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REFERENCE COPY ' FOR LIBRARY USE ONLY

INSTITUTE OF MEDICINE

AN INTER-AUERICAN WORKSHOP

N NAS R NAE C IOM

'í ' LEGISLATIVE APPROACHES TO PREVENTION

OF ALCOHOL-RELATED PROBLEMS: AN INTER-AMERICAN WORKSHOP

P r o c e e d i n g s

INSTITUTE OF MEDICINE * > $ b. t <-,

June 1 9 8 2

N a t i o n a l Academy P r e s s Washington, D. C.

N AS-N A€

JUL2 6 1982

LlBR ARY

This volume o£ proceedings was compiled and edi ted by the s t a f f o£ t h e I n s t i t u t e of Medicine with t h e advice and a s s i s t a n c e of t h e workshop's advisory committee, whose members a r e l i s t e d on the following page. The opinions expressed by authors and d iscussants and t h e statements about conseneus o£ workshop pa r t i c ipan te a r e t h e i r views and do not represent pol icy pos i t ions o£ the I n s t i t u t e o£ Medicine o r o£ organizat ions sponsor- ing o r cooperating i n t h e projec t .

The I n s t i t u t e o£ Medicine was char tered i n 1970 by the National Academy o£ Sciences t o e n l i s t dist inguiehed members of appropr ia te professione i n t h e exmnination of pol icy mat ters per ta in ing t o t h e hea l th of the public . In t h i s , t he I n s t i t u t e a c t s both under t h e Academy's 1863 congreesional c h a r t e r reeponaibi l i ty t o be a n advisor t o t h e f e d e r a l government, and i t s own i n i t i a t i v e i n ident i fy ing i s s u e s of medical care , research, and educat ion.

2101 Const i tu t ion Avenue, N.W. Washington, D. C. 20418

(202)334-3300

Publicat ion IOM-82-003

WORKSHOP ADV ISORY COMMITTEE, DEPARTMENT OF HEALTH AND HUMAN SERVICES AND PAN AMERICAN HEALTH ORGANIZATION LIAISON,

INSTITUTE OF MEDICINE STAFF

Advisory Committee Department of Heal th and Human Serv ices Liaieon

d *Robert J. Blendon, Chairman Senior V i ce-President The Robert Wood Johnson Foundation Pr ince ton , New Je r sey

Linda A. Bennett A s s i s t a n t Research Professor Center f o r Family Research Department of Peychiatry and

Behavioral Sciences George Washington Univers i ty

Medical Center Washington, D.C.

Linda Vogel Of f i ce of I n t e r n a t i o n a l Health Department of Health and

Human Serv ices Rockvil le , Maryland

Berkley C. Hathorne I n t e r n a t i o n a l A c t i v i t i e e Of f i ce r Of f i ce of t h e Administrator Alcohol, Drug Abuse and Mental

Heal th Administration Rockvil le , Maryland

Rene Gonzalez Regional Advisor i n Mental t i ea l th Div is ion of Disease Prevent ion

and Control Pan American Heal th Organizat ion Washington, D.C.

Dwight B. Heath Department of Anthropology Brown Univers i ty Providence , Rhode I s l and

Robin Room S c i e n t i f i c Di rec tor Alcohol Research Group Berkely, Ca l i fo rn i a

Wolfgang Schmidt Department of Socia l S tud ie s Alcoholism and Drug Addiction

Research Foundation Toronto, Ontar io , Canada

Leland H. Towle Chief, I n t e r n a t i o n a l and In t e r -

governmental Affa i re National I n s t i t u t e on Alcohol Abuse

and Alcoholism Rockvil le , Maryland

Pan American Health Organization Lia ison

Marilynn Katatsky Regional Advisor on Alcoholiem

and Drug Abuse Divis ion of Dieease Prevent ion

and Control Pan American Health Organization Washington, D.C.

I n s t i t u t e of Medicine S ta f f

W i l l i a m A. Lybrand, M r e c t o r *Robert S t r aus Div is ion of I n t e r n a t i o n a l Health Professor and Chairman Department of Behavioral Science @ d a n Y. ~ a p l a n College of Medicine Workshop Coordinator and Univerei ty of Kentucky Medical Center Ed i to r of Proceedings Lexington, Kentucky

Bet ty L. Craig Administrat ive Coordinator and

%ember, I n s t i t u t e of Medicine Associate Edi tor of Proceedings

The inter-American workshop on a l coho l - r e l a t ed problems, which was made p o s s i b l e by a c o n t r a c t from t h e Of f i ce of I n t e r n a t i o n a l Health(OIH), United S t a t e s Publ ic Health Se rv i ce , Department of Hea l th and Human Serv ices , r e s u l t e d from t h e e f f o r t s and c o n t r i b u t i o n s of numerous i nd iv idua l s .

The Pan American Heal th Organizat ion provided v i t a l a s s i s t a n c e i n t h e planning and execut ion of t h e workshop through Rene Gonzalez, a member o f t h e workshop advisory committee, and Marilynn Katatsky, who served as l i a i s o n between PAHO and t h e I n s t i t u t e of Medicine. A s hos t f o r t h e workshop, PAHO a l s o provided superb f a c i l i t i e s and u n f a i l i n g l y respons ive s t a f f suppor t i n t h e persons of Luis Larrea Alba, Jr., ch i e f of conference and gene ra l s e r v i c e s , and Luiz Gonzalez, conference of f icer.

The s t i m u l a t i n g con ten t of t h e workshop stemmed from both t h e very h igh c a l i b e r of t h e w r i t t e n c o n t r i b u t i o n s of a l 1 t h e p re sen t e r e and d i scus san t s , and t h e advice of a most e n t h u s i a s t i c and know- ledgeable group: John Bryant, former Deputy Ass i s t an t Sec re t a ry f o r I n t e r n a t i o n a l Health and h i s s t a f f i n OIH--Linda Vogel, Rose Belmont and Marlyn Kefauver; t h e members of t h e workshop advisory committee; and Leland Towle and Berkley Hathorne o f t h e Nat ional I n s t i t u t e on Alcohol Abuse and Aicoholism, and Alcohol, Drug Abuse and Mental Heal th Adminis t ra t ion, r e spec t ive ly .

Workshop p a r t i c i p a n t s were moet a p p r e c i a t i v e of t h e i l l u m i n a t i n g i n s i g h t s provided by P e t e r D. B e l l , P res ident of t h e Inter-American Foundation, who spoke informal ly fol lowing d inne r a t t h e Nat ional Academy of Sciences t h e f irst n igh t of t h e workshop. B e 1 1 o f f e r e d comments on t h e l o c a l impact of a l coho l consumption from t h e pe r spec t ive of t h e ex t ens ive experience i n community development a c t i v i t i e s i n a number of c o u n t r i e s i n t h e Americas.

An important c o n t r i b u t i o n t o t h e o rgan iza t ion of t h e e f f o r t was made by Mar t i t a Marx and Maria Gil-del-Real of The Robert Wood Johnson Foundation who used t h e i r b i l i n g u a l s k i l l s t o f a c i l i t a t e communication wi th Spanish-speaking p a r t i c i p a n t s .

F i n a l l y , my g r e a t a p p r e c i a t i o n goes t o t hose a t t h e I n e t i t u t e of Medicine who provided v i t a l i npu t and helped br ing t h e workshop t o f r u i t i o n : my co l l eagues W i l Lybrand, Karen Be11 and Barbara F i l n e r ; Be t ty Craig, f o r h e r tireless a s s i s t a n c e and wise counsel i n both t h e p r e r o r k s h o p phase and i n t h e e d i t i n g o f t h e s e proceedings; M i r e i l l e Mesias and Azora I rby , who provided a b l e admin i s t r a t i ve a s s i s t a n c e p r i o r t o t h e workshop; and Lynet te Bates, whose e x p e r t i s e on t h e word processor helped make t imely product ion of t h e s e pro- ceedings poss ib le .

Aian K. Kaplan

CONTENTS

P r e f ace Robert C. B l e n d o n

W o r k s h o p B a c k g r o u n d and O v e r v i e w Aian K . K a p l a n

C h a p t e r O n e

WELCOME AND INTRODUCTORY BEMABKS F r e d e r i c k C. R o b b i n s Hector R. Acuna John H. B r y a n t

KEYNOTE ADDRESS C h a r l e s Chassoul Morige

C h a p t e r Two

A u s T R I m z A T I o N . E c o N o m c D w E L o P m N T , m w o m R DRINKiNG: HISTORICAL AND SOCIOLOGICAL OBSERVATIONS

Harry G e n e Le i n e J' /+HE IMPACT OF ECONOMIC DEVELOPMENT ON DUNKING PATTERNS

AND PROBLiMS: THE CASE O F TOUBISM sher and L e n o r e D.

C h a p t e r niree

. ~NIFESTATIONS AND PERCEPTIONS OF ALCOHOL-BELATED PROBLEMS I N THE AMERICAS

Raul Cpetano 1

D i s c u s e a n t Ca r los C a m p i l l o - S e r r a n o

d

C h a p t e r F o u r

~ISTORICAL m CULTURAL FACTOBS a~wciriw: ~ O L AVAILABILITY AND CONSUMPTION I N LATIN AMERICA

Fath D i s c u s s a n t S J E d u a r d o M e d i n a C a d e n a s

Juan C a r l o s Negrete J

C h a p t e r F i v e

km ANATOMY OF ALCOHOL POLICY: PREVENTIVE MEASUBES Dean G e r s t e i n

d

Di s c u s s a n t s M a r i l y n J k t a t s k y I r v i ng Roo tman

V'

,ANTERNATIONAL STUDY OF ALCOHOL CONTROL EXPERiENCES (ISACE): COMHENTS ON THE FINAL REPORT

James Mosher

C h a p t e r S i x

A IWACT OF PREVENTION LEGISLATION: AN EXAMINATION OF RESEARCH FINDINGS

R e g i n a l d mrt 9 D i s c u s s a n t s

M i c h a e l iJeaubrun Mar i a E l e n a Medina-Mora

\

v * A SURVEY OF ALCOHOL-RELATED LEGISLATION J a i m e Arroyo S u c r e

u

Appendix A

/ CONSENSUS VIEWS ON DEVELOPMENT OF ALCOHOL POLICIES A l t e r n a t i v e Non-Consensue Views

Appendix B

LIST OF PARTICIPANTS

P RE FACE

It has long been recognized t h a t n a t i o n a l economic progress o f t e n c a r r i e s wi th i t some unforeseen r i p p l e e f f e c t s . One such e f f e c t i s seen i n the problems t h a t a r e a s s o c i a t e d with the i ncreased inges t i o n of a l cohol-containing beverages. I n r e cen t years , widespread problems i n the world economy have turned the s p o t l i g h t on the need f o r g r e a t e r m a t e r i a l p rogress i n many p a r t s of the world. The sudden, sha rp r i s e i n o i l p r i c e s , a cu t e sho r t ages of food i n c e r t a i n na t ions , the f a l l o f f i n p r o d u c t i v i t y i n the OECD (Organiza t ion f o r Economic Cooperation and Development) coun t r i e s , and the problems produced by r i s i n g popula t ions i n developing c o u n t r i e s have r a i s e d s e r i o u s ques t i ons about the a b i l i t y of governments t o improve t h e i r domes t i c e conomic s i tua t ion. The response t o these developments i n the Americas has been f o r governmen ts t o concentra t e s ing le -mindedly on economi c growth t o a v e r t a n immediate d e c l i n e i n t h e i r s t anda rd of l i v i n g , o r t o a cce l e r a te t h e i r longer-range economic well-being .

This workshop was thus unusual. I t a t tempted to l ook a t one phenomenon which o f t e n accompanies economic progress -- i nc reased a l coho l consumption. The r e p o r t i s a unique con t r ibu t ion to La t in American/Uni ted S t a t e s understanding of t h i s a s p e c t of economic growth. I t examines t he impact t h a t a c c e l e r a t e d e f f o r t s t o improve a c o u n t r y f s m a t e r i a l circumstances can have on one f a c e t of t h e b e t t e r l i f e -- the p o t e n t i a l r i s e i n a lcohol ism and a lcohol - re la ted h e a l t h problems, inc lud ing a cc idents and violence. It exp lo re s the l e s s o n s , bo t h p o s i t i v e and nega t ive , t h a t may be l ea rned from the exper ience of a v a r i e t y of na t ions and t h a t might have a bear ing on those t ry ing t o encourage improved economi c performance, while a t the same time a t tempt ing t o avo id the s e r i o u s p i t f a l l s a s s o c i a t e d wi th the l i k e l i h o o d of i nc reased a l coho l consumption. The papers i nc luded i n t h i s volume were presen ted a t a workshop sponsored by the I n s t i t u t e of Medicine of the Nat ional Academy of Sciences, and h e l d a t the Pan American Heal th Organizat ion i n Washington, D.C. from March 8 t o March 10, 1982. 3 1

The i d e a f o r t h i s workshop grew ou t of a r ecogn i t i on t h a t an exc lus ive focus by governments on economic growth has sometimes had a d e s t a b i l i z i n g e f f e c t on t h e h e a l t h and well-being of t h e i r populat ions. In some, a sharp rise i n d r ink ing , a l coho l abuse, and a lcohol i sm has gone hand-in-hand wi th "progrese." These problems have come t o be a s s o c i a t e d wi th Engel ' s law: i .e . , when family incomes rise, t h e propor t ions spen t on food and o t h e r n e c e s s i t i e s dec l ine . Monies spent on d i s c r e t i o n a r y items such a s imported o r domestic a l c o h o l i c beverages g e n e r a l l y i nc rease . I n a d d i t i o n , growth p o l i c i e s can a l s o i n d i r e c t l y a f f e c t t h e prevalence of important a l coho l - r e l a t ed problems inc luding v io l ence , motor v e h i c l e a c c i d e n t s , mental h e a l t h problems, a lcohol ism, c i r r h o s i s of the l i v e r , and o t h e r d i s e a s e s of a l coho l .

Many p o l i c i e s , designed t o i n c r e a s e economic p r o d u c t i v i t y , o f t e n encourage la rge-sca le i n t e r n a 1 migra t ions from t h e r u r a l coun t rys ide t o towns, and changes i n employment f rom farming toward i n d u s t r y and s e r v i c e s i n urban loca t ions . This o f t e n r e s u l t a i n more f a m i l i e s d i s s o l v i n g , more people l i v i n g i n crowded forms of housing, and more stress a r i s i n g from employment i n d i f f e r e n t t ypes of s e t t i n g s , r equ i r ing d i f f e r e n t s k i l l s and a p t i t u d e s . A l 1 of t he se provide a c l ima te f o r t h e increased use and abuse of a l c o h o l i c beverages. Thus, a number of c o u n t r i e s wi th i nc reas ing economic growth have found themselves w i th a t h r i v i n g domestic a l c o h o l i n d u s t r y , providing d e s i r a b l e jobs and t a x revenue, a longs ide a r a p i d l y r i s i n g s e r i e s of s e r i o u s h e a l t h problems r e l a t e d t o a lcohol .

This workshop was organized t o examine whether t h e s e phenomena could be d i s s o c i a t e d . I t sought t o review t h e d a t a a v a i l a b l e , and t h e exper iences of many c o u n t r i e s , and t o b r ing t h i s information more e f f e c t i v e l y t o bear on t h e important po l i cy ques t i ons r e l a t i n g t o economic growth, a lcohol i sm, and alcohol- r e l a t e d h e a l t h problems. The aim was t o provide t hose wi th policy-making r e s p o n s i b i l i t i e s throughout t h e Americas w i th improved knowledge t o apply t o t h e inescapable t a s k of making d e c i s i o n s about t h i s i n t e n s e l y c o n t r o v e r s i a l i s sue . The focus of t h e conference was on t h e a l c o h o l "dr inking" problem a s i t i s seen by e l e c t e d o r appointed publ ic o f f i c i a l s , a s d i s t i n c t from t h e views of those h e a l t h p r o f e s s i o n a l s who s p e c i a l i z e i n t h e f i e l d of a l c o h o l t rea tment o r research .

Over t h e p a s t ha l f -cen tury , peoples of t h e Americas have i n c r e a s i n g l y turned t o t h e i r governments f o r t h e r e s o l u t i o n of many c o n t r o v e r s i a l ques t ions . These problems have been vide-ranging i n t h e i r economic c u l t u r a l , r e l i g i o u s , s o c i a l , and geographic implica- t i o n s . They have o f t e n requi red a d i f f i c u l t balancing of judgements about both c o s t s and bene f i t s . A s t h e s e governmental responsi- b i l i t i e s have grown, pub l i c p r i o r i t y cho ices have become an immensely more d i f f i c u l t t ask .

Because of t h i e r e a l i t y , t h e quee t ione aeked by i n d i v i d u a l s i n pub l i c l i f e about h e a l t h probleme euch as alcohol iem and a l coho l abuse a r e q u i t e fundamental and bas ic . The f i r s t is g e n e r a l l y whether an i s s u e can be ignored because i t i e not t h a t s e r i o u s a problem o r because i t s r e s o l u t i o n would be h ighly c o n t r o v e r s i a l . So wi th a l coho l . Given o t h e r p r i o r i t y concerns, is t h i s an i s s u e t h a t w i l l go away without much a t t e n t i o n , o r a r e t h e economic and h e a l t h consequences of a lcohol ism and a l c o h o l abuse l i k e l y t o be so s i g n i f i c a n t -- involv ing huge inc reaees i n dea th r a t e s , a c c i d e n t s , and o t h e r probleme - that governments w i l l have t o addrese t h e problem?

The second ques t i on i s o f t e n asked by c o u n t r i e s t h a t f e e l they have t o respond t o t h i s growing h e a l t h problem. Given t h e i r p a r t i - c u l a r c u l t u r e , h i s t o r y , p o l i t i c a l i n s t i t u t i o n s , and exper ience wi th t he temperance movement, a r e t h e r e governmental p o l i c i e s t h a t could be adopted t o moderate t h e a l c o h o l problem i n t h e i r n a t i o n ?

The t h i r d ques t i on i s e q u a l l y pragmatic. I f t h e r e a r e po l i - c i e s which can be adopted, what a r e t h e i r p o t e n t i a l p o l i t i c a l and economic consequences and what a r e t h e l i k e l y h e a l t h ga ine t o be der ived from t h e i r adopt ion?

The o rgan ize r s of t h i s conference recognize t h a t t he se a r e no t easy ques t i ons , nor do they have a e i m p l i s t i c o r a uniform answer. For h e r e i n l i e s a tau to logy . I n o r d e r t o address t he se ques t i ons f o r each country i n t h e Americas, one needs t h e r e s u l t s of long-term re sea rch s t u d i e s and t h e exper ience of p o l i c i e e t r i e d w i th in t h e limits of each n a t i o n ' s p o l i t i c a l i n s t i t u t i o n s .

On t h e o t h e r hand, a s Odin Anderson of t h e Univer i ty of Chicago has w r i t t e n , i n a r e a s such a s t h i s one, h i s t o r y shows that r e sea rch fo l lows a pub l i c consensus t h a t t h e r e is a problem, no t t h e o t h e r way around. Thus, major r eeea rch cannot be undertaken u n t i l t h e p u b l i c a g r e e s t h a t a s e r i o u s problem e x i s t a .

One way ou t of t h i s dilemma would be t o use one count ry ' s exper ience as a n a t u r a l l a b o r a t o r y f o r answering another coun t ry ' s ques t i ons about i t s e l f . Recognizing t h e l i m i t s i n t h e a p p l i c a b i l i t y of f i n d i n g s a c r o s s geographic bordere , i t provides an approach f o r ga in ing a consensus on a need f o r a c t i o n i n one na t ion based on the r e s e a r c h and p r a c t i c a 1 exper ience of another .

The need f o r t h i s type of exchange takee on an i nc reas ing importance i n today ' s world. U e a r e l i v i n g i n a n e r a where t h e ma jo r i t y of governments, r e g a r d l e s s of t h e i r p o l i t i c a l form, a r e g e n e r a l l y shor t - l ived . I n r ecen t y e a r s , t h e average government, whether e l e c t e d o r appointed, has been a b l e t o s t a y i n o f f i c e such a b r i e f t i m e t h a t i t i s u s u a l l y unable t o implement i t s own domestic o r f b r e i g n p o l i c i e s . Thie t r end has r e s u l t e d i n a change i n t h e

p r i o r i t i e s o£ people i n p u b l i c l i f e . To s u r v i v e i n t he p u b l i c a r ena , they mus t poseees a n extreme e e n s i t i v i t y t o understanding the consequences i n p r a c t i c e o f proposed domest ic p o l i c i e s before t hey implement them. Nowhere i e t h i e more t r u e than i n t he a r e a of p o t e n t i a l a l c o h o l abuse, where t he p u b l i c response may o f t e n be h i g h l y charged and emotional.

The r e c o g n i t i o n o£ t h i e need l e d t h e workshop p a r t i c i p a n t s t o s p e c i f i c a l l y focus on address ing theee t h r e e sets of p r a c t i c a 1 p o l i c y r e l a t e d ques t ions . T h i s concern i s r e f l e c t e d i n t he papers i nc luded i n these proceedings and the conaensus document growing o u t o £ t h e workshop se s s ions .

Th i s p r o j e c t was undertaken wi th t h e b e l i e f t h a t progresa i n both h e a l t h and economic f i e l d e can be more s u c c e s s f u l l y achieved i f though t f u1 people s y s tema t i c a l l y examine v a r i o u s approaches t o so lv ing problems used by d i f f e r e n t c o u n t r i e s and consider t h e i r degree o £ f a i l u r e o r success . It i s my hope t h a t these de l ibe ra - t i o n s may he lp o t h e r s t o th ink more informedly abou t t he p o t e n t i a l h e a l th problems r e l a t i ng t o i nc reased a l c o h o l consump t i on and t h e consequences of va r ious p o s s i b l e courees of f u t u r e a c t i o n .

Robert J. Blendon Chairman Advisory Committee

WORKSHOP BACKGROUND AND OVE RV IEW

Alan K. Kaplan

The I n s t i t u t e o f Medicine's inter-American workshop on a lcohol - re la te d problems w a s a product of t he convergence of growing i n t e r n a t i o n a l i n teres t i n the r e l a t i onsh ip be tween h e a l t h and economic development, and inc reas ing concern among p u b l i c h e a l t h l e a d e r s abou t t he medical, s o c i a l , and economic consequences of a l c o h o l consumption. "It 1s a ma t t e r of concern," Char les Chassoul t o l d t he p a r t i c i p a n t s i n h i s keynote add re s s , " t h a t , i n r e c e n t decades, the consump t i o n of a l coho l and t h e problems a s s o c i a t e d wi t h i t have inc reased throughout the world, both i n the r i c h and i n t he poor countr ies . . . . We must appea l t o the sense of r e s p o n s i b i l i t y o£ n a t i o n a l l e a d e r s t o induce them t o adop t the appropr ia te cont ro ls . "

Genesis of the Workshop

I n p u r s u i t o£ t he World Heal th Organiza t ion ' s g o a l of "Health f o r A 1 1 by the year 2000," the WHO European Regional Of f i ce convened a meeting i n May 1980 i n Copenhagen t o exp lo re the need f o r g r e a t e r unders tanding of the r e l a t i o n s h i p s between hea l t h and e conomi c development. Meeting p a r t i c i p a n t s agreed on the d e s i r a b i l i t y o£ exchanging i d e a s on comon h e a l t h problems a c r o s s n a t i o n a l boundaries and between developing and developed nat ions.

The Of f i ce of I n t e r n a t i o n a l Heal th i n the U.S. Deparhnent o£ Heal th and Human Se rv i ce s (DHHS) then suggested t h a t t he I n s t i t u t e of Medicine (IOM) cons ider conducting one o r two workshops t h a t would f a c i l i t a t e such a n exchange. Fur ther d i s cus s ions involv ing WBO, the Pan American Heal t h Organizat ion, and cognizant Publ i c Hea l th Serv ice agenc ies , l e d t o dec i s ions a ) t o focus on the i s s u e of prevent ion of a l coho l - r e l a t ed problems i n t h e region of the Americas, and b) t o examine l e g i s l a t i v e approaches toward such prevent ion, a n a s p e c t of the problem t h a t had rece ived l i t t l e a t t en t ion o u t s i d e o£ the indus t r i a l i z e d coun t r i e s bu t was emerging a s of immediate i n t e r e s t i n the region. Accordingly, a n adv i so ry group was assembled i n October 1981 under t h e d i r e c t i o n of Robert J. Blendon t o adv i se the I n s t i t u t e on the workshop agenda and p a r t i c i - pants. The workshop took p l ace March 8-10, 1982 a t the Pan American Heal t h Organizat ion i n Washington, D . C . .

This background and the concerns g iv ing r i s e t o the workshop a r e recounted i n d e t a i l i n the opening remarks of Freder ick Robbins, Hector Acuna, and John Bryan t. Subsequen t chapters inc lude the f u l l t e x t s of t he papers de l ive red i n t h e r e spec t ive s e s s ions . Four p r e s e n t a t i o n s were fol lowed by d i scus san t s ' prepared remarks (two each, excep t f o r one p r e s e n t a t i o n when a scheduled d i scus san t va s unable t o a t t e n d ) . I n a d d i t i o n t o the formal p re sen t a t i ons , the workshop schedule inc luded d i scus s ion regard ing both the s p e c i f i c papers and more gene ra l a l coho l p o l i c y i s s u e s .

Workshop Overview

The func t ion of t h i s overview i s t o s e r v e a s a b r i e f gu ide t o t he proceedings. A t t he o u t s e t , however, t h r ee key concepts guiding workshop p lanners warran t f u r t h e r comment.

The emphasis on l e g i s l a t i v e approaches toward reducing a l coho l problema r e f l e c t s growing i n t e r e s t of the PAHO reg ion i n explor ing t h e r e s u l t s of making a l c o h o l consumption e i t h e r les8 convenient ( through fewer hours of s a l e and/or number of s a l e s o u t l e t s ) o r more expensive (by r a i s i n g the p r i c e through t axa t ion ) . Thus, c o n t r o l s on supply, which g e n e r a l l y a r e considered the core of l e g i s l a t i v e measures a f f e c t i n g a l c o h o l consump t i on , a r e d i scussed a t leng th. P a r t i c i p a n t s a l s o focused on ways t o a f f e c t consumer demand, inc lud ing p u b l i c educa t i o n and a d v e r t i s i n g regula t i ons , a s w e l l a s environmental i n t e r v e n t i o n s .

The second ke y concep t, preven t i on , s i g n a l s an i nc reas ing i n t e r e s t i n the u se of non-personalized, s o c i e t p o r i e n t e d measures t o r e duce the burden of a l coho l - r e l a t ed - problems, a s d i s t inguished from programs and p o l i c i e s aimed a t helping persons who experience problems d i r e c t l y caused by dr inking. P a r t i c i p a n ts i n t h i s workshop thus focused on prevent ion and n o t t reatment , b u t i n s o doing d i d no t i n t e n d t o minimize important p o l i c y and research ques t i o n s r ega rd i ng ( l eav ing def i n i t i o n a s i de) those who experience the d i s e a s e of alcoholism.

The l a s t concept i s embodied i n the choice of the phrase "a lcohol - re la ted problema." An a l t e r n a t i v e would have been "alcoholism," b u t the o v e r a l l goa l of the workshop was a n examination of a l c o h o l ' s broad economic and s o c i a l e f f e c t s on indus t r i a l i z e d and developing ria t i ons i n t he Americas, r a ther than on s p e c i f i c d r inkers . The choice was n o t meant t o exclude cons ide ra t i on of e f f e c t s on i n d i v i d u a l h e a l t h , b u t was a n e f f o r t t o expand the focus of t h i s p a r t i c u l a r meeting t o encornpass t he r e l a t i o n s h i p be tween a l c o h o l and such problema a s p roduc t iv i t y i n the workplace , t r a f f i c acciden ts, v io l ence and crime , and f ami ly d i s rup tion.

The F i r s t Day

The opening se s s ion , i n keeping wi th t he o r i g i n a l impetus f o r the e f f o r t , concent ra ted on the impact of a l c o h o l problems on e conomic development. S t a r t i n g w i th t h e ques t i o n of whe the r a l c o h o l consumption can be s a i d t o have adve r se ly a f f e c t e d such development and the growth of p e r c a p i t a Gross Nat ional Product i n t he indus- t r i a l i z e d na t ions , Levine argued t h a t "on t h e b a s i s of the h i s t o r i c a l exper ience of t he United S t a t e s , B r i t a i n and o t h e r European coun t r i e s , consumption does n o t appear t o have i n h i b i t e d (such) development."

Mosher then examined the obverse ques t ion : the e x t e n t t o which development might i t s e l f engender a l coho l - r e l a t ed problems. H i s s p e d f i c focus vas tourism and the assumed economic b e n e f i t s of i t s expansion i n the developing world. "There i s the p o s s i b i l i t y , " he s tates, " t h a t expansion (along wi th suppor t ive f i s c a l and t ax p o l i c i e s ) f u e l s i n c r e a s e s i n a l coho l a v a i l a b i l i t y and consumption, which i n t u rn l e a d s t o i nc reases i n the inc idence of a l coho l problems i n l e a s developed h o s t count r ies . I f s o , then the s t r u c t u r e of the tourism i n d u s t r y i t s e l f becomes a p u b l i c h e a l t h concern. "

Against t h i s backdrop the workshop succes s ive ly examined r e sea rch f i n d i n g s abou t t he e x t e n t of a l coho l - r e l a t ed problems i n t he Ameri cas, s t u d i e s of communi t y dr ink ing pra tices, and Lat in-Amerian h i s t o r i a l and c u l t u r a l f a c t o r s con t r ibu t ing t o cur ren t consump t i o n pa t terns .

What one f i n d s , Caetano t o l d the p a r t i c i p a n t s , i s evidence i n many coun t r i e s o f s i g n i f i c a n t h e a l t h damage s u f f e r e d by ind iv idua l8 a s a r e s u l t of a l c o h o l consumption ( l i v e r d i s e a s e and p s y c h i a t r i c h o s p i t a l i z a t i o n ) , a s well a s s t u d i e s i n d i c a t i n g a l i n k between consumption and such problems a s a c c i d e n t s and violence. However, he argued, the l egacy of emphasizing t h e d i s ea se of a lcohol ism i n a l c o h o l r e sea rch h a s been a de l ay i n a s c e r t a i n i n g and thereby c o n f r o n t i q the f u l l range of a l coho l - r e l a t ed problems: "Those diagnosed a s a l c o h o l i c s a r e a d i f f e r e n t popula t ion f rom those w i th a l coho l problems who have n o t reached the c l i n i c door." Despi te the d i s e a s e model's impor tan t con t r ibu t ion t o f o s t e r i n g t reatment of a l c o h o l i c s , he concluded, the t i m e ha s come f o r more broadly focused r e sea rch and prevent ion e f f o r t s .

An th ropologis t Heath, a f ter reviewing i n de tal1 the socio- c u l t u r a l h i s t o r y of a l c o h o l consumption i n L a t i n America, suggested t h a t the t a r g e t of the broader e f f o r t might be e lu s ive : "An impor tan t g e n e r a l i z a t i o n from Latin-American experence i s t h a t a l coho l - r e l a t ed problems a r e , l i k e a l c o h o l i c s and a l coholism, t r u l y v e r y r a r e -- a t l e a s t i n comparision wi th popula t ions i n the res t of t h i s hemisphere, and much of the rest of the world... Latin-

Americans, by and l a r g e , seem t o f e e l t h a t they s u f f e r few problema t h a t can be r e l a t e d t o a l c o h o l use, either t h e i r own o r on the p a r t of s i g n i f i c a n t o the r s . I t i s even more s i g n i f i c a n t when one cons iders t h a t these s t u d i e s of ten r e f e r t o popula t ions among whom heavy dr inking occurs r e g u l a r l y and where drunkenness i s both f requen t and a ccep t a b l e . "

The Cae tan0 and Hea th presen ta t i ons r a i s e d s e r i o u s ques t i o n s abou t the na tu re and ex t en t of a l coho l - r e l a t ed problems and brought i n t o f ocus the d ive rgen t pe r spec t ives o£ two d i s c i p l i n e s : epidemio- l ogy and anthropology. "Although i t i s p o s s i b l e t o agree wi th D r . Heath t h a t a l coho l causes l e s s s o c i a l d i s r u p t i o n o r devian t behavior i n La t ín America than i n , f o r example, Anglo America," Negrete a s s e r t e d , "da ta on m o r t a l i t y from a l coho l - r e l a t ed causes i n d i c a t e t h a t a l coho l abuse c o n s t i t u t e s a n e q u a l l y major p u b l i c h e a l t h pro blem i n bo th regions. "

Endorsing the development of i n t e r d i s c i p l i n a r y s t u d i e s (epidemiological and an th ropo log ica l ) , Medina urged tha t g r e a t e r a t ten t i o n be g iven t o t he impact of c u r r e n t s o cioeconomi c t rends upon the pa t t e r n s of a l coho l consumption s t e d n g f rom h i s t o r i c a l even t s : "Modera te consump t i o n o b t a i n s o n l y i f the s o c i o c u l t u r a l environment of f e r s a coherent context . The s e c u l a r i z a t i o n of modern l i f e tends t o weaken the common r u l e s i n t h i s regard and, t he re fo re , t o f a c i l i t a t e anomalous behaviors. Fur thermore , the low socio- economic l e v e l , t he marg ina l i t y , and the anomie of many urban popula t i o n groups w i l l genera te g r e a t e r intemperante . "

The Se cond Da y

The focus s h i f t e d t o a n examination of a l t e r n a t i v e p u b l i c p o l i c i e s f o r the prevent ion of a l coho l - r e l a t ed problems, w í t h spec i f i c emphasis on l e g i s l a t i v e c o n t r o l measures. Se t t i n g the framework f o r the d i s cus s ion were p re sen t a t i ons concerning the re c e n t l y comple ted I n t e r n a t i o n a l S tudy of Alcohol Cont ro l Experiences (Makela 198 1 ) and the Na t i o n a l Academy of Sciences ' r e p o r t on a l coho l p o l i c y (Moore and Ger s t e in 1981). Formal presen ta t i o n s a l s o inc luded a n examina t i o n of r e sea rch f ind ings on the impact of s p e c i f i c c o n t r o l measures and a survey o£ alcohol- r e l a t e d l e g i s l a t i o n i n Cen t r a l America and Panama.

"There a r e t h r ee k inds of p revent ive p o l i c i e s , " Ge r s t e in s a i d : " r egu la t i ng the terme and condi t ions of a v a i l a b i l i t y o£ a l coho l and p l a c e s i n which t o d r i n k i t ( r e g u l a t i n g supply) ; t r y ing t o i n f luence people 's d r ink ing p r a c t i c e s d i r e c t l y through pedagogical e f f o r t s and l e g a l s t i p u l a t i o n s (shaping dr ink ing p r a c t i c e s d i r e c t l y ) ; and making the ex t e rna1 environment l e e s hos t i le o r r i s k y s o tha t po t e n t i a l l y damaging consequences of i n t o x i c a t i o n a r e reduced (reducing environmental r i s k ) . These t h r e e types a r e r e l a t e d t o each o t h e r

q u i t e d i r e c t l y . Supply p o l i c i e s t r y t o c o n t r o l two of the elements t h a t a r e necessary t o eve ry a l coho l - r e l a t ed problem: a l c o h o l i t s e l f and p l aces i n which t o d r i n k i t . Po l i cy on dr ink ing p r a c t i c e s presumes t h a t a l coho l and consumption p l aces ( p u b l i c and p r i v a t e ) a r e a v a i l a b l e , and tries t o i n f luence how people take advantage of them, i n terme of how much, how o f t e n , o r what a c t i v i t i e s d r i n k e r s p a i r w i th consumption. F i n a l l y a p o l i c y designed t o reduce envi- ronmental r i s k presumes t h a t people w i l l be dr ink ing , g e t t i n g drunk, and p u t t i n g themselves i n danger i n va r ious ways. The o b j e c t of t he se p o l i c i e s i s t o l i m i t the s e v e r i t y of the consequences by making the environmen t less hos tile."

Smart 's review of t he impact of va r ious c o n t r o l measures covered s t u d i e s of a l c o h o l a v a i l a b i l i t y and consump t i on , changes i n laws governing o u t l e t s and hours of s a l e , p r i c e and taxa t ion , laws r e l a t i n g t o age of purchase and consumption, and a d v e r t i s i n g con t ro l s . "While a l l ow( ing ) o n l y some t e n t a t i v e conclusions," Smart observed, " the empír ica1 evidence i n t o t a l sugges ts t h a t prevent ion of a l coho l - r e l a t ed problema depende upon holding a v a i l a b i l i t y and p r i c e s cons t an t o r even reducing a v a i l a b i l i t y , keeping access f o r young people l i m i t e d , and hoping t h a t the p r e s e n t t rend towards a p l a t eau i n a l coho l consumption cont inues where i t has begun. I n c e r t a i n coun t r i e s i t may be pos s ib l e t o make l a r g e changes i n p r i c e o r a v a i l a b i l i t y , b u t i n o r d e r t o have a s u b e t a n t i a l e f f e c t they must be ve ry l a r g e , probably l a r g e r than most governments w i l l consider. "

Endorsing Smart 's o v e r a l l conciusions abou t prevent ion po l i cy , Beaubrun emphasized seve ra1 s t u d i e s i n d i c a t i n g a n i nve r se r e l a t i o n s h i p between the r e a l p r i c e of a l coho l and l i v e r c i r r h o s i s m o r t a l i t y , h o s p i t a l aclmissions f o r a lcohol ism, and road t r a f f i c acc iden t s . He then addressed the drunk d r iv ing problem i n g r e a t e r d e t a i l . " I n t e r n a t i o n a l exper ience shows us , " he s a i d , " t h a t i n the s h o r t run Scandinavian- type (S t r i c t blood a l coho l concentra t i o n ) laws, e s p e c i a l l y i f coupled w i th some r e spons ib l e implementa t i o n and high v i s i b i l i t y , r e s u l t i n s i g n i f i c a n t reduc t ion i n acciden ts and m o r t a l i t y b u t t h a t i n t he long run t h i s d e t e r r e n t e f f e c t tends t o be l o s t even i n a few years , a s p u b l i c pe rcep t ion of the t h r e a t of being caught recedes. C e r t a i n t y of d e t e c t i o n is the important v a r i a b l e and n o t s e v e r i t y of punishment. C e l e r i t y of punishment has ye t t o be p rope r ly evaluated."

L e g i s l a t i o n pe r t a in ing t o a l coho l i n va r ious coun t r i e s of Cen t r a l A m e r i c a was reviewed by Arroyo. Summarizing a survey done i n 1981 f o r t he C e n t r a l American Min i s t e r s of Heal th , he r epo r t ed t h a t " A l 1 the coun t r i e s of the a r e a have comprehensive a l coho l l e g i s l a t i o n . Laws enac t ed a t the beginning o f independence a r e s t i l l i n f o r c e and r e f l e c t t he l e g a l system t h a t r u l e d our r e l a t i o n s wi th Spain during the c o l o n i a l e r a . (But) l e g i s l a t i o n h a s been p r i m a r i l y cen te red on economic and f i s c a l mat ters . . . . P r i o r i t y has r a r e l y been a s s igned t o the h e a l t h a s p e c t s of the problem, and w e

pro fe s s iona l s and o t h e r persons i n t e r e s t e d i n these t a sks have been unable t o provide s c i e n t i f i c and t echn ica l d a t a t o suppor t passage of adequate l e g i s l a t i o n . The magnitude of t he problem t o be faced i s e v i d e n t i f , i n a d d i t i o n , w e bear i n mind t h a t i n some coun t r i e s morbidi t y and m o r t a l i t y r a t e s sugges t o t h e r p r i o r i ties; tha t the e conomi c s t r u c t u r e of these coun t r i e s encourages t he c u l t i v a t i o n of g r a i n s and the product ion, marketing and consumption of a l coho l , and, e s p e c i a l l y , t h a t the popula t ion a t l a r g e and even h e a l t h workers accep t and t o l e r a te these habi ts."

From Katatsky, Medina-Mora, and Rootman came words of cau t ion abou t the a p p l i c a b i l i t y of a heav i l y con t ro l -o r i en t ed po l icy . Grea te r impact i n t he s h o r t run, Katatsky argued, 1s l i k e l y t o come from educa t iona l programs t h a t can be mounted by the h e a l t h a u t h o r i t i e s on t h e i r own without the n e c e s s i t y of b a t t l i n g f o r l e g i s l a t i v e changes a f f e c t i n g a l coho l a v a i l a b i l i ty. "Short term," s h e s a i d , "1 don ' t t h ink we a r e going t o see any s i g n i f i c a n t d e l i b e r a t e a t t empt s a t changing supply. 1 th ink w e can expec t t o cont inue t o see emphasis on the demand s i d e , wi th a n i nc reas ing number of educa t i o n a l programs . "

Medina-Mora po in t ed t o " t r ade -o f f " cons idera t i ons : " In many reg ions i t might be economical t o d r ink a l c o h o l i c beverages because t h e y have c a l o r i e s and a r e cheaper, l e s 8 harmful, and more a v a i l a b l e than o t h e r beverages such a s water o r milk. I n such s i t u a t i o n s i t would be necessary t o r a i s e t he s tandard of l i v i n g s imul taneous ly w i t h i nc reas ing c o n t r o l of a l coho l a v a i l a b i l i t y , o r else s i d e e f f e c t s might become more dangerous than permi t t ing the s a l e of a lcohol ."

"Furthermore," s h e continued, " the a l c o h o l indus t r y does r ep re sen t a cons iderab le amount of economi c a c t i v i ty. Count r ies t h a t wish t o promote t h e i r economic development w i l l have t o d e a l w i t h the dichotomy t h a t a l though they want t o reduce t h e product ion of a lcohol , they a l s o have a n i n t e r e s t i n i nc reas ing tax revenues."

For Rootman the re was concern about the locus of a c t i v i t y a s w e l l a s i t s content . Rather than emphasize l e g i s l a t i v e c o n t r o l s imposed from a c e n t r a l a u t h o r i t y , he observed, a community l e v e 1 response t o a l coho l - r e l a t ed problems ( a s exemplif ied i n WHO's Communi t y Kesponse Pro j e c t i n i t i a t e d i n 1976 w i t h the p a r t i c i p a t i o n o f Mexico, Scot land and Zambia) was a l s o c r u c i a l t o a comprehensive prevent ion pol icy.

The importance of the community response s t u d y a s c a r r i e d o u t i n Mexico, Campillo-Serrano had observed the day before , "is tha t i n v a r i o u s ways w e overcame the l i m i t a t i o n s o u t l i n e d by D r . Caetano i n c o n n e c t i o n w i t h previous s t u d i e s undertaken i n L a t i n America. We responded ... f i r s t by abandoning the r i g i d medical model of a l coho l a s a d i s ea se , and then by looking a t s o c i a l and l e g a l problems . . . . 1 be l i eve t h a t t h i s s t u d y c r ea t ed a model t h a t 1s worthy of being copied i n o t h e r coun t r i e s of the region."

The Thi rd Day

Norman S a r t o r i u s opened the morning s e s s i o n wi th a wide-rangiry a n a l y s i s of WiO'e e f f o r t s t o move toward i t s g o a l of "Health f o r Al1 by the Year 2000." Rela t ing the g o a l t o mental h e a l th programe i n gene ra l and a l c o h o l problems spec i f i c a l l y , S a r t o r i u s reviewed a number of o r g a n i z a t i o n a l and s c i e n t i f i c dilemmas conf ron t ing a l c o h o l p o l i c y makers. Never t h e l e s s , he concluded, " the s i z e of the problem and i t s urgency f o r c e u s t o a c t i n s p i t e of ambigui ty. We have th ings i n f r o n t of u8 t h a t we can do a t the l e v e 1 of t h e i n d i v i d u a l and the communi ty.. We don' t have t o wait ."

The l a s t p a r t of the workshop cons i s t ed of smal l group d i scus s ions of a d r a f t s t a t emen t of consensus views t h a t sought t o r e f l e c t t he exchanges of t h e f i r s t two days. Tha t d r a f t , developed by William Lybrand (who had served a s workshop r appor t eu r ) , a long wi th comments of t he sma l l group chairmen (Caetano, Gers te in , and Room), formed the b a s i s of a r ev i sed consensus s ta tement t h a t was s e n t t o t he Advisory Committee and p a r t i c i p a n t e f o r review. The re su1 t ing document appears i n the appendix. 1

Conclusion

The inter-American workshop was a meeting o f e x p e r t s from a v a r i e t y of backgrounds, c u l t u r e s and na t ions . I t was by a l 1 a ccounts a succes s fu l ven ture i n t ransna t i o n a l connnunica t i o n and d e l i b e r a t ion. Bu t i t was a l s o a s p i r i t e d meeting , encompassing deba te a s w e l l a s consensus, and probably l eav ing a s many a r e a s f o r f u t u r e i n q u i r y as those on which i t shed new l i g h t . Accordingly, t he r eade r 1s encouraged t o delve f i r s t i n t o these proceedings i n o r d e r t o c o l l e c t contex t and nuance f o r the s ta tements i n the appendix. The workshop o b j e c t i v e was n o t s o much consensus, a l though a s i g n i f i c a n t amount emerged, a s i t was exp lo ra t i on and ana lys i s . The o b j e c t i v e of these proceedings, then, is t o con t r i b u te to g r e a t e r unders tanding of the complexi ties of a compelling p u b l i c p o l i c y i s s u e -- complexi t ies apparen t i n t he f ol lowing quo t e d commen ts made by var ious pa r ti cipan ts during the workshop sess ions : .

. . . I f 1 unders tand the an thropologica l me thod c o r r e c t l y , i t 1s t o l ook a t the o r d i n a r y ev=ryday even t s and t o ignore , i f poes ib l e , the unusual. So the a n th ropologis t might w e l l i d e n t i f y a s a r a r e e v e n t what the ep idemiologis t begins t o cons ider a n epidemic because t h e latter goes o u t and focuses on devian t behavior, and, i f he f i n d s a 3, 4, o r 5 pe rcen t o ccurrence r a te, he cons iders t h i s a h igh ly prevalen t problem. Thus, these two ways of looking a t a g iven s i t u a t i o n might g i v e u s d i f f e r e n t p i c t u r e s of r e a l i t y . Yet i n t he t o t a l i t y of o u r t a s k t hey both inform us , because what the an th ropo log i s t views a s behavior i n t e g r a l t o a c u l t u r e i s

t he re fo re behavior u n l i k e l y t o be e a s i l y s u s c e p t i b l e t o modif i c a t i o n by l e g i s l a t i o n . On the o t he r hand epidemio- l o g i s t s may te11 u8 t h a t such behavior i s bound t o c r e a t e a c e r t a i n l e v e 1 of problems t h a t r e q u i r e s behavior changes i n o r d e r t o prevent s e r i o u s p u b l i c h e a l t h problems. I t i s i n t h i s i n t e r p l a y t h a t w e may y e t f i n d the information w e need t o make a p u b l i c p o l i c y approach workable a t a l l .

. . .I don' t t h ink the analogy t o e a r l y indus t r i a l i z a t i o n a p p l i e s a s much today. We a r e s ee ing more and more workers engaged i n a c t i v i ties t h a t , r e l a t i v e l y speaking, a r e sedentary , s o t h a t the advantages of a l c o h o l ' s c a l o r i c con ten t a r e somewhat minimized. I n a d d i t i o n , w i th the s h i f t i n a c t i v i t y from brawn to b ra in , workers a r e engaged i n a c t i v i t i e s t h a t p l a c e a high premium on motor con t ro l , judgment, percept ion , and r a p i d i t y of response i n ope ra t i ng ve ry demanding t echn ica l machinery. Al1 t h i s c r e a t e s a d i f f e r e n t kind of chal lenge t o some of the t r a d i t i o n a l p a t t e r n s of a l c o h o l use.

. . .With r e s p e c t t o the h i s t o r y of a l coho l r e sea rch i n L a t í n America, we must keep i n mind t h a t i t i s v e r y cos t l y ; a s o c i e t y might dec ide i ts p r i o r i ties f o r expendi ture of v e r y s ca rce resources p o i n t i n o t h e r d i r e c t i o n s .

. . . I f w e wish t o have laws on a l coho l problems passed, we must convince communi ties, no t jus t p o l i t i c i a n s , tha t t he re t r u l y a r e problems. U n t i l we do t h i s , laws may be passed, bu t they may n o t be enforced.

. . .The d a t a on the dangers of a l c o h o l consumption from t h i s hemisphere a r e ex t remely high. Forty-seven percent of a l 1 male admissions t o ou r l a r g e s t gene ra l h o s p i t a l were a l coho l - r e l a t ed i n one survey by a doc to ra l s t u d e n t i n 1973, f orty-seven pe rcen t of a l1 male admissions and twenty-six percent of the t o t a l admissions, male and female.

... We have a n i n i t i a l s t u d y showing t h a t the expendi tures f o r a l coho l - r e l a t ed problems represen t 6 30 m i l l i o n d o l l a r s p e r year i n o u r currency. Tha t r ep re sen t e a n enomous c o s t , b u t w e can seldom no te t h i s because i t i s a hidden cos t . I t i s hidden i n th ings such a s l o e s of worker p roduc t iv i t y , a cc iden t s i n cons t ruc t ion o r o t h e r types of i ndus t ry , absenteeism, and a lowered s tandard of l i v i n g . S ince a l 1 of t h i s 1s n o t r e a d i l y apparen t , i t i s d i f f i c u l t f o r s o c i e t y t o comprehend the f u l l magnitude of t he problem.

.. .The not ion t h a t a lcohol i sm as a d i s ea se somehow c o n t r a d i c t s o r s t a n d s i n c o n t r a s t t o a l coho l problems is f a l s e . A s a d i s ea se , a lcohol i sm is a v e r y importan t a lcohol - re la ted

problem. I n f a c t we a r e r e a l l y beginning t o recognize that prevent ion e t r a t e g i e s and the broader concepts of a l coho l problems can be viewed a s being i n tandem o r p a r a l l e l wi th the a lcohol i sm concep t.

... One needs t o t h ink of p revent ion i n tenas of a n i n t e g r a t e d approa ch, no t l i m i t e d t o changing dr ink ing behavior a lone , bu t dea l ing wi th a number of s o c i e t a l i s s u e s . We went i n t o one community wi th a g r e a t i d e a of t r y ing t o i n t e r e s t people i n a lcohol i sm t rea tment i n o r d e r t o i n c r e a s e t h e i r awareness o f a lcohol ism a s a s e r i o u s problem, and w h a t w e met were people say ing , 'Look, t h a t i s n o t a problem. 1 mean, yes, i t i s a problem, bu t what about the f a c t t h a t 1 don' t have a house t o l i v e i n ? What about the f a c t t h a t there i s no sewage system? What about the f a c t t h a t the o i l company t h a t moved i n here j u s t c losed down one of t he two p l a n t s f o r s i x months, and 1 have t o go somewhere e l s e ? ' And 1 th ink one o f the l e s s o n s from t h a t exper ience was t h a t i n terms of t ry ing t o work prevent ion of a l coho l - r e l a t ed problems i n t o those s e t t i n g s , w e have t o conf ront t he o v e r a l l problems of those communities, and i n f a c t , a l c o h o l does touch on a l1 of those community i ssues.

Notes and Referencee

1. On A p r i l 14, 1982 the s ta tement of consensus views, a s reviewed by the adv i so ry committee and DHHS and PAHO l i a i s o n , was de l ive red t o t he Of f ice of I n t e r n a t i o n a l Heal th (DHHS) , f o r i ts use i n p repa ra t i on f o r t he WHO World Heal th Assembly techni c a l d i s cus s ions on a l coho l problems. 1 t was emphasized t h a t the s t a t emen t comprised a perce ived consensus of the m a j o r i t y of the p a r t i c i p a n t s , n o t n e c e s s a r i l y the views of each and eve ry one, inasmuch as t i m e had n o t permi t ted a complete d i s tri bu t i o n f o r review. The consensus s t a tement appearing i n Appendix A does r e f l e c t review by a l 1 the p a r t i c i p a n t s and, while incorpora t ing s eve ra1 p a r t i c i p a n t responses , i s i n a l 1 e s e e n t i a l r e s p e c t s t he same compilation t h a t was t r ansmi t t ed t o OIH. The s t a t emen t embodies t he op in ions of a l 1 those i d e n t i f i e d a s workshop p a r t i c i p a n t s i n Appendix B excep t two, whose a l t e r n a t i v e op in ions appear i n t h e i r e n t i r e t y fo l lowing the consensus views.

Ref erencee

Makela, K. e t a1.(1381) Alcohol, Soc ie ty and the S t a t e 1: A Com- p a r a t i v e Study of Alcohol Control and J.E. Single , P. Morgan, J. de L i n t , eds.(1982), Alcohol, S o c i e t y and the S t a t e 2: The S o c i a l H i s to ry of ~ o n t r o i Po l i cy i n Seven Countr ies . Toronto: Addict ion Re eearch Founda t i on

Moore, M. and D. Ge r s t e in , ede. (1981) Alcohol and Pub l i c Pol icy: Be yond the Shadow of P roh ib i t ion. Waehing ton, D .C. : Na t i o n a l Academy Pree e.

CHAPTER ONE

WELCOME AND INTRODUCTORY REMARKS

Frederi ck C. Robbins

Hector R. Acuna

John H . Bryant

KEYNOTE ADDRESS

Charles Chaseoul k n g e

WELCOKE AND INTRODUCTORY REMARKS

Frederi ck C. Robbins

1 t i s my pleasure t o welcome you on behalf o£ the Ins t i tu te of Medicine and the National Academy of Sciences, of which i t i s a par t . We a r e most apprecia t ive of the sponsors of t h i s conference, p a r t i c u l a r l y D r . John Bryant o£ the U.S. Department o£ Health and Human Services, f o r s t imula t i ag and encouragiag the development o£ t h i s workshop. The Pan American Health Organization (PAHO) has been, of course, very he lp fu l and these f a c i l i t i e s a r e an exce l l en t place t o have t h i s kind of a conference. My esteemed colleague, D r . Hector Acuna, i s a marvelous hos t , and 1 always enjoy my assoc ia t ion with him. D r . Bobert Blendon has done an exceptional job a s chairman o£ the Advisory Commi t tee responsible f o r the organiza t ion o£ t h i s meeting, along wi th the o ther members l i s t e d i n your program.

We a l s o a r e de l ighted t h a t so many of you agreed t o pa r t i c ipa te . The s u b j e c t o£ t h i s workshop i s obviously one o£ irnportance around the world and one of g r e a t d i f f i c u l t y of so lu t ion . Al1 of our countr ies have had experiences with i t . The Uni ted S t a t e s has had some very notable experiences, p a r t i c u l a r l y between 1920 and 1933 when w e had na t iona l Prohibi t ion. The pers is tance of the problem r e f l e c t s i t s very importance and s ize .

The National Academy of Sciences and the Ins t i t u t e of Medicine have been very i n t e r e s t e d i n t h i s top ic over some time and have issued severa l re levant reporte. From our po in t o£ view, t h i s i s a n important a rea , and we hope t o l e a n from you; perhaps there i s something w e can cont r ibute a s well , and 1 look f o w a r d to pa r t i c ipa t ing a s much a s 1 can.

Hector R. Acuna

I t i s , indeed, a g r e a t p leasure t o welcome you t o the Pan American Heal th Organizat ion today, and 1 want t o exp re s s my s i n c e r e a p p r e c i a t i o n t o t he I n s t i t u t e of Medicine f o r a f fo rd ing u s the oppor t un i t y t o hos t t h i s Inter-American Workshop on Leg i s l a t i v e Approaches Towards t he Preven t i o n of Ai cohol-Rela ted Problems.

When the I n s t i t u t e of Medicine approached u s two years ago, r eques t i ng ou r a s s i s t a n c e i n s e l e c t i n g a t o p i c f o r t h i s workshop, the World Heal th Organizat ion was deeply involved i n a number of s i g n i f i c a n t a c t i v i t i e s i n the a l c o h o l f i e l d . The paesage of Reeolut ion 32.40 by the World Heal th Assembly i n 1979 marked a major s h i f t i n o u r th ink ing and pol icy . Tha t r e s o l u t i o n recognized the importance of a l coho l - r e l a t ed problems and urged member s tates t o take a p p r o p r i a t e measures t o reduce t he consumption o£ a lcohol . While the p o s s i b l e r e l a t i o n s h i p between a l coho l - r e l a t ed problems and the o v e r a l l consumption l e v e 1 of a l coho l has been p rev ious ly d i scussed i n o t h e r p u b l i c forums, i t was t he f i r s t time t h a t the World Health Assembly had g iven i t such a t t e n t i o n . I t 1s a con t rove r s i a1 i d e a , and one t h a t some contend s t e p s f a r beyond the t r a d i t i o n a l domain of p u b l i c h e a l t h p rac t i ce . However, much o£ what w e w i l l be doing over the n e x t 1a years t o accomplish t h e g o a l of "Health f o r A l 1 by t h e Year 2000" could a l s o be considered a s " r ad i ca l . " What w e a r e t a l k i n g about 1s a dramatic s h i f t i n th ink ing , the import of w h i a i s j u s t beginning t o be apprec ia ted . For t h i s reason, tnis workshop 1s p a r t i c u l a r l y important t o u s a t t h i s time.

d h i l e w e have been aware of tlie need t o cooperate with o t h e r s e c t o r s , nowhere 1s this need g r e a t e r than i n t he ca se of a l coho l problems. If prevent ion 1s envisaged i n i ts broades t terms, then we w i l l have t o t u r n ou r a t t e n t i o n t o i s s u e s o£ s o c i a l wel fa re , educa t ion , and economics which h e r e t o f o r e w e d i d n o t analyze thoroughl y.

The s imple f a c t i s t h a t while governments a s a whole can s i g n i f i c a n t l y a f f e c t dr ink ing p r a c t i c e s and, concomi t a n t l y reduce a l coho l - r e l a t ed problems, t h e h e a l t h s e c t o r per se cannot. What we can do, however, 1s p u t toge ther a convincing case f o r a c t i o n and t r y t o d e l i n e a t e how t h a t a c t i o n might be c a r r i e d ou t . A l though a cons iderab le amoun t of r e sea rch has been d i r e c t e d a t the app l i ca t i o n of demand-reducing s t r a t eg i e s , we have r e l a t i v e l y 11 t t l e d a t a on the impact o£ euppl y r educ t ion meaeures, par t i c u l a r l y i n developing coun t r i e s .

i~ t m e s a y a few words abou t the developing coun t r i e s of our r e g i o n and the work w e have been doing i n t h e a l c o h o l f i e l d , f i r s t , because 1 th ink i t i s germane t o your d i s cus s ions , and secondly, because w e a r e proud of some of o u r accomplishments of t he p a s t decade o r so. I n g e n e r a l , t h e t rends i n a l c o h o l problems which w e are beginning t o see i n t h e reg ion a r e alarming. A m u l t i n a t i o n a l survey conducted by the Pan American Heal th Organizat ion i n t he mid- 1970 ' s showed t h a t heavy dr ink ing , p a r t i c u l a r l y by young a d u l t males, was much more widespread than w e had p rev ious ly thought. The numbers o£ people a f f e c t e d o r p o t e n t i a l l y a f f e c t e d by a l coho l problems i s . s tagger ing . W i th more than one- th i rd of adul t males r epo r t i ng high l e v e l s of heavy dr ink ing i n t h r e e of t he f i v e ci t ies eurveyed, the impact on hea l th , s o c i a l wel fa re , and econoadc development i s c l e a r l y of such propor t ion a s t o warran t e w i f t and d i r e c t governmen t i n te rvent ion .

While few of t he governments of t he r eg ion have e e t a b l i s h e d a l c o h o l programe, t he re a r e cons iderab ly more today than the re were a decade ago, and t h e l i s t keeps growing. The inc reased world-wide a t t e n t i o n g iven t o a l coho l - r e l a t ed problems has had a l o t t o do w i t h t h i s developmen t. However , more impor t a n t l y , governments a r e beginning t o recognize tha t prevent ion can be e f f e c t i v e l y achieved a t a s o c i a l and economic c o s t which i s w e l l w i th in t h e i r reach.

1 would jus t l i k e t o remind you tha t the World Heal t h Assembl y h a s scheduled Technical Discussions on Alcohol i n May (19821. For this reason w e w i l l be looking forward t o t h e r e s u l t s o£ t h i s work- shop with keen i n t e r e s t.

1 a m v e r y much impreeeed with t h e v e r y demanding agenda f o r the n e x t th ree days, and wish you eve ry succes s i n your de l ibera- t ions .

John H. Bryant

It i s a p l ea su re t o be he re and t o see s o many d i s t i ngu i shed people i n t h i s f i e l d here t o d e a l with t h i s impor tan t sub j ec t .

1 th ink you w i l l b e i n t e r e s t e d i n the genes i e of t h e s e t of i deas l ead ing t o t h i s conference. I n May 1980, immediately p r i o r t o tha t year 'S World Heal th Assembly i n Geneva, a few of u s convened a small conference w i th t h e World Heal th Organiza t i on , and pa r t icu- l a r l y i ts European o f f i c e , a long wi t h t he Pan American Heal th

Organizat ion, a s i n teres t e d p a r t i c i p a n t s . Shor t l y before , the World Heal th Organizat ion had p u t forward the i d e a of "Health f o r A l 1 by the Year 2000," a t t h a t t i m e a somewhat i l l - d e f i n e d but v e r y importan t concep t.

A number of u8 f e l t i t was v e r y impor t a n t t h a t "hea l th f o r a l l " should be s e e n a s a goa l , n o t f o r poor coun t r i e s a lone , b u t r a t h e r t h a t i t should be s een a p p r o p r i a t e l y a s applying t o a l 1 count r ies . A s a coneequence, f o r the Geneva meeting we brought toge ther r ep re sen t a t i v e s f rom abou t 20 na t i o n s t o examine the imp l i ca t i ons f o r t h e more developed count r ies . Four -- the Sov ie t Union, Norway, Canada, and the United S t a t e s -- o f f e r e d themselves as case s t u d i e s . We had i n v i t e d a number of developing coun t r i e s t o p a r t i c i p a t e s o a s t o provide pe r spec t ive i n looking a t t he problems of the more developed count r ies . The i n p u t of t h e l e s 8 developed coun t r i e s brought a n unpredic ted outcome, one which l e d t o our being he re today. Bu t l e t m e come t o tha t i n a moment.

The problem t h a t f aced the more developed coun t r i e s was how t o de f ine "hea l th f o r a l l . " I t was most s u c c i n c t l y s t a t e d by the de l ega t e from the Nether lands, who s a i d t h a t i f "hea l th f o r a l l " means u n i v e r s a l a c c e s s t o b a s i c hea l th s e r v i c e s , h i s country has had t h a t f o r 20 years , b u t i t does n o t have "hea l th f o r a l l . " H e no ted problems of a lcohol ism and drug abuse, and i n d u s t r i a l t o x i c i t y , and s t a t i s t i c s showing t h a t on a n y g iven day 20 pe rcen t of the l a b o r f o r c e was absen t from work, o s t e n s i b l y f o r hea l t h reasons.

These obse rva t ions l e d i n t o a long l i s t of problems t h a t e x i s t i n the mos t developed coun t r i e s and t h a t r e l a t e t o hea l th. I n the course of developing t h a t l i s t , t he l e e s developed coun t r i e s pointed o u t t h a t even though t h e i r c u r r e n t p r i o r i t i e s might be i n a r e a s of communicable d i s e a s e s and provis ion of h e a l t h s e r v i c e s , t he re was n o t a s i n g l e problem on the l i s t of t he more developed coun t r i e s t n a t those from l e a s developed na t ions could n o t claim a s one of t h e i r own: pa t t e r n s of d i s ea se ; problems of planning , implementing and managing h e a l t h s y s tems; h e a l th manpower development; r e s e a r ch i s s u e s ; e t c .

This r e v e l a t i o n , i f you w i l l , t h a t a l 1 c o u n t r i e s d i d indeed s h a r e the same se t of problems, even though d i f f e r e n t coun t r i e s would have d i f f e r e n t p r i o r i ties, l e d u s t o a s k another se t of ques t ions . I f w e a l 1 have the same set of problems, b u t a t d i f f e r e n t e tages , wha t i s t h e sequence through which spec i f i c problems w i l l emerge a s p r i o r i t i e s ? That i s , which c u r r e n t problems may demand p r i o r i t y a t t e n t i o n i n the f u t u r e ? And, can coun t r i e s l e a r n from one another? Should we think i n terms of prospec t ive p r i o r i ties s o t h a t coun t r i e s which do n o t y e t f a c e a ma jor problem w i l l recognize t h a t i t may be on t h e i r doors tep a decade o r two from now? That brought u s t o the f u r t h e r ques t i on of whether coun t r i e s can l e a r n from one a n o t h e r ' s exper iences i n o rde r t o steer around

c e r t a i n problems. I f they can p red ic t which problems a r e on the way, to what e x t e n t can they avoid them and/or a t l e a s t prepare f o r them i n a more e f f e c t i v e way?

There vas a s u b e t a n t i a l amount of i n t e r e s t i n t h i s s e t of quest ions, and we decided t o pursue i t fu r the r . I n the fa11 of 1980 -- encouraged by D r . Acuna a t PAHO and by D r . L.A. Caprio, the d i r e c t o r of the European o f f i c e of WHO -- D r . Blendon, &s. Karen Be11 from the i n s t i t u t e of Medicine, and 1 went t o Copenhagen f o r a meeting t o f u r t h e r d iscuss the matter and t o t r y to decide on some concrete s t eps t h a t could be taken a t t h a t time. I n the course of those diecussions, D r . Blendon, i n p a r t i c u l a r , helped us focus on s u b j e c t a reas t h a t ve could define c l e a r l y and concretely enough t o develop a series of r e a l i s t i c pol icy options. One encompassed probleme of the e l d e r l y ; o t h e r s were the problems of alcoholism, vehicular acc idents , occupational hea l th hazards, and the f inancing of heal tn services . We f e l t t h i s l i s t could be used a s an agenda f o r more developed and less developed countr ies t o come together t o look a t po l i cy op t ions t o consider f o r the f uture.

We f i r s t addressed problems of the e l d e r l y , and 1 w i l l note t h a t we had some q u i t e successful coneultat ions t h a t w i l l r e l a t e very d i r e c t l y t o the upcoming World Assembly on the Elderly.

Then the I n s ti tu t e of Medicine, w i th D r . Blendon' e a s e i s tance, generously agreed t o take on the p ro jec t of organizing a workehop on a lcohol- re la ted problems. 1 would s a y t h a t our i n t e n t was t o provide a forum t o def ine the problem and to i d e n t i f y the pol icy options, i n t h i s ine tance i n the a r e a of l e g i s l a t i o n . Thus, a s na t ions f a c e these p a r t i c u l a r problems i n t h e i r f u t u r e they can be guided, a t l e a s t t o some ex ten t , by the experience of o the r coun tries .

Against t h a t background we a r e ve ry pleased t o see t h i e conference underway, and w e look forward t o learning from a l 1 of you.

KEYNOTE ADDRES S

Char les Chassoul Monge

I t 1s a s a L a t i n American t h a t 1 am a t t e n d i n g t h i s meeting. I n L a t i n America, many b a s i c a r e a s a r e v e r y inadequate o r con- spicuous by t h e i r absence -- h e a l t h , f ood, educa t i o n , l a b o r and employmen t, consump t i o n , t r ade and sav ings , t r anspo r t a t i o n and communications, housing , c lo th ing , re c r e a t i o n o r l e i s u r e , s o c i a l s e c u r i t y , and human f reedom. Con t r a s ts a r e a d i s t inguish ing £ e a t u r e of t h i s cont inent : he re , a c i t y o£ more than 10 m i l l i o n i n h a b i t a n t s w i th the h i g h e s t degree of s o p h i s t i c a t i o n , there , o n l y a few hundred kilome ters away, a pover t y-s tri cken communi t y whose i nhab i t an ts do n o t even speak Spanish, b u t o n l y t he d i a l e c t s they have i n h e r i t e d f rom t h e i r ances tral c u l tures .

But w e La t i n Americans are imbued w i th a s p i r i t o£ o p t i m i s t i c p e r s i s t e n c e , t o ach ieve new s o c i a l and economic g o a l s t h a t w i l l a f f e c t ou r models of development and, consequently, our h e a l t h a c t i v i t i e s and thus enab le u s t o f i n d some way o£ prevent ing the problems r e l a t i n g t o a l c o h o l and alcoholism.

When 1 l e a r n e d abou t t h i s meeting, 1 imagined t h a t i t was yoing t o a t t e m p t t o emulate the 1889 Brusse ls meeting a t which a group of European powers agreed to ab ide by c e r t a i n moral principies regard ing A f r i can terri t o r i e s , inc lud ing the p r i n c i p l e of l i m i t i n g the impor ta t ion of ha rd l i q u o r i n t o Afr ica . 1 imagined t h a t w e were going t o d i s c u s s a s i m i l a r p ropos i t i on f o r L a t i n America and the developed coun t r i e s , and 1 was n o t d i s t r e s s e d . 1 f u r t h e r imagined t h a t w e were going t o have a f r a n k , open, s i n c e r e and, consequently, animated meeting wi th the r e p r e s e n t a t i v e s of t he producers of a l c o h o l i c beverages i n t he United S t a t e s , Canada, and Mexico, and t h a t w e might f i n d ou r se lves involved i n wide-ranging and s e r i o u s v e r b a l disagreements. And t h i s d i d n o t upse t m e i n t he l e a s t .

But when 1 rece ived the pre l iminary d r a f t o£ the agenda of t h i s meeting, t o which 1 had been i n v i t e d t o make t h i s speech, and when 1 saw who would be p re sen t there , 1 must confess f e e l i n g some anxie ty . 1 a m c a l l e d upon t o g i v e you my opin ion on a problem t h a t a t p r e sen t can o n l y be handled by s p e c i a l i s t s i n t h a t f i e l d . 1 am n o t such a s y e c i a l i s t and my presence he re 1s j u s t i f i e d s o l e l y by the f a c t t h a t 1 have been working wi th a n a lcohol i sm program i n my own country and have some knowledge of s i m i l a r programs i n o t h e r La t i n American coun tries.

We s t a r t from c e r t a i n gene ra l assumptions: we take f o r g r an ted tha t we a r e a cquainted w i th world t r ends i n t he product ion and consumption of a l c o h o l i c beverages; the manufacture and marketing of these products , a s w e l l a s the many commercial agreements t h a t suppor t them; and t h a t , i n add i t i on , we know the e f f e c t s and the damage caused by the consumption of a l coho l on o u r peoples a t t h e i r d i f f e r i n g l e v e l s of economic and s o c i a l development. We assume, i n accordance wi th what t he e x p e r t s t e11 us , t h a t i f we a r e t o d e a l wi th these gene ra l a s p e c t s of a lcohol , we cannot adopt i s o l a t e d measures i n our count r ies ; r a t h e r , when we p a r t i c i p a t e i n any a c t i v i t y i n this f i e l d , we must take i n t o account a l 1 t he ps ycho-social, p o l i t i c a l , and economic f a c t o r s tha t may de termine i t .

We a r e t o l d t h a t , i f we a r e t o prevent the damage a l coho l causes i n ou r communi t i e s , we should design ef f e c t i v e regula t o r y measures and i n t e g r a t e them i n t o a p o l i t i c a l pos ture t h a t w i l l l e a d t o clearl y def i n e d and cons is ten t governmen t ac t ion . I n addi t i on , we should simul taneous ly conduct o ther mul t i - s e c t o r a l suppor t a c t i v i t i e s s o a s t o ensure t h a t ou r prevent ive program i s both complete and coordinated and, before beginning any program, we should inform the p u b l i c hones t ly and a c c u r a t e l y s o t h a t i t w i l l recognize the problem and p a r t i c i p a t e i n o u r a c t i v i t i e s . I t i s a mat te r of concern t h a t , i n r ecen t decades, the consumption of a l coho l and the problems a s soc i a t ed wi th i t have increased throughout the world, both i n the r i c h and i n t he poor countr ies; t h a t i n the t r a d i t i o n a l l y wine-drinking coun t r i e s t he consumption of beer and hard l i q u o r i s increas ing; t h a t i n the beer-drinking coun t r i e s the consumption of wine and hard l i q u o r i s increas ing; and t h a t i n the coun t r i e s where hard l i q u o r i s r e g u l a r l y consumed, the consumption of wine and beer i s increas ing . Any admin i s t r a to r o r s c i e n t i s t who p lans t o design a prevent ive program should no te what has happened when a populat ion t h a t has a s p e c i f i e d r a t e of consumption o f t r a d i t i o n a l beverages 1s urged t o lower i t s t o t a l a l coho l i n t a k e by switching t o o t h e r dr inks . The outcome 1s t h a t tha t popula t i o n con t i n u e s t o consume the t r a d i t i o n a l beverage , as we l l as the beverage t h a t has been urged upon i t a s a moderating elemen t.

A s a l r e a d y no ted, i n approaching alcoholism, most e f f o r ts should be d i r e c t e d towards prevent ion, wi th educat ion a fundamental element. iiowever , t he eva lua t i o n of a lcoholism educat ion programs i s undeniably complicated by a g r e a t many economic and s o c i a l f a c t o r s ; and i f we dec ide t o d i r e c t a lcoholism educa t ion exc lus ive ly a t ch i ld ren i n schools , we know t h a t i t w i l l have l i t t l e chance of success . Educat ional programa, which f r e q u e n t l y l a & resources and a r e t imid i n t h e i r approach, a r e o f f s e t by a l 1 the organized and unorganized s t imul i t h a t induae consumption.

I n a d d i t i o n t o the inducements por t rayed i n the mas8 media, there a r e a l 1 the th ings ch i ld ren l e a r n i n the s t r e e t , a t home, o r

i n o t h e r con tex t s abou t how and when and why a l coho l i s consumed. And i f a hypo the t i ca l program were t o become succes s fu l , and reduce t he rate of consumption, t h e p o l i t i c i a n s i n t he government a r e l i k e l y t o c o n t r a d i c t i t by changing p o l i c i e s because government revenue i s f a l l i n g ; o r a c i t i z e n may invoke h i s c o n s t i t u t i o n a l r i g h t s , c la iming t h a t no one should i n t e r f e r e wi th h i s personal l i f e , t h a t he may d r i n k wherever, whenever, f o r whatever reason, and w i th whomever he wants. Tha t same c i t i z e n can e a s i l y s a y t h a t he d r i n k s because he has t he problems of being a n educated person, o r t h a t he wants t o d r ink more because he has t h e problems of being an i l l i t e r a t e . O r he may s a y he d r inks because he h a s t he burdens of power, o r t h a t he d r inks because he i s powerless. Or else he says t h a t phys ic lans recommend the consumption of a c e r t a i n amount of a l coho l t o preven t coronary d i s e a s e , o r tha t t o f o r c e the populat ion t o d r i n k less by whatever means may mean a subsequent i n c r e a s e i n h e a r t d i sease .

What 1 have s a i d b r i l y s t o mind Groussac 's complaint about Emerson, t h a t he u s u a l l y became obacure by being too profound o r t h a t he f e a r e d he sometimes appeared profound by being too obscure. The d i f f i c u l t y i n h e r e n t i n dea l ing wi th a s u b j e c t such a s w e a r e d i s cus s ing 1s c l e a r l y apparen t t o t he average person.

The l e g a l a s p e c t s of c o n t r o l and the prevent ion of a lcohol ism a r e the c e n t r a l theme of t h i s conference; Popham and Schmidt f ill u s wi th enthusiasm when they s a y t h a t t he p o s s i b l e prevent ive va lue of l e g a l measures has a g a i n become important i n the prevent ion o£ alcohol ism and tha t the a v a i l a b l e i n f ormation on t h e i r e f f e c t i v e n e s s i s worth analyzing. We t h e r e f o r e b e l i e v e t h a t t h i s conference i s both necessary and t ime ly f o r the coun t r i e s of L a t i n America, many of which a r e t ry ing new approaches i n t h i s f i e l d .

From Popham and Schmidt w e a l s o take a paragraph of Edwards which f u r t h e r e x p l a i n s t h i a mat te r : Edwards saya t h a t i f w e a r e n o t capable of managing p e r s o n a l i t i e s and producing a human group wi thout neuroses , t h e o n l y a l terna t i v e t o c o n t r o l the prevalence of a l coho l a d d i c t i o n i s c o n t r o l of the environmental condi t ions of d r ink ing . Ge r s t e in a l s o g i v e s u s guidance when he o u t l i n e s i n h i s paper f o r t h i s conference t he need f o r p r a c t i c a 1 and organized thought i n consider ing the l e g i s l a t i v e approach a s a n i n c e n t i v e f o r p revent ion i n matters of a l coho l and alcoholism. The s ta tement i n Smart ' s paper t h a t governments have an impor tan t r o l e t h a t goes beyond the t r ea tmen t of a l c o h o l i c s t o cons ider ing laws and p o l i c i e s on va r ious a s p e c t s of t he prevent ion of a lcohol ism, i s a l s o a n exce l l en t mesaage. When Hea th , i n h i s wide-ranging observa t i o n s on t h i s mat te r tel ls us , i n a l 1 modesty, t h a t he i s o n l y supplying a fragmented glimpse of a complex r e a l i t y , he s t i l l provides cause f o r op t i m i s m .

A l 1 L a t i n Americans know the o rde r of p r i o r i t i e s e s t a b l i s h e d by the M í n i s t r i e s of Heal th i n t h i s f i e l d . We must add t h a t i t i a

n e i t h e r a p r i v i l e g e nor a n a t t r a c t i v e p o s i t i o n t o defend i n the f i e l d of a lcoholism a n a c t i v i t y o r program t h a t i n some way f a i l s t o dea l comprehensively wi th t h i s h e a l t h hazard. Worthy of mention a r e t he a c t i v i t i e s c a r r i e d o u t i n La t in America by the Pan American Heal th Organizat ion (PAHO) t o c o r r e c t t h i s s i t u a t i o n . The many a c t i v i t i e s t h i s organiza t i o n has under taken i n t he f i e l d have made many people aware of the problem i n many count r ies . An example of PAHO's i n i t i a t i v e s -- i f you w i l l a l l ow me t o mention i t -- i s the enactment i n Costa Rica of a l a w e s t a b l i s h i n g a n a lcohol con t ro l agency w i th na t i o n a l j u r i s d i c t i o n t h a t i s r e spons ib l e f o r r e s e a r ch, planning, community work, educat ion i n the p u b l i c primary schools , adver t i s i n g , and even s p e c i a l i z e d u n i t s f o r t he h o s p i t a l i z a t i o n of a l c o h o l i c p a t i e n t s . Today we should l i k e t o pay t r i b u t e t o the Pan Ameri can Heal th Organiza t i o n f o r i ts e f f o r ts i n t h i s regard.

1 would have l i k e d t o g i v e you a n o v e r a l l view of the h i s t o r i a l development o£ a lcohol - re la ted problems and a l coho l con t ro l programs i n L a t i n America. However, the l i m i t e d information 1 have a v a i l a b l e and l a c k of time would have caused me t o make many e r r o r s and omissions i f 1 had undertaken t o deal wi th t h i s topic . Accordingly, and with the permiesion of t he audience, 1 am going t o dea l wi th eomething wi th which 1 a m more f a m i l i a r , namely, the s i t u a t i o n i n my country, which i n essence i s n o t ve ry d i f f e r e n t from t h a t i n the r e s t of La t in America, and may b e taken as more o r l e s s r ep re sen ta t i v e of t he o ther coun t r i e s .

Neverthelees, 1 must emphasize t h a t what 1 have j u s t s a i d r e f e r s t o the l e g i s l a t i v e s i t u a t i o n , s i n c e the conduct of programs and s e r v i c e s , and prevent ion r a t e a , v a r y g r e a t l y from one country t o another .

An a l coho l monopoly was e e t a b l i s h e d i n U 4 8 under Decree No. 13 i s s u e d by the P res iden t General of Costa Rica, with the r a t i o n a l e t h a t : "The two most product ive branches of the P u b l i c Treasury, namely the revenues from tobacco and a l coho l , a r e s t e a d i l y decreas- i n g because the laws and r egu la t ions t h a t underpin them have been relaxed." It was n o t u n t i l 1337 t h a t a General Liquor Law was enacted. I n ou r country today there a r e many ways of o u t w i t d n g the law and regula t i o n s governing a l c o h o l i c beverages . Such regula t i ons inc lude con t ro l of the frequency of s a l e s of a l c o h o l i c dr inks , r egu la t ions governing the type of s a l e , hours a t which beverages a r e s o l d , age lid ts f o r consuming a l c o h o l i c beverages, p r i c e cont ro la (of ten w i th q u i t e a r b i t r a r y d i f f e rences) , and d i f f e r e n t i a l taxes ( aga in seemingly w i thout rhyme o r reason) . Although these cover v i r t u a l l y a l 1 a s p e c t s of a lcohol con t ro l , t h e i r enforcement i s l i m i t e d . I n s h o r t , t h a t i s our s i t u a t i o n , and the same could be s a i d of many coun t r i e s i n L a t i n America. This phenomenon may posa ib ly be even more important i n o t h e r count r iee i n L a t i n America. D r . Jaime Arroyo, our d is t inguiahed v i s i t o r from Panama, has s tud ied t h i s a s p e c t i n Cen t r a l America, and r e i t e r a t e s there a r e some laws, a c t u a l l y q u i t e a few, b u t t h e i r r e a l and p r a c t i c a 1 enforcement i s unsa t i s f ac to ry .

1 cannot resist t h e temptat ion of g i v i n g another example, from my own country, where a rather unusual s i t u a t i o n p r e v a i l s a t t h i s t i m e . Changes i n the va lue of the cur rency have s u b s t a n t i a l l y i nc reased the p r i c e of a l c o h o l i c beverages, and t h i s ha s l e d a l a r g e segment of the p u b l i c t o s t o p dr ink ing imported beverages and t o consume the much cheaper beveragee produced i n t he country. I t should be noted t h a t s i n c e t he end of 1979 t h e pe r c a p i t a con- sumption of l i c i t a l c o h o l i n Costa Rica has been decreasing, f o r the f i rs t t i m e i n 75 years . T h i s w i l l s u r e l y be accompanied by a l a r g e i n c r e a s e i n consumption of t he illicit beverages t h a t a r e widely home-brewed by ou r r u r a l populat ion. I n 1974 a law and r e g u l a t i o n s f o r con t r o l l i n g adver t i s i n g f o r a l c o h o l i c beverages was enacted. By 1982 tha t adver t i s i n g h a s be come more a t t r a c t i v e , more s u b t l e , and i n gene ra l , much b e t ter designed. We had some con t rove r s i e s , whi ch 1s n a t u r a l i n t h i s f i e l d , b u t which we would have avoided i f t h e in format ion w e now have had been a v a i l a b l e a t t h a t time. But one fundamental concern 1s t o ques t i o n why the ou t l a y s on adver t i s i n g f o r a l c o h o l i c beverages i n our coun t r i e s should be as g r e a t a s the budget of the Department of S t a t e , of t he Min i s t ry of Youth, Cu l tu re and Spor t s o r of the Nat ional Alcoholism I n s ti t u t e . We need t o f i n d why l a r g e amounts a r e being inves t ed i n c o n t r o l e f f o r t s without any e f f e c t on reducing the consumption of a l c o h o l i c beverages i n genera l .

1 do n o t wish t o l i s t the many Costa Rican laws on the prevent ion of a lcohol i sm problems. You w i l l be a b l e t o app rec i a t e t he l e g a l h i s t o r y i f w e p r e s e n t o n l y p a r t of t h e s ta tement of reasons of the Nat ional Alcohol and Alcoholism Code,* which a t t h i s time i s being d i scus sed by our L e g i s l a t i v e Assembly. This s tatement of reasons 1s a v e r y modest con t r ibu t ion t o t h e purpose and o b j e c t i v e of t h e meeting, t o which t h e I n s t i t u t e of Medicine of t he Un1 ted S t a t e s Nat ional Academy of Sciences has been k ind enough t o i n v i t e u s t o d i s c u s s these matters.

The opin ion states t h a t s i n c e October 7 , 1936, no comprehensive law on a l c o h o l and alcohol ism has been enac ted i n Costa Rica. The p r e s e n t Na t i o n a l Alcohol and Alcoholism Code:

o de£ i n e s a l c o h o l i c beverages and the types of beverages a v a i l a b l e on t h e na t i o n a l and i n t e r n a t i o n a l marke t, bo th f ermented and d i s t i l l e d ;

o p lace8 the p rospec t s of a Nat ional D i s t i l l e r y i n a broader dimension, r e q u i r i n g t h e D i s t i l l e r y t o e s t a b l i s h i t s own marketing and d i s t r i b u t i o n s ystems;

o v e r y c l e a r l y i n d i c a t e s where n a t i o n a l and imported a l c o h o l i c beverages a r e t o be analyzed, as w e l l a s de£ i n i n g

*Legis la t i v e Assembl y: AFFIRMATIVE MAJORITY OPINION, draf t law " N a t i o n a l Alcohol and Alcoholism Code", publ i shed i n Supplemen t 108 of La Gaceta No.151 of 11 August 1977.

illicit, f a l s i f i e d , and a d u l t e r a t e d and p roh ib i ted a l coho l s , and how each of them 1s t o be t r ea t ed ;

o dea l s with the manufacture and b o t t l i n g of d i s t i l l e d beverages, a s w e l l a s i n d u s t r i a l products that use alcohol . I n t h i s regard i t mentions the c h a r a c t e r i s t i c e of a l c o h o l i c beverages f o r import and expor t and s e t s o u t the r u l e s t o be f ollowed f o r t he expor t , import , and t r a n s i t of a l c o h o l i c beverage S i n the coun tr y;

o r e g u l a t e s the gene ra l a s p e c t s of import ing houses, s p e c i f i e s the p o r t s of loading and unloading of these beverages, and p r e s c r i b e s c a r e f u l handling of them i n the n a t i o n a l t e r r i t o r y;

o s t i p u l a t e s who can o b t a i n l i c e n c e s f o r s e l l i n g a l c o h o l i c beverages, d e f i n e s the type of shops t h a t can se11 these beveragee, and r e g u l a t e s t h e i r s a l e , which w i l l be e x c l u s i v e l y between 11 a.m. and 2 p.m;

o r e g u l a t e s the procedure f o r ob ta in ing o rd ina ry l i c e n s e s , a s we l l a s the q u a l i f i c a t i o n s of t he l i c e n s e holder8 and e s t a b l i s h e s the r u l e t h a t n o t more than one l i c e n a e w i l l be i e sued f o r eve ry 200 ci t izens ;

o e t i p u l a t e s where shops s e l l i n g a l cohol ic beverages a r e t o be l o c a t e d and p r o h i b i t s t he presence i n the shops of minors and the s a l e of such beverages t o them;

o p r o h i b i t s the s a l e of a l c o h o l i c beverages i n work p l a a s , municipal o r p r iva t e marke t e , o r mul ti-£ amily housing pro j e c t s sponsored by government i n s ti tu t ions .

The Code d e a l s s p e c i f i c a l l y with the t rea tment t o be given t o a l coho l i ce by the a u t h o r i t i e s and a l s o wi th the approach t o a l c o h o l i c s to be taken by government i n s t i t u t i ons , i n p a r t i c u l a r the N a t i o n a l Alcoholism I n s t i tu te . 1 t de£ i n e s alcoholism a s a d i sease and s p e l l e o u t the func t ions o£ the National Aicoholism I n s t i t u t e . The Code:

o simply and c l e a r l y p roh ib i t a persona from d r iv ing passenger U a n s p o r t a t i o n while drunk,and s e t s o u t the a u t h o r i t y of the p o l i c e t o adminie ter exper t examina t i o n s f o r determining the presence of a l coho l i n the human body;

o c l e a r l y de f ines the r e s p o n s i b i l i t i e s of the a l c o h o l i c p a t i e n t wi th r e s p e c t t o h i s family, and e s t a b l i s h e s the procedures f o r ensur ing t h a t these r e s p o n s i b i l i t i e s a r e f u l f i l l e d;

o r e q u i r e s primary, secondary, voca t i o n a l and techni c a l s chools, bo th p u b l i c and p r i v a te, t o g i v e preven t i v e educa t ion on a l coho l and alcoholism;

o r e g u l a t e s a d v e r t i s i n g f o r a l c o h o l i c d r inks and e s t a b l i s h e a a r e g i s t r y of l i c e n s e s f o r the s a l e of a l c o h o l i c beverages, l o c a t ed i n t h e N a t i o n a l A l coholism I n s ti tu t e .

F i n a l l y , i t names c e r t a i n o f f i c i a l s of t he INSA a s h e a l t h i n s p e c t o r s and con fe r s on them the same powers and d u t i e s a s t h e General Heal t h Law a s s i g n s t o the h e a l t h a u t h o r i t i e s . I t s t i p u l a t e s t h a t i t i s a p u b l i c o rde r law, and the most impor tan t of t h e t r a n s i - t i o n a l p rovis ions i s t h a t which f r e e z e s t h e p r e s e n t number of l i c e n s e s f o r t he s a l e of a l c o h o l i c beverages, a s w e l l a s t h e i r l o c a t i o n , u n t i l the p r e s e n t s u r p l u s i s reduced t o t he number prescr ibed .

The l e g a l measures f o r the con t ro l of a l coho l - r e l a ted problems have s o f a r been l o c a l o r n a t i o n a l measures. I t should be pointed o u t t h a t the a v a i l a b i l i t y of a l c o h o l i c beverages and the methods f o r promo t i n g t h e i r consump t i o n r e a ch beyond na t i o n a l f r o n t i e r s . I n a s hor t-s igh t ed endeavor t o promo te developmen t, r eg iona l and sub-regional economi c coopera t i o n p a c t s have come t o favor i n t e r n a t i o n a l i n t e r e s t s i n t h e product ion and d i s t r i b u t i o n of a l c o h o l i c beverages. The t ransna t i o n a l c a r t e l a w i l l cer t a i n l y be i n c l i n e d t o promote a n i n c r e a s e i n t he product ion and impor ta t ion of such beverages i n many count r ies .

We do n o t b e l i e v e t he re i s any sup rana t iona l agency t h a t can impose l e g a l measures t o c o n t r o l these a i t u a t i o n s . We must appea l t o t he sense of r e s p o n s i b i l i t y of n a t i o n a l l e a d e r s t o induce them t o adop t the a p p r o p r i a t e con t ro l s . I n t he f i r s t p l ace they mus t be made t o understand t h a t a l coho l problems a r e n o t o n l y a heavy burden on h e a l t h systems and a n impor tan t f a c t o r i n m o r t a l i t y and morbid i ty , b u t a l s o a n o b s t a c l e t o development. Nat ional o r i n t e r n a t i o n a l f i n a n c i a l i n s ti t u t i o n s and s o c i a l and economic agenc i e s should have been aware of these f a c t a a long t i m e ago.

The h i s t o r y of humanity i s f u l l of no t ab l e even t s t h a t a r e the work of man. I t i s sometimea d i f f i c u l t t o p o i n t o u t the small d e t a i l s t h a t gave rise t o those ou ts tanding events . Because of the na tu re of the agenc i e s and persons t h a t promoted and organized t h i a meeting, w e a r e h i g h l y o p t i m i a t i c and f u l l of hope t h a t w e a r e a t tending the g e n e s i s of a v e r y important endeavor f o r the i nhab i t an ts of our coun t r i e a .

Chap ter Two

INDUSTRIALIZATION, ECONOMIC DEVELOPMENT, AND WORKER DRINKING: HISTORICAL AND SOCIOLOGICAL OBSERVATIONS

Harry G e n e L e v i n e

TBE W A C T OF ECONOMIC DEVELOPMENT ON DRINKING PATTERNS AND PROBLWS: THE CASE OF TOURISH

J a m e s F . Mosher an d

L e n o r e D. R a l s t o n

1 NDUSTRIALIZATION, ECONOMIC DEVELOPMENT, AND WORKER DRINKING : HISTOIUCAL AND SOCIOLOGICAL OBSERVATIONS

Harry Gene Levine

ühen f i r s t approached abou t w r i t i n g a paper on the r e l a t i o n - s h i p of a l c o h o l t o economic development, and whether some g e n e r a l l e s s o n s d g h t be drawn from the h i s t o r i c a l exper iences of the U.S. and o t h e r developed coun t r i e s , 1 suggested focus ing on the s u b j e c t o f a l c o h o l and work. I n d u s t r i a l and economic development u s u a l l y i nvo lves t he c r e a t i o n of a l a r g e c l a s s of wage l a b o r e r s , and w n t i n u o u s s t r u g g l e s between employers and workers a r e among the mos t prominent f e a t u r e s o f developed and developing s o c i e t i e s . During the v a r i o u s pe r iods o f B r i t i s h and American i n d u s t r i a l development, t h e c o n f l i c t s o f t e n inc iuded the ques t i on of a l w h o l i c d r in k .

Acwrdingly , i n t h e f i r s t two p a r t s o f t h e paper 1 b r i e f l y d i s c u s s two d i s t i n c t bu t c i o s e l y r e l a t e d e f f o r ts whi ch involved employer-sponsored a t t a c k s on worker dr inking. The f i r s t was t he attemp t of e a r l y manufacturing and i n d u s t r i a l employers t o change t h e i r employees work h a b i t a and gene ra l s t y l e of l i f e . This e f f o r t va s no t p r imar i l y aimed a t changing dr ink ing p a t t e r n s , b u t included d r i n k a s p a r t of a broader e f f o r t . The second employer-sponsored e f f o r t 1 d i s c u s s was the e a r l y temperance o r an t i -d r ink reform i n t h e Uni ted S t a t e s . Bere t h e e f f o r t was aimed p r imar i l y a t changing workers dr ink ing p a t t e r n s d i r e c t l y i n o rde r t o secure a more o r d e r l y and d i s c í p l i n e d work fo rce . I n t h e t h i r d s e c t i o n 1 d i s c u s s some g e n e r a l conclusions t o be drawn from the broad European and North A m e r i can experience -- i n p a r t i c u l a r , t h a t worker dr inking taken by i t s e l f does n o t appear t o be an impediment o r o b s t a c l e t o economic development and growth. I n t he f ou r th s e c t i o n 1 in t roduce some con- temporary q u a n t i ta t i v e d a t a t o test and expand upon the h i s t o r i c a l evidente.

I n d u s t r i a l Employers and P re - Indus t r i a l Workers

"It i s nowadays i n c r e a s i n g l y coming t o be accepted t h a t one of t h e mos t c r i t i c a l , and one of t he most d i £ f i c u l t, t ransf ormations r equ i r ed i n a n i ndus t r i a l i z i n g s o c i e t y i s the a d jus tmen t of l abour

t o the r egu la r i t y and d i s c i p l i n e of f a c t o r y work." So begins Sidney Pol lard i n a n a r t i c i e on "Factory Disc ip l ine i n the I n d u s t r i a l Revolution" (The Economic His tory Review, 1963). This a r t i c i e i s p a r t of a growing body of scholarship exploring the e ighteenth and nine teen t h century con£ ron ta t ion of manufacturers and indue t r i a l i s ts with the people who became the working c l a s s i n Europe and America (See: Thompson (1963); Gutman (1976); Dawley and Faler (1976); Dawley (1970); Laurie (1980); Rock (1979); Reid (1976); Harrison (1911); Johnson (1976); Thompson (1967). The top ic of a l coho l i c drinic runs through a l 1 of t h i s wr i t ing -- i t i s p a r t of the s t rugg le be tween employer and worker .

The c e n t r a l quest ion f o r much of the wr i t ing and a n a l p i s on e a r l y i n d u s t r i a l and c a p i t a l i s t development 1s the res is tance of r u r a l , peasant, o r pre-indus trial people t o the rout ines , schedules, and pa t t e r n e of indus t r ial work. The o l d , pre-indus t r i a l pat terna of work, s o c i a b i l i t y , and time conf l i c t ed with the needs of the f a c t o r y system and the des i res of i n d u s t r i a l c a p i t a l i s t s . En trepreneurs and indus t r i a l i s ts f ound themselves i n a permanen t and ongoing s truggle t o transform the l i v e s of t h e i r workers.

A s Pol lard (1963) po in t s o u t , t he e a r l y i n d u s t r i a l i s t s were engaged i n a major c u l t u r a l conf l i c t :

The worker who l e f t the background of h i s domestic workshop o r peasant holding f o r the f ac to ry , entered a new cu l tu re a s we l l a s a new sense of d i rec t ion . It was not o n l y t h a t " the new economic order needed . . part-humana: s o u l l e s s , depersonalized, disem- bodied, who could become members, o r l i t t l e wheels r a t h e r , of a complex mechanism." I t was a l s o t h a t men who were non-accumulative, non-acquisitive, accustomed t o work f o r subsistente, n o t f o r maxi- mization of income, had t o be made obedient t o the cash st imulus, and obedient i n such a way a s to r e a c t p r e c i s e l y t o the s t i m u l i provided.

Recruit ing workers was of ten a d i £ f i c u l t problem, a s observers i n e ighteen century B r i t a i n noted. "Labourers from a g r i c u l t u r e o r domestic indus t ry do n o t a t f i rst take k indly t o the monotony of f a c t o r y l i f e , " noted one obsemer , who pointed o u t t h a t "the pioneering employer no t inf requent ly f inds h i s mos t ser ious obs t ac le i n the problem of building up a s t a b l e supply of e f f i c i e n t and wi l l ing labour" (Po l l a rd L363:254). I n Scotland i t was concluded t h a t "on the f i r s t in t roduct ion of the business, the people were found very i l l -d ieposed t o submit t o the long confinement and regular indus t r y t h a t i s required from them.. . ." It was s a i d t h a t the highlander "never sits a t ease a t a loom, i t i s l i k e putt ing a deer i n the plough." Workers would of ten leave without no t i ce and then send f o r t h e i r back wages. A l abor turnover o£ 100 percent a year was not unusual f o r e a r l y i n d u s t r i a l firme.

Even when workers s tayed , employers r epo r t ed major problems i n overcoming t h e i r employees' a ttachment t o t r a d i t i o n a l s o c i a l custome tha t c o n f l i c t e d w i t h the new i n d u s t r i a l e t h i c . F e s t i v a l e , f e a s t s , and wakes were ex t remely impor tan t s o c i a l and community even t s f o r mos t preindus t r i a l people, and t h i s d i d n o t change when they went t o work i n f a c t o r i e s . I n U 72 J o a i a h Wedgwood complained tha t : "Our men w i l l g o t o the Wakes, i f they were s u r e t o go t o the D--1 the next . 1 have n o t spa red them i n t h r e a t s and 1 would have th r a sh ' d them r i g h t h e a r t i l y i f 1 could." I n U76 t h e r e was t he same problem: "Our men have been a t p l a y 4 days t h i s week, i t being Burslem Wakes. 1 have rough'd & smoothed them over , & promiaed them a 10% Xmas, b u t 1 know i t i s a l 1 i n va in , f o r Wakes must be obaerved though the World was t o end w i t h them ( P o l l a r d 1963:256).

The quea t ion of t h e t i m e and r o u t i n e of work l i f e was c e n t r a l t o the s t rugg le s between working people and t h e i r employers. I n d u s t r i a l i a t s wanted workera t o come t o work s i x days a week, and work a t a s e t number of hours each day -- of t e n 12 o r 14. T r a d i t i ona l , p re indus t r i a l work pa t t e r n a , however , were q u i t e d i f f e r e n t , emphasizing pe r iods of v e r y i n t e n a e work f o r about f o u r days, and then th ree days of much more l e i s u r e l y work and of p l a y (Thompson 196 7 ). Monday v a s c a l l e d "Sa in t Monday" i n B r i t a i n and America, and was a n o f f i c i a l ho l iday among workers (Reid 1976). One e a r l y n ine t een th cen tury observer r epo r t ed t h a t weavers would "play f r e q u e n t l y a l 1 day on Monday, and t h e g r e a t e r p a r t of Tuesday, and work v e r y l a t e on Thursday n i g h t , and f r e q u e n t l y a l 1 n i g h t on Fr iday ( P o l l a r d 1963:256). Re id (1376 :81) r e p o r t s t h a t i n England i n t he U3408 Monday was "gene ra l l y kep t a a a ho l iday by a grea t p o r t i o n of t h e working c l a s se s . " A s l a t e a s l a 6 4 i t was a s popular a s ever ; i n Birmingham, f o r example , emplo yer e complaine d tha t "an enormous amount of t i m e i s l o s t , n o t o n l y by want of p u n c t u a l i t y i n coming t o work i n the morning and beginning aga in af t e r meals, b u t a t i l l more by t h e gene ra l observance of ' S a i n t Monday' " (Reid 1976 :a l ) .

The p r e i n d u s t r i a l p a t t e r n of work developed i n a contex t i n which people had c o n t r o l over t h e i r own t i m e and working environ- ment. Ar t iaana and independent craf tsmen, working a t t h e i r homes o r workshops, s e t t h e i r own pace. (Rock 1978:236) desc r ibes t he g e n e r a l pa t t e r n f o r New York C i t y i n the e a r l y n ine t een th century.

A j ourne yman s hoemaker , f o r example , migh t spend Monday and Tuesday i n dr ink ing and s p o r t o n l y t o t o i l a t a r a p i d pace the rest of the week (through Sa turday) t o make enough t o suppor t h i s family.. . . Work was task-or iented r a ther than t ime-or ien ted (many a r t i a a n s , i n f a c t , d i d n o t even own a watch). Labor p a t t e r n s were i r r e g u l a r , vary ing enormously from shop t o shop, from t rade t o t rade , from week t o week. The most n o t a b l e symbol of premodern work p a t t e r n s was the venerab le S a i n t Monday. This was t h e conmion p r a c t i c e of c r a f tsmen taking each Monday

(and sometimes Tuesday) o f f f o r r e l a x a t i o n i n a neighborhood tavern, excurs ions t o t he coun tr y, o r o ther l e i s u r e l y a c t i v i t i e s .

I t w a s p r e c i s e l y t h i s p a t t e r n of independent work which t h e i n d u s t r i a l i s t s would n o t t o l e r a t e ; and i t was t h i s p a t t e r n which workers t r i e d t o main ta in i n t h e f a c e of s trong oppost ion and harsh p e n a l i t i e s . Gutman (1976) p o i n t s o u t t h a t i n t he United S t a t e s , because of t he waves of immigration through t h e n ine t een th century and i n t o the twent ie th , t he re was a continuous encounter between p r e i n d u s t r i a l people (from I r e l a n d , Northern Europe, Southern and Eas te rn Europe, Aeia, L a t i n A m e r i c a , Afr ica , and the American South) and the i n d u s t r i a l system. Generat ion a f ter genera t ion were forced t o g i v e up some of the o l d e r and valued p a t t e r n s and adap t t o the harsh regime of f a c t o r y l i f e .

The i n d u s t r i a l i s t s ' methods of overcoming t h e i r l abo r problems can be "grouped under t h ree headings: t h e p rove rb ia l s t i c k , the p rove rb ia l c a r r o t , and t h i r d l y , the a t t empt t o c r e a t e a new e t h o s of work, o rde r and obedience." It was the t h i r d approach which was d i s d n c t i v e of e a r l y i n d u s t r i a l i z a t i o n . "U t t l e new i n t h e way of the ' s t i c k , ' o r d e t e r r e n t , was discovered by the e a r l y f a c t o r y masters. Unsa t i s f ac to ry work was punished by corpora l punishment, by f i n e s , o r by diamiseal." I n a d d i t i o n , employers f i r e d workers who a s s o c i a t e d w i th workers' o rganiza t i o n s and unions, and sometimes had workers a r r e s t e d f o r engaging i n the i l l e g a l a c t i v i t y of organiz ing employees. Fur t he r , "Employers were as conservat ive i n the use of the c a r r o t a s they were i n t he u s e of the s t i c k . For a gene ra t ion d r iv ing i ts ch i ld ren t o l abour i n t h e m i l l s f o r twelve t o fou r t een hours a day, p o s i t i v e i n c e n t i v e s must indeed have been hard t o devise." The chief i n c e n t i v e was a d d i t i o n a l money, though a few employer s experimen t e d w i t h s t a t u s awards f o r excep t i o n a l worker S

(Po l l a rd U65:266-7 ).

E a r l y indus t r i a l i s ts be l ieved tha t the ma jor problem f acing them was workers who were i n s u f f i c i e n t l y "endowed wlth the e s s e n t i a l q u a l i t i e s of i n d u s t r y , ambi t ion , s o b r i e t y and t h r i f t" t h a t t he f a c t o r y system requi red . I n t h e i r e f f o r t s t o d i s c i p l i n e t h e i r workers, employers concluded they were dea l ing w i th behavior t h a t went on o u t s i d e the f a c t o r y as w e l l a s i n s ide . The c a p i t a l i s t a sought , t he re fo re , t o reform " t h e whole man . . . by i n d o c t r i n a t i n g him w i th the bourgeois va lues he lacked" ( P o l l a r d 1963: 267 ).

The q u a l i t i e s of cha rac t e r which employers admired have, s i n c e Weber's day, been t o some e x t e n t a s s o c i a t e d with t h e P r o t e s t a n t e t h i c . To import these q u a l i t i e s , wi th the one a d d i t i o n of obedience, t o t he working c l a s se s , could n o t b u t appear a formidable task . (The r e s u l t ) was the preoccupation

w i th t he cha rac t e r and morals of the working c l a s s e s which a r e s o marked a f e a t u r e of t h e e a r l y s t a g e s of indus t r i a l i z a t i o n . . . . Fa c t o r y v i l l a g e s . . . had s p e c i a l p rov i s ions and, i n some cases, fu l l - t ime s t a f f t o check the morals of t h e i r workers. Contemporaries tended t o p r a i s e these a c t i o n s most h igh ly , and i t was be l i eved t h a t f i rma l ay ing stress on morals , and employing foremen who "supress anyth ing bad" would g e t t he p i ck of l abour . Almost everywhere churches, chapels and Sunday s chools were suppor ted by employers, bo t h t o encourage moral educa t ion i n i t s more u sua l aense, and t o i n c u l c a te obedience. Drink and drunkenness became a major t a r g e t of reform, wi th the short-term aim of i n c r e a s i n g the ueefu lness of s c a r c e s k i l l e d workers s u & a s Soho's engineer e r e c t o r s , who were of t en i n c a p a c i t a t e d by dr ink , and the long-term a i m o f spreading bourgeois v i r t u e s .

I n t h i s procese much of the e x i s t i n g v i l l a g e c u l t u r e came under a t t ack . T r a d i t i o n a l s o c i a l h a b i t a and customs seldom f i t t e d i n t o the new p a t t e r n of i n d u s t r i a l l i f e , and t h e y had t h e r e f o r e t o be dis c red i t e d as hindrances t o progress" (Pol la rd : 2 6 7 4 ).

The indus t r i a l i s ts' cha l lenge t o t r a d i t i o n a l pa t t e r n s , customs and va lues reached deep i n t o the l i v e s of working people. I t was a n e f f o r t t o r e o r i e n t t h e i r l i v e s t o mesh wi th t h e needs of f a c t o r y d i s c i p l i n e . However, i t w a s n o t a t o t a l a s s a u l t on t r a d i t i o n a l p a t t e r n s , and the e t h i c a l code employers sought t o promulgate was l i m i t e d i n p a r t i c u l a r ways. "Warnings aga ins t greed , s e l f i shnes s , ma te r i a l i sm o r p r i d e seldom played a l a r g e p a r t " i n t h e i r a t t a c k s . Fur t h e r , and s i g n i f i can t ly , "sexual morals r a r e l y became a n impor tan t i s s u e t o t h e f a c t o r y d i s c i p l i n a r i a n s ( a s d i s t i n c t from o u t s i d e m o r a l i s t s ) and, by and l a r g e t hey d i d n o t mind which God was worshipped, a s long a s t h e worshipper was under t h e i n f luence of some r e s p e c t a b l e clergyman." I n s h o r t , i t was r a t h e r p a r t i c u l a r a s p e c t s of t r a d i t i o n a l c u l t u r e -- hours and days of work, p a t t e r n s of s o c i a b i l i t y , i n t e g r a t i o n of work w i t h p lay , importante of o t h e r e v e n t s which made claims on t h e i nd iv idua l ( f e s t i v a l s , wakes, etc.) -- tha t rece ived the b run t of reform e f f o r t s . A s P o l l a r d sugges ts : "The conclusion canno t be avoided t h a t. w i th some honorable excep t ions , me d r i v e t o r a i s e t he l e v e l - of r e a p e c t a b i l i t y and m o r a l i t y amo% t h e working c l a s s e s was n o t undertaken f o r t h e i r own sakes b u t p r imar i l y , o r even e x c l u s i v e l y , a s a n a s p e c t of bu i ld ing up a new f a c t o r y d i s c i p l i n e " (P.270).

To sum up, i n d u s t r i a l i e a t i o n i n B r i t a i n (and the United S t a t e s ) involved the emergence of a new c l a s s of c a p i t a l i s t en t r ep reneur s and i n d u s t r i a l i s t s who wanted t h e i r workers t o work i n h i s t o r i c a l l y new ways ( regard ing hours pe r day, days pe r week, manner when working, number of breaks, degree of s o c i a b i l i t y , e t c . ) , and i n h i s t o r i c a l l y ex t r ao rd ina ry waye ( i n f a c t o r i e s and shops, wi th machinery, e tc. ). I n o r d e r t o g e t woricere who would work i n t h e ways they wanted, indus t r i a l i s ts engaged i n e f f o r ts t o transform the l i v e s , h a b i t e and c u l t u r e s of t h e i r employees, and t o some e x t e n t of the lower classes i n genera l .

iiowever, working people, f rom t h e beginning , resis ted t h e e f f o r t s of employers t o transform t h e i r l i v e s . Workers clung t enac ious ly t o p a t t e r n s where the i n d i v i d u a l o r the peer group exe rc i sed con t r o l over the speed, timing , and o.rganiza t i o n of work; where p l a y was i n t e g r a t e d wi th work; and where f e s d v a l s , f e a s t s , and wakes were important , even sac red events .

The pe r iod before i n d u s t r i a l i z a t i o n o r s i g n i f i c a n t cap1 talis t development, i n B r i t a i n and North America, was a t i m e i n which a l c o h o l i c beverages were h i g h l y regarded and widely consumed. Regular dr inking and f r equen t drunkeMeSS were p a r t of ord inary l i f e f o r most people, upper c l a s e a s w e l l a s lower. Regular dr inking was connnon; d r u n k e ~ e s e was regarded as a n o r d i n a r y and non-problema ti c consequence of dr inking (Dorchester U88; Shadwell 1903; Dulles 1940; Rorabaugh 197 9 ) .

Because i n t h e t r a d i t i o n a l , pre-indus t r i a l c u l t u r e dr inking was s o widespread and i n t e g r a t e d i n t o s o many p a r t s of l i f e , the a t tack on tha t c u l t u re sponsored by e n t r e p r e n e u r i a l c a p i t a l i s t e encompassed dr inking p rac t i ce s . ün S a i n t Monday workers went t o taverns and they drank; when they went t o wakes, weddings, f e s t i v a l a , and f e a s t s they drank; when they took breaks from work they had a dr ink; when doing hard phys i ca l l abo r they drank. The new d i s c i p l i n a r y o r d e r being puehed by businessmen, i n d u s t r i a l - ists, and middle c l a s e reformers condemued many of the t r a d i t i o n a l s o c i a l forma and o f f e r e d new ones t h a t promoted s e l f - d i s c i p l i n e , s o b r i e t y , p i e ty, t h r i f t l n e s s , o r d e r l i n e s s . Drink was one p a r t of the rowdy, bo is te rous , and d i s r u p t i v e t r a d i t i o n a l cu l t u r e tha t businesemen f e l t needed t o be suppressed i n t he i n t e r e s t s of t h e developing indus t r i a l o r d e r .

Drink, Temperante, and Capi talis t Development i n the United S t a t e s

I n seventeenth and e i g h teenth century Ameri ca, l i q u o r was c a l l e d the "Good Crea ture of God," even by Puri tana. Doctora p re sc r ibed a l coho l f o r v i r t u a l l y a l 1 i l ls ; i t was widely used a s a pa in r e l i e v e r , s timulan t and seda t i ve . The predominan t drinking

p a t t e r n i n the seventeenth cen tu ry was the r e g u l a r , d a i l y u se of a l c o h o l i n moderate q u a n t i t i e s wi th some incidente of drunkenness. By the e a r l y e i g h t e e n t h cen tu ry dr ink ing and drunkenness had i n a e a s e d and cont inued t o do s o throughout t h e century. Rum manufacture began around UOO, and d x e d wi th j u i c e s rum became the f a v o r i t e d r ink . The g e n e r a l p a t t e r n i n t h e e igh t een th cen tury was f o r men and women t o d r ink a l c o h o l e v e r y day, a t a l 1 times during t h e day, and i n l a r g e q u a n t i t i e s a t most e v e r y s p e c l a l occasion. The r e s p e c t a b l e e lements of s o c l e t y , e a p e c l a l l y t he upper c l a s s , e e t a p rodig ious dr ink ing s t anda rd (Rorabaugh 1979 : 27 ; Krout 19 25).

The lower c l a s s e s probably equa l l ed t he s tandarde set by the upper c l a s s . Heavy d r ink ing was p a r t of occasiona l i k e corn huakinge, barn r a i s i n g s , c o u r t and meeting days, and m i l i t i a t r a i n i n g days. Workers i n a l 1 occupat ions drank on the job and a t scheduled breaks a t t e n d e d the t ave rn , of t en a t t h e employer's expense. I n New England t h e ahops and o f f i c e a were c losed whi le workers enjoyed t h e i r "eleven o' d o c k b i tters"; the same thing happened a t f o u r o ' clock. I n Po r t l and , Maine, i n honor of t he breaks the town h a l l be11 v a s rung a t e l even and f o u r o ' c iock (Kobler U73:29; Furnas 1965:22). Sometimes employers provided t h e a l coho l t o be drunk o u t s i d e working hours as w e l l . For example, George Waehington'e agreement wi th h i e gardner inc luded " four d o l l a r s a t Christmas wi th which he may be drunk f o r f o u r days and n igh t s ; two d o l l a r s a t E a s t e r t o e f f e c t t h e same purpose; two d o l l a r s a t Whitsuntide t o be drunk f o r two days." The agreement a l s o inc luded "a dram i n t h e morning and a d r i n k of g rog a t noon" (Kobler 191 3:31).

The beginnings of t h e an t i - a l coho l campaign can be marked by the p u b l i c a t i o n of a pamphlet i n 'Ud6 by the prominent American phys ic lan Benjamín Rush. The pamphlet, "An Inqu i ry i n t o the Ef f e c t s of Ardent S p i r i t e , " wae a founding document i n t he American, and then world-wide , temperance and p r o h i b i t i o n campaigns . I n h i s p i ece , Rush a rgued t h a t d i s t i l l e d l i q u o r was d e s t r u c t i v e of hea l th , m o r a l i t y and o r d e r , and he encouraged everyone t o a b s t a i n from i t. Beer, v ine , and hard c l d e r , he s a i d , could be drunk i n moderate q u a n t i ties. I n 50 years , by t h e mid-l8 308, t h e temperance cause had grown i n t o a popular mas8 movement of the middle c l a s s . Much of con temporary medi cal, S c i en t i £ i c and popular though t about t he problematic consequences of a l c o h o l -- inc lud ing as w e a h a l l eee , t h e i d e a t h a t economic development r equ i r ed r e s t r i c t i n g o r e l i m i - n a t i n g worker dr ink ing -- was f i r s t developed and popular ized by the ternperance movement i n t h e n ine t een th cen tury (Levine 1978, 1980).

I n the l a te e i g h t e e n t h cen tury and e a r l y n ine t een th century, temperance was s t i l l o n l y a n e l i t e concern: t h e e f f o r t of upper- c l a s e and upper middle-clase men concerned wi th t he dr ink ing comportment of t he l abo r ing c l ae s . C r i t i c l s m of t h e c o l o n i a l i d e a of a l coho l a s the Good Crea ture wae begun, i n p a r t , a s a n e f f o r t t o

c o n t r o l the behavior of workers. I n h i s pamphlet, Rush had encouraged farmere who h i r e d workers t o s t o p g iv ing the customary d a i l y po r t ion of d r ink (rum o r whiskey), and t o o f f e r o t h e r beverages in s t ead . As a n i n f l u e n t i a l c i t i z e n , Rush a l s o t r i e d t o spread the idea ; "at harvee t t i m e each year Rush republiehed and c i r c u l a t e d t h i s e s s a y i n t h e hope t h a t farmers might be persuaded t o abandon the p r a c t i c e of f u r n i s h i n g l i q u o r a s p a r t of t he day'e wage. " Newspapers and almanaca a l s o r e p r i n ted h i s sugges t i o n s (Krout 1925:7 3).

The f i r s t formal temperance a s s o c i a t i o n i n America was formed by employers concerned with t h e dr inking of t h e i r workere. A newspaper a t t he time (U89) r epo r t ed t h a t "Upward of two hundred of the most r e spec t ab le farmere i n L i t c h f i e l d County, Conn., have formed a n a s s o c i a t i o n t o encourage the d i s u s e of s p i r i t u o u s l i q u o r s , and have determined n o t t o u se any k ind of d i s t i l l e d s p i r i t s i n doin(3 t h e i r f arming work the eneuing season" (Dorches t e r 1833 :16 5 ) . Th i s dec ls ion , by a group of weal thy commercial farmers , t o band toge ther t o break wi th t r a d i t i o n a l p a t t e r n s of work and d r ink r ep re sen ta a s i g n i f i c a n t change i n a t t i tudes among a n importan t segment o£ American employers. The United S t a t e s a t t h i s time v a s overwhelmingly a n a g r i c u l t u r a 1 na t ion , and on the e a s t e r n coas t l a r g e commercial farms were run a e businesaes producing f o r t h e market. It w a s on these farma t h a t many of t h e f i r e t encounters be tween modern, e f f i c i ency - and p roduc t iv i t y -o r i en t ed employers, and t r a d i t ion-oriented workers took place. However, t h i e i n i t i a l e f f o r t i n Connect icut t o e l i m í n a t e the s p i r i t e r a t i o n was n o t picked up by o t h e r employers, o r i n o t h e r regione. Labor was sca rce , and i n high demand and, i n t h i e caee, workers could g e t what they wanted. The New Haven Gazet te expla ined t h a t the l a b o r e r would n o t work without " h i e ha l f p i n t o r p i n t every day, and a t n i g h t ha l f h i s wage i n rum" (Rorabough 1979 :46 ) . Like the e a r l y i n d u s t r i a l en t repreneurs i n B r i t a i n , American employers encountered r e s i s t a n c e t o t h e i r new l abor d i s c i p l i n e s chemee .

I n U 1 3 the e f f o r t t o l i m i t worker dr inking picked up s i g n i f i c a n t suppor t when the f i r a t importan t temperance s o c i e t y was founded, the Massachusettes Soc ie ty f o r t he Suppression of Intemperante. Composed of men from the economic, p o l i t i c a l , and r e l i g i o u s e l i t e , the MSSI sought t o c o n t r o l t he behavior and h a b i t s -- e e p e c i a l l y the dr inking h a b i t s -- of t he mas8 of worldng people. The h i s t o r i a n I a n T y r e l l has pointed o u t t h e i r i n t e r e e t s and aims:

MSSI temperance r e f ormers f ocused on t h e dr inking h a b i t s of t he masa of comnon people, whose mannere and morals the temperance advocates no longer seemed t o control . . . . Habita of intemperance threatened, i n tne view of Henry Warren, a BDxbury lawyer, t o unleash t e r r i b l e passione on s o c i e t y by "nouriehing

among ue t h a t i d l e and miechievous epec i e s of popula t ion c a l l e d i n Europe the mob." Although temperance r e f ormere hoped tha t " the l abo r ing c l a se would be t h e e t r e n g t h of t h e na t ion , " t hey bel ieved t h a t i t e e t r e n g t h was " r a p i d l y ... becoming weak- neee" under t he b a l e f u l i n f luence of intemperance.

u i e g o a l of the f i r e t temperance reformere wae t o a v e r t euch p o t e n t i a l t h r e a t e t o t he e x i s t i n g s o c i a l e t r u c t u r e by in f luenc ing the common people. For t h i e purpose, t he Maesachueette e o d e t y devo ted much of i t e energy t o the prevent ion of exceeeive dr inking among l a b o r e r e i n both urban and r u r a l a reae . Members were alarmed a t the common p r a c t i c e o f g iv ing l a b o r e r s a r a t i o n i n g of s p i r i t e as p a r t payment f o r t h e i r work... . The MSSI the re fo re s e t a s one of i t s foremoet t a c t i c a of reform a " f r i e n d l y concern of merchante, sea-cap t a i n e , and wharf i nge re , of r e spec t ab le f armere, mechanics, and manufactur- e r s ; i n a word, of a l1 h i r e r e of labour , n o t t o f urnieh a rden t s p i r i t t o the labourers" ( T y r e l l 1979 :41).

i5y the e a r l y 18206 t h e MSSI had l o s t momentum, and by the mi d-20s a new group, the American Temperance Socie t y , aeeumed l eade reh ip and committed the movement t o abe t inence from d i e t i l l e d l i quor . The men who puehed the temperance and e e p e d a l l y the abe t inence cause were no t, a s l e eometimee though t , backvard looking men who eought t o r e e t o r e the t r a d i t i o n a l o rde r . Rather , as T y r e l l po in t e out : "The temperance reform a t t r a c t e d from i t e beginninge ambitioue and upwardly mobile men." They were n o t "from r u r a l backwa t e r e eeeking t o r e a s s e r t tradi t i o n a l va lues on a changing eociety."

On the cont ra ry , ternperance reformere sanc t ioned the a q u i e i t i v e and i n d i v i d u a l i e ti c economic o rde r developing i n America. Viewed from the perepect ive of h inde ight , temperance reformers appear a s a y o l o g i s t e f o r economic change; t hey were men who were working t o c r e a t e a e o c i e t y of competit ive ind iv idua le i n e t i l l e d with the v i r t u e e of e o b r i e t y and indue t r y ( T y r e l l 1979 : 125).

A s J eeee Goodrich, a bueineeeman from Worceeter, Maeeachueette, expla ined , he and o t h e r temperance advoca t e e eough t the triumph of : "Co l d Wa t e r ,--Cap1 tal ,--En t e r p r i s e ,--1ndus ay,--Morale, --and R e l i - gion." ( T y r e l l 1979 : 130).

The transforma t i o n of ternperance f rom a f undamen tal1 y modera- t i o n i e t e f f o r t t o a n abe t inence campaign i n t he mid-U20s marke the

b e g i m i n g of temperance a e a maee movement. The Rev. Jue t i n Edwards, one of t he moet important l e a d e r s of t he temperance reform i n the 18208 and 308, launched the abs t inence campaign vi th a widel y c i r c u l a t e d pamphle t c a l l e d "The Well-Conducted Farm." One pro-temperance h i e t o r i a n l a t e r gave Edwarde c red i t f o r " t he chief impetue i n e t a r t i n g the temperance reform upon a new epoch" ( Fehland t 19 04 : 48 ) .

"The Well Conducted Farm" wae a well-wri t ten pamphlet t h a t repea ted and e l a b o r a t e d argumente t h a t Rueh had f i r e t made, and that had a l e o been a t t he h e a r t of the e a r l y modera t ion ie t campaign. Now, however, the premise wae t h a t complete abe t inence from e p i r i t e would br ing remarkable r e s u l t e f o r t h e employere of labor . The pamphle t r epo r t ed the experience of "Mr. B., a reepec tab le farmer i n Maeeachuse t te" whose workere, l i k e v i r t u a l l y a l1 o ther working men a t the time, drank "a po r t ion of a r d e n t e p i r i t " when they worked. " It wae the comon opin ion i n t h e p lace , t h a t , f o r labor ing men, who had t o work hard, eome a r d e n t e p i r i t wae necessary." Mr. B., however, decided t h a t h i s workere ehould t r y abe t inence , and i f they wouldn't g i v e up e p i r i t s they couldn ' t work f o r him. The r e e u l t of t h e experiment wae r epor t ed a s followe:

Hie men went t o work. And h i e bueineee proepered exceedingly. Hie men were remarkably uniform i n temper and deportment; e t i l l and peaceable. H e found them everyday a l i k e , and he could always e a f e l y t rue t them. What he expected t o have done, he f ound was done i n good eeaeon, and i n t he b e e t manner. tUe men never made eo few mistakee, and had eo f e w diepu t e s among themeelves; they never i n jured and destroyed eo few too le , found s o l i t t l e f a u l t wi th t h e i r manner of l i v i n g , o r were, on t h e whole, s o p l easan t t o one another , and t o t h e i r employer. The men appeared, more than eve r before , l i k e bre thren of the eame family, e a t i e f i e d wi th t h e i r busineee, contented, and happy.

"The Well Conducted Farm" deecribed the proceee t h a t w e e a r l i e r discueeed of t he d i e c i p l i n i n g of a t r a d i t i o n a l o r pre-modern l abo r fo rce . Thie farmer wae concerned wi th breaking t r a d i t i o n a l work hab i t e and p a t t e r n s , and with c r e a t i n g a new e t h i c of i n d u s t r y and t h r i f t. Thie wae a bueineeeman concerned wi th the maintenance of h i e c a p i t a l , and wi th developing t h e g r e a t e s t p roduc t iv i ty and e f f i c i e n c y from h i e workere.

Ae i n t he case of the e a r l y B r i t i s h i n d u s t r i a l l e t e , e a r l y temperance reform was a l e o a n a t t a c k on the s o c i a l forme, pa t t e rne and cuetoms of t h e t r a d i t i o n a l cu l tu re . The a i m of temperance advocatee wae change; they eought t o transform the work and s o c i a l hab i t e , a t t i t u d e e and l i f e e t y l e of the l a b o r i q c laes . I n

p a r t i c u l a r , t hey sought t o change the l i f e s t y l e of workers t o make them more ef f i c i e n t , product ive, and order ly . The e f f o r t he re was a l s o t o reform " the t o t a l man" f o r t he good of the employer. The key d i f f e r e n c e 1s t h a t i n t h i s case the t ransformation was t o be e f f e c t e d by d i r e c t l y confront ing the t r a d i t i o n a l dr inking h a b i t s of workers. "Sobriety" i n the narrowest senee of t he term was seen as the key t o reforming the whole out look and l i f e s t y l e of t he worker.

The argumen t tha t employers had a prof ound s e l f - i n t e r e s t i n changing the dr inking h a b i t s of t h e i r workers, o r i n reducing o r e l imina t ing t h e i r d r inking , remained a t the h e a r t of the temperance and p r o h i b i t i o n campaigns i n t he n ine t een th and twent ie th centu- r i e e . And i t i s now a l s o important i n the alcoholism movement and i n p u b l i c h e a l t h appea l s regarding a l coho l problems. Businesees and indus t r i e s of a l1 kinde, i t has been s a i d r epea t ed ly e ince the e a r l y n ine teenth cen tury, w i l l benef i t g r e a t l y by c o n u o l l i n g o r e l imina t- i n g the dr inking of t h e i r workers. Ef f ic iency , product iv i ty , and g r e a t e r p r o f i t s w i l l be t h e r e s u l t .

Indus U i a l i z a t i o n and Drink: Observations and Condus ions

Thue f a r 1 have discuseed two d i s t i n c t employer-sponeored dr ink- re la ted e f f o r ts t o traneform t r a d i t i o n a l c u l t u r a l p r a c t i c e s aimed a t secur ing a more s t a b l e and o r d e r l y work force . The f i r s t was concerned wi th dr inking o n l y as p a r t of t he broader mat te r of t r a d i t i o n a l work p a t t e r n s and s o c i a l l i f e . The second s a w d r i n k reform a s the primary l e v e r f o r c h a n g i q o t h e r h a b i t s and pa t t e rns . These two d i f f e r e n t approachee a r e r e a l l y two s i d e s of the eame e f f o r t , and they have been c l o s e l y r e l a t e d f o r over two hundred years. On t he one hand, employer campaigns aimed a t making workers more d i s c i p l i n e d and o r d e r l y have o f t e n sought t o change some a s p e c t s of worker dr inking. And, on the o t h e r hand, most a t tempts focused p r imar i ly on changing worker dr inking pa t t e r n s , whether by temperance and p roh ib i t i o n movements, o r a l coholiem and pub l i c hea l th p ro fe s s iona l s , have e i t h e r been motivated by, o r j u s t i f i e d i n p a r t i n terme of t h e i r bene f i c i a1 e f f e c t s f o r employers.

1 have emphasized the l a r g e r c u l t u r a l and economic s t r u g g l e s between e a r l y e n t r e p r e n u r i a l and i n d u s t r i a l c a p i t a l i s t s and t h e i r u a d i t i o n - o r i e n t e d workers because 1 am sugges t ing t h a t i t wae those c o n f l i c t s which were c e n t r a l t o the conf l i c t s about a lcohol . Alcohol ic dr ink was seen by employers as a symbol and a n element of t h e t r a d i t i o n a l c u l t u r e , and as a way of marking o u t the d i f f e r ences between the l i f e - s t y l e they d e s i r e d of t h e i r workers and the ones

whi ch the workers' had t r a d i t i o n a l l y valued. Alcohol ic d r ink was a site of dass c o n f l i c t between employers and workers about broad i s s u e s of c u l t u re and l i f e - s ty1e.l

However , a n impor t a n t que8 t i o n remains : vas worker dr inking by i t s e l f a n o b s t a c l e o r hindrance t o i n d u s t r i a l development? Or, more gene ra l ly : independent of t h e c u l t u r a l i s s u e s a t tached t o i t, does worker dr inking -- i n d u d i n g high leve18 of i t -- r e t a r d o r block indus t r ia l and e conomi c developmen t ?

Based on the broad h i s t o r i c a l record , the answer appears t o be "no." I n B r i t a i n per c a p i t a a l coho l consumption increased over t he course of the n ine t een th century dipping and r i s i n g somewhat wi th the economy (Shadwell, 1903). S imi l a r ly , i n t he United S t a t e s , d e s p i t e the claims of temperance advocatee i n the n ine teenth century o r p r o h i b i t i o n i e t s i n t he twent ie th century, worker dr inking on o r of f the job was no t incompatable w i th r a p i d i n d u s t r i a l development. Per c a p i t a dr inkiag d i d d e a e a s e i n t h e n ine teenth century, b u t much of that was among the broad middle c l a s s of smal l businessmen, f armers, prof e s s i o n a l s , and t h e i r wives, mo the r s , 81s t e r 8 and daughters. Despi te i t e bes t e f f o r t s , the n ine t een th century temperance campaign ( a genuine mass movement throughout t he n ine t een th century) was unable t o g e t most workers t o g i v e up dr ink , o r even t o g e t d r ink o u t of t he f a c t o r y and workshops.

J u e t a s workers r e s i s t e d with varying degrees of success employer e f f o r t s t o reform t h e i r cha rac t e r s , r e s t r u c t u r e t h e i r s o c i a l l i f e , and reorganize t h e i r work l i f e , they a l s o r e s i s t e d e f f o r t s a t g e t t i n g them t o change t h e i r d r inking hab i t s . Alcohol had long been p a r t of the ceremonies, r i t u a l s , and events which ce l eb ra t ed and a f f i rmed community and fe l lowship , and workers fought t o preserve those dr ink- re la ted events . They d i d n o t always succeed, however, and the ongoing s t o r y of work and dr ink has been the s t o r y of a cyc le of o l d p a t t e r n s being defended, some of which were l o s t , and new p a t t e r n s being c rea t ed , some of which were opposed, some of which were a l s o l o s t , some of which were defended, and s o on.

Fu r the r , as t h e experience of o t h e r European count r ies ehows, indus a l a l developmen t and the a t temp t by employers t o t ransf orm t r a d i t i o n a l work pa t t e r n s does no t n e c e s s a r i l y involve any chal lenge t o dr inking a t a l l . France, I t a l y and Germany, f o r example, changed f r o n a g r i c u l t u r a l t o i n d u s t r i a l s o c i e t i e s w i thout experiencing sube t a n t i a l temperance, prohib i t i o n , o r ant i -alcoholism movements. A l though i ndus t r i a l emplo yers i n a l 1 these coun t r i e s t a rge ted some a s p e c t s of p re - indus t r i a l work and s o c i a l l i f e , they d i d n o t i n gene ra l s e e d r i n k as a primary, o r even secondary, i s sue . Wine and beer dr inking were s o f i r m l y rooted i n the n a t i o n a l c u l t u r e s t h a t d r i n k was v i r t u a l l y invulnerable t o a t tack. I t 1s worth not ing t h a t France, Germany, and I t a l y have per c a p i t a consumption l e v e l s ,

s u b s t a n t i a l l y above those of B r i t a i n o r t h e United S t a t e s . High a l c o h o l consumption d i d no t prevent those n a t i o n s f rom developing s k i l l e d , p roduct ive work f o r c e s o r h igh l e v e l s of i n d u s t r i a l development (Cherring ton 19 24-30).

Fu r the r , when w e l ook beyond t h e e a r l y n ine t een th cen t ry , i t 1s c l e a r t h a t the a s s e r t i o n of temperance suppor t e r s t h a t worker dr ink ing was a n o b s t a c l e t o economic development was n o t co r r ec t . By 1900 the Uni t ed S t a t e s had become the r i c h e s t and mos t developed i n d u s t r i a l n a t i o n i n t h e world, and i t d i d s o d e s p i t e the f a c t t h a t the working c l a s e drank more than i n d u s t r i a l c ap i talis ts and middle class reformers might have wished. The United S t a t e s cont inued t o grow and prosper from 1900 t o 1920, ano the r pe r iod i n which worker dr ink ing cont inued, and i n which t h e number o f urban sa loons i nc reased e ign i f i c a n t l y . During the pe r iod of na t i o n a l p roh ib i t i on i n America, from 1919 t o 1934, working c l a s s dr ink ing reduced s i g n i f i c a n t l y because l i q u o r was expensive and harder t o g e t . The e a r l y p a r t of t h a t pe r iod v a s a t i m e of cont inuing p rospe r i t y ; t h e l a t ter encompassed the mos t devas t a t i n g depreseion i n American h i s tory. Be tween 19 35 and 197 0 t he American economy and i n d u s t r i a l ou tpu t expanded, and World War 11 saw the United S t a t e s become the mos t powerf u1 n a t i o n i n t h e world. During the whole per iod U.S. per cap i ta consump t i o n gradua l1 y increased .

One reasonable conclusion t o be drawn from the broad European and North American exper ience i s t h a t high l e v e l s of worker dr ink ing -- i nc lud ing r o u t i n e bouts of i n t o x i c a t i o n and ch ron ic heavy dr ink ing -- have n o t been incompatable wi th a s k i l l e d , e f f i c l e n t , and product ive work f o r c e , o r wi th r a p i d economic development. Employers i n some western coun t r i ee have t r i e d t o change t h e i r workers ' d r ink ing p a t t e r n s ( e i t h e r d i r e c t l y , o r through temperance r e£ ormer S, p roh ib i t i o n i s t e , a lcohol i sm advoca tes , o r p u b l i c h e a l th pro£ e s s i o n a l s ) . Workers i n t he Un1 ted S tates and o t he r coun t r i e s have resis t e d w i th vary ing degrees of success employer e f f o r ts t o res t r i c t o r e l i m i n a t e t h e i r d r ink ing . However, worker r e s i s t a n c e , even when e x tremel y successf u1 , does no t appear t o have s e r i o u s l y h indered the processes of i n d u s t r i a l and economic development of these na t i ons .

Employer a t temp t e t o r e £ orm worker dr ink ing pa t t e r n s a r e n e i t h e r i n e v i t a b l y a p a r t of i n d u s t r i a l development, nor do they appear t o be necessary o r even b e n e f i c i a 1 f o r economic growth and developmen t. Uhile emplo yer a t temp t e t o l i m i t worker dr ink lng have sometimes been j u s t i f i e d on moral grounds and a s p u b l i c h e a l t h concerns, by and l a r g e t hey have been d i r e c t e d a t secur ing a more d i s c l p l i n e d and o r d e r l y work f orce.2

Economi c Developmen t and Drink : Observa t i o n s and Conclusions

On t h e b a s i s of t h e h i s t o r i c a l exper ience of the United S t a t e s , B r i t a i n , and o t h e r European coun t r i e s , a l coho l consumption does n o t appear t o have i n h i b i t e d i n d u s t r i a l development. Obviously, more contemporary and q u a n t i t a t i v e data, e s p e c i a l l y using a cross- n a t i o n a l sample, would be usef u1 i n t e s t i ng t h i s hypothesis . Although data h a s never been c o l l e c t e d on t h i s t o p i c d i r e c t l y , 1 have found some r e l a t i v e l y r e l i a b l e and comparable da t a t h a t can be analyzed i n terms of t h i s quest ion.

The World Bank-sponsored s t u d y Twenty-Five Years of Economic Developmen t: 1350-197 5 , by David Morawe t z , compiled sta tisti c s on economic growth f o r moet coun t r i e s i n t h e world. The 8 tudy examined the problems involvd i n measuring economic development and conduded t h a t growth r a t e s , as measured by i n a e a s e s i n GNP per cap i t a , a r e r e l a t i v e l y r e l i a b l e i n d i c a t o r s of the changes w i t h i n a coun t ry.

Probably t h e b e s t c ross -na t ioaa l d a t a on a l coho l consumption has been compiled by Mark Kel le r and Caro1 Guro i l i , and publ ished by the Rutgers Center of Alcohol Studies . Ke l l e r was f o r many years the eLtor of the Jou rna l of S tud ie s on Alcohol, a n d their ~ u b l i c a t ion. S t a tis tics on Consum~tion of Alcohol and Al coholism. l i s t e per capi ta dr inking age consump t i o n s ta t i 8 t ics according t o beverage type f o r 27 coun t r i e s , and the percentage i n c r e a s e o r decrease f o r 21 coun t r i e s from the la te 1950s (average year 1958) t o t he e a r l y U706 (average year 1973).

Table 1 l is ts the 21 coun t r i e s wi th the per c a p i t a dr inking a g e consumption i n l i t r e s of pure a l coho l i n t he e a r l y 1970s. Table 1 a l s o i d e n t i f i e s the beverage which 1s respons ib le f o r more than 50 pe rcen t of t h e a l coho l consumed; i f no one beverage accounts f o r more than h a l f of the a l coho l , the second beverage 1s ind ica t ed i n brackets . F i n a l l y , the t a b l e lists the World Bank's growth r a t e f i g u r e s f o r the years 196 0-197 5.

Table 2 ca t egor i zes t he sample coun t r i e s by high, medium, and low coneumption l e v e l s , and high, medium, and low growth r a t e s . The h ighes t consump t i o n coun t r i e s averaged 14.9 li t r e s a year, t h e medium 10.0, and the lowes t 6 .l. u i l y 19 coun t r i e s were included i n the c a l c u l a t i o n s because growth r a t e f i g u r e s were n o t a v a i l a b l e f o r Poland o r the Sovie t Union. Based on the r e c e n t news about Poland's economic d i f f i c u l t i e s , i t seems reasonable t o assume t h a t i t s growth r a t e has been q u i t e low. Poland 1s l i s t e d on the c h a r t i n bracke ts , b u t was n o t c a l c u l a t e d i n t o the c o r r e l a t i o n statistics. The t a b l e shows no r e l a t i o n s h i p between consumption and growth r a t e . Same coun t r i e s have high consumption and high growth, o t h e r s have low consumption and low growth, and there are many i n between.

TABLE 1

Per Capi ta Consumption of Alcohol, a s Well as Predominant Beverage, Growth Ra t e , and Percentage Change i n Aicohol Consumption

f o r 21 Countr ies

Per Capi ta Age 15+ Per centage Change Consump t i o n i n i n Alcohol Litres of Pure Consumption From

Alcohol i n E a r l y Growth Ra t e La t e 1950s t o e a r l y Coun t r i e s 1 9 7 O s 196 0-197 5 197 O s

1. France 2. Wes t Gennany 3. Belgium 4. Swi t ze r l and 5. I t a l y Ó . Aus t r a l i a 7 . New Zealand d . Denmark 9 . Canada

10. N e ther lands 11. USA 12. United Kingdom 13. S o v i e t Union 14. I r e l a n d 15. Poland 16. Finland 1 7 . Peru U . Sweden 19. Norway 20. I ce l and 21. I s r a e l

U, d and S i n d i c a t e t h a t Wine, Beer o r S p i r i t e c o n s t i t u t e more than - - 50% of the a l coho l consumed. I f no one beverage accounts f o r more than ha l f the a l coho l , then the second beverage i s l i s t e d i n paren theses .

Average years f o r computing a l coho l consump t i o n inc rease a r e 1958-191 3. Average year f o r per cap i t a f i g u r e s i s 1 9 7 3.

SOURCES: Mark Ke l l e r and Caro1 G u r i o l i (1376) S t a t i s t i c s on Con- sumption of Alcohol and on Alcoholism, Jou rna l of S tudies on Alcohol, New Brunswidr, New Je r sey ; David Morawetz (1977) Twenty- Five Years of Economic Developmen t: 1950-197 5 Bal timore : John Hopkins Universi t y Press .

TABLE 2

Count r ies Categor ized by Growth Rate and Per Capi ta Consump t i o n i n Li tres of Pure Alcohol

Growth Rate 1960-7 5 Per Capi ta High Growth Medium Growth Low Growth Co nsump t i o n Mean 3.9 4 Mean 3.17 Mean 2.28

H i gh France W Aus t r a l i a B Swi t ze r l and W(B) Consump t i o n I t a l y W West Germany B New Zealand B Mean 14.9 Belgium B

Me dium Consump t i o n Mean 10.0

Canada B USA B(S) Denmark B Uni ted Kingdom B Nether lands B(S) I r e l a n d B

Low I s r a e l S Sweden S Ice land S Consump t i o n Norway B(S) Peru S Mean 6 .1 F in land S [Poland S]

W , B and S i n d i c a t e t h a t Wine, Beer o r S p i r i ts cons t i t u t e more than 50~-o f th; a l coho l consumed. I f no one beverage accounts f o r more than h a i f the a l c o h o l , then the second beverage i s l i s t e d i n parentheses .

SOURCE: See TABLE 1.

Table 3 shows the mean growth rete of t h e high, medium and low consump t i o n coun tries. Growth rate does n o t c o r r e l a te d i r e c t l y w i th consump t ion. The medium coneump t i o n c o u n t r i e s have the lowes t growth r a t e , the highes t consumption have t h e medium growth rate, and the low consumption have t h e h i g h e s t growth r a t e . The d i f - f -erences are a l 1 v e r y s l i g h t , and show no 8 tatistical s ign i f i cance .

Table 4 r e v e r s e s the a n a l y s i s of Table 3. It shows the consumption l e v e l s of the high, medium, and low growth rate count r ies . I n this case the re i s a s l i g h t p o s i t i v e r e l a t i o n s h i p : the h igh growth c o u n t r i e s averaged 11.1 li t res of pure a l coho l per c a p i t a , t h e medium 10.8, and t h e low 9.9. The h igher t he growth r a t e the h ighe r the pe r c a p i t a consumption l e v e l s , though the d i f f e r e n c e s a r e n o t persuas ive .

TABLE 3

Mean Growth Rate by Per Capi t a Consump t i o n i n L i tres of Pure Alcohol

Per Capi t a Consumption Growth Rate

gh 3 .O9

Medium 2 -9 8

Low 3.35

SOURCE: See TABLE 1.

TABLE 4

Mean Per Capi ta Consumption i n L i t r e s of Pure Alcohol By Growth Rate

Per Capi ta Consumption Growth Ra t e

High 11.1

Me dium 10 .8

SOURCE: See TABLE 1

Table 5 ca t egor i zes t he coun t r i e s by high, medium, and low inc rease i n a l coho l consumption from the l a t e 1960s t o t he e a r l y 1370s (average pe r iod 13%-1373), and the high, medium, and low growth r a t e from 1960-1975. The average h igh i n c r e a s e i n consump- t i o n w a s 38 percent , the medium inc rease 5 2 percent , and the low 1 4 percent . I f a dramatic i n c r e a s e i n consumption a f f e c t e d economic growth i t ehould be r e f l e c t e d i n t h i e t ab l e . The t a b l e shows t h a t consump t i o n i n c r e a s e s do no t adve r se ly a f f e c t the growth r a t e a

TABLE 5

Countr ies Categorized by Pe rcen t Inc rease i n Alcohol Consumption and Growth Ra te

Growth Rate Inc rease i n

A l cohol High Growth Nedium Growth Low Growth Consump t i o n Mean 3.35 Mean 3.U Mean 2.28

l3h Finland S Denmark B I ce l and S Mean 98% Belgium B I r e l a n d B

West Germany B

Me dium Norway S Aus t r a l l a B United Kingdom B Mean 52Z Canada B USA B(S)

Ne ther lands B(S) Sweden S (B)

Lo w I s r a e l S Mean 14% France W

I t a l y W

New Zealand B Peru S Svi tzer land W(B) (Poland S )

W , B and S i n d i c a t e t h a t Wine, Beer o r S p i r i t s c o n s t i t u t e more than - - 50 p e r c e n t o f the a l coho l consumed. I f no one beverage accounts f o r more than ha l f the a lcohol , then the eecond beverage i s l i s t e d i n paren theses.

SOURCE : See TABLE 1.

Table 6 shows the mean growth r a t e of t h e coun t r i e s with high, medium, and low inc reaees i n consumption. This t a b l e shows d e a r l y t h a t growth r e t e doee n o t nega t ive ly c o r r e l a t e wi th inc reae ing consump t ion . Indeed, the r eve r se i s true: grow th r a t e pos i t i v e l y c o r r e l a t e e with i n a e a s i ~ consumption t o a s l i g h t degree.

TABLE 6

Wan Growth Rate by Increase i n Per Capita Alcohol Consump t i o n

Increase i n Consump t i o n

tfigh

Medium

Growth Rate

3 a 0 2 Low

SOUKCE: See TABLE 1.

Table 7 r eve rees the a n a l y s i s o£ Table 6 . I t shows the mean i n c r e a s e i n consumption of the high, medium and low growth r a t e count r ies . There i s no c o r r e l a t i o n o£ inc reased consumption w i th growth r a t e . The coun t r i e s w i t h the medium growth r a t e had the h ighes t inc reases i n coneumption, those wi th the highes t growth had the medium inc reases , and those wi th the loweet growth r a t e had the lowes t i nc reases . The d i f f e r encee a r e a l1 n e g l i g i b l e and show no 8 t a t i s t i c a l s i g n i f icance.3

TABLE 7

Mean Inc rease i n Per Cayi ta Alcohol Consumption by Growth Ra t e

Growth Rate

High

Me dium

LOW

Increase i n Consump t i o n

SOURCE: See TABLE 1.

Other than the f i n d i n g t h a t growth r a t e doee n o t c o r r e l a t e wi th e i t h e r pe r c a p i t a coneumption o r i nc reaeee i n coneumption, perhape the o n l y o ther s i g n i f i c a n t rela t ionehip comee d i r e c t l y f r o a he tablesl of Ke l l e r and Gur io l i : t he h igh coneumption count r iee a r e predominantly wine and beer dr inking, and the lowes t coneumption coun t r i ee d r ink e p i r i te. However , a l 1 t h r e e ca t egor i ee conta in examples of v e r y h igh and low economic growth. S p i r i t-drinking I s r a e l and Norway have very low coneumption l e v e l e (3.25 and 5.58) and v e r y h igh growth r a t e s (4.4 and 3.6). Wine-drinking France and I t a l y have very high coneumption l e v e l e (22.44 and 13.56) and they a l e o have high growth r a t e s (3.9 and 3.7). The French i n t a k e i s the equ iva l en t of 44 l i t r e e of 100 proof l i q u o r , o r ha l f a l i t r e of wine, eve ry day of the year f o r every man, woman and c h i l d over 14 yeare of ape. By t h e e tandarde of many na t ione , t h a t would c o n e t i t u t e chronic heavy drinking. Yet, i n a d d i t i o n t o t h e i r high dr0Wt.h r a t e , the French a l s o have a eoph ie t i ca t ed technological and indue t r i a l appara tus .

S p i r i t-drinkirig F in land , whoee people a r e f amoue f o r t h e i r attachmen t t o e p i e o d i c i n t o x i c a t i o n , has a medium coneumption l e v e l , a n almoe t a s tronomi cal inc reaee i n a l coho l coneump t ion (157.7 pe rcen t ) , and the second h ighee t growth r a t e i n the eample (4.1 percent ) . Beer -d r ink iq Denmark hae a medium coneumption l e v e l , a n extremely high inc reaee i n conslumption (111.6 pe rcen t ) and a medium growth r a t e . The United Kingdom 1s bee r -d r ink iw , and the ün i t ed S t a t e s dr inke beer and s p i r i t e . Both had a medium inc reaee i n a l c o h o l coneump t ion , t he y have almoe t i d e n t i c a l coneump t i o n l e v e l s , and bo th have low growth r a t e s (2.7 and 2.2). Poland and Finland have very s i m i l a r per c a p i t a coneumption l eve l e ; F in land 'e coneump t i o n increaeed drama ti c a l l y , while Poland ' e increaeed r e l a t i v e l y l i t t l e . But Finland hae a high growth r a t e , and Poland hae been i n s e r i o u e economi c t rouble .

These f i g u r e s thue e i r o n g l y eugges t the re i e no r e l a t i o n e h i p between a l coho l coneumption and the economi c d i f f i c u l t i e e of the United S ta t ee , Poland, New Zealand, Peru, o r t he United Kingdom, o r the economic succeeees of France, I t a l y , Finland, I s r a e l , o r Norway. The determining f a c t o r 8 i n the economic l i f e of a na t ion , o r f o r t h a t mat te r a corpora t ion , a r e major f i s c a l and productive ma t t e r s euch a e i n t e r e e t r a t e e , c a p i t a l inveetment, wage and p r i c e l e v e l e , and eo on. Today, i n the United S t a t e e and Great B r i t a i n , 10% o r more of the l a b o r f o r c e i e o u t of work. I f a l 1 the unemployed heavy d r inke re i n e t a n t l y became sober , i t would n o t a f f e c t the unemployment r a t e e i n thoee count r iee . And i f a l 1 t he unproductive working chronic d r inke r s -- a t moet 1 percent of the work f o r c e -- became a b e t i n e n t , i t would n o t i nc rease economic developmen t o r the growth r a t e .

Thie i e by no means t o argue t h a t a l coho l coneumption i s n o t a l eg i t ima t e and impor t a n t p u b l i c hea l t h concern. C l e a r l y eome people d r i n k too much and, a e a r e s u l t , r u i n t h e i r l i v e r e , etomachs and

bra ins , o r i n j u r e o r k i l l themselves o r o t h e r s i n automobile wrecks. There a r e humanitar ian and e t h i c a l reasone t o be concerned w i t h a l c o h o l consumption. However, t h e broad h i s t o r i c a l and s o d o - l o g i c a l evidence s t rong ly euggee t e tha t , compared t o ma j o r economi c and p o l i t i c a l f a c t o r s , a l c o h o l consumption 1s n o t important i n de termining economi c growth and development .

Acknowledgements Research £ o r t h i e paper was i n p a r t suppor ted by a g r a n t from Dean Helen Cai rns , Off ice of Graduate S tud ie s and Research, Queens Col lege , C i t y Universi t y of New York. 1 would l i k e t o thank Steven M. Cohen f o r h i e he lp i n performing the s t a t i e t i c a l a n a l y s i s and f o r a l 1 h i s comments and suggest ions.

THE IMPACT OF ECONOMIC DEVELOPMENT ON DRINKING PATTERNS AND PROBLEMS: THE CASE OF TOURiSM

Jamee F. Moeher an d

Lenore D. Raleton

Recen t i n t e r n a t i o n a l s tud iee and reviews concerning a l c o h o l consumption and a l c o h o l problems i n modero s o d e t i e s have s t r e s s e d the need f o r more c a r e f u l examination of the impact of i nc reased consumption i n less developed coun t r i e s (LDCe) (e.g. WHO 1980; Moser 1380; Edwards 19 7 9 ) . Publ ica t i o n s by the World Heal th Organiza t i o n (WHO) have documented r a p i d i n c r e a e e s i n a l c o h o l problem i n d i c a t o r s i n LDCe and a rgue t h a t t he se i n c r e a s e s c r e a t e a s e r i o u s o b e t a c l e t o socioeconomic development and a seve re f i n a n c i a 1 burden on a v a i l a b l e h e a l t h s e r v i c e s (e.g. Moeer USO, Globe 1979).

WHO, i n a n e f f o r t t o document and b e t t e r understand thls phenomenon, h a s begun a s t u d y o£ the p u b l i c h e a l t h a s p e c t s of i n t e r n a t i o n a l product ion, marketing , and d i s t r i b u t i o n of a l c o h o l i c beverages. An impor tan t a s p e c t o£ such a s tudy concerns t he r e l a t i o n s h i p of the i n t e r n a t i o n a l t rade i n a l coho l t o the r a p i d development o£ the i n t e r n a t i o n a l touriem indus t ry . Tourism n o t o n l y provides a n impor tan t i n t e r n a t i o n a l a l coho l marke t b u t a l s o creates new a v a i l a b i l i t y S t r uc tu ree , which i n t u rn may a f f e c t d r ink ing pa t t e r n s and the r a tes o£ a lcohol - re la t ed problems w i t h i n LDC s o c i e t i e s . The Alcohol Research Group (ARG), i n cooperat ion w i th

the üHO s tudy , h a s t h e r e f o r e embarked on a r e sea rch program t o test and document t he impact of the i n t e r n a t i o n a l tourism indus t r y on a l c o h o l consumption, a v a i l a b i l i t y , and problems i n LDC h o s t coun trie s.

The tourism pro ject i s impor tan t t o t h i s workshop i n a t least th ree ways: a ) mas8 tourism, w i t h i t s heavy r e l i a n c e on a l coho l consumption, r e p r e s e n t e a m a j o r and r a p i d l y expanding indus t r y i n the lesser developed world today, and thus provides a case s t u d y f o r explor ing some impor tan t a l coho l / e conomic development i s s u e s ; b ) tourism i s r a p i d l y expandlng i n many r eg ions of L a t i n A m e r i c a , p a r t i c u l a r l y i n t he Caribbean, which ARG h a s chosen a s a s t u d y region; and c) our r e sea rch has uncovered c r u c i a l l e g a l componente t o t h e alcohol- tourism l i n k t h a t may provide impor tan t avenues f o r developing l e g a l ay proaches f o r f u t u r e prevent ion s tra t e g i e s .

Because of t he b r e v i t y of my t a l & today, 1 cannot f u l l y presea t the curren t s t a t u s of the tourism/alcohol pro ject. I n s tead 1 w i l l d i s c u s s t h e l i n k between mass tourism and a l c o h o l a v a i l - a b i l i t y , p a r t i c u l a r l y i n L a t i n America, and provide a b r i e f d e s c r i p t i o n of ou r r e sea rch design. 1 w i l l conclude wi th a b r i e f r e p o r t on one a s p e c t of the S tudy -- c u r r e n t U.S. t rade and t a x p rov i s ions r e l a t e d t o a l c o h o l and tourism i n Pue r to Rico and t h e U.S. Virg in I s l a n d s and t h e i r impact on a l c o h o l a v a i l a b i l i t y and problema i n t h e Caribbean region.

The Wnk Between Tourism and Alcohol A v a i l a b i l i t y

P r i o r t o t h e 1 3 7 0 ' ~ ~ l i t t l e a t t e n t i o n v a s g iven t o t h e socio- economic impact o£ i n t e r n a t i o n a l tourism on e i t h e r h o s t o r g u e s t c o u n t r i e s (Nash 1381; Graburn 1380; Mings 1978). Most p lanners and economists s imply assumed t h a t t he revenues brought by t o u r i s t s provided e conomic benef i t e t o hos t c o u n t r i e s t ha t f a r o u t s t r ipped any s o c i a l o r c u l t u r a l problema tha t migh t r e s u l t (cf . Zinder 1969 ; Clement 1361). During t h e l a t e 1360s and 13708, tourism expanded r a p i d l y , p a r t i c u l a r l y i n the l e e s developed world, where t he assumed e conomi c benef i ts were e a g e r l y sough t. T h i s r a p i d growth coun t i nues today and i s f u e l e d by t echn ica l and f i n a n c i a 1 a s s i s t a n c e from developed coun t r i e s , i n t e r n a t i o n a l a i d agenc ies , and indus t r y lobbying groups (World Tourism Organizat ion 1976 ). LDCs, i n a d d i t i o n t o a ccep t i ng t h i s a i d , have provided ma jo r economic concessions t o tourism mul t i n a t i o n a l s and have made massive c a p i t a l expendi t u r e s t o i n c r e a s e t h e i r r e s p e c t i v e s h a r e s of the marke t (deKadt lY79; Cleverdon 1979). The investments i nc lude such tourism-orien ted pro j e c t s as l a r g e a i r p o r t e , deepsea por ts, and new roads and sewage sys tema f o r mas t a l developments.

L a t i n America and t h e Caribbean have been a t t he f o r e f r o n t of these developments. Tourism has become a n e s s e n t i a l p a r t of n a t i o n a l economies i n t h e Caribbean, Mexico, and many p a r t s of

C e n t r a l and South America. Many n a t i o n a l governmente are involved i n l a r g e touriem developmente (euch a e Mexico'e development of Ix t apa and t h e i s l a n d of Cancun) and sponeor expensive t o u r i s t a d v e r t i s i n g campaigns i n the U.S., Canada, and p a r t s of Europe. I n t e r n a t i o n a l t o u r i e t a r r i v a l s i n La t i n America and the Caribbean have increaeed a t a tremendous r a t e i n the l a e t 15 yeare: from 3.1 m i l l i o n a r r i v a l s i n 1366 t o ó .5 m i l l i o n i n 1971 and 13.4 m i l l i o n i n 1979 (World Tourism Organizat ion 1976, Wt3 O). S t a t i s t i c 8 on excurs ion and c r u i e e s h i p passenger a r r i v a l e were n o t a v a i l a b l e u n t i l r e c e n t l y . When inc luded i n the 191 9 f i g u r e s , t h e t o t a l number of i n t e r n a t i o n a l a r r i v a l s i n La t i n America and the Caribbean jumpe t o 82.8 m i l l i o n , i n d i c a t i n g tha t t h i e componen t has become ex tremely impor t a n t , i f n o t dominant, i n t h e a r e a (World Touriem Organizat ion 1980).

The revenue genera ted by tourism has grown a t a s i m i l a r r a t e . La t i n America g r o s s t o u r i e t r e c e i p t s t o t a l e d $1.5 b i l l i o n i n 1964 and $1.1 b i l l i o n i n 1979, approximately 10 pe rcen t of t o t a l world tourism r e c e i p ts ( I U O T O 1965; World Tourism Organizat ion 1980). Mexico, the Bahamas, and Pue r to Rico have by f a r the l a r g e s t sha re s o f both t o u r i s t a r r i v a l s and t o u r i e t r e c e i p t s i n L a t i n America. According t o Cleverdon (1979), tourism r e c e i p t e r ep reeen t a l a r g e percentage of bo th t o t a l expor ts of goode and groee n a t i o n a l product i n s eve ra1 Caribbean and C e n t r a l American count r iee . South American coun t r i ee g e n e r a l l y have more d i v e r e i f i e d i n d u s t r i a l e e c t o r s , b u t tourism r e c e i p t s remain i n c r e a s i n g l y impor tan t i n n a t i o n a l economies t h e r e , a l s o .

W i th the expansion, however, have come eome s e r i o u s quee t i o n s concerni ng the assumed economi c benef i ts . Numerous case s tud i ee from many p a r t e of t he world document s o c i a l and c u l t u r a l d i s rup t i o n s whi ch accompany the development of mass tourism (e.g . deKadt 1979; Boiseevain 1979; Eeh and Roeeblume 1975; Finney and Wateon U 1 5) . Even the eupposed economic b e n e f i t e have been chal lenged. Bryden, i n h i e landmark e tudy Tourism and Development (1913). a rgues t h a t c u r r e n t forme of maee tourism a r e a c t u a l l y e c o n o i i c a l i y de t r imen ta l t o hos t coun t r i ee , even wi thout r e f erence t o i n t a n g i b l e f a c t o r 8 of s o c i a l and c u l t u r a l d i e rup t ion . B i s examination of i n t e r n a t i o n a l tourism and i t e impact on l o c a l indus t r i e S, employmen t oppor t u n i t y , and c a p i t a l inves tmen t choi e s providee a s t rong b a e i s f o r urging major reforma i n t he f u t u r e developmen t of tourism .

An a d d i t i o n a l se t of probleme concerns t h e con t ro l of tourism by i n t e r n a t i o n a l f i rme loca t e d o u t s i d e the LDCs. I n t e r n a t i o n a l ho te1 chains , t r a n s p o r t a t i o n indus tries, and tour-opera t i n g companies , whi ch are i n c r e a e i n g l y domina t i n g the indus tr y and whi ch a r e u s u a l l y l o c a ted i n ttie t o u r i s t-genera t i ng coun t r i e s , monopolize the promotion of t o u r s -- t h e i r des t i n a t i one , a c t i v i t i e e , and f a c i l i t i e s . According t o t h e World Touriem Organizat ion (1376 :82):

The trend towards the concentrat ion of power i n the d i s t r i b u t i o n of tourism se rv ices t o the consumers i n the major t o u r i s t generat ing countr ies i s f e l t by developing countr ies , on the one hand, t o g ive the l a r g e opera to r s the chance of inf luencing demand and, on the o the r , t o weaken the negot ia t ing power of the receiving (developing ) coun t r i e s . The tourism li te ra tu re , then, has begun t o examine cri t i c a l l y

the indus t r y 'S character and impact, mostly from an anthropological , p o l i t i c a l , o r economic framework. What i s s t i l l lacking, however, i s any sys temat ic s tudy of the pub l i c heal th impl ica t ions of tourism development. Severa1 authors a t l e a s t mention such t r a d i t i o n a l pub l i c heal th concerns a s water po l lu t ion , sewage treatment, and d i sease cont ro l (e.g., Smaoui 1979; Evans 1979; üiller 1976; Bryden 191 3), bu t even these va r i ab les a r e usua l ly ignored i n the calculus of tourism's c o s t s and benef i t s .

Even more in f requen t i n the tourism l i t e r a t u r e i s the mention of the impact of tourism on a lcohol a v a i l a b i l i t y , consumption, and problems i n h o s t countr ies . Some s t u d i e s have made cursory referentes t o a lcohol , but the desc r ip t ions a r e usua l ly set i n a more genera l f r amework of "1 i f e s t y l e changes" o r wha t Bryden (19 7 3) and o t h e r s t e r m the "demonstration e f f e c t " (e.8. Wilson 1979; Reyoso y Valle and deRegt 1979; Cleverdon 1379; MacCannel 1976; Manning 1 9 7 3). Tour i s t s from the developed world bring t h e i r own l i f e s t y l e with them, including many consumption i teme which, a t l e a s t from a LDC perspective , a r e l w u r y comodi ties. The demons t r a t i o n ef f e c t hypo thes izes tha t the importa t ion of these ameni t i e s crea t e s a demand f o r them among those i n the h o s t s o c l e t i e s . Tourism a l s o encourages the developoment of a cash economy (by of f e r ing wage l abor i n unski l led se rv ice jobs), therefore making the purchases of f oreign ameni ties a r e a l i s t i c p o s s i b i l i ty. Severa1 tourimu s tudies have provided l i m i t ed da ta t o suppor t t h i s demons t r a t i o n ef f e c t hypothesis (cf . Bryden 197 3 ) , b u t a lcohol importation, production and consumption va r i ab les continue t o be ignored (c f . Kemper 1979; Smith 1377).

Writers i n the a lcohol f i e l d provide some i n s i g h t i n t o the r e l a t i o n s h i p of tourism and a lcohol problems not found i n the tourism l i t e r a t u r e , but , because of a l imi ted focus, have n o t cri t i c a l l y examined the c r u c i a l economi c and heal t h va r i ab les involved. Nordic scho la r s have been i n the f o re f ron t i n t h i s a rea , examiniry the changes i n Nordic drinking p a t t e r n s which have a ccompanied increased Nordi c tourism t o southern, Medi terranean, wine-drinking coun tries. The y have sugges ted tha t tour i s ts have "brought home" the fo re ign drinking p a t t e r n s and added them t o e x i s t i n g home pa t t e rns (Makela 197 9 ) . The Nordic l i t e r a tu re a l s o inc ludes s tudies of the du ty-f r e e a lcohol t r ade t h a t accompanies i n t e r n a t i o n a l f e r r i e s i n nor thern European waters (e.g . Granqvis t

1981). Trave l by boa t between v a r i o u s European coun t r i e s t y p i c a l l y i nvo lves ex t ens ive dr ink ing and purchases of a l c o h o l i c beverages f o r home consump t i on . These a l c o h o l s t u d i e s have f ocused almos t e x c l u s i v e l y on the impact on "gues t" d r ink ing hab i ts. Leisure , t r a v e l , and r e c r e a t i o n a l a c t i v i ties, a s expanding a s p e c t s of everyday l i f e i n developed coun t r i e s , a r e becoming i n c r e a s i n g l y a s s o c i a t e d wi th a l c o h o l consumption, which may l e a d t o i n c r e a s e s i n a l coho l - r e l a t ed problems f o r those who p a r t i c i p a t e ( c f . Makela e t a l . 1982).

The l e i s u r e - o r i e n t e d r e sea rch i s augmented by some fragmentary s t u d i e s whi ch sugges t tha t a l c o h o l a v a i l a b i l i t y i n c r e a s e s i n t o u r i s t a r e a s and i s accompanied by i n c r e a s e s i n consumption (Watts and Rabow 19d0; Mosher 1979; Koskika l l io 1979; Cahannes 1979; Sulkunen 1378). Makela e t a l . (1981: IV-20) r e p o r t t h a t t h e expansion of t h e mass tourism indus t r y has had a n important impact on government p o l i c i e s regard ing a l c o h o l a v a i l a b i l i t y i n developed c o u n t r i e s during the pe r iod 1950 t o 197 5:

Mass tourism r e q u i r e s a c t i v e marketing, h igh ly developed organiza t i o n , ex t ens ive planning and a wide a r r a y of s e rv i ce s . The s t a t e h a s i n many coun tries taken a s trong r e s y o n s i b i l i t y i n car ry ing o u t t he se func t ions . A less r e s t r i c t i v e l i c e n s i n g p o l i c y has of t en been j u s t i f i e d on the b a s i s of b e n e f i t s t o t h e t o u r i s t t rade . . . . I n some cases the S t a t e has promoted the r e s t a u r a n t ond h o t e l i n d u s t r i e s n o t o n l y by l i b e r a l l i c e n s i n g b u t a l s o w i th o ther suppor t i ve measures and i n t h i s way a c t i v e l y con t r ibu t ed t o the i n c r e a s e i n the a v a i l a b i l i t y of a l c o h o l i c beverages.

Only l i m i t ed d a t a i s a v a i l a b l e t o de termine whose consumption -- l o c a l r e s i d e n t s , t o u r i s t s , o r both -- i n c r e a s e s i n these s i t u a - t i o n s , a l though a t l e a s t one s t u d y sugges ts t h a t l o c a l r e s i d e n t s are more of f e c t e d than t o u r i s ts (Koskika l l io 1979).

Tnere i s even l e s s r e sea rch concerning t h e impact of tourism on a l c o h o l a v a i l a b i l i t y and a l coho l problems i n LDC h o s t popula t ions , a l though a t l e a s t two r e sea rche r s have commented on t h e sub j e c t . Beaubrun (197 5 ) noted tha t c e r t a i n coun t r i e s vi t h h igh ly developed tourism i n d u s t r y and a poor ly d e l i n e a t e d na t i o n a l i d e n t i t y (such a s the U.S. V i rg in I s l a n d s and the Bahamas) a l s o have a high prevalence of a lcohol ism. He hypothesizes about a pos s ib l e "demons t r a t i o n e f f e c t " (p. 430): " the t o u r i s t (may) provide a r o l e model t o emulate -- someone who i s c o n s t a n t l y playing and dr ink ing and never seems t o work." More r e c e n t l y , Moser (1980), i n a WHO-sponsored i n t e r n a t i o n a l review of p o l i c i e s designed t o preven t a l coho l - r e l a t e d problems, s t a t e s (p. 14 ) : "The economi c importante o f tourism, and the recognized p a r t played by e a s y a v a i l a b i l i t y of a l c o h o l i n a t t r a c t i n g t o u r i s t s , has had a cons iderab le e f f e c t on

f o rmer ly res t r i c t i v e p o l i c i e s ( i n hos t count r ies ) . " A l though Moser's a s s e r t i o n does n o t appear t o be based on any d e t a i l e d r e sea rch f i n d i n g s , o r e c e n t r e p o r t from Mexico provides some suppor t f o r h e r t e n t a t i v e conclusion. Medina-Mora and Campillo-Serrano ( f o r thcoming ) repor t t h a t a s t a t u t e res t r i c t i n g t he number of a l c o h o l o u t l e ts i n Mexico spec i f i c a l l y exemp ts those o u t l e ts se rv ing t o u r i s t s . Th i s except ion has been broadly i n t e r p r e t e d t o subs t a n t i o l l y undermine the law 's i n t e n t .

Moser and Beaubrun thus sugges t t h a t t h e observa t ions found i n Makela e t a l . concerning t h e impact of tourism w i t h i n developed c o u n t r i e s may a l s o a p p l y t o LDC s o c i e t i e s . The i r obse rva t ions provide a n impor tan t s t a r t i n g p o i n t f o r more d e t a i l e d research . Beaubrun r a i s e s the p o s s i b i l i t y of p o t e n t i a l h e a l t h consequences t o h o s t s o c i e t i e s , and Moser d i s cus se s t h e po t e n t i a l economic and l e g a l consequences -- a l c o h o l becomes i n c r e a s i n g l y a v a i l a b l e and l e g a l restri c t i o n s a r e loosened, thus i nc reas ing the r i s k t o na t i v e popula t ions . Taken toge t h e r , the y sugges t the p o s s i b i l i t y tha t tourism development f u e l s i n c r e a s e s i n a l c o h o l a v a i l a b i l i t y and consumption, which i n t u r n l e a d s t o i n c r e a s e s i n t he incidente of a l c o h o l problems i n LDC h o s t coun t r i e s . I f s o , then the s t r u c t u r e of the tourism indus t r y i t s e l f becomes a p u b l i c h e a l t h concern and changes i n t h e r e l a t i o n s h i p of a l c o h o l t o t h a t i n d u s t r y may r e q u i r e s e r i o u s cons idera t ion . These i s s u e s provide t he s e t t i n g f o r the ARG p ro j e c t de sc r ibed below.

Tourism and Al cohol i n t h e Caribbean: The Impact of U.S. Tax P o l i c y

An a n a l y s i s of t h e alcohol- tourism l i n k based on survey, an th ropo log ica l , and p o l i c y d a t a i s now i n the planning s tage . Two s tudy sites -- t h e U.S. Vi rg in I s l a n d s and S t . Ki t ts-Nevis -- have been chosen, and more ex t ens ive geographica l coverage may be p o s s i b l e i n t h e f u t u r e . I n s t e a d of o u t l i n i n g the pre l iminary d a t a concerning ou r S tudy s i tes, whi ch are s ti11 i n the p repa ra to ry s t a t e , 1 w i l l i n s t e a d f ocus on a more developed l e g a l component of the s tudy.

U.S. t a x p o l i c i e s concerning the U.S. V i rg in I s l a n d s -- a U.S. t e r r i t o r y which i s a n impor tan t Caribbean t o u r i s t c en t e r -- i l l u s t r a tes the r o l e of governmental i n t e rven t ion i n c r e a t i n g and main ta in ing the a lcohol / tourism l i n k . Severa1 r e l a ted f i s c a l provi- s i o n s a s s u r e t h e dominante of the a l c o h o l t r a d e i n t h e t e r r i t o r y . F i r s t , the U. S. government re funds t o the t e r r i t o r i a l t r e a s u r y a l1 e x c i s e t axes c o l l e c t e d on island-produced rum expor ted t o t he mainland (I.R.S. 26 U.S.CA. Sec t ion 1562 (Supp. 1981)). Th i s tax expendi ture has o profound impact on the l o c a l rum i n d u s t r y ' s i n f luence i n l o c a l a f f a i r e . I n t he U.S. V i rg in I s l a n d s t he re i s o n l y one o p e r a t i o n a l rum d i s t i l l e r y , and t h i s i s a wholly-owned s u b s i d i a r y of Schenley, a l a r g e U.S.-based a l c o h o l i c beverage

producer. Th i s d i s t i l l e r y must import a l 1 of i t s raw m a t e r i a l s and i s of r e l a t i v e l y minor economic importance on t h e i s l a n d s i n terms of employment and c a p i t a l investment (U.S. Federa l Maritime Commission 1979). Y e t through i t s e x p o r t s t o t h e mainland i t provided $24.5 m i l l i o n t o t h e V i rg in I s l a n d s ' t r e a s u r y i n 1978 and $36.2 m i l l i o n i n 1980. o r 1 7 pe rcen t of n e t government revenues (U.S. Federa l Mari t i m e - ~ommlss ion 1979 ; car ibbean Business 1981e; U. S. Vi rg in I s l a n d s Annual Economic Review 1980).

The Vi rg in I s l a n d s government, t he re fo re , has a n obvious s t a k e , i n promoting t h e l o c a l rum indus t ry . I t imposes no e x p o r t o r e x c i s e taxes on l o c a l l y produced rum and h a s g iven the rum i n d u s t r y f a v o r a b l e tax concessions regard ing co rpo ra t e income, proper ty , and s a l e s t axes (cf . Oldman and Taylor 197 0 ; Danielson 197 4). I n o rde r t o a t t r a c t more a l coho l - r e l a t ed indus tries t o t ake advantage of t h e e x c i s e t a x r e b a t e , the government a l s o o f f e r s ex t remely a t t r a c t i v e t a x exemptions t o p rospec t ive i n d u s t r i e s , and, a s a r e s u l t , a t l e a s t one U.S. d i s t i l l e r ha s decided i n the las t th ree years t o l o c a t e a blending f a c t o r y on the I s l a n d s (Hedman 1979b). The government even o p e r a t e s a rum promotion o f f i c e , which 1s designed t o encourage rum consumption both l o c a l l y and n a t i o n a l l y i n t h e U. S., and the Vi rg in I s l a n d Commissioner of Commerce has l i s t e d rum promotion a s one of h i s major p r i o r i t i e s (U.S. V i rg in I s l a n d s Governor 's Report 1978; Hedman 197 9a) .

The U.S. and Vi rg in I s l a n d f i s c a l p o l i c i e s go beyond encouraging the l o c a l i ndus t ry . Nei ther government imposes any e x c i s e t ax on U.S.-produced a l coho l products purchased i n t he Vi rg in I s l ands . The Virg in I s l a n d s has a ó pe rcen t du ty on f o r e i g n brands, which i s a n ex t remely low r o t e , b u t the t a x has s t i l l been a t t a c k e d by the t o u r i s t s e c t o r a s de t r imen ta l t o bo th the government and i n d u s t r y (Hedman 1981a). These tax ing p o l i c i e s r e s u l t i n some of the cheopest a l c o h o l i c beverage p r i c e s i n t he world. U.S.-produced rum, f o r example, can be purchased f o r a s l i t t l e as $1.50 pe r f i f t h as compared t o $5.00 o r more on the mainland (Hedman 193lb) . The U. S. government f u r t h e r encourages t o u r i s t purchases on the Vi rg in I s l a n d s by pe rmi t t i ng v i s i t o r s t o r e t u r n t o t h e mainland w i t h one g a l l o n of tax-free rum, a quota f o u r times t h e permiss ib le amount a l lowed when r e tu rn ing f rom f o r e ign coun tries (Caribbean Business 19d la , 13dlb) .

Most of t he se f i s c a l p o l i c i e s a l s o a p p l y t o Puer to Rico, ano the r U.S . Caribbean terri t o r y heovi ly dependen t on rum product ion and tourism. Because Pue r to Rico has a much l a r g e r rum indus t ry , the e f f e c t s of t he t a x p o l i c i e s a r e correspondingly more impressive. The i n d u s t r y produced $200 m i l l i o n i n e x c i s e t ax r e t u r n s from the U.S. Treasury t o the Commonwealth government i n f i s c a l year 1 9 7 9 4 0 , and t h e t o t a l i s expected t o have increased s u b s t a n t i a l l y f o r the n e x t year (Blasor 1981). To i n s u r e the hea l t h of t h e i n d u s t r y , t he Puer to Rican government has g iven rum producers a n exemption f o r most of i ts l o c a l t a x l i a b i l i t i e s , inc lud ing most

sales, income, and p rope r ty taxes . The examption w i l l r u n u n t i l 1990 and reduced Bacard i ' s t a x b i l l by $10.5 m i l l i o n i n 1979 and $13.2 i n 1980 (Bacardi 1980; O t N e i l l 1981; Wynne 1974).

Pue r to Rico, i n of f i c i a l r ecogn i t i on of t h e importance of rug t o the economy, has made the p ina colada c o c k t a i l the o f f i c i a l i s l a n d d r ink , p a r t o f i t s o v e r a l l campaign t o encourage tourism (Caribbean Business 1 9 8 1 ~ ) . A spokesperson f o r Coco Lopez, the p ina colada producer, no t ed t h a t i t s product i s now v e r y popular a m o q l o c a l r e s i d e n t s , who had u n t i l r e c e n t l y n o t been i n t e r e s t e d i n t h i s t o u r i s t dr ink. The spokesyerson, i n a s ta tement o f f e r i n g some suppor t f o r the "demons t r a t i o n ef f ec t", a t t r i b u t e d t he new l o c a l popu la r i t y t o t h e company's heavy l o c a l adver t i s i q promo t i o n (Caribbean Business 1 9 8 1 ~ ) .

The U.S. government provides a n a d d i t i o n a l boos t t o the a l c o h o l market on both the V i ry in I s l a n d s and Puer to Rico w i th i t s t a x t rea tment of bus ines s convention expenses. P r i o r t o 1976, co rpo ra t e and i n d i v i d u a l expenses i n c u r r e d f o r sponsoring andlor a t t e n d i n g convent ions were deduc t ib l e r e g a r d l e s s of t h e convent ion ts l oca t ion . Conyress, as p a r t of t h e Tax Reform Act of 1976, p r o h i b i t e d such deduct ions f o r conventions h e l d overseas (U.S. Federa l Maritime Commission 1979). Pue r to Rico and the Vi rg in I s l a n d s , however, were s p e c i f i c a l l y exemp ted f r o n t h i s res t r i c t ion . A s a r e s u l t, the annual conven t ion- tourism bus iness on t h e Vi rg in I s l a n d s more than t r i p l e d between 1976 and 1979, t o 30,000 annual convention v i s i t o r s (U.S. Federa l Mari time Commission 1979 ).

Conven t i o n s a r e no ted f o r providing e x t ens ive dr ink ing occasions. Thus, i n add i t i o n t o a t t r a c t i n g more a l coho l consumers, i n c r e a s e s i n the number of conventions a l s o t r a n s l a t e s i n t o i n c r e a s e s i n the nuatber of d r ink ing s e t t i n g s on t h e i s l a n d s (Mosher 1981). A l though a ccu ra t e d a t a are no t a v a i l a b l e , severa1 i n d i c a t o r s sugges t tha t a l c o h o l 1s a ma j o r expense a t many i f no t mos t bus iness conventions. The bus ines s market i t s e l f i s ex t remely l a r g e i n t h e U.S., account ing f o r 12 pe rcen t of a l1 a l coho l s a l e s , o r $8 b i l l i o n 13 79 (Mosher f o r thcoming ). Business conventions c o n s t i t u t e a s u b s t a n t i a l s h a r e of t h a t market.

ñecent t r a d e concessions by the U.S. i l l u s t r a t e t he importance of these a l coho l - r e l a t ed f i s c a l p rovis ions t o t he development of t o u r i s t economies and the need f o r a region-wide, p u b l i e h e a l t h - o r i e n t e d a l c o h o l a v a i l a b i l i t y pol icy. I n 1979 t h e Car ter AdmLnis- t r a t i o n i n s t i t u t e d s i g n i f i c a n t r educ t ions i n U. S. e x d s e t axes on impor t e d a l cohol i c beverages (being phased i n over s eve ra1 years ) , i n p a r t t o encourage the rum i n d u s t r i e s i n t h e Caribbean r eg ion (Caribbean Business 197 9 ; DISCUS 1381). (Wes t e r n European coun tries nave a l s o provided s p e c i a l t r a d e concessions regard ing t h e rum i n d u s t r i e s of t h e i r former Caribbean i s l a n d co lonies . A s a r e s u l t , t he s t a t u s of t he rum t r ade has been t h e s u b j e c t of cons iderab le deba t e i n European Economic Communi t y nego t i a t i o n s (Wine and S p i r i t s

Magazine l g d l ) . ) Most r e c e n t l y , t h e Reagan Adminis t ra t ion, i n a n a t t e m p t t o r ev ive t h e Jamaican t o u r i s t economy, h a s g iven Jamaica the same s t a t u s a s t h e V i rg in I s l a n d s and Puer to Rico regard ing tax-deduct ible bus ines s convention expenses (Caribbean Business 19dld) . The Adminis t ra t ion has a l s o proposed a c c e l e r a t i n g the t a r i f f r educ t ions imposed by the Car ter government. These a l coho l - r e l a t e d concessions f o r o t h e r par ts of t he Caribbean have been h e a t e d l y opposed by the V i rg in I s l a n d and Puer to Rican governmen ts, whi ch consider t h e i r s p e c i a l t rea tment regard ing a l c o h o l a major advantage i n developing t h e i r r e s p e c t i v e t o u r i s t indus tries (Caribbean Business 1981d, 198 1 f ).

P o l i c i e s designed t o promote t h e a l c o h o l t r a d e a r e n o t a necessary p a r t of tourism development. Other economic a s p e c t s of t he tourism indus tr y could as e a s i l y be promoted through s p e c i a l t a x treatmen t. Alcohol could remain a s a r e l a t i v e l y high-priced luxu ry good and a source of t a x revenue, j u s t a s i t 1s t r e a t e d i n t he ma j o r i t y of gues t coun tries. Curren t tourism p o l i c i e s , i n add i ton t o pushing doun a l c o h o l p r i c e s , t end t o g r e a t l y i n f l a t e t h e c o s t of food, housing, and r e a l e s t a t e (cf. Bryden 1973). Reforme i n f i s c a l p o l i c i e s of gues t c o u n t r i e s could s i g n i f i c a n t l y a l t e r t h i s p i c t u r e .

Perhaps mos t s i g n i f i c a n t 1s the impact of t he U.S.-sponsored t r a d e concessions on t h e r eg ion a s a whole. With tourism a s one of the mos t impor t a n t focuses of development, t he U. S. Vi rg in I s l ands , a s w e l l a s o t h e r f r ee -po r t i s l a n d s , have made a l coho l a major, h i g h l y successf u l , t o u r i s t a t t r a c t i o n . A s o t h e r i s l a n d s s eek t o compete f o r the t o u r i s t d o l l a r , then, s i m i l a r concessions a r e l i k e l y t o appear necessary. I n Venezuela, f o r example, the government r e c e n t l y c r e a t e d a f r e e p o r t on t h e i s l a n d of Margari ty , o f f i t s c o a s t , i n par t t o compete wi th the nearby f r e e por t of Aruba. Moser (1980: 11-2) r epo r t a : "thousands of Venezuelans go the re d a i l y t o pur chase a l c o h o l i c beverages. Each t i m e t he v i s i t o r s a r e permi t ted t o take away 5 o r 6 l i t e r s of t he most widely consumed types, 89 l i te rs t o t a l . Much of t h i s i s r e s o l d on the maialand."

Nations which choose n o t t o compete f o r t h e t o u r i s t i n d u s t r y through the use i n inexpensive a l c o h o l products may f i n d t h e i r a l t e r n a t i v e p o l i c i e s s e r i o u s l y eroded. Not o n l y do they r i s k l o s i n g t o u r i s ts t o o t h e r coun tries, they a l s o may l o s e a lcohol - re la ted revenues . High i mpor t du ties may encourage a n e x tens ive boo t legging t rade , which w i l l i n t u rn cause a major l o s s of t a x revenues and a t h r e a t t o locally-produced beverages. Th i s phenomenon may w e l l be occu r r ing throughout t he r eg ion today, a l though t h e e x t e n t of the boo t legging t r a d e has n o t been adequate ly researched.

Conclusion

P o l i c i e s regard ing i n t e r n a t i o n a l t r a d e and tourism appear t o have a profound i n f l u e n c e on the e t r u c t u r e , l o c a t i o n , and s i z e of

a l c o h o l product ion and a v a i l a b i l i t y i n t h e Caribbean. Extensive and d e t a i l e d r e sea rch 1s necessary t o understand t h i s impact, a s w e l l a s the r e l a t i o n s h i p of tourism-inf luenced a l c o h o l a v a i l a b i l i t y t o dr ink ing pa t t e r n s and a l c o h o l problems. Exis t i n g da t a , however , sugges t t h a t a publ ic-heal th-or iented a l c o h o l p o l i c y i n the Caribbean must take a v e r y broad pe r spec t ive on t h e economic and p o l i t i c a l f a c t o r s whi ch i n f luence t he reg ion , par t í c u l a r l y those regard ing tourism development.

Acknowledgemen t: T h i s r e sea rch was par t l y suppor ted by t h e Na t i o n a l I n s t i t u t e on Alcohol Abuse and Alcoholism, Nat iona l Alcohol Research Center Grant (M-05595) t o t h e Alcohol Research Group, Berkeley, C a l i f o r n i a .

Chapter No tes and Referentes

Indus t r i a l i z a t i on . Economic Develo~ment. and Worker Dr ink im: H i s t o r i c a l and

1. It was Joseph Gus f i e ld i n Symbolic Crusade: S t a t u s P o l i t i c s and the A m e r i can Tem~erance Movement (Univers i t v of I l l i n o i s - - - - . ~

Pres s : 1963) who f i r s t argued t h a t c o n f l i c t s over a l c o h o l should be s i e n as symbolic s t r u g g l e s abou t c u l t u r e and l i f e - s ty l e . Al though my a n a l y s i s d i f f e r s from h i s on a number of p o i n t s , 1 am indeb ted t o Gusf ie ld f o r f i r s t po in t ing the way.

1 do n o t mean t o imply t h a t t h e r e 1s anything wrong wi th vo lun ta ry programe t o h e l p workers wi th dr ink ing problems. However, s u & programs a r e by no means adequate t o d e a l wi th the f u l l range of worker h e a l t h needs. A s t r o n g p u b l i c h e a l t h pe r spec t ive concerned w i th workers would push f o r q u a l i t y medical ca re , i nc lud ing mental h e a l t h coverage, and would be concerned t h a t work environments a r e f r e e from t o x i c and noxious m a t e r i a l 8 and t h a t workers ' wages a r e suf f i c i e n t t o f eed, house, and ca re f o r t h e i r f ami l i e s .

3. Because the c ross - tabular a n a l y s i s l o s e s in format ion by col- l a p s i q observa t i o n s i n t o ca t ego r i e s , 1 perf ormed a r eg re se ion

a n a l y s i s t o assess the v a l i d i t y of i n fe rences drawn from t h e tab les . The r e g r e s s i o n of e i t h e r a l coho l consumption ind i - c a t o r on growth showed l i t t l e i f a n y r e l a t i o n s h i p , a s d i d the r eg re s s ions of growth upon each a l coho l measure. I n two i n s t a n c e s the unstandardized coef f i c i e n t (B) were e x a c t l y zero , and i n the o t h e r two i n s t a n c e s they were s l i g h t l y posi- t i v e (*.O7 ), d i r e c t l y contravening the not ion t h a t growth and consumption a r e i n v e r s e l y r e l a t e d .

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Chap ter T h r e e

MANIFESTATIONS AND PERCEPTIONS OP ALCOHOL-RELATED PROBLEMS IN THE AMERICAS

Raul C a e tano

D I SCUSSANT

C a r l o s C a m p i l l o - S e r r a n o

MANIFESTATIONS AND PERCEPTIONS OF ALCOHOL-RELATED PROBLEMS I N LATIN AMERICA

Raul Caetano

Concern f o r t he pa tho log ica l e f f e c t s o f a l c o h o l i n g e s t i o n i n human h e a l t h have been p re sen t i n the s c i e n t i f i c l i t e r a t u r e of L a t i n American coun t r i e s s i n c e t h e l a te p a r t of t h e 19 t h century. But, as i n o t h e r p a r t e of the world, i t took more than 50 years f o r a l coho l r e sea rch t o become a n organized e f f o r t i n t he se count r ies . I t was o n l y during the 1950s t h a t the p u b l i c h e a l t h approach t o the s tudy of a l c o h o l problems, expressed a s a concern f o r epidemiological s t u d i e s of a l c o h o l problems and f o r o rganiz ing t h e i r t rea tment and yrevent ion , emerged i n La t i n America.

uie purpose of t h i s paper 1s t o review the epidemiological l i t e r a t u r e on a l c o h o l i n t he se coun t r i e s . Such a t a s k can o n l y be performed i n a s e l e c t i v e manner, t h a t is , by examining papers judged t o be r e p r e s e n t a t i v e of t h e development of research . Even then, t h e f i n a l product w i l l have a n e s s e n t i a l l y panoramic na tu re , and i t should n o t b e s een a s more than a bird 's-eye view of t he f i e l d . I n a d d i t i o n , t he re i s the f a c t t h a t t h i s paper a t t empt s t o cover r e sea rch which has been publ i shed i n more than 50 s c i e n t i f i c p u b l i c a t i o n s and which 1s s o s c a t t e r e d a s t o be almost impossible t o reassemble. Consequently, top ica which one o r another r eade r may deem a s importan t migh t be l e £ t un touched.

The p l an f o r t h i s review 1s a s fo l lows: I n t he f i rst s e c t i o n some demographic, s o c i a l , and g e n e r a l h e a l th i n d i c a t o r s f o r c o u n t r i e s i n La t i n America w i l l be reviewed i n a n a t t empt t o cha rac t e r i ze the h e a l t h and socioeconomi c s t a t u e of na t i o n s i n the region. These i n d i c a t o r s w i l l be con t r a s t ed wi th those f o r the U.S. and Canada. A second s e c t i o n reviews d a t a on a l coho l problems a s i n d i c a t e d by a l coho l - r e l a t ed mor ta l1 t y , ps y c h i a t r i c problems, t r a f f i c acc iden te , s u i c i d e s , and crime. I n the t h i r d s e c t i o n surveys of d r ink ing p a t t e r n s and alcohol ism i n s eve ra1 coun t r i e s a r e summarized. The f i n a l s e c t i o n d i s cus se s the La t in American conceptual approach t o a l c o h o l problems and i ts impact on e f f o r ts t o a l l e v i a t e such problems i n the region.

L a t i n America: Se l ec t ed Demographic, Soc i a l , and Health Rela ted I n d i c a t o r s

L a t i n America i s composed of some 26 coun t r i e s and o t h e r p o l i t i c a l u n i t s . A s such, i t i s a mosaic of c u l t u r e s w i th s i m i l a r i t i e s as w e l l as d i f f e r ences . Many of the na t ione i n the r eg ion s h a r e t he common h i s t o r y of having been former co lon ie s of Spain; B r a z i l , of course, i s a former colony of Por tuga l , while some of tlie i s l a n d and l i t t o r a l na t i one of t he Caribbean a r e former co lon ie s of England, Prance, and Holland. Another commonality among L a t i n American c o u n t r i e s i s t h e i r i n c l u s i o n among t h e developing na t ions . However, t h i s should n o t be taken a e implying uni formi ty o f economic development. There i s a wide gu l f between Mexico and Venezuela on one s i d e , bo t h pe troleum expor t i n g coun tries, and Bo l iv i a and H a i t i on t h e o ther , of ten c i ted a s t h e poores t na t i o n s i n the a r ea . Also, while economic, h e a l t h , and s o c i a l i n d i c a t o r s presen ted he re t r a n s l a te exper iences a t t h e na t i o n a l l e v e l , w i t h i n mos t of these na t i o n s d i £ f e r e n t r eg ions presen t qu i te di£ f e r e n t l e v e l s of economic and s o c i a l development. Thus, l i f e i n t he b ig ci t ies of the i n d u s t r i a l i z e d s o u t h e a s t of B r a z i l -- cities such as Rio de J a n e i r o o r Sao Paulo -- may be i n many a s p e c t s more s i m i l a r t o l i f e i n New York, Buenos Aires, o r Caracas than t o l i f e i n the r a i n f o r e s t of t he B r a z i l i a n Amazon o r i n t h e d r y quas i -dese r t r eg ion of the B r a z i l i a n no r theas t . These same d i f f e r e n c e s may be observed between t h e south and no r th o f Argent ina, o r between t h e c o a s t a l and Andean reg ione of Chi le and Peru.

Apart f rom t h e s e s u b r e g i o n a l d i £ f e r ences , and of c r u c i a l impor tance t o the s tudy of a l coho l consump t i o n and a lcohol - re la t ed problems, i s the f a c t t h a t w i th in many L a t i n American c o u n t r i e s there s t i l l i s a n impor tan t n a t i v e o r Ind i an c u l t u r e which has i n many i n s t a n c e s remained q u i t e d i s t i n c t from the European one. These Ind i an c u l t u r e s and the impor tance and c h a r a c t e r i s ti cs of t h e i r a l c o h o l consumption have been deecr ibed by a n th ropologis te. W i thout the i n t e n t of providing a review of t h i e l i t e r a t u r e , which h a s a l r e a d y been a p t l y examined by Heath (1974, 137 5) , these papera w i l l be c i t e d he re as a means of shedding l i g h t on, and a s gauges f o r making comparison wi th , ep idemiologica l f ind inge . Negrete (1976a) has underscored the importante of these c u l t u r e s and the e x t e n t t o which t r a d i t i o n a l f ermen ted beverages (pulque, chicha) a r e ueed by n a t i v e peoples i n c o u n t r i e s w i th numeroue indigenous popula t ions such a s Bol iv ia , Mexico, Guatemala, and Peru.

Table 1 presen t e eome i n d i c a t o r e wi th a bear ing on h e a l t h s t a t u s i n t he Americas. A l 1 of t h e i n d i c a t o r s i n t h e t a b l e show s i g n i f i c a n t v a r i a t i one among the di£ f e r e n t coun tries of La t i n America. The age-s tandardized dea th ra te shows dramatic v a r i a t i o n s , ranging from 1,900 deathe per 100,000 i n Bol iv ia t o 431.6 per 100,000 i n Cuba. The U.S. and Canada show r a t e s between 440 and 420 pe r 100,000, a t l e a s t one- th i rd sma l l e r than f o r t he m a j o r i t y of La t i n American na t ione . Inf a n t m o r t a l i t y r a t e e va ry from a high of

86 .O per 1 ,000 l i v e b i r t h s i n Guatemala t o a low o£ 20.8 per 1,000 l i v e b i r t h e i n Pue r to Rico. For the whole of South America the r a t e i s 49.4 per 1,000 l i v e b i r t h s , whi le f o r North America (U.S. and Canada) i t i e one- th i rd a s much, 15.8 p e r 1 ,000 l i v e b i r t h s . The g r o s s na t i o n a l p roduct shows more dramat ic v a r i a t i o n s than o t h e r i n d i c a t o r s . The d i £ f e r ences between Nor t h America (U.S. and Canada) and L a t i n America a r e ve ry marked. Both t h e U.S. and Canada have GNPs, which a r e 6 , o r 10 , o r i n the case of some of t he poo re s t c o u n t r i e s (Uai ti, Honduras, Guyana, Bo l iv i a ) , 20 times g r e a t e r than La t i n American n a t i o n s .

A l cohol-Rela ted Ind i ca to r s*

From 196 2 t o 1964 the Pan American Heal th Organiza t i o n (PAHO) (Pu f f e r and G r i f f i th 1967 ) conducted a s t u d y of p a t t e r n s of urban m o r t a l i t y i n 10 c i t ies of L a t i n America p l u s B r i s t o l i n England and San Franc isco i n t he U.S. I n each of t he c i t i e e 2,000 deathe were s e l e c t e d through a s y s tema t i c sampling procedure f rom a l 1 t he dea ths of persons aged 15 t o 1 4 years of age. The f a m i l i e s and phys ic ians o f t he deceased were in te rv iewed by l o c a l co l l abo ra t i ng r e s e a r c h e r s and the d a t a were s e n t t o a c e n t r a l o f f i c e where t he cause of death was diagnosed w i t h t h e u se of s tandardized procedures.

The i n v e s t i g a t i o n showed tha t a lcohol - re la t ed dea the ( c i r r h o s i s , a l coho l i c ps ychosie, and alcohol iem) comprised 4.9 percen t of a l 1 dea ths i n the s tudy. Table 2 shows a wide d i f f e r e n c e be tween males and f emales w i th r ega rd t o a l coho l - r e l a ted mor t a l i t y and a l s o ve ry s i g n i f i c a n t d i f f e r e n c e s among the va r ious cities i n t n e s tudy . The dea th r a t e f o r a l c o h o l i c psychosie and a lcohol i sm i s , f o r i n s tance, s i x time8 h igher i n Guatemala c i t y and two times higher i n Sant iago, Ch i l e , than i n San ~ r a n c i 8 c o . l B r i s t o l , England, ha s the lowes t r a t e s both f o r females and f o r males. Among men Sant iago and Mexico C i t y have h igher r a t e s than San Francieco, the r a t e i n Sant iago being twice as high. Among females , San Francieco has t he h ighes t r a t e e , f ollowed c l o e e l y by Sant iago. Mexico C i t y and La P l a t a , Argentina, a l s o have high r a t e s , bo t h i n t h e neighborhood of 30 dea ths per 100,000 populat ion.

* A l 1 of t he d a t a have t o be examined wi th care s i n c e they u s u a l l y r e f l e c t n o t o n l y d i f f e r e n c e s i n a l c o h o l use and a l coho l - r e l a t ed yroblems i n a p a r t i c u l a r s e t of coun t r i e s , b u t a l s o t he d i f f e r encee i n the e x t e n t and o rgan iza t ion o£ medical s e r v i c e e o r i n t he way i n which d i f f e r e n t l e g a l systems d e a l wi th euch problems.

TABLE 1

Heal th Rela te d Ind i ca t o r s i n Se l ec t ed Count r ies o£ t h e Americas*

Al3 e I n f a n t Crude Standardized Mor t a l i t y Hoepi tal

B i r t h R a t e D e a t h R a t e Rate Phys ic ians Beds Per 1,000 Per 100,000 Per 1,000 Per 10,000 Per 1,000 G.N.P.

Popula t i o n Popula t i o n Popula t i o n Popula t i o n Popula t i o n (197 7 )

Argent ina Ba hamas Barbado S

Bo l iv i a B r a z i l C h i l e Colombia Coeta Rica Cuba Domini can

Republ ic Ecuador E l Salvador Grenada Guatemala Guyana Hai ti Honduras

. Jamaica Mexi co N i caragua Panama Paraguay Per u Puer to Rico Surinam Tr in idad 6

To bago Uruguay Venezuela United S t a t e s Cana da

*The crude b i r t h r a t e , the age s t anda rd i zed death r a t e , the i n f a n t mor t a l i t y r a t e , t h e number of phys ic ians per 10,000 popula t ion and the number of hoe- p i t a 1 beds pe r 1,000 popula t ion were a l 1 abs t r a c t e d from PAHO (1978 ). The G.N.P. was taken from t h e World Bank (1980).

+The r a t e e were taken from World Bank (1980).

TABLE 2

Annual Age-Adjusted Death Rates f o r Alcohol ic Psychosis and Alcohol ic C i r r h o s i s per 100,000 Popula t ion age 15-74 years

i n 1 0 L a t i n American Cities, San Franc isco (U.S.A.) and B r i s t o l (England) , 196 2-196 4*

A l cohol i c Ps ychosis and Alcohol i c

A l coholiam C i r r h o s i s C i t y Male Female - Male Female -

Bogo t a 1 .a O -1 11.2 2.2

C a l i 4 .1 O 09 1.2 0.3

Caracas 3.0 0.5 13.1 0.7

Guatemala C i t y 52 .9 2 -9 26 .9 4 .6

La P l a t a 1.4 1.1 20.6 3 .O

Lima 6 .1 0 .5 8.0 0.7

Mexico C i t y 14.4 1 .ó 102.5 31.1

Ribe i rao Pre t o 7 .7 3 .a 13.1 1.8

Sant iago 21 .o 1.6 143.0 38.4

Sao Paulo 12.2 1.7 l7 .6 2 .O

San Franc isco , U.S. 8.4 5.1 71.3 43.4

Bris t o l , England 0.2 0 .O 1.2 0.3

To t a l Male Femaie -

"SOURCE: P u f f e r and G r i f f i t h (1967).

The s e x d i f f e r e n c e s f o r these r a t e e r e f l e c t , of couree, t h e w e l l known d i f f e r e n c e i n p a t t e r n e of a l c o h o l i n g e s t l o n between men and women. They occur n o t o n l y i n t he se L a t i n American c i t i e s b u t p r a c t i c a l l y a l1 over the world. Once t h e i n f l u e n c e of d i f f e r e n t methods of d a t a c o l l e c t i o n and au topsy procedures i s e e t aside, as i s l a r g e l y t rue i n t h i s s tudy , the d i f f e r e n c e i n r a t e e among cities can o n l y be expla ined by e o c i a l and c u l t u r a l f a c t o r s l i n k e d t o p a t t e r n s of a l c o h o l i nges t i on . Marconi and A d i s Cae t ro (1967) sugges t, however, t h a t San t i ago ' e h igh r a tes migh t be expla ined e i t h e r by a n i nc reased g e n e t i c d i s p o s i t l o n t o h e p a t i c pathology o r by b e t t e r d iagnos is of t he se a l coho l - r e l a t ed condi t ions .

ühen broken down by age , m o r t a l i t y d a t a f o r bo th alcohol iem and a l c o h o l i c psychosis fol lowed the same p a t t e r n i n a l 1 c i t i e s s tud i ed : t he re was a n i n c r e a s e up through age 54 and a d e c l i n e t h e r e a f t e r . The dea th r a t e f o r a l c o h o l i c c i r r h o s i e a l s o i nc reased w i th age , reaching a peak i n the age group 5 5 4 4 f o r both males and f emales. Thus, among malee, combined d a t a f o r a l 1 t he c i t i e e i n t h e s t u d y ehow t h a t the r a t e i n the age group 5 5 4 5 years l e more than a hunQed times g r e a t e r than t h a t i n t h e age group 15-25 years (approxima te1 y 100/100,000 ve r sus 0 .ó /100,000), and approxima t e l y 10 times g r e a t e r than f o r ages 25-35 yeare (approximately 100/100,000 ve r sus 10/100,000). These d i£ f e r ences r e e u l t bo t h from the chroni- c i t y o£ l i v e r c i r r h o s i s and from i t s development i n t h e middie-age year s.

Ano ther i n teres t i ng f inding o£ t h i s invee t i g a t i o n was t he e x t e n t t o which the number of c i r r h o s i s dea ths was a f f e c t e d by changes i n ass ignment of cause of death. Of t h e o r i g i n a l 1 ,231 dea ths diagnosed a s c i r r h o s i s wi thou t alcohol ism, 57 percen t (7 08 ) were changed t o c i r r h o e i s wi th alcohol ism. With these add i t i one and o t h e r s from o t h e r groupe, the number of dea ths due t o c i r r h o s i e wi th a lcohol i sm went from 700 t o 1,545, a p ropor t i ona l i n c r e a s e of 235 percent . C i r r h o s i s dea ths w i thout mention of a lcohol ism, whi ch numbered 1,231, decreaeed by 300 pe rcen t t o 391. A s a r e s u l t o£ these changes t he re were i n c r e a s e s i n t he number of dea ths due t o c i r r h o s i s w i t h a lcohol i sm i n every c i t y i n t he s tudy , wi th the f i n a l coun t being twice the i n i t i a 1 i n 9 c i t i e e .

When examining c i r r h o s i s mor t a l i t y d a t a f o r La t i n America, Pu f f e r and G r i f f i t h (1367), sugges ted t h a t 8 0 pe rcen t of al1 c i r r h o s i s dea ths were a l c o h o l r e l a t e d . Be cause of t h i e s i g n i f i c a n t a s s o c i a t i o n be tween heavy a l coho l coneump t i o n and c i r r h o s i s , m o r t a l i t y d a t a f o r t h i s pathology can be viewed a s a n i n d i c a t o r of a l c o h o l problems and i t 1s the re fo re worth examining i n a more e x t e n s i v e way. Table 3 shows such d a t a a s publ i shed i n 1978 f o r s e l e c t e d c o u n t r i e s of L a t i n America, Canada, and the U.S. The r a t e s va ry cons iderab ly from country t o country f o r both t he males and females. Men's r a t e s range from a h igh of 35/100,000 populat lon i n C h i l e o r Mexico t o a low of 4/100,000 i n Cuba o r Panama. Female r a t e s a r e lower than male f o r a l 1 coun t r i ee , w i t h t he except ion of

the Bahamas. S e t t i n g a s i d e t h i s l a t t e r country, the range of v a r i a t i o n o£ f emale rates i s emal le r than t h a t of malee: the highee t rate is 12.4/100,000 i n Ch i l e and t h e lowes t is 1.6/100,000 f o r Barbadoe. The f a c t t h a t two Caribbean coun t r i e s , Bahamae and Barbados, have such d i £ f e r e n t c i r r h o s i s dea th r a t e s should be no ted and f u r t h e r i nves t i g a t e d .

When compared t o r a t e e i n Canada and the U.S., 7 o£ t h e 22 coun t r i e s i n Table 3 have h igher r a t e e of male c i r r h o s i e . These c o u n t r i e s a r e : Argent ina, Bahamas, Ch i l e , Dominican Republic, Guatemala, Mexico, and Puer to Rico. Venezuela and E l Salvador have r a t e e s i m i l a r t o t h e U.S. and Canada. A s f o r female dea th r a t e e , bo th the U.S. and Canada have r a t e e h igher than Barbados, Colombia, Costa Rica, Cuba, Jamaica, Nicaragua, Panama, o r Surinam. Rates i n Ecuador, Hondurae, and Peru a r e s i m i l a r t o those i n Canada b u t lower than the U.S. r a t e . Argent ina has a female death r a t e f o r c i r r h o s i s s i m i l a r t o the U. S.

Admissions t o Mental Hoepi tals

Another common i n d i c a t o r of a l coho l - r e l a t ed problems 1s t h e propor t ion of persons trea ted f o r a lcohol i sm and a s s o c i a t e d diagnoses i n p s y c h i a u i c f a c i l i t i e s . As wi th o t h e r í n d i c e s , t h i e measure s u f f e r s from l i m i t a t i o n s s i n c e i t is in f luenced by the p a r t i c u l a r o rgan iza t ion o£ medical c a r e i n each country. Thus, i n the U.S. the propor t ion of admissions f o r a l coho l - r e l a t ed p s y c h i a u i c diagnoses v a r i e s according t o t he type o£ f a c i l i t y being considered. I n 137 5, a l coho l d i so rde re accounted f o r 27 pe rcen t of a l 1 admiesions t o county and s t a t e mental h o s p i t a l s , whi le t he propor t ion f o r p r iva te mental hoepi t a l e and communi t y mental hea l th c e n t e r s v a s (3 pe rcen t and 9.7 percent , r e s p e c t i v e l y ( P r e e i d e n t ' s Commiesion on Mental Heal t h , 1378). Another example of changes i n a l coho l - r e l a t ed admissione, i n t h i s case due t o s h i f t s i n adminie- t r a t i v e p o l i c i e s , i s i l l u s t r a t e d by what has happened i n C a l i f o r n i a i n tiie l a s t 30 yeare. I n 1950, admiseions wi th d iagnos is of a lco- holism t o s t a t e p s y c h i a t r i c h o s p i t a l s comprised 22 pe rcen t of a l 1 admissions. With t he a t t e m p t t o reduce t h e emphasis on i n p a t i e n t c a r e i n e t a te mental i n s ti tu t i o n s and the developmen t of ou tpa t i e n t communi t y mental h e a l th cen t e r e and alcohol ism t rea tment cen t e r s a s a l t e r n a t i v e types of f a c i l i t i e s , by 1970 the propor t ion of a lcohol i sm admissione t o s t a t e mental h o s p i t a l e i n C a l i f o r n i a had dropped t o 0.1 pe rcen t (Cameron 198 0).

TABLE 3

Age-Ad j u s t e d Dea t h Ra tes Per 100,000 Popula t i o n f o r C i r r h o s i s of L iver i n Se l ec t ed C o u n u i e s of t h e Americas*

Argent ina

Bahamas

Bar bados

Ch i l e

Colombia

Costa Rica

Cuba

Domini can Republi c

Ecuador

El Salvador

Guatemala

Honduras

Jamaica

t4ld co

N i caragua

Panama

Paraguay

Per u

Pue r to Rico

Surinam

Uruguay

Venezuela

Canada

United S t a t e s

Year - Tota l -

*SOUHCE: PAHO (1378).

Alcohol-Rela t e d Admieeione t o Mental Hospi t a l e i n Se l ec t ed Countr iee o£ t h e Americas

Argent ina 8.3% o£ admissione t o p e y c h i a t r i c F a c i l i t y i n Lanus

Costa Rica 32% o£ a l1 admiseions

Venezuela 3.5 t o 5.4 % o£ a l 1 admissione

B r a z i l

C h i l e

Peru

4.5% o£ a l 1 female f i r e t admissione 28% of a l 1 male f i r s t admissione i n 1974

-- 19% £ o r both s exes

35X of a l 1 admissions t o p e y c h i a t r i c hospi t a l e i n Sant iago

4% t o 13% o£ admissions t o p e y c h i a t r i c ee rv i cee i n the country

Colombia 15% of admíssione t o p s y c h i a t r i c s e rv i cee i n gene ra l h o s p i t a l 8

Pue r to Rico ló .6 % o£ admiseions t o a ps y c h i a t r i c h o s p i t a l - 1971

20% o£ a d u l t p a t i e n t e admi t ted t o psychia t r i c h o s p i t a l through the INASS

United S t a t e s 27% of a l 1 admiesions t o s t a t e and county mental h o s p i t a l s ;

¿ .3% o£ a l1 admissions t o p r í v a t e hoep i t a l e ;

9.1 % o£ a l 1 admissione t o communi t y mental h e a l t h cen te r e;

8 % o£ a l 1 admiesions t o a l 1 f a c i l i t i e e

Ld .6 X o£ a l 1 £ irs t admissione t o i npa t i e n t p s y c h i a t r i c i n e ti tu t i ons ;

15% of a l1 readmieeions t o i n p a t i e n t pe ychia t r i c i n s ti t u t i o n s

S luzki 196 6

Moralee and Chaeeoul (Moeer 1980)

O r done z (Moeer 1980)

Cae tan0 198 1

Mar coni 196 7 b

A l m e i da 196 9

Min i s t e r io de Salud 197 7

Aviller-Roig 197 3

Toro Perez 197 3

P r e s i d e n t 'S

Commiesion on Mental Heal th

1978

A.R.F. S t a t i e t i c a l Supplemen t

1977-78

Data f o r a l coho l - r e l a t ed admiseions t o psychia t r i c hospi t a l e i n e e v e r a l c o u n t r i e s of L a t i n Arnerica p l u s Canada and the U.S. a r e summarized i n Table 4. The burden of a l coho l - r e l a t ed d i so rde re on t h e p s y c h i a t r i c s y s t e m of t he se c o u u i e s v a r i e e coneiderably, f rom a h igh of 36 p e r c e n t of a l 1 admiesions i n Ch i l e t o a low of 4 pe rcen t i n Venezuela. Argent ina, Costa Rica, B r a z i l , Canada, Mexico and the U.S. a l 1 have r a t e e h igher than o r c lo se t o 20 percent .

I n t he Caribbean r eg ion rates of admiseione t o p e y c h i a t r i c h o s p i t a l s f o r a l coho l - r e l a t ed problema a l s o v a r y e i g n i f i c a n t l y . Beaubrun (1967a) r e p o r t e a r a t e of 47 .ó pe rcen t i n Naeeau, 53 pe rcen t i n Mart inique, and 3 pe rcen t i n Kingeton, Jamaica. Th i s au tho r sugges t s f o u r i n t e r a c t i n g f a c t o r 8 t o e x p l a i n t h i s v a r i a t i o n , no t ing h igh rates would be f o w d i n thoee p lace8 of t h e Caribbean r eg ion where :

1) touriem i s h i g h l y developed and t h e count ry ' s own n a t i o n a l i d e n t i t y i e poo r l y de l inea t ed and disparaged; (Examplee of t h i s would be Bahamae and t h e U.S. V i rg in I s l ands . I t is thought t h a t the t o u r i s t provides a r o l e model t o emulate -- someone who i e cone t an t ly playing and d r i n k i q and never seems t o work. ) 2 ) where indigenoue Ind i an popula t ions e x i s t, f o r example Aruba; 3) where E a s t Indiana (Hindue and Mosleme) are a l a r g e p a r t of the popula t ion (examplee of t h i s would be T r in idad and Guyana); and f i n a l l y , 4 ) another v a r i a b l e would be where French c u l t u r a l i n f luencee predomina te, l i k e Mar t i n i q u e and Guadelope (Beaubrun 197 5:490).

The low rates i n Jamaica a r e expla ined by Beaubrun a 8 due t o the use of gan ja , which i e endemic on t h e i s l a n d and might s e r v e a s a n a l t e rna t i v e t o dr ink ing . Pr ince e t a l . (ci t ed by Beaubrun 197 5 ) , a g r e e wi th t h i e conten t ion and c i t e economic reasons: the poor Jamaican would p r e f e r the cheaper gan ja t o a lcohol . Discuesing the t op i c , Rubin and Lomitae (1975) deny t h i e economic in f luence . I n t h e i r e tudy , gan j a u se re eaw t h i s drug as a n a l t e r n a t i v e t o a l coho l and p r e f e r r e d i t because of i t e perce ived bene f i c i a1 e f f e c t e compared t o dr inking.

T r a f f i c Accidents , Ar re s t e , and Suic ide

Data on a l coho l - r e l a t ed u a f f i c acc iden t s , a r r e s t e and s u i c i d e are more d i f f i c u l t t o ana lyze than t h a t f o r c i r r h o s i s m o r t a l i t y o r mental h e a l t h admissions. For one th ing , a s ea rch of the 11 t e r a t u r e on t h e epec i f i c t o p i c of a l coho l - r e l a t ed t r a f f i c acc iden t s , a r r e s t e , and s u i c i d e s showed t h a t moet of t he publ i shed d a t a f o r L a t i n American c o u n t r i e s a r e now more than 20 yeare o l d and r e f e r moetly t o the U508 and 19óOe.

More s i g n i f i c a n t l y , d i f f e r e n t c o u n t r i e s have varying pro- cedures t o d e a l w i th a l coho l - r e l a t ed probleme t h a t f a l 1 w i t h i n t h e law enforcement a r e a , a s w e l l a8 d i £ f e r e n t enforcemen t p rac t i ce s ; eve ry p o l i c e o f f i c e r ha s immense d i s c r e t i o n a r y powers a s t o when and how t o en fo rce the law. Gonzalez and Kataeky (1978) comment on the appa ren t l a & of concern f o r t r a f f i c s a f e t y i n gene ra l and f o r t h e consequences o£ a l c o h o l involvement wi t h t r a f f i c acc iden te i n L a t i n America. "Data on t r a f f i c acc iden te are o f t e n incomplete. The in f luence of drugs and a l c o h o l i n t r a f f i c acc iden te 1s n o t u s u a l l y recorded, and even where i t is , t h e source o f t h e r e p o r t 1s n o t always uniform and c l e a r . I n mos t cases the repor t i s baeed on the p o l i c e o f f i c e r ' s impression a t t h e t i m e . Blood a l coho l t e s t i n g and a u t o p s i e s a r e v e r y uncommon. Hence, i t 1s d i f f i c u l t , wi thout a

c o n d u c t i q s p e c i a l S tud ies , t o es t imate what p ropor t ion of t r a f f i c f a t a l i t i e s and i n j u r i e s a r e due t o a l coho l and lo r drugs" (Pp. 6 0) .

Negre t e (19 7Óa, 13 1ob) , and Saavedra and Mariategui (197 O), a f ter examining the li t e r a t u r e i n previous reviews , concluded tha t a l c o h o l 1s h i g h l y a s s o c i a t e d w i th t r a f f i c a c c i d e n t s and o t h e r l e g a l problems i n L a t i n America. A more r e c e n t estimate (PAHO 1973) i n d i c a t e s t h a t between 25 pe rcen t and 6 0 pe rcen t of a l 1 t r a f f i c a c c i d e n t s i n L a t i n America a r e caused by drunk d r ive re . Marconi and Adis Cas t ro (1367), commenting on da t a f o r s i x L a t i n American coun mies (Cos t a Rica, Chi l e , E l Salvador, Honduras, Nicaragua, and Peru) , i n d i c a t e t ha t a r r e s ts f o r p u b l i c drunkenness comprise 40 pe rcen t t o 58 pe rcen t of a l 1 a r r e s t s i n these na t ions .

I n Argentina, between the years of 1960 and 1965 t h e percentage of homicides a s s o c i a t e d wi th a l c o h o l i n g e e t i o n v a r i e d from 2 pe rcen t t o 10 pe rcen t , wi th f i v e years i n t h i s per iod showing f i g u r e s h igher than 5 pe rcen t (percentages c a l c u l a t e d by the au thor wi th f i g u r e s from Vida1 1967a). I n 1961, of those persone a r r e s t e d i n shan ty towns ( v i l l a s m i s e r i a ) , ó7 pe rcen t were "a l coho l i c s " (Calderon Narvaez, c i t e d by Saavedra and Mariategui 1970). I n a more r e c e n t s t udy i n Buenos Ai res , 20 pe rcen t of the d r i v e r 8 examined by a n "a lcohol tes t" had blood a l c o h o l l e v e l s considered "dangerous" (Mardones 1980). Negre te (1967 b) i n d i c a t e s 28 pe rcen t of i n d i v i d u a l s involved i n "crimes a g a i n s t persons" admi t ted having been under the i n f l uence of a l c o h o l a t the time of the crime.

I n Ch i l e , Marconi (1967a) quotes d a t a from t h e I n s t i t u t e of Legal Medicine of Sant iago showing t h a t 25 pe rcen t of those who committed s u i c i d e i n 1965 had p o s i t i v e blood a l c o h o l l e v e l s . H e a l s o quotes f i g u r e s from the Chilean p o l i c e i n d i c a t i n g t h a t 52 pe rcen t of a l 1 crimes a g a i n s t persone were c o d t t e d under the i n f l u e n c e o£ a lcohol . A s f o r the r o l e of a l coho l i n t r a f f i c acc iden te , Vargas ( c i t e d by Moeer 1974) shows t h a t among males involved i n t r a f f i c acc iden te , 7 0 pe rcen t had p o s i t i v e "alcohol- emia". Viel e t a l . (1970) r e p o r t f ind ings from a sample of 1,662 a u t o p s i e s perf ormed during the pe r iod of 196 0-196 4 a t the I n s ti t u t e of Legal Medicine i n Santiago. I n t h i e sample 41 pe rcen t of t he

males were heavy d r i n k e r s a s compared t o 5 pe rcen t of t h e females. I n 943 dea ths from t r a f f i c a c c i d e n t s , 46 p e r c e n t had alcoholemiae over 0.10 percent . Among females ( N J 8 ) , t h e propor t ion was o n l y 6 percent .

I n Mexico, among t h e r epo r t ed causes o f s u i c i d e i n 1967, 4 pe rcen t were a s s o c i a t e d wi th a l c o h o l i n g e s t i o n (de l a Fuente and Campillo-Serrano W 78). A more r e c e n t s t u d y done by the I n s t i t u t o Mexicano de P s i q u i a t r i a on 266 cases o£ s u i c i d e rece ived by the S e r v i c i o Medico Forense d u r i r y 1979 show t h a t 113 of t he caees had p o s i t i v e l e v e l s o£ a l c o h o l i n t he blood ( R i p s t e i n 1981). Alcohol involvement i n i n j u r i e s by v io l ence reaches 58 pe rcen t and 6 4 pe rcen t , r e s p e c t i v e l y (Cabildo, c i t e d i n de La Fuente and Campillo 1978). A s t o t r a f f i c a c c i d e n t s i n gene ra l , S i l v a Martinez (1972) r e p o r t e d a l c o h o l involvement i n 7 pe rcen t f o r the country a s a whole. Looking a t each of the Mexican s t a t e s s e p a r a t e l y , t he propor t ion v a r i e d from a h i g h of 19 pe rcen t i n Baja C a l i f o r n i a t o a low o£ 2.3 pe rcen t i n Vera Cruz. Calderon and Cabildo (1967) a l e o repor t a n o v e r a l l t o t a l of o n l y 7 percent . I n Mexico C i ty , however, t he propor t ion of a l coho l - r e l a t ed t r a f f i c acc iden te was U .5 pe rcen t i n N1 4 (Navarro 191 5) .

I n Pue r to Rico, Kaye (1974) has analyzed the a s s o c i a t i o n between a l coho l and t r a f f i c acc iden t s . Th i s d a t a shows t h a t between 1968 and W7 2, a l c o h o l involvement i n t r a f f i c f a t a l i t i e s ranged from 46 - o 3 percent . I n a n a n a l y a i s o£ 508 t r a f f i c deathe f o r the year o f 1373, Kaye r e p o r t s p o s i t i v e blood a l c o h o l conten t i n 44 pe rcen t o£ 386 examined cases . The remaining 122 cases were n o t examined either because t h e deceased was under t h e age of 1 5 o r because more than 5 hours had e l apsed between a c c i d e n t and death. Among the a l c o h o l p o s i t i v e ca se s t he propor t i o n of d r i v e r s , pedes t r i a n s , and passengere wae 40 pe rcen t , 30 percent , and 25 pe rcen t r e spec t ive ly .

I n Venezuela, Boada (1376 ) r e p o r t s t h a t i n t he per iod between 1961 and 1964 a l c o h o l was involved i n no l e s s than 50 percen t of al1 t r a f f i c acc iden t s . I n Guatemala, o n l y 9 percent of t r a f f i c a c c i d e n t s occu r r ing between 1967 and 1971 were r epo r t ed as r e l a t e d t o a l c o h o l i n g e s t i o n (Rivera-Lima 1973). Of a l1 a r r e s t s i n the same count ry i n the pe r iod 1962-1963, 66 pe rcen t were f o r drunkenness. I n Costa Rica, Morales and Chassoul ( c i t e d by Moser 1380) r e p o r t t h a t the r a t e o£ road a c c i d e n t s connected w i th a l c o h o l i n the t o t a l popula t ion went from U /100,000 i n 1961 t o 25/100,000 i n 1965. Two-thirds of a l 1 a r r e e t s i n 1965 (9,166 o u t of 13,370) were f o r drunkennes (Adis Cas t ro and F lo re s 1967 ). I n 1977 the f i g u r e was 59 pe rcen t (20,557 o u t o£ 34,945) ( I n s t i t u t o Nacional Sobre Alcoholismo, c i t e d i n Moser 1980).

Turning t o North America, t he U.S. between 1965 and 1975 saw a r r e e ts f o r drunkenness d e c l i n e from 35 pe rcen t t o 15 pe rcen t of a l 1 r e p o r t e d l e g a l o f f e n s e s (Roizen and Schneberk 1978). I n t he same

time pe r iod the t o t a l propor t i o n of a l coho l - r e l a t ed of f enses decreased from 53 pe rcen t t o 38 percent . W i t h r ega rd t o a l c o h o l ' s a s s o c í a t i o n w i th crime, as a s s e s s e d by whether the of fender had been dr ink ing be fo re the crime, f i g u r e s v a r y by type of c r i m e and from s tudy t o s tudy . Roizen and Schneberk (1978), summarizing 1ó U.S. S t ud i e s , found f i g u r e s ranging from 15 pe rcen t t o 6 0 percent .

Alcohol involvement wi th s u i c i d e s and at tempted s u i c i d e s a l s o v a r i e s markedly a c r o s s s t u d i e s . Aarens and Roizen (1978), i n a review of t h i s l i t e r a t u r e , r e p o r t f i g u r e s ranging from Id pe rcen t t o 40 percent . A s f o r the propor t ion of a l c o h o l i c s i n samples of completed and a t tempted s u i c í d e s , t h e range i s from 0.5 pe rcen t t o 48 percent . Alcohol '8 a s s o c i a t i o n w i t h t r a f f i c a c c i d e n t s changes according t o the s e r iousnes s of the event . When a l 1 t r a f f i c a c c í d e n t s a r e considered, roughly 10 pecent a r e a l coho l - r e l a t ed (Cameron 1378). The more s e r i o u s t h e a c c i d e n t t he more l i k e l y t h a t a l c o h o l was involved. Cameron (1978), summarizing a number of s tud i e s on t r a f f i c f a t a l i ties, repor ts tha t t h e percentage of d r i v e r s k i l l e d i n c rashes who had BACs 0.1 pe rcen t o r h igher v a r i e s from 35 pe rcen t t o 59 percent .

I n Canada, between 1961 and 1974, 41 pe rcen t of a l 1 so lved murders involved a t l e a s t one person who had been dr ink ing p r i o r t o t h e murder (Addiction Research Foundation 1978). I n 1978 between 30 pe rcen t and 45 pe rcen t of r epo r t ed crimes of v io l ence were alcohol- r e l a t e d (Canada, S p e c í a l Report on Alcohol S t a t i s t i c e 1931). With r ega rd t o t r a f f i c a c c í d e n t s , a t o t a l of 4.5 pe rcen t of a l 1 d r i v e r s involved i n a c c i d e n t s i n 1975 were l i s t e d a s having been dr ink ing o r having t h e i r a b i l i t y t o d r i v e impaired by a lcohol . A s f o r pedes t r i ans , 12 pe rcen t of those k i l l e d i n t r a f f i c a c c í d e n t s were l i s t e d a s having been dr ink ing o r having t h e i r a b i l i t y impaired by a l c o h o l (Addiction Research Foundation 1978).

Se l ec t ed f i nd ings f rom the l i t e r a t u r e reviewed above are summarized i n Table 5.

Communi t y S t ud i e s of Drinking Pa t t e rns and Al coholism

Before the 19501s, a l c o h o l r e sea rch i n L a t i n A m e r i c a was d i r e c t e d mainly a t the d e s c r i p t i o n and i n t e r p r e t a t i o n of a lcohol- r e l a t e d s t a t i s tic6 such a s consump t i o n , l e g a l of f enses , and mos t of ten, h o s p i t a l admissions f o r a l coho l - r e l a t ed diagnoses. Progres- s i v e l y , L a t i n American coun t r i e s began t o develop epidemiological S t ud i e s aimed a t a s s e s s i n g dr ink ing pa t t e r n s and alcohol ism i n t h e g e n e r a l populat ion. Th i s r e sea rch w a s g r e a t l y suppor ted by PAüO

TABLE 5: Percentage of Legal Offensee Associated wi th Alcohol i n Se lec ted Countr iee of t h e Americas

Percentage of Offenses Aseociated

Count r y Years wi th Alcohol Of f ensee

Argentina 1960 - 1965 2 - 1 0 a l 1 homicidee 1961 67 a l 1 a r r e e t e i n shanty towns 1980 20 a eample of d r i v e r s with

p o s i t i v e BACs*

Chi le

Mexico

5 2 a l 1 cr imes aga ine t pereon 25 a l 1 s u i c i d e s 46 male t r a f f i c f a t a l i t i e s wi th

p o s i t i v e BACs 7 O male d r i v e r 8

7 a l 1 t r a f f i c acc iden te i n t h e count ry

17 a l 1 t r a f f i c acc iden t s i n Mexico C i t y

3 0 su i c ide8 autopeied had p o e i t i v e BACs

Puerto Rico 1968-1972 46 - 63 t r a f f i c f a t a l i t i e s

Venezuela 1961-1 964 5 0 a l 1 t r a f f i c acc iden te

Guatemala 1967-1972 9 a l 1 t r a f f i c acc iden t s 66 a l1 a r r e s t e

Coeta Rica 1965

1977

30 a l 1 a r r e s t e were f o r pub l i c drunkennese

59 a l1 a r r e s t e were f o r pub l i c drunkennees

Canada 1961-1974 41 a l 1 solved murders - one of t h e persons had been d r ink ing

1975 4 5 a l 1 d r i v e r s involved i n acc iden te had p o e i t i v e BACs

1975 12 a l 1 pedee t r iane involved i n t r a f f i c acc iden te

1978 30 - 45 a l 1 v i o l e n t crimes

United S t a t e e 1975 1 5 repor ted l e g a l o f f enees were f o r drunkenness

var ious 1 5 - 60 a l 1 cr imes a r e a lcohol - re la ted var ious 18 - 40 a l1 s u i c i d e s and attempted

s u i c i d e s 1978 10 a l 1 t r a f f i c acc idente

a c t i v i t i e s i n t h e a r ea . ühen funde f o r r e sea rch d i d no t come d i r e c t l y from PAHO, PAHO provided c o n s u l t a n t s and organized meeting8 i n va r ious c o u n t r i e s of t h e r eg ion which helped b r ing toge the r r e s e a r c h e r s w i th i n t e r e s t i n t h e f i e l d .

I n t h i s s e c t i o n we examine a v a r i e t y of i n v e s t i g a t i o n s t h a t d e s c r i b e d r ink ing p a t t e r n s among popula t ion segments of a number o£ coun t r i e s . This l i t e r a t u r e 1s reviewed count ry by count ry and an overview of i t s f i n d i n g s and l i m i t a t i o n s i s provided i n t he conc lus ions . But before moving t o t h e community s t u d i e s review, w e should n o t e Marconi's o p e r a t i o n a l d e f i n i t i o n s f o r d i f f e r e n t t ypes of d r i n k e r s s i n c e they have been used no t on ly i n Chi lean surveys but a l s o i n s t u d i e s i n o t h e r L a t í n American coun t r i e s . These concepts have been d iscussed by Marconi i n a series of papera (Marconi 1965, 1967b, 1 9 6 7 ~ ) .

Alcohol ics a r e i d e n t i f i e d by t h e i r " i n a b i l i t y t o a b s t a i n " and lo r " i n a b i l i t y t o s top" ( " lo s8 of c o n t r o l " i n J e l l i n e k ' s terminology). Besides a l c o h o l i c s , Marconi recognizes a b s t a i n e r s , moderate, and exces s ive d r inke r s . Abs ta iners a r e those who had never drunk o r who had drunk less than a 100 cc.* of a b s o l u t e a l coho l i n a day and had done t h i s l e s s than f i v e t imes i n t h e year previous t o t h e survey. Moderate d r i n k e r s a r e those wi th a r e g u l a r i n g e s t i o n of l e a s than 100 cc. of abso lu t e a l c o h o l pe r day and less than 12 ep isodes of drunkenness per year (Marconi 1 9 6 7 ~ ) . The l i m i t of 100cc. of abso lu t e a l c o h o l was a r b i t r a r i l y set up by Marconi according t o t h e s tandard t h a t moderate d r i n k e r s should no t d e r i v e more than 20 percent of t h e i r t o t a l d a i l y c a l o r i c i n t a k e f r m a lcohol . Assuming t h a t t h e d a i l y c a l o r i c i n t a k e i s 3,000 c a l o r i e s , and t h a t each gram of a l coho l g e n e r a t e s 7.1 c a l o r i e s , 100 cc. o r 80 grams of abso lu t e a l c o h o l w i l l provide 6 0 0 . c a l o r i e s o r 20 percent of 3,000. Excessive d r i n k e r s a r e those who d r i n k h a b i t u a l l y (more t han 3 days i n a week) more than 100 cc. of a b s o l u t e a l c o h o l i n any day and lo r p re sen t 12 o r more ep isodes of drunkenness i n a year .

In t h e U.S. r e s e a r c h e r s have used l e s s e r q u a n t i t i e s t o c h a r a c t e r i z e heavy dr ink ing , a ca tegory which may inc lude not only Marconi 's excess ive d r i n k e r s bu t a l s o h i s a l c o h o l i c s . More d e t a i l e d comparisons between Marconi ' S and U. S. def i n i t i o n s a r e d i f f i c u l t because of t h e p r o l i f e r a t i o n i . e . of d r ink ing typologies i n t h e l a t t e r country. Rom (1977) has reviewed t h e s e measures a t l ength . The impact of d i f f e r e n t d e f i n i t i o n s of heavy d r ink ing on survey r e s u l t s i s not n e g l i g i b l e , and t h e r e l a t i o n s h i p between heavy

- -

dr ink ing and s o c i a l c l a s s can be t o t a l l y reversed according t o t h e d e f i n i t i o n being used (Room 1971).

*One hundred cub ic cen t ime te r s a l l ows f o r t h e i n g e s t i o n o£ approxi- mately 9 d r inks , each of which h a s 9 grama of abso lu t e a l coho l and corresponds t o a 112 p i n t of beer ( 4 percent ) . o r a 4 oz. g l a s s of wine (10 pe rcen t ) , o r a 1 oz. sho t of s p i r i t s (40 percent ) .

Chi l e

C h i l e 1s one o£ t h e coun t r i e s i n t he southern cone o£ L a t i n America, and 1s a wine producing and consuming country. J e l l i n e k (Popham 1976) desc r ibed Chi lean problems wi th a l c o h o l a s reaching "ex t r ao rd lna ry magni tude." I t 1s t r u e tha t t h e r e 1s a h igh r a t e o£ c i r r h o s i s m o r t a l i t y and l e g a l o£ f enses a s s o c i a t e d w i t h a l coho l , b u t the r a tes o£ "alcoholism" do no t seem t o be d r a m a t i c a l l y h igher than those found i n o t h e r n a t i o n s o£ the region.

The f i r s t surveys o£ d r i n k i q p r a c t i c e s developed i n Ch i l e were a l 1 aimed a t t he urban popula t ion o£ Sant iago. Honorato ( c i t e d by Marconi U 6 7 a ) and Horwi t z ( c i t e d by Marconi 1967a), and Marconi e t a l . (1955) r e p o r t r a t e s of pa tho log ica l d r ink ing , and a l s o o£ modera te dr ink ing , abs ten t i o n , and £ requency o£ i n tox ica t ion. The b e s t known o£ a l 1 t he se surveys, perhaps because i t 1s t h e o n l y one publ i shed i n Engl i sh , 1s t h a t r epo r t ed by Marconi e t a l . i n 1955.

Marconi e t a l . s e t o u t t o o b t a i n in format ion abou t the prevalence o£ alcohol ism. The popula t ion s t u d i e d was t h a t o£ a working c l a s s suburb of Sant iago which, according t o the au tho r s , w a s t y p i c a l o£ t he Chilean working c l a s s i n urban areas.

The prevalence o£ a lcohol i sm was 4.2 pe rcen t (8.3 pe rcen t f o r males and 0.6 pe rcen t f o r females). Excessive d r i n k e r s inc luded 28 pe rcen t o£ the males and 0.5 pe rcen t of t he females. Drunkenness was v e r y f r e q u e n t among males, wi th 43 pe rcen t of them g e t t i n g i n t o x i c a t e d a t least "each weekend." k l s o , 22 pe rcen t of the men drank before b r e a k f a s t everyday. Marconi r i g h t l y concluded t h a t s i n c e dr ink ing f i r s t th ing i n the morning was s o p reva l en t i n t h i s Chi lean sample i t could n o t be considered a s i g n o£ a d d i c t i o n i n t h i s popula t ion.

Honorato e t a l . ( c i t e d by Marconi 1967a) surveyed dr ink ing p a t t e r n s i n a working popula t ion of Santiago. The r e s u l t a showed 19 pe rcen t a b s t a i n e r s , 54 percent i r r e g u l a r modera te d r inke r s , 21 percen t r e g u l a r modera te d r inke r s , 2 p e r c e n t excess ive dr inkers . The p ropor t i on o£ a l c o h o l i c s i n t he sample, 6 percent , was a l i t t l e h igher than tha t p rev ious ly found by Marconi e t a l . . Horwi t z e t a l . ( c i t e d by Marconi 1967a) i n a s t u d y o£ "Gran Sant iago" found a s i m i l a r p ropor t ion o£ a l coho l i c s : 5 percent . H i s d e f i n i t i o n of a lcohol i sm u t i l i z e d a s opera t i o n a l i n d i c a t o r s " i n a b i l i t y t o a b s t a i n " and " i n a b i l i t y t o s t o p dr ink ing ," according to t he concepts developed by J e l l i n e k (1960) and adopted by Marconi (1967 c) t o i n d i c a t e phys i ca l a d d i c t i o n to a lcohol . There a l s o were 8 pe rcen t exces s ive d r i n k e r s (de f ined a s those who had more than 12 ep isodes o£ drunkenness i n the previous year ) , 54 pe rcen t moderate d r inke r s , and 34 pe rcen t a b s t a i n e r s . Among women o n l y 0.8 pe rcen t were a l c o h o l i c s , as compared t o 11 percen t of the men.

Studying the prevalence of mental d i so rde re i n t he n o r t h area o f Sant iago, Moya e t a l . (1969) found a r a t e of a lcohol ism ranging from 1.9 pe rcen t i n a popula t ion of middle lower c l a s s t o 3.9 p e r c e n t i n a n "organized" working c l a s s popula t ion and inc reas ing t o 7 .6 pe rcen t i n a marginal populat ion. The typology o f d r i n k e r s employed was t ha t proposed by Marconi.

a i t s i d e Sant iago, d r ink ing p a t t e r n s have been s tud ied i n the i s l a n d of Chi loe by Tapia e t a l . (1966) and by Ruiz e t a l . (1967), i n Cant in by Medina and Marconi (197 O ) , and i n Ta lca by Medina e t a l . (1980). The Medina and Marconi s t u d y (1970) d e s c r i b e s t he dr ink ing pa t te rne of a d u l t Mapuches f rom f i v e r e se rva t i o n s l o c a t e d i n a r u r a l a r e a of Chi le . Nearly a l 1 i n d i v i d u a l s 15 years of age and o l d e r were in te rv iewed and t h e i r d r ink ing h a b i t s assessed. The dr ink ing c a t e g o r i e s u t i l i z e d were those proposed by Marconi i n previous work d i scus sed above (Marconi 1967 c).

With these d e f i n i t i o n s 3 percent o£ the men (N-70) and 15 pe rcen t o£ the women (N17 5) were a b s t a i n e r s . Among the men the propor t ion of modera te d r i n k e r s , exces s ive d r i n k e r s , and a l coho l1 cs w a s 46 pe rcen t , 26 pe rcen t and 26 pe rcen t , r e spec t ive ly . The prevalence of a lcohol i sm among the Mapuche 1s thus t h r ee times h ighe r than t h a t i n the working popula t ion of Santiago. I t 1s p o s s i b l e , however, t h a t t h i s f i g u r e 1s a r t i f i c i a l l y i n f l a t e d by the d e f i n i t i o n of a lcohol iem employed i n the s tudy. Medina and Marconi, i n d i scuss ing t h i s r e s u l t , acknowledge t h a t the ope ra t i ona l ind ica- t o r s p r ev ious ly a p p l i e d t o urban popula t ions i n Sant iago were of l i t t l e u t i l i t y among t h e Mapuche t o diagnose alcoholism. I t was d i f f i c u l t t o a s c e r t a i n volume of i n g e s t i on , and a l c o h o l consumption days could n o t be c l a s s i f i e d a s working o r non-working days, due t o Mapuche d i v i s i o n of time i n t o pe r iods r a t h e r than days of work and of rest.

Among women 8 3 pe rcen t were moderate d r inke r s , 1 pe rcen t were exces s ive d r i n k e r s and ano the r 1.3 pe rcen t were a lcohol ice . The norms surrounding a l c o h o l i n g e s t i o n i n these Mapuche communi ties e x p l a i n t o some e x t e n t the d i f f e r e n c e s i n p a t t e r n s of d r ink lng between men and women: men d r ink among themselves; sometimes women p a r t i c i p a t e i n these dr ink ing s e s s i o n s , b u t t hey never d r ink among themselves excep t during p a r t i e s and f e s t i v i ties. Wine i s the pref er r e d beverage .

These r e s u l t a from Medina and Marconi's work map w e l l on to the an th ropologica l observa t i one made by Lomni t z (1976 ) among the Mapuche. According t o he r , Mapuche dr ink ing i s b a s i c a l l y a " s o c i a l a c t between males." Th i s c h a r a c t e r i s t i c has been p re sen t i n Mapuche dr ink ing f o r more than 400 years , having surv ived changes i n dr ink ing h a b i t s due t o Spanish co lon iza t ion and migra t ion t o t he c i t i e s . Changes i n Mapuche a l c o h o l i n g e s t i o n over t i m e have inc luded a swi tch t o wine and s p i r i t s , d r ink ing i n ba r s , new r i t u a l d r ink ing occas ions of non-Mapuche o r i g i n , and changes i n female dr ink ing norms.

Besides s tudylng the g e n e r a l populat ion, some Chilean research- ers have desc r ibed a t t i tudes towards a l c o h o l i nges t i o n among s chool popula t i o n s o£ adolescen ts (Garcia 1976 , Norambuena 198 0). These s tud i e s i l l u m i n a t e some a s p e c t s of a t t i t u d e s and behaviors wi th r ega rd t o a l c o h o l i n g e s t i o n which have n o t been touched upon by surveys o£ the a d u l t popula t ion i n Chi le . They p u t more emphasis on mapping the a d o l e s c e n t ' s knowledge o£ and r e a c t i o n t o dr ink ing than on a s c e r t a i n i w pa tho log ica l consumption. Such a n approach seems t o stem from the n o t i o n s t h a t a ) t he re a r e n ' t many pa tho log ica l d r i n k e r s i n t h i s popula t ion worth counting; and b) i t 1s necessary t o know what ado le scen t s th ink about a l c o h o l i n g e s t i o n i n o r d e r t o implemen t preven t i v e campaigns be tter .

Argent ina

Argent ina, a s Ch i l e , 1s one o£ the wine producing and wine consuming coun tries i n the sou thern par t o£ Sou th Ameri ca. A l though n o t possessing such a t r a d l t i o n o£ a l c o h o l r e sea rch a s Ch i l e , a group of r e sea rche re working i n Buenos Aires has produced a s i g n i f i c a n t su rvey o i a tti tudes towards dr ink ing i n t h e g e n e r a l popula t ion (Goldenberg e t a l . 1968) a s w e l l a s a v e r y i l l umina t ing su rvey o£ "alcohol ism and exces s ive dr ink ing" (Tarnopolsky e t a l . 1 9 7 5).

J e l l i n e k descr ibed Argent inian dr ink ing a s fol lows:

. . . both men and women d r ink wine wi th t h e i r meals . . . i t 1s s t r i c t l y understood t h a t women a r e n o t supposed to become even s l i g h t l y i n t ox i ca ted. There 18 some dr ink ing o u t s i d e meals. I n t he upper s o c i a l classes c o c k t a i l dances a r e v e r y popular , b u t one does n o t see drunkenness on these occasions. Genera l ly , the Argent in ian does n o t g e t drunk p u b l i c l y , bu t he may do s o a t home. I n Argent ina, a s i n many o t h e r South American coun t r i e s , one may speak o£ "domes t i c drunkenness" (Popham 1976 :17 3).

Some o£ J e l l i n e k ' s obse rva t ions have been conf i rned by empi r i ca l da ta . The d i f f e r e n c e i n the propor t ion o£ a l c o h o l i c s and exces s ive d r inke re between man and women ( r a t i o o£ 15 : l i n Tarnopolsky e t a l . 1975) and t h e high propor t ion o£ moderate d r i n k e r s among women (76 pe rcen t o£ a l 1 the respondents i n the same survey) sugges t t h a t women d r i n k o n l y s o c i a l l y , w i t h no g r e a t r i s k of i n t o x i c a t i o n . Wine 1s the p re fe r r ed beverage.

I n the s tudy o£ a t ti tudes towards a l c o h o l consump t i on , Goldenberp e t a l . (1968) compared two groups o£ respondents: a sample o£ i n d i v i d u a l e from the c i t y o£ Buenos Ai res , and a sample o£

i n d i v i d u a l e from the d i s t r i c t of Lanus, a n i n d u s t r i a l suburb of t h a t c i t y . The r e s u l t s showed t h a t 74 pe rcen t of t he f a m i l i e s drank wine w i t h meals. I n Lanus, 51 pe rcen t of t he sample r ega rd "under 12 years of age" t o be a n accep tab l e l i m i t a t which people can begin dr inking. The p ropor t i on of respondents i n t he Buenos A i r e s sample endorsing the same l i m i t was even h igher , 7 1 percent . The sample from Lanus was more concerned abou t harmful e f f e c t s o f a l c o h o l (90 pe rcen t of the respondents i n Lanus a g a i n s t 30 pe rcen t i n Buenos A i r e s ) . A m a j o r i t y of t h e respondents i n both samples, 7 5 pe rcen t i n Lanus and 51% i n Buenos Aires, considered alcohol ism a v ice . When the samples were d iv ided by s o c i a l s t r a t a , t h e low s t r a tum showe d more permissiveness towards a l coho l use and a g rea ter suppor t f o r "puni t i ve" s o l u t i o n s t o alcoholisrh (p roh ib i t i o n o£ s a l e s , f i n e s a s punishrnen t f o r a l c o h o l i c s ) . The middle c l a s e suppor ted medical and s o c i a l s o l u t i o n s s u & a s t reatment , educa t ion , socioeconomic improvements.

The au tho r s a l s o r e p o r t t h a t 6 2 pe rcen t of t h i s sample accepted a s i d e a l d a i l y i n t a k e a t l e a s t 114 of a l i t e r of wine (approximately 112 p i n t ) , and 44 pe rcen t accepted a d a i l y i n t a k e of more than 112 l i ter of wine (approximately 1 U.S. p i n t ) . The a c t u a l d a i l y i n t a k e of wine i n t he sample was a s fol lows: 114 t o 112 l i t e r , 21 percent ; more than 112 l i t e r , 58 percent .

I n the survey descr ibed by Tarnopolsky e t a l . (1975), which a l s o used the Lanus d i s t r ic t a s a r e sea rch s i te , the d a i l y i n t a k e of v i n e among males wae 500 m l . , whi le i o r females i t was 100 m l . However, these average8 a r e s t rongly c l a s s r e l a t e d . I n a slum a r e a Tarnopolsky e t a l . found a n average of 1 l i t e r of wine per day, whi le i n the bee t r e s i d e n t i a l a r e a e t h i s went down to 300 m l . per day. C r i t e r i a f o r de f in ing the va r ious types of d r i n k e r s were those developed by Marconi ( 1 9 6 7 ~ ) . The in t e rv i ewer s were phys ic ians and r e s i d e n t s i n ps ychia t ry . The prevalence of a l c o h o l i c s and exces s ive d r inke r s i n the male popula t ion was 4.4 pe rcen t and 12 percent , r e s p e c t i v e l y . There were no a l c o h o l i c s among women, and o n l y 1 pe rcen t of them were exces s ive dr inkers . The r a te of a b s t e n t i o n and moderate dr ink ing was 11 percen t and 7 1 pe rcen t among females. ühen these r e s u l t s a r e compared t o Chi lean surveys, Lanus has one-half t he number of a l c o h o l i c s found by Marconi e t a l . (1955) and one-third of t h a t found by Horwitz e t a l . ( c i t e d i n Marconi 1967a). A s f o r exces s ive d r inke r s , t h e 12 pe rcen t i n Lanus i s aga in les8 than the U pe rcen t r epo r t ed by Horwitz and l e e s than ha l f t h e 28 pe rcen t r epo r t ed by Marconi, both i n Sant iago.

I n the r e p o r t from Lanus, a b s t e n t i o n has a U-shaped r e l a t i o n s h i p wi th age , being h igher both among those 15-24 years of age (23 pe rcen t ) and those 55 years of age and over (16 percent a s r e c a l c u l a t e d by t h i s au tho r ) . Alcohol ics and excess ive d r i n k e r s were concent ra ted i n t he 25-54 age group, wi th r a t e e of a lcohol ism

around 6 percent. Moderate drinking does n o t show much v a r i a t i o n with age; approximately 7 0 percent of those i n a l 1 age groups a r e w i t h i n t h i s ca tegory. Drinking w a s negat ive ly associa ted w i t h education, occupation, and degree of urbanizat ion of r e s i d e n t i a l area. The assoc ia t ion between a lcohol in take and t h i s last c h a r a c t e r i s t i c i s the most marked i n t h i s survey. The d i f fe rences are no t s o much i n the r a t e s of abs tent ion , bu t i n the proportion of a l coho l i c s and excessive drinkers. While the wealthier a r e a had a r a t e of 0.b percent a l coho l i c s and 7 .5 percent excessive dr inkers (males only) , the poorer a r e a had a r a t e of 13 percent a l coho l i c s and 20 percent excessive drinkers.

Migrants from r u r a l a r e a s of Argentina had s i g n i f i c a n t l y more "pathological drinkers" (excessive dr inkers p lus a l coho l i c s ) than those born i n the province of Buenos Aires. When compared t o fore igners , Argentinians as a group (born i n the ci t y o r i n r u r a l a r e a s ) d i d no t have s i g n i f i c a n t l y d i f f e r e n t r a t e s of alcoholism o r excessive drinking (Tarnopolsky e t al . 197 7 ) .

Grimson e t , a l . (1972) assessed the prevalence of a l coho l i c s and excessive dr inkers , i n a random sample of 3,357 Buenos Aires res iden ts . The def i n i t ions of excessive dr inkers and a l coholics a r e modified vers ions of those proposed by Marconi i n Chile and followed by Tarnopolsky i n h i s survey of Lanus. Grimson found l a r g e proport ions o£ both a l coho l i c s and excessive dr inkers i n his sample. Thus, while Tarnopolsky e t a l . (1975) r e p o r t 1.9 percent a l c o h o l i c s and 6.4 percent excessive dr inkers , Grimson's r e s u l t e show 16 percent excessive dr inkers and 6 .? percent alcoholice. The number of abs ta ine r s , 15 percent , i s similar to t h a t found by Tarnopolsky, which was 16 percent. Modera t e dr inkers represented 6 1 percent of Grimson's sample, b u t 73 percent of Tarnopolsky's.

Other r e e u l t s from Grimson's work a r e s imi la r to those from o t h e r surveys i n La t in America. There 1s a concentrat ion of excessive dr inkers and a lcoho l i c s i n the 22-39 age group, the percentage of a l coho l i c s among males i s much l a r g e r than among females (13 percent versus 2 percent) , who have l a r g e r r a t e s of abs ten t ion than males (20 percent versus 9 percent) . There a l s o 1s a concentrat ion o£ excessive dr inkers and a lcohol ice i n the lower socioe conomi c groups. Comparing the d i s t r i b u t i o n of dif f eren t types of dr inkers among the population l i v i n g i n slunu with t h a t l i v i n g i n urbanized a reas , Grimson found a r a t e of alcoholism four times higher i n the slums (21 percent versus 6 percent) . The slums a l s o had a s l i g h t l y higher frequency of a b s t a i n e r s (19 percent versus 15 percent ) , l e s s moderate dr inkers (49 percent versus 6 3 percent) , and less excessive dr inkers (12 percent versus U percent) .

Per u

Alcohol reeearch i n Peru h a s been a p t l y examined by Mariategui (190 7 a , U7 4 , 191 Y , 198 1 ) . According t o Maria t egu i (197 9 ) , d i f f er- e n t geographica l a r e a s of t he count ry p r e f e r d i s t i n c t types of a l c o h o l i c beverages. I n t h e Peruvian Amazon the t r a d i t i o n a l beverage i s chicha, fermented from the yuca p l a n t (Manihot sucu len t a ) . I n the c o s t a l zone the most consumed beveranes a- - and d i s t i l l e d s p i r i t e , wi th v e r y l i t t l e wine. I n t he Andean r eg ion the more t r a d i t i o n a l fermented beverages (chicha, ~ u a r a p o ) and canazo, a d i e t i l l e d e p i r i t from the sugar-cane, a r e t he p r e f e r r e d beverages. Almeida (1971) comments t h a t o n l y 20 pe rcen t of the sugarcane s p i r i t s consumed i n the Andean r eg ion 1s r e c t i f i e d . The o t h e r 8 0 pe rcen t i s consumed wi thout r e c t i f i c a t i o n and the t o x i c componente add t o t h e r i s k s of developing o r g a n i c pa thologies comon ly a e s o c i a t e d wi th abus ive a l coho l consumption. S ide by s i d e w i th a l c o h o l consump t i on , t h e widespride habi t of coca-leaf chewing t o m í t i g a te hunger and f a t i g u e cons ti tu tes a n add i t i o n a l publ i c h e a l t h problem i n t he Andean popula t ion of Peru. Caravedo and Almeida ( U 7 1 ) repor t tha t t h i s hab i t a f f e c t s approximately 50 pe rcen t of t he economical ly a c t i v e r u r a l popula t ion and t h a t i ts prevalence i n the t o t a l Andean popula t ion v a r i e s from 25 pe rcen t t o 1 3 percent .

Epidemiologi cal s tud i e s i n Peru have been developed w i th t he o v e r a l l aim of a e s e s s i n g psychia t r i c d i s e a s e s i n gene ra l , w i th a lcohol i sm a s one of t he e n t i t i e s being s tud i ed . Rotondo e t a l . ( c i t e d by Mariategui 196Ja) developed one euch s t u d y i n a e o c i a l l y uns t ab l e and d isorganized community of c e n t r a l Lima. Mariategui ( U 7 0 ) surveyed Lince, ano ther urban d i s t r ic t of Lima, while Ro tondo e t a l . ( c i t e d by Mariategui 1379) r e p o r t a survey i n a r u r a l province nea r Lima, and Chr i s t i aneen and Malca ( c i t e d by Mariategui 1979) s t u d i e d prevalence of a lcohol ism i n t he c o a s t a l c i t y of T r u j i l l o i n no r the rn Peru. Three of theee s t u d i e s found a r a t e of a lcohol i sm andar exces s ive dr ink ing around 9 percent , wi th t h e except ion of the urban d i s t r i c t of Lince, where two-thirds of the popula t ion i s middle c l a s s and the r e p o r t prevalence of a lcohol i sm and r e g u l a r exces s ive d r ink ing was much lower, 2.68 percent . Ro tondo and Bazan (1976) r e p o r t mixed r e s u l t e from a survey of d r idc ing p r a c t i c e e among workers of two f a c t o r i e s on the o u t s k i r s of Lima .

Inf ormation on a l c o h o l consump t i o n and d r i n k i q pa t t e r n s among the n a t i v e i n h a b i t a n t s of Peru, a n impor tan t segment of the countr y ' s popula t ion , comes almos t e x c l u s i v e l y f rom e thnographi c e t u d i e s . These have been developed among the peoples of the Andean reg ion , and the re i e ve ry l i t t l e information about dr inking customs i n the Peruvian Amazon (Maria t egu i 197 9 ). Manguin (1957 ) decribed dr ink ing pa t t e r n s and a l coho l - r e l a ted cus toms of t h e 1,8 00 r e s i d e n t e o£ the Vicoe community i n t he Peruvian Andes. According t o h i s

desc r ip t ion , dr inking 1s un ive r sa l among Indiana i n Peru, and a l 1 of t h e populat ion 1ó years of age and o l d e r dr inks. Among a d u l t males dr inking o f t e n l e a d s to drunkenness, and al though dr inking 1s f r e q u e n t i t remains a s o c i a l a c t i v i t y " i n t e g r a t e d wi th the most b a s i c and powerf u1 s o c i a l i n s ti tu t i o n s i n the communi ty. " Since most of the dr inking 1s done i n s o c i a l s i t u a t i o n s , a s wi th the Mapuche s t u d i e d by Medina and Marconi (1970) and by Lomnitz (1976 ), t he re a r e no s o l i t a r y drunkards i n Vicos. The absence o£ a l coho l - r e l a t ed pathology i n Vicos 1s expla ined by Manguin a s a f unc t ion of t he i n t e g r a t i on of dr inking and c u l ture.

Drinking i n Lunahuana, a mes t i z o communi t y south of Lima, has been descr ibed by Simmons (1359, 1968). As i n Vicos, d r inking i n t h i s communi t y 1s widespread and v e r y f requent. A t t i tudes towards dr inking a r e permissive, and there are no d e f i n i t i o n s of dr inking a s a " s o c i a l problem." Alcohol consumption 1s a s o c i a l a c t i v i t y and has bo th anx ie ty-reducing and i n t e g r a t i v e r o l e s i n the s o c i e ty. I n t e g r a t i o n 1s done through compliance wi th dr inking norms d i c t a t e d by the group. Because aggress ive behavior 1s disapproved, dr inking becomes a means of r e l i e v i n g tension. S o l i t a r y dr inking 1s seen a s abnormal, and "1 t l e g e n e r a l l y be l ieved t h a t these men d r ink a lone because they a r e e t i n g y and do n o t want t o s h a r e t h e i r l i q u o r " (Simmons l!3 58 :lo9 ) . Drinking pa thologies a r e r a r e . There 1s a l s o a p o s i t i v e a s s o c i a t i o n between drinking and work. Many of the working a c t i v i t i e s connected wi th the product ion of a l coho l and c u l t i v a t i o n of grapevines a r e punctuated by dr inking. The beverage 1s provided by t h e employer, and by the end o£ the day, e s p e c i a l l y during grape harves t time, many o i the workers a r e drunk.

J e l l i n e k (Popham 1976) descr ibed B r a z i l a s a s p i r i t and wine dr inking country. However, a l though wine 1s indeed consumed i n the south , i n t he n a t i o n a s a whole beer 1s the second most consumed beverage, a f t e r d i 8 t i l l e d s p i r i ts irom sugarcane. Thus, as occurs i n Peru, d i f f e r e n t reg ions may have d i f i e r e n t beverage preferentes. I n the s t a t e s of the sou th where grapevine c u l t i v a t i o n and wine product ion 1s a growing indus t ry , wine dr inking 1s f a i r l y common. This eeems t o be a custom which 1s f i n d i n g acceptance i n the upper s o c i a l c l a s s e s o£ the sou theas t region, e s p e c i a l l y i n urban a r e a s such a s Rio de J a n e i r o and Sao Paulo.

Cachaca, t he d i s t i l l e d s p i r i t f rom sugarcane, 1s a beverage whose consumption c u t s a c r o s s a l1 reg ions of the country and s o c i a l c l a s se s . It 1s f r e q u e n t l y consumed a lone o r mixed with the ju i ce of t r o p i c a l f r u i ts and sugar. I t l e , together w i t h beer , the p re fe r r ed beverage of t he lower socioeconomic s tratum both i n urban and r u r a l a r eas . I t 1s a l s o r e g u l a r l y consumed i n r e l i g i o u s ceremonies o i Afro-Brazilian c u l t a , where i t has t he e f f e c t o£ i n t e g r a t i n g the cu l t membership (Leacock 1979).

Knowledge abou t a l c o h o l consumption and d r ink ing pa t t e r n s 1s very l imi t ed . The most o f t e n c i t e d assessment o£ the magnitude of a l c o h o l problems i n B r a z i l 1s the percentage o£ a l coho l - r e l a t ed acimissions t o p s y c h i a t r i c hosp i tals; between 1960 and 197 4 t he percentage o£ a l coho l - r e l a t ed admissions went from 3 pe rcen t t o 5 pe rcen t f o r females and from 21 pe rcen t t o 29 pe rcen t f o r males (Cae tan0 19d l ) .

The f i r s t survey of dr ink ing p r a c t i c e conducted i n t he gene ra l popula t i o n was by Azoubel Neto (1967 ), who s tud ied a l c o h o l i nges t i o n i n a d i s t r i c t o£ Ribe i rao P re to , a town i n t he state of Sao Paulo.

Among males (N438), t he re were 22 p e r c e n t a b s t a i n e r s , 48 p e r c e n t moderate d r i n k e r s , and 14 pe rcen t pa tho log ica l d r inkers . The d e f i n i t i o n s £ o r these ca t ego r i e s a r e no t given. Among females t h e a b s t e n t i o n r a t e was 36.5 percent , whi le moderate, excess ive , and pa tho log ica l i n g e s t i o n occured i n 52 pe rcen t , 10 percent , and 1 percent , r e s p e c t i v e l y .

Another su rvey was c a r r i e d o u t by Luz ( c i t e d i n Negrete, iYbla) i n a lower c l a s s suburb o£ Por to Alegre i n the south p a r t of t h e country. Respondente were a r e p r e s e n t a t i v e random sample o£ the d i s t r i c t . The d e f i n i t i o n s u t i l i z e d were those used by Grimson e t a l . (1372) i n Argentina. The r a t e of problem d r i n k e r s was 10 pe rcen t , which 1s l e e s than ha l f of the 23 pe rcen t r epo r t ed by Grimson.

More r e c e n t l y , Vianna F i l h o e t a l . (1978) r e p o r t on dr ink ing pa t t e r n s o£ a sample of r e s i d e n t s o£ the I e l and o£ Santa Ca ta r ina , a d i s t r i c t o£ F lo r i anopo l i s , a s t a t e c a p i t a l i n the south o£ Braz i l . Approxima t e l y 8 0 percen t o£ the respondents were f emales, a n over- r e p r e s e n t a t i o n r e s u l t i n g from no p r e e e l e c t i o n of in te rv iewees and the f a c t t h a t i n t e r v i e w s were conducted during t h e a f t e rnoon when mos t of t he men were a t work.

The r a t e o i a b s t e n t i o n was 39 pe rcen t i n t he more urbanized p a r t o£ the d i 8 t r i c t and 55 pe rcen t i n the o t h e r a rea . I nges t i on of a l c o h o l i c beveragee was done u s u a l l y a t p a r t i e s and s o c i a l ga ther - i ngs . Only 3 pe rcen t o£ the respondents i n t he urban a r e a and 6 pe rcen t i n t he r u r a l a r e a s t a t e d they drank eve ry day. Drinking 1s u s u a l l y done a t home, and the beverage mos t £ r equen t ly drunk i s cachaca, f ollowed by beer and then wine.

Two r e c e n t papers by Masur e t a l . (1980) and by Moreira e t a l . (1381) repor t on t h e dr inking pa t t e r n s of pa t i e n ts hospi t a l i z e d i n g e n e r a l h o s p i t a l s i n two r eg ions o£ Braz i l . Masur e t a l . (1980) s e l e c t e d a t random 6 3 women and 50 men who were h o s p i t a l i z e d f o r t rea tment o£ v a r i o u s o r g a n i c pathologies . The a u t h o r s used as an i n d i c a t o r o£ a lcohol i sm t h e d a i l y i n g e s t i o n of a t l e a s t 150 m l . o£ e thano l ( t h i s a l l ows f o r the i r y e s t i o n of approximately 1 3 dr inks ,

each of which would have 9 grams o f a b s o l u t e a l c o h o l ) o r the i n g e s t i o n o£ 450 m l . of e t h a n o l during weekend8 ( t h i s a l l ows f o r 40 d r inks , each of which would aga in have 9 grams of abso lu t e a l coho l , o r 1 112 b o t t l e s of dOo proof s p i r i t s ) . They found t h a t 59 pe rcen t of the men and U pe rcen t of the women r e p o r t e d enough dr in ldng t o be c l a s s i f i e d a s a l coho l i c s . Comparing these f i n d i n g s w i t h t h e in format ion on medical record8 showed that t h e medical h i s t o r i e s d i d n o t have mudi in format ion concerning a l c o h o l i n t ake . For men, t h e propor t ion recognized i n d o c t o r ' s n o t e s a s having the above mentioned l e v e l s of a l c o h o l i n t a k e was 32 percent ; f o r women t h e propor t ion was 10 percent .

Th i s r e sea rch was r e p l i c a t e d i n two h o s p i t a l s i n t he n o r t h e a s t p a r t of the count ry by Moreira e t a l . (1380). The r e s u l t s showed lower r a t e s of d r i n k i q than those repor ted by Masur e t a l . Th i s 1s e s p e c i a l l y s o f o r the r u r a l h o s p i t a l where r a t e s f o r men were ha l f o f those f ound by Masur e t a l . , while r a tes f o r women a r e o n l y one- f i f th a s high. A t o t a l of 3 0 pecent of these d r i n k e r s r epo r t ed consump t i o n of d i s t i l l e d s p i r i t e f rom sugarcane.

Colombia

Previous rev iewers have a l r e a d y commented on the l a c k o£ ep idemiologica l r e sea rch on dr ink ing problems i n Colombia (Velasquez 1367; Mariategui 1974). Th i s seems t o be s t i l l t r u e today. Madsenzie and Osorio (197 7 ) r e p o r t a s t u d y of dr ink ing p a t t e r n s , the f i r s t one undertaken i n Colombia, i n a r u r a l c o m u n i t y i n t he e a s t e r n p a r t of the country. I n t e rv i ewer s f o r t h i s s t u d y were school teachers r e c r u i t e d i n t h e l o c a l school d i s t r i c t . The e f f e c t of u s ing these i n t e r v i e w e r s on respondents ' r e p o r t i n g 1s n o t d i s cus sed by t h e au thors ; cons iderab le under-report ing may have been caused by having these a u t h o r i t y f i g u r e s i n q u i r e about dr ink ing pa t te rns .

The p r e f e r r e d beverages were d i s t i l l e d s p i r i t s from sugarcane and beer . Drunkenness ep isodes were f r e q u e n t and, according to the au thore , seemed t o fo l l ow a n a t i v e p a t t e r n o i a l c o h o l i n g e s t i o n whi ch i n v a r i a b l y l e a d s t o i n tox i ca t ion . Among males 7 0 pe rcen t de l ca red a t least one ep isode o i drunkenness per pa r . Among females t h i s p ropor t ion was 20 percent . Drunkenness was e s p e c i a l l y common d u r i w Christmas, New Year, f a m l l y ga the r ings , and o t h e r s o c i a l occasions. A t o t a l of 19 pe rcen t of the men were a b s t a i n e r s , 46 pe rcen t were moderate d r i n k e r s , 24 pe rcen t were exces s ive dr inker S, and 10 percen t a l coho l1 cs. Women had a l a r g e r propor t i o n of a b s t a i n e r s , fewer exces s ive d r i n k e r s and no a l coho l i ce . I n both s exes abs ten t i o n was pos1 t i v e l y a s s o c i a ted w i th age.

Uruguay

Munoz (1967) reviews d a t a on a l c o h o l involvement i n t r a f f i c a c c i d e n t s , as we l l a s l aws and r e g u l a t i o n s which a p p l y t o a l coho l - r e l a t ed o f f enses . The d a t a i n t h e paper r e f e r s t o t h e beginning of the '50s and must be ou tda t ed by now. The same has i n e v i t a b l y happened t o J e l l i n e k ' s (Popham 1976 ) comments on l i q u o r product ion and a l c o h o l consumption i n the coun t ry .

Bo l iv i a

The most s i g n i f i c a n t r e sea rch on a l c o h o l t o come o u t of Bol iv ia has been Heath 's s t u d i e s of the Camba (Heath 1958 ) and the Camba and Aymara (Heath 1971). The Camba d r i n k a l coho l during f es t i v i ties. The i r beverage 1s a po t en t d i s t i l l e d s p i r i t c a l l e d s imply "alcohol" -- f o r v e r y good reasons , s i n c e i t con ta in s 89 pe rcen t e t h y l a lcohol . I t burns the mouth and the t h r o a t , and t o t he Camba i t has some medical u se s ( " i t k i l l s t he p a r a s i t e s " ) . According t o Hea t h '8 a n a l y s i s , dr ink ing among the Camba usua l1 y l e a d s t o i n t o x i c a t i o n , b u t never t o aggress ion o r s o l i t a r y dr inking. By the v i r t u e of being a non-corporate people, d r ink ing groups among the Camba may take on a n important i n t e g r a t i v e £ unct ion , s e rv ing t o f orm "primary re£ e r ence groups. "

Heath's (1971) d e s c r i p t i o n o£ dr ink ing i n Montero, a town popula t ed by the Camba, and Coroico, i n h a b i t e d by the Aymara, a r e a tes timony t o t h e r e l a t i onsh ip be tween dr ink ing pa t t e r n s and the s o c i a l s t r u c t u r e . I n 1952, Bol iv ia was the s t a g e f o r a p o l i t i c a l revolu t i o n tha t changed s i g n i f i c a n t l y t he p o l i tical and s o c i a l s t r u c t u r e o£ the country. I n Montero the peasants l e £ t the farms t o e s t a b l i s h themselves on t h e i r own l and , and a s a r e s u l t t he p rev ious ly f r i e n d l y r e l a t i o n s h i p with the landowner was broken. I n C O ~ O ~ C O , the landowners became merchante and now s e r v e a s middlemen between former peasants and wholesa le rs i n La Paz. The r e l a t i o n s h i p b e tween these f ormer landowners and the peasants , a l though commercial i n n a t u r e , now inc ludes s o c i a l d r ink ing a s a mode t o keep the commercial a l l i a n c e OD good terms.

Ecuador

I n t h i s country t h e p r e f e r r e d beverage 1s d i s t i l l e d s p i r i t s from sugarcane. I n 1966 c u l t i v a t i o n of t h i s crop a lone took up 11 percen t of a l 1 t he c u l t i v a t e d l a n d i n the count ry (Pacuru C a s t i l l o 1 9 7 2 ) .

Endara (1967 ) d e s c r i b e s t he s tudy of a lcohol i sm by Canelos and Ceval los i n a n Ind i an community on the o u t s k i r t s of Quito, the count ry ' s c a p i t a l . The ia format ion was ob ta ined from 9 0

i n d i v i d u a l s , s e l e c t e d through s y s tema t i c random procedures f rom among those t r e a t e d i n a medical o f f i c e . They c o n s t i t u t e d a 10 pe rcen t sample of t he popula t ion i n t h e community. According t o Endara, d r ink ing was a s s o c i t ed w i t h being male, s i n g l e , of young age , and of lower socioeconomic s t a t u s .

Venezuela

Quijada (1961) d e s c r i bes a su rvey of prevalence of p s y c h i a t r i c morbidi t y i n the popula t ion of three d i s tricts: urban, semirura l , and r u r a l . I n t h e urban a r e a two d i s t r i c t s were surveyed. I n one of them 221 i n d i v i d u a l s were in te rv iewed and t h e au tho r s found a prevalence of a lcohol i sm of 1.8 percent . I n the second a r e a d a t a were ob ta ined £ o r 120 i n d i v i d u a l s , and t h e prevalance of a lcohol ism w a s 2.5 percent . The semi-rural a r e a (N-210) and the r u r a l popula t ion ( N 4 31) had prevalence r a t e s f o r a lcohol i sm of 5 pe rcen t ( C a e t r i l l o and Sanjuan 1361) and 1 pe rcen t (Quijada 1961) r e spec t ive ly . Unf o r tuna t e l y none of these a u t h o r s provides adequa te informat ion abou t t he m e thodology employed i n t h i s s tudy. N e i t he r sampling precedures nor d e f i n i t i o n s of a lcohol ism a r e given.

Costa Rica

Costa Rica i s one of the few La t i n American n a t i o n s wi th a cons t an t o u t p u t of a l c o h o l s t u d i e s . Most of t h i s r e sea rch has been developed by the I n s t i t u t o Nacional Sobre Alcoholismo (INSA) s i n c e i ts i n c e p t i o n i n 1913 (INSA 1981a).

I n s p i t e of a l 1 t he e f f o r t s developed by t h i s i n s t i t u t e i n t he a r e a of t reatment and prevent ion, a l coho l consumption i n the country has been growing s t e a d i l y . I n 1961 the annual per c a p i t a consumption i n l i t e r s of abso lu t e a l c o h o l f o r t he popula t ion 15 yea r s o£ age and o l d e r was 2.7ó. I n 1979 i t w a s 4.76, a n i n c r e a s e of approximately 70 pe rcen t (Miguez 1980). About 2 pe rcen t of the annual per c a p i t a consumption i s o£ wine. The o t h e r 9d percent is e q u a l l y d iv ided among d i s t i l l e d s p i r i ts from sugarcane (rum) , o t h e r d i s t i l l e d s p i r i ts, and beer. Changes i n coneumption i n t h e two la t te r beverages accounted f o r the bulk o£ the i n c r e a s e i n the annual pe r c a p i t a consumption between 1361 and 1969. There were d i f f e r e n t r a t e s of change i n per c a p i t a consumption between 1969 and 1379 i n t h e d i f f e r e n t r eg ions of t he country. I n t he A t l a n t i c r eg ion the annual per cap i t a consumption r o s e from 4.3 t o 4.7 l i ters o£ a b s o l u t e a l coho l , a n i n a e a s e o£ 10 percent . I n the C e n t r a l r eg ion the p ropor t i ona l i n c r e a s e was 55 pe rcen t (from 3.3 t o 5.2 li t e r s ) . I n o ther r eg ions the i n c r e a s e ranged from 28 pe rcen t t o 66 percen t.

A L 1 these f i g u r e s on consumption do n o t take i n t o cons idera t i o n t h e c landes t i n e product ion o£ a l coho l1 c beverages , which accord ing t o Chassoul ( c i t e d i n Miguez 1980) i s s i m i l a r i n volume t o t h e product ion by the s t a t e monopoly. An example of t h i s i l l e g a l product ion and s a l e of a l c o h o l i c beverages su r f aced r e c e n t l y i n a survey of d r i n k i q p a t t e r n s i n the d i s t r i c t of Limon, l o c a t e d i n the A t l a n t i c r eg ion of Costa Rica. I n a community which o f f i c i a l l y had one l i c e n s e d p l ace t o se11 a l c o h o l i c beverages, t h e r e s e a r chers f ound 10 i l l e g a l opera t i o n s l o c a ted i n p r i v a t e r e s idences (INSA 1380a).

One o£ t h e f i r s t surveye on a l coho l - r e l a t ed problems i n Costa Rica i s t h a t of Adis Cas t ro and F lo re s (1967) who were a s se s s ing the prevalence of p s y c h i a t r i c d i s o r d e r s i n t he community. One of t he c a t e g o r i e s i n v e s t i g a t e d was alcoholism. The prevalence rates i n a s imple random sample of a r u r a l popula t ion was 1 3 pe rcen t among males , w i t h none among the females. I n a n urban sample, the p ropor t i on of a l c o h o l i c s was 24 pe rcen t and once aga in no a l c o h o l i c s were found among women.

More r e c e n t l y INSA has been sponsoring a series of surveys o£ the g e n e r a l popula t ion throughout Costa Rica i n a n e f f o r t t o o b t a i n d a t a on dr ink ing p a t t e r n s (INSA 1980a, b; U d l b , c , d , e , f ) . So f a r t he .pub l i shed surveys have covered 69 pe rcen t of t he a r e a of the countr y (pe r sona l conversa t i on , H.A. Miguez) . They a l1 p re sen t s i m i l a r m e thodologica l f e a t u r e s and u t i l i z e the same ca t ego r i e s and de£ i n i t i ons f o r t he va r ious types of d r inkers . Respondents were s e l e c t e d through a two-stage sampling procedure and were i n t e r v i e e d a t home by t r a i n e d personnel. Data were c o l l e c t e d through quest ion- n a i r e s and i n some surveys those diagnosed as a l c o h o l i c s were f u r t h e r in te rv iewed by a phys ic ian , who conf irmed o r re j ec t ed t h e i n i t i a 1 c l a s s i f ica t i o n , The de£ i n i t i o n s used t o i den t i f y abs t a i n e r s and d i f f e r e n t c a t e g o r i e s of d r i n k e r s were a s fol lows:

Abstainers : Never d r ink a l c o h o l i c beverages

Moderates: Drinks les8 than 120 cc.* (males) o r 6 0 cc. ( females) of a b s o l u t e a l coho l , i n one day o r per d r in ldng occasion, wi th a maximum frequency of t w i c e a month o r i t s e q u i v a l e n t i n a year . Excessives: Drinks 120 cc. o r more (males) o r 6 0 cc. o r more (females) i n one day o r i n one d r ink ing occasion, wi th a mínimum frequency of t w i c e a month o r i t s equ iva l en t i n a year.

Alcohol ics : Those who p re sen t any of t he f ollowing: i n a b i l i t y t o a b s t a i n , i n a b i l i t y t o s t o p dr ink ing , withdrawal syndrome (INSA 198 Oa: 39 ) . When g iv ing these d e f i n i t i o n s the au tho r s o f t he r e p o r t a do

n o t comment on why men were allowed twice a s much a l c o h o l a s women.

The r a t e of abs ten t ion among males v a r i e s from a minimum of 12 percent i n the c i t y o£ Limon t o almost twice a s much i n Santa ~ r u z . 2 Females have higher proportions of a b s t a i n e r s i n a l 1 the a r e a s s tudied. I n genera l t h i s proportion 1s three times higher than t h a t f o r males, with the exception of Puntarenas and San Iz id ro , where i t i s four times higher. A s with males, female abs tent ion r a t e s a l s o vary considerably ac ross a reas , going from 34 percent i n Limon t o almost twice a s much i n Santa Cruz. The propor t ion of modera te dr inkers a l s o presents v a r i a t i o n s ac ross a r e a s among both males and females. I n some a r e a s (Talamanca, Desamparados, Santa Cruz) men a r e more o f t e n moderate dr inkers than women, wtiile i n o the r a reas the opposite occurs.

Honduras

There have been very few s t u d i e s of a lcohol consumption and drinking p rac t i ces i n Honduras. Natera e t a l . (1982) summarizes eome o£ these s t u d i e s while describing the inves t iga t ion they c a r r i e d o u t i n t h a t country and Mexico. Two a reas of c e n t r a l Honduras were inves t iga ted using the "informant" me thod proposed by ~ e l l i n e k . 3 The informants were s e l e c t e d from r u r a l a r e a s and 30 groups were formed, with a t o t a l of U 8 pa r t i c ipan t s . A l 1 were males, a f a c t which p laces some l i m i t a t i o n s on the f ind ings , e s p e c i a l l y when the y ref e r t o women's sentiments towards alcohol inges t ion and drinking habi ts.

The ma j o r i t y o£ groups indica ted t h a t men i n Honduras begin to drink before U years o£ age, wtiile women begin t o do so a l i t t l e l a t e r , af t e r 19 years o£ age. This f i r s t drink 1s usua l ly taken "wi th f r i e n d s without pa ren t ' s permission." The groups reported a s t r i k i n g d i f ference i n the p laces where men and women do t h e i r drinking; 70 percent of the groups s t a t e d t h a t men do most of t h e i r drinking "only i n pub l i c places," while 60 percent declared t h a t women's drinking occurs "only a t home." Norms associa ted with drinking by men and wamen seem t o be very d i f f e r e n t . Most of the groups (57 percent ) declared t h a t both men and women disapprove of moderate drinking by wamen. According t o the groups, however, women would have a high degree of tolerance f o r drunkenness among men. Thus, 50 percent declared t h a t women s e e men's in tox ica t ion a s eomething wtiich i s "undesirable but t h a t one has to tolerate." Drinking was a l s o associa ted with s o c i a l and s p o r t a c t i v i t i e s .

*me-hundred- twenty cubic centime ters of absolute alcohol allows f o r the inges t ion o£ approximately 10.5 drinks each of which contains 9 grams of absolute alcohol. This 1s the a lcohol content of a 1 /2 p i n t o£ beer (4 percent ) , a 1 oz. drink of s p i r i t s (40 percent) , and a 4 oz. g l a s s of t ab le wine (10 percent) .

Guatemala

A g u i l l i e r a (1967 ) desc r ibes s o c i o c u l t u r a l a s p e c t s of a l coho l consump t ion , t r e a tmen t , and prevent ive programa. Rivera-Lima (197 3) p r s e n t s da t a on a l coho l production, a l coho l - r e l a t ed l e g a l of fensea , and the t reatment system. Bunzel (1940) desc r ibes dr inking i n a n Ind ian Community. A s wi th o t h e r Ind ian communities s t u d i e s , d r inkinp 1s a s s o c i a t e d w i t h f i e s t a s and market days, a l coho l 1s a l s o consuned i n l a r g e q u a n t i t i e s during dancing p a r t i e s , and dr in ldng may develop i n t o long s p r e e s t h a t may l a s t f o r days. Such s p r e e s a r e marked by d i s t r u p t i v e behavior inc luding q u a r r e l s between neighbors and f a m i l i e s and l o s 8 o£ money; t h e i r r e s u l t i s , a s Bunzel p u t s i t , "an enduring a f termath of g u i l t and anxiety."

Caribbean

Rum has been acknowledged t o p l a y a n important p a r t i n t he Caribbean cu l tu re . Rals ton (1980) t raced t h i s i n f luence back t o the seven teenth cen tury, when sugar p l an ta t ione rep laced tobacco £ arma i n the i s l ands . Beaubrun (1967 a ) , commenting on the r a t e s of a l c o h o l i c admissions t o mental h o s p i t a l s i n t he a r e a a t a t i m e when no prevalence d a t a w a s a v a i l a b l e , s t a t e d t h a t these i n d i c a t o r s suggested the e x i s t e n c e of a problem o£ "some s ize ." Y e t , t he re have been few s t u d i e s of dr inking p a t t e r n s and the r o l e o£ a lcohol i n t he c u l t u r e s of t he region.

I n Jamaica, Beaubrun (1967b) r e p o r t s a s t u d y o£ alcoholism and drinking p a t t e r n s i n Kingston, the c a p i t a l and the l a r g e s t c t i y on the i e l and . A t o t a l of 1,317 i n d i v i d u a l s Id years of age and o lde r were interviewed, comprising a random sample of four socioeconomic l e v e l s o£ the c i t y . The d a t a c o l l e c t i o n ins t rument was a question- n a i r e developed by the Aicohol Impact Study Group o£ the Maudsley Hospi ta l , London. The r e s u l t a showed a r a t e o£ a b s t e n t i o n of 10 percent among males and o£ 25 percent among females. The prevalance of heavy drinking among men was 38 percent . Drinking was p o s i t i v e l y a s s o c i a t e d wi th age , w i th the h ighes t r a t e s o£ d r inke r s being found i n the 40-44 age group. Heavy dr inking was p o s i t i v e l y a s s o c i a t e d wi th income (us ing r e s i d e n t i a l s t a t u s a s a n i n d i c a t o r ) , educat ion, being white o r of East Indian o r i g i n , and lacking r e l i g i o u s a f f i l i a t i o n . The e s t ima ted prevalence of a lcoholism i n the t o t a l populat ion of t he i s l a n d was 5 percent .

I n Tr in idad , Yawney (1979) s t u d i e d alcoholism and drinking p a t t e r n s among E a s t Ind ian men and blacks. She emphasizes the g r e a t a v a i l a b i l i t y o£ rum, which can be purchased i n "rumshops" i n any amount by the l o c a l populat ion. These shops a r e a combination o£ "corner s t o r e " and "neighborhood tavern ," a l s o se rv ing food and s e l l i n g provisions. Drinking 1s casual , women a r e h a r d l y eve r presen t , and there l e a gene ra l a t ti tude o£ permissiveness towards a l coho l inges t ion.

Pa t t e rns of drinking i n Barbados were s tudied by Dann (1980). Data c a e from in terviews with 437 respondents s e l e c t e d through a e tra t i f i e d random procedure f rom amo* the Barbadian adul t population. The o v e r a l l response r a t e f o r the s tudy was 97 percent. The r e s u l t s showed 26 percent abs ta ine r s among men (54 o u t of 2 8 ) , and 57 percent (13 o u t of 231) among women. Drinking was pos1 t i v e l y a s soc ia ted wi th being young, unmarried, wi thout r e l i g i o u s a f f i l i a t i o n , employed, having a high income, and l i v i n g i n a semi-urban o r urban area . The average annual per cap i t a consumption i n liters of absolute a lcohol f o r the sample wae 7.24. The prefer red beverages were rum and beer f o r both men and wmen, bu t preference changed according t o place of ingest ion. Rum was the most coneumed beverage i n rumshops, a t home, a t o the re ' homee, and " i n the open a i r . " Beer was the most coneumed beverage a t p a r t i e s , p icnics , bars , and nightclube. I n the workplace, during lunch breake, the beverage of preference was gin. The prefer red l o c a l e f o r drinking was the home, followed by o t h e r ' s homes, followed by p a r t i e s . The ma jor sex d i f ference was t h a t a l a r g e r proportion of men than women prefer red t o drink i n rumshops. The rumehop was i n f i rs t place i n r e l a t i o n t o a l 1 o the r drinldng loca les , when the number of hours spent drinking, the quan t i ty conernd , and expendi tures on a lcohol were considered.

Using d e f i n i t i o n s based on percentage of t i m e spent drinklng, annual amount of a lcohol drunk, and percentage of annual n e t incopie spent on a lcohol , Dann cone tructed a typology of dr inkers a s f ollows : o ccasional, r egu la r , and heavy. The prevalence of each type of drinker among males (whole sample), a s reca lcula ted by t h i s reviewer, were: o ccaeional, 34 percent; r egu la r , 27 percent; heavy, 13 percent. Por women the r a t e e were: occasional , 40 percent; r egu la r 2 percent; heavy, 0.4 percent.

A p r o f i l e of the heavy drinker, a e o f fe red by Dann, may serve t o charac ter ize t h i s r u b r i c when contras ted t o drinldng pa t t e rns of the sample a s a whole. Thue, while the average number of hours epent dr inki ry per year f o r al1 drinkers i n the sample was 293.16 hours, the heavy dr inkers ' average was f i v e timee t h i e number. Mean annual consunption f o r dr inkers i n the sample w a s 12.7 l i t e r e of absolute a lcohol , while f o r heavy dr inkers i t wae 83.7 l i t e r e . This allowe f o r the consumption of 1 p i n t of s p i r i t e per day. Frequency of drunkenness among heavy dr inkers was once every 8 days, while 75 percent of a l1 dr inkers g o t drunk l e e s than once a year.

Mexico 1s one of the La t in American countr ies where a lcohol probleme have received coneiderable a t t e n t i o n f rom resear chers, and a nunber of s t u d i e s have been c a r r i e d o u t there i n both general population and epec ia l groups. Some of these have been reviewed by Cabildo (1967), and the information below 1s taken from h i s review.

Three o£ the i n t i t i a l e tud iee providing informat ion about a l coho l probleme i n Mexico were c a r r i e d o u t t o a e s e s s the prevalence o£ p e y c h i a t r i c pathology i n genera l . A s such, they focused on the d iagnoeis o£ a lcohol i sm only , wi thou t touching o t h e r dr inking problene o r dr inking p a t t e r n s . The Direccion de Salud Mental y l l i reccion de B i o e s t a d i s t i c a ( c i t e d by Cabildo, 1967 ) eurveyed a n a t i o n a l sample and found the r a t e of a lcoholism was 0.55 percent . Cabildo (1967) s t u d i e d employeee from the Mexican government. uit of a t o t a l popula t ion o£ 568,396 a 2 percent eample w a s taken; t he rate o£ alcoholism was 0.7 percent . The quee t ionnai re used i n the Cabildo survey was ueed by Ayuso e t a l . ( c i t e d by Cabildo, 1967 ) on a eample (N=3,231) o£ m i l i t a r y personnel. The prevalence o£ alcoholism was the same 0.7 percent .

Maccoby ( U 7 2 ) c a r r i e d o u t a s tudy o£ alcoholiem among males 16 yeare and above i n a mest izo a g r i c u l t u r a 1 community. Drinkere were c l a s s i f i e d according t o Marconi 'e typology o£ moderate, exceeeive, and a l coho l i c s . But Maccoby d i d n o t u se Marconi's opera t i o n a l de£ i n i t i ons . Alcoholiem wae de termined by the degree of f a i l u r e t o me t s o c i a l ob l iga t ions . Exceesive dr inking was def ined by dr inking beyond c u l t u r a l norme, e.g., l o s i n g workdaye becauee of dr inking. Moderate dr inking was t h a t mode o£ i n g e s t i o n which d i d no t i n t e r f ere w i t h s o c i a l r e s p o n s i b i l i t i e e . W i t h theee de£ i n i t i ons the r a t e o£ alcoholiem among malee i n t he v i l l a g e wae 14.4 percent. There were 13 pe rcen t excess ive d r inke r s , 52 percent moderate d r inke r s , and 16 pe rcen t abe t a ine re . Another 4 percent of the men were c l a s s i f i e d a s c u r r r e n t abe ta inere . Heavy dr inking wae p o e i t i v e l y a s s o c i a t e d with age. Of the male populat ion 40 years o£ age and o l d e r , 32 pe rcen t were a l c o h o l i c s and 16 percent were excess ive dr inkers . Among those l e e s than 40 yeare o£ age t h e propor t ion o£ a l coho l i ce and exceseive dr inkere was 8 percent and 12 percent , r e spec t ive ly .

Another e tudy i n a r u r a l community l e t h a t descr ibed by Smart e t a l . (1980), and Natera e t a l . (lY81, 1982) which u t i l i z e d the "informan t" me thod t o c o l l e c t i n f ormation on dr inking pa t t e r n e .3 The community 1s l o c a t e d eouthwest of Mexico C i t y and has 5,198 inha- b i t a n t s . The i n v e s t i g a t i o n c o l l e c t e d information from 30 groups o£ 5 people each. The average d a i l y consumption o£ d i f f e r e n t t ypes of a l c o h o l i c beverages among the male populat ion was 1.5 l i t e r a o£ pulque, 2 b o t t l e e o£ beer , and ha l f a g l aee o£ d i e t i l l e d e p i r i t s . Women r e p o r t e d l y dr ink most ly a t home and dr ink l e e s than men, bu t have a g r e a t to le rance f o r men's heavy drinking. Reasone £ o r dr inking, i n decteaeing order o£ importance, a r e : "habi t , " " t o br ing f r i e n d e c loee r , " " to r e s t , " " to calm d o n the nervee," " to make work eas i e r . " Reaeone f o r n o t dr inking , a l e o i n decreasing o rde r o£ importance , a re : "heal th reasons, " "moral reasons , " "e conomic reasone, " "af r a i d o£ the coneequencee, " "f amily problems, " "work problems , " " d i e l i k e the t a s te . "

More recent ly , the I n s t i t u t o kkxicano de P e i q u i a t r i a (kkxican P s y c h i a t r i c I n s t i t u t e ) h a s c a r r i e d o u t a number of surveye of drinking p rac t i ces i n severa1 Hexican cides. The infonnation srnnmarized here are from s t u d i e s of drinking among the population of La Paz (Medina-Mora e t a l . 1978), San Luis Potos i ( D e l a Parra e t a l . 1980), and Xexico C i t y (Hedina+íora e t a l . 1980). I n a l 1 three eurveys the eampling methodology, da ta c o l l e c t i o n proceduree, and drinldng c l a s s i f i c a t i o n s were the same. These s t u d i e s found one-fourth to one-third of malee, and one-half of the women, were abs ta iners . Another one-third of both men and women were infrequent dr inkers , 1.e. drank les8 than once a month, bu t a t least once a year. Drinking c l a s s i f i c a t i o n s r e f l e c t e d a much lower l eve1 of a lcohol inges t ion than i n o the r s tudies . For example, regular hab i tua l dr inkers were deecribed a s those who drink three o r more times per day a t l e a s t once o r M c e a month, and consume f i v e o r more drinks per occasion. Excessive drinking and alcoholism were no t l i s t e d a s i d e n t i f i e d categories.

The moet r ecen t , and c e r t a i n l y the most comprehensive, s tudy of drinking p a t t e r n s i n the general populardon i n Hexico i s t h a t c a r r i e d o u t a s p a r t o £ the üHO s tudy of coaununity responses t o alcohol-related problems. This s tudy w a s ca r r i ed o u t i n two other c o u n u i e s besides Hexico -- Zambia and Scotland -- i n the framework of in te rna t iona l col laborat ion. The same i n s truments f o r data co l l ec t ion and the same methodology were appl ied i n each country. Adherente to the agreed procedures was ensured by a series of meeting8 which brought together the research teams and where the me thods were discussed and agreed upon.

Complete r e p o r t s f o r t h i s s tudy a r e forthcorning. Data from Mexico have been described both by Calderon e t a l . (1981) i n the r e p o r t from t h a t country and by Roizen (1981) i n a cross-cultural review of f ind ings from kkxico, Zambia, and Scotland. According t o Calderon e t a l . the work i n Mexico began i n 1976 and the objec t ives to be achieved were: a ) t o s tudy drinking p a t t e r n s and alcohol- r e l a t e d problems and d i s a b i l i ties; b) t o s tudy community responsee t o d r i n k i q and the ways i n which the coaununity i n general and i ts speci f i c i n s ti tu t ions handled a l cohol-rela ted problems. The two coaununities s tudied i n Mexico, one r u r a l and the o the r urban, a r e both i n the v i c i n i t y of Hexico C i t y and had a h i e t o r y of drinking problems. Subjects f o r the s tudy were se lec ted by a two-step eampling procedure from among the population 15 years of age and o lder . Because drinking problems a r e more prevalent among the male population, i t was decided t o oversample t h i s population s o t h a t two-thirds of the respondents would be males.

Among males 22 percent were c l a s s i f i e d a s regular dr inkers (dr ink a t l e a s t once a week). Approximately 25 percent were judged t o be intermediate dr inkers (dr ink between one and three t i m e s a month) and another 30 percent f e11 i n the category of occasional

dr inke r s (d r ink l e s s than once a month b u t a t l e a s e once a year) . The prevalence of a b s t a i n e r s was 19 percent . Among females t he propor t ion of both r egu la r and in te rmedia te d r inke r s w a s 9 percent . Occasional d r inke r s and a b s t a i n e r s had prevalence r a t e s o£ 40 percent and 42 percent , r e spec t ive ly .

h i z e n (1981) provides a d e t a i l e d a n a l y s i s o£ the Mexican da t a from the WHO study. Approximately 40 percent o£ the a lcohol consmed i n Mexico 1s es t imated t o come from d i s t i l l e d s p i r i t s ( e s p e c i a l l y t e q u i l a and rum). Beer and s p i r i t s together comprise 88 pe rcen t o£ the t o t a l a l c o h o l consumption. Aimost a l 1 t h e r e s t 1s supp l i ed by pulque, a fermented beverage made from the sap of the maque y cactus.

The a s s o c i a t i o n of dr inking wi th age 1s such t h a t middle-aged men show the l a r g e r percentage o£ d r inke r s (91 pe rcen t ) , followed by young men (83 pe rcen t ) , followed by o l d e r men (76 pe rcen t ) . Among women there i s n o t much change i n the percentage o£ d r inke r s i n r e l a t i o n t o age. I n gene ra l 50 percent of t he women, independent o£ age, a r e dr inkers . D r i n k i w a t l e a s t once a week 1s more f requent among men than among women, among r u r a l tnan among urban respond- e n t e , among the o l d than among the young. Twenty-seven percent o£ wmen d r inke r s and 59 percent of male d r inke r s g e t drunk l e e s than o r about once a month. Frequency of being drunk a t l e a s t once a week i e 7 percent among male d r inke r s and 1 percent among female dr inker s.

The most f r e q u e n t l y s t a t e d reasons f o r dr inking a r e a s fol lows: "a good way t o ce l eb ra t e " (rilen, 50 percent ; women, 38 pe rcen t ) , " l i k e the f e e l i n g of g e t t i n g high o r drunk" (rnen, 43 percent ; women, 27 pe rcen t ) , "i t i s what most o£ my f r i e n d s do" (men, 55 percent ; women, 44 percent) . The high propor t ion of d r inke r s dec l a r ing a s reason f o r dr inking "ge t t i ng high o r drunk" seems t o i n d i c a t e approval o£ dr inking t o i n t o x i c a t i o n .

Norma r egu la t ing dr inking by s e x i n t he communities a r e ve ry d i f f e r e n t . While 27 pe rcen t o£ the sample would condone drinking by a man 21 p a r e o£ age, twice a s many o r 53 percent would n o t condone i t f o r a woman the same age. A man 40 years o l d should d r ink , according t o 15 percent of the sub jec t s ; 43 percent disapproved o£ dr inking by a woman of 40.

Male d r inke r s r e p o r t high r a t e s o£ personal problems: 55 pe rcen t r e p o r t g u i l t over dr inking , 55 percent £ e l t they shouid c u t down o r s t o p dr inking a l t o g e t h e r , 36 percent experienced hands shaking i n the morning a f t e r drinking. Male d r inke r s i n the r u r a l area repor ted approxima t e l y twice a s many problems a s t h e i r urban counterpar t s .

The presence of problems o r i g i n a t i n g from adverse s o c i a l r e a c t i o n e t o t h e s u b j e c t ' s d r ink ing was a l s o i n v e s t i g a t e d i n t h e WHO study. The s o c i a l problems most of t e n r epo r t ed by male d r inke r s were: " f e l t e f f e c t s o£ a l c o h o l a t work" (35 pe rcen t of urban d r inke r s , 49 pe rcen t o£ r u r a l d r inke r s ) ; "family and f r i e n d s problems" (32 pe rcen t o£ urban d r i n k e r s , 41 pe rcen t of r u r a l d r inke r s ) ; "ashamed o£ what you d i d whi le drunk" (28 pe rcen t o£ the urban d r inke r s , 45 pe rcen t o£ t h e r u r a l d r inke r s ) . Problema i n t h e workplace, wi th p o l i c e , and a c c i d e n t s were r epo r t ed by 1 pe rcen t t o 6 pe rcen t of t h e male d r inke r s . Female d r i n k e r s both i n t h e urban and i n the r u r a l community r epo r t ed fewer problems than male d r inke r s . However, t h e type o£ s o c i a l problems r epo r t ed most £ r equen t ly were the same as those r epo r t ed b jr men.

Although t h e above provides some d e t a l l , i t does n o t s u f f i c i e n t l y r e v e a l t h e r i c h n e s s o£ t h e d a t a provided by the WHO s tudy. Many o£ these r e s u l t s acqu i r e more s i g n i f i cance when they a r e compared w i t h s i m i l a r d a t a £ rom t h e two o t h e r coun t r i e s i n the s tudy , Zambia and Scot land. Roizen 1s i n a much b e t t e r p o s i t i o n t o i n t e r p r e t the Mexican d a t a than t h i s reviewer, and t h i s 1s what he had t o say:

And what should we make o£ the Mexican circumstance, where i n s p i t e of the e x t r a o r d i n a r y in f requency of dr ink ing , 8 ti11 suba t an t i a 1 a lcohol - re la ted problems a r e r epo r t ed , even by n e a r l y abstemious women? I n t h e Mexican d a t a one has t h e d i s t i n c t f e e l o£ t h e presence o£ a n ove r r id ing c u l t u r a l nega t i v i t y toward a lcohol : perhaps a r h e t o r i c a l d i s p o s i t i o n s o 8 t rong ly i n c l i n e d aga ins t dr ink ing a s t o promp t e x t r a o r d i n a r y r e p o r t a o£ i ts e v i l doings.. .This body of an t id r inkng r h e t o r i c , then, may f u n c t i o n a s a k ind of w e l l o u t o£ which those who a r e n o t permi t ted acces s t o d r ink a r e ob l iged t o d i p their l a d l e s . . .We have seen, i n the Mexican case e s p e c i a l l y , a circumstance i n which v e r y high pos1 t i v e repor t8 on i n d i c a t o r s sometimes regarded a s i n d i c a t i v e o£ a dependence on a l coho l never theless a r e q u i t e compatible wi th a ve ry low frequency o£ dr ink ing on the whole (Roizen 1981: 51-52).

The Per cep t i o n o£ A l cohol-Problems i n La t i n America: J e l l i n e k ' s Chi lean Connection

From the vantage p o i n t of t h e 'dos i t appears t h a t the 19% v i s i t t o Ch i l e by E.M. J e l l i n e k was t he most important f a c t o r i n the development of a l c o h o l epidemiology i n L a t i n America. This 1s n o t t o i gno re the f a c t t h a t by 1956 Ch i l e a l r e a d y had a t r a d i t i o n i n d l coho l research . J o r g e Mardones, t o whom J e l l i n e k dedica ted h i s

book Tne Disease Concept of Alcoholism, and who w a s a member of t h e WHO Expert Committee on Mental Heal th and on Alcohol wi t h J e l l i n e k and o &eres w a s t h e head of t h e I n s t i t u t o de Inves t i gac iones sobre Alcoholismo of the Un ive r s i t y of Chi le . Mardones had been a c t i v e l y developing exper imenta l ly -or ien ted r e sea rch on a l coho l p r i o r t o J e l l i n e k t s v i s i t . H i s work a t the time was d i r e c t e d towards research ing t h e a s s o c i a t i o n be tweeu a l c o h o l i n t a k e and v i tamin de f i c i ency , and i t 1s discussed i n d e t a l l by J e l l i n e k (1960). Also, Varela and Marconi (1952) had a l r e a d y publ ished what probably i s t h e f irs t r e p l i c a t i o n of J e l l i n e k ' s U46 s tudy of symptoms of a lcohol ism ( J e l l i n e k 19 46 ) .

Bu t a f t e r J e l l i n e k t s v i s i t ep idemiologica l r e sea rch f l o u r i s h e d , and Marconi publ i shed h i s f i r s t paper on the d i s ea se concept based on J e l l i n e k ' s work (Marconi 1959).4 Other papera fol lowed (Marconi, 1964, 1905, 1967b, 1 9 8 7 ~ ) i n which Marconi was n o t o n l y concerned w i t h f u r t h e r i n g t h e d i s e a s e concept, bu t a l s o w i th de£ i n i n g a lconol i sm a t a n opera t i o n a l l e v e l . These opera t i o n a l d e f i n i t i ons , developed f o r u s e i n ep idemiologica l surveys i n t h e communi t y , f ound enormous accep tance among a l c o h o l - epidemiologis t e i n La t i n A m e r i can na t i ons , and became a s tandard concep t a p p l i e d i n a number of prevalence s t u d i e s i n Ch i l e , Argent ina, B r a z i l , Peru, hiexico, and Costa Rica.

Athough Marconi subscr ibed e n t i r e l y t o J e l l i u e k ' s d i s e a s e concept, t he re a r e many p o i n t s of s u b s t a n t i a l d i f f e r e n c e between their work. Thus, J e l l i n e k ' s d e f i n i t i o n of a lcohol i sm 1s purposely l oose and vague. H e understands alcohol ism as :

. . .any use of a l c o h o l i c beverage t h a t causes any -

damage t o the i n d i v i d u a l o r s o c i e t y o r both ( J e l l i n e k , 1960:35) .5

Marconi de£ i n e s a lcohol i sm as:

. . .a ch ron ic d i s e a s e cha rac t e r i zed by a fundamental d i s turbance of the c e n t r a l nervous system whi ch mani fes t s i t s e l f i n a group of bod i ly symptoms and s i g n s t h a t g i v e a n imperious cha rac t e r t o the concomitant d e s i r e t o d r ink a lcohol . On the behavioral l e v e l , the d i s ea se mani fes t s i t s e l f by a yrimary o r secondary s t a t e of phys ica l dependen- on the drug. The symptoms disappear temporar i ly a f ter t h e consumption of a c e r t a i n q u a n t i t y of a l coho l (Marconi 1959:221).5

Marconi's d e f i n i t i o n 1s more p r e c i s e from t h e beginning and does n o t mention a l coho l - r e l a t ed "damage" o r problema a s a pos s ib l e i n d i c a t o r of t he d i s ea se . The absence of a l coho l - r e l a t ed problems from the d e f i n i t i o n s of both excess ive d r i n k e r s and a l c o h o l i c s i n

L a t i n America i s one of t he major d i f f e r e n c e s between drinking typologies developed i n t h e U.S. and La t i n America. Thus, t he U.S. concept o£ "problem dr inker" does n o t have a p a r a l l e l i n L a t i n American epidemiological l i t e r a t u r e . Marconi's excess ive dr inker i s roughly comparable t o the heavy d r inke r ca tegory i n the U.S. l i t e r a t u r e , bu t even he re t h e l i m i t e of i u e s t i o n may v a r y widely. The U. S. concep t o£ "problem dr inker" encompasses bo th excess ive d r i n k e r s and a l c o h o l i c e a s def ined by Marconi.

Marconi '8 de£ i n i t i o n cha rac t e r i ze s alcoholism as a pathology of t h e c e n t r a l nervous system. Por him t h i s conception i s a n unavoidable conseyuence o£ cha rac t e r i z ing alcoholism by the phenomenon o£ phys i ca l dependence. Th i s i s how he pu t s i t:

. . . i £ (phys i ca l dependence) i s def ined as the coexistence of a e t a t e o£ i n t e n s e d i s t r e s s , u s u a l l y one o£ anx ie ty , and o£ s trong d e s i r e t o i n g e s t a lco- h o l i c beverages, we mus t pos t u l a te the e x i s tence o£ c e n t r a l neurona1 c i r c u i t s capable o£ unchaining spontaneously o r under t he s timulus of small doses o£ e thano l those phenomena coneciously r e g i s t e r e d by the p a t i e n t (Marconi 1967 b:634).

Br i e f ly , Marconi (1965, 1967 b, 1971) and Marconi e t a l . (1965, 1310) p o s t u l a t e t he e x i s t e n c e o£ two c e n t r a l nervous c i r c u i t s l oca t ed i n the hypothalamus: one would r e g u l a t e t h e a p p e t i t e f o r a l c o h o l and the second the appearance of anxie ty . I n t he " intermi t t e n t" type o£ a l coho l i c , whi ch Marconi (1959 ) descr ibes as experiencing shor t pe r iods (days o r weeks) of a b s t inence, a l coho l i n g e s t i o n d i r e c t l y s t i m u l a t e s these c i r c u i t s , w i th t he wnsequent appearance o£ "phys ica l dependence" a s evidenced by " i n a b i l i t y t o s top" ( l o s s o£ con t ro l ) . I n the "continuous" type of a l coho l i c , de f ined a s thoee d r inke r s who experience i n t e r v a l s o£ severa1 hours between one dr inking occasion and the nex t , the mechanism t r igge r ing t h e appearance o£ phys i ca l dependence i s d i f f e r e n t . I n t h i s ca se the c e n t r a l nervous system c i r c u i t s a r e depressed by the continuous i n g e s t i o n of a l coho l , and i t i s the ab rup t r educ t ion o r t he decrease i n the £ requency o£ a l coho l i n t a k e tha t t r i g g e r s the pa thologica l r e a c t i o n causing phys i ca l dependence, which then appears as " i n a b i l i t y t o abs ta in."

These two mechanisms exp la in the appearance o£ one o£ the forms o£ phys ica l dependence. Thie i s the type o£ dependence which i s a t t he foundat ion, as mentioned, o£ two o£ the t h r e e c l i n i c a l forme o£ alcoholism a s proposed by Marconi: t he " in t e rmi t t en t" and the "continoue" a l c o h o l i cs. Using J e l l i n e k ' s t ypology, t hese would be the "gamma" and the "de l t a " a l c o h o l i c s , r e spec t ive ly . A t h i r d c l i n i c a l £ orm p u t £ orward by Marconi, t h e " remi t ten t" a l c o h o l i c , corresponds t o J e l l i n e k '8 "epsilon", a f orm o£ alcoholism w h i ch

J e l l i n e k d i d n o t i n c l u d e w i t h i n the boundaries of the d i sease concept. Thie type of a l c o h o l i c i s cha rac t e r i zed by Marconi (1959) a s presen t ing long pe r iods o£ e l t he r abe t i nence o r modera te dr ink ing between pe r iods of a d d i c t i v e dr inking. I n t h i s case, t h e phys ica l dependence appears epontaneousl y w i thou t any a l c o h o l i nges t ion .

Th i s pa thogenic theory o£ a lcohol i sm puta forward a r e l a t i o n s h i p between cause and e f f e c t which 1s d i f f i c u l t t o accept . The mal£ unct ioning of t h e c e n t r a l nervous s ystem neurona1 c i r c u i ts, a s proposed by Marconi, 1s a t one t i m e t r i g s e r e d by the presence of a l coho l , a t another time by i t s absence o r by a r educ t ion i n a l c o h o l i n t a k e , and a t a t h i r d t i m e occurs spontaneously. Empir ical evidence i n suppor t of t h i s theory 1s l adc ing a s of today and, t he re fo re , Marconi '8 i d e a s remain t e n t a t i v e .

How can wide acceptance o£ Marconite concepts by L a t i n American r e sea rche r s be expla ined i n t he l i g h t o£ t h i s c r i t i c i s m ? F i r s t , Marconi 1s concerned n o t o n l y with f u r t h e r i n g t h e d ieeaee concep t , bu t a l s o w i th def i n i n g alcohol ism, modera te dr ink ing , and exces s ive dr ink ing a t a o p e r a t i o n a l l e v e l . It 1s pose ib l e then t o i d e n t i f y two d i e t i n c t (a l though connected) themes i n Marconi 'S

papers. One i s eminen t l y neurophysiological and 1s a s s o c i a ted w i th h i s pathogenic theory of alcoholism. The o t h e r l e epidemiological and can be exemplif i e d by h i s concern wi th l a y i n g o u t "ob jec t ive i n d i c a to re" of a lcohol iem whi ch would a l low £ o r the i d e n t i f i c a t i o n o£ t h i s condi t ion i n ep idemiologica l surveys. Alcohol epidemio- l o g i s t s may w e l l have been u t i l i z i n g Marconi's ope ra t i ona l d e f i n i t i o n s wi thout n e c e s e a r i l y subscr ib ing t o h i e pathogenic theory of a lcohol ism.

Second, i n t h e overwhelming m a j o r i t y o£ ca se s epidemiological s t u d i e s of a l c o h o l i n L a t i n America have been authored by phys ic ians , and the no t ion t h a t a lcohol iem per se could be considered a s a e p e c i f i c d i s ea se was t he re fo re n o t s o f 0 r e i ~ n . 7

I n the U.S. and i n some Scandinavian coun t r i e s , on t he o t h e r hand, s o c i o l o g i s t s have been ve ry a c t i v e i n t h e f i e l d of a l coho l research. Th i s i n t e r e s t seems t o have emerged from the combination o£ a g e n e r a l concern f o r a n important s o c i o c u l t u r a l t o p i c (a lcohol and i t s u s e s ) and the empi r i ca l o r i e n t a t i o n o£ U.S. sociology, which provided the knowledge and the t o o l s ( survey r eeea rch ) necessary t o develop r e sea rch i n the sub jec t . Thue, one of t he main p o i n t s of d i f f e r e n c e be tween t h e U. S. and ia t i n America wi th regard t o a l c o h o l s t u d i e s 1s the involvement of s o c i a l s c i ences and the consequent development of competing a l t e r n a t i v e s t o t he d i s ea se model of alcoholism.

Both i n t h e U.S. and La t i n America, suppor t e r s of t h e d i eease concept have been q u i d t o p o i n t o u t t h a t t h e understanding o£ a lcohol i sm a s a d i s e a s e helped t o change t h e l a b e l l i n g of a l c o h o l i c s

as mora l ly degraded, and paved the way f o r t h e p u b l i c h e a l t h approa ch t o a l c o h o l problems .

I t i s a l s o yo in t ed o u t t h a t the d i s e a s e concept helped t o c r e a t e a new f i e l d of r e sea rch and t h e r e f o r e l e g i t i m a t e d the a s p i r a t i o n s o£ a l c o h o l r e s e a r c h e r s f o r career development, f unding , and p ro fe s s iona l r e s p e c t a b i l i t y . It brought this new f i e l d under t h e w i q g of a n a l r e a d y powerful e s t a b l i s h e d p ro fe s s iona l group -- medicine -- thus i n c r e a s i n g i t s chancea f o r r ecogn i t i on i n the s c i e n t i f i c communi ty. W i th t h i s new paradigm, a l c o h o l s p e c i a l i s ts became more organized and developed i n t o a n e f f e c t i v e group.8

Undoubtedly, these p o i n t s have v a l i d i ty. However, the widespread acceptance o£ the d i s e a s e concept and of Marconi's opera t i o n a l de£ i n i t i o n s has no t been w i thou t consequences t o L a t i n American r e sea rch on a l c o h o l problems. C la rk (1975) h a s d i scussed adequa te ly some of the imp l i ca t i ons of t h e d i s e a s e concept f o r r e sea rch . I n L a t i n America, t h e fo l lowing consequences a r e r e a d i l y i d e n t i f i a b l e :

1 ) General popula t ion surveys i n L a t i n America have been basi- c a l l y concerned wi th a s s e s s i w t h e prevalence of alcoholism. Even those who estimate t h e prevalence of d i f f e r e n t types of d r inke r s do s o o n l y secondar i ly , focus ing t h e i r d i s cus s ion and a n a l y s i s on t h e pa tho log ica l dr inlrers (excess ive d r inke r s and a l c o h o l i c s ) . Once t h e gene ra l popula t ion surveys of t h e l a t e '50s and ' Ó O s were developed, and the prevalence o£ a lcohol i sm was e s t a b l i s h e d , epidemiologically-oriented r e sea rch j u s t ground t o a h a l t i n many count r ies . However, l i t t l e can be done w i t h such nose-count in format ion o t h e r than using i t t o provide a n adequate number of h o s p i t a l beds f o r t h e discovered a l coho l1 cs .9

2 ) As a c o r o l l a r y o£ t h i s concent ra t ion of e f f o r t s t o assess t h e number of exces s ive d r i n k e r s and a l c o h o l i c s , s o c i o c u l t u r a l f a c t o r s a s s o c i a t e d wi th dr ink ing have been l e £ t neglec ted i n the L a t i n American a l c o h o l l i t e r a t u r e . Th i s i s n o t t o s a y t h a t r e sea rche r s have n o t under l ined t h e importance o£ such f a c t o r s f o r understanding a l coho l abuse. A number o£ au tho r s (Negrete 1973, 1974, 1976a; Adis Cas t ro 1966; Heath 1974; Mariateyui 1961 b, U87 c) have emphasized t h e n e c e s s i t y o£ paying a t t e n t i o n t o those c h a r a c t e r i s t i c s of t he s o c i a l environment t h a t have a bear ing o n a l c o h o l use. Y e t , when i t comes t o s tudying t h e phenomenon i n t he community, o n l y t h e more s eve re forms o£ i n g e s t i o n are addressed. The o n l y except ion t o t h i s seems t o be t he e thnographic s t u d i e s developed amow n a t i v e peoples , some o£ which have been mentioned here . Ou t s i d e these popula t ions , which a r e concent ra ted i n sma l l towns and r u r a l a r e a s , l i t t l e i a known abou t reasons £ o r d r i d c i w , dr ink ing contex ts, norms, a t t i t u d e s , and b e l i e f s a s s o c i a t e d w i th a l coho l u se i n L a t i n Ameri ca.

3) The use of i n d i c a t o r s such a s " i n a b i l i t y t o s top" o r " i n a b i l i t y t o a b s t a i n " a l l ows f o r t h e i d e n t i f i c a t i o n o£ a group of d r i n k e r s w i t h s eve re a l coho l problems i n t h e gene ra l popula t ion and who may be i n need o£ he lp . Whether t hey have a d i s e a s e c a l l e d a lcohol i sm o r n o t becomes secondary i f the purpose i s t o i d e n t i f y and assess the prevalence o£ these d r inke r s . However, by us ing o n l y these i n d i c a t o r s , a long wi th amount and f requency of dr ink ing , t o i d e n t i f y " a t r i s k " d r i n k e r s , the broader range o£ a l coho l - r e l a t ed problems remains l a r g e l y unexamined. Clark (1976 ) has a l r e a d y demonstrated f o r t he U.S., a t l e a s t , t h a t " l o s s o£ cont ro l" does n o t c o r r e l a t e h i g h l y w i th s c a l e s t h a t a s s e s s problems i n s o c i a l f unc t ion ing caused by dr inking. Thus, l i t t l e 1s known abou t t he a s s o d a t i o n between dr ink ing and the occurrence o£ problems i n a r e a s such as i n t e r p e r s o n a l r e l a t i o n s h i p s (wife , f r i e n d s , r e l a t i v e s , working r e l a t i o n s , and l e g a l problems) amo% t h e g e n e r a l popula t ion i n La t i n ~ m e r i c a . 1 0

4 ) The majori t y of ef f o r t s t o prevent a l c o h o l problems have been concent ra ted i n Ch i l e , a s r e f l e c t e d i n r e a d i l y a v a i l a b l e , publ ished research . These programe have been developed under t he framework of t he d i s e a s e concept and thus aimed a t t h e prevent ion of a lcohol i8m (Marconi 1966, 1969, 1976 ; Feuerhake e t a l . 1980; M i n o l e t t i and Demjean 1976) r a t h e r than t h e whole gamu t of a l coho l - r e l a t e d problems.

Data from the g e n e r a l popula t ion i n t he U.S. show t h a t there a r e b a s i c d i f f e r e n c e s i n c h a r a c t e r i s t i c s such a s age , s o c i a l class, o ccupa t i o n a l s t a tus , and mar1 tal s t a tus be tween c l i n i cal popula t i o n s and problem d r i n k e r s i n the community. Th i s sugges t s t h a t those diagnosed a s a l c o h o l i c s a r e a d i f f e r e n t popula t ion from those wi th a l coho l problems who have n o t reached the c l i n i c door. Fu r the r , problems i n t ne g e n e r a l popula t ion do n o t a t a l 1 resemble problems i n d i n i c a l groups. I n the g e n e r a l popula t ion problems a r e "d i f fu se and sporad ic , " and the presence of a p a r t i c u l a r problem has o n l y a modest c o r r e l a t i o n w i th t h e presence of problems i n o t h e r a r e a s o r i n t he f u t u r e (Room 1979). Tnus, by i d e n t i f y i n g a populat ion of a l c o h o l i c s based on " l o s s of cont ro l" and " i n a b i l i t y t o a b s t a i n , " o r a popula t ion of exces s ive d r i n k e r s by the amount and frequency of d r i n k i i y , ep idemiologica l surveys i n L a t i n America provide o n l y a v e r y lid ted p i c t u r e of t h e t a rge t popula t i o n f o r prevent ion s t r a t e g i e s and o£ the k inds of problems that should be prevented. The g o a l s of p revent ive e f f o r t s have remained l a r g e l y r e s t r i c t e d t o l o c a t i o n of e a r l y case and p u b l i c educa t ion about t he dangers o£ a l coho l , w i th t he se educa t i o n a l e £ f o r t e concentra ted on teaching t h e p u b l i c how t o recognize e a r l y s i g n s o£ a l coho l i sm. l l

Conclusions

The epidemiology of a l coho l - r e l a t ed problems i n L a t i n America goes back almost 30 years. During theee yecirs o n l y a few coun t r i e s were a b l e t o main ta in a s u s t a i n e d i n t e r e s t i n a l c o h o l s t u d i e s a s evidenced by the l i t e r a t u r e i n the f i e l d . Amo- those doing s o were Ch i l e and Costa Rica. More r e c e n t l y , Mexico has developed s t u d i e s on the communi t y response t o a lcohol - re la t e d problems wi t h i n t h e f ramework of a n i n t e r n a t i o n a l co l l abo ra t ion w i t h t he World Heal th Organiza t ion .

From a n o v e r a l l perspec t ive i t 1s poss ib l e t o perce ive t h a t a l coho l cons ti t u t e s a l eg i t ima t e source of concern f o r researchera i n La t i n America. Th i s conclusion takes i n t o cons idera t ion the e x t e n t t o which a l c o h o l use 1s a s s o c i a t e d wi th everyday l i f e i n L a t i n America: dr inking takes p l ace " f i r s t thing i n t h e rnorning," during the day, i n t he evening, during weekdays o r weekends, a t r e l i g i o u a ceremonies , bap t i s m s , f une ra l e , marriages, s p o r t a c t i v i ties, i n toas t i n g one 'S hea l th o r t o promote s o c i a l i z i n g , t o c e l e b r a t e r evo lu t ions o r t o mourn them, t o br ing f r i e n d s c lose together; i t t akes p l ace because t r a d i t i o n t e l l s one t o dr ink , because there 1s l i t t l e e l e e t o do, and because dr inking 1s what men a r e supyosed t o do -- t o name j u s t a few reasons.

What emerges a r e mcirked d i f f e rences i n the norms a e s o d a t e d w i t h a l coho l u se by men and women and the consequent c o n t r a s t s i n the dr inking p a t t e r n s of t h e two sexes. Except perhaps among the upper s o c i a l classes, f o r which the re 1s v e r y l i t t l e evidence, exces s ive dr inking 1s a t e r r i t o r y occupied by males. The women's domain i s t h a t of a b s t e n t i o n o r moderate dr inking. Drinking t o i n t o x i c a t i o n 1s aga in a male prerogat ive , t o l e r a t e d by both men and women a l i k e . This c o n t r a s t i n normal p a t t e r n s of a lcohol u se 1s one of the f a c t o r 8 expla in ing t n e l a r g e r a t i o of men over women who a r e re cognize d i n the communi t y as having a lcohol - re la t e d problems and a r e r e ceiving t reatment f o r them i n ps ychia tri c hospi t a l s .

Looking a t the r e s u l t e a c r o s s coun t r i e s , i t i s poss ib l e t o see major d i f f e r ences i n t he e x t e n t of excess ive dr inking and the composition of a l coho l - r e l a t ed problems. There a r e , f o r example, cons iderable d i f f e rences i n the propor t i o n of "cilcoholics" and excess ive dr inkers . Among males, t he propor t i o n considered a l c o h o l i c s r a ~ g e s from 5 percent i n Argentina t o 10 percent i n Colombia, and f o r exces s ive dr inking from 12 pe rcen t i n Argentina t o 23 percent i n C h i l e o r 26 percent i n some p a r t s of Costa Rica. Data from Costa Rica, Mexico, and Chi le a l s o i n d i c a t e s i g n i f i c a n t v a r i a t i o n s among r eg ions wi th in these na t ions . A i l these d i f f e r e n c e s , p l u s those i n choice of a l c o h o l i c beverages, make i t unwarranted t o i d e n t i f y one s i n g l e p a t t e r n of dr inking a s t y p i c a l of L a t i n America as a whole.

The s t u d i e s reviewed f o r this paper a l s o show d i f f e r e n c e s i n t h e percept ion of a l c o h o l u se and a l coho l - r e l a t ed problems between the urban s o c i e t y of L a t i n America coun t r i e s , w i th i t s European r o o t s , and the n a t i v e peoples of t h e reg ion . Ethnographic s tud i e s sugges t t h a t a l though dr ink ing and heavy dr ink ing 1s common p r a c t i c e amo* n a t i v e s , t h e r e seems t o be more t o l e r ance f o r t h e e f f e c t s of these p r a c t i c e s and a lower r a t e o£ problems.

L a t i n American s t u d i e s have concent ra ted on urban and working c l a s e popula t i o n s , w i t h li t t l e a t t e n t i o n g iven t o marginal urban groups, r u r a l popula t ions , o r t he upper c l a s s e s . The dr ink ing of na t i v e popula t i o n s has no t been inves t i g a t e d ep idemiologica l ly , b u t o n l y wi th e thnographic methods. A s a r e s u l t a l c o h o l s t u d i e s i n L a t i n America comyrise a n epidemiology of a lcohol iem i n the urban working c l a s s r a t h e r than a g e n e r a l epidemiology of a l coho l - r e l a t ed problems. The window i n t o t he community opened by these s t u d i e s 1s tne re fo re ve ry narrow, and a l l ows o n l y a ve ry p a r t i a l view o£ the na t u r e and c h a r a c t e r i s t ics of a l coho l - r e l a t ed problems.

Di f fe rences i n t he percept ion o£ a l c o h o l problems a r e e v i d e n t i n the way i n which yrof e s s i o n a l s go about s tudying a l coho l problems and what may be s e e n a s the p u b l i c pe rcep t ion of these problems. Uhile r e sea rche r s understand a l coho l problems a s even t s r e l a t e d t o a cond i t i on c a l l e d a lcohol i sm, t he popular view seems t o s e e t h e dominant p a t t e r n o£ dr ink ing a s spo rad i c and t h e problems of i n t e r e s t a s occasion- r a t h e r than condi t ion- re la ted ; i .e., s e r i o u s a l c o h o l problems a r e those more dramat ic e v e n t s such a s road a c c i d e n t s o r v io lence . I t 1s q u i t e t r u e t h a t l a & of money t o buy p rov i s ions toward the end o£ the month may be a major problem t o those f a m i l i e s where money i s being epent i n heavy dr ink ing by t h e head o£ the household. However, here w e a r e making r e f e r ence t o the g e n e r a l popular view of a l c o h o l problems and n o t t he view of those a f f e c t e d by heavy dr inking. These two v e r y d i f f e r e n t p r o f i l e s of a l c o h o l problems a r e of importance i n r e - o r i e n t i n g prevent ive and t r e a tmen t i n t e r v e n t i o n s .

Given t h i s g e n e r a l panorama, t he fo l lowing recommendations can be made:

1) A b a s i c r e q u i s i t e f o r the succes s fu l o rgan iza t ion and development o£ any r e sea rch p r o j e c t 1s a n assessment of the l i t e r a t u r e i n t h e f i e l d . As mentioned i n t h i s review, t h e a l coho l 11 t e r a t u r e of L a t i n American coun t r i e s 1s widely sca t t e r ed . Many jou rna l s have l i m i t ed and i r r e g u l a r c i r c u l a t i o n , and e u b s t a n t i a l r e sea rch remains unpublished a s mas ter 'S o r d o c t o r a l d i s s e r t a t ions . 1 t would seem theref o r e tha t the organiza t i o n of a c lear inghouse f o r the s c i e n t i f i c l i t e r a t u r e on a l c o h o l 1s a necessarv s t e D i n f u r t h e r i n x t h e development o£ a l c o h o l r e sea rch i n - t he -region. The PAHO- sponsored B i b l i o t e c a Regional de Medicina (BIREME), l o c a t e d i n Sao Paulo, B r a z i l , would be one of many p o t e n t i a l sites f o r su& a clear inghouse.

2 ) Methodological shortcomings appear i n some of t h e epidemio- l o g i c a l s t u d i e s c a r r i e d o u t i n L a t í n America. The problems encountered a£ f ect sampling procedures , d a t a c o l l e c t i o n , and the s t a t i s t í c a l t rea tment , o £ the data . I t would seem there- f o r e d e s i r a b l e t o provide more t r a i n i n g oppor t un i t ies f o r r e s e a r c h e r s i n the f i e l d i n L a t í n America. This could be done e i ther by oryaniz ing r e sea rch seminars ( t h e example o£ t h e s choo l s of a lcohol i sm s t u d i e s may be invoked h e r e ) , o r , b e t t e r y e t , by developing r e sea rch p r o j e c t s i n t h e area, which would provide on- the- job t r a i n i n g f o r research personnel . The WHO S tudy o£ Communi t y Responsea t o Al cohol-Rela ted Problems i s one example of t h i s type of e f f o r t .

3 ) Epidemiological s tud i e s i n La t i n A m e r i ca should be re-£ ocused t o i n d u d e a broad range of a l coho l - r e l a t ed problems, n o t o n l y those a s s o c i a t e d w i t h s eve re forms o£ dr ink ing . Research on the a s s o c i a t i o n b e tween a l coho l and r e l a t ed casua l t ies should a l s o be s t imu la t ed . A f i r s t s t e p i n t h i s d i r e c t i o n should i nc lude a n a t t empt t o desc r ibe how l e g a l systems i n s e l e c t e d c o u n t r i e s of t h e r eg ion handle a l coho l - r e l a t ed problema.

4 ) Prevent ion e f f o r ts should a l s o be re -or ien ted and broadened. These i n t e r v e n t i o n s should aim a t minimizing n o t o n l y alcohol ism, bu t a l 1 t he a lcohol - re la t e d problems i n the communi ty. Accordingly, the " t a r g e t" popula t i o n s should be r ead jus t ed t o i nc lude a l 1 those d r i n k e r s who p re sen t problems, and n o t o n l y those midway t o t h e c l i n i c door, a s happens wi th " e a r l y case f i nd ing" procedures. Neglected s t r a t e g i e s of p revent ion should be developed and implemented, and t h e formal and int'ormal responses o£ the community t o a lcohol - re la ted problems should a l s o be taken i n t o account when planning prevent ive i n t e r v e n t i o n s . It may a l s o be more f e a s i b l e t o prevent undes i r ab l e even t s than undes i rab le condi t i o n s , e s p e c i a l l y when t h e condi t íon , such a s i s the case wlth "alcoholism," i s poor ly de l inea ted . F i n a l l y , t h e eva iua t i o n of p revent ion e f f o r t s should i nc lude n o t o n l y a n overview o£ t h e i r implementation, b u t a l s o a measure of t h e i r e f f e c t s i n the communi ty .

Acknowledgments: R. Room provided much u s e f u l adv ice and " t i p s " throughout t h i s research . G. C o l l i n s provided e x p e r t e d i t o r i a l a s s i s t a n c e . R. Alacon, G. Caetano, C. Campillo, W. Clark , R. Gonzalez, D. Heath, J. Mariategui , J . Masur, M.E. Medina-Mora, H. A. Higuez, J. Moser, L. Rals ton and R. Roizen provided sugges- t i o n s and r e p r i n t s o£ t h e i r work and o£ col leagues. Th i s r e sea rch was p a r t l y suppor ted by t h e Na t i o n a l I n s t i t u t e on Alcohol Abuse and Alcoholism, Na t i o n a l Alcohol Resear ch Center Gran t (M-0559 5 ) t o t he Alcohol Research Group, Berkeley, Ca l i f o rn i a .

DISCUSSANT

Car lo s Campillo-Serrano

I t i s , f o r m e , a t r u e p l ea su re t o have the p r i v i l e g e of commenting on the work of D r . Raul Caetano. H e 1s a n o l d and dear f r i e n d and a l s o , a co l league s i n c e our days i n epidemiological p sych ia t ry a few years ago a t t h e P s y c h i a t r i c I n s t i t u t e of London. 1 now have t h e g r e a t p l ea su re of s ee ing him a s a p ro fe s s iona l and r e sea rche r i n the f i e l d of alcoholism.

Works o£ t h e q u a l i t y t h a t w e have j u s t heard a r e seldom found i n the l i t e r a t u r e of L a t i n America. D r . Caetano p re sen t ed a n excel- l e n t and d e t a i l e d review of t h e t op i c , g iv ing u s a panorama o£ t h e problema r e l a t e d t o a l c o h o l i n L a t i n America and tak ing the occasion t o p o i n t o u t methodological weaknesses t h a t e x i s t i n t h e va r ious pub l i ca t i ons . Bis paper a l s o emphasizes t h e l a& of da t a i n spec i f i c and impor t a n t a r e a s , and e x p l a i n s why ep idemiologica l r e sea rch i n ou r p a r t i c u l a r r eg ion has rather r i g i d l y adhered t o t he medical model, and d i scus se s the l i m i t a t i o n s of t h a t approach.

Obviously, t h i s i s a work t h a t w i l l £111 a gap i n our b ib l i o - g r a p h i e s and one t h a t ha s been needed f o r q u i t e some t i m e . We have n o t had t h i s before because, among o t h e r reasons , of a l a c k of t r a i n e d and capable people i n ou r reg ion and, a l s o , because of t h e e x t e n t of e f f o r t needed t o compile b ib l i og raph ie s from widely s c a t t e r e d sou rces i n L a t i n America. For a l 1 o£ these reasons 1 would l i k e t o most h e a r t i l y congra tu l a t e D r . Caetano f o r t he q u a l i t y o f t he work presen ted t o us .

H i s work can be d iv ided i n t o £ our p a r t s ; a ) a review of h e a l t h i n d i c a t o r s i n L a t i n America; b) a review of the e f f e c t s of a lco- nolism: dea ths due t o h e p a t i c c i r r h o s i s , a lcohol ism, a l c o h o l i c psychoses, crime, s u i c i d e , con£ inement i n mental i n s ti tu t i ons ; c ) a s tudy o£ a l c o h o l consumption pa t t e r n s and a lcohol i sm w i t h i n communi- ties; and d ) the L a t i n American pe r spec t ive on a l coho l - r e l a t ed problems.

L a t i n America - The Beal th Pe r spec t ive

W i th the d a t a tha t D r . Caetano has g iven u s , i t i s v e r y ciear t n a t L a t i n America 1s a r a t h e r heterogeneous r eg ion wi th g r e a t d i f f e r e n c e s between coun t r i e s , b u t a t the same t i m e sha r ing a series

of common characteris ti cs whi ch d i f f e r e n t i a te i t f rom o t h e r r eg ions o f t h e world. As a group, t h e coun t r i e s of La t i n America r e t a i n a q u i t e s e p a r a t e i d e n t i t y from more developed c o u n t r i e s such as Canada, t h e ü n i t e d S t a t e s , and those of western Europe. We are r e f e r r i n g t o c o u n t r i e s t h a t g e n e r a l l y are e i t h e r poor o r a t a median l e v e 1 of p r o s p e r i t y , under-developed o r developing, where r e sou rces t o d e a l wi th domest ic problems a r e f r e q u e n t l y s ca rce .

The m o r t a l i t y r a tes from h e p a t i c c i r r h o s i s , a l c o h o l i c psycho- sis, and alconol ism, a e D r . Caetano has po in ted o u t , are high i n La t i n America, predominantly a f f e c t i n g men between 55 t o ó 5 years of age. Important d i f f e r e n c e s a r e shown between cities; these could be exp la ined by s o c i o c u l t u r a l f a c t o r s , b u t w e should n o t d i scount c e r t a i n p r a c t i c e s i n medical diagnoses and f a c i l i t i e s , and d i f f e r e n c e s i n au topsy procedures. The d a t a t h a t D r . Caetano h a s presen ted a l s o sugges t s t h a t t he t o p i c should be researched f u r t h e r s o as t o e x p l a i n more s a t i s f a c t o r i l y the d i £ f e r ences be tween coun t r i e s .

The d a t a r e f e r e n c e s t o s u i c i d e s , t r a f f i c dea ths , t r a f f i c a c c i d e n t s , and the l i k e are more d i f f i c u l t t o i n t e r p r e t than those p e r t a i n i n g t o c i r r h o s i s of t he l i v e r . E x i s t i n g s t u d i e s a r e incom- p l e te, inconc lus ive , and l i m i t themselves t o supplying s t a tis ti cs; no r e f e r ence 1s made t o t h e complex r e l a t i o n s h i p be tween a l c o h o l consumption and l e g a l responses t o t he se problems i n the r e spec t ive coun t r i e s . There 1s a l ack of adequate methodology, a l s o , t o compile d a t a on u a f f i c acc iden te s o that, a l though a c c i d e n t s a r e a s e r i o u s problem, t he re 1s l i t t l e awareness of t h e n e c e s s i t y of s t u d y i n s this matter. It 1s a t o p i c t h a t ha s been r a t h e r shunted a s i d e i n L a t i n America, b u t one whose s i g n i f i c a n c e merits g r e a t a t t e n t i o n . S t u d i e s of admissions t o mental h o s p i t a l s are even more d i f f i c u l t t o e v a l u a t e because q u i t e of t en they speak about t h e a v a i l a b i l i t y of f a c i l i t i e s and psychia tri c t rea tment r a t h e r than the pro blems r e l a t e d t o a lcohol .

Community S t u d i e s on Alcohol Consumption P a t t e r n s

D r . Caetano 's review has covered s t u d i e s undertaken i n e a & of the coun t r i e s of L a t i n America. IUs review 1s d e t a i l e d and inc ludes n o t o n l y t he r e s u l t s ob ta ined , b u t a l s o a n e v a l u a t i o n of t h e methods used. A main p o i n t 1s t h a t i n L a t i n A m e r i c a community surveys of a l c o h o l consumption p a t t e r n s d a t e o n l y from t h e 1950s. E a r l i e r statistics focused on morbidi ty , m o r t a l i t y , and acc iden t s .

The f i r s t ep idemiologica l s t u d i e s were i n i t i a t e d by ü ü O us ing Marconi 'S o p e r a t i v e d e f i n i t i o n s , which a r e more p r e c i s e and objec- t i v e than the c l a s s i f i c a t i o n proposed by J e l l i n e k . The ma j o r i t y of s t u d i e s do have methodological weaknesses. There 1s a l s o a n absence o f d a t a a n a l y s i s . I n s eve ra1 ways, t h e r e s u l t s of t h e s tud i e s a r e

d i f f i c u l t t o compare. We f i n d wi th t h e Marconi c l a s s i f i c a t i o n , f o r example , tha t s t a t i 8 ti cs f o r e i t h e r exces s ive d r i n k e r s o r a l c o h o l i cs could correspond, a l though n o t e x a c t l y , t o t h e ca tegory of problem d r inke r i n the United S t a t e s . We do n o t e t h a t t h e c o u n t r i e s w i th t h e g r e a t e s t t r a d i t i o n of r e sea rch i n a l c o h o l a r e Ch i l e , Costa R i c a , Peru , Argent ina, B r a z i l , and most r e c e n t l y Hexico.

Tne La t i n American V i e w of Alcohol-Related Problema

D r . Caetano observes t h a t J e l l i n e k ' s work has been the g r e a t e s t i n f luence i n t he s t u d y of a lcohol i sm i n L a t i n America. D r . J e l l i n e k ' s concept of a lcohol i sm a s a d i s e a s e i s the one that h a s p reva i l ed i n t h e region. The p r i n c i p a l proponent of t h i s p o i n t of view has been Marconi, whose ope ra t i ve de£ i n i t i o n s have been ueed widely. Research h a s been under t he supe rv i s ion of doc to r s , w i th a l a c k of a t t e n t i o n to s o c i o l o g i c a l concerns t h a t are s o t y p i c a l i n t h e ün i t ed S t a t e s .

The l i m i t a t i o i i s of t he medical approach r e s t i n t h e f a c t t h a t a t t e n t i o n goes a lmos t e x c l u s i v e l y t o those who a r e c l a s s i f i e d "a lcohol ics . " However, t he se are a minor i t y and have a low degree of v i s i b i l i t y i n the community. The medical response a l s o ignores eoc iocu l t u r a l f a c t o r s fundamental f o r t he design of p revent ive campaigns; i .e., the reasons , contex t , and b e l i e f S, a t t i t u d e s and s tandards a s s o c i a t e d w i th a l c o h o l use.

F i n a l l y , the fo l lowing i s a most i n t e r e s t i n g conclusion presen ted by D r . Cae tano, which 1 s t rong ly suppor t: Epidemiological s t u d i e s i n L a t i n America, p a r t i a l l y due t o u se of t he concept o£ a lcohol i sm a s a d i s e a s e , have examined o n l y p a r t of t he problem and a smal l percentage of the populat ion, p r i m a r i l y t h e working c lase . They have n o t d e a l t adequate ly wi th t he r u r a l popula t ion o r t h e h igher s o c i a l c l a s s e s . They do show t h a t the consumption of a l coho l i n L a t i n America i s i n t i m a t e l y connected t o t h e d a i l y l i f e o£ i t s i n h a b i t a n t s , and t h a t t he re is a g r e a t d i f f e r e n c e i n the p a t t e r n s of consumption of men and women.

We f i n d t h a t t he coun t r i e s t h a t have c o l l e c t e d t he most d a t a a r e Ch i l e , Mexico, and Guatemala. Avai lab le d a t a show t h a t d r ink ing p r a c t i c e s i n e a & count ry and reg ion a r e ve ry d i f f e r e n t and as a r e s u l t , r a t he r d i £ f i c u l t t o compare. Also, resear cher s ' percep t i o n s of t he dimensions of a l w h o l - r e l a t e d problems of ten d i £ f e r f rom those h e l d by m e g e n e r a l populat ion.

Mexican Par t i c i p a t i o n i n t h e WHO Mul t ina t iona l Study

Now moving on from the vork of previous r e sea rche r s , 1 w u l d l i k e t o b r i e f l y d e s c r i b e t he p r o j e c t i n which ou r i n s t i t u t e has

r e c e n t l y been involved and t o which Dr. Caetano and Dr. Rene Gonzalez have r e f e r r e d i n commenting on community response t o alcohol-related problems. This i s a mul t ina t ional e tudy d r a m up by the World Health Organization and f inanced by the U.S. National I n e t i t u t e on Alcoholiem and Alcohol Abuse. The countr iee s tud ied were Scotland, Zambia, and Mexico. The ob jec t ives were t o note the nature, ex ten t , and manner i n which the comuni ty deale with alcohol-related probleme i n three countr iee w i th d i£ f e ren t degrees o£ eocioeconomic developmen t.

The etudy l e a p a r t o£ a n extens ive WHO program r e l a t i n g t o a lcohol which l e t o be c a r r i e d o u t i n varioue stagee. I n the £ i r e t e tage we compiled information according t o a guidel ine proposed by the eponsoring organiza t ion on production, d ie t r ibu t ion , legie- l a t i o n , economice, and programe of treatment and r e h a b i l i ta t ion . The r e s u l t e of t h i e p a r t i c u l a r compila t ion have a l ready been published i n a WHO monograph.

Next, i n order t o obta in more e p e c i f i c and more de ta i l ed information, we examined reeponeee t o alcohol-related probleme through community eurveye i n two areae to the south o£ Mexico City. uie was r u r a l and one was urban. We researched pa t t e rne o£ con- eumption and norme of drinking. We a l e o eurveyed agencies and agente i n the community who deal w i th these probleme, such a e the po l i ce , hoep i t a l s , churchee, hea l th au thor i tee, e tc . We then i d e n t i f i e d a group o£ drinkere recognized i n the community a s having a lcohol probleme and ueed our e tandard comuni t y queetionnaire f o r them aleo .

During the whole pro j e c t we had the advice and eupervieion o£ various experte i n t h i e p a r t i c u l a r f i e l d . Special care wae given t o meeting t e chnical requiremente, euch a s de termining adequate eample e i z e , s e l e c t i o n o£ thoee t o be eurveyed, content of queetionnaire, and compilation o£ data. I n order t o aesure t h a t we would be a b l e to make comparieone betweeen countr iee, w e held varioue meetlngs during which we were very ca re fu l t o determine t h a t the co l l ec t ion of da ta and compilation o£ que6 t ionnai re r eeu l t e would guarantee the p o s e i b i l i t y o£ comparison.

This pro j e c t was i n i t i a t e d i n 1976 and wae concluded i n 1980. The preliminary r e e u l t s were presented a t an i n t e r n a t i o n a l meeting i n Mexico C i t y i n J u l y 1981; Mexican a u t h o r i t i e e comected w i t h a lcohol programe and gues ts o£ various coun tries of La t i n America pa r t i c ipa ted . M t e r the meeting we worked with Mexican a u t h o r i t i e e deal ing with probleme of alcoholiem and took s t e p s t o ehare our experiencee with our colleaguee i n Lat in America i n order to l e y the groundwork f o r f u t u r e collaborat ion.

The l a s t phase o£ the p ro jec t , now underway, i e t o t r y t o i n i t i a t e concrete a c t l o n i n one o£ the communitiee s tud ied i n order

t o demons t r a t e t o Mexican a u t h o r i t í e e a t t h e n a t i o n a l l e v e 1 that p reven t ive a c t i o n s are f e a s i b l e . We w i l l a l s o work t o e s t a b l i s h formal con tac t w i t h o t h e r co l leagues i n L a t í n Anterica s o as t o i n i t iate j o i n t pro j e c t s .

The importance of t he p r o j e c t t h a t 1 have j u s t descr ibed i s t h a t i n va r ious ways w e overcame the l i m i t a t i o n s o u t l i n e d by D r . Caetano i n c o m e c t i o n wi th previous s t u d i e s undertaken i n L a t í n America. We responded t o some o£ h i s sugges t ione f i r s t by abandon- i n g t h e r i g i d medical model of a l c o h o l a s a d i s ea se , and then by looking a t s o d a 1 and l e g a l problems. We used the advice o£ s p e c i a l i s t s , and during t h e course of t he i n v e s t i g a t i o n developed and t r a ined a team of r e sea rche re under t h e d i r e c t i o n of the I n s t i t u t e of Mexican Psychia t ry .

Th i s s t u d y made i t p o s s i b l e t o consider t he problems of a l c o h o l i n a wider pe r spec t ive , w i th the g o a l o£ £ollowing through wi th prevent ive p o l i c i e s . One advantage was t h a t t h e p r e s t i g e o£ WHO gave u8 a c c e s s t o Mexican a u t h o r i t i e s . And 1 would l i k e t o r e p e a t t h a t w e now have a group of t r a i n e d r e s e a r c h e r s t o cont inue work on t h i s top ic . 1 b e l i e v e t h a t t h i s s t udy c r ea t ed a model that i s worthy of being copied i n o t h e r coun t r i e s o£ the region.

Chapter Notes and Referentes

Manif esta t i o n s and P e r c e ~ t i o n s o£ Al cohol-Related Problems i n t h e Americas

No tes

1. I n s t anda rd comparisons of c i r r h o s i s m o r t a l i t y r a t e s between U.S. d t i e s , San Franc isco ehows the highee t r a t e . However, t h i s par t l y r e £ l e c t s the h i g h l y p ro fe s s iona l death c e r t í f i c a t i o n proceduree and the re8 t r i c t e d boundaries o£ the c i t y (Room 1372).

2. The ca tegory of c u r r e n t a b s t a i n e r s was c r ea t ed by t h e reviewer by combining ex-drinkers and ex-problem d r i n k e r s , who, accord- i ng t o the r e p o r t s , were def ined a s those d r i n k e r s who had

been i n continuous abs ten t ion f o r a t least one year p r io r t o the survey date. ühen added to the l i f e t i m e abs ta ine r s , the new group narrows the d i f f erence f o r abs ten t ion r a t e s be tween the two sexes.

3- With this method the information on a lcohol use and drinking pa t terne 1s co l l ec ted f ron severa1 groups of people assembled according t o occupation and which meet t o discuss pa t t e rns of a lcohol use i n t h e i r profess ional groups. The discussion 1s coordina ted by a t r a ined leader who f ollows a pre-arranged schedule o£ topics f o r discussion. The mater ia l from the groups 1s c o l l a t e d and a p ic ture of alcohol use i n the conununity can then be formed. The "infonuant" method provides a descr ip t ion o£ how a group of s e l e c t e d inv id idua l s perceive the place of a lcohol i n t h e i r cu l tu re , but whether this perception corresponde to the r e a l positiom and use of a lcohol i n thot cu l tu re 1s debatable.

4. It should be noted t h a t the disease concept had a l ready found acceptance among Chilean psychia tris te. liorwi tz (1965), a l r eady i n t e r p r e ting the increase i n a l cohol-related admissions t o Chilean mental hospi t a l e af ter 1947 , ascr ibed these changes t o a sh i f t i n physicians ' perspectives about alcoholism treatment due to the d i f fus ion of the disease concept. Alow w i t h t h i s sh i f t came acceptance o£ the kind of c l i n i c-based t r ea tmen t programs developed a t Yale i n 1943.

5 . J e l l i n e k becomes more s p e c i f i c when he def ines the various species of alcoholism (alpha, be ta, gama , d e l t a , eps i lon) . Also, i n J e l l i n e k the r o l e of alcohol-related problems i n charac ter iz ing alcoholism changes according t o the type being considered: the r o l e 1s per iphera l i n gaama and d e l t a a l coho l i c s , s ince these a r e i d e n t i f i e d by "loes of control" and " i n a b i l i t y t o abs ta in , " but i t has a more cen t ra l meaning i n the alpha and beta types. The alpha a lcoho l i c drinks t o r e l i e v e tensions and the "damage" 1s both o rgan ica l ly and s o c i a l 1 y-rela t ed ( in terpersonal r e l a t ions , work, e tc. ) . Beta a l coho l i c s a r e characterized by the presence of alcohol- r e l a ted organic problema (polyneuropathy, gas tri tls, c i r rhos i s ) .

6 . In a l a ter paper, Marconi (1967 c ) quotes t h i s same d e f i n i t ion but s u b s t i t u t e s the word i l l n e s s f o r d isease , among o the r a l t e r a t ions i n wording .

7 . The reasons why i t was l e f t t o physicians to publish papers on the dis t r i b u t i o n and pa t t e rns of a lcohol consumptlon i n the genera l population o£ La t in American nat ions a r e complex and involve such f a c t o r s a s f unding pa t t e rns , the development of medicine and o ther heal th r e l a t e d profess ions , and the general

understanding o£ what p ro fe s s ion 1s supposed t o take a n i n t e r e s t i n what s u b j e c t s i n L a t i n Americn s o d e t i e s . I n La t ia America, a s i n many p a r t s o£ t he world, many psychia- trists and psychoanalysts have n o t embraced the d i s e a s e concept. Among t h e former, many see a lcohol i sm a s a symptom of a n under ly ing psychia t r i c d i s turbance. Among the la t ter , a lcohol i sm i s a symptom of a n unresolved c o n f l i c t which has r o o t s i n e a r l y phases of p e r s o n a l i t y development. However, a s might b e expected consider ing t h e i r views o£ the problem, n e i t h e r o£ these groups has been a c t i v e l y involved i n a l coho l research ; whi le t h e i r p o s i t i o n s may have a bear ing on the handl ing o£ c l i n i c a l cases , i t has n o t i n f luenced epidemio- l o g i c a l s t u d i e s . One advantage o£ Marconi 's fo rmula t ion and of tne d i s e a s e concept, i n gene ra l , over p s y c h i a t r i c o r psychoanaly t ica l views i s t h a t the former does encompass epidemiology and the c o l l e c t i o n of d a t a on dr ink ing p r a c t i c e s i n t he g e n e r a l populat ion.

d . Recently, t he re have been i n d i c a t i o n s of a s h i f t i n t he way a l c o h o l problems a r e understood. Room (1981) has a l r e a d y commented on the WHO 1980 Expert Committee Repor t, which does n o t make referente t o alcohol ism a s was t h e p r a c t i c e i n the '50s , bu t i s concerned i n s tead w i th " t h e a l c o h o l dependence syndrome" and wi tn "problems r e l a t e d t o a l coho l consumption." I n La t in America t he s i g n s of such a s h i f t a r e a l s o presen t . A l though the recen t a l coho l l i t e r a t u r e does no t make re f erence t o t h e "a lcohol dependence syndrome," a n a s s o c i a t i o n r e c e n t l y c r ea t ed t o l i n k r e sea rche r s i n the f i e l d has been named Asociacion Ibero-Ameri cana de E s t ud ios de l o s Problemas d e l Alcohol (Ibero-American Assoc ia t ion f o r t h e Study o£ Alcohol Problems) . Fur t h e r , the r e c e n t l y developed "Plan o£ Alcoholism" (P lan de Alcoholismo) o£ the Chilean Min i s t ry o£ Heal th (Medina 1960) i n t roduces t he concep t o£ "problem dr inkers" t o encompass "excessive d r inke r s " and "alcohol ics ."

9 . Research wi th a framework d i f f e r e n t £ ron t h a t provided by t h e disease concept h a s been v e r y s c a r c e indeed. Vidal (1967 b, 197 1 ) has done work on pe reona l i t y c h a r a c t e r i s t i c s o£ a l coho l i c s . S luzk i (196 7 ) i n i t i a t e d s t u d i e s f ocussed on the p a t t e r n of i n t e r a c t i o n s i n f a m i l i e s of a l coho l i ce . Diaz (1980), us ing e thnographic methodology, has descr ibed the func t ion ing of a c lub of a b s t a i n e r s composed o£ recovered a l c o h o l i cs . Masur (1980) has been a c t i v e l y pursuing r e s e a r ch which uses t he "problem dr inker" approach developed by Cahalan (1909) and h i s a e s o c i a t e s .

10. It should be noted, however, t h a t whi le the d i s e a s e concept undeniabl y f ocuse d the a t t e n t i o n o£ r e s e a r chers on s e l e c t e d problems i n d i c a t i v e of phys i ca l a d d i c t i o n t o a l coho l , i t d i d n o t n e c e s s a r i l y imply ignor ing s o c i a l o r c a s u a l t y problems.

The WHO d e f i n i t i o n of a lmhol i sm (UHO 1952), as w e l l a s that proposed by Kel ler (1962), advocates using s o c i a l problems a s indica tor 8 of a l mholism.

11. It seas t n a t the only ca l1 t o adapt preventive a c t i o n t o the type of problem presented by the drinker was made by Sluzki (1962). Af t e r e s t ab l i sh ing that a l m h o l i c e i n d i f f e r e n t s o c i a l classecl and w i th d i f f e r e n t l e v e l s of education c a e t o treatment w i th d i f f e r e n t problems, Sluzki suggested tha t preventive campaigns whi ch f ocused on those problems would s tand a b e t t e r chance of achieving success than those which aimed a t e a r l y case f inding. This approach has s i m i l a r i t i e s with t h a t propoeed by U.S. reeearchers , which takes i n t o account n o t on ly problems such as " loes of control" o r " i n a b i l i t y t o abs ta in , " but the whole spectrum of a lmhol - r e l a t ed problems i n the conununity. Unf o r tuna t e ly , Sluzki 'S

proposal was n o t pureued i n Lat in America.

Ref erences

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Addiction ñesearch Foundation (1978). S t a t i s t i c a l Supplement t o the Annual Report 1317 - 1976. Addiction Research Foundation, Toron to.

Adis Cae t ro , G. (1966 ) . A l coholismo y enfermedad: concepcion popular (proyecto para s u inves t igacion). Acta Psiquia t r i c a y Psicoloitica de America La tina. 12: 343-350.

Adic l Castro, G. and 1. Flores (1967 ). Estado a c t u a l de l a epidemio- l o g i a de l alcoholismo y problemas de l alcohol e n algunos paises de America Latina: Costa Rica. Pp.86-91 i n J. Horwitz, J . Marconi, G. Adis Castro, eds. Epidemiologia d e l Alcholiemo e n America La t ina . Buenos Aires: Acta.

Agui l le ra , A. (1967 ) Estado a c t u a l de l a epidemiologia d e l alcohol- ismo y problemas d e l alcohol e n algunos paises de America La tina: Guatemala. Pp. 106-111 i n J.Horwitz, J. Marconi, G. Adis Cae t r o , eds . Epidemiologia d e l Alcoholismo en America Latina, Buenos Aires: Acta.

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Chapter Four

HISTORICAL AND CULTURAL FACTOBS AFPECTING ALCOHOL AVAILABILITY AND CONSUHPTION IN LATIN AHEBICA

DISCUSSANTS

Eduardo bkdina Cardenae

Juan Carlos Negrete

HISTORICAL AND CULTURAL FACTORS AFFECTING ALCOHOL AVAILABILITY AND CONSUMPTION I N LATIN AMERICA

Dwigh t B. Hea th

I t i e now g e n e r a l l y recognized t h a t a l coho l i e t he peycho- a c t i v e drug moet widely ueed throughout the world, and t h a t i t i e probably a l e o the o l d e e t i n cue tomary ueage. There a r e few a reae of the world where a l c o h o l i c beveragee a r e more common among d iveree popula t ione than i n L a t i n ~ m e r i a , ~ o r where they have more v a r i e d meaninge and func t ione , o r where we know eo much about t h e i r importance throughout h i e to ry . For a l 1 of theee reaeone, a b r i e f review of h i s t o r i a l 2 and c u l t u r a l 3 f a c t o r e a f f e c t i n g a l coho l a v a i l a b i l i t y and consumption i n L a t i n America ehould be uee fu l i n helping t o provide context f o r ou r diecueeion of approachee toward the underetanding and prevent ion of a lcohol - re la ted probleme.

Thie p r e s e n t a t i o n begine wi th a n in t roduc t ion to the impor tance of h i e t o r i c a l and c u l t u r a l f a c t o r e together w i t h an o u t l i n e of major r e l e v a n t work t h a t has a l r e a d y been acampl i ehed i n t h i s connection. A b r i e f diecueeion of the pre-Columbian per iod d e a l s w i th t he broad d i e t r i b u t i o n of a l c o h o l i c beveragee among n a t i v e populat ione p r i o r t o con tac t w i t h Europeane, and with eome of what we know of the p a t t e r n e of behavior and aeeoc ia t ed meaninge. I n r e l a t i o n t o the c o l o n i a l per iod w e examine new standard8 of behavior and d i f f e r e n t meaninge t h a t were introduced, and how the f o r c e of law sometimes in te rvened i n var ioue waye. A eec t ion on c u l t u r a l v a r i a n t s i n modern h i e t o r y providee a sampling of t he r i c h d i v e r s i t y t h a t has been found among severa1 L a t i n American popula t i o n s during the n ine teenth and twent ie th centur iee . It dea le w i th some b e l i e f s and a t t i t u d e s about dr inking a8 euch, and with some of the ways i n which a l c o h o l i c beveragee a r e i n t e g r a t e d with economic, p o l i t i c a l , r e l i g i o u s , and o t h e r a spec t e of the c u l t u r a l eystems. It a l s o inc ludee r e fe rence t o e t h n i c , c l aee , and o t h e r v a r i a n t e w i th in na t ions . A few t e n t a t i v e conclueions a r e o f f e r e d t h a t may be h e l p f u l i n broad d e s c r i p t i v e and a n a l y t i c terme, and i n i d e n t i f y i n g some i m p l i a t i o n s f o r ac t ion .

Thie workehop hae provided a n appropr i a t e and t imely occaeion f o r r e v i e w i q a l a r g e and d iveree corpue of l i t e r a t u r e from a f r e e h out look, and t h i e review of the widely e c a t t e r e d m a t e r i a l should be in fo rma t ive and u s e f u l even t o col leaguee who have worked i n the f i e l d f o r many years.

We a r e aware t h a t , f o r eome time, t he re has been coneiderable ambivalence about euch broad l a b e l e as "Lat in America" o r "Ibero- America." L e t u8 remember t h a t a f t e r Luis Alber to Sanchez publiehed a n eeeay wi th the provocat ive t i t l e "Doee L a t i n America Exiet?" t he re vas on ly a b r i e f r aeh of uncomfortable jokes i n reeponee: "Yes, i n the t a b l e of o rgan iza t ion of the U.S. Department of S t a t e , " o r "Yes, i n 30 d i f f e r e n t i n e t i t u t e e and reeearch centere i n European and Nor th American u n i v e r s i t i e e . " But t h a t d i d n o t las t 10%. When Sanchez expanded the eeeay t o a book he answered h i e own ques t ion i n the a f f i rmative: "Among the count r iee of L a t i n American there a r e as many d i f f e rences a e among the e t a t e s t h a t make up t h e U n i ted S t a t e e , b u t fewer than thoee among the na t ions of Europe. " (1944: 10).

Other L a t i n Americans addressed t h i e concern i n t he uneaey yeare immediately fo l lowing World War 11, when ind iv idua le and groupe throughout much of the world were grappl ing wi th newly impor tan t -- and newly unce r t a in -- i s s u e e of i d e n t l t y . Excerpte f rom severa1 au tho r s i l l u s t r a t e t h i e soul-eearching, which i n v a r i a b l y managed t o r ea ch beyond the narrow na t i o n a l i e ti c views t h a t had r e c e n t l y eeemed t o become s o p a t e n t l y obeole te . "Modern La t i n Ameri can c u l tu re" mue t be cons t rued a s " . . . the cona t r u c t i v e and c r e a t i v e s y n t h e s i s of Europe and America, of Spaniarde and Indiane...a e p i r i t u a l eymbioeis which i s e t i l l i n f u l l evolu t ion" (Alvarado U 52). S i m i l a r l y , b u t i n a more s t r i d e n t l y r e g i o n a l l e t i c tone: " In the t a c i t conspiracy a g a i n e t the r ecogn i t i on of our e t h i c a l and c u l t u r a l u n i t y a r e w r i t e r s , c a p i t a l i s t e , and e o l d i e r e of imperialiem. C u l t i v a t e d Europe hae been accustomed t o judge u s and t r e a t u s a s t he d iepersed remaine of a shipwreck" (Vaeconceloe n.d.: 11 ). Even those who pay a t t e n t i o n t o s i g n i f i c a n t d i f f e r ences tend t o emphasize uni ty . For example, "The d i f f e rencee come, n o t from d i f f e rencee i n h i e t o r i c a l e i t u a t i o n , b u t from the temperamente of t h e ac to re" (P icon 1951:335-336), o r "Central America and South America belong, as do North America, South Af r i ca , A u s t r a l i a and New Zealand t o t he 'Western World' ; t hey form, toge ther wi th Braz i l , a n I b e r i c-Criollo-Indian Zone" (Basadre 1951: 3% ). Ariel (Rodo 1900) remaine a v i t a l i n t e l l e c t u a l f o r c e symbolizing L a t i n e p i r i t u a l i t y and dynamlem, even while caud i l l o s f a n the embers of xenophobia to eerve t h e i r p r iva t e purposee.

A North American an th ropo log ie t who has long wree t led with the confusion over u n i t y and d i v e r s i t y wi th r eepec t t o L a t i n America a e a reg ion o f f e r e a eucc inc t summary of t he problem: "A b a e i c theme . . . has been the r i c h d i v e r e i t y of cu l tu ree and e o c i e t i e e throughout contemporary La t i n America. The r e a l i t y of d i£ f erence, however, ehould no t obecure tha t wideepread underlylng un1 t y which der ives ,

i n l a r g e p a r t , from the I b e r i a n her i tage . L a t i n Americane and o the r s g e n e r a l l y a g r e e on t h e impor tance of personaliemo, dignidad de l a persona, and machismo i n the l i f e of i nd iv idua le , and a v a r i e t y of i n s t i t u t i one can be f rui tf u l l y i n t e r p r e ted a8 expreeeing these bas i c e thos componen ts, even though the re l e of t en a marked divergence between i d e a l e and a c t i o n ... [and even though] the dominant n a t i o n a l p a t t e r n s a l s o s t a n d 1x1 marked contrae t t o the views of the Ind ians who comprise a s i g n i f i c a n t po r t ion of the popula t ion i n many of thoee coun tries" (Hea th 197 4b:424).

With t h i s j u e t i f i c a t i o n of the "ia t i n American" component, l e t ' e b r i e f l y examine the j u s t i f i c a t i o n f o r focus ing on h i e t o r i c a l and c u l t u r a l f a c t o r s . It 1s g r a t i f y i n g t h a t i n r e c e n t decadee v i r t u a l l y a l 1 who work i n any f i e l d r e l a t e d t o the e tudy of a lcohol and i t s r e l a t i o n t o human behavior have accepted the gene ra l p ropoei t ion t h a t s o c i a l and c u l t u r a l f a c t o r 8 a r e r e l evan t , i n combina t i on w i th phys io logica l , ps ychological , and o ther f a c t o r s . I n eome i n s tances , however , such acceptance may be r e l a t i v e l y paas ive and pro-forma, implying l i t t l e understanding and even l e e s commitment. For t h a t reason, a n extreme i l l u s t r a t i o n may deserve a t t e n t i o n a t the outset-- to show t h a t we a r e t a lk ing about real and s i g n i f i c a n t d i£ f e r ences r a t h e r than s imply overemphaeizing minor f e a t u r e s w i th in a narrow range of v a r i a t i o n . For t h i e reaeon, 1 sugges t now t h a t we b r i e f l y consider t he f a c t t h a t , among many of t h e Indian t r i b e s i n c e n t r a l B r a z i l t he v e r y a c t of i ngee t ing -- whether e a t i n g s o l i d s o r dr inking l i q u i d s , wi th no regard t o t h e i r a l c o h o l i c conten t o r s o c i a l o r economic va lue -- i e e u b j e c t t o ex treme modes ty , accompanied by shyneee , blushing , hid ing f rom the view of o the re , and s o f o r t h -- 1x1 much the way t h a t some of u s may f e e l about de£ e c a t i o n , sexual i n t e r couree , o r o t h e r a c t i v i ties (von den Ste inen l894) . Thie 1s n o t a n appropr i a t e context f o r t ry ing t o i n t e r p r e t o r a e s e s s imp l i ca t ions of euch a n a t t i t u d e . However, s imple r ecogn i t i on of t h e range of c u l t u r a l f a c t o r 8 t h a t ehould be considered i n any a t t empt t o i n f luence p a t t e r n e of a lcohol consumption i n t h a t a r e a should dramat ica l ly underecore the need f o r and va lue of d e t a i l e d unders tanding of l o c a l p a t t e r n s , which of ten range f a r ou ta ide t h e ca t egor i e s t h a t have become cuetomary even i n s p e c i a l i z e d surve y-ins trumen t e , o r i n the minds of researchere o r o t he r s who a r e concerned with hea l th .

Fortuna t e l y , s c h o l a r s from La t in America have been ex tremely progressive--in comparison w i th col leaguee i n o ther par t e of t he world--in t h e i r recogni t i o n and apprec i a t ion of the impor tance of such c u l t u r a l v a r i a t i o n . P a r t of t h i s de r ives from t h e i r e a r l y i n t e r e s t i n h i e t o r i c a l s tud ie s on a lcohol - re la ted top ice (e.g., Herrero 1940, P iga 1342, F. Ro j ae 1942, Ruiz 1939, Mendieta 1939), a t o p i c t h a t o n l y l a t e r became a focus of concern f o r a few echolare i n o t h e r p a r t e of the world.4 Another reason f o r the e a r l y and broad acceptance of s o c iocu l t u r a l pe r spec t ives i s the recogni t i o n tha t the d ive r se popula t i o n s wi th in each n a t i o n of La t i n A m e r i c a had

d i f f e r e n t viewe about a lcohol , ueed i t d i f f e r e n t l y , and s o were di f f e r e n t l a l l y sub j e c t t o kinde and r a t e e of alcohol-related probleme. Such a view ha8 become increaeingly wideepread i n r ecen t yeare, even among e p e c i a l i e t e i n the b io logica l and medical eciencee (eee , e.g., Kisein and Begle i ter 1976, Medina 1978, Negrete 1974), b u t our colleaguee i n La t in America were v i r t u a l pioneere.

One of the beet known e a r l y contr ibutione t o the eystematic s tudy of a lcohol had a e i t e focue "epidemlology" (Horwitz, Marconi, and Adie 1967a), b u t i t l e noteworthy t h a t the major a r t i c i e e i n t h a t c o l l e c t l o n d e a l t with "eociocul tura l f ac to re" i n alcohol use ( J . Maria tegui 1967 ) , me thods and r e s u l t e of "epidemiological and eocioan thropological invee t iga tione" (Marconi and Adle 1967 ) , "epidemiolog y and eocioanthropolog y of alcoholiem and alcohol-related probleme" (Marconi, Horwitz and Adie 1967 ), and a " f i n a l commentary" t h a t wae l a r g e l y devo ted t o eociocul t u r a l v a r i a t l o n (Horwitz, Marconi and Adie 1967 b). The exceptlonal breadth and high q u a l i t y of the component essays make t h a t volume an important miles tone i n the etudy of a lcohol use i n La t in America.

I n 1974, another s p e c í a l ieeue of the eame per iodica l wae devoted to a lcohol , eerving a e both a complement and a n update of the 1367 monograph. I n i t , J. Mariategui 'e (1974) inventory of e tudiee on the epidemiology of alcoholiem i n Lat in America l e f a r broader and deeper than one might gueee on the baeie of the t i t l e alone, combining ca re fu l d e f i n i t i o n of terme w i t h br ief c o u n t r p b p country euii~nurriee of r e c e n t f indinge and commentary t h a t in teg ra tee anthropological da ta and perepectlvee i n a n e f f e c t l v e manner. An o u t l i n e of eoc iocu l tu ra l perepectivee on a lcohol i n Lat in America by Heath (1974a) l e a b r i e f bu t compreheneive in t roduct ion t o the broad raage of l i t e r a t u r e t h a t wae ava i l ab le on the eubject. A summary of c u l t u r a l f a c t o r e i n epidemlological e tudiee of alcoholiem by Negre te (19 7 4) eucc inc t ly i n t e g r a t e e the pub l i c hea l th model w i t h peychological and eociologica l theor iee about why people drink. Sugees t ione f o r a n i n t e r n a t i o n a l comparative e tudy of alcoholiem and a lcohol abuse were o f fe red by Murphy (1974), an t l c ipa t lng eome of the methodological problems tha t have been encountered i n the prel imlnary at tempte t h a t have e ince been made. Brief notes by Negrete on a lcohol and t r a f f i c , and by Adie on mental hea l th and alcoholiem ehow tha t, although few inveet lga tore were e tudying a lcohol i n La t i n America a t t h a t time, t h e i r work wae re levan t t o the eame ieeuee t h a t occupied colleaguee eleewhere.

Thie i e n o t an appropr ia te context i n which t o venture a more thorough review of the l i t e r a t u r e -- preeumably the proceedinge of t h i s conference w i l l c o l l e c t i v e l y eerve t h a t purpoee -- but i t 1s important i n terme of our h i e t o r i c a l perepectlve to note t h a t there have been severa1 valuable contr ibutione made by La t i n Americane with reepect t o the etudy of alcohol. I t a l s o deeervee t o be mentioned t h a t euch worke were w r i t t e n by authore whoee diveree

na t i o n a l and pro£ e s s i o n a l backgrounde have e i g n i f i c a n t l y enr iched our underetanding of t he e u b j e c t ma t t e r , and a t t he same t i m e demone t r a t e t ha t the material i e of broad impor tance and relevan- f ar beyond mere academi c invee t i ga t ion .

The Pre-Columbian Per iod

It i e of c r u c i a l importance t o recognize that every c u l t u r e i n human h i e t o r y has shown c l e a r evidence of both c o n t i n u i t y ( o r , eome would eay, e t a b i l i t y ) i n c e r t a i n r e spec t e on the one hand, and change ( o r , i n s o c i o l o g i c a l terma, dynamics) on the o t h e r hand. There e x i e t e no people wi thout t h e i r unique h i e t o r y , and the euppoeedly "unchanged" l i f e of "pr imi t ive" popula t ions o n l y appeare s o becauee the rate of change i s s o r e l a t i v e l y d i f f e r e n t from our - own.

W i thout a t temp t i q t o provide anything approaching a comprehensive review of t he evidence f o r pre-Colombian uses and meanings of a l c o h o l i c beverages i n the Americae, i t may be u s e f u l t o mention a few d a t a t h a t demonstrate t h e i r e a r l y d i e t r i b u t i o n and importance i n e e l e c t e d ine t ances tha t eerve t o i l l u s t r a t e c u l t u r a l f a c t o r 8 of enduring relevan-.

There a r e ve ry few p a r t s of the world where the n a t u r a l procees of fe rmenta t ion wae n o t ve ry e a r l y recognized and e l abora t ed by n a t i v e people t o produce beere, wines, meada, and o t h e r typee of homebrew. It remains a paradox t h a t moet of t he a r e a t h a t i s now ~ n g l o - ~ m e r i c a 5 lacked indigenous a l c o h o l i c beveragee (La Barre 19 38, Driver 196 9). An i r o n i c s i d e l i g h t i s tha t the siaall por t i o n of North America where Indiane d i d d r ink i n pre-Columbian times happene t o co inc ide , t o a remarkable degree, wi th t he e x t e n t of c o n t r o l a chieve d by the Spaniarde during the co lon ia l per iod, i nc lud ing what i e now Mexico a e we l l as t h e s t a t e s of C a l i f o r n i a , New Mexico, Arizona, and Texae (Waddell 1980; Bruman 1940).

Ae a re£ inement beyond s imple fe rmenta t ion , t he technology of d i s t i l l a t i o n need n o t be complex nor involve h i g h l y r e f i n e d ma te r i a l s . Nevertheless , the technique seems n o t t o have been invented by any of the populat ione i n t h i s hemisphere i n the pre-Columbian e ra . There wae eome controverey during the e a r l y p a r t of t h i s century abou t whether d i s t i l l a t i o n had been known among a t l e a e t a few groups i n pre-Conquest Mexico (Bourke 1893, 1894), b u t t h e tenuoue evidence o f f e r e d i n suppor t of t h a t i dea i e unconvincing (Bruman 1944, Driver 1969).

The most famoue pre-Columbian cu l tu ree i n L a t i n America a r e unquee t i onab l y the so-ca l led "high c i v i l i z a t i o n s " of Az t e c , Maya, and Inca , ea& of which combined complex s o c i a l o rganiza t ion , ex tene ive p o l i ti cal and economi c con t ro l e , l a r g e ci t i e e , complex networke of communication and t ranepor ta t ion , and a n e x tremely

eophie t lca ted e c i e n t i f i c and technological eystem. Each of them a l e o produced fernented beveragee tha t played a v a r i e t y of important eymbolic and economic r o l e s i n the l i v e e of both leadere (eome of whom were thought t o be descended from the gode) and comnonere.

The Aztece of c e n t r a l Mexico a r e bee t known i n t h i e reepect , p a r t l y on the baeie of documente t h a t eurvive from pre-contact tlmee and p a r t l y on the baeie of rereiniecencee r e m r d e d by Spaniarde during the e ix teen th century. Pulque wae the predominant beverage, and i t remaine important today. It l e f ermented from the eap of the maguey (Agave a t rovi rene , a l e o known var iouely a8 a loee , agave, o r century-plant), which l e a l e o an important eource of f i b e r e ueed t o make rope, eandale, and t e x t i l e s . A remarkably de ta i l ed analys ie of the bibl iography and iconography of maguey and pulque i n the pre-Columbian Mexican codicee has been compiled (Goncalvee de Lima [19%]) , b u t i t revea le l i t t l e about workaday behavior o r about nonne and valuee. I n eymbolic t e m e , i t eeeme importan t tha t pulque wae thoiyht t o have been invented by the gode (eepec ia l ly Mayahuel, a female f i g u r e with 400 breaete, aeeoclated with Tlaloc, the p r i n c i p a l "rain-god"), and t h a t acceee t o i t wae r e e t r i c t e d i n eome regione .

The epec ia l relevan- of pulque i n Aztec cu l tu re has long been remgnized; i t wae deecribed i n eome d e t a l l i n the so-called "Florentine ~ o d e x , ' 6 and has been b r i e f l y eummarized by severa1 authors i n r ecen t p a r e (e.g., Calderon 1968, Paredes 1975). Pe r iod i c drinklng and drunkenneee were impor t a n t ritual a c t i v i t i e e of the n o b i l i t y , and both p r i e e t s and the e l d e r l y were allowed o ccaeionally t o d r i d t considerable amounte. Bu t o ther conmonere were eub jec t t o eevere pena l t i e s , including death, i f they became drunk, and even a nobleman could be k i l l e d f o r being drudt a t a n inappropr ia te t i m e . Thie well-known account i e probably not inaccura te , having been compiled a e o r a l h i e t o r y by a p r i e e t and pro toe thnographer , Bernardlno de Sahagun, f rom in f orman t e who had been nobles i n Tla te lo lco , near the center of Mexica control . But, f o r t h a t eame reaeon, i t wae* probably no t repreeenta t lve of workaday realitles i n moet of the rest of t h a t far-flung and looeely organized "empire." It 1s unfortunate t h a t , f o r l a & of o ther da ta , t h i e epec ia l view has long been general ized t o a l 1 of the a r e a t h a t ha8 become the nat ion-e ta te of Mexico.

S imi lar ly , the a t ti tudee of ano ther unrepreeenta t i v e eample have been genera l ized i n an inappropr ia te bu t widely ehared view of maee drunkenneee on the part of Meldcan Indiane during the colonia l period. The Relacloneé Geograficae were compiled af ter two generat ione of Indiana had been eubjected t o Spanieh domination i n c e n t r a l Mexico, and thoee informante descended from Aztec noblee appear t o have been nos t a l g i c a bou t the l o s t preroga t ivee previouely enjoyed by their famil lee , the "uppityneee" of commonere who would have been t h e i r eubjecte, and s o f o r t h . It l e d i f f i c u l t t o diecern

how much of t h i s c h a r a c t e r i z a t i o n l e a confueion between " r ea l " and " idea l" c u l t u r e -- i .e. , between what people d i d and what they ehould have done -- and how much may have been wiehfu l thinking o r eome o ther kind of d i 8 t o r tion.7

A more p l a u s i b l e view wae r e c e n t l y o f f e r e d , c a r e f u l l y and imagina t ive ly reconet ruc ted on the bas ie of a compreheneive review of a w i d e r a w e of unpubliehed documente from var ioue regione of bkxico (Taylor 1979). According t o t h i s i n t e r p r e t a t i o n , t he re wae cons iderable v a r i a t i o n i n dr inking p r a c t i c e e and norms i n var ioue communities--as l e the case today. A common p a t t e r n wae t h a t of y e r i o d i c f i e e t a s , i n which most of the a d u l t s drank t o t h e p o i n t of intoxicat ion--also a common p a t t e r n i n the a t e a today. Both dr inking and drunkenneee were e o c i a l l y approved i n t he context of vene ra t ion of major d e i t i e s , a e a n i n t e g r a l p a r t of e i g n i f i c a n t a g r i c u l t u r a l ceremonies, o r i n ce lebra t i o n of impor t a n t evente i n the l i v e e of l o c a l l eade re . We w i l l r e t u r n t o both of theee poin te , l o c a l v a r i a t i o n and e p i e o d i c eanct ioned gene ra l drunkennees, l a te r .

Native fermented bee r s throughout much of South America are g e n e r a l l y c a l l e d chicha (Cu t l e r and Cardenae 1947) d e s p i t e a wide v a r i e t y of i ng red ien t e , mamers of prepara t i on , and o t h e r k inds of v a r i a t i o n . The word h a s come i n t o English as meanlng "maize beer ," the beverage t h a t wae (and l e ) s t a p l e throughout the v a e t Inca "Dnpire, " which domina ted v i r t u a l l y a11 of t h e Andean highlande f rom Colombia eou thward i n t o Chile .

Like pulque i n Mexico, chicha 1s a n u t r i t i o u s beverage drunk by people of both eexee and a l 1 agee (Nicholeon 1960). Aleo l i k e pulque, i t has syrnbolic va lue t h a t i s v e r y d i f f e r e n t from i t e economi c and food value. Excavatione a t ma j o r Inca f o r t e and ci t i e e have unmvered v a e t breweriee and s torehoueee of chicha, which l end eupport t o the view t h a t i t wae a n e e p e c i a l l y important medium of exchange, r e g u l a t e d by the s t a t e . Presumably i t wae p a r t of a complex s y s tem of r e d i s t r i b u t i o n , whereby raw ma t e r i a l s were c o l l e c t e d i n t h e name of t he Inca and f i n i s h e d producte were then d i s t r i b u t e d by Inca l eade re . Such p a t t e r n s of exchange occur throughou t the world, and an thropologie t e have demone t r a ted how ef f e c t i v e they a r e i n maintaining s o c i a l e t r a t i f i c a t i o n and i n t e g r a t i o n . C l e a r l y t he va lue of a g i f t depende i n p a r t on who i e g i v i n g i t , and a g i f t i n such a system impliee a cont inuing ob l iga t ion . No t o n l y doee su& a eyetem demonetrate t he beneficence of a l e a d e r , b u t i t a l e o can e u b e t i t u t e f o r markete and money. Unlike pulque i n Mexico, which began a 8 a small-ecale cot tage- i ndue t ry , chicha i n Peru eeeme t o have been produced on a l a r g e e c a l e by the mamakuna, t he famoue "chosen women" of t h e Inca, eome- t i m e s r e f e r r e d t o as "Virgine of the Sun" (Morrie 1979). I n euch a context , dr inking occurred as a n accompaniment t o work, a e a reward f o r ee rv i ce , and occae iona l ly as par t of a r e l i g i o u e f i e e t a , during which drunkenness was n o t o n l y a c e p t a b l e b u t a c t i v e l y eought a 8 a

kind of t ranecendental experience. We w i l l pay a t t e n t i o n l a t e r t o eome aepecte of t h i e p a t t e r n that have changed markedly, and t o o the re t h a t have ehoni remarkable consietency over four centuriee of t ranecul t u r a l contac t .

Among the Mayae of Meeoamerica, w e know l i t t l e about the d e t a i l e of production and d i e t r i b u t l o n , b u t both pulque and maize-baeed chicha appear t o have had eymbolic inportance i n r e l ig ioue and p o l i t i c a l contexte. The h y a e a l e o had a d i e t i n c t i v e regional beer ( b a l d e ) fermented from the bark of a tree (Barrera 1941, Goncalvee a l . 7 7 ) .

Brief deecr ip t ione of preeumably t r a d i t i o n a l drinking pa t t e rne occur i n many of the journale of explorere and conquietadore, and i n r epor te from mieeionariee and admlnietratore who extended the f r o n t i e r e of European contac t throughout La t ln America. However, d e t a i l e on euch drinking a r e nowhere e l e e eo r i c h a s i n thoee areae of pre-Columbian c i v i l i z a t l o n .

The Colonial Period

The a r r i v a l of Europeane had a n enormoue impact on both the c u l t u r a l and n a t u r a l ecology of the Weetern Hemiephere. I n one eenee, i t wae f a r from being a "New World," having a l ready been occupied by homo eapiene f o r more than ten mil lennia; evidence i e mountlng t h a t euggee t e almoe t double t h a t t i m e . I n another eense, however, i t wae a "New World" f o r the Europeane, who encountered na t ive populatione t h a t d id n o t f i t their coemology, much l e e s t h e i r l e g a l and p o l i t i c a l eysteme. It l e n o t t h a t there had been no p r i o r confrontat ion w i t h c u l t u r a l d i f ferencee o r w i t h the kínde of pheno typic v a r i a t i o n t h a t w e c a l 1 " rac ia l" ; contacte with Afr ica and the Orient had been many and va r i ed during the precedlng centuriee. But Native Americane were d i f f e r e n t i n a eenee t h a t wae fundamentally important a t t h a t t i m e . Not having re jec ted Chr ie t i an i ty , they were t o be protec ted and helped i n waye t h a t p r a c t i t i o n e r e of o the r recognized r e l i g i o n e were not. Of couree, the r e a l i t y of s o c i a l r e l a t l o n e i n a context of imperial conqueet, freebooting a n expanding m i l i t a r y f r o n t i e r , and attempte t o g a i n wealth and l e i e u r e from conqueet r eeu l t ed i n wideepread exp lo i t a t ion , b r u t a l i ty , and o ther abueee t h a t diverged f a r from the utopian ideal . Nevertheleee, reepect f o r Indian cul turee wae a n important thread throughout the Conqueet, and i t l e c r u c i a l t o recognize t h a t " the Conqueet" wae a 10%-term proceee r a t h e r than a n event. Obviouely, the confrontat ion wlth Europeane made t h i e a "New World" f o r the na t lvee , a l eo , i n a v a r i e t y of reepecte. I n eome a reae they were l i t e r a l l y enelaved o r maeeacred; i n o there they were dieplaced from t h e i r t r a d i t i o n a l homee, eometimes obliged t o work a t unaccuetomed jobe o r t o l i v e i n unaccuetomed p r o x i d t y t o each o ther and t o a l i e n people. New kinde of l iveetock dieturbed the ecology

t o which they were adapted, j u s t a e new d i seases t o which they had no r e e i s t a n c e took a heavy toll among them. Ae more d e t a i l e d h i e t o r i c a l s t u d i e s a r e being made with r eepec t t o l i m i t e d aepec te of c u l t u r e and focueing on s p e c i f i c reg ions o r communitiee, 1 t l e clear t h a t n e i t h e r of the o l d s tereotypee about the conquest f i t s well . The "black legend" t h a t cha rac t e r i zed the Spaniarde a e r u t h l e s e monsters conta ins a s much faleehood -- and a s much t r u t h -- a e d i d the " o f f i c i a l " image t h a t por t rayed them as e e l f l e e e l y undergoing extreme hardships t o br ing s a l v a t i o n and enlightenment t o t he savage hordes.

I n order t o have a n apprec i a t ion of t h e ways i n which some c u l t u r a l f a c t o r s have p e r s i s t ed e ince p reh i s t o r i c timee and o t h e r s have been a l t e r e d i n var ioue waye, i t l e impor tan t t h a t w e t r y t o undere tand no t o n l y the dynaml ce of colonialism--wi t h the p r e s e n t a t i o n of new behaviors and a t t i t u d e e a e modele, the impos i t ion of new laws, some d i s c r e d i t i n g of o l d waye on the one hand, and some n o s t a l g i a f o r them o r t he o the r . I t l e a l s o impor tan t t h a t we t r y t o underetand the h i s t o r i c a l and c u l t u r a l f a c t o r s t h a t had a l r e a d y shaped the p a t t e r n s borne from the met ropol i tan center . We must n o t l o e e s i g h t of the f a c t t h a t the I b e r i a ( n o t y e t even "Spain" and "Portugal") of the e r a of the Conquee t was c u l t u r a l l y and e t h n i c a l l y d ive r se i n the mame way tha t t h e New World wae, and t h a t i t s o n i drinlring p a t t e r n s der ived from cen t u r i e s of con tac t among many peoples. Ar chaeologica l evidence shows t h a t the c u l t i v a t i o n of grapes and the product ion of wine on a smal l s c a l e had been in t roduced i n southern Spain by 600 B.C. The Romans forbade both u n t i l 280 A.D., when v a e t p l an t ings were au tho r i zed i n the r eg ion of Baet ica ( roughly correspondlng t o contemporary J e r e z ) a n d product ion promptly expanded t o t he p o i n t where m i l l i o n s of amphorae of wine were being exported t o I t a l y each year .

The southern s t r i p of I b e r i a , i n which moet of the conquis tadors had been reared , ehared the medieval Medi te r ranean p a t t e r n i n which wine wae both a n everyday beverage i n normal u se and some times a conse cra ted medlum of Chr is t i a n communion. Drinklng was c e r t a i n l y n o t confused wi th drunlrenness, a s when Alfonso X l i e t e d " f e r t i l e l ands t o y l e l d good wine" among h i s primary c r i t e r i a f o r choosing the s i t e of a un ive r s i t y . The s t a p l e d r i n h were what we would cal1 a l c o h o l i c beveragee; wine w a s drunk t o r e l i e v e t h i r e t , wi th meals, and as a r e g u l a r refreehment, i n a l 1 of t he waye t h a t co f f ee , t e a , water, o r eof t dr inke a r e now ueed i n the United ~ t a t e s . ~ For t h a t mat te r , f ew people anywhere i n the world during tha t time would have recognize d the term "a l coho l i c beverages" as any kind of meaningful category.

Moderation was a t r a i t much reepec ted i n t h e men of I b e r i a . C e r t a i n l y commente about t he a u s t e r i t y of Bernan Cortez wi th r eepec t t o drinlr have the r i n g of p r a i s e about thern. Th i s l e a l 1 t he more

convincing be cauee the eame paragraph, w r i t t e n by an adula to ry contemporary, includee ref erence t o the Conquie tador 'e weakneee f o r women, h i e gueto i n e a t í n g , and h i e e k í l l i n ehooting d ice ( b p e z de Conara 1954).

One wideepread mieconception about the bureaucracy of Ibe r i an colonialiem l e t h a t of uniformity of law and of i t e adminietrat ion throughout the far-f lung empire. I n f a c t , there wae l i t t l e uniformity and n o t even much correepondence between law and r e a l i t y i n much of colonia l Iberoamerica. I n p a r t , t h i e r eeu l t ed from the f a l l a c i o u e at tempt, by people unfamil iar with the a r e a , t o formulate a e ing le code t h a t would apply t o the diveree e i t u a t i o n e found throughou t the d ispara te and of ten remo te dependenciee. In par t, i t reeu l t ed from the adminie t ra t ive and l o g i e t i c a l problems t h a t inhere i n any a t tempt by a emall and diepereed group to cont ro l l a r g e r groupe, e e p e c í a l l y i n d i f f i c u l t t e r r a i n with l i m í t e d meane of conmunicatíon. I n ehor t , the e f f e c t i v e con t ro l of the government d i d n o t extend f a r beyond the eea te of government. Another importan t cont r ibut íng f a c t o r wae the a t t i tude of the admínie t r a t o r e themeelvee, of ten e x p l i c í t l y uncommi t t e d t o the enforcement of lawe and regula t ione , a e e p i tomízed i n the -11-known phraee, " l a l e ee a c a t a pero no se cumple" ( t h e law l e reepected bu t n o t Nevertheleee. the record of lawe t h a t remain and the abundante of ' c l o s e l y r e G t e d documente, euch a e t r anec r ip te of t r i a l e and p e t i t i o n e f o r r e l i e f from eome regula t ione o r f o r e tricter enforcement of o there , make them valuable guidee t o both " rea l" and "ideal" aepecte of the cu l tu ree of remote timee. Although the t e x t of a law doee n o t te11 ue what people a c t u a l l y did, i t r e f l e c t e what a u t h o r i t í e e thought they ought t o be doing, and a n c i l l a r y documente of the kinds mentíoned above o f t e n shed l i g h t on the e i z e and nature of the gap beween thoee two kinds of norme.9 Por theee reaeone, l e g a l decreee and many o the r kinde of documente w i l l be c i t e d i n t h i e diecueeion. *

The beginninge of grape-growing i n the New World have n o t been eys temat ica l ly inveet iga ted t o date, bu t i t l e c l e a r l y poet- Colurabian. I n the e a r l y yeare of European explora t ion and m i l i t a r y incureione throughou t the Wee t e r n Heniephere, the in t roduct íon of the v ine wae encouraged. I n 1519, the Spanieh Board of Trade decreed t h a t every ehip coming to the Indiee ehould bring grape- vinee, preeumably eo t h a t l o c a l production could leeeen the need f o r European wine, ehor ten eupply routee, and f r e e valuable ehipping epace. Bu t i n l a t e r yeare the m e t ropo l i t an center t r i e d t o regain

*This diecueeion of drinlring i n the colonia l period r e l i e e heavi ly on eourcee t h a t have n o t y e t been publiehed and t h a t 1 have w t pereonally analyzed. Di rec t quotat ione and decreee t h a t a r e n o t f u l l y referenced i n the next eevera l pagee a r e quoted i n and c i t e d by Taylor (1979), Hernandez (1374), o r Belaecuain e t a l . (1981).

i t s monopoly on the commerce of wines and l i quore . I n a b r i e f h i s t o r i cal ske t ch tha t deserves t o be s treng thened w i t h more d e t a i l s , Belascuain and h i e col leaguee (1981) c i t e 1551 as the f i r e t v in t age i n Peru, w i t h Bol iv ia and Argentina c l o s e behind. Braz i l and Ch i l e followed, b u t o t h e r L a t i n American coun t r i e s never d i d develop the indus t r y i n any s i g n i f i c a n t degree.

Changes i n a t t i t u d e s appear i n broad h i s t o r i c a l perspec t ive , a l though we know l i t t l e of how o r when eome p o l i d e s were reversed by v a r i o u s important i n s t i tu t ions . I t is , of course, a l s o l i k e l y tha t appa ren t l y i n c o n s i s ten t a c t i v i t i e s were i n f a c t simul taneously c a r r i e d o u t by v a r i o u s arme of s o l a r g e and d ive r se a n o rgan iza t ion a s , f o r example, the Soc ie ty of J e s u s , o r the Crown. The J e s u i t s a r e c r e d l t e d wi th having in t roduced the c u l t i v a t i o n of grapes t o Argentina, and t h e i r ex t ens ive vineyards i n c o a s t a l Peru were e conomlcally s i g n i f i c a n t (Cushner 1980) i n suppor t of t h e i r so-ca l led "Republi cs" i n the c o n t i n e n t a l hear t l and , hundreds of mi l e s away. The "Republice" i n t u r n gained some of t h e i r fame and f o r t u n e from the c u l t i v a t i o n and s a l e of yerba mate (sometimes c a l l e d " J e s u i t t ea") , which was promoted a s (among o t h e r th ings) a hea l thf u 1 sube ti tu t e f o r a l c o h o l i c beverages (Ruiz 1939 ) . Whe the r t he marketing of t hese products r e f l e c t s changed a t t i t u d e e toward dr ink , o r s imply shrewd bus iness p r a c t i c e i n a t t e n d i n g t o d i f f e r e n t s e c t o r s of a world market, remains t o be s tudied.

Another unc lea r Corpus of evidence r e l a t e s t o the view t h a t t h e Spanish admin ie t r a t ion had wi th r e s p e c t t o t he product ion of a l c o h o l i c beveragee i n t he Indiee. We have a l r e a d y noted t h a t i t was encouraged i n t h e e a r l y years , presumably f o r l o g i s t i c a l reasons. But, i n keeping wi th a gene ra l p a t t e r n of concern f o r balance- f - t rade and domina t i o n of marke t e , r egu la t i o n s were l a t e r i s s u e d t h a t disal lowed shipment of a l c o h o l i c beverages from one adminis t r a t i v e j u r i s d i c t i o n t o another w i t h in the I n d i e s , j u s t a s o t h e r s disal lowed impor ta t ion from s h i p s of o t h e r f l a g s . Some of t h e i r r e g u l a r i t i e e i n t he f o r c e of law a s a r e s t r a i n t on a v a i l a b i l i t y of a l coho l c l e a r l y r e l a t e d t o short-term l o c a l ex igenc ie s a s , f o r example, when a 10%-s tanding ban on the s a l e of coconut wine was l i f t e d i n o rde r t o provide more income f o r the r eg ion around Colima, Mexico, a f t e r i t had been devas ta ted by a n ear thquake (Bruman 1945).

(Ale a s p e c t of t he p a t e r n a l l a t i c a t t i t u d e toward Ind ians w a s a s e r i e s of decrees t h a t were o s t e n s i b l y in tended , i n t he terminology o f today, a s l e g i s l a t i v e approaches t o t he prevent ion of a lcohol- r e l a t e d problema. A s e a r l y as 1523, Car los forbade the sale t o Ind ians of " adu l t e r a ted pulque, " on the bas i e tha t the preserva t i vee "stupef y and e a s i l y k i l l . " I n 1594, Fe l ipe 11 decreed that v ine n o t be s o l d nor even in t roduced t o "place8 and pueblos of Indiana." Fe l ipe 111 forbade payment of wages t o Indians i n wine, on the p e n a l t y of a f i n e of 20 pesos i n 1609.

The experience of Mexico i e e e p e c i a l l y valuable a e an i l l u a t r a t i v e case etudy f o r a number of reaeone. It i e a l a r g e and d iveree country; c a l l e d m e v a Eepana, i t wae ne i the r the f i r e t nor the l a e t t o be colonized, and there i e r e l a t i v e l y r i c h h i e t o r i c a l documentation. I n terne of our epec ia l i n t e r e e t i n alcohol-related probleme, i t ha8 a l e o been deecribed by severa1 authore a e a c l a e e i c i l l u e t r a t i o n of the anomic impact of conqueet and the wideepread breakdown of norma againe t drinking and drunkenneee . I l l u e t r a t i v e of the view t h a t ha8 gained wideepread acceptance i n t h i e comect ion i e the ead parayraph wi th which a thoughtful h i s t o r i a n concludee h i e d e t a i l e d e tudy of the Aztece under Spanieh ru le : "What w e have e tudied i e the d e t a r i o r a t i o n of a na t ive empire and c i v i l i z a t i o n . ...If our eourcee may be believed, few peoplee i n the whole of h i e t o r y were more prone t o d r u n k e ~ e 8 8 than the Indiane of the Spanieh Colony" (Gibeon 1964:409). Even a n h i s t o r i a n who ueua l ly paya meticuloue a t t e n t i o n t o d e t a i l e i n o the r p a r t e of the world accepte the ext rapola t ione t h a t eeem t o have grown o u t of the d ieea t i e fac t ione of the diepoeeeeeed h e i r e of Aztec noblee: "The Indian people euf f e red tremendouely f rom the alcoholiem i n which they were encouraged t o indulge. It would r e a l l y eeem a e i f the c i v i l i e a t i o n of the Mexican plateau, loe ing i t e anc ien t f ramework and tabooe, abandoned i t e e l f t o a tamptation which wrought havoc with i t a f t e r 1600" (Braudel 1973:177).

As w e have noted above, what has been ignored i n t h i e widely a c e p t a d view i e the abundant evidence t h a t has only recen t ly been gleaned from cour t recorde, e a r l y Inqu ie i t ion t r i a l e , v i e i tore ' accounte, aan ln ie t r a t o r e ' repor t e , and s imi la r documente. They ehow that the image of pre-contact prohibi t ion (with exceptione on ly f o r p r i e e t e , noblee, and the aged) wae n o t accura te f o r many comiuni t i e e t h a t l a y on the periphery of Aztec domination, b u t t h a t per iodic f i e e t a e w i t h heavy drinking by coanonere were rou t ine (Taylor 1979 ~29-34)

It may ve11 be t h a t a ma jor por t ion of the alarm expreeeed by Spaniarde i n r e l a t i o n t o the i n e b r i e t y they deplored i n Indiane r e l a t e s t o fundamental d i f ferencee i n viewe about how and why one ehould drink i n the f i r e t place. It may well be t h a t Indiane were no t drinking exceeeively " t o f orge t t h e i r eorrowe, " b u t r a the r were continuing t o dr ink , f o r t h e i r ueual reaeone and i n t h e i r ueual manner, and thue the t r a d i t i o n a l p a t t e r n of drinking wae offeneive t o Europeane who valued eobriety. An i n t e l l e c t u a l h i s t o r i a n has put the po in t t h i e way: "That f ea ture of the Spanieh temperament t h a t remaine moe t conetant over the centur iee i e eobriety... Two thoueand yeare, with a l 1 the racial modif i c a t i o n e t h a t invaeione and the mixing of peoplee can bring, have done nothing t o b lu r t h i e cha rac te r i e t ic . . . " (Nenendez 19 59 : 33).

Such a view i e n o t eimply a wiehful reconetruct ion by a Spaniard proud of h i e her i tage; i t i e i n cloee conformity with the

medieval Chrie t i a n view tha t emphaeized man' e uniqueneee among the c rea tu ree of the e a r t h , d ie t inguiehed by h i e r a t i o n a l eoul. According t o t h i e view, reaeon etande as the l i n k between heaven and e a r t h i n a n o r d e r l y cha in of r e l a t i o n e h i p e t h a t pervade the universe. Reaeon 1s the d i v i n e part-- that by which human beinge know God (and thereby a c c e p t t he C h r i e t i a n coemology). I t i s evidenced i n poieed e t a t u r e , g race of h a b i t e , beauty of epeech, and -- c r u c i a l from the p o i n t of view of theology -- e t a b i l i t y through v i r t u e . From euch a pe r spec t ive , the drunken pagan i l l u s t r a t e e the power of Satan from without , and the e t r e n g t h of i r r a t i o n a l fo rcee wi th in -- e v i l tendencias abroad i n t h e world and a l s o i n h e r e n t i n man -- whi ch combine t o undercut one 'e v i r t u e , i f one doee no t have the Chrie t i a n moral e t rength t o r e e i s t. I n eho r t , t he conquietadore, the f riars , and t h e i r European con temporaries were convinced t h a t pagana, l ack ing a " e t a t e of grace ," were e a e i l y overwhelmed by temptat ione and by t h e i r baeer i n s t i n c t e , of which drunkennese wae both proof and a r e e u l t . A good C h r i s t i a n , by c o n t r a e t , would n o t g i v e way t o drunkenneee, which i n t e r f e r e s u i t h Go d-g iven reason.

I l l u e t r a t i v e of Spanieh viewe t h a t seem t o r e f l e c t t h i e concern f o r moderation a r e the following: " I f t he Indian drank pulque the way Spaniards d r i n k wine (which i e n o t the case, nor ha8 i t been, nor l e t he re any hope of t h e i r ever doing e o ) i t could be permitted... b u t t hese a r e Indiane and i t l e proven t h a t t h e i r cuetom i s t o g e t drunk, and i t i e f o r t h a t reaeon t h a t they drink." A l o r l e v e l Spanieh bureaucra t complained t o the e f f e c t t h a t "Everyone knowe tha t f o r them [ Indiane] dr inking e timula t e e g a i e t y and, i n gene ra l , t hey do n o t d r ink wi th app ropr i a t e moderation. From t h i e , undignif i e d a c t a , proa ti t u t i o n , and crime r e e u l t . " P r i e e t e , whether r e cognizing tha t drunkenneee wae of ten i n t ima te ly aeeoc ia t e d w i t h t r a d i t i o n a l r e l i g i o u e p r a c t i c e s o r f ea r f u1 tha t " the re l e no manner of e i n t h a t w i l l n o t be committed by drunken Indiane ," viewed i t a s a t h r e a t t o t h e i r charges, whom they a l s o coneidered normally weak and po t e n t i a l backel idere. Frequen t r e fe rence t o " incee t" as a e p e c i f i c abominable outcome of drunkenneee almoe t c e r t a i n l y l e colored by Spanieh unf a m i l i a r i t y w i th Indian s o c i a l e t ruc tu re .

I n e p i t e of theee and s i m i l a r miegivinge t h a t were expreeeed about Ind ian drunkenneee, the provieion of pulque wae n o t even r e g u l a t e d u n t i l t he middle of the eeventeenth century. A crude meaeure of i nc reae ing e a l e e ( a t a t i m e when monetary i n f l a t i o n wae minimal) 1s the r i e e i n t he va lue of t he f r a n c h i e e ( a s i e n t o ) f o r c o l l e c t i n g the pulque t a x i n Mexico Ci ty . I t wae eo ld a t 66,000 peeoe f o r the f i r e t year , 1668, and had r i e e n t o 92,000 j u e t e i x yeare l a t e r .

I r o n i c a l l y, t he aeeoc ia t i o n be tween drunkenneee and d i e reepec t f o r o f f i c i a l e t h a t i e mentioned i n gene ra l e tatemente by c i v i l and

r e l i g i o u e epokeeman i e n o t r e f l e c t e d i n t he recorde of t r i a l e o r var ioue r e l a t e d a r c h i v a 1 m a t e r i a l e t h a t have been combed i n a c a r e f u l eearch f o r jue t euch evidence (Taylor 1979 :44-45). Perhape more e t r i k i n g i e the f a c t t h a t t he a e e o c i a t i o n poe i ted between drunkennees and v i o l e n t crimee i e e i m i l a r l y uneube t a n t i a t e d , a l though the recorde a r e euff i c i e n t l y r i c h i n d e t a i l t o a l l ow many o t h e r aeeoc ia t ione , eome of them q u i t e unexpected, t o be diecerned (Taylor 1979).

Obviouely, n o t a l 1 o f f i c i a l t raneac t ione concerning a l c o h o l i c beveragas were negat ive . Taxee on pulque and f e e e f o r l i c e n s e e of pu lquer iae and taverne added e ign i f i c a n t l y t o t h e income o£ s e v e r a l j u r i e d i c t i o n e , eepe c i a l l y thoee w i th denee populat ione . Furthermore, pulque was recognized, even by t h e Spaniarde, t o have va lue apa r t £roa i t e q u a l i t y a s a n in tox ican t . Amo- the severa1 medicinal ueee of pulque t h a t were mentioned f avorab ly i n c o l o n i a l record6 o£ Mexican c o u r t proceedinge are the cure of headache, e tomach ache, and d i a r rhea , a e d i u r e t i c , t o prevent l ice, t o promote l a c t a t i o n o r a r r e e t menetruat ion, t o h e a l wounde, a e a purga t ive , "f o r pain," and "good f o r any i l l n e e s . "

The progrees ive impoei t ion o£ l e g a l con t ro l e on pulque eugges t e a d m i n i s t r a t i v e concern, whether f o r f i e c a l reaeone o r i n terme o£ e o c i a l con t ro l . There were eucceeeive a t tempte ( i n 1579, 1585, and 1586) t o l i m i t s a l e e t o a f e w e p e c i f i c e i t e e i n and around Mexico City. I n lb08, i t wae decreed t h a t t h e r e ehould be no more than one l i c e n e e per hundred Indians i n a neighborhood. Tax evaeion may have prompted regula t i one ( i n 16 35 and 16 39 ) t h a t e p e c i f i e d t h a t pulque could be brough t i n t o the c i t y on ly during the day.

Native beveragee were n o t the on ly onee ava i l ab l e . For a wh i l e there appears t o have been a d r i v e t o encourage Indiane t o buy Spanieh wines and brandiee. This may have been p a r t l y a n a t tempt t o unload poor q u a l i t y goode on a n u n c r i t i c a l market, and/or i t may have had t o do wi th increae ing revenuee through cuetome d u t í e e and o t h e r taxee. There i s no i n d i c a t i o n t h a t t h i e t r ade representad any d e l i b e r a t e a t t empt t o e u b e t i t u t e a more " c i v i l i z e d " d r ink f o r a "eavage" one; i n f a c t , t he a l t e r n a t i o n of permieeion w i t h p e r i o d i c p r o h i b i t i o n ( a s , e.g., i n 1594, 1637, 1640) eeeme t o r e f l e c t i ndec i e ion o r inconeietency.

Deepite a l 1 our caveate a g a i n e t overeet imating o r miecone t ru ing pub l i c i n e b r i e t y i n e ix t een th-century Mexico , i t would be u n r e a l i e t i c t o ignore o r deny t h a t there doee appear t o have been a n inc rease i n per-capi ta coneumption of pulque. What had been a f ami ly e n t e r p r i e e became rnarket-oriented a e l a r g a numbere of Indiana were r e loca t ed i n new se t t l emen te o r deprived of t h e i r land. The c u l t i v a t i on of maguey wae e ign i f i c a n t l y expanded t o eerve the burgeoning urban populat ion. Taxee on a l c o h o l i c beveragee became e i g n i f i c a n t eourcee of revenue f o r p u b l i c worke; l i c e n e e e t o s e11 became bo th more numeroue and more valuable .

It i e a l toge the r poeeible that a por t ion of the increaeed coneump t ion of pulque may indeed have r e e u l ted f rom f r u s t r a t ion , anomie, and o the r kinde of e t r e e e t h a t accompanied Spanieh domination. But we muet n o t ignore a v a r i e t y of o the r important f a c t o r e t h a t may have contr ibuted t o i t . The pool of f requent coneumere increaeed enormouely a s t r a d i t i o n a l eumptuary lawe broke down; pulque, l i k e meat, cacao, and c e r t a i n kinde of clothee, had been l i m i t a d t o the n o b i l i t y f o r d a i l y uee, bu t euch t u l e s were r a p i d l y eroded a e t i a d i t i o n a l l eadere were replaced by Europeane. The Ca t h o l i c calendar introduced add i t iona l f eae t-days. Miecege- na t ion contr ibuted a new s o c i a l category, meetizoe, who of ten grew up with l a x o r confused pat terne of e o c i a l i z a t i o n and many of whom had a e take i n n e i t h e r Indian nor Spanieh eoc ie ty o r norme.

A number of the e a r l y chroniclere -- and eome wr i t e re today whoee obeervatione a r e e u p e r f i c i a l and a t a coneiderable dietance from the r e a l rhythme of everyday Indian l i f e -- have pointed t o drunkenneee a e eymp toma t i c of laz ineee , and rendering Indiane incapable of work. Anyone who pays cloee and euetained a t t e n t i o n , of couree, would recognize t h a t the l e a s t e n e r g e t i c Indian ueual ly worke harder than any euch obeerver i n the couree of normal subeietence a c t i v i t i e s . The d i f ference l i e e i n the rhythm of work, which tende t o be in tens iva during b r i e f peake during the a g r i c u l t u r a l cycle, w i t h i n tervening periode when li t t le can conet ruct ive ly be done. Leieure and drunkennees a r e accepted and even encouraged a t epecif i c times i n moe t urban i n d u s t r i a l cul turee , and both a r e deplorad "a t the wrong time;" the sama i e t rua of most Indian cul turee.

But when a r i o t t h a t devastated much of Mexico C i t y i n 1692 wae blamed on "drunken Indiane, " prohibi t i o n wae impoeed. Enforcement wae l a x , however, and wi th in a few yeare the pulque trade wae again a major enterprise--although contro l had e h i f t e d t o a few s o c i a l l y e l i t e f ami l i ee who have continuad t o dominate i t wherever the population i e l a r g a enough t o aeeure a e izeable and regu la r p r o f i t (Kicza 1980). I n squeezing the Indiane o u t from t h i s l u c r a t i v e trade, spanieh10 entrepreneure were r ep l i ca t ing an advantapeoue move they had made earlier with reepect t o maize and cacao.

A epec ia l commieeion comprising four membere of the audiencia of Mexico C i t y made a d e t a l l a d r e p o r t on pulqueriae and taverne i n the c i ty during the l a e t qua r t e r of the U t h century. Carlos 111 had ordered the etudy i n reeponee t o repeated complainte from p r i e e t e about murdere, thef t e , aeeaul te on epoueee and children, and o ther "indecencies" and "eacr i leges" tha t were euppoeedly being committed by drunken Indiane. They found 45 pulqueriae, moet o£ them eerving both eexee, where there ehould have been only 24 f o r men and 12 f o r women. (The f a c t t h a t eo many epec ia l drinking placee were provided f o r women i n the f i r e t place i e a curioue f a c t ,

given t h a t i t f i t v i th n e i t h e r t r a d i t i o n a l Spanieh nor Indian pat terne . ) Regulatione epecif ylng t h a t they were t o be small , open, and unfurniehed were genera l ly ignored. ( b l y women vere euppoeed t o be i n the busineee, b u t few were. There were few pol ice i n the ci t y , and enf orcemen t of unpopular lawe wae no t preeeed, e e p e c i a l l y e ince moet of the pulqueriae were owned by wealthy and powerful individuale who ren ted them o u t o r had eubal terne working there. The recommendation of the commiseion, which wae eoon enacted, wae n o t t o increaee cont ro le o r t o res t r i c t d i e t r i b u t i o n o r coneumption, but t o inc rease the tax and e e t a b l i s h a r egu la r category within the aya teme of taxat ion and adminis t r a t ion .

What happened with reepect t o chicha i n Peru during the co lon ia l period l e bo th d i f f e r e n t from and e imi la r t o what happened with reepect t o pulque i n Mexico. I n 1556, a judge i n Cuenca r e e t r i c t e d the use of chicha and, i n h i e decieion, revealed much about the epec ia l p o l i t i c a l and economic impl ica t ions of t h a t beverage: "Becauee e a i d chiefe and leadere ueed t o have ' taverne' and placee where a l 1 who came t o them were given chicha t o drink, and i t i e the cause of drunkenneee of the people, and i t occupies many men and women i n making the chicha, and i t i s a thing of bad example, and the s a i d chiefe epend exceesively on i t ; i t 1s ordered t h a t from now on they n o t have euch ' taverne' nor publ ic o r e e c r e t placee f o r drinking" (archiva1 me, ci ted i n Roetworoweki 1977 :241). I n t h i e way, the conquistadore were a b l e t o undercut one of the p r i n c i p a l baeee of power t h a t the Inca nobles had enjoyed, and t o d r ive a wedge between them and the commoners who had benef i t e d f ron the t r a d i t i o n a l r e d i s t r ibu t i v e eya tem. I ron i ca l ly , t h i e r eeu l ted i n wide diepersion of what had been r e l a t i v e l y concentrated production; the new cottage induet ry of chicha-making wae more d í f f i c u l t t o tax and d i d n o t come under the cont ro l of the European e l i t e , i n eharp con t r a s t w i th wha t happened t o pulque i n Mexico.

Although the Andean a r e a has n o t been s o c a r e f u l l y e tudíed w i th reepect t o what co lon ia l documente can reveal about drinking, there a r e eome e imi la r a l lue ions t o drunkenneee a e commonplace, promp t ing Indiane t o violence, crime , l a z i n e s s , eac r i l ege , and eo fo r th . The world-view of Spaniards colors t h e i r eetimatione i n t h i e a r e a , a s i n Mexico. Amo- Indiana, drunkenneee i s s a i d t o be "congenital," " i n the blood," "worsened by the burning climate of the t ropics ," and s o f o r th. Prohibi t ion was recomuended by Cler ics and adminietra t o r s "f o r t h e i r own [Indiane ' j good" (assuming weak w i l l and chi ld ieh ignorance) and "for the g r e a t e r g l o r y of God." A Chilean archbishop epe l l ed o u t d e t a l l a d r e s t r i c t i o n s on the s a l e of "wine o r chicha" t o Indiane, and threatened v i o l a t o r e with exwm- munication, whipping, and e x i l e . Among h i e epecif i ca t ione were the following: 10 percent a 8 maximum p r o f i t , no credi t ea lee , no uee a e wages, no more than 2 r e a l e s worth a t a time, and no more i f a customer has drunk eleewhere (eources c i t e d i n Lejarza 1941).

Paren the t í ca l ly , one cannot help b u t be e t ruck by how very e imi lar theee r e e t r i c t i o n e a r e , i n some respecte , t o l e g i s l a t i v e cont ro ls i n many modern a t a te6 and provinoes.

A l though pulque was by f a r the moet popular a l c o h o l i c beverage i n co lon ia l Mexico, t h i e doee n o t imply t h a t d i e t i l l e d l iquors were unknown. Cor tea himeelf i n s t a l l e d the f ir8 t sugarmil l a year af ter h i e a r r i v a l i n Cuernavaca, and the production of aguardiente (cane a lcohol) followed eoon a f ter. An h i s t o r i a n who has pa id epec ia l a t t e n t i o n to t h i e (Hernandez 1974) euggeete t h a t economic protectioniem, with epec la l concern f o r the brandy induet ry i n Cataluna and the rum indue t ry i n the Canary and Caribbean i s lande , wae probably moe t impor t a n t among the reaeone f o r long-term prohibi t ion on the manufacture and s a l e of aguardiente i n Mexico. H e chroniclee the controversiee, provides eome evidence of bootlegging , and ehowe how l e g a l i z a t i o n , wi t h heavy taxee, provided a major new eource of revenue from U96 on.

The a v a i l a b i l i t y and coneumption of a l c o h o l i c beveragee were a l e o a eource of concern during the colonia l period i n the a r e a tha t l e now Colombia. Ambivalence l e evidenced i n teetimony by phyeicians who h a i l e d aguardiente a s a invaluable p a r t of their pharmacopaea, adminis t ra tore who pointed o u t t h a t chicha increaeee the work-efficiency of Indiane, and c l e r i c s who deplored the immorali t y tha t they f e 1 t wae caueed by drunkennese. I n the f ace of admlnietra t i v e ind i f f erence, the archbishop there, too, impoeed h i e own eanction, including excommunication f o r thoee who made, eold, o r bought aguardiente, f inee f o r thoee who owned the t rapiches (normally "cane-preeeee, " but i n contex t presumably " e t i l l e " ) a s we l l a s 20 laehee f o r blacks (or e x i l e f o r whitee) who operated them (unpubliehed documente i n Archivo General de Indias , Sev i l l a , ex t rac ted i n U. Ro jae 1960).

Lomnitz'e account of the Mapuche i n Chi le (1973) was a pioneering a t tempt t o t r ace the changing meaninge and ueee of a lcohol through four centur ies , and Medina (1978) ha8 provided n o t on l y a e trong endorsemen t of my recommendation tha t more h ie t o r i c a l e tudiee of drinking be done, b u t a l s o a ueeful l i e t of appropr ia te eourcee wr i t t en by people who were eye-witneseee o r good repor te r s i n La t i n America during the colonia l period.

Throughou t the e r a of explora t ion and coloniza t ion , European contac ts with membere of o the r racee were i n t e r p r e t e d i n r e l ig ioue r a t h e r than r a c i a l terme, and even today, although discueeione of varioue populations a r e o f t e n couched i n the vocabulary of "race," the diet inguiehing c r i t e r i a that a r e important tend t o be s o c i a l and c u l t u r a l r a t h e r than phenotypic o r phyeiological. Clothing, language, r e l i g i o n , and o ther aepecte of cuetomary behavior tend t o be the cha rac te r i s tic6 tha t people use f o r i d e n t i f ying "race, " r a t h e r than physical c h a r a c t e r i s t i c e , and i t 1s widely recognized

tha t an individual can l e a r n new pat terne and thue move (o r "pase") from one euch category t o another. Obviouely, w e a r e n o t deal ing here with g e n e t i c inher i tance; i f the term "inheri tance" 1s p e r t i n e n t a t a l l , i t i e i n terme of "learned inher i tance ," the product of e o c i a l i z a t i o n by meane of vhich chi ldren a r e encouraged t o r e p l i c a t e the be l i e f e , a t t i t udee , valuee, and o the r pa t terne t h a t t h e i r e l d e r e f i n d congenial.

Cu l tu ra l Variante i n Modern His tory

We have a l r eady examined, i n the in t roduct ion t o t h i e chapter, one e i d e of the d i a l e c t i c concerning c u l t u r a l u n i t y and d i v e r s i t y i n La t in America. A number of Iberoamerican authors were c i t e d i n euppor t of the proposi t ion tha t, f o r cer t a i n a n a l y t i c purposes, i t 1s both ueeful and meaningful t o diecuss h i e t o r i c a l and c u l t u r a l f a c t o r 6 a8 having a degree of u n i t y throughout Lat in America. We have a l e o eeen t h a t regional d i f ferencee , i n both pre-Colombian and co lon ia l timee, included eome s i g n i f i c a n t kinde of v a r i a t i o n with reepect t o the a v a i l a b i l i t y and coneumption of a l coho l i c beverages.

I n t h i e eec t ion , we w i l l b r i e f l y and e e l e c t i v e l y examine r e l a ted f orces during the n ine teen th and twentie th centuree .ll Such a n at tempt ehould i l l u s t r a t e a v a r i e t y of coneideratione t h a t a r e important n o t on ly ineofa r a e they r e f l e c t the d i v e r s i t y of e thnographic f a c t e bu t a l e o insofa r a e they provide h i n t s about reaeone f o r p a r t i c u l a r drinking pa t t e r n s , meanings of p a r t i c u l a r alcohol-related problems, behaviore o r a t ti tudee tha t appear t o be s a l u t a r y with reepect t o drinking, o t h e r s t h a t a r e aseocia ted with varioue kinde and r a t e e of eoc ia l o r physical pathology, and 80

f o r th. The experience of l e g i s l a tore , adminie t r a t o r e , and a wide range of persone who a r e engaged i n the enhancement of publ ic hea l th has demonetrated v iv id ly , i n a l 1 pa r t e of the world, t h a t a ttempte t o preven t o r a l l e v i a te any kind of heal th-rela ted problem ehould take i n t o account varioue aspects of the cul turee of the populatione t h a t a r e t o be af fec ted . Fa i lu re t o do s o has, almoet without exception, r eeu l t ed i n the f a i l u r e of euch programe, whether aimed a t the l eve1 of primary, eecondary, o r ter t i a r y "prevention. "

W i t h reepect t o the sub jec t rnatter of t h i e eec t ion , a s with previoue onee, a number of important f a c t o r e have a l r eady been diecueeed i n o ther contexts. Negra te's (1976 ) exce l l en t and euccinct review of eoc iocu l tu ra l f ac to re i n alcoholiem n i c e l y combinee br ief summariee of important eocio logica l and anthropo- l o g i c a l theoriee with notes on c l i n i c a l impl ica t ions , ueing data from throughout La t in America. The pioneering work of J. Mariategui ( l967) , with s i m i l a r scope, hae a l r eady been c i t e d a8 an important contr ibution. Heath'e (197 4a) review of the l i t e r a t u r e l e he lpful , and Medina'e ( U l d ) hae the add i t iona l value of euggeeting f r u i t f u l new d i rec t ions f o r reeearch. Amar (1977) t r ea ted eevera l topics i n

depth, inc ludi ry " t y p i c a l urban l i f e, " "conf l ic t ing r a c i a l r e l a t ione , " "whi te immigration" during the l a s t 100 years, " the r e l a t ioneh ip between town and country," and both formal and informal " soc ia l controle." A number of ethnographic s tud iee t h a t have a l r eady been repeatedly eummarized i n the a lcohol l i t e r a t u r a w i l l n o t be diecueeed here i n d e t a i l ; those who a r e no t f ami l i a r with euch bae ic worke a s Bunzel (1940), Mangin (1957 ), Madeen and Madeen ( l969), Heath ( l958), Simmons (1959, W60, 1968) and o there w i l l f ind t h e i r p r inc ipa l da ta and i n t e r p r e t a t i o n e c i t e d i n various of the review a r t i c l e e a l r eady mentioned.

Among topica t h a t a r e euf f i c i e n t l y impor t an t , but probably no t ye t e u f f i c i e n t l y f a m i l i a r t o many, a r e the waye i n which d i f f e r e n t aepecte of cu l tu re a r e in t ima te ly l inked with be l i e fe and behaviore about a lcohol , and the impreeeive r a s e of euch pa t t e rns t h a t a r e noted throughout Lat in America -- o r even wi th in a s i n g l e na t ion -- when a t t e n t i o n l e pa id t o d i f f e r e n t kinde of " spec ia l populatione" (Heath 1381) euch a s e t h n i c groupe, r e l i g i o u e s e c t s , t r ibee , and socioeconomi c claeeee .

Moet e o c i a l e c i e n t i e t e i n r ecen t yeare have tended t o be wary of t a lk ing abou t "nat ional character" o r "bas ic pereonali t y type, " bu t euch a groes l eve1 of genera l i za t ion tends t o p lay an important r o l e i n t e m e of popular i n t e r p r e t a t i o n e about drinlring pat terne and t h e i r sequelae. Diecueeion of na t iona l character l e f raught w i th daryer , p a r t l y becauee of the d i f f i c u l t y of ext rapola t ing from ind iv idua l s t o populations, and p a r t l y becauee of the reeenanent tha t the a c t of e tereotyping almo8 t i n e v i t a b l y engendere.

Despi te the f a c t tha t people may r e s e n t e tereo typee a t t r i b u t e d t o them by ou t s ide re , they o f t e n ehare -- and even cherieh -- etereotypee t h a t a r e e luc idated by members of t h e i r own group o r e o c i a l category. Thus, while Angloe may be derided and ecorned f o r exaggera t ing and c a r i ca turing the impor tance of par tying and machiemo among Latinos, a Nexican poet, eeeayie t , and diplomat has been l i o n i z e d f o r h i e penet ra t ing i n s i g h t s about the importante of f i e s t a s : "F ies ta s a r e our only luxury. .. .During theee days the s i l e n t Mexican whie t l e e , ehoute, einge, ehoote of f h i e f ireworks, diechargee h i e p i e t o l i n t o the a i r . ... Thie i e the n igh t when f r i ends who have no t exchanged more than the prescribed cour tee iee f o r months ge t drunk together , t rade con£ idencee, weep ovar the eame troublee, discover t h a t they a r e brothere, and eometimee, t o prove i t , k i l l each o the r" (Paz 1961:49). S imi lar ly , although an outs ider would be viewed a e being a t l e a e t one-sided, and more l i k e l y bigoted, i f he charac ter ized "the Latin" a s i r reeponeible , wily, and more concerned w i th worde than with a c t ion , the qu in teesen t i a l clown-hero f o r two genera t ions of La t i n Americane has unquee t ionably been "Cantinflae" (Mario Moreno), a s l i g h t l y eeedy character whoee combination of p e r e m i a l i r r e e p o n e i b i l i t y , a b i l i t y t o confound o the re with g l i b bu t noneeneical verbiage, and eeeningly unconecioue

b u t i n f i n i t e l y g race fu l dodging of a l 1 kinds of obetaclee make him a n o b j e c t of eyapathy and emphathy a 8 w e l l a e of guffaws. No one would claim t h a t a clown i e the "culture-hero" o r s o c i a l cynoeure of an i n t e r n a t i o n a l soc ie ty , b u t when the valuee and ac t ione he portraye e t r i k e a reeponeive chord s o deeply and s o broadly f o r eo lo-, there muet be a n important element of t r u t h i n the charac ter iza tion.

Another kind of evidence beare on t h i e groee leve1 of peycho-hie t o r i cal a n a l p i s : a li t e r a r y genre of c u l t u r a l in t roepect ion i n which La t in Americane have long been vocal and a r t i c u l a t e . According t o a prevalent view, the Conquest wae a profound "peychic trauma," a second "orginal s i n f o r the conquerors and a a u s h i n g d e f e a t f o r the vanquiehed, and i t e t i l l weighe heavi ly on a l 1 t h e deecendante." A more v i v i d charac ter iza t ion repreeents the craes European male raping the noble American female, and then ignoring the half-breed ( 1 e . , meetizo) of fepring. Argwdas (1909) e a r l y ueed t h a t image to expla in why Boliviana a r e "a e i ck people"; c l o s e l y r e l a t e d viewe have been a r t i c u l a t e d by Aramoni (W61), Gonzalez Pineda (1961), Paz (1961), Bodriguez Sala ( l965), Freyre (1956, 1966), and othere.

(be by-product of t h i e i e " the c r i o l l o outlook" deecribed by Simmone (1955) i n coaeta l Peru. Sociable b u t a s o c i a l , f u l l of g u i l e , exce l l ing i n verbal f a c i l i t y and mental a g i l i t y , one ehould be a b l e t o l i v e well without apparent ef f o r t and t o "get away with" anything. Although euch a character may n o t be h a i l e d a8 the i d e a l son-in-law, he i e l i k e l y t o be the eub jec t of a t l e a e t grudging admiration, n o t only i n Peru b u t a l s o i n Argentina ( l i k e the fabled gaucho), i n Mexico (c loee ly r e l a t e d t o the charro) , and elsewhere.

J u e t a8 there i e an important d i a l e c t i c between u n i t y and d i v e r e i t y within the v a s t region we have been ca l l ing Lat in America, there l e a e i m i l a r l y important d i a l e c t i c between u n i t y and d i v e r s i t y wi th in each of the component ecologica l a r e a s ( a s when geographere epeak of "the Amazon baein," "the Chaco," "the a l t i p l a n o , " etc .) . The eame holde t r u e with reepect t o c u l t u r a l a reae , baeed on t r a i t-die t r ibu t ione ( a s when e thnologie t e epeak of "Tropical Foree t, " "Circum-Caribbean, " "Marginal, " "Meeo-American, " o r o ther types of cul turee) . I t l e a l e o t rue with reepect t o moe t of the ind iv idua l na tion-e t a t e s which have become such apparent ly un i t a r y e n t i t i e e i n modern times, even though t h e i r p o l i t i c a l boundariee of ten do violence t o c u l t u r a l and h i e t o r i c a l systeme t h a t a r e important t o people a t the praeeroote l e v e l .

E thnographi c S tudies

A major cont r ibut ion t h a t anthropologiste have nade t o our underetandinp of a lcohol and i t e i n t e r a c t i o n with the human animal

has been the d e e c r i p t i o n of p a t t e r n s among i d e n t i f i a b l e l o c a l communitiee. Th i s hae the advantage of ehowing how the p a r t e of a c u l t u r e r e l a t e t o each o ther . I t can a l e o ehow how h i s t o r i c a l f a c t o r 8 in f luence p r e s e n t choicee (whether i n a s t a b i l i z i n g , c a t a l y t i c , o r d e s t r u c t i v e eense) . I n some in s t ancee , i t can r evea l much about t he range of i n d i v i d u a l v a r i a t i o n wi th r e s p e c t t o a normative norm, o r w i th r e e p e c t t o a d e s c r i p t i v a n o n . I n o t h e r ine tancee , i t can i l l u m i n a t e how " rea l " c u l t u r e f i t e -- o r d i f f e r s from -- the " idea l " c u l t u r e , r ega rd l e se of whether t h a t i d e a l i s epitomized i n lawe, gene ra l i zed deec r ip t ions , e t h i c a l o r r e l i g i o u s precepte , the r e s u l t e of a queet ionnaire-survey, o r eome o t h e r eource t h a t i e removed from the r e a l i t y of everyday l i f e . Por a l 1 of theee reaeone, e thnographic e tud iee of a l coho l uee have been va luable , d e s p i t e the f a c t t h a t few anthropologie te eve r e e t o u t wi th the s p e c i f i c i n t e n t i o n of focusing on t h a t realm of behavior . l 2

Among e thnographic s t u d i e e of L a t i n America, t he re a r e on ly a few t h a t have no mention of dr inking and drunkenneee; t h i s 1s t rue of both peaeant communi t i e e and r e l a t i v e l y i e o l a t e d t r i b e e which have had o n l y deeu l to ry con tac t with r e p r e e e n t a t i v e s of Weetern i n d u e t r i a l i z e d cu l tu ree . I n the context of t h i e workshop, a r eg iona l eurvey would be of l i t t l e value, b u t a broad sampling w i l l demonetra t e t he i n t e r p l a y of h i e t o r i c a l and c u l t u r a l f a c t o r e a t var ioue l e v e l e of contemporary e o d e t y , and enable ue b e t t e r t o app rec i a t e t he v a r í e t y of a t ti tudes and i n t e r e e t e tha t a r e involved i n the a v a i l a b i l i t y and coneumption of a l c o h o l i c beveragee .

One p a t t e r n of d r i n k i r y t h a t has been remarkably cone ie t en t through t i m e and t h a t is widely d i s t r i b u t e d throughout L a t i n America i e t h a t of dr inking boute, o r group bingee. C h a r a c t e r i e t i c s of t h i s p a t t e r n a r e t h a t the men d r ink t o the p o i n t of s tupe fac t ion ; the beverage hae no r e l i g i o u s connotation; and al though dr inkiqg i n a group i e a s o c i a l impera t ive , s o l i t a r y dr inking i e unthinkable. The broad geographic range of t h i s s t y l e i e cha rac t e r i zed i n Cooper (1949), and Mandelbaum euggested i t wae p ro to typ ica l of the a r e a (1365). A few of t h e d e t a i l e d l o c a l e t u d i e s where i t i s exemplif ied r e f e r t o Ch i l e (e.g., Lomni t z 1969a, b, Medina and Ptarconi 1970); Colombia (Sayree 1356); Ecuador (Maynard e t a l . 1965, Rodriguez Sandoval 1945); Guatemala (Reiche 1970); Mexico (Maccoby 1965, Wileon 1372); and Peru (Gomez 1966, Mangin 1957, Marroquin 1943, S imone 1968). Thie widely d i e t r i b u t e d p a t t e r n was preeumably what J e l l i n e k had i n mind when he spoke of contemporary L a t i n America as having "an a l c o h o l i c c u l tu re . "

I t i e probably a l e o the p a t t e r n t h a t has prompted many twent ie th century obeervers t o be outepoken i n t h e i r c r i t i c i s m of dr inking and drunkenneee as important obs t ac l ee t o modernization and progrese. A P r o t e e t a n t miss ionary ' s view i s perhape more s t a r k l y phrased than eome o the re , b u t i t r e f l e c t e a wideepread a t t i t u d e

among urban i n t e r n a t i o n a l l y o r i en tad people i n U t i n America today: "Neither Government nor the RDman Cathol ic Church hae done anything t o cont ro l the drinking h a b i t s of the people--habite which, accordiqg t o many Indianie tae , a r e des troying more Indiane than any o ther s i n g l e cauee" (Rycrof t 1946 : 12-7 3) .

However , among the indigenis tas, whoee work continues t o have a e i g n i f i c a n t impact on thinking about these eame Andean popula t ione, the drinking hab i t e a r e almoe t invar i ab ly por trayed i n very d i f f e r e n t tenue--f avorably, a e i n t e g r a l p a r t e of na t ive l i f e , important f o r r e l i g i o u e reasone a e well a s f o r s o c i a b i l i t y . Thie view i s n o t r e e t r i c t e d t o ethnographere, b u t i s ehared by the coemopoli tan li t e t a ti who cherieh f o l k t r a d i t ions ae importan t par t e of the worldwide human her i tage . I n h i e famoue novel about quaei-eerf dom i n highland Ecuador, Icaza (1937 ) doee no t ignore the violence t h a t eometimes eneuee, but a l e o shows the immenee value of men'e going on a binge together. Writing about a c loeely r e l a t e d y opula t ion i n highland Bolivia, Arguedas (19 19 ) caref u l l y por trayed drunkemees a8 eynbol ica l ly important and e o c i a l l y usef u l ; the few r e £ erences t o i t i n J.C. Maria tegui ' s (197 1 ) almoe t timeleee cha rac te r i za t ion of Peruvian r e a l i t y ehow alcohol-relatad probleme a e more a r e e u l t of i n t e r e t h n i c prejudice and domination than a cauee. A s imi la r view with r e spec t t o Mexican Indians i e of fered i n a c l a e e i c ind igen ie t novel by Lopez y Fuentes (1937), and i n a quaei-autobiography (e .g . , Pozae 1968 ) , a e w e l l a e i n innumerable e thnographic monographe and communi t y e tudiee.

Thie emphasie on the e o c i a l value of eharing drink i e by no meane d i e t i n c t t o La t i n America, of couree. Throughout the world, one of the m08 t widely recognized values of alcohol l e tha t , i n r e l a t i v e l y low concentra t ions, i t of ten increaeee e o c i a b i l i ty. S i n i l a r l y wideepread i n geopraphical tenue, and even b e t t e r documentad over a long span of h i s to ry , i s the eynbolic value t h a t of ten a t t a c h e s to the a c t of drinking together. I n f a c t , i t i s i r o n i c t h a t eo much concern has been devoted t o alcoholiem a e an a f f l i c t i o n of lone ly people, o r on the diminiehing eoc ia l networke of drinkere a e t h e i r probleme increaee. In moet of the world, drinldng i e e e e e n t i a l l y a e o c i a l a c t , o f t e n to the point t h a t e o l i t a r y drinking i s unknown and even unimaginable. It i e important t o keep t h i e i n mind, becauee a t l e a e t tha t , among the alcohol-relatad probleme t h a t loom l a r g e e t i n eome p a r t e of the world, i e v i r t u a l l y abeen t i n many La t in American communitiee.

Without exploring i n d e t a l l the r i c h f und of epecif i c d e t a i l e t h a t have been amaeeed by ethnographere concerning the poei t ive e o c i a l functione of drinking, a few of t h e i r srunmary i n t e r p r e t i v e etatemente should help t o convey eome of the benef ic ia1 eenee t h a t a c a u e e from drinking -- and even drunkenneee -- i n euch a context. Among the Camba of Bolivia, f o r example, ". . . f i e s t a 8 cons t i tu te v i r t u a l l y the only corporate form of s o c i a l expreesion. Drinking

p a r t i e e predominate amory r a r e s o c i a l a c t i v i t i e e , and a l coho l eervee t o f a c i l i t a t e r a p p o r t between ind iv idua le who are normally i e o l a t e d and i n a o v e r t e d " (Heath 19%:507 ). On t he bae i e of h i e work i n e e v e r a l comiuni t i e e i n h ighland Peru, ano the r observar concluQd tha t : "Where the use of i n t o x i c a t i n g beveragee i e expected and commonplace, t h e i r s p e c i a l q u a l i t i e s a r e coneciouely u t i l i z e d a s a device t o e t r u c t u r e and promote s o c i a l i n t e r couree and t o f a c i l i t a t e the achievement of c u l t u r a l i d e a l e " (Doughty 1971: 188). Remember t h a t both of these comen te r e f e r t o populat ione of Spanieh-epeaking peaean t e who par tl c ipa te i n the n a t i o n a l economy, and no t t o a emall i s o l a ted t r i b e .

I t i s n o t o n l y i n Andean coun t r i e s t h a t dr inking i s o f t e n c i t a d as a n a c t t h a t has important va lue i n promoting s o c i a l cohesion o r conv iv i a l i t y . The same i s t r u e i n t he Caribbean (e.g., Yawney 1969, P r ince e t a l . 197 2, Manning 1979, Abad and Suarez 197 5, Beaubrun iY68), Cen t r a l America (e.g., A r r i o l a 1965, Chaesoul e t a l . 1973, P re s t an 1975, Reiche 1970), Mexico (e.g., Pozas 1957; Kearney 1970, Kennedy U 6 3 , Madsen and Madeen 1969), and i n lowland a r e a s of South America (e.g., Leacock 1964, Goldenberg e t a l . 1965).

Drinking As R l t u a l Behavior

I n many of t h e e t h n i c cu l tu ree throughout L a t i n America, s o c i a l d r inking i s s o important t h a t i t l e imbedded i n eequencee of ve rba l and o the r behavior t h a t a r e s o f ormally pa t t e rned a s t o be c a l l e d r i t u a l s . The case o£ the Chamula o£ southern Mexico hae been more c a r e f u l l y analyzed than many: "Symbolically, t he drinlsing r i t u a l ach ieves a t l e a s t f o u r objec t ivee . I t emphaeizee the p r i n c i p l e of e q u a l i t y , f o r e a & p a r t i c i p a n t r ece ivee a n equal amount. It emphasizes t he p r i n c i p l e of rank, f o r equal por t ione a r e served according t o rank order . ... I t l i t e r a l l y producee and a l e o symbolizes the h e a t t h a t 1s considered dee i r ab le f o r human i n t e r a c t i o n wi th d e i t i e s and wi th ea& o the r . F ina l ly , i t symbolizes s o l i d a r i t y amonp the p a r t i c i p a n ts.. . " (Goeeen 197 4 : U 4).

The symbolism of d r ink i ry together a e a n important con t r ibu t ion t o s o c i a l u n i t y becomee even more dramatic i n those popula t ione where dr inking pa t t e r n e themeelvee are e x p l i c i t l y re cognized a s importan t f e a t u r e s tha t d i e t l ngu i sh membere of one group from those of another (e.g., Heath 1971, Viqueira and Palerm 19 54, Sir~mons 19 55). Ano ther usage r e l a t e s a l coho l and drunkennees t o i n t e r - e t hn ic r e l a t i o n e , a theme of pervaeive concern i n most L a t i n American s o c i e t i e e . V i l l a g e r s i n southern Mexico are g l a d t o have drunken ind iv idua l8 p l a y a v a r i e t y of p o l i t i c a l l y and dramaturg ica l ly s i g n i f i c a n t r o l e s , en joyíng a pecu l i a r permiseiveness tha t l e t e them "speak the unepeakable" (Dennie 197 5) .

Secular r i tua le a r e n o t the on ly onee i n which a lcohol playa an important eymbolic t o l e ; drinking and drunkenneee a r e h ighiy valued aspecte of the f i e e t a s t h a t accompany re l ig ioue obeervancee of a e i g n i f i c a n t por t ion of the population of La t in America. Thie r e f e r e n o t oniy t o r e l i g i o n e of abor ig ina l tribes, bu t a l80 t o Roman Catholiciem a 8 i t i e prac t iced by the f o l k of urban a e w e l l a8 r u r a l comiunitiee i n many countriee. This p a t t e r n i e eo f a m i l i a r a 8 n o t t o r equ i re d e t a l l a d documenta t i o n i n t h i e context; ( i l l u s t r a t i v e caees from varioue a reae include Kearney 1970, Holmberg 1971, Owen 1905, Goeeen 1974, and o there) . Another kind of s y n c r e t i c r e l ig ion , combining t r a d i t i o n a l non-Wee tern w i th Chr is t i a n elemen t e , i e exemplified i n the so-cal lad "Afro-American c u l t s , " where a lcohol l e of ten ueed both a s a n o f fe r ing t o the e a i n t e and a e an adjunct t o the ece t a t i c r e l i g i o u e experience tha t involvee a e p i r i t 'e "poeeeesion" of a devotee (e.g., Bourgignon 1964, Leacock 1964). Other groups i n whi ch a l c o h o l i c beverages are thought t o be highiy eeteemed by supernatura l beings and, hence, cone t i tu te valuable o f f e r i a g s , a l s o include eome peaeante who p rac t i ce l o c a l va r i an te of folk-Catholiciem (e.g., Bunzel 1940, Wagner 1978, Maynard e t a l . 196 5 )

I f d e i t i e e apprec ia te alcohol a s a comodity, eo do individual humn beinge i n workaday e i tua t ions . The economic value of a l c o h o l i c beveragee a e a commodity, both i n terme of s a l e s and i n tenue of taxat ion, i e n o t only widely recognized but has probably been the s u b j e c t of more q u a n t i t a t i v e documentation than any o ther aepect of a lcohol i n eoc iocu l tu ra l perepective. There a r e , of couree, a number of o the r vaya i n which a l c o h o l i c beveragee f i g u r e i n eyeteme of exchange t h a t a r e never considered by s t a t i e t i c i a n e o r macro-leve1 economie te. The beverage i tee l f i s eometimee a medium of exchange f o r paying wagee, f i n e s , o r taxee (e.g., Bodriguez Sandoval 13 45, Pozas 19 57 , Mendieta 19 39 ) . As was the case i n the Inca Empire, e t r a t eg i c di6 t r i b u t i o n of a l coho l i c beveragee can a l s o be a valuable way of accruing p ree t ige (e.g., Vasquez 1967, Lomnitz l969a). One t h e o r i e t went s o f a r a e t o euggeet t h a t beer i s of ca rd ina l impor tance i n local- leve1 p o l i ti ca i n the Amazon basin: "The c r u c i a l mechaniem by which one Tropica l Fores t v i l l a g e could achieve o r maintain a pos i t ion t h a t would impreee i t e neighbors wae t o g ive a f i e s t a which l a e t e d longer, expended more beer, and unleaehed more drunken brawle than any o the r f i e s t a i n memory" (La thrap 197 0:54).

One p a r t i c u l a r economic use has received epec ia l a t t e n t i o n becauee of i t e i n t e g r a l aeeocia t ion with s o c i a l e t ruc tu re , namely, the provision of beer by the l a n d o ~ e r i n s i t u a t i o n e of rec iprocal labor exchange, where teame of neighbors work j o i n t l y on each o t h e r ' s proper t iee by turn; t h i s p a t t e r n 1s important i n widely e c a t t e r e d areae (e.g., Doughty 1 9 7 1, Kennedy 1963, Muratorio 1980). Inc iden ta l ly , the outs idere ' view t h a t a lcohol i n t e r f e r e e with work and such a c t i v i t i e e turn i n t o drunken orgiee has been teeted, and,

n o t only l e the e o d a b i l i t y enjoyable, but i n t e m e of thermo- dynamice " the beer work p a r t y i e a r e l a t i v e l y e f f i d e n t meane of mobilizing a y r i c u l t u r a l labor" (Gregeon 1969 ) .

J u e t a s outs ider8 of ten err i n t h e i r negative evaluat ion of drinking i n r e l a t i o n t o work, they of ten a r e mietaken i n t h e i r judgmen t abou t the ph ye ica l impact of a l coholi c beveragee . I l l u s t r a t i v e of t h i e l e the uneubetantiated view that : "(bce the noble beverage of the Incae, chicha i e now claseed by general coneent, along u i t h coca, a s the Indiana' dead l i ee t enemy. ...The corn t h a t before had nouriehed s o wel l thue turned t o poieon; what wae a bleeeing before became a curse. For centur iee now, unchecked, i t has eapped the v i t a l i t y of the Indian people" (Tunon de Lara 19% : 19-20). The r e a l i t y l e ve ry d i f f e r e n t from t h i e biaeed oute ider ' e i n t e r p r e ta t lon . Nu t r i t lona l ana lys ie leaves no doubt t h a t the maize e t i l l nouriehee; f a r from being a poieon, chicha i e extremely r i c h i n B-complex and C vitamins, and calcium, a l 1 of which a r e genera l ly lac ldng i n the balance of the typ ica l Andean d i e t (eee, e.g., S teinkraues 1979). Phyeiciane and b io logie te from abroad a r e n o t the only onee who haeten t o point o u t tha t , f a r from sapping the v i t a l i t y o£ La t i n American Indian populatione, chicha eeeme t o r e in fo rce it. An eloquent Peruvian writer makee much the sama point t h a t Paz d i d with reepect t o Mexico: "In d a i l y needs, f r u g a l i t y ru lee . But the g r e a t event of the f i e e t a comes, and there l e drinlc, v a r i e t y of dishee, dancing, and a community of happy belags. The f i e s t a i e v o l a t i l e ; under i t e inf luence , heavinees 1s f orgotten, and the worth of being a l i v e experienced anew" (Valcarcel 1950: 1st of un-numbered pagee).

The contraet ing view eeeme t o have gained wider recognit ion, however. (be eource commonly c i t e d i e the r e p o r t of a committee e e n t by the In te rna t iona l Labor Orpanization t o invee t iga te aepecte of e o c i a l r e l a t i o n e and hea l th t h a t might a f f e c t product iv i ty i n the Andean region. Although nona of the membere had t ra in ing i n any of the e o c i a l , behavioral , b io log ica l , o r medical ecienoee, t h e i r pa t roniz i ry and e thnocen t r i c conclueion ha8 f o r many yeare been genera l ly accepted by p l a m e r s : "The abuse of alcohol and the chewing of coca leavee help explain, i n eome measure, i r r e g u l a r i t i e s i n the e o c i a l , economic, and hea l th realme t h a t o f t e n a f f e c t the Indian of the Andean a l t iplano" ( Of i d n a In ternacional de Trabajo 1953: L í 4 ) . Another h ighly queetlonable view l e t h a t the toxíc eubetancee i n chicha a r e cumulative, s o t h a t the peasante of highland Ecuador a r e yradual ly poieoning themeelvee by iageet ing a dr ink t h a t they coneider hea l th fu l (Maynard 1965).

For thoee of ue who have paid cloee a t t e n t l o n t o "folk uiedom" o r popular b e l i e f s about n u t r i t i o n and heal th , i t ha8 been f a s c i n a t i = -- and even g r a t i f y i n g -- t o eee t h a t Western e c i e n t i s t e a r e eometimee re-discovering impor t a n t f a c t a t h a t our informants knew a l 1 the t i m e . Thie i e n o t to say t h a t we expect al1 "folk

wiedom" t o be confirmed, nor t h a t p r a c t i t i o n e r e i n t h e b io logica l and medical eciencee make few o r i g i n a l contr ibutione. But i t i e e t r i k i n g t h a t t h e n u t r i t i o n a l value of fermented beveragee, long preeumed and ex to l l ed by peaeant and t r i b a l peoplee around the world, ha8 recen t ly been e n t h u s i a s t i c a l l y confirmed i n g r e a t d e t a i l by e p e c i a l i e t s from many d i s c i p l i n e s (Gaetineau e t a l . 1979). The food value of chicha ha8 a l ready been c i t e d (Steinkrauee 1979); pulque i e eecond only t o t o r t i l l a s a e a eource of e e e e n t i a l vitamins and minerale i n t h e d i e t of some populatione i n c e n t r a l Mexico (R. Andereon e t a l . 1946).

Furthermore, the re a r e a l e o e tud ies t h a t eupport t h e wideepread folk-bel ief t h a t a lcohol ic beveragee (especia l ly chicha a nd o the r f ermented homebrew) have medicinal propert i e e i n a d d i t ion t o t h e i r genera l n u t r i t i o n a l value. It may seem remarkable t h a t theee medicinal values a r e , i n many respecte , the eame ones s igna l l ed by phyeicians during the co lon ia l period: a s a d i u r e t i c , a s a n a i d t o nureing mothere, and f o r the r e l i e f of d iar rhea , a s w e l l a e the more genera l ton ic qua l i ty (Gastineau e t a l . 1979).

It muet a l s o be admitted t h a t not a l 1 of those who recognize h i e t o r i c a l and c u l t u r a l f ac to r6 a8 important influencee a f f e c t i n g t h e a v a i l a b i l i t y and coneumption of a l coho l i c beveragee consider them appropr ia te o r advantageoue. Even w h i l e recognizing bo t h t h e t r a d i t i o n a l and contemporary c u l t u r a l e igni f icance of drinking and drunkennese among many Mexican Indian populatione, a socio logie t concluded " tha t t h e inf luence of alcoholiem i n t h e economy of t h e indigenee of Mexico i e d ieaet rous ," c i t i n g , among o the r probleme, t h a t " the coet of in tox ica t ing beverages occupies more than f i f t y percent of the family budget"; alcoholiem provokee among them the commission of crimee agains t the pereon"; p o l i t i c i a n e buy votes with drinke; landlords pay p a r t i a l s a l a r i e s i n drink; and eo f o r t h (Mendieta 1939: 89).

The cha rac te r i za t ion of e igni f i c a n t d i £ ferences among "eubcultures" o r "claeeee" has been an i n t e g r a l p a r t of the t r a d i t i o n of nat ional- leve1 descr ip t ione of a lcohol use i n i a t i n America, even before eyetematic s t u d i e s were made (Horwitz, Marconi, and M i e 1967a: 61-137). When surveys a r e conducted, "socioeconomic c la se" tende t o be one of the major demographic var iables (e.g., Chaesoul e t a l . 1973, Tarnapolsky e t a l . 1965). Some have expreeeed eurpr iee t h a t i t i e not neceesar i ly thoee of lower c l a s e who dr ink more. In f a c t , i n varioue regions throughout Brazi l Paetore (1965) demonetrated t h a t members of the upper-clase dr ink more. H e a l e o euggeeted t h a t they can be expected t o increaee t h e i r consumption of a l coho l i c beveragee, becauee drinking eerves not only t o symbolize f r iendehip but a l s o becauee i t has become a meane of conepicuoue coneumption and of demonetrating one 's "coemopolitanism."

Rural-urban d i £ ferences a r e s i m i l a r l y no ted i n ms t nat ional surveys. Chi le provides an i l l u s t r a t i v e case where popular views about drunkenness have remained s t r i k i n g l y d i f f e r e n t i n r u r a l and urban a r e a s f o r severa1 years (e.g., Marconi, Varela, e t a l . 1955, iiorwitz and Marconi 1965, Marconi 1969, Medína and Marconi 1970, Medína [ i n press] ). The data a r e ne i the r s t a t i s t i c a l l y overwhelming nor l o g i c a l l y compelling ( i n view of m e thodological shor tcomings), b u t i t i s noteworthy nonetheless t h a t the r ecen t UHO survey of dr inki ry p a t t e r n s i n Mexico revealed t h a t r u r a l people drank more, drank more of ten, and spen t more time drinking than those i n the c i t y (WBO 1981: 120 e t seq. ). This deserves mention i f only because i t contradíc ts a widely he ld view t h a t the pressures of urban l i f e , w i th high unemployment, crowdíry, a l í e n life-ways, and s o f o r t h , make f o r heavier drinking i n c i ties.

Illici t Production l 1

It is widely recognized t h a t a s i g n i f i c a n t por t ion of the a l c o h o l i c beverages used i n many Lat in American communities i s no t recorded i n the s t a t i s t i c e t h a t would normally be used a s a bas i s f o r es tima t ing per-capi t a consumption. Domes t i c production of f ermented drinks, su& a s pulque i n Mexico ( m 0 1981, Garcia 1972, Roufs and Bregenzer 1968), o r chicha i n the Andean countr ies (e.g., Vasquez 1367, Muelle 1945) i s widespread and customary, s o t h a t s ign i f i can t quan t i ties of them a r e drunk w i thou t leaving any record. The same i s undoubtedly t rue of home-ade wines i n Argentina and Chile, a s with o the r l o r a l c o h o l beverages elsewhere. Another por t ion of a lcohol consumption t h a t goes uncounted i s t h a t of i l l i c i t l y d i s t i l l e d aguardiente, a c h a c a , o r rum. Such production has no t received the sye tematic a t t e n t i o n of scholars i n La t in American contexts a s i t has i n Anglo America; my o m work i n Costa Rica remains unpublished because i t would be incriminating t o many f r i e n d s who were helpful . I n t h a t same country, illicit rum (guaro) has long been recognized a s posing a major heal th problem (Chassoul 1 9 7 1 , Escobar e t a l . 1974), and clandest ine d i s t i l l a t i o n i s mentioned a s a n important economic a c t i v i t y i n a t l e a s t a few peasant communi t i e s elsewhere (e .g . , Reichel-Dolmatof f and Reichel-Dolmatof f 1361, Bunzel 1340).

The reason t h a t home-dist i l lat ion i s i l l e g a l i n most a reas probably has l e s 8 t o do with pub l i c hea l th than with publ ic wealth. D i s t i l l e d a l c o h o l i c beverages a r e usua l ly heav i ly taxed, s o that "moonshining" represente major losses t o the na t ional treasury. The s i t u a t i o n i n Costa Rica i s even more problematic, because d i s t i l - l a t i o n i s supposedly a monopoly of the s t a t e . It should n o t be su rp r i s ing t h a t the p o t e n t i a l c o n f l i c t of i n t e r e s t between the government a s benef ic iary of the l iquor business on the one hand, and the government a s benefactor i n attempting to prevent alcohol-rela ted problems on the o ther , i s no t on ly recognized bu t

a c u t e l y f e l t i n many La t ín American natione. I n informal conversa t ion , concerned Chileans of ten a r e ambivalen t abou t the personal advantage of having l i q u o r s ava i l ab le ve ry cheaply -- a r a r e ine tance of low taxat ion -- and the pub l i c disadvantages r e f l e c t e d i n high r a t e s of c i r r h o e i s from long-term heavy drinklng. Similar1 y, eome Argen t i n e s who en joy excel len t winee a t reaeonable p r i ces a r e a l e o d i8 t reseed tha t t h e i r impoveriehed compa t r í o ts can buy mediocre wines f o r l e s 8 than they would pay f o r milk, coffee, o r eof t drinke. Another important f a c t with r e spec t t o the beverages, and alcohol-related problema, i s the remarkable exerc iee i n s o c i a l epidemiology i n which i t was demonstrated, f o r Trinidad and Tobago, tha t: "The ex t r a o r d i n a r i l y cloee r e l a t ionship ( r = -0.978 ) between road accidente and the r e l a t i v e p r i c e of rum suggests t h a t the l a t t e r may be a b e t t e r ind ica to r of t rue coneumption than the f igures obtained f rom production and impor ts minue expor te" (Beaubrun 1977 : 49).

The l inkage between accidents and drinking r a i s e s the queetion of diminished r e e p o n e i b i l i t y when an individual 1s intoxicated. I n Uruguay, f o r example, drunkennese can be coneidered an extenuating circume tance w i th reepe c t t o cr iminal r eepons ib i l i ty , although pub l i c inebr ia t ion 1s punishable (Galeano 1367 : 130-131). Similar ambivalence i e evidenced i n wideepread acceptance o£ "the disease model of alcoholism" on the one hand, and continuing s t igmat iza t ion of problem dr inkers a s lacking wíth reepect to willpower and moral i ty ( ib id : 136) on the other .

Cloeely r e l a ted t o the queetion o£ respone ib i l i t y f o r drunken compor tmen t i s the ques t i o n o£ apprecia t i o n of drinking i n pos1 t i v e t e m e , when su& apprecia t ion does n o t r e l a t e to economic, r e l ig ioue , o r o the r e t r u c t u r a l l y important valuee. The r e a l and symbolic l inkage between drinking rum and other forme of "play" 1s a major theme i n the l i v e s of young Bermudan males (Manning 1979). Another curioue f inding i n the r ecen t WHO croee-national survey was i d e n t i f i e d by the soc io log ie t who wae commissioned t o analyze the f indings i n t e m e of crose-cultural s i m i l a r i t i e s and d i f £ erencee: "The degree to which Mexican reepondente s a i d no t o the idea t h a t 'having a drink i e one of l i f e f s p leasureef i e something of a mystery," and "In the Mexican data one has the d i s t i n c t f e e l o£ the preeence of an overriding c u l t u r a l n e g a t i v i t y toward alcohol" ( Ib izen 1981: 18, 51) .13

Thie view of c u l t u r a l va r i an te i n r ecen t h i s t o r y i s intended to be ne i the r encyclopedic i n breadth nor comprehensive i n depth. The sampling o£ v a r i a n t a t t i t u d e s and p rac t i ces with respect t o a l c o h o l i c beveragee i n r ecen t times has been d e l i b e r a t e l y diverse i n t e m e of eubjecte, t o r e f l e c t the pervaeiveness of c u l t u r a l f a c t o r s tha t should be unders tood bef o re anyone a t temp ts to formula t e plans f o r prevention of alcohol-related problema. I t has a l s o been diveree i n terms of geographic di6 t r ibu t ion , to demone t r a t e tha t each nat ion and ea& region can contr ibute valuable da ta and r a i s e important que8 t ione i n euch connectlon.

Conclusions

I n the context of a workshop such a s t h i s , i t seems appropri- a t e t h a t one no t f e e l constrained i n the sense t h a t conclusions need be based s o l e l y on evidence presented i n the body of the paper. I n f a c t , i t seems more appropr ia te , i n addressing the broad sub jec t of h i s t o r i cal and c u l t u r a l f ac to r8 af f e c t i n g the a v a i l a b i l i t y and consumption of a l c o h o l i c beverages, t o draw on a number of impres- s ions t h a t a r e n o t easy t o document i n a b ib l iographic sense, a s wel l a s on the many and diverse sources t h a t have been c i t e d above.

For example, immersing myself again i n the l i t e r a t u r e , 1 f ind a few new ques t ions a r i s i n g . 1s there perhaps an i n t e r n a t i o n a l type of "Caribbean rum-cul ture , " assoc ia ted w i th a complex of f e a tures such a s pe r iod ic unemployment o r underemploymen t, f emale-domina ted households, t r o p i c a l clima te, a d i e t high i n carbohydra t e s , and some o the r f ea tu res? If so , i s i t a l s o associa ted with a f a i r amount o£ boasting and horse-play among dr inkers , and few s o c i a l , psycho- l o g i c a l , o r economic problems t h a t could be blamed on alcohol? 1s there perhaps ano ther tha t migh t be ca l l ed the "highland-cargo- cul tu re , " combining p a r t i c i p a t i o n i n a h i e r a r chica1 r e l i g i o u s and/or p o l i t i c a l system i n which men take turns holding short-term publ ic of £ i c e , a climate tempered by higher e l eva t ions ( a t l e a s t 2,000 meters) , with in tens ive ag r i cu l tu re , and a more var ied d i e t ? I f so, a r e boasting and horse-play probably absent , and drunkenness on the job expected? I f there i s a " f r o n t i e r beer-culture," does i t typ i fy newly es tab l i shed towns and include a high l ike l ihood of f igh t ing , even t o the death. 1s there perhaps an "upper-class whiskey cul ture" even more widely dispersed i n c i t i e s throughout La t in America? I f so , i s i t the only "a lcohol ic subculture" i n which women p a r t i c i p a t e almost a s of ten a s men? I f any of these is, i n f a c t , a meaniryful category, then we would do well t o a sk ourselves why. Bu t i t may a l s o be tha t they a r e no t even use£ u1 categories.

Some of the ca tegor ies t h a t have enjoyed some currency and t h a t have a l r eady proven t h e i r worth f o r a v a r i e t y of a n a l y t i c purposes probably deserve much more a t t en t ion . Negrete (1374) has a l r eady ef f e c t i v e l y addressed " types of a lcohol use" and t h e i r implica tion.

The Conques t didn' t necessa r i ly d r ive the Mexican Indiana to drink i n the co lon ia l period, any more than c i t y l i f e dr ives t h e i r descendants to dr ink today. Prohibi t ion appears always t o have been d i f f i c u l t t o enforce and, except when imbedded i n r e l ig ious precep te , tends t o be shor t-lived. Though t f u l planners have di£ f e r e d about whe ther s a l e s of a l coho l i c beverages should be r e s t r i c t e d t o holidays--or forbidden only on holidays. Similarly, various j u r i s d i c t i o n s i n La t i n Ameri ca have experimented wi th

requi r ing t h a t drinking p laces be open t o pub l i c view--or t h a t they be cloeed from view. Some have favored development of pub-like atmoephere, congenial t o women o r f ami l i e s a s w e l l a 8 to m n , whereae o there have i n s i e ted tha t pub l i c drinking placee ehould be s t a r k l y bare and f o r men only. The deba t e over whether food should be ava i l ab le with dr ink has been resolved i n d i f f e r e n t waye i n d i f f e ren t places--and i n d i f f e ren t ways a l s o a t dif f eren t times i n some s p e c i f i c placee.

I f a man has been taught t h a t he muet never acheit t o being weaker than anyone o r anything, he l e n o t l i k e l y t o be comfortable w i th the guidel ines of A l coholics Anonymoue, emphasizing r e aogni t ion tha t "alcohol 1s e tronger" and surrender to "a higher power. " I f , however, eomeone f e e l s comfortable i n the s e c u r i t y of having a cloee personal r e l a t ioneh ip w i th a s a i n t o r a p a r t i c u l a r manifestat ion of the Virgin m r y , then a pledge of abstinente devoted t o t h a t r e l i g i o u e f i g u r e may be the rapeu t i ca l ly ef f ec t ive .

But there may n o t be s o much need f o r t h i s eolu t ion among La t in Americane. One of the moet important genera l iza t ions t h a t emergee from an overview of my quarter-century of watching, reading, l i e t e n i n g , and otherwise paying a t t e n t i o n to a lcohol use i n La t in America 1s the r a r i t y with which "alcoholism" occurs.14 To be su re , i t l e a se r ioue problem tha t few of the authore define what they mean by "addict ion, " "alcoholism, " o r "alcoholics. " Never the- l e e s i t 1s e t r i k i n g t h a t s o many invee t iga to re -- most of them preeumably a t l e a e t f a m i l i a r with the ma jor controversiee over thoee terms -- e x p l i c i t l y make the point t h a t thoee phenomena a r e abeent i n the populations e tudied. Medina's (1978) recommendation tha t more ca re fu l a t t e n t i o n be given t o defining the t e m e a s they a r e ueed i n varioue reeearch p r o j e c t s deeerves n o t on ly a eeaond bu t a l e o a f o l l o r u p . I t l e s t r ik ing t h a t t h i e shortcoming occure not on ly amo= s o c i a l s c i e n t i s t s . There a r e a t l e a s t a s high a proport ion of peychia t r i c , epidemiological, and o the r e tudiee f rom Lat in America i n which the terms "alcoholic" and "alcoholism" a r e ueed v i thou t specif i c a t i o n , including many where the sub ject-matter has no thing to do w i t h losa-of -control , dependency, w i thdrawal , o r o ther alcohol-rela t ed probleme tha t ueual ly a r e ci ted a 8 diagnoe t i c o r def ining cha rac te r i s tia.

1 w i l l go a e tep f u r t h e r and euggeet t h a t w e may soon f i n d oureelvee i n a s i tua t i o n where the t i r e d o l d ques tion-"prevention of what?" takes on new and immediate eignif icance. This may occur becauee ano ther impor tan t genera l iza t i o n f rom Lat in American experience 1s tha t a l cohol-related probleme, l i k e " a l coholice" and "alcoholiem," a r e rare--at l e a s t i n comparieon with populatione i n the r e e t of t h i s hemisphere, and even i n comparison with much of the r e e t of the world. A few natione a r e exceptions t o t h i e , a e evidenced i n D r . Cae tano' s preeen ta t ion on epidemiolog y, bu t moe t eurveye and communi ty-s tudies sugges t tha t La t in Ameri cane, by and

l a r g e , seem t o f e e l t h a t they s u f f e r few se r ious problems t h a t can be r e l a t e d t o a lcohol use, e i t h e r t h e i r own o r on the p a r t of e i g n i f i c a n t o thers . This i s a l 1 the more s i g n i f i c a n t when one considers t h a t there i s , i n a very r e a l sense, some b i a s toward f ind ing probleme when one i e doing reeearch on alcohol use.

I t is even more e i g n i f i c a n t when one considers t h a t these s t u d i e s o f t e n r e f e r t o populatione among whom heavy drinking occure r e g u l a r l y and where drunkenness i s both f requent and acceptable. It i s now genera l ly recognized t h a t c e r t a i n alcohol-related problems tend t o be as soc ia ted with p a r t i c u l a r pa t t e rns o r s t y l e s of drinking. One o£ the bes t known i l l u s t r a t i v e cases i s French a l coolisa t ion, i n which the alcohol dependence e yndrome, o£ ten c a l l e d phyeiological addic t ion , can develop among individuale who have been constant wine-drinkers over seve ra l years , even i f they have never drunk enough t o show a blood-alcohol concentrat ion of .O8 percent o r any r e l a t e d phyeical o r mental impairment (Ledennann 1956). I t should s u r p r i e e no one t h a t the ep i sod ic binge-drinking t h a t t y p i f i e s l a r g e segmente o£ the Lat ín American population does no t produce anything l i b e a l c o o l i s a t ion , nor f requen t c i r r h o s i s , nor damage to o the r i n t e r n a 1 organs. But i t may be eurpr is ing t h a t ne i the r is i t l inked with high r a t e s o£ accidents (with a few dramatic l o c a l exceptione), nor with high r a t e s of crimes o£ violence.

Ano ther s t r ik ing contras t w i th alcohol-related probleme i n o the r p a r t s of the world i s the r a r i t y o£ individuale who s u f f e r g r e a t l y i n terms of mental heal th. The gui l t - r idden s o l i t a r y drinker who i s so commonplace i n Anglo-America i s fo r tuna te ly miesing i n moet of La t i n America, where drinking i s usua l ly done i n a s e t t i n g tha t emphasizee e o c i a b i l i t y .

A s trong caveat i s i n order a t t h i s point . It may well be t h a t the foregoing "conclueions" a r e based on inadequate evidente. By t h a t , 1 do n o t mean t h a t my comments diverge from o r ignore the da ta t h a t a r e ava i l ab le . On the contrary, i t seems appropriate t o s t r e s s t h a t the da ta -- r i c h and diverse a s they a r e -- s t i l l leave much t o be desired. One o£ the g r e a t e s t shortcomings i s shared with the v a s t majori t y o£ s tud iee , wherever they may have been con- ducted. A s Medina (1978) noted, i t i s unfortunate tha t , deepite increasing ef f o r t e toward t ranediec ip l inary col labora t ion i n r ecen t years , there have n o t y e t been c lose ly in teg ra ted s tud ies o£ drinking t h a t combine epidemiological assessmente of the eequelae of drinking w i th diagnos ti c and psychoevalua t i v e measures andlor analysee o£ re levan t s o c i a l and c u l t u r a l £ eatures . Various populations have been S tudied by various methods. I t i s probably no s u r p r i s e t h a t those r e l a t i v e l y small and i eo la ted " t r i b a l " populatione t h a t have been analyzed i n ethnographic terms have r a r e l y been e tudied i n terms o£ b io logica l and medical sciences. I r o n i c a l l y , i t i s a l s o t rue t h a t the populations bes t known i n

b io log ica l and medical terms have r a r e l y been sys temat ica l ly s tudied i n ways t h a t behavioral and s o c i a l s c i e n t i s t s would f i n d he lp fu l i n understanding the s u b j e c t of a lcohol use, i t s meanings, and f unctions.

By point ing o u t tha t many people dr ink of ten and without su f fe r ing se r ious problems, 1 do no t in tend t o t r y to steer u s away f rom the important c e n t r a l theme t h a t has brought us together. What 1 want t o accomplish, on the contrary, i s to confront a l 1 o£ us with the p rac t i ca1 implica t ions of t h i s h i s t o r i c a l and c u l t u r a l d i v e r s i t y t h a t w e have a l 1 accepted a s being i n some sense relevant . Let us br ief l y explore, i n some wide-ranging and occas ional ly unor thodox ways, various senses i n whi ch the c u l t u r a l and h i s t o r i c a l f e a tures may be informative and useful .

I n s imples t terms, s o c i a l acceptance of drinking and o£ drunkenness throughout much of La t in American provides an emotional context i n which both drinkiug and drunkenness a r e l i k e l y t o occur, and i n which they can e a e i l y be viewed a s unproblematic. But l i f e i s r a r e l y s o simple, and we should begin t o experiment with themes and va r i a t ione , harking badc to some of the míscellaneoue information t h a t was discussed e a r l i e r i n t h i s chapter. For example, i n those instantes where drinking is considered a r e l ig ious a c t , and drunkenness a transcendant s t a t e , i t i s un l ike ly t h a t in te rpe r sona l aggreseion would be a common alcohol-related problem. Uhere drinking i s a normal acmmpaniment t o plowing, planting, weeding , harves t ing , house-building , and o ther ma jor work-pro j ec t s , i t i s n o t l i k e l y t o be used a s a means of psychological escape. But i f a youth i s indoc t r ina ted t h a t the measure o£ a man i e h i s capaci ty t o drink, he i s n o t l i k e l y t o be temperate, e s p e c i a l l y i n h i s e a r l y experimentation with alcohol.

In s e t t i n g s where a lcohol i s o f fe red t o the gods, o r l i t i g a n t s drink together to s i g n a l acceptance of a se t t lement a r r i v e d a t i n a discussion t h a t has been open t o a l 1 passers-by, there may develop a c e r t a i n eymbolic reserve concerning t h a t beverage, such tha t incont inent drinking might seem d i s respec t fu l . I n s e t t i n g s where - being drunk is scorned a s b ru t i sh behavior, and transgressions of propr ie t y are n o t excused, regardlees of one ' s s t a t e of i n e b r i e ty, s o c i a l pressures may help keep people sober.

I n s u , the value o£ a comparative h i s t o r i c a l and soc iocu l tu ra l perspective is t h a t i t brings to our a t t e n t i o n the w i d e raqge o£ "na tu ra l experimente" tha t have o ccurred among various h w n populations. To recognize the d i v e r s i t y o£ the hunan experience is valuable i n i t e e l f . To understand t h a t i t can provide examples -- bo th favorable and unfavorable - can transform such re cogni t ion i n t o a poten t i a l l y valuable inventory o£ opt ions .

This workshop has been a n important f i r s t s t e p i n bringing a number of i n t e r e e t íng and knowledgeable La t i n Ameri cans toge ther t o exchange ideas w i th some i n t e r e s ted and knowledgeable people f rom o the r areas . I t i s c r u c i a l t h a t those who b e s t know and work within the ia t i n American eystems of p o l i t i c a l , economic, and o ther s o c i a l r e l a t i o n s be the ones who i d e n t i f y wha tever a l cohol-related probleme may deserve t o be addressed, and t h a t they f ashion, from whatever sources, the aeans of prevention t h a t they bel ieve would be most f r u i t f ul.

Acknowledgements: This i s the f i r s t i n a projec ted s e r i e s of papera emphasizing the i n t e g r a l r o l e t h a t soc iocu l tu ra l f ac to r8 p lay with r e spec t t o pub l i c p o l i c i e s , prepared i n connection with the Center f o r Alcohol Studies a t Brown University. A s usual , A.M. Cooper provided use fu l i d e a s and ass i s t ance throughout i ts preparation: Jose Amor y Vazquez helped round o u t the h i s t o r i a l perspective; and the comente by Eduardo Medina Cardenas and Juan Carlos Negrete (published elsewhere i n t h i s volume) a r e much appreciated.

Eduardo Medina Cardenae

The exis tence of a l c o h o l i c beverages and t h e i r var ied s o c i a l l y prescribed and proscribed uses have probably been the sub jec t of more concordant o r conjoin t a c t i v i ties by anthropology and medicine than o the r a r e a s of comaon i n t e r e s t to the s o c i a l and hea l th sciences. This l i k i n g f o r ethanol and the conditions surrounding i t s uses among a l 1 the human groups of which we know, despi te the f a c t t h a t i t is physio logica l ly unnecessary, has meant t h a t any e thnographic i n q u i r y f i n d s something to record and t o i n t e r p r e t ; f urthermore, s ince anthropology has advanced from the s tudy of simple groupe t o the s tudy of complex modern s o c i e t i e s , these customs have turned o u t t o be dynamia l ly a s soc ia ted with such various a spec t s a s communi t y developmen t, rural-urban migration,

miscegenation, sociocul t u r a l change, developmen t and under- development and s o f or th . For i ts par t, medicine, inso fa r as i t has been gradual ly showing a more preventive than cura t ive a t t i t u d e t o s ickness and a concep t i o n of hea l th more r e l a t e d t o well-being and q u a l i t y of l i f e than t o the absence of spec i f i ed d iseases , has had t o begin t o look a t i ts f i e l d of endeavor through new eyes. ü h i l e applying i t e own corpus of knowledge, medicine has had t o l e a r n from o ther academic d i s c i p l i n e s and f ron d i r e c t observatione i n the groups i t seeks t o a s e i s t .

There i e no doubt t h a t the probleme r e s u l t i n g from the drinking of a l coho l i c beverages a r e somewha t more extensive and complex than the pharmacological e f f e c t o£ ethanol on the l i v i n g organiem o r the varioue individual phyeical and psychopathological phenomena assoc ia ted with i t s chronic and excessive use. Examples a r e what can be considered normal o r abnormal consumption o£ a l c o h o l i c beverages, the individual and/or social-environmental va r i ab les a f f e c t i n g t h e i r use, the many negative e f f e c t s o£ intemperate consump t ion, the ques t ionable e £ £ ect iveness o£ eo many h e a l t h programa desp i t e the resources involved, and s o fo r th . Furthermore, t o coneider addic t ion t o e thanol a disease -- alcoholism -- i s i n many respecta a flawed approach, eince the medical model has n o t been a b l e t o account f o r , much l e s s influence, the g r e a t many f a c t o r s connected with the use of and access t o a l c o h o l i c beverages .

I n shor t , the epidemiological approach o£ pub l i c hea l th has been subs t a n t i a l l y e n r i ched by the f indinge o£ anthropology concerning drinking and the problema r e s u l t i n g from excessive use o£ s p i r i tuous l iquors .

Despi t e the s i tua t ion described, the convergence o£ anthropology and medicine has s o f a r been due more t o personal than t o i n s t i t u t i o n a l i n t e r e s t s , more t o casual coincidente than t o predetermined planning. Anyone who examines the many plan8 and programs o£ the various countr ies o r regions can confirm th i s ; su& an examination shows t h a t t h a t convergence has been due no t so much t o the program i n t e r e s t o£ a p a r t i c u l a r medical care i n s t i t u t i o n i n using ava i l ab le an thropologi c a l knowledge a s to the c lears igh tedness o £ persons who have a n t i c i p a t e d the demands o£ t h e i r sphere o£ endeavor and, by t h e i r own e f f o r t s , have expanded t h e i r usual prof e s s iona l perspective. When these persone a r e i n the managemen t of a spec i f i ed program, such a c t i v i t i e s show more soc iocu l tu ra l s e n s i t i v i t y ; when t h i s has n o t been so , a c r i t i c a 1 review of the principies underlying the use of the hea l th reeources and of the e x t e n t t o which i n i t i a l t a r g e t s were achieved shows, i n hindsight , t h a t the lower l eve1 of e f f i c i e n c y vas due to some ex ten t t o the omission o£ key soc iocu l tu ra l f ac tors .

Accordingly, the p o e e i b i l i t y of improving the e f f i c i e n c y of the reeources and the ef fec t iveneee of a c t i v i t i e s designed t o prevent excessive drinking and alcoholiem s t i l l appear t o depend i n l a r g e measure on accees t o a body of soc iocu l tu ra l knowledge t h a t 1s r a t h e r eca t tered , o u t of reach, and, f o r thoee n o t f amí l i a r with bae ic anthropological concepte, even unusable. Oa the o the r hand, a l 1 e f f o r t s t o f a c i l i t a t e and i n s t i t u t i o n a l i z e t h i e meeting of minde from two ve ry d i f f e r e n t f i e l d s deeerve to be emphasized and encouraged.

D r . Heath deserves a s p e c i a l place among those who have helped narrow the gap between anthropology and medicine i n t h e i r approach t o the use of a l c o h o l i c beverages. We who have known him, from h i s pioneering e thnographi c a l worc Drinking Pa t terne of the- Bolivian Camba t o h i e i n t e res t inn l e c t u r e "Socio-anthro~olonical Factors i n - - - - - - - - - -

the Pathogeny of ~ l c o h & i s m , " have been abler t o w l é a r n from the r e s u l t e ok h i s f i e l d work, h i e theorizing about drinking, and h i s extensive and probably unequalled knowledge of the world l i t e r a t u r e on a lcohol and i t e p lace i n the c u l t u r a l environment.

" B i s t o r i c a l and Cul tu ra l Factore Aff ec t ing Alcohol Avail- a b i l i t y and Coneumption i n Lat in America" appears i n circumetancee worthy of mention. Indeed, from the broad p ic tu re 1 have j u s t ou t l ined i t may be deduced that :

1 ) It cone t i tu tes a new contr ibution toward narrowing the gap between anthropology and medicine i n t h e i r approach to the s tudy of alcohol .

2 ) The well-deeerved p res t ige of the author guaranteee the q u a l i t y of the new contr ibut ion and enhances the importance of t h i s s c i e n t i f i c meeting even more.

3) By r e s t r i c t i n g the ana lys i s to the La t in American region, he i s a b l e t o g ive more depth t o h i s explanation of aspects t h a t a r e omitted o r hardly coneidered when more exteneive e tudies a r e attempted ( f o r example, the importance of specif i e d socioeconomíc, geographic, h i e t o r i c a l , p o l i t i c a l and o ther f a c t o r s ) .

4 ) It is worthwhile commenting on eome f a c t e from the eec t ions e n t i t l e d "The Pre-Columbian Period, " "The Colonial Period, " and "Cultural Variat ione i n Modern Híetory" t h a t a r e s t i l l top ica l becauee they a r e to eome ex ten t recurrent .

o Pre-Columbian s o c i e t i e e and groupe coneumed fermented drinke i n accordance with more o r l e s e e t r i c t t u l e s of varioue kinds. Al though D r . Heath r i g h t l y f inde t h a t i n the a v a i l a b l e accounts of theee cuetome i t is d i f f i c u l t

t o d i f f e r e n t i a t e the " rea l" from the "ideal" cu l tu re , he supports what has s o of ten been noted by o ther inves ti- g a t o r s about the f e a s i b i l i t y of moderating consumption on ly i f i t i e func t iona l ly in teg ra ted i n t o the socio- c u l t u r a l contex t t o which the drinker belongs.

The common, and s o d a l l y approved, p a t t e r n wae t o drink to the p o i n t of in tox ica t ion (ceremonial o r r i t u a l drinking). Such a mode of consumption was normal within i t e own context. Because i t was in teg ra ted i n some way v i th o ther custome, i t d id no t g r e a t l y d i s t u r b them.

o The nu t r i t i o n a l q u a l i ties of f ermen ted drinke were important; although i t was no t e x p l i c i t l y s p e l l e d o u t i n t h a t period, the chicha o r beer t h a t was consumed did rep resen t a s ign i f i c a n t d i e t a r y supplement. This undoub t e d l y euppor ted those economi c, S ymboli c, and p o l i t i c a l valuee t o which w e now tend t o g ive more emphaeis, i.e., the a t t r i b u t e s of fermented drinks a e t rade goods, a s o f fe r ings t o d e i t i e s , and a s products t o be d ie t r i b u t e d by the c e n t r a l a u t h o r i t i e s , r e i n f o r d n g t h e i r domina t ion of the s o c i a l e t ructure.

o The a t t i t u d e of the colonia l a u t h o r i t i e e towards drinking by the nat ive populations i s another chapter i n t h a t ve ry heterogeneous and dramatic period of contact and a c a l tura tion. The European e tandard of f requen t , a l though modera te, drinking came i n t o c o n f l i c t w i th the na t i v e cue ton o£ pe r iod i c bu t i n tempera te consump t ion , now more f requent and with well-known negative consequences .

o D r . Heath emphasizes the at tempt of the a u t h o r i t i e s t o introduce preventive l e g i s l a t i o n w i thou t having a f u l l knowledge of the dyaamic f a c t o r s a s s o d a t e d with the drinking of the dominated population. I n addi t ion , the ambigui ty , inconsis tency, and/or v a r i a b i l i t y of such r u l e s , more motivated by the i n t e r e s t e of the authori- t i e s than by a r e a l concern f o r the well-being of those groups, a r e well-known.

o In t h i s f i e l d a s i n o thers there was a s t rugg le wi th in the r u l i n g c l a s s between the business groups, more motivated by economic motives and the des i re f o r p r o f i t , and o the r groups t h a t sought t o p ro tec t , educate, andlor conver t the na t i v e population to Chris t i a n i t y (governmen t of f i c i a l s , p r i e s ts, e tc . ) .

o The s o d o c u l t u r a l gap between the r u l e r e and the ru led o r ig ina ted f rom the various e ter0 types tha t f u r ther d i s t o r t e d ob jec t ive understanding of those phenomena.

The en t i r e poss ib le range, f rom i n t e g r a t ing ceremonial consump t i o n t o individual pa thologi c a l drinkíng , was unders tood r a t h e r a s manif e s t a t i o n s of behavior typica l o£ decadent, exhausted, lazy , v ic ious , andlor weak popula t ion groups .

o The ethnographic cont r ibut ions o£ various anthropolo- g i s t e who have inves t iga ted groups of Indiana andlor mestizos i n modern t i m e s a r e outstanding. Better understandíng o£ the s o c i a l r o l e of the use of a l coho l i c beverages i s complemented by epidemíological s t u d i e s ca r r i ed o u t by hea l th profess ionals among low-income and marginal s t r a t a o£ the population. The i n t e g r a t i o n o£ these s t u d i e e has t o a c e r t a i n e x t e n t guaranteed a c o r r e c t unders tanding of the f a c t o r s af £ ec t ing the drinking phenomena; furthermore, i t has a l s o provided a b a s i s £ o r ext rapola t ing the va r i ab les i d e n t i f i e d t o o ther groups o r contexts i n our present complex urban soc ie t i e s .

A br ief eummary of two of the conclusione of D r . Heath's paper i s warranted.

One conclusion i s t h a t t o continue t o at tempt t o charac ter ize c e r t a i n s p e c i f i c groupe o r subcul tures on the b a s i s of t h e i r pat- te rne of drinking i s unhelpful a t present , because of tendencies t o r epea t descr ip t ions of e a r l y s t u d i e s using t h i s approach without contr ibuting anything t o a dynamic underetanding of them. It would be b e t t e r t o add depth t o the comprehensive epidemiological approach, t h a t is , the approach based on the t r i a d "agent", "host", "environmen t"; and i n addi t ion , t o conduct mul t i d i s c i p l i n a r y s tudíes tha t corabine compara t i v e research on prevalence w i th diagnos t i c and psycho-evaluative measurements and re levan t soc iocu l tu ra l cha rac te r i s tics.

The r a r i t y of alcoholism, desp i t e general ized drinking among the adul t population, i s another important impression given by D r . Heath. However, he f i n d s alcoholism a vague concept, t o s a y the least, because of the l ack of common, unambiguous concepts and parameters a m o s scho la r s both i n the s o c i a l sciences and i n heal th.

More comments could be made on the e x c e l l e n t work of D r . Heath, e s p e c i a l l y s ince the sub jec t i s v i r t u a l l y inexhauetible both a s regards i t s academíc aspec t s and i t s impl ica t ions f o r preventive medicine. From a review of these aspects , i t appears c l e a r t h a t specif i e d sociocul t u r a l circums tances tend t o genera t e s p e c i f i c p a t t e r n s of drinking, o r inverse ly , t h a t t o ignore such determinante of drinking i n a group w i l l r e s u l t i n misunderstanding t h e i r s igni f icance . 1 should now l i k e t o add a few other comments t h a t the paper euggests t o a medical reader:

o Hodera te consumption obta ine on ly i f the soc iocu l tu ra l env i roment of f e r s a coherent context. The secu la r i za t ion of modern l i f e tends t o waken the common r u l e s i n this regard and, theref ore , t o f a c i l i t a te ananalous behaviors; f u r thetnore , the low socioeconomí c l e v e l , the marginali ty, and the ananie of many urban population groupe w i l l generate grea ter i n temperante .

o The n u t r i t i o n a l cont r ibut ion of na t ive fermented drinlrs i e probably i r r e l e v a n t i n the modern urban context , i n t h a t t h e i r consirmption i s due t o many d i f f e r e n t reaeons. Today, the diet of a g r e a t many people i s determined by a l imi ted monetary budget, which must be d i e t r i b u t e d among products t h a t can be acquired i n the market place and whose purchase i s o f t e n influenced by the non-objective f a c t o r of adver t i s ing .

On the other hand, the use fu l n u t r i t i o n a l q u a l i t i e s of home-brewed fermented beverages a r e n o t found i n those produced by modern indust ry , and much l e e s i n hard l iquors . I n these, on ly the c a l o r i c cont r ibut ion of e thanol i e s i g n i f i c a n t and, therefore, they a r e n o t a d i e t a r y eupplemen t.

o The i n t e r e s t s of those t h a t b e n e f i t from the production, d i s t r i b u t i o n , and marketing of these beverages and of thoee who must f a c e the adverse consequences of exceseive consumption are f requent ly f a r a p a r t and even opposed. Those who ea rn inccwe from the manufacture, taxat ion, o r sale of a lcohol f i n d i t hard t o understand, much l e s e t o agree with, those who must p r o t e c t the s o c i a l group from the r i s k s of drunkennees, from the organic daouige of a l coho l i c s , and from the many individual , family, and s o c i a l problems of chronic exceseive use.

o Many more i n t e r d i s c i p l i n a r y inves t iga t ione by anthro- pologis ts and physicians a r e neceeeary. Separa te e tudies by each d i s c i p l i n e of custopis and mannere o r epidemio- l o g i c a l da ta too of ten repea t one another. Although they may r e f i n e e a r l i e r contr ibutione, they add no s i g n i f i c a n t new f a c t s t o the body of knowledge ava i l ab le . Such j o in t reeearch ne ceesa r i ly preeupposes a p r i o r i n t e r p r e t i v e ef f o r t. Thue , the basi c conceptual ca tegoriee used by e c i e n t i s t s i n each f i e l d should be improved and etandardized, the methods used ehould be improved, and the information obtained should be c r i t i c a l l y exchanged. ü n t i l such contac ts a r e i n s t i t u t i o n a l i z e d , t h i s approach w i l l not be easy.

ühat anthropology alone can contr ibute concerning the a v a i l a b i l i t y and consumption of a l c o h o l i c beverages i n La t in America cannot cover o the r critica1 f a c t o r s t h a t a f f e c t the physician i n hís preven t i v e and cura t i v e work. The f ollowing considera t ions , whi ch a r e o f fe red by way of eltample, a l s o suggest the advantages of the j o i n t approach a l ready mentioned.

F i r s t , the s tudy of consumption should be re f ined n o t only i n r e l a t i o n t o the socioeconomic and/or c u l t u r a l conter te , b u t a l s o by age group and sex. For the physician, the present increase i n excessive drinking by women and adolescente is a noteworthy phenaaenon.

Second, and e e p e c i a l l y i n the case of adoleecents , the pa t t e rn of drinking i s mixed w i t h the use of o ther pe ycho trophi c sube tances such a s mar1 juana, s t imulants , and/or v o l a t i l e eolvents , i f n o t with hard drugs such a s cocaine and opia tes . Hard drugs e t i l l appear t o be more widely used i n the English-speaking countr ies than i n La t in America.

Third, the many f a c t o r s involved i n the use of a l 1 these substances should n o t on ly be inves t iga ted by anthropology and medicine, bu t a l s o with the a s s i s t ance of o the r eciences such a s sociology, economics, psychology. Indeed, any aepect of complex modern s o c i e t y should be approached caaprehensively, even though the i n t e r d i s c i p l i n a r y approach is s t i l l f a r from easy.

Fourth, and 1 r e t u r n t o my i n i t i a l comment, the cont r ibut ion of anthropology has helped t o improve the usual medical model f o r prevention i n these areae. But i t must go beyond t h a t point ; i t must ensure t h a t the body of knowledge obtained a l s o reaches and a f f e c t s the decis ions and a c t i o n s of the higher government authori- t i e s . A t our technica l and academic l e v e l , there are usua l ly no impor t a n t d i f f erences i n approach t o wha t a r e the mos t appropriate ways of preventing excessive drinking and alcoholism; t h a t i s a o t necessa r i ly the case with government a u t h o r i t i e s who a r e influenced by o the r value judgements. That i s t o say, anthropology and the o ther s o c i a l sc iences can make a s i g n i f i c a n t cont r ibut ion t o the development of p o l i t i c a l modele of preventive heal th a c t i v i t i e s which, together w i th epidemiological models, should be extended t o i n t e r s e c t o r a l and intracommuni t y a c t i v i t i e s .

F inal ly , the mere exchange of i n t e r d i s c i p l i n a r y information a t a l1 leve18 improves the e f f i c i e n c y of any system. This workshop can e f f e c t i v e l y cont r ibute t o the prevention of alcoholism n o t on ly i n that i t a f f o r d s the p a r t i c i p a n t s an opportunity of e q a g i n g i n a dialogue, bu t a l s o t o the ex ten t t h a t i t s conclusions a r e access ib le t o bo th the sen io r hea l th a u t h o r i t i e e and the profeesional heal th workers of our countr ies .

DISCUSSANT

Juan Carlos Negrete

Profeesor l ieath 's review shows h i s extensive knowledge of the f i e l d and h i e f a m i l i a r i t y with Lat in American h i s t o r y and ethnol- ogy. Of course, he himself i s a pioneer cont r ibutor on the subjec t , from h i e o r i g i n a l f i e l d r o r k i n Bolivia through h i s severa1 wri t ings on the soc iocu l tu ra l model of alcoholism t o h i s exce l l en t c l a s s i f i e d bibl iography on a lcohol and cu l tu re published l a s t year. Written a s i t i s by a n anthropologis t , t h i s paper ' s main emphasie i s on o r i g i n a l na t ive p a t t e r n s and the changes wtiich have r e s u l t e d from the e a r l y i n t e r a c t i o n between the abor ig ina l populations and t h e i r European colonizers . Professor Heath's h i s t o r i c a l a n a l p i e sheds l i g h t , n o t on ly on the genera l development of Lat in American drinking behaviour, b u t a l s o on some of the most r e l evan t s o c i a l a t t i tudes and values which provide its c u l t u r a l frame of reference.

A l though t h i s review includee a s e c t i o n on "Cultural Variante i n Mo&rn History," containing valuable descr ip t ions of some current c u l t u r a l a a i t e , i t appears t o pay les8 a t t e n t i o n t o c u l t u r a l changes wrough t by urbanizat ion, indus t r i a l i z a t i o n , the inpu t of the more recen t immígrante, increas ing contamination by fore ign l i f e - s t y l e e , and the pressure of a much more developed a lcohol industry. Socia l customs i n La t in America a r e b e i q subjec ted t o a procese of i n t e r n a t i o n a l homogenization. The e a s i e r and more in teneive trane- c u l t u r a l contacts , a s w e l l a s growing access t o pub l i c eourcee of information and t o the i n t e r n a t i o n a l mas8 media, eerve t o expose l a r g e sec t ions of the La t in American population to the same c u l t u r a l messages t h a t a r e inf luencing o ther s o c i e t i e s . I n o the r worde, La t i n Ameri can c u l t u r a l pa t terne a r e constan tl y evolving and appear t o be changing a t a much quicker pace than ever before. Any deecr ip t ion -de of them a t t h i s po in t must acknowledge such a dynamic procese.

Profeseor Heath, who has kept i n a c t i v e contac t with La t in America over the l a s t 25 years, propoees a d i f f e r e n t i a t i o n between a nuuber of a lcohol use p a t t e r n s which he has eeen developing during this time. Hie l is t includee the so-cal led "upper c l aes whisky cu l tu re , " which well i l l u s t r a t e s some of the changes caused by i n t e r n a t i o n a l c u l t u r a l d i f fus ion i n recent years. Lat in American upper c l a s ses a r e r e a d i l y adopting what they bel ieve t o be sophis- tica ted l i f ee t y l e s prevalent i n leading fo re ign soc ie ties. Women

drink almos t a s much a s men and the choice of beverage 1s deternlned by faehionable trends. Products a v a i l a b l e on the i n t e r n a t i o n a l market a r e much pr ized , and inc red ib ly high markup p r i ces a r e paid f o r them. To be a b l e t o t r e a t gues ts t o a n "imported" whisky ha8 become a s t a t u s symbol among the pr iv i leged c lasees i n Lat in American socie ty .

One long-established c u l t u r a l t r a d i t i o n with a d i r e c t bearing on alcohol a v a i l a b i l i t y i n La t in America i s the continued production of home-brewed a l c o h o l i c beverages. D r . Heath a s s e r t e t h a t i t had been prac t iced by na t ive population long before the a r r i v a l of the f i r s t European colonizere. He a l s o remarks t h a t , curiously, i t was known mostly i n the a r e a t h a t f e11 under Spanish cont ro l and n o t i n what i s now Anglo America. I t would appear t h a t brewing techniques were unluiown, a l s o , t o the s c a t t e r e d inhab i t an t s of Patagonia and the Argentine pampas. The abeence of na t ive a l c o h o l i c beverages i n e i t h e r the A r c t i c o r southern Patagonia may e a s i l y be j u e t i f i e d on the basie of the unf avourable geo-clima t i c condi t ions prevai l ing i n those regions. However , sugary subs tances were a v a i l a b l e f o r ga ther ing o r could have been grown f o r the purpose of a lcohol making i n o the r p a r t s of North America a s w e l l a s on the humid pampas, but the l o c a l na t ive groups d id n o t do th i s . A reaeon could perhaps be found i n the degree of development required. I n order t o master the technique of alcohol-making, a s o c i a l group must be a b l e t o operate on a long-term bas i s , t o engage i n e f f o r t e t h a t w i l l f r u c t i f y only a f t e r a waiting period. To make use of a psychological paradigm, the capaci ty to postpone g r a t i f i c a t i o n i s a s much a s ign of c u l t u r a l development i n a group a s i t is of peychological matur i ty i n an individual . A p rac t i ce such a s brewing implies a r a t h e r s e t t l e d way of l i f e with time and e f f o r t devoted t o growing, harveeting, pro- ceesing, and preserving. These a c t i v i t i e s were n o t typ ica l of the less organized hunting and gathering cul turee which inhabi ted the alcohol-f r e e regions.

Home-brewing i s s t i l l widespread throughout Lat in A m e r i c a ; homemade "chicha" and sugarcane beverages produced i n domestic stills represent a l a r g e proport ion of the ava i l ab le supply i n the c e n t r a l Andes region. Priva te, independen t and uncon t r o l l e d production of "pulque," sugarcane d i s t i l l a t e s , wines and "pisco" (grape aquavi t a ) i e cu r ren t l y taking place throughou t mos t coun t r i e e i n Lat in America i n s i g n i f i c a n t volune. The es t imate i n Costa Rica, f o r example, i s t h a t the i l l e g a l production of sugarcane "guaro" equale t h a t of the s t a t e l i q u o r monopoly. Underetandably, t h i s c u l t u r a l pa t t e r n grea t l y jeopardizes publi c prevention campaigne aimed a t reducing a lcohol a v a i l a b i l i t y .

Ano ther major c u l t u r a l obs tac le t o the implementation of preventive meaeures i s the t r a d i t i o n a l Lat in American dieregard f o r r u l e s and regula t ions ; Prof e s so r Hea th, somewha t apologet ica l ly , suggests tha t , indeed, t h i s may be a c u l t u r a l t r a i t throughout the

region. His reference t o a Mexican folk-hero whose a b i l i t y t o evade r e s t r i c t i o n s de l ighted audiences throughout La t in America i s a t e l l i n g example. In Brazi l , a much admired personal a b i l i t y i s t o have e i t o (knorhow), t h a t is , the a b i l i t y t o bypass r e d tape and b l e g a l ur les and have one 's way. I n Argentina, a g r e a t deal of s o c i a l p res t ige is accorded t o those capable of "beating the sya tem"; i n the l o c a l s lang , these ind iv idua l s a r e ca l l ed p i o l a s o r cancheros. Thus, Professor Heath need n o t have h e s i t a t e d t o underl ine a c u l t u r a l cha rac te r i s t i c tha t i s cer t a i n l y prevalent throughout Lat in American socle ty . By a l 1 the evidence, ignoring o r circunventing e s t a b l i s h e d l e g a l r e s t r i c t i o n s i s n o t seen a s necessa r i ly immoral o r even reprehensible i n La t in America. Such behavior i s perceived r a t h e r a s a jus t i f i a b l e r eac t ion agains t " the au thor i t i e s . "

By and l a rge , La t i n Americans tend t o d i sassoc ia te themselves from those i n power; one senses i n the population a total l a & of i d e n t i f i c a t i o n with the a u t h o r i t i e s , a s i f the l a t t e r were a l í e n t o the s o c l e t y under their ru le . This , of course, may be a s i t u a t i o n o r ig ina t ing from the days when the government was i n the hands of the European colonia l au thor i ties and the na t ive populations had no p a r t i c i p a t i o n i n i t . Later on, and t o a l a r g e e x t e n t up to t h i s date, pos i t ions of a u t h o r i t y have been reserved t o a pr iv i leged and small s e c t o r , q u i t e d i s t a n t from the mass of the population. Ae long a s these maese8 perceive no d i f ference between the law and the a u t h o r i t y imposing i t , they a r e un l ike ly t o s e e anything wrong i n t h e i r unwillingness t o comply.

ALthough poor obeervance of r u l e s and regula t ions l imi t ing the a v a i l a b i l i t y of a lcohol i s perhaps more prevalent among the peasants, campesinos, and na t ive populations, t h i s a t t i t u d e i s by no means confined t o such s e c t o r s of the socie ty . Professor Heath g ives an account of the incons i s t en t behavior exhibi ted during colonia l times by the Spanish themselves w i t h regard t o the r e s t r i c t i o n s imposed by the Crown on the s a l e and use of a l c o h o l i c beverages. H e quotes a n o l d Spanish sayíng: "Laws a r e t o be aolrnowledged bu t n o t observed." W t t le wonder, then, t h a t there a r e p r a c t l c a l l y no e f f e c t i v e measures governing the a v a i l a b i l i t y of a lcohol i n Lat in American soc ie t i e s . Beverages can be obtained from pub l i c o u t l e t s a t any t i m e and by anybody. Oa Sundays and o ther daya on which s t o r e s a r e t o be closed t o the public , f o r instante, i t i s n o t unusual t o s e e chi ldren purchasing l iquor through the back door. They a r e s e n t by t h e i r e l d e r s , who a r e most l i k e l y engaging i n one of those day-long l i b a t i o n s t h a t Professor Heath s o r i g h t l y descr ibes a s a t y p i c a l La t i n American pat tern .

Ano ther important m a d i t i o n a l f e a t u r e i d e n t i f i e d by Professor Heath a s p a r t of La t in American cu l tu re i s the frequency of drunkenness and the degree of s o c l a l acceptance t h i s behavior enjoys. H i s t o r i c a l evidence would suggest t h a t t h i s t r a d i t i o n has

i ts roo t s i n pre-Colunbian socie ty . Native groups then used a lcohol and o the r psychoactlve eubstances f o r the expresa purpose of inebr ia t ion . Drunkenness was n o t on ly n o t avoided bu t , on the contrary, pureued in ten t lona l ly . Today a s imi la r a t t l t u d e inf luences the a lcohol use p a t t e r n of t h e i r descendante. For a l a r g e proportlon, t o drink 1s e t í l l synonymoue with g e t t i n g drunk. I n f a c t , popular language o f t e n makes no d i s t i n c t i o n between drinking and drunkenness. For ins tance , when i t 1s s a i d of someone, " e l bebe" (he d r inks ) , i t 1s meant t h a t he drinks t o excess. This p a r t i c u l a r c u l t u r a l connotation of the verb " to drink" must be taken i n t o considerat ion when a lcohol use i n La t in America 1s surveyed, eepec ia l ly amng the l e e s educated.

The recen t WHO genera l population s tudy i n Mexico t o which Professor Heath r e f e r s i n h i s review found t h a t more than one-third of the a d u l t s interviewed r e p l i e d "No" t o the quest ion: "Do you drink?". Anyone who has had the opportunity t o observe the same population behaving spontaneously i n n a t u r a l s e t t i n g e must doubt the correctnese of such an answer. I t w l l may be t h a t the Mexican respondente f e l t they were being asked whether they g e t drunk and, seneing a n i m p l i c i t c r i t i c i s m i n the quest lon, gave a n answer which they assrnned would p lease the interviewer. It must be s a i d t h a t a non- judgmental o r l en ien t s o c i a l a t t i t u d e towards drunkemess 1s more typica l of the lower c l a s ses and more widespread i n those Lat in American coun t r i e e wi th l a r g e r concentra t ione of na t ive and mes t i z o (half-breed) populations. In Argentina, Uruguay, and the southern par t of Braz i l , where recen t European immigran t e con8 ti t u t e a s i zeab le ma j o r i ty , f requent drunkenness i s c l e a r l y l e s e prevalent. These immigrants, mostly from Spain, Por tugal , and I t a l y , have brought with them a t r a d i t i o n of s o b r i e t y e s t ab l i shed i n t h e i r o r i g i n a l cul tures . In add i t ion , they found i n t h e i r new environment geo-clima ti c condi t ions permi t t ing them t o continue w i th t h e i r European p a t t e r n of drinking wine, a s opposed t o the 8 tronger beverages u t l l i z e d elsewhere on the continent.

Perhaps because of pressure from an expanding l iquor induetry, the l a r g e Amerindian and mestizo populations around the Caribbean basin and i n some Andean countr ies have tended t o s u b e t i t u t e d i 8 t i l l e d beverages f o r their t r a d i t iona l l o r g r a d e brews. Fermented drinks were, of course, m r e s u i t e d to t h e i r cul tura1 pa t t e r n of prolonged celebra t ion and f i e s t a drinking , which a l s o involves a high volume intake. The switch-over t o d i e t i l l a t e s changed the content but n o t the f orm of t h e i r habi ts and resu l t ed i n mu ch m r e severe i n toxica tlons. Foreign v i s i t o r s t o Centra l America, f o r example, may be a l i t t l e su rp r i sed t h a t patrona i n pub l i c drinking place8 o f t e n order drinks t o t h e i r t ab les such a s whisky, rum o r even cognac--not i n individual measures, b u t by the whole bo t t l e . The comparative coneumptlon f i g u r e s i n Table 1 i l l u s t r a t e the regional tendencies jus t described.

Absolu te Alcohol Consumption* and Beverage Clase Preferente**

COUNTBIES Absolu t e Percentage d i s t r i b u t i o n Year Al cohol s p i r i ts beer v ine

LATIN AMERICA

Mexi co 1967 4 .S8 27 .3 53.0 19.1 ( a ) c .~merí ca(b) 1967 6 .O7 14.2 24.0 1.8 ~ e r u 197 O 7 .22 78 .O 18 .O 4.0 C h i l e 1972 14.0 10 .8 10 .7 78 .5 Argent ina 1965 18.2 13 .5 3.6 82.9

F in land 1968 4.12 50.0 34.0 16.0 Swede n 1968 6.96 49.5 38.0 12.5 U * Ki~lgdan 19 66 7 &O 1 5 -2 7 5.3 9 03 W. Germany 1966 1 3 .O4 21.3 60.4 12.3 I t a l y 1968 16 004 13.1 4.0 82.3 France 1966 26 O12 18 .O 12.7 69 .3

NORTH AMERICA

SOURCE: Negrete, J .C. (1976) Alcoholism i n L a t í n America. Annals of t he New York Academy of Sciences 27 3:9-23.

*liters per pereon age 15+, i n one year. **percentage cont r ibu t i o n of e a & beverage c l a s s t o t he

t o t a l aanual abso lu t e a l coho l coneumption. (a) includee "pulquew (b)average of 6 coun t r i e s , populat ion age U+:

Gua temla , Hondura e , Nicaragua , El Salvador, Cos ta Rí ca and Panama

From the e a r l y f i e l d observations among the Camba of Bolivia, Prof eesor Hea th concluded tha t frequen t a l c o h o l i c in tox ica t ion , wtren c u l t u r a l l y in teg ra ted and e o c i a l l y approved, i e n o t neceeear i ly aesocia ted with deviant behaviour and &es no t f i t the concept of alcoholism. In f a c t , he noted t h a t the ve ry not íon of alcoholiem wae a l i e n t o the Camba. I n t h i e preeent review D r . Heath a l s o quo tee severa l o ther e thnologis ts who, a f t e r S tudying na t íve coaununitiee i n La t ín America, have concluded t h a t alcoholism 1s m t a problem i n cu l tu ree where the uee of a lcohol eervee sucia poei t ive functione a s helping group cohesiveneee, s o c i a b i l i t y , and r o l e def i n i tion.

Of couree, the s o c i a l e c i e n t i e t e ' view of alcoholism l e one of deviant behaviour, t h a t i e , a form of a lcohol use which &es not conform with e s t ab l i ehed and e o d a l l y acceptable c u l t u r a l pat terne. However, a lcohol dependence a e underetood i n b io log ica l terme i e u n l i k e l y t o be eeen a e not iceably d i f f e r e n t behaviour i n a mi l ieu which provides eo much opportunity f o r e o c i a l l y approved inebria- t ion. Profeseor Heath'e remark about the need t o complement ethnographic obeervatione of drinking behaviour with biomedical e tudiee i e very w e l l taken indeed.

A word of caution ehould be given t o the indigenie te who tend t o i d e a l i z e pre-Columbian cul turee and eee no wrong i n t h e i r ancient pa t terne . Their reepect f o r the t r u l y amazing degree of e o d a l organiza t íon a t t a i n e d by eome of these cul turee ehould n o t obscure judgement when i n t e r p r e ti= the h i e t o r i c a l evidence about drinkíng behaviour .

In a l 1 f a i rneee , however , the European coloniza t ion has profoundly a l t e r e d the meaning and pa t t e rn of a lcohol uee among na t ive populatione. It hae a l e o introduced a new and problematic s o c i a l element -- the meetízo populatíon -- whoee c u l t u r a l frame of reference i e undefined and e treeef ul .

An i n t e r e e t í n g ethno-philoeophical a n a l y s i s of t h i e change procese 1s found i n a paper by Pages i a r r a y a (1976) on drinldng pat terne among Chaco culturee. Thie author deale with the t o t a l c u l t u r a l change undergone by the aboriginee through t h e i r expoeure t o European inf luence and eeee the a l t e r a t í o n i n t h e i r drinking hab i t e a e only an epiphenomenon of accul tura t ion . Pages Larraya aeee r t e t h a t a lcohol in tox ica t ion took place o r i g i n a l l y within a ceremonial context; i t was only a meane t o cause i n the drinker a " t raneubstant ia t ion ," a change i n t o a d i f f e r e n t -- eomewha t supernatura l -- i d e n t i t y i n order t o enable him t o p a r t i c i p a t e i n varioue r i tuale. Through the teachinge of f ore ign miesionariee the na t ive was induced t o a t tach a meaning t o a lcohol i t e e l f ; he learned that i t was e v i l , and therefore , drinking wae an a c t of wrongnees. Thie moralie t i c view carne t o involve the na t ives ' whole univeree and

be l i e f system. They learned t o look a t the white man's world a s the good one and t o perceive t h e i r own a s s i n f u l and demoniacal. According t o Pages Larraya, such a ca tas t roph ic self-perception l e d t o the developmant of se l f -des t ruc t ive p a t t e r n s of a lcohol use on the p a r t of the nat ives. (Of course, he was analyzing groups l e s s c u l t u r a l l y developed and s o c i a l l y organized than the higher c i v i l i z a t i o n s of meso-America and the Andes). I n t h a t sense the Chaco abor ig ines were perhaps more vulnerable t o the de le te r ious e f f e c t of fore ign influences. A comparative s tudy on the prevalance of a lcohol probleme among d i f f e r e n t t r i b a l groups i n Olclahoma ( S t r a t t o n U78) l ends support t o the view t h a t those l e s s s o c i a l l y organized were more af-fected by contac t with the white man.

Professor Heath concludes t h a t i n s p i t e of heavy drinkíng pa t t e rns , the frequency of alcoholism i s low i n La t in America. Spec i f i ca l ly , he i s impressed by the apparent s c a r c i t y of the s o l i t a r y , gui l t - r idden a l c o h o l i c s o commonly found i n l a r g e urban centers of more i n d u s t r i a l i z e d s o c i e t i e s . H e remarks t h a t epidemiologists i n La t in America f i n d higher r a t e s of problem drinking i n r u r a l populations than among urban dwellers, and c o r r e c t l y notes t h a t an opposi te tendency 1s the r u l e elsewhere. Urbanization could perhaps be a d i s rup t íve f a c t o r f o r those r u r a l populations whi ch present a high degree of s o c i a l organizat íon, group control , o r r e l i g i o u s influence; however, i t 1s l i k e l y t o have a benef ic ia1 inf luence on the behavior of individuale from o the r r u r a l a reas i n La t in America who f i n d g rea te r s o c i a l support i n the ci tles. Pover ty , unemploymen t, seasonal and nomadi c pa t t e r n s of o ccupa t ion, and the a bsence of organized s o c i a l resour ces a r e f a c t o r 8 t h a t f r equen t ly make l i v i n g i n r u r a l regions more s t r e s s f u l than i n urban centere i n La t i n America.

Although i t 1s poss ib le t o agree with D r . Heath t h a t alcohol causes l e s s s o c i a l d i s rup t íon o r deviant behaviour i n Lat in America than i n , f o r example, Anglo America, da ta on m o r t a l i t y from alcohol- r e l a t e d causes i n d i c a t e t h a t a lcohol abuse c o n s t i t u t e s an equa l ly ma jor pub l i c heal th problem i n both regions.

Chapter Notes and lbleferenoes

Historial and Cul tu ra l Factor8 Af fec t ing A l cohol Ava i l ab i l i t y and Consumptíon i n La t ín American

No tes

l. "Latin America" 1s here used t o include n o t only Centra l and South America, bu t a l s o Mexico and the i s l ands of the Caribbean zone.

2. "His t o r i c a l " perspective i s r e l a t i v e l y deep, including reference t o pre-Columbian pa t t e rns i n s o f a r a s they appear t o have influenced subsequent developments.

3 . The tenn "cu l tu ra l " 1s used i n the broad anthropological sense , including e x i s t e n t i a l , evalua t ive , e conomic, p o l i ti ca l , r e l i g i o u s , and o the r aspects of the complex syetems of be l ief and behavior tha t d i f f eren t i a t e human popula t ions , one f rom ano the r .

4. Por a well indexed bibl iography of s t u d i e s on a lcohol use i n h i s t o r i a l perspective, i n a l 1 p a r t s of the world, s e e Heath and Cooper (1981); t o keep a b r e a s t of current work, s e e the Alcohol and Temperance H i s t o ry Group N e w s l e tter (occasional, s ince 1980).

5. The term "Anglo-America" i s used here a s a convenient shorthand l a b e l i n keeping with a popular convention t h a t cont ras te "Anglo-" with "Latin America." It ignores the "Franco" component of Canada and o the r l i n g u i s t i c and e t h n i c va r i an te , i n much the same way t h a t the "La tia" l a b e l ignores "Anglo, " "Afro , " "Dutch, " and other componente.

6 Or ig inal ly published i n 1569, the encyclopedic His to r i a de l a s Cosas de l a Nueva Espana has been metículously t r ans la ted and annotated (A. Anderson and Díbble 1950- ).

I . If 50 years seems a shor t time i n which t o encounter ma jor h i s t o r i c a l revisionism, 1 sugges t people consider events i n t h e i r own na t ion ' s r ecen t h is tory . 1 used t o be l ieve t h a t c u l t u r a l t r a i t s were n o t e a s i l y l o s t , b u t observations of what happened t o s l ide - ru les , wire-recorders, and o the r phenomena have convinced me t h a t major i teme can e f f e c t i v e l y "disappear" qu ids ly from even a l i t e r a t e cul ture. This idea was most

f o r c e f u l l y brought home when L u d l l e Hanna, my former high echo01 teacher , r e can t ly lamented t h a t the Roman Cathol ic Tr ident ine maes ( i n Lat in) has v i r t u a l l y ceased t o have meaning "within hal f a l i fe t íme."

8. Some may no t be aware t h a t the f i r e t s e t t l e r s of Anglo-America were s í m i l a r l y accue twed t o ueing beer, mead, and o the r a l c o h o l i c beveragee t o s l ake t h e i r t h i r s t . The movemente toward temperante, and l a t e r prohibi t ion , were n o t begun by the e a r l y ee t t le rs - -not even by the Pur i tans , who were smail i n nunbers and f a r more t o l e r a n t of drinklng than i e usua l ly bel ieved (Lender 131 3). A br ief but e f f e c t i v e eumnary of the h i e t o r i c a l and c u l t u r a l f ac tor8 a f f ec t ing the a v a i l a b i l i t y and consumptlon of a lcohol i n the United S t a t e s 1s ava i l ab le (Aaron and Mueto 1981); more d e t a i l e d ana lye i s , including pe r iod lc est imatione of per-capita consumptlon, l e i n Borabaugh (1979).

9. The word "norm" l e used i n severa1 d i f f e r e n t senses i n the s o d a 1 e d e n c e e , and t h i s inconsistency l e no t always addressed i n works t h a t deal with norms i n r e l a t i o n t o drinking. Brief discuesion of varioue kinds of norms 1s of fe red by Heath (1980).

10. For our present purpose, the word "Spanish" r e f e r s t o anyone who might have been c a l l e d "white." Although the d le t inc t ion be tween European-born peninsulares and Ameri can-born c r i o l l o s was important i n c e r t a i n respecte , the d i s t i n c t i o n t h a t i e more e i g n i f i c a n t and pervaeive i n t e m e of t h i s discuseion l e t h a t between blancos ("whites") and caetae ( a l 1 o the r s , includlng Indians , me8 t izos , blacke , mula t tos, zambos, e t a l . ) .

11. Although 1 t wae convenient t o r e f e r t o the s ix teen th through e ighteenth cen tu r i e s a s "the colonia l period," i t eeeme more appropria t e t o ref er t o the nine teenth and twen t i e th centuriee as "modern history." Many of today's La t in American nat ions were born i n 1825; a few won independence e a r l i e r , a few later, and some areae s t i l l have a provincia l , co lonia l , o r analogoue r e l a t ionehip wi th ano ther na tion.

We a r e fo r tuna te i n having more thorough coverage of the an thropologi c a l con t r i b u t lons t o a lcohol e tudiee than 1s ava i l ab le f o r moet f i e l d s of r e l a t e d i n t e r e e t . An h i e t o r i c a l perepactive 1s a v a i l a b l e i n Heath (1975); a thorough review of the 11 te ra ture , organized i n conceptual and theore t i c terme (Heath 1916) has r e c e n t l y been updated (Heath [ i n prese] ); a n indexed bibl iography provides easy acceee t o the 11 te ra tu re (Heath and Cooper 1981).

13. The reason why Roizen views t h i e a s "something of a mystery" l e preeumably because the reeponee t o a s i n g l e multiple-choice

ques t ion , t r ane la ted from ano the r language, i e inconeis tent with a l 1 of the o t h e r d i f f e r e n t kinds of evidence about h x i c a n a t t i t u d e s toward drinking. This may be an ins tance where a "curious f inding" i s , i n l a r g e p a r t , a n a r t i f a c t of the method.

14. This s tatement i s d e l i b e r a t e l y phrased i n ve ry genera l terma. The reference t o "alcoholism" i s intended t o encompass a broad range of the severa1 d e f i n i t i o n s t h a t have been proposed by profess ional researchers i n various f i e l d s , a s well a s "alcohol dependence eyndrome. " Al though reference t o " r a r i ty" admi t t e d l y ref l e c t s a socio logica l and anthropological emphasis on dominant pa t t e rns , i t seems n o t t o be s i g n i f i c a n t l y d iscrepant with those o the r kinds of da ta which r e f l e c t the epidemiological emphasis on inciden--ratee of cases, however abe r ran t the d i s t inguishing pa t t e r n s may be.

ñef erence 8

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CHAPTER FIVE

THE ANATOMY OF ALCOHOL POLICY: PREVENTIVE APPROACHES

D e a n G e r e t e i n

DISCUSSANTS

Marilynn K a t a t e k y

Irving Rootman

INTERNATIONAL STUDY OF ALCOHOL CONTROL EXPERIENCES (ISACE): COMMENTS ON 'RE FINAL REPORT

Jamee M o e h e r

THE ANATOMY OF ALCOHOL POLICY: PREVENTIVE APPROACHES*

Dean Ger s t e in

Pub l i c p o l i c i e s a r e important though no t d e f i n i t i v e gu ides t o understanding government a c t i o n s and t h e i r e f f e c t s , i n much t h e same way a s a handful of r e c i p e s may inform t h e p rospec t ive d i n e r bu t are no guaran tee of t h e meal. This dictum a p p l i e s a s much t o p o l i c i e s r e l a t i n g t o a l c o h o l a s those r e l a t i n g t o war, cr ime, banking, o r farming .

Thi s essay concerns t h e format ive a s p e c t s of a l c o h o l p o l i c i e s . In p a r t i c u l a r i t g i v e s d e t a i l e d a t t e n t i o n t o prevent ive approaches i n c o n t r a s t t o r e e t o r a t i v e ones. The d i s c u s s i o n begins wi th t h e concept of governing ideas , wi th examples drawn from t h e h i s t o r y of t h e United S t a t e s . A ske t ch of t h e va r ioue e f f e c t s of a l c o h o l use fo l lows , t h e s e being t h e p r i n c i p a l s u b j e c t s of a l coho l po l i cy . A t t en t ion i s then turned t o t h e a n a l y t i c , normative, and pragmatic i s s u e s t h a t surround prevent ive p o l i c i e s r e l a t i n g t o a l c o h o l , such a s : ü h a t k inds of p o l i c i e s can be d i scerned? What are a p p r o p r i a t e r o l e s f o r government i n t h i s a r e a ? ü h a t a r e t h e important e f f e c t s of government programe concerning a l c o h o l use? The d iecues ion i s meant f o r gene ra l a p p l i c a t i o n ; i t does no t t r y t o se t t l e t h e s e m a t t e r s i n r e l a t i o n t o s p e c i f i c p o l i c i e s , bu t t o d e f i n e and i l l u s t r a t e t h e ques t i ons and conceptual t o o l e needed t o understand and e v a l u a t e t h e a l t e r n a t i v e s .

*This e s say l e a n s heav i ly on Alcohol and Publ ic Pol icy : Beyond t h e Shadow of P roh ib i t i on , t h e r e p o r t of t h e Panel on A l t e r n a t i v e P o l i c i e s Affec t ing t h e Prevent ion of Alcohol Abuse and Alcoholism (Moore and Ger s t e in 1981). However, t h i s work depa r t a from t h e p a n e l ' s i n a number of p a r t i c u l a r e , f o r which my co l l eagues cannot be he ld reepons ib le . A paper by Mark Moore (n.d.) suggested t h e t i t le .

Governing Ideae*

In t h e beginning of p o l i t i c a l dialogue, the re a r e governing ideae. This i e not t o eay that euch ideae fa11 from the eky; they a r e alwaye h i e t o r i c a l l y rooted i n productive s o c i a l and c u l t u r a l e o i l . Rather, i t l e t o eay t h a t among people with many and diveree i n t e r e e t e , a thoughtful o r successful exchange on any e ing le p o l i t i c a l subjec t can proceed only i f the dialogue hae eome bas ie f o r mutual understanding. This must a r i e e from c l e a r , etraightforward, broadly-agreed-upon, though genera l ly unepoken, conceptione t h a t def ine t h e diecueeante' understanding of the eubject .

There need not be only one, and no more than one, of these simple t a c i t conceptione regarding a given sub jec t ; t h e r e may be two o r th ree o r eometimee -- r a r e l y -- more of theee ideae may operate a t a given time i n a given socie ty . But ineofa r a s a governing idea de f ines what moet people view a s "p la in comon eenee" about a topic , t h a t idea w i l l def ine the boundariee wi th in which policy optione can be exercieed. I f any new a c t i o n of government i s t o be undertaken, i t muet be coneie tent with t h a t idea. Moreover, while a l a r g e p l u r a l i e t i c eocie ty may have i n it t h e i n e t i t u t i o n a l legaciee of varying ideas t h a t achieved dominante i n one o r another h i e t o r i c a l period, theee legaciee w i l l be under eteady preeeure t o change. I f e t rongly competing idea8 co-exiet a t a given time, soc ie ty w i l l e i t h e r c r e a t e a c lean d iv ie ion of l abor between i n e t i t u t i o n s t h a t r e f l e c t the d i f f e r i n g ideae, o r theee i n e t i t u t i o n s w i l l be caught i n a continuoue ideologica l t u g - o f r a r . Policy makers w i l l t o a l a r g e degree t a l k past one another - f a i l i n g t o comunicate -- i n p o l i t i c a l discueeion on the top ic of concern.

In analyzing alcohol po l i c i ee i n t h e United S ta tee , a few euch governing ideae can be diecerned. Two of them reach wel l back i n t o the country ' e h ie tory; they have becorne s t rongly entrenched and can be b r i e f l y charac ter ized and l abe l l ed . F i r e t i e the co lon ia l view, t h a t drinking i e a valued eoc ia l cuetom, t h a t overindulgence i s a f law i n moral cha rac te r , and t h a t i f neceeeary a doee of public d i e c i p l i n e i e the appropriate reeponee (Rorabaugh 1979). Second i e the temperance view, that a lcohol ( o r a t l e a s t , e trong l i q u o r ) l e bae ica l ly an addic t ing poieon, t h a t e e l l i n g o r coneuming i t can c o n e t i t u t e a public hazard, and t h a t uee of the law t o r e e t r i c t (perhape even ban) i t e s a l e i s the neceeeary reeponee (Aaron and Mueto 1981; Levine 1978; Guefield 1963).

*A8 a general background on the r o l e of ideas i n c o l l e c t i v e ac t ion , eee Pareone (1937). For more e p e c i f i c appl ica t ione t o alcohol , eee Boom (1974) and Levine (1978).

Each of t h e s e i d e a s h a s proven t o have s t a y i n g power, s u s t a i n i n g i n s t i t u t i o n a l support i n programe that implement pub l i c p o l i c y and i n p r i v a t e b e l i e f s and p r a c t i c e s , even as t h e i d e a s have matured w i t h sometimes d i s a s t r o u s l y misguided experience, and accommodated t o s h i f t i n g s o c i a l t i d e s . A t t h e same t i m e w e can i d e n t i f y some more r ecen t i d e a s whoae s t a y i n g power and a b i l i t y t o ach ieve a p o s i t i o n of long-term dominance have no t y e t f i r m l y o r convincingly e s t ab l i shed .

The f i r s t of t h e s e 1s t h e pe r spec t ive of a lcohol iem as a d i s e a s e ( J e l l i n e k 1960). It ho lds t h a t w h i l e t h e causes a r e as y e t unknown, a lcohol ism 1s a d i s e a s e t o which a small minor i ty of t h e popula t ion , p e r f e c t l y normal i n o t h e r r e spec t a , i s vulnerab le . Alcoholism can and c e r t a i n l y should be t r e a t e d w i t h one o r more of s e v e r a 1 proven -- though not of cou r se p e r f e c t -- t he rapeu t i c methods ( c f . Wiener 1980).

Another governing i d e a 1s t h e view t h a t i t 1s i n s o c i e t y ' s i n t e r e s t s t o c o n t r o l t h e d i s t r i b u t i o n of a l coho l . (Levine 1980; Fosdick and S c o t t 1933). T h i s concept ion was q u i t e s t r o n g about t h e t i m e of P r o h i b i t i o n ' s r epea l , and l e d t o t h e c u r r e n t U.S. syatem of s t a t e and n a t i o n a l a l c o h o l i c beverage c o n t r o l . Alcohol 1s con- s ide red a comonly-sought and c e r t a i n l y non-suppressable commodity, but one s u b j e c t t o e x p l o i t a t i o n by c r i m i n a l g reed , s o t h a t i t s marketing needs t o be overaeen by a s t rong r e g u l a t o r y watchdog.

The f i n a l (and c u r r e n t l y l e a s t commanding) of t h e governing i d e a s 1s t h e p u b l i c h e a l t h pe r spec t ive , i n which a l coho l l a viewed a s benign when used i n ama11 q u a n t i t i e s , but i n c r e a s i n g l y damaging and r i s k y t o h e a l t h when drunk t o excess . I n t h i s view discourage- ment of exces s ive consumption by s t r o n g pub l i c h e a l t h warnings, h igh t a x a t i o n , and reasonable l i m i ts on a v a i l a b i l i t y a r e important measures i n t h e i n t e r e s t s of p u b l i c h e a l t h (Bruun e t a l . 1975).

The i d e n t i f i c a t i o n of governing i d e a s o u t s i d e t h e United S t a t e s cannot be done a p r i o r i , bu t r e q u i r e s c a r e f u l a n a l y s i s of h i s t o r i c a l and contemporary m a t e r i a l 8 t h a t d i s p l a y t h e i d e o l o g i c a l foundat ions of s o c i a l and p o l i t i c a l movements regard ing a l coho l , and t e 1 1 us how w e l l t he se i d e a s have become entrenched i n common ideology and i n s t i t u t i o n a l p r a c t i c e ( c f . Moser 1979; World Heal th Organiza t ion 1981; S ing le , Morgan, and de L i n t 1982)-

It 1s c l e a r t h a t a su s t a ined s t r a t e g y v i a l e g i s l a t i v e and o t h e r means f o r l i m i t i n g o r p revent ing a lcohol - re la ted problema must b u i l d on t h e base of a governing idea. An e s t a b l i s h e d i d e a may convenien t ly support t he a v a i l a b l e ins t ruments of po l icy ; a newer one may r e q u i r e sus t a ined work t o spread i t and persuade people of i t s v a l i d i t y .

It ehould be evident t h a t a governing idea covere much more than government policy. A governing idea about a lcohol p r i n c i p a l l y concerns people ' e everyday aeeumpt ione and ac t ione , and only secondari ly how they expect governmente t o behave. Theee expectat ione of government w i l l be ehaped, a l eo , by genera l philoeophiee of t h e e t a t e ' s r o l e i n soc ie ty , a s w e l l a s p rac t i ca1 o r h i a t o r i c a l judgments about how e f f e c t i v e epecif i c klnde of programe w i l l be o r have been.

What i s moet notable about a governing idea i e t h a t i t can t i e together i n a penetrat ing and convincing way a judgment about the na ture and e i z e of the p r i n c i p a l e f f e c t of a lcohol uee, a view of the appropr ia te r o l e of t h e e t a t e , and a e p e c i f i c idea about t h e inetrument o r program which t h e government, i f c a l l e d upon t o a c t , ehould uee. It doee t h i e even though t h e grounds f o r tying these elemente together may be l o g i c a l l y vague o r h i e t o r i c a l l y f o r t u i t o u e r a t h e r than l o g i c a l l y r igorous o r empir ica l ly compelling.

The subeequent eec t ions of t h i e eseay cover t h e baeic ca tegor iea of e f f e c t e of a lcohol use, the main kinde of pol icy inetrinnents and normative conceptions t h a t may be ac t iva ted i n preventive alcohol policy, and comente on the waye i n which policy in tervent ione may o r may not produce intended resu l t e . No p a r t i c u l a r governing idea i e propounded, though the re a r e remarke re levant t o severa l . I n s h o r t , what followe is an o u t l i n e of the comparative anatomy of a lcohol pol icy , with epecia l a t t e n t i o n t o preventive approaches.

The Effec te of Aicohol Use

Vi r tua l ly every known human eoc ie ty uees beverage alcohol. There l e conaequently enormoue v a r i a t i o n i n how i t 1s ueed, what the e o c i a l l y v i e i b l e r e e u l t e a r e , and how much concern o r i n t e r e e t i a shown i n theee resu l t e . Theae va r i a t ione acrose e o c i e t i e s a r e reviewed i n d e t a l l eleewhere (e.g. Gaetineau e t a l . 1979; MacAndrew and Edgerton 1969; Marshall 1980; Single, Morgan, and de Lint 1982; Sulkunen 1978; World Health Organization 1981). Since my i n t e n t i o n here l e simply t o def ine t h e axes of v a r i a t i o n i n government po l i c i ee , only a few echematic remarke need be made here about how the e f f e c t s of a lcohol a r e conceived.

Theee e f f e c t s vary i n q u a l i t y and i n quanti ty. There a r e th ree baeic dimeneione of q u a l i t y , t h a t l e , t h ree typee of e f f e c t s : moral, physical , and economic. Theee e f f e c t s can be poe i t ive a s well a s negative, and they a r e not mutually exclueive.

Moral e f f e c t s r e f e r t o changea i n personal s a t i e f a c t i o n and e o c i a l s o l i d a r i t y (Cahalan, Cis in , and Croesley 1969). On the

p o s i t i v e s i d e , a l c o h o l use c a n g i v e rise t o r e l a x a t i o n o r p l ea san t s ensa t ions , can mark important even t s , and can f a c i l i t a t e c o m u n a l occaeions. On t h e nega t ive s i d e , a l c o h o l use can r e s u l t i n l o s s of mot iva t ion t o l i v e happi ly o r s u c c e s s f u l l y , l e ad ing t o s u i c i d e o r depress ion , w i thdrawal f rom i n t i m a t e r e l a t i o n s , o r v i o l e n t behavior. Alcohol can demoral ize people who use i t unwisely o r unf o r t u n a t e l y , and can f u r t h e r demoral ize people who come i n t o c o n t a c t wi th o r depend on such use r s . I f t h e moral e f f e c t s a r e of p r i n c i p a l concern, t h e focus of p o l i c y deba te o r o t h e r conmunication tends t o be a l c o h o l ' s nega t ive e f f e c t s on fami ly l i f e , o r i n c o n t r a s t , i t s p o s i t i v e r o l e i n cementing ex t r a - f ami l i a1 f r i endsh ips .

Economic e f f e c t s r e f e r t o changes i n weal th o r u t i l i t y . On t h e p o s i t i v e s i d e , a l c o h o l 1s a commodity t h a t i s o f t e n d e s i r e d f o r i t s e l f and thus " c r e a t e s jobs" and "pu t s c a p i t a l t o work" i n i ts product ion and d i s t r i b u t i o n . On t h e nega t ive s i d e t h e r e 1s d e s t r u c t i o n of p roper ty i n a c c i d e n t s , poor management due t o alcohol-impaired d e c i s i o n s , l o s s i n product ive l a b o r c a p a c i t y , and d i v e r s i o n of l a b o r and c a p i t a l from o t h e r uses t o t h e a l coho l t r a d e (Berry and Boland 1977; Luce and Schweitzer 1978). ühere economic e f f e c t s a r e g iven p r i o r i t y , t h e nega t ives of job abeenteeism and u n f i t n e s s w i t h consequent economic d e c l i n e and dependency a r e con t r a s t ed w i th t h e s u b s t a n t i a l e i z e of employment and p r o f i t i n t h e a l c o h o l i c beverage i n d u s t r y , w i t h i t s r e s u l t i n g b e n e f i t s f o r r e t a i l t r a d e and government t a x revenues.

Phys ica l e f f e c t s involve h e a l t h . The p r i n c i p a l p o s i t i v e e f f e c t of a l coho l appears t o be a s a s a n i t a r y c a l o r i e source and

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p o s s i b l y a p a r t i a l a n t i d o t e t o a the rogen ic o r a r te ry-c logging d i e t s (Nat iona l I n s t i t u t e on Alcohol Abuse and Alcoholism, 1981). The nega t ive e f f e c t s on h e a l t h a r e bo th immediate (hangovers, a d d i c t i o n , f a t a l overdosea, i n j u r y , and dea th due t o trauma) and ch ron ic (organ damage such a s l i v e r c i r r h o s i s , Korsakoff b r a i n syndrome, hyper tens ion , and weakening of t h e h e a r t muscle). Focus on t h e nega t ive h e a l t h e f f e c t s t ends t o be split between t h e m o r t a l i t y and major d i s a b i l i t i e s a s c r i b a b l e t o d i s eaeee of t h e l i v e r and o t h e r p a r t s of t h e body among o l d e r heavy d r i n k e r s o r a u t o c r a s h f a t a l i t i e s among the young. The c o n t r a s t i n g no t ion of a p o s i t i v e h e a l t h va lence f o r moderate d r i n k i n g r e l a t i v e t o abe t inence o r heavy dr ink ing has gained currency ( c f . Schmidt and Popham 1982).

For each c l a s s of e f f e c t s , p o s i t i v e and nega t ive , t h e r e 1s a b a s i c range i n q u a n t i t y from small t o l a rge . It i s poss ib l e , however, t o d i s t i n g u i s h f o u r s u b t l y d i f f e r e n t components of judgment about t h e o v e r a l l s i z e of an a l coho l e f f e c t . F i r s t i s judgment of t h e c a u s a l s i g n i f i c a n c e of a l c o h o l a s a genera tor of t h e e f f e c t . Alcohol may o r may not be considered a key c a u s a l e lemento For example, i n some reg ions a n a l c o h o l i c beverage (e.g. wine o r beer ) i s a d i e t a r y s t a p l e a k i n t o bread o r cheese; and even though t h e ch ron ic drunkard l a cons idered a s o c i a l nuisance and a n

embarrassment o r poseibly a nightmare f o r h i e (very eeldom lier) - family, the p r inc ipa l problem i s viewed a s a de fec t i n individual o r family charac ter . Alcohol 1s no more blamed f o r the drunkard's behavior than g r a v i t y 1s fau l t ed f o r making some ch i ld ren accident-prone. I n add i t ion , the e i z e of the e f f e c t -- be i t benef ic ia1 o r damaging -- depende on a ) the extent of t h e population " a t r i sk" (how many people a r e p o t e n t i a l l y eubjec t t o i t ) , b) the degree of i ts episodic o r ind iv idua l l ike l ihood (whether t h e chances of i ts happening t o any e i n g l e eubjec t i n t h i e population a r e high o r low), and c ) its individual impact o r s e v e r i t y when i t does occur.

For the rnoet p a r t , t he degree of e f f e c t i s not ca l ib ra ted by s c i e n t i f i c ana lys i s of these f ac to re , but 1s r a t h e r compounded from t r a d i t i o n a l b e l i e f s , p o l i t i c a l r h e t o r i c , and t o some degree, empirical inquiry. The r e e u l t is t h a t moet i n t e r e s t e d p a r t i e s d i sp lay a c e n t r a l concern wi th only one o r two presumptively l a r g e e f f e c t e ee lec ted from the a r r a y of p o e s i b i l i t i e s . The one o r two may be drunk dr iv ing, medical sequelae of chronic addic t ion , poor job performance, i l l e g a l production, violence, o r revenue. In the next s e c t i o n we w i l l coneider how these concerns r e l a t e t o o the r conceptions t o form a governing idea.

Def in ing Alcohol Policy

General Coneideratione

Some genera l and obvious axioms t h a t should be kept continu- ously i n mind i n thinking about a lcohol policy ( f o r i t is remarkably easy t o overlook the obvious) a r e t h a t a ) policy on one subjec t i s always made wíth an eye t o policy about o ther subjec ts ; b) a r t i cu - l a t i o n of pol icy i s only one funct ion of governments; and c ) govern- mente a r e always a p a r t of a e p e c i f i c socie ty . A r a t i o n a l e f o r a c t i o n which eeems powerful t o those whose concern 1s focused on a s i n g l e subjec t may appear t r i v i a l o r even inconceivable t o o ther p a r t i e s because i t c o n f l i c t s with an o v e r a l l d i r e c t i o n of government a t the time, requi res the use of capac i t i e s o r resources t h a t do not e x i s t o r have o t h e r p r i o r i t i e s , o r f l i e s i n the f ace of powerful cont rary eoc ia l i n t e r e s t s o r values. On the o the r hand, po l i c i e s a r e o f t e n made poss ib le because, i n add i t ion t o s t rong i n t r i n s i c argumenta i n t h e i r favor, they happen t o be cons is tent with an o v e r a l l t rend i n power, o r because an underut i l ized o r e a s i l y ava i l ab le i n e t i t u t i o n a l mane l í e s c lose a t hand, o r because the argumente l i n e up nea t ly wi th a powerful extragovernmental s o c i a l movement. Most o f t e n i n a p l u r a l i e t i c eociety with a degree of decent ra l ized government, one f i n d s t h a t any cogent pol icy idea can imbue some patch of p o l i t i c a l l i f e .

With these gene ra l axioms gran ted , i t l e t i m e t o ask: what l e a governmental a l c o h o l po l i cy? - I n t h e broades t eense, a pub l i c po l i cy is a concept ion of a n i d e a l form of c o l l e c t i v e o r aggrega te behavior i n t h e s o c i e t y ( o r i n t h e c a s e of " fo re ign pol icy" , i n t h e behavior of o t h e r s o c i e t i e s ) t h a t t h e government espouses o r wishes t o encourage. The d e s i r e d behavior may be i d e n t i f i e d p o e i t i v e l y , e.g. cont inuous economic growth, o r p r o e c r i p t i v e l y , e.g. p u t t i n g an end t o v i o l e n t crime. Theee concept ions of t h e d e s i r a b l e can be c a l l e d po l i cy i d e a l s . In t h e c a s e of a l coho l po l i cy t h e i d e a l might range from no a l c o h o l use t o a s much a l c o h o l u se a s people wish, bu t i n most i n s t a n c e s i t t a k e s t h e g e n e r a l form: s t o p a l coho l abuee and alcohol ism.

Such i d e a l s a r e u s u a l l y f a r from t h e l e v e 1 of day-to-day government a c t i v i t y . Much c l o s e r t o t h e s u r f a c e a r e what can be c a l l e d incrementa l N, such a s an x-percentage i n c r e a s e i n g ros s n a t i o n a l product (GNP) o r a slowing of t h e i nc rease i n crime r a t e s . I n t h e U.S., examples o f a l c o h o l p o l i c y s t a t e d a s such g o a l s a t one time o r another have included s t a b i l i z a t i o n of pe r c a p i t a coneump- t i o n , i nc reas ing alcohol ism t rea tment " s l o t s , " r a p i d r educ t ion of i l l e g a l a l coho l product ion, l a r g e r government revenues from a l coho l t a x e s , decreases i n t h e number o f drunk-driving d e a t h s , and epread of r e spons ib l e dr ink ing p r a c t i c e s .

Yet t h e most u s e f u l way t o analyze t h e range of p o s s i b l e prevent ive a l coho l p o l i c i e s 1s n e i t h e r i n terms of b a s i c a l l y unreachable i d e a l s nor pe r iod i ca l ly - ad jus t ed incremental g o a l s , bu t r a t h e r i n terms of po l i cy ins t ruments , t h e s p e c i f i c mechanisms o r programa used t o implement t h e p o l i c i e s . Looked a t t h i s way, w e can qu i ck ly recognize two fundamental d i v i s i o n s of a l coho l po l i c i ee : p revent ive and r e s t o r a t i v e .

Prevent ive and Res to ra t i ve P o l i c i e s

Prevent ive p o l i c i e s meant t o a f f e c t a l coho l - r e l a t ed problems have been f u l l y def ined a s fo l lows:

They a r e a l 1 p o l i c i e s t h a t ope ra t e i n a non- pe r sona l i zed way t o a l t e r t h e s e t of cont ingenc ies a f f e c t i n g i n d i v i d u a l s a s they d r i n k o r engage i n a c t i v i t i e s t h a t (when combined wi th i n t o x i c a t i o n ) a r e considered r i sky . . . . None of t h e s e p o l i c i e s dependa on a cont inu ing persona l ized r e l a t i o n s h i p between a program and a d r inke r . I n s t ead , they o p e r a t e through t h e remote manipulat ion of a r e l e v e n t s e t of i n c e n t i v e s and cont ingenc ies : t h e terms and circumstances under which a l coho l 1s a v a i l a b l e , t h e a t t i t u d e s of people surrounding t h e d r i n k e r , and the ben ign i ty of t h e phys i ca l and

s o c i a l environment toward drunkenness. [Such] programe o p e r a t e g e n e r a l l y throughout t h e s o c i e t y . The i n c e n t i v e s and con t ingenc i e s a r e e s t a b l i s h e d f o r everyone (Moore and G e r s t e i n 1981:53).

in b r i e f , p revent ive p o l i c i e s are non-personalized and genera l .

Res to ra t i ve p o l i c i e s , i n immediate c o n t r a s t t o p reven t ive ones, f i r s t i d e n t i f y i n d i v i d u a l s who have c r e a t e d o r su f f e r ed problems t h a t a r e d i r e c t l y due t o d r ink ing , and then begin and main ta in f o r some per iod of t ime a cont inu ing face-to-face r e l a t i o n s h i p between these i n d i v i d u a l s and a s e r v i c e o r i n s t i t u t i o n . The r e l a t i o n s h i p 1s based on the i n d i v i d u a l ' s having m e t some f a i r l y narrow o r e x p l i c i t l e g a l o r c l i n i c a l c r i t e r i o n ; t h e t e rmina t ion of t h i s arrangement 1s usua l ly based on a c r i t e r i o n of t h e i n d i v i d u a l ' s performance o r r e l a t i o n t o t h e i n s t i t u t i o n . The d i f f e r e n t v a r i e t i e s of agency-client s t a t u s i nc lude " t rea tment , " i n which a process of medical o r psychological hea l ing 1s involved; " r e h a b i l i t a t i o n , " i n which t h e r e i s t r a i n i n g i n c o g n i t i v e o r psychomotor s k i l l s and o r i e n t a t i o n ; and "punishment," i n which t h e i n d i v i d u a l is penal ized f o r engaging i n w i l l f u l c r imina l a c t i v i t y . S ince t h e focus of t h i s paper i s prevent ive p o l i c i e s , f u r t h e r a n a l y s i s of t he se r e s t o r a t i v e approaches w i l l be suspended, and we w i l l t u r n t o t h e subd iv i s ions of p revent ive approaches.

There a r e t h r e e k inds of p revent ive p o l i c i e s : a ) r e g u l a t i n g t h e terms and cond i t i ons of a v a i l a b i l i t y of bo th a l c o h o l and p l aces i n which t o d r i n k i t ( r e g u l a t i n g supply) ; b) t r y i n g t o i n f luence people ' s d r ink ing p r a c t i c e s d i r e c t l y through pedagogical e f f o r t s and l e g a l s t i p u l a t i o n s (shaping d r ink ing p r a c t i c e s d i r e c t l y ) ; and c ) making t h e e x t e r n a 1 environment l e s 8 h o s t i l e o r r i s k y s o t h a t p o t e n t i a l l y damaging consequences of i n t o x i c a t i o n a r e reduced ( reduc ing environmental r i s k ) . These t h r e e types a r e r e l a t e d t o each o t h e r q u i t e d i r e c t l y . Supply p o l i c i e s t r y t o c o n t r o l two of t h e elernents t h a t a r e necessary t o every a l coho l - r e l a t ed problem: a l c o h o l i t s e l f and p l aces i n which t o d r i n k i t . Po l i cy on dr ink ing p r a c t i c e presumes t h a t a l c o h o l and d r ink ing p l a c e s ( p u b l i c and p r i v a t e ) are a v a i l a b l e and tries t o i n f luence how people take advantage of them, i n terms of how much, how o f t e n , o r what a c t i v i t i e s d r i n k e r s p a i r wi th consumption. F i n a l l y , a po l icy designed t o reduce environmental r i s k presumes t h a t people w i l l be d r ink ing , g e t t i n g drunk, and p u t t i n g themselves i n danger i n var ious ways; t h e o b j e c t of t he se p o l i c i e s is t o l i m i t t h e s e v e r i t y of t h e consequences by amking the environment less h o s t i l e .

It should be noted t h a t each o f t h e t h r e e t ypes of p revent ive po l i cy can subserve a number of governing ideas . But more p e r t i n e n t t o ou r purpose he re i s t o observe t h a t each type of p o l i c y subsumes a number of po l icy ins t ruments t h a t fo l low t h e g e n e r a l l o g i c o u t l i n e d , but vary i n fo rce , emphasis, and s t y l e .

V a r i e t i e s of Prevent ive P o l i c i e s

Regulat ing Supply

Regulat ion of supply g e n e r a l l y has f o r i t s o b j e c t s t h e s e p a r a t i o n of c r i m i n a l o r i r r e g u l a r e lements from t h e l e g i t i m a t e t r a d e ; t h e maintenance of c i v i l o r d e r and decorum i n d r ink ing p l aces ; t h e l i m i t a t i o n of exces s ive coneumption*; o r t h e keeping of a l coho l e n t i r e l y away from c e r t a i n c a t e g o r i e s of people f o r whom ( a t a p a r t i c u l a r h i s t o r i c a l j unc tu re ) i t i s considered e s p e c i a l l y dangerous, such a s people of a p a r t i c u l a r e t h n i c group, people occupied i n hazardous a c t i v i t i e s , o r ch i ld ren . The most t y p i c a l supply po l i cy ins t ruments i nvo lve product ion c o n t r o l s , r e g u l a t i o n of t h e ownership, number, l o c a t i o n , and r e t a i l hours of o u t l e t s , p r i c e c o n t r o l s , and r e s t r i c t i o n s on purchase of a l c o h o l i c beverages cont ingent on age, ' r a ce , o r some o t h e r q u a l i f i c a t i o n . The most c o n t r o v e r s i a 1 of t h e s e ins t ruments a t t h e c u r r e n t t i m e i n t h e United S t a t e s a r e p r i c e c o n t r o l s and a g e r e s t r i c t i o n s .

P r i c e s and Taxes P r i c e s can be c o n t r o l l e d e i t h e r by adminis te r ing them d i r e c t l y by " f a i r t rade" o r p r i c e support p lans , o r by ensur ing c e r t a i n minimum p r i c e " f l o o r s " w i t h e x c i s e t axa t ion . The e s s e n t i a l p r a c t i c a l ques t i on t h a t t h i s kind of p revent ion po l i cy needs t o a s k 1s: Do p r i c e c o n t r o l s a f f e c t t h e most d e l e t e r i o u s d r ink ing p r a c t i c e s , i. e. , ch ron ic heavy consumption and pe r iod i c s eve re i n t o x i c a t i o n ? I n gene ra l , t h e weight of evidence a f f i r m s t h a t p r i c e s do a f f e c t heavy d r ink ing p r a c t i c e s (Moore and Ger s t e in 1981: 68-83; Cook 1981). But some o t h e r argumenta a r e e q u a l l y r e l e v a n t : normative o b j e c t i o n s t h a t a l c o h o l t a x e s a r e u n f a i r t o l i g h t and moderate d r i n k e r s , and t h a t exc i se t a x e s on consumer i t e m s f a 1 1 most heav i ly on t h e poor, who can l e a s t a f f o r d them; p r a c t i c a l i s s u e s concerning t h e r e l a t i v e weight of t axes on beer , wine, and s p i r i t s ; and i n t h e United S t a t e s , p o l i t i c a l o b j e c t i o n s based on t h e uneasy f e e l i n g t h a t t h e use o f heavy t a x a t i o n a s a prevent ive r a t h e r

* C r i t i c s and advoca tes a l i k e tend t o focus h e a v i l y on t h i s a s p e c t of supply p o l i c i e s , t o t he po in t t h a t t h e s e p o l i c i e s have come t o be c a l l e d t h e "con t ro l of consumption" approach (P i t tman 1981). They might b e t t e r be c a l l e d t h e "con t ro l of product ion and d i s t r i b u t i o n " approach, s i n c e t h e main burden of a c t i v a t i n g t h e s e p o l i c i e s f a l l s on t h e c o m e r c i a l s e c t o r r a t h e r than t h e p r i v a t e consumer. The most i n f l u e n t i a l advocate of c o n t r o l p o l i c i e s i n t h e l a t e P r o h i b i t i o n e r a put t h e ca se simply a s : t ake t he high p r o f i t s o u t of a l coho l (John D. Rocke fe l l e r Jr., i n Fosdick and S c o t t 1933).

than e t r i c t l y a revenue meaeure beare t o o much reeemblance t o Vol- e t e a d i m , that l e , t h a t t h i e approach i e t a i n t e d by the exceeeive moraliem and dieaet roue r e e u l t e of na t iona l P roh ib i t ion (implemented under the Voletead Act).

Thie domination of the alcohol pol icy p i c t u r e i n the United S t a t e e by the ehadow of Prohibi t ion i e probably not app l i cab le t o many o the r countr iee. I n s i m i l a r faehion, t h e much l i g h t e r taxee here on beer and wine than on e p i r i t e have some p a r t i c u l a r h i e t o r i c a l antecedente. I n general , a preventive pol icy would be moet e f f i c i e n t i f i t taxed q u a n t i t i e e of e t h y l a lcohol equally, whether packaged i n weak o r etrong eolut ion. tiowever, a n increaee i n any p a r t of the a lcohol t ax e t ruc tu re would probably eerve preventive objec t ivee r e l a t i n g t o exceeeive coneumption, though eomewhat l e e s e f f i c i e n t l y . It ehould be noted t h a t the highly ca~nnerc ia l ized , r e l a t i v e l y concentrated, and thoroughly regulated nature of the manufacture of a l coho l i c beveragee i n the United S t a t e e 1s more conducive t o c o l l e c t i o n of an exciee t a x than would be the case i n a more dispersed, l e e s camnercial, o r l e s e c loeely regulated manufacturing economy.

The normative i e s w e a r e twofold. F i r s t , i e i t f a i r f o r a l 1 dr inkere t o be taxed i f only eome d r ink dangerouely o r exceeeively? In p a r t , the way the queetion l e phraeed misees the point : a high preventive t a x i e meant prec iee ly t o keep people from drinklng so much and thue put t ing themeelvee a t g r e a t e r r i ek . Many people who become exceeeive dr inkere were l i g h t o r moderate d r inkers a t one t i m e , s o i t i e d i f f i c u l t t o s u e t a i n t h e notion that t h i s group of dr inkere shouldn't be af fec ted . It i e i n f a c t t h e heavieet dr inkere who pay moet of the tax , e ince they d r ink most of t h e alcohol . I n add i t ion , many of the damagee from exceeeive dr inking (e.8. i n j u r i e s due t o a seau l t e and accidente) fa11 on people who were not dr inking exceeeively themeelvee but were unfortunate enough t o be around soPPeone who did. Thus t h e preventive e f f e c t of taxee would benef i t even t o thoee who drink eafe ly themeelvee.

The o ther normative ieeue 1s equity: t h e be l i e f t h a t a lcohol taxee fa11 moet heavily on the poor, and hardly a f f e c t the wealthy. In f a c t , econometric e tudiee euggeet t h a t higher t axes on a lcoho l i c beveragee r e e u l t i n moet people spending about the same on drinlring, but drinking l e s e ; thoee who do increaee t h e i r expenditure appear t o be l a r g e l y thoee who can a f fo rd t o do 80 without f inancia1 d ie t r eee . Since wealthier people genera l ly epend coneiderably more on a lcohol t o begin with, a n increaeed t a x would i n f a c t a f f e c t them coneiderably.

Age Ree t r i c t ions The debate about age r e e t r i c t i o n e i n t h e United S ta tee has not been over whether the re ehould be any r e e t r i c t i o n e , but whether t h e r i g h t t o purchaee a lcoho l i c beveragee ehould be i n i t i a t e d a t 1 8 yeare of age o r a t 21 years o r eomewhere

i n between. Complicating and dominating t h i s deba te a r e two somewhat d i f f e r e n t i s s u e s : drunken d r i v i n g a c c i d e n t e and d r i n k i n g by young people under t he age of 18 (Wechsler 1980).

The downward movement of t h e minimum l e g a l d r ink ing age f rom 21 t o 19 o r 18 yea r s i n roughly ha l f t h e s t a t e s dur ing t h e e a r l y 1970s p a r a l l e l l e d r educ t ions i n t h e minimum v o t i n g age. These r educ t ions , i n t u r n , were t h e coneequence p r i n c i p a l l y of t h e V i e t Nam war, when 18-year-old d r a f t e e s were c a l l e d on f o r a d i s t a n t war of u n c e r t a i n support and leg i t imacy , without t h e f r a n c h i e e t o p a r t i c i p a t e i n t h e most fundamental r i t e of r e p r e s e n t a t i v e democrat ic p o l i t i c s .

The r e c e n t t i d e of r e v e r s a l s i n t h i s r e l a t i v e l y sma l l adjustment i n t h e dr ink ing age has occurred almost e x c l u s i v e l y on t h e grounds t h a t many 18, 19, and 20 y e a r o l d l i v e s a r e being l o s t i n drunken d r i v i n g a c c i d e n t s , and t h a t t he se newly e n t i t l e d purchasers a r e themselves i l l i c i t l y i nc reas ing t h e a v a i l a b i l i t y of a l coho l t o even younger c h i l d r e n . The evidence i n d i c a t e s t h a t changes i n t h e l e g a l purchasing age do no t g r e a t l y change t h e o v e r a l l q u a n t i t y of a l c o h o l t h a t t hose d i r e c t l y a f f e c t e d consume. There i s , however, a cons ide rab l e e f f e c t on where they do t h e i r d r ink ing . When purchase 1s i l l e g a l , young people of t h e s e ages a r e excluded from b a r s and o t h e r by-the-drink s e r v i c e e s t ab l i shmen t s , and thus spend cons iderab ly l e s s t ime d r i v i n g t o and from such places . I n s t ead they con f ine t h e i r d r ink ing l a r g e l y t o p r i v a t e homes. There i s then a measurable d i f f e r e n c e i n a u t o c r a s h f a t a l i t i e s i n t h i s age band (Douglass 1979-80). For t h e United S t a t e s a s a whole, t he se d i f f e r e n c e s e a s i l y add up t o hundreds of l i v e s a year .

Although some a t t e n t i o n has been pa id t o t h e e f f e c t of purchasing age minima on p rov i s ion of a l coho l t o ado le scen t s w e l l below t h e con t rove r s i a1 age range, t h e r e 1s r e a l l y no persuas ive evidence t h a t adjustments t o t h e age minimum have much e f f e c t on d r ink ing behavior i n t h i s group.

Th i s i s s u e r a i e e s t o v i s i b i l i t y a n important dimension of t h e po l i cy i s s u e s surrounding a l c o h o l use. There 1s c l e a r l y a s t rong n a t i o n a l consensus t h a t P r o h i b i t i o n i n t h e 1920s was a bad mistake. It f o s t e r e d v i o l e n t c r imina l o rgan iza t ions , c r ea t ed open o r ba re ly d i sgu i sed contempt f o r t h e law, and f a i l e d t o e l i m i n a t e drinking--although t h e consensus does g l o s s over t h e f a c t t h a t d r ink ing d i d r e t r e a t dur ing P r o h i b i t i o n t o t h e lowest l e v e l e i n t h e h i s t o r y of t h e country, a t l e a s t one-third less and perhape only h a l f a s much a s a t p resen t o r immediately before P r o h i b i t i o n (Warburton 1932, J e l l i n e k 1947/8). The g r e a t ma jo r i t y of people i n t h e United S t a t e s s t i l l c l e a r l y be l i eve i n t h e v a l i d i t y of p r o h i b i t i n g a l coho l t o a l a r g e p o r t i o n of t h e popula t ion , inc lud ing some who a r e vo t ing c i t i z e n s , because they a r e t o o young. Thie 1s a

cont inued endorsement of p a r t i a l p r o h i b i t i o n , and of measuree t o implement i t which do not d e s t r o y l e g i t i m a t e business . This endoreement g i v e s dramatic evidence of t h e b e l i e f t h a t a l c o h o l i s d i f f e r e n t from o t h e r k inds of beverages i n t h a t i t 1s too dangerous t o be made r e a d i l y a v a i l a b l e t o t hose no t possess ing t h e s k i l l s o r judgment t o use i t s a f e l y and app rop r i a t e ly . But what i e s a f e and a p p r o p r i a t e use? üha t i s being done t o see t h a t t h e necessary e k i l l s and judgment a r e i n p l ace by t h e e igh t een th o r s h o r t l y - fo l lowing b i r thday? And what measures can o r should t h e government t ake t h e r e a f t e r t o see t h a t t h e s e u s e f u l f a c u l t i e s a r e exerc i sed? These a r e t h e prominent ques t i ons t h a t a r i s e i n cons ider ing p o l i c i e s t h a t t r y t o shape d r ink ing p r a c t i c e s d i r e c t l y .

Shaping u r ink ing P r a c t i c e s D i r e c t l y

Adults a r e on t h e whole l e g a l l y l i c ensed t o d r ink , but powerful f o r c e s c o n s t r a i n t h e i r freedom t o e x e r c i s e t h i s l i c ense . Undoubtedly t h e most powerf u1 c o n s t r a i n t s a r e t h e in formal norms that c h i l d r e n l e a r n e a r l y i n l i f e i n t h e home, and then go on t o test, modify, and t r ansmi t t o each o t h e r a s a d u l t expec t a t i ons i n f a m i l i e s , f r i e n d s h i p s , and work r e l a t i o n s . Whether governments undertake t o shape d r ink ing p r a c t i c e s o r n o t , t h e s e i n fo rma l s o c i a l and c u l t u r a l con t ro l8 w i l l ope ra t e , and they a r e t h e major f a c t t h a t any po l i cy i n t e r v e n t i o n must t a k e i n t o account.

I f t h e s t a t e tr ies t o c o n s t r u c t a p revent ive p o l i c y focused on d r ink ing p r a c t i c e s , a number of d i f f i c u l t i e s a r i s e . F i r s t , a t t h e l e v e 1 of i d e a l s , t h e problem i s t o d e f i n e t h e k inds of d r ink ing p r a c t i c e s -- amounts, f requenc ies , and occas ions -- t ha t a r e considered s a f e and a p p r o p r i a t e , and c l e a r l y set o f f t hose t h a t f a 1 1 ou te ide t h e s e boundaries. The problem here i s t h e s h e e r v a r i e t y of d r ink ing customs i n a s o c i e t y wi th more than a s i n g l e c u l t u r a l heritage--and v i r t u a l l y a l 1 n a t i o n a l s o c i e t i e s a r e mu l t i - e thn i c . No ma t t e r where t h e boundary l i n e s a r e drawn, t h e r e w i l l be uproar. I n e v i t a b l y , a set of boundaries on a c c e p t a b i l i t y w i l l exc lude ways of d r ink ing t h a t s u b s t a n t i a l f r a c t i o n s of t h e popula t ion w i l l cons ider t o be q u i t e normal and accep tab l e , and none of t h e government's business . The same s e t of l i n e s w i l l a l s o permit d r ink ing p r a c t i c e s t h a t s u b s t a n t i a l f r a c t i o n s of t h e populace w i l l cone ider q u i t e outrageous and unusual , l ead ing them t o accuse t he government of g iv ing p o s i t i v e a s s e n t t o behavior t h a t they cons ide r f r i g h t e n i n g , hazardous, o r wrong. The t a s k of drawing a s e t of g u i d e l i n e s t h a t minimize i r r e c o n c i l a b l e viewpoints is not an enviab le one.

There a r e some ways i n which policymakers can tune such p o l i c i e s s o a s t o c r e a t e less d iscord . In p a r t i c u l a r , no t a l 1 l i n e s need t o be drawn wi th equa l f o r c e .

A l i n e defended by c r i m i n a l s t a t u t e s must command wider compliance ( 1 . . , admit more of c u r r e n t d r ink ing p r a c t i c e s ) and be focused on behavior t h a t produces more adverse e x t e r n a 1 e f f e c t s t han a l i n e defended by weaker measures such a s economic i n c e n t i v e s , c i v i l s a n c t i o n s , advisory educa t iona l programs, o r exemplary a c t i o n s of government. This sugges t s t h a t one might want t o e s t a b l i s h a v a r i e t y of l i n e s wi th varying deg rees of force . Criminal s t a t u t e s should be s p a r s e l y used t o d i scourage only t h e r a r e s t and most dangerous conduct. Other pro- grams could be used more l i b e r a l l y and e s t a b l i s h somewhat more c o n t r o v e r s i a 1 g o a l s (Moore and Ger s t e in 1981: 57-58.)

The ins t ruments o u t l i n e d here--8tatutory r e g u l a t i o n of i n d i v i d u a l conduct o r more simply, t h e - law; educa t ion , in format ion , and t r a i n i n g programs under government ausp i ce s conducted i n t h e schools , mass media, and elsewhere, o r b r i e f l y , educat ion; and a c t i o n s of government meant t o set a good example f o r p r i v a t e c i t i z e n s o r p r i v a t e s e c t o r i n s t i t u t i o n s , 1.e. symbolic action--are t h e ways i n which governments can t r y t o implement concept ions of s a f e t y and app rop r i a t enes s i n d r i n k i n g p r a c t i c e s .

Assuming t h a t consensus can be reached about which p r a c t i c e s a r e s u f f i c i e n t l y hazardous o r dev i an t t o merit one o r another leve1 of a c t i o n , t h e government must f ace the coun te rva i l i ng c o n s i d e r a t i o n s of e f f e c t i v e n e s s and of compet i t ion f o r resources . I n t h e shaping of d r ink ing p r a c t i c e s , t h e r e w i l l be s t r o n g r e s i s t a n c e t o any e f f o r t t h a t t r i e s t o move very f a r beyond d iscourag ing what in formal norms a l r eady condemn, o r approving what t h e s e norms a l r eady esteem. I n o rde r t o e f f e c t i v e l y overcome such r e s i s t a n c e s , f o r example by s t r eng then ing discouragement i n t o e f f e c t i v e de t e r r ence o r backing approva l wi th e f f i c i e n t educa t ion , t h e government must be prepared t o devote i t s e l f t o t h e s e t a s k s e i t h e r a t t h e expense of o t h e r t a s k s o r a s a n a d d i t i o n a l d i f f i c u l t job.

Drunk Driving and t h e Law The handl ing of drunk d r i v i n g may se rve a s a n example. I f t h e problem is t o prevent people f r m d r i v i n g drunk, i t i s important - t o recognize how l i t t l e - l l k e l i h o o d t h e r e 1s t h a t any i n d i v i d u a l ep isode of drunkenness a t t h e wheel w i l l be de tec ted when i t occu r s (Borkenstein 1974). The ch ron ic v i o l a t o r 1s c e r t a i n l y l i k e l y t o be caught sooner o r l a t e r , and caught once, i s more l i k e l y t o be caught again. But most of t h e d r i v e r s r e spons ib l e f o r drunk d r i v i n g acc iden t s a r e " f i r s t o f fenders" i n terms of prev ious p o l i c e detection--and d e t e c t i o n as a r e s u l t of a n acc ident does not seem a powerful p r even t ive s t r a t e g y (Ross 1981). Y e t major e f f o r t s t o launch e x t r a p o l i c e on s p e c i a l p a t r o l s i n the l a t e n i g h t d r i v i n g l a n e s where most s e r i o u s drunk

driving accidente occur, e f f o r t e t h a t can a t t r a c t media p u b l i c í t y without which there w í l l be l i t t l e preventiva e f f e c t , a r e q u i t e expeneive (Levy e t a l . 1978; cf . Reed 1981). There a r e l i m i t e t o how much of the po l i ce budget can be e h i f t e d i n t o drunk driving deterrence i f the community i e n o t wi l l ing t o forego o r reduce p o l i ce a c t i o n on aeeaul t e , robberiee , areon, drug traneactions, rapes, and s o fo r th . Ae i t etands, of the 10 mi l l ion a r r e e t e annually recorded i n the Federal Bureau of Inveet iga t ion c r i m e index f o r the United S ta tee , over 1 114 m i l l i o n a r e a l r eady f o r drunk driving. Another 1 114 mi l l ion a r e f o r pub l i c drunkenneee.

There i s considerable sentiment f o r increaeing the drunk driving pena l t i e s now on the books, o r f o r applying them wi t h f u l l e r f orce ine tead of diepoeing of theee v io la t ione eo f requent ly with p lea bargaine, divereione t o t r ea tmen t, probation, and suspended eentencee (Alcoholiem Report 1982a,b). But there a r e no empty j a i l c e l l e awaiting drunk drivere. J a i l cells a r e ecarce, expeneive reeourcee t h a t the j u e t i c e eys t e m mus t marshall careful ly . Every decíeion t o imprieon eomeone f o r a l eng th of t i m e neceeear i ly meane delaying o r denying imprieonment f o r some o the r v i o l a t o r whose conviction could be eub jec t t o t h i e eanction. ühen the quest ion i s whether w e f r e e the a r s o d e t o r th ief i n o rde r t o imprieon the drunk dr iver , the answer doee n o t come eae i ly .

Education, Alcohol, and Children. The a r e a of education faces eomewha t s i m i l a r i e e w e , b u t eomewhat d i f f e r e n t onee a s well. The rudiments of education -- reading, wr i t ing , and a r i thmet ic -- a r e the p r inc ipa l thinge that edioole a r e meant t o teach. The quan t i ty of educational time t h a t can be devoted t o "heal th and safe ty" i s l imi ted . There i e l i t t l e doubt that the s a f e and appropriate use of a lcohol ehould be a n important p a r t of t h i e curriculum. The queetions a r e what i s t o be taught, and how?

What chi ldren l e a n from t h e i r teachere i n echo01 i s l a r g e l y how t o behave i n non-f a d l y - o r i e n t e d envi romente , how t o work euccess fu l ly through a e e r i e e of graded, progreseively more d i f f i c u l t leeeone, and how t o remember and make use of euch f a c t u a l knowledge a s when Columbue landed i n the New World. By e x e p l e , ca jo lery , and d i s c i p l i n e , teachere t r a n m i t habi t e of though t , of c i v i l i t y , and of i n t e r e s t i n the p rac t i ca1 world and i t s leesons. By eystem, t r i a l , and e r r o r , p a r t i c u l a r sldlls can be trained. In the context of prohibí t ion f o r chi ldren and detached profeseionaliem among teachere, what can eerve a s a leeeon plan i n e a f e and appropr ia te drinking? I f o ther a reae of curriculum a r e coneidered, the con t ras t becomes q u i t e clear: i t i e n o t expected t h a t etudente w i l l l e a r n how t o mul t ip l y w i thout p r a c t i cíng mul t ip l i ca t ion tablee , o r tha t anyone can l e a r n t o read without takíng booke home f o r etudy and bringing homework i n f o r c r i t i c i em and praiee? I f we wish ctLil&en n o t t o drink a t a l l , t h i e meesage can c e r t a i n l y be tranemitted. But i f a d u l t e can te11 chi ldren nothing more than "not

u n t i l you're o lde r " , t h i s does n o t go v e r y f a r toward i n c u l c a t i n g s a f e o r a p p r o p r i a t e behavior once they a r e o lde r .

The most e f f e c t i v e b a s i s f o r educa t ing c h i l d r e n t o prevent problems i n the u s e of a l c o h o l i s t o recognize that moet of them w i l l have t o l e a r n f o r themselves, and what t hey need most e s p e c i a l l y i s the b e n e f i t of a d u l t exper ience and example i n gauging t h e t i m e s , p l aces , amounts, and r i s k s involved i n dr ink ing and n o t dr inking. Alcohol educa t ion f o r s choo lch i ld ren should focus on y r e s e n t s i tua t i o n s i n s tead of t h e d i s t a n t f u t u r e , and temper r e e p e c t f o r l e g a l p r o h i b i t i o n -- which needs t o be e t r e s s e d f o r i t s pro t e c t i v e s i g n i f i cance (drunkenness i s a poor l e a r n i n g condi t i o n ) -- w i t h r e s p e c t f o r t h e r e a l exper iences t h a t c h i l d r e n have, which they must i n t e r p r e t and l e a r n t o c o n t r o l f o r themselves.

Reducing Environmental Risk

Even t h e most s t renuous e f f o r t s t h a t might be devoted t o reducing unsaf e o r inappropr ia te dr ink ing p r a c t i c e s canno t be expec ted t o e l i m i n a t e o r r a d i c a l l y cu r t a11 them. I f w e a c c e p t t h i e premise, i t becomes s e n s i b l e t o exp lo re prevent ive p o l i c i e s t h a t a r e designed t o reduce t h e damage a s s o c i a ted w i t h wha t eve r dr ink ing p r a c t i c e s a c t u a l l y occur.

Th i s approach -- manipulat ing the environment s o t h a t r i s k s o f harmful e f f e c t s a r e reduced even i n the presence of drunken behavior -- has been cha rac t e r i zed a s "making the world s a f e f o r drunks", a c h a r a c t e r i z a t i o n t h a t tends t o evoke moral uneas iness o r even ou t r age i n some q u a r t e r s , roo ted i n t h e longs tanding view t h a t drunkenness i s moral e r r o r tha t should ge t i t e jus t dese r t a . . . . The approach can be more a c c u r a t e l y , i f more awkwardly, de sc r ibed as "making the world s a f e r f o r , and f r m , people who a r e a f f e c t e d by a lcohol" (Moore and Ger s t e in 1981:lOO-101).

I t i s n o t d i f f i c u l t t o understand t h e o b j e c t i o n s t h a t some people might have t o p o l i c i e s t h a t do n o t seem t o a t t a & d i r e c t l y t h e causes of a l coho l - r e l a t ed problems, b u t i n s t e a d seem t o t a c i t l y a c c e p t exces s ive o r 111-timed drunkenness and a r r ange t o make i t s consequences les8 s t e r n . Aside from t h e p r a c t i c a 1 p o i n t t h a t '

deplor ing a cond i t i on does n o t make i t l e a s real, there are some sound norma t i v e arguments de£ ending t h i s approach. F i r e t, p r o t e c t i o n a g a i n e t the coneequencee of drtinken behavior i s b e n e f i c i a 1 n o t o n l y t o drunks. To s e l e c t a dramat ic example: a n i n t o x i c a t ed p i l o t , mechani c , bus d r i v e r , r a i l r o a d engineer , o r swi tch o p e r a t o r menaces t he l i v e s of many o t h e r s i n a d d i t i o n t o h i e o r h e r own. Second, whi le drunkenness may have a g r e a t e r vo lun ta ry component than f a t i g u e , absent-mindedness, i r r i t a t i o n , o r a previous

i n j u r y , the r eeu l t ing inpairmente and aesocia ted r i e k e of "human e r r o r " a r e s imi la r . Meaeuree taken t o reduce the harm of drunken miehape w i l l reduce the h a m of o the r niehape t o the eame degree.

F inal ly , there i e ample precedent i n o the r areae f o r goverment in te rven t ion t o reduce diecomfort o r i l l n e e e w i thout epecia l regard f o r the moral i ty o r l e g a l i t y of cont r ibutory ac t ione . Preventive meaeuree a s w e l l a s the rapeu t i c onee a r e used t o cont ro l venereal dieeaee, without cav i l e o r b a r r i e r s concerning m a r i t a l e t a t u e o r p a r t i c u l a r sexual prac t icee . Neither c i g a r e t t e enokere nor obese people a r e denied otherwiee-available pub l i c funde f o r treatment of h e a r t d isease , while blood preeeure t ee t ing and cardiopulmonary resusc i t a t i o n t r a in ing a r e encouraged even though many -- indeed most -- su& vict ims have been indulgent i n d i e t and def i d e n t i n physical d i sc ip l ine .

The two p r i n c i p a l categoriee of env i romenta l r i e k a r e in terpereonal hazarde and physical caeual t iee . I n regard t o the f i r e t , the most common impreeeion about drunkenneee and in terpereonal c o n f l i c t i s t h a t drunke endanger o thers ; y e t there i e nuch euggeetive evidence t h a t in tox ica t ion leade more of ten t o v i c t i n i z a t i o n of the drunk than by the drunk. "Rolling drunke" 1s a eube tan t i a l cr iminal paetime; and a h i e t o r y of alcoholism can c o s t people important l i f e chancee regardlese of t h e i r current and proepective e t a t e of eobr ie ty .

In regard t o the caeual t iee , e ince a lcohol in tox ica t ion tends t o make people ciumey and i n a t t e n t i v e , i t has been implicated t o eone degree i n many Linde of trauma (Aarene e t a l . 1977 ): drownings, burns, f a l l e , and nonentum i n j u r i e s , no t ab ly motor vehic ie accidents . If everyday mater ia le and nachinee were made l e e s l i k e l y t o r i p , t r i p , bludgeon, o r burn people who might be l e e 8 than f u l l y e f f i c i e n t (whether due t o drunkenneee o r some o ther reason) , alcohol-related (and o t h e r ) caeual ties would be fewer. Further , "e ince a l cohol-rela ted caeual t i e e tend t o be concentra ted i n the n o e t severe categoriee -- dea the and permanen t d i s a b i l i t i e e -- e a f e t y improvemente w i l l a f f e c t alcohol-related i n j u r i e s moet dramatically." (Moore and Geretein 1981 :102).

The major example of e a f e t y technologies t h a t can prevent a l a r g e number of a lcohol caeual t iee a r e automobile e a f e t y devices t h a t increase the craehworthiness of vehic lee with respect t o occupant i n jury; e.g., automatic res training-be1 t e ys teme (lap-e houlder loope) and "a i r bage" ( inpact- t r iggered pneuma ti c ba r r i e r s ) . There a r e , of couree, many craehes i n which no re e t ra in ing devi ce would preven t mortal wounding , bu t i t would be i n e u u c t i v e i f newe repor te of eerioue t r a f f i c acc idente indica ted n o t on ly the e o b r i e t y of the dead and the survivore, bu t which were wearing e e a t be l t e .

There are a number of ways i n which s a f e t y technologies can be advanced by government po l icy : educa t ing consumers t o d e s i r e them, sponsoring r e sea rch and development t o improve them, o f f e r i n g f avo rab l e t a x i n c e n t i v e s o r c r e d i t s , r e q u i r i n g t h a t manufacturers make them a v a i l a b l e a s paid op t ions , o r r equ i r ing a l 1 automobilee t o have them. A s i m i l a r range of po l i cy op t ions 1s a v a i l a b l e f o r o t h e r s a f e t y devices (e.g. , household smoke d e t e c t o r s , "dead man" c o n t r o l s on t r a i n engines , s e l f - ex t ingu i sh ing c i g a r e t t e s . ) There seem t o be s u b s t a n t i a l grounds f o r those who a r e broadly concerned w i t l i p revent ing a l coho l problems t o t ake an i n t e r e s t i n s a f e t y i s s u e s and p o l i c i e s (Mosher and Mot t l 1981).

Conclusion

This e s say has o u t l i n e d a series of u s e f u l a n a l y t i c , normative, and pragmatic po l i cy concepts t h a t a r i s e i n connect ion wi th t h e prevent ion of a l coho l - r e l a t ed problems. The e f f e c t s o£ a l c o h o l t h a t come i n t o p lay when cons ider ing t h e s e p o l i c i e s have been sketched; t h e n a t u r e and s i g n i f i c a n c e of governing ideas have been descr ibed and i l l u s t r a t e d ; a scheme de f in ing types of p o l i c i e s i n terms of t he ins t ruments -- government programs o r mechanisms- used t o achieve them has been o f f e r e d ; and t h i s scheme h a s been f i l l e d ou t wi th some examples of p revent ive p o l i c i e s , cover ing the p r i n c i p l e i s s u e s involved i n t h e i r s e l e c t i o n and implementation.

Crea t ing and ca r ry ing o u t a l coho l po l i cy w í l l never approach t h e p u r i t y of ches s o r l abo ra to ry s c i ence , but p o l i c i e s do have consequences which can be f o r b e t t e r o r worse. Well-organized p r a c t i c a 1 th ink ing i s o f t e n p a r t o f t h e d i f f e r e n c e between b e t t e r o r worse po l i cy r e s u l t s . It i s t h e aim of t h e p re sen t p i ece t o a i d such th ink ing .

DISCUSSANT

Marilynn Katatsky

1 would l i k e t o thank D r . Ge r s t e in f o r h i s marvelous, very a r t i c u l a t e p re sen t a t i on . Having read Alcohol and Publ ic Pol icy myself , 1 can app rec i a t e j u s t how much work went i n t o d i s t i l l i n g t h e key concepts a n d - i s s u e s t h a t Dean h igh l igh t ed f o r u s today.

Bas i ca l l y , 1 am h e r e t o p re sen t t h e view from t h e t r enches -- what i t i s l i k e o u t t h e r e i n t h e f i e l d -- and t o ask from t h a t

pe r spec t ive whether t h i e paper has re levance f o r t h e c o u n t r i e s i n t h e Region of t h e Americas.

This whole d i s cues ion of a l c o h o l problems, as w e have heard, should be put i n t o t h e con tex t of w h a t has been happening i n t h e a l c o h o l f i e l d i n t h e r eg ion over , eay, t h e p a s t 20 t o 30 yea r s . 1 would l i k e t o br ing you up t o d a t e wi th what has been happening i n t h e p o l i t i c a l a r ena as w e e e e i t from t h e h e a l t h s i d e , p a r t i c u l a r l y where d i s cues ions on a l coho l c o n t r o l p o l i c i e s a r e j u s t beginning t o t a b place.

It i s of i n t e r e e t t o no t e t h a t i n Ju ly , 1981 t h e Cen t r a l American M i n i s t e r s of Hea l th discueeed t h i s i s s u e of a l coho l and a l coho l c o n t r o l , and D r . Arroyo, who i s wi th u s today, presented a review of l e g i s l a t i o n i n t h e Cen t r a l American isthmus. I n that review, he def ined sme of t h e major i s s u e s that were p a r t i c u l a r l y r e l evan t t h e r e ; f o r example, t he f a c t t h a t t h e r e was cons iderab le emphasis on f i s c a l c o n s i d e r a t i o n s i n t h e i r l e g i s l a t i o n . Many d i f - f i c u l t i e s i n implementing t h e l e g i s l a t i o n were discuesed. Also, D r . Arroyo emphasized such problems a s t he l a c k of e v a l u a t i o n of l e g i s l a t i o n and t h e existente of a number of outdated and c o n f l i c t - i ng p o l i c i e s .

A s a r e s u l t of t he d i s cues ions i n C e n t r a l America i n 1981, t h e Ministers of Heal th e e t f o r t h recommendations t o e s t a b l i s h i n t e r d i s c i p l i n a r y , m u l t i e e c t o r i a l committees o r commissions which would compile e x i e t i n g l e g i s l a t i o n , e v a l u a t e i t e impact, and recommend neceesary l e g i s l a t i v e changes based on s c i e n t i f i c c r i t e r i a . Much of what they recommended would be d e e i r a b l e , bu t i t i s h ighly un l ike ly t h a t t he se c o u n t r i e s w i l l a c t u a l l y implement recommendations. One recommendation wae lowering of t h e s p e c i f i c percentage of a l coho l i n a l c o h o l i c beverages a s a meane of reducing a l c o h o l r e l a t e d problems. Another wae t o promote t h e paesage of l e g i s l a t i o n t o r e q u i r e d iesemina t ion of in format ion on t h e nega t ive e f f e c t s of a l c o h o l through t h e mas8 media and formal educa t iona l system.

1 t h i n k t h e Cen t r a l American Minis ter8 Conf e rence d i s c u s s i o n s r ep re sen t a depa r tu re from t h e t e n o r and con ten t of previous cons ide ra t i one of t h i s t o p i c wherein, f o r example, emphasis had been placed on t h e need t o do epidemiological r e sea rch on alcohol ism, t o adopt p o l i c i e s which would f a v o r t reatment and prevent ion , and t o develop t h e neceseary manpower

C lea r ly the change i n focus towarde a lcohol -cont ro l - re la ted i e s w s i s i n d i c a t i v e t h a t r ecen t üHO i n i t i a t i v e s i n t h i s a r e a have had some impact. S i m i l a r l y , t h e S i x t h Meeting of t h e Conference of t á in ie te re Responsible f o r Heal th of t h e Caribbean Community, which took p l ace i n Grenada i n J u l y 1980, reso lved t h a t e f f o r t s " t o reduce t he l eve1 of coneumption by pereuaeion and educa t ion a s wel l as l e g a l and f i s c a l measures ehould be considered." I n a d d i t i o n ,

conference p a r t i c i p a n t s c a l l e d on t h e m e m b e r governments t o cons ide r banning a lcohol a d v e r t i s i n g i n t he mass media.

A t t h e n a t i o n a l l e v e l t h e r e were a l s o some s t r o n g i n d i c a t i o n s t h a t governments were moving towards c o n s i d e r a t i o n of a l coho l c o n t r o l p o l i c i e s t h a t might reduce a l c o h o l consumption i n t h e popula t ion , and concommitantly, t h e r a t e of a l coho l problems. 1 t h i n k w e have seen i n Argent ina, f o r example, an i n t e r e s t on t h e p a r t of t h a t Government t o review some of t h e United S t a t e e and Canadian exper ience i n p a r t i c u l a r . It i s our understanding t h a t i n t r o d u c t i o n o£ some form of a l c o h o l c o n t r o l l e g i s l a t i o n 1s now pending i n Argentina.

While few c o u n t r i e s r e a l l y have looked very c a r e f u l l y a t methods of c o n t r o l l i n g t h e a v a i l a b i l i t y of a l c o h o l i c beverages, s e v e r a l have i n s t i t u t e d programs t o i n f l u e n c e and reduce consumer demand. There a r e a number of reasons why t h e r e i s t h i s emphasis on demand. F i r s t of a l l , i t i s something t h a t t h e h e a l t h s e c t o r can in f luence . It 1s something on which people working i n t h e Health Minis t ry and the Education Minis t ry can g e t t o g e t h e r and a c t u a l l y have a n impact. They can develop a program and set u t up, and i t r e a l l y does no t t a k e a whole l o t of coo rd ina t ion w i t h o t h e r s ec to r s . Obtaining t h e consensus of t h e Min i s t e r s i n a v a r i e t y o£ M i n i s t r i e s , of course , would be d i f f i c u l t because you have a number of competing i n t e r e s t s involved.

There i s one book 1 thought 1 would mention i n passing simply because 1 l i k e d i t s o much, and 1 d o n ' t know t h a t i t has g o t t e n a s much play i n t h e d i s cus s ion today a s i t should. Th i s 1s t h e Addict ion Research Foundation book on Publ ic Education and S o c i a l Po l i cy , which 1 found very h e l p f u l i n understanding some of t h e f o r c e s a t work i n La t in America. The book h i g h l i g h t s t h e importance of pub l i c a t t i t u d e s i n t h e po l i cy making process and o u t l i n e s some of t h e key i s s u e s very c l e a r l y .

While one e s t ima te s a t ime l a g of about 20 t o 30 y e a r s i n t he more developed c o u n t r i e s , such a s Canada, betweem c e r t a i n research f i n d i n g s and subsequent changes i n publ ic a t t i t u d e s and po l i cy , t h e l a g 1s much longer i n t he l e s s e r developed coun t r i ee . Publ ic educa t ion i n t h e more developed c o u n t r i e s w i l l s h o r t e n t h a t l ag . However, t he o b s t a c l e s , not only t o publ ic educa t ion but t o a c h i e ~ i n g t h e necessary l e v e l of s o p h i s t i c a t i o n i n t h e popula t ion , a r e a l o t more formidable i n t he less developed coun t r i e s .

Another reason why w e a r e see ing l e s s i n t e r e s t on a l c o h o l c o n t r o l p o l i c i e s and a g r e a t e r i n t e r e s t on i n t e r v e n i n g wi th consumer demand 1s t h a t i n L a t i n America t h e r e has been cons ide rab l e empha- sis on t h e d i s e a s e concept of alcoholism. Indeed, t h a t concept 1s not f u l l y accepted i n a l 1 c i r c l e s ; y e t i t 1s t h e most p reva len t concept t h a t w e f i nd i n La t in America.

In our survey of public a t t i t u d e s about alcoholism and the causes of alcoholism genera l ly , people i n f i v e coun t r i e s we eurveyed were of the opinion t h a t alcoholiem l e eole ly the r eepone ib i l i ty of the individual . For the major i ty of those surveyed, i f i t 1s not eome type of moral queetion, then i t 1s some s o r t of d isease quest ion, but i t implicatee the ind iv idua l a s opposed t o socie ty . So, 1 think you have t o recognize and grapple with public a t t i t u d e s about alcoholism, because they se r ious ly a f f e c t t h e way a government i s going t o formulate policy.

Another i s s u e we might mention l e that the re a r e a l o t of veeted i n t e r e e t e i n the dieeaee model of alcoholism i n Lat in America. There a r e many people who have worked long and hard t o make the d iseaee model of alcoholism more widely accepted, and thoee people d e f i n i t e l y have much vested i n promoting t h a t concept. You a l s o have Alcoholice Anonymous which represente a very important fo rce i n t h e Region 1 think, i n terms of shaping public a t t i t u d e s i n general ; t h a t group would c e r t a i n l y not have very much t o ga in f r m a s h i f t i n thinking on t h i s point .

I n any case, i n looking towarde t h e f u t u r e i n t h i s Region, 1 would l i k e t o say a b i t about what we might expect t o see i n terms of fu tu re l e g i s l a t i o n and pol ic iee . In the shor t term, 1 don' t th ink that we a r e going t o see any s i g n i f i c a n t d e l i b e r a t e at tempts a t changing eupply. 1 think we can expect t o continue t o see emphasie on the demand e ide , with an increas ing number of educa- t i o n a l programs. Costa Rica is one example of a country with a very e x t e m i v e educational program on alcohol. 1 think we a r e going t o continue t o see many of these.

We may begin t o eee a few governmente taking s t e p s i n the a reas of taxat ion, reduction of a lcohol content , and s o on. However, 1 don't think the re w i l l be any very eystematic, broad- based at tempts a t reducing alcohol problems through goverment in tervent ion .

1 must again i n s i s t t h a t my remarks a r e t o t a l l y personal opinione. 1 am not a p o l i t i c a l s c i e n t i s t , and 1 have checked the background of everybody i n t h i s room t o make eure t h a t we did not have any p o l i t i c a l s c i e n t i s t e here; therefore , 1 f e e l t h a t my p o l i t i c a l opinione a r e e n t i r e l y a s good ae anyone e l s e ' s guess. To summarize, 1 j u s t do not th ink t h a t we a r e going t o see a trend toward supply reduction s t r a t e g i e e and p o l i c i e s i n La t in America f o r a very long time.

DISCUSSANT

I r v i n g Rootman

There 1s no doubt i n my mind t h a t t h e aim o£ D r . G e r s t e i n ' s e x c e l l e n t paper has been and w i l l con t inue t o be achieved. That is, drawing on t h e ou ts tanding work of t h e Nat ional Academy of Sc iences panel on A l t e r n a t i v e P o l i c i e s Affec t ing t h e Prevent ion of Alcohol Abuse and Alcoholism, it most c e r t a i n l y has a ided us i n organiz ing our p r a c t i c a 1 th ink ing about a l coho l yrevent ion p o l i c i e s and w i l l a i d o t h e r s o u t s i d e o£ t h i s room. 1 t h i n k t h a t w e a l 1 owe D r . Ge r s t e in and t h e o t h e r p a r t i c i p a n t s i n t h e panel , some of whom are among u s , a s i n c e r e vo t e of thanks f o r t h e i r e f f o r t s . They have succeeded i n i l l u m i n a t i n g t h e landscape o£ p reven t ive a l coho l p o l i c i e s with a l i g h t of unpa ra l l e l ed i n t e n s i t y and c l a r i t y . I n f a c t , 1 f i n d very l i t t l e i n t h e paper which has been presen ted , o r i n t h e r epo r t on which i t l eans , w i th which 1 d i sag ree .

Having s a i d t h i s , however, 1 do have some concerne and comments about t he paper and t h e r epo r t which 1 would l i k e t o br ing t o your a t t e n t i o n .

n i e f i r s t ha s t o d o w i t h t he emphasis on government and i t s r o l e i n developing and implementing a l coho l p o l i c i e s . While 1 would be t he l a s t person t o deny t h a t government has a c r i t i c a 1 r o l e t o p lay i n t h i s f i e l d , 1 do f e e l t h a t governments a r e not t h e only bodies t h a t can develop and implement p o l i c i e s f o r t h e prevent ion o r management of a l coho l problems. Such p o l i c i e s can be and a r e developed and implemented by a v a r i e t y of u n i t s a t d i f f e r e n t l e v e l e inc lud ing schools , t reatment agenc ies , vo luntary a s s o c i a t i o n s , work o rgan iza t ions , and community groups. It might even be argued t h a t such bodies a r e p o t e n t i a l l y more e f f e c t i v e than governments i n t h a t they a r e c l o s e r t o t h e s i t u a t i o n s of concern.

It was, i n f a c t , t h i s kind of th ink ing which s t imula ted t h e development of t h e WHO Community Response t o Alcohol Problems p r o j e c t which 1 have had t h e p r i v i l e g e o£ managing f o r t h e p a s t two and a h a l f years . Th i s p r o j e c t was i n i t i a t e d w i th support £ rom t h e Nat ional I n s t i t u t e on Alcohol Abuse and Alcoholism i n 1976. To d a t e , t h r e e c o u n t r i e s -- Mexico, Scot land and Zambia -- have p a r t i c i p a t e d . D r . Campillo presen ted some o£ t h e f i n d i n g s o£ one s tudy c a r r i e d out a s p a r t of t h e Mexican p r o j e c t . While t heee f i n d i n g s a r e c e r t a i n l y i n t e r e s t i n g , they do not f u l l y exp re s s t he s i g n i f i c a n c e o£ the p r o j e c t . Its importance is p r imar i l y t o s t i m u l a t e app rop ia t e responses t o a l c o h o l problems, inc lud ing those of a po l i cy na tu re , a t l o c a l , i n t e rmed ia t e , and n a t i o n a l l e v e l s .

Aithough the p ro jec t 1s e t i l l ongoing i n the th ree countr iee , there a r e some s i g n s t h a t i t has a l ready eucceeded i n et imulat ing reeponsee a t a l 1 of these l eve l s . For ins tance , i n Zambia, a s a r e e u l t of t h e p ro jec t , Community Action Groupe have been eetabliehed i n the p a r t i c i p a t i n g r u r a l and urban communities. These groups d i f f e r i n t h e i r compoeition, concerns, and approaches to' a lcohol problems. A l 1 of them, however, have taken alcohol probleme eeriouely and have attempted t o develop eolut ions t h a t f i t the l o c a l circumstancee, drawing i n pa r t on the information obtained a s pa r t of the community reeponse project . As an example, a goal of the group i n one community was t o reduce home brewing. This group arranged f o r add i t iona l e t a l l e a t the market 80 t h a t home brewers could se11 other producte, thereby removing t h e economic necess i ty f o r home brewing. We do not a s ye t h o w whether t h i s a c t i o n wae euccessful , but i t i l l u s t r a t e s how a l o c a l group can develop and implement a preventive policy.

In addi t ion , i n both Mexico and Zambia na t iona l meetings have been held which considered the implicat ione of the projec t f o r na t iona l p o l i c i e s t o reepond t o alcohol-related problems. While not a l 1 of the recommended p o l i c i e s emerged d i r e c t l y f rom the completed e tudiee , many d id , and the p ro jec t served a s an opportunity t o focus na t iona l a t t e n t i o n on a lcohol problems and yossible preventive pol ic iee . ühether o r not such p o l i c i e s w i l l be implemented remains t o be seen, but it should be noted t h a t not a l 1 of the recammendatione required government ac t ion . Same were d i rec ted t o ac t ion by o the r bodies such a s voluntary organizat ione and induetry. It may i n p rac t i ce t u r n out t h a t more w i l l be accomplished by the policy a c t i o n s of euch i n s t i t u t i o n s than by government .

Thus, the community responee p ro jec t suggests t o me t h a t the development of p o l i c i e s t o prevent alcohol problems by non- governmental bodiee i e poss ib le and des i rab le . 1 am c e r t a i n t h a t a l 1 of you can think of o ther examples t o eupport t h i e point. It, therefore , would be a grave e r r o r i f we l o s t s i g h t of such p o e s i b i l i t i e e by a n exclueive focue on government. Fortunately, most of the principies and concepte a r t i c u l a t e d i n D r . Gers te in ' s paper can be applied t o policy development a t these o the r l e v e l s a s well .

A second concern 1s t h a t most of the experience described i n the National Academy of Science repor t and c rye ta l i zed i n D r . Gerstein 'e paper 1s North American o r European. This probably does not make much d i f fe rence with regard t o the relevance of the conceptual framework f o r o the r countr iee. It may, however, be very important with regard t o the relevance of the p a r t i c u l a r p o l i c i e s t h a t have been given a s examples. A s D r . Caetano c l e a r l y pointed out i n h i s paper, circumetances i n La t ín American countr ies a r e s u b s t a n t i a l l y d i f f e r e n t from thoee i n the United S t a t e s and Canada.

The community response p r o j e c t demonstrated a s i m i l a r po in t . D r . Smart 's conclueion t h e r e f o r e , t h a t "it i s very doubt fu l t h a t r e s u l t s from t h e more developed world can be app l i ed without change t o L a t i n American and t h e Caribbean" must be h e a r t i l y endorsed and emphasized.

It i s c l e a r t o me from D r . G e r s t e i n ' s p r e s e n t a t i o n t h a t he a g r e e s with t h i s po in t of view, but o t h e r s may not . It i s thus necessary t o r e i t e r a t e i t whenever p o s s i b l e and t o t r y t o ensu re t h a t i t s imp l i ca t i ons a r e recognized i n c o u n t r i e s t h a t may wish t o develop prevent i v e p o l i c i e s .

One such imp l i ca t i on i s t h a t a c r i t i c a 1 s t e p i n development of p revent ive p o l i c i e s by any count ry should be a n e a r l y a t tempt t o d e f i n e t h e magnitude and n a t u r e of t h e a l c o h o l problems t h a t t h e count ry i t s e l f i s fac ing . Recent WHO work i n t h i s a r e a , inc lud ing t h e community response p r o j e c t , may be h e l p f u l i n t h i s regard .

Another imp l i ca t i on i s t h a t i t i s important t o e v a l u a t e t h e impact of p revent ive p o l i c i e s t r i e d i n p a r t i c u l a r developing c o u n t r i e s and t o make the r e s u l t s a v a i l a b l e t o o t h e r developing c o u n t r i e s . The es tab l i shment of r e g i o n a l c l e a r i n g houses a s suggested by D r . Caetano i s one mechanism f o r accomplishing t h i s . Another might be r e g i o n a l workshops o r conferences on a l c o h o l p o l i c y development which could be designed t o sha re no t only t h e r e s u l t s of r e sea rch , but a l s o t h e exper iences involved i n po l i cy development and implementation.

mis b r i w s me t o ano the r concern a r i s i n g from D r . Ge r s t e in ' e paper--namely, how does, o r should, a government o r o t h e r body a c t u a l l y go about developing and implementing a l c o h o l prevent ion p o l i c i e s ? Unfortunately, D r . G e r s t e i n ' s paper i s s i l e n t on t h i s ques t ion , but i t i s a n important one and i t must be addressed i n o rde r t o f u l l y understand why a l coho l po l i cy development can never approach t h e p u r i t y of chess o r l a b o r a t o r y sc ience . Perhaps t h i s i s a t o p i c which we might cons ide r i n our d i s cus s ions , a s 1 am s u r e we a l 1 have some p r a c t i c a 1 exper iences t o b r ing t o bear on i t . Une i d e a which w e may, i n p a r t i c u l a r , wish t o cons ider i s t h e va lue of n a t i o n a l o r sub-nat ional coord ina t ing committees t o develop a l coho l p o l i c i e s .

A f i n a l concern which 1 have with D r . G e r s t e i n ' s paper has t o do wi th t h e emphasis on a lcohol . While such a n emphasis i s c e r t a i n l y understandable i n terms of t h e mandate of t h e Nat iona l Academy o£ Sc iences panel , 1 wonder i f i t doesn ' t t o some e x t e n t i n h i b i t our c r e a t i v e t h ink ing about yrevent ive p o l i c i e s . Aiter a l l , we know from our r e sea rch t h a t a l coho l use c o v a r i e s wi th o t h e r h e a l t k r e l a t e d behaviours such a s smoking, cannabis use , n u t r i t i o n a l , and sexua l p r a c t i c e s . Thus, another pose ib l e prevent ive s t r a t e g y is t o a t tempt t o i n f luence a lcohol consumption and a s s o c i a t e d consequences

by inf luencing o the r health-comprieing o r health-enhancing behav- ioure. In the terminology ueed by D r . Gerstein, euch a e t ra tegy might be described a s "ehaping drinking p rac t i cas indi rec t ly ." Al ternat ive ly , one might r e f e r t o i t a s a "heal th yromotion etrategy." Such a e t r a t egy c e r t a i n l y has implicat ione f o r pol icy development .

This 1s not t o eay t h a t t h e s t r a t e g i e e ou t l ined by D r . Cere te in should not be pureued. They ehould however, be pursued with due regard t o circumetances and coneiderat ion of o ther p o s s i b i l i t i e e .

TIlE INTERNATIONAL STUDY OF ALCOHOL CONTROL EXPERIENCES (ISACE): SUMHARY OF THE FINAL REPORT

Jamee F. Moeher

The In te rna t iona l Study of Alcohol Control Experiencee (ISACE), which was conducted with the help and coordinat ion of the World Health Organization'e European regional o f f i c e , brought together alcohol-policy reeearchere from eeven countriee--the United S t a t ee , Canada, I re land, Finland, Poland, Switzerland, and Holland. Its purpoee wae t o study within an h i e t o r i c a l frame the re l a t ionsh ipe between a lcohol con t ro l po l i c i ee , drinking pat terne , and alcohol-related probleme i n d i f f e r e n t e o c i e t a l se t t inge . The etudy extended from 1978 t o 1981; i t reeul ted i n a two-volume repor t , severa1 dozen reeearch papers, and a wealth of h i e t o r i c a l and s t a t i s t i c a l da ta . For my preeenta t ion today, 1 w i l l First b r i e f l y descr ibe the background t o the etudy, including i t s o r i g i n a l goal8 and methodology, and then w i l l repor t i t e major f ind ings and conclueions.

To some ex ten t , the foundation f o r t h e ISACE pro jec t was l a i d by an e a r l i e r p ro jec t involving Finnieh, Canadian, Br i t i eh , Norwegian, and U.S. reeearchere which cuiminated i n t h e 1975 repor t Alcohol Control Pol ic iee i n Public Health Perepective (known a s the Purple Book). That study documented two important re la t ionehipe: f i r e t , the study found s t rong evidence t h a t coneumption i n a populat ion influencee the r a t e of long-tenn physiological complicatione from drinking, euch a8 c i r r h o e i s ; eecond, a p a r t i c u l a r population's r a t e of coneumption wae found t o be influenced by s o c i e t a l cont ro le of alcohol a v a i l a b i l i t y , notably price. The reeearchere concluded: "changee i n the o v e r a l l coneumption of a lcohol ic beveragee have a bearing on the hea l th of t h e people of any society. Alcohol con t ro l meaeuree can be used t o l i m i t coneumption: thue con t ro l of alcohol a v a i l a b i l i t y becomes a public heal th i s s u e ."

The Purple Book was w r i t t e n i n t h e contex t of a worldwide r i e e i n a l coho l consumption du r ing t h e preceding cen tu ry and was a r a d i c a l depa r tu re from t h e wel l -es tab l i shed d i s i n t e r e s t i n a l coho l c o n t r o l p o l i c i e s among most pub l i c h e a l t h policy-makere. The d i sease model of a lcohol ism, which h a s provided t h e bas i c framework f o r most po l i cy dec i s ions , has r e l i e d v i r t u a l l y exc lue ive ly on t rea tment and educa t iona l s t r a t e g i e s f o r dea l ing wi th alcohol- r e l a t e d problems. The r e p o r t ' s aim was q u i t e e x p l i c i t l y t o provide new a l t e r n a t i v e prevent ion approaches. The r e sea rche re s t a t e d : "...it w i l l have served i t s purpose i f i t s t i m u l a t e e deba te and, i n t h e procesa, l e a d s t o a renewed i n t e r e s t i n t h e p o t e n t i a l importance of c o n t r o l po l i cy i n t h e prevent ion of a l coho l problems" (p. 12). I n t h i s aim, i t may be cons idered t o have been q u i t e succesefu l . For i ne t ance , i n t he l a s t yeare of t h e 1970s a t t i t u d e s and a c t i v i t i e s of t h e World Heal th Organiza t ion i n t h e a l c o h o l a r e a s h i f t e d q u i t e d rama t i ca l l y t o i nc lude s u b e t a n t i a l a t t e n t i o n t o a l c o h o l consumption l e v e l s and a l coho l c o n t r o l p o l i c i e s a s important e lements of a pub l i c h e a l t h approach. This s h i f t culminated i n a 1979 WHO Expert Committee r e p o r t , wi th recommendations regarding t h e pub l i c h e a l t h a s p e c t s of c o n t r o l p o l i c i e s i n more sweepi- and more d i r e c t l y p o l i t i c a l tems than found i n the 1975 r e p o r t . I n t h e United S t a t e s -- a f t e r a long per iod o£ avoidance on t h e p a r t of t he pub l i c h e a l t h es tab l i shment -- s e r i o u e d i s c u s s i o n of t he i s s u e s involved has r e c e n t l y emerged, i nc lud ing t h e r e c e n t Nat ional Academy of Sciencee panel r e p o r t t i t l e d Alcohol and Publ ic Po l i cy (Moore and Ger s t e in 1981).

The Purple Book was on ly an i n i t i a l s t e p i n t h e underetanding of a l coho l c o n t r o l exper iences from a pub l i c h e a l t h pe r spec t ive - Two important dimensions were most appa ren t ly l ack ing i n t h e 1975 s tudy: t h e r e l a t i o n s h i p of con t ro l e , consumption, and s o c i a l ( a s opposed t o phys io logica l ) problems r e l a t e d t o a l c o h o l (drunk d r i v i n g , acc iden te , work, family l i f e , e t c . ) ; and a h i s t o r i c a l and comparative a n a l y e i s of t he impact of c u l t u r a l , p o l i t i c a l and s o c i e t a l f a c t o r s on these t h r ee key v a r i a b l e s .

ISACE' s primary agendas concerned t hese two dimensione. Thus i t s methodological emphasie was on undertaking comparative case s t u d i e s o£ n a t i o n a l ( o r r e g i o n a l i n t he i ne t ancee o f C a l i f o r n i a and Ontar io) exper iences , c e n t e r i n g on t h e per iod of worldwide r i s i n g consumption from 1950 t o 1975. An ambi t ious program o£ r e sea rch d a t a c o l l e c t i o n focused on a l c o h o l c o n t r o l s , consumption, and consequences a s wel l a s p o t e n t i a l l y explana tory background informa- t i on . A s t h e p r o j e c t p rogressed , t h e unique h i s t o r i c a l experiences found i n each s tudy s i t e became obvious. The p a r t i c i p a n t s t h e r e f o r e decided t h a t t h e f i n a l r e p o r t needed two volumes: one t o inc lude t h e seven ind iv idua l c a s e s t u d i e s , and another t o a t tempt t o i n t e g r a t e t h e f i n d i n g s of t h e s tudy i n a comparative frame.

Aithough ISACE served t o emphasize t h e c u l t u r a l spec i f i c i t y of dr inking p a t t e r n s , probleme, and a l coho l c o n t r o l p o l i c i e e , many uni fy ing t r ends can a l s o be repor ted a c r o s s s tudy s i t e e . 1 w i l l review t h e h igh l igh te very b r i e f l y . There were sharp i n c r e a s e s i n per c a p i t a consumption i n a l 1 p a r t i c i p a t i n g coun t r i e s , wi th t he g r e a t e e t i n c r e a s e s occu r r ing i n coun t r i ee w i t h the loweet coneumption r a t e s a t the beginning of t h e s tudy period. Alcohol became more i n t e g r a t e d i n t o family and s o c i a l l i f e , and t h e number of d r ink ing occasions increased. These broad changee, however, d id not r ep l ace t r a d i t i o n a l d r ink ing pa t t e rns . The s tudy s i t e s , d e s p i t e experiencing t h i e uni fy ing t rend toward a n " i n t e r n a t i o n a l " dr inking c u l t u r e , a l 1 maintained t h e i r c u l t u r a l d i s t i n c t i v e n e s s . The new d r ink ing occaeione, new beverages, and new dr inking e t y l e e were in s t ead added onto the e x i e t i n g , t r a d i t i o n a l dr inking c u l t u r e .

Changing dr inking p a t t e r n s , then , c o n s t i t u t e d one aepect of t h e broad changes i n l i f e e t y l e and c u l t u r a l p a t t e r n s t h a t occurred i n t h i e period. The r a t e e of d r ink ing problem i n d i c a t o r s changed simultaneouely. ( 1 should here d i g r e s s f o r j u s t a moment t o eay ISACE used a n "alcohol-probleme" approach, i n which s p e c i f i c alcohol- r e l a t e d damagee were disaggregated. The p r o j e c t decided not t o a t tempt t o de f ine "alcoholiem," not ing t h e varying approaches t o t h a t concept. Ins tead we choee t o t r e a t a lcoholism a s a s e p a r a t e a l coho l problem.) The ISACE p r o j e c t grappled, o f t e n unsucceesful ly , wl th t h e d i f f i c u l t y of i n t e r p r e t i n g problem i n d i c a t o r s , inc luding those f o r a lcoholism, a c r o s s c u l t u r a l s e t t i n g s . Aicohol problems were viewed d i f f e r e n t l y i n each s o c i e t y , and t h e methods of de f in ing them and recording t h e i r ex t en t made comparieons extremely d i f f i c u l t . Even the most r e l i a b l e s t a t i s t i c a l i n d i c a t o r s -- a lcohol - re la ted c i r r h o s i s and t r a f f i c dea ths -- were not t r e a t e d uniformly acrose study s i t e s . S t a t i s t i c s concerning t r ends i n t h e r a t e e of a lcoholism, t reatment admissions , and pub l i c drunkenness a r r e s t a were the l e a s t r e l i a b l e and t h e moet l i k e l y t o r e f l e c t changes i n t he s o c i e t a l handling of a lcohol problems.

The ISACE study documented these d i f f i c u l t i e s and at tempted t o use them t o t h e i r bes t advantage. Severa1 t r e n d s were discovered: a ) a l 1 s tudy s i t e s d id r epo r t i n c r e a s e s i n c i r r h o s i s dea ths and a lcohol - re la ted t r a f f i c f a t a l i t i e s , a l though the inc reases were not d i r e c t l y p ropor t iona l t o i n c r e a s e s i n per c a p i t a consumption; b) dr inking problems became l e s e s t r i c t l y confined t o s o c i a l o u t c a s t s and v i e i b l y deviant subgroups; c ) t h e s o c i a l handling of a l coho l problems, a s w e l l as t h e c u l t u r a l percept ions of t hese problems, changed r a d i c a l l y dur ing the s tudy per iod; d) t rea tment f a c i l i t i e s expanded r ap id ly , and t h i s t rend included a g r e a t p r o l i f e r a t ion i n types of a lcohol - re la ted serv icee , w i th a concomitant decreaee i n t he r o l e of p o l i c e and s o c i a l a u t h o r i t i e s . I n t e r e s t i n g l y , t hese t r ends were found t o a t l e a s t some e x t e n t i n a l 1 etudy s i t e s , a l though t h e p a r t i c u l a r mixee of va r ious problems found i n each s i t e d i £ f e r ed markedly. Those mixes remained d i s t i n c t i v e dur ing t h e etudy period d e e p i t e r a d i c a l changes i n t h e i r composition.

ISACE descr ibed t h e most r e c e n t t r end concerning problems management a s a s h i f t of emphasis from " t h e b o t t l e " t o " t h e man." Alcohol problems became a m a t t e r def ined i n terme of s p e c i f i c i n d i v i d u a l d e f e c t s , which meant t h a t t h e r e was no need t o c o n t r o l t he d r ink ing of t he v a s t m a j o r i t y of d r inke r s . The t r ends concerning c o n t r o l s t r u c t u r e s i n t he s tudy sites r e f l e c t e d t h i s new i n t e r p r e t a t i o n of a l c o h o l problems. Control s t r u c t u r e s gene ra l l y accommodated, o r a t l e a s t d i d no t i n t e r f e r e with, t h e l a r g e i n c r e a s e s i n per c a p i t a l consumption and number of d r ink ing occasions. Because of t he wide v a r i a t i o n i n c o n t r o l e t r u c t u r e s a c r o s s s tudy sites, t h i s accommodation took many d i f f e r e n t forms. For example, i n Finland r e t a i l expansion r equ i r ed major l e g i s l a t i v e reforme, inc lud ing laws pe rmi t t i ng s a l e s i n r e s t a u r a n t s and off-premises r e t a i l shops i n r u r a l communities. I n C a l i f o r n i a and On ta r io gradua l loosening of l i c e n s i n g r e s t r i c t i o n e occur red , while i n Switzer land and Holland l i t t l e l e g i s l a t i v e a c t i o n was neceesary.

Control s t r u c t u r e s , then, g e n e r a l l y responded t o economic f a c t o r s r e l a t e d t o t h e changes i n the a l coho l market i t e e l f . A t t h e product ion l eve1 t h e a l coho l i n d u s t r y became inc reas ing ly concen- t r a t e d , a s l o c a l and small-scale product ion became economically more d i f f i c u l t . Agr i cu l tu ra1 p r i o r i t i e s played a l a r g e p a r t i n d e f i n í % t h e producing i n d u s t r y ' s r o l e i n t h e economy, which u s u a l l y r e s u l t e d i n va r ious measures t o expand yroduct ion. The r e t a i l s t r u c t u r e a l e o witnessed dramatic changee. dew o u t l e t s emerged, a s a l coho l became a s s o c i a t e d wi th va r ious new l i f e s i t u a t i o n s . Le i su re i n d u s t r i e s , r e s t a u r a n t s , s p o r t 8 and a r t e promoters a l 1 became i n c r e a s i n g l y dependent on a lcohol s a l e s . A s t h e number and s i z e of t he se vested i n t e r e s t s i n a l coho l i nc reased , s o d i d t h e i r i n f luence i n n a t i o n a l a f f a i r s . Thus t h e t r end toward increased product ion and d i s t r i b u - t i o n of a l c o h o l tended t o f u e 1 i t s e l f , a s governments found i t much e a s i e r t o open new o u t l e t s and manufacturing es tab l i shment8 than t o redeploy e x i s t i n g ones.

A s t h e s e f i nd ings i n d i c a t e , ISACE became i n p a r t a n e x e r c i s e i n docurnenting d i v e r s e economic, s o c i a l , p o l i t i c a l , and c u l t u r a l f a c t o r s which i n t e r p l a y w i th d r ink ing p r a c t i c e s , problems, and a l c o h o l c o n t r o l s t r u c t u r e s . The dramatic changes i n dr ink íng p r a c t i c e s r e f l e c t corresponding changes i n l i f e s t y l e s and l e i s u r e a c t i v i t i e s ; t h e emergence of t h e we l f a r e s t a t e had a profound impact on t h e d e f i n i t i o n and measurement of a l coho l - r e l a t ed problems; d i v e r s e economic and h i s t o r i c a l f a c t o r s helped determine changee i n t h e c o n t r o l s t r u c t u r e s i n response t o an increased demand f o r a lcohol .

This p i c t u r e t r a n s l a t e d i n t o cons iderab le unce r t a in ty regard ing t h e r e s o l u t i o n of ISACE's o r i g i n a l assignment. We found t i ia t a g iven c o n t r o l r e g u l a t i o n - minimum d r ink ing age , r e t a i l p r a c t i c e s , t a x a t i o n p o l i c i e s , e t c . -- had vary ing impacts i n d i f f e r e n t s o c i e t i e s . Although ISACE wae a b l e t o conclude t h a t

r e l a t i o n s h i p s d i d e x i s t between d r ink ing y r a c t i c e s , problems, and c o n t r o l p o l i c i e s , l i t t l e guidance was forthcoming concerning those r e l a t i o n s h i p s on an a b s t r a c t l e v e l .

This canp lex i ty and unce r t a in ty , however, d i d not mean t h a t t h e common experiences that were found d i d no t provide important imp l i ca t ions f o r prevent ion pol icy. ISACE o f f e r s s i x b a s i c conclus ions t o i t s i n t e r n a t i o n a l audience f o r cons ide ra t ion i n developing a l coho l p o l i c i e s :

n i e s t a t e ' s dua l r o l e s -- economic and h e a l t h -- regard ing a lcohol have been c a r e f u l l y separa ted during t h e l a s t t h ree decades. t ieal th i s s u e s c a r r y l i t t l e weight i n those agencies determining economic pol icy regarding a lcohol , and h e a l t h and wel fare agencies gene ra l ly ignore economic i s s u e s . Because c o n t r o l measures do a f f e c t t he incidente of var ious dr inking problems, even i f i n a complex and c u l t u r a l l y spec i f i c manner, t hese two agency f unc t ions need t o be combined i n p a r t i c u l a r s o c i e t a l s e t t i n g s .

2) Prevent ive a l coho l p o l i c i e s provide a d e s i r a b l e a l t e r n a t i v e t o those s t r a t e g i e s which tend t o s i n g l e o u t i nd iv idua l8 f o r s p e c i a l handling. S p e c i a l handling means l abe l ing i n d i v i d u a l s a s devian ts , and i n a per iod of dec l in ing resources f o r s o c i a l wel fa re may we l l be t r a n s l a t e d i n t o pun i t i ve r a t h e r than the rapeu t i c responses.

3) Although the inc reasee i n consumption and problems during t h e study period cannot be a t t r i b u t e d t o t h e r e l a x a t i o n of c o n t r o l s , most governmental responses r e in f orced these t rends . Fur ther r e l a x a t i o n s should, t he re fo re , be made wi th cau t ion and with a sense of experiment. A s mentioned e a r l i e r , i t is very d i f f i c u l t t o r e sc ind a s t e p toward r e l a x a t i o n once t h e ves ted i n t e r e s t s a r e i n place.

4) Contro l and t reatment responses appear inadequate t o d e a l w i th many event-based a lcohol - re la ted problems, such a s t r a f f i c c a s u a l t i e s and violente. Use o£ governmental powers t o manipulate t h e environment of dr inking i n order t o reduce the adverse consequences of dr inking (wi thout n e c e s s a r i l y reducing consumption o r changing dr inking p a t t e r n s ) should the re fo re be c a r e f u l l y considered.

5) Governments should recons ider any f i s c a l o r o t h e r i ncen t ive p r m o t i n g investments i n t h e product ion and d i s t r i b u t i o n of a l c o h o l i c beverages. The prospect of i nc reas ing excess capac i ty i n t h e a l coho l i n d u s t r y r a i s e s t h e i s s u e s of i n t e n s i f i e d i n t e r n a t i o n a l competi t ion and of economic p re s su res pushing a lcohol producers t o conquer new markets i n l e a s developed count r ies .

6) As suggested by t h e f i f t h concern, new mechanisms a t t h e i n t e r n a t i o n a l l e v e 1 may be needed t o add re s s t h e h e a l t h and s o c i a l c o s t e a s s o c i a t e d wi th a lcohol . Exporting coun t r i e s g a i n t h e economic b e n e f i t e o f t h e a l c o h o l t r a d e without any of t h e c o s t s a s s o c i a t e d w i t h domeetic consumption. The World t leal th Organiza t ion and o t h e r i n t e r n a t i o n a l o rgan iza t ions should g i v e c l o s e a t t e n t i o n t o t r a d e p o l i c i e s and arrangements a f f e c t i n g t h e i n t e r n a t i o n a l a v a i l a b i l i t y of a lcohol .

These conc lus ions were designed t o be r e l e v a n t t o t h e i n t e r - n a t i o n a l audience, but obviously t h e i r r e l a t i v e importance w i l l vary according t o t h e p a r t i c u l a r c i rcumetances of each soc i e ty . 1 suggest t h a t , d e s p i t e t h e very l i m i t e d r e p r e s e n t a t i o n i n ISACE, they can provide some guidance a s w e d e a l w i th t h e i s s u e s of t h i e con- fe rence . Perhaps an o v e r a l l l e e son from t h e y r o j e c t is t h e need f o r c a r e f u l a t t e n t i o n t o s p e c i f i c c u l t u r a l , h i s t o r i c a l , and economic f a c t o r s i n each s o c i e t y a s they a f f e c t a lcohol po l i cy and dr ink ing p a t t e r n s and problems. Only wi th c a r e f u l etudy and help from t h e r e g i o n a l and i n t e r n a t i o n a l conmunit ies can a n e f f e c t i v e o v e r a l l a l coho l prevent ion pol icy be developed.

Acknowledgment: This research was p a r t l y supported by t h e Nat ional I n s t i t u t e on Alcohol Abuse and Alcoholism, Na t i o n a l Alcohol Research Center Grant (AA-05595) t o t h e Alcohol Research Group, Berkeley, Ca l i fo rn i a .

Chapter Notes and Keferencee

The Anatomy of Alcohol Pol icy: Prevent ive Approachee

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C h a p t e r S i x

THE IMPACT OF PREVENTION LEGISLATION: AN EXAMINATION OF RESEARCH FINDINGS

R e g i n a l d S m a r t

DlSCUSSANTS

M i c h a e l H. B e a u b r u n

M a r i a E l e n a Medina-Mora

A SURVEY OF ALCOUOL-RELATED LEGISLATION

J a i m e Arroyo S u c r e

THE IMPACT OF PREVENTION MEASURES: AN EXAMINATION OF RESEARCH FINDINGS

Reginald G. Smart

The l a s t f i v e y e a r s have seen a remarkable t u r n away from an exc lus ive emphasis on t rea tment a s a prevent ive measure f o r a lcohol problems and towards government c o n t r o l s and r e s t r i c t i o n s . There seems t o be gene ra l acceptance now i n many, but no t a l l , a r e a s of e a r l i e r r e s i s t a n c e t h a t governments should h e l p t o prevent a lchohol problems and t h a t c e r t a i n t ypes of p o l i c i e s and laws a r e more h e l p f u l t han o the r s . For a long t i m e i t was argued t h a t t h e main r o l e of government was t o provide t rea tment f a c i l i t i e s and t h a t governments had l i t t l e t o do wi th how many o r what type of a l coho l problems occur i n a soc i e ty . Even World Heal th Organiza t ion r epo r t a (1980), which e a r l i e r emphasized alcohol ism and t rea tment needs, s t a t e the c a s e c l e a r l y f o r government p o l i c i e s r e l a t e d t o the prevent ion , not of "alcohol ism," bu t of a l c o h o l problems. The problem now i s t o d i s t i l l a l 1 of t h e a v a i l a b l e empi r i ca l and t h e o r e t i c a l study i n t o some c l e a r conc lus ions which can be t h e b a s i s f o r p r even t ive programa. The aims of t h i s paper a r e t o come t o t h e s e conclusions.

Severa1 major reviews of t h i s a r e a were made i n t h e p a s t severa1 yea r s , s t a r t i n g wi th Alcohol Control P o l i c i e s i n Publ ic Heal th Pe r spec t ive (Bruun e t a l . 1975) sponsored by t h e World Heal th Organizat ion. A book by Moser (1980), The Prevent ion of Alcohol- r e l a t e d Problema summarizes d a t a on c o n t r o l s from some 80 coun t r i e s . A l a rge-sca le s tudy of a l coho l po l i cy anii c o n t r o l s has r e c e n t l y been publ ished by t h e Nat iona l Academy of Sc iences (Moore and Ger s t e in 1981). Two volumes a r e i n p re s s from t h e WHO I n t e r n a t i o n a l Study of Alcohol Control Experiences (ISACE), which looks a t a l coho l c o n t r o l s i n seven c o u n t r i e s (Makela e t a l . 1982). In a d d i t i o n , t h e r e a r e many sma l l e r papera on i n d i v i d u a l c o n t r o l s o r p o l i c i e s . A l 1 of t he l a r g e s t u d i e s can be s a i d t o reach a roughly s i m i l a r conc lus ion -- t h a t govemments can reduce a l c o h o l problems by means of c o n t r o l p o l i c i e s .

With such a l a r g e amount of m a t e r i a l t o be cons idered , some s e l e c t i v i t y i s e s s e n t i a l . Thi s review concen t r a t e s on empi r i ca l , a s opposed t o t h e o r e t i c a l , s t u d i e s and pays p a r t i c u l a r a t t e n t i o n t o those a r e a s i n which the re has been most r ecen t work, namely:

o o v e r a l l s tud ies of a v a i l a b i l i t y and consumption

o changes i n laws governing o u t l e t s and hours of s a l e

o p r i ce and t axa t ion

o laws r e l a t i n g t o age of purchase and consumption

o adver t i s ing con t ro l s

The main aim i s t o decide on warrantable a s s e r t i o n s i n a l 1 of these a reas , and a secondary aim i s t o i n d i c a t e the needs f o r f u r t h e r research, e s p e c i a l l y i n the coun t r i e s of the WO Region of the Americas.

Overal l Ava i l ab i l i ty and Consumption of Alcohol

Aimost a l 1 government l e g i s l a t i o n about a lcohol serves t o increase o r decrease i ts a v a i l a b i l i t y . Most empírica1 s t u d i e s d i r e c t l y r e l a t e d t o alcohol a v a i l a b i l i t y and consumption have been concerned wi th d i s c r e t e changes i n a lcohol con t ro l pol ices o r procedures. A m a j o r problem i s t h a t usual ly " a v a i l a b i l i ty" changes slowly.

The trend i n most countr ies over the past 20 yea r s has been f o r a gradual l i b e r a l i z a t i o n i n alcohol cont ro l laws. However, few s i n g l e changee can be expected t o have a de tec tab le e f f e c t on alcohol consumption o r alcohol problems. For example, the re have been more than 30 l i b e r a l i e a t i o n s of minor aspects of the con t ro l l a w s i n Ontario during the pas t 20 years. Similar changes occurred i n o the r Canadian provinces during the same time. ühat proportion of the i a rge increase i n alcohol consumption could be a t t r i b u t e d t o increased a v a i l a b i l i t y or t o any of the individual changes? Liow do we answer t h i s quest ion when severa1 changes were usual ly made a t t h e same time ami no changes appeared i n i s o l a t i o n ? i a r g e inc reases i n af f luence had a l s o occurred, the sobering influence of the temperante movement had decl ined, and adver t i s ing of a l coho l i c beverages had increased. Furthermore , people' S d e s i r e t o drink grew. Methods f o r i s o l a t i n g t h e inf luence of each of these f a c t o r s do not seem a t hand.

P o l i t i c i a n s who enact changes usual ly argue t h a t they a r e merely keeping up with public opinion, i .e . , t ha t increased d e s i r e t o dr ink precedes r a t h e r than followe increases i n a v a i l a b i l i t y . Currently, i t is d i f f i c u l t t o d ispute t h i s proposi t ion. The report of the World Health Organieation on a lcohol con t ro l p o l i c i e s (Bruun e t a l . 1975) concluded t h a t " the a v a i l a b i l i t y of a lcohol 1s an important f a c t o r i n the genera l leve1 of consumpti~n." A statement of the Addiction Research Foundation on a lcohol p o l i c i e s (Addiction Research Foundation 1978) s t a t e d t h a t " the cumulative e f f e c t (of a l 1

t h e i n d i v i d u a l l i b e r a l i z a t i o n s ) h a s represen ted a major a l t e r a t i o n i n a v a i l a b i l i t y , and t h e r e f o r e , ha s undoubtedly con t r ibu t ed t o i n c r e a s e s i n consumption and a t t e n d a n t problems ..."

Unfortunately, t h e r e a r e only a few s t u d i e s examining t h e t o t a l range of v a r i a b l e s which may a f f e c t a v a i l a b i l i t y . Bacon (1977) s tud i ed n ine communities i n f i v e s t a t e s and concluded t h a t v a r i a t i o n s i n a v a i l a b i l i t y had l i t t l e e f f e c t on consumption. There appear t o be no s t u d i e s which have empi r i ca l l y examined gene ra l a v a i l a b i l i t y i n a v a r i e t y of c o u n t r i e s f o r e f f e c t s on consumption. Smart (1977b) examined t h e r e l a t i o n s h i p between o v e r a l l ava i l - a b i l i t y , p e r c a p i t a consumption, and a lcohol i sm r a t e s i n t h e United S t a t e s . lie found t h a t t h e c o r r e l a t i o n between pe r c a p i t a consumption and a v a i l a b i l i t y was p o s i t i v e and s i g n i f i c a n t . iíowever, t h e c o r r e l a t i o n between per c a p i t a consumption and urbanism was a l s o p o s i t i v e and t h e c o r r e l a t i o n w i th income was even g r e a t e r . P a r t i a l c o r r e l a t i o n s showed t h a t much of t h e s t a t i s t i c a l r e l a t i o n s h i p between per c a p i t a consumption and a v a i l a b i l i t y i s accounted f o r by income and urbanism. Thus, changes i n a v a i l a b i l i t y may have l i t t l e e f f e c t upon e i t h e r consumption o r a l c o h o l problems i f changes i n l eve1 of income o r degree of u rban iza t ion a r e no t a l s o considered.

La t e r s t u d i e s by Harford (1979) and Colon (1981) have shown t h a t a v a i l a b i l i t y is not a s i n g l e dimension; s p e c i f i c a l l y , d i f f e r e n c e s between on-premise and off-premise a v a i l a b i l i t y w i l l have d i f f e r e n t impacts a s r ega rds l i v e r c i r r h o s i s . The ISACE study by i4akela e t a l . (1982) concluded t h a t "while t h e o v e r a l l i n c r e a s e i n a l c o h o l consumption could no t be a t t r i b u t e d t o t h e gene ra l r e l a x a t i o n of c o n t r o l r e g u l a t i o n s i n t h e s tudy s o c i e t i e s , t h e p o l i c y approach taken by most governments r e in fo rced t h e i nc reas ing acceptance of a l coho l i n t o peop le ' s everyday l i f e , and made way f o r expanding t h e supply." The au tho r s of t h i s s tudy put more emphasis on gene ra l i n c r e a s e s i n a f f l u e n c e and u rban iza t ion and the way temperance i n f l u e n c e s have decreased a s c a u s a l f a c t o r s . They a l s o po in t ou t t h a t a l coho l has become more c l o s e l y a s s o c i a t e d w i th l e i s u r e p u r s u i t s and t h e i r commercial izat ion. The a u t h o r s a l s o show t h e i nc reas ing economic importance of a l c o h o l a s a commodity, a n element i n i n t e r n a t i o n a l t r a d e , and a n a g r i c u l t u r a 1 product.

A t p r e sen t , e x i s t i n g ana lyses do no t a l low u s t o a s s i g n any g r e a t importance t o o v e r a l l a v a i l a b i l i t y a s a f a c t o r i n increased a l coho l consumption. hiuch l a r g e r s o c i a l , c u l t u r a l , and economic changes seem equa l ly important and i n t he aggrega te probably more important i n some c o u n t r i e s .

Alcohol O u t l e t s and Hours of Sa l e : Re la t ionsh ips t o Consumption and Problems

V i r t u a l l y a l 1 c o u n t r i e s have numerous c o n t r o l e on t h e number and type of o u t l e t s and t h e hours of s a l e f o r a l c o h o l i c beverages. Some i d e a of t h e v a r i a t i o n i n types of c o n t r o l on a world-wide b a s i s

can be gained from Moser's book (1980). We can make i n t e r n a t i o n a l comparisons, a s well a s more l o c a l before-and-af t e r s tudies , wlien con t ro l s a r e changed. Most changes i n o u t l e t frequency o r type and i n hours of s a l e a r e small i n nature. Often t hey a r e l o c a l and may apply i n a s ing le s t a t e o r province o r even a small c i t y . Limited va r i ab les s tudied include the s a l e of l iquor by t h e dr ink , t h e in t roduc t ion of Sunday s a l e s , t h e lengthening of hours of sa le s , e t c . Broader changes examined include prohibi t ion and the shortages brought on by war o r o the r d i s loca t ions of a s o c i a l nature.

Severa1 s t u d i e s (Mass Observation 1943; Popham e t a l . 1975) found that c o r r e l a t i o n s between drunkenness r a t e s and o u t l e t s per population base a r e negative. In any given a r e a i t 1s l i k e l y t h a t public to lerance f o r drunkenness c o r r e l a t e s with the number of o u t l e t s . Also, c o r r e l a t i o n s between numbers of o u t l e t s and per c a p i t a s a l e s a r e i n s i g n i f i c a n t (Popham e t a l . 1976), but the v a r i a t i o n s tudied has not been very g rea t . It seems unl ike ly t h a t adding o r taking away a few alcohol o u t l e t s makes much d i f fe rence t o most a r e a s unless the number drops t o zero.

Small Changes i n liumber of Out l e t s and Hours of Sale

Numerous sma11 changes i n a s ing le c o n t r o l measure have crea ted l i t t l e e f f e c t . For example, Bryant (1954) found no e f f e c t on consumption with the in t roduct ion of l i q u o r by the drink. Dewar and Sommer (1962) found no e f f e c t from replacing the male beer par lour with a tavern serving both beer and wine t o both sexes. Smart and Docherty (1976) f a i l e d t o f ind the expected e f f e c t s from the in t roduc t ion of on-premise consumption on drinking dr iv ing y roblems.

Popham e t a l . (1975) s tudied t h e in t roduct ion of lounges and taverns i n Ontario, which p r i o r t o 1947 had only d u l l and u n a t t r a c t i v e beer parlours frequented mostly by men. The lounges allowed the s a l e of a l 1 types of a lcohol ic beverage by the drink; many provided entertainment and oppor tuni t ies t o dance and made s p e c i a l e f f o r t s t o a t t r a c t women and middle-class customers. Per c a p i t a s a l e s increased more i n Ontario than i n neighboring Manitoba, but drunkenness convict ions and l i v e r c i r r h o s i s deaths increased more i n Manitoba. Of course, t h i s change did not simply increase a v a i l a b i l i t y , but g r e a t l y enhanced the a t t r a c t i v e n e s s of on-premise drinking environmente.

Smart (1974b) compared s a l e s of a l coho l i c beverages made i n se l f -service and clerk-service package s t o r e s i n Ontario. In se l f - se rv ice s t o r e s a l 1 a lcohol ic beverages a r e displayed, much a s i n any grocery supermarket. In the clerk-service s t o r e s , customers make s e l e c t i o n s from a l is t and a c l e r k br ings t h e purchase from the r e a r of the s to re . Displays of beverages a r e small o r non-existent. Customers i n se l f -service s t o r e s made l a r g e r

purchases than those i n c l e rk - se rv i ce a t o r e s . They a l s o repor ted more impulse buying and a h ighe r average consumption dur ing the previous week.

Numerous pe r iods when l i q u o r s t o r e personnel were on s t r i k e have a l s o been i n v e s t i g a t e d . They p re sen t one of t h e few o p p o r t u n i t i e s t o s tudy r educ t ion i n a v a i l a b i l i t y , a s most changes a r e toward l i b e r a l i z a t i o n . The b e s t known s tudy i s one by Makela (1974) of t he F innish Alko personnel s t r i k e . This s t r i k e l a s t e d f i v e weeks and a f f e c t e d r e t a i l o u t l e t s , but no t r e s t a u r a n t s o r t h e s a l e of l i g h t beer (3.7 percent a l c o h o l o r l e s s ) . E f f e c t s on consumption by "average c i t i z e n s " were very -11; however, a r r e s t s f o r drunkenness and d i s tu rbance of t he peace dec l ined s u b s t a n t i a l l y .

Smart (1977a) s t u d i e d two l i q u o r s t o r e s t r i k e s i n Canada. They were f o r s h o r t pe r iods of t i m e ( fou r and nine weeks) and completely a f f e c t e d only package s t o r e s a l e s , wi th l e s s e r e f f e c t s on h o t e l s and r e s t a u r a n t s . Nei ther of t h e strikes reduced t h e t o t a l s f o r t r a f f i c a c c i d e n t s , impaired d r i v i n g , o r t r a f f i c f a t a l i t i e s . However, dur ing one s t r i k e per iod a r r e s t s f o r pub l i c drunkenness s u b s t a n t i a l l y decreased. This f i nd ing shows, a s does d a t a from the Alko s t r i k e per iod , t h a t persons whose d r ink ing i s exces s ive and beyond c o n t r o l can be a f f e c t e d by a l coho l a v a i l a b i l i t y . It i s known t h a t most of those a r r e s t e d f o r drunkenness a r e t y p i c a l l y s o c i a l l y d e t e r i o r a t e d o r skid-row a l c o h o l i c s .

S tud i e s of s t r i k e pe r iods i n Manitoba have shown s i m i l a r r e s u l t s (Harper e t a l . 1981b), w i t h fewer admissions t o a medical d e t o x i f i c a t i o n f a c i l i t y dur ing a l i q u o r s t r i k e but no d e c l i n e du r ing a beer s t r i k e . Ove ra l l consumption was lowered only du r ing the l i q u o r s t r i k e .

Brown (1978b) found a n e s p e c i a l l y l a r g e e f f e c t r e s u l t i n g from a beer s t r i k e i n New Zealand, where t y p i c a l beer consumption i s very h igh and o t h e r beverages a r e no t popular . The f o u r r e e k s t r i k e had a major e f f e c t on drunkenness and o t h e r a l coho l - r e l a t ed of fences , a s w e l l a s t r a f f i c acc idents .

Some i n t e r e s t has been taken i n changes of hours of s a l e . They have been a f a v o r i t e means of r egu la t i on , bu t few con t ro l l ed , e m p i r i c a l s t u d i e s of t h e i r e f f e c t s a r e a v a i l a b l e . Shadwell (1923) contended t h a t of a l 1 wartime measures i n B r i t a i n a f f e c t i n g a v a i l a b i l i t y , s h o r t e r s e l l i n g hours were t h e most important. However, such a l a r g e v a r i e t y of changes were made t h a t t h e value of any one i s d i f f i c u l t t o a s s e s s (Smart 1974a).

A p o s i t i v e c o r r e l a t i o n between opening hours of beer pa r lou r s and a r r e s t s f o r drunkenness has been found i n s eve ra1 s t u d i e s (e.g. Popham 1962). However, t h e same hourly p a t t e r n of a r r e s t s occurs on Sunday i n Toronto when beer p a r l o u r s are c losed . Popham (1962) has suggested t h a t "hours of s a l e r e f l e c t e d t h e d r ink ing p a t t e r n of a t l e a s t one segment of t h e community r a t h e r t han t h e reverse ."

Kaymond (1969) hae s tud ied t h e change i n on-premise c loe ing houre i n Aus t r a l i a . T r a d i t i o n a l l y , t averne c losed a t 6:00 p.m. t o a l low workers t o d r i n k a f t e r work but s t i l l g e t home f o r d inner . Thie l e d t o t h e "6 o 'c lock e w í l l , " t h a t is , hu r r i ed dr inking from about 5:30 onwards. When hours were extended t o 10:OO p.m. i n V i c t o r i a , Raymond found no e f f e c t on t o t a l personal i n j u r y acc idente . However, t h e peak hour f o r acc iden t s changed from 6:00 - 7:00 p.m. t o 10:OO - 1 1 : O O p.m.

A t r i a l Saturday c l o s i n g of Alko s t o r e s i n Finland was eva lua ted by S a i l a (1978). A chronic problem i n Finland has been pub l i c i n t o x i c a t i o n , e e p e c i a l l y on Saturdays. Alko s t o r e s were cloeed on Saturdays f o r e i g h t months, s topping off-premise s a l e s of e p i r i t s and wine, a l though l i g h t and medium beer was a v a i l a b l e a t g rocery e toree . The c losu re reduced pub l i c drunkenness and a lcohol - re la ted violente, a s w e l l a s t o t a l consumption. There vas no evidence of a n i n c r e a s e i n non-beverage a l coho l o r i l l i c i t a l coho l consumption.

Numerous s m a l l t o medium changes have apparent ly had no e p e c i a l study. This would inc lude : opening hours f o r package s t o r e e ; Sunday s t o r e openings; ho l iday c l o s i n g s ; c l o s i n g s on vo t ing daye; and in t roduc t ion of beer and wine i n t o grocery s t o r e s . This i s unfor tuna te a s small changes a r e f r equen t ly in t roduced , and t h e a l coho l research community o f t e n has l i t t l e t o add t o t h e pol icy decision-making process i f no empi r i ca l s t u d i e s have been done.

From the s t u d i e s diecussed above, one might ag ree with Popham e t a l . (1975) t h a t " v a r i a t i o n i n i n d i c a t o r s of t he prevalence of i n e b r i e t y i s not dependent upon o u t l e t frequency." Ou t l e t frequency a l e o does not appear t o govern average consumption. The e f f e c t s of changes i n houre of s a l e on consumption a r e v a r i a b l e from one study t o another and d i f f i c u l t t o p red ic t . I n s h o r t , small changes i n a v a i l a b i l i t y of t he type examined above t y p i c a l l y have small o r i n e i g n i f i c a n t e f f e c t s on dr inking and d r ink ing problems. However, a major e f f e c t on consumption and problems of i n t o x i c a t i o n i s found where s t o r e s can be closed f o r a whole day each week.

Some Large Changes i n Alcohol A v a i l a b i l i t y

Moet s i t u a t i o n s involving l a r g e changes i n a v a i l a b i l i t y involve p roh ib i t i on , wartime shor tages , o r t h e i n t r o d u c t i o n of s t o r e s t o previously dry a r e a s , such a s i n Finland.

The e f f e c t s of p roh ib i t i on on d r ink ing have been we l l s tud ied i n t h e United S t a t e s (Warburton 1932), Canada (Popham 1956) and Finland (Bruun e t a l . 1960). In a l 1 of these , p r o h i b i t i o n c rea t ed a major r educ t ion i n per c a p i t a a l coho l consumption and i n such a l coho l problems a s drunkenness, l i v e r c i r r h o s i s , a lcohol - re la ted dea th r a t e e , and t h e l i k e . To some e x t e n t t he changes were

temporary, a s t h e l a r g e s t changes were e a r l y i n t h e per iod of p r o h i b i t i o n . Arguments made a g a i n s t p roh ib i t i on , e s p e c i a l l y i n t h e United S t a t e s , were t h a t i t encouraged i l l i c i t t r a d e i n a l coho l and f o s t e r e d t h e development of ganga and c r i m i n a l elements. A Nat ional Academy of Sciences s tudy (Ger s t e in and Moore 1981) concluded t h a t " t h e p r o h i b i t i o n e r a ... l e f t a sour t a s t e on the n a t i o n a l pa la te" and l e d t o a r e j e c t i o n of c o n t r o l measures and of a l c o h o l prevent ion i n genera l . Probably t he se argumente have some v a l i d i t y f o r many coun t r i e s . It t h e r e f o r e becomee a mat te r of i n d i v i d u a l judgement whether n a t i o n a l p r o h i b i t i o n w a s r e a l l y worth t h e e f f o r t .

Limited p r o h i b i t i o n has been in t roduced r e c e n t l y i n t o eome no r then i communities i n Canada i n reeponee t o s o c i a l problems a seoc i a t ed wi th very high a l coho l consumption. A s tudy by Smart (1979) showed v a r i a b l e e f f e c t s on drunkenness, a s e a u l t , and impaired d r i v i n g charges. However, i n t h e most i e o l a t e d communities, where p r o h i b i t i o n was most succees fu l , t h e r e was a s u b e t a n t i a l reduc t ion i n a l coho l probleme a f t e r p roh ib i t i on . Such l i m i t e d p r o h i b i t i o n s might wel l be expanded t o o t h e r n a t i v e o r i s o l a t e d a r e a s o r t o thoee w i t h l o c a l op t ions concerning a lcohol .

Many d i f f i c u l t i e e e x i s t i n a s s e s s i n g the cons ide rab l e e f f e c t of wartime r e s t r i c t i o n s on dr ink ing . They p re sen t s i t u a t i o n s which can never be dup l i ca t ed a s p a r t of government pol icy. Aleo, too many o t h e r v a r i a b l e s occur during wartime t o be s u r e t h a t r educ t ions a r e p r i m a r i l y reeponeib le f o r changes i n d r ink ing p a t t e r n s .

The bes t s t u d i e s of wartime r e s t r i c t i o n s were probably t hose a f f e c t i n g B r i t a i n during t h e 1914-1918 war (Shadwell 1923; Smart 1974a). Shadwell concluded t h a t "excessive d r ink ing can be e f f e c t i v e l y checked and the d i s a b i l i t y caueed by i t reduced by app rop r i a t e measuree. " He saw t h e p r i n c i p a l meaeures t o be cu r t a i lmen t of hours of s a l e , l i n i i t a t i o n of eupply, and r a i s e d p r i c e s . Aithough important , n e i t h e r t h e s e p a r a t e va lue of each f a c t o r nor t h e i r combined va lue can be aseessed . A h i e t o r i c a l a n a l y s i s (Smart 1947a) shows t h a t t h e fol lowing a l e o i n f luenced t h e e f f e c t e of wartime r e s t r i c t i o n s :

1 ) During the years 1916 t o 1918 t h e r e were r e s t r i c t i o n s on beverage output and importat ion.

2) Many people had l i t t l e t ime t o d r i n k a s work loads increased up t o 60 hours per week.

3) Bombings, and b lackouts made people l e s s w i l l i n g t o move o u t s i d e t h e i r houses f o r d r ink ing occas ions o r o f f - l i c ense purchases.

4) A gene ra l wave of p a t r i o t i e m perhaps l e d some people t o reduce t h e i r d r ink ing i n keeping wi th t h e examples and exhor t a t i ons of n a t i o n a l l e ade r s .

5) The war probably increased p r o h i b i t i o n i s t and modera t ion is t f e e l i n g s which had e x i s t e d b e f o r e ' t h e war. I n f a c t , per c a p i t a consumption of a l coho l and drunkenness conv ic t i ons had peaked around 1900 and were on the way down a t t h e time of t h e war.

6) Shortages of policemen and phys ic ians made t h e d e t e c t i o n o f drunkenness and l i v e r c i r r h o s i s dea ths l e s s l i k e l y .

Severa1 i n t e r e s t i n g s t u d i e s of a v a i l a b i l i t y have examined t h e i n t r o d u c t i o n of a l c o h o l o u t l e t s t o i s o l a t e d a r e a s of Finland. A s i n Norway and Sweden, Finland has had a long temperance t r a d i t i o n , a low per c a p i t a rate of a l coho l consumption, and a s p i r i t s - d r i n k i n g t r a d i t i o n . Access t o a l c o h o l i c beverages is s t i l l d i f f i c u l t i n many p a r t e of F in land; l i q u o r s t o r e s a r e d i f f i c u l t t o f i n d and o f t e n crowded, a l though beer is more ava i l ab l e . For many yea r s no a lco- h o l i c beverages a t a l 1 were so ld i n most r u r a l a r e a s and smal l towns i n Finland. A l i m i t e d number of s t o r e s were in t roduced i n 1951 t o market towns. Numerous comparisons of d r ink ing and drunkenness p a t t e r n s were made between those towns and o t h e r s which d i d not have s t o r e s (Kuusi 1957). The major f i n d i n g s were t h a t t h e opening of s t o r e s increased t h e frequency of d r ink ing , e s p e c i a l l y of bee r and wine, decreased t h e use of i l l i c i t s p i r i t s , but had l i t t l e e f f e c t on exces s ive dr ink ing o r drunkemess .

Another Yinnish experiment i n t h e yea r s 1969-1970 involved even l a r g e r changes i n a v a i l a b i l i t y (Makela 1972). Previous t o 1969 l i q u o r s t o r e s were not allowed i n r u r a l a r e a s and l i c e n s e d res tau- r a n t s were few i n number. Publ ic op in ion favored l i b e r a l i z a t i o n of t h e s e c o n t r o l laws s o t h a t : a ) t h e number of l i q u o r s t o r e s was increased s u b s t a n t i a l l y (132 i n 1968 t o 167 i n 1970); b) t h e number of fu l l y - l i censed r e s t a u r a n t s was increased by about 80 percent ; c ) some 17,431 new medium beer o u t l e t s were in t roduced; and d ) 3,000 medium beer b a r s were opened.

The aims were t o l i b e r a l i z e t h e e x i s t i n g laws and t o make a v a i l a b l e l o r a l c o h o l beverages which would s u b s t i t u t e f o r t he favored s p i r i t s . It was hoped t h a t t h i s would c o n t r o l t h e exp los ive i n t o x i c a t i o n r e s u l t i n g from the r ap id d r ink ing of s p i r i t s s o t y p i c a l i n Finland.

As might have been expected, t o t a l per c a p i t a consumption inc reased about 48 percent i n t h e f i r s t year a f t e r t h e changes. Also, numbers of heavy u s e r s increased p ropor t i ona t e ly . There was l i t t l e s i g n t h a t beer-drinking s u b s t i t u t e d f o r s p i r i t s - d r i n k i n g a s had been expected. Beer accounted f o r much of t he i nc rease , but t h e r e was no compensatory r educ t ion i n s p i r i t s use. Of course , i t i s u n c e r t a i n whether t h e f i n d i n g s from t h i s s t udy could be gene ra l i zed t o o t h e r c o u n t r i e s w i t h d i f f e r e n t d r ink ing s i t u a t i o n s . Because of t he r a p i d i t y of t h e change, i t is very l i k e l y t h a t t h e

i nc reased a v a i l a b i l i t y con t r ibu t ed most t o t he i nc rease . It i s d i f f i c u l t , however, t o be s u r e t h a t pub l i c d e s i r e t o d r i n k more was no t a n important c o n t r i b u t o r i n t e r a c t i n g wi th i nc reased a v a i l a b i l i t y .

Governments o t h e r than Finland have made a t tempts t o s u b s t i t u t e one beverage f o r another , u sua l ly beer o r wine f o r d i s t i l l e d s p i r i t s . Not a l 1 e f f o r t s a t s u b s t i t u t i o n have been eva lua ted , but some have. The i n t r o d u c t i o n of low and medium b e e r s i n Finland served t o i nc rease o v e r a l l consumption. The in t roduc t ion of l i g h t beer i n Ontar io was found by ühi tehead and Szandorowski (1977) t o be mostly a s u b s t i t u t i o n of one a l c o h o l i c beverage f o r another . However, t h e r e was some i n c r e a s e i n consumption w i t h t he change t o l i g h t beer w i th meals. There a r e some s i g n s t h a t t he u n a v a i l a b i l i t y of one beverage ( a s during s t r i k e s ) l e a d s t o l i m i t e d s u b s t i t u t i o n of o t h e r s but a decrease i n o v e r a l l consumption (S ingle 1979). This r e sea rch i n d i c a t e s t h a t most a t t empt s a t s u b s t i t u t i o n a r e l i k e l y t o f a i l un l e s s a p p r o p r i a t e changes i n p r i c e and ava i l - a b i l i t y a r e made a t the same t i m e .

Government Cont ro ls and Alcohol Use i n t h e Future

It i s worth specu la t i ng about what t h e f u t u r e may hold f o r t h e r e l a t i o n s h i p s between a v a i l a b i l i t y and dr ink ing . One approach i s t o examine worldwide t r e n d s i n dr ink ing . Sulkunen (1976) r epo r t ed d a t a from t h e World Alcohol P r o j e c t (WAP) on a l coho l consumption and d r ink ing p a t t e r n s i n more than 30 c o u n t r i e s over a per iod of about 20 yea r s between 1950 and 1970. Unfortunately, no d a t a were ga thered on the l e v e l s of a v a i l a b i l i t y i n v a r i o u s c o u n t r i e s and hence c ross -na t iona l comparisons a r e not f e a s i b l e ; nor were many developing c o u n t r i e s from L a t i n America o r t h e Caribbean included. Nevertheless , some of Sulkunen's conc lus ions , providing grounds f o r specu la t i on , inc lud ing t h e fol lowing:

1 ) There has been a world wide r i s e i n a l coho l consumption i n t he y e a r s 1950-1970.

2) The r i s e has been g r e a t e s t i n c o u n t r i e s where s p i r i t s a r e t h e p re fe r r ed beverage.

3) There i s homogenization of d r ink ing I iab i t s throughout t h e world. That i s , beer i s becoming more popular i n wine-drinking coun t r i e s ; wine i n s p i r i t s - d r i n k i n g c o u n t r i e s , e t c .

4) The homogenization 1s not a t t h e expense of t r a d i t i o n a l beverages, but i n a d d i t i o n t o them.

There i s evidence now from a v a r i e t y of c o u n t r i e s -- f o r example, Canada, The United S t a t e s , Finland , Poland, e t c ( s e e iiakela e t a l . 1982 f o r a review) -- t h a t a l coho l consumption has

s t a b i l i z e d o r has even s l i g h t l y decreased s i n c e about 1975. This may be e i t h e r temporary o r a long-term t r end such a s t h e "long wave" of postwar consumption inc rease . The r ea sons f o r t h i s r educ t ion probably i nc lude s t a b i l i z a t i o n of r e a l income, a new emphasis on h e a l t h y l i f e - s t y l e s and f i t n e e s , and changes i n t he demographic composition of t he populat ion, f o r example, adding l a r g e numbers of young l i g h t d r i n k e r s t o t h e d r ink ing populat ion. We can a s k what e f f e c t t h i s s t a b i l i z a t i o n w i l l have on a l coho l c o n t r o l p o l i c i e s . W i l l i t mean t h a t governments w i l l i n c r ea se a v a i l a b i l i t y i n o r d e r t o s t i m u l a t e more d r ink ing and hence more t ax revenues? W i l l t h e r e be dec reases i n r e a l p r i c e s f o r a l c o h o l i c beveragea?

There a r e sane l i m i t e d i n d i c a t i o n s t h a t t h e g r e a t i n c r e a s e s i n a v a i l a b i l i t y seen i n t h e y e a r s 1950-1970 i n a lmost a l 1 c o u n t r i e s a r e on the wane. Many governments appear more c a u t i o u s now than formerly. P roh ib i t i on has been introduced i n Poland and Pakis tan ; age laws have been increased i n many a r e a s of Canada and t h e U.S.A., and a d v e r t i s i n g r e s t r i c t i o n s o r o u t r i g h t bans have been put i n t o f o r c e i n many coun t r i e s . It may be t h a t a g e n e r a l l y more r e s t r i c - t i v e approach i n government c o n t r o l s is t h e c u r r e n t z e i t g e i s t .

P r i c e and Taxat ion

V i r t u a l l y a l 1 governments set t h e p r i c e s of a l c o h o l i c beverages, e i t h e r i n d i r e c t l y tlirough va r ious t a x a t i o n schemes o r d i r e c t l y by s e l l i n g through government monopoly s t o r e s . The ISACE s tudy (Nakela e t a l . 1982) found t h a t " t h e p ropor t i on of t h e f i n a l p r i c e of a l c o h o l i c beverages t h a t 1s a t t r i b u t a b l e t o t a x a t i o n v a r i e s g r e a t l y among beverages and among s o c i e t i e s . " General ly , d i s t i l l e d beverages were more heav i ly taxed than o t h e r s and over h a l f of t h e f i n a l p r i c e may be due t o t axa t ion . S ince governments cons t an t ly a d j u s t a l c o h o l p r i c e s i n response t o economic and t a x a t i o n needs, t hose concerned wi th a l c o h o l po l i cy might a l s o cons ide r h e a l t h m a t t e r s when s e t t i n g p r i c e l e v e l s .

P r i c e c o n t r o l s Imve been a major recommendation a r i s i n g from re sea rch on d i s t r i b u t i o n p a t t e r n s of a l coho l consumption. I t has been argued (Popham e t a l . 1975) t h a t both pe r c a p i t a c o n s m p t i o n and a lcohol - re la ted problems, such a s l i v e r c i r r h o s i s , can be reduced by s u b s t a n t i a l changes i n t he r e a l p r i c e of a l c o h o l i c beverages. Recommendations by t h e s i n g l e d i s t r i b u t i o n t h e o r i s t s have u s u a l l y been more moderate: a ) t h a t t h e p re sen t r e a l p r i c e of a l c o h o l i c beverages merely be maintained and not lowered a s i n f l a t i o n i nc reases ; and b) t h a t t h e r e be a unifonn p r i c e c o n t r o l p o l i c y whereby p r i c e s a r e based on t h e amount of a l coho l i n each beverage .

Probably no c o n t r o l f a c t o r has been s o o f t e n s t u d i e d a s has p r i c e . Severa1 e a r l y s t u d i e s o f d r a s t i c p r i ce - t axa t ion i n c r e a s e s i n Denmark and Belgium found s u b s t a n t i a l decreases i n t h e consumption

of d i s t i l l e d beverages and a less marked d rop i n t o t a l consumption ( s e e reviews of Sruun e t a l . 1975; Popham e t a l . 1975). The tax i n c r e a s e s l e v i e d were much h igher t han could now be done i n most Western coun t r i e s . For example, t h e t a x on d i s t i l l e d s p i r i t s i n Denmark was r a i s ed by a f a c t o r of 11, c h i e f l y because of wartime shor tages .

Our knowledge of how p r i c e changes can a f f e c t consumption and a l coho l - r e l a t ed problems i s based on econometric ana lyses r a t h e r than experimental o r quasi-experimental s tudy. Such s t u d i e s examine how n a t u r a l l y occur r ing f l u c t u a t i o n s i n p r i c e r e l a t e t o per c a p i t a consumption and a l coho l problems, u s u a l l y l i v e r c i r r h o s i s . Such s t u d i e s a r e decep t ive ly e a s y t o do, but i n t h e aggrega te t h e i r r e s u l t a have been d i f f i c u l t t o i n t e r p r e t .

The f i r s t l a r g e econometric s tudy was done by Seeley (1960), who examined time series d a t a f o r Ontar io . H e examined t h e r a t i o of a l coho l p r i c e s t o d i sposab le income and found t h a t i t var ied i n v e r s e l y wi th both a l c o h o l s a l e s and l i v e r c i r r h o s i s d e a t h r a t e s . This prompted t h e sugges t ion t h a t i f r e a l p r i c e s were r a i s e d by 20 o r 30 percent over s eve ra1 y e a r s i t could be determined whether t h e r e was a r e a l e f f e c t on consumption and l i v e r c i r r h o s i s . The suggested experiment has appa ren t ly no t ye t been done.

An important element i n t h e argument about p r i c e s and consumption is t h e ques t i on of t he e l a s t i c i t y of demand Eor a l c o h o l i c beverages. I f demand i s r e l a t i v e l y i n e l a s t i c v i t h regard t o p r i c e s , then the re i s l i t t l e any government can do s h o r t of i n c r e a s i n g p r i c e s t o phenomenal l e v e l s . Some products , such as bread i n Western c o u n t r i e s , have an i n e l a s t i c demand and few s u b s t i t u t e s . I f p r i c e s a r e i nc reased , then people simply spend more without decreas ing t h e i r consumption by a s i g n i f i c a n t amount.

Argumente about p r i c e i n e l a s t i c i t y f o r a l c o h o l i c beverages a r e now very t o p i c a l . Popham e t a l . (1976) and Bruun e t a l . (1975) have reviewed a l a r g e number of empi r i ca l s t u d i e s and concluded t h a t "when o t h e r f a c t o r s remain unchanged, a r i s e i n a l c o h o l p r i c e s has g e n e r a l l y l e d t o a drop i n t h e consumption of a lcohol ." The Nat iona l Academy of Sc iences s tudy (Moore and Ger s t e in 1981) concluded that "an increased t a x on a l c o h o l i c beverages has t he p a r t i c u l a r e f f e c t of improving the chronic h e a l t h p i c t u r e " and t h e r e f o r e recommended such i n c r e a s e i n conjunc t ion wi th prevent ive programe. Others (e.g. Parker and Harman 1978) have claimed t h a t income, no t p r i c e , i s the main determinant of a l coho l consumption, and t h a t demand f o r beer and s p i r i t s i s r e l a t i v e l y i n e l a s t i c and hence not modi f iab le by p r i c e changes. A review and re -ana lys i s by Orns t e in (1980) has shown t h a t n e i t h e r po in t of view i s e n t i r e l y c o r r e c t ; t h a t is , t h e r e was no support f o r t h e view t h a t "income e f f e c t s dominate p r i c e e f f e c t s , " nor i s t h e r e " i n e l a s t i c demand f o r s p i r i t s " ( a t l e a s t i n The United S t a t e s ) . The main conc lus ion of Schmidt and Popham was suppor ted ; t ha t is, consumpt i on i s s e n s i t i v e

t o p r i c e changes, but " t h e s e n s i t i v i t y v a r i e s a c r o s s beverages." Orns t e in concluded t h a t "demand e s t i m a t i o n 1s a d i f f i c u l t and i n e x a c t business" and " t h e r e s u l t s a r e s t r o n g l y a f f e c t e d by t h e d a t a and econometric techniques used."

Econometric ana lyses have not l e d t o very c l e a r conc lus ions about what type of p r i c e i nc rease could be expected t o lead t o what decrease o r change i n a l c o h o l consumption o r problems. Demand f o r beverages may vary cons iderab ly a c r o s s j u r i s d i c t i o n s and i n response t o many f a c t o r s o t h e r t han p r i c e , i nc lud ing income. Heavy d r i n k e r s may no t be much a f f e c t e d by p r i c e i n c r e a s e s , and cheaper beverages can be s u b s t i t u t e d f o r t h e more expensive. I n gene ra l , p r i c e seems t o af f e c t consumpt i o n but w e cannot of f e r very def i n i t e sugges t ions t o governments a s t o how t o change p r i c e s t o ach ieve any d e s i r e d p reven t ive e f f e c t w i thout undesired l o s se s .

Perhaps a l 1 that can be learned from econometric s t u d i e s has been l ea rned a l r eady , and new experimental approaches should be t r i e d . The o r i g i n a l paper by See ley c a l l e d Eor a l a rge - sca l e s o c i a l experiment , and t h i s i s s t i l l needed today.

Another a r e a f o r t h e experimental s tudy of p r i c e has been opened up by Babor e t a l . (1978). They s tud i ed "happy hour" cond i t i ons i n a n experimental bar s i t u a t i o n . Male vo lun tee r s were g iven a c c e s s t o a l c o h o l i c beverages f o r a 20-day per iod. Some were charged 50 c e n t s per d r i n k and o t h e r s ( t h e happy hour group) 25 c e n t s during a three-hour per iod. Both c a s u a l d r i n k e r s and heavy d r i n k e r s s i g n i f i c a n t l y increased t h e i r consumption dur ing t h e happy hours. However, heavy d r i n k e r s increased much more than d i d ca sua l d r i n k e r s . The happy hour consumption was no t a s u b s t i t u t e f o r consumption a t o t h e r times.

Research of t h i s s o r t should be extended i n t o o t h e r s i t u a t i o n s where cheap a l c o h o l i c beverages a r e made a v a i l a b l e , such a s c o c k t a i l p a r t i e s , r ecep t ions , Oktober fes t s , and c e r t a i n kinds o£ a i r t r a v e l . Var iab les a s soc i a t ed wi th increased consumption, such a s d i sposable income and p e r s o n a l i t y charac teris t i c s , could a l s o be i n v e s t i g a t e d . The experimental s i t u a t i o n a l lows a c o n t r o l over v a r i a b l e s which has been d i f f i c u l t t o o b t a i n i n econometric ana lyses . Perhaps governments could be persuaded t o decrease t h e number of s i t u a t i o n s where a l coho l i s g iven away o r so ld a t very low cos t .

A f i n a l problem wi th c o n t r o l l i n g a l c o h o l problems through reducing pe r c a p i t a consumption r e l a t e s t o t h e s e l e c t i o n of t h e problems t o be con t ro l l ed . The bes t c o r r e l a t i o n s between consumption and r e l a t e d problems are f o r consumption and l i v e r c i r r h o s i s . Much r e sea rch i n d i c a t e s t h a t a l c o h o l problems and consumption a r e not c o n s i s t e n t l y c o r r e l a t e d ( s e e Makela 1975) , and hence a c t i o n s c o n t r o l l i n g one problem may not c o n t r o l another .

La te ly , r e sea rch has i nd i ca t ed t he b e n e f i c i a 1 e f f e c t s of small amounts of a l coho l (up t o two d r i n k s per day) (Yano e t a l . 1977;

Barboriak e t a l . 1977) i n prevent ing coronary h e a r t d i sease . Current ana lyses a r e i n d i c a t i n g (Popham 1982) t h a t t he p r o t e c t i v e e f f e c t of a l coho l may not peak a t two d r inks , but i n c r e a s e wi th t h e amount taken. I n t h a t ca se , encouraging t h e popula t ion by whatever means t o d r i n k l e e s may mean a l a t e r i n c r e a s e i n h e a r t d i sease . J u s t how t h i s i s t o be balanced a g a i n s t t h e expected r educ t ion i n l i v e r d i s e a s e cannot be seen a t p resen t .

Changes i n t h e Drinking o r Purchasing Age f o r Aicohol ic Beverages

Expec ta t ions about t he consequences of reducing t h e d r ink ing age vary i n accordance wi th t h e view gene ra l l y taken about a lcohol c o n t r o l p o l i c i e s . For some i t i s seen a s a prevent ive measure. For example, Wilkinson (1970) argued a "forbidden f r u i t " theory i n which a l c o h o l becomes e s p e c i a l l y a t t r a c t i v e t o young people because of i t s i l l e g a l i t y . According t o t h i s view, d r ink ing nonns develop once i t becomes l e g a l f o r young people t o d r ink , t h u s l ielping t o prevent l a t e r problems. Wilkinson recommended lowering t h e d r ink ing age t o 18 i n a l 1 j u r i s d i c t i o n s . On t h e o t h e r hand, those i n favour o f t h e " d i s t r i b u t i o n " theory ( f o r example, Popham e t a l . 1975) argued t h a t l i b e r a l i z a t i o n c o n t r i b u t e s t o higher per c a p i t a consumption and hence t o a l coho l - r e l a t ed problems.

Some argue t h a t changing t h e law should have no e f f e c t on consumption a t a l l . Since many young people d r i n k before t he l e g a l age, lowering t h e age on ly l e g a l i z e s t h e s t a t u s quo. We a l s o know t h a t many European c o u n t r i e s , such a s B r i t a i n , have always had low d r ink ing ages w i th r e l a t i v e l y low per c a p i t a consumption and alcohol ism r a t e s . However, France and I t a l y a l s o have low dr ink ing ages and l ead t h e world i n both a l coho l consumption and i t s problems. I n t e r n a t i o n a l comparisons may be of l i t t l e va lue compared t o before and a f t e r s t u d i e s i n s i n g l e j u r i s d i c t i o n s .

Apparently no a s p e c t of a l coho l c o n t r o l l e g i s l a t i o n has been s o o f t e n changed i n recent yea r s a s t h e l e g a l age f o r d r ink ing o r t h e purchase of a l c o h o l i c beverages. In some j u r i s d i c t i o n s age laws govern on ly t he purchase of a l c o h o l i c beverages, but i n o t h e r s , such a s On ta r io they govern purchase, possession, and consumption. During t h e y e a r s 1970 t o 1975, a l 1 10 Canadian provinces and 26 of 50 American s t a t e s decreased t h e l e g a l purchasing o r d r ink ing age. Smart and Goodstadt (1977), Wechsler (1980), and o t h e r s have summarized r e sea rch bear ing on t h e e f f e c t s of t he se age reduc t ions- I n gene ra l , t h e a v a i l a b l e d a t a provide evidence o f : a ) i n c r e a s e s i n you th fu l d r ink ing a f t e r t h e age reduc t ions (Smart and Schmidt, 1975) ; b) increased admissions t o t reataient f a c i l i t i e s f o r young people (Smart and F in l ey 1975); and c ) s u b e t a n t i a l i n c r e a s e s i n a l coho l - r e l a t ed a c c i d e n t s and f a t a l i t i e s both f o r those g iven t h e r i g h t t o d r i n k and those i n t h e next lower age ca tegory (Williams e t a l . 1974; Brown and i.laghsood100 1981; Vhitehead e t a l . 1975).

However, where l a r g e s t u d i e s have been done, t h e e f f e c t s o f t h e s e laws have o f t e n been small and v a r i a b l e from one j u r i s d i c t i o n t o another (Douglass and F i l k i n s 1974).

Af t e r pub l i c pressure , t h e d r ink ing age has been inc reased i n Michigan (18 t o 21); Maine, Massachuset ts and New Hampshire (18 t o 20); Iowa, Minnesota, Montana, Tennessee, Ontar io and Saskatchewan (18 t o 19) . We now lmve d a t a from a v a r i e t y of sources on t h e e f f e c t s of t h e i nc rease i n t h e dr ink ing age i n Ontar io from 1 8 t o 19 yea r s ( V i n g i l i s and Smart 1982).

Although i t seems c l e a r t h a t reducing t h e d r ink ing age increased youthfu l d r ink ing and d r i n k i n g l d r i v i n g problems, i t i s not c l e a r t h a t i nc reases i n t he age would dec rease them s u b s t a n t i a l l y . For one th ing , w i th t h e excep t ion of Michigan, a l 1 s t a t e s and provinces which increased d r ink ing ages d id s o by only one o r two yea r s (18 t o 1 9 o r 20), whereas t h e e a r l i e r r educ t ions had usua l ly dropped t h e d r ink ing age t h r e e yea r s ( 2 1 t o 18). Therefore , a r e l a t i v e l y smal le r segment of t h e d r i n k i n g popula t ion was a f f e c t e d by t h e i nc reases . Also, "grandfa ther" c l a u s e s were o f t e n inc luded so t h a t those who had a l r e a d y reached t h e lower age could l e g a l l y cont inue t o d r i n k when t h e age was r a i s ed .

Unfortunately, d a t a on t h e e f f e c t s of i n c r e a s i n g t h e d r ink ing age a r e very sparse . Only a handful of s t u d i e s bear d i r e c t l y on t h e ques t ion . One i n v e s t i g a t e d s choo l o f f i c i a l s ' percept ions of d r ink ing problems among youth; o t h e r s i n v e s t i g a t e d t r e n d s i n p o l i c e s t a t i s t i c s and acc iden t r a t e s .

In an anonymous s tudy (Anon 1979) ques t i onna i r e s were mailed t o h igh school p r i n c i p a l s i n Michigan a f t e r t h e l e g a l age was increased from 18 t o 21 i n December 1978. A ma jo r i t y of t h e p r i n c i p a l s r epo r t ed t h a t a f t e r t h e age was i nc reased t h e r e were fewer a lcohol - re la ted problems i n t h e i r school (74 pe rcen t ) , less d r ink ing among younger s t u d e n t s (69 pe rcen t ) , less d r ink ing a t school func t ions (67 pe rcen t ) , and l e s s d r ink ing du r ing school hours (79 percent ) . It was concluded t h a t r a i s i n g t h e d r ink ing age had made a p o s i t i v e d i f f e r e n c e i n t h e d r ink ing of h igh school s tuden t s .

Roy and Greenbla t t (1979) conducted a comparative s tudy of dr ink ing-dr iver defendants i n Massachuset ts i n February and October 1979. This r e sea rch was undertaken t o e v a l u a t e t h e e f f e c t i v e n e s s of a new dr ink ing law which r a i s e d t h e l e g a l d r ink ing age i n Massachu- setts from 1 8 t o 20 yea r s on A p r i l 16, 1979. When a n October sample was compared t o an e a r l i e r sample in February, a 26 pe rcen t i n c r e a s e was found i n t h e number of t eenagers (15-19 years of age) who were charged wi th d r i n k i ~ l d r i v i n p o f f ences , while an 8 percent dec rease was found i n t h e number of 20-25 year o l d s who were charged wi th t h e s e of fences . Aithough tests of s i g n i f i c a n c e were no t o f f e r e d , suf f i c i e n t in format ion vas a v a i l a b l e f o r a n a l y s i s . While teenagers comprised about 14 percent of the Pebruary d r i n k i n g l d r i v i n g

defendants , they accounted f o r over 17 percent i n October. However, t h e o v e r a l l t o t a l s f o r bo th months were almost t h e same. The unexpected i n c r e a s e i n charges could be due t o i n t e n s i v e p o l i c e enforcement and/or youthfu l disobedience of t h e law. The au tho r s suggested t h a t youths might be d r ink ing more i n ca ra because they could no t l e g a l l y d r i n k i n l i q u o r es tab l i shments . However, not enough informat ion was a v a i l a b l e t o determine whether enforcement p r a c t i c e s had changed. Teenagers were a l s o found t o have a h igher than expected frequency of m u l t i p l e o f f ences , i nc lud ing ope ra t i ng t o endanger, use of motor veh ic l e without a u t h o r i t y , l e av ing t h e scene of an acc iden t w i th proper ty damage and persona l i n j u r y , c r imes a g a i n s t p roper ty , and pub l i c o r d e r offences. Thus, t h e r e s u l t s demonstrated an i n c r e a s e i n o f f ences r a t h e r than t h e expected decrease.

Severa1 s t u d i e s of t h e age law changes have been made i n Michigan. Wagenaar (1980) c o l l e c t e d acc iden t m o r t a l i t y r a t e s based on a 20 percent random sample of a l 1 r epo r t ed motor v e h i c l e c r a s h e s i n t he S t a t e of Michigan from 1972 through 1979. The t h r e e dependent v a r i a b l e s were: a ) p o l i c e r epo r t ed "had been dr ink ing" a c c i d e n t s (HBD); b) p o l i c e r epo r t ed "had not been dr ink ing" a c c i d e n t s (HNBD); and c ) l a t e -n igh t , s i n g l e v e h i c l e w i th male d r i v e r a c c i d e n t s (3FS). The t h r e e age groups i n v e s t i g a t e d were: 18-20, 21-25, and 25-45 year o lds . The r e s u l t s i n d i c a t e d a n i n s i g n i f i c a n t downward t rend f o r non-alcohol-related acc iden t s f o r a l 1 age groups, and a s i g n i f i c a n t downward t rend f o r a l coho l - r e l a t ed a c c i d e n t s and t h e 3FS acc iden t s f o r 18-20 yea r o l d s , but a s i g n i f i c a n t i nc rease f o r t h e 21-24 yea r o l d s i n t h e HBD ca tegory and i n s i g n i f i c a n t i n c r e a s e s i n t h e remaining ca t ego r i e s . Wagenaar concluded t h a t r a i s i n g the d r ink ing age was "an e f f e c t i v e countermeasure f o r t h e major cause of morbidi ty and m o r t a l i t y among young people."

In Ontar io , the d r ink ing and purchasing age for . a l c o h o l i c beverages was reduced i n J u l y 1971. Soon a f t e r , r e p o r t s from school o f f i c i a l s i nd i ca t ed t h a t d i s c i p l i n a r y problema involv ing s t u d e n t s had increased g r e a t l y . Data were a l s o widely pub l i c i zed which i n d i c a t e d l a r g e i nc reases i n a l coho l - r e l a t ed a c c i d e n t s among young people (Whitehead 1977). C i t i z e n groups and a n a s s o c i a t i o n of school p r i n c i p a l s p e t i t i o n e d the government t o r a i s e t h e d r ink ing age. A government-appointed commission held a s e r i e s of publ ic i n q u i r i e s about youthfu l d r ink ing , examined t h e evidence and e v e n t u a l l y concluded t h a t t h e d r ink ing age should be increased (Ontar io Youth S e c r e t a r i a t 1976). The l e g a l age was increased from 1 8 t o 19 y e a r s a s of January 1, 1979; those aged 1 8 before January 1, 1979 could s t i l l l e g a l l y d r ink . The new law r equ i r ed age-of-majori ty c a r d s wi th a photo and increased p e n a l t i e s f o r s e rv ing underage d r inke r s .

A new s tudy from t h e Addict ion Research Foundation ( V i n g i l i s and Smart 1982) ana lyzes f o u r t ypes of d a t a r e l e v a n t t o t h e e f f e c t s of t h e i n c r e a s e i n the Ontar io d r ink ing age. The d a t a a r e from:

o surveys of d r ink ing and d r ink ing problema i n l a r g e samples (n = 4687 and 5794) of h igh school s tuden t s ;

o a s tudy of percept ions of 531 v i ce -p r inc ipa l s ;

o a t r end a n a l y s i s of young d r ink ing o f f ende r charges; and

o a t r end a n a l y s i s of d r i n k i n g l d r i v i n g s t a t i s t i c s .

It was expected t h a t because of t h e n a t u r e of t h e change (one- yea r i n c r e a s e only) t h e e f f e c t s would be smal l but p o s i t i v e . Since r e sea rch on the d e t e r r e n t e f f e c t s of l e g i s l a t i o n has c o n s i s t e n t l y shown i n i t i a l p o s i t i v e e f f e c t s of s h o r t du ra t i on , i t was p red i c t ed t h a t any e f f e c t s would be most v i s i b l e dur ing t h e f i r s t few months of t h e new law.

The r e s u l t e of t h e f o u r s t u d i e s i n d i c a t e few s t a t i s t i c a l l y s i g n i f i c a n t changes s i n c e t h e r a i s i n g of t he d r ink ing age. The high school surveys found t h a t among t h e r e u l a r d r i n k e r s , t h e r e v a s no s i g n i f i c a n t change between 1977 and 1 d- i n t he p ropor t i on of o lde r versus younger s t u d e n t s r e p o r t i n g occur rences of s l i g h t i n t o x i c a t i o n o r heavier a l coho l use i n t h e p r i o r month. The v i ce -p r inc ipa l s tudy found t h a t t h e ma jo r i t y of v ice-pr inc ipa l8 r epo r t ed observing no changes i n dr ink- re la ted behaviors . The d a t a on dr inking-offender charges showed no s i g n i f i c a n t d i f f e r e n c e s a f t e r t h e l e g a l d r ink ing age change. S imi l a r ly , no d i f f e r e n c e s were found f o r d r iv ing conv ic t i ons o r f a t a l i t i e s .

There was some ev idence of minimal, though i n t e r e s t i n g , e f f e c t s o£ t h e dr ink ing law on those i n t he non-regular d r inke r ca tegory . ' The high school survey found a f t e r t h e law change a s i g n i f i c a n t decrease among 1 8 t o 19 y e a r o l d s , but a s i g n i f i c a n t i n c r e a s e i n those under 18 who r epo r t ed dr ink ing and g e t t i n g " t i g h t " du r ing t h e p r i o r month. Add i t i ona l ly , between 20 and 30 percent of t h e v ice-pr inc ipa l8 r epo r t ed a dec rease i n d r ink - r e l a t ed behaviors . Charges a g a i n s t young d r ink ing of f ende r s have moved s l i g h t l y downward s i n c e the i n c r e a s e i n t h e d r ink ing age ; however, t h i s t r end i s i n s i g n i f i c a n t and, with no c o n t r o l group, d i f f i c u l t t o i n t e r p r e t . In summary, t h e s e f i n d i n g s t e n t a t i v e l y seem t o sugges t some minimal e f f e c t f o r 18-19 yea r o l d h igh school s t u d e n t s , but not f o r t h e r e g u l a r (once a week o r more) o r t h e younger d r i n k e r s .

The conv ic t i on and f a t a l i t y s t a t i s t i c s a r e no t s e n s i t i v e enough a s measures; they seem t o show t h a t t o o few tiigh-accident- and-arrest- r i s k youths a r e changing t h e i r d r ink ing p a t t e r n s f o r a c a u s e l e f f e c t r e l a t i o n s h i p t o emerge. These r e s u l t e a r e con t r a ry t o Wagenaar's f i n d i n g s (1980) i n Michigan, where s i g n i f i c a n t downward t r e n d s i n f a t a l i t i e s d i d occur. Iiowever, t h e r e t h e l e g a l age

i n c r e a s e was from 1 8 t o 21 yea r s of age. The minimal e f f e c t i n t h e Ontar io s tudy was p red i c t ed , a s t h e one year i n c r e a s e was not s u f f i c i e n t t o cause a major impact on you th fu l d r i n k i n g behavior .

There seems t o be a sma l l and s e l e c t i v e prevent ion e f f e c t from inc reas ing t h e d r ink ing age by one yea r and a g r e a t e r one from i n c r e a s i n g i t by three . Research of g r e a t e r ref inement and with fewer methodological problems is needed t o v a l i d a t e t he se pre l iminary f indings.

Adver t i s ing of Aicohol ic Beverages

A s u r p r i s i n g amount of energy has been expended on c o n t r o l e on t h e a d v e r t i s i n g of a l c o h o l i c beverages. I n t h e p a s t f i v e yea r s l e g i s l a t i v e deba tes and d i s c u s s i o n s have looked a t a lcohol a d v e r t i s i n g i n Canada, t h e United S t a t e s , England, Finland, Mexico, Honduras, Norway, Spain, Switzer land and Sweden ( s e e Moser 1980 f o r a review). New a d v e r t i s i n g bans have been imposed i n Pak i s t an , Sweden, Norway, and Poland, but s t u d i e s of t h e i r e f f e c t s have not been found. There a r e long-standing bans on a l c o h o l a d v e r t i s i n g i n many Is lamic c o u n t r i e s such a s Egypt, Saudi Arabia , and Kuwait, a s w e l l a s i n Ind ia and Kussia. Aicohol a d v e r t i s i n g seems t o be one a r e a of l e g i s l a t i v e prevent ion i n which p o l i t i c i a n s and government o f f i c i a l s i n a l 1 c o u n t r i e s a r e w i l l i n g t o a c t . There seems t o be no count ry i n which a l coho l a d v e r t i s i n g i s no t s u b j e c t t o government c o n t r o l a a s t o con ten t , time, and space.

Much of the concern a t t he p o l i t i c a l and policy-making l e v e l s i s about the p o s s i b l e impact of a l coho l a d v e r t i s i n g on a c t u a l consumption, both immediately and a s i t a f f e c t s t h e younger genera t ion . Probable sources of concern a r e t h e s h e e r volume of a l c o h o l a d v e r t i s i n g r e l a t i v e t o publ ic -serv ice announcements f o r moderation (McEwan and Hanneman 1974; Smart and Krakowski 1973) , t h e use of l i f e s t y l e appea l s ( Jordan and Goldberg 1977, McEwan and Hanneman 1974), t h e p o s s i b i l i t y of r e s o r t t o subl imina l e r o t i c appea l (Key 1976) , and the imp l i ca t i ons of p o s s i b l e i n f l u e n c e over t he e d i t o r i a l and news t reatment of a l coho l problems i n t h e media.

Representa t ives of t h e a l c o h o l i n d u s t r y t y p i c a l l y main ta in t h a t t h e i r a d v e r t i s i n g does no t a f f e c t o v e r a l l consumption i n t h e popula t ion a t l a r g e , but r a t h e r i n f luences market-shares and brand cho ices w i t h i n t h e i ndus t ry . Research t o d a t e has no t answered t h e ques t i ons of whe t h e r a l coho l a d v e r t i s i n g does i n c r e a s e aggregate consumption ( t h a t is, consumption a c r o s s brands) , a l though many s t u d i e s seem t o support t he i n d u s t r y pos i t ion .

Unfortunately, t he impact of a l coho l a d v e r t i s i n g on consumption i s a d i f f i c u l t a r e a t o research . Simon (1969) put i t t h i s way: "The e f f e c t of l i q u o r a d v e r t i s i n g i s among t h e harder a d v e r t i s i n g e f f e c t s t o measure . . . Liquor execu t ives commonly say

t h a t no one knows and no one can know t h e e f f e c t s o£ l i q u o r - adve r t i s i ng . " In p a r t i c u l a r , he pointed t o two problems: a ) t h e d i f f i c u l t y of p inpoin t ing which s a l e s r e f l e c t which exposure t o what adver t i sments i n which media; and b) t h e p o s s i b l e d i f f u s i o n and cumulation o£ a d v e r t i s i n g e f f e c t s over time. Blane and Hewitt (1980) a r e s i m i l a r l y p e s s i m i s t i c about t h e c u r r e n t s t a t e of knowledge: "Examination of what i s known about a d v e r t i s i n g i n r e l a t i o n t o s a l e s and marketing l e a d s t o no c l ea r - cu t conc lus ion concerning i t s e f f e c t on consumption. " They p a r t i c u l a r l y emphasized t h e d i f f i c u l t y o£ i n t e r p r e t i n g t h e d i r e c t i o n of c a u s a l i t y i n any observed c o r r e l a t i o n between a l coho l s a l e s and a d v e r t i s i n g expendi tures . That is , i t seems j u s t a s l i k e l y t h a t i nc reased s a l e s v i l 1 s t i m u l a t e a d v e r t i s i n g expend i tu re s a s t h a t a d v e r t i s i n g vil1 s t i m u l a t e s a l e s . The fo l lowing s e c t i o n reviews seve ra1 s t u d i e s t h a t show t h e i r concern v a s j u s t i f i e d .

Fo r tuna t e ly , t h e pas t f i v e yea r s have seen a cons iderab le development of empi r i ca l s t u d i e s of a l coho l a d v e r t i s i n g . Research- ers employed econometric and t rend ana lyses , quasi-experimental s t u d i e s and experimental paradigms.

Econometric Analyses

Econometric ana lyses a r e e s s e n t i a l l y m u l t i p l e r e g r e s s i o n ana lyses of s a l e s a s a f u n c t i o n o£ seve ra1 v a r i a b l e s , inc lud ing a d v e r t i s i n g spending o r volume. A number of s t u d i e s have examined a l coho l s a l e s i n r e l a t i o n t o a p r e d i c t o r e e t which inc ludes a d v e r t i s i n g (Bourgeois and Barnes 1979; Grabowski 1976; McGuiness 1979; P e l e s 1971a, 1971b; Simon 1969).

Bourgeois and Barnes (1979) examined t h e pe r c a p i t a consumption of a l coho l i n t h e 1 0 provinces of Canada over 24 years , and conducted s epa ra t e a n a l y s e s f o r beer , wine, l i q u o r and t o t a l consumption of abso lu t e a l coho l . The i r r e s u l t s were complex, t o put i t mildly. Beer consumption was r epo r t ed t o be p o s i t i v e l y r e l a t e d t o p r in t - adve r t i s i ng expendi tures , but nega t ive ly t o those f o r broadcast adver t i s i n g . Liquor , on t he o t h e r hand , r e l a t e d nega- t i v e l y t o p r i n t a d v e r t i s i n g and p o s i t i v e l y t o broadcas t a d v e r t i s i n g -- a s u r p r i s i n g r e s u l t s i nce t h e r e i s no broadcast a d v e r t i s i n g of l i q u o r anywhere i n Canada. Wine s a l e s r e l a t e d p o s i t i v e l y t o broadcast a d v e r t i s i n g only. f i n a l l y , t h e r e was no s i g n i f i c a n t impact of e i t h e r p r i n t o r broadcast a d v e r t i s i n g on s a l e s of t o t a l a lcohol . Presumably, t h e c o n t r a d i c t o r y e £ f e c t e on beer and l i q u o r s a l e s cance l led each o t h e r ou t . These somewhat implaus ib le r e s u l t s may r e f l e c t severa1 problems, t o r example: a ) only f i v e d a t a poir i ts were a v a i l a b l e f o r a d v e r t i s i n g expendi tures ; and b) ques t ionable assumptions had t o be made t o a l l o c a t e a d v e r t i s i n g expend i tu re s i n t o p r o v i n c i a l shares .

Grabowski (1976), no t ing t h a t t h e ques t i on of whether a d v e r t i s i n g p r imar i l y a f f e c t e d s a l e s o r v i c e ve r sa v a s a gene ra l i s s u e i n economlc theory, examined h i e d a t a f o r bo th k inds of i n f luence . His r e s u l t s f o r a d v e r t i e i n g ' s e f f e c t on s a l e s were nega t ive . However, he found, f o r a l coho l a s w e l l a s o t h e r product c a t e g o r i e s , t h a t s a l e s s t r o n g l y p red i c t ed a d v e r t i s i n g expendi tures . When companies have a popular product wi th growing s a l e s , they tend t o i nc rease a d v e r t i s i n g .

McGuiness (1979) examined demand f o r a l c o h o l i c beverages i n t h e United Kingdom over the per iod 1956-1975. He found s i g n i f i c a n t evidence t h a t a d v e r t i s i n g had a modest impact on l i q u o r s a l e s , but t h e r e was no comparable evidence of impact on t he s a l e s of beer , wine, o r c ide r .

P e l e s (1971a, 1971b) came t o t h e conc lus ion t h a t g e n e r a l l y a d v e r t i s i n g a f f e c t s market s h a r e s of beer s a l e s w i t h i n t he a l coho l i n d u s t r y r a t h e r than t o t a l beer s a l e s . He a l s o showed t h a t a d v e r t i s i n g does more f o r t h e market sha re of l a r g e producers than of small producers. Pe les po in ted o u t t h a t adve r t i e ing does eeem t o i n c r e a s e t h e t o t a l demand f o r o t h e r product c a t e g o r i e s , e i t h e r s t a b l y (e.g. c i g a r e t t e s ) o r t emporar i ly (e.g. automobiles , where s a l e s i n a g iven year a r e a t t h e expense of s a l e s i n t h e succeeding year ) .

A pioneering s tudy by Simon (1969) d id no t bear on t o t a l product-category demand, but r a t h e r on market share. He found g r e a t product l o y a l t y , i nd i ca t ed by annual r e t e n t i o n r a t e e of 75 percent . He repor ted t h a t a l coho l a d v e r t i s i n g brought diminishing r e t u r n s a t each l e v e 1 o£ increased expendi ture . F i n a l l y , un l ike P e l e s (1971a) , he concluded t h a t t he p r o f i t r e t u r n s on a d v e r t i s i n g a r e h ighe r f o r smal le r t han f o r l a r g e r a d v e r t isers.

J u r i s d i c t i o n a l Quasi-Experiments

Campbell (1969) was t h e f i r s t t o advocate quaei-experimental s t u d i e s of t h e e f f e c t s of l a rge - sca l e s o c i a l changes. One kind of s o c i a l change t h a t can be s t u d i e d i n t h i s way i s t h e e f f e c t of i n t r o d u c t i o n o r removal of r e s t r i c t i o n s on a l coho l adve r t i s i ng .

Smart and Cut le r (1976) s t u d i e d t h e e f f e c t of t h e 1971 a l coho l a d v e r t i s i n g ban i n B r i t i s h Columbia by comparing consumption f i g u r e s f o r B.C. and Ontar io , t he most comparable j u r i s d i c t i o n s . They concluded t h a t t h e i r data" . . . l e n t l i t t l e suppor t f o r t h e view t h a t t h e B.C. a d v e r t i s i n g ban reduced a l coho l coneumption" (p.20). However, t h e e f f e c t i v e n e s s of t h e ban was compromised by continued exposure t o a d v e r t i s i n g i n n a t i o n a l newspapers and magazinee, and broadcas t a d v e r t i s i n g from Albe r t a and t h e s t a t e of Washington a c r o s s t h e U.S. border.

More r e c e n t l y , Ogborne and Smart (1980) s t u d i e d t h e 1974 beer a d v e r t i s i n g ban i n Manitoba. They repor ted t h a t beer consumption showed a s i g n i f i c a n t i n c r e a s e under t h e ban, comparable t o t h e p a t t e r n i n Alber ta (where t h e r e was no ban) over t h e sanie i n t e r v a l . The same problem of cont inued exposure t o out-of-province adver- t i s i n g app l i ed he re a s i n t h e Smart and C u t l e r (1976 ) study. The r e sea rch team a l s o found no s i g n i f i c a n t r e l a t i o n s h i p s between t h e comprehensiveness of a d v e r t i s i n g r e s t r i c t i o n s i n t h e v a r i o u s states of t h e United S t a t e s and measures of a l coho l consumption o r alcoholism.

Experimental S t u d i e s

Few experimental s t u d i e s of a l coho l a d v e r t i s i n g have been done. Brown (1978a) ass igned 30 s o c i a l d r i n k e r s t h e t a s k o£ e s t ima t ing t h e l i q u o r and mix con ten t of vodka and t o n i c mix tures of varying concent ra t ion . The t a s k provided an oppor tun i ty f o r measurable d i f f e r e n t i a l consumption of the vodka. Sub jec t s were a l t e r n a t i v e l y exposed t o c i g a r e t t e and a l coho l a d v e r t i s i n g i n a counterbalanced within-subject experimental des ign . Sub jec t s d rank s i g n i f i c a n t l y more vodka a f t e r exposure t o a l c o h o l a d v e r t i s i n g than a f t e r exposure t o c i g a r e t t e a d v e r t i s i n g . Brown concluded t h a t a l coho l a d v e r t i s i n g i n c r e a s e s t h e subsequent consumption of ava i l - a b l e a lcohol . iiowever, t h e r e is an a l t e r n a t i v e i n t e r p r e t a t i o n : pos s ib ly , the a l coho l a d v e r t i s i n g heigntened s u b j e c t s t awareness of t h e range of a l coho l a l t e r n a t i v e s . Because t o n i c heav i ly masks t h e f l a v o r of l i q u o r , and vodka i s e a s i l y masked i n t h e p ropor t i ons used by Brown (0:10, 1:9, 1:7, 1:5, and 1:3) , t he s u b j e c t s might have drunken more because they were t r y i n g harder t o i d e n t i f y t h e l i q u o r i n u se , being i n a s t a t e of heightened app rec i a t i on of a l t e r n a t i v e p o s s i b i l i t i e s .

Kohn, Smart, and Ogborne, i n an as-yet-unreported s tudy (1979), examined t h e impact of two k inds of p r i n t a d v e r t i s i n g f o r Heinekents beer -- s o c i a l con tex t o r l i f e s t y l e a d v e r t i s i n g and product -qua l i ty a d v e r t i s í n g -- on short-term and long-term a l coho l consumption. Short-term consumption was measured by g i v i n g s u b j e c t s a 5 d o l l a r food voucher t o e a t i n a l o c a l l i c ensed r e s t a u r a n t f r a n which t h e experimenters ob ta ined feedback on s u b j e c t s ' a l c o h o l consumption. Long-term consumption was measured by a r e t r o s p e c t i v e te lephone in t e rv i ew ( a t l e a s t s i x weeks l a t e r ) on consumption of both non-alcoholic and a l c o h o l i c beverages. Experimental s u b j e c t s were asked t o e v a l u a t e e i t h e r f i v e soc ia l -contex t adver t i sements o r f i v e produc t -qua l i t y adver t i sements i n a t y p i c a l marke t - research manner. Control s u b j e c t s were quest ioned about t h e i r e v a l u a t i o n s of t he shopping mal1 where t h e d a t a were c o l l e c t e d and rece ived t h e same voucher a s experimental s u b j e c t s . Although t h e d a t a a r e no t y e t f u l l y analyzed, i t was found t h a t a d v e r t i s i n g exposure had no s i g n i f i c a n t e f f e c t on purchase of a l c o h o l i c beverages a t t h e r e s t a u r a n t , n e i t h e r when combining a l 1 c a t e g o r i e s of a l coho l ( i . e .

wine, domestic beer , imported beer , and l i q u o r ) no r when cons ider ing them sepa ra t e ly . The te lephone in t e rv i ewer s , a l s o , found no long-term e f f e c t .

üha t can be concluded about t h e e f f e c t s of a l c o h o l a d v e r t i s i n g on t o t a l consumption? It would be u s e f u l t o have more s t u d i e s of a d v e r t i s i n g bans, e s p e c i a l l y t hose i n Scandinavia, as w e l l a s more experimental s t u d i e s . Also, t h e e f f e c t s of a d v e r t i s i n g over a l onge r per iod of t i m e , a s f o r example a genera t ion , need t o be examined. A t p r e sen t , however , t h e evidence t h a t a d v e r t i s i n g has much e f f e c t on s p e c i f i c o r t o t a l s a l e s of a l c o h o l i c beverages 1s very weak and inconclusive. It may wel l be t h a t al1 t h e l e g i s l a t i v e e f f o r t s a t c o n t r o l i n t h i s a r e a w i l l have l i t t l e impact. E f f o r t s miglit b e t t e r be d i r e c t e d elsewhere, f o r example towards p r i c e o r a v a i l a b i l i t y c o n t r o l s .

Research on Legal Control i n t h e WHO Region of t h e Americas

To d a t e , t h e s t u d i e s o£ l e g a l c o n t r o l s and a l c o h o l problems have looked a t Europe , North America, and Aus t r a l a s i a . S imi la r s t u d i e s a r e almost non-exis tent i n La t in American and Caribbean coun t r i e s . Indeed, good d a t a on a l coho l consumption over time seem t o be almost unava i lab le f o r many such coun t r i e s . For example, t h e World Alcohol P ro j ec t (Sulkunen 1976) contained d a t a on 33 c o u n t r i e s , but only Cuba and Peru were included from t h e l e s s developed c o u n t r i e s of t h e Americas. An e a r l i e r World Health Organizat ion r epo r t (Moser 1974) developed d a t a on a l c o h o l problems and programs i n Chi le , but no o t h e r L a t i n American country.

A more recent r epo r t (Moser 1980) does, however, have a wide v a r i e t y of information on a l c o h o l consumption and c o n t r o l s i n t h e reg ion . Probably many c o u n t r i e s now have s u f f i c i e n t in format ion t o do s t u d i e s of l e g a l c o n t r o l s and consumption. However, t h e r e a r e s t i l l v i r t u a l l y no La t in American o r Caribbean s t u d i e s of : a ) a v a i l a b i l i t y and consumption; b) t h e working of i n d i v i d u a l a l coho l c o n t r o l s d i r e c t e d toward a d v e r t i s i n g , age , hours of s a l e , e t c . ; c ) t he i n f luence of p r i c e on consumption; and d ) p r i c e e l a s t i c i t i e s f o r v a r i o u s beverages. An except ion 1s t h e work of Beaubrun (1977) on t h e c l o s e c o r r e l a t i o n s between t h e p r i c e of rum, consumption, and a c c i d e n t s i n Tr in idad and Tobago.

It 1s very doubt fu l t h a t r e s u l t s from t h e more developed world can be app l i ed wi thout change t o L a t i n America and the Caribbean. Local consurnption h a b i t s and t h e s o c i o c u l t u r a l m i l i e u a r e s o d i f f e r e n t as t o make such a p p l i c a t i o n very r i sky . Perhaps a few examples w i l l s u f f i c e . I n many a r e a s of L a t i n America l o c a l l y produced beverages, such as pulque, chicha, and rum, a r e o f t e n not c o n t r o l l e d o r taxed by t h e government. Attempts a t p r i c e o r l e g a l c o n t r o l s of o t h e r a l c o h o l i c beverages may simply l ead t o a s h i f t

towards t he l o c a l l y produced v a r i e t i e s . I n many r u r a l a r e a s , too , i t may be economic t o d r i n k a l c o h o l i c beverages because t hey c o n t a i n c a l o r i e s and a r e cheaper , s a f e r , and more a v a i l a b l e than water o r milk (Negrete 1976). Las t l y , such c o u n t r i e s o f t e n have l a r g e a r e a s where a l coho l consumption i s inc reas ing r ap id ly , due t o tourism o r a l a r g e in f l ux of workers, a s f o r t h e petrochemical i ndus t ry . Typical- l y , such s i t u a t i o n s a r e d i f f i c u l t f o r governments t o c o n t r o l and a l c o h o l problems a r e o f t e n s u b s t a n t i a l .

C lea r ly , t h e r e is a need f o r s t u d i e s of p revent ion and l e g a l c o n t r o l s i n L a t i n American and Caribbean c o u n t r i e s . Such s t u d i e s might be done with t h e a i d of t h e World Heal th Organiza t ion o r o t h e r i n t e r n a t i o n a l agenc ies . A s t a r t h a s been made i n Mexico w i t h a WHO- sponsored s tudy of community responses t o a l coho l problems. However, t h i s s tudy does no t bea r d i r e c t l y on t h e working of l e g a l con t ro l s .

Conclusions

The a v a i l a b l e e m p i r i c a l s t u d i e s a l l ow on ly some t e n t a t i v e conc lus ions about the prevent ion of a l coho l - r e l a t ed problems. Research i n t h i s a r e a is expanding quick ly and any conc lus ion can e a s i l y become da ted . A t l e a s t the fo l lowing can be suggested:

1 ) There is widespread agreement t h a t governments have a r o l e i n prevent ion of a l coho l problems which inc ludes , but goes we l l beyond , the need t o provide t rea tment f o r a l coho l i c s . That r o l e is t o examine how c u r r e n t p o l i c i e s and laws r e spec t ing a v a i l a b i l i t y , p r i c e , and a d v e r t i s i n g of a l c o h o l i c beverages a f f e c t both s a l e s and a l c o h o l problems and t o seek me t hod s of reducing problems through government a c t ion.

2) Overa l l s t u d i e s of a v a i l a b i l i t y show t h a t i t has i nc reased along with a f f l u e n c e , u rban iza t ion , and t h e g e n e r a l accept- a b i l i t y of a l coho l i n s o c i e t y . Aithough a v a i l a b i l i t y of a l coho l has i nc reased i n many c o u n t r i e s , i t s e f f e c t s on consumption a r e impossible t o s e p a r a t e from broader s o c i a l and c u l t u r a l changes.

Numerous smal l changes i n hours of s a l e and numbers of d r ink ing e s t ab l i shmen t s have no s i g n i f i c a n t e f f e c t on t h e amount of d r ink ing . However, many l a r g e r changes i n numbers of o u t l e t s , f o r example i n Finland i n t h e 196OVs, do have a g r e a t e f f e c t . S t r i k e s by l i q u o r s t o r e employees and c l o s i n g s t o r e s on Saturdays have both a f f ec t ed consumption and drunkenness. P roh ib i t i on , bo th t o t a l and p a r t i a l ( a s i n no r the rn Ontar io) , h a s had cons iderab le e f f e c t on consumption and problems. When governments wish t o decrease consumption through changing a v a i l a b i l i t y , d r a s t i c measures w i l l u s u a l l y be requi red .

4 ) Per c a p i t a a l coho l consumption seems t o have s t a b i l i z e d i n many c o u n t r i e s over t h e pas t f i v e years . A t p r e sen t we do not have good exp lana t ions f o r t h i s phenomenon, nor do w e know what e f f e c t i t w i l l have on governrnent revenues and t h e tendency of governments t o c r e a t e new demand o r i n c r e a s e a v a i l a b i l i t y .

5) There a r e some i n d i c a t i o n s t h a t t h e d r e a t i n c r e a s e s i n a l coho l a v a i l a b i l i t y s i n c e World War 11 may be ended, a t l e a s t t emporar i ly , i n many Wes t e r n coun t r i e s .

6) Both econometric and experimental s t u d i e s sugges t t h a t s a l e s of a l c o h o l i c beverages u s u a l l y behave much as s a l e s of o t h e r consumer goods. People buy more when they a r e cheap and l e s s when they a r e a r e not . However, t h e exac t r e l a t i o n s h i p s between p r i c e and consumption a r e v a r i a b l e and sub jec t t o many f a c t o r s d i f f i c u l t t o c o n t r o l and study. Experimental s t u d i e s of s i t u a t i o n s where p r i c e is manipulated may g ive b e t t e r r e s u l t s t han pursuing la rge-sca le econometric s t u d i e s .

7 ) Some s t u d i e s show t h a t a l coho l use lowers t h e r i s k o£ coronary h e a r t d i s e a s e ; many show t h a t i t i n c r e a s e s t h e r i s k of l i v e r c i r r h o s i s . Governments, i n s e l e c t i n g a l c o h o l c o n t r o l p o l i c i e s , may be r equ i r ed t o decide between these e f f e c t s .

8) b w e r i n g the d r ink ing age appeared t o i n c r e a s e con- sumption, a l coho l - r e l a t ed t r a f f i c acc iden te , and admissions t o t rea tment f o r t h e age group a f f e c t e d . Rais ing dr ink ing ages has been shown t o dec rease con- sumption and, where t h e change is s u b s t a n t i a l , decrease a lcohol - re la ted acc iden t s .

9) Research on a d v e r t i s i n g of a l c o h o l i c beverages does not i n d i c a t e t h a t i t h a s an important e f f e c t on s a l e s o r consumption. L e g i s l a t i v e e f f o r t s a t p revent ion of a l c o h o l problems a r e misd i rec ted i f focused on a d v e r t i s i n g .

10) Kesearch on a v a i l a b i l i t y , p r i c e , consumption, and problems i s needed i n L a t i n American and Caribbean count r ies . Research from o t h e r c o u n t r i e s cannot be e a s i l y gene ra l i zed t o these coun t r i e s .

The empir ica l evidence i n t o t a l sugges t s t h a t p revent ion of a lcohol - re la ted problems depends upon holding a v a i l a b i l i t y and p r i c e s cons tan t o r even reducing a v a i l a b i l i t y , keeping acces s f o r young people l i m i t e d and hoping t h a t t h e p re sen t t r end towards a p l a t e a u i n a l c o h o l consumption cont inues where i t has begun. I n c e r t a i n c o u n t r i e s i t may be p o s s i b l e t o make l a r g e changes i n p r i c e o r a v a i l a b i l i t y , bu t i n o r d e r t o have a s u b s t a n t i a l e f f e c t they must be very l a r g e , probably l a r g e r t han most governments w i l l consider .

2 46

DISCUSSANT

Michael H. Beaubrun

It would be d i f f i c u l t t o d i s ag ree w i t h t h e o v e r a l l conc lus ion of D r . Smart t h a t " the a v a i l a b l e empi r i ca l s t u d i e s a l low only some t e n t a t i v e conc lus ions about t h e prevent ion of a l coho l - r e l a t ed problems . " Yet, t h e r e i s i n c r e a s i n g worldwide consensus t h a t a v a i l a b i l i t y and p r i c e a r e everywhere c l e a r l y r e l a t e d t o consumption and t o problems due t o a l coho l , though s o c i o c u l t u r a l f a c t o r s modify t h e p i c t u r e considerably.

It i s t r u e t h a t c o r r e l a t i o n s a r e no t ipso- fac to evidence of causa t ion , and i t i s no t easy t o s e p a r a t e t h e v a r i a b l e s involved- However, t h e sheer weight of the i nc reas ing evidence from econometric and experimental s t u d i e s s t r o n g l y sugges ts t h a t t here i s a cause and e f f e c t r e l a t i o n s h i p , and t h e r e a r e s u f f i c i e n t i n s t a n c e s of " n a t u r a l experiments" t o j u s t i f y ou r advocacy of some c o n t r o l s t r a t e g i e s aimed a t reducing a v a i l a b i l i t y , provided we recognize t h e l i m i t s of such con t ro l s .

1 w i l l t r y t o avoid going over t h e ground covered i n the e x c e l l e n t review by D r . Smart of t h e a v a i l a b l e r e sea rch and w i l l t r y i n s t e a d t o d i s c u s s some of t h e imp l i ca t i ons of h i s f i n d i n g s and t o r e l a t e them t o ou r Caribbean experience.

"Supply Side" S t r a t e g i e s

D r . Smart f ound a s i g n i f i c a n t , p o s i t i v e c o r r e l a t i o n between per c a p i t a consumption and o v e r a l l a v a i l a b i l i t y i n t h e United S t a t e s (Smart 1977b). Yet he no t e s t h a t t he c o r r e l a t i o n of consumption with income w a s even g r e a t e r , and t h e r e was a c l o s e p o s i t i v e c o r r e l a t i o n wi th urbaniza t ion .

Makela e t a l . (1982), i n t h e ISACE s tudy , a l s o emphasized t h e importance of a f f l u e n c e and u rban iza t ion , as w e l l a s l i b e r a l i z e d a t t i t u d e s and o t h e r s o c i o c u l t u r a l f a c t o r s . The conc lus ion i s t h a t i t i s impossible t o s e p a r a t e a v a i l a b i l i t y from income and o t h e r s o c i a l and c u l t u r a l f a c t o r s .

Economic A v a i l a b i l i t y A f i e l d s tudy of d r ink ing p r a c t i c e s i n suburban Kingston, Jamaica, conducted i n 1966 (Beaubrun 1968) showed a very c l e a r c o r r e l a t i o n between d r ink ing and s o c i a l c l a s s a s de f ined by housing a r ea . Here, too , income seemed t h e most important s i n g l e v a r i a b l e . We have no s t u d i e s of t h e e f f e c t of l i b e r a l i z a t i o n of c o n t r o l s o r of t h e e f f e c t of l i q u o r s t o r e s t r i k e s , bu t economic a v a i l a b i l i t y i n Jamaica seemed r e l a t e d t o heavy dr ink ing . In most of t h e Caribbean i s l a n d s , a l c o h o l i s f r ee ly a v a i l a b l e and can be purchased i n supermarkets, g r o c e r i e s and, i n some p laces , even i n vending machines. The only r e a l cu rb on a v a i l a b i l i t y i s economic a v a i l a b i l i t y determined by income and p r i ce .

C i r r h o s i s m o r t a l i t y rates i n t h e Caribbean bear a rough r e l a t i o n s h i p t o t h e r a t i o between income and t h e p r i c e of beverage a lcohol . Tourism c e n t r e s l i k e t h e Bahamas, Puerto Rico, Mart inique, Aruba, and t h e Vi rg in I s l a n d s have very h igh r a t e s . There t h e p r i c e of a l c o h o l i s low and incomes r e l a t i v e l y h igh by Caribbean s t a r r dards . Mor t a l i t y r a t e s from a l coho l - r e l a t ed causes a r e h igher i n t he Vi rg in I s l ands than i n any s t a t e i n t h e United S t a t e s . (U.S. Department of t ieal th and Human Se rv i ce s r epo r t 1981)

Alcohol O u t l e t s and llours of Sa l e : Re la t ionsh ip t o Consumption and Problems It i s no t s u r ~ r i s i n n t o f i n d t h a t small channes i n hours of s a l e and numbers of o;tletsWhad few s i g n i f i c a n t e f f e G s , bu t t h a t l a r g e r changes d i d . It would be important t o s tudy no t on ly t h e frequency of o u t l e t s but t h e i r l oca t ion .

We have the impression t h a t t h e l o c a t i o n of ba r s nea r t o p laces where men a r e paid poses a d i s t i n c t hazard. In those Caribbean I s l ands where t h e r e a r e o i l r e f i n e r i e s , suga r f a c t o r i e s , and o t h e r i n d u s t r i e s , b a r s l o c a t e d near t h e en t r ance of t h e work p lace do a roa r ing t r a d e on pay day, and even i n t h e absence of r e sea rch f i nd ings , we have gone on record as recommending t h a t no bar should be l oca t ed nea r t h e p l ace where workers a r e paid (Beaubrun and Mahy 1980).

P r i ce and Taxat ion The s i n g l e - d i s t r i b u t i o n t h e o r i s t s have u s u a l l y made p r i c e c o n t r o l t h e i r major reconnnendation based on t h e c l e a r r e c i p r o c a l r e l a t i o n s h i p between r e a l p r i c e and consumption, which i n t u r n i s r e l a t e d t o h e a l t h and s o c i a l damage (Sealey 1960, Popham, Schmidt and de L in t 1975). The inve r se r e l a t i o n s h i p between p r i c e and l i v e r c i r r h o s i s m o r t a l i t y demonstrated i n Ontar io h a s s i n c e been shown t o r e l a t e t o o t h e r damage a s wel l . Hospi ta l admissions f o r a lcohol i sm i n Scotland showed a s i m i l a r i n v e r s e r e l a t i o n s h i p with r e a l p r i c e of a l coho l (Semple and Yarrow 1974), and we have found i n Tr in idad and Tobago an even c l o s e r r e c i p r o c a l r e l a t i o n s h i p between r e a l p r i c e and road t r a f f i c a c c i d e n t s (Beaubrun 1977).

I n t h e Tr in idad s tudy , t h e c o r r e l a t i o n we ob t a ined between t h e r e l a t i v e p r i c e and a c c i d e n t s over the 10-year per iod 1966-1975 was s o c l o s e ( R = -0.978) t h a t i t seemed unbel ievable . Subsequent small changes i n t h e f i g u r e s put o u t by t h e c e n t r a l s t a t i s t i c a l o f f i c e may reduce t h e l e v e 1 of t h i s c o r r e l a t i o n but i t s t i l l remains h i g h l y s i g n i f i c a n t . ühat i s most s i g n i f i c a n t i s t h a t b reaks i n t h e graphs showing sudden dec reases i n road a c c i d e n t s i n 1968 and a g a i n i n 1973 were c o r r e l a t e d w i th s i g n i f i c a n t i n c r e a s e s i n t h e e x c i s e and purchase t a x e s on a l coho l r e f l e c t e d by r i s e s i n r e l a t i v e p r i ce . I n each of those two years , purchase t a x on rum was i nc reased by 100 percent . In 1968, t h e r e was a l s o a n i n c r e a s e of t h e e x c i s e t a x on a l coho l from TT 89.50 t o TT $12.00 p e r impe r i a l proof ga l lon . These t a x i nc reaees were introduced a s revenue earn ing measures, bu t t h e i r e f f e c t on t h e acc iden t r a t e was dramatic.

A c l o s e r look a t t h e acc iden t statist ics shows us t h a t most of t he se a c c i d e n t s were caused by d r i v e r s under t h e age of 25, who were u n l i k e l y t o be a l c o h o l i c s a s y e t . A r ecen t f i e l d s t u d y of d r ink ing i n Tobago showed the mean age of heavy d r ink ing was 25 t o 34 years ( P a t r i c k and P a t r i c k 1980). I nc reases i n t h e p r i c e of beverage a l coho l a r e more l i k e l y t o be f e l t by young people who have less money i n t h e i r pockets, and t h i s may be why p r i c e e f f e c t s on t h e t o t a l a cc iden t rate a r e s o g r e a t .

These graphs were presen ted t o t h e upper liouse of t h e Parl iament of Trinidad and Tobago i n December 1977 dur ing a budget debate . I n January 1978, t h e rum manufacturers i nc reased t h e p r i c e of rum by 25 percent and t h e acc iden t rate showed a corresponding d e c l i n e (Beaubrun and Mahy 1980).

One of the major problems i n implementing c o n t r o l s t r a t e g i e s i s t h e problem of mobil iz ing t h e p o l i t i c a l w i l l . P o l i t i c i a n s w i l l i n t h e main do what t hey f e e l t h e v o t e r s would want, and t h e b e s t approach t o them i s through t h e publ ic . But, t he re i s a l s o t he problem of convincing m i n i s t e r s of f i nance o r chance l lo r s of t h e excheqwr t h a t s t r a t e g i e s proposed as a h e a l t h measure w i l l not i n t e r f e r e wi th t a x revenue. It i s t h e r e f o r e important a l s o t o conduct econometric s t u d i e s which c l e a r l y i n d i c a t e what t ax i n c r e a s e s a r e compatible wi th both improved h e a l t h and improved revenue. A r ecen t econometric s tudy by Duffy i n t h e United Kingdom examined t h e inf luence of " p r i c e s , consumer incomes and a d v e r t i s i n g upon t h e demand f o r a l c o h o l i c d r i n k i n t he U.K." Among o t h e r t h i n g s , i t c l e a r l y showed t h a t t a x revenue could be increased and consumption reduced q u i t e s i g n i f i c a n t l y by r a i s i n g t h e r a t e s of duty, e s p e c i a l l y on s p i r i t s (Duffy 1981).

Another f i nd ing of t h a t s tudy suppor t s t h e conc lus ion a r r i v e d a t by D r . Smart, t h a t s t u d i e s t o d a t e i n d i c a t e that a d v e r t i s i n g c o n t r o l s a r e a r e l a t i v e l y i n e f f e c t i v e way of r e s t r a i n i n g a lcohol consumption (Duff y 1981).

Changes i n t he Drinking o r Purchasing Age Limi ts The s t u d i e s reviewed seemed t o negate the "forbidden f r u i t " hypotheeis - - (Wilkinson 1970). ~ower i& t h e d r ink ing age increased consumption and d r ink ing /d r iv ing problems. Increas ing t h e d r ink ing age seemed t o r e s u l t i n fewer a l coho l - r e l a t ed problems.

Our f i e l d stuciy i n Jamaica i n 1966 showed t h a t heavy d r ink ing was r e l a t e d t o t h e age a t which Jamaicans s t a r t t o dr ink . This f i n d i n g was s i g n i f i c a n t a t t h e .O5 l e v e l , sugges t ing t h a t any measure which could de lay t h e s t a r t o f d r ink ing might r e s u l t i n fewer excess ive d r i n k e r s and, t h e r e f o r e , fewer d r ink ing problems.

There may be o t h e r ways of de lay ing t h e s t a r t of d r ink ing . We have a l r eady spoken of the s t r a t e g y of p r i c i n g a l c o h o l o u t s i d e t h e reach of youngsters . It is important t h a t the p r i c e of beer be c l e a r l y h igher than t h a t of a s o f t d r i n k l i k e Pepsi o r Coke. In some of our i s l a n d s , however, t h i s i s not s o and we have even encountered s i t u a t i o n s where s o f t d r inks would on ly be served a s a "chaser."

Sometimes, too , t h e r e a r e l e g a l age limits which a r e not enforced a t a l l . In most Caribbean c o u n t r i e s t h e r e is a l e g a l age l i m i t , bu t c h i l d r e n walk i n t o supermarkets and buy a l c o h o l without being questioned.

D r . Smart concludes t h a t t h e "empir ical evidence i n t o t a l sugges ts t h a t t he prevent ion of a l coho l - r e l a t ed problems depende upon holding a v a i l a b i l i t y and p r i c e s cons t an t o r even reducing a v a i l a b i l i t y , keeping a c c e s s f o r young people l i m i t e d , and hoping t h a t t he presen t t r end toward the p l a t eau of a l c o h o l consumption cont inues where i t has begun."

With t h i s view 1 am i n complete agreement. There is need t o index t axes and p r i c e s of beverage a l coho l s o t h a t t he r e a l p r i c e does no t f a 1 1 i n r e l a t i o n t o income. And y e t , t h i s measure a l o n e would no t be enough, f o r each count ry has s o c i o c u l t u r a l f a c t o r 8 which modify t h e p i c t u r e .

I n 1980, a meeting of t h e ministers r e spons ib l e f o r h e a l t h o f t h e Caribbean community passed Resolu t ion 26 on t h e s u b j e c t of alcoholism. That r e s o l u t i o n adopted r educ t ion of consumption a s a g o a l of h e a l t h po l i cy , and member governments were urged t o adopt S t r a t e g i e s aimed a t reduc ing a v a i l a b i l i t y a s w e l l a s s t r a t e g i e s aimed a t reducing t h e demand f o r a lcohol . The a u t h o r s of t h a t r e s o l u t i o n s t a t e d t h a t they wished t o draw a t t e n t i o n e s p e c i a l l y :

. . . t o t h e f a c t t h a t t h e most important s i n g l e method of reducing demand i s p r i c e manipulat ion by t axa t ion , a s wel l a s t o t h e a s s e r t i o n t h a t : "Alcohol i s s o much a p a r t of our way of l i f e i n t h e Carib- bean t h a t i t would be a mistake t o a t tempt t o reduce

consumption by too d r a s t i c a p rog rame of f i s c a l and l e g a l measures. The aim should be t o at tempt t o lower consumption g radua l ly over t h e next decade by a combination of educa t ion about t h e hazards of a l coho l use combined wi th such f i s c a l and l e g a l measures a s may be necessary t o prevent t h e r e a l p r i c e of a l coho l from f a l l i n g , while we at tempt t o moderate our dr inking l i f e - s t y l e . (Caricom Heal th Min i s t e r s Meeting 1980).

Demand Control Fac to r s

A c r i t i c i s m t h a t might be made of t h i s review i s t h a t i t s scope was t o o l imi ted . It d e a l t exc lus ive ly wi th l e g i s l a t i o n a f f e c t i n g a v a i l a b i l i t y , concent ra t ing on p r i c e manipulat ion, c o n t r o l s of marketing, numbers of o u t l e t s , and age limits. I n a supply and demand model t h e s e would a l1 be "supply s ide" s t r a t e g i e s . The only measure d iscussed which might be seen as a f f e c t i n g "demand" would be t h e c o n t r o l of adve r t i s ing .

The Brea tha lyser and Scandinavian-type laws have n o t been mentioned, nor have compulsory d r i v e r educa t ion programs f o r "d r iv ing while i n tox ica t ed" (DWI) offences. The f i n a l r e p o r t of t he U.S. Department of T ranspor t a t ion on "Deterrence of t he Drinking Driver: An I n t e r n a t i o n a l Survey" (Ross 1981) has been g iven t o us and i t would be appropr i a t e t o have mentioned some of t hese f ind ings .

I n t e r n a t i o n a l experience shows u s t h a t i n t h e s h o r t run Scandinavian-type laws, e s p e c i a l l y i f coupled wi th some res ons ib l e Sh-r im~lemen ta t ion . and hinh v i s i b i l i t v . r e s u l t i n s i n n i f i c a n t r e uc t on - i n a c c i d e n t s and m o r t a l i t y bu t t h a t i n the l o w run this d e t e r r e n t e f f e c t t ends t o be l o s t cien i n a few yea r s , a s -public percept ion of t h e t h r e a t of being caught recedes. Ce r t a in ty of d e t e c t i o n i s t h e important v a r i a b l e and not s e v e r i t y of punishment. C e l e r i t y of punishment has y e t t o be proper ly eva lua ted .

Even i n t he l i g h t of t h e tendency f o r e f f e c t s t o diminish i n t h e long term, we cannot e a s i l y ignore t h e tremendous saving of himran l i f e represented by t h e e a r l y ga ins , which a lone would j u s t i f y t h e l e g i s l a t i o n . We must, however, cont inue t o search f o r b e t t e r ways of enhancing the perceived t h r e a t of de t ec t ion .

As D r . Heath's paper was concerned with eva lua t ing e x i s t i n g research , i t may not be app ropr i a t e t o d i s c u s s prevent ive l e g i s - l a t i o n which has never been t e s t e d o r assessed . However, t h e r e have been some proposed measures, such a s l e g i s l a t i o n r equ i r ing a t echno log ica l device t h a t would r e q u i r e a c e r t a i n degree of d e x t e r i t y i n o rde r t o s t a r t a c a r .

One method of l e g a l i n t e r v e n t i o n which, i f i t had been supported i n t h e Appeals Court , might have had a s i g n i f i c a n t e f f e c t on drunken d r i v i n g was a C a l i f o r n i a ca se which n e a r l y became a precedent . T h i s was t h e ca se where t h e p r o p r i e t o r of a ba r was he ld t o be r e spons ib l e i n law f o r t h e acc iden t i n which h i s drunken customer became involved. Had t h i s judgement been upheld i t might have made ba r t ende r s r e f u s e t o s e11 d r i n k s t o people who were becoming in tox i ca t ed . 1 am t o l d t h a t f o r a while i t d i d have j u s t t h i s e f f e c t -- u n t i l t h e c a s e went t o appeal. Concluding Remarks

Cont ro ls a r e od ious , p a r t i c u l a r l y i n democracies where a h igh va lue 1s placed on persona l freedom; y e t t h e r e 1s some evidence t o show t h a t c o n t r o l s a r e s t i l l t h e most e f f e c t i v e method a v a i l a b l e t o u s f o r changing behaviour. Treatment and educa t ion have done l i t t l e t o d a t e t o stem t h e t i d e of t h i s world-class problem.

I n a n e a r l i e r l e c t u r e , 1 r e f e r r e d t o t h e words of Shakespeare 's S i r Toby Belch who, wlien chided f o r h i s drunken r e v e l r y , s a i d t o Malvolio: "Dost thou th ink , because thou a r t v i r t u o u s , t h e r e s h a l l be no more cakes and a l e ? " S i r Toby, l i k e t he rest of us , r e sen t ed having h i s p l ea su re con t ro l l ed .

DISCUSSANT

Maria Elena Medina-Mora

Using D r . Smart ' s e x c e l l e n t paper a s a po in t of depa r tu re , 1 w i l l concen t r a t e my remarks on t h e impact of p revent ive measures i n L a t i n American coun t r i e s . There 1s agreement t h a t some p o l i c i e s o r i n t e r v e n t i o n s could have more e f f e c t than o t h e r s . The problem 1s t o dec ide how and under what c i rcumstances they w i l l be e f f e c t i v e , t o whom they should be geared , and what s o c i o c u l t u r a l cond i t i ons f a c i l i t a t e o r l i m i t t h e prevent ive p o t e n t i a l of t h e d i f f e r e n t types of measures. Only then can we make concre te reconnnendations.

The count ry of Mexico 1s a p a r t i c u l a r l y u s e f u l example t o s tudy prevent ive measures , because i t 1s r e p r e s e n t a t i v e of a number o£ o t h e r s w i t h s i m i l a r c h a r a c t e r i s t i c s such a s s t a g e of development, socioeconomic change, c u l t u r a l norms and va lues , p g t t e r n s of consumption, d i v e r s i t y i n t h e e x i s t i n g l e g i s l a t i o n , and a l a c k of r e sea rch t o support p o s s i b l e p o l i c y recommendations. I n any case,

recommendations f o r p revent ive measures must t ake i n t o account t h e g e n e r a l con tex t , inc lud ing t h e a v a i l a b i l i t y o r l i m i t a t i o n of resources , t h e l e v e 1 of l i t e r a c y , c u l t u r a l b a r r i e r e , e t c .

The d a t a reviewed by D r . Smart c l e a r l y show that small and i s o l a t e d changes i n c o n t r o l s b r ing about only shor t - l ived and moderate changes i n consumption, and he lp d imin ish confidence i n t h e judgement of those who proposed such changes. Any a l t e r n a t i v e proposed must be a complete a l t e r n a t i v e , an adequate one. It must be eva lua ted from a l 1 p o i n t s of view, i n s o f a r a s pos s ib l e , p e r t a i n i n g t o both t he economic and s o c i a l e f f e c t s , bu t a l s o t h e c o l l a t e r a l r e s u l t s t h a t could be der ived .

I n many reg ions i t might be economical t o d r i n k a l c o h o l i c beverages because they have c a l o r i e s and a r e cheaper , l e s s harmful, and more a v a i l a b l e than o t h e r beverages such a s water o r milk. I n such s i t u a t i o n s it would be necessary t o r a i s e t h e s tandard of l i v i n g s imultaneously w i th i n c r e a s i n g c o n t r o l of a l c o h o l a v a i l - a b i l i t y , o r e l s e s i d e e f f e c t s might become more dangerous than pe rmi t t i ng t h e s a l e of a lcohol .

Mexico h a s a l r e a d y had some exper iences w i th l i m i t a t i o n of a v a i l a b i l i t y of a l c o h o l i c beverages. The f e d e r a l d i s t r i c t , f o r a per iod of f i v e years , beginning i n 1950, p roh ib i t ed t h e r e t a i l i n g of beverages wi th a l coho l con ten t g r e a t e r than f i v e percent . I n t h e s h o r t term t h i s measure appa ren t ly l e d t o a r educ t ion i n a l c o h o l consumption and a decrease i n t h e numbers of problems a s soc i a t ed w i th dr ink ing . The r e s u l t s i n t h e long term were d i sappoin t ing . The me t ropo l i t an a r e a of t h e Mexican c a p i t a l i nc ludes a f r a c t i o n of a neighboring s t a t e , a n a r e a t h a t has s een development of some of t h e most important i n d u s t r i e s i n t h e country. With l i m i t s on t h e a v a i l a b i l i t y of a l coho l i n t h e f e d e r a l d i s t r i c t , t h e r e was a p r o l i f e r a t i o n a c r o s s t h e border of n igh t spo t s , package s t o r e s t h a t were open 24 hours , and p l a c e s where one could buy and d r i n k l a r g e q u a n t i t i e s of a l c o h o l i c beverages. Soon t h i s a r e a was known a s t h e " b e l t of d i s s i p a t i o n . " By 1955 t h e laws p e r t a i n i n g t o t h e s a l e of l i q u o r i n t h e f e d e r a l d i s t r i c t were changed and l i b e r a l i z e d , a l though t h e new code d i d l i m i t t h e c o n s t r u c t i o n of package s t o r e s t o a d i s t a n c e of 500 meters from schools , work c e n t e r s , h o s p i t a l s , e t c .

E f f e c t i v e prevent ive measures must a l s o t ake i n t o considera- t i o n purchasing p a t t e r n s , consumption norms, and va lues and a t t i t u d e s connected wi th use of a l coho l . Research r e s u l t s show d i f f e r i n g p a t t e r n s f o r those who buy i n s e l f - s e r v i c e supermarkets and those who buy i n sma l l e r s t o r e s . S ince i n Mexico a l c o h o l i c beverages can be bought i n supermarket S, one might reconnnend c o n t r o l s f o r t h e s e p a r t i c u l a r e s t ab l i shmen t s on the theory t h a t impulse buying i n s e l f - s e r v i c e s t o r e s i s r e spons ib l e f o r a h igher volume of s a l e s . üowever, market in format ion i n d i c a t e s t h a t less than 20 percent of s a l e s a r e made i n t h e s e l f - s e rv i ce supermarkets.

Furthermore, i n t he se s t o r e s t h e customers a r e housewives of t h e h ighe r economic c l a s s who come i n t o s t o c k up f o r t h e fami ly and u s u a l l y buy imported l i q u o r s . I n c o n t r a s t , i n t h e -11 s t o r e s customers purchase much l a r g e r volumes of l i q u o r , u sua l ly f o r i m e d i a t e use (Rosovsky 1982). Customers of t he sma l l e r s t o r e s a r e g e n e r a l l y males from t h e lower socioeconomic s t r a t a ; u s u a l l y they consume a moderate l eve1 every day, augmented on s p e c i a l occasions, weekends, days of pay, ho l idays , and t h e l i k e (Calderon 1981). Thus, a measure t o d i scourage impulse buying i n s e l f - s e r v i c e supermarkets would a f f e c t j u s t a small p a r t of t h e popula t ion , whi le a s t r a t e g y aimed towards t h e smal l e s t ab l i shmen t s might be more e f f e c t i v e .

Not on ly a r e t h e p a t t e r n s of consumption and purchase impor tan t , but a l s o t h e c u l t u r a l f a c t o r s , norms, and va lues t h a t a r e r e f l e c t e d i n t he p a t t e r n s of consumption. S i m i l a r p a t t e r n s have been observed i n reg ions throughout L a t i n America (Negrete 1979)- D r . Smart s t a t e s t h a t on t h e b a s i s of c u r r e n t evidence g e n e r a l a v a i l a b i l i t y of a l coho l does no t appear t o be a n important f a c t o r a f f e c t i n e consumption. The s o c i a l , c u l t u r a l , and economic changes, when grouped toge the r , w i l l probably loom eve r more important i n some coun t r i e s . For example, i n Mexico and o t h e r c o u n t r i e s of L a t i n America where consumption of a l c o h o l and drunkenness a r e considered p a r t of t he male r o l e , and where s t r o n g sanc t ions e x i s t a g a i n s t consumption of a l coho l by women, one would no t expect women t o i n c r e a s e consumption i n p ropor t i on t o r e l a x a t i o n of c o n t r o l s . I n February 1981, i n t h e f e d e r a l d i s t r i c t of Mexico C i ty , laws prevent ing women from e n t e r i n g t h e can teens o r ba r s , and r e s t r i c t i n g where they could buy l i q u o r , were repealed. Although now women could buy a l coho l anywhere, no s i g n i f i c a n t change i n a l c o h o l consumption has occurred. Even i f a n i n c r e a s e i n consumption by women i s measured even tua l ly , r e sea rche r s w i l l have t o look a t such poss ib ly a s s o c i a t e d f a c t o r s a s r e l a x a t i o n of s o c i a l norms and g r e a t e r e q u a l i t y of t h e sexes.

Ex i s t i ng l e g i s l a t i o n should be eva lua ted . There a r e a number of laws t h a t have been proposed t o r e g u l a t e a l coho l consumption i n L a t i n America. However, i n many c a s e s t h e s e laws a r e no t put i n t o p r a c t i c e . They a r e no t enforced because q u i t e o f t e n t h e law i s too e l e v a t e d , t o o l o f t y , and i s o l a t e d from r e a l i t y -- a consequence of s o c i o c u l t u r a l d i f f e r e n c e s between t h e few who a r e p o l i t i c a l l y a c t i v e and t h e m a j o r i t y of t h e populat ion. Before cons ider ing new measures, i t would be wise t o eva lua t e e x i s t i n g l e g i s l a t i o n and t o educa te t h e popula t ion about t h e h e a l t h , s o c i a l , and economic problems a s soc i a t ed wi th a l coho l consumption.

Three exauiples i l l u s t r a t e t h e a p p l i c a b i l i t y o r l a c k thereof of c u r r e n t r egu la t i ons :

o The law p r o h i b i t i n g t h e opening of l i q u o r s t o r e s near i n d u s t r i a l parks , h e a l t h f a c i l i t i e s , o r s choo l s has been rendered moot by t h e exp los ive growth of Mexico C i ty and t h e p r o l i f e r a t i o n o f t h e s e f a c i l i t i e s .

o Strong enforcement of one r e g u l a t i o n , whose o b j e c t i v e 1s t o c o n t r o l a v a i l a b i l i t y of a l c o h o l by l i m i t i n g t h e s a l e of a l coho l t o 20 percent of t o t a l s a l e s i n t h e smal l neighborhood grocery s t o r e s , would l ead t o bankruptcy of neighborhood s t o r e s . Due t o t h e c m p e t i t i o n on food p r i c e s from t h e l a r g e supermarkets, t h e small s t o r e s t u r n t o t h e s a l e of a l coho l t o surv ive .

o In t h e month of December 1981, a decrease i n t h e number of acc iden te , a r r e s t s , e t c . , occurred i n one Mexican s t a t e t h a t c a r r i e d ou t a n experiment t o s e e i f a l c o h o l consump- t i o n would drop when s a l e of l i q u o r w a s l i m i t e d t o c e r t a i n hours and days of t h e week. Aithough i t 1s t o o soon t o eva lua t e t h e r e a l e f f e c t s of t he se measures, they r ep re sen t a n i s o l a t e d example of innovat ion and experimentat ion.

We know t h e r e a r e many i n t e r e s t s i n t h e a l coho l i ndus t ry t h a t might be a f f e c t e d by meesures t o c o n t r o l a lcohol . One sugges t ion f o r counter ing i n d u s t r y p re s su re s 1s t o e s t a b l i s h a government monopoly c o n t r o l l i n g product ion and sale of a lcohol . However, i n Costa Rica, where such a monopoly e x i s t s and s a l e s of a l coho l have s t a b i l i z e d , t h e r e has been a l a r g e volume of boot leg a l c o h o l produced and so ld i l l e g a l l y . Uruguay was a l s o no t succes s fu l i n reducing consumption wi th a government monopoly (Negrete 1981).

Furthermore, t h e a l c o h o l i n d u s t r y does r ep re sen t a cons ide rab l e amount of economic a c t i v i t y . Count r ies t h a t wish t o promote t h e i r economic development w i l l have t o d e a l wi th t h e dichotomy t h a t a l though they want t o reduce t h e product ion of a l coho l , they a l s o have an i n t e r e s t i n i nc reas ing t a x revenues. Quite o f t e n t h e i s s u e s involve more than j u s t t h e r e l a t i o n s h i p between pub l i c and p r i v a t e i n t e r e s t s . Within t h e pub l i c s e c t o r , f o r example, va r ious agenc ies a r e concerned with t h e promotion and r e s t o r a t i o n of h e a l t h , and o t h e r s a r e t r y i n g t o s t i m u l a t e t h e economic development of t h e country. Mechanisms t o coo rd ina t e d i f f e r e n t governmental i n i t i a t i v e s might be bene f i c i a1 i n s e t t i n g congruent p o l i c i e s .

To d a t e t h e r e sea rch h a s been modest i n scope, and f u r t h e r r e sea rch 1s requi red . One recommended d i r e c t i o n would be towards developing u s e f u l i n d i r e c t i n d i c a t o r s t o measure t h e e f f e c t s of changing p o l i c i e s . It would be u s e f u l t o mount s t u d i e s t o eva lua t e t h e measures a l r eady i n e x i s t e n c e p r o h i b i t i n g t h e s a l e of l i q u o r on e l e c t i o n days, on n a t i o n a l ho l idays , e t c . Research on p a t t e r n s of s a l e and consumption might l e a d t o developing and eva lua t ing new

i n t e r v e n t i o n s i n o rde r t o d i s cove r t hose p o l i c i e s which w i l l have the most b e n e f i t i n c o u n t r i e s experiencing rap id socioeconomic and p o l i t i c a l change.

F i n a l l y , t h e r e i s no q u e s t i o n t h a t changes i n t h e s o c i a l mores p e r t a i n i n g t o a l coho l a r e t ak ing p lace and t h a t p revent ive measures cannot awai t t h e r e s u l t s of r e sea rch t h a t i s g o i y t o come i n t he f u t u r e . For t h i s reason many of our p o l i c i e s w i l l be based t o a cons iderab le e x t e n t on t h e exper ience of o t h e r coun t r i e s . For t h e moment we w i l l have t o cons ider t h e r e s u l t s s h o m from r a i s i n g t h e l e g a l age f o r d r ink ing and t h e e f f e c t s of massive educa t ion programs.

STUDY ON ALCOHOL-RELATED LEGISLATION I N CENTRAL AMERICA AND PANAMA

Jaime Arroyo Sucre

The use and abuse of a l c o h o l i s p a r t of t h e c u l t u r a l t r a d i - t i o n s of t he peoples of Cen t r a l America and Panama. ü h i l e t h e adopt ion of a l i e n customs i n r e c e n t yea r s has l e d t o changes i n consumption p a t t e r n s , t r a d i t i o n a l customs have remained substan- t i a l l y unchanged, and pe r c a p i t a consumption shows a n upward t r end . The coun t r i e s have recognized t h e problems a r i s i n g from these circumstances on many occasions. Their s tudy and d i scus s ion i s always a mat te r of concern, no t only t o h e a l t h workers but a l s o t o a l 1 prof e s s i o n a l s and t h e connnunity a t l a r g e . Because d r ink ing customs a r e s o important i n t h e s o c i a l , c u l t u r a l , economic, and r e l i g i o u s l i f e of t h e community, t hey have been approached i n a v a r i e t y of ways, f r equen t ly opposed and i n c o n f l i c t w i th one another -

P r i o r i t y has r a r e l y been ass igned t o t h e h e a l t h a s p e c t s of t h e problem and we p ro fe s s iona l s , and o t h e r persons i n t e r e s t e d i n t he se t a s k s , have been unable t o provide s c i e n t i f i c and t e c h n i c a l d a t a t o suppor t passage of adequate l e g i s l a t i o n . The magnitude of t h e problem t o be faced i s ev iden t i f , i n a d d i t i o n , w e bear i n mind: t h a t i n some c o u n t r i e s morbidi ty and m o r t a l i t y r a t e e sugges t o t h e r p r i o r i t i e s ; t h a t t h e economic s t r u c t u r e of t he se c o u n t r i e s encourages t he c u l t i v a t i o n of g r a i n s and t h e product ion, marketing and consumption of a l coho l ; and , e s p e c i a l l y , t h a t t h e popula t ion a t l a r g e and even h e a l t h workers accept and t o l e r a t e t h e s e hab i t s .

Throughout t h e h i s t o r y of pub l i c h e a l t h , government a c t i o n has been one of t h e most important f a c t o r s i n d i s e a s e c o n t r o l and h e a l t h promotion. P o l i t i c a l d e c i s i o n s embodied i n laws a r e t h e b a s i s f o r t h e i r execut ion. L e g i s l a t i o n governing t h e dynamic balance of t h e e c o l o g i c a l t r i a d -- c a u s a l agent/environment/susceptible hos t - c o n s t i t u t e s a b a s i c ins t rument f o r p revent ing a l coho l - r e l a t ed problems.

Although t h e c o u n t r i e s of t h e a r e a recognize t h e s e r iousnes s and magnitude of t h e problems r e l a t i n g t o a l coho l consumption, few of them have compi la t ions of e x i s t i n g l e g i s l a t i o n on t h e t op i c . A t t h e i r XXV Meeting i n 1980 t h e Min i s t e r s of Heal th demonstrated t h e i r i n t e r e s t when they c a l l e d upon t h e Pan American Organizat ion t o prepare a s tudy t h a t would c o l l e c t , ana lyze , draw conclusions, and make recommendations on e x i s t i n g l e g i s l a t i o n (Resolu t ion V I 1 1 of t h e XXV Meeting of t h e M i n i s t e r s of Hea l th of Cen t r a l America and Panama). It was t h a t r e s o l u t i o n t h a t gave rise t o t he document t h a t i s t h e b a s i s of my p r e s e n t a t i o n today.

PAHO Study: Methodology

The f i r s t s t age of t he i n v e s t i g a t i o n was devoted t o c o l l e c t i n g t h e in format ion a v a i l a b l e i n Panama, Honduras, Guatemala, Nicaragua, and E l Salvador. To o b t a i n comparable d a t a , a gene ra l ques t i onna i r e was prepared covering laws r e l a t i n g t o t h e c a u s a l agen t , t h e envi- ronment, and t h e s u s c e p t i b l e host . The ques t i ons d e a l t wi th t he types and c h a r a c t e r i s t i c s o f a l c o h o l s f o r consumption; product ion, impor ta t ion , d i s t r i b u t i o n , q u a l i t y c o n t r o l , s a l e , and consumption; c o n t r o l of p l aces of s a l e and t h e i r bus ines s hours; and t h e age, sex , and occupat ion of purchasers and/or consumers. I n add i t i on , s p e c i f i c a s p e c t s such a s t h e ope ra t i on of motor v e h i c l e s , employ- ment, educa t ion , penal and c i v i l m a t t e r s were a l s o included. A s e p a r a t e ques t i onna i r e covered t h e promotion of a d v e r t i s i n g f o r a l coho l consumption.

Given t h e scope of t h e problem, t h e ques t i onna i r e is, of course, not exhaus t ive , but i t does r ep re sen t a f i r s t a t tempt t o g a t h e r in format ion on t h e e x i s t i n g l e g i s l a t i o n of t h e coun t r i e s . It needs t o be f l e shed ou t by n a t i o n a l surveys designed t o o b t a i n a b e t t e r understanding of t h e problem and t o develop b e t t e r p r even t ive l e g i s l a t i o n .

The informat ion was ob ta ined through in t e rv i ews wi th o f f i c i a l s des igna ted by t h e h e a l t h a u t h o r i t i e s of t h e coun t r i e s . I n most c a s e s t h e y had only a very g e n e r a l knowledge of t h e l e g i s l a t i o n , bu t they a l 1 subsequent ly s e n t t h e au tho r in format ion on codes, laws, r u l e s and r egu la t i ons . Uhen t h e d a t a were compared, d i f f e r e n c e s were found between what t h e o f f i c i a l s had s a i d and what t h e laws prescr ibed .

The in t e rv i ews and t h e q u e s t i o n n a i r e s t o g e t h e r gave u s a n i d e a of what l e g i s l a t i o n e x i s t s i n t h i s r ega rd , and of what was being enforced i n each country. Although d i f f e r e n c e s were found between t h e s t a t u t e s on t h e books and t h e r e a l i t i e s of t h e l e g a l system, t h e s e w i l l have t o be covered by subseqwnt i n v e s t i g a t i o n s , which obviously should be c a r r i e d ou t by o f f i c i a l s o r r e s e a r c h e r s w i t h i n each count ry .

L e g i s l a t i o n i n Cen t r a l America

A l 1 t h e c o u n t r i e s of t h e a r e a have comprehensive a l coho l l e g i s l a t i o n . Laws enac ted a t t h e beginning of independence a r e s t i l l i n f o r c e and r e f l e c t t h e l e g a l system t h a t ru l ed o u r r e l a t i o n s w i th Spain dur ing t h e c o l o n i a l e r a . L e g i s l a t i o n has been p r i m a r i l y cen t e r ed on economic and f i s c a l mat te rs . The governments have promoted g r a i n c u l t i v a t i o n and t h e product ion, d i s t r i b u t i o n , marketing, and consumption of a l coho l , t ak ing i n t o account t a x and f i s c a l advantaees and t h e gene ra t i on of economic growth and expor t a c t i v i t y . I n most of t h e c o u n t r i e s t he se a c t i v i t i e s , inc lud ing q u a l i t y c o n t r o l , a r e t h e r e s p o n s i b i l i t y of t h e X i n i s t r y of Finance, and i n some of t h e Minis t ry of Heal th , a l b e i t on ly t a n g e n t i a l l y .

Alcohol Tax Laws

The l e g i s l a t i o n on t h e product ion, impor ta t ion , d i s t r i b u t i o n , s a l e , and consumption of a l c o h o l i c beverages i s abundant. I n most of t h e c o u n t r i e s the p e r t i n e n t l e g a l r u l e s a r e p a r t of t h e t a x o r commercial codea, o r of what a r e c a l l e d "a lcohol dec rees o r laws." The d i f f e r e n c e s between what was s a i d i n t h e in te rv iews and what t h e law p r e s c r i b e s and t h e d i f f i c u l t i e s encountered i n ob t a in ing cop ie s o£ t h e r e l evan t p rov i s ions showed t h a t t h e l e g i s l a t i o n 1s s c a t t e r e d i n many sources and t h a t , from t h e po in t of view of h e a l t h , i t i s of l i t t l e use and r a r e l y appl ied .

To overcome t h i s d i f f i c u l t y , one of t h e c o u n t r i e s 1s s tudying a d r a f t Nat ional Alcohol and Alcoholism Code, which b r ings t oge the r t h e s c a t t e r e d l e g i s l a t i o n and w i l l f i l l t h e gaps i n i t (Newsle t te r No. 6, Nat iona l Alcoholism I n s t i t u t e , San Jose , Costa Rica).

S ince t h e M i n i s t r i e s of Hea l th a r e r e spons ib l e f o r t h e well-being of t h e populat ion, they must have t h e l e g a l means t o perform t h i s f u n c t i o n a s i t r e l a t e s t o a widely consumed and very harmful substance. I n most of t h e c o u n t r i e s , even t h e q u a l i t y c o n t r o l of a l c o h o l i c beverages i s i n t h e hands of t h e M i n i s t r y of Finance o r t h e I n t e r n a 1 Revenue Service. The most important chemical a n a l y s i s is t h e de te rmina t ion of t h e a l c o h o l i c s t r e n g t h of t h e beverages, but f o r t a x c o l l e c t i o n purposes, r a t h e r than f o r p r o t e c t i n e the h e a l t h of t h e consumer.

Alcohol ic Content

The amount of a l c o h o l permi t ted o r i n some c a s e s r equ i r ed i n d i f f e r e n t types of a l c o h o l i c beverages i s similar i n t h e va r ious c o u n t r i e s of t h e a rea . Surveys of d r i n k i n g p a t t e r n s i n d i c a t e that most d r i n k e r s a r e more concerned about t h e q u a n t i t y -- t h e number of d r i n k s o r rounde consumed. Accordingly, p revent ive measures s i m i l a r t o t hose used t o reduce t h e percentage of harmful eubetances i n tobacco products could be app l i ed ; t h a t l e , t h e a l c o h o l i c c o n t e n t of t h e beveragee could be reduced. Manufacturere i n d i c a t e t h a t they can produce beverages w i t h a lower a l c o h o l i c con ten t but wi th t h e same teste. This type of measure would reduce product ion c o s t e and thus enab le some governments t o e x t r a c t more t a x d o l l a r s without adverse ly a f f e c t i n g t h e h e a l t h of t h e populat ion.

Product ion and U i s t r i b u t i o n Controla

Alcohol product ion, which was i n i t i a l l y a s t a t e monopoly throughout t h e reg ion , has i n most c a s e s now been t r a n s f e r r e d t o p r i v a t e e n t e r p r i s e . Qual i ty c o n t r o l is f r equen t ly t h e responsi- b i l i t y of t h e t a x agenc ies , which d i s r e g a r d t h e p o s s i b i l i t y t l i a t a l c o h o l i c beverages may con ta in t o x i c substances. This r i e k is much g r e a t e r i n t h e c a s e of contraband l i q u o r , but none of t h e laws 1 have reviewed a u t h o r i z e t h e M i n i s t r i e s of Heal th t o t ake app rop r i a t e measuree i n t h i s regard.

The impor ta t ion of a l c o h o l i c beverages i s covered by many t a x r egu la t i one . With regard t o h e a l t h , however, t h e only requirement i e a r e g i s t r a t i o n w i th t h e h e a l t h a u t h o r i t i e e which con t inues i n f o r c e f o r a v a r i a b l e number of yea r s . During t h i s per iod , v i r t u a l l y no q u a l i t y c o n t r o l a a r e c a r r i e d ou t f o r t h e p r o t e c t i o n of t h e coneuming populat ion.

The t a x r egu la t i one of t h e c o u n t r i e s d o p r e s c r i b e t h e t ypes of con ta ine r and r e g u l a t e t h e i r d i e t r i b u t i o n . Although my review found no a p e c i f i c r e f e r encee t o t h e r o l e o f h e a l t h a u t h o r i t i e s , t h e laws not on ly permit but would f a c i l i t a t e c o n t r o l d i r e c t e d a t improvement of h e a l t h .

Regula t ion of S a l e s and Consumption

The t a x r e g u l a t i o n s r a t h e r a c c u r a t e l y d e f i n e t h e scope of sales. The provia ions r e l a t i n g t o t h e l o c a t i o n of shops, t h e i r c l a s s i f i c a t i o n , and- bus iness hours imply mandates t h a t f a c i l i t a t e t h e execut ion of p revent ive measuree f o r eome high-r iek groups. However, i n t h e op in ion of t h e persone i n t e n i e w e d most euch r e g u l a t i o n s a r e no t observed, and t h e h e a l t h a u t h o r i t i e s have no l e g a l means of enforc ing them. I n t h i s regard a l 1 my informante em- phasized t h e l a c k of g u i d e l i n e s f o r e e t a b l i s h i n g necessary

coopera t ion between government agencies . Most of t h e r u l e s were enacted t o p r o t e c t t h e h e a l t h of purchasers , e s p e c i a l l y wi th r e s p e c t t o age. According t o t h e op in ions ob ta ined , t h e p rov i s ions a r e no t ob l iga to ry .

Almost a l 1 t he Cen t r a l American c o u n t r i e s have r e g u l a t i o n s on t h e consumption o£ a l c o h o l i c beverages, a l though they a r e sometimes s c a t t e r e d throughout va r ious s t a t u t e s . Tax p rov i s ions d e f i n e t h e d i f f e r e n t types o£ a l c o h o l i c beverages which a r e l e g a l l y permit ted. Nat iona l laws o r c i v i l , s o c i a l , p o l i c e and o t h e r r e g u l a t i o n s may l i m i t consumption f o r reasons of age, t r a d e o r p ro fe s s ion , o r i n r e l a t i o n t o working hours. There a r e no s i m i l a r p rov i s ions based on h e a l t h grounds.

Although a l 1 t h e c o u n t r i e s have s t anda rds f o r t h e hours dur ing which a l c o h o l i c beverages may be so ld , they a r e not ob l iga tory . According t o t h e laws, a l c o h o l i c beverages may not be consumed i n pub l i c p laces . Never the less , t h e persons interviewed were of t h e op in ion t h a t t h e t o l e r a n t a t t i t u d e of t he popula t ion not on ly f a c i l i t a t e s but even encourages t h e h a b i t of d r ink ing i n pub l i c -

The r u l e s t h a t govern t h e p l aces i n which a l c o h o l i c beverages a r e consumed f i n d t h e i r l e g a l b a s i s i n t h e h e a l t h codes o r regula- t i o n s and a r e t h e same a s f o r t h e s a l e of food s t u f f s . These r u l e s a r e u s u a l l y appl ied more f l e x i b l y t o shops t h a t s e r v e a l c o h o l i c beverages.

With t h e except ion of those mentioned i n t h e foregoing paragraph, t he o t h e r p rov i s ions a r e no t embodied i n what is usua l ly considered h e a l t h l e g i s l a t i o n .

Prevent ion of Alcohol-related Problems

In most o£ the c o u n t r i e s , r e g u l a t i o n s on t h e o p e r a t i o n of motor v e h i c l e s and alcohol ism a r e p a r t o£ t h e T r a f f i c o r Po l i ce Regulat ions. The r o l e of t h e h e a l t h s e r v i c e s i n determining blood a l coho l conten t 1s not w e l l de f ined , and i n many c o u n t r i e s t h e M i n i s t r i e s of Health do not have t h e necessary r e sou rces t o d e a l wi th t h e problem.

T r a f f i c educa t ion and a l c o h o l consumption programs do not come under t h e a u t h o r i t y o f , and sometimes a r e n o t even coordinated with, h e a l t h a c t i v i t i e s . They a r e t h e r e s p o n s i b i l i t y of o t h e r government agencies . Information i n d i c a t i n g t h a t permanent educa t ion programe a r e coord ina ted , promoted, and executed by t h e M i n i s t r i e s of Hea l th and Educat ion wi th in t h e formal educa t ion system 1s a v a i l a b l e f o r on ly one count ry i n t he a rea .

Provis ions on employment problema a r e p a r t o£ l a b o r l e g i s - l a t i o n and cover t h e employer/employee r e l a t i o n s h i p when t h e

dr ink ing of a l c o h o l i c beverages is involved and dr inking i s a cause f o r dismieeal . I n very few caees a r e r e f e rences made t o o t h e r aepec t s of t h e problem.

I n gene ra l , p e r t i n e n t laws a r e aimed a t so lv ing probleme caused by t h e use of a lcohol . Few e s t a b l i e h those means of p ro t ec t ing a l c o h o l i c s t h a t would r e f l e c t modern knowledge of t h e top ic .

Fu r the r , i n most of t h e c o u n t r i e s t h e r e i s a l e g a l void i n r e spec t t o s o c i a l l e g i s l a t i o n on t h e prevent ion and t reatment of alcoholiem and the r e h a b i l i t a t i o n of a l coho l i ce . I n one count ry , a n a r t i c l e of a prel iminary d r a f t of the Cone t i t u t ion s e t s f o r t h gene ra l gu ide l inee f o r t h e c a r e of a l coho l i ce ; i n another , a prel iminary d r a f t of a code con ta ins more s p e c i f i c gu ide l ines f o r dea l ing comprehensively wi th t h e problem.

Alcohol Advert is ing

A w a r e of t he h e a l t h hazards involved i n the use of a lcohol , t he promotion of a lcohol consumption i n t h e media, t h e existente of laws f o r t he c o n t r o l of a d v e r t i s i n g , and t h e need t o focus h e a l t h educa t ion programe on these t o x i c substancee, t h e Min i s t r i ee of ü e a l t h requested PAHO t o prepare a s tudy.

The more knowledge i e a v a i l a b l e on t h i s t o p i c and the more c e r t a i n t h e r i s k s caused by the uee of t hese substancee become, t h e more ev ident t he need t o c o n t r o l advert isemente f o r them.

Plost of t he c o u n t r i e s have laws t h a t c o n t r o l a d v e r t i s i n g f o r consumption of a l coho l i c beveragee. This c o n t r o l i e exerc ised through m u l t i d i s c i p l i n a r y commissions appointed f o r t h a t purpose. In some coun t r i e s , t he membere of theee commissions a r e appointed d i r e c t l y by t h e Pres ident of t h e Republic; i n o t h e r s , t he law s t i p u l a t e s t he pos t s whose incumbents w i l l be membere. I n a l 1 caeee, t h e p a r t i c i p a t i o n of h e a l t h o f f i c i a l s is c e n t r a l .

I n many coun t r i e s , c o n t r o l ex tends t o t h e presa , rad io , t e l e v i e i o n , p o s t e r s and b i l l b o a r d s , a s w e l l a s t o o t h e r a d v e r t i s i n g media. It is not appl ied wi th the same e t r i c t n e e s i n a l 1 the coun t r i e s , nor does i t a f f e c t a l 1 media uniformly.

Control extends t o the form, content , p r eeen ta t ion , and o b j e c t i v e of t he message, a s we l l a e t h e a c t i v i t i e s i t promotes and the behavior i t f o s t e r e . The e f f e c t i v e n e s s of t h i s c o n t r o l should be eva lua ted and, where neceesary, app ropr i a t e changes introduced.

In most of t he coun t r i ee i t i s d i f f i c u l t t o e s t a b l i e h c o n t r o l s of t h e d u r a t i o n of t h e message, t h e frequency wi th which i t i e repea ted , and the hours a t which i t i s broadcaet , a l 1 of which would inf luence whp t h e r e c i p i e n t e of t he meseage a r e and what i ts impact

on them i s l i k e l y t o be. Thus, t he meesages cont inue t o a f f e c t c h i l d r e n and youths, who a r e l i k e l y t o be suscep t ib l e .

The l e g i s l a t i o n reviewed contained no p rov i s ions on t h e censorsh ip o£ f i lms , comic s t r i p s o r o the r mas8 media i n which the heroes appear dr inking , nor do any o£ t h e laws f o r b i d o r l i m i t t h e a d v e r t i s i n g of t hese eubstances.

Conclusions

1. The study showed t h a t t h e r e 1s abundant l e g i s l a t i o n on a lcohol use. Most of t h e p rov i s ions a r e s c a t t e r e d and t h e h e a l t h a u t h o r i t i e s a r e u sua l ly unfami l ia r wi th them.

Recommendation: The coun t r i e s t h a t have not a l r eady done s o should appoin t an i n t e r - d i s c i p l i n a r y committee t o review and compile t h e e x i s t i n g l e g i s l a t i o n on a l coho l consumpt ion.

2. Many of t h e laws and r g u l a t i o n s i n f o r c e a r e not h e a l t h r e l a t e d , and some t h a t could be u s e f u l a r e not appl ied.

Recommendation: The above-mentioned committee should be respons ib le f o r analyzing the r u l e s r e l a t i n g t o h e a l t h and recommending g u i d e l i n e s f o r t h e i r b e t t e r app l i ca t ion .

3. A c o m p a r i e o n o f e x i s t i n g r u l e s a n d o f r u l e s d e s i r a b l e f r o m t h e poin t of view of h e a l t h would make i t poss ib l e t o develop appropr i a t e guiding principies f o r new l e g i s l a t i o n .

Recommendation: On t h e b a s i s of t h e above-mentioned review and a n a l y s i s , t h e committee should make recommen- d a t i o n s on appropr i a t e gu ide l ines f o r amending o r r e v i s i n g the l e g a l provis ions on t h e s e a spec t s .

40 Most of t h e c o u n t r i e s have l e g a l provis ions t h a t c o n t r o l a lcohol adve r t i s ing . Thei r enforcement has no t been evaluated.

Recommendation: Programs f o r t h e c o n t r o l of a l coho l a d v e r t i s i n g should be evaluated.

5 . During the survey, no laws o r r egu la t ions were encountered enabl ing the mas8 media t o be used t o exp la in t h e adverse h e a l t h e f f e c t s of a l coho l use.

Recommendation: The a d v i s a b i l i t y of proposing laws t h a t w i l l f a c i l i t a t e h e a l t h promotion through p u b l i c i t y on t h e adverse a s p e c t s of a l coho l consumption should be examined. Th i s l e g i s l a t i o n should provide t h e necessary resources f o r ensur ing t h a t the q u a l i t y and p re sen ta t ion of t h e messages i s such t h a t they can compete wi th commercial adve r t i s ing .

6. The c l a s s i f i c a t i o n of a l coho l i c beverages according t o t h e i r a lcohol content is eometimee r i g i d . I n a l 1 the coun t r i e s , t h e range of the alcohol contents defined by law 1s s imi lar .

Recomnendation: The p o s s i b i l i t y of reducing the a l coho l i c s t r eng th of the beverages ehould be studied.

7. I n most of the countr ies , the q u a l i t y c o n t r o l of a l coho l i c beverages, whether produced l e g a l l y , smuggled, o r imported, 1s not the r e s p o n s i b i l i t y of the hea l th a u t h o r i t i e s . The purpose of q u a l i t y cont ro l l e t o determine the amount of the pe r t inen t t a x r a t h e r than t o p ro tec t the consumer.

Recommendation : The p a r t i c i p a t i o n of the hea l th a u t h o r i t i e s i n the q u a l i t y con t ro l of n a t i o n a l o r imported beverages should be b e t t e r defined.

8- The laws and regula t ions reviewed do not g ive the hea l th a u t h o r i t i e s con t ro l of the hea l th aspects of the d i s t r i b u t i o n of a l coho l i c beverages and de r iva t ives o r of the enforcement of the provisions r e l a t i n g t o t h e i r s a l e ( loca t ion , r e s t r i c t i o n s f o r reasons of heal th , e t c . ) .

Recommendation: The hea l th a u t h o r i t i e s should study and propose l e g a l meane t h a t riould enable them t o p a r t i c i p a t e i n the con t ro l of c e r t a i n hea l th a spec t s t h a t a r e not covered i n the d i s t r i b u t i o n and s a l e of a l coho l i c beverages.

9. National s t a t u t e s do not def ine the r o l e of the hea l th a u t h o r i t i e s i n programe f o r the prevention of t r a f f i c accidente due t o alcohol use. Frequently, no resources a r e a l loca ted t o these programe.

Recommendation: The coun t r i e s t h a t have not a l ready done s o ehould study and c l e a r l y def ine the r o l e of the heal th team i n programs f o r the prevention of t r a f f i c acc idents associa ted with the use of alcohol .

10. Most of the countr ies do not have any l e g a l r u l e s permit t ing the conduct of education programs on the r i s k s of alcohol use i n the formal education system.

Recommendation: The coun t r i e s tha t have not already done s o should review t h e i r l e g i s l a t i o n with a view t o the incorporat ion of a hea l th education program on the r i s k s caused by alcohol consumption i n the formal education syetem.

11. The laws deal ing with probleme caused by the use of a lcohol i n l abor , penal, c i v i l and o the r l e g a l a reas have not been updated and omit a spec t s of the problem.

Recommendation: Some c o u n t r i e s should review t h e p rov i s ions on problems .caused by t h e consumption of a l coho l i n l a b o r , pena l , c i v i l and o t h e r l e g a l f i e l d s .

12. I n many c o u n t r i e s t h e a lcohol i sm laws a r e no t c o n s i s t e n t wi th p re sen t s c i e n t i f i c knowledge.

Recommendation: The l e g i s l a t i o n on a lcohol i sm should be updated. For t h a t purpose, coopera t ion between the c o u n t r i e s and lo r t e c h n i c a l advisory s e r v i c e s by PAHo/WHO and o t h e r i n t e r n a t i o n a l agenc ies would be advisab le .

13. During t h e survey no l e g a l p rov i s ions r e g u l a t i n g t h e coo rd ina t ion of t h e a c t i v i t i e s of t h e va r ious government agenc i e s d e a l i n g wi th problems due t o a l coho l use were encountered.

Recommendation: S t r a t e g i e s should be s tud i ed f o r proposing l e g a l p rov i s ions on t h e coo rd ina t ion of t he va r ious government agenc i e s d e a l i n g w i t h problems due t o a l coho l use should be s tud ied .

Chapter Notes and Keferences

The I m ~ a c t of Prevent ion L e n i s l a t i o n : An Examination of Research F indings

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A p p e n d i x A

CONSENSUS VIWJS ON DEVELOPMENT OF ALCOHOL POLICIES

Alternative Non-coneensus viewe

A p p e n d i x B

LIST OF PAETICIPANTS

APPENDIX A

CONSENSUS VIEWS O N DEVELOPMENT OF ALCOHOL POLICIES

A s noted i n t h e Background and Overview of t h e Proceedings, t h e following statement of consensus views 1s t h e product of a d e l i - be ra t ive process t h a t began the l a s t morning of t h e workshop. A t t h a t time, p a r t i c i p a n t s m e t i n three small groups t o review a d r a f t statement prepared t h e previous evening by t h e workshop rapporteur. The d r a f t presented the rappor teur ' s impression of the consensus t h a t emerged amo- t h e p a r t i c i p a n t s during t h e f i r s t two days regarding cur ren t understandings about alcohol-related problems and prevention of those problems, p a r t i c u l a r l y legislat ively-based approaches t o prevention. The d r a f t was based on t h e s tud ies and o t h e r empirical evidence contained i n t h e papers commissioned f o r the workshop and the plenary d iscuss ions center ing on, but not r e s t r i c t e d t o , those papers during t h e f irst two days. In reviewing the d r a f t , each of the small groups suggested changes, de le t ions , add i t ions and rev i s ions i n t h e d r a f t t o more accura te ly r e f l e c t t h e i r own understandings. The chairmen of the small groups reported these reac t ions a t t h e f i n a l plenary sess ion of t h e workshop and s h o r t l y t h e r e a f t e r submitted wr i t t en repor t s t o t h e IOM s t a f f .

Based on those comments, t h e I O M s t a f f redraf ted t h e statement of the consensus views and c i rcu la ted i t t o t h e Advisory Committee members f o r f i n a l review. Their comments were incorporated i n t o a f i n a l statement t h a t was del ivered on Apri l 14 t o t h e Office of In te rna t iona l Health, (OIH), U.S. Department of Health and Human Services, f o r i t s use i n preparat ion f o r t h e World Health Assembly t echn ica l d iscuss ions on a lcohol i n May 1982. It was emphasized t h a t the statement comprised a perceived consensus of t h e majori ty of t h e p a r t i c i p a n t s , not necessar i ly t h e views of each and every one, inasmuch a s time had not permitted a complete d i s t r i b u t i o n t o a l 1 p a r t i c i p a n t s f o r review.

In e a r l y May t h e statement a s de l ivered t o O I H was sent t o a l 1 o t h e r workshop p a r t i c i p a n t s l i s t e d i n Appendix B, with a request t h a t they review i t and s e d back any qual i fy ing o r d issent ing views. Several responses were he lp fu l i n f u r t h e r c l a r i f y i n g the statement, although i t s basic content d i d not change. lbo non-coneensus views a r e repr in ted i n t h e i r e n t i r e t y f o l l o w i ~ the

consensus statements. A l 1 o the r p a r t i c i p a n t s accepted the statement a s d i s t r i b u t e d t o them. The consensus statement t h a t appears next thus r e f l e c t s , wi th two exceptions, the views of a l 1 pa r t i c ipan t s .

It must be emphasized again t h a t t h e views expressed here in r e f l e c t a consensus of the workshop p a r t i c i p a n t s i n t h e i r indiv idual capacity. They do not represent t h e pos i t ion of any government o r country of a p a r t i c i p a n t , t h e I n s t i t u t e of Medicine, t h e National Academy of Sciences, o r t h e Pan American Health Organízation.

1. I N THE COUNTRIES OF THE AMERICAS, THE MAJOR NEGLECTED BURDEN TO SOCIETY OF ALCOHOL CONSUMPTION IS THE HEALTH, ECONOMIC, AND SOCIAL COST OF PROBLmS ASSOCIATED WITH EPISODIC INTOXICATIONm

o Most s o c i e t i e s have in tegra ted p a t t e r n s of alcohol use i n t o t h e i r s o c i a l and c u l t u r a l norms of behavior. Episodic in tox ica t ion , which may be in tegra ted i n t o those norms, c r e a t e s very se r ious and c o s t l y problems and burdens f o r the individual family and society.

Whether o r not associa ted with chronic heavy drinking, episodic in tox ica t ion i s re la t ed d i r e c t l y t o accidents , p a r t i c u l a r l y motor vehic le acc idents , wi th premature death o r d isabl ing in ju ry both f o r t h e in toxica ted pa r ty and o t h e r s a f f e c t e d by t h e accident; v io len t andlor cr iminal behavior; famíly d is rupt ion; c h i l d neglec t ; and impairment of work capaci ty and a t tendant l o s s of productive capacity . Alcohol a l s o has been l inked t o f e t a l damage when drinking occurs i n r e l a t i o n t o pregnancy. Chronic heavy drinking, i n which i n t o x i c a t i o n occurs more f requent ly , a l s o c a r r i e s a high r i s k of long term medical consequences f o r the individual , both physical (e. g., c i r r h o s i s of t h e l i v e r and s u s c e p t i b i l i t y t o cancer) and psychological (e-g., dependency o r l o s s of c o n t r o l ) , which i n t u r n can cause f u r t h e r physical and mental d i so rde r s and suic ide .

In add i t ion t o l o s s of l i f e and well-being t o individual8 and fami l i e s , the burden t o soc ie ty of episodic in tox ica t ion and chronic heavy drinking 1s s u b s t a n t i a l i n l o s t cont r ibut ions t o economic productivi ty and s o c i a l development, a s w e l l a s i n t h e use of scarce resources f o r r e s t o r a t i v e and long term hea l th care , and f o r r e h a b i l i t a t i v e s o c i a l services.

o Each country of t h e Americae now neede t o aeeeee more adequately t h e epec i f i c na ture and extent of t h e burden t o each eoc ie ty of t h e f u l l range of alcohol-related probleme. Such a n e f f o r t would include hproved public record-keepiqg and repor t ina systeme of alcohol-related problems, epidemiological e tudiee , and targeted case etudiee. Re eearch on alcohol-related problems should be conducted i n the context of cuetomary and normative drinking behavior i n each eocie ty-

2 - T U PUBLIC HEALTH AND HEALTH SCIENCES COEMUNITIES I N MOST OF THE WUNTBIES OF THE AMERICAS, WILE WNTINUING TO IMPROVE TREATMENT OF ALCOHOLISM I N INDIVIDUALS, SHOULD DEVELOP GREATER INTEREST I N GROUP-ORiENTED HEASüRES AMED AT THE PREVENTION OF ALCOHOL-RELATED PROBLEMS

o Buildiqg on t h e increaeed f low o£ information and t h e r e s u l t e of e tud iee i d e n t i f i e d i n I t e m 1 preceding, nat ione i n t h e Americas can t a r g e t pol icy-or iented research and demonetration projec te on prevention e f f o r t s - As p a r t of theee pro jec te , empirical evaluat ion should f ocus on both intended e f f e c t s and "eide" e f f e c t s of p a r t i c u l a r prevention e t r a t eg iee .

o A s u b e t a n t i a l accumulation of a lcohol l e g i e l a t i o n i n many countr iee of the Americae appeare t o be unknown t o present day policymakere and l i t t l e enforced. There i s a need f o r h i e t o r i c a l reeaarch on alcohol-related l e g i s l a t i o n , includiqg t h e reasone f o r i t e enactment, i n order t o i d e n t i f y l e g i e l a t i v e e f f o r t e that have been e f f e c t i v e o r i n e f f e c t i v e , o r t h a t have produced e f f e c t e paradoxical t o tbose that were intended- Such reeearch could suggest f u t u r e l e g i e l a t i v e ac t ion , a s w e l l a e i d e n t i f y exie t ing laws o r r u l e e t h a t mlght be enforced a e p a r t of a prevention programe

3 - AVAILABLE EMPIRICAL EVIDENCE SUGGESTS THAT A NWBER OF PBEVENTION-OKIENTED, MOSTLY LEGISLATIVELY BASED POLICIES CAN REDUCE THE BURDEN OF ALOOHOL-RELATED PROBLEWS.

o Caution i n Generalizing. Studies on the e f f e c t s of prevention-oriented public po l i c i ee a r e l iml ted i n number and have been do& l a r g e l y i n a few indue t r i a l i zed countr ies . Por theee reasone, genera l i za t ions must be cautioue.

o Per c a p i t a Consumption. In te rna t iona l experience euggests that the r e l a t ioneh ip betueen t h e growth o£ per cap i t a coneumption and the &te of alcohol-related problems cannot be ignored. Increases i n per c a p i t a consumption of alcohol

a r e associa ted wi th increaeed frequency of epieodic in tox ica t ion andlor incidence of chronic heavy drinking, and these r e s u l t i n increasee i n a t l e a s t some v a r i e t i e e of alcohol-related problems.

o P r i ce t o Consumet. Alcoholic beverages, l i k e o the r commoditie S, a r e price-sensi t ive; s ign i f i can t increases i n t h e r e a l c o s t of alcohol , v i a t axa t ion o r r e l a t ed p o l i c i e s , reduce average per c a p i t a consumption. In many countr ies , t h e r e a l c o s t of alcohol t o consumers has been dropping because t a x r a t e s have not been adjusted t o r e f l e c t i n f l a t i o n .

o Alcohol Avai labi l i ty . While minor reductions i n t h e number of s a l e s o u t l e t s o r c los ing hours do not appear t o measurably a f f e c t consumption, major changes have had a considerable e f f e c t on per c a p i t a consumption. In addi t ion , prohibi t iog accese t o a lcohol f o r s p e c i f i c ca tegor ies of t h e population (e.g., s i g n i f i c a n t l y r a i e ing the l e g a l drinking age) demonstratively reduces alcohol-related problems, such a s alcohol- r e l a t e d t r a f f i c accident S, among t h e ca tegor ies of people a f fec ted .

o Drudc-Driving Lawe. Short-run reductions i n harmful consequences of dr iv ing while in toxica ted typ ica l ly occur f o l l o i i n g t h e in t roduct ion of new, s t r i o g e n t l y enforced and well-publicized laws; longer-term e f f e c t s appear t o depend on cont inuat ion of in tense enforcement and publ ic i ty .

o Environmental Interventions. Pol ic iee that r e s u l t i n reduciog t h e problem consequencee of alcohol-related behavior by reducing environmental r i s k a r e a promising category of interventions. Examples of such p o l i c i e s inc lude increased use of automobile s e a t b e l t e t o reduce passeoger/driver f a t a l i t i e s i n motor vehic le accidente, and the use of smoke detec tor8 t o reduce deaths and d i s a b i l i t i e e f rom acc iden ta l f ires.

o Advertising and Education. Evidence i s - not conclusive about the impact of adver t i s ing on drinking p rac t i ces and problems, nor about t h e use of t h e schools and mass media i n educational ef f o r t s t o modif y present and f u ture de le te r ious drinking behavior; add i t iona l research neede t o be done on these prevention s t r a t e g i e s .

4. POLICY INITUTIVES TOWARD PBKVENTING ALCOHOL-BELATBD PBOBLW SHOULD INTEGRATE HTBLIC BEALTE SECTOR BENBFITS AND COSTS WITH TmSE BELATED TO ECONOMIC DWELOPXENT AND VALUBS IMPORTANT TO THE SOCIAL, CULTUBAL, AND POLITICAL FABBIC OF THE SOCIETYa

o In countriee where alcohol coneumption i e permítted, i t e production andlor coneumption i e a eource of tax revenue and employment- In countriee where t o u r i m is e i t he r a n exieting o r developing induetry, a lcohol ic beveragee of ten contribute a eignif i can t portion of aeeociated revenwe. With reepect t o individual and eocial uee of alcohol, t he obvioue functione tha t have eupported drinking customs throughout hietory a r e thoee phanuacological ef f e c t s accompanying moderate drinking , euch a e relaxation, a sense of well-being, and mild t ranqui l izat ion- A l 1 euch factore , par t i cu la r ly thoee concerning increaeed revenue and employment , cmpr i ee eignif icant elemente i n a society 'e approach t o policy fonuulation on alcohol-related problema.

o In moet countriee there i e a dietreesing lack of communication i n alcohol policy fonuulation between pereons concerned with the public health aepecte of those po l ic ies and othere concerned w i t h the revenue and employment-producing ro l e of alcohol. To address t h i s problem, the public health sector i n each country needs t o begin a dialogue with other minietriee and i n s t i t u t e e of finance, comnerce, juetice, traneportation and l a w enforcement- The f a c t t ha t alcohol coneumption patterns and levele a r e relevant t o ra tee of alcohol problema mane tha t alcohol production and ava i l ab i l i t y muet be t reated leg ie la t ive ly and po l i t i c a l l y a e a public health concern, a s well ae a f i s c a l and ecominic concern.

o There a r e e ignif icant in ternat ional incentives and conetrainte, both global and regional, influencing national alcohol policy fonuulation. In each country, the views of e n t i t i e e concerned with trade agreemente and controle on alcoholic-beverage-producing induetriee need to be coneidered i n diecueeione of public health concerns re la ted t o alcohol coneumption. Such diecueeione míght be organized on a regional baeie, with collaborative e f f o r t s among countriee i n appropriate geographic c ~ n f i g u r a t i o n s ~ WHO and i t e regional off icee , including PAHO, could have an inportant communication and coordination ro l e t o play i n f urthering internat ional collaborative reeearch.

5 . WETHER OR NOT LEGISLATIVELY BASED, IMPLWNTATION OF EFFECTIVE POLICIES POR PREVENTING ALCOHOL-RELATED PBOBLEWS MUST BEGIN W I T H CREATION OF PUBLIC AND GOVERiWENTAL &ARE- NESS OF THE ENORMOUS BURDEN OF THOSE PROBLEMS TO THE SOCIETY.

o b s u l t s of improved record+eeping and report ing systeme and expanded research, noted i n I t e m 1 preceding, can cont r ibute s i g n i f i c a n t l y t o t h e development of a successful public awarenese s t r a t egy . Such a s t r a t egy w i l l have t o be aimed a t showing t h a t problems r e l a t e d t o episodic in tox ica t ion , whether o r not r e l a t e d t o chronic heavy drinking, a t e n d beyond t h e problems of alcoholism, a r e j u s t a e d ie turbing t o the ind iv idua l s involved, t h e i r f ami l i e s , and socie ty , and the re fo re merit i n t e n e i f i e d nat ional a t t e n t i o n and ac t ion .

o Prevention pol icy formulation i n the a lcohol a r e a may focus primari ly on public sec to r l e g i s l a t i o n and ac t ions a t various l e v e l s of governraent . In many countr ies , however, pol icy formulat ion a l s o needs t o involve c r i t i c a 1 p r iva te s e c t o r i n s t i t u t i o n s and groups such ae voluntary organizat ions, l abor and indust ry , and re l ig ious , educational , s o c i a l , and community organizat ions.

6 . THE EXPERIENCE OF ONE COUNTRY FREQUENTLY CAN BE HELPFUL TO OTHER COUNTRIES I N DEVELOPING ALCOHOL POLICIES. I N THE FINAL ANALYSIS, HOWEVER, EACH COUNTRY'S PUBLIC AWARENESS STRATEGIES AND PREVENTION PROGRAMS REGARDING ALCOHOL-RELATED PBOBLEMS MUST BE SHAPED BY ITS OWN UNIQUE SOCIAL, CULTURAL, POLITICAL AND ECONOMIC SITUATIONS.

Alternat ive Non-Consensus V i e w s

Eech p a r t i c i p a n t was given t h e opportunity t o submit f o r publ ica t ion any disagreements with t h e coneensue statements. Two such statements were received.

Harry Gene ievine: Like some o the r recent s tuden t s of t h e a lcohol f i e l d , 1 am i n t e r e s t e d i n the way knowledge and f a c t e a r e produced, promulgated and legi t imized (See a i s f i e l d 1981, Weiner 1981). h o n g the questione one can a s k a r e : Why these f a c t s and not o the r f a c t s ? Why 1s knowledge presented i n t h i s fonu? ühy a r e these points s ingled out and emphasized and not o the r s? Why, indeed, i e the re a "coneensus" statement a t a l l ?

It 1s not c l e a r what t h i s i s a "consensue" of . 1s t h i s a consensue of d a t a and conclusions of t h e papers presented a t the conference, o r of a l 1 t h e statements made? O r l e t h i s a consensus of the genera l opinions of t h e a lcohol and public hea l th pro- f e s s i o n a l s assembled a t t h e conference regardless of whether anything was s a i d on the subjec t a t the conference o r no t?

The f i r s t point of t h e document makes a number of s tatements f o r which, i n my opinion, l i t t l e o r no evidence was preeented a t the conference f o r most of the coun t r i e s of t h e Americas. There was v i r t u a l l y no evidence presented on t h e r e l a t ionsh ip of alcohol t o "vio lent andlor cr iminal behavior; family d is rupt ion; c h i l d neglect ; and impairment of work capaci ty and a t tendant l o s s of productive capacity.. . . [and] f e t a l damage." There was no evidence t o support the statement that the "burden t o soc ie ty of episodic in tox ica t ion and chronic heavy drinicing 1s s u b s t a n t i a l i n l o s t contr ibutione t o economíc product iv i ty and s o c i a l development . " (On t h i s l a s t point my paper drew t h e opposi te conclusion). F ina l ly , the re was no evidence t o support the statement t h a t the coun t r i e s of t h e Americas experience s u b s t a n t i a l l o s s e s becauee of t h e "uee of scarce resources f o r r e s t o r a t i v e and long-term hea l th care , and f o r r e h a b i l i t a t i v e s o c i a l cervices" f o r a lcohol problema. Indeed, t h e overwhelming t h r u s t of t h e d iscuss ion a t t h e conference was t h a t the re 1s l i t t l e d a t a ava i l ab le on t h e r e l a t ionsh ip of alcohol t o s o c i a l problems f o r most of the countr iee of t h e Americas.

The consensus statement a l s o g ives t h e impression t h a t chronic heavy drinldng and per iodic in tox ica t ion a r e reeponeible f o r , o r the cause o f , these problems and "enonuous burdens" ( o r a t l e a s t a e i g d f i c a n t percentage of them). And i t g ives the impression t h a t

by doing something t o prevent a lcohol problems -- primari ly by s i g n i f i c a n t l y r a i s iug p r i c e and reducing a v a i l a b i l i t y -- a country can eave considerable sums of money and reduce a number of major s o c i a l problems. This would t r u l y be a wonderful thing i f i t were t rue . Unfortunately, i t i s not . Although this type of argument i s o f t e n used t o publ ic ize alcohol problems, and t o secure more funding f o r research, treatment , and prevention, t h e r e i s no empírica1 data , i n my opinion, t o support t h e statement t h a t a lcohol consumption d i r e c t l y causes these problems.

The consensus statement recognizes t h i s i m p l i c i t l y by using a terminology , common i n the a lcohol f i e l d , t o suggest c a u s a l i t y without saying s o d i r e c t l y . Thus t h e statement points out t h a t in tox ica t ion and heavy drinking a r e "associated with," "linked to , " and "d i rec t ly r e l a t e d to" t h e various problems and economic cos te . While the tone and s t y l e of these statements eound s u b s t a n t i a l and a u t h o r i t a t i v e , none of t h e phrases means t h a t drinking o r in toxi - c a t i o n causes the problema.

Indeed , t h e t erminology of "associat ion" and "re la t ion" leavee the d i s t i n c t p o s s i b i l i t y t h a t the causal r e l a t ionsh ip could go the o t h e r way -- t h a t various economic and s o c i a l problems cause harmful drinking and in toxica t ion . Further, what i s l e f t of f the l i s t of "alcohol-related problems" i e j u s t a s i n t e r e e t i n g a s what is included. Left of f a re : poverty, inadequate s a n i t a t i o n , poor d i e t , unemployment, i n f a n t mor ta l i ty , inadequate housing, war, urban slums, oppreseive work condit ions, recessions and depressione, l ack of medical ca te , and so on. Like t h e o the r problems, a l 1 of theee could be responsible f o r heavy drinking and in tox ica t ion a s much a e t h e reverse. However, the re was no more evidence presented f o r these alcohol-related problems than f o r the o thers .

1 do not mean t o imply t h a t t h e consensus statement i e t h e r e e u l t of i n t e n t i o n a l f a l s i f i c a t i o n . On t h e cont rary , t h i s i s the work of c a r e f u l and caut ious people using t h e standard r h e t o r i c a l format and language of t h e a lcohol f i e l d ; c e r t a i n problems a r e "natura l ly" l inked with alcohol , and o the r s a r e not. Thue, although there was l i t t l e da ta , i n my opinion, f o r most of t h e claims d e under t h e f i r s t point of t h e consensus statement, they could i n good conecience be included because "everybody" knows they a r e t rue . And t h i s consensus statement adds i t s own b i t t o what "everybody knows."

The promise of the consensue statement i s t h a t by following what a r e c a l l e d "group-oriented prevention measuree" -- primari ly r a i s i n g p r i ces and reducing a v a i l a b i l i t y -- major s o c i a l problems of t h e Americas w i l l be reduced. 1 th ink t h i s o f f e r s a f a l s e so lu t ion t o r e a l s o c i a l and economic problems. Even i f , f o r example, the a lcohol consumption of t h e countr ies of t h e Americas was s i g n i f i - c a n t l y reduced, 1 do not th ink the re would be s ign i f i can t

reductione i n v i o l e n t o r cr iminal bahavior, family dieruptione, c h i l d neglec t , o r a n increaee i n o v e r a l l e c o m d c productivi ty. During the 19208 i n t h e United S ta tee , f o r example when alcobol consumption dropped very e ign i f i can t ly , t h e r e wae no reduction i n major e o c i a l and economic probleme. Indeed, under Prohibi t ion the U.S. experienced t h e growth of organized crime, t h e youth rebe l l ion of the f l apper e r a , and the woret depreseion i n America hietory.

Like automobile s a f e t y deeign, a i r and water pol lu t ion , in fan t mor ta l i ty , c i g a r e t t e smoking, tox ic wastee and environmental hazards, a lcohol consumption l e a l eg i t ima te and important public heal t h concern. Howeve r, overee l l ing the e v i l coneequences of a lcohol does not help public heal th. Further , although reducing t h e incidente of publ ic h e a l t h probleme br ings ma te r i a l and q u a l i t y of l i f e improvemente f o r many people, i t w i l l no t ueually produce socie ta l - leve1 economic benef i t s . Deeigning s a f e r automobiles and reducing i n d u e t r i a l pol lu t ion , f o r example, save l i v e s but coet money. Similarly, reducing a lcohol consumption w i l l not produce t h e s o c i a l and economic bargin t h i s coneensus statement promiees.

Marcelo Selowsky: My f i r s t objec t ion t o the etatement of consensue views stems from t h e f a c t t h a t t h e workshop concentrated much too heavily on l e g i s l a t i v e con t ro le and p roh ib i t ion on the eupply ( a v a i l a b i l i t y ) of alcohol . The f a c t t h a t people a r e a b l e t o e u b s t i t u t e the t i m e and e i t e of purchaee, a e wel l a s t o switch t o o t h e r sources of a lcohol ( i .e . , informal o r domestic), was thus not c a r e f u l l y enough considered. Thie l e p a r t i c u l a r l y important i n r u r a l a reae of developiqg countr iee. Also, i t i e not c l e a r t h a t from a broader welfare point of view, r e e t r i c t i o n e on the eupply s i d e make people happier (we a r e not i n t e r e s t e d i n bringing down a lcohol coneumption per e e but i n increased welfare) . What o t h e r behavioral changes can we expect by r e s t r i c t i n g t h e eupply of a l coho l i c beverages? The a l t e r n a t i v e in tervent ion , on the demand s i d e , which 1 bel ieve t o be more cons ie tent with these broader objec t ivee , should have been given equal importance.

Second, 1 don' t t h ink t h e empirical evidence on the ef fec t ivenese of supply e ide versus demand e ide in tervent ions 1s strong enough t o make some of t h e statements included i n t h e consensus statements.

Third, t h e r o l e of t axa t ion l e diecussed with a very narrow objec t ive , namely, again, t o bring down t h e consrmiption of alcohol. I f t h e e f f e c t of a lcohol t axa t ion on low income groupe reduces t h e i r

ne t r e a l income ( the incone l e f t t o buy other comnoditiee), then the purchaee of other comodit iee , euch a s food, medicine, and, clothing, w i l l go down, par t i cu la r ly i f t h e i r demand f o r alcohol i e ine lae t ic . i b w do we take t h i e i n t o account? Again, i t l e the reeu l t of looldng a t a very narmw objective -- consmption of alcohol -- inetead of a t the general welfare of thoee income groupe-

ñe f erencee

Guefield, Joeeph R. (1981) The Culture of Public Problema: Drinking Driving and the Symbolic Order, Chicago : Univereity of Chicago Preee.

Wiener, Carolyn L. (1981) The Pol i t i ce of Alcoholiem, New Brunswick, New Jersey: Traneaction Booke.

WORKSHOP PARTICIPANTS, GUEST SPEAKERS, AND INVITED OBSERVERS

Workshop Par t i c ipan t s

Jaime Arroyo Sucre Prof. Medicina Preventiva y Socia l Univereidad de Panama Panama, Panama

M i chael Beaubrun Direc tor , Caribbean I n s t i t u t e

on Alcoholism Univerei t y of the Wes t Indlee P o r t of Spain, Trinidad

Linda A. Bennett Center f o r Family Research George Washington Univereity

Medical Center Washington, D .C.

Robert J. Blendon Senior Vice-President The Robe r t Woo d Johnson Founda t ion Princeton, New J e r s e y

Raul Cae tano Aseociate Professor of Peychiatry Federal Universi t y of Rio de

Jane i ro (on leave) Research Analyst, Alcohol Research

Group Bericeley, Calif o rn ia

Charles Chassoul Plionge Direc tor I n s t i t u t o Nacional Sobre Alcoholismo San Jose, Costa Rica

Carlos Campillo-Serrano I n s t i t u t o Mexi cano de Psiquia t r i a Mexico C i ty , Mexico

Dean Gerstein Assembly of Behavioral and

Socia l Sciences National Academy of Sciences Washiag ton, D .C.

U n e Gonzalez Regional Advisor i n Manta1 Health Pan Ameri can Health Organiza t ion Washiag ton, D.C.

Berkley C. Hathorne In terna t i o n a l Act iv i ties Of f i cer Off ice of the Administrator Alcohol, Drug Abuse, and

Mental üea l th Administra t i o n

Dwight B. k a t h Professor of Anthropology B ~ O M Universi t y Providence, Rhode I s l and

Marilynn Katatsky Regional Advisor on Alcoholism

and Drug Abuse Pan American Health and Human Services Washington, D.C.

Harry Gene Levine Professor of Sociology Queene College New York, New York

Eduardo Me dina Cardenas Minieterio de Salud Santiago, Chile

Mari a Elena Me dina-Mo ra I n s t i t u t o Mexicano de Ps iquia t r i a Mexico C i ty , Mexico

James Moeher Alcohol Reeearch Group Bericeley, Cal i fornia

Juan Carlos Negrete Associate Direc tor , Departppent

of Ps ychia t ry , Montreal General Hospital Montreal, Quebec, Canada

Robin Room S c i e n t i f i c Director Alcohol Research Group Be rkeley, Calif ornia

I r v i n g Rootman Chief , Heal th Promotion S tud lee Health and Welfare Canada Ottawa, Ontar io, CAnada

Wolf gang Schmidt Al coholism and Drug Addic t i o n

Resear ch Founda t i o n Toron t o , Ontario , Canada

Marcelo Selowsky Economi c Advisor The World Bank Washington, D.C.

Reginald Smart Alcoholism and Drug Addi c t i o n

Re search Founda t i o n Toronto , Ontario , Canada

Robe r t S t r aus Prof e s s o r and Chairman, Deparment

o f Behavioral S cíence College of Medicine Universi t y of Kentucky Lexing ton, Kentucky

Leland H. Towle Chief , I n t e r n a t i o n a l and In t e r -

governmental A f f a i r s Na t i o n a l I n s ti t u t e on Alcohol Abuse

and Alcoholism Ro c k v i l l e , Maryland

Gues t Speaker8

k c t o r R. cuna Di rec to r , Pan Americen Heal t h

Organiza t i o n Washington, D.C.

P e t e r D. Be11 Pres iden t Inter-Ameri can Heal t h Founda t i o n Washington, D.C.

John H. Bryant Deputy A s s i s t a n t Sec re t a ry f o r

I n t e r n a t i o n a l Heal t h Department of Heal t h and Human Serv lces Washing ton, D .C.

Thomas F. Malone Foreign Sec re t a ry Na t i o n a l Academy of Sciencee Washington, D.C.

F rede r idc C. Robbins Pres iden t I n s t i t u t e of Medicine National Academy of S d e n c e s Washington, D .C.

Norman S a r t o r i u s D i rec to r , Div is ion of Mental Health World Heal t h Organization Geneva, Swi tzer land

I n v i ted Observers

George Alleyne Chief of Research, Promotion

and Coordination Pan American Heal t h Organiza t i o n Washing ton, D .C.

Fabio Arango Economlc Advisor Economic Commission f o r La t i n America Washing ton, D .C.

Loran Archer Acting Di rec to r , Na t i o n a l I n e t i t u t e

on Alcohol Abuse and Alcoholism Department of Health and Human Serv icee Washing ton, D .C.

Karen Be11 Board on Science and Technology f o r

I n t e r n a t i o n a l Development N a t i o n a l Academy of S ciences Washington, D.C.

N e i l Boyer Agency Director f o r Health and Naraoticr Bureau of In te rna t iona l

Organization Aff a i r s U.S. Department of S t a t e Washing ton, D .C.

Gordon B ~ O M Direc tor , Office of In te rna t iona l

Economi c Po l i cy Bureau of In te rna t iona l Orgadza t ion

Af f a i r s U.S. Department of S t a t e Waehing ton, D .C.

John Deering Economlc Advisor Pan American Heal t h Organization Washington, D.C.

Abraham Drobny Chief , Pub l i c iiealth Projec te InterAmerican Development Bank Washington, D.C.

Paul Ehrl ich Depu t y Direc tor Pan American k a l t h Organization Washington, D.C.

John Evans Direc tor , Population, Health and

Nu t r i t i o n Departmen t The World Bank Washington, D.C.

Barbara F i l n e r I n e t i t u t e of Hedicine National Academy of Sciences Washington, D .C.

Mar t i ta M a n t S e d o r Program Officer The Robert Wood Johnson Foundatin Princeton, New Je r sey

William Player Adminis t r a t o r , Al cohol, Drug and

Mental Health Admlnistration De par tment o£ Heal th and Human Services Washington, D .C.

Alice M c G i l l Office of üea l th Promo t ion Department of Health and Human Services Washington, D.C.

Lane Por te r Norris and Norrie, In te rna t iona l

Lawyers Bos ton, Massachuse tts

David Promisel Army Research Ins ti tu t e Arling ton, Virginia

Edward S. Sanda S cien t i f i c Research and

Education Division Die t i l l e d S p i r i ts Council

of the U.S.

Mark Schneider Off icer of Long-Range Planning Pan American Heal th Organiza t ion Washing ton, D .C.

Nancy Woli cki S t a f f , U.S. Senate Subcommittee on

Alcohol im and Drug Abuse Washing ton, D .C.

Alvaro Gomez Secre t a r i a t of Legal A f f a i r s Organization of American S ta tee Washing ton, D .C.