HEALTH HAZARDS FROM ALCOHOL
T.G. Jacob
The health hazards of alcohol are universal in nature with quantitative and qualitative differences between societies, which are on different levels of social and economic developments, often determined by factors beyond the control of the respective peoples. Alcohol had worked as a political weapon, notably in the African continent, where the colonialists doused the plantation workers in high alcohol content rum at very low prices with the resultant impact of keeping them in a continuous and permanent stage of stupor and numbness. This resulted in a tardy awakening of the labouring masses against colonial plunder. In India, it is common to find that the colonies within colonies, otherwise called the fourth world syndrome, are subject to severe exploitation, and alcohol plays a dominant role. The Adivasi areas of India are inundated with alcohol of the worst variety and so are urban slums. In the case of Keralam the Adivasi land alienation is found to be strongly linked to cheap liquor supplied from outside by outsiders.
Alcohol has a long-term and short-term impact on the mental and physical health of the drinkers and their immediate near and dear, with the short-term immediate catastrophes happening mostly in the poor countries and again in the poorer areas and sections in the poor countries. No doubt, the history of alcohol is very old, and when we look at the ancient civilizations and their epics and rituals we find alcohol almost everywhere. Babylonians, Syrians, Hebrews, Indians, Chinese, Egyptians, Incas all developed and ritualized spirit. The term spirit itself has highly metaphysical and religious connotations. Even modern monotheistic religions like Christianity could not discount the role of wine in the lives of human beings. The sayings of Jesus during the last supper and on the cross are remarkable episodes with very deep meaning in the Bible. This Biblical tradition continues uninterrupted till today in the rituals of the Church.
Manufacturing of wine had remained a domestic affair for a very long time. In other words, it was considered as one of the essential food items. When it became a commodity to be marketed for profit it became controlled by the laws of the market, which essentially centred on the principle of maximization of profit. This process gained a lot of momentum with the dawn of capitalism. Even in ancient civilizations wine had become a commodity for trade, but the innovations that happened with the development of capitalism were unprecedented. Regions specializing in liquor manufacture emerged based on the resource availability, but they were dependent on external markets for realization. The advent of colonialism and the opening up of large scale sugar plantations using indentured colonised people as the labour force gave a great fillip to the global liquor industry. With this absolute commoditisation of alcohol using cheap labour health hazards also came up, more in some places than in others. During the twentieth century there were numerous attempts by many countries, including Scotland and the United States of America, to implement prohibition on alcoholic drinks. All the attempts were abject failures. Liquor had become inextricably woven into the physical and spiritual fabric of human beings.
Liquor as a brain and mind changer has many times produced classics of world literature. On the one extreme you have Omar Khayyam’s “Rubaiyat” and Baudelaire’s “An Ode to Wine.” On the other extreme you have Emile Zola’s “The Dram Shop”. The former are singing about the spiritual ecstasy of wine, while the latter is portraying the madness of alcohol under conditions of capitalist relations of production. Similar works of varying quality and temper can be found in every language. In modern world class literature also this dichotomy exists. What St. Augustine called “sweet poison” continues to hold sway in a multitude of ways.
The health impact of alcohol has been fairly well documented in Europe and North America unlike in the poor countries of the world. The direct and indirect costs of alcohol consumption have been subjected to detailed analysis in these reports and books. Though the details differ from a country like India, certain general conclusions regarding the health hazards created by alcohol are very much relevant. The quality of drinks varies enormously between Europe and India, and instantaneous mass liquor tragedies are absent in Europe while such tragedies are common in India. However, it is pertinent to have a general understanding of the ill effects of alcohol consumption.
Direct Impact
It is not possible to exactly gauge the health hazards arising from excessive consumption of alcohol with hundred per cent accuracy due to a variety of factors. Among these is the lack of scientific clarity on how much any specific problem is due to alcohol and the reportage lacuna. The broader social costs gets billed with umpteen other health problems like pollution with the result that the borderlines gets blurred beyond recognition. Still, modern western medical scientists and social scientists have evolved tolerably accurate indices which can throw light on the issues at hand. Many of the studies are based on extensive samples spanning generations
The incidence of alcoholism is probably the highest in West Europe, and hence it is natural that more studies have happened there. These studies have a specific Eurocentric approach because the problems are identified as Eurocentric. But as alcohol is a universal commodity with certain rudimentary general/universal characteristics, it will be better to draw upon these scientific investigations for the good of all humankind.
One general characteristic of the majority of these studies is that the problems of alcohol and alcoholism cannot be treated as a one-dimensional affair. It simply can’t be treated as a purely medical problem. It has to be treated as a political, social and economic problem too. This makes it an all embracing issue. Only a multi-disciplinary approach can make real sense. Education on abstinence has proved a failure all over the world and fiscal measures to reduce consumption have also resulted only in partial downward slides at best. An economic solution is as ineffective or effective as an educational, moral solution. To this day these two ways of taking on the alcohol question are juxtaposed to each other but with an increasing convergence of views. What is becoming increasingly evident is that it needs a holistic approach embracing a whole lot of disciplines like social psychology, economics, political science, fiscal management, environmental studies, gender studies and other related disciplines. The alcohol industry has grown into a Frankenstein and it is by no means easy to take it on. The alcohol policy is riddled with enormous vagueness and the first requirement is to demand a clear alcohol policy with as few loopholes as possible. This is something that Keralam lacks entirely though there is a network of albeit disconnected anti-alcohol activism in the State.
The fiscal measures with the government to decrease liquor consumption are limited to hiking up the tax rates. This is based on the assumption that when the prices go up the consumption will automatically go down. In neoclassical theoretical economics of demand and supply itself this law is subject to many conditions, i.e., it can never be an absolute law governing the actions of the consumers. The famous Giffon’s paradox which discovered the consumer behaviour of demanding more of an essential commodity like potatoes when there was great all-round price increases is an illustration. In the case of alcohol, the experience of Britain and a host of other countries (including some of the poor ones) do not give evidence of such a one-to-one relation about the consumption pattern in response to fiscal changes of alcohol. In the case of many countries the industry occupies such commanding heights that established norms and theories of trade practices do not make it easy for any government to arbitrarily deflect widely on the price front. Often it is a hands-tied situation.
Organizations like Alcoholics Anonymous operating worldwide had been striving for several decades to educate drinkers about the harms involved, but what we see is that though the activities of such organizations may have a marginally positive impact on individuals, society as an entity is not being altered on this count. Alcoholism has increased and alcohol related diseases have increased. These increases could possibly be bridled in by the activities of these organizations. But no sustaining solution is visible.
It is important to take note of the fact that alcohol is not operating independently to harm human beings. A whole lot of other serious debilitating factors like deforestation, environmental pollution, noise pollution, ecological degradation, depletion of the ozone layer, the outer space being converted into a junkyard of radiation waste, mass-scale unemployment and poverty, proliferation of killer drugs globally are all acting in conjunction, and alcohol is only a part of this destructive juggernaut. The clout of the alcohol lobby in influencing state fiscal policies to its advantage had been amplified when, faced with the growing alcohol menace, the British budgets of 1987 and 1988 did not increase the tax on alcohol. Read with the rate of inflation, this resulted in a decrease in the price of alcohol (See Alex Paton (ed.): ABC of Alcohol, British Medical Journal and Oxford University Press, 1990). This is the continuing behaviour pattern of most of the European governments. What it shows is that in the industrialised countries, which for the first time introduced alcohol as a revenue farming means for the public exchequer, the governments are going slow in garnering revenues from the home market in this account. This also coincides with the introduction of their brands of liquor into the colonised countries. One can presume that the burden is being shifted to the less fortunate geographical territories of the world. During centuries of direct colonialism the people of Africa and South America got inundated with cheap liquor which served both political and economic purposes. In India, IMFL and tax on local drinks was first introduced by the colonialists. At present, there is new invasion of foreign liquor into the country, the global liquor majors are aggressively entering the upper deciles segment of the market which is now estimated to constitute 7-10 per cent of the total population, the combined population of several European countries.
Though fiscal measures can possibly have a marginal impact on the consumption of liquor, they cannot be treated as an unqualified panacea. Studies do show a decline in consumption as a result of the price differentials from one year to another. Fiscal measures play an ameliorative role, but do nothing much to eradicate the problem altogether. A sense of desperation has set in the industrialised countries on this question. On the one hand, the profits from the industry are enormous with all its concomitants like employment and income generation. At the same time, the industry, like the tobacco industry, can have disastrous consequences on a much wider scale if it gets a decisive setback. The aggressive penetration of multinational liquor giants into hitherto unexplored markets worldwide is considered an obvious way out. In India we are witnessing such a penetration not only in the premium quality drinks vector, but also the cheaper mass consumption segments of the market.
The term “alcoholism” does not convey the full implications of the effects of alcohol by giving the impression that it is a single decease while it should actually cover the entire gamut of issues involving physical, psychological, social and economic problems. Dependence is a crucial aspect which is a syndrome from which it is very difficult to extricate oneself. Scholars divide alcohol drinkers into social drinkers or medical drinkers, heavy drinkers, the dependent (addicted) drinkers, binge drinkers or skid row alcoholics. Skid row drinkers may have repeated convictions for alcohol abuse, but seldom develop physical diseases because of prolonged abstinence. Prolonged heavy drinking causes serious physical damages like liver cirrhosis, heart disease and brain damage. Problem drinkers are those who continue drinking in spite of serious problems. According to medical experts, the three categories of heavy drinkers, problem drinkers and addicted drinkers are the most seriously affected by alcohol.
According to the British Medical Journal (1982) alcohol caused serious problems in one million drinkers and 500 deaths under 25 years of age in Britain. Further, alcohol was associated with half a million acute admissions to hospitals, 14000 psychiatric admissions, and was the cause of 80 per cent deaths from fire, 50 per cent of murders, 40 per cent of road traffic accidents, 30 per cent of fatal accidents, 30 per cent of domestic accidents and 14 per cent of drownings. One in three cases of divorces and one in three cases of child abuses sprang from alcohol abuse. 8 million working days were lost costing more than 1600 million pounds an year. During the same year, out of a total population of 55 million, 36 million were regular drinkers, two million were heavy drinkers, 700,000 were problem drinkers and 200,000 were dependent addicted drinkers. Statistics are alarming. More or less the same situation exists in other European countries like France, Germany and Finland.
Because alcohol is distributed throughout the body water most tissues are affected by the same concentrations as the blood. The absorption rate varies and this is done through both the stomach and small intestine. In undernourished bodies the absorption rate is higher than in healthy well fed bodies, a factor that is particularly relevant to those in poor countries. To quote “ABC of Alcohol”, “the amount customarily taken by heavy drinkers represents an enormous metabolic load, and the liver’s “capacity for dealing with such quantities is limited, although the heavy drinker may adapt by enzyme induction for a considerable time before his liver finally fails. Half a bottle of spirits, for example, is equivalent in molar terms to 500 gm of aspirin or 1.2 kg of tetracycline” (page 18). The load on vital organs is truly phenomenal. About the chemistry of metabolism the study says: “Most alcohol is metabolised to acetaldehyde, a highly reactive and toxic substance, which has been suspected for many years of being responsible for the physical damage caused by the excess consumption of alcohol. Attempts to incriminate it have so far been unsuccessful. It is normally rapidly metabolised to acetate, which is not toxic, and concentrations in most tissues are extremely low. Several metabolic abnormalities result from the oxidization of excess alcohol, including overproduction of lactic and keto acids, retention of uric acid, hyperlipidaemia, and accumulation of fat in the liver” (ibid.). What this shows in the best of conditions is that excess consumption of alcohol is a direct health hazard.
The chart given below lists the definite and potential health hazards of alcohol:
Definite
* Acute intoxication leads to changes in mood, loss of social inhibitions, slurring of speech, staggering and reduced intellectual performance; if enough alcohol is taken death will eventually occur from respiration stopping or from choking on vomit.
* Blackouts – loss of memory for hours or even days; sometimes associated with long distance wandering.
* Withdrawal in those addicted is associated with tremor, hallucinations and fits
* Wernicke’s encephalopathy - confusion, apathy, disorientation, grossly disturbed memory, drowsiness, abnormal eye movements; patients may recover fully, but this condition is often fatal and may be undetected during life.
* Korsakoff’s syndrome – severe and permanent disturbance of memory
* Cerebellar deterioration – predominantly unsteady stance and gait
* Head injury, sometimes with subdural and extradural haematomas
* Damage to nerves in hands and feet causing burning discomfort.
* Weakness of hip and thigh bones.
* Degeneration of nerves in the larynx leading to hoarseness
* Temporary paralysis of nerves due to pressure on them due to stupor.
* Acute muscle damage with pain, swelling and weakness; may be complicated by kidney failure
* Symptomless enlargement of liver
* Infiltration of liver with fat
* Alcoholic hepatitis
* Cirrhosis
* Liver failure with mental confusion, jaundice, fluid in the abdomen, and bleeding from
the gut
* Liver cancer
* Reflux of acid into the oesophagus
* Inflammation of the stomach
* Tearing and occasionally rupture of the oesophagus
* Cancer of the oesophagus
* Inflammation of the stomach
* Aggravation and impaired healing of peptic ulcer
* Diarrhoea
* Chronic inflammation of the pancreas leading in some to diabetes and malabsorption of
food.
* Diverticulitis
* Malnutrition from reduced intake of food, toxic effect of alcohol on intestines, and impaired metabolism, leading to weight loss
* Obesity, particularly in early stages of heavy drinking
* Folate deficiency
* Abnormal rhythms
* High blood pressure
* Fractured ribs
* Pneumonia from inhalation of vomit
* Overproduction of cortisol leading to obesity, increased facial hair, and high blood pressure
* Condition mimicking overactivity of the thyroid with loss of weight, anxiety, palpitations, sweating and tremor
* Severe fall in blood glucose sometimes leading to coma
* Diabetes
* In men loss of libido, reduced potency, shrinkage in size of testis and penis, reduced or absent sperm formation and so infertility, and loss of sexual hair
* In women sexual difficulties, menstrual irregularities, and shrinkage of breasts and
external genitalia
* Increased risk of miscarriage and recurrent abortion
* Fetal alcohol syndrome – small babies with development abnormalities (including mental
handicap) typical facial features, and congenital malformations
* Acne
* Lobulated growth of the nose with severe acne
* Increased tendency to bleeding
Possible
* Provocation of Parkinsonism by withdrawal of chronic intoxication
* Dementia
* Strokes, even in young people
* Chronic muscle damage
* Subarachnoid haemorrhage
* Chronic cardiomyopathy
* Chronic chest disease
* Tuberculosis
* Cancer of the lung
* A chronic alcohol induced lung disease
___________________________________________________ Source: Introduction by Richard Smith in: Alex Paton (ed.) ABC of Alcohol, BMJ, OUP, 1990, p. 2
It is to be kept in mind that this impressive list of health hazards researched out by medical professionals is based on the parameters prevalent in the countries of western Europe, where liquor tragedies as we know about in poor countries are not strictly applicable, because the quality of drinks is such that instantaneous mass killings by poison liquor are not a concrete reality. But in the case of Keralam as well in that of other Indian States, the conditions are drastically different. There is a clear-cut dichotomy between the common people and the upper classes in relation to the quality of drinks imbibed. And scientific studies as are done in Europe are not done here, though competent manpower is not wanting. This is mainly due to the apathy and callousness towards the common man built into the medical profession itself. In the absence of serious studies it is possible to look only at the openly visible health aspects of alcohol consumption.
The per capita availability of health services in Keralam is higher than in the other States, but this is a highly relative parameter. Such an abstract statistic does not help us to gauge the requirement nor the quality of the available health services. Most of the patients who go to hospitals are handled by general practitioners whose range is limited. That is why even detailed interviews with doctors in general hospitals do not yield anything much about what exactly is the role of alcohol in the illnesses of their patients. Treatment is according to the dictionary meaning of symptoms. The victims of the hootch tragedy in Bangalore, or the Bhopal gas tragedy, are poignant examples of this criminal incompetence. Vypeen’s case was no different. At the same time it can’t be helped in the immediate future. Serious long-term planning and drastic change in orientation only can really dent the present situation.
Many of the people suffering from the health hazards of liquor are not even aware of why they are having all these mental and physical problems. The case study of a ‘toddy’ shop in Thiruvananthapuram conducted by this writer is illustrative. It is a big and busy shop with a turnover of at least Rs 3 lakhs daily. Before the arrack ban this toddy shop, which was licensed to sell only toddy and eatables, was openly selling the two types of arrack (legal and illegal) as well as the cheaper varieties of rum and whisky. The shop is open from five in the morning to midnight, and even after the front door is bolted anyone can get a bottle from the rear. Now the shop sells only spurious toddy at the price of Rs 35 for a bottle.
Interviews with 30 regular drinkers (actually every drinker there is a regular) revealed that 26 of them are suffering chronically. Problems cover a vast range – from stomach disorders to raving insanity. None of them has ever gone to hospital to check on alcohol-related problems. That is, they will most probably die without knowing what has hit them. One of them who could drink a full bottle of rum in one sitting and still walk home without falling down anywhere is now floored by a single bottle of spurious toddy. He is in some way an exception because he is aware to some extent that what he is imbibing is poison, but as it gives him sleep it is considered the lesser of two evils. In his own words: “if I can’t sleep for a few hours at least I go mad. This toddy is the only thing that can give me sleep”. The toddy that is sold in this shop as well as all the shops in the range is supplied by a single contractor and it is liberal doses of diazepam that makes it such a favourite concoction. His is not an isolated example. Several others corroborated the same. The border line between physical and mental illnesses is fast disappearing.
A universal complaint is perpetually upset stomach and loss of appetite with steady deterioration of eye-sight. Loss of stamina to work for any decent length of time is not considered a serious problem because in the first place there is no steady work available and then no one will give such people steady work. Unexplained diseases like eruption of abscesses on the legs and hands and problems with walking with no visible causes and continuous headaches are common. Two persons are covered on their hands and legs with pus-filled scabies and both reported that they got this illness after starting to consume doctored toddy. They can dimly see a linkage but are unwilling and incapable of leaving the drink. The spurious drinks with deadly chemical components are highly addictive and it is this addictiveness coupled with lack of affordable alternatives that make them loyal to the chemical drinks. The accusing finger is clearly on the alcohol policy of the State. The addictiveness is such that even if you offer other drinks the person who is conditioned to spurious toddy may decline them and instead ask for Rs. 35 so that he can get a bottle of toddy.
Many places in Keralam still have the traditional locally produced hard drink which has a faithful clientele. In the wake of the arrack ban this has become costly. It is interesting to note that serious physical problems are relatively absent among them. Or even if these are present they are to be found among heavy long standing drinkers, which is no surprise at all. But this traditional drinks market is a fast shrinking one, particularly for those made from cashew fruit and toddy. The reason for this vanishing is the legal hazards and the proliferation of poison liquor. Nowadays these drinks are also not entirely free from chemicals because of the adding of chemical fermentation agents like ammonium sulphate, which produce stomach disorders. Ready availability is another problem. Many people testify that you will have to wait for a couple of days if you want the “pure” stuff. For special occasions people book earlier. Obviously, regular drinkers can’t afford to wait for two days to have their drink.
Keralam tops the list not only in literacy but also in the number of insanity cases along with a high rate of suicides. Of course, it may not be possible to correlate alcohol and these indices in a one-to-one fashion. Drugs may be playing an equally prominent role in the increasing number of schizophrenics among the youth of Keralam. Also, unemployment, poverty and the resultant lack of zest for living can easily result in the increasing number of suicides in the State. Family suicides have become common since the last many years. In a recent study conducted by the Kozhikode Medical College (“AIDS and Suicide Tendency”) it is said that suicides increased by 93.9 per cent over the period 1986-96 which is almost four times the rate of increase in deaths due to accidents. A perusal of a single edition of a single Malayalam newspaper for the first five months of 2000 by this writer showed that every day there were 7.5 reports on an average. This certainly does not cover the entire State, nor do all the actual incidents find their way to the newspapers. The number of suicides has taken a leap forward. So is the case with the number of mentally ill people.
Once again alarm bells are ringing loud. The expression “Malayalees on the way to mass suicide,” seen in the background of increasing evidence on the drowning of the State in poison liquor is not at all incredible. Changes in the orientation of health services are nowhere in sight and even if some positive changes do happen by some miracle their effectiveness is subject to serious doubts in the face of the horrendous ground realities. The putrefaction has become so deep that any cosmetic adjustments will miserably fail. During the first half of 2000 there were at least 4-5 reported cases of illicit liquor smuggling, spirit smuggling and poison liquor incidents every day. As the whole affair is an underworld business with the active participation of the concerned departments and politicians the reported cases form only the tip of the iceberg. The structural reasons seem to be more important to us.
(The above is an extract from a chapter in the book, “Alcohol and Keralam” written in 2000)