Alcohol & Health

Alcohol and its relationship to ill health have been recognized as an important public health challenge even though alcohol use has been part of the cultural traditions in different societies. In India, the earliest public health oriented report on alcohol can be traced to a chapter in the Bhore Committee Report of 1946, which showed great foresight by separating out two groups of people who might have been subjected to the ill effects of alcohol: 
(i) those driven to drinking by misery, poor living conditions and lack of educational and of recreational facilities and 
(ii) those that may result by the excesses of folk customs and group habits. 
The Committee suggestions included a rise in the standard of living accompanied by the provision of education and recreation facility, balanced by health education to bring home to the people the harmful effects of convivial drinking.
The NIMHANS team led by Dr. Gururaj have brought together a significant, evidence-based pre-policy document, probably the most comprehensive one after the chapter in the Bhore Committee Report. The evidence they have gathered is particularly strong on the biomedical, legal, social, and economic determinants of the problem with some mention of the cultural determinants and the complex political economy of the problem.
While bringing together a wide body of evidence from a range of sources, they have quite rightly emphasized the paucity of good data and evidence-based, policy-oriented research, making an emphatic demand for more policy research as well as its translation into policy. The division of the document into sections such as introduction, objectives and methodologies of the review, production type and sales of alcoholic beverages, prevalence and pattern of alcohol consumption, biological influences and health consequences, social implications, responses to the problem, key policy issues, and conclusion and recommendations, makes this document a very comprehensive one. It particularly emphasizes the multidisciplinary nature of the problem and the multisectoral nature of the response required to meet this challenge.
The document very effectively underlines the 'public health framework' within which this policy should evolve so that it supports the 'Health for All' commitment of the government and its efforts towards the Millennium Development Goals (MDGs). The challenge will be to ensure
ii
that the market and trade policies and other vested interests do not distort the efforts towards a rational policy. As the authors have rightly emphasized, only 'scientific evidence' and a 'public health focus' can be a bulwark against such policy distortions.
Almost sixty years ago, the Bhore committee had showed great prophetic oversight by suggesting that "little economic merit can be claimed for a system of taxation which raises any considerable part of the public revenue from the sale of alcohol, unless, as a part of the plan of government, this tax money is used to reduce the extent of facilities for the sale of alcoholic beverages; to promote the observance of restrictive laws; to meet the cost of prevention, care and treatment of alcoholism among the considerable number of persons whose health will be injured and whose earning capacity will be reduced by the use of alcohol". The Bhore committee  suggested a plan of action that included: instructions in schools on the effects of alcohol and narcotics; strict control of existing liquor shops; treatment facilities for acute and chronic alcoholism; health promotion; legal sanction for detention of those who need segregation and treatment; active role for NGO's and voluntary effort; and restriction of alcohol consumption during working hours.
This comprehensive report from NIMHANS makes a similar case for a multidimensional response to the problem in today's context backed by substantial evidence. It is sincerely hoped that this report will be a major instrument of advocacy and policy development.
A lcohol has now become a common word in the Indian society. With the impact of globalization, urbanization, industrialization, media influence and changing life styles, alcohol has entered into the lives of Indians in a big and unrestricted manner. From times when alcohol sale was restricted to a few bars and pubs, today, alcohol is available in plenty and in several local outlets, and is within the easy reach of today's young generation. As always, when any product is not adequately controlled and regulated, its ill effects begin to take an upper hand resulting in a huge negative impact on people's health. The response to this epidemic and to the host of deleterious consequences has been rather slow and without direction.
Research in the past few years has conclusively demonstrated that nearly one in 3 male adults consume alcohol, and 5% of Indian women are already regular users. Interestingly, the age of initiation of drinking is progressively coming down. Majority of young Indians after experimenting with alcohol for pleasure seeking and peer influence, end up as habitual users. A significant amount of the public health burden comes from intoxicated behavior, resulting in accidents, violence and other Behavioral consequences. With Indian patterns of drinking being different from the west and more than 500 million adults using a variety of licit and illicit liquor, the negative impact for the country is huge.
Over years, our attempts to address the growing problem has been limited, fragmented and piecemeal. While revenue departments have worked relentlessly on filling coffers, health professionals are preoccupied in providing care for the ever-increasing number of alcohol users; police are battling to curb the menace of alcohol on roads, at home and in work places, NGOs are busy in increasing awareness; social welfare officials are waging a losing battle to rehabilitate alcohol addicts and courts are regularly hearing cases of alcohol impact and awarding compensations and verdicts. Ironically, health professionals and media colleagues have only fuelled this debate with confusing messages regarding alcohol use. What is apparent amidst the controversies of how much of alcohol use is right or wrong, is the absence of a unified vision, a public health approach and the common goal of a healthy society.
FOREWORD
iv
It is true that alcohol use is a problem in every country. One look around the globe, especially the High Income Countries (HIC), reveals that the impact of alcohol use is on the downslide: seen as decreased production, reduced consumption and increased efforts to minimizing harm from alcohol use. Integrated and coordinated policies, sustainable action plans, public health perspective vis-à-vis revenue perspective of alcohol, a better informed society, and strict governmental control of alcohol have paved the way for emergence of societies with less harmful effects of alcohol. The Indian experience of prohibition, education, timings of sale, sales to minors, drink drive laws and others have all remained on paper, with no tangible effects seen on the ground.

It is time the Indian society wakes up to this epidemic, before many more lives are destroyed and families wiped out. The need of the hour is to have a public health approach with sustainable policies and comprehensive programs which are based on evidence and research and on an intersectoral platform. The Indian Government and the Ministry of Health are in the process of formulating a rational alcohol control policy. To facilitate this process and foster a scientific decision making process, NIMHANS has brought together all available evidence from India and lessons from around the globe, highlighted issues of concern and provided an overview of the past efforts in this area. We need to now address alcohol problems through a variety of measures including strict control measures as well as reduction of demand and early intervention. I hope this effort of NIMHANS team will help, support and facilitate the national effort towards making our present and future generations safe and healthy.