Extreme policies of prohibition and the current permissive strategies are both counter-productive. A nuanced approach involving the regulation of alcohol availability and a rigorous enforcement of public health perspectives and legislation is needed.

Alcohol consumption is a significant contributor to the burden of disease in India and is a major public health concern.

Alcohol production and use: The recent social and economic changes in the country are paralleled by a steady increase in the production and use of alcohol manufactured by the organized sector. Nevertheless, a large proportion of the alcohol produced in India is illicit and is a cottage industry outside governmental control. Non-commercial alcohol includes traditional beverages brewed using local farm produce and illicit alcohol, produced by adding chemicals or spiked with pharmaceutical medication. The low cost illicit alcohol makes it an attractive option for the poorer sections. The lack of regulation and quality control leads to mortality and blindness due to methanol poisoning, in addition to physical morbidity due to harmful use.

The pattern of consumption in India has changed from occasional and ritualistic use to social drinking and has become an acceptable leisure activity. A recent study from Bangalore reported that one in four adult males consume alcohol. Hazardous drinking is recorded in people with a range of educational and socio-economic backgrounds. While drinking is portrayed as a consequence of poverty, it is also associated with relative affluence. The patterns of drinking are changing rapidly with major changes in economic policies and growing consumerism in the country.

Health outcomes: Injuries, suicides and many chronic diseases result from harmful use of alcohol. Harmful use also contributes to road traffic injuries and fatalities, occupational problems, domestic violence, marital and social difficulties, including financial debt. Harmful use results in loss of productivity, income and trained manpower. The effects of alcohol aggravate those of poverty.

Income and economics: On the other hand, the production and sale of alcohol results in substantial taxes and is a major source of revenue for governments. Duties on alcohol constitutes nearly a fourth of the budget of some states, making it a seemingly attractive option to promote. The industry also provides jobs and large amounts to non-taxed income (black money).

Politics and policies: Many election campaigns of political parties often include promises to restrict access to alcohol, a vote-winner among women. However, governments rarely implement these promises as a complete ban has a major impact on revenue. High taxation strategies and high cost of alcohol result in increases in moonshine markets with their lack of regulation, poor quality and dangers of methanol poisoning, in addition to loss of revenue to the exchequer. Cheap alcohol and low taxes, on the other hand, while reducing the demand and supply of illicit alcohol, increase the consumption of alcohol from the organised sector and are associated with increased health risks. The complete ban on the production and sale of alcohol (for example, prohibition in Gujarat), while reducing total consumption, does not imply that alcohol is not available in the region. The rich and the powerful have easy access while the poor rely on a thriving illicit industry with its associated criminal activity and deaths due to methanol poisoning. Other countries, which have employed prohibition as a strategy, have changed their approach; such enforcement does not actually work on the ground.

The alcohol industry and its sophisticated advertising campaigns project successful lifestyles and aim to recruit untapped segments of society. While the alcohol industry is a legitimate operation, the availability of alcohol with minimal checks results in significant health consequences to individuals at risk. The media and mass education campaigns, with their limited budgets, are no match for industry-sponsored advertising and promotion.

Laws and enforcement: There are many laws in the statute books related to alcohol. However, many regulations including those related to drink-driving are observed more in the breach. The strict enforcement of drink-driving laws in the west is a major reason for responsible drinking and for responsible driving and thus argues for the need for similar implementation in India. Similarly, the enforcement of rules, rather than the current permissiveness linked to work-related accidents and absenteeism secondary to alcohol use, will reduce the loss of productivity and manage alcohol-related problems at an early and reversible stage.

Identification and treatment: While psychiatric treatment and rehabilitation do help individuals to quit the habit, the delay in referral often results in individuals seeking help at the end-stages of the problem when family, social and financial supports are low, and the motivation to quit is limited. Early identification of problem drinking at the workplace and by general physicians will pay greater dividends in breaking the cycle of poor choices.

Cost: The only systematic study from India on the expenditure related to alcohol, employing conservative costs, estimated that more money is spent every year to manage the direct and indirect consequences of alcohol use (including health care costs, absenteeism, loss of productivity, premature deaths, loss of trained manpower) than gained in terms of taxes from the sale of alcohol. While revenue from alcohol appears to help in social and economic development in the short term, it clearly results in huge costs in the medium and long-term. The government’s failure to include the true costs, its shifting of responsibility for problems on to individuals and its sole focus on revenue generated allows it to continue with permissive policies without the necessary enforcement of regulations.

Public health perspectives: To view alcohol-related problems as a personal issue is to fail to understand the complex dynamics related to alcohol policies and their impact on individual health. Population and public health interventions have a greater impact on alcohol-related morbidity and mortality than individual therapy. While holding individuals responsible for their lifestyle choices is crucial, the government cannot abdicate its responsibility and fail to use public health approaches, which have a greater impact on the population rates of use and consequences of excess alcohol consumption. The enforcement of laws related to alcohol (for example, drinking and driving and monitoring alcohol intoxication at work) will have a major impact on alcohol consumption and on individual health. In addition, personnel and legal departments at the workplace need to implement rules and labour courts should support their enforcement.

Policies aimed at reducing alcohol-associated morbidity must cover both commercial and non-commercial alcohol. India should review policies and support legislation that promote health, prevent harm and address the many social problems associated with the use of alcohol. These should include a broad range of policies and approaches including those related to licensing, taxation, restrictions on availability and purchasing, education and media information campaigns, advertising and sponsorship, laws on drink driving and alcohol-related offences and those related to treatment and rehabilitation. Serious attempts should be made at achieving a balance between economic and political issues related to alcohol and the public health values of demand and harm reduction. The current ad-hoc planning should change to one with long-term inter-sectoral perspectives and policies. Health perspectives demand increased advocacy to implement public health approaches to reduce alcohol consumption. There is a need to balance regulation by governments, industry and individuals. This calls for a community-based participatory approach to deal with alcohol misuse and problem drinking while conserving its economic benefits, avoiding penalizing the majority who drink sensibly, and preventing deaths and crime due to illegal bootlegging.

Extreme policies of prohibition and the current permissive strategies are both counter-productive. There is a need for a nuanced approach integrating both the regulation of alcohol production and sale on one hand while rigorously enforcing public health regulations on the other. The goal of sustainable and effective alcohol policy can only be achieved by coordinated action by multiple stakeholders. The current divergent frameworks employed result in confusion and inaction. Multiple agencies including the Ministries of Law, Industry, Agriculture, Revenue, Health, Home, Customs and Enforcement, non-governmental organisations, and medical associations should be involved. While complete prohibition has been shown to be a failure, the current permissiveness without the enforcement of regulations also represents a lack of responsibility from a public health perspective. Indian society and governments need to take a longer term view of issues and plan a coordinated and comprehensive approach.

( K.S. Jacob is Professor of Psychiatry at the Christian Medical College, Vellore.)

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