Alcoholics are stereotyped as binge drinkers, or have physical and financial problems because of their expensive addiction. Insensitive pop songs and music videos that glorify drinking as a form of escapism enforce the stereotype, while advertisements that present it as socially respectable make it aceptable.
The commonly held Nepali perceptions of alcoholism prevent many people from identifying their problem. If the family is aware, it is swept under the rug. Instead of seeking professional help the alcoholic family member is shamed and isolated, forcing them to drink more.
A recovering alcoholic in his early 20s confessed to us: "When my drinking became a problem, my family forcibly sent me to the Gulf for employment by concealing the fact that I had a drinking problem." Now back from three long dry years in Saudi Arabia, he is undergoing rehabilitation in Kathmandu.
"Nepalis should learn to accept alcoholism like diabetes-a disease genetically carried and triggered by an environment a person is born to," says Mike Krajniak, of the Recovery from Alcohol Abuse Program (RAAP) in Kathmandu.
Studies have shown that Asians are genetically weak in tolerating intoxication, and the children of alcoholic parents are more likely to become alcoholic if there are environmental triggers. Treatment is impossible without the help and support of family and friends, something that is in short supply for alcoholics.
"Nepalis should learn to accept alcoholism like diabetes-a disease genetically carried and triggered by an environment a person is born to," says Mike Krajniak, of the Recovery from Alcohol Abuse Program (RAAP) in Kathmandu. Studies have shown that Asians are genetically weak in tolerating intoxication, and the children of alcoholic parents are more likely to become alcoholic if there are environmental triggers. Treatment is impossible without the help and support of family and friends, something that is in short supply for alcoholics.
The fact that alcohol is readily available even to minors accentuates the dangers of abuse. Many social organisations and support groups are working on an alcoholism agenda, but there aren't enough. Only about 200 persons a year receive professional counselling and treatment for alcoholism in Kathmandu. None of the existing organisations deal with women. Counsellors say most people don't know that alcoholism is a disease, and recovery is possible.
Another problem is the cost of the treatment. A standard three-month recovery program costs between Rs 3,000- 5,000 a month. Those who can afford to, go abroad for confidentiality.
There has never been a study in Nepal about the social and economic cost of alcohol abuse. Neither is there any reliable statistics regarding alcohol consumption. Jagadish Lohani of Youth Vision, a drug rehabilitation centre, told us: "Nepali society is firmly in the grip of an alcohol epidemic, and this is the first step towards other substance abuse." He is worried that most of us are unaware of the social and economic burden caused by alcoholism when we persist in ignoring the social implications of the disease.
In the last fiscal year, the National Trading Company imported alcohol and cigarettes worth Rs 50 million. Unofficial sources say the consumption of home brewed alcohol is five times that of branded liquor. A source at the Nepal Brewery and Cigarette Association estimated more than 40 million litres of liquor are produced and consumed by individuals at home.
After the government officially recognised the liquor industry as a potential major revenue generator, the consumption of alcohol has increased greatly. Restrictions on mass production and sale of liquor were loosened more than 30 years ago. That decision encouraged both the import and the manufacture of cheap alcohol in the country, which suddenly increased availability and access.
Within a decade of licensing, liquor industries became one of the highest investment sectors and also the strongest lobby group. The huge investment, an average of Rs 70 million, and the huge revenues it contributes to the exchequer have gained the liquor industry a strong standing. In the last fiscal year, these distilleries produced more than 5.9 million litres of liquor, approximately 3.8 million litres were exported.
Alcohol commercials have been banned on radio and television, but liquor manufactures are sponsoring socially valued activities like popular sports and public gardens. They have also started putting up street hoardings highlighting the health hazards of drinking.
A drug addict who claims his substance abuse started with alcohol says, "The government is happy with the revenue from liquor. I think it should stop and rethink its policies. It should realise that the nation's youth and families are paying a high social and emotional price to generate those revenues." So far, the only group that seems to be listening are the Maoists who have declared parts of rural Nepal dry, and have threatened liquor manufacturers.
Alcoholism goes far beyond hangovers and liver damage, and therefore does not just have medical consequences for the drinker. It is a progressive disease, and a social one that claims primary and secondary victims. The family, especially the women and children, bear the burnt of it.
A startling 15-30 percent of inpatients at hospitals in Nepal come with problems directly or indirectly related to alcohol abuse. The ratio of males to females average 60:40 and most of them are between 20- 40 years. "Drug addiction has a high profile appeal for social organisations, but in the Nepali context alcohol abuse is almost 15 times a bigger problem," says Dr Mark Zimmerman, medical director at Patan Hospital which is Nepal's first to start an alcoholic support group. But even here, the problem is so vast that doctors are stretched too thin to provide adequate counselling.
Over the last decade, the Nepali chapter of Alcoholics Anonymous (AA) has tried to reach more Nepali alcoholics but without much success. Says Krajniak: "There is only so much the support groups and rehabilitation centres can do. We must take the social stigma out of alcoholism and recognise it as a disease that can be treated."
Alcohol, poverty and development
The use of alcohol presents a dual challenge in developing societies. Alcohol related problems, including addiction, family violence and so on, become an additional burden on families and communities already struggling with poverty. Perversely, experience shows that, once developing societies have begun to reduce poverty problems and create economic growth, alcohol consumption tends to rise, with a corresponding rise in related harm. In this guest editorial, Øystein Bakke introduces us to these issues.
Alcohol has long been in use in most societies throughout history. Normally its use has been regulated by traditions and social norms concerning when, how and by whom it should be consumed. In many locations, however, traditional production is still going on, and new alcoholic products and drinking patterns are compounding already existing problems.
Alcohol is a double-edged sword in the developing world. On one hand, drinking is a severe and additional burden to the poor and underprivileged. On the other hand, we are seeing new drinking habits, increasing consumption levels and increasing problems occurring among a growing middle-class. While consumption is stagnating or even decreasing in the Western world, the two regions showing recent and continuing increases in consumption are South East Asia and the Western Pacific. According to the World Health Organization (WHO) and World Bank sponsored Global Burden of Disease study, alcohol is the fi fth-ranked risk factor for premature death and disability in the world, and the greatest risk factor in some developing countries. This underscores that alcohol is not just any ordinary commodity.
Numerous development policy papers describe the importance of good health to combat poverty. That drinking alcohol can be detrimental to health is a well accepted fact. Harm is generated from consequences of long term use related to the toxic properties of alcohol and dependence that some users develop, as well as from unintentional injuries and violence from intoxication.
Thus the alcohol problem is much bigger than dependency alone. Alcohol is the substance abuse problem that affects the highest number of people worldwide. Unlike other lifestyle related health problems (tobacco, heart disease etc.), alcohol kills and disables at a relatively young age.
Risky sexual behaviour often occurs under the infl uence of alcohol. This contributes to the spreading of HIV/AIDS, which has dramatic consequences in certain regions. A WHO report, Alcohol Use and Sexual Risk Behaviour: A Cross-Cultural Study in Eight Countries, shows the patterns of interaction between alcohol use and sexual behaviour, including: the meaning of masculinity and alcohol use; denial and neglect of risk as a way of coping with life; the use of alcohol-serving venues as contact places for sexual encounters; the use of alcohol during (first) sexual encounters; and the promotion of alcohol use in pornography. The fi ndings of the study imply that alcohol use should be taken into consideration in HIV/AIDS prevention programmes.
Poor people around the globe are vulnerable, even to small changes that destabilise their daily hand-to-mouth economy. For those living in harsh circumstances, with few possibilities for relaxation, alcohol may seem an easy way out. This ties in with images often portrayed in marketing, that alcohol offers a taste of luxury, recreation and an entrée into a world beyond everyday worries. But the problems created by alcohol use are, in fact, additional burdens for poor people.
In many places, a pattern of male drunkenness, limited income spent on alcohol and other drugs, and domestic violence is all too commonplace. In several studies, women report that their husbands have been drinking when violent incidents occur. Some of these studies support the conclusion that alcohol may play a direct precipitating role in domestic violence, though the nature of the association is complex, and simplistic conclusions should not be drawn.
In a qualitative study in Sri Lanka, numerous incidences of domestic violence were reported by field workers. They pointed out that the women see the connection between men’s drinking and their violence very clearly.
Children are also affected. A Child Workers in Nepal study, Alcohol and Drug Use in Nepal, found that more than one third of the children (aged under 18) interviewed identified negative effects from parental drinking, including domestic violence, loss of wealth, increased debt, and inability to pay for children’s education. In addition, children face mental stress when parents drink excessively, and parental drinking is identifi ed as a ‘push factor’ for children running away from home.
When alcohol is raised as a poverty issue, expenditures on alcohol are often highlighted as an important aspect. A Sri Lankan study found that over 10 percent of male respondents reported spending as much as or more than their regular income on alcohol.
Researchers also discovered that calculations of the expenditures on alcohol grossly under-represent reality. Not only do drinkers deliberately or unwittingly underestimate the amount of money they spend on alcohol, they also make others pay for it. These expenditures are registered neither by those who consume nor by those who pay. Also, amounts spent during special occasions, such as weddings and other celebrations, can entail large expenditures on alcohol, and while these tend not to be included in calculations of ‘average’ alcohol expenditures, people did report becoming indebted because of them.
Over the last 20 years of the twentieth century, rapid income differentiation and economic marginalisation have spurred production and consumption of alcohol in Africa. With the backlash against economic development in that continent since the 1980s, alcohol production has become a substitute economic activity for large numbers of people in both rural and urban areas. In many localities, an expanding supply of alcohol has led to drinking patterns that impinge on general social welfare.
Alcohol revenue is not only economically important at a family level. Many poor countries are also dependent on it. In Nepal, national revenue from alcohol remained steady for the seven years preceding 2000, exceeding 6 percent of government totals, and alcohol contributed more than 50 percent of total excise duties. Nepal is thus in a similar situation to many western countries in the early twentieth century, where alcohol was a major source of state revenue prior to the advent of income tax. Many other developing countries have a similarly high dependence on national revenues from alcohol.
Countries may seek to maximise income from alcohol, but alcohol’s social and economic costs are often overlooked. These include the direct costs of treating injuries and diseases as well as treatment and rehabilitation costs, property losses, law enforcement costs, and losses in productivity due to absenteeism or loss of productive years of life. But the invisibility of these costs can combine with dependence on alcohol revenues to make finance ministries look unfavourably upon any attempts to reduce alcohol consumption.