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
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
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
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
- 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
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
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
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
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.