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Reducing harm from alcohol use in the community

Symposium held in Bali, Indonesia
4-6th October 2007
Organised by The Mental Health and Substance Abuse Unit (MHS) of the World Health Organization, Regional Office for South-East Asia


Opening Address to the symposium
by Dr Samlee Plianbangchang, Regional Director, WHO South-EastAsia Region

It is with great pleasure that I welcome you all to the Symposium on Reducing Harm from Alcohol Use in the Community. This symposium, I am sure, will be of great help as we embark on a programme to reduce harm from alcohol.

In recent years awareness about harm from alcohol use has increased not only with regard to the user but also harm to the family, the community and the entire nation. Traditionally alcohol use has been considered a matter of personal choice and only harm has been seen as a matter to be addressed by the individual and the family. In our Region, community action against harm from alcohol use has been limited to sporadic confrontations between alcohol suppliers and women’s groups. However,we now realize that a coordinated multi-sectoral approach is needed to address the complex issues of prevention of harm from alcohol use.

Before suggesting some points for your consideration, I would like to highlight the current situation of harm from alcohol use in the community. WHO has estimated in its Global Status Report on Alcohol 2004, that there are about 2 billion people worldwide who consume alcoholic beverages, and 76.3 million with disorders arising out of harmful use of alcohol. A causal relationship between alcohol use and over 60 types of diseases and injury has been documented. Unintentional injuries account for around one-third of the 1.8million deaths due to alcohol. These data clearly point to a huge burden of harm.

Moreover, in the South-East Asia Region studies have indicated that health, social and economic harm from alcohol is widespread. On average use of alcohol has been on the increase in the Region, imposing numerous challenges on policymakers, professionals, civil society and public health.This is well documented by WHO/SEARO in its series of publications on alcohol use.

The Fifty-eighth World Health Assembly in May 2005 adopted resolution WHA58.26, requesting the Director-General, among others, to collaborate with Member States, intergovernmental organizations, health professionals, nongovernmental organizations and other relevant stakeholders to promote the implementation of effective policies and programmes to reduce harmful alcohol consumption. The Fifty-ninth session of the WHO Regional Committee for South-East Asia held at Dhaka, Bangladesh in September 2006, debated various policy options on reducing harm from alcohol use. It adopted resolution SEA/RC59/R8 which requested the Regional Director among other measures to hold a biennial regional forum of key partners from Members States and other international partners to share progress, experiences and lessons on alcohol control programmes.

Socio-cultural, political, geographic and religious diversity are the hallmark of the South-East Asia Region. Such diversity leads to many different behaviour patterns and perceptions related to the use of alcohol, not only between countries but also within countries. For example, communities with similar religious beliefs may have different levels of use and harm from alcohol use.

There are also many unique features of alcohol consumption in the Region. For example there are large abstinent populations in many countries, and consumption among women is quite low. But among alcohol users, the number of people abusing alcohol is substantial. Also, there are many patterns of alcohol use that are very deleterious, for example, binge drinking, pay-day drinking, driving while drunk, consuming illicit alcohol, home brewing of alcohol and domestic violence linked to alcohol. The relationship between alcohol and poverty is a major concern in our Region.

Though there is a large body of information related to alcohol use, policies and interventions around the world, it should not be assumed that transplanting measures found to be successful elsewhere, under completely different circumstances, is appropriate for our Region. This is because culture plays an important role in alcohol use. Whatever programmes are developed should be culturally appropriate.

To address the issues of harm from alcohol use community empowerment is essential. Unless communities own the interventions, their sustainability cannot be guaranteed. We are very well aware that controlling and minimizing harm from alcohol is beyond the capacity of the health sector alone. In addition to health, issues related to economics, trade, commerce, legislation, law, enforcement, education and research are included. Therefore, a sustained and coordinated approach addressing all these spheres is needed to address harm from alcohol. This symposium is bringing together multiple stakeholders to discuss the contribution different disciplines can make. But please remember, we not only need new ideas, we also need to operationalise them.

I look forward to new and innovative ideas emerging from this symposium. Any new idea, however, needs to be assessed for its appropriateness and impact. So, as you proceed, please build into your programmes the element of impact evaluation. Appropriate measures of impact should be developed so that the burden of suffering in the community can be reduced. This is our ultimate goal. I hope this symposium will further strengthen WHO’s initiative to assist Member States in the area of prevention of harm from alcohol use in the community.

The Symposium considered a wide spectrum of policy and practice responses to alcohol related harm across the South East-Asia Region. In this report we summarise some of the papers given at the symposium.

The harmful use of alcohol causes considerable public health problems and is ranked as the fifth leading risk factor for premature death and disability in the world stated Dr Vladimir Poznyak, Coordinator of the Management of Substance Abuse,Department of Mental Health and Substance Abuse atWHO, at the opening of the symposium.He went on to say that in 2002, 2,300,000 people died worldwide from alcohol related causes and that 64,975,000 disability adjusted life years (DALYs) were lost due to alcohol related causes.

Referring to a number of studies in relation to alcohol-related social harms, he pointed out that:

  • from 10% to 69% of suicides are committed under the influence of alcohol;
  • 80% of homicides in Russia and
  • 33% of divorces in the UK are alcohol-related, and
  • between 5% to 14% of parents abusing their children in Japan have alcohol use disorders or a drinking problem.

The Adult Per Capita (APC) consumption levels in the WHO South-East Asian and Western Pacific Regions (WHO Global Alcohol Database) have been increasing across the region from the 1960s and the prevalence of alcohol use disorders is a major cause for concern.

Dr Poznyak ended with the extent of the activities of WHO Regional Offices following the WHA resolution 2005:

EURO: Framework for Alcohol Policy in the WHO European Region – resolution adopted by the Regional Committee for Europe;

AMRO 2005: First Pan American Conference on Alcohol Public Policies;

SEARO 2005: Resolution on public health problems caused by harmful use of alcohol adopted by the Regional Committee, August 2006;

EMRO: Resolution adopted by the Regional Committee (2006);

WPRO: Regional strategy developed and endorsed by the Regional Committee (September 2006);

AFRO: Technical consultation on public health problems caused by harmful use of alcohol, May 2006; discussion of the report of the Regional Director on harmful use of alcohol in the African region at the Regional Committee in August 2007.

On the theme of Alcohol and Health, Professor R Ray,Chief of the National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, noted the extent and magnitude of alcohol use and dependence in India, Sri Lanka, Myanmar, Nepal and Thailand.

India: 21.4% of adult males current alcohol users and among women 5% across studies; 44-62% dependent on alcohol among those attending treatment centres.

In the mid 1990s a hospital based study showed 12% of all admissions had alcoholism and alcohol accounted for around 31% of the all liver disease, 42% of total cases of liver cirrhosis.

Sri Lanka: 53.1% of males above 15 years old are current alcohol users; a survey of 150 randomly selected GPs showed that 80% were frequently confronted with alcohol misuse related problems. From 1975 to 2002: increase in deaths from liver diseases from 3.8 to 15.2 per 100,000.

Myanmar: A Community household survey in Daw Pone township of 825 households (5106 subjects) showed that 23/1000 population (7% of males over 18 years) were alcohol dependent. A hospital study based on Madalay Mental Hospital found that 27.8% of patients had alcohol related disorders.

Nepal: A community household survey in 2003 of 2,344 adults in Dharan showed a prevalence of alcohol dependence of 25.8%. A 2002 demographic and health survey showed that 67% of the males (15- 60 years) were alcohol users and the largest percentage (73.3%) was the in 25-29 year age.

Thailand: Alcohol is estimated to be the third most important health risk factor in the country - 56% males and 10% females consume alcohol. A cross-sectional community survey of 2 urban/5 rural areas in Southern Thailand using AUDIT: 1,005 subjects aged 35 years or more noted a 10% prevalence of hazardous-harmful drinking (27% in males/ 1% in females). 62% of traffic accident victims had a positive blood alcohol concentration and 45% of deaths from traffic accidents are due to alcohol consumption.

Dr Ray referred to the cross cultural study carried out by WHO on the alcohol use and sexual risk behaviours in eight countries including India (2004) which found:

  • key patterns of interaction between alcohol use and sexual behaviour across the cultures
  • use of alcohol was associated with high risk sexual behaviour in terms of a denial and neglect of risk as a way of coping with life
  • use of alcohol-serving venues as contact places for sexual encounters.

The Bangalore Study on the Burden and Socioeconomic Impact of Alcohol undertaken by Gururaj G,Girish and N,Vivek Benegal of the Departments of Epidemiology and Psychiatry, NIMHANS, Bangalore, was presented by Dr Girish.

Against a backdrop of increasing consumption and accelerated process of globalisation they noted significant changes in patterns of consumption resulting in alcohol disorders becoming the‘number one’ burden among all non-communicable disorders.These changes are:

  • emergence of wine and beer drinking
  • increase in female drinking
  • early experimentation and decreasing age of initiation
  • shift from urban to rural areas and transitional towns
  • more binge drinking
  • greater acceptability of drinking as an accepted social norm
  • alcohol use along with high risk behaviours

From the study it was estimated that the combined health and socio-economic impact of alcohol outweighs the perceived national economic gain. The cost of alcohol to the Indian community was estimated to be around 244 billion rupees compared with revenue receipts of 216 billion rupees. At an All-India level the question had to be posed “Are we losing more than gaining?”

Dr Girish referred to the impact of the tsunami on alcohol consumption. Immediately after the tsunami, consumption decreased in both male and females. However when relief money was made available, consumption shot up well beyond the level before the tsunami and continued to rise among women.

The Regional Perspective on Trade, Commerce and Alcohol was presented by Thaksaphon Thamarangsi from IHPP (International Health Policy Program), Ministry of Public Health,Thailand.

The relationship between alcohol per capita consumption (APC) and gross domestic product (GDP) per capita in Thailand 1962 – 2001 shows the association of alcohol consumption to economic well being. The amount of unrecorded consumption varies within the region from about 0.3 to 2.2. litres.

Changes are taking place within the region on supply. New operators and more brands have resulted in creating more competition; increasing cross-border transactions; concentration of investment; mergers and take overs; joint ventures, i.e. brewing contract (especially locally produced international brands); up scaling of domestic producers; more beverage categories - flavoured alcoholic beverages and clearer market segments.

Dr Yot Teerawattananon, Leader of Health Intervention and Technology Assessment Program, Thailand illustrated the manner in which the multinational drinks companies exploit film celebrities to spread the western drink culture.

It is known that direct education approaches have met with limited success, but Dr Adulyanon of the Thai Health Promotion Foundation in his presentation on ‘Interventions on Alcohol in Educational Settings – the Thai Experience’ argued that it was important as it underpinned all other interventions. He agreed with Foxcroft et al 2003 “Education programmes encourage opinion leaders and policy makers to support structural change.”

Thai Health has involved the youth movement as a key actor. Youth’s role is perceived as a strength, not as a problem. Youth’s role is solving problems and as positive role models in marked contrast to the blame culture so often associated with the portrayal of youth as being the cause of problems.

Mass media and public education campaigns are aimed at raising awareness, reinforcing health related messages, changing perceived norms and “fostering a receptive climate for implementing effective policies” (Howard, et al 2007).

Cultural and religion specific approaches are utilised to maximise engagement. An example is the call to stop drinking in Buddhist lent.

Mass media campaigns, including TV ads and newspaper articles, are used to counteract the ‘normalisation’ of alcohol use – a key feature of the industry’s marketing tactics – and to ‘de-normalise’ the drinking of alcohol through the sponsorship of cultural events and sport.

TheThai Health Foundation has monitored the mobilisation of social networks to support the alcohol control bill and the impact of the campaign to change attitudes.

A results-based monitoring and evaluation system has been developed and the communication and social marketing aspects evaluated. 95.2% of respondents agreed with the campaign.

Dr Vijay Chandra ,Regional Adviser, Mental Health
and Substance Abuse, WHO SEARO
, stated that since the 1980’s the average age of initiation has reduced from 28 to 20 years of age. Alcohol use is higher in poorer communities. Traditionally alcohol is used by men but use by women is increasing. However, even among men significant proportions are life-time abstainers. Among users, the proportion of dependent users is large. Frequent use of small quantities of alcohol is not the predominant pattern of use as is common in Europe. The number of drinking occasions is fewer, but the amounts consumed at these occasions are large. Issues for concern are: pay-day drinking, violence, including domestic violence, alcohol as a contributor to poverty and illicit and home-brewed alcohol.

Dr Chandra emphasized the need for evidence-based interventions. There was evidence on what works: taxation, restricting availability and accessibility, health promotion, community action - change in social climate, drunk-driving countermeasures, provision of appropriate services for users and restriction of advertising and promotions. What had limited effectiveness were: school programmes based on health harms of alcohol and promoting refusal skills, provision and encouragement of alternate activities, provision of health information related to alcohol through mass media and server training.

Dr Chandra maintained that SEARO initiatives have been successful at many levels: in advocacy, assessment of alcohol use in the community, and in the development of community-based interventions including the use of self-learning material for community volunteers and empowering adolescents.

SEARO’s future initiatives would include advocacy with governments and civil society on prevention of harm from alcohol, assessment of use and harm in the community and specifically addressing regional issues.

Other key presentations during the symposium concentrated on the role of the community and of NGOs in promoting alcohol control policies.There were also presentations on the issue of drink-driving and alcohol related enforcement issues and alcohol industry marketing strategies.These themes will be featured in future editions of The Globe, and these presentations will be highlighted at that time. They will provide a valuable contribution to the debate.