Living dangerously: The World Health Report, 2002
Dr Brundtland

Global alcohol consumption has increased in recent decades, with most or all of this increase occurring in developing countries, according to The World Health Report 2002, published recently by the World Health Organization. Throughout the world, alcohol caused 1.8 million deaths, equal to 4 per cent of the global disease burden – the highest proportion being in the Americas and Europe. It is estimated that worldwide, alcohol caused between 20 and 30 per cent of all oesophagal cancer, liver disease, epilepsy, motor vehicle accidents, and homicide and other intentional injuries.

Until recently, says the report, "blood pressure, cholesterol, tobacco, alcohol and obesity, and the diseases linked to them has been thought to be most common in industrialised countries. Unfortunately, they are now becoming more prevalent in developing countries, where they create a double burden in addition to the remaining, unconquered infectious diseases that have always afflicted poorer countries.

"In a number of ways, then, this report shows that the world is living dangerously – either because it has little choice, which is often the case among the poor, or because it is making the wrong choices in terms of consumption and its activities."

The report goes on to point out: "Meanwhile, tobacco and alcohol are being marketed increasingly in low and middle income countries. Today, more people than ever before are exposed to such products and patterns, imported or adopted from other countries, which pose serious long-term risks to their health."

The section of the report which concentrates on alcohol use says:

Alcohol has been consumed in human populations for millennia, but the considerable and varied adverse health effects, as well as some benefits, have only been characterized recently. Alcohol consumption has health and social consequences via intoxication (drunkenness), dependence (habitual, compulsive, long-term heavy drinking) and other biochemical effects.

Intoxication is a powerful mediator for acute outcomes, such as car crashes or domestic violence, and can also cause chronic health and social problems. Alcohol dependence is a disorder in itself. There is increasing evidence that patterns of drinking are relevant to health as well as volume of alcohol consumed, binge drinking being hazardous.

Global alcohol consumption has increased in recent decades, with most or all of this increase occurring in developing countries. Both average volume of alcohol consumption and patterns of drinking vary dramatically between sub-regions. Average volume of drinking is highest in Europe and North America, and lowest in the Eastern Mediterranean and SEAR-D. Patterns are most detrimental in EUR-C, AMR-B, AMR-D and AFR-E. Patterns are least detrimental in Western Europe (EUR-A) and the more economically established parts of the Western Pacific region (WPR-A).

Overall, there are causal relationships between average volume of alcohol consumption and more than 60 types of disease and injury. Most of these relationships are detrimental, but there are beneficial relationships with coronary heart disease, stroke and diabetes mellitus, provided low-to-moderate average volume of consumption is combined with non-binge patterns of drinking. For example, it is estimated that ischaemic stroke would be about 17 per cent higher in AMR-A, EUR-A and WPR-A subregions if no-one consumed alcohol.

Worldwide, alcohol causes 3.2 per cent of deaths (1.8 million) and 4.0 per cent of DALYs (58.3 million)[DALY is Disability Adjusted Life Year]. Of this global burden, 24 per cent occurs in WPR-B, 16 per cent in EUR-C, and 16 per cent in AMR-B. This proportion is much higher in males (5.6 per cent of deaths, 6.5 per cent of DALYs) than females (0.6 per cent of deaths, 1.3 per cent of DALYs). Within subregions, the proportion of disease burden attributable to alcohol is greatest in the Americas and Europe, where it ranges from 8 per cent to 18 per cent of total burden for males and 2 per cent to 4 per cent for females. Besides the direct effects of intoxication and addiction resulting in alcohol use disorders, alcohol is estimated to cause about 20ñ30 per cent of each of the following worldwide: oesophageal cancer, liver cancer, cirrhosis of the liver, homicide, epilepsy, and motor vehicle accidents. For males in EUR-C, 50ñ75 per cent of drownings, oesophagus cancer, epilepsy, unintentional injuries, homicide, motor vehicle crashes and cirrhosis of the liver are attributed to alcohol.

The World Health Report 2002 unequivocally places alcohol alongside illicit drugs, the section on which immediately follows:

Illicit drug use includes the non-medical use of a variety of drugs that are prohibited by international law. The current analysis focuses on the burden attributable to the injection of amphetamines and opioids, including cocaine and heroin. Other illegal drugs, such as ecstasy, solvents and cannabis have not been included because there is insufficient research to quantify their health risks globally.

Because the use of these drugs is illicit and often hidden, it is difficult to estimate the prevalence of their use and the occurrence of adverse health consequences. Despite these difficulties, it is apparent that illicit drugs cause considerable disease burden and their use is increasing in many countries, including those with little past history of such use.

The estimated prevalence of illicit drug use varies considerably across WHO regions. For example, estimates from the United Nations Drug Control Programme of the prevalence of opioid use in the past 12 months among people over the age of 15 years varies by an order of magnitude or more, from 0.02–0.04 per cent in the Western Pacific region to 0.4–0.6 per cent in the Eastern Mediterranean region. Cocaine use varies to a similar extent, but the prevalence of amphetamine use is estimated to be 0.1 per cent–0.3 per cent in most regions.

The mortality risks of illicit drugs increase with frequency and quantity of use. The most hazardous patterns are found among dependent users who typically inject drugs daily or near daily over periods of years. Studies of treated injecting opioid users show this pattern is associated with increased overall mortality, including that caused by HIV/AIDS, overdose, suicide and trauma. Other adverse health and social effects that could not be quantified include other blood-borne diseases such as hepatitis B and hepatitis C, and criminal activity associated with the drug habit.

Globally, 0.4 per cent of deaths (0.2 million) and 0.8 per cent of DALYs (11.2 million) are attributed to overall illicit drug use. Attributable burden is consistently several times higher among men than women. Illicit drugs account for the highest proportion of disease burden among low mortality, industrialized countries in the Americas, Eastern Mediterranean and European regions. In these areas illicit drug use accounts for 2–4 per cent of all disease burden among men.

In her message at the beginning of the report, Gro Haarlem Brundtland, the Director General of the World Health Organization spells out one of the options open to governments:

"Legislation enables risks to health to be reduced in the workplace and on the roads, whether through the wearing of a safety helmet in a factory or a seat belt in a car. Sometimes laws, education and persuasion combine to diminish risks, as with health warnings on cigarette packets, bans on tobacco advertising, and restrictions on the sale of alcohol."

The report is particularly concerned with the increase in alcohol consumption in poorer, developing countries: "All of these risk factors -- blood pressure, cholesterol, tobacco, alcohol and obesity -- and the diseases linked to them are well known to wealthy societies. The real drama is that they now also increasingly dominate in low mortality developing countries where they create a double burden on top of the infectious diseases that always have afflicted poorer countries. They are even becoming more prevalent in high mortality developing countries."