from a given level of alcohol use or a particular drinking pattern. The vulnerability of females to alcohol-related harm is a major public health concern because alcohol use among women has been increasing steadily in line with economic development and changing gender roles and because it can have severe health and social consequences for newborns…. For health outcomes such as cancers, gastrointestinal diseases or cardiovascular diseases, the same level of consumption leads to more pronounced outcomes for women.”
The vulnerability of women may be explained by a wide range of factors. For example, women typically have lower body weight, smaller liver capacity to metabolize alcohol, and a higher proportion of body fat, which together contribute to women achieving higher blood alcohol concentrations than men for the same amount of alcohol intake. Women are also affected by interpersonal violence and risky sexual behavior as a result of the drinking problems and drinking behavior of male partners. Moreover, alcohol use has been shown to be a risk factor for breast cancer. Also many societies hold more negative attitudes towards women’s drinking alcohol than men’s drinking, which, depending on the cultural context, may increase women’s vulnerability to social harm. Finally, women who drink during pregnancy may increase the risk of fetal alcohol spectrum disorder (FASD), and other preventable health conditions in their newborns.
The WHO Status Report on Alcohol and Health 2018 has clearly stated that alcohol use during pregnancy has been established as a risk factor for adverse pregnancy outcomes, including stillbirth, spontaneous abortion, premature birth, intrauterine growth retardation and low birth weight, and can result in a range of lifelong conditions known as fetal alcohol spectrum disorders (FASD).
As pointed out in this WHO Report, FASD is an umbrella term which includes fetal alcohol syndrome (FAS), partial fetal alcohol syndrome (pFAS), alcohol-related neuro-developmental disorder (ARND) and, depending on the diagnostic and classification system, alcohol-related birth defects (ARBD) . FASD is characterized by central nervous system damage and its manifestations include physical, mental and behavioral features and learning disabilities with possible lifelong implications.
Presenting a review of the available research on this issue the WHO status report states -- A systematic review and meta-analysis by Popova and colleagues estimated that the global prevalence of alcohol use during pregnancy in the general population amounts to 9.8%. In addition, Lange and colleagues observed, at the country level, that binge drinking during pregnancy ranged from 0.2% to 13.9% ( Note—health risks from binge drinking can be much higher than from normal drinking ). Drinking during pregnancy resulted in an estimated prevalence of FAS in the general population of 14.6 per 10 000 people and a prevalence of FASD of 77.3 per 10 000 people . The prevalence of FAS and FASD varies by WHO region, with the prevalence being highest in the Region of the Americas (AMR) and the European Region (EUR) . Additionally, a recent systematic review and meta-analysis by Popova and colleagues found that 428 conditions co-occurred with FASD. Some of the most common health problems are congenital malformations, chromosomal abnormalities, prenatal and postnatal growth delays, intellectual disability, behavioral disorders, speech and language difficulties, visual and audiological impairments, cardiac deformities and urogenital problems.
In some cultures women have been protected from alcohol consumption by strong traditional values. Imagine the public health and social disaster that could result if alcohol consumption by women in India reaches the level of the USA. Yet, promoting alcohol consumption among women as a sign and symbol of liberating modern trends is widely practiced in India and the alcohol industry puts in a lot of effort and money to promote this view. Some recent Bollywood movies which promoted this view in a big way were widely praised by big media as a liberating trend. Such perceptions should be corrected before it is too late.
8. Dangerous trend of ‘Drunkorexia’
In recent years a new dangerous trend has emerged in several western countries particularly in the college campuses of these countries. Young women (and to a much lesser extent young men also) have been skipping meals to reduce their calorie intake so as to make room for calories they derive from alcohol consumption. This is happening despite the well-known fact that consuming alcohol on an empty stomach is more dangerous. This trend is called ‘Drunkorexia.The Independent newspaper quoted a regular practitioner of drunkorexia saying, “all alcohol contains loads of empty calories, yet we are also expected to be slim. I and others I know do as many shots of vodka as we can so we get drunk on the least amount of calories and make bloating less likely. “
The Independent also quoted a study which revealed that a surprisingly high per cent of female under graduates exhibit drunkorexic tendencies.
According to the Eating Disorder Center of Denver, of the participating college- aged females in an adjunct research study, about 75 per cent met the criteria for alcohol abuse.
In a study in Australia involving women aged between 18 to 29 years, who were enrolled in university, 79 per cent of participants demonstrated engaging in characterized drunkorexia behavior.
Drinking on an empty stomach makes it possible for ethanol to reach the blood system at a faster pace and to raise a person’s blood alcohol content at a high risk speed. This can increase the chances of alcohol related brain damage. In addition, drunkorexia also increases the possibility of black outs, alcohol poisoning, injury and illness. These harmful impacts are more likely in the case of women compared to men as women are generally less capable of metabolizing alcohol than men.
In some cases drunkorexia also involves self induced vomiting soon after the consumption of alcohol.
9. Youth
Recent research has drawn attention to evidence from several parts of world regarding increasing and many-sided health, learning capacity and safety risks to students and youth from alcohol .The latest available data for 2016 given in the WHO Status Report on Alcohol and Health released in September 2018 tells us that worldwide, more than a quarter (26.5%) of all 15–19-year-olds are current drinkers, amounting to 155 million adolescents.Further this report says that results of school surveys indicate that in many countries of the Americas, Europe and Western Pacific alcohol use starts before the age of 15 years and prevalence of alcohol use among 15-year-old students can be in the range of 50–70% with remarkably small differences between boys and girls.
Summarizing the result of several studies this report tells us that alcohol use in adolescents is associated with alterations in verbal learning, visual–spatial processing, memory and attention as well as with deficits in development and integrity of grey and white matter of the central nervous system . These neuro-cognitive alterations by adolescents’ alcohol use seem to be related to behavioral, emotional, social and academic problems in later life, the report adds.
Some problems are also passed on to children and youths from alcoholic parents, particularly father. Parental drinking and poor parent–adolescent relationship quality are among the factors related to adolescent alcohol use, this report says quoting several researchers.
As this report points out, there is a consistent and large amount of evidence demonstrating the positive association between parental and offspring drinking. Parental alcohol problems were associated significantly with a higher likelihood of frequent emotional symptoms, depression, low self-esteem and loneliness among both boys and girls. In addition, parental heavy drinking and alcohol problems were shown to be associated with worsening outcomes in children, including educational outcomes, drug use, conduct problems and criminality. Parental alcohol use disorders (AUDs) are associated with a higher risk of their children developing depression in adulthood.
According to the WHO, alcohol consumption in adolescents, especially binge drinking, negatively affects school performance, increases participation in crime and leads to risky sexual behavior. The WHO quotes growing scientific evidence that has demonstrated the special harmful effects of alcohol consumption prior to adulthood on brain; mental, cognitive and social functioning of youth and increased likelihood of adult alcohol dependence and alcohol related problems among those who drink before physiological maturity.
The World Report on Violence and Health ( WRVH) says, especially in the context of youth violence, that drunkenness is an important immediate situational factor that can precipitate violence. In a Swedish study on youth-violence, about three-quarters of violent offenders and around half the victims of violence were intoxicated at the time of the incident.
Several surveys indicate high and rapidly increasing consumption of alcohol amongst youth. What is particularly worrying is high consumption at a very tender age which is likely to be very harmful for brain and also lead to much higher risk of alcohol dependence in later years. For example, in UK binge drinking thrice or more a month is reported among 33 per cent of adolescents in the 15-16 age groups. Binge drinking levels affecting between 25 to 40 per cent of youth are quite common now.
Coming now to the situation in India the WHO status Report on Alcohol and Health has said that India has emerged as a country which is recording some of the highest increase in liquor consumption in the entire world. Although it is not specifically mentioned in this report to what extent this increase in liquor consumption has also led to an increase among students and youth there is a lot of sporadic evidence from many parts of India which indicates that the increase of alcohol among youths in India may be even higher than the overall trend of increase in liquor consumption in the country.
In many parts of the country which this writer visited to write about anti-liquor movements, it was generally seen that women were taking the lead in these movements and their biggest grievance was that their adolescent children are also falling prey to the liquor habit due to the overall increasing trend of liquor consumption and the location of liquor vends within the village.
Heavy episodic drinking, often called binge drinking, is generally regarded as a more risky form of liquor consumption. The WHO Status Report defines this as the consumption of at least 60 grams or more of pure alcohol on at least one occasion in the past 30 days. In India in the 15-19 age group 12.6 per cent of adolescents had indulged in this ( 21.1 per cent of males and 3.6 per cent of females).
Clearly there are several very worrying aspects of these trends and we need to wake up these problems and carry out special campaigns among youth and students before it is too late.
10. Elderly
Among elderly people the possibility of alcohol reaching and affecting sensitive organs including brain, liver and muscles is higher compared to younger people.11. Crime and Violence
The WRVH report says that reducing the availability of liquor can be an important community strategy to reduce crime and violence as research has shown alcohol to be an important situational factor that can precipitate violence.In a 4-year study conducted in New Zealand crime rates in situations of high and low availability of alcohol were compared. This study revealed that crime rates fell significantly for 2 years in areas of reduced alcohol availability.
According to a report prepared by the National Council on Alcoholism and Drug Dependence, USA (NCADD), alcohol and drugs are implicated in estimated 80 per cent of offences leading to incarceration in the USA such as domestic violence, driving while intoxicated, property offences, drug offences and public ordered offences. Alcohol is a factor in 40 per cent of all violent crimes and according to the department of justice, 37 per cent of about 2 million convicted offenders currently in jail report that they were drinking at the time of the event. Alcohol, more than any illegal drug, was found to be closely associated with violent crimes including murder, rape, assault, child and spousal abuse. About 3 million violent crimes occurred each year in the USA in which victims perceived the offenders to have been drinking and statistics related to alcohol use by violent offenders show that about half of all homicides and assaults are committed when the offender, victim or both have drinking.
This report by NCADD points out that alcohol is often a factor in violence where the attacker and the victim know each other. Two thirds of victim who were attacked by an intimate (including a current or formal spouse, boyfriend or girlfriend) reported that alcohol had been involved.
More than 1 million are arrested for driving while intoxicated in a year in the USA. Drinking and drugged driving is the number one cause of death, injury and disability of young people under the age of 21.
12. Impact of Alcohol Consumption on Others
Most research on impact of alcohol consumption is concerned with the impact on the actual consumer, but more recently there has been a welcome trend to look at the impacts on others. The most discussed study of this kind was conducted in Australia and has been mentioned as a very significant study by the WHO which is trying to take this further. This study supported by the Foundation for Alcohol Research and Education found the following impacts in one year in Australia.(i) 367 persons were killed
(ii) 13,660 persons were hospitalized
(iii) Special care had to be arranged for 19,443 children
(iv) 25,481 family members were attacked
(v) 44,852 strangers were attacked
(vi) 73 per cent persons were affected in some way or the other to a lesser or greater extent
Beyond causing harm to the drinker, alcohol intoxication is often the main mechanism of harm to others from drinking.
Studies of drinking by the offender and by the victim in homicides have chiefly been in societies where drinking to intoxication is common. Meta-analyses of these studies have found that 48% both of victims and of perpetrators had been drinking when the homicide occurred, and that 37% of the offenders and 33–35% of the victims had drunk enough to be intoxicate.
13. Overall Social Impact
There are very heavy social costs of alcohol consumption in the form of various forms of violence, crime and disruption of relationships. The WHO status report has presented various estimates that have been made from time to time about financial implications of these social costs:i) Estimate for the European Union, Year 2003 - 125 billion euros
ii) Estimate for UK, Year 2009 – 21 billion pounds
iii) Estimate for USA, Year 2006 – 233 billion dollars
iv) Estimate for South Africa, Year 2009 – 300 billion Rand (10-12 per cent of GNP)
While this data about financial implications of social costs is very disturbing, at the same time it needs to be emphasized that violence leading to loss of life and disruption of close relationships caused by alcohol can never be fully calculated in money terms; it goes beyond that.
14. Increasing Consumption in Developing Countries Like India
The WHO status report points out that the most prevalent tendency worldwide is increase in recorded per capita alcohol consumption. Further this report says that while per capita consumption of alcohol at present is highest in developed countries like the USA and European countries, the trend of increasing consumption is mainly driven by increase in alcohol consumption in China and India and this in turn is driven by the active marketing by the alcohol industry.Another cause of concern is the increasing consumption of liquor by women in several countries despite the fact that alcohol has some special health risks for women. For example, fetal alcohol syndrome and fetal alcohol effects, preventable causes of mental retardation may result from alcohol consumption during pregnancy.
15. Environmental Ruin
Very high levels of ecological ruin and greenhouse gas emissions are involved in the liquor industry. Several water sources including rivers are heavily polluted. A lot of water is wasted. The Economist reported some time back that 960 liter of water are used to produce one liter of wine. Environment of areas located close to distilleries is often badly contaminated as they suffer from pollution of water as well as foul smell. There are several agitations against distilleries by people living in nearby areas to protest against the pollution caused by them.16. Food Security
In order to get the raw material for the liquor industry a lot of land is diverted from food crops, or else some crops are diverted from food to alcohol due to high profit motive. A lot of irrigation water is also diverted from supporting nutrition to supporting intoxication. Increasing diversion of highly nutritious grains, millets and fruits for the production of intoxicating, very harmful drinks is aggravating the food crisis. The foods that could feed a thousand hungry people are downed in a few glasses of liquor. When industrial interests control farming for getting the raw material for their liquor, they generally use highly input intensive, chemical intensive methods which are also bad for soil, water and environment.17. Policy Initiatives Needed to Check Increasing Devastation Caused By Alcohol
The many sided devastation of health and social relations as well as the huge number of injuries and violent episodes caused by alcohol consumption and addiction, as also the huge economic and ecological costs associated with this have been well documented at the world level. In developing countries like India there are three factors that accentuate this loss. Firstly many of the families affected are already so poor or economically stressed that the recurring expenditure on liquor simply ruins them. Secondly the low availability of de-addiction facilities means that the way out of the morass is available to only a few who need this desperately. Thirdly the gender equation is such that despite very low levels of liquor consumption of women in countries like India it is women and children who end up bearing the heaviest burden of increasing liquor consumption in terms of denial of basic needs, increasing domestic and sexual violence.It is in this context that the demands for curbs on increasing liquor sale and consumption have been raised by several anti-liquor movements in various parts of India, particularly rural India. These include social movements with a larger agenda which have also felt the need for resisting liquor related problems and also very specific anti-liquor movements focusing mainly or only on this issue. Women have played the most important role in most of these movements and have brought a strong sense of urgency and passion into these movements. One important specific demand of several of these movements has been to remove the liquor vend or shop from their village so that easy availability of liquor within the village or very near to the village can be checked.
While most governments have paid lip sympathy to anti liquor sentiments, in reality they have been happy to collect massive revenue from sale of liquor. In addition several politicians have close links with liquor mafias and some of them have themselves entered liquor production and trade. Despite all this, several governments have been forced to respond to growing public sentiments against liquor, particularly in the context of women voters. They have responded to the anti-liquor sentiments of people particularly women in various ways. Prohibition has been in existence in Gujarat and parts of North-East India and was more recently introduced in Bihar. Other state governments have agreed at times to removing liquor vends if certain conditions such as opposition by more than 50 per cent local population are satisfied and proved. Others have withdrawn specific vends following opposition.
On the whole, however, the massive, many-sided damage caused by alcohol has been increasing. However one ray of hope is provided by the fact that where sustained efforts by people’s movements are made there alcohol consumption comes down significantly and this reduction is sustained for a long time. One example is the anti-liquor effort associated with the Chattisgarh movement of iron ore miners led by Shankar Guha Niyogi where several thousand miners gave up liquor motivated by women as well as by wider trade union loyalty and commitment. The big lesson here is that sustained public campaigns and community efforts are necessary for sustainable reduction of alcohol consumption and other substance abuse. Merely government action cannot succeed in a significant and sustainable way even if it is well-intentioned, this has to be supplemented by a sustained, continuing public campaign against liquor and other intoxicants and various forms of substance abuse. This should involve various respected members of community who have credibility. This campaign should have strong links with schools and colleges so that a strong anti-liquor message can be imparted in friendly and interesting ways at an early age and can be included in the curriculum.
Thus a combination of suitable, well-thought government policies suited to local conditions and sustained, broad-based public campaigns with women and respected community leaders playing an important role can together succeed in reducing liquor consumption and all the associated problems to a considerable extent.
18. Strong Anti-Liquor Policy Needed
There should be a clear and consistent policy guideline that alcohol consumption needs to be minimized and discouraged as much as possible. There is adequate evidence of many- sided serious adverse impacts of alcohol consumption to support such a policy. Although efforts are been made all the time by the alcohol industry and its lobbyists, as well as many layers of liquor mafia in many countries including India, to dilute the evidence against alcohol and even promote its imaginary benefits, such misrepresentations of facts and analysis should not be allowed to dilute any strong policy decisions to discourage and minimize consumption of liquor.What exact form this policy takes will depend on diverse conditions of various societies. What is perhaps common to all societies is that there should be a well- informed sustained campaign against many- sided adverse impacts of alcohol. Such campaigns should be adequately supported by governments. All containers of alcoholic drinks should carry strong warnings of health and social adverse impacts. Efforts to present alcohol in attractive settings should be discouraged in various ways. There should be a ban on not just direct but also indirect advertisements of alcoholic drinks.
More specifically in conditions of rural India there should be clear policy that no liquor vends or shop can be opened in a village where 50 per cent or more people sign a petition against it. At the same time there should be very strong action against illegal or secretive sale points of liquor.
Similar decisions can be taken for urban localities keeping in view their specific conditions.
The government policy should cease to see liquor as a source of obtaining more and more revenue. Instead looking at the wider, much higher adverse impacts of liquor the government should make available resources for strong action to minimize the consumption of liquor as well as for efforts of de-addiction and rehabilitation.
The government should try to take the active participation of people, particularly women, in many sided efforts to curb liquor consumption. Once such widespread public participation is ensured, using legal efforts to curb liquor consumption in various ways will also be more successful.
19. Dangerous Trend of Diverting Tea Leaves and Highly Nutritious Fruits For Liquor Production
Very worrying trends have been reported recently from Himachal Pradesh that highly nutritious fruits are being diverted from direct consumption to the production of wine on a large scale. Such trends if left unchecked can easily spread to other parts of the country.First a leading newspaper Dainik Jagran reported that apples as well as other highly nutritious fruits in the state will be diverted on a large scale for production of wine and the existing processing facilities of a public sector unit will be made available to a private company for taking this new wine to many parts of country. Then on May 1, 2018 another news appeared in another leading newspaper Navbharat Times that along with fruits special Kangra Tea Leaves will be used to prepare tea wine with alcohol content of 12 per cent ( much higher than beer) . A government science lab is being used to prepare this and a private company has been contracted to sell this as tea wine on a large scale. The government will also be earning from this deal.
It is very worrying that even such a staple drink as tea which is consumed by an overwhelming majority of people in the country is being imitated to prepare an alcoholic drink based on tea leaves with a high alcohol content and at the same time fruits are being diverted for the production of this wine, at a time when children from poor families in this apple-producing state find it very difficult to eat apples.
It is likely that soon there will be a drive by unlicensed shops to sell these new forms of liquor, as can already by seen as some general merchants and fruit juice shops are seen selling fruit wine. What is even worse is that high alcohol content drink or liquor is being promoted for health benefits, a trend which has already been exposed for all its falsehood, deceit and pressures of liquor lobby in the context of red wine.
It is now well known that the completely false promotion of red wine as a healthy drink led to massive damage to health and a huge increase in liver disease as well as other serious health problems. The same tragedy will be repeated in India on an even larger scale when fruit wine and tea wine are promoted for their false health benefits while covering up the conspiracy of the liquor lobby in taking liquor to more and more people.
Hence this dangerous trend and the distorted thinking behind it should be checked as early as possible.
20. Powerful Interests
While a number of recent research reports have drawn attention to health risks from alcohol which are much higher than what was widely believed a few years back and also to very devastating social impacts of alcohol, this has not led to the necessary public action to significantly reduce liquor consumption due to lobbying by highly powerful alcohol industry interests. It is widely realized that more efforts to curb liquor consumption are needed at the level of various nations which should also have much stronger international support.The recently released World Status Report on Alcohol and Health 2018 prepared by the WHO has also argued along similar lines. This report says—“ At the international level, the broad scope and magnitude of health and social problems caused by the harmful use of alcohol require coordinated and concerted actions by different parts of the United Nations system and regional intergovernmental organizations in the context of the 2030 Agenda for Sustainable Development.”
The Status Report has pointed out that neither alcohol nor tobacco was included in the modern international drug control treaties when they were adopted during 1961–1988. With development and ratification of the Framework Convention on Tobacco Control (FCTC) in response to the globalization of the tobacco epidemic, now “alcohol remains the only psychoactive and dependence-producing substance with significant global impact on population health that is not controlled at the international level by legally-binding regulatory frameworks.” Hence clearly strong international action to check alcohol consumption is overdue.
The latest WHO status further draws attention to the fact that as a consumer product and trade item, alcohol comes under the jurisdiction of international trade treaties and the international trade system, which have focused on maximizing the freedom of international trade and investment and thereby minimizing “technical barriers to trade and other alcohol control measures” that national or local governments may impose. While there are “public health” exceptions in the treaties, the WHO report points out, these are interpreted narrowly, so that a provision in the interest of public health is not accepted if an alternative measure can be put forward as an option, whether or not the measure would be effective.
Hence the WHO Status Report on Alcohol and Health states very clearly, “Given the increasing encroachment of international trade and investment on the ability of national and sub-national governments to control their alcohol markets, and the increasingly consolidated global alcohol producers, a strong public health case for considering the negotiation of a Framework Convention on Alcohol Control, or alternatively for including alcohol within other international control systems has been repeatedly presented and discussed by public health entities, experts and advocates.”
This report quotes studies to make the point that alcoholic beverage production has become increasingly concentrated and globalized in recent decades, particularly in beer and spirits, but increasingly also in wine. An additional adverse factor from the point of view of health impacts is that very significant proportions of the commercial alcohol market are consumed in heavy drinking occasions meaning the “central interests of alcoholic beverage producers are inherently at odds with the public health interest.”
This report points out that significant influence of alcohol industries on political decisions which affect them has been documented at national and sub-national levels. In some countries with substantial alcohol production and trade, this influence extends to the international level, both through national delegations in international organizations and negotiations, and through national, regional and global alliances within and across industries What is more, this report states, this interference was reported on several levels, including industry presence during legislative meetings as well as challenges to the legal basis of existing alcohol policies.
Despite this troubling evidence the WHO report regrets that there is no public health-oriented international agreement on alcohol to counter the strong influence of the producers through the international trade institutions and agreements.
On the contrary, the status report tells us, general trends towards deregulation in recent decades have often resulted in the weakening of alcohol controls – to the benefit of economic interests but “at the expense of public health and welfare.”
Keeping in view all these adverse factors this report asserts that substantial added resources are needed to provide leadership at the international level to pursue the public health agendas for alcohol in the face of the strong presence of the global industry at the international policy level.
This report refers to studies which tell us that alcohol producers may also influence public health and welfare perspectives in research .A glaring example given in the status report is that a study of potential health benefits of light drinking (one drink per day) versus abstention, with alcohol industry multinationals and alliances as the main sources of the US$ 100 million funding, was discontinued after a government review group concluded that the interactions of the study’s investigators “and the alcohol industry ‘appear to have intentionally biased the framing of the scientific premise of the study’ in the direction of focusing on possible benefits of alcohol” . This is by no means an isolated example. The status report informs us that such efforts to bias research and public health policies to accommodate industry’s interests, often with as little record of the influence as possible, can also be found in other countries and situations.
21. Conclusion
In India very powerful and resourceful lobbyists have been at work overtime to increase alcohol consumption even in the remotest villages while women in distant villages have been struggling to stop the rapid increase of liquor consumption, We need to stand on the side of these brave women and support them.---
Bharat Dogra is a journalist who has been involved with several social movements and initiatives. His work has been recognized in the form of several prestigious awards. He has travelled to several places of anti-liquor movements to report on them. His recent books include A Day in 2071, Planet in Peril, Protecting Earth for Children and Man over Machine
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