11. Alcohol Consumption, A Public H e a l t h Issue
2
Ths section provides support for t h e p u b l i c health concern about alcohol c o n s u m p t i o n a n d
abuse. T h e discussion on the effects o f a l c o h o l on health a n d social w e l l b e i n g i s organized
into two parts. T h e f i r s t p a r t focuses on the dseases a n d injuries associated with a l c o h o l use,
a n d t h e ways i t s i m p a c t primarily falls on t h e individual. T h e second p a r t focuses on t h e
effects t h a t extend b e y o n d the i n d i v i d u a l to t h e family a n d community, through violence a n d
t h e risk behaviors associated with alcohol.
Effects o f Alcohol o n Disease and Injury
T h e World H e a l t h Organization (WHO, 1999) has identified a l c o h o l use as o n e o f t h e m a j o r
causes o f the g l o b a l disease burden. T h e G l o b a l B u r d e n of Disease' study estimated that, in
1990, a l c o h o l was responsible for 3.5 percent o f t h e world's t o t a l disability-adjusted life-years
lost. Ths exceeds t h e tolls taken by tobacco (2.6 percent) a n d f i c i t drugs (0.6 percent)
c o m b i n e d (Murray a n d Lopez, 1996). T h e adverse effects o f a l c o h o l c o n s u m p t i o n on dsease
a n d injury characterized by steady heavy drinking a n d i n t o x i c a t i o n are w e l l documented in
t h e scientific literature. Among men, a l c o h o l i s t h e leadmg cause o f d s a b h t y in industriahzed
countries a n d ranks fourth in causing disabihties in developing countries (WHO, 1999).
A l c o h o l also plays a significant r o l e in causing disability through neuro-psychiatric conditions
t h a t i m p a i r t h e w e l l b e i n g o f indviduals, f a d e s , a n d communities. Moreover, a l c o h o l i s
closely associated with acute as w e l l as l o n g - t e r m chronic conditions ranging from addiction,
b r a i n damage, hgh blood pressure, a n d stroke to cancers a n d muscle a n d b o n e dseases
(Edwards a n d others, 1995). Furthermore, a l c o h o l i s a trigger for violence, injury, a n d
accidents. All these facts bear particularly acute importance in LAC, the r e g i o n ht t h e
hardest by the m o r t a l effects o f alcohol: c o m p a r e d to other geographical regions, L a t i n
A m e r i c a h a d the highest percentage (4.5 percent) o f t o t a l deaths attributed to a l c o h o l (see
T a b l e 1).
V i e w i n g alcohol c o n s u m p t i o n as a c o n t i n u u m from abstinence to addiction, WHO
r e c o p z e s two m a i n patterns o f drinking t h a t have the greatest adverse effects on health:
sustained moderate or heavy drinking over a n extended p e r i o d o f time, a n d single or
repeated e p i s o d c intoxication. An episode o f i n t o x i c a t i o n resulting from a single dnnkmg
occasion can i m p a i r a n individual's health, as w e l l as t h e social w e l l being, through accidents,
assaults, a n d injuries. Steady heavy drinking i s associated with numerous chronic physical
a n d m e n t a l health problems.
In analyzing the attributable b u r d e n d u e to alcohol, M u r r a y a n d L o p e z examined three dimensions:
detrimental effect o n injuries; detrimental effect on disease; a n d protective effect o n ischaemic heart disease.
(For discussion o f methodology f o r deriving t h e estimates, see M u r r a y a n d Lopez, 1996).
3
Table 1: Burden of Disease and Injury Attributable to Alcohol Use, 1990
Deaths
As YOo f
(ooos)
total
Years o f
l i f e lost
A s YOo f
total
deaths
(YLLs)
YLL
(000’s)
Years l i v e d
w/
(disabihty
. I s YOo f
total
YLD
Disability
adjusted
l i f e years
YLDs)
PSYS)
(000’s)
(000’s)
As YOo f
total
DALYs
LAC
136.1
4.5
3,319
5.9
6,201
14.7
9,520
9.7
Industrialized
regions
136.8
1.3
4,601
5.4
10,797
14.3
15,398
9.6
Developing
636.8
1.6
14, 868
1.8
17,603
4.4
32,289
2.7
773.6
1.5
19, 287
2.1
28,400
6.0
47,687
3.5
regions
Total
Source: Murray, C. a n d Lopez,
A. 1996
Furthermore, a l c o h o l i s a psychoactive substance that can lead to addiction a n d dependency.
T h e p u b l i c health a n d meQcal communities regard alcohol dependency, also referred to as
alcoholism, as a Qsease.’ T h e DSM I V classification system classifies a l c o h o l use disorders as
substance-related disorder^.^ These are d i v i d e d into two groups: substance use disorders,
w h i c h include dependence a n d abuse; a n d substance-induced disorders, i n c l u d i n g
intoxication, withdrawal, delirium, dementia, amnestic disorder, psychotic disorder, mood
disorder, anxiety disorder, sexual dysfunction, a n d sleep Qsorder (see A n n e x 2 for m o r e
detailed d e h t i o n s o f substance-use Qsorders) .4 A l c o h o l dependence a n d abuse-both
characterized by maladaptive patterns o f use leading to clinically s i p f i c a n t i m p a i r m e n t or
&stress a n d manifested by tolerance, withdrawal, inablllty to fulfill r o l e obligations, recurrent
substance related legal problems, a n d social a n d interpersonal problems-are issues o f
p u b l i c health concern.
WHO estimates a prevalence o f 9.7 to 35.6 percent heavy dnnkers in t h e L A C region..‘
Research in t h e 1960s a n d 1970s estimated that in L a t i n A m e r i c a a b o u t 1 0 percent o f t h e
p o p u l a t i o n were excessive drinkers a n d another 5 percent alcoholics (Caetano, 1984). Table
2 inQcates the prevalence o f a l c o h o l dependency in B r a z i l a n d M e x i c o . Sex disaggregation
highlights the dramatically higher prevalence rates o f alcoholism a m o n g m e n c o m p a r e d to
w o m e n . In Mexico, for example, 12.5 percent o f m e n were found to b e alcoholics, compared
to only .06 percent o f w o m e n (Medina-Mora, 1999).
Alcoholism, though s i p f i c a n t , i s but o n e o f t h e m a n y health problems associated with
a l c o h o l use. Cirrhosis i s a c o m m o n l y known disease that i s related to a l c o h o l abuse. ,
* T h e health a n d medical literature employs terms such as alcohol abuse a n d alcohol dependency that are based
on a disease model, placing the issue p r i m a r i l y in the realm o f medicine a n d psychiatry rather t h a n in the realm
o f social science. A l c o h o l abuse i s defined as patterns o f heavy alcohol intake in nondependent persons in
w h i c h health consequences and/or i m p a i r m e n t in social f u n c t i o n i n g are associated (US. D H H S , 1990, p. x i ) .
A l c o h o l dependence syndrome i s defined as a severe disability in w h i c h dependence brings a b o u t a reduction in
the individual’s ability t o c o n t r o l the drinking behavior. International Classification o f Diseases o f WHO a n d
Diagnostic and Statistical M a n u a l o f M e n t a l Disorders differentiate alcohol abuse (a nondependent, p r o b l e m
drinking condition) from alcohol dependence. T h e definitions a n d the differentiation m a d e b e t w e e n t h e two
condltions are constructed primarily for clinical reasons;, treatment o f each c o n d i t i o n requires dlfferent
intervention goals and approaches.
DSM I V i s the f o u r t h edition o f the A m e r i c a n P s y c h a t r i c Association Diagnostic a n d Statistical Manual.
i i m e r i c a n Psychiatric Association Diagnostic a n d Statistical Manual, Fourth Edition, t h e A m e r i c a n Psychiatric
Association, 1994.
Because of a l a c k o f data on alcohol abuse a n d alcohol-related problems, cirrhosis o f t e n
serves as a proxy for heavy drinkmg levels.
4
Table 2: Prevalence of Alcohol Dependency, by Gender
Country/ City
Male
Female
Age
Diagnostic
test
Rio d e Janeiro
4.9%
1.7%
18 a n d older
CAGE
Sao P a u l o
13.0%
3.0%
15-49
CAGE
Porto A l e g r e
16.0%
4.0%
18 a n d older
CAGE
Bahai
6.3%
0.9%
?
DSM I11
?
ICD-10
Brazil
12.5%
0.6%
Source: C a r h i - C o t r i m , 1999, Medina-Mora, 1999.
Mexico
-
Measuring cirrhosis m o r t a l i t y has i t s h t a t i o n s ; but i t possesses o n e great advantage: t h e
data are w i d e l y r e p o r t e d a n d therefore allow for comparisons between countries. Figure 1
indicates cirrhosis m o r t a l i t y rates for some countries in LAC. N o t a b l y , t h e rates show stark
gender differences. Interpretation o f these cirrhosis statistics, however, calls for a n o t e o f
caution: age standardization based on E u r o p e a n populations was used, raising t h e m o r t a l i t y
rates. I t should b e considered that 36 percent o f L a t i n A m e r i c a i s b e l o w t h e age of 15, as
compared to 19 percent o f E u r o p e (Madngal, 1998). I t i s also i m p o r t a n t to n o t e that the
proportion o f t o t a l cirrhosis deaths caused by alcohol varies a m o n g countries as a result of
other environmental factors t h a t contribute to cirrhosis m o r t a l i t y . Poor living conditions a n d
hygiene as w e l l as m a l n u t r i t i o n can cause infectious a n d degenerative l i v e r conditions, both
acute a n d chronic, m e a n i n g t h a t alcohol i s only o n e o f t h e m a n y factors t h a t contribute to
cirrhosis deaths.
Essentially, however, i t i s i m p o r t a n t to n o t e that cirrhosis remains a significant health
p r o b l e m in m a n y o f t h e countries in LAC, particularly a m o n g m e n . Cirrhosis i s o n e o f t h e
t e n leadmg causes of death in Mexico. Among m e n b e t w e e n t h e ages o f 35 a n d 45, i t i s t h e
n u m b e r o n e M e r (Madrigal, 1998, Medma-Mora, 1999). In M e x i c o , Venezuela R.B.,
Argentina, a n d T r i n i d a d a n d Tobago, cirrhosis deaths a m o n g m e n are as m u c h as three times
h g h e r t h a n t h e deaths a m o n g w o m e n . This concurs with e p i d e m i o l o g c a l findings that
reveal that higher proportions o f m e n in L A C are heavy drinkers c o m p a r e d to their female
counterparts (see Section 10.
A l c o h o l dependency a n d cirrhosis are far from t h e only p r o b l e m s associated with a l c o h o l
use. T h e scientific literature has p o i n t e d out t h a t a l c o h o l i s associated with m a n y other
diseases, injuries, a n d accidents, such as traffic-related fatalities, homicides, a n d suicides.
W e i t i s i m p o r t a n t to recognize that socio-economic c o n d t i o n s , enforcement measures,
a n d safety regulations (such as seat-belt laws) m e d a t e t h e relationship between a l c o h o l
consumption a n d traffic accidents, some studies c o n d u c t e d in L A C justify t h e c o n c e m about
h s relationship, as demonstrated in Table 3.
Figure 1: Cirrhosis Mortality
5
Deaths from Cirrhosis Per 100,000 in the Americas and the Carribbean
among men and women (age standardized)
80.0
0
r
v
70.0
60.0
50.0
..."
40.0
CU
r
.-ln
30.0
g 20.0
E
6
10.0
0.0
'ource: E d w a r d s a n d others, 1995
G e n d e r dfferences in alcohol-related p r o b l e m s were further highlighted by E d w a r d s a n d
others (1995), who determined the degree to w h i c h a l c o h o l contributes to h e s s a n d injury
by conducting a meta-analysis of scientific studles p u b l i s h e d since 1980. T h e researchers
t h e n p r o d u c e d estimates t h a t were c o m b i n e d with the existing data on prevalence of a l c o h o l
use a m o n g the Australian population. In 1998, a similar exercise was carried out for t h e
C a n a d a n population. This methodology was employed to determine t h e f r a c t i o n o f each
disease a n d injury attributable to alcohol. T h e attributable fraction was f u r t h e r disaggregated
by sex. Some health conditions are, by definition,
caused by alcohol, such as alcoholic
poisoning a n d alcohol dependence, a n d would, therefore, b e designated with a n attributable
fraction o f 1.OO. O t h e r conditions that h a d relatively high attributable fractions w e r e
unspecific liver cirrhosis, chronic pancreatitis, r o a d injuries, fire injuries, drowning, suicide,
a n d assault.
T h e two s t u d e s h g h h g h t e d a w i d e range o f health p r o b l e m s caused by alcohol, includmg:
0
cancers (for instance, l i v e r or laryngeal)
0
heart diseases
0
maternal a n d c h i l d health p r o b l e m (for instance, low birth weight, or spontaneous
abortion)
0
injuries (for instance, falls, burns, or work related)
0
accidents (for instance, water or auto transport)
0
violence (for instance, suicide, assault, or c u d abuse).
6
Table 3: Relationship between Alcohol and Traffic-Related Accidents and Fatalities
in Some L a t i n American Countries
~~
Country
Year
Percent o f drivers with positive blood alcohol content
Argentina
Brazil
1980
1995
1974
20% o f drivers in Buenos Aires*
Chde
PAC)
30% o f drivers in Salvador**
70% o f male drivers"
Percent o f accidents attributed to alcohol
Bo h i a
1990s
1990s
1990s
1972
1974
Brazil
Ecuador
Mexico
Mexico
1gO/o**
25%**
33%**
7% nationwide*
17% in M e x i c o City*
~
Percent o f traffic
Chde
Colombia
Costa &ca
Peru
Sources:
1970
1990s
1990s
1990s
fatalities attributed to alcohol
46% (male traffic deaths)*
6O%**
46%""
50°/o**
(*) Caetano, 1984; (**) Madngal, 1998
A l c o h o l contributed to certain problems, such as fire injuries, chronic pancreatitis, a n d
assault, to the same extent a m o n g w o m e n as a m o n g m e n in Australia a n d Canada. W h e r e
there were gender dfferences in attributable fractions, however, alcohol played a greater r o l e
(that is, was designated with a higher fraction) in causing illnesses a n d injuries a m o n g m e n
t h a n a m o n g w o m e n F a b l e 4). For example, alcohol was estimated to cause 41 percent o f
suicide cases a m o n g m e n in Australia, compared to only 16 percent a m o n g their female
counterparts. Country dfferences were also evident. W e alcohol contributed to nearly h a l f
o f r o a d injuries in both C a n a d a n m e n a n d women, i t was m o r e instrumental in causing r o a d
injuries a m o n g m e n (0.37) in Australia t h a n a m o n g w o m e n (0.18).
These two studies, w h c h estimated the r o l e o f alcohol in causing illnesses a n d injuries
among the Australian a n d Canadian populations, o f f e r a useful methodology. However, their
findmgs cannot b e g e n e r a k e d to other populations, especially in the developing world.
Three key reasons for exercising caution in interpreting the data for other populations are:
levels a n d patterns of drinkmg vary greatly across d f f e r e n t populations, particularly
between m e n a n d women;
0
0
the meta-analysis only included scientific studies published in t h e English language; a n d
social a n d environmental conditions that interact with drinkmg v a r y greatly across
different populations.
7
Table 4: Selected H e a l t h Issues by Alcohol Attributable Fractions
H e a l t h issue
Liver cancer
Australian
Canadian
Male
Female
Male
Female
0.18
0.12
0.29
0.16
0.03
Breast cancer
0.04
Unspecific liver cirrhosis
0.54
0.43
0.54
0.54
Chronic pancreatitis
0.84
0.84
0.84
0.84
0.20
0.04
Spontaneous abortion
Road injuries
0.37
0.18
0.43
0.43
Fall injuries
0.34
0.34
0.24
0.15
F i r e injuries
0.44
0.44
0.38
0.38
Drowning
0.34
0.34
0.30
0.23
Suicide
0.41
0.16
0.27
0.17
Assault
0.47
0.47
0.27
0.27
Source: E d w a r d s a n d others, 1995, Single a n d others, 1998
Gender-Differentiated Effects o f Alcohol
W o m e n are affected differently by a l c o h o l t h a n are m e n because o f physiological differences
( N U , 1999 a n d 2000; G r a h a m a n d others, 1998; Schenker, 1997). Schenker (1997)
reviewed t h e m e Q c a l literature a n d highlighted t h e following k e y issues affecting w o m e n :
0
0
0
W o m e n o b t a i n a h g h e r concentration o f a l c o h o l in t h e blood for a s d a r intake o f
a l c o h o l because o f the l o w e r t o t a l water c o n t e n t in their bodies.
A l c o h o l enters t h e bloodstream in a m o r e concentrated form in women, because t h e
stomach enzyme that breaks down a l c o h o l b e f o r e i t enters t h e bloodstream i s less active
in w o m e n .
Alcohol's effects vary accordmg to t h e m e n s t r u a l cycle, because, research suggests, t h e
intensity o f a l c o h o l intake i s affected by monthly h o r m o n a l fluctuations.
These physiological Qfferences have i m p o r t a n t implications (for detailed description of
mechanisms, see NIAAA, 2000):
0
W o m e n are m o r e susceptible to alcoholic l i v e r hsease. W o m e n develop alcoholinduced l i v e r disease m o r e rapidly-over
a shorter p e r i o d o f t i m e a n d after
consuming less alcohol t h a n m e n . Furthermore, w o m e n are m o r e hkely t h a n m e n
to develop alcohol hepatitis a n d to die from cirrhosis.
0
Women's hearts exhibit greater sensitivity to t h e adverse effects o f alcohol.
8
0
0
0
W o m e n t e n d to b e c o m e m o r e intoxicated than m e n w h e n they ingest t h e same
a m o u n t o f alcohol a n d to experience m o r e sedation (measured by four visual
analog scales a n d by choice reaction time), suggesting that women's brains have a
greater sensitivity to alcohol.
W o m e n who are heavy drinkers have a n increased risk o f breast cancer.
W o m e n who drink during pregnancy can adversely affect t h e fetus, dependmg on
the a m o u n t consumed, manner o f consumption, a n d t h e phase o f pregnancy).
M a t e r n a l c o n s u m p t i o n o f a l c o h o l during pregnancy increases t h e r i s k of h a v i n g children with
birth defects. H e a v y a n d binge drinking i s t h e most hazardous drinkmg p a t t e r n during
pregnancy, l t n k e d strongly to t h e birth o f chddren with Fetal A l c o h o l Syndrome. In t h e
U n i t e d States, FAS i s considered t h e most c o m m o n nonhereditary cause of m e n t a l
retardation ( N U ,2000). C h i l d r e n with FAS share a characteristic set of minor facial traits
a t birth; suffer from growth deficiencies; a n d the damage to their developing brains affects
t h e m throughout their l i v e s 5 FAS i s a n example of the intergenerational effects o f alcohol
consumption-the
consequences of drinking passed on by a m o t h e r to h e r infant.
Beneficial Effects o f Alcohol o n Health
Alcohol's negative effects on h u m a n health are a w e l l documented, longstanding p a r t o f t h e
scientific literature. However, o v e r t h e past decade seemingly paradoxical evidence has
emerged that alcohol c o n s u m p t i o n m a y have a protective effect on o n e aspect o f h u m a n
health: coronary heart dlsease. S t u h e s have shown that individuals who consume small to
moderate amounts o f a l c o h o l are less likely to have a m y o c a r h a l i n f a r c t i o n t h a n those who
do not drink. (For a r e v i e w o f t h e studies in t h e U n i t e d States on t h e h e a l t h benefits o f
alcohol, see NIAAA, 2000).
These studies, however, have b e e n challenged on two fronts: a p p l i c a b h t y o f t h e fmdings to
women; a n d m e t h o d o l o g y (see detailed discussion in World B a n k Group, 2000). T h e
m a j o r i t y o f participants in t h e studies were m e n . In those w h e r e w o m e n did participate, t h e
protective r e l a t i o n s h p was not s o clear. Studies found that light c o n s u m p t i o n o f a l c o h o l (1.5
to 29.9 grams per day) protected older w o m e n (50 years o f age a n d over) from CHD; light
c o n s u m p t i o n also conferred protective benefits on w o m e n with o n e or m o r e risk factors for
CHD. . These benefits dld not hold true, however, for w o m e n with no C H D risk factors.
Such w o m e n enjoyed no significant protective effects. Notably, w o m e n who drank m o r e
t h a n 30 grams per day h a d significantly higher mortality, largely d u e to t h e i r higher risk o f
death from breast cancer. T h e research on beneficial effects o f a l c o h o l remains inconclusive
for women. Furthermore, w h e n hscussing t h e beneficial effects o f a l c o h o l on t h e risk o f
CHD, it i s i m p o r t a n t not to i g n o r e t h e prevalence of C H D in a g i v e n developing c o u n t r y in
relation to other health a n d social problems t h a t are caused or exacerbated by alcohol.
N L U i (2000) has conducted a n extensive review a n d analysis o f FAS p r e v e n t i o n research. Although
research i s largely US-based, t h e review offers a valuable framework for developing p r e v e n t i o n programs.
Effect o f Impurities in Alcohol on Health
9
A large proportion o f the alcohol consumed in t h e developing world comes from illicit
p r o d u c t i o n . A n o t h e r p u b l i c health concern about drinking involves t h e effect of impurities
in alcohol, a n d illicitly p r o d u c e d alcohol i s t h e greatest culprit. For instance, some poisoning
deaths from drinking illicitly m a d e alcohol have b e e n attributed to iron particles leachmg
from t h e disalling barrels. In a small r u r a l c o m m u n i t y in Mexico, 49 people d i e d after
drinkmg illegally m a d e 9 6 - p r o o f agztardienteb (Medma-Mora, 1999). I t i s i m p o r t a n t to n o t e that
t h e a l c o h o l industry has cited t h e potential dangers of illicitly p r o d u c e d alcohol as a n
argument for c o n t r o l l i n g h o m e b r e w i n g a n d for promotingindustrial production; most
often, these a l c o h o l industry campaigns are waged on b e h a l f o f foreign-made imports. T h e
scope a n d s i p f i c a n c e of the effects of alcohol impurities r e m a i n hghly anecdotal, however,
a n d d e m a n d f u r t h e r investigation.
Effect o f Alcohol o n Risk Behaviors
A third d i m e n s i o n o f t h e p u b l i c health concern over a l c o h o l c o n s u m p t i o n involves the
effect o f a l c o h o l on risk behaviors. As l s c u s s e d above, substantial evidence from t h e
medical a n d h e a l t h literature supports the conclusion t h a t dtsease a n d injury are a m o n g t h e
d u e c t effects o f a l c o h o l consumption. Drinking can also i n d u e c t l y affect health by
encouraging risk behaviors, such as unsafe sex. T h e AIDS epidemic makes such concerns
even m o r e u r g e n t a n d hghlights t h e need to examine t h e relationship between alcohol a n d
HIV risk behaviors.
A survey of sexual behaviors a m o n g l o w - i n c o m e youths in Barrios Altos a n d C a n t o Grande
in L i m a , P e r u found that, after c o n t r o l l i n g for age, sex, a n d socio-economic status, h a v i n g a
sexually transmitted dtsease (past a n d present) a n d a n u n i n t e n d e d pregnancy were
significantly related to c o m b i n i n g sex with a l c o h o l a n d drug use. T h e U e l i h o o d that a girl’s
&st sexual intercourse happened a t a n early age increased if she h a d consumed alcohol
(Caceres a n d others, 1997).
A n o t h e r study, w h c h examined risk factors for HIV i n f e c t i o n a m o n g Guatemalan soldiers
o f indigenous backgrounds, revealed that a l c o h o l c o n s u m p t i o n was strongly associated with
HIV infection. Drinkmg, along with poor c o n d o m use a n d sex with prostitutes, was found
to increase by a factor o f 15.6 t h e soldiers’ risk o f acquiring sexually transmitted diseases
(Flores a n d Arathoon, 1994).
Studies o f AIDS in other countries, such as Thailand, i n l c a t e t h a t a l c o h o l c o n s u m p t i o n
influences m a n y dunensions o f sexual behavior. O n e such study, w h i c h i n c l u d e d students,
soldiers, a n d clerks in the sample o f 1,472 men, revealed t h a t heavy drinking increased t h e
odds o f h a v i n g h a d sexual intercourse; increased t h e odds o f h a v i n g visited prostitutes; a n d
decreased the odds of consistent c o n d o m use in sexual encounters with sex workers
(VanLandmgham a n d others, 1993). In addition to t h e survey, focus group l s c u s s i o n s with
m e n identified drinkmg as t h e most i m p o r t a n t precursor to visiting sex workers.
T h e r e l a t i o n s h p b e t w e e n drinkmg a n d HIV risk behaviors, such as visiting commercial sex
workers or h a v i n g sex without condoms, i s not o n e o f simple causality. I t has b e e n argued
that drinking behavior co-occurs with other dangerous factors, such as risk-taking
Includes beverages made f r o m sugar cane alcohol and agaves, such as mescal and sotol. Aguardiente means
“burning water” ( M e h a - M o r a , 1999).
10
personality traits, suggesting that those who drink are also those who are likely to engage
in r i s k y behaviors. As demonstrated by t h e T h a i study, a l c o h o l use i s most hkely to b e a n
excuse for, rather t h a n a cause of, unsafe sexual behaviors; additionally, alcohol use serves as
a p r e d x t o r o f hgh-risk behaviors. Consequently, HTV p r e v e n t i o n efforts n e e d to consider
t h e r o l e o f drinkmg in the spread o f t h e AIDS virus.
Effect of Alcohol U s e on Families and Communities
U n d o u b t e d l y , a l c o h o l use has played a s i p f i c a n t a n d integral r o l e in m a n y cultural a n d
religious events a n d has also facilitated social interactions throughout h u m a n history
(Lomitz, 1973; Heath, 1974; Bunzel, 1973). Though dtfficult to quantify, m a n y qualitative
studies, particularly ethnographies, have demonstrated t h e r o l e o f alcohol as a social
lubricant. However, these studies o f traditional or indigenous societies also indicate t h a t t h e
secondary effects of alcohol vary greatly depending upon t h e socio-cultural c o n t e x t in w h i c h
dnnkmg occurs (see Section 19.T h e studtes clearly find that t h e beneficial effects on social
interactions are m a r r e d by the negative social impacts
A l c o h o l - i n d u c e d problems (such as dtsease a n d injury) are b o r n e not only by t h e i n d i v i d u a l
who consumes t h e alcohol, but also by his/her family a n d community. A l c o h o l reportedly
plays a n i m p o r t a n t r o l e in instigating v i o l e n t behaviors, particularly within t h e famdy. Such
behaviors include c h d d abuse a n d partner violence, the m a j o r i t y o f w h i c h i s against w o m e n .
H o w e v e r , t h e relationship between a l c o h o l a n d family violence i s not o n e of simple causality.
Levinson’s exhaustive 1989 review o f t h e anthropological literature on 90 preliterate a n d
peasant societies explored the issues o f family violence in a cross-cultural perspective. H e
found that only seven societies indicated t h a t a l c o h o l use was a key c o m p o n e n t in t h e
sequence of events leadmg up to wife-beating. In those societies, i n t o x i c a t i o n p r o v i d e d a n
excuse for the v i o l e n t behaviors of men; w h e n a v i o l e n t m a n was not intoxicated, wives,
f a d e s , a n d communities would not tolerate h s violence. M e n o f the Tzeltal p e o p l e o f
Mexico, L e v i n s o n found, drank heavily during fiestas. During these social events, they o f t e n
became physically aggressive t o w a r d o n e another, a n d c o m m o n l y t h e male aggression w e n t
on to b e du-ected t o w a r d female partners. Child abuse was not i n c l u d e d in t h e study.
Studtes conducted in the 1990s have also found that a l c o h o l plays a significant r o l e in
domestic violence. For example, m o r e t h a n a quarter (26 percent) o f t h e w o m e n seekmg
counseling services in the u r b a n areas o f M e x i c o r e p o r t e d t h a t their partners’ abusive
behaviors were fueled by intoxication (Ramirez a n d others, 1992). In t h e Solomon Islands,
32 percent o f f a d y violence offenses w e r e related to p r o b l e m drinking (McDonald, 1995).
E v e n h g h e r rates were found in South A f r i c a : 67.4 percent o f domestic violence cases in
Cape Town a n d 76.4 percent in r u r a l areas i n v o l v e d a l c o h o l use (Parry, 1995).
A n o t h e r form o f f a d y violence i s c h i l d abuse. In both Canada a n d Australia, 16 percent o f
c h i l d abuse cases c o u l d b e attvibuted to alcohol. InJapan, 20 percent o f abused c h d d r e n h a d
alcoholic parents, a n d in H u n g a r y 8.6 percent o f c h i l d abuse cases in 1994 i n v o l v e d a l c o h o l
(Fekete, 1996). A l c o h o l has also b e e n associated with a high proportion o f c h d d abuse cases
in t h e UK (30 percent) a n d N o r w a y (50 percent) (Moser, 1992).
Physical abuse during c h d d h o o d has also b e e n found to b e t h e risk factor for b e c o m i n g
a l c o h o l dependent as a n adult. Ths highlights t h e intergenerational effect a n d t h e c o m p l e x
relationship between violence a n d a l c o h o l abuse. In a case c o n t r o l study o f t h e relationship
between physical a n d sexual abuse during c h i l d h o o d a m o n g N a v a j o N a t i v e Americans,
a l c o h o l dependence was found to b e a n independent risk factor for b e i n g i n v o l v e d in
domestic violence, either as a v i c t i m or as a perpetrator (Kunitz, a n d others, 1998).
11
Summary
Throughout h u m a n history, alcohol use has evolved m a n y profound meanings in culture a n d
religion. Particularly a m o n g men, i t has served to fachtate social interactions.
A l c o h o l use i s o n e o f t h e m a j o r causes o f t h e global disease burden. Among m e n in t h e
industrialized regons, a l c o h o l ranks as t h e f u s t cause of Qsabhty; in t h e developing world, it
ranks fourth. Adverse effects o f alcohol c o n s u m p t i o n on disease are w e l l documented in t h e
scientific literature. These range from acute maladies to a host o f l o n g - t e r m chronic
conditions, a m o n g t h e m b r a i n damage, hgh blood pressure, stroke, cancers, a n d muscle a n d
b o n e diseases-as
w e l l as injury a n d i t s consequences.
Evidence has emerged to indicate that alcohol c o n s u m p t i o n has a protective effect against
coronary heart diseases in m e n above forty who drlnk in moderation. T h e evidence for such
a protective effect against coronary Qseases in w o m e n remains inconclusive. M e d i c a l
research carried out in industrialized countries has found that g i r l s a n d w o m e n have far m o r e
biological vulnerability to alcohol-related problems.
T h e L A C r e g i o n has the highest percentage o f t o t a l deaths attributed to a l c o h o l use. M e n
bear most o f t h e b u r d e n o f alcohol-related diseases, such as alcoholism a n d cirrhosis.
Moreover, a higher proportion o f Qseases a n d injuries a m o n g m e n are attributable to
alcohol t h a n a m o n g w o m e n . I t i s also i m p o r t a n t to emphasize t h a t t h e i n d i v i d u a l who
consumes t h e alcohol i s not t h e only o n e affected by it. T h e drinker’s family a n d c o m m u n i t y
also bear i t s costs. In addition, alcohol plays a n i m p o r t a n t r o l e in instigating unsafe sex
practices a n d v i o l e n t behaviors, particularly within t h e family. A p r i m a r y example i s domestic
violence, m u c h o f w h c h i s du-ected against w o m e n a n d children.