Y K Prevention of Harm World Health From Organization Regional Office for Alcohol Use South-East Asia M C M K Y K C M Y K SEA/Ment/122 Distr: General authors Dr Nimesh G. Desai Professor and Head Department of Psychiatry Institute of Human Behaviour and Allied Sciences Post Box 9520, Jhilmil, Delhi Dr Boonchai Nawamongkolwattana, Director, Phrasri Mahabodhi Hospital 121 Changsanit Road Muang Ubonrajchathani Province 3400, Thailand M C M K Dr Sajeeva Ranaweera Y K 605A, Nawala Road Rajagiriya, Sri Lanka Dr Dhruba Man Shrestha Chairman, Maryknoll Mental Hospital Lagankhel, Lalitpur, Nepal Professor M A Sobhan Chairman, Department of Psychiatry Bangabandhu Sheikh Mujib Medical University Bangladesh c World Health Organization 2003 This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced or translated, in part or in whole, but not for sale or for use in conjunction with commercial purposes. The views expressed in documents by named authors are solely the responsibility of those authors. Visuals on pages 9, 15, 25, 28, 29, 33, 35, 38, 44, 53, 99, 101, 108, 111 have been digitally created by Poonam Bevli Sahi. Illustrations on Pages 7, 27, 30, 66, 71, 75, 77, 83, 85, 94, 96, 114 are courtesy Alcohol & Drug Information Centre (ADIC)-India. They have been reproduced with permission. Paintings on pages 16, 41, 43, 78 are part of a WHO-sponsored global school contest on mental health for children aged 6-9 years. They have been painted by Dhruv Suri. Artwork on pages 13, 36, 46, 48, 51, 54, 59, 64, 68, 73, 80, 89, 103, 105, 107 have been produced by Nitin Kishanchand a 20-year old mentally challenged boy diagnosed with Down’s Syndrome. He began painting at the age of 10 as a part of therapy, but developed a full fledged interest in it. He is studying at ‘Muskaan’, a vocational institute for the mentally challenged in New Delhi. 2 C M Y K Prevention of Harm from Alcohol Use M C M K contents Y K Introduction 6 Historical background 8 Myths and misconceptions about alcohol 14 Types of alcohol and Alcoholic beverages 17 Some facts and figures 21 Consequences of alcohol use 66 Identification and assessment of Alcohol-related problems 82 What can be done? 97 Help yourself approach 115 C M Y K Message from the Regional Director Populations of Member Countries of the World Health Organization's South-East Asia Region have suffered for ages from many communicable diseases. While some of these have been successfully controlled, others continue as serious public health problems. However, recently, it has become increasingly clear that noncommunicable diseases, including mental and neurological disorders, are important causes of suffering and death in the Region. An estimated 400 million people worldwide suffer from mental and neurological disorders or from psychosocial problems such as those related to alcohol and drug abuse. Our Region accounts for a substantial proportion of such people. Thus, the Region faces the double burden of diseases - both communicable and noncommunicable. Moreover, with the population increasing in number and age, Member Countries will be burdened with an ever-growing number of patients with mental and neurological disorders. As Dr Gro Harlem Brundtland, Director-General of the World Health Organization says, "Many of them suffer silently, and beyond the suffering and beyond the absence of care lie the frontiers of stigma, shame, exclusion and, more often than we care to know, death". While stigma and discrimination continue to be the biggest obstacles M facing the mentally ill, inexpensive drugs are not reaching many people C M K with mental and neurological illnesses. Although successful methods of Y K involving the family and the community to help in recovery and reduce suffering and accompanying disabilities have been identified, these are yet to be used extensively. Thus, many population groups still remain deprived of the benefits of advancement in medical sciences. Dr Brundtland has said, "By accident or design, we are all responsible for this situation today". The World Health Organization recently developed a new global policy and strategy for work in the area of mental health. Launched by the Director-General in Beijing in November 1999, the policy emphasizes three priority areas of work: (1) Advocacy to raise the profile of mental health and fight discrimination; (2) Policy to integrate mental health into the general health sector, and (3) Effective interventions for treatment and prevention and their dissemination. The South-East Asia Regional Office of the World Health Organization is committed to promoting this policy. Mental health care, unlike many other areas of health, does not generally demand costly technology. Rather, it requires the sensitive deployment of personnel who have been properly trained in the use of relatively inexpensive drugs and psychological support skills on an outpatient basis. What is needed, above all, is for all concerned to work closely to address the multi-faceted challenges of mental health. Dr Uton Muchtar Rafei Regional Director World Health Organization Regional Office for South-East Asia C M Y K Preface "Cheers, let's celebrate the good life". This innocuous remark frequently heard as liquor glasses are raised, appears to imply that alcohol consumption is linked to health and prosperity. However, the facts reveal a different scenario. Countries comprising the South-East Asia Region of the World Health Organization, which had low levels of consumption of alcohol until recently, are steadily moving towards a higher level of alcohol use. The influence of the West and global cultural pressures seem to have accelerated this movement in the last decade. It is well established that an increase in alcohol consumption by a community or a nation leads to a higher proportion of persons with what can be considered problem use (abuse/harmful use) and addiction (dependence). Alcohol abuse has a significantly adverse impact on the lives of affected persons and their families, most notably in health aspects. Simultaneously, the substantial socio-economic impact and the burden on the communities or nations facing increasing alcohol use warrants attention. There is, therefore, an urgent need to focus on prevention of harm from alcohol use and abuse in countries of the Region, both from the perspectives of health promotion as well as social development. Recognition of the consequences of alcohol abuse on the physical and mental health of affected people, as well as, on their socio-occupational life, is necessary for initiating appropriate action to reduce the harm from alcohol abuse. The facts and figures available from the countries in the Region, although not exhaustive or complete, provide an adequate M basis for initiating such action. C M K Y K The international experience on (a) early identification not only in health settings but also in the social sector; (b) sensitizing and mobilizing the community for prevention of harm from alcohol, and (c) development and implementation of service delivery systems including low cost interventions, requires to be appropriately utilized for the benefit of the communities in the Region. More active and vigorous research on the epidemiological trends, consequences of alcohol abuse, the socio-cultural mechanisms related to alcohol use and abuse and effective treatment and prevention strategies needs to be conducted. This is essential to generate information which can be useful for policy-makers and others concerned about alcohol abuse. At the same time, there is a need to understand and clarify some myths related to alcohol use and abuse. The global experience with alcohol control measures and the available scientific evidence are also compelling enough reasons to accept the need for pragmatic solutions as compared to extreme positions like total prohibition. A public health approach which takes into account the trends of alcohol use, the factors contributing to use and abuse, the range of issues for those affected and the strategies for less harmful use for various groups in the population on a scientific basis, is more likely to be effective in preventing harm from alcohol abuse. This monograph, prepared by a panel of experts provides the currently available information on alcohol use and abuse in WHO's South-East Asia Region. It makes practical suggestions on what the individual, the community and governments can do to protect each and every one from the harmful effects of alcohol abuse, and to GET HIGH ON LIFE, BUT WITHOUT ALCOHOL. Dr Vijay Chandra Regional Adviser, Health & Behaviour World Health Organization Regional Office for South-East Asia C M Y K What is alcohol? lcohol is a generic term for many different chemi- cal compounds, each with its own distinct proper- ties. The type of alcohol consumed by humans is Aethyl alcohol or ethanol. It is produced by a chemical reac- INTRODUCTION tion of fermentation in which yeast feeds on sugar or starch in certain plants, such as barley or grapes, and pro- duces alcohol along with carbon dioxide. Ethanol can have different colours, tastes, potencies and flavours depending on the fruits or vegetables used in its manufacture, the process of manufacture and the additives used. What is harmful use of alcohol and alcohol abuse? Traditionally, any alcohol use pattern which is significant- ly problematic has been called alcohol abuse. This term is still in common use to indicate a destructive pattern of alcohol use, leading to significant social, occupational or medical impairment. The International Classification of Diseases (ICD-10), published by the World Health Organization, uses the term "harmful use" to indicate a M pattern of alcohol use similar to alcohol abuse. Harmful C M K use is described as "a pattern of psychoactive substance Y K use that is causing damage to health".