Issue 2 2005

G l o b a l A l c o h o l P o l i c y A l l i a n c e

Launch of

Indian Alcohol Policy

Alliance

GLOBAL ALCOHOL POLICY ALLIANCE

Editor in Chief

Derek Rutherford

Editor

Andrew McNeill

Assistant Editor

Andrew Varley

Design and production

2b Graphic Design

Published by The Global Alcohol Policy Alliance

12 Caxton Street

London SW1H 0QS

Tel: 020 7222 4001

Fax: 020 7799 2510

Email: gapa@ias.org.uk

ISSN 1460-9142

Contents Issue 2, 2005

3. Editorial

4. Opening Address of Dr S Arul Rhaj at the launch of the

Indian Alcohol Policy Alliance

5. Indian Alcohol Policy Alliance launched

7. India:

Alcohol and public health

11. Embrace life. Avoid alcohol – IAPA brochure

17. Treatment services and strategies

20. Drink driving in India

22. Road accidents in Kerala

22. WHO World Assembly resolution

With the launch of the Indian Alcohol

Policy Alliance, a global network of

alcohol policy advocates continues to be

built. IAPA’s launch is the result of a two

- year feasibility study, and the gathering

together of an expert group from the

Indian medical, social, public health,

research and nongovernmental

organizations, with core financial help

from FORUT a Norwegian development

agency.

The necessity for such an alliance in India may

come as a surprise to many outsiders who

consider India as an example of an abstinence

culture. However, as this edition of the Globe

shows, alcohol consumption is on the increase

in India with a consequential rise in alcohol

related harm. The launch of the new alliance is

timely. The Indian economic growth rate is

expected to increase over the next decades by

8% per year. Such an economic forecast makes

India a prime target for the marketing strategies

of the international drinks industry.

In the last edition of the Globe we

reported the placing by the WHO

Executive Board of a resolution on the

public health problems caused by alcohol

on the World Health Assembly agenda

for the first time since 1983.

The American delegation over the years has

supported the demands of the alcohol industry

to have its voice heard in Geneva. It came

therefore as no surprise that the industry lobby

was very active. Thailand made a determined

effort to strengthen the resolution by including

a critical review of the marketing strategies of

the industry. Despite the fact that the move was

not successful (the resolution could have been

lost) the concerns expressed by the Thais

should not go unnoticed by WHO officials. It

may be that the resolution appearing too

atlantist and eurocentric caused the Iranians to

insist on placing a caveat which defended those

member states which do not endorse the use of

alcohol.

Whilst we are supportive of the views of the

Thai representatives, we congratulate WHO on

the successful passing of a resolution which is

both timely and welcome. We commend it to all

advocates urging them to encourage its

implementation (see pages 22-23).

Indian Alcohol Policy Alliance

World Health Organization

4

� Alcohol use is on the increaseand it is estimated that there are62.5 million users;

� Age of initiating consumptionhas declined from 30 to 19 yearsof age;

� More women have started usingalcohol;

� Per capita consumption has goneup by 106.7% over a 15 yearperiod;

� Sale of alcohol is growing at arate of 8% per year;

� Alcohol related diseases aregrowing leading to theoccupation of 1 in 5 HospitalBeds. This assertion is based onmy three decades of experiencein Cardiology and Intensive Careas a Senior Physician;

� Alcohol related liver, cardiacdisorders, neurological andpsychiatric problems are increasing;

� 20% of all traffic accidents and35% of injuries treated inhospitals are alcohol related;

� 34% of all suicides are eithercommitted under the influence ofalcohol or related to alcohol use;

� 270,000 people die due to useand abuse of alcohol every year;

� Domestic Violence is on theincrease - 3000 family abusecases are registered every year.

In some states of India revenuefrom alcohol sales is Rs.250,000million. Expenditure on health careand loss due to decrease inmanpower is three times more thanthe revenue received. Yet,Government, on the one hand,needs this Revenue to meet itsexpenditure and, on the otherhand, remains concerned about thesocial, economic and health hazardsarising out of alcohol use.

The alcohol Industry is keen onincreasing its business through awide range of marketing strategiesand through surrogate advertisingcircumventing advertising bans. Inaddition the media provides a greatdeal of information to the populationincluding the message “alcohol isgood for your heart” – a messagewhich is inappropriate to India.

The Indian Alcohol Policy Alliance(IAPA) has a vision of promoting a“Healthy India”. It will strive tosensitize decision makers and thegeneral public to understand theneed for a comprehensive alcoholpolicy strategy.

IAPA’s Mission

The Indian Alcohol Policy Alliancewill:� be an advocacy body seeking to

control availability and to reducealcohol related harm. Achievingthis through policy interventionand capacity building especiallyamong youth and women;

� work in close association withGovernment both Central, Stateand Non Governmental Agencies;

� be a watch dog for the activitiesof the Industry more so on theirpromotional strategies;

� be an awareness creating body insociety;

� invite research to assess theimpact of use and abuse ofalcohol on various fields such asfamily, occupation, and finance;

� will support and encourageabstinence, mainly while driving,at work, in sport and forpregnant women.

IAPA has to be culturally sensitiveand pragmatic in its approach andmessage. Whilst the number ofalcohol users grow, the majority ofthe population is abstinent. IAPA’smessage is succinctly summed up inthe slogan: Less is Better:Abstinence is Best

IAPA will give a platform toeveryone interested in reducing theharms of alcohol use. In 2005 – 06the focus will be on “Drinking andDriving”.

In a developing country health isthe foundation upon which thewealth of the nation is built. “Healthis wealth” but “Wealth is not Health”However, “Health with Wealthequals Strength”

IAPA wants to see a “Healthy India”progressing to a “Wealthy India”leading to a “Strong India”.

Let us all see a strong India through ahealthy India free from alcohol abuse.

Address of Dr S Arul Rhaj atthe launch of the IndianAlcohol Policy Alliance

India is a country whose tradition, culture and values

anticipated the temperance movement that started in

the West in the middle of the nineteenth century. The

Father of our nation, Mohandas Karam Chand Gandhi had

asked us to “leave alone the vices of the West and strive

to adopt the best it has to give”. Today the scenario is entirely

different. Alcohol consumption in India is not only growing but it has

become a threat to public health. Western alcohol industries are

targeting the Indian market. This is worrying in the light of the extent

of the alcohol problem in India. Dr Arul Rhaj made the following points:

5

The ceremonial lighting of the lampwas performed by Shri YoganandShastri, the Minister of State forHealth & Family Welfare and SocialWelfare of Delhi. In addressing themeeting he said the governmentwould provide all possible help tothe alliance in its work and “hopedthat the association would go a longway in acting as a watchdog for thegovernment assisting in formulatingand implementing alcohol controlpolicies”.

Dr S Arul Rhaj the President of IAPAis a former President of the IndianMedical Association; a VicePresident of the CommonwealthMedical Association and honouredby the President of India with the DrB C Roy National ~Award for Socio-

Medical Relief. . In launching theAlliance Dr Arul Rhaj said that theincrease in alcohol consumption inIndia was worrying and was a majorcontributory factor in roadaccidents and family violence. Hewished to see a strong Indiathrough a healthy India free fromalcohol abuse

Dr. Vivek Benegal pointed out thatIndia is generally considered to be adry culture and a rather largeproportion of its people do notdrink at all. Still alcoholconsumption is quite high in somesections of the population. Bothprevalence and consumption seemsto be on the rise while the age ofinitiation to alcohol drinking hasfallen drastically over the pastdecades.

Mr. Derek Rutherford of the GlobalAlcohol Policy Alliance stated thatfor him it was not a question ofwhat the world could teach India,but what India could teach the

Indian Alcohol PolicyAlliance launchedDr Hariharan, Chief Executive reports:

The newly established Indian Alcohol Policy Alliance (IAPA) was

launched in New Delhi in May this year.

Above: The lighting of the lamp and the

unveiling of the logo

Right: School choir at opening ceremony

6

Indian Alcohol Policy Alliance launched

world. Alcohol consumption in thewest had reached a very high leveland it is worrying if countries likeIndia and China would follow onthat path. The drink industry sawboth countries as emerging andpromising markets for expansion.He said: “Growth rate in India isexpected to be around 8% per yearand that by 2040 India is likely to bethe third largest economy after theUSA and China. With such anexpected growth rate, theinternational drinks industry clearlysees India as a lucrative market withenormous potential for shareholderprofit.”

Dr. Shanthi Ranganathan, chiefexecutive of the well known T TRanganathan Clinical ResearchFoundation and RehabilitationCentre in Chennai is the honorarysecretary of IAPA. Presenting theroad map of IAPA she stated that thefocus would be on controlling theavailability of alcohol, addressing

specific social contexts andchanging the social climate andattitudes towards drinking. Asuccessful policy initiative includesinvolving multiple stake holders:Government and non government,presenting clear, specific ‘do-able’policy suggestions based on data,developing policies that have fairlyimmediate and direct effects as wellas those with more indirect andlong-term effects by changing thegeneral social climate.

IAPAs’ objectives include providinga forum for alcohol policy and todisseminate information on alcohol

policies and best practice in policyadvocacy. The alliance willencourage and promotegovernmental and non-governmental efforts to prevent andreduce alcohol-related harm andbring attention to the social,economic and health consequencesof alcohol use. It will monitoradvertising, marketing and otheractivities of the alcohol beverageindustry including their socialaspect organizations; encourageresearch on all aspects related toalcohol use and policies; conductawareness programmes andorganise de-addiction camps. IAPAwill co-operate and encouragepartnership with local, national andinternational organizations and civilsociety to prevent and alleviatealcohol-related harm.

Below: Derek Rutherford

Cherian Varghese of WHO India chairing

the seminar

Answering press questions: Ms Monica Arora and Dr Hariharan

Dr Hariharan, Ms Monica Arora, Oystein Bakke (FORUT), Derek Rutherford (GAPA), Dr S Arul Rhaj, Dr Shanthi Ranganathan, Mr

Johnson Edayaranmula and Dr Shobhangi Parkar.

7

Dr Vivek Benegal

Associate Professor of

Psychiatry

National Institute of Mental

Health and Neurosciences,

Bangalore

Prevalence of alcohol use

India is generally regarded as atraditional ‘dry’ or ‘abstaining’culture. A recent NationalHousehold Survey of Drug Use inthe country, the only systematiceffort to document the nation-wideprevalence of drug use, recordedalcohol use in only 21% of adultmales. Expectedly, this figurecannot accurately mirror the widevariation that obtains in a large andcomplex country like India. Theprevalence of current use ofalcohol ranged from a low of 7% inthe western state of Gujarat(officially under Prohibition) to75% in the Northeastern state ofArunachal Pradesh. There is also anextreme gender difference.Prevalence among women hasconsistently been estimated at lessthan 5 per cent but is much higherin the Northeastern states.Significantly higher use has beenrecorded among tribal, rural andlower socioeconomic urbansections).

The per capita consumption is 2litres/adult /year (calculated fromofficial 2003 sales and populationfigures). After adjusting forundocumented consumption,which accounts for 45-50% of totalconsumption, this is likely to bearound 4 litres, but still lowcompared to that in wet nations.Licit and illicit spirits i.e.government licensed country

India: Alcohol and public health

The article is published by kind permission of the Editor of Addictions. Copyright is retained by The Society of Addiction.

References are available from The Society, National Addiction Centre, 4 Windsor Walk, London SE5 8AF.

Illustrations are from Dr Benegal’s lecture at the IAPA Seminar.

Prevalence of alcohol use in men in India.

National Survey Drug Abuse 2004

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India: Alcohol and public health

liquor (rectified spirit mixed withwater at Indian made foreignliquors like whisky, rum, vodka andgin (42.8%v/v); and illicitly distilledspirits (of indeterminatecomposition) constitute more than95% of the beverages drunk byboth men and women. Beeraccounts for less than 5% ofconsumption (70% of beer sales isdominated by strong beers atstrengths over 8% v/v). Wine is anascent but growing market.

The historical construction of an

ambivalent drinking culture

However this tradition ofabstinence, may be a construct ofrelatively recent origin. Theextensive records of diversefermented and distilled beveragesproduced from fruits, grains andflowers, archeological evidence ofstills [circa 200 B.C.E.], theelaborate sets of rules governingproduction, sales, taxation andpublic intoxication, the lyricaldescriptions of ritual fiestadrinking by both sexes in secularliterature, the early recognition ofthe medical consequences of

excess and the frequentadmonitions against the use ofalcohol by the priestly elite do notquite support the notion of a long-standing dry culture. The period ofrapid social change during thecolonial era, transformed a society,which barring a segment of thebrahminical (priestly class) elite,

had until then what appears to be arelatively relaxed attitude to drink.The emergence of an urban middleclass, participating in the rapidindustrial development of the 19thcentury, led to socio-economicempowerment of the lower rungsof the caste hierarchy. Changes indietary practices were one of themeans adopted by the lower stratato acquire higher social status. As aresult of this phenomenon ofSanskritisation the growing middleclasses embraced upper castenorms of vegetarianism andabstinence from alcohol.

In parallel, the abkari (excise)policies of the colonialgovernment, restrictingmanufacture of alcoholic beveragesto licensed government distilleries,led to the rapid replacement oftraditional alcoholic beverages bymass-produced-factory-madeproducts, with greater alcoholcontent and less variety, whichwere progressively more expensivedue to ever-increasing taxation.The enormous increase in thenumber of distilleries, and thepractice of auctioning rights todistill and sell unlimited amounts

Alcohol related profits and losses 1997

Initiation of alcohol use. 1920-1990

of beverage alcohol led toincreased consumption,drunkenness and crime.Increasingly, viewed as anunpopular imposition of Englishrule and drinking a peculiarlyEnglish vice, alcohol use, came tobe regarded by the power elite asan atavistic trait of the primitiveand poor (tribals and the sociallybackward drinking to transcendtheir miserable existence) or alicentious affectation of the upperclasses.

Gandhi and the nationalistmovement harnessed thetemperance aspirations of themiddle classes into massmovements against drinking as asymbol of colonial oppression.Fired by the belief that the Indiannation should be ritually pure, theyevolved a demand for totalprohibition. The ConstituentAssembly of independent Indiaincluded prohibition as one of theDirective Principles of state policy.

In practice, alcohol policy devolvedto individual states to formulatetheir own regulations and levy

their own taxes. Most states derive15-20% of their revenue fromtaxation on alcohol, which is thesecond largest source of the states’exchequers after sales tax. This hascreated an “ambivalent” drinkingculture – neither dry nor wet.Alcohol use attracts socialopprobrium at the same time thatgovernments and alcoholmanufacturers promote alcoholsales in pursuit of profit. In severalstates renewal of retail licences arecontingent on meeting stiff salesquotas which are revised upwardlyfrom time to time.

The alcoholic beverage industry,visibly influences the politicalprocess with contributions topolitical parties and in the form ofinducements to voters duringelections. A few years ago, thePrime Minister designate of thecountry flew in for his investitureceremony in the private aeroplaneof a prominent liquormanufacturer! Nevertheless,alcohol use for the majority isfurtive and guilt-ridden!

The social cost of an ambivalent

drinking culture

Expectedly, in such a situationwhere traditional social regulationof drinking has been supplanted bycenturies of temperance orprohibitionist controls, noprescribed patterns of behaviourexist to regulate drinkingbehaviours. This is known topredispose to deviant,unacceptable and asocialbehaviour, as well as chronicdisabling alcoholism. Repeatedobservations have documented thatmore than 50% of all drinkers,satisfy criteria for hazardousdrinking. The signature pattern isone of heavy drinking, typicallymore than 5 standard drinks ontypical occasions.

There is surprisingly littledifference between amounts drunkby men and women. Though alarge proportion of drinkers ofboth genders, drink daily or almostdaily, the frequency is significantlyhigher in men. Under-socialized,solitary drinking of mainly spirits,drinking to intoxication andexpectancies of drink relateddisinhibition and violence add tothe hazardous patterns.

Needless-to-say, this translates intosignificant alcohol relatedmorbidity. Alcohol relatedproblems account for over a fifth ofhospital admissions but are underrecognized by primary carephysicians. Alcohol misuse hasbeen implicated in over 20% oftraumatic brain injuries and 60% ofall injuries reporting to emergencyrooms. It has a disproportionatelyhigh association with deliberateself-harm, high-risk sexualbehaviour, HIV infection,tuberculosis, oesophageal cancer,liver disease and duodenal ulcer.

Alcohol misuse wreaks a high

social cost

A study from the state of Karnatakain South India estimated that

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India: Alcohol and public health

Rise in sales in Karnataka 1998-2001

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India: Alcohol and public health

monetizable direct and indirectcosts attributable to people withalcohol dependence alone, wasmore than 3 times the profits fromalcohol taxation and several timesmore than the annual healthbudget of that state.

All these studies on morbidity areregional estimates, but given theubiquitous presence of hazardousdrinking patterns, should begeneralizable across the country.Yet, there is inadequate recognitionthat alcohol misuse is a majorpublic health problem in India.

Economic liberalization, social

change and changes in drinking

patterns

Indian society is currentlyundergoing another tectonic shiftin its socio-economic fabric. Theimpact of globalisation andeconomic liberalization (exposureto satellite television, rapidsocioeconomic transition andgrowing disposable incomes)appears to have influenced awidespread attitudinal shift togreater normalization of alcoholuse.

There has been a significantlowering of age at initiation ofdrinking. Data from Karnatakashowed a drop from a mean of 28years to 20 years, between the birthcohorts of 1920-30 and 1980-1990.Alcohol sales have registered asteady growth rate of 7-8% in thepast three years. The largestexpansion is seen in southernIndia, which has been driving mostof this economic growth. It isvisibly focused on the non-traditional segment of urbanwomen and young people, with anoticeable upward shift in rates ofdrinking among urban middle andupper socioeconomic sections. Thecountry liquor and whisky segmentthat earlier accounted for over 95%of documented consumption, hasseen stagnation; the growth is inthe non-traditional sectors of beer,

white spirits and wine. A newsegment of consumers is formingand a novel, convivial pattern issupplanting older drinking norms.

The local alcohol industry, quick toseize upon this emerging market,has introduced new products suchas flavoured and mild alcoholicproducts, aimed to recruit non-drinkers, targeted primarily atwomen and young men.Theindustry circumvents bans onadvertising by surrogateadvertising, and the subject ofalcohol advertising (surrogate andpoint-of-purchase) has changedfrom voluptuous pinups (targetingthe traditional market of middleaged male consumers), to lifestyleadvertisements promoting thespirit of good times, clearly aimedat women and youth.

Multinational alcohol beveragecompanies redeploying fromshrinking markets in the developedworld have identified India, with itsgrowing consumer base, vastunexploited markets andcommitments to the World TradeOrganisation to reduce quantitativerestrictions on alcohol imports asone of the most attractive marketsfor investment.

The trade papers in recent timeshave reported a spate of buy-outs

of local beverage companies byMNCs. The revenue aims of stategovernments are at odds with theirhealth and welfare aims, as theypush sales by imposing annuallyincremental quotas on productionand sales.

As the rising prevalence convergeson the signature pattern offrequent heavy drinking, theburden of health attributable toalcohol will mount dramatically. Itis often assumed that non-communicable diseases affecthigher social classesdisproportionately, as mortalitylevels fall and national incomesincrease.

In low-income countries, like Indiathe prevalence of alcohol andtobacco use is higher among thepoor, which increases the risk ofcardiovascular disease, cancer, liverdisease, and injuries among thepoor relative to the better off.There is also a strong associationbetween use of tobacco andalcohol, and impoverishmentthrough borrowing and distressselling of assets due to costs ofhospitalization.

Alcohol misuse in India is aprominent node in an inter-relatedmatrix of high risk behaviours whichhas begun to impose an ever

growing burden on the social andeconomic health of the nation. Theseinclude violence and injuries, high-risk sexual behaviours and HIVinfection, industrial losses, retardedeconomic development ofindividuals and families whichultimately impact on nationalgrowth.

The official response to the

alcohol problem

Unfortunately, the official responseremains focused on the visible tipof the alcohol problem, – personswith alcohol dependence (around4% of the adult male population)instead of on the emerging crisisdue to hazardous drinking in morethan 20% of the adult population.This is reflected in the approach toalcohol control policies at federaland state levels. The focus isexclusively on supply reduction(prohibition-centric) and tertiaryprevention.

Every attempt by individual stategovernments to prevent misusethrough prohibition has beenhastily reversed in the face ofmounting revenue deficits, costs ofpolicing smuggling fromneighbouring states and resultingunderground alcohol economies,notwithstanding evidence ofdecreased consumption andimproved indices of economic wellbeing. Increased taxation has beenused in other countries, to reduceconsumption. In India, the impactof such measures is weak asconsumers have easy access toundocumented (illicit and exciseevaded) alcohol, beyond thepurview of taxation.

There is also concern that alcoholas a commodity is relatively priceinelastic and, therefore, an increasein its price would simply increasethe expense of alcohol consumersaggravating the economic hardshipof their family members, withoutnecessarily reducing any of theother negative impacts.

Regulatory laws pertaining tohours of sale, sale to minors anddrunken driving are observed inthe breach. The Indian MotorVehicles Act specifies a bloodalcohol cut-off of 30mg.% fordrivers, which is arguably one ofthe strictest in the world. Yet, arecent study in Bangalore cityacross a calendar month, found40% of drivers were over the legallimit.

The Government of India, hasfunded 483 detoxification and 90counselling centres country-wide,under the auspices of the NationalDrug Deaddiction Programme, totreat people with substance abusedisorders. 45% of people seekingtreatment in these centres are foralcohol dependence. Most of theseare defunct as they received a one-time grant. Paradoxically, the ratesof help seeking in these centres arethe lowest in states with thehighest prevalence of alcohol useand the overall efficacy oftreatment programmes provided islow.

The evidence from India issubstantial that the direction forpolicy is to focus on macroenvironments and make themmore conducive to promotinghealth behaviours than bank onindividual behavioural change. Butthat is hardly likely as stategovernments publicly recant theirbeliefs in prohibition and alcoholcontrol and try to extricatethemselves from public funding ofhealth care. Private expenditurealready accounts for 82% of thetotal expenditure on health.

The popular media favour luriddescriptions of alcohol relatedviolence and heroic accounts ofsporadic, short-lived anti-alcoholagitations by women’s groups.These paradoxically serve tofurther marginalize the issue anddetract from a balanced publicdiscourse. Since the subject is oflow priority, funding for research is

low; there is little by way of a bodyof published literature, which caninform public policy, by projectingthe socio-economic impact ofalcohol misuse on a national scale.

Social aspect organizations of theliquor majors advocating safedrinking and sections of themainstream English languagemedia extolling the health benefitsof alcohol have invaded that space.Hopefully, the impetus for arational public health approach toalcohol policy will stem from theefforts of non-governmentalorganizations which are waking upto the sizeable negative impact thatharmful alcohol use has on thedelivery of their health anddevelopment programmes.

An alcohol policy for the 21st

century

A combination of a) a population-based approach

reducing overall consumption,and

b) a high-risk approach targetinghigh-risk behaviours is essentialto reduce the impact of thesignature pattern of hazardousalcohol use in the country.

This requires an urgent shift to apublic health paradigm in theapproach to alcohol use. Healthsystems, especially at primary carelevels must be geared to play agreater role in the early detectionand prevention of alcohol relatedharm, perhaps through brief, cost-effective interventions that havebeen demonstrated to be useful.

The social welfare system and thecriminal justice system, often thefirst to come into contact withalcohol related problems, can besensitized in identifying andassisting individuals and families atrisk from heavy drinking and actingas early referral systems. Extensiveopportunities exist to lessenalcohol problems throughcommunity education and the

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India: Alcohol and public health

12

prevention of drink driving,domestic violence, public disorder,unintentional injuries and criminaldamage .

Community programmessupporting healthier lifestyles,mass media campaigns that presentthe advantages of reducedconsumption rather than thedangers of heavy alcohol andcommunity development ingeneral, (job creation, skillsdevelopment and upgradinginfrastructure or recreationalfacilities in communities with highlevels of alcohol abuse) should beutilized to encourage alternativesto drinking among the young anddisadvantaged. Community actioncan also serve to shape attitudes,values and norms about drinking.Recently, several effectivetemperance campaigns have beenled by heads of certain Hindureligious orders, though the impacthas been limited to theirimmediate followers.

Existing legislation relating tocontrols on availability andmarketing, restrictions onadvertising and especiallyminimum drinking age, need to berigorously enforced. Simulationshave demonstrated thatimplementing a nationwide legaldrinking age of 21 years can

achieve about 50-60 per cent of thealcohol consumption reducingeffects of prohibition. Each yearthat drinking is delayed,significantly reduces the likelihoodof developing alcoholism and thelifetime risk of alcohol abuse.

Dialogue and a degree ofconsensus between the health andrevenue arms of government iscrucial to reduce the centripetaldirections of profit and welfare. Aproportion of the considerablerevenue on alcohol should beploughed back into treatment andresearch. The priority for alcoholresearchers in India surely is tofocus on the public healthdimensions of alcohol misuse andto focus on appropriateinterventions. It is equallyimportant for research findings tobe published and publicized.

Hopefully, the imminentcentralized system of value addedtaxation, will reduce the inequitiesin alcohol taxes between states,and thus diminish inter-statesmuggling, which nullifies thepotential benefits of increasingalcohol prices to reduceconsumption. Volume-based-taxation (wherein a litre of beer istaxed equally as a litre of spirits)that promotes excess consumptionof spirits requires rationalization

and stricter control on the entry ofillicit (often toxic) alcoholicbeverages into circulation isessential. There is also a need toconsider public health interests inissues relating to trade agreements.Investment in alcohol productionand distribution by trans-nationalcompanies in India and theremoval of tariff barriers is likely toincrease availability andconsumption and limit the effect ofprevention programmes.

For all this to happen, a vital firststep is for health planners andother stakeholders to debate anddraft an explicit and rationalalcohol policy, appropriate forIndia as it marches into theuncertain future of the 21stcentury.

The platform at the official launch with the Minister of Health Shri Yoganand Shastri in the centre with Dr Arul Rhaj at the podium.

India: Alcohol and public health

14

15

16

17

Dr. Shanthi Ranganathan

T T Ranganathan Clinical

Research Foundation

“TTK Hospital”

Indira Nagar, Chennai

Abuse of alcohol is not a

problem restricted to metro

and cities, it is also rampant in

villages and in smaller towns.

There is an increased incidence

of multiple addiction and

incidence of HIV is also high

among them.

Uniqueness of this problem

The need for treatment is notwidely known or accepted due todenial of the problem by the clientand his family members. Unlikeother illnesses, not only the addictbut other family members are alsoaffected psychologically. A conditionwhere relapse is not uncommon,the clients and their family questionthe efficacy of and the need fortreatment.

Availability of treatment

In India, the Ministry of SocialJustice & Empowermentcoordinates the treatment andrehabilitation services. Around 393treatment-cum-rehabilitationcentres and 53 counselling andawareness centres are offeringservices all over the country fundedby the Ministry of Social Justice &Empowerment. 100 centres havebeen empowered to providepreventive support for HIV-AIDS. 15workplace prevention programmes

have been set up in industries andenterprises.

For the first time in social servicepractice, minimum standards ofcare to be complied with by theNGOs who are providingrehabilitation services have beenintroduced. To help the NGOs tofollow minimum standards of care,eight Regional Resource & TrainingCentres have been established inthe south, north, east, west andnorth-east. The responsibilities ofthe Regional Resource & TrainingCentres are:� Providing training to NGOs

working in this region andhelping them improve theirquality of service and complywith the minimum standards ofcare;

� Preparing training materials inthe form of manuals;

� Undertaking research activitiesand documenting them;

� Monitoring drug abuse situationin this zone.

Treatment services andstrategies

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Treatment services and strategies

Treatment –

Research Findings

Cost of untreated addiction due tomorbidity of people of working age,drug related crimes and health carecost are substantial. These expensesare a great burden to thegovernment and society. Hence,treatment interventions are morecost effective than the nontreatment criminal justice system.

The theme of United Nations Officeon Drugs and Crime for theInternational Day against Drugabuse and illicit trafficking for theyear 2004 was “Treatment Works”.Patients in treatment either reduceor stop alcohol and other drug use.They also make positive changestowards physical health, psychosocial functioning, stability inemployment, reduction in criminaljustice involvement and preventionof relapses.

Principles of effective treatment

– NIDA

The National Institute on DrugAbuse USA has recommended thefollowing principles to ensureeffective treatment andrehabilitation services: � No single treatment is

appropriate for all individuals.There is a need to offer a rangeof services based on individualneeds;

� Treatment needs to be readilyavailable;

� Remaining in treatment for anadequate period of time iscritical for treatmenteffectiveness;

� Treatment does not need to bevoluntary to be effective;

� Medical detoxification is only thefirst stage of addiction treatmentand by itself does little to changelong-term drug use;

� Addicted or drug abusingindividuals with coexistingmental disorders should haveboth disorders treated in anintegrated way;

� Counselling and otherbehavioural therapies are criticalcomponents of effectivetreatment;

� An individual’s treatment andservice plan must be assessedcontinually and modified asnecessary to ensure that the planmeets the person’s changingneeds;

� Possible drug use duringtreatment must be monitoredcontinuously;

� Treatment programme shouldprovide assessment for HIV-AIDS, hepatitis B & C,tuberculosis and other infectiousdiseases and counselling to helpclients modify or changebehaviours that place themselvesor others at risk of infection.

� Recovery from addiction can be along-term process andfrequently requires multipleepisodes of treatment.

Addiction treatment needs to bestructured in a way that addressesthe wide range of issues. Mann(1991) described the principles oftreatment succinctly:� Treatment does not cure the

disease. The expectation is that,

by instituting an achievablemethod of abstinence, thecondition will be put intoremission;

� All therapeutic efforts aredirected at helping the clientreach a level of motivation thatwill enable him / her to committo abstinence;

� An educational programme isnecessary to make the clientfamiliar with the addictiveprocess, giving the individual aninsight into compulsivebehaviour, medicalcomplications, emotionalproblems and maintenance ofphysical, mental and spiritualhealth;

� Group and individual therapyare directed at selfunderstanding and acceptancewith emphasis on how drugshave affected the client’s life;

� The client is indoctrinated intothe self-help programmes(AA/NA) instructed about thecontent and application of the12 steps of the programme;

� The client’s family and othersignificant persons are included inthe therapeutic process to makethem understand the problem of

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Treatment services and strategies

addiction and the support theymust extend to the client;

� Insistence on participation in alongitudinal support and follow-up programme based on thebelief that, as in the managementof all chronic disease processes,maintenance is criticallyimportant to the ultimateoutcome of any therapy.

The popular model of treatment

available in India

In India, the majority of thetreatment centres provideresidential care for a period of 21– 30 days. Both detoxification andpsychological therapy are offeredas part of treatment. Some of thecomponents of therapy are re-educative sessions, group therapyand individual counselling. In re-educative sessions, informationand practical guidance onaddiction, relapse and recoveryand issues related to qualitativesobriety are provided. Grouptherapy is the most importanttherapy in treatment. Opensharing / mutual understandingand support are the benefits.Individual counselling is providedto deal with personal issues anddeveloping an individualizedtreatment plan. Some of the goalsof individual counselling aredeveloping a therapeuticrelationship and strengthening themotivation; assessment ofaddiction and related problems;identifying needs and resources;helping to develop recovery plansand support in sustainingrecovery.

The need for family therapy

Addiction has an impact on eachand every member of the family. Inthe process, trust, love, respect andcooperation are eroded. There is nohealthy relationship betweenhusband and wife, parent andchildren. There is emotional,financial and social damage. A series

of escalating crises intensifies over aperiod of time and reality is deniedby blaming, rationalizing. Thisresults in responding to theproblem inappropriately anddeveloping co-dependency traits.

Family support is the greatest

asset India has.

All treatment centres provide familyprogrammes of short duration. Thegoals of family therapy are toprovide information aboutaddiction and its effects on thefamily system; help the familyunderstand their inappropriateresponses and deal with theirdefects of character; to provide asafe and acceptable environment forthe family to discuss and deal withtheir problems; to improveinteraction among family members;to equip parents with the skillsneeded to raise adolescents / toimprove marital relationship.

The family programme componentsare re-educative sessions, grouptherapy, self-help group meetings(Al-anon) and counselling.

Follow-up is an important aspect inthe rehabilitation of addiction. Thegoals of follow-up are to enableclients attain whole person recovery– alcohol / drug free, crime free,gainfully employed and having ahealthy family relationship. Follow-up also helps clients who have hadrelapses and to assist familymembers in their own recovery.

Some of the components of follow-up are medical care and counsellingclient and family members: RelapsePrevention Programme; self-helpgroups, home visits and othermethods of communication are alsoused to provide support to clientswho are not regular for follow-up.

Factors facilitating recovery� Group setting contributes to

deeper understanding of theproblem and enables supportfrom one another.

� Medical and psychological issueshandled.

� Structure provides discipline andopportunities to take upresponsibilities.

� Offering emotional support tofamily members and motivatingthem to provide support duringrecovery.

� Long-term follow-up andrecognition of sobriety byawarding medals.

� Specific programme to deal withrelapses.

� Taking efforts to contact patientswho do not turn up for follow-up.

Strategies for improvement � Community approach of

treatment which is cost effectiveto be promoted in villages / smalltowns.

� Accessibility of treatmentthrough primary health centreswhich are available in the entirecountry.

� Availability of flexible treatmentmodalities to suit individualneeds by networking with otherNGOs. Longer treatment forpatients with psychiatricproblems, poor social support,lack of employment. Longerretention in treatment throughshort term in patient carefollowed up by out patient carein the community.

� Incorporating relapse preventionand long term after care servicesinto existing programmes.

� Opportunities for vocationalrehabilitation / training.

� Medical insurance to covertreatment cost.

� Organising regular trainingprogrammes to upgrade theknowledge and skills of staff.

� Documentation and evaluationto be made essentialcomponents.

Drink driving is prevalent amongdrivers after sunset. There are atleast 5 to 6 truck accidents on SherShah Suri Marg(National Highway)between Ambala Cantt and NewDelhi (A stretch of 200km) atdifferent locations daily. 50% ofthese accidents are said to be due todrunken driving. Most of the truckdrivers indulge in drug abuse, too.

Car owners who attend dinners /parties tend to get drunk, indulge inrash driving and are unable tocontrol the vehicle and meet withaccidents. About 60% and 65% ofaccidents are being caused by drinkdrivers of cars and two wheelersduring the night and early hours ofthe morning.

A recent survey about drinking anddriving in Delhi found that morethan 45% vehicles are driven bydrivers who had consumedalcoholic drinks. Youngstersparticularly students of 9th and 10th

standards and college students mixdrink with driving for “a high” orexhilaration and meet withaccidents. “Speed thrills but kills isvery much applicable to this class ofdrivers. The incidence of drinkdriving practices is increasingamong the students and youngerprofessional drivers. Drink drivingand road accidents among womenhave also increased.

Accidents in pub city

A study reported under the title“High spirits take toll on Bangaloreroads” reveals that driving underthe influence of alcohol is commonamong Bangalore residents onSaturdays and Sundays leading toaccidents, death.

The pub capital of India - Bangalorecity, reports the highest number ofroad accident deaths on week endsbetween 6.00 p.m. and 10.00 p.m.and there is little reason to believe

that this could be for any reasonother than drink driving, say the citypolice, 579 road accident deaths in1993, 106 were on Saturday nightsand an average of 60-90 deaths werereported on the other days of theweek. In 1994, there were 91 deathson Sundays, 89 on Saturdays and anaverage of 70-80 on weekdays.

What is one of the most difficultfactors to determine is whether anaccident was because of drinkingand driving. The drivers invariablyabscond, only to be found laterwhen the effect of alcohol wouldhave safely worn off. The people atthe accident spot concentrate ongetting the injured to hospitalrather than nabbing the driverresponsible and if they do find thedriver, he would be badly beaten.

Besides the swank pubs which arethe toast of the city, smaller barshave sprung up along the high wayscausing accidents to rise on these

Drink driving in IndiaDr Vinay Aggarwal, Secretary General Indian Medical Association.

Little or no recorded data are available on drink driving in India.

Attempts have been made to discuss the issue with the departments

of social preventive medicine and forensic and emergency wards at

hospital. Similarly views have been collected from Drivers of Trucks,

Taxies, Buses, Two Wheelers, and Cars. The matter was also

discussed with police officers and a few top officers of Government

Roadways Transport Corporation. The summary of the information

available on drink driving in India is given below:

Percentages of accidents that are alcohol related

Vehicle Trucks & Matadors Cars Two Wheelers Pedestrians Cyclists Buses

Percentage 40 60 65 5 5 2

Age-group (years) 15-20 20-30 30-45 >45

Percentage 25 50 15 10

Students involvement School (9th & 10th standard) and college students Professional colleges

Percentage 10% 20%

20

21

already dangerous roads. There isnot a single stretch of highway inIndia where no accident takes placeduring 24 hours. The most effectiveway to regulate traffic on highwaysis primarily to check drink driving.The abundance of liquor shops,bars and ‘ahtas’ on highways are themajor causes for the risingincidence of fatal accidents onhighways. Trucks and Buses parkedclose to liquor shops on highways isa common sight. In some biggercities, there are tests to detect drinkdriving. But there are no suchfacilities on highways. And alsothere is no equipment available tocheck effectively on drink driving.The old method of blowing into aballoon has become obsolete.

It is desirable that the prohibitionand excise departments frameregulations to be observed by barsand liquor shops to make highwayssafe for drivers and peopletravelling by road.

Laws on drink driving

Though the laws to check drinkingand driving do exist in India, thereis a need to effectively implementthe law. The motor vehicle Act,1939, amended in 1989 containsclause 117 which reads as:

Driving by a drunken person or by aperson under the influence of drugs- whoever while driving orattempting to drive a motor vehicleor riding or attempting to ride, amotor cycle - (a) has in his blood,alcohol in any quantity, howsoeversmall the quantity may be or (b) isunder the influence of a drug to suchan extent as to be incapable ofexercising proper control over thevehicle shall be punishable for thefirst offence with imprisonment for aterm which may extend to sixmonths or with a fine which mayextend to two thousand rupees orwith both; and for a second orsubsequent offence, if committedwithin three years of the commissionof the previous similar offence, with

imprisonment for a term which mayextend to three thousand rupees, orwith both”. The above law is veryeffective only if imposed. But thepsychology of drunken drivers issuch that they get away by payingsome money to the police.

1994 – Amendment

Any alcohol in the blood, howeversmall the quantity, had been anoffence till November l994 but afterNovember 1994 the law wasamended. Since then up to 30milligrams of intake per 100m1 ofblood has been permitted to driversbefore getting behind the wheel. Aresearch agency conducted a surveyin the capital to know the publicreaction to the 1994-Amendment.86% felt that this would increase thenumber of road accidents and 88%felt that it would render roadsunsafe. Across the worldgovernments have defined differentacceptable blood alcohol levels. TheSwedes allow 20m1 of alcohol in theblood; the Irish 80 and the U.S. 100.

Less is better but abstinence is

the best

Delhi police consider that theexisting breath analyser will have tobe supplemented by moresophisticated equipment approvedby the Union Government. Thepresent tube and plastic bag breathanalysers just indicate the presenceof alcohol. They give no idea of theamount of alcohol. “Anybody can becalled a drunkard,” says one official.Several Ayurvedic medicines,common cough syrups and otherpreparations, have alcohol. And adriver who had any of these may wellfail the present test.

IAPA’S Role:

Keeping in view of the above factualsituations IAPA plans to launch a“CAMPAIGN AGAINST DRINKING &DRIVING” with the aim of puttingscience into action with thefollowing objectives:

� To undertake experimentalstudies on drinking and drivingfor correct assessment of trafficsafety situation on Indian roads;

� Blood alcohol screening shouldbe routinely performed;

� Major publicity campaigns willneed to be mounted to informdrivers on drinking and driving,the harm that results fromdrinking and driving and thepenalties;

� A monitoring system, withcommon and agreedmeasurement and reportingprocedures across India shouldbe put in place with BAC to bezero if possible otherwise notmore than 0.02%;

� Describing the implementationof any new measures andmonitoring the progress towardsachieving the target of halvingdrink driving related death anddisabilities;

� Road side liquor shops, bars and‘ahatas’ should be shiftedminimizing their use by drivers;

� Strict enforcement of MotorVehicle Act on drink driving;

� Developing the high taxationpolicies for alcohol beverageswhich reduces the buying powerof drivers;

� Time of Sales to be restricted to8pm. National Holidays, and payday closure of outlets.

Conclusions

An intensive drive against drinkdriving is needed to promote roadsafety. Alcohol causes deterioration ofdriving skills even at low levels andthe probability of crashes increaseswith rising blood alcohol levels.

Drivers aged 16 to 21 years havehighest rate of alcohol involved fatalcrashes in United States even thoughlower average BACs were found thanin older drivers. But in India (wheresignificant research in this field islacking) this age group can beidentified between 20 to 25 years.

22

Public health problemscaused by alcohol

FIFTY-EIGHTH WORLD HEALTH ASSEMBLY May 2005

Reaffirming resolutionsWHA32.40 on developmentof the WHO programme onalcohol-related problems,

WHA36.12 on alcohol consumption and

alcohol-related problems: developmentof national policies and programmes,WHA42.20 on prevention and control ofdrug and alcohol abuse, WHA55.10 onmental health: responding to the call for

action, WHA57.10 on road safety andhealth, WHA57.16 on health promotionand healthy lifestyles and WHA57.17 onthe Global Strategy on Diet, PhysicalActivity and Health;

As per the road accident datacompiled by the NationalTransportation Planning andResearch Centre (NATPAC), Keralahas become the second mostaccident-prone State in the countryafter Maharashtra. The total cost onaccount of fatalities, injuries andvehicles damaged in the 41,306road accidents that occurred in theState during 2004 has beenestimated at Rs. 4537.8 millionwhich is roughly 1.5 per cent of theState’s GDP. The cost on account ofroad accidents, which was Rs. 3160million in 1998, is going up five to

six per cent annually according tothe Chief Project Coordinator ofNATPAC Mr. Mahesh Chand.

The analysis of the accident costs hasrevealed that 57% was due to loss ofproduction, 14% due to medicalexpenses, 7% due to administrativeexpenses of police and insurancecompanies, 6% due to court relatedexpenses and 16% due to notionalvalue for pain, grief and suffering ofthe victims. Of the 41,306 accidents,11,106 took place in the NationalHighway stretches passing throughthe State, 5,184 in State Highway andthe remaining in other roads.

A study conducted by the Alcohol &Drug Information Centre (ADIC)-India revealed that around 40% ofthe road accidents have occurredbecause the driver was under theinfluence of alcohol. In the case ofaccidents in national highways,more than 72% was related to drinkdriving. The number of Roadaccidents in Kerala has a close linkto the alcohol per-capitaconsumption in the State. Keralahas one of the highest per capitaconsumption of alcohol in thecountry and hence it is notsurprising that in Road Accidentstoo Kerala tops the country’s list.

Road accidents in Kerala

Source: State Crime Records Bureau, Kerala

Year 2000 2001 2002 2003 2004

Road accidents 37.072 38,361 38,762 39,496 41,306

Killed 2,710 2,674 2,792 2,905 3,055

Injured 49,403 49,675 49,460 48,640 51,352

Report from Johnson J. Edayaranmula, Director ADIC India

The number of road-accident deaths in Kerala State has risen steeply,

with 3,066 people being killed and 51,352 injured in 41,306

accidents in 2004. Statistics compiled by the State Crime Records

Bureau show that the annual figures for such deaths in the State

crossed 3,000 for the first time last year. The number was 2,905 in

2003; 2,792 in 2002; 2,674 in 2001; and 2,710 in 2000. There

were 50,917 vehicles damaged in 2004.

23

Recalling The world health report2002,1 which indicated that 4% of theburden of disease and 3.2% of all deathsglobally are attributed to alcohol, andthat alcohol is the foremost risk tohealth in low-mortality developingcountries and the third in developedcountries;

Recognizing that the patterns, contextand overall level of alcoholconsumption influence the health of thepopulation as a whole, and that harmfuldrinking is among the foremostunderlying causes of disease, injury,violence – especially domestic violenceagainst women and children – disability,social problems and premature deaths,is associated with mental ill-health, has aserious impact on human welfareaffecting individuals, families,communities and society as a whole,and contributes to social and healthinequalities;

Emphasizing the risk of harm due toalcohol consumption, particularly, in thecontext of driving a vehicle, at theworkplace and during pregnancy;

Alarmed by the extent of public healthproblems associated with harmfulconsumption of alcohol and the trendsin hazardous drinking, particularlyamong young people, in many MemberStates;

Recognizing that intoxication withalcohol is associated with high-riskbehaviours, including the use of otherpsychoactive substances and unsafe sex;

Concerned about the economic loss tosociety resulting from harmful alcoholconsumption, including costs to thehealth services, social welfare andcriminal justice systems, lostproductivity and reduced economicdevelopment;

Recognizing the threats posed to publichealth by the factors that have given riseto increasing availability andaccessibility of alcoholic beverages insome Member States;

Noting the growing body of evidence ofthe effectiveness of strategies andmeasures aimed at reducing alcohol-related harm;

Mindful that individuals should beempowered to make positive, life-

changing decisions for themselves onmatters such as consumption of alcohol;

Taking due consideration of thereligious and cultural sensitivities of aconsiderable number of Member Stateswith regard to consumption of alcohol,and emphasizing that use of the word“harmful” in this resolution refers onlyto public-health effects of alcoholconsumption, without prejudice toreligious beliefs and cultural norms inany way,

1. REQUESTS Member States:

1 to develop, implement and evaluateeffective strategies and programmesfor reducing the negative health andsocial consequences of harmful useof alcohol;

2 to encourage mobilization andactive and appropriate engagementof all concerned social andeconomic groups, includingscientific, professional,nongovernmental and voluntarybodies, the private sector, civilsociety and industry associations, inreducing harmful use of alcohol;

3 to support the work requested ofthe Director-General below,including, if necessary, throughvoluntary contributions byinterested Member States;

2. REQUESTS the Director-General:

1 to strengthen the Secretariat’scapacity to provide support toMember States in monitoringalcohol-related harm and toreinforce the scientific and empiricalevidence of effectiveness of policies;

2 to consider intensifyinginternational cooperation inreducing public health problemscaused by the harmful use of alcoholand to mobilize the necessarysupport at global and regionallevels;

3 to consider also conducting furtherscientific studies pertaining todifferent aspects of possible impactof alcohol consumption on publichealth;

4 to report to the Sixtieth WorldHealth Assembly on evidence-basedstrategies and interventions toreduce alcohol-related harm,including a comprehensiveassessment of public health

problems caused by harmful use ofalcohol;

5 to draw up recommendations foreffective policies and interventionsto reduce alcohol- related harm andto develop technical tools that willsupport Member States inimplementing and evaluatingrecommended strategies andprogrammes;

6 to strengthen global and regionalinformation systems through furthercollection and analysis of data onalcohol consumption and its healthand social consequences, providingtechnical support to Member Statesand promoting research where suchdata are not available;

7 to promote and support global andregional activities aimed atidentifying and managing alcohol-use disorders in health-care settingsand enhancing the capacity ofhealth-care professionals to addressproblems of their patients associatedwith harmful patterns of alcoholconsumption;

8 to collaborate with Member States,intergovernmental organizations,health professionals,nongovernmental organizations andother relevant stakeholders topromote the implementation ofeffective policies and programmes toreduce harmful alcoholconsumption;

9 to organize open consultations withrepresentatives of industry andagriculture and trade sectors ofalcoholic beverages in order to limitthe health impact of harmful alcoholconsumption;

10 to report through the ExecutiveBoard to the Sixtieth World HealthAssembly on progress made inimplementation of this resolution.

1. The world health report 2002. Reducingrisks, promoting healthy life. Geneva, WorldHealth Organization, 2002.

G l o b a l A l c o h o l P o l i c y A l l i a n c e

Contact

Published by The Global Alcohol Policy Alliance

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London SW1H 0QS

United Kingdom

Tel: 020 7222 4001

Fax: 020 7799 2510

Email: gapa@ias.org.uk