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REFERENCE COPY
' FOR LIBRARY USE ONLY
INSTITUTE OF MEDICINE
AN INTER-AUERICAN
WORKSHOP
N NAS
R NAE
C IOM
' '
LEGISLATIVE APPROACHES TO PREVENTION
OF ALCOHOL-RELATED PROBLEMS: AN INTER-AMERICAN WORKSHOP
Pr o c e e d i n g s
INSTITUTE OF MEDICINE
* > $ b. t <-,
June 1 9 8 2
Na t i o n a l Academy P r e s s
Washington, D. C.
N AS-N A
JUL2 6 1982
LlBR ARY
Thi s volume o proceedings was compiled and edi t ed by
t he s t a f f o t he I ns t i t ut e of Medicine wi t h t he advi ce
and as s i s t ance of t he workshop's advi sory committee,
whose members a r e l i s t e d on t he fol l owi ng page. The
opi ni ons expressed by aut hor s and di scussant s and t he
st at ement s about conseneus o workshop par t i ci pant e a r e
t he i r views and do not represent pol i cy posi t i ons o
t he I ns t i t ut e o Medicine o r o organi zat i ons sponsor-
i ng o r cooperat i ng i n t he pr oj ect .
The I n s t i t u t e o Medicine was char t er ed i n 1970 by t he
National Academy o Sci ences t o e n l i s t di st i ngui ehed
members of appr opr i at e professi one i n t he exmnination
of pol i cy mat t er s per t ai ni ng t o t he heal t h of t he
publ i c. I n t hi s , t he I ns t i t ut e a c t s both under t he
Academy's 1863 congreesi onal char t er r eeponai bi l i t y t o
be a n advi sor t o t he f eder al government, and i t s own
i n i t i a t i v e i n i dent i f yi ng i s s ue s of medical car e,
research, and educat ion.
2101 Const i t ut i on Avenue, N.W.
Washington, D. C. 20418
(202)334-3300
Publ i cat i on IOM-82-003
WORKSHOP ADV ISORY COMMITTEE, DEPARTMENT OF HEALTH AND HUMAN SERVICES
AND PAN AMERICAN HEALTH ORGANIZATION LIAISON,
INSTITUTE OF MEDICINE STAFF
Advisory Committee Department of Heal t h and Human
Ser vi ces Li ai eon
d
*Robert J. Blendon, Chairman
Seni or V i ce-Presi dent
The Robert Wood Johnson Foundation
Pr i ncet on, New J er s ey
Linda A. Bennett
As s i s t ant Research Pr of essor
Cent er f o r Family Research
Department of Peychi at ry and
Behavi oral Sci ences
George Washington Uni ver si t y
Medical Cent er
Washington, D.C.
Linda Vogel
Of f i ce of I nt er nat i onal Heal t h
Department of Heal t h and
Human Ser vi ces
Rockvi l l e, Maryland
Berkley C. Hathorne
I nt er nat i onal Act i vi t i ee Of f i cer
Of f i ce of t he Admi ni st rat or
Alcohol, Drug Abuse and Mental
Heal t h Admi ni st rat i on
Rockvi l l e, Maryland
Rene Gonzalez
Regional Advisor i n Mental t i eal t h
Di vi si on of Disease Prevent i on
and Cont rol
Pan American Heal t h Organi zat i on
Washington, D.C.
Dwight B. Heath
Department of Anthropology
Brown Uni ver si t y
Providence , Rhode I s l and
Robin Room
Sc i e n t i f i c Di r ect or
Alcohol Research Group
Berkely, Cal i f or ni a
Wolfgang Schmidt
Department of Soci al St udi es
Alcoholism and Drug Addi ct i on
Research Foundation
Toronto, Ont ar i o, Canada
Leland H. Towle
Chi ef, I nt er nat i onal and I nt er -
governmental Af f ai r e
Nat i onal I n s t i t u t e on Alcohol Abuse
and Alcoholism
Rockvi l l e, Maryland
Pan American Heal t h Organi zat i on
Li ai son
Marilynn Katatsky
Regional Advisor on Alcoholiem
and Drug Abuse
Di vi si on of Dieease Prevent i on
and Cont rol
Pan American Heal t h Organi zat i on
Washington, D.C.
I n s t i t u t e of Medicine St af f
W i l l i a m A. Lybrand, Mr e c t or
*Robert St r aus Di vi si on of I nt er nat i onal Heal t h
Pr of essor and Chairman
Department of Behavi oral Sci ence @ d a n Y. ~ a p l a n
Col l ege of Medicine Workshop Coordinator and
Uni verei t y of Kentucky Medical Cent er Edi t or of Proceedings
Lexington, Kentucky
Bet t y L. Crai g
Admi ni st rat i ve Coordinator and
%ember, I n s t i t u t e of Medicine
Associ at e Edi t or of Proceedings
The inter-American workshop on al cohol - r el at ed problems, which
was made pos s i bl e by a c ont r a c t from t h e Of f i ce of I nt e r na t i ona l
Health(OIH), United St a t e s Publ i c Heal t h Ser vi ce, Department of
Heal t h and Human Ser vi ces, r e s ul t e d from t h e e f f o r t s and
c ont r i but i ons of numerous i ndi vi dual s .
The Pan American Heal t h Or gani zat i on provi ded v i t a l a s s i s t a nc e
i n t h e pl anni ng and execut i on of t h e workshop t hrough Rene Gonzalez,
a member of t h e workshop advi sor y committee, and Marilynn Kat at sky,
who ser ved as l i a i s o n between PAHO and t h e I n s t i t u t e of Medicine.
As hos t f o r t h e workshop, PAHO a l s o provi ded super b f a c i l i t i e s and
unf a i l i ngl y r esponsi ve s t a f f suppor t i n t h e per sons of Lui s Lar r ea
Alba, Jr., chi ef of conf er ence and gener al s e r vi c e s , and Luiz
Gonzalez, conf er ence of f icer.
The s t i mul a t i ng cont ent of t h e workshop stemmed from both t h e
ver y hi gh c a l i b e r of t h e wr i t t e n c ont r i but i ons of a l 1 t h e pr es ent er e
and di s cus s ant s , and t h e advi ce of a most e nt hus i a s t i c and know-
l edgeabl e group: John Bryant, former Deputy As s i s t ant Secr et ar y f o r
I nt e r na t i ona l Heal t h and h i s s t a f f i n OIH--Linda Vogel, Rose Belmont
and Marlyn Kefauver; t h e members of t h e workshop advi sor y
committee; and Leland Towle and Berkley Hathorne of t h e Nat i onal
I n s t i t u t e on Alcohol Abuse and Aicoholism, and Alcohol, Drug Abuse
and Mental Heal t h Admi ni st r at i on, r es pect i vel y.
Workshop pa r t i c i pa nt s were moet a ppr e c i a t i ve of t h e i l l umi na t i ng
i n s i g h t s provi ded by Pe t e r D. B e l l , Pr esi dent of t h e Inter-American
Foundation, who spoke i nf or mal l y f ol l owi ng di nner a t t h e Nat i onal
Academy of Sci ences t h e f irst ni ght of t h e workshop. Be 1 1 of f e r e d
comments on t h e l o c a l impact of al cohol consumption from t h e
per s pect i ve of t h e ext ens i ve exper i ence i n community development
a c t i v i t i e s i n a number of c ount r i e s i n t h e Americas.
An i mpor t ant c ont r i but i on t o t h e or gani zat i on of t h e e f f o r t was
made by Mar t i t a Marx and Maria Gil-del-Real of The Robert Wood
Johnson Foundat i on who used t h e i r bi l i ngua l s k i l l s t o f a c i l i t a t e
communication wi t h Spanish-speaking pa r t i c i pa nt s .
Fi na l l y, my g r e a t a ppr e c i a t i on goes t o t hos e a t t h e I n e t i t u t e
of Medicine who provided v i t a l i nput and hel ped br i ng t h e workshop
t o f r u i t i o n : my col l eagues W i l Lybrand, Karen Be11 and Barbara
Fi l ne r ; Bet t y Cr ai g, f o r he r tireless a s s i s t a nc e and wise counsel i n
bot h t h e pr e r or ks hop phase and i n t h e e di t i ng of t he s e proceedi ngs;
Mi r e i l l e Mesias and Azora I r by, who provided a b l e admi ni s t r at i ve
a s s i s t a nc e p r i o r t o t h e workshop; and Lynet t e Bates, whose e xpe r t i s e
on t h e word pr ocessor hel ped make t i mel y pr oduct i on of t he s e pro-
ceedi ngs possi bl e.
Aian K. Kaplan
CONTENTS
P r e f ace
Robert C. B l e n d o n
Wo r k s h o p Ba c k g r o u n d and Ov e r v i e w
Aian K. Ka p l a n
C h a p t e r On e
WELCOME AND INTRODUCTORY BEMABKS
F r e d e r i c k C. R o b b i n s
Hector R. Acuna
John H. B r y a n t
KEYNOTE ADDRESS
C h a r l e s Chassoul Mori ge
C h a p t e r Two
Au s T R I mz AT I o N. E c o N o m c DwELo P mNT, m w o m R
DRINKiNG: HISTORICAL AND SOCIOLOGICAL OBSERVATIONS
Harry Ge n e Le i ne
J'
/+HE IMPACT OF ECONOMIC DEVELOPMENT ON DUNKING PATTERNS
AND PROBLiMS: THE CASE OF TOUBISM
sher and L e n o r e D.
C h a p t e r niree
. ~NI FESTATI ONS AND PERCEPTIONS OF ALCOHOL-BELATED
PROBLEMS I N THE AMERICAS
Raul Cpetano
1
D i s c u s e a n t
Ca rl os C a mp i l l o - S e r r a n o
d
C h a p t e r F o u r
~ISTORICAL m CULTURAL FACTOBS a~wciriw: ~ O L
AVAILABILITY AND CONSUMPTION I N LATIN AMERICA
Fath
D i s c u s s a n t S
J
E d u a r d o Me d i n a C a d e n a s
Juan C a r l o s Negrete
J
Cha pt e r Fi v e
km ANATOMY OF ALCOHOL POLICY: PREVENTIVE MEASUBES
Dean Ge r s t e i n
d
Di s c u s s a n t s
Ma r i l yn J kt a t s ky
I r v i ng Roo t man
V'
,ANTERNATIONAL STUDY OF ALCOHOL CONTROL
EXPERiENCES (ISACE): COMHENTS ON THE FINAL REPORT
James Mosher
Cha pt e r S i x
A IWACT OF PREVENTION LEGISLATION: AN EXAMINATION
OF RESEARCH FINDINGS
Re gi na l d mrt
9
Di s c us s a nt s
Mi c ha e l iJeaubrun
Mar i a El e na Medina-Mora
\
v * A SURVEY OF ALCOHOL-RELATED LEGISLATION
J a i me Ar r oyo Suc r e
u
Appendi x A
/
CONSENSUS VIEWS ON DEVELOPMENT OF ALCOHOL POLICIES
Al t e r n a t i v e Non-Consensue Views
Appendi x B
LIST OF PARTICIPANTS
P RE FACE
It has l ong been recogni zed t h a t na t i ona l economic pr ogr ess
o f t e n c a r r i e s wi t h i t some unf or eseen r i p p l e e f f e c t s . One such
e f f e c t i s seen i n t he problems t h a t a r e a s s oc i a t e d wi t h t he
i ncreased i nges t i on of a l cohol-containing beverages. I n r e cen t
year s, wi despread problems i n t he world economy have t ur ned t he
s p o t l i g h t on t he need f o r g r e a t e r ma t e r i a l pr ogr ess i n many p a r t s of
t he world. The sudden, s har p r i s e i n o i l pr i c e s , acut e s hor t ages of
f ood i n c e r t a i n nat i ons , t he f a l l o f f i n pr oduc t i vi t y i n t he OECD
( Or gani zat i on f o r Economic Cooperat i on and Development) count r i es ,
and t he problems produced by r i s i n g popul at i ons i n devel opi ng
c ount r i e s have r a i s e d s e r i ous ques t i ons about t he a b i l i t y of
governments t o improve t h e i r domes t i c e conomic s i t ua t i on. The
response t o t hese developments i n t he Americas has been f o r
governmen ts t o concent r a t e si ngl e- mi ndedl y on economi c growth t o
a v e r t a n immediate de c l i ne i n t h e i r s t andar d of l i vi ng, o r t o
a ccel er a te t h e i r l onger-range economic well-being .
Thi s workshop was t hus unusual. It at t empt ed t o l ook a t one
phenomenon which o f t e n accompanies economic pr ogr ess -- i ncr eas ed
al cohol consumption. The r e por t i s a unique cont r i but i on t o Lat i n
American/Uni t ed S t a t e s underst andi ng of t h i s a s pe c t of economic
growth. It examines t he impact t ha t a c c e l e r a t e d e f f o r t s t o improve
a c ount r yf s ma t e r i a l ci rcumst ances can have on one f a c e t of t he
b e t t e r l i f e -- t he pot e nt i a l r i s e i n al cohol i sm and al cohol - r el at ed
he a l t h problems, i ncl udi ng a cci dent s and vi ol ence. It expl or es t he
l e s s ons , bo t h pos i t i ve and negat i ve, t h a t may be l ear ned from t he
exper i ence of a v a r i e t y of nat i ons and t h a t might have a bear i ng on
t hose t r yi ng t o encourage improved economi c performance, whi l e a t
t he same time at t empt i ng t o avoi d t he s e r i ous p i t f a l l s a s s oc i a t e d
wi t h t he l i ke l i hood of i ncr eas ed al cohol consumption. The papers
i ncl uded i n t h i s volume were pr esent ed a t a workshop sponsored by
t he I n s t i t u t e of Medicine of t he Nat i onal Academy of Sci ences, and
he l d a t t he Pan American Heal t h Or gani zat i on i n Washington, D.C.
from March 8 t o March 10, 1982. 3 1
The i de a f o r t h i s workshop grew out of a r ecogni t i on t h a t an
excl us i ve f ocus by governments on economic growth has sometimes had
a de s t a bi l i z i ng e f f e c t on t h e he a l t h and wel l -bei ng of t h e i r
popul at i ons. In some, a shar p rise i n dr i nki ng, al cohol abuse, and
al cohol i sm has gone hand-in-hand wi t h "progrese. " These problems
have come t o be a s s oc i a t e d wi t h Engel ' s law: i . e. , when f ami l y
incomes rise, t h e pr opor t i ons s pent on food and ot he r n e c e s s i t i e s
decl i ne. Monies spent on di s c r e t i ona r y items such a s imported o r
domest i c a l c ohol i c beverages ge ne r a l l y i ncr eas e. I n a ddi t i on,
growth pol i c i e s can a l s o i n d i r e c t l y a f f e c t t he pr eval ence of
i mpor t ant al cohol - r el at ed problems i ncl udi ng vi ol ence, motor ve hi c l e
a c c i de nt s , ment al he a l t h problems, al cohol i sm, c i r r h o s i s of t he
l i v e r , and ot he r di s e a s e s of al cohol .
Many pol i c i e s , desi gned t o i nc r e a s e economic pr oduc t i vi t y,
o f t e n encourage l ar ge- scal e i nt e r na 1 mi gr at i ons from t h e r u r a l
count r ys i de t o towns, and changes i n employment f rom farmi ng toward
i ndus t r y and s e r vi c e s i n urban l ocat i ons . Thi s o f t e n r e s u l t a i n
more f a mi l i e s di s s ol vi ng, more peopl e l i v i n g i n crowded forms of
housi ng, and more stress a r i s i n g from employment i n d i f f e r e n t t ypes
of s e t t i n g s , r equi r i ng d i f f e r e n t s k i l l s and a pt i t ude s . A l 1 of t hes e
provi de a cl i mat e f o r t he i ncr eased use and abuse of a l c ohol i c
beverages. Thus, a number of c ount r i e s wi t h i ncr eas i ng economic
growth have found t hemsel ves wi t h a t hr i vi ng domest i c a l c ohol
i ndus t r y, pr ovi di ng de s i r a bl e j obs and t a x revenue, al ongsi de a
r a pi dl y r i s i n g s e r i e s of s e r i o u s he a l t h problems r e l a t e d t o al cohol .
Thi s workshop was or gani zed t o examine whether t he s e phenomena
coul d be di s s oc i a t e d. It sought t o revi ew t he d a t a a va i l a bl e , and
t he exper i ences of many c ount r i e s , and t o br i ng t h i s i nf or mat i on
more e f f e c t i v e l y t o bear on t he i mpor t ant pol i cy ques t i ons r e l a t i n g
t o economic growth, al cohol i sm, and al cohol - r e l a t e d he a l t h
problems. The aim was t o pr ovi de t hos e wi t h policy-making
r e s p o n s i b i l i t i e s throughout t h e Americas wi t h improved knowledge t o
appl y t o t he i nescapabl e t a s k of making de c i s i ons about t h i s
i nt e ns e l y c ont r ove r s i a l i s s ue. The f ocus of t he conf er ence was on
t he a l c ohol "dr i nki ng" problem a s i t i s seen by e l e c t e d o r appoi nt ed
publ i c o f f i c i a l s , a s d i s t i n c t from t h e views of t hose he a l t h
pr of e s s i ona l s who s pe c i a l i z e i n t he f i e l d of a l c ohol t r eat ment o r
r esear ch.
Over t he pa s t hal f - cent ur y, peopl es of t h e Americas have
i nc r e a s i ngl y t ur ned t o t h e i r governments f o r t he r e s ol ut i on of many
c ont r ove r s i a l quest i ons. These problems have been vi de-rangi ng i n
t h e i r economic c u l t u r a l , r e l i gi ous , s o c i a l , and geogr aphi c i mpl i ca-
t i ons . They have of t e n r equi r ed a d i f f i c u l t bal anci ng of judgements
about bot h c os t s and benef i t s . As t he s e governmental r esponsi -
b i l i t i e s have grown, publ i c p r i o r i t y choi ces have become an
immensely more d i f f i c u l t t ask.
Because of t h i e r e a l i t y , t h e queet i one aeked by i ndi vi dua l s i n
publ i c l i f e about he a l t h probleme euch as al cohol i em and al cohol
abuse a r e q u i t e fundamental and basi c. The f i r s t i s ge ne r a l l y
whether an i s s ue can be i gnored because it i e not t h a t s e r i ous a
problem o r because i t s r e s ol ut i on would be hi ghl y c ont r ove r s i a l . So
wi t h al cohol . Given ot he r p r i o r i t y concer ns, is t h i s an i s s ue t ha t
w i l l go away wi t hout much a t t e n t i o n , o r a r e t he economic and he a l t h
consequences of al cohol i sm and a l c ohol abuse l i k e l y t o be so
s i g n i f i c a n t -- i nvol vi ng huge i ncr eaees i n deat h r a t e s , a c c i de nt s ,
and ot he r probleme - that governments w i l l have t o addr ese t he
problem?
The second ques t i on i s o f t e n asked by c ount r i e s t h a t f e e l t hey
have t o respond t o t h i s growing he a l t h problem. Given t h e i r pa r t i -
c u l a r c u l t u r e , hi s t or y, p o l i t i c a l i n s t i t u t i o n s , and exper i ence wi t h
t he temperance movement, a r e t he r e governmental pol i c i e s t h a t coul d
be adopt ed t o moderate t he a l c ohol problem i n t h e i r na t i on?
The t h i r d ques t i on i s e qua l l y pragmatic. I f t he r e a r e pol i -
c i e s which can be adopt ed, what a r e t h e i r p o t e n t i a l p o l i t i c a l and
economic consequences and what a r e t he l i k e l y he a l t h gai ne t o be
der i ved from t h e i r adopt i on?
The or gani zer s of t h i s conf er ence r ecogni ze t h a t t hes e a r e not
easy ques t i ons , nor do t hey have a e i mpl i s t i c o r a uniform answer.
For he r e i n l i es a t aut ol ogy. I n or de r t o addr ess t hes e ques t i ons
f o r each count r y i n t h e Americas, one needs t he r e s u l t s of long-term
r es ear ch s t u d i e s and t he exper i ence of pol i c i e e t r i e d wi t hi n t h e
limits of each na t i on' s p o l i t i c a l i n s t i t u t i o n s .
On t he ot he r hand, a s Odin Anderson of t he Uni ver i t y of
Chicago has wr i t t e n, i n a r e a s such a s t h i s one, hi s t or y shows that
r es ear ch f ol l ows a publ i c consensus t h a t t he r e is a problem, not t he
ot he r way around. Thus, major r eeear ch cannot be undert aken u n t i l
t he publ i c a gr e e s t h a t a s e r i ous problem e xi s t a .
One way out of t h i s dilemma would be t o use one count r y' s
exper i ence as a na t ur a l l a bor a t or y f o r answering anot her count r y' s
ques t i ons about i t s e l f . Recognizing t he l i m i t s i n t he a p p l i c a b i l i t y
of f i ndi ngs a c r os s geogr aphi c bor der e, i t pr ovi des an approach f o r
gai ni ng a consensus on a need f o r a c t i on i n one nat i on based on t he
r e s e a r c h and pr a c t i c a 1 exper i ence of anot her .
The need f or t h i s t ype of exchange t akee on an i ncr eas i ng
i mport ance i n t oday' s world. U e a r e l i v i n g i n a n e r a where t he
maj or i t y of governments, r e ga r dl e s s of t h e i r p o l i t i c a l form, a r e
ge ne r a l l y shor t - l i ved. I n r ecent ye a r s , t he aver age government,
whether e l e c t e d o r appoi nt ed, has been a bl e t o s t a y i n o f f i c e such a
br i e f t i m e t h a t i t i s us ua l l y unabl e t o implement i t s own domest i c
o r f br e i gn pol i c i e s . Thie t r end has r e s ul t e d i n a change i n t he
p r i o r i t i e s o peopl e i n publ i c l i f e . To s ur vi ve i n t he publ i c
ar ena, t hey mus t poseees a n ext reme e e n s i t i v i t y t o under st andi ng t he
consequences i n p r a c t i c e of proposed domest i c p o l i c i e s bef or e t hey
implement them. Nowhere i e t h i e more t r ue t han i n t he a r e a of
p o t e n t i a l a l c ohol abuse, where t he publ i c r esponse may o f t e n be
hi ghl y charged and emot i onal .
The r e c ogni t i on o t h i e need l e d t he workshop pa r t i c i pa nt s t o
s p e c i f i c a l l y f ocus on addr essi ng t heee t hr e e sets of pr a c t i c a 1
p o l i c y r e l a t e d ques t i ons. Thi s concern i s r e f l e c t e d i n t he paper s
i ncl uded i n t hese proceedi ngs and t he conaensus document growing o u t
o t he workshop s es s i ons .
Thi s p r o j e c t was under t aken wi t h t he be l i e f t h a t pr ogr esa i n
bot h he a l t h and economic f i e l d e can be more s uc c e s s f ul l y achi eved i f
though t f u1 peopl e s y s tema t i c a l l y examine va r i ous approaches t o
s ol vi ng problems used by di f f e r e n t c ount r i e s and consi der t h e i r
degr ee o f a i l u r e o r success. It i s my hope t h a t t hese del i ber a-
t i ons may hel p o t h e r s t o t hi nk more i nf or medl y about t he pot e nt i a l
he a l t h problems r e l a t i ng t o i ncr eas ed a l c ohol consump t i on and t he
consequences of var i ous pos s i bl e cour ees of f u t u r e a c t i on.
Robert J. Blendon
Chairman
Advisory Committee
WORKSHOP BACKGROUND AND OVERV IEW
Alan K. Kaplan
The I n s t i t u t e of Medicine' s inter-American workshop on
al cohol - r el a te d problems wa s a pr oduct of t he convergence of growing
i n t e r n a t i ona l i n teres t i n t he r e l a t i ons hi p be tween he a l t h and
economic development, and i ncr eas i ng concern among publ i c he a l t h
l e a de r s about t he medi cal , s oc i a l , and economic consequences of
a l c ohol consumption. "It 1s a mat t er of concern, " Char l es Chassoul
t o l d t he p a r t i c i p a n t s i n h i s keynot e addr es s , " t ha t , i n r e c e nt
decades, t he consump t i on of al cohol and t he problems a s s oc i a t e d wi t h
i t have i ncr eas ed throughout t he world, bot h i n t he r i c h and i n t he
poor count r i es. . . . We must appeal t o t he sense of r e s pons i bi l i t y o
na t i ona l l e a de r s t o i nduce them t o adopt t he appr opr i a te cont r ol s. "
Genesi s of t he Workshop
I n pur s ui t o t he World Heal t h Or gani zat i on' s goa l of "Health
f o r A 1 1 by t he year 2000," t he WHO European Regional Of f i ce convened
a meeting i n May 1980 i n Copenhagen t o expl or e t he need f o r gr e a t e r
under s t andi ng of t he r e l a t i ons hi ps between heal t h and e conomi c
development. Meeting pa r t i c i pa nt s agr eed on t he d e s i r a b i l i t y o
exchanging i de a s on comon he a l t h problems a c r os s na t i ona l
boundar i es and between developing and developed nat i ons.
The Of f i ce of I nt e r na t i ona l Heal t h i n t he U.S. Deparhnent o
Heal t h and Human Ser vi ces (DHHS) t hen suggest ed t h a t t he I n s t i t u t e
of Medicine (IOM) consi der conducting one o r two workshops t h a t
would f a c i l i t a t e such a n exchange. Fur t her di s cus s i ons i nvol vi ng
WBO, the Pan American Heal t h Or gani zat i on, and cogni zant Publ i c
Heal t h Ser vi ce agenci es, l e d t o deci s i ons a ) t o f ocus on t he i s s ue
of pr event i on of al cohol - r el at ed problems i n t he r egi on of t he
Americas, and b) t o examine l e g i s l a t i v e approaches toward such
pr event i on, a n a s pe c t of t he problem t h a t had r ecei ved l i t t l e
a t t ent i on out s i de o t he i ndus t r i a l i z e d count r i es bu t was emerging
a s of immediate i n t e r e s t i n t he regi on. Accordingly, a n advi s or y
group was assembled i n October 1981 under t he di r e c t i on of Robert J.
Blendon t o advi s e t he I n s t i t u t e on t he workshop agenda and pa r t i c i -
pant s. The workshop took pl ace March 8-10, 1982 a t t he Pan American
Heal t h Or gani zat i on i n Washington, D. C. .
Thi s background and t he concerns gi vi ng r i s e t o t he workshop
a r e r ecount ed i n d e t a i l i n t he opening remarks of Fr eder i ck
Robbins, Hector Acuna, and John Bryan t. Subsequen t chapt er s i ncl ude
t he f u l l t e x t s of t he paper s del i ver ed i n t he r es pect i ve s es s i ons .
Four pr e s e nt a t i ons were f ol l owed by di s cus s ant s ' pr epar ed remarks
(two each, except f o r one pr e s e nt a t i on when a schedul ed di s cus s ant
vas unabl e t o a t t e nd) . I n a ddi t i on t o t he formal pr es ent at i ons , t he
workshop schedul e i ncl uded di s cus s i on r egar di ng bot h t he s p e c i f i c
paper s and more gener al al cohol pol i c y i s s ue s .
Workshop Overview
The f unct i on of t h i s overview i s t o s e r ve a s a br i e f gui de t o
t he proceedi ngs. A t t he out s e t , however, t hr ee key concept s gui di ng
workshop pl anner s war r ant f ur t he r comment.
The emphasis on l e g i s l a t i v e approaches toward reduci ng al cohol
problema r e f l e c t s growing i n t e r e s t of t he PAHO r egi on i n expl or i ng
t h e r e s u l t s of making a l c ohol consumption e i t h e r les8 conveni ent
( t hr ough fewer hours of s a l e and/ or number of s a l e s o u t l e t s ) o r more
expensi ve ( by r a i s i n g t he pr i c e through t axat i on) . Thus, c ont r ol s
on suppl y, which ge ne r a l l y a r e consi der ed t he cor e of l e g i s l a t i v e
measures af f e c t i ng a l c ohol consump t i on, a r e di scussed a t l eng th.
Pa r t i c i pa nt s a l s o f ocused on ways t o a f f e c t consumer demand,
i ncl udi ng publ i c educa t i on and a dve r t i s i ng r egul a t i ons , a s w e l l a s
envi ronment al i nt e r ve nt i ons .
The second ke y concep t, pr even t i on, s i g n a l s an i ncr eas i ng
i n t e r e s t i n t he us e of non-personal i zed, s oc i e t p o r i e n t e d measures
t o r e duce t he burden of al cohol - r el a t ed- problems, a s d i s t i ngui shed
from programs and pol i c i e s aimed a t hel pi ng per sons who exper i ence
problems d i r e c t l y caused by dr i nki ng. Pa r t i c i pa n ts i n t h i s workshop
t hus f ocused on pr event i on and n o t t r eat ment , but i n s o doing di d
no t i nt e nd t o minimize i mpor t ant pol i c y and r esear ch ques t i ons
r egar di ng ( l eavi ng def i n i t i on a s i de) t hose who exper i ence t he
di s e a s e of al cohol i sm.
The l a s t concept i s embodied i n t he choi ce of t he phr ase
"al cohol - r el a t ed problema." An a l t e r na t i ve would have been
"al cohol i sm, " but t he ove r a l l goal of t he workshop was a n
exami nat i on of a l c ohol ' s broad economic and s o c i a l e f f e c t s on
i ndus t r i a l i z e d and devel opi ng ria t i ons i n t he Americas, r a t her t han
on s p e c i f i c dr i nker s. The choi ce was n o t meant t o excl ude
cons i der at i on of e f f e c t s on i ndi vi dua l he a l t h, but was a n e f f o r t t o
expand t he f ocus of t h i s p a r t i c u l a r meet i ng t o encornpass t he
r e l a t i ons hi p be tween a l c ohol and such problema a s pr oduct i vi t y i n
t he workplace , t r a f f i c acci den ts, vi ol ence and crime , and f ami l y
di s r up t i on.
The F i r s t Day
The opening s es s i on, i n keepi ng wi t h t he o r i g i n a l i mpet us f o r
t he e f f o r t , concent r at ed on t he impact of a l c ohol problems on
e conomic development. S t a r t i n g w i t h t he ques t i on of whe t her a l c ohol
consumption can be s a i d t o have adver s el y a f f e c t e d such development
and t he growth of pe r c a pi t a Gross Nat i onal Pr oduct i n t he indus-
t r i a l i z e d nat i ons , Levine ar gued t h a t "on t he ba s i s of t he
h i s t o r i c a l exper i ence of t he Uni t ed St a t e s , Br i t a i n and ot he r
European count r i es , consumption does n o t appear t o have i nhi bi t e d
( such) development."
Mosher t hen examined t he obver se quest i on: t he e xt e nt t o which
development might i t s e l f engender al cohol - r el at ed problems. H i s
s p e d f i c f ocus vas t ouri sm and t he assumed economic be ne f i t s of i t s
expansi on i n t he devel opi ng world. "There i s t he pos s i bi l i t y, " he
s tates, " t h a t expansi on ( al ong wi t h suppor t i ve f i s c a l and t ax
pol i c i e s ) f u e l s i nc r e a s e s i n al cohol a v a i l a b i l i t y and consumption,
which i n t ur n l e a ds t o i ncr eas es i n t he i nci dence of al cohol
problems i n l e a s developed hos t count r i es. I f s o, t hen t he
s t r u c t u r e of t he t ouri sm i ndus t r y i t s e l f becomes a publ i c he a l t h
concern. "
Agai nst t h i s backdrop t he workshop s ucces s i vel y examined
r es ear ch f i ndi ngs about t he e xt e nt of al cohol - r el at ed problems i n
t he Ameri cas, s t udi e s of communi t y dr i nki ng pr a tices, and
Lat i n- Amer i an h i s t o r i a l and c u l t u r a l f a c t o r s cont r i but i ng t o
cur r en t consump t i on pa t t er ns.
What one f i nds , Caetano t ol d t he pa r t i c i pa nt s , i s evi dence i n
many count r i es of s i g n i f i c a n t he a l t h damage s uf f e r e d by i ndi vi dual 8
a s a r e s u l t of a l c ohol consumption ( l i v e r di s e a s e and ps yc hi a t r i c
hos pi t a l i z a t i on) , a s well a s s t udi e s i ndi c a t i ng a l i n k between
consumption and such problems a s a c c i de nt s and vi ol ence. However,
he ar gued, t he l egacy of emphasizing t he di s eas e of al cohol i sm i n
a l c ohol r es ear ch ha s been a del ay i n a s c e r t a i ni ng and t her eby
c o n f r o n t i q the f u l l range of al cohol - r el at ed problems: "Those
di agnosed a s a l c ohol i c s a r e a di f f e r e n t popul at i on f rom those w i t h
al cohol problems who have not reached t he c l i n i c door." Despi t e t he
di s e a s e model' s i mpor t ant cont r i but i on t o f o s t e r i ng t r eat ment of
a l c ohol i c s , he concluded, t he t i m e has come f o r more br oadl y focused
r es ear ch and pr event i on e f f o r t s .
An t hr opol ogi s t Heath, a f ter reviewing i n de tal1 t he soci o-
c u l t u r a l h i s t o r y of a l c ohol consumption i n La t i n America, suggest ed
t h a t t he t a r g e t of t he broader e f f o r t might be el us i ve: "An
i mpor t ant ge ne r a l i z a t i on from Latin-American experence i s t h a t
al cohol - r el at ed problems a r e , l i k e a l c ohol i c s and a l coholism, t r u l y
ve r y r a r e -- a t l e a s t i n comparision wi t h popul at i ons i n t he res t of
t h i s hemisphere, and much of t he rest of t he world... Lat i n-
Americans, by and l a r ge , seem t o f e e l t h a t t hey s u f f e r few problema
t h a t can be r e l a t e d t o a l c ohol use, either t h e i r own o r on t he p a r t
of s i g n i f i c a n t ot her s . I t i s even more s i g n i f i c a n t when one
consi der s t h a t t hese s t u d i e s of t en r e f e r t o popul at i ons among whom
heavy dr i nki ng occur s r e gul a r l y and where drunkenness i s bot h
f requen t and a ccep t a bl e . "
The Cae tan0 and Hea t h pr esent a t i ons r a i s e d s e r i ous ques t i ons
abou t t he nat ur e and ext en t of al cohol - r el at ed problems and brought
i n t o f ocus t he di ver gent per s pect i ves o two di s c i pl i ne s : epidemio-
l ogy and ant hropol ogy. "Although i t i s pos s i bl e t o agr ee wi t h Dr .
Heath t h a t al cohol causes l e s s s o c i a l di s r upt i on o r devi ant behavi or
i n Lat n America t han i n , f o r example, Anglo America," Negrete
a s s e r t e d, "dat a on mor t a l i t y from al cohol - r el at ed causes i ndi c a t e
t ha t al cohol abuse c ons t i t ut e s a n e qua l l y major publ i c he a l t h
pro blem i n bo th r egi ons. "
Endorsing t he development of i n t e r d i s c i p l i n a r y s t u d i e s
( epi demi ol ogi cal and ant hr opol ogi cal ) , Medina urged t ha t gr e a t e r
a t t en t i on be gi ven t o t he i mpact of c ur r e nt s o cioeconomi c t r ends
upon t he pa t t e r n s of al cohol consumption s t e d n g f rom h i s t o r i c a l
event s : "Modera te consump t i on obt a i ns onl y i f t he s oc i oc ul t ur a l
environment of f e r s a coher ent cont ext . The s e c ul a r i z a t i on of modern
l i f e t ends t o weaken t he common r u l e s i n t h i s r egar d and, t her ef or e,
t o f a c i l i t a t e anomalous behavi ors. Fur thermore , t he low soci o-
economic l e ve l , t he mar gi nal i t y, and t he anomie of many urban
popula t i on groups w i l l genera te gr e a t e r intemperante . "
The Se cond Da y
The f ocus s h i f t e d t o a n exami nat i on of a l t e r n a t i v e publ i c
pol i c i e s f o r t he pr event i on of al cohol - r el at ed problems, w t h
s peci f i c emphasis on l e g i s l a t i ve c ont r ol measures. Se t t i n g t he
framework f o r t he di s cus s i on were pr es ent at i ons concerning t he
re c e nt l y comple t ed I nt e r na t i ona l S tudy of Alcohol Cont r ol
Experi ences (Makela 198 1 ) and t he Na t i o n a l Academy of Sci ences'
r e por t on al cohol pol i c y (Moore and Ger s t ei n 1981). Formal
pr esent a t i ons a l s o i ncl uded a n examina t i o n of r es ear ch f i ndi ngs on
t he i mpact of s p e c i f i c c ont r ol measures and a sur vey o al cohol -
r e l a t e d l e g i s l a t i o n i n Cent r al America and Panama.
"There a r e t hr ee ki nds of pr event i ve pol i c i e s , " Ger s t ei n s a i d:
"r egul at i ng t he terme and condi t i ons of a v a i l a b i l i t y o al cohol and
pl a c e s i n which t o dr i nk i t ( r e gul a t i ng suppl y) ; t r yi ng t o i nf l uence
peopl e' s dr i nki ng pr a c t i c e s d i r e c t l y through pedagogi cal ef f o r t s and
l e g a l s t i pul a t i ons (shapi ng dr i nki ng pr a c t i c e s di r e c t l y) ; and making
t he ext er na1 environment l e e s hos t i l e o r r i s k y s o t ha t po t e n t i a l l y
damaging consequences of i nt oxi c a t i on a r e reduced ( r educi ng
envi ronment al r i s k) . These t hr e e t ypes a r e r e l a t e d t o each ot he r
q u i t e di r e c t l y. Supply p o l i c i e s t r y t o c ont r ol two of t he el ement s
t h a t a r e necessar y t o ever y al cohol - r el at ed problem: a l c ohol i t s e l f
and pl aces i n which t o dr i nk i t . Pol i cy on dr i nki ng pr a c t i c e s
presumes t h a t al cohol and consumption pl aces ( publ i c and pr i va t e )
a r e a va i l a bl e , and tries t o i nf l uence how peopl e t ake advant age of
them, i n terme of how much, how of t e n, o r what a c t i v i t i e s dr i nke r s
p a i r wi t h consumption. Fi na l l y a pol i c y desi gned t o reduce envi -
ronmental r i s k presumes t h a t peopl e w i l l be dr i nki ng, g e t t i n g drunk,
and put t i ng themselves i n danger i n var i ous ways. The obj e c t of
t hes e pol i c i e s i s t o l i m i t t he s e ve r i t y of t he consequences by
making t he environmen t less hos tile."
Smart ' s revi ew of t he i mpact of var i ous c ont r ol measures
covered s t udi e s of a l c ohol a v a i l a b i l i t y and consump t i on, changes i n
l aws governi ng o u t l e t s and hours of s a l e , p r i c e and t axat i on, l aws
r e l a t i n g t o age of purchase and consumption, and a dve r t i s i ng
cont r ol s . "While al l ow( i ng) onl y some t e nt a t i ve concl usi ons, " Smart
observed, "t he emp r i ca1 evi dence i n t o t a l suggest s t h a t pr event i on
of al cohol - r el at ed problema depende upon hol di ng a v a i l a b i l i t y and
pr i c e s cons t ant o r even reduci ng a v a i l a b i l i t y , keeping access f o r
young peopl e l i mi t e d, and hoping t h a t t he pr e s e nt t r end towards a
pl at eau i n al cohol consumption cont i nues where i t has begun. I n
c e r t a i n count r i es i t may be pos s i bl e t o make l a r g e changes i n p r i c e
o r a v a i l a b i l i t y , but i n or de r t o have a s ube t a nt i a l e f f e c t t hey must
be ver y l a r ge , pr obabl y l a r ge r t han most governments w i l l consi der. "
Endorsing Smart ' s o v e r a l l conci usi ons about pr event i on pol i cy,
Beaubrun emphasized s ever a1 s t udi e s i ndi c a t i ng a n i nver s e
r e l a t i ons hi p between the r e a l pr i c e of al cohol and l i v e r c i r r h o s i s
mor t a l i t y, hos pi t a l aclmissions f o r al cohol i sm, and r oad t r a f f i c
acci dent s . He t hen addr essed t he drunk dr i vi ng problem i n gr e a t e r
d e t a i l . " I nt e r na t i ona l exper i ence shows us , " he s a i d, " t h a t i n t he
s h o r t r un Scandinavian- type (S t r i c t bl ood al cohol concent ra t i on)
l aws, e s p e c i a l l y i f coupl ed w i th some r es pons i bl e implementa t i on and
hi gh v i s i b i l i t y, r e s u l t i n s i gni f i c a n t r educt i on i n acci den ts and
mor t a l i t y but t h a t i n t he l ong r un t h i s de t e r r e nt e f f e c t t ends t o be
l o s t even i n a few year s, a s publ i c per cept i on of t he t hr e a t of
being caught recedes. Ce r t a i nt y of de t e c t i on i s t he i mpor t ant
va r i a bl e and n o t s e ve r i t y of punishment. Ce l e r i t y of punishment has
ye t t o be pr oper l y eval uat ed. "
Le gi s l a t i on per t ai ni ng t o al cohol i n var i ous count r i es of
Cent r al Ame r i c a was reviewed by Arroyo. Summarizing a sur vey done
i n 1981 f o r t he Ce nt r a l American Mi ni s t er s of Heal t h, he r epor t ed
t h a t " A l 1 t he count r i es of t he a r e a have comprehensive al cohol
l e gi s l a t i on. Laws enact ed a t t he begi nni ng of independence a r e
st i l l i n f or c e and r e f l e c t t he l e g a l syst em t h a t r ul e d our r e l a t i o n s
wi t h Spai n duri ng t he c ol oni a l er a. (But ) l e g i s l a t i o n ha s been
pr i ma r i l y cent er ed on economic and f i s c a l mat t er s. . . . Pr i o r i t y has
r a r e l y been as s i gned t o t he he a l t h a s pe c t s of t he problem, and we
pr of es s i onal s and o t h e r per sons i n t e r e s t e d i n t hese t as ks have been
unabl e t o pr ovi de s c i e n t i f i c and t echni cal da t a t o suppor t passage
of adequat e l e g i s l a t i o n . The magnitude of t he problem t o be f aced
i s e vi de nt i f , i n a ddi t i on, we bear i n mind t h a t i n some count r i es
morbidi t y and mor t a l i t y r a t e s sugges t ot he r p r i o r i ties; t ha t t he
e conomi c s t r uc t ur e of t hese count r i es encourages t he c ul t i va t i on of
gr a i ns and t he pr oduct i on, market i ng and consumption of al cohol ,
and, e s pe c i a l l y, t h a t t he popul at i on a t l a r g e and even he a l t h
workers accep t and t ol e r a te t hese habi ts."
From Kat at sky, Medina-Mora, and Rootman came words of caut i on
abou t the a p p l i c a b i l i t y of a heavi l y con t r ol - or i ent ed pol i cy.
Gr eat er i mpact i n t he s h o r t run, Kat at sky ar gued, 1s l i k e l y t o come
from educat i onal programs t h a t can be mounted by t he he a l t h
a u t h o r i t i e s on t h e i r own wi t hout t he ne c e s s i t y of ba t t l i ng f o r
l e g i s l a t i v e changes af f e c t i ng al cohol a v a i l a b i l i t y. "Short term,"
s he s a i d, "1 don' t t hi nk we a r e goi ng t o see any s i g n i f i c a n t
de l i be r a t e at t empt s a t changing supply. 1 t hi nk we can expect t o
cont i nue t o see emphasis on t he demand s i de , wi t h a n i ncr eas i ng
number of educa t i o n a l programs . "
Medina-Mora poi nt ed t o " t r ade- of f " consi der a t i ons : "I n many
r egi ons i t mi ght be economical t o dr i nk a l c ohol i c beverages because
t he y have c a l or i e s and a r e cheaper, l e s 8 harmful, and more a va i l a bl e
t han ot he r beverages such a s wat er o r milk. I n such s i t u a t i o n s i t
would be necessar y t o r a i s e t he st andar d of l i v i n g si mul t aneousl y
w i t h i ncr eas i ng c ont r ol of al cohol a v a i l a b i l i t y , o r else s i d e
e f f e c t s might become more dangerous t han per mi t t i ng t he s a l e of
al cohol . "
"Furthermore, " s he cont i nued, " t he a l c ohol i ndus t r y does
r epr es ent a consi der abl e amount of economi c a c t i v i ty. Count r i es
t h a t wish t o promote t h e i r economic development w i l l have t o de a l
w i t h t he dichotomy t h a t al t hough t hey want t o reduce t he pr oduct i on
of al cohol , t hey a l s o have a n i n t e r e s t i n i ncr eas i ng t ax revenues."
For Rootman t her e was concern about t he l ocus of a c t i v i t y a s
w e l l a s i t s cont ent . Rat her t han emphasize l e g i s l a t i v e c ont r ol s
imposed from a c e n t r a l a ut hor i t y, he observed, a community l e ve 1
r esponse t o al cohol - r el at ed problems ( a s exempl i f i ed i n WHO' s
Communi t y Kesponse Pro j e c t i n i t i a t e d i n 1976 w i t h t he pa r t i c i pa t i on
of Mexico, Scot l and and Zambia) was a l s o c r uc i a l t o a comprehensive
pr event i on pol i cy.
The i mport ance of t he community response s t udy a s c a r r i e d o u t
i n Mexico, Campillo-Serrano had observed t he day bef or e, "is t ha t i n
va r i ous ways we overcame t he l i mi t a t i ons out l i ne d by Dr . Caetano i n
c o n n e c t i o n w i t h pr evi ous s t udi e s undert aken i n La t i n America. We
responded ... f i r s t by abandoning t he r i g i d medi cal model of al cohol
a s a di s eas e, and t hen by l ooki ng a t s o c i a l and l e g a l problems . . . .
1 bel i eve t h a t t h i s s t udy cr eat ed a model t h a t 1s worthy of bei ng
copi ed i n ot he r count r i es of t he region. "
The Thi r d Day
Norman Sa r t or i us opened t he morning s e s s i on wi t h a
wide-rangiry a n a l y s i s of WiO'e e f f o r t s t o move toward i t s goa l of
"Heal t h f o r Al 1 by t he Year 2000." Rel at i ng t he goa l t o ment al
he a l t h programe i n gener al and a l c ohol problems speci f i c a l l y ,
Sa r t or i us reviewed a number of or ga ni z a t i ona l and s c i e n t i f i c
dilemmas conf r ont i ng a l c ohol pol i c y makers. Never t he l e s s , he
concluded, "t he s i z e of t he problem and i t s urgency f or c e us t o a c t
i n s p i t e of ambigui t y. We have t hi ngs i n f r o n t of u8 t h a t we can do
a t t he l e ve 1 of t he i ndi vi dua l and t he communi ty.. We don' t have t o
wai t . "
The l a s t p a r t of t he workshop cons i s t ed of smal l group
di s cus s i ons of a d r a f t s t at ement of consensus views t h a t sought t o
r e f l e c t t he exchanges of t he f i r s t two days. That d r a f t , developed
by William Lybrand (who had ser ved a s workshop r appor t eur ) , al ong
wi t h comments of t he s mal l group chairmen (Caetano, Ger st ei n, and
Room), formed t he ba s i s of a r evi s ed consensus st at ement t h a t was
s e n t t o t he Advisory Committee and pa r t i c i pa nt e f o r review. The
re s u1 t i ng document appear s i n t he appendix. 1
Conclusion
The inter-American workshop was a meeting of e xpe r t s from a
v a r i e t y of backgrounds, c ul t ur e s and nat i ons. I t was by a l 1
a ccount s a s ucces s f ul vent ur e i n t r ansna t i ona l connnunica t i on and
de l i be r a t i on. Bu t i t was a l s o a s p i r i t e d meeting , encompassing
debat e a s w e l l a s consensus, and pr obabl y l eavi ng a s many a r e a s f o r
f u t u r e i nqui r y as t hose on which i t shed new l i g h t . Accordingly,
t he r eader 1s encouraged t o del ve f i r s t i n t o t hese proceedi ngs i n
or de r t o c o l l e c t cont ext and nuance f o r t he st at ement s i n t he
appendix. The workshop obj e c t i ve was not s o much consensus,
al t hough a s i g n i f i c a n t amount emerged, a s i t was expl or at i on and
anal ys i s . The obj e c t i ve of t hese proceedi ngs, then, i s t o
con t r i bu te t o gr e a t e r unders t andi ng of t he complexi ties of a
compelling publ i c pol i c y i s s u e -- compl exi t i es appar ent i n t he
f ol l owi ng quo t e d commen ts made by var i ous par ti ci pan ts dur i ng t he
workshop sessi ons: .
. . . I f 1 under s t and t he ant hr opol ogi cal me thod c or r e c t l y, i t 1s
t o l ook a t t he or di na r y ev=ryday event s and t o i gnor e, i f
poes i bl e, t he unusual . So t he a n t hr opol ogi s t might w e l l
i de nt i f y a s a r a r e e ve nt what t he epi demi ol ogi st begi ns t o
consi der a n epi demi c because t he l at t er goes o u t and f ocuses
on devi ant behavi or, and, i f he f i n d s a 3, 4, o r 5 per cent
o ccurrence r a te, he consi der s t h i s a hi ghl y pr eval en t
problem. Thus, t hese two ways of l ooki ng a t a gi ven si t ua t i on
might gi ve u s d i f f e r e n t pi c t ur e s of r e a l i t y . Yet i n t he
t o t a l i t y of our t a s k t hey bot h i nform us , because what t he
ant hr opol ogi s t views a s behavi or i n t e g r a l t o a c ul t ur e i s
t her ef or e behavi or unl i ke l y t o be e a s i l y s us c e pt i bl e t o
modif i c a t i o n by l e g i s l a t i o n . On t he o t her hand epidemio-
l o g i s t s may te11 u8 t h a t such behavi or i s bound t o c r e a t e a
c e r t a i n l e ve 1 of problems t h a t r e qui r e s behavi or changes i n
or de r t o pr event s e r i ous publ i c he a l t h problems. It i s i n
t h i s i n t e r p l a y t h a t we may ye t f i n d t he i nf or mat i on we need t o
make a publ i c pol i c y approach workable a t a l l .
. . .I don' t t hi nk t he anal ogy t o e a r l y i ndus t r i a l i z a t i on
a ppl i e s a s much today. We a r e s eei ng more and more workers
engaged i n a c t i v i ties t ha t , r e l a t i v e l y speaki ng, a r e
sedent ar y, s o t h a t t he advant ages of a l c ohol ' s c a l o r i c cont ent
a r e somewhat minimized. I n a ddi t i on, wi t h t he s h i f t i n
a c t i v i t y from brawn t o br ai n, workers a r e engaged i n
a c t i v i t i e s t h a t pl a c e a hi gh premium on motor cont r ol ,
judgment, per cept i on, and r a p i d i t y of response i n oper at i ng
ver y demanding t echni cal machinery. Al 1 t h i s c r e a t e s a
d i f f e r e n t ki nd of chal l enge t o some of t he t r a di t i ona l
pa t t e r ns of a l c ohol use.
. . .With r e s pe c t t o t he h i s t o r y of al cohol r es ear ch i n La t n
America, we must keep i n mind t h a t i t i s ve r y cos t l y; a
s o c i e t y might deci de i ts p r i o r i ties f o r expendi t ur e of ve r y
s car ce r esour ces poi nt i n ot he r di r e c t i ons .
. . . I f w e wi sh t o have laws on al cohol problems passed, we must
convince communi ties, no t j us t p o l i t i c i a n s , t ha t t her e t r u l y
a r e problems. Un t i l we do t hi s , l aws may be passed, but t hey
may n o t be enf or ced.
. . .The da t a on t he dangers of a l c ohol consumption from t h i s
hemisphere a r e ext r emel y high. Forty-seven per cent of a l 1
male admi ssi ons t o our l a r g e s t gener al hos pi t a l were
al cohol - r el at ed i n one sur vey by a doct or al s t ude nt i n 1973,
f orty-seven per cent of al 1 male admi ssi ons and twenty-six
per cent of the t o t a l admi ssi ons, male and female.
... We have a n i n i t i a l s t udy showing t h a t t he expendi t ur es f o r
al cohol - r el at ed problems r epr esen t 6 30 mi l l i on d o l l a r s pe r
year i n our currency. That r epr es ent e a n enomous c os t , b u t
we can seldom not e t h i s because i t i s a hi dden cost . I t i s
hi dden i n t hi ngs such a s l o e s of worker pr oduct i vi t y,
acci dent s i n cons t r uct i on o r ot he r t ypes of i ndus t r y,
absent eei sm, and a lowered st andar d of l i vi ng. Si nce a l 1 of
t h i s 1s n o t r e a d i l y appar ent , i t i s d i f f i c u l t f o r s o c i e t y t o
comprehend t he f u l l magnitude of t he problem.
.. .The not i on t h a t al cohol i sm as a di s eas e somehow c ont r a di c t s
o r s t a nds i n c ont r a s t t o al cohol problems i s f a l s e . As a
di s eas e, al cohol i sm i s a ve r y i mport an t al cohol - r el a t ed
problem. I n f a c t we a r e r e a l l y begi nni ng t o r ecogni ze that
pr event i on e t r a t e g i e s and t he br oader concept s of al cohol
problems can be viewed a s bei ng i n tandem o r p a r a l l e l wi t h the
al cohol i sm concep t.
... One needs t o t hi nk of pr event i on i n tenas of a n i nt e gr a t e d
approa ch, no t l i m i t e d t o changing dr i nki ng behavi or al one , bu t
deal i ng wi t h a number of s o c i e t a l i s s ue s . We went i n t o one
community wi t h a g r e a t i de a of t r yi ng t o i n t e r e s t people i n
al cohol i sm t r eat ment i n or de r t o i nc r e a s e t h e i r awareness of
al cohol i sm a s a s e r i ous problem, and w h a t we met were peopl e
sayi ng, 'Look, t h a t i s not a problem. 1 mean, yes, i t i s a
problem, but what about the f a c t t h a t 1 don' t have a house t o
l i v e i n? What about t he f a c t t h a t t her e i s no sewage system?
What about t he f a c t t h a t t he o i l company t h a t moved i n her e
j u s t cl osed down one of t he two pl a nt s f o r s i x months, and 1
have t o go somewhere e l s e ? ' And 1 t hi nk one of t he l e s s ons
from t h a t exper i ence was t h a t i n terms of t r yi ng t o work
pr event i on of al cohol - r el at ed problems i n t o t hose s e t t i ngs , we
have t o conf r ont t he o v e r a l l problems of t hose communities,
and i n f a c t , a l c ohol does touch on al 1 of t hose community
i ssues.
Notes and Referencee
1. On Apr i l 14, 1982 t he st at ement of consensus views, a s
reviewed by t he advi s or y committee and DHHS and PAHO l i a i s o n ,
was del i ver ed t o t he Of f ice of I nt e r na t i ona l Heal t h (DHHS) ,
f o r i t s us e i n pr epar at i on f o r t he WHO World Heal t h Assembly
t echni c a l di s cus s i ons on al cohol problems. 1 t was emphasized
t h a t t he s t at ement comprised a per cei ved consensus of t he
ma j or i t y of t he pa r t i c i pa nt s , n o t ne c e s s a r i l y t he views of
each and ever y one, inasmuch as t i m e had n o t per mi t t ed a
complete d i s tri bu t i on f o r review. The consensus s t a tement
appear i ng i n Appendix A does r e f l e c t revi ew by a l 1 t he
pa r t i c i pa nt s and, whi l e i ncor por at i ng s ever a1 pa r t i c i pa nt
r esponses, i s i n a l 1 e s e e n t i a l r e s pe c t s t he same compi l at i on
t h a t was t r ans mi t t ed t o OI H. The s t at ement embodies t he
opi ni ons of a l 1 t hose i de nt i f i e d a s workshop pa r t i c i pa nt s i n
Appendix B except two, whose a l t e r n a t i v e opi ni ons appear i n
t h e i r e n t i r e t y f ol l owi ng t he consensus views.
Ref erencee
Makela, K. e t a1.(1381) Alcohol, Soci et y and t he St a t e 1: A Com-
pa r a t i ve St udy of Alcohol Cont rol and J.E. Si ngl e, P. Morgan,
J. de Li nt , eds. (1982), Alcohol, Soci et y and t he St a t e 2: The
Soci al Hi s t or y of ~ o n t r o i Pol i cy i n Seven Count ri es. Toronto:
Addi ct i on Re eearch Founda t i on
Moore, M. and D. Ger s t ei n, ede. (1981) Alcohol and Publ i c Pol i cy:
Be yond t he Shadow of Pr ohi bi t i on. Waehing ton, D .C. : Na t i onal
Academy Pree e.
CHAPTER ONE
WELCOME AND INTRODUCTORY REMARKS
Frederi ck C. Robbins
Hector R. Acuna
John H. Bryant
KEYNOTE ADDRESS
Charles Chaseoul knge
WELCOKE AND INTRODUCTORY REMARKS
Frederi ck C. Robbins
1 t i s my pl easure t o welcome you on behalf o t he I ns t i t ut e of
Medicine and t he Nat i onal Academy of Sci ences, of which i t i s a
par t . We a r e most appr eci at i ve of t he sponsors of t h i s conference,
pa r t i c ul a r l y Dr . John Bryant o t he U.S. Department o Health and
Human Servi ces, f o r s t i mul at i ag and encouragiag t he development o
t hi s workshop. The Pan American Health Organi zat i on (PAHO) has
been, of course, very hel pf ul and t hese f a c i l i t i e s a r e an excel l ent
pl ace t o have t hi s ki nd of a conference. My esteemed colleague, Dr .
Hector Acuna, i s a marvelous host , and 1 always enj oy my as s oci at i on
wi t h him. Dr . Bobert Blendon has done an except i onal job a s
chairman o t he Advisory Commi t t ee responsi bl e f o r t he organi za t i on
o t hi s meeting, al ong wi t h t he ot her members l i s t e d i n your program.
We a l s o a r e del i ght ed t ha t s o many of you agreed t o
par t i ci pat e. The s ubj ect o t hi s workshop i s obvi ousl y one o
irnportance around t he world and one of gr e a t di f f i c ul t y of
sol ut i on. Al1 of our count r i es have had experi ences wi t h i t . The
Uni ted St at es has had some very not abl e experi ences, pa r t i c ul a r l y
between 1920 and 1933 when we had nat i onal Prohi bi t i on. The
per si st ance of t he problem r e f l e c t s i t s very importance and si ze.
The National Academy of Sciences and t he I ns t i t u t e of Medicine
have been very i nt e r e s t e d i n t h i s t opi c over some time and have
i ssued sever al r el evant report e. From our poi nt o view, t h i s i s a n
i mport ant ar ea, and we hope t o l e a n from you; perhaps t here i s
something we can cont r i but e a s wel l , and 1 l ook f owa r d t o
par t i ci pat i ng a s much a s 1 can.
Hect or R. Acuna
It i s, i ndeed, a g r e a t pl easur e t o welcome you t o t he Pan
American Heal t h Or gani zat i on today, and 1 want t o expr es s my s i nc e r e
a ppr e c i a t i on t o t he I n s t i t u t e of Medicine f o r af f or di ng us t he
oppor t uni t y t o hos t t h i s Inter-American Workshop on Legi s l a t i v e
Approaches Towards t he Preven t i on of Ai cohol-Rela t ed Problems.
When t he I n s t i t u t e of Medicine approached us two year s ago,
r eques t i ng our a s s i s t a nc e i n s e l e c t i ng a t opi c f o r t h i s workshop,
t he World Heal t h Or gani zat i on was deepl y i nvol ved i n a number of
s i g n i f i c a n t a c t i v i t i e s i n t he a l c ohol f i e l d . The paesage of
Reeol ut i on 32.40 by t he World Heal t h Assembly i n 1979 marked a major
s h i f t i n our t hi nki ng and pol i cy. That r e s ol ut i on recogni zed t he
i mport ance of al cohol - r el at ed problems and ur ged member s tates t o
t ake a ppr opr i a t e measures t o reduce t he consumption o al cohol .
While t he pos s i bl e r e l a t i ons hi p between al cohol - r el at ed problems and
the o v e r a l l consumption l e ve 1 of al cohol has been pr evi ous l y
di scussed i n o t h e r publ i c forums, i t was t he f i r s t time t h a t t he
World Heal t h Assembly had gi ven i t such a t t e nt i on. It 1s a
cont r over s i a1 i de a , and one t h a t some cont end s t e p s f a r beyond t he
t r a d i t i o n a l domain of publ i c he a l t h pr act i ce. However, much o what
we w i l l be doing over the ne xt 1a year s t o accompl i sh t he goa l of
"Heal t h f o r A l 1 by t he Year 2000" coul d a l s o be consi der ed a s
"r adi cal . " What we a r e t a l ki ng about 1s a dr amat i c s h i f t i n
t hi nki ng, the i mpor t of w h i a i s j u s t beginning t o be appr eci at ed.
For t h i s r eason, tnis workshop 1s p a r t i c u l a r l y i mpor t ant t o u s a t
t h i s time.
d h i l e we have been aware of tlie need t o cooper at e wi t h ot he r
s e c t or s , nowhere 1s this need g r e a t e r t han i n t he cas e of al cohol
problems. If pr event i on 1s envi saged i n i ts broades t terms, t hen we
w i l l have t o t ur n our a t t e n t i o n t o i s s ue s o s o c i a l wel f ar e,
educat i on, and economics which he r e t of or e we d i d n o t anal yze
thoroughl y.
The si mpl e f a c t i s t h a t whi l e governments a s a whole can
s i gni f i c a nt l y af f e c t dr i nki ng pr a c t i c e s and, concomi t a n t l y reduce
al cohol - r el at ed problems, t he he a l t h s e c t or per se cannot. What we
can do, however, 1s put t oget her a convi nci ng case f o r a c t i on and
t r y t o de l i ne a t e how t h a t a c t i on mi ght be c a r r i e d out . A l though a
consi der abl e amoun t of r es ear ch has been di r e c t e d a t t he appl i ca t i on
of demand-reducing s t r a t egi es , we have r e l a t i v e l y 11 t t l e da t a on t he
i mpact o euppl y r educt i on meaeures, par t i c u l a r l y i n devel opi ng
count r i es .
i~ t me s a y a few words about t he devel opi ng count r i es of our
r e gi on and t he work we have been doing i n t he a l c ohol f i e l d , f i r s t ,
because 1 t hi nk i t i s germane t o your di s cus s i ons , and secondl y,
because we a r e proud of some of our accomplishments of t he p a s t
decade o r so. I n ge ne r a l , t he t r ends i n a l c ohol problems which we
are beginning t o see i n t he r egi on a r e al armi ng. A mul t i na t i ona l
sur vey conducted by t he Pan American Heal t h Or gani zat i on i n t he mid-
1970' s showed t h a t heavy dr i nki ng, p a r t i c u l a r l y by young a d u l t
males, was much more widespread t han we had pr evi ous l y thought. The
numbers o peopl e a f f e c t e d o r p o t e n t i a l l y a f f e c t e d by al cohol
problems i s . st agger i ng. W i th more t han one- t hi r d of adul t males
r epor t i ng hi gh l e v e l s of heavy dr i nki ng i n t hr e e of t he f i v e ci t i es
eurveyed, t he i mpact on heal t h, s o c i a l wel f ar e, and econoadc
development i s c l e a r l y of such pr opor t i on a s t o war r ant e wi f t and
d i r e c t governmen t i n t er vent i on.
While few of t he governments of t he r egi on have e e t a bl i s he d
a l c ohol programe, t her e a r e consi der abl y more t oday t han t her e were
a decade ago, and t he l i s t keeps growing. The i ncr eas ed world-wide
a t t e n t i o n gi ven t o al cohol - r el at ed problems has had a l o t t o do w i t h
t h i s developmen t. However , more impor t a nt l y, governments a r e
begi nni ng t o r ecogni ze t ha t pr event i on can be ef f e c t i v e l y achi eved
a t a s o c i a l and economic c os t which i s w e l l wi t hi n t he i r reach.
1 would j us t l i k e t o remind you t ha t t he World Heal t h Assembl y
ha s schedul ed Techni cal Di scussi ons on Al cohol i n May (19821. For
this r eason w e w i l l be l ooki ng forward t o t he r e s u l t s o t h i s work-
shop wi t h keen i n t e r e s t.
1 a m ve r y much impreeeed wi t h t he ve r y demanding agenda f o r
t he ne xt t hr ee days, and wish you ever y s ucces s i n your del i ber a-
t i ons.
John H. Bryant
It i s a pl eas ur e t o be her e and t o see s o many di s t i ngui s hed
peopl e i n t h i s f i e l d her e t o de a l wi t h t h i s i mpor t ant s ubj ect .
1 t hi nk you w i l l be i n t e r e s t e d i n t he genes i e of t he s et of
i deas l eadi ng t o t h i s conference. I n May 1980, i mmedi at el y pr i or t o
tha t year 'S World Heal th Assembly i n Geneva, a few of us convened a
small conference w i t h t he World Heal t h Organiza t i on, and par t i cu-
l a r l y i ts European o f f i c e , al ong wi t h t he Pan American Heal t h
Or gani zat i on, a s i n teres t e d pa r t i c i pa nt s . Shor t l y bef or e, t he World
Heal t h Or gani zat i on had p u t forward t he i de a of "Heal t h f o r A l 1 by
t he Year 2000," a t t h a t t i m e a somewhat i l l - de f i ne d but ve r y
i mport an t concep t.
A number of u8 f e l t i t was ve r y impor t a nt t h a t "heal t h f o r
a l l " shoul d be s e e n a s a goal , n o t f o r poor count r i es al one, but
r a t he r t h a t i t shoul d be s een a ppr opr i a t e l y a s appl yi ng t o a l 1
count r i es. A s a coneequence, f o r t he Geneva meeting we brought
t oge t her r epr es ent a t i ve s f rom abou t 20 na t i ons t o examine t he
i mpl i cat i ons f o r t he more developed count r i es. Four -- t he Sovi et
Union, Norway, Canada, and t he United St a t e s -- of f e r e d themselves
as case s t udi e s . We had i n v i t e d a number of devel opi ng count r i es t o
p a r t i c i p a t e s o a s t o pr ovi de per s pect i ve i n l ooki ng a t t he problems
of t he more developed count r i es. The i nput of t he l e s 8 developed
count r i es brought a n unpr edi ct ed outcome, one which l e d t o our bei ng
her e today. Bu t l e t m e come t o t ha t i n a moment.
The problem t h a t f aced t he more developed count r i es was how t o
def i ne "heal t h f o r a l l . " It was most s uc c i nc t l y s t a t e d by t he
del egat e from t he Net her l ands, who s a i d t h a t i f "heal t h f o r a l l "
means uni ve r s a l a c c e s s t o b a s i c heal t h s e r vi c e s , h i s count r y has had
t h a t f o r 20 year s, b u t i t does n o t have "heal t h f o r a l l . " H e no t ed
problems of al cohol i sm and drug abuse, and i n d u s t r i a l t oxi c i t y, and
s t a t i s t i c s showing t h a t on a ny gi ven day 20 per cent of t he l a bor
f or c e was absen t from work, os t e ns i bl y f o r heal t h r easons.
These obs er vat i ons l e d i n t o a l ong l i s t of problems t h a t e x i s t
i n t he mos t developed count r i es and t h a t r e l a t e t o heal th. I n t he
cour se of devel opi ng t h a t l i st , t he l e e s developed count r i es poi nt ed
o u t t ha t even though t h e i r c ur r e nt p r i o r i t i e s mi ght be i n a r e a s of
communicable di s e a s e s and pr ovi si on of he a l t h s e r vi c e s , t her e was
not a s i n g l e problem on the l i st of t he more developed count r i es
t n a t t hose from l e a s developed nat i ons coul d n o t cl ai m a s one of
t he i r own: pa t t e r n s of di s eas e; problems of pl anni ng , implementing
and managing he a l t h s y s tems; he a l t h manpower development; r e s e a r ch
i s s ue s ; e t c .
Thi s r e ve l a t i on, i f you w i l l , t h a t a l 1 c ount r i e s di d i ndeed
s ha r e t he same set of problems, even though d i f f e r e n t count r i es
would have d i f f e r e n t p r i o r i ties, l e d us t o a s k anot her set of
quest i ons. I f we a l 1 have t he same set of problems, but a t
d i f f e r e n t e t ages, wha t i s t he sequence through which s peci f i c
problems w i l l emerge a s p r i o r i t i e s ? That i s, which c ur r e nt problems
may demand p r i o r i t y a t t e n t i o n i n t he f ut ur e ? And, can count r i es
l e a r n from one anot her ? Should we t hi nk i n terms of pr ospect i ve
p r i o r i ties s o t h a t count r i es which do n o t ye t f a c e a ma j or problem
w i l l r ecogni ze t h a t i t may be on t h e i r door st ep a decade o r two from
now? That brought us t o t he f u r t h e r ques t i on of whether count r i es
can l e a r n from one a not he r ' s exper i ences i n or der t o steer around
cer t ai n problems. I f they can pr edi ct which problems a r e on t he
way, t o what ext ent can they avoi d them and/or a t l e a s t prepare f o r
them i n a more e f f e c t i ve way?
There vas a s ubet ant i al amount of i n t e r e s t i n t h i s s e t of
quest i ons, and we decided t o pursue i t f ur t her . I n t he f a11 of
1980 -- encouraged by Dr . Acuna a t PAHO and by Dr . L.A. Caprio, t he
di r ect or of t he European of f i c e of WHO -- Dr . Blendon, &s. Karen
Be11 from t he i n s t i t u t e of Medicine, and 1 went t o Copenhagen f o r a
meeting t o f ur t he r di scuss t he mat t er and t o t r y t o deci de on some
concret e s t eps t ha t could be taken a t t ha t time. I n t he course of
those di ecussi ons, Dr . Blendon, i n par t i cul ar , helped us focus on
s ubj ect ar eas t ha t ve could defi ne c l e a r l y and concret el y enough t o
develop a series of r e a l i s t i c pol i cy opt i ons. One encompassed
probleme of t he el der l y; ot her s were t he problems of alcoholism,
vehi cul ar acci dent s, occupat i onal heal t h hazards, and t he fi nanci ng
of heal t n ser vi ces. We f e l t t hi s l i st could be used a s an agenda
f o r more developed and less developed count r i es t o come t oget her t o
l ook a t pol i cy op t i ons t o consider f or t he f ut ure.
We f i r s t addressed problems of t he el der l y, and 1 w i l l not e
t h a t we had some qui t e successf ul coneul t at i ons t ha t w i l l r e l a t e
ver y di r e c t l y t o t he upcoming World Assembly on t he El derl y.
Then t he I ns ti t u t e of Medicine, w i t h Dr . Blendon' e a s e i s tance,
generousl y agreed t o t ake on t he pr oj ect of organi zi ng a workehop on
al cohol - r el at ed problems. 1 would s a y t ha t our i nt e nt was t o
provide a forum t o def i ne t he problem and t o i de nt i f y t he pol i cy
opt i ons, i n t h i s i net ance i n t he a r e a of l egi s l at i on. Thus, a s
nat i ons f ace t hese par t i cul ar problems i n t he i r f ut ur e t hey can be
guided, a t l e a s t t o some ext ent , by t he experi ence of ot her
coun tries .
Against t ha t background we a r e ver y pl eased t o s ee t hi e
conference underway, and we look forward t o l ear ni ng from a l 1 of you.
KEYNOTE ADDRES S
Char l es Chassoul Monge
I t 1s a s a La t i n American t h a t 1 am a t t e ndi ng t h i s meeting.
I n La t i n America, many b a s i c a r e a s a r e ve r y i nadequat e o r con-
spi cuous by t h e i r absence -- he a l t h, f ood, educa t i on, l a bor and
employmen t, consump t i on, t r ade and savi ngs, t r ans por t a t i on and
communications, housi ng , cl ot hi ng, re c r e a t i on o r l e i s u r e , s o c i a l
s e c ur i t y, and human f reedom. Con t r a s ts a r e a d i s t i ngui shi ng e a t ur e
of t h i s cont i nent : her e, a c i t y o more t han 10 mi l l i on i nha bi t a nt s
w i t h t he hi ghe s t degr ee of s ophi s t i c a t i on, t her e, onl y a few hundred
kilome ters away, a pover t y-s t ri cken communi t y whose i nhabi t an ts do
n o t even speak Spani sh, b u t onl y t he d i a l e c t s t hey have i nhe r i t e d
f rom t he i r ances tral c u l t ur es.
But we La t i n Americans are imbued w i th a s p i r i t o opt i mi s t i c
pe r s i s t e nc e , t o achi eve new s o c i a l and economic goa l s t ha t w i l l
a f f e c t our models of development and, consequent l y, our he a l t h
a c t i v i t i e s and t hus enabl e us t o f i n d some way o pr event i ng t he
problems r e l a t i n g t o a l c ohol and al cohol i sm.
When 1 l e a r ne d about t h i s meet i ng, 1 imagined t h a t i t was
yoi ng t o a t t e mpt t o emul at e the 1889 Br ussel s meeting a t which a
group of European powers agr eed t o abi de by c e r t a i n moral principies
r egar di ng Af r i can terri t or i e s , i ncl udi ng t he pr i nc i pl e of l i mi t i n g
t he i mpor t at i on of har d l i quor i n t o Af r i ca. 1 imagined t h a t we were
goi ng t o di s c us s a s i mi l a r pr opos i t i on f o r La t i n America and t he
developed count r i es , and 1 was n o t di s t r e s s e d. 1 f ur t he r imagined
t h a t w e were goi ng t o have a f r a nk, open, s i nc e r e and, consequent l y,
ani mat ed meeting wi t h t he r e pr e s e nt a t i ve s of t he producers of
a l c o h o l i c beverages i n t he Uni t ed St a t e s , Canada, and Mexico, and
t h a t we might f i n d our s el ves i nvol ved i n wide-ranging and s e r i ous
ve r ba l di sagreement s. And t h i s di d not ups et m e i n t he l e a s t .
But when 1 r ecei ved t he pr el i mi nar y d r a f t o t he agenda of
t h i s meet i ng, t o which 1 had been i n v i t e d t o make t h i s speech, and
when 1 saw who would be pr es ent t her e, 1 must conf ess f e e l i ng some
anxi et y. 1 a m c a l l e d upon t o gi ve you my opi ni on on a problem t h a t
a t pr es ent can onl y be handl ed by s p e c i a l i s t s i n t h a t f i e l d . 1 am
n o t such a s y e c i a l i s t and my presence her e 1s j u s t i f i e d s o l e l y by
t he f a c t t ha t 1 have been working wi t h a n al cohol i sm program i n my
own count r y and have some knowledge of s i mi l a r programs i n ot he r
La t i n American coun tries.
We s t a r t from c e r t a i n gener al assumptions: we t ake f o r
g r ant ed t ha t we a r e a cquai nt ed w i t h world t r ends i n t he product i on
and consumption of a l c ohol i c beverages; t he manufacture and
market i ng of t hese product s, a s w e l l a s t he many commercial
agreements t ha t suppor t them; and t hat , i n addi t i on, we know t he
e f f e c t s and t he damage caused by t he consumption of al cohol on our
peopl es a t t h e i r d i f f e r i n g l e v e l s of economic and s o c i a l
development. We assume, i n accordance wi t h what t he exper t s t e11
us , t h a t i f we a r e t o deal wi t h t hese gener al as pect s of al cohol , we
cannot adopt i s o l a t e d measures i n our count r i es; r a t he r , when we
p a r t i c i p a t e i n any a c t i v i t y i n this f i e l d , we must t ake i n t o account
a l 1 t he ps ycho-social, p o l i t i c a l , and economic f a c t or s t ha t may
de termine i t .
We a r e t o l d t ha t , i f we a r e t o pr event t he damage al cohol
causes i n our communi t i e s , we shoul d desi gn ef f e c t i ve r egul a t or y
measures and i n t e g r a t e them i n t o a p o l i t i c a l post ur e t h a t w i l l l ead
t o clearl y def i ned and consi st en t governmen t act i on. I n addi t i on,
we shoul d si mul t aneousl y conduct o t her mul t i - s ect or al suppor t
a c t i v i t i e s s o a s t o ensur e t h a t our pr event i ve program i s bot h
complete and coordi nat ed and, bef or e beginning any program, we
shoul d i nform t he publ i c hones t l y and accur at el y s o t h a t i t w i l l
recogni ze t he problem and pa r t i c i pa t e i n our a c t i v i t i e s . It i s a
mat t er of concern t hat , i n r ecent decades, t he consumption of
al cohol and t he problems as s oci at ed wi t h i t have i ncr eased
throughout t he world, bot h i n t he r i c h and i n t he poor count ri es;
t h a t i n t he t r a d i t i o n a l l y wine-drinking count r i es t he consumption of
beer and har d l i quor i s i ncr easi ng; t h a t i n t he beer-drinking
count r i es t he consumption of wine and hard l i quor i s i ncr easi ng; and
t ha t i n t he count r i es where hard l i quor i s r e gul a r l y consumed, t he
consumption of wine and beer i s i ncr easi ng. Any admi ni s t r at or o r
s c i e n t i s t who pl ans t o desi gn a pr event i ve program shoul d not e what
has happened when a popul at i on t h a t has a s peci f i ed r a t e of
consumption of t r a d i t i o n a l beverages 1s urged t o lower i t s t o t a l
al cohol i nt ake by swi t chi ng t o ot her dr i nks. The outcome 1s t h a t
t ha t popula t i on con t i nues t o consume t he t r a d i t i ona l beverage , as
wel l as t he beverage t h a t has been urged upon i t a s a moderating
elemen t.
As al r eady no t ed, i n approaching al cohol i sm, most ef f o r ts
shoul d be di r ect ed towards prevent i on, wi t h educat i on a fundamental
element. iiowever , t he eval ua t i on of al cohol i sm educat i on programs
i s undeni abl y compl i cat ed by a g r e a t many economic and s o c i a l
f a c t or s ; and i f we deci de t o d i r e c t al cohol i sm educat i on excl us i vel y
a t chi l dr en i n school s, we know t h a t i t w i l l have l i t t l e chance of
success. Educat i onal programa, which f r equent l y l a & r esour ces and
a r e t i mi d i n t he i r approach, a r e o f f s e t by a l 1 t he organi zed and
unorganized s t i mul i t h a t induae consumption.
I n addi t i on t o t he inducements por t r ayed i n t he mas8 media,
t her e a r e a l 1 t he t hi ngs chi l dr en l e a r n i n t he s t r e e t , a t home, o r
i n ot he r cont ext s about how and when and why al cohol i s consumed.
And i f a hypot het i cal program were t o become s ucces s f ul , and reduce
t he rate of consumption, t he p o l i t i c i a n s i n t he government a r e
l i k e l y t o c ont r a di c t i t by changing p o l i c i e s because government
revenue i s f a l l i n g ; o r a c i t i z e n may i nvoke h i s c ons t i t ut i ona l
r i g h t s , cl ai mi ng t h a t no one shoul d i n t e r f e r e wi t h h i s per sonal
l i f e , t h a t he may dr i nk wherever, whenever, f o r whatever r eason, and
w i t h whomever he wants. That same c i t i z e n can e a s i l y s a y t h a t he
dr i nks because he has t he problems of bei ng a n educat ed person, o r
t ha t he wants t o dr i nk more because he has t he problems of bei ng an
i l l i t e r a t e . O r he may s a y he dr i nks because he ha s t he burdens of
power, o r t h a t he dr i nks because he i s powerl ess. Or else he says
t h a t physi cl ans recommend t he consumption of a c e r t a i n amount of
al cohol t o preven t cor onar y di s e a s e , o r t ha t t o f or c e t he popul at i on
t o dr i nk less by whatever means may mean a subsequent i nc r e a s e i n
h e a r t di sease.
What 1 have s a i d b r i l y s t o mind Gr oussac' s complaint about
Emerson, t h a t he us ua l l y became obacure by being t oo profound o r
t h a t he f e a r e d he sometimes appeared profound by being t oo obscure.
The d i f f i c u l t y i nhe r e nt i n deal i ng wi t h a s ubj e c t such a s we a r e
di s cus s i ng 1s c l e a r l y appar ent t o t he aver age person.
The l e g a l a s pe c t s of c ont r ol and t he pr event i on of al cohol i sm
a r e t he c e nt r a l theme of t h i s conference; Popham and Schmidt f ill us
wi t h ent husi asm when t hey s a y t h a t t he pos s i bl e pr event i ve val ue of
l e g a l measures has a ga i n become i mpor t ant i n t he pr event i on o
al cohol i sm and tha t the a va i l a bl e i nf ormat i on on t h e i r e f f e c t i ve ne s s
i s worth anal yzi ng. We t he r e f or e be l i e ve t h a t t h i s conference i s
bot h necessar y and t i mel y f o r the count r i es of La t i n America, many
of which a r e t r yi ng new approaches i n t h i s f i e l d .
From Popham and Schmidt we a l s o t ake a paragraph of Edwards
which f ur t he r e xpl a i ns t hi a mat t er : Edwards saya t h a t i f we a r e n o t
capabl e of managing pe r s ona l i t i e s and producing a human group
wi t hout neur oses, t he onl y a l terna t i ve t o c ont r ol t he pr eval ence of
al cohol a ddi c t i on i s c ont r ol of t he envi ronment al condi t i ons of
dr i nki ng. Ger s t ei n a l s o gi ve s us gui dance when he out l i ne s i n h i s
paper f o r t h i s conf er ence t he need f o r pr a c t i c a 1 and or gani zed
t hought i n consi der i ng t he l e g i s l a t i v e approach a s a n i nc e nt i ve f o r
pr event i on i n matters of al cohol and al cohol i sm. The st at ement i n
Smar t ' s paper t h a t governments have an i mpor t ant r o l e t h a t goes
beyond t he t r ea tmen t of a l c ohol i c s t o consi der i ng l aws and pol i c i e s
on var i ous a s pe c t s of t he pr event i on of al cohol i sm, i s a l s o a n
excel l en t mesaage. When Hea t h, i n h i s wide-ranging observa t i ons on
t h i s mat t er t el l s us, i n a l 1 modesty, t h a t he i s onl y suppl yi ng a
fragmented gl i mpse of a complex r e a l i t y , he st i l l pr ovi des cause f o r
op t i mi s m.
A l 1 La t i n Americans know t he or der of p r i o r i t i e s e s t a bl i s he d
by t he M ni s t r i e s of Heal t h i n t h i s f i e l d . We must add t h a t i t i a
nei t her a pr i vi l e ge nor an a t t r a c t i v e pos i t i on t o defend i n t he
f i e l d of al cohol i sm a n a c t i v i t y o r program t ha t i n some way f a i l s t o
deal comprehensively wi t h t h i s heal t h hazard. Worthy of mention a r e
t he a c t i v i t i e s c a r r i e d o u t i n Lat i n America by t he Pan American
Heal t h Organi zat i on (PAHO) t o c or r e c t t h i s s i t ua t i on. The many
a c t i v i t i e s t h i s or gani za t i on has under taken i n t he f i e l d have made
many people aware of t he problem i n many count r i es. An example of
PAHO's i n i t i a t i v e s -- i f you w i l l al l ow me t o mention i t -- i s t he
enactment i n Cost a Rica of a l a w e s t a bl i s hi ng a n al cohol cont r ol
agency w i th na t i ona l j ur i s di c t i on t h a t i s r es pons i bl e f o r r es ear ch,
pl anni ng, community work, educat i on i n t he publ i c pri mary school s,
adver t i s i ng, and even s peci al i zed u n i t s f o r t he hos pi t al i zat i on of
a l c ohol i c pat i ent s . Today we shoul d l i k e t o pay t r i b u t e t o t he Pan
Ameri can Heal t h Organiza t i on f or i ts e f f o r ts i n t h i s regard.
1 would have l i k e d t o gi ve you a n ove r a l l view of t he
h i s t o r i a l development o al cohol - r el at ed problems and al cohol
cont r ol programs i n Lat i n America. However, t he l i mi t ed i nformat i on
1 have a va i l a bl e and l ack of time would have caused me t o make many
e r r o r s and omi ssi ons i f 1 had undert aken t o deal wi t h t h i s t opi c.
Accordi ngl y, and wi t h t he permiesion of t he audi ence, 1 am goi ng t o
deal wi t h eomething wi t h which 1 a m more f a mi l i a r , namely, t he
s i t u a t i o n i n my count ry, which i n essence i s n o t ver y d i f f e r e n t from
t h a t i n t he r e s t of Lat i n America, and may b e t aken as more o r l e s s
r epr es ent a t i ve of t he o t her coun t r i e s .
Nevert hel ees, 1 must emphasize t h a t what 1 have j u s t s a i d
r e f e r s t o t he l e g i s l a t i v e s i t ua t i on, s i nc e t he conduct of programs
and s er vi ces , and prevent i on r at ea, var y g r e a t l y from one count ry t o
anot her .
An al cohol monopoly was eet abl i s hed i n U 4 8 under Decree No.
13 i s s ued by t he Pr es i dent General of Costa Rica, wi t h t he r a t i ona l e
t hat : "The two most product i ve branches of t he Publ i c Treasury,
namely t he revenues from tobacco and al cohol , a r e s t e a d i l y decreas-
i ng because t he l aws and r egul at i ons t h a t underpi n them have been
rel axed. " It was n o t u n t i l 1337 t ha t a General Liquor Law was
enact ed. I n our count ry t oday t her e a r e many ways of out wi t dng t he
l aw and r egul a t i ons governi ng al cohol i c beverages . Such r egul a t i ons
i ncl ude cont r ol of t he frequency of s a l e s of a l c ohol i c dr i nks,
r egul at i ons governi ng t he type of s a l e , hours a t which beverages a r e
s ol d, age lid ts f o r consuming a l c ohol i c beverages, pr i ce cont r ol a
(of t en w i t h q u i t e a r b i t r a r y di f f er ences) , and di f f e r e n t i a l t axes
( agai n seemingly w i t hout rhyme o r reason). Although t hese cover
v i r t u a l l y a l 1 as pect s of al cohol cont r ol , t h e i r enforcement i s
l i mi t ed. I n s hor t , t h a t i s our s i t u a t i o n , and t he same coul d be
s a i d of many count r i es i n Lat i n America. Thi s phenomenon may
pos ai bl y be even more i mport ant i n ot her count r i ee i n Lat i n
America. Dr . Jaime Arroyo, our di st i ngui ahed v i s i t o r from Panama,
has s t udi ed t h i s as pect i n Cent r al America, and r e i t e r a t e s t her e a r e
some laws, a c t u a l l y q u i t e a few, but t h e i r r e a l and pr act i ca1
enforcement i s uns at i s f act or y.
1 cannot resist t he t empt at i on of gi vi ng anot her example, from
my own count r y, where a rather unusual s i t u a t i o n pr e va i l s a t t h i s
t i me . Changes i n the val ue of t he cur r ency have s u b s t a n t i a l l y
i ncr eas ed t he p r i c e of a l c ohol i c beverages, and t h i s has l e d a l a r g e
segment of t he publ i c t o s t o p dr i nki ng i mpor t ed beverages and t o
consume t he much cheaper beveragee produced i n t he count ry. I t
shoul d be not ed t h a t s i nc e t he end of 1979 t he per c a pi t a con-
sumption of l i ci t a l c ohol i n Cost a Rica has been decr easi ng, f o r t he
f i r st t i m e i n 75 year s. Thi s w i l l s u r e l y be accompanied by a l a r g e
i nc r e a s e i n consumption of t he illicit beverages t h a t a r e wi del y
home-brewed by our r u r a l popul at i on. I n 1974 a l aw and r e gul a t i ons
f o r con t r o l l i n g adver t i s i n g f o r a l c ohol i c beverages was enact ed. By
1982 t ha t adver t i s i n g ha s be come more a t t r a c t i ve , more s ubt l e , and
i n gener al , much b e t ter desi gned. We had some cont r over s i es , whi ch
1s na t ur a l i n t h i s f i e l d , but which we would have avoi ded i f t he
i nf or mat i on we now have had been a va i l a bl e a t t h a t time. But one
fundament al concern 1s t o ques t i on why t he ou t l a ys on adver t i s i n g
f o r a l c ohol i c beverages i n our count r i es shoul d be as g r e a t a s the
budget of t he Department of St a t e , of t he Mi ni s t r y of Youth, Cul t ur e
and Spor t s o r of the Nat i onal Alcoholism I ns ti t ut e . We need t o f i n d
why l a r g e amounts a r e being i nves t ed i n c ont r ol e f f o r t s wi t hout any
e f f e c t on reduci ng the consumption of a l c ohol i c beverages i n gener al .
1 do n o t wish t o l i st t he many Cost a Rican l aws on t he
pr event i on of al cohol i sm problems. You w i l l be a b l e t o appr eci at e
t he l e g a l h i s t o r y i f we pr e s e nt onl y p a r t of t he st at ement of
r easons of t he Nat i onal Alcohol and Alcoholism Code,* which a t t h i s
time i s being di s cus s ed by our Le gi s l a t i ve Assembly. Thi s s t at ement
of r easons 1s a ve r y modest cont r i but i on t o t he purpose and
obj e c t i ve of t he meet i ng, t o which t he I n s t i t u t e of Medicine of t he
Un1 t ed St a t e s Nat i onal Academy of Sci ences has been ki nd enough t o
i n v i t e us t o di s c us s t hese matters.
The opi ni on states t h a t s i nc e October 7 , 1936, no
comprehensive l aw on a l c ohol and al cohol i sm has been enact ed i n
Cost a Rica. The pr e s e nt Na t i ona l Alcohol and Alcoholism Code:
o de i n e s a l c ohol i c beverages and t he t ypes of beverages
a va i l a bl e on t he na t i ona l and i nt e r na t i ona l marke t, bo t h
f ermented and d i s t i l l e d ;
o pl ace8 t he pr os pect s of a Nat i onal Di s t i l l e r y i n a broader
dimension, r e qui r i ng t he Di s t i l l e r y t o e s t a b l i s h i t s own
market i ng and d i s t r i b u t i o n s ystems;
o ve r y c l e a r l y i ndi c a t e s where na t i ona l and imported
a l c ohol i c beverages a r e t o be anal yzed, as w e l l a s
de i ni ng
*Legi sl a t i v e Assembl y: AFFIRMATIVE MAJORITY OPINION, dr af t l aw
" Na t i ona l Alcohol and Alcoholism Code", publ i shed i n Supplemen t 108
of La Gaceta No.151 of 11 August 1977.
illicit, f a l s i f i ed, and adul t er at ed and pr ohi bi t ed al cohol s ,
and how each of them 1s t o be t r eat ed;
o deal s wi t h t he manufacture and bot t l i ng of d i s t i l l e d
beverages, a s w e l l a s i n d u s t r i a l product s that use al cohol .
I n t h i s r egar d i t mentions t he c ha r a c t e r i s t i c e of a l c ohol i c
beverages f o r i mport and expor t and s e t s o u t t he r u l e s t o be
f ollowed f o r t he expor t , i mport , and t r a n s i t of a l c ohol i c
beverage S i n the coun tr y;
o r egul at es t he gener al as pect s of i mport i ng houses, s pe c i f i e s
t he p o r t s of l oadi ng and unl oadi ng of t hese beverages, and
pr es cr i bes c a r e f ul handl i ng of them i n t he nat i onal
t e r r i t o r y;
o s t i p u l a t e s who can obt ai n l i c e nc e s f o r s e l l i n g a l c ohol i c
beverages, def i nes t he type of shops t h a t can se11 t hese
beveragee, and r egul at es t h e i r s a l e , which wi l l be
excl us i vel y between 11 a.m. and 2 p.m;
o r egul at es t he procedure f o r obt ai ni ng or di nar y l i cens es , a s
wel l a s t he qua l i f i c a t i ons of t he l i c e ns e hol der8 and
e s t a bl i s he s t he r u l e t ha t not more t han one l i cenae w i l l be
i es ued f o r ever y 200 ci t i zens;
o e t i pul a t e s where shops s e l l i n g a l cohol i c beverages a r e t o be
l ocat ed and pr ohi bi t s t he presence i n t he shops of minors
and t he s a l e of such beverages t o them;
o pr ohi bi t s t he s a l e of a l c ohol i c beverages i n work p l a a s ,
muni ci pal o r pr i va t e marke t e , o r mul ti- ami l y housing
pro j e c t s sponsored by government i n s ti t ut i ons .
The Code deal s s p e c i f i c a l l y wi t h t he t r eat ment t o be gi ven t o
al cohol i ce by t he a u t h o r i t i e s and a l s o wi t h t he approach t o
al cohol i cs t o be t aken by government i n s t i t ut i ons , i n pa r t i c ul a r t he
Na t i ona l Alcoholism I ns t i t ut e. 1 t de i n e s al cohol i sm a s a di sease
and s p e l l e o u t t he f unct i ons o t he Nat i onal Aicoholism I n s t i t u t e .
The Code:
o si mpl y and c l e a r l y pr ohi bi t a persona from dr i vi ng passenger
Uans por t at i on whi l e drunk,and s e t s out t he a ut hor i t y of t he
pol i ce t o adminie ter exper t examina t i ons f o r determining t he
presence of al cohol i n t he human body;
o c l e a r l y def i nes t he r e s p o n s i b i l i t i e s of t he a l c ohol i c
pa t i e nt wi t h r es pect t o h i s fami l y, and e s t a bl i s he s t he
procedures f o r ensur i ng t h a t t hese r e s p o n s i b i l i t i e s a r e
f ul f i l l e d;
o r e qui r e s pri mary, secondary, voca t i ona l and t echni c a l
s chool s, bo t h publ i c and pr i va te, t o gi ve preven t i v e
educat i on on al cohol and al cohol i sm;
o r e gul a t e s a dve r t i s i ng f o r a l c ohol i c dr i nks and e s t a bl i s he a a
r e g i s t r y of l i c e n s e s f o r t he s a l e of a l c ohol i c beverages,
l oc a t ed i n t he Na t i ona l Al coholism I n s ti t ut e.
Fi na l l y, i t names c e r t a i n o f f i c i a l s of t he INSA a s he a l t h
i ns pe c t or s and conf er s on them t he same powers and dut i e s a s t he
General Heal t h Law a s s i gns t o the he a l t h a ut hor i t i e s . It s t i p u l a t e s
t h a t i t i s a publ i c or der law, and t he most i mpor t ant of t he t r a ns i -
t i o n a l pr ovi si ons i s t h a t which f r e e z e s t he pr e s e nt number of
l i c e n s e s f o r t he s a l e of a l c ohol i c beverages, a s w e l l a s t h e i r
l oc a t i on, u n t i l t he pr e s e nt s ur pl us i s reduced t o t he number
pr escr i bed.
The l e g a l measures f o r the cont r ol of al cohol - r el a t ed problems
have s o f a r been l o c a l o r na t i ona l measures. It shoul d be poi nt ed
o u t t h a t the a v a i l a b i l i t y of a l c ohol i c beverages and t he methods f o r
promo t i n g t he i r consump t i on r e a ch beyond na t i ona l f r ont i e r s . I n a
s hor t-s i gh t ed endeavor t o promo te developmen t, r egi onal and
sub- r egi onal economi c coopera t i o n pa c t s have come t o f avor
i n t e r n a t i o n a l i n t e r e s t s i n t he pr oduct i on and d i s t r i b u t i o n of
a l c ohol i c beverages. The t r ansna t i ona l c a r t e l a w i l l cer t a i n l y be
i nc l i ne d t o promote a n i nc r e a s e i n t he pr oduct i on and i mpor t at i on of
such beverages i n many count r i es.
We do n o t be l i e ve t her e i s any s upr anat i onal agency t h a t can
impose l e g a l measures t o c ont r ol these a i t ua t i ons . We must appeal
t o t he sense of r e s p o n s i b i l i t y of na t i ona l l e a de r s t o i nduce them t o
adopt t he a ppr opr i a t e cont r ol s . I n t he f i r s t pl ace t hey mus t be
made t o under st and t h a t al cohol problems a r e n o t onl y a heavy burden
on he a l t h syst ems and a n i mpor t ant f a c t o r i n mor t a l i t y and
mor bi di t y, but a l s o a n obs t a c l e t o development. Nat i onal o r
i nt e r na t i o n a l f i na nc i a l i n s ti t ut i ons and s o c i a l and economic
agenci es shoul d have been aware of t hese f a c t a a l ong t i m e ago.
The h i s t o r y of humanity i s f u l l of not abl e event s t h a t a r e the
work of man. I t i s sometimea d i f f i c u l t t o poi nt o u t t he small
d e t a i l s t h a t gave rise t o t hose out st andi ng event s. Because of t he
nat ur e of t he agenci es and per sons t h a t promoted and or gani zed t hi a
meet i ng, we a r e hi ghl y opt i mi a t i c and f u l l of hope t h a t we a r e
a t t endi ng t he ge ne s i s of a ve r y i mpor t ant endeavor f o r t he
i nhabi t an ts of our coun t r i e a .
Chap ter Two
INDUSTRIALIZATION, ECONOMIC DEVELOPMENT, AND WORKER DRINKING:
HISTORICAL AND SOCIOLOGICAL OBSERVATIONS
Harry Ge ne L e v i n e
TBE W A C T OF ECONOMIC DEVELOPMENT ON DRINKING PATTERNS
AND PROBLWS: THE CASE OF TOURISH
J a me s F. Mosher
an d
L e n o r e D. R a l s t o n
1 NDUSTRIALIZATION, ECONOMIC DEVELOPMENT, AND WORKER DRI NKI NG :
HISTOIUCAL AND SOCIOLOGICAL OBSERVATIONS
Harry Gene Levine
hen f i r s t approached about wr i t i ng a paper on t he r e l a t i on-
s h i p of a l c ohol t o economic development, and whether some ge ne r a l
l e s s ons d g h t be drawn from the h i s t o r i c a l exper i ences of t he U.S.
and ot he r developed count r i es , 1 suggest ed f ocusi ng on t he s ubj e c t
of a l c ohol and work. I n d u s t r i a l and economic development us ua l l y
i nvol ves t he c r e a t i on of a l a r g e c l a s s of wage l a bor e r s , and
wnt i nuous s t r uggl e s between employers and workers a r e among t he
mos t prominent f e a t ur e s of developed and devel opi ng s oc i e t i e s .
During t he va r i ous per i ods of Br i t i s h and American i n d u s t r i a l
development, t he c o n f l i c t s o f t e n i nci uded t he ques t i on of a l wh o l i c
dr i n k .
Acwr di ngl y, i n t he f i r st two p a r t s of t he paper 1 b r i e f l y
di s c us s two d i s t i n c t bu t c i os e l y r e l a t e d ef f o r ts whi ch i nvol ved
employer-sponsored a t t a c ks on worker dr i nki ng. The f i r s t was t he
at t emp t of e a r l y manufact uri ng and i n d u s t r i a l employers t o change
t h e i r employees work ha bi t a and gener al s t y l e of l i f e . Thi s e f f o r t
vas no t pr i mar i l y aimed a t changing dr i nki ng pa t t e r ns , but i ncl uded
dr i nk a s p a r t of a broader e f f o r t . The second employer-sponsored
e f f o r t 1 di s c us s was t he e a r l y temperance o r ant i - dr i nk reform i n
t he Uni t ed St a t e s . Bere t he e f f o r t was aimed pr i mar i l y a t changing
workers dr i nki ng pa t t e r ns d i r e c t l y i n or der t o secur e a more or de r l y
and di s c pl i ne d work f or ce. I n t he t h i r d s e c t i o n 1 di s c us s some
ge ne r a l concl usi ons t o be drawn from t he br oad European and North
Ame r i can exper i ence -- i n pa r t i c ul a r , t ha t worker dr i nki ng t aken by
i t s e l f does n o t appear t o be an impediment o r obs t a c l e t o economic
development and growth. I n t he f our t h s e c t i o n 1 i nt r oduce some con-
temporary qua nt i ta t i v e da t a t o test and expand upon t he h i s t o r i c a l
evidente.
I n d u s t r i a l Employers and Pr e- I ndus t r i al Workers
"It i s nowadays i nc r e a s i ngl y coming t o be accept ed t h a t one of
t he mos t c r i t i c a l , and one of t he most d i f i c u l t, t r ansf ormat i ons
r equi r ed i n a n i ndus t r i a l i z i n g s oc i e t y i s t he a d j us tmen t of l abour
t o the r egul ar i t y and di s ci pl i ne of f act or y work." So begins Sidney
Pol l ar d i n a n a r t i c i e on "Factory Di s ci pl i ne i n t he I ndus t r i a l
Revolution" (The Economic Hi st or y Review, 1963). Thi s a r t i c i e i s
pa r t of a growing body of schol ar shi p expl ori ng t he ei ght eent h and
ni ne teen t h cent ury con r ont at i on of manufacturers and indue t r i a l i s ts
wi t h t he people who became t he working cl as s i n Europe and America
(See: Thompson (1963); Gutman (1976); Dawley and Fal er (1976);
Dawley (1970); Lauri e (1980); Rock (1979); Reid (1976); Harri son
(1911); Johnson (1976); Thompson (1967). The t opi c of al cohol i c
drinic runs through a l 1 of t h i s wr i t i ng -- i t i s pa r t of t he s t r uggl e
be tween employer and worker .
The cent r al quest i on f o r much of t he wr i t i ng and a n a l p i s on
e a r l y i ndus t r i a l and c a p i t a l i s t development 1s t he r esi st ance of
r ur al , peasant , o r pre-indus trial people t o t he r out i nes, schedul es,
and pa t t er ne of i ndus t ri al work. The ol d, pre-indus t r i a l pat t erna
of work, s oc i a bi l i t y, and time conf l i ct ed wi t h t he needs of t he
f act or y system and the des i r es of i ndus t r i a l c a pi t a l i s t s .
En t repreneurs and i ndus t r i a l i s ts f ound themselves i n a permanen t and
ongoing s t ruggl e t o transform t he l i ve s of t hei r workers.
As Pol l ar d (1963) poi nt s out , t he e a r l y i ndus t r i a l i s t s were
engaged i n a major cul t ur al conf l i ct :
The worker who l e f t t he background of h i s domestic
workshop o r peasant holding f o r t he f act or y, ent er ed
a new cul t ur e a s wel l a s a new sense of di r ect i on.
It was not onl y t ha t "t he new economic order needed
. . part-humana: s oul l es s , depersonal i zed, disem-
bodied, who could become members, o r l i t t l e wheels
r at her , of a complex mechanism." It was a l s o t ha t
men who were non-accumulative, non-acqui si t i ve,
accustomed t o work f o r subsistente, not f or maxi-
mi zat i on of income, had t o be made obedi ent t o the
cash st i mul us, and obedi ent i n such a way a s t o
r e a c t pr eci s el y t o t he s t i mul i provided.
Recrui t i ng workers was of ten a di f i c u l t problem, a s observers
i n ei ght een cent ury Br i t ai n noted. "Labourers from agr i cul t ur e o r
domestic i ndus t r y do not a t f i rst t ake ki ndl y t o t he monotony of
f act or y l i f e , " not ed one obsemer , who poi nt ed out t ha t "t he
pi oneeri ng employer no t i nf r equent l y f i nds h i s mos t ser i ous obs t acl e
i n t he problem of bui l di ng up a s t a bl e suppl y of e f f i c i e nt and
wi l l i ng l abour" ( Pol l ar d L363:254). I n Scot l and i t was concluded
t ha t "on t he f i r s t i nt r oduct i on of t he busi ness, t he people were
found very i l l - di eposed t o submit t o t he l ong confinement and
r egul ar i ndus t r y t ha t i s requi red from them.. . ." It was s a i d t hat
t he highlander "never sits a t eas e a t a loom, i t i s l i k e put t i ng a
deer i n the plough." Workers would of t en l eave wi t hout not i ce and
then send f o r t hei r back wages. A l abor turnover o 100 percent a
year was not unusual f o r e a r l y i ndus t r i a l firme.
Even when workers st ayed, employers r epor t ed major problems i n
overcoming t h e i r employees' a ttachment t o t r a d i t i o n a l s oc i a l custome
tha t c onf l i c t e d w i t h t he new i n d u s t r i a l e t hi c. Fe s t i va l e , f e a s t s ,
and wakes were ext r emel y i mpor t ant s o c i a l and community event s f o r
mos t pr ei ndus t r i a l peopl e, and t h i s di d n o t change when t hey went t o
work i n f a c t or i e s . I n U 72 J oa i a h Wedgwood complained t hat : "Our
men w i l l go t o t he Wakes, i f t hey were s u r e t o go t o t he D--1 t he
next . 1 have n o t s par ed them i n t h r e a t s and 1 would have t hr as h' d
them r i g h t h e a r t i l y i f 1 could." I n U76 t he r e was t he same
problem: "Our men have been a t p l a y 4 days t h i s week, i t bei ng
Burslem Wakes. 1 have rough' d & smoothed them over , & promiaed them
a 10% Xmas, b u t 1 know i t i s a l 1 i n vai n, f o r Wakes must be
obaerved though the World was t o end w i t h them ( Pol l a r d 1963:256).
The queat i on of t he t i m e and r out i ne of work l i f e was c e nt r a l
t o t he s t r uggl es between working peopl e and t h e i r employers.
I n d u s t r i a l i a t s wanted workera t o come t o work s i x days a week, and
work a t a s et number of hour s each day -- of t e n 12 o r 14.
Tr a di t i onal , pr ei ndus t r i a l work pa t t e r na , however , were q u i t e
d i f f e r e n t , emphasizing per i ods of ve r y i nt e na e work f o r about f our
days, and t hen t hr ee days of much more l e i s u r e l y work and of p l a y
(Thompson 196 7 ). Monday va s c a l l e d "Sai nt Monday" i n Br i t a i n and
America, and was a n o f f i c i a l hol i day among workers (Reid 1976). One
e a r l y ni net eent h cent ur y obser ver r epor t ed t h a t weavers would "pl ay
f r e que nt l y a l 1 day on Monday, and t he g r e a t e r p a r t of Tuesday, and
work ve r y l a t e on Thursday ni ght , and f r e que nt l y a l 1 ni ght on Fr i day
( Pol l a r d 1963:256). Rei d (1376 :81) r e p o r t s t h a t i n England i n t he
U3408 Monday was "gener al l y kep t a a a hol i day by a gr ea t por t i on of
t he working cl as s es . " As l a t e a s l a 64 i t was a s popul ar a s ever ; i n
Birmingham, f o r example , emplo yer e complaine d t ha t "an enormous
amount of t i m e i s l o s t , n o t onl y by want of punc t ua l i t y i n coming t o
work i n t he morning and begi nni ng agai n af t e r meal s, but a t i l l more
by t he gener al observance of ' Sa i nt Monday' " (Rei d 1976 : al ) .
The pr e i ndus t r i a l pa t t e r n of work developed i n a cont ext i n
which peopl e had c ont r ol over t h e i r own t i m e and working environ-
ment. Ar t i aana and i ndependent craf tsmen, working a t t he i r homes o r
workshops, s et t h e i r own pace. (Rock 1978:236) des cr i bes t he
ge ne r a l pa t t e r n f o r New York Ci t y i n t he e a r l y ni net eent h cent ury.
A j ourne yman s hoemaker , f o r example , migh t spend
Monday and Tuesday i n dr i nki ng and s p o r t onl y t o
t o i l a t a r a p i d pace t he rest of t he week (t hrough
Sa t ur day) t o make enough t o suppor t h i s family. . . .
Work was t ask- or i ent ed r a t her t han t i me- or i ent ed
(many a r t i a a n s , i n f a c t , d i d not even own a watch).
Labor p a t t e r n s were i r r e g u l a r , var yi ng enormously
from shop t o shop, from t r ade t o t r ade, from week t o
week. The most not a bl e symbol of premodern work
pa t t e r ns was t he vener abl e Sa i nt Monday. Thi s was
t he conmion p r a c t i c e of cr af tsmen t aki ng each Monday
(and sometimes Tuesday) o f f f o r r el axat i on i n a
neighborhood t avern, excur si ons t o t he coun tr y, o r
o t her l e i s u r e l y a c t i v i t i e s .
It w a s pr e c i s e l y t h i s pa t t e r n of i ndependent work which t he
i n d u s t r i a l i s t s would n o t t ol er at e; and i t was t h i s pa t t e r n which
workers t r i e d t o mai nt ai n i n t he f a c e of s t rong oppost i on and har sh
pe na l i t i e s . Gutman (1976) poi nt s o u t t h a t i n t he Uni t ed St a t e s ,
because of t he waves of i mmi grat i on through t he ni net eent h cent ur y
and i n t o t he t went i et h, t her e was a cont i nuous encount er between
pr e i ndus t r i a l peopl e (from I r el and, Nort hern Europe, Sout hern and
East er n Europe, Aei a, Lat i n Ame r i c a , Af r i ca, and t he American Sout h)
and t he i n d u s t r i a l system. Generat i on a f ter gener at i on were f or ced
t o gi ve up some of t he ol der and val ued pa t t e r ns and adap t t o t he
harsh regime of f act or y l i f e .
The i n d u s t r i a l i s t s ' methods of overcoming t he i r l abor problems
can be "grouped under t hr ee headings: t he pr over bi al s t i c k , t he
pr over bi al car r ot , and t hi r dl y, t he at t empt t o cr eat e a new et hos of
work, or der and obedience." It was t he t h i r d approach which was
d i s d n c t i v e of e a r l y i ndus t r i a l i z a t i on. "U t t l e new i n t he way of
the ' s t i c k , ' o r de t e r r e nt , was di scovered by t he e a r l y f a c t o r y
mast ers. Uns at i s f act or y work was punished by cor por al punishment,
by f i n e s , o r by di ami seal . " I n addi t i on, employers f i r e d workers
who as s oci at ed w i t h workers' or gani za t i ons and uni ons, and sometimes
had workers a r r e s t e d f o r engaging i n t he i l l e g a l a c t i v i t y of
or gani zi ng employees. Fur t her , "Employers were as conservat i ve i n
t he us e of t he c a r r o t a s t hey were i n t he us e of t he s t i c k. For a
gener at i on dr i vi ng i ts chi l dr en t o l abour i n t he m i l l s f o r twelve t o
f our t een hours a day, pos i t i ve i ncent i ves must i ndeed have been har d
t o devise. " The chi ef i ncent i ve was addi t i onal money, though a few
employer s experimen t e d w i t h s t a t u s awards f o r excep t i ona l worker S
( Pol l ar d U65:266-7 ).
Ear l y i ndus t r i a l i s ts bel i eved t ha t t he ma j or problem f aci ng
them was workers who were i n s u f f i c i e n t l y "endowed wl t h t he e s s e n t i a l
q u a l i t i e s of i ndus t r y, ambi t i on, s o b r i e t y and t h r i f t" t h a t t he
f a c t o r y syst em r equi r ed. I n t he i r e f f o r t s t o di s c i pl i ne t he i r
workers, employers concluded t hey were deal i ng w i t h behavi or t ha t
went on out s i de t he f a c t o r y as w e l l a s i ns i de. The c a p i t a l i s t a
sought , t her ef or e, t o reform " t he whole man . . . by i ndoct r i nat i ng
him w i th t he bourgeoi s val ues he l acked" ( Pol l ar d 1963: 267 ).
The q u a l i t i e s of char act er which employers admired
have, s i nc e Weber' s day, been t o some ext ent
as s oci at ed wi t h t he Pr ot e s t a nt e t hi c . To i mport
t hese q u a l i t i e s , wi t h t he one a ddi t i on of obedi ence,
t o t he working cl as s es , coul d n o t b u t appear a
formi dabl e t ask. (The r e s u l t ) was t he preoccupat i on
w i t h t he char act er and mor al s of the working c l a s s e s
which a r e s o marked a f e a t u r e of t he e a r l y s t a ge s of
i ndus t r i a l i z a t i on. . . .
Fa c t or y v i l l a g e s . . . had s p e c i a l pr ovi s i ons and, i n
some cases, f ul l - t i me s t a f f t o check t he moral s of
t h e i r workers. Contemporaries t ended t o pr a i s e
t hese a c t i ons most hi ghl y, and i t was bel i eved t h a t
f i r ma l ayi ng stress on mor al s, and employing foremen
who "supr ess anyt hi ng bad" would g e t t he pi ck of
l abour . Almost everywhere churches, chapel s and
Sunday s chool s were suppor t ed by employers, bo t h t o
encourage moral educat i on i n i t s more us ual aense,
and t o i nc ul c a t e obedi ence. Drink and drunkenness
became a major t a r g e t of reform, wi t h t he short -t erm
aim of i nc r e a s i ng t he ueef ul ness of s c a r c e s k i l l e d
workers s u& a s Soho' s engi neer e r e c t or s , who were
of t en i nc a pa c i t a t e d by dr i nk, and the long-term a i m
of spr eadi ng bour geoi s vi r t ue s .
I n t h i s procese much of the e xi s t i ng v i l l a g e c ul t ur e
came under a t t ack. Tr a di t i ona l s o c i a l ha bi t a and
customs seldom f i t t e d i n t o t he new pa t t e r n of
i n d u s t r i a l l i f e , and t he y had t he r e f or e t o be
dis cr edi t e d as hi ndr ances t o pr ogr ess" ( Pol l ar d:
2 6 7 4 ).
The i ndus t r i a l i s ts' chal l enge t o t r a d i t i ona l pa t t e r ns , customs
and val ues r eached deep i n t o t he l i v e s of working people. It was a n
e f f o r t t o r e o r i e n t t h e i r l i v e s t o mesh wi t h t he needs of f a c t o r y
di s c i pl i ne . However, i t wa s not a t o t a l a s s a u l t on t r a d i t i o n a l
pa t t e r ns , and t he e t h i c a l code employers sought t o promulgate was
l i mi t e d i n p a r t i c u l a r ways. "Warnings agai ns t gr eed, s e l f i s hnes s ,
mat er i al i s m o r pr i de seldom pl ayed a l a r g e pa r t " i n t h e i r a t t a c ks .
Fur t he r , and s i gni f i cant l y, "sexual moral s r a r e l y became a n
i mpor t ant i s s u e t o t he f a c t o r y di s c i pl i na r i a ns ( a s d i s t i n c t from
out s i de mor a l i s t s ) and, by and l a r g e t hey d i d not mind which God was
worshipped, a s l ong a s t he worshipper was under t he i nf l uence of
some r e s pe c t a bl e clergyman." I n s hor t , i t was r a t he r pa r t i c ul a r
a s pe c t s of t r a d i t i o n a l c ul t ur e -- hours and days of work, pa t t e r ns
of s o c i a b i l i t y , i n t e g r a t i o n of work w i t h pl ay, importante of ot he r
e ve nt s which made cl ai ms on t h e i ndi vi dual ( f e s t i v a l s , wakes, et c. )
-- tha t r ecei ved t he br unt of reform e f f o r t s . As Pol l a r d suggest s:
"The concl usi on canno t be avoi ded t ha t. w i t h some honor abl e
except i ons , me dr i ve t o r a i s e t he l e v e l - of r e a p e c t a b i l i t y and
mor a l i t y amo% t h e working c l a s s e s was n o t under t aken f o r t h e i r own
sakes but pr i mar i l y, o r even e xc l us i ve l y, a s a n a s pe c t of bui l di ng
up a new f a c t o r y di s c i pl i ne " (P.270).
To sum up, i n d u s t r i a l i e a t i o n i n Br i t a i n (and t he United
St a t e s ) i nvol ved t he emergence of a new c l a s s of c a p i t a l i s t
ent r epr eneur s and i n d u s t r i a l i s t s who wanted t h e i r workers t o work i n
h i s t o r i c a l l y new ways ( r egar di ng hours per day, days per week,
manner when working, number of breaks, degree of s o c i a b i l i t y , et c. ) ,
and i n h i s t o r i c a l l y ext r aor di nar y waye ( i n f a c t o r i e s and shops, wi t h
machinery, e t c. ). I n or der t o g e t woricere who would work i n t he
ways t hey wanted, i ndus t r i a l i s ts engaged i n e f f o r ts t o t ransform t he
l i v e s , habi t e and cul t ur es of t h e i r employees, and t o some e xt e nt of
t he lower classes i n gener al .
iiowever, working peopl e, f rom t he beginning , resis t ed t he
e f f o r t s of employers t o t ransform t h e i r l i ve s . Workers clung
t enaci ous l y t o pa t t e r ns where t he i ndi vi dual o r t he peer group
exer ci s ed con t r o l over t he speed, timing , and o. rganiza t i on of work;
where p l a y was i nt e gr a t e d wi t h work; and where f e s d v a l s , f e a s t s ,
and wakes were i mport ant , even s acr ed event s.
The per i od bef or e i ndus t r i a l i z a t i on o r s i gni f i c a n t cap1 t al i s t
development, i n Br i t a i n and North America, was a t i m e i n which
a l c ohol i c beverages were hi ghl y regarded and wi del y consumed.
Regular dri nki ng and f r equent drunkeMeSS were p a r t of or di nar y l i f e
f o r most peopl e, upper cl as e a s w e l l a s lower. Regular dri nki ng was
connnon; d r u n k e ~ e s e was regarded as an or di nar y and non-problema ti c
consequence of dr i nki ng (Dorchest er U88; Shadwell 1903; Dul l es
1940; Rorabaugh 197 9 ) .
Because i n t he t r a d i t i onal , pre-indus t r i a l cul t ur e dr i nki ng
was s o widespread and i nt e gr a t e d i n t o s o many p a r t s of l i f e , t he
a t tack on t ha t c u l t ur e sponsored by ent r epr eneur i al c a p i t a l i s t e
encompassed dr i nki ng pr act i ces . n Sa i nt Monday workers went t o
t aver ns and t hey drank; when t hey went t o wakes, weddings,
f e s t i v a l a , and f e a s t s t hey drank; when t hey took breaks from work
t hey had a dri nk; when doing hard phys i cal l abor t hey drank. The
new di s c i pl i na r y or der bei ng puehed by businessmen, i ndus t r i al -
ists, and middle c l a s e reformers condemued many of t he t r a di t i ona l
s o c i a l forma and of f e r e d new ones t h a t promoted s el f - di s ci pl i ne,
s obr i e t y, p i e ty, t h r i f t l nes s , or der l i nes s . Dri nk was one p a r t of
t he rowdy, boi s t er ous, and di s r upt i ve t r a d i t i ona l cul t ur e tha t
businesemen f e l t needed t o be suppressed i n t he i n t e r e s t s of t he
developing i ndus t r i a l or der .
Drink, Temperante, and Capi talis t Development
i n t he United St a t e s
I n sevent eent h and ei gh t eent h cent ur y Ameri ca, l i quor was
c a l l e d t he "Good Cr eat ur e of God," even by Puri t ana. Doctora
pr es cr i bed al cohol f o r v i r t u a l l y a l 1 i l l s; i t was wi del y used a s a
pai n r e l i e ve r , s timulan t and seda t i ve. The predominan t dri nki ng
p a t t e r n i n t he sevent eent h cent ur y was the r e gul a r , d a i l y us e of
a l c ohol i n moderate q u a n t i t i e s wi t h some incidente of drunkenness.
By t he e a r l y e i ght e e nt h cent ur y dr i nki ng and drunkenness had
i n a e a s e d and cont i nued t o do s o t hroughout t he cent ur y. Rum
manufact ure began around UOO, and d x e d wi t h j ui c e s rum became t he
f a v o r i t e dr i nk. The ge ne r a l pa t t e r n i n t he ei ght eent h cent ur y was
f o r men and women t o dr i nk a l c ohol e ve r y day, a t a l 1 times dur i ng
t h e day, and i n l a r g e q u a n t i t i e s a t most e ve r y s p e c l a l occasi on.
The r e s pe c t a bl e el ement s of s oc l e t y, e a pe c l a l l y t he upper c l a s s , e e t
a pr odi gi ous dr i nki ng s t andar d (Rorabaugh 1979 : 27 ; Krout 19 25).
The l ower c l a s s e s probabl y equal l ed t he st andar de set by t he
upper c l a s s . Heavy dr i nki ng was p a r t of occasi ona l i k e cor n
huaki nge, bar n r a i s i n g s , c our t and meeting days, and mi l i t i a
t r a i ni ng days. Workers i n a l 1 occupat i ons drank on t he j ob and a t
schedul ed br eaks a t t e nde d the t aver n, of t en a t t he employer' s
expense. I n New England t he ahops and of f i c e a were cl osed whi l e
workers enj oyed t h e i r "el even o' d o c k b i tters"; t he same t hi ng
happened a t f our o' clock. I n Por t l and, Maine, i n honor of t he
br eaks t he town h a l l be11 va s rung a t el even and f our o' ci ock
(Kobler U73:29; Furnas 1965:22). Sometimes employers provi ded t he
al cohol t o be drunk out s i de working hour s as w e l l . For example,
George Waehington' e agreement wi t h h i e gar dner i ncl uded "f our
d o l l a r s a t Chri st mas wi t h which he may be drunk f o r f our days and
ni ght s ; two d o l l a r s a t Ea s t e r t o e f f e c t t he same purpose; two
d o l l a r s a t Whi t sunt i de t o be drunk f o r two days." The agreement
a l s o i ncl uded "a dram i n t he morning and a dr i nk of gr og a t noon"
(Kobler 191 3:31).
The begi nni ngs of t he ant i - al cohol campaign can be marked by
the publ i c a t i on of a pamphlet i n 'Ud6 by t he prominent American
physi cl an Benjamn Rush. The pamphlet, "An I nqui r y i n t o t he Ef f e c t s
of Ardent Sp i r i t e , " wae a foundi ng document i n t he American, and
t hen world-wide , temperance and pr ohi bi t i on campaigns . I n h i s
pi ece, Rush ar gued t h a t d i s t i l l e d l i quor was de s t r uc t i ve of heal t h,
mor a l i t y and or de r , and he encouraged everyone t o a b s t a i n from i t.
Beer, vi ne, and har d c l de r , he s a i d, coul d be drunk i n moderate
qua nt i ties. I n 50 year s, by t he mid-l8 308, t he temperance cause had
grown i n t o a popul ar mas8 movement of the middle c l a s s . Much of
con temporary medi cal, S ci en t i i c and popul ar though t about t he
pr obl emat i c consequences of a l c ohol -- i ncl udi ng as we a h a l l eee,
t he i de a t h a t economic development r equi r ed r e s t r i c t i n g o r e l i m i -
na t i ng worker dr i nki ng -- was f i r s t developed and popul ar i zed by t he
ternperance movement i n t he ni net eent h cent ur y (Levine 1978, 1980).
I n t he l at e e i ght e e nt h cent ur y and e a r l y ni net eent h cent ur y,
temperance was s t i l l o n l y a n e l i t e concern: t he e f f o r t of upper-
c l a s e and upper mi ddl e-cl ase men concerned wi t h t he dr i nki ng
comportment of t he l abor i ng cl aes . C r i t i c l s m of t he c ol oni a l i de a
of al cohol a s t he Good Cr eat ur e wae begun, i n p a r t , a s a n e f f o r t t o
cont r ol t he behavi or of workers. I n h i s pamphlet, Rush had
encouraged farmere who hi r e d workers t o s t op gi vi ng t he customary
d a i l y por t i on of dr i nk (rum o r whiskey), and t o o f f e r ot he r
beverages i ns t ead. As a n i n f l u e n t i a l c i t i z e n, Rush a l s o t r i e d t o
spr ead t he i dea; "at harvee t t i m e each year Rush republ i ehed and
c i r c ul a t e d t h i s es s ay i n t he hope t h a t farmers might be persuaded t o
abandon t he pr act i ce of f ur ni s hi ng l i quor a s p a r t of t he day' e
wage. " Newspapers and almanaca a l s o r e pr i n t ed h i s sugges t i ons
(Krout 1925:7 3).
The f i r s t formal temperance a s s oc i a t i on i n America was formed
by employers concerned wi t h t he dr i nki ng of t h e i r workere. A
newspaper a t t he time (U89) r epor t ed t h a t "Upward of two hundred of
t he most r es pect abl e farmere i n Li t c hf i e l d County, Conn., have
formed a n a s s oc i a t i on t o encourage t he di s us e of s pi r i t uous l i quor s ,
and have det ermi ned n o t t o us e any ki nd of d i s t i l l e d s p i r i t s i n
doin(3 t h e i r f arming work t he eneuing season" (Dorches t e r 1833 :16 5) .
Thi s decl si on, by a group of weal t hy commercial farmers, t o band
t oget her t o break wi t h t r a d i t i o n a l pa t t e r ns of work and dr i nk
r epr es ent a a s i gni f i can t change i n at t i t udes among a n importan t
segment o American employers. The Uni t ed St a t e s a t t h i s time vas
overwhelmingly a n a gr i c ul t ur a 1 nat i on, and on t he eas t er n coas t
l a r g e commercial farms were r un a e busi nesaes producing f o r t he
market. It wa s on t hese farma t h a t many of t he f i r e t encount ers
be tween modern, e f f i ci ency- and pr oduct i vi t y- or i ent ed employers, and
t r a di t i on-ori ent ed workers took pl ace. However, t h i e i n i t i a l ef f o r t
i n Connect i cut t o el i m nat e t he s p i r i t e r a t i o n was not pi cked up by
ot her employers, o r i n ot her regi one. Labor was s car ce, and i n hi gh
demand and, i n t hi e caee, workers coul d g e t what t hey wanted. The
New Haven Gazet t e expl ai ned t ha t t he l abor er would not work wi t hout
" hi e hal f p i n t o r p i n t ever y day, and a t ni ght hal f h i s wage i n rum"
(Rorabough 1979 :46 ) . Li ke t he e a r l y i n d u s t r i a l ent r epr eneur s i n
Br i t ai n, American employers encount ered r e s i s t a nc e t o t h e i r new
l abor di s c i pl i ne s chemee .
I n U1 3 t he e f f o r t t o l i m i t worker dri nki ng pi cked up
s i gni f i c a n t suppor t when t he f i r a t importan t temperance s oci e t y was
founded, t he Massachuset t es Soci et y f o r t he Suppressi on of
Intemperante. Composed of men from t he economic, p o l i t i c a l , and
r e l i g i o u s e l i t e , t he MSSI sought t o cont r ol t he behavior and ha bi t s
-- e e pe c i a l l y t he dr i nki ng ha bi t s -- of t he mas8 of worldng people.
The h i s t o r i a n I an Tyr e l l has poi nt ed o u t t h e i r i n t e r e e t s and aims:
MSSI temperance r ef ormers f ocused on t he dri nki ng
h a b i t s of t he masa of comnon peopl e, whose mannere
and moral s t he temperance advocat es no l onger seemed
t o cont rol . . . . Habi t a of intemperance t hreat ened,
i n tne view of Henry Warren, a BDxbury l awyer, t o
unl eash t e r r i b l e passi one on s oc i e t y by "nouri ehi ng
among ue t h a t i d l e and miechievous epeci es of
popul at i on c a l l e d i n Europe t he mob." Although
temperance r ef ormere hoped t ha t " t he l abor i ng cl as e
would be t he et r engt h of t he nat i on, " t hey bel i eved
t h a t i t e et r engt h was " r api dl y ... becoming weak-
neee" under t he bal ef ul i nf l uence of intemperance.
ui e goa l of t he f i r e t temperance reformere wae t o
a v e r t euch p o t e n t i a l t hr eat e t o t he e xi s t i ng s o c i a l
e t r uc t ur e by i nf l uenci ng t he common people. For
t h i e purpose, t he Maesachueette e o d e t y devo t ed much
of i t e energy t o t he prevent i on of exceeei ve
dri nki ng among l abor er e i n bot h urban and r u r a l
ar eae. Members were al armed a t t he common pr act i ce
of gi vi ng l a bor e r s a r at i oni ng of s p i r i t e as p a r t
payment f o r t h e i r work... . The MSSI t her ef or e s e t
a s one of i t s foremoet t a c t i c a of reform a " f r i endl y
concern of merchante, sea-cap t ai ne , and wharf i nger e,
of r es pect abl e f armere, mechanics, and manufactur-
e r s ; i n a word, of al 1 h i r e r e of l abour , n o t t o
f ur ni eh ar den t s p i r i t t o t he l abour er s" ( Tyr el l
1979 :41).
i5y t he e a r l y 18206 t he MSSI had l o s t momentum, and by t he
mi d-20s a new group, t he American Temperance Soci e t y, aeeumed
l eader ehi p and committed t he movement t o abet i nence from d i e t i l l e d
l i quor . The men who puehed t he temperance and e e p e d a l l y t he
abet i nence cause were no t, a s l e eometimee though t , backvard l ooki ng
men who eought t o r e e t or e t he t r a di t i ona l or der . Rat her, as Tyr el l
poi nt e out : "The temperance reform a t t r a c t e d from i t e beginninge
ambi t i oue and upwardly mobi l e men." They were not "from r u r a l
backwa t e r e eeeki ng t o r eas s er t tradi t i ona l val ues on a changing
eoci et y. "
On t he cont r ar y, ternperance reformere sanct i oned t he
a q u i e i t i v e and i ndi vi dual i e ti c economic or der
developing i n America. Viewed from t he perepect i ve
of hi ndei ght , temperance reformers appear a s
ayol ogi s t e f o r economic change; t hey were men who
were working t o cr eat e a eoci et y of compet i t i ve
i ndi vi dual e i n e t i l l e d wi t h t he v i r t u e e of eobr i et y
and indue t r y ( Tyr e l l 1979 : 125).
As J eeee Goodrich, a bueineeeman from Worceeter, Maeeachueette,
expl ai ned, he and o t her temperance advoca t ee eough t t he triumph of :
"Co l d Wa t e r ,--Cap1 tal ,--En t e r pr i s e ,--1ndus ay, --Morale, --and R e l i -
gion. " ( Tyr e l l 1979 : 130).
The t ransforma t i on of ternperance f rom a f undamen tal1 y modera-
t i oni e t e f f o r t t o a n abet i nence campaign i n t he mid-U20s marke t he
begi mi ng of temperance a e a maee movement. The Rev. Jue t i n
Edwards, one of t he moet i mport ant l eader s of t he temperance reform
i n t he 18208 and 308, l aunched t he abs t i nence campaign vi t h a wi del y
c i r c ul a t e d pamphle t c a l l e d "The Well-Conducted Farm." One
pro-temperance hi e t o r i a n l a t e r gave Edwarde cr edi t f o r " t he chi ef
impetue i n e t a r t i n g t he temperance reform upon a new epoch"
( Fehland t 19 04 : 48 ) .
"The Well Conducted Farm" wae a wel l -wri t t en pamphlet t h a t
r epeat ed and el abor at ed argumente t h a t Rueh had f i r e t made, and that
had a l e o been a t t he he a r t of t he e a r l y moder at i oni et campaign.
Now, however, t he premise wae t ha t complete abet i nence from e p i r i t e
would bri ng remarkable r e s u l t e f o r t he employere of l abor . The
pamphle t r epor t ed t he experi ence of "Mr. B., a r eepect abl e farmer i n
Maeeachuse t t e" whose workere, l i k e v i r t u a l l y al 1 o t her working men
a t t he time, drank "a por t i on of a r de nt e p i r i t " when t hey worked.
" It wae t he comon opi ni on i n t he pl ace, t ha t , f or l abor i ng men, who
had t o work hard, eome a r de nt e p i r i t wae necessary. " Mr. B.,
however, deci ded t h a t h i s workere ehoul d t r y abet i nence, and i f t hey
wouldn' t gi ve up e p i r i t s t hey coul dn' t work f o r him. The r e e u l t of
t he experi ment wae r epor t ed a s fol l owe:
Hie men went t o work. And h i e buei neee proepered
exceedi ngl y. Hie men were remarkably uniform i n
temper and deportment; e t i l l and peaceable. He
found them everyday a l i k e , and he coul d always
e a f e l y t r ue t them. What he expect ed t o have done,
he f ound was done i n good eeaeon, and i n t he be e t
manner. tUe men never made eo few mi st akee, and had
eo f e w di epu t e s among themeelves; t hey never i n j ured
and dest royed eo few t ool e, found s o l i t t l e f a u l t
wi t h t h e i r manner of l i v i n g , o r were, on t he whole,
s o pl eas ant t o one anot her , and t o t h e i r employer.
The men appeared, more t han ever bef or e, l i k e
br et hr en of t he eame fami l y, e a t i e f i e d wi t h t he i r
busi neee, cont ent ed, and happy.
"The Well Conducted Farm" deecri bed t he proceee t h a t we
e a r l i e r di scueeed of t he di eci pl i ni ng of a t r a d i t i o n a l o r pre-modern
l abor f or ce. Thi e farmer wae concerned wi t h breaki ng t r a di t i ona l
work habi t e and pat t er ns , and wi t h cr eat i ng a new e t h i c of i ndus t r y
and t hr i f t. Thi e wae a bueineeeman concerned wi t h t he maintenance
of h i e c a pi t a l , and wi t h developing t he g r e a t e s t pr oduct i vi t y and
e f f i c i e n c y from h i e workere.
Ae i n t he case of t he e a r l y Br i t i s h i n d u s t r i a l l e t e , e a r l y
temperance reform was a l e o a n a t t a c k on t he s o c i a l forme, pat t er ne
and cuetoms of t he t r a d i t i o n a l cul t ur e. The a i m of temperance
advocat ee wae change; t hey eought t o t ransform t he work and s o c i a l
habi t e, a t t i t u d e e and l i f e e t y l e of the l a b o r i q cl aes. I n
pa r t i c ul a r , t hey sought t o change t he l i f e s t yl e of workers t o make
them more ef f i c i e n t , product i ve, and or der l y. The e f f o r t her e was
a l s o t o reform "t he t o t a l man" f o r t he good of the employer. The
key di f f er ence 1s t h a t i n t h i s case t he t ransformat i on was t o be
e f f ect ed by d i r e c t l y confront i ng t he t r a d i t i ona l dri nki ng h a b i t s of
workers. "Sobri et y" i n t he narrowest senee of t he term was seen as
t he key t o reformi ng t he whole out l ook and l i f e s t y l e of t he worker.
The argumen t t ha t employers had a prof ound s e l f - i nt e r e s t i n
changing t he dr i nki ng h a b i t s of t he i r workers, o r i n reduci ng o r
el i mi nat i ng t h e i r dr i nki ng, remained a t t he h e a r t of t he temperance
and pr ohi bi t i on campaigns i n t he ni net eent h and t went i et h centu-
r i e e . And i t i s now a l s o i mport ant i n t he al cohol i sm movement and
i n publ i c heal t h appeal s regardi ng al cohol problems. Busi nesees and
i ndus t r i e s of al 1 ki nde, i t has been s a i d r epeat edl y ei nce t he e a r l y
ni ne t eent h cen t ury, w i l l benef i t g r e a t l y by c o n u o l l i n g o r el i mi na t-
i ng t he dr i nki ng of t h e i r workers. Ef f i ci ency, pr oduct i vi t y, and
g r e a t e r p r o f i t s w i l l be t he r e s u l t .
Indus Ui a l i z a t i o n and Drink: Observat i ons and Condusi ons
Thue f a r 1 have di scuseed two d i s t i n c t employer-sponeored
dr i nk- r el at ed ef f o r ts t o t raneform t r a d i t i ona l c u l t u r a l pr act i ces
aimed a t secur i ng a more s t a b l e and or de r l y work f or ce. The f i r s t
was concerned wi t h dr i nki ng onl y as p a r t of t he broader mat t er of
t r a d i t i o n a l work pa t t e r ns and s o c i a l l i f e . The second s a w dr i nk
reform a s t he pri mary l ever f o r c ha ngi q ot he r ha bi t s and pat t er ns .
These two d i f f e r e n t approachee a r e r e a l l y two s i de s of t he eame
e f f o r t , and t hey have been c l os e l y r e l a t e d f o r over two hundred
years. On t he one hand, employer campaigns aimed a t making workers
more di s c i pl i ne d and or de r l y have o f t e n sought t o change some
as pect s of worker dri nki ng. And, on t he ot her hand, most at t empt s
focused pr i mar i l y on changing worker dri nki ng pa t t e r ns , whether by
temperance and pr ohi bi t i on movements, o r a l coholiem and publ i c
heal t h pr of es s i onal s , have e i t h e r been mot i vat ed by, o r j u s t i f i e d i n
p a r t i n terme of t h e i r benef i ci a1 e f f e c t s f o r employers.
1 have emphasized t he l a r g e r c u l t u r a l and economic s t r uggl es
between e a r l y ent r epr enur i al and i n d u s t r i a l c a p i t a l i s t s and t h e i r
uadi t i on- or i ent ed workers because 1 am suggest i ng t h a t i t wae t hose
c o n f l i c t s which were c e nt r a l t o t he conf l i c t s about al cohol .
Al cohol i c dr i nk was s een by employers as a symbol and an element of
t he t r a d i t i ona l cul t ur e, and as a way of marking o u t t he di f f er ences
between t he l i f e - s t y l e t hey des i r ed of t he i r workers and t he ones
whi ch t he workers' had t r a d i t i o n a l l y val ued. Al cohol i c dr i nk was a
site of dass c o n f l i c t between employers and workers about broad
i s s u e s of c ul t ur e and l i f e - s t y1e. l
However , a n impor t a n t que8 t i on remains : vas worker dri nki ng by
i t s e l f a n obs t acl e o r hi ndrance t o i n d u s t r i a l development?
Or, more
gener al l y: i ndependent of t he c u l t u r a l i s s u e s a t t ached t o i t, does
worker dri nki ng -- i n d u d i n g hi gh l eve18 of i t -- r e t a r d o r bl ock
i ndus t r i al and e conomi c developmen t ?
Based on t he broad h i s t o r i c a l r ecor d, t he answer appears t o be
"no." I n B r i t a i n per capi t a al cohol consumption i ncr eased over t he
course of t he ni net eent h cent ur y di ppi ng and r i s i n g somewhat wi t h
t he economy (Shadwell, 1903). Si mi l ar l y, i n t he United St a t e s ,
des pi t e t he cl ai ms of temperance advocat ee i n t he ni net eent h cent ur y
o r pr ohi bi t i oni e t s i n t he t went i et h cent ury, worker dri nki ng on o r
of f t he j ob was no t incompatable w i t h r a pi d i n d u s t r i a l development.
Per capi t a dr i nki ag d i d d e a e a s e i n t he ni net eent h cent ury, but much
of that was among t he broad middle c l a s s of smal l businessmen,
f armers, prof es s i onal s , and t h e i r wives, mot her s , 81s t er 8 and
daught ers. Despi te i t e bes t e f f o r t s , t he ni net eent h cent ur y
temperance campaign ( a genui ne mass movement throughout t he
ni net eent h cent ury) was unabl e t o g e t most workers t o gi ve up dr i nk,
o r even t o g e t dr i nk o u t of t he f a c t or y and workshops.
J u e t a s workers r e s i s t e d wi t h varyi ng degrees of success
employer e f f o r t s t o reform t h e i r char act er s , r e s t r uc t ur e t h e i r
s o c i a l l i f e , and r eor gani ze t h e i r work l i f e , t hey a l s o r e s i s t e d
e f f o r t s a t ge t t i ng them t o change t h e i r dr i nki ng habi t s . Alcohol
had l ong been p a r t of t he ceremonies, r i t u a l s , and event s which
cel ebr at ed and af f i r med community and f el l owshi p, and workers fought
t o pr eser ve t hose dr i nk- r el at ed event s. They di d not always
succeed, however, and t he ongoing s t o r y of work and dr i nk has been
t he s t o r y of a cycl e of o l d pat t er ns bei ng defended, some of which
were l o s t , and new pa t t e r ns being cr eat ed, some of which were
opposed, some of which were a l s o l o s t , some of which were defended,
and s o on.
Fur t her , as t he experi ence of ot her European count r i es ehows,
i ndus a l a l developmen t and t he a t temp t by employers t o t r ansf orm
t r a d i t i ona l work pa t t e r n s does no t neces s ar i l y i nvol ve any chal l enge
t o dri nki ng a t al l . France, I t a l y and Germany, f o r example, changed
f r on a g r i c u l t u r a l t o i n d u s t r i a l s oci e t i e s w i t hout experi enci ng
sube t a n t i a l temperance, pr ohi bi t i on, o r ant i -al cohol i sm movements.
A l though i ndus t r i a l emplo yers i n al 1 t hes e count r i es t ar ge t ed some
as pect s of pr e- i ndus t r i al work and s o c i a l l i f e , t hey d i d not i n
gener al s e e dr i nk as a primary, o r even secondary, i s s ue. Wine and
beer dri nki ng were s o f i r ml y r oot ed i n t he nat i onal cul t ur es t ha t
dr i nk was v i r t u a l l y i nvul ner abl e t o a t t ack. It 1s worth not i ng t h a t
France, Germany, and I t a l y have per capi t a consumption l e ve l s ,
s u b s t a n t i a l l y above t hose of Br i t a i n o r t he Uni t ed St a t e s . High
a l c ohol consumption d i d no t pr event t hose na t i ons f rom devel opi ng
s k i l l e d , pr oduct i ve work f or c e s o r hi gh l e v e l s of i n d u s t r i a l
development (Cherri ng ton 19 24-30).
Fur t her , when we l ook beyond t he e a r l y ni net eent h cent r y, i t
1s c l e a r t h a t t he a s s e r t i o n of temperance s uppor t er s t h a t worker
dr i nki ng was a n obs t a c l e t o economic development was n o t cor r ect .
By 1900 t he Uni t ed St a t e s had become t he r i c he s t and mos t developed
i n d u s t r i a l na t i on i n t he worl d, and i t d i d s o de s pi t e t he f a c t t h a t
the working c l a s e drank more t han i n d u s t r i a l capi talis ts and middle
class r ef or mer s mi ght have wished. The Uni t ed St a t e s cont i nued t o
grow and pr osper from 1900 t o 1920, anot her per i od i n which worker
dr i nki ng cont i nued, and i n which t he number of urban s al oons
i ncr eas ed ei gni f i c a nt l y. During t he per i od of na t i o n a l pr ohi bi t i on
i n America, from 1919 t o 1934, working c l a s s dr i nki ng reduced
s i g n i f i c a n t l y because l i quor was expensi ve and har der t o ge t . The
e a r l y p a r t of t h a t per i od va s a t i m e of cont i nui ng pr os per i t y; t he
l a t ter encompassed t he mos t devas t a t i n g depr esei on i n American
h i s t or y. Be tween 19 35 and 197 0 t he American economy and i n d u s t r i a l
out put expanded, and World War 11 saw t he Uni t ed St a t e s become t he
mos t powerf u1 na t i on i n t he world. During t he whole per i od U.S. per
capi ta consump t i o n gr adual 1 y i ncr eased.
One r easonabl e concl usi on t o be drawn from t he broad European
and North American exper i ence i s t h a t hi gh l e v e l s of worker dr i nki ng
-- i ncl udi ng r out i ne bout s of i nt oxi c a t i on and chr oni c heavy
dr i nki ng -- have n o t been i ncompat abl e wi t h a s k i l l e d , e f f i c l e n t ,
and pr oduct i ve work f or c e , o r wi t h r a pi d economic development.
Employers i n some west er n count r i ee have t r i e d t o change t he i r
workers' dr i nki ng pa t t e r ns ( e i t h e r d i r e c t l y , o r through temperance
r e ormer S, pr ohi bi t i o n i s t e , al cohol i sm advocat es, o r publ i c he a l t h
pro e s s i ona l s ) . Workers i n t he Un1 t ed S tates and o t her count r i es
have resis t e d w i t h var yi ng degr ees of success employer ef f o r ts t o
res t r i ct o r e l i mi na t e t h e i r dr i nki ng. However, worker r e s i s t a nc e ,
even when e x tremel y successf u1 , does no t appear t o have s e r i ous l y
hi nder ed t he pr ocesses of i n d u s t r i a l and economic development of
t hese na t i ons .
Employer a t temp t e t o r e orm worker dr i nki ng pa t t e r n s a r e
n e i t h e r i n e v i t a b l y a p a r t of i n d u s t r i a l development, nor do t hey
appear t o be necessar y o r even be ne f i c i a 1 f o r economic growth and
developmen t. Uhi l e emplo yer a t temp t e t o l i m i t worker dr i nkl ng have
sometimes been j u s t i f i e d on moral grounds and a s publ i c he a l t h
concerns, by and l a r g e t hey have been di r e c t e d a t secur i ng a more
di s c l pl i ne d and o r d e r l y work f orce.2
Economi c Developmen t and Drink : Observa t i ons and Conclusions
On t he b a s i s of t he h i s t o r i c a l exper i ence of t he Uni t ed
St a t e s , B r i t a i n, and ot he r European count r i es , al cohol consumption
does n o t appear t o have i nhi bi t e d i n d u s t r i a l development. Obviously,
more contemporary and qua nt i t a t i ve data, e s p e c i a l l y usi ng a cross-
nat i onal sample, would be usef u1 i n t e s t i ng t h i s hypot hesi s.
Although data has never been col l ect ed on t h i s t opi c d i r e c t l y , 1
have found some r e l a t i v e l y r e l i a b l e and comparable dat a t h a t can be
anal yzed i n terms of t h i s quest i on.
The World Bank-sponsored s t udy Twenty-Five Years of Economic
Developmen t: 1350-197 5, by David Morawe t z , compiled sta tisti cs on
economic growth f o r moet count r i es i n t he world. The 8 tudy examined
t he problems i nvol vd i n measuring economic development and conduded
t h a t growth r a t e s , as measured by i n a e a s e s i n GNP per capi t a, a r e
r e l a t i v e l y r e l i a b l e i ndi ca t o r s of t he changes w i t h i n a coun t ry.
Probabl y t he b e s t cr oss- nat i oaal dat a on al cohol consumption
has been compiled by Mark Kel l er and Caro1 Gur oi l i , and publ i shed by
t he Rut gers Cent er of Alcohol St udi es. Kel l er was f o r many year s
t he eLt or of t he J our nal of St udi es on Alcohol, a n d their
~ u b l i c a t i on. St a tis tics on Consum~t i on of Alcohol and Al coholism.
l i s t e per capi ta dr i nki ng age consump t i on s ta t i 8 t i cs accordi ng t o
beverage t ype f o r 27 count r i es , and t he percent age i ncr eas e o r
decrease f o r 21 count r i es from t he l at e 1950s (average year 1958) t o
t he e a r l y U706 (average year 1973).
Table 1 l i st s t he 21 count r i es wi t h t he per capi t a dri nki ng
age consumption i n l i t r e s of pure al cohol i n t he e a r l y 1970s.
Table 1 a l s o i d e n t i f i e s t he beverage which 1s r esponsi bl e f o r more
t han 50 per cent of t he al cohol consumed; i f no one beverage account s
f o r more than hal f of t he al cohol , t he second beverage 1s i ndi cat ed
i n bracket s. Fi nal l y, t he t abl e lists t he World Bank's growth r a t e
f i gur e s f o r t he year s 196 0-197 5.
Tabl e 2 cat egor i zes t he sample count r i es by hi gh, medium, and
low coneumption l e v e l s , and hi gh, medium, and low growth r a t e s . The
hi ghes t consump t i on count r i es averaged 14.9 li t r e s a year, t he
medium 10.0, and t he l owest 6 .l. u i l y 19 count r i es were i ncl uded i n
t he cal cul at i ons because growth r a t e f i gur e s were n o t avai l abl e f o r
Poland o r t he Sovi et Union. Based on t he r ecent news about Pol and' s
economic d i f f i c u l t i e s , i t seems reasonabl e t o assume t ha t i t s growth
r a t e has been q u i t e low. Poland 1s l i s t e d on t he char t i n br acket s,
b u t was not cal cul at ed i n t o t he c or r e l a t i on statistics. The t a bl e
shows no r e l a t i ons hi p between consumption and growth r a t e . Same
count r i es have hi gh consumption and hi gh growth, ot her s have low
consumption and low growth, and t her e are many i n between.
TABLE 1
Per Capi t a Consumption of Alcohol, a s Well as Predominant Beverage,
Growth Ra t e , and Percent age Change i n Aicohol Consumption
f o r 21 Count ri es
Per Capi t a Age 15+ Per cent age Change
Consump t i on i n i n Alcohol
Litres of Pure Consumption From
Al cohol i n Ea r l y Growth Ra t e La t e 1950s t o e a r l y
Coun t r i e s 1 9 7 O s 196 0-197 5 197 O s
1. France
2. Wes t Gennany
3. Belgium
4. Swi t zer l and
5. I t a l y
. Aus t r a l i a
7 . New Zealand
d . Denmark
9. Canada
10. Ne t her l ands
11. USA
12. United Kingdom
13. Sovi et Union
14. I r el and
15. Poland
16. Fi nl and
1 7 . Per u
U. Sweden
19. Norway
20. I cel and
21. I s r a e l
U, d and S i ndi c a t e t h a t Wine, Beer o r Sp i r i t e cons t i t ut e more t han
- -
50% of the al cohol consumed. I f no one beverage account s f o r more
t han hal f t he al cohol , t hen t he second beverage i s l i s t e d i n
paren t heses.
Average year s f o r computing al cohol consump t i on i ncr eas e a r e
1958-191 3. Average year f o r per capi t a f i g u r e s i s 1 9 7 3.
SOURCES: Mark Kel l er and Caro1 Gur i ol i (1376) S t a t i s t i c s on Con-
sumption of Alcohol and on Alcoholism, J our nal of St udi es on
Alcohol, New Brunswidr, New J er s ey; David Morawetz (1977) Twenty-
Five Years of Economic Developmen t: 1950-197 5 Bal timore : John
Hopkins Uni versi t y Press.
TABLE 2
Count r i es Cat egor i zed by Growth Rate and Per Capi t a
Consump t i o n i n Li tres of Pur e Al cohol
Growth Rat e 1960-7 5
Per Capi t a High Growth Medium Growth Low Growth
Co nsump t i on Mean 3.9 4 Mean 3.17 Mean 2.28
H i gh Fr ance W Aus t r a l i a B Swi t zer l and W(B)
Consump t i on I t a l y W West Germany B New Zealand B
Mean 14.9 Belgium B
Medium
Consump t i o n
Mean 10.0
Canada B USA B(S)
Denmark B Uni t ed Kingdom B
Net her l ands B(S)
I r e l a nd B
Low I s r a e l S Sweden S I cel and S
Consump t i on Norway B(S) Per u S
Mean 6. 1 Fi nl and S [Pol and S]
W, B and S i n d i c a t e t h a t Wine, Beer o r Sp i r i ts cons t i t u t e more t han
50~- of th; al cohol consumed. I f no one beverage account s f o r more
t han ha i f t he a l c ohol , t hen t he second beverage i s l i s t e d i n
par ent heses.
SOURCE: See TABLE 1.
Tabl e 3 shows t he mean growth rete of t he hi gh, medium and low
consump t i on coun tries. Growth rate does n o t c or r e l a te d i r e c t l y w i th
consump t i on. The medium coneump t i on c ount r i e s have t he lowes t
growth r a t e , t he hi ghes t consumption have t he medium growth rate,
and t he low consumption have t he hi ghe s t growth r a t e . The di f -
f - er ences are a l 1 ve r y s l i g h t , and show no 8 tatistical s i gni f i cance.
Tabl e 4 r e ve r s e s the a n a l y s i s of Tabl e 3. It shows t he
consumption l e v e l s of the hi gh, medium, and low growth rate
count r i es. I n this case t her e i s a s l i g h t pos i t i ve r e l a t i ons hi p:
t he hi gh growth c ount r i e s aver aged 11.1 l i t res of pure al cohol per
c a pi t a , t he medium 10.8, and t he low 9.9. The hi gher t he growth
r a t e t he hi gher t he per c a pi t a consumption l e v e l s , though t he
di f f e r e nc e s a r e n o t per suasi ve.
TABLE 3
Mean Growth Rat e by Per Capi t a Consump t i on
i n L i tres of Pure Alcohol
Per Capi t a Consumption Growth Rate
gh 3 .O9
Medium 2 -9 8
Low 3.35
SOURCE: See TABLE 1.
TABLE 4
Mean Per Capi ta Consumption i n Li t r e s of
Pure Alcohol By Growth Rate
Per Capi ta Consumption Growth Ra t e
High 11.1
Me dium 10 .8
SOURCE: See TABLE 1
Tabl e 5 cat egor i zes t he count r i es by hi gh, medium, and low
i ncr eas e i n al cohol consumption from the l a t e 1960s t o t he e a r l y
1370s (average per i od 13%-1373), and t he hi gh, medium, and low
growth r a t e from 1960-1975. The average hi gh i ncr eas e i n consump-
t i on wa s 38 per cent , t he medium i ncr eas e 52 per cent , and t he low
14 percent . I f a dramat i c i ncr eas e i n consumption af f ect ed economic
growth i t ehoul d be r e f l e c t e d i n t h i e t abl e. The t abl e shows t h a t
consump t i on i ncr eas es do no t adver s el y af f e c t t he growth r a t e a
TABLE 5
Count ri es Cat egori zed by Per cent I ncr eas e i n Alcohol
Consumption and Growth Ra te
Growth Rate
I ncr eas e i n
A l cohol High Growth Nedium Growth Low Growth
Consump t i on Mean 3.35 Mean 3.U Mean 2.28
l3h Fi nl and S Denmark B I cel and S
Mean 98% Belgium B I r e l a nd B
West Germany B
Medium Norway S Aus t r a l l a B United Kingdom B
Mean 52Z Canada B USA B(S)
Ne t her l ands B(S)
Sweden S (B)
Lo w I s r a e l S
Mean 14% France W
I t a l y W
New Zealand B
Peru S
Svi t zer l and W(B)
(Pol and S)
W, B and S i ndi c a t e t h a t Wine, Beer o r S p i r i t s cons t i t ut e more t han
- -
50 p e r c e n t o f t he al cohol consumed. I f no one beverage account s f o r
more t han hal f t he al cohol , t hen t he eecond beverage i s l i s t e d i n
paren t heses.
SOURCE : See TABLE 1.
Tabl e 6 shows t he mean growth r a t e of t he count r i es wi t h hi gh,
medium, and low i ncr eaees i n consumption. Thi s t a bl e shows d e a r l y
t h a t growth r e t e doee n o t negat i vel y c or r e l a t e wi t h i ncr eaei ng
consump t i on. Indeed, t he r ever s e i s t rue: grow t h r a t e posi t i v e l y
cor r el at ee wi t h i n a e a s i ~ consumption t o a s l i g h t degree.
TABLE 6
Wan Growth Rate by I ncr ease i n Per Capi t a
Alcohol Consump t i on
I ncr ease i n Consump t i on
tfigh
Medium
Growth Rate
3 a 0 2 Low
SOUKCE: See TABLE 1.
Tabl e 7 r ever ees t he a na l ys i s o Tabl e 6. I t shows t he mean
i ncr eas e i n consumption of t he hi gh, medium and low growth r a t e
count r i es. There i s no c or r e l a t i on o i ncr eas ed consumption w i t h
growth r a t e . The count r i es w i t h t he medium growth r a t e had t he
hi ghes t i ncr eas es i n coneumption, t hose wi t h t he hi ghes t growth had
t he medium i ncr eas es , and t hose wi t h t he l oweet growth r a t e had t he
l owest i ncr eas es . The di f f er encee a r e al 1 negl i gi bl e and show no
8 t a t i s t i c a l s i gni f icance. 3
TABLE 7
Mean I ncr eas e i n Per Cayi t a Alcohol
Consumption by Growth Ra t e
Growth Rat e
High
Medium
LOW
I ncr ease i n Consump t i on
SOURCE: See TABLE 1.
Other than t he f i ndi ng t h a t growth r a t e doee n o t c or r e l a t e
wi t h e i t h e r per c a pi t a coneumption o r i ncr eaeee i n coneumption,
perhape t he onl y o t her s i gni f i c a n t rela t i onehi p comee d i r e c t l y f r oa
he tablesl of Kel l er and Gur i ol i : t he hi gh coneumption count r i ee a r e
predominantly wine and beer dri nki ng, and t he l owest coneumption
count r i ee dr i nk e p i r i t e. However , al 1 t hr ee cat egor i ee cont ai n
examples of ver y hi gh and low economic growth. Sp i r i t -dri nki ng
I s r a e l and Norway have ver y l ow coneumption l e v e l e (3.25 and 5.58)
and ver y hi gh growth r a t e s (4.4 and 3.6). Wine-drinking France and
I t a l y have ver y hi gh coneumption l e v e l e (22.44 and 13.56) and t hey
a l e o have hi gh growth r a t e s (3.9 and 3.7). The French i nt ake i s t he
equi val ent of 44 l i t r e e of 100 proof l i quor , o r hal f a l i t r e of
wine, ever y day of t he year f o r ever y man, woman and c hi l d over 14
yeare of ape. By t he e t andarde of many nat i one, t h a t would
c one t i t ut e chr oni c heavy dri nki ng. Yet, i n addi t i on t o t he i r hi gh
dr0Wt.h r a t e , t he French a l s o have a eophi et i cat ed t echnol ogi cal and
indue t r i a l appara t us.
Sp i r i t-drinkirig Fi nl and, whoee peopl e a r e f amoue f o r t h e i r
attachmen t t o epi eodi c i nt oxi cat i on, has a medium coneumption l e v e l ,
a n almoe t a s tronomi cal i ncr eaee i n al cohol coneump t i on (157.7
per cent ) , and t he second hi gheet growth r a t e i n t he eample (4.1
per cent ) . Beer - dr i nki q Denmark hae a medium coneumption l e v e l , a n
ext remel y hi gh i ncr eaee i n conslumption (111.6 per cent ) and a medium
growth r a t e . The Uni t ed Kingdom 1s beer - dr i nki w, and t he ni t ed
St a t e s dr i nke beer and s p i r i t e . Both had a medium i ncr eaee i n
al cohol coneump t i on, t he y have almoe t i d e n t i c a l coneump t i on l e ve l s ,
and bo th have low growth r a t e s (2.7 and 2.2). Poland and Fi nl and
have ver y s i mi l a r per capi t a coneumption l evel e; Fi nl and' e
coneump t i o n i ncr eaeed drama ti c a l l y, whi l e Poland ' e i ncr eaeed
r e l a t i v e l y l i t t l e . But Fi nl and hae a hi gh growth r a t e , and Poland
hae been i n s er i oue economi c t r oubl e .
These f i g u r e s thue ei r ongl y eugges t t her e i e no r el at i onehi p
between al cohol coneumption and t he economi c d i f f i c u l t i e e of t he
Uni t ed St at ee, Poland, New Zealand, Peru, o r t he United Kingdom, o r
t he economic succeeees of France, I t a l y , Fi nl and, I s r a e l , o r
Norway. The det ermi ni ng f act or 8 i n t he economic l i f e of a nat i on,
o r f o r t h a t mat t er a cor por at i on, a r e major f i s c a l and product i ve
mat t er s euch a e i n t e r e e t r at ee, c a p i t a l i nveet ment , wage and pr i c e
l e ve l e , and eo on. Today, i n t he United St at ee and Great Br i t ai n,
10% o r more of t he l a bor f or c e i e o u t of work. I f a l 1 t he
unemployed heavy dr i nker e i n e t a n t l y became sober , i t would not
a f f e c t t he unemployment r a t e e i n thoee count r i ee. And i f a l 1 t he
unproduct i ve working chr oni c dr i nker s -- a t moet 1 per cent of t he
work f or c e -- became abet i nent , i t would n o t i ncr eas e economic
developmen t o r t he growth r at e.
Thi e i e by no means t o argue t h a t al cohol coneumption i s not a
l egi t i ma t e and impor t a n t publ i c heal t h concern. Cl ear l y eome people
dr i nk t oo much and, a e a r e s u l t , r u i n t h e i r l i v e r e , etomachs and
br ai ns , o r i n j u r e o r k i l l themselves o r o t h e r s i n aut omobi l e wrecks.
There a r e humani t ar i an and e t h i c a l r easone t o be concerned w i t h
a l c ohol consumption. However, t he br oad h i s t o r i c a l and s o d o -
l o g i c a l evi dence s t r ongl y euggee t e tha t , compared t o maj or economi c
and p o l i t i c a l f a c t o r s , a l c ohol consumption 1s n o t i mpor t ant i n
de t ermi ni ng economi c growth and development .
Acknowledgements Research o r t h i e paper was i n p a r t suppor t ed by a
g r a n t from Dean Helen Cai r ns, Of f i ce of Graduate St udi es and
Research, Queens Col l ege, C i t y Uni ver si t y of New York. 1 would l i k e
t o thank St even M. Cohen f o r h i e hel p i n performing t he s t a t i e t i c a l
a n a l y s i s and f o r a l 1 h i s comments and suggest i ons.
THE IMPACT OF ECONOMIC DEVELOPMENT ON DRI NKI NG PATTERNS
AND PROBLEMS: THE CASE OF TOURiSM
Jamee F. Moeher
an d
Lenore D. Ral et on
Recen t i nt e r na t i ona l s t udi ee and revi ews concerning a l c ohol
consumption and a l c ohol problems i n modero s o d e t i e s have s t r e s s e d
t he need f o r more c a r e f ul exami nat i on of t he impact of i ncr eas ed
consumption i n less developed count r i es (LDCe) (e.g. WHO 1980; Moser
1380; Edwards 19 79) . Publ i ca t i ons by t he World Heal t h Organiza t i on
(WHO) have documented r a pi d i nc r e a e e s i n a l c ohol problem i ndi c a t or s
i n LDCe and ar gue t h a t t hes e i nc r e a s e s c r e a t e a s e r i ous obe t a c l e t o
socioeconomic development and a s ever e f i na nc i a 1 burden on a va i l a bl e
he a l t h s e r vi c e s (e. g. Moeer USO, Globe 1979).
WHO, i n a n e f f o r t t o document and be t t e r underst and thls
phenomenon, ha s begun a s t udy o t he publ i c he a l t h a s pe c t s of
i n t e r n a t i o n a l pr oduct i on, market i ng , and d i s t r i but i on of a l c ohol i c
beverages. An i mpor t ant a s pe c t o such a s t udy concerns t he
r e l a t i ons hi p of t he i nt e r na t i ona l t r ade i n al cohol t o t he r a pi d
development o t he i nt e r na t i ona l touriem i ndus t r y. Tourism not onl y
pr ovi des a n i mpor t ant i nt e r na t i ona l al cohol marke t b u t a l s o creates
new a v a i l a b i l i t y S t r uct ur ee, which i n t ur n may a f f e c t dr i nki ng
pa t t e r n s and t he r a tes o al cohol - r el a t ed problems w i t h i n LDC
s o c i e t i e s . The Al cohol Research Group (ARG), i n cooper at i on w i t h
t he HO st udy, ha s t he r e f or e embarked on a r es ear ch program t o t est
and document t he i mpact of t he i n t e r n a t i o n a l t ouri sm i ndus t r y on
a l c ohol consumption, a v a i l a b i l i t y , and problems i n LDC h o s t
coun trie s.
The t our i sm pr o ject i s i mpor t ant t o t h i s workshop i n a t least
t hr ee ways: a ) mas8 t ouri sm, w i t h i t s heavy r e l i a nc e on al cohol
consumption, r e pr e s e nt e a ma j or and r a p i d l y expanding i ndus t r y i n
t he lesser developed world today, and t hus pr ovi des a case s t udy f o r
expl or i ng some i mpor t ant al cohol / e conomic development i s s ue s ; b)
t ouri sm i s r a p i d l y expandlng i n many r egi ons of La t i n A me r i c a ,
p a r t i c u l a r l y i n t he Cari bbean, which ARG ha s chosen a s a s t udy
r egi on; and c) our r es ear ch has uncovered c r u c i a l l e g a l componente
t o t he al cohol - t our i sm l i n k t h a t may pr ovi de i mpor t ant avenues f o r
devel opi ng l e g a l ay proaches f o r f ut ur e pr event i on s tra t e gi e s .
Because of t he br e vi t y of my t a l & t oday, 1 cannot f u l l y
pr esea t t he cur r en t s t a t u s of the t our i sm/ al cohol pro ject. I ns t ead
1 w i l l di s c us s t he l i n k between mass t ouri sm and a l c ohol a va i l -
a b i l i t y , p a r t i c u l a r l y i n La t i n America, and provi de a br i e f
de s c r i pt i on of our r es ear ch desi gn. 1 w i l l conclude wi t h a br i e f
r e p o r t on one a s pe c t of the S t udy -- c ur r e nt U.S. t r ade and t a x
pr ovi s i ons r e l a t e d t o a l c ohol and t our i sm i n Puer t o Rico and t he
U.S. Vi r gi n I s l a nds and t h e i r i mpact on a l c ohol a v a i l a b i l i t y and
problema i n t he Cari bbean r egi on.
The Wnk Between Tourism and Alcohol Ava i l a bi l i t y
Pr i o r t o t he 1 3 7 0 ' ~ ~ l i t t l e a t t e n t i o n va s gi ven t o t he soci o-
economic i mpact o i n t e r n a t i o n a l t ouri sm on e i t h e r hos t o r gue s t
c ount r i e s (Nash 1381; Graburn 1380; Mings 1978). Most pl anner s and
economi st s si mpl y assumed t h a t t he revenues brought by t o u r i s t s
pr ovi ded e conomic benef i t e t o hos t c ount r i e s t ha t f a r out s t r i pped
any s o c i a l o r c u l t u r a l problema t ha t migh t r e s u l t (cf . Zinder 1969 ;
Clement 1361). During t he l a t e 1360s and 13708, t ouri sm expanded
r a pi dl y, p a r t i c u l a r l y i n the l e e s developed world, where t he assumed
e conomi c benef i ts were e a ge r l y sough t. Thi s r a pi d growth coun t i nues
t oday and i s f ue l e d by t echni cal and f i na nc i a 1 a s s i s t a nc e from
developed count r i es , i n t e r n a t i ona l a i d agenci es, and i ndus t r y
l obbyi ng groups (World Tourism Or gani zat i on 1976 ). LDCs, i n
a ddi t i on t o a ccep t i ng t h i s a i d , have pr ovi ded ma j or economic
concessi ons t o t ouri sm mul t i na t i ona l s and have made massive c a p i t a l
expendi t ur es t o i nc r e a s e t h e i r r e s pe c t i ve s ha r e s of t he marke t
(deKadt lY79; Cleverdon 1979). The i nvest ment s i ncl ude such
t ouri sm-ori en t ed pr o j e c t s as l a r g e a i r p o r t e , deepsea por ts, and new
r oads and sewage sys tema f o r mas t a l developments.
La t i n America and t he Cari bbean have been a t t he f or e f r ont of
t hese developments. Tourism has become a n e s s e n t i a l p a r t of
na t i ona l economies i n t he Cari bbean, Mexico, and many p a r t s of
Ce nt r a l and South America. Many na t i ona l governmente are i nvol ved i n
l a r g e t ouri em developmente (euch a e Mexico' e development of I xt apa
and t he i s l a n d of Cancun) and sponeor expensi ve t our i s t a dve r t i s i ng
campaigns i n t he U.S., Canada, and p a r t s of Europe. I nt e r na t i ona l
t our i e t a r r i v a l s i n La t i n America and t he Cari bbean have i ncr eaeed
a t a tremendous r a t e i n the l a e t 15 yeare: from 3.1 mi l l i on a r r i v a l s
i n 1366 t o .5 mi l l i on i n 1971 and 13.4 mi l l i on i n 1979 (World
Tourism Or gani zat i on 1976, Wt3 O). S t a t i s t i c 8 on excur si on and
c r ui e e s hi p passenger a r r i v a l e were n o t a va i l a bl e u n t i l r e c e nt l y.
When i ncl uded i n the 191 9 f i gur e s , t he t o t a l number of i nt e r na t i ona l
a r r i v a l s i n La t i n America and t he Cari bbean jumpe t o 82.8 mi l l i on,
i ndi c a t i n g t ha t t h i e componen t has become ex t remel y impor t a n t , i f
n o t dominant, i n t he a r e a (World Touriem Or gani zat i on 1980).
The revenue gener at ed by t ouri sm has grown a t a s i mi l a r r a t e .
La t i n America gr os s t o u r i e t r e c e i p t s t ot a l e d $1.5 b i l l i o n i n 1964
and $1.1 b i l l i o n i n 1979, appr oxi mat el y 10 per cent of t o t a l world
t our i sm r e c e i p ts ( I UOTO 1965; World Tourism Or gani zat i on 1980).
Mexico, t he Bahamas, and Puer t o Rico have by f a r the l a r ge s t s har es
of both t o u r i s t a r r i v a l s and t o u r i e t r e c e i p t s i n La t i n America.
According t o Cleverdon (1979), t ouri sm r e c e i pt e r epr eeent a l a r ge
per cent age of bo th t o t a l expor ts of goode and gr oee na t i ona l pr oduct
i n s ever a1 Cari bbean and Ce nt r a l American count r i ee. South American
count r i ee ge ne r a l l y have more di ve r e i f i e d i n d u s t r i a l e e c t or s , but
t ouri sm r e c e i p t s remain i nc r e a s i ngl y i mpor t ant i n na t i ona l economies
t he r e , a l s o.
W i t h t he expansi on, however, have come eome s e r i ous quee t i ons
concerni ng t he assumed economi c benef i ts . Numerous case s t udi ee
from many pa r t e of t he world document s o c i a l and c u l t u r a l
di s r up t i ons whi ch accompany t he development of mass t ouri sm (e.g .
deKadt 1979; Boi seevai n 1979; Eeh and Roeeblume 1975; Fi nney and
Wateon U1 5) . Even t he eupposed economic be ne f i t e have been
chal l enged. Bryden, i n h i e landmark et udy Tourism and Development
(1913). ar gues t h a t c ur r e nt forme of maee t ouri sm a r e a c t u a l l y
e c onoi i c a l i y de t r i ment al t o hos t count r i ee, even wi t hout r e f er ence
t o i nt a ngi bl e f a c t o r 8 of s o c i a l and c u l t u r a l di er upt i on. Bi s
exami nat i on of i n t e r n a t i o n a l t ouri sm and i t e i mpact on l o c a l
i ndus t r i e S, employmen t oppor t uni t y, and c a p i t a l i nves tmen t choi e s
pr ovi dee a s t r ong ba e i s f o r ur gi ng major reforma i n t he f u t u r e
developmen t of t ouri sm .
An a ddi t i ona l set of probleme concerns t he cont r ol of t our i sm
by i n t e r n a t i o n a l f i r me l oca t e d out s i de the LDCs. I nt e r na t i ona l
ho te1 chai ns, t r a ns por t a t i on i ndus tries, and tour-opera t i ng
companies , whi ch are i nc r e a e i ngl y domina t i ng the i ndus tr y and whi ch
a r e us ua l l y l oc a t ed i n ttie t o u r i s t-genera t i ng count r i es , monopolize
t he promotion of t our s -- t h e i r des t i na t i one, a c t i v i t i e e , and
f a c i l i t i e s . According t o t he World Touriem Or gani zat i on (1376 :82):
The t rend towards t he concent rat i on of power i n t he
di s t r i but i on of tourism s er vi ces t o t he consumers i n
the major t our i s t generat i ng count r i es i s f e l t by
developing count r i es, on t he one hand, t o gi ve t he
l a r ge oper at or s t he chance of i nf l uenci ng demand
and, on t he ot her , t o weaken t he negot i at i ng power
of the recei vi ng (developing ) coun t r i e s .
The tourism li t er at ur e, then, has begun t o examine cri t i c a l l y
the i ndus t r y ' S charact er and impact, most l y from an ant hropol ogi cal ,
pol i t i c a l , o r economic framework. What i s st i l l l acki ng, however,
i s any syst emat i c s t udy of t he publ i c heal t h i mpl i cat i ons of tourism
development. Severa1 aut hor s a t l e a s t mention such t r a di t i ona l
publ i c heal th concerns a s water pol l ut i on, sewage t reat ment , and
di s eas e cont r ol (e.g., Smaoui 1979; Evans 1979; iller 1976; Bryden
191 3), bu t even t hese var i abl es a r e us ual l y i gnored i n t he cal cul us
of tourism' s cos t s and benef i t s.
Even more i nf r equent i n t he tourism l i t e r a t u r e i s t he mention
of t he impact of tourism on al cohol a va i l a bi l i t y, consumption, and
problems i n hos t count ri es. Some s t udi e s have made cursory
referentes t o al cohol , but t he des cr i pt i ons a r e us ual l y set i n a
more gener al f r amework of "1 i f e s t yl e changes" o r wha t Bryden (19 7 3)
and ot her s t e r m t he "demonstration e f f e c t " (e.8. Wilson 1979; Reyoso
y Val l e and deRegt 1979; Cleverdon 1379; MacCannel 1976; Manning
1 9 7 3). Tour i s t s from t he developed world bri ng t he i r own l i f e s t y l e
with them, i ncl udi ng many consumption i teme which, a t l e a s t from a
LDC perspect i ve , a r e l wu r y comodi ties. The demons t r at i on ef f e c t
hypo t hesi zes t ha t t he importa t i on of t hese ameni t i e s cr ea t es a
demand f o r them among those i n t he hos t s ocl et i es . Tourism a l s o
encourages t he developoment of a cash economy (by of f er i ng wage
l abor i n unski l l ed s er vi ce j obs), t herefore making t he purchases of
f orei gn ameni ties a r e a l i s t i c pos s i bi l i ty. Severa1 tourimu s t udi es
have provided l i mi t ed dat a t o suppor t t h i s demons t r at i on ef f e c t
hypot hesi s ( cf . Bryden 197 3 ) , but al cohol i mport at i on, product i on
and consumption var i abl es cont i nue t o be i gnored ( cf . Kemper 1979;
Smith 1377).
Writers i n t he al cohol f i e l d provi de some i ns i ght i n t o t he
r el at i ons hi p of tourism and al cohol problems not found i n t he
tourism l i t e r a t ur e , but , because of a l i mi t ed focus, have not
cri t i c a l l y examined t he cr uci al economi c and heal t h var i abl es
involved. Nordic s chol ar s have been i n t he f or ef r ont i n t h i s ar ea,
examiniry t he changes i n Nordic dri nki ng pat t er ns which have
a ccompanied i ncr eased Nordi c tourism t o sout hern, Medi t erranean,
wine-drinking coun tries. The y have sugges t ed tha t t our i s ts have
"brought home" t he f or ei gn dri nki ng pat t er ns and added them t o
exi s t i ng home pa t t er ns (Makela 197 9 ) . The Nordic l i t e r a t ur e a l s o
i ncl udes s t udi es of t he du ty-f r e e al cohol t r ade t ha t accompanies
i nt er nat i onal f e r r i e s i n nor t hern European wat ers (e.g . Granqvis t
1981). Tr avel by boat between va r i ous European count r i es t y p i c a l l y
i nvol ves ext ens i ve dr i nki ng and pur chases of a l c ohol i c beverages f o r
home consump t i on. These a l c ohol s t udi e s have f ocused almos t
e xc l us i ve l y on t he i mpact on "gues t" dr i nki ng habi ts. Lei sur e,
t r a ve l , and r e c r e a t i ona l a c t i v i ties, a s expanding a s pe c t s of
ever yday l i f e i n devel oped count r i es , a r e becoming i nc r e a s i ngl y
a s s oc i a t e d wi t h a l c ohol consumption, which may l e a d t o i nc r e a s e s i n
al cohol - r el at ed problems f o r t hose who p a r t i c i p a t e ( c f . Makela e t
a l . 1982).
The l e i s ur e - or i e nt e d r es ear ch i s augmented by some f r agment ar y
s t udi e s whi ch sugges t t ha t a l c ohol a v a i l a b i l i t y i nc r e a s e s i n t our i s t
a r e a s and i s accompanied by i nc r e a s e s i n consumption (Watts and
Rabow 19d0; Mosher 1979; Koski kal l i o 1979; Cahannes 1979; Sulkunen
1378). Makela e t a l . (1981: IV-20) r e por t t h a t t he expansi on of t he
mass t ouri sm i ndus t r y has had a n i mpor t ant impact on government
p o l i c i e s r egar di ng a l c ohol a v a i l a b i l i t y i n developed c ount r i e s
dur i ng t he per i od 1950 t o 197 5:
Mass t ouri sm r e qui r e s a c t i v e market i ng, hi ghl y
developed or gani za t i on, ex t ens i ve pl anni ng and a
wide a r r a y of s er vi ces . The s t a t e ha s i n many
coun tries t aken a s t rong r e s yons i bi l i t y i n car r yi ng
o u t t hes e f unct i ons . A less r e s t r i c t i v e l i c e ns i ng
pol i c y has of t en been j u s t i f i e d on t he b a s i s of
be ne f i t s t o t he t o u r i s t t r ade. . . . I n some cases
t he St a t e has promoted t he r e s t a ur a nt ond hot e l
i n d u s t r i e s n o t onl y by l i b e r a l l i c e ns i ng b u t a l s o
w i t h o ther s uppor t i ve measures and i n t h i s way
a c t i v e l y cont r i but ed t o t he i nc r e a s e i n t he
a v a i l a b i l i t y of a l c ohol i c beverages.
Only l i m i t ed da t a i s a va i l a bl e t o de termine whose consumption
-- l o c a l r e s i de nt s , t o u r i s t s , o r bot h -- i nc r e a s e s i n t hese s i t ua -
t i ons , al t hough a t l e a s t one s t udy suggest s t h a t l o c a l r e s i de nt s are
more of f e c t e d t han t our i s ts ( Koski kal l i o 1979).
Tnere i s even l e s s r es ear ch concerni ng t he i mpact of t ouri sm
on a l c ohol a v a i l a b i l i t y and al cohol problems i n LDC hos t
popul at i ons, al t hough a t l e a s t two r es ear cher s have commented on t he
sub j e c t . Beaubrun (197 5) not ed tha t c e r t a i n count r i es vi t h hi ghl y
devel oped t ouri sm i ndus t r y and a poor l y de l i ne a t e d na t i ona l i d e n t i t y
(such a s t he U.S. Vi r gi n I s l a nds and t he Bahamas) a l s o have a hi gh
pr eval ence of al cohol i sm. He hypot hesi zes about a pos s i bl e
"demons t r a t i o n e f f e c t " (p. 430): "t he t our i s t (may) provi de a r o l e
model t o emul at e -- someone who i s c ons t a nt l y pl ayi ng and dr i nki ng
and never seems t o work." More r e c e nt l y, Moser (1980), i n a
WHO-sponsored i n t e r n a t i ona l revi ew of p o l i c i e s desi gned t o preven t
al cohol - r el a t e d problems, s t a t e s (p. 14 ) : "The economi c importante
of tourism, and t he r ecogni zed p a r t pl ayed by e a s y a v a i l a b i l i t y of
a l c ohol i n a t t r a c t i n g t o u r i s t s , has had a consi der abl e e f f e c t on
f or mer l y res t r i c t i v e p o l i c i e s ( i n hos t count r i es) . " A l though
Moser' s a s s e r t i o n does n o t appear t o be based on any d e t a i l e d
r es ear ch f i ndi ngs , o r e c e nt r e p o r t from Mexico pr ovi des some s uppor t
f o r he r t e nt a t i ve concl usi on. Medina-Mora and Campillo-Serrano
( f o r thcoming ) r epor t t h a t a s t a t u t e res t r i c t i n g t he number of
a l c ohol o u t l e ts i n Mexico s peci f i c a l l y exemp ts t hose o u t l e ts s er vi ng
t o u r i s t s . Thi s except i on has been br oadl y i nt e r pr e t e d t o
subs t a n t i o l l y undermine t he l aw' s i n t e n t .
Moser and Beaubrun t hus s ugges t t h a t t he obser vat i ons found i n
Makela e t a l . concerni ng t he impact of t our i sm wi t hi n developed
c ount r i e s may a l s o a ppl y t o LDC s o c i e t i e s . Thei r obs er vat i ons
pr ovi de a n i mpor t ant s t a r t i n g poi nt f o r more de t a i l e d r esear ch.
Beaubrun r a i s e s t he p o s s i b i l i t y of p o t e n t i a l he a l t h consequences t o
hos t s o c i e t i e s , and Moser di s cus s es t he po t e n t i a l economic and l e g a l
consequences -- a l c ohol becomes i nc r e a s i ngl y a va i l a bl e and l e g a l
rest ri c t i ons a r e l oosened, t hus i ncr eas i ng t he r i s k t o na t i ve
popula t i ons. Taken t oge t he r , t he y sugges t t he p o s s i b i l i t y t ha t
t our i sm development f u e l s i nc r e a s e s i n a l c ohol a v a i l a b i l i t y and
consumption, which i n t ur n l e a ds t o i nc r e a s e s i n t he incidente of
a l c ohol problems i n LDC h o s t count r i es . I f s o, t hen t he s t r u c t u r e
of t he t ouri sm i ndus t r y i t s e l f becomes a publ i c he a l t h concern and
changes i n t he r e l a t i ons hi p of a l c ohol t o t h a t i ndus t r y may r e qui r e
s e r i ous consi der at i on. These i s s ue s provi de t he s e t t i n g f o r t he ARG
pr o j e c t des cr i bed below.
Tourism and Al cohol i n t h e Caribbean:
The Impact of U.S. Tax Pol i c y
An a n a l y s i s of t he al cohol - t our i sm l i n k based on sur vey,
ant hr opol ogi cal , and pol i c y da t a i s now i n t he pl anni ng st age. Two
s t udy sites -- t he U.S. Vi r gi n I s l a nds and St . Ki t t s-Nevi s -- have
been chosen, and more ext ens i ve geogr aphi cal coverage may be
pos s i bl e i n t he f ut ur e . I ns t e a d of out l i ni ng t he pr el i mi nar y da t a
concerni ng our S t udy s i tes, whi ch are s ti11 i n t he pr epar at or y
s t a t e , 1 w i l l i ns t e a d f ocus on a more developed l e g a l component of
t he s tudy.
U.S. t a x p o l i c i e s concerning t he U.S. Vi r gi n I s l a nds -- a U.S.
t e r r i t o r y which i s a n i mpor t ant Cari bbean t o u r i s t cent er --
i l l u s t r a tes t he r o l e of governmental i n t er vent i on i n c r e a t i ng and
mai nt ai ni ng t he al cohol / t ouri sm l i nk. Sever a1 r e l a t ed f i s c a l provi-
s i o n s a s s ur e t he dominante of t he a l c ohol t r a de i n t he t e r r i t o r y .
Fi r s t , the U. S. government r ef unds t o t he t e r r i t o r i a l t r e a s ur y al 1
e xc i s e t axes c ol l e c t e d on i sl and-produced rum expor t ed t o t he
mainland (I.R.S. 26 U.S.CA. Sect i on 1562 (Supp. 1981)). Thi s t ax
expendi t ur e has o profound i mpact on t he l o c a l rum i ndus t r y' s
i nf l uence i n l o c a l a f f a i r e . I n t he U.S. Vi r gi n I s l a nds t her e i s
onl y one ope r a t i ona l rum d i s t i l l e r y , and t h i s i s a wholly-owned
s ubs i di a r y of Schenl ey, a l a r g e U.S.-based a l c ohol i c beverage
producer. Thi s d i s t i l l e r y must i mpor t a l 1 of i t s raw ma t e r i a l s and
i s of r e l a t i v e l y minor economic i mport ance on t he i s l a n d s i n terms
of employment and c a p i t a l i nvest ment (U.S. Feder al Maritime
Commission 1979). Ye t through i t s e xpor t s t o t he mainland i t
pr ovi ded $24.5 mi l l i on t o t he Vi r gi n I s l a nds ' t r e a s ur y i n 1978 and
$36.2 mi l l i on i n 1980. o r 1 7 per cent of n e t government revenues
(U.S. Feder al Mari t i m e - ~omml s s i on 1979 ; car i bbean Busi ness 1981e;
U. S. Vi r gi n I s l a nds Annual Economic Review 1980).
The Vi r gi n I s l a nds government, t her ef or e, has a n obvi ous s t a ke ,
i n promoting t he l o c a l rum i ndus t r y. I t imposes no e xpor t o r e xc i s e
t axes on l o c a l l y produced rum and ha s gi ven t he rum i ndus t r y
f a vor a bl e t ax concessi ons r egar di ng cor por at e income, pr oper t y, and
s a l e s t axes (cf . Oldman and Tayl or 197 0; Dani el son 197 4). I n or der
t o a t t r a c t more al cohol - r el at ed i ndus tries t o t ake advant age of t he
e xc i s e t a x r e ba t e , t he government a l s o o f f e r s ext r emel y a t t r a c t i v e
t a x exemptions t o pr os pect i ve i ndus t r i e s , and, a s a r e s u l t , a t l e a s t
one U.S. d i s t i l l e r has deci ded i n t he l ast t hr ee year s t o l oc a t e a
bl endi ng f a c t or y on t he I s l a nds (Hedman 1979b). The government even
ope r a t e s a rum promotion o f f i c e , which 1s desi gned t o encourage rum
consumption bot h l o c a l l y and na t i ona l l y i n t he U. S., and t he Vi r gi n
I s l a nd Commissioner of Commerce has l i s t e d rum promotion a s one of
h i s major p r i o r i t i e s (U.S. Vi r gi n I s l a nds Governor' s Report 1978;
Hedman 197 9a) .
The U.S. and Vi r gi n I s l a nd f i s c a l pol i c i e s go beyond
encouragi ng the l o c a l i ndus t r y. Nei t her government imposes any
e xc i s e t ax on U.S.-produced al cohol pr oduct s purchased i n t he Vi r gi n
I s l ands . The Vi r gi n I s l a nds has a per cent dut y on f or e i gn brands,
which i s a n ext r emel y low r ot e , b u t t he t a x has st i l l been a t t a c ke d
by t he t o u r i s t s e c t or a s det r i ment al t o bot h t he government and
i ndus t r y (Hedman 1981a). These t axi ng p o l i c i e s r e s u l t i n some of
t he cheopest a l c ohol i c beverage pr i c e s i n t he world. U.S.-produced
rum, f o r example, can be purchased f o r a s l i t t l e as $1.50 per f i f t h
as compared t o $5.00 o r more on t he mainland (Hedman 193l b) . The
U. S. government f ur t he r encourages t o u r i s t pur chases on t he Vi r gi n
I s l a nds by per mi t t i ng v i s i t o r s t o r e t u r n t o t he mainland w i t h one
ga l l on of t ax- f r ee rum, a quot a f our times t he per mi ssi bl e amount
al l owed when r e t ur ni ng f rom f or ei gn coun tries (Cari bbean Busi ness
19dl a, 13dl b) .
Most of t hes e f i s c a l p o l i c i e s a l s o a ppl y t o Puer t o Ri co,
ano t her U.S . Cari bbean terri t o r y heovi l y dependen t on rum pr oduct i on
and t ouri sm. Because Puer t o Rico has a much l a r g e r rum i ndus t r y,
t he e f f e c t s of t he t a x p o l i c i e s a r e cor r espondi ngl y more
i mpr essi ve. The i ndus t r y produced $200 mi l l i on i n e xc i s e t ax
r e t u r n s from t he U.S. Tr easur y t o the Commonwealth government i n
f i s c a l year 197940, and t he t o t a l i s expect ed t o have i ncr eased
s u b s t a n t i a l l y f o r t he ne xt year ( Bl asor 1981). To i ns ur e t he heal t h
of t he i ndus t r y, t he Puer t o Rican government has gi ven rum producers
a n exemption f o r most of i ts l o c a l t a x l i a b i l i t i e s , i ncl udi ng most
sales, income, and pr oper t y t axes. The examption w i l l r un u n t i l
1990 and reduced Bacar di ' s t a x b i l l by $10.5 mi l l i on i n 1979 and
$13.2 i n 1980 ( Bacar di 1980; Ot Ne i l l 1981; Wynne 1974).
Puer t o Rico, i n of f i c i a l r ecogni t i on of t he importance of rug
t o t he economy, has made t he pi na col ada c oc kt a i l the o f f i c i a l
i s l a n d dr i nk, p a r t of i t s o v e r a l l campaign t o encourage t our i sm
(Cari bbean Busi ness 1 9 8 1 ~ ) . A spokesperson f o r Coco Lopez, the pi na
col ada producer, not ed t h a t i t s pr oduct i s now ve r y popul ar a moq
l o c a l r e s i de nt s , who had u n t i l r e c e nt l y n o t been i n t e r e s t e d i n t h i s
t o u r i s t dr i nk. The spokesyerson, i n a st at ement of f e r i ng some
s uppor t f o r t he "demons t r a t i o n ef f ec t", a t t r i but e d t he new l o c a l
popul ar i t y t o t he company's heavy l o c a l adver t i s i q promo t i on
(Cari bbean Busi ness 1 9 8 1 ~ ) .
The U.S. government pr ovi des a n a ddi t i ona l boost t o the
a l c ohol market on bot h t he Vi r yi n I s l a nds and Puer t o Rico w i t h i t s
t a x t r eat ment of bus i nes s convent i on expenses. Pr i or t o 1976,
cor por at e and i ndi vi dua l expenses i nc ur r e d f o r sponsor i ng andl or
a t t e ndi ng convent i ons were deduct i bl e r e ga r dl e s s of t he convent i ont s
l ocat i on. Conyress, as p a r t of t he Tax Reform Act of 1976,
pr ohi bi t e d such deduct i ons f o r convent i ons he l d over seas (U.S.
Feder al Maritime Commission 1979). Puer t o Rico and t he Vi r gi n
I s l a nds , however, were s pe c i f i c a l l y exemp t ed f r on t h i s res t ri ct i on.
A s a r e s ul t, the annual conven t i on- t our i sm busi ness on t he Vi r gi n
I s l a nds more t han t r i p l e d between 1976 and 1979, t o 30,000 annual
convent i on v i s i t o r s (U.S. Feder al Mari time Commission 1979 ).
Conven t i ons a r e no t ed f o r pr ovi di ng e x t ens i ve dr i nki ng
occasi ons. Thus, i n addi t i o n t o a t t r a c t i ng more al cohol consumers,
i nc r e a s e s i n the number of convent i ons a l s o t r a n s l a t e s i n t o
i nc r e a s e s i n the nuatber of dr i nki ng s e t t i n g s on t he i s l a nds (Mosher
1981). A l though a ccur at e da t a are no t a va i l a bl e , sever a1 i ndi c a t or s
sugges t tha t a l c ohol 1s a ma j or expense a t many i f no t mos t busi ness
convent i ons. The bus i nes s market i t s e l f i s ext r emel y l a r g e i n t he
U.S., account i ng f o r 12 per cent of al 1 al cohol s a l e s , o r $8 b i l l i o n
13 79 (Mosher f o r thcoming ). Busi ness convent i ons c ons t i t u t e a
s u b s t a n t i a l s ha r e of t h a t market.
ecent t r a de concessi ons by t he U.S. i l l u s t r a t e t he importance
of t hese al cohol - r el at ed f i s c a l pr ovi si ons t o t he development of
t o u r i s t economies and t he need f o r a region-wide, p u b l i e h e a l t h -
or i e nt e d a l c ohol a v a i l a b i l i t y pol i cy. I n 1979 t he Car ter AdmLnis-
t r a t i o n i n s t i t ut e d s i g n i f i c a n t r educt i ons i n U. S. e x d s e t axes on
impor t e d a l cohol i c beverages ( bei ng phased i n over s ever a1 year s) ,
i n p a r t t o encourage t he rum i n d u s t r i e s i n t he Cari bbean r egi on
(Cari bbean Busi ness 197 9 ; DISCUS 1381). (Wes t e r n European coun tries
nave a l s o pr ovi ded s p e c i a l t r a de concessi ons r egar di ng t he rum
i n d u s t r i e s of t h e i r former Caribbean i s l a n d col oni es. A s a r e s u l t ,
t he s t a t u s of t he rum t r ade has been t he s u b j e c t of consi der abl e
deba t e i n European Economic Communi t y nego t i a t i ons (Wine and S p i r i t s
Magazine l gdl ) . ) Most r e c e nt l y, t he Reagan Admi ni st r at i on, i n a n
a t t e mpt t o r evi ve t he Jamai can t o u r i s t economy, ha s gi ven Jamai ca
t he same s t a t u s a s t he Vi r gi n I s l a nds and Puer t o Rico r egar di ng
t ax- deduct i bl e bus i nes s convent i on expenses (Cari bbean Busi ness
19dl d) . The Admi ni st r at i on has a l s o proposed a c c e l e r a t i ng t he
t a r i f f r educt i ons imposed by t he Car ter government. These
al cohol - r el a t e d concessi ons f o r ot he r par ts of t he Cari bbean have
been he a t e dl y opposed by t he Vi r gi n I s l a nd and Puer t o Rican
governmen ts, whi ch consi der t h e i r s p e c i a l t r eat ment r egar di ng
a l c ohol a major advant age i n devel opi ng t h e i r r e s pe c t i ve t o u r i s t
i ndus tries (Cari bbean Busi ness 1981d, 198 1f ).
Po l i c i e s desi gned t o promote t he a l c ohol t r a de a r e n o t a
necessar y p a r t of t ouri sm development. Other economic a s pe c t s of
t he t ouri sm i ndus tr y coul d as e a s i l y be promoted through s p e c i a l t a x
treatmen t. Alcohol coul d remain a s a r e l a t i v e l y hi gh-pri ced l uxur y
good and a sour ce of t a x revenue, j u s t a s i t 1s t r e a t e d i n t he
ma j o r i t y of gues t coun tries. Curren t t ouri sm pol i c i e s , i n addi ton
t o pushing doun a l c ohol pr i c e s , t end t o g r e a t l y i n f l a t e t he c os t of
food, housi ng, and r e a l e s t a t e (cf. Bryden 1973). Reforme i n f i s c a l
p o l i c i e s of gues t c ount r i e s coul d s i gni f i c a n t l y a l t e r t h i s pi c t ur e .
Perhaps mos t s i gni f i c a n t 1s t he i mpact of t he U.S.-sponsored
t r a de concessi ons on t he r egi on a s a whole. With tourism a s one of
t he mos t impor t a n t f ocuses of development, t he U. S. Vi r gi n I s l ands ,
a s w e l l a s ot he r f r ee- por t i s l a n d s , have made al cohol a major,
hi ghl y successf u l , t o u r i s t a t t r a c t i o n . A s ot he r i s l a nds s eek t o
compete f o r t he t o u r i s t dol l a r , t hen, s i mi l a r concessi ons a r e l i k e l y
t o appear necessar y. I n Venezuela, f o r example, t he government
r e c e n t l y c r e a t e d a f r e e por t on t he i s l a n d of Mar gar i t y, of f i t s
c oa s t , i n par t t o compete wi t h t he near by f r e e por t of Aruba. Moser
(1980: 11-2) r epor t a: "t housands of Venezuelans go t her e d a i l y t o
pur chase a l c ohol i c beverages. Each t i m e t he v i s i t o r s a r e per mi t t ed
t o t ake away 5 o r 6 l i t e r s of t he most wi del y consumed t ypes, 89
l i t er s t o t a l . Much of t h i s i s r e s ol d on t he maialand. "
Nat i ons which choose n o t t o compete f o r t he t o u r i s t i ndus t r y
through t he use i n i nexpensi ve a l c ohol pr oduct s may f i n d t h e i r
a l t e r n a t i v e p o l i c i e s s e r i o u s l y eroded. Not onl y do t hey r i s k l os i ng
t our i s ts t o o t he r coun tries, t hey a l s o may l o s e al cohol - r el at ed
revenues . High i mpor t du ties may encourage a n e x t ensi ve boo t l eggi ng
t r ade, which w i l l i n t ur n cause a major l o s s of t a x revenues and a
t hr e a t t o l ocal l y-produced beverages. Thi s phenomenon may w e l l be
occur r i ng t hroughout t he r egi on today, al t hough t he e xt e nt of t he
boo t l eggi ng t r a de has n o t been adequat el y r esear ched.
Concl usi on
Po l i c i e s r egar di ng i n t e r n a t i o n a l t r a de and t ouri sm appear t o
have a profound i nf l ue nc e on t he e t r uc t ur e , l oc a t i on, and s i z e of
a l c ohol pr oduct i on and a v a i l a b i l i t y i n t he Caribbean. Ext ensi ve and
d e t a i l e d r es ear ch 1s necessar y t o under st and t h i s i mpact , a s w e l l a s
t he r e l a t i ons hi p of tourism-inf l uenced a l c ohol a v a i l a b i l i t y t o
dr i nki ng pa t t e r n s and a l c ohol problems. Exi s t i ng dat a, however ,
s ugges t t h a t a publ i c- heal t h- or i ent ed a l c ohol pol i c y i n t he
Car i bbean must t ake a ve r y broad per s pect i ve on t he economic and
p o l i t i c a l f a c t o r s whi ch i nf l uence t he r egi on, par t c u l a r l y t hose
r egar di ng t ouri sm development.
Acknowledgemen t: Thi s r es ear ch was par t l y suppor t ed by t he Na t i ona l
I n s t i t u t e on Alcohol Abuse and Alcoholism, Nat i onal Al cohol Research
Cent er Gr ant ( M- 05595) t o t he Al cohol Research Group, Berkel ey,
Ca l i f or ni a .
Chapt er No tes and Referentes
Indus t r i a l i z a t i on. Economic Devel o~ment .
and Worker Dr i nki m: H i s t o r i c a l and
1. It was Joseph Gus f i el d i n Symbolic Crusade: St a t us P o l i t i c s
and t he A m e r i can Tem~er ance Movement ( Uni ver si t v of I l l i n o i s - - - -
. ~
Pr es s : 1963) who f i r s t ar gued t h a t c o n f l i c t s over a l c ohol
shoul d be s i e n as symbol i c s t r u g g l e s about c ul t ur e and l i f e -
s t yl e. Al though my a na l ys i s d i f f e r s from h i s on a number of
poi nt s , 1 am i ndebt ed t o Gusf i el d f o r f i r s t poi nt i ng t he way.
1 do n o t mean t o imply t h a t t he r e 1s anyt hi ng wrong wi t h
vol unt ar y programe t o he l p workers wi t h dr i nki ng problems.
However, s u & programs a r e by no means adequat e t o de a l wi t h
the f u l l r ange of worker he a l t h needs. A s t r ong publ i c he a l t h
per s pect i ve concerned w i th workers would push f o r q u a l i t y
medi cal car e, i ncl udi ng ment al he a l t h coverage, and would be
concerned t h a t work environments a r e f r e e from t oxi c and
noxi ous ma t e r i a l 8 and t h a t workers' wages a r e suf f i c i e n t t o
f eed, house, and car e f o r t he i r f ami l i es .
3. Because t he cr oss- t abul ar a na l ys i s l o s e s i nf or mat i on by col-
l a p s i q obser va t i ons i n t o cat egor i es , 1 per f ormed a r egr es ei on
a na l ys i s t o assess t he v a l i d i t y of i nf er ences drawn from t he
t abl es. The r egr es s i on of e i t h e r al cohol consumption i ndi -
cat or on growth showed l i t t l e i f any r el at i ons hi p, a s di d t he
r egr es s i ons of growth upon each al cohol measure. I n two
i ns t ances t he unst andardi zed coef f i c i e n t (B) were e xa c t l y
zer o, and i n t he ot her two i ns t ances t hey were s l i g h t l y posi -
t i v e (*.O7 ), d i r e c t l y cont raveni ng t he not i on t h a t growth and
consumption a r e i nver s el y r el at ed.
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Chap ter Th r e e
MANIFESTATIONS AND PERCEPTIONS OP
ALCOHOL-RELATED PROBLEMS I N THE AMERICAS
Raul Ca e tano
DI SCUSSANT
C a r l o s Ca mpi l l o - Se r r a no
MANIFESTATIONS AND PERCEPTIONS OF ALCOHOL-RELATED PROBLEMS
I N LATIN AMERICA
Raul Caetano
Concern f o r t he pat hol ogi cal ef f e c t s of a l c ohol i nge s t i on i n
human he a l t h have been pr es ent i n t he s c i e n t i f i c l i t e r a t u r e of La t i n
American count r i es s i nc e t he l at e p a r t of t he 19 t h cent ury. But, as
i n ot he r pa r t e of t he worl d, i t took more t han 50 year s f o r al cohol
r es ear ch t o become a n or gani zed e f f o r t i n t hes e count r i es. It was
onl y dur i ng t he 1950s t h a t t he publ i c he a l t h approach t o t he s t udy
of a l c ohol problems, expr essed a s a concern f o r epi demi ol ogi cal
s t u d i e s of a l c ohol problems and f o r or gani zi ng t h e i r t r eat ment and
yr event i on, emerged i n La t i n America.
uie purpose of t h i s paper 1s t o revi ew t he epi demi ol ogi cal
l i t e r a t u r e on a l c ohol i n t hes e count r i es . Such a t a s k can onl y be
performed i n a s e l e c t i v e manner, t h a t i s, by examining papers judged
t o be r e pr e s e nt a t i ve of t he development of r esear ch. Even t hen, t he
f i n a l pr oduct w i l l have a n e s s e n t i a l l y panoramic nat ur e, and i t
shoul d n o t be s een a s more t han a bi r d' s- eye view of t he f i e l d . I n
a ddi t i on, t her e i s t he f a c t t h a t t h i s paper at t empt s t o cover
r es ear ch which has been publ i shed i n more t han 50 s c i e n t i f i c
publ i c a t i ons and which 1s s o s c a t t e r e d a s t o be al most i mpossi bl e t o
reassembl e. Consequently, t opi ca which one o r anot her r eader may
deem a s i mport an t migh t be l e t un touched.
The pl an f o r t h i s revi ew 1s a s f ol l ows: I n t he f i rst s e c t i on
some demographic, s o c i a l , and ge ne r a l he a l t h i ndi c a t o r s f o r
c ount r i e s i n La t i n America w i l l be reviewed i n a n at t empt t o
char act er i ze t he he a l t h and socioeconomi c s t a t ue of na t i ons i n t he
r egi on. These i ndi c a t or s w i l l be cont r as t ed wi t h t hose f o r t he U.S.
and Canada. A second s e c t i o n revi ews da t a on al cohol problems a s
i ndi c a t e d by al cohol - r el at ed mor t al 1 t y, ps yc hi a t r i c problems,
t r a f f i c acci dent e, s ui c i de s , and crime. I n t he t h i r d s e c t i on
sur veys of dr i nki ng pa t t e r ns and al cohol i sm i n s ever a1 count r i es a r e
summarized. The f i n a l s e c t i o n di s cus s es t he Lat i n American
concept ual approach t o a l c ohol problems and i t s i mpact on e f f o r ts t o
a l l e v i a t e such problems i n t he regi on.
La t i n America: Sel ect ed Demographic,
Soci al , and Heal t h Rel at ed I ndi c a t or s
La t i n America i s composed of some 26 count r i es and ot he r
p o l i t i c a l uni t s . A s such, i t i s a mosai c of c ul t ur e s wi t h
s i mi l a r i t i e s as w e l l as di f f er ences . Many of t he nat i one i n t he
r egi on s ha r e t he common h i s t o r y of having been former col oni es of
Spai n; Br a z i l , of cour se, i s a former col ony of Por t ugal , whi l e some
of tlie i s l a n d and l i t t o r a l nat i one of t he Cari bbean a r e former
col oni es of England, Pr ance, and Holland. Another commonality among
La t i n American c ount r i e s i s t h e i r i nc l us i on among t he devel opi ng
nat i ons . However, t h i s shoul d n o t be t aken a e i mpl yi ng uni f or mi t y
of economic development. There i s a wide gul f between Mexico and
Venezuela on one s i d e , bo t h pe troleum expor t i ng coun tries, and
Bol i vi a and Ha i t i on t h e o t her , of t en ci t ed a s t he poores t na t i ons
i n t he ar ea. Al so, whi l e economic, he a l t h, and s o c i a l i ndi c a t or s
pr esen t ed her e t r a ns l a te exper i ences a t t he na t i ona l l e v e l , w i t hi n
mos t of t hese na t i ons di f e r e n t r egi ons pr esen t qui te di f e r e n t
l e v e l s of economic and s o c i a l development. Thus, l i f e i n t he bi g
ci t i es of t he i n d u s t r i a l i z e d s out he a s t of Br a z i l -- cities such as
Rio de J a ne i r o o r Sao Paul o -- may be i n many a s pe c t s more s i mi l a r
t o l i f e i n New York, Buenos Aires, o r Caracas t han t o l i f e i n t he
r a i n f o r e s t of t he Br a z i l i a n Amazon o r i n t he dr y quas i - des er t
r egi on of t he Br a z i l i a n nor t heas t . These same di f f e r e nc e s may be
obser ved between t he sout h and nor t h of Ar gent i na, o r between t he
c oa s t a l and Andean r egi one of Chi l e and Peru.
Apar t f rom t he s e s u b r e g i o n a l d i f er ences , and of c r uc i a l
impor t ance t o t he s t udy of al cohol consump t i o n and al cohol - r el a t ed
problems, i s t he f a c t t h a t wi t hi n many La t i n American c ount r i e s
t her e s t i l l i s a n i mpor t ant na t i ve o r I ndi an c ul t ur e which has i n
many i ns t a nc e s remained q u i t e d i s t i n c t from t he European one. These
I ndi an c ul t ur e s and the impor t ance and c ha r a c t e r i s ti cs of t h e i r
a l c ohol consumption have been deecr i bed by a n t hr opol ogi s t e. W i t hout
t he i n t e n t of pr ovi di ng a review of t h i e l i t e r a t u r e , which ha s
a l r e a dy been a p t l y examined by Heath (1974, 137 5) , t hese papera w i l l
be c i t e d her e as a means of sheddi ng l i g h t on, and a s gauges f o r
making comparison wi t h, epi demi ol ogi cal f i ndi nge. Negrete (1976a)
has underscored t he importante of t hese c ul t ur e s and t he e xt e nt t o
which t r a d i t i ona l f ermen t ed beverages ( pul que, chi cha) a r e ueed by
na t i ve peopl es i n c ount r i e s w i t h numeroue i ndi genous popul at i ons
such a s Bol i vi a, Mexico, Guatemala, and Peru.
Tabl e 1 pr es ent e eome i ndi c a t or e wi t h a bear i ng on he a l t h
s t a t u s i n t he Americas. A l 1 of t he i n d i c a t o r s i n t he t a bl e show
s i gni f i c a n t v a r i a t i one among the di f e r e n t coun tries of La t i n
America. The age-s t andar di zed deat h ra te shows dr amat i c va r i a t i ons ,
r angi ng from 1, 900 deat he per 100, 000 i n Bol i vi a t o 431.6 per
100, 000 i n Cuba. The U.S. and Canada show r a t e s between 440 and 420
per 100,000, a t l e a s t one- t hi r d s mal l er t han f o r t he ma j or i t y of
La t i n American nat i one. I nf a n t mor t a l i t y r a t e e var y from a hi gh of
86 .O per 1, 000 l i v e b i r t h s i n Guatemala t o a low o 20.8 per 1, 000
l i v e b i r t h e i n Puer t o Rico. For t he whole of South America t he r a t e
i s 49.4 per 1, 000 l i v e b i r t h s , whi l e f o r North America (U.S. and
Canada) i t i e one- t hi r d a s much, 15.8 pe r 1, 000 l i v e bi r t hs . The
gr os s na t i ona l pr oduct shows more dr amat i c va r i a t i ons t han o t he r
i ndi c a t or s . The di f er ences between Nor t h America (U.S. and Canada)
and La t i n America a r e ver y marked. Both t he U.S. and Canada have
GNPs, which a r e 6 , o r 10, o r i n t he case of some of t he poor es t
c ount r i e s (Uai ti, Honduras, Guyana, Bol i vi a) , 20 times gr e a t e r t han
La t i n American na t i ons .
A l cohol-Rela t ed I ndi cat or s *
From 196 2 t o 1964 t he Pan American Heal t h Organiza t i on (PAHO)
( Puf f er and Gr i f f i t h 1967 ) conducted a s t udy of pa t t e r ns of urban
mor t a l i t y i n 10 ci t i es of La t i n America pl us Br i s t o l i n England and
San Fr anci sco i n t he U.S. I n each of t he c i t i e e 2,000 deat he were
s e l e c t e d through a s y s tema t i c sampling procedure f rom a l 1 t he deat hs
of per sons aged 15 t o 1 4 year s of age. The f a mi l i e s and physi ci ans
of t he deceased were i nt er vi ewed by l o c a l col l abor a t i ng r e s e a r c he r s
and t he da t a were s e n t t o a c e nt r a l o f f i c e where t he cause of deat h
was di agnosed w i t h t he us e of s t andar di zed procedures.
The i nve s t i ga t i on showed t ha t al cohol - r el a t ed dea t he
( c i r r h o s i s , a l cohol i c ps ychosi e, and al cohol i em) comprised 4.9
percen t of a l 1 deat hs i n t he st udy. Tabl e 2 shows a wide di f f e r e nc e
be tween males and f emales w i t h r egar d t o al cohol - r el a t ed mor t al i t y
and a l s o ver y s i g n i f i c a n t di f f e r e nc e s among t he var i ous cities i n
t n e st udy. The deat h r a t e f o r a l c ohol i c psychosi e and al cohol i sm
i s , f o r i n s t ance, s i x time8 hi gher i n Guatemala c i t y and two times
hi gher i n Sant i ago, Chi l e, t han i n San ~ r a n c i 8 c o . l Br i s t ol ,
England, has t he lowes t r a t e s bot h f o r f emal es and f o r males. Among
men Sant i ago and Mexico C i t y have hi gher r a t e s t han San Fr anci eco,
t he r a t e i n Sant i ago bei ng twice as high. Among f emal es, San
Fr anci eco has t he hi ghes t r a t e e , f ollowed c l oe e l y by Sant i ago.
Mexico C i t y and La Pl a t a , Argent i na, a l s o have hi gh r a t e s , bo t h i n
t he neighborhood of 30 deat hs per 100, 000 popul at i on.
* Al 1 of t he da t a have t o be examined wi t h care s i nc e t hey us ua l l y
r e f l e c t n o t onl y di f f e r e nc e s i n a l c ohol use and al cohol - r el at ed
yroblems i n a p a r t i c u l a r s et of count r i es , but a l s o t he di f f er encee
i n t he e x t e n t and or gani zat i on o medi cal s e r vi c e e o r i n t he way i n
which d i f f e r e n t l e g a l systems de a l wi t h euch problems.
TABLE 1
Heal t h Rela te d I ndi ca t or s i n
Sel ect ed Count r i es o t he Americas*
Al3 e I n f a n t
Crude St andar di zed Mor t a l i t y Hoepi tal
Bi r t h Ra t e De a t hRa t e Rate Physi ci ans Beds
Per 1, 000 Per 100,000 Per 1, 000 Per 10,000 Per 1, 000 G.N.P.
Popul a t i on Popula t i on Popula t i on Popula t i on Popula t i on (197 7 )
Ar gent i na
Ba hamas
Barbado S
Bol i vi a
Br a z i l
Chi l e
Colombia
Coet a Rica
Cuba
Domini can
Republ i c
Ecuador
E l Sal vador
Grenada
Guatemala
Guyana
Hai ti
Honduras
. Jamai ca
Mexi co
N i caragua
Panama
Paraguay
Per u
Puer t o Rico
Surinam
Tr i ni dad 6
To bago
Uruguay
Venezuela
Uni t ed St a t e s
Cana da
*The crude b i r t h r a t e , t he age s t andar di zed deat h r a t e , t he i n f a n t mor t a l i t y
r a t e , t he number of physi ci ans per 10, 000 popul at i on and t he number of hoe-
p i t a 1 beds per 1, 000 popul at i on were a l 1 abs t r a c t e d from PAHO (1978 ). The
G.N.P. was t aken from t he World Bank (1980).
+The r a t e e were t aken from World Bank (1980).
TABLE 2
Annual Age-Adjusted Death Rat es f o r Al cohol i c Psychosi s and
Al cohol i c Ci r r hos i s per 100,000 Popul at i on age 15-74 year s
i n 10 La t i n American Cities, San Fr anci sco (U.S.A.) and Br i s t ol
(England) , 196 2-196 4*
A l cohol i c Ps ychosi s
and Al cohol i c
A l coholiam C i r r hos i s
C i t y Male Female
-
Male Female
-
Bogo t a 1 .a O -1 11.2 2.2
C a l i 4 .1 O 09 1.2 0.3
Car acas 3.0 0.5 13. 1 0.7
Guatemala C i t y 52 .9 2 -9 26 .9 4 .6
La Pl a t a 1.4 1.1 20.6 3 .O
Lima 6 .1 0 .5 8.0 0.7
Mexico C i t y 14.4 1 . 102.5 31.1
Ri bei r ao Pre t o 7 .7 3 .a 13.1 1.8
Sant i ago 21 .o 1.6 143.0 38.4
Sao Paul o 12.2 1.7 l7 .6 2 .O
San Fr anci sco, U.S. 8.4 5.1 71.3 43.4
Bris t o l , England 0.2 0 .O 1.2 0.3
To t a l
Male Femaie
-
"SOURCE: Puf f e r and Gr i f f i t h (1967).
The s e x di f f e r e nc e s f o r t hese r a t e e r e f l e c t , of couree, t he
w e l l known di f f e r e nc e i n pa t t e r ne of a l c ohol i nge s t l on between men
and women. They occur n o t onl y i n t hes e La t i n American c i t i e s b u t
p r a c t i c a l l y al 1 over t he world. Once t he i nf l ue nc e of d i f f e r e n t
methods of da t a c ol l e c t i on and aut opsy pr ocedur es i s e e t aside, as
i s l a r g e l y t r ue i n t h i s st udy, t he di f f e r e nc e i n r a t e e among cities
can onl y be expl ai ned by e o c i a l and c u l t u r a l f a c t o r s l i nke d t o
pa t t e r ns of a l c ohol i nges t i on. Marconi and A d i s Caet r o (1967)
sugges t, however, t ha t San t i ago' e hi gh r a tes migh t be expl ai ned
e i t h e r by a n i ncr eas ed ge ne t i c di s pos i t l on t o he pa t i c pat hol ogy o r
by b e t t e r di agnosi s of t hes e al cohol - r el at ed condi t i ons.
hen broken down by age, mor t a l i t y da t a f o r bot h al cohol i em
and a l c ohol i c psychosi s f ol l owed t he same pa t t e r n i n a l 1 c i t i e s
s t udi ed: t her e was a n i nc r e a s e up through age 54 and a de c l i ne
t he r e a f t e r . The deat h r a t e f o r a l c ohol i c c i r r hos i e a l s o i ncr eas ed
w i t h age, r eachi ng a peak i n the age group 5 5 4 4 f o r bot h males and
f emales. Thus, among malee, combined da t a f o r a l 1 t he c i t i e e i n t he
s t udy ehow t ha t t he r a t e i n the age group 5 5 4 5 year s l e more than a
hunQed times g r e a t e r t han t h a t i n t he age group 15-25 year s
(approxima te1 y 100/100,000 ver s us 0 . /100, 000), and approxima t e l y 10
times g r e a t e r t han f o r ages 25-35 year e ( appr oxi mat el y 100/100,000
ver s us 10/100,000). These di f er ences r e e ul t bo t h from t he chroni-
c i t y o l i v e r c i r r h o s i s and from i t s development i n t he middie-age
year s.
Ano t her i n teres t i ng f i ndi ng o t h i s i nvee t i ga t i on was t he
e x t e n t t o which t he number of c i r r h o s i s deat hs was a f f e c t e d by
changes i n assi gnment of cause of deat h. Of t he o r i g i n a l 1, 231
dea ths di agnosed a s c i r r h o s i s wi thou t al cohol i sm, 57 percen t (7 08 )
were changed t o c i r r h o e i s wi t h al cohol i sm. With t hese addi t i one and
o t he r s from ot he r groupe, t he number of deat hs due t o c i r r hos i e wi t h
al cohol i sm went from 700 t o 1, 545, a pr opor t i onal i nc r e a s e of 235
per cent . Ci r r hos i s deat hs w i t hout mention of al cohol i sm, whi ch
numbered 1, 231, decr eaeed by 300 per cent t o 391. A s a r e s u l t o
t hese changes t her e were i nc r e a s e s i n t he number of deat hs due t o
c i r r h o s i s w i t h al cohol i sm i n ever y c i t y i n t he st udy, wi t h t he f i n a l
coun t bei ng twice t he i n i t i a 1 i n 9 c i t i e e .
When examining c i r r h o s i s mor t al i t y da t a f o r La t i n America,
Puf f er and Gr i f f i t h (1367), suggest ed t h a t 8 0 per cent of al 1
c i r r h o s i s deat hs were a l c ohol r e l a t e d. Be cause of t h i e s i gni f i c a n t
a s s oc i a t i on be tween heavy al cohol coneump t i on and c i r r hos i s ,
mor t a l i t y da t a f o r t h i s pat hol ogy can be viewed a s a n i ndi c a t or of
a l c ohol problems and i t 1s t her ef or e worth examining i n a more
e xt e ns i ve way. Tabl e 3 shows such da t a a s publ i shed i n 1978 f o r
s e l e c t e d c ount r i e s of La t i n America, Canada, and t he U.S. The r a t e s
var y consi der abl y from count r y t o count r y f o r bot h t he males and
femal es. Men's r a t e s range from a hi gh of 35/100,000 popul at l on i n
Chi l e o r Mexico t o a l ow of 4/100,000 i n Cuba o r Panama. Female
r a t e s a r e lower t han male f o r a l 1 count r i ee, w i t h t he except i on of
t he Bahamas. Se t t i ng a s i d e t h i s l a t t e r count r y, t he r ange of
v a r i a t i o n o f emale rates i s emal l er t han t h a t of malee: t he hi ghee t
rate i s 12.4/100,000 i n Chi l e and t he l owest is 1.6/100,000 f o r
Barbadoe. The f a c t t h a t two Cari bbean count r i es , Bahamae and
Barbados, have such di f e r e n t c i r r h o s i s deat h r a t e s shoul d be no t ed
and f ur t he r i nves t i ga t e d.
When compared t o r a t e e i n Canada and t he U.S., 7 o t he 22
count r i es i n Tabl e 3 have hi gher r a t e e of male c i r r hos i e . These
c ount r i e s ar e: Ar gent i na, Bahamas, Chi l e, Dominican Republ i c,
Guatemala, Mexico, and Puer t o Rico. Venezuela and El Sal vador have
r a t e e s i mi l a r t o t he U.S. and Canada. As f o r female deat h r a t e e ,
bo t h t he U.S. and Canada have r a t e e hi gher t han Barbados, Colombia,
Cost a Ri ca, Cuba, Jamai ca, Nicaragua, Panama, o r Surinam. Rates i n
Ecuador, Hondurae, and Peru a r e s i mi l a r t o t hose i n Canada but lower
t han t he U.S. r a t e . Ar gent i na has a femal e deat h r a t e f o r c i r r h o s i s
s i mi l a r t o t he U. S.
Admissions t o Mental Hoepi tals
Another common i ndi c a t or of al cohol - r el at ed problems 1s t he
pr opor t i on of per sons trea t ed f o r al cohol i sm and a s s oc i a t e d
di agnoses i n p s y c h i a u i c f a c i l i t i e s . As wi t h ot he r ndi c e s , t h i e
measure s u f f e r s from l i mi t a t i o n s s i nc e i t i s i nf l uenced by t he
p a r t i c u l a r or gani zat i on o medi cal c a r e i n each count ry. Thus, i n
the U.S. t he pr opor t i on of admi ssi ons f o r al cohol - r el at ed
p s y c h i a u i c di agnoses v a r i e s accor di ng t o t he t ype o f a c i l i t y bei ng
consi dered. I n 137 5, al cohol di s or der e account ed f o r 27 per cent of
a l 1 admi esi ons t o count y and s t a t e ment al hos pi t a l s , whi l e t he
pr opor t i on f o r pr i va te ment al hoepi t a l e and communi t y ment al heal th
c e nt e r s va s (3 per cent and 9.7 per cent , r e s pe c t i ve l y ( Pr e e i de nt ' s
Commiesion on Mental Heal t h, 1378). Another example of changes i n
al cohol - r el at ed admi ssi one, i n t h i s case due t o s h i f t s i n adminie-
t r a t i v e pol i c i e s , i s i l l u s t r a t e d by what has happened i n Ca l i f or ni a
i n tiie l a s t 30 yeare. I n 1950, admi sei ons wi t h di agnosi s of al co-
hol i sm t o s t a t e ps yc hi a t r i c hos pi t a l s comprised 22 per cent of a l 1
admi ssi ons. With t he a t t e mpt t o reduce t he emphasis on i n p a t i e n t
c a r e i n e t a te ment al i n s ti t u t i ons and t he developmen t of ou t pa t i e n t
communi t y mental he a l t h cent er e and al cohol i sm t r eat ment cent er s a s
a l t e r n a t i v e t ypes of f a c i l i t i e s , by 1970 t he pr opor t i on of
al cohol i sm admi ssi one t o s t a t e ment al hos pi t a l e i n Ca l i f or ni a had
dropped t o 0.1 per cent (Cameron 198 0).
TABLE 3
Age-Ad j us t e d Dea t h Ra tes Per 100,000 Popula t i on f o r Ci r r hos i s
of Li ver i n Sel ect ed Counui e s of t he Americas*
Ar gent i na
Bahamas
Bar bados
Chi l e
Colombia
Cost a Rica
Cuba
Domini can Republi c
Ecuador
El Sal vador
Guatemala
Honduras
Jamai ca
t4ld co
N i caragua
Panama
Paraguay
Per u
Puer t o Rico
Surinam
Uruguay
Venezuela
Canada
United St a t e s
Year
-
Tot al
-
*SOUHCE: PAHO (1378).
Alcohol-Rela t e d Admieeione t o Mental Hospi t a l e
i n Sel ect ed Count r i ee o t he Americas
Ar gent i na 8.3% o admi ssi one t o pe yc hi a t r i c
F a c i l i t y i n Lanus
Cost a Rica 32% o al 1 admi sei ons
Venezuela 3.5 t o 5.4 % o a l 1 admi ssi one
Br a z i l
Chi l e
Per u
4.5% o a l 1 female f i r e t admi ssi one
28% of a l 1 male f i r s t admi ssi one i n 1974
-- 19% o r bot h s exes
35X of a l 1 admi ssi ons t o pe yc hi a t r i c
hospi t a l e i n Sant i ago
4% t o 13% o admi ssi ons t o pe yc hi a t r i c
eer vi cee i n t he count r y
Colombia 15% of adm ssi one t o ps yc hi a t r i c s er vi cee
i n gener al hos pi t a l 8
Puer t o Ri co l .6 % o admi sei ons t o a ps y c h i a t r i c
h o s p i t a l - 1971
20% o a d u l t pa t i e nt e admi t t ed t o
psychi a t r i c hos pi t a l through t he INASS
Uni t ed St a t e s 27% of a l 1 admi esi ons t o s t a t e and
count y ment al hos pi t a l s ;
.3% o al 1 admi ssi ons t o pr va t e
hoepi t al e;
9.1 % o a l 1 admi ssi one t o communi t y ment al
he a l t h cent er e;
8% o a l 1 admi esi ons t o a l 1 f a c i l i t i e e
Ld .6 X o a l 1 irs t admi ssi one t o
i npa t i e n t ps yc hi a t r i c i n e ti t ut i ons ;
15% of al 1 readmi eei ons t o i n p a t i e n t
pe ychi a t ri c i n s ti t u t i ons
Sl uzki
196 6
Moralee and Chaeeoul
(Moeer 1980)
Or done z
(Moeer 1980)
Cae t an0
198 1
Marconi
196 7 b
A l me i da
196 9
Mi ni s t er i o de Sal ud
197 7
Avi l l er-Roi g
197 3
Toro Perez
197 3
Pr e s i de nt ' S
Commiesion on
Mental Heal t h
1978
A.R.F. S t a t i e t i c a l
Supplemen t
1977-78
Data f o r al cohol - r el at ed admi sei ons t o psychi a t r i c hospi t a l e
i n e e ve r a l c ount r i e s of La t i n Arnerica p l u s Canada and t he U.S. a r e
summarized i n Tabl e 4. The burden of al cohol - r el at ed di s or der e on
t he ps yc hi a t r i c s y s t e m of t hes e c o u u i e s va r i e e conei der abl y, f rom a
hi gh of 36 pe r c e nt of a l 1 admi esi ons i n Chi l e t o a low of 4 per cent
i n Venezuela. Ar gent i na, Cost a Rica, Br a z i l , Canada, Mexico and t he
U.S. a l 1 have r a t e e hi gher t han o r cl os e t o 20 per cent .
I n t he Cari bbean r egi on rates of admi sei one t o pe yc hi a t r i c
hos pi t a l s f o r al cohol - r el at ed problema a l s o va r y e i gni f i c a nt l y.
Beaubrun (1967a) r e por t e a r a t e of 47 . per cent i n Naeeau, 53
per cent i n Mar t i ni que, and 3 per cent i n Kingeton, Jamaica. Thi s
aut hor s ugges t s f our i n t e r a c t i n g f a c t or 8 t o e xpl a i n t h i s va r i a t i on,
not i ng hi gh rates would be f o wd i n t hoee pl ace8 of t he Cari bbean
r egi on where :
1) t ouri em i s hi ghl y developed and t he count r y' s own na t i ona l
i d e n t i t y i e poor l y del i nea t ed and di spar aged; (Examplee of
t h i s would be Bahamae and t he U.S. Vi r gi n I s l ands . It i s
t hought t h a t t he t o u r i s t pr ovi des a r o l e model t o emul at e --
someone who i e conet ant l y pl ayi ng and d r i n k i q and never seems
t o work. ) 2 ) where i ndi genoue I ndi an popul at i ons e x i s t, f o r
example Aruba; 3) where Ea s t I ndi ana (Hindue and Mosleme) are
a l a r g e p a r t of the popul at i on (examplee of t h i s would be
Tr i ni dad and Guyana); and f i n a l l y , 4) anot her va r i a bl e would
be where French c u l t u r a l i nf l uencee predomina te, l i k e
Mar t i ni que and Guadelope (Beaubrun 197 5:490).
The low rates i n Jamaica a r e expl ai ned by Beaubrun a 8 due t o
the us e of ganj a, which i e endemic on t he i s l a n d and might s e r ve a s
a n a l t er na t i v e t o dr i nki ng . Pr i nce e t al . (ci t ed by Beaubrun 197 5) ,
a gr e e wi t h t h i e cont ent i on and c i t e economic r easons: t he poor
Jamaican would pr e f e r the cheaper ganj a t o al cohol . Di scuesi ng t he
t opi c, Rubin and Lomitae (1975) deny t h i e economic i nf l uence. I n
t h e i r et udy, ganj a us er e eaw t h i s drug as a n a l t e r n a t i v e t o al cohol
and pr e f e r r e d i t because of i t e per cei ved benef i ci a1 e f f e c t e
compared t o dr i nki ng.
Tr a f f i c Acci dent s, Ar r es t e, and Sui ci de
Data on al cohol - r el at ed u a f f i c acci dent s , a r r e s t e and s ui c i de
are more d i f f i c u l t t o anal yze t han t h a t f o r c i r r h o s i s mor t a l i t y o r
ment al he a l t h admi ssi ons. For one t hi ng, a s ear ch of t he 11 t e r a t ur e
on t he epeci f i c t opi c of al cohol - r el at ed t r a f f i c acci dent s , a r r e s t e ,
and s u i c i d e s showed t h a t moet of t he publ i shed da t a f o r La t i n
American c ount r i e s a r e now more t han 20 year e o l d and r e f e r moet l y
t o the U508 and 19Oe.
More s i g n i f i c a n t l y , d i f f e r e n t c ount r i e s have var yi ng pro-
cedur es t o de a l w i t h al cohol - r el at ed probleme t h a t f a l 1 w i t hi n t he
l aw enforcement a r e a , a s w e l l a8 di f e r e n t enforcemen t pr act i ces ;
ever y pol i c e o f f i c e r has immense di s c r e t i ona r y powers a s t o when and
how t o enf or ce t he law. Gonzalez and Kataeky (1978) comment on t he
appar ent l a & of concern f o r t r a f f i c s a f e t y i n gener al and f o r t he
consequences o a l c ohol i nvol vement wi t h t r a f f i c acci dent e i n La t i n
America. "Data on t r a f f i c acci dent e are o f t e n i ncompl et e. The
i nf l uence of drugs and a l c ohol i n t r a f f i c acci dent e 1s n o t us ua l l y
r ecor ded, and even where i t i s, t he sour ce of t he r e por t 1s n o t
always uniform and c l e a r . I n mos t cases t he r epor t i s baeed on t he
pol i c e o f f i c e r ' s i mpr essi on a t t he t i m e . Blood al cohol t e s t i ng and
a ut ops i e s a r e ve r y uncommon. Hence, i t 1s d i f f i c u l t , wi t hout a
c o n d u c t i q s p e c i a l S t udi es, t o es t i mat e what pr opor t i on of t r a f f i c
f a t a l i t i e s and i n j u r i e s a r e due t o al cohol andl or drugs" (Pp. 6 0) .
Negre t e (19 7a, 13 1ob) , and Saavedra and Mar i at egui (197 O),
af ter examining t he li t e r a t ur e i n pr evi ous revi ews , concluded tha t
a l c ohol 1s hi ghl y a s s oc i a t e d wi t h t r a f f i c a c c i de nt s and ot he r l e g a l
problems i n La t i n America. A more r e c e nt estimate (PAHO 1973)
i ndi c a t e s t h a t between 25 per cent and 60 per cent of a l 1 t r a f f i c
a c c i de nt s i n La t i n America a r e caused by drunk dr i ver e. Marconi and
Adi s Cas t r o (1367), commenting on dat a f o r s i x La t i n American
coun mi es (Cos t a Rica, Chi l e, El Sal vador, Honduras, Nicaragua, and
Per u) , i ndi c a t e t ha t a r r e s ts f o r publ i c drunkenness comprise 40
per cent t o 58 per cent of a l 1 a r r e s t s i n t hese nat i ons.
I n Argent i na, between t he year s of 1960 and 1965 t he
per cent age of homicides a s s oc i a t e d wi t h a l c ohol i nge e t i on va r i e d
from 2 per cent t o 10 per cent , wi t h f i ve year s i n t h i s per i od showing
f i g u r e s hi gher t han 5 per cent ( per cent ages c a l c ul a t e d by t he aut hor
wi t h f i gur e s from Vida1 1967a). I n 1961, of t hose persone a r r e s t e d
i n s hant y towns ( v i l l a s mi s e r i a ) , 7 per cent were "al cohol i cs "
(Cal deron Narvaez, c i t e d by Saavedra and Mar i at egui 1970). I n a
more r e c e nt s t udy i n Buenos Ai r es, 20 per cent of t he dr i ve r 8
examined by a n "al cohol tes t" had bl ood a l c ohol l e v e l s consi der ed
"dangerous" (Mardones 1980). Negre te (1967 b) i ndi c a t e s 28 per cent
of i ndi vi dua l s i nvol ved i n "crimes a g a i n s t persons" admi t t ed having
been under t he i nf l uence of a l c ohol a t t he time of t he crime.
I n Chi l e, Marconi (1967a) quot es da t a from t he I n s t i t u t e of
Legal Medicine of Sant i ago showing t h a t 25 per cent of t hose who
committed s ui c i de i n 1965 had pos i t i ve bl ood a l c ohol l e ve l s . He
a l s o quot es f i g u r e s from t he Chi l ean pol i c e i ndi c a t i ng t h a t 52
per cent of a l 1 cri mes a g a i n s t persone were c o d t t e d under t he
i nf l ue nc e o al cohol . As f o r t he r o l e of al cohol i n t r a f f i c
acci dent e, Vargas ( c i t e d by Moeer 1974) shows t h a t among males
i nvol ved i n t r a f f i c acci dent e, 7 0 per cent had pos i t i ve "al cohol -
emia". Viel e t a l . (1970) r e p o r t f i ndi ngs from a sample of 1, 662
a ut ops i e s perf ormed dur i ng t he per i od of 196 0-196 4 a t the I ns ti t u t e
of Legal Medicine i n Sant i ago. I n t h i e sample 41 per cent of t he
males were heavy dr i nke r s a s compared t o 5 per cent of t he femal es.
I n 943 deat hs from t r a f f i c a c c i de nt s , 46 pe r c e nt had al cohol emi ae
over 0.10 per cent . Among f emal es ( NJ 8 ) , t he pr opor t i on was onl y 6
per cent .
I n Mexico, among t he r epor t ed causes of s ui c i de i n 1967, 4
per cent were a s s oc i a t e d wi t h a l c ohol i nge s t i on ( de l a Fuente and
Campillo-Serrano W 78). A more r e c e nt s t udy done by t he I n s t i t u t o
Mexicano de Ps i q u i a t r i a on 266 cases o s ui c i de r ecei ved by t he
Se r vi c i o Medico Forense dur i r y 1979 show t h a t 113 of t he caees had
pos i t i ve l e v e l s o a l c ohol i n t he bl ood ( Ri ps t e i n 1981). Alcohol
i nvol vement i n i n j u r i e s by vi ol ence r eaches 58 per cent and 64
per cent , r e s pe c t i ve l y (Cabi l do, c i t e d i n de La Fuente and Campillo
1978). A s t o t r a f f i c a c c i de nt s i n gener al , Si l va Mart i nez (1972)
r e por t e d a l c ohol i nvol vement i n 7 per cent f o r t he count r y a s a
whole. Looking a t each of t he Mexican s t a t e s s e pa r a t e l y, t he
pr opor t i on va r i e d from a hi gh of 19 per cent i n Baj a Ca l i f or ni a t o a
l ow o 2.3 per cent i n Vera Cruz. Cal deron and Cabi l do (1967) a l e o
r epor t a n o v e r a l l t o t a l of onl y 7 per cent . I n Mexico C i t y, however,
t he pr opor t i on of al cohol - r el at ed t r a f f i c acci dent e was U .5 per cent
i n N1 4 (Navarro 191 5) .
I n Puer t o Ri co, Kaye (1974) has anal yzed t he a s s oc i a t i on
between al cohol and t r af f i c acci dent s . Thi s da t a shows t h a t between
1968 and W7 2, a l c ohol involvement i n t r a f f i c f a t a l i t i e s ranged from
46 - o 3 per cent . I n a n a na l ya i s o 508 t r a f f i c deat he f o r the year
of 1373, Kaye r e p o r t s pos i t i ve bl ood a l c ohol cont ent i n 44 per cent
o 386 examined cases. The remai ni ng 122 cases were n o t examined
either because t he deceased was under t he age of 15 o r because more
t han 5 hour s had el aps ed between a c c i de nt and deat h. Among t he
a l c ohol pos i t i v e cas es t he propor t i on of dr i ve r s , pedes t r i a ns , and
passengere wae 40 per cent , 30 per cent , and 25 per cent r es pect i vel y.
I n Venezuela, Boada (1376 ) r e p o r t s t h a t i n t he per i od between
1961 and 1964 a l c ohol was i nvol ved i n no l e s s t han 50 percen t of al 1
t r a f f i c acci dent s . I n Guatemala, onl y 9 per cent of t r a f f i c
a c c i de nt s occur r i ng between 1967 and 1971 were r epor t ed as r e l a t e d
t o a l c ohol i nge s t i on (Rivera-Lima 1973). Of al 1 a r r e s t s i n t he same
count r y i n t he per i od 1962-1963, 66 per cent were f o r drunkenness.
I n Cost a Rica, Morales and Chassoul ( c i t e d by Moser 1380) r e p o r t
t h a t t he r a t e o r oad a c c i de nt s connect ed wi t h a l c ohol i n t he t o t a l
popul at i on went from U /100,000 i n 1961 t o 25/100,000 i n 1965.
Two-thirds of a l 1 a r r e e t s i n 1965 (9,166 o u t of 13, 370) were f o r
drunkennes (Adis Cas t r o and Fl or es 1967 ). I n 1977 t he f i gur e was 59
per cent (20,557 o u t o 34,945) ( I n s t i t u t o Nacional Sobre
Alcoholismo, c i t e d i n Moser 1980).
Turning t o North America, t he U.S. between 1965 and 1975 saw
a r r e e ts f o r drunkenness de c l i ne from 35 per cent t o 15 per cent of a l 1
r e por t e d l e g a l of f e ns e s (Roizen and Schneberk 1978). I n t he same
time per i od t he t o t a l propor t i on of al cohol - r el at ed of f enses
decr eased from 53 per cent t o 38 per cent . W i t h r egar d t o a l c ohol ' s
a s s oc a t i on w i th crime, as a s s e s s e d by whether t he of f ender had been
dr i nki ng bef or e t he crime, f i g u r e s va r y by t ype of c r i m e and from
s tudy t o st udy. Roizen and Schneberk (1978), summarizing 1 U.S.
S t udi es , found f i gur e s r angi ng from 15 per cent t o 6 0 per cent .
Alcohol i nvol vement wi t h s ui c i de s and at t empt ed s ui c i de s a l s o
v a r i e s markedly a c r os s s t udi e s . Aarens and Roizen (1978), i n a
r evi ew of t h i s l i t e r a t u r e , r e por t f i gur e s r angi ng from Id per cent t o
40 per cent . As f o r the pr opor t i on of a l c ohol i c s i n samples of
completed and at t empt ed s ui c de s , t he range i s from 0.5 per cent t o
48 per cent . Alcohol ' 8 a s s oc i a t i on w i t h t r a f f i c a c c i de nt s changes
accor di ng t o t he s er i ous nes s of the event . When a l 1 t r a f f i c
a c c de nt s a r e consi der ed, r oughl y 10 pecent a r e al cohol - r el at ed
(Cameron 1378). The more s e r i ous t he a c c i de nt t he more l i k e l y t h a t
a l c ohol was i nvol ved. Cameron (1978), summarizing a number of
s t udi es on t r a f f i c f at al i ties, r epor ts t ha t t he per cent age of
dr i ve r s k i l l e d i n cr ashes who had BACs 0.1 per cent o r hi gher va r i e s
from 35 per cent t o 59 per cent .
I n Canada, between 1961 and 1974, 41 per cent of a l 1 s ol ved
murders i nvol ved a t l e a s t one person who had been dr i nki ng pr i or t o
t he murder (Addi ct i on Research Foundat i on 1978). I n 1978 between 30
per cent and 45 per cent of r epor t ed crimes of vi ol ence were al cohol -
r e l a t e d (Canada, Spe c a l Report on Alcohol S t a t i s t i c e 1931). With
r egar d t o t r a f f i c a c c de nt s , a t o t a l of 4.5 per cent of a l 1 dr i ve r s
i nvol ved i n a c c i de nt s i n 1975 were l i s t e d a s having been dr i nki ng o r
havi ng t h e i r a b i l i t y t o dr i ve i mpai r ed by al cohol . As f o r
pedes t r i ans , 12 per cent of t hose k i l l e d i n t r a f f i c a c c de nt s were
l i s t e d a s havi ng been dr i nki ng o r havi ng t h e i r a b i l i t y i mpai r ed by
a l c ohol (Addi ct i on Research Foundation 1978).
Sel ect ed f i ndi ngs f rom the l i t e r a t ur e reviewed above are
summarized i n Tabl e 5.
Communi t y S t udi es of Dri nki ng Pa t t er ns and Al coholism
Before t he 19501s, a l c ohol r es ear ch i n La t i n Ame r i c a was
d i r e c t e d mai nl y a t t he de s c r i pt i on and i n t e r p r e t a t i o n of al cohol -
r e l a t e d s t a t i s tic6 such a s consump t i on, l e g a l of f ens es , and mos t
of ten, hos pi t a l admi ssi ons f o r al cohol - r el at ed di agnoses. Progres-
s i v e l y , La t i n American count r i es began t o devel op epi demi ol ogi cal
S t udi es aimed a t a s s e s s i ng dr i nki ng pa t t e r n s and al cohol i sm i n t he
ge ne r a l popul at i on. Thi s r es ear ch wa s g r e a t l y suppor t ed by PAO
TABLE 5: Percent age of Legal Offensee Associ at ed wi t h Alcohol
i n Sel ect ed Count ri ee of t he Americas
Percent age of
Offenses Aseociated
Count r y Years wi t h Alcohol Of f ensee
Argentina 1960 - 1965 2 - 10 a l 1 homicidee
1961 67 a l 1 a r r e e t e i n shant y towns
1980 20 a eample of d r i v e r s wi t h
pos i t i ve BACs*
Chi l e
Mexico
5 2 a l 1 cri mes agai net pereon
25 a l 1 s ui ci des
46 male t r a f f i c f a t a l i t i e s wi t h
pos i t i ve BACs
7 O male dr i ver 8
7 a l 1 t r a f f i c acci dent e i n t he
count ry
17 a l 1 t r a f f i c acci dent s i n Mexico
C i t y
3 0 s ui ci de8 aut opei ed had poei t i ve
BACs
Puert o Rico 1968-1972 46 - 63 t r a f f i c f a t a l i t i e s
Venezuela 1961-1 964 5 0 a l 1 t r a f f i c acci dent e
Guatemala 1967-1972 9 a l 1 t r a f f i c acci dent s
66 al 1 a r r e s t e
Coeta Rica 1965
1977
30 a l 1 a r r e s t e were f o r publ i c
drunkennese
59 al 1 a r r e s t e were f o r publ i c
drunkennees
Canada 1961-1974 41 a l 1 sol ved murders - one of t h e
persons had been dr i nki ng
1975 4 5 a l 1 d r i v e r s i nvol ved i n acci dent e
had poei t i ve BACs
1975 12 a l 1 pedeet r i ane i nvol ved i n
t r a f f i c acci dent e
1978 30 - 45 a l 1 vi ol ent cri mes
United St a t e e 1975 1 5 r epor t ed l e g a l of f enees were f o r
drunkenness
var i ous 1 5 - 60 a l 1 cri mes a r e al cohol - r el at ed
var i ous 18 - 40 al 1 s ui c i de s and at t empt ed
s ui ci des
1978 10 a l 1 t r a f f i c acci dent e
a c t i v i t i e s i n t he ar ea. hen funde f o r r es ear ch di d not come
d i r e c t l y from PAHO, PAHO provi ded c ons ul t a nt s and or gani zed meeting8
i n var i ous c ount r i e s of t h e r egi on which hel ped br i ng t oget her
r e s e a r c he r s wi t h i n t e r e s t i n t h e f i e l d .
I n t h i s s e c t i on we examine a va r i e t y of i nve s t i ga t i ons t h a t
de s c r i be dr i nki ng pa t t e r ns among popul at i on segments of a number o
count r i es . Thi s l i t e r a t u r e 1s reviewed count r y by count r y and an
overview of i t s f i ndi ngs and l i mi t a t i o n s i s provi ded i n t he
concl usi ons. But bef or e moving t o t h e community s t udi e s review, we
shoul d not e Marconi' s ope r a t i ona l d e f i n i t i o n s f o r d i f f e r e n t t ypes of
dr i nke r s s i nc e t hey have been used not onl y i n Chi l ean sur veys but
a l s o i n s t u d i e s i n ot he r La t n American count r i es . These concept s
have been di scussed by Marconi i n a series of papera (Marconi 1965,
1967b, 1 9 6 7 ~ ) .
Al cohol i cs a r e i d e n t i f i e d by t h e i r " i n a b i l i t y t o a bs t a i n"
andl or " i n a b i l i t y t o st op" ( "l os 8 of c ont r ol " i n J e l l i n e k ' s
t ermi nol ogy). Besi des a l c ohol i c s , Marconi r ecogni zes a bs t a i ne r s ,
moderate, and exces s i ve dr i nker s . Abst ai ner s a r e t hose who had
never drunk o r who had drunk less t han a 100 cc. * of a bs ol ut e
al cohol i n a day and had done t h i s l e s s t han f i v e t i mes i n t h e year
pr evi ous t o t h e survey. Moderate dr i nke r s a r e t hose wi t h a r e gul a r
i nge s t i on of l e a s t han 100 cc. of abs ol ut e a l c ohol per day and less
t han 12 epi sodes of drunkenness per year (Marconi 1 9 6 7 ~ ) . The l i m i t
of 100cc. of abs ol ut e a l c ohol was a r b i t r a r i l y set up by Marconi
accor di ng t o t h e st andar d t h a t moderate dr i nke r s shoul d not de r i ve
more t han 20 per cent of t h e i r t o t a l d a i l y c a l o r i c i nt a ke f r m
al cohol . Assuming t h a t t he d a i l y c a l o r i c i nt a ke i s 3,000 c a l o r i e s ,
and t h a t each gram of al cohol ge ne r a t e s 7.1 c a l o r i e s , 100 cc. o r 80
grams of abs ol ut e a l c ohol w i l l pr ovi de 600. c a l or i e s o r 20 per cent of
3,000. Excessi ve dr i nke r s a r e t hose who dr i nk ha bi t ua l l y (more t han
3 days i n a week) more t han 100 cc. of a bs ol ut e a l c ohol i n any day
andl or pr es ent 12 o r more epi sodes of drunkenness i n a year .
I n t he U.S. r e s e a r c he r s have used l e s s e r q u a n t i t i e s t o
c ha r a c t e r i z e heavy dr i nki ng, a cat egor y which may i ncl ude not onl y
Marconi ' s excessi ve dr i nke r s but a l s o h i s a l c ohol i c s . More de t a i l e d
comparisons between Marconi ' S and U. S. def i n i t i o n s a r e d i f f i c u l t
because of t h e p r o l i f e r a t i o n i . e . of dr i nki ng t ypol ogi es i n t h e
l a t t e r count r y. Rom (1977) has reviewed t he s e measures a t l engt h.
The impact of d i f f e r e n t d e f i n i t i o n s of heavy dr i nki ng on sur vey
r e s u l t s i s not ne gl i gi bl e , and t h e r e l a t i ons hi p between heavy
- -
dr i nki ng and s o c i a l c l a s s can be t o t a l l y r ever sed accor di ng t o t h e
d e f i n i t i o n being used (Room 1971).
*One hundred cubi c cent i met er s al l ows f o r t h e i nge s t i on o approxi -
mat el y 9 dr i nks , each of which ha s 9 grama of abs ol ut e al cohol and
cor r esponds t o a 112 p i n t of beer ( 4 per cent ) . o r a 4 oz. g l a s s of
wine (10 per cent ) , o r a 1 oz. s hot of s p i r i t s ( 40 per cent ) .
Chi l e
Chi l e 1s one o t he count r i es i n t he sout her n cone o La t i n
America, and 1s a wine producing and consuming count ry. J e l l i n e k
(Popham 1976) des cr i bed Chi l ean problems wi t h a l c ohol a s r eachi ng
"ext r aor dl nar y magni tude." It 1s t r ue t ha t t he r e 1s a hi gh r a t e o
c i r r h o s i s mor t a l i t y and l e g a l o f ens es a s s oc i a t e d w i t h al cohol , but
t he r a tes o "al cohol i sm" do no t seem t o be dr a ma t i c a l l y hi gher t han
t hose found i n ot he r na t i ons o t he r egi on.
The f i r s t sur veys o d r i n k i q pr a c t i c e s developed i n Chi l e
were a l 1 aimed a t t he urban popul at i on o Sant i ago. Honorato ( c i t e d
by Marconi U67a ) and Horwi t z ( c i t e d by Marconi 1967a), and Marconi
e t a l . (1955) r e p o r t r a t e s of pat hol ogi cal dr i nki ng, and a l s o o
modera te dr i nki ng , abs t en t i on, and requency o i n t oxi ca t i on. The
b e s t known o a l 1 t hes e sur veys, perhaps because i t 1s t he onl y one
publ i shed i n Engl i sh, 1s t h a t r epor t ed by Marconi e t a l . i n 1955.
Marconi e t a l . s et o u t t o obt a i n i nf or mat i on about t he
pr eval ence o al cohol i sm. The popul at i on s t udi e d was t h a t o a
working c l a s s subur b of Sant i ago which, accor di ng t o t he aut hor s ,
wa s t ypi c a l o t he Chi l ean working c l a s s i n urban areas.
The pr eval ence o al cohol i sm was 4.2 per cent (8.3 per cent f o r
males and 0.6 per cent f o r femal es). Excessi ve dr i nke r s i ncl uded 28
per cent o t he mal es and 0.5 per cent of t he femal es. Drunkenness
was v e r y f r e que nt among males, wi t h 43 per cent of them g e t t i n g
i nt oxi c a t e d a t l east "each weekend." kl s o, 22 per cent of t he men
drank bef or e br e a kf a s t everyday. Marconi r i g h t l y concluded t h a t
s i nc e dr i nki ng f i r s t t hi ng i n t he morning was s o pr eval ent i n t h i s
Chi l ean sample i t coul d n o t be consi der ed a s i g n o a ddi c t i on i n
t h i s popula t i on.
Honorato e t a l . ( c i t e d by Marconi 1967a) surveyed dr i nki ng
pa t t e r ns i n a working popul at i on of Sant i ago. The r e s u l t a showed
19 per cent a bs t a i ne r s , 54 per cent i r r e g u l a r modera te dr i nker s ,
21 percen t r e gul a r modera te dr i nker s , 2 pe r c e nt excessi ve dr i nker s.
The pr opor t i on o a l c ohol i c s i n t he sample, 6 per cent , was a l i t t l e
hi gher than t ha t pr evi ous l y found by Marconi e t al . . Horwi t z e t a l .
( c i t e d by Marconi 1967a) i n a s t udy o "Gran Sant i ago" found a
s i mi l a r pr opor t i on o al cohol i cs : 5 per cent . H i s d e f i n i t i o n of
al cohol i sm u t i l i z e d a s oper a t i ona l i ndi c a t or s " i n a b i l i t y t o a bs t a i n"
and " i n a b i l i t y t o s t o p dr i nki ng, " accor di ng t o t he concept s
developed by J e l l i n e k (1960) and adopt ed by Marconi (1967 c) t o
i n d i c a t e phys i cal a ddi c t i on t o al cohol . There a l s o were 8 per cent
exces s i ve dr i nke r s ( def i ned a s t hose who had more t han 12 epi sodes
o drunkenness i n the pr evi ous year ) , 54 per cent moderate dr i nker s ,
and 34 per cent a bs t a i ne r s . Among women onl y 0.8 per cent were
a l c ohol i c s , as compared t o 11 per cent of t he men.
St udyi ng t he pr eval ence of ment al di s or der e i n t he nor t h area
of Sant i ago, Moya e t a l . (1969) found a r a t e of al cohol i sm r angi ng
from 1.9 per cent i n a popul at i on of middle l ower c l a s s t o 3.9
pe r c e nt i n a n "organi zed" working c l a s s popul at i on and i ncr eas i ng t o
7 .6 per cent i n a mar gi nal popul at i on. The t ypol ogy of dr i nke r s
employed was t ha t proposed by Marconi.
a i t s i d e Sant i ago, dr i nki ng pa t t e r ns have been s t udi ed i n t he
i s l a n d of Chi l oe by Tapi a e t al . (1966) and by Ruiz e t a l . (1967),
i n Cant i n by Medina and Marconi (197 O) , and i n Tal ca by Medina e t
a l . (1980). The Medina and Marconi s t udy (1970) de s c r i be s t he
dr i nki ng pa t t er ne of a dul t Mapuches f rom f i v e r es er va t i ons l oc a t e d
i n a r u r a l a r e a of Chi l e. Near l y a l 1 i ndi vi dua l s 15 year s of age
and ol de r were i nt er vi ewed and t h e i r dr i nki ng h a b i t s assessed. The
dr i nki ng c a t e gor i e s u t i l i z e d were t hose proposed by Marconi i n
pr evi ous work di s cus s ed above (Marconi 1967 c).
With these d e f i n i t i o n s 3 per cent o t he men (N-70) and 15
per cent o the women (N17 5) were a bs t a i ne r s . Among t he men t he
pr opor t i on of modera te dr i nke r s , exces s i ve dr i nke r s , and al cohol 1 cs
wa s 46 per cent , 26 per cent and 26 per cent , r es pect i vel y. The
pr eval ence of al cohol i sm among t he Mapuche 1s t hus t hr ee times
hi gher t han t h a t i n the working popul at i on of Sant i ago. I t 1s
pos s i bl e , however, t h a t t h i s f i gur e 1s a r t i f i c i a l l y i nf l a t e d by t he
d e f i n i t i o n of al cohol i em employed i n the s tudy. Medina and Marconi,
i n di scussi ng t h i s r e s u l t , acknowledge t h a t t he oper at i onal i ndi ca-
t o r s pr evi ous l y a ppl i e d t o urban popul at i ons i n Sant i ago were of
l i t t l e u t i l i t y among t he Mapuche t o di agnose al cohol i sm. It was
di f f i c u l t t o a s c e r t a i n volume of i nge s t i on, and a l c ohol consumption
days coul d n o t be c l a s s i f i e d a s working o r non-working days, due t o
Mapuche di vi s i on of time i n t o per i ods r a t h e r t han days of work and
of rest.
Among women 8 3 per cent were moderate dr i nker s , 1 per cent were
exces s i ve dr i nke r s and anot her 1. 3 per cent were al cohol i ce. The
norms surroundi ng a l c ohol i nge s t i on i n t hese Mapuche communi ties
e xpl a i n t o some e x t e n t the di f f e r e nc e s i n pa t t e r ns of dr i nkl ng
between men and women: men dr i nk among themselves; sometimes women
p a r t i c i p a t e i n t hese dr i nki ng s e s s i ons , but t hey never dr i nk among
themselves except dur i ng p a r t i e s and f e s t i v i ties. Wine i s t he
pref er r e d beverage .
These r e s u l t a from Medina and Marconi' s work map w e l l ont o t he
an t hr opol ogi cal observa t i one made by Lomni t z (1976 ) among t he
Mapuche. According t o her , Mapuche dr i nki ng i s ba s i c a l l y a " s oc i a l
a c t between males." Thi s c h a r a c t e r i s t i c has been pr es ent i n Mapuche
dr i nki ng f o r more t han 400 year s, having sur vi ved changes i n
dr i nki ng h a b i t s due t o Spani sh col oni zat i on and mi gr at i on t o t he
c i t i e s . Changes i n Mapuche a l c ohol i nge s t i on over t i m e have
i ncl uded a swi t ch t o wine and s p i r i t s , dr i nki ng i n bar s , new r i t u a l
dr i nki ng occasi ons of non-Mapuche or i gi n, and changes i n femal e
dr i nki ng norms.
Besi des st udyl ng t he ge ne r a l popul at i on, some Chi l ean r esear ch-
ers have des cr i bed a t t i t udes towards a l c ohol i nges t i on among s chool
popula t i ons o adol escen ts ( Gar ci a 1976 , Norambuena 198 0). These
s t udi es i l l umi na t e some a s pe c t s of a t t i t u d e s and behavi or s wi t h
r egar d t o a l c ohol i nge s t i on which have n o t been touched upon by
sur veys o t he a d u l t popul at i on i n Chi l e. They put more emphasis on
mapping t he a dol e s c e nt ' s knowledge o and r e a c t i on t o dr i nki ng t han
on a s c e r t a i n i w pat hol ogi cal consumption. Such a n approach seems t o
stem from t he not i ons t h a t a ) t her e a r e n' t many pat hol ogi cal
dr i nke r s i n t h i s popul at i on wort h count i ng; and b) i t 1s necessar y
t o know what adol es cent s t hi nk about a l c ohol i nge s t i on i n or de r t o
implemen t preven t i ve campaigns be tter .
Ar gent i na
Ar gent i na, a s Chi l e, 1s one o t he wine producing and wine
consuming coun tries i n t he sou t her n par t o Sou t h Ameri ca. A l though
n o t possessi ng such a t r a d l t i o n o a l c ohol r es ear ch a s Chi l e, a
group of r es ear cher e working i n Buenos Aires has produced a
s i g n i f i c a n t s ur vey o i a tti t udes towards dr i nki ng i n t he ge ne r a l
popul at i on (Goldenberg e t a l . 1968) a s w e l l a s a ve r y i l l umi nat i ng
s ur vey o "al cohol i sm and exces s i ve dr i nki ng" (Tarnopol sky e t a l .
1 9 7 5).
J e l l i n e k descr i bed Ar gent i ni an dr i nki ng a s f ol l ows:
. . . bot h men and women dr i nk wine wi t h t h e i r meals
. . . i t 1s s t r i c t l y underst ood t h a t women a r e n o t
supposed t o become even s l i g h t l y i n t oxi ca t ed. There
18 some dr i nki ng out s i de meals. I n t he upper s o c i a l
classes c oc kt a i l dances a r e v e r y popul ar , but one
does n o t see drunkenness on t hese occasi ons.
Gener al l y, t he Ar gent i ni an does not g e t drunk
publ i c l y, but he may do s o a t home. I n Ar gent i na,
a s i n many ot he r South American count r i es , one may
speak o "domes t i c drunkenness" (Popham 1976 : 17 3).
Some o J e l l i n e k ' s obs er vat i ons have been conf i r ned by
empi r i cal dat a. The di f f e r e nc e i n t he pr opor t i on o a l c ohol i c s and
exces s i ve dr i nker e between man and women ( r a t i o o 15: l i n
Tarnopol sky e t a l . 1975) and t he hi gh pr opor t i on o moderate
dr i nke r s among women (76 per cent o a l 1 t he r espondent s i n the same
sur vey) s ugges t t h a t women dr i nk onl y s o c i a l l y , w i t h no g r e a t r i s k
of i nt oxi c a t i on. Wine 1s t he pr ef er r ed beverage.
I n t he s t udy o a t ti t udes towards a l c ohol consump t i on,
Goldenberp e t a l . (1968) compared two groups o respondent s: a
sample o i ndi vi dua l e from t he c i t y o Buenos Ai r es, and a sample o
i ndi vi dua l e from t he d i s t r i c t of Lanus, a n i n d u s t r i a l suburb of t h a t
c i t y. The r e s u l t s showed t h a t 74 per cent of t he f a mi l i e s drank wine
w i t h meals. I n Lanus, 51 per cent of t he sample r egar d "under 12
year s of age" t o be a n accept abl e l i m i t a t which peopl e can begi n
dr i nki ng. The pr opor t i on of r espondent s i n t he Buenos Ai r es sample
endor si ng t he same l i m i t was even hi gher , 7 1 per cent . The sample
from Lanus was more concerned about harmful e f f e c t s of a l c ohol (90
per cent of t he r espondent s i n Lanus a g a i n s t 30 per cent i n Buenos
Ai r es ) . A ma j or i t y of t he r espondent s i n bot h samples, 7 5 per cent
i n Lanus and 51% i n Buenos Aires, consi der ed al cohol i sm a vi ce.
When t he samples were di vi ded by s o c i a l s t r a t a , t he low s t r at um
showe d more per mi ssi veness towards al cohol use and a gr ea ter suppor t
f o r "puni t i ve" s ol ut i ons t o al cohol i srh ( pr ohi bi t i on o s a l e s , f i n e s
a s punishrnen t f o r a l c ohol i c s ) . The middle c l a s e suppor t ed medical
and s o c i a l s ol ut i ons s u& a s t r eat ment , educat i on, socioeconomic
improvements.
The aut hor s a l s o r e p o r t t h a t 6 2 per cent of t h i s sample
accept ed a s i d e a l d a i l y i nt a ke a t l e a s t 114 of a l i t er of wine
( appr oxi mat el y 112 p i n t ) , and 44 per cent accept ed a d a i l y i nt a ke of
more t han 112 l i t er of wine (approxi mat el y 1 U.S. pi nt ) . The a c t u a l
d a i l y i nt a ke of wine i n t he sample was a s f ol l ows: 114 t o 112 l i t er ,
21 per cent ; more t han 112 l i t er , 58 per cent .
I n t he sur vey descr i bed by Tarnopolsky e t a l . (1975), which
a l s o used t he Lanus d i s t r i ct a s a r es ear ch si t e, t he d a i l y i nt a ke of
vi ne among males wae 500 m l . , whi l e i o r femal es i t was 100 m l .
However, t hese aver age8 a r e s t r ongl y c l a s s r e l a t e d. I n a slum a r e a
Tarnopol sky e t a l . found a n aver age of 1 l i t er of wine per day,
whi l e i n t he beet r e s i d e n t i a l a r e a e t h i s went down t o 300 m l . per
day. C r i t e r i a f o r def i ni ng t he var i ous t ypes of dr i nke r s were t hose
developed by Marconi ( 1 9 6 7 ~) . The i nt er vi ewer s were physi ci ans and
r e s i de nt s i n ps ychi at r y. The pr eval ence of a l c ohol i c s and exces s i ve
dr i nker s i n t he male popul at i on was 4.4 per cent and 12 per cent ,
r e s pe c t i ve l y. There were no a l c ohol i c s among women, and onl y 1
per cent of them were exces s i ve dr i nker s. The r a te of a bs t e nt i on and
moderate dr i nki ng was 11 per cent and 7 1 per cent among females. hen
t hese r e s u l t s a r e compared t o Chi l ean sur veys, Lanus has one-half
t he number of a l c ohol i c s found by Marconi e t a l . (1955) and
one- t hi r d of t h a t found by Horwitz e t a l . ( c i t e d i n Marconi 1967a).
As f o r exces s i ve dr i nker s , t he 12 per cent i n Lanus i s agai n les8
than t he U per cent r epor t ed by Horwitz and l e e s t han hal f t he 28
per cent r epor t ed by Marconi, bot h i n Sant i ago.
I n the r e por t from Lanus, a bs t e nt i on has a U-shaped
r e l a t i ons hi p wi t h age, bei ng hi gher bot h among t hose 15-24 year s of
age (23 per cent ) and t hose 55 year s of age and over (16 per cent a s
r e c a l c ul a t e d by t h i s aut hor ) . Al cohol i cs and excessi ve dr i nke r s
were concent r at ed i n t he 25-54 age group, wi t h r a t e e of al cohol i sm
around 6 percent . Moderate dri nki ng does not show much var i at i on
wi t h age; approxi mat el y 7 0 percent of those i n a l 1 age groups a r e
w i t hi n t hi s ca tegory. Drinking w a s negat i vel y associ a t ed w i t h
educat i on, occupation, and degree of urbani zat i on of r e s i de nt i a l
area. The as s oci at i on between al cohol i nt ake and t hi s last
c ha r a c t e r i s t i c i s t he most marked i n t hi s survey. The di f f er ences
are no t s o much i n t he r a t e s of abst ent i on, but i n t he proport i on of
al cohol i cs and excessi ve dri nkers. While t he weal t hi er ar ea had a
r a t e of 0.b percent al cohol i cs and 7 .5 per cent excessi ve dr i nker s
(males onl y), t he poorer a r e a had a r a t e of 13 percent al cohol i cs
and 20 percent excessi ve dri nkers.
Migrants from r u r a l ar eas of Argentina had s i gni f i c a nt l y more
"pat hol ogi cal dri nkers" (excessi ve dr i nker s pl us al cohol i cs ) than
t hose born i n t he province of Buenos Aires. When compared t o
f or ei gner s, Argent i ni ans as a group (born i n t he ci t y o r i n r ur a l
ar eas ) di d no t have s i gni f i c a nt l y di f f e r e nt r a t e s of al cohol i sm o r
excessi ve dri nki ng (Tarnopolsky e t al . 197 7 ) .
Grimson e t , a l . (1972) assessed t he prevalence of al cohol i cs
and excessi ve dr i nker s, i n a random sample of 3,357 Buenos Aires
r esi den ts . The def i n i t i ons of excessi ve dr i nker s and a l cohol i cs a r e
modified ver si ons of t hose proposed by Marconi i n Chi l e and followed
by Tarnopolsky i n h i s survey of Lanus. Grimson found l a r ge
proport i ons o bot h al cohol i cs and excessi ve dr i nker s i n his
sample. Thus, whi l e Tarnopolsky e t a l . (1975) r epor t 1.9 percent
al cohol i cs and 6. 4 per cent excessi ve dr i nker s, Grimson's r e s ul t e
show 16 percent excessi ve dr i nker s and 6 .? percent al cohol i ce. The
number of abs t ai ner s , 15 percent , i s similar t o t ha t found by
Tarnopolsky, which was 16 percent . Modera t e dr i nker s represent ed
6 1 per cent of Grimson's sample, but 73 per cent of Tarnopolsky' s.
Other r e e ul t s from Grimson's work a r e s i mi l ar t o those from
ot her surveys i n Lat i n America. There 1s a concent rat i on of
excessi ve dr i nker s and al cohol i cs i n t he 22-39 age group, t he
percent age of al cohol i cs among males i s much l a r ge r than among
females (13 percent versus 2 percent ), who have l a r ge r r a t e s of
abs t ent i on than males (20 percent versus 9 percent ). There a l s o 1s
a concent rat i on o excessi ve dr i nker s and al cohol i ce i n t he lower
soci oe conomi c groups. Comparing t he di s t r i but i on of di f f eren t types
of dr i nker s among t he popul at i on l i vi ng i n slunu wi t h t ha t l i vi ng i n
urbani zed ar eas , Grimson found a r a t e of al cohol i sm four times
hi gher i n t he slums (21 percent versus 6 percent ). The slums a l s o
had a s l i g h t l y hi gher frequency of abs t ai ner s (19 percent versus 15
per cent ) , l e s s moderate dr i nker s (49 per cent versus 6 3 percent ), and
less excessi ve dr i nker s (12 percent versus U percent ).
Per u
Alcohol r eeear ch i n Per u ha s been a p t l y examined by Mar i at egui
(190 7 a , U7 4, 191 Y , 198 1) . According t o Maria t egui (197 9 ) , di f f er-
e n t geogr aphi cal a r e a s of t he count r y pr e f e r d i s t i n c t t ypes of
a l c o h o l i c beverages. I n t he Per uvi an Amazon t he t r a d i t i o n a l
beverage i s chi cha, ferment ed from t he yuca p l a n t (Manihot
s ucul ent a) . I n the c o s t a l zone the most consumed beveranes a -
-
and d i s t i l l e d s p i r i t e, wi t h ve r y l i t t l e wine. I n t he Andean r egi on
t he more t r a di t i o n a l f er ment ed beverages ( chi cha, ~ u a r a p o ) and
canazo, a d i e t i l l e d e p i r i t from t he sugar-cane, a r e t he pr e f e r r e d
beverages. Almeida (1971) comments t h a t onl y 20 per cent of t he
sugar cane s p i r i t s consumed i n t he Andean r egi on 1s r e c t i f i e d . The
ot he r 8 0 per cent i s consumed wi t hout r e c t i f i c a t i o n and t he t oxi c
componente add t o t he r i s k s of devel opi ng or ga ni c pat hol ogi es
comonl y a e s oc i a t e d wi t h abusi ve al cohol consumption. Si de by s i d e
w i t h a l c ohol consump t i on, t he wi despr i de habi t of coca-leaf chewing
t o m t i ga te hunger and f a t i g u e cons ti t u tes a n addi t i ona l publ i c
he a l t h problem i n t he Andean popul at i on of Peru. Caravedo and
Almeida ( U7 1 ) r epor t t ha t t h i s habi t af f e c t s appr oxi mat el y 50
per cent of t he economi cal l y a c t i v e r u r a l popul at i on and t h a t i t s
pr eval ence i n the t o t a l Andean popul at i on v a r i e s from 25 per cent t o
1 3 per cent .
Epidemiologi cal s t udi es i n Per u have been developed w i t h t he
o v e r a l l aim of a e s e s s i ng psychi a t r i c di s e a s e s i n gener al , w i t h
al cohol i sm a s one of t he e n t i t i e s being s t udi ed. Rotondo e t a l .
( c i t e d by Mar i at egui 196Ja) developed one euch s t udy i n a e o c i a l l y
uns t abl e and di sor gani zed community of c e nt r a l Lima. Mar i at egui
( U7 0) surveyed Li nce, ano t her urban d i s t r i ct of Lima, whi l e Ro tondo
e t a l . ( c i t e d by Mar i at egui 1379) r e p o r t a sur vey i n a r u r a l
pr ovi nce near Lima, and Chr i s t i aneen and Malca ( c i t e d by Mari at egui
1979) s t udi e d pr eval ence of al cohol i sm i n t he c oa s t a l c i t y of
Tr u j i l l o i n nor t her n Peru. Three of t heee s t u d i e s found a r a t e of
al cohol i sm andar exces s i ve dr i nki ng around 9 per cent , wi t h t he
except i on of t he urban d i s t r i c t of Li nce, where t wo-t hi rds of t he
popul at i on i s mi ddl e c l a s s and t he r e por t pr eval ence of al cohol i sm
and r e gul a r exces s i ve dr i nki ng was much l ower, 2.68 per cent .
Ro tondo and Bazan (1976) r e p o r t mixed r e s u l t e from a sur vey of
dr i dci ng pr a c t i c e e among workers of two f a c t o r i e s on t he out s ki r s of
Lima .
Inf ormat i on on a l c ohol consump t i on and d r i n k i q pa t t e r ns among
t he na t i ve i nha bi t a nt s of Per u, a n i mpor t ant segment of t he
count r y' s popula t i on, comes almos t e xc l us i ve l y f rom e t hnographi c
e t udi e s . These have been developed among t he peopl es of t he Andean
r egi on, and t her e i e ver y l i t t l e i nf or mat i on about dr i nki ng customs
i n the Per uvi an Amazon (Maria t egui 197 9 ). Manguin (1957 ) decr i bed
dr i nki ng pa t t e r ns and al cohol - r el a t ed cus toms of t he 1,8 00 r e s i de nt e
o t he Vicoe community i n t he Peruvi an Andes. According t o h i s
des cr i pt i on, dr i nki ng 1s uni ver s al among Indi ana i n Peru, and a l 1 of
t he popul at i on 1 year s of age and ol der dri nks. Among a d u l t males
dr i nki ng o f t e n l eads t o drunkenness, and al t hough dr i nki ng 1s
f r equent i t remains a s o c i a l a c t i v i t y " i nt egr at ed wi t h t he most
bas i c and powerf u1 s o c i a l i n s ti t u t i ons i n t he communi t y. " Si nce
most of t he dr i nki ng 1s done i n s o c i a l s i t ua t i ons , a s wi t h t he
Mapuche s t udi ed by Medina and Marconi (1970) and by Lomnitz (1976 ),
t her e a r e no s o l i t a r y drunkards i n Vicos. The absence o
al cohol - r el at ed pat hol ogy i n Vicos 1s expl ai ned by Manguin a s a
f unct i on of t he i nt e gr a t i on of dri nki ng and c ul t ure.
Drinking i n Lunahuana, a mes t i z o communi t y sout h of Lima, has
been descr i bed by Simmons (1359, 1968). As i n Vicos, dr i nki ng i n
t h i s communi t y 1s widespread and ve r y f requent . A t t i t udes towards
dri nki ng a r e permi ssi ve, and t her e are no de f i ni t i ons of dr i nki ng a s
a " s oc i a l problem." Alcohol consumption 1s a s o c i a l a c t i v i t y and
has bo th anxi e ty-reducing and i nt e gr a t i ve r o l e s i n t he s oci e ty.
I nt e gr a t i on 1s done through compliance wi t h dr i nki ng norms di c t a t e d
by t he group. Because aggr essi ve behavi or 1s disapproved, dr i nki ng
becomes a means of r e l i e vi ng t ensi on. So l i t a r y dr i nki ng 1s seen a s
abnormal, and "1 t l e ge ne r a l l y bel i eved t h a t t hese men dr i nk al one
because t hey a r e e t i ngy and do n o t want t o s har e t he i r l i quor "
(Simmons l!3 58 :lo9 ) . Drinking pat hol ogi es a r e r ar e. There 1s a l s o a
pos i t i ve a s s oc i a t i on between dri nki ng and work. Many of t he working
a c t i v i t i e s connected wi t h t he product i on of al cohol and c ul t i va t i on
of grapevi nes a r e punct uat ed by dri nki ng. The beverage 1s provided
by t h e employer, and by t he end o t he day, e s pe c i a l l y duri ng grape
harves t time, many o i t he workers a r e drunk.
J e l l i n e k (Popham 1976) descr i bed Br a z i l a s a s p i r i t and wine
dri nki ng country. However, al t hough wine 1s i ndeed consumed i n t he
sout h, i n t he nat i on a s a whole beer 1s t he second most consumed
beverage, af t e r di 8 t i l l e d s p i r i ts irom sugarcane. Thus, as occur s
i n Peru, d i f f e r e n t r egi ons may have di f i e r e n t beverage preferentes.
I n the s t a t e s of t he s out h where grapevi ne c ul t i va t i on and wine
product i on 1s a growing i ndus t r y, wine dri nki ng 1s f a i r l y common.
Thi s eeems t o be a custom which 1s f i ndi ng accept ance i n t he upper
s o c i a l cl as s es o t he s out heas t regi on, e s pe c i a l l y i n urban a r e a s
such a s Rio de J anei r o and Sao Paulo.
Cachaca, t he d i s t i l l e d s p i r i t f rom sugarcane, 1s a beverage
whose consumption c ut s acr os s al 1 r egi ons of t he count ry and s o c i a l
cl as s es . It 1s f r equent l y consumed al one o r mixed wi t h t he j ui ce of
t r opi cal f r u i ts and sugar. It l e , t oget her w i t h beer , t he pr ef er r ed
beverage of t he lower socioeconomic s tratum bot h i n urban and r u r a l
ar eas . It 1s a l s o r e gul a r l y consumed i n r e l i g i o u s ceremonies o i
Afro-Brazi l i an c ul t a , where i t has t he e f f e c t o i nt egr at i ng t he
cul t membership (Leacock 1979).
Knowledge abou t a l c ohol consumption and dr i nki ng pa t t e r ns 1s
ver y l i mi t ed. The most o f t e n c i t e d assessment o t he magnitude of
a l c ohol problems i n Br a z i l 1s the per cent age o al cohol - r el at ed
acimissions t o p s y c h i a t r i c hospi tals; between 1960 and 197 4 t he
per cent age o al cohol - r el at ed admi ssi ons went from 3 per cent t o 5
per cent f o r f emal es and from 21 per cent t o 29 per cent f o r males
(Cae t an0 19dl ) .
The f i r s t sur vey of dr i nki ng pr a c t i c e conducted i n t he gener al
popula t i on was by Azoubel Neto (1967 ), who s t udi ed a l c ohol i nges t i on
i n a d i s t r i c t o Ri bei r ao Pr et o, a town i n t he state of Sao Paulo.
Among males (N438), t her e were 22 pe r c e nt a bs t a i ne r s , 48
pe r c e nt moderate dr i nke r s , and 14 per cent pat hol ogi cal dr i nker s.
The d e f i n i t i ons o r t hese ca t egor i es a r e no t gi ven. Among femal es
t he a bs t e nt i on r a t e was 36.5 per cent , whi l e moderate, excessi ve, and
pat hol ogi cal i nge s t i on occur ed i n 52 per cent , 10 per cent , and
1 per cent , r e s pe c t i ve l y.
Another s ur vey was c a r r i e d o u t by Luz ( c i t e d i n Negrete,
i Ybl a) i n a lower c l a s s suburb o Por t o Al egre i n t he sout h p a r t of
t he count ry. Respondente were a r e pr e s e nt a t i ve random sample o t he
d i s t r i c t . The d e f i n i t i o n s u t i l i z e d were t hose used by Grimson e t
a l . (1372) i n Argent i na. The r a t e of problem dr i nke r s was 10
per cent , which 1s l e e s t han hal f of t he 23 per cent r epor t ed by
Grimson.
More r e c e nt l y, Vianna Fi l ho e t a l . (1978) r e p o r t on dr i nki ng
pa t t e r n s o a sample of r e s i de nt s o t he I el and o Sant a Cat ar i na, a
d i s t r i c t o Fl or i anopol i s , a s t a t e c a p i t a l i n t he sout h o Br azi l .
Approxima t e l y 8 0 percen t o the r espondent s were f emal es, a n over-
r e pr e s e nt a t i on r e s u l t i n g from no pr e e e l e c t i on of i nt er vi ewees and
t he f a c t t h a t i nt e r vi e ws were conducted dur i ng t he af t er noon when
mos t of t he men were a t work.
The r a t e o i a bs t e nt i on was 39 per cent i n t he more ur bani zed
p a r t o t he di 8 t r i c t and 55 per cent i n the ot he r ar ea. I nges t i on of
a l c o h o l i c beveragee was done us ua l l y a t p a r t i e s and s o c i a l gat her -
i ngs . Only 3 per cent o the r espondent s i n t he urban a r e a and
6 per cent i n t he r u r a l a r e a s t a t e d t hey drank ever y day. Drinking
1s us ua l l y done a t home, and the beverage mos t r equent l y drunk i s
cachaca, f ollowed by beer and t hen wine.
Two r e c e nt paper s by Masur e t a l . (1980) and by Moreira e t a l .
(1381) r epor t on t he dr i nki ng pa t t e r ns of pa t i e n ts hospi t a l i z e d i n
ge ne r a l hos pi t a l s i n two r egi ons o Br azi l . Masur e t a l . (1980)
s e l e c t e d a t random 6 3 women and 50 men who were hos pi t a l i z e d f o r
t r eat ment o va r i ous or ga ni c pat hol ogi es. The a ut hor s used as an
i ndi c a t or o al cohol i sm t he d a i l y i nge s t i on of a t l e a s t 150 m l . o
et hanol ( t h i s al l ows f o r t he i r y e s t i o n of appr oxi mat el y 13 dr i nks,
each of which would have 9 grams of a bs ol ut e a l c ohol ) o r the
i nge s t i on o 450 ml . of e t ha nol dur i ng weekend8 ( t h i s al l ows f o r 40
dr i nks , each of which would agai n have 9 grams of abs ol ut e al cohol ,
o r 1 112 b o t t l e s of dOo proof s p i r i t s ) . They found t h a t 59 per cent
of t he men and U per cent of the women r e por t e d enough dr i nl dng t o
be c l a s s i f i e d a s al cohol i cs . Comparing t hes e f i ndi ngs w i t h t he
i nf or mat i on on medi cal r ecor d8 showed that t he medi cal h i s t o r i e s di d
n o t have mudi i nf or mat i on concerning a l c ohol i nt ake. For men, t he
pr opor t i on r ecogni zed i n doc t or ' s not e s a s having t he above
mentioned l e v e l s of a l c ohol i nt a ke was 32 per cent ; f o r women t he
pr opor t i on was 10 per cent .
Thi s r es ear ch was r e pl i c a t e d i n two hos pi t a l s i n t he nor t he a s t
p a r t of t he count r y by Moreira e t a l . (1380). The r e s u l t s showed
l ower r a t e s of d r i n k i q t han t hose r epor t ed by Masur e t a l . Thi s 1s
e s p e c i a l l y s o f o r t he r u r a l hos pi t a l where r a t e s f o r men were hal f
of t hose f ound by Masur e t al . , whi l e r a tes f o r women a r e onl y one-
f i f t h a s hi gh. A t o t a l of 30 pecent of these dr i nke r s r epor t ed
consump t i on of d i s t i l l e d s p i r i t e f rom sugarcane.
Colombia
Pr evi ous r evi ewer s have a l r e a dy commented on t he l a c k o
epi demi ol ogi cal r es ear ch on dr i nki ng problems i n Colombia (Velasquez
1367; Mar i at egui 1974). Thi s seems t o be st i l l t r ue today.
Madsenzie and Osori o (197 7 ) r e por t a s t udy of dr i nki ng pa t t e r ns , t he
f i r st one undert aken i n Colombia, i n a r u r a l c omuni t y i n t he
e a s t e r n p a r t of the count ry. I nt er vi ewer s f o r t h i s s t udy were
school t eacher s r e c r u i t e d i n t he l o c a l school d i s t r i c t . The e f f e c t
of us i ng t hese i nt e r vi e we r s on r espondent s' r e por t i ng 1s n o t
di s cus s ed by t he aut hor s; consi der abl e under - r epor t i ng may have been
caused by havi ng t hese a u t h o r i t y f i g u r e s i nqui r e about dr i nki ng
pa t t er ns.
The pr e f e r r e d beverages were d i s t i l l e d s p i r i t s from sugar cane
and beer . Drunkenness epi sodes were f r e que nt and, accor di ng t o t he
aut hor e, seemed t o f ol l ow a na t i ve p a t t e r n o i a l c ohol i nge s t i on
whi ch i nva r i a bl y l e a ds t o i nt oxi cat i on. Among males 7 0 per cent
del car ed a t least one epi sode o i drunkenness per par . Among
femal es t h i s pr opor t i on was 20 per cent . Drunkenness was e s p e c i a l l y
common d u r i w Chri st mas, New Year, f a ml l y gat her i ngs , and ot he r
s o c i a l occasi ons. A t o t a l of 19 per cent of t he men were a bs t a i ne r s ,
46 per cent were moderate dr i nke r s , 24 per cent were exces s i ve
dr i nker S, and 10 percen t al cohol 1 cs. Women had a l a r g e r propor t i on
of a bs t a i ne r s , fewer exces s i ve dr i nke r s and no al cohol i ce. I n bot h
s exes abs t en t i on was pos1 t i v e l y a s s oc i a t ed w i th age.
Uruguay
Munoz (1967) r evi ews da t a on a l c ohol i nvol vement i n t r a f f i c
a c c i de nt s , as wel l a s l aws and r e gul a t i ons which a ppl y t o
al cohol - r el at ed of f ens es . The da t a i n t he paper r e f e r s t o t he
begi nni ng of t he ' 50s and must be out dat ed by now. The same has
i n e v i t a bl y happened t o J e l l i n e k ' s (Popham 1976 ) comments on l i quor
pr oduct i on and a l c ohol consumption i n the coun t r y.
Bol i vi a
The most s i g n i f i c a n t r es ear ch on a l c ohol t o come o u t of
Bol i vi a has been Heat h' s s t u d i e s of t he Camba (Heath 1958 ) and t he
Camba and Aymara (Heath 1971). The Camba dr i nk al cohol dur i ng
f es t i v i ties. Thei r beverage 1s a po t en t d i s t i l l e d s p i r i t c a l l e d
si mpl y "al cohol " -- f o r ve r y good r easons, s i n c e i t cont ai ns 89
per cent e t hyl al cohol . I t burns t he mouth and t he t hr oa t , and t o
t he Camba i t has some medi cal us es ( " i t k i l l s t he pa r a s i t e s " ) .
According t o Hea t h ' 8 a n a l ys i s , dr i nki ng among t he Camba usual 1 y
l e a ds t o i nt oxi c a t i on, but never t o aggr essi on o r s o l i t a r y
dr i nki ng. By t he v i r t u e of bei ng a non-corporate peopl e, dr i nki ng
groups among t he Camba may t ake on a n i mpor t ant i n t e g r a t i v e
unct i on, s er vi ng t o f orm "pri mary r e er ence groups. "
Heat h' s (1971) de s c r i pt i on o dr i nki ng i n Montero, a town
popula t ed by t he Camba, and Coroi co, i nha bi t e d by t he Aymara, a r e a
tes timony t o t he r e l a t i ons hi p be tween dr i nki ng pa t t e r n s and t he
s o c i a l s t r uc t ur e . I n 1952, Bol i vi a was t he s t a ge f o r a p o l i t i c a l
r evol u t i on t ha t changed s i gni f i c a n t l y t he p o l i tical and s o c i a l
s t r uc t ur e o t he count ry. I n Montero t he peasant s l e t t he farms t o
e s t a b l i s h themselves on t h e i r own l and, and a s a r e s u l t t he
pr evi ous l y f r i e n d l y r e l a t i ons hi p wi t h t he landowner was broken. I n
C O ~ O ~ C O , t he landowners became merchante and now s e r ve a s middlemen
between former peasant s and whol esal er s i n La Paz. The r e l a t i ons hi p
b e tween t hes e f ormer landowners and t he peasant s, a l though
commercial i n na t ur e , now i ncl udes s o c i a l dr i nki ng a s a mode t o keep
t he commercial a l l i a n c e OD good terms.
Ecuador
I n t h i s count r y t he pr e f e r r e d beverage 1s d i s t i l l e d s p i r i t s
from sugarcane. I n 1966 c ul t i va t i on of t h i s cr op al one took up 11
per cent of a l 1 t he c ul t i va t e d l a nd i n t he count r y (Pacuru Ca s t i l l o
1 9 7 2) .
Endara (1967 ) de s c r i be s t he s tudy of al cohol i sm by Canel os and
Ceval l os i n a n I ndi an community on the o u t s k i r t s of Qui t o, the
count r y' s c a pi t a l . The i af or mat i on was obt ai ned from 90
i ndi vi dua l s , s e l e c t e d through s y s tema t i c random pr ocedur es f rom
among t hose t r e a t e d i n a medi cal of f i c e . They c ons t i t ut e d a 10
per cent sample of t he popul at i on i n t he community. According t o
Endara, dr i nki ng was a s s oc i t ed w i t h bei ng male, s i ngl e , of young
age, and of l ower socioeconomic s t a t us .
Venezuela
Qui j ada (1961) de s c r i bes a s ur vey of pr eval ence of ps yc hi a t r i c
morbidi t y i n t he popul at i on of three d i s tricts: urban, semi r ur al ,
and r ur a l . I n t he ur ban a r e a two d i s t r i c t s were surveyed. I n one
of them 221 i ndi vi dua l s were i nt er vi ewed and t he aut hor s found a
pr eval ence of al cohol i sm of 1.8 per cent . I n t he second a r e a da t a
were obt ai ned o r 120 i ndi vi dua l s , and t he pr eval ance of al cohol i sm
wa s 2.5 per cent . The semi - r ur al a r e a (N-210) and t he r u r a l
popul at i on ( N 4 31) had pr eval ence r a t e s f o r al cohol i sm of 5 per cent
( Ca e t r i l l o and Sanj uan 1361) and 1 per cent (Qui j ada 1961)
r es pect i vel y. Unf o r tuna t e l y none of these a ut hor s pr ovi des adequa te
i nf or mat i on about t he me thodology employed i n t h i s s tudy. N e i t her
sampl i ng pr ecedur es nor d e f i n i t i o n s of al cohol i sm a r e given.
Cost a Rica
Cost a Rica i s one of t he few La t i n American na t i ons wi t h a
cons t ant out put of a l c ohol s t udi e s . Most of t h i s r es ear ch has been
developed by t he I n s t i t u t o Nacional Sobre Alcoholismo (INSA) s i nc e
i t s i nc e pt i on i n 1913 (INSA 1981a).
I n s p i t e of a l 1 t he e f f o r t s developed by t h i s i n s t i t u t e i n t he
a r e a of t r eat ment and pr event i on, al cohol consumption i n t he count r y
has been growing s t e a d i l y . I n 1961 t he annual per c a pi t a
consumption i n l i t er s of abs ol ut e a l c ohol f o r t he popul at i on 15
year s o age and ol de r was 2.7. I n 1979 i t w a s 4.76, a n i nc r e a s e
of appr oxi mat el y 70 per cent (Miguez 1980). About 2 per cent of t he
annual per c a pi t a consumption i s o wine. The ot he r 9d per cent i s
e qua l l y di vi ded among d i s t i l l e d s p i r i ts from sugar cane (rum) , ot he r
d i s t i l l e d s p i r i ts, and beer. Changes i n coneumption i n t he two
l at t er beverages account ed f o r t he bul k o t he i nc r e a s e i n t he
annual per c a pi t a consumption between 1361 and 1969. There were
d i f f e r e n t r a t e s of change i n per c a pi t a consumption between 1969 and
1379 i n t he d i f f e r e n t r egi ons of t he count ry. I n t he At l a n t i c
r egi on t he annual per capi t a consumption r os e from 4.3 t o 4.7 l i t ers
o a bs ol ut e al cohol , a n i n a e a s e o 10 per cent . I n t he Ce nt r a l
r egi on t he pr opor t i onal i nc r e a s e was 55 per cent (from 3.3 t o 5.2
li t e r s ) . I n o t her r egi ons t he i nc r e a s e ranged from 28 per cent t o 66
percen t.
AL1 t hese f i g u r e s on consumption do n o t t ake i n t o
consi der a t i on t he cl andes t i n e pr oduct i on o al cohol 1 c beverages ,
which accor di ng t o Chassoul ( c i t e d i n Miguez 1980) i s s i mi l a r i n
volume t o t he pr oduct i on by t he s t a t e monopoly. An example of t h i s
i l l e g a l pr oduct i on and s a l e of a l c ohol i c beverages s ur f aced r e c e nt l y
i n a sur vey of d r i n k i q pa t t e r ns i n t he d i s t r i c t of Limon, l oc a t e d
i n the At l a n t i c r egi on of Cost a Rica. I n a community which
o f f i c i a l l y had one l i c e ns e d pl ace t o se11 a l c o h o l i c beverages, t he
r e s e a r cher s f ound 10 i l l e g a l oper a t i ons l oc a t ed i n pr i va t e
r es i dences (INSA 1380a).
One o t he f i r s t sur veye on al cohol - r el at ed problems i n Cost a
Rica i s t h a t of Adis Cas t r o and Fl or es (1967) who were as s es s i ng t he
pr eval ence of ps yc hi a t r i c di s or de r s i n t he community. One of t he
c a t e gor i e s i nve s t i ga t e d was al cohol i sm. The pr eval ence rates i n a
si mpl e random sample of a r u r a l popul at i on was 13 per cent among
mal es, w i t h none among the femal es. I n a n urban sample, the
pr opor t i on of a l c ohol i c s was 24 per cent and once agai n no a l c ohol i c s
were found among women.
More r e c e nt l y INSA has been sponsor i ng a series of sur veys o
t he ge ne r a l popul at i on t hroughout Cost a Ri ca i n a n e f f o r t t o obt a i n
da t a on dr i nki ng pa t t e r ns (INSA 1980a, b; Ud l b , c, d, e, f ) . So
f a r t he. publ i s hed sur veys have covered 69 per cent of t he a r e a of t he
count r y ( per s onal conversa t i on, H.A. Miguez) . They al 1 pr es ent
s i mi l a r me t hodol ogi cal f e a t ur e s and u t i l i z e t he same cat egor i es and
de i n i t i ons f o r t he var i ous t ypes of dr i nker s. Respondents were
s e l e c t e d through a two-stage sampling procedure and were i n t e r v i e e d
a t home by t r a i ne d personnel . Data were c ol l e c t e d through quest i on-
n a i r e s and i n some sur veys t hose di agnosed as a l c ohol i c s were
f ur t he r i nt er vi ewed by a physi ci an, who conf irmed o r re j ect ed t he
i n i t i a 1 c l a s s i f ica t i on, The de i n i t i ons used t o i den t i f y abs t a i ne r s
and d i f f e r e n t c a t e gor i e s of dr i nke r s were a s f ol l ows:
Abst ai ner s: Never dr i nk a l c ohol i c beverages
Moderates: Dri nks les8 t han 120 cc.* (mal es) o r 6 0 cc.
( f emal es) of a bs ol ut e al cohol , i n one day o r per dr i nl dng
occasi on, wi t h a maximum f r equency of t w i c e a month o r i t s
e qui va l e nt i n a year .
Excessi ves: Dri nks 120 cc. o r more (mal es) o r 6 0 cc. o r more
( f emal es) i n one day o r i n one dr i nki ng occasi on, wi t h a
mnimum f r equency of t w i c e a month o r i t s equi val ent i n a year.
Al cohol i cs: Those who pr es ent any of t he f ol l owi ng: i n a b i l i t y
t o a bs t a i n, i n a b i l i t y t o s t o p dr i nki ng, wi t hdrawal syndrome
(INSA 198 Oa: 39 ) .
When gi vi ng t hese d e f i n i t i o n s t he aut hor s of t he r e por t a do
not comment on why men were al l owed twice a s much a l c ohol a s women.
The r a t e of abs t ent i on among males va r i e s from a minimum of 12
percent i n t he c i t y o Limon t o al most twice a s much i n Santa
~ r u z . 2 Females have hi gher proport i ons of abs t ai ner s i n a l 1 t he
ar eas st udi ed. I n gener al t h i s proport i on 1s three times hi gher
than t ha t f o r males, wi t h t he except i on of Puntarenas and San
I zi dr o, where i t i s f our times higher. A s with males, female
abst ent i on r a t e s a l s o vary consi derabl y acr os s ar eas , going from 34
per cent i n Limon t o al most twice a s much i n Santa Cruz. The
propor t i on of modera te dr i nker s a l s o pr esent s var i at i ons acr os s
ar eas among bot h males and females. I n some ar eas (Talamanca,
Desamparados, Santa Cruz) men a r e more of t en moderate dr i nker s than
women, wtiile i n ot her ar eas t he opposi t e occurs.
Honduras
There have been very few s t udi es of al cohol consumption and
dri nki ng pr act i ces i n Honduras. Natera e t a l . (1982) summarizes
eome o t hese s t udi es while descri bi ng t he i nves t i gat i on t hey
car r i ed out i n t ha t count ry and Mexico. Two ar eas of cent r al
Honduras were i nves t i ga t ed using t he "informant" me thod proposed by
~ e l l i n e k . 3 The i nformant s were s el ect ed from r ur a l ar eas and 30
groups were formed, wi t h a t ot a l of U8 par t i ci pant s . A l 1 were
males, a f a c t which pl aces some l i mi t at i ons on t he f i ndi ngs ,
es peci al l y when the y ref e r t o women's sent i ment s towards al cohol
i nges t i on and dri nki ng habi ts.
The ma j or i t y o groups i ndi cat ed t h a t men i n Honduras begin t o
dri nk before U years o age, wtiile women begin t o do so a l i t t l e
l a t e r , af t er 19 years o age. Thi s f i r s t dri nk 1s us ual l y taken
"wi th f r i ends wi t hout par ent ' s permission." The groups report ed a
s t r i ki ng di f f er ence i n t he pl aces where men and women do t he i r
drinking; 70 percent of t he groups s t a t e d t ha t men do most of t he i r
dri nki ng "onl y i n publ i c pl aces, " whi l e 60 percent decl ared t ha t
women's dri nki ng occurs "onl y a t home." Norms associ at ed with
dri nki ng by men and wamen seem t o be very di f f er ent . Most of t he
groups (57 per cent ) decl ared t ha t both men and women disapprove of
moderate dri nki ng by wamen. According t o t he groups, however, women
would have a high degree of t ol erance f o r drunkenness among men.
Thus, 50 per cent decl ared t ha t women s e e men's i nt oxi cat i on a s
eomething wtiich i s "undesi rabl e but t ha t one has t o t ol erat e. "
Drinking was a l s o associ at ed with s oc i a l and s por t a c t i vi t i e s .
*me-hundred- twenty cubi c centime ters of absol ut e al cohol al l ows f o r
t he i nges t i on o approximately 10.5 dri nks each of which cont ai ns 9
grams of absol ut e al cohol . Thi s 1s t he al cohol cont ent of a 1/ 2
pi nt o beer (4 per cent ) , a 1 oz. dri nk of s p i r i t s (40 percent ), and
a 4 oz. gl as s of t abl e wine (10 percent ).
Guatemala
Agui l l i er a (1967 ) des cr i bes s oci ocul t ur al as pect s of al cohol
consump t i on, t r ea tmen t , and pr event i ve programa. Rivera-Lima (197 3)
pr s ent s dat a on al cohol product i on, al cohol - r el at ed l e g a l of f ensea,
and t he t reat ment system. Bunzel (1940) des cr i bes dri nki ng i n a n
I ndi an Community. As wi t h ot her I ndi an communities s t udi e s ,
dr i nki np 1s as s oci at ed w i t h f i e s t a s and market days, al cohol 1s a l s o
consuned i n l a r g e q u a n t i t i e s duri ng dancing pa r t i e s , and dr i nl dng
may devel op i n t o l ong s pr ees t h a t may l a s t f o r days. Such s pr ees
a r e marked by di s t r upt i ve behavi or i ncl udi ng qua r r e l s between
nei ghbors and f ami l i es and l os 8 o money; t h e i r r e s u l t i s, a s Bunzel
put s i t , "an enduri ng a f termath of g u i l t and anxi et y. "
Caribbean
Rum has been acknowledged t o pl ay a n i mport ant p a r t i n t he
Caribbean cul t ur e. Ral st on (1980) t r aced t h i s i nf l uence back t o t he
seven t eent h cen t ury, when sugar pl ant a t i one r epl aced tobacco arma
i n t he i s l ands . Beaubrun (1967 a ) , commenting on t he r a t e s of
a l c ohol i c admi ssi ons t o ment al hos pi t al s i n t he a r e a a t a t i m e when
no preval ence dat a wa s avai l abl e, s t a t e d t h a t t hese i ndi cat or s
suggest ed t he exi s t ence of a problem o "some si ze. " Y e t , t her e
have been few s t udi e s of dr i nki ng pat t er ns and t he r o l e o al cohol
i n t he cul t ur es of t he regi on.
I n Jamaica, Beaubrun (1967b) r e por t s a s t udy o al cohol i sm and
dri nki ng pa t t e r ns i n Kingston, t he c a pi t a l and t he l a r g e s t c t i y on
t he i el and. A t o t a l of 1,317 i ndi vi dual s Id years of age and ol der
were i nt ervi ewed, comprising a random sample of f our socioeconomic
l e v e l s o t he ci t y. The dat a col l ect i on i nst r ument was a quest i on-
n a i r e developed by t he Aicohol Impact St udy Group o t he Maudsley
Hospi t al , London. The r e s u l t a showed a r a t e o abs t ent i on of 10
per cent among males and o 25 per cent among females. The preval ance
of heavy dri nki ng among men was 38 percent . Drinking was pos i t i ve l y
as s oci at ed wi t h age, w i t h t he hi ghes t r a t e s o dr i nker s being found
i n t he 40-44 age group. Heavy dr i nki ng was p o s i t i v e l y as s oci at ed
wi t h income ( usi ng r e s i d e n t i a l s t a t u s a s a n i ndi cat or ) , educat i on,
being whi t e o r of East I ndi an or i gi n, and l acki ng r e l i gi ous
a f f i l i a t i o n . The es t i mat ed preval ence of al cohol i sm i n t he t o t a l
popul at i on of t he i s l a n d was 5 percent .
I n Tr i ni dad, Yawney (1979) s t udi ed al cohol i sm and dri nki ng
pa t t e r ns among Eas t I ndi an men and blacks. She emphasizes t he g r e a t
a v a i l a b i l i t y o rum, which can be purchased i n "rumshops" i n any
amount by t he l o c a l popul at i on. These shops a r e a combination o
"corner s t or e " and "neighborhood t aver n, " a l s o s er vi ng food and
s e l l i n g provi si ons. Drinking 1s casual , women a r e har dl y ever
presen t , and t her e l e a gener al a t ti tude o permi ssi veness towards
al cohol i nges t i on.
Pat t er ns of dri nki ng i n Barbados were s t udi ed by Dann (1980).
Data c a e from i nt er vi ews wi t h 437 respondents s el ect ed through a
e tra t i f i e d random procedure f rom amo* t he Barbadian adul t
population. The ove r a l l response r a t e f o r t he st udy was 97
percent . The r e s ul t s showed 26 percent abs t ai ner s among men (54 out
of 2 8 ) , and 57 percent (13 out of 231) among women. Drinking was
pos1 t i ve l y as s oci a t ed wi t h being young, unmarried, wi t hout r el i gi ous
a f f i l i a t i o n , employed, having a hi gh income, and l i vi ng i n a
semi-urban o r urban ar ea. The average annual per capi t a consumption
i n liters of absol ut e al cohol f o r t he sample wae 7.24. The
pr ef er r ed beverages were rum and beer f o r bot h men and wmen, but
preference changed accordi ng t o pl ace of i ngest i on. Rum was t he
most coneumed beverage i n rumshops, a t home, a t ot her e' homee, and
" i n t he open ai r . " Beer was t he most coneumed beverage a t par t i es ,
pi cni cs, bar s, and ni ght cl ube. I n t he workplace, during l unch
breake, t he beverage of preference was gin. The pr ef er r ed l ocal e
f o r dri nki ng was t he home, followed by ot her ' s homes, followed by
par t i es . The ma j or sex di f f er ence was t ha t a l a r ge r proport i on of
men than women pr ef er r ed t o dri nk i n rumshops. The rumehop was i n
f i r st pl ace i n r e l a t i on t o a l 1 ot her dri nl dng l ocal es , when the
number of hours spent dri nki ng, t he quant i t y coner nd, and
expendi t ur es on al cohol were considered.
Using def i ni t i ons based on percentage of t i m e spent dri nkl ng,
annual amount of al cohol drunk, and percentage of annual n e t incopie
spent on al cohol , Dann cone t ruct ed a typology of dr i nker s a s
f ollows : o ccasi onal , r egul ar , and heavy. The prevalence of each
type of dri nker among males (whole sample), a s r ecal cul at ed by t hi s
reviewer, were: o ccaei onal , 34 percent ; r egul ar , 27 percent ; heavy,
13 percent . Por women t he r a t e e were: occasi onal , 40 percent ;
r egul ar 2 percent ; heavy, 0.4 percent .
A pr of i l e of t he heavy dri nker, a e of f er ed by Dann, may ser ve
t o char act er i ze t h i s r ubr i c when cont r ast ed t o dri nl dng pat t er ns of
the sample a s a whole. Thue, while t he average number of hours epent
dr i nki r y per year f o r al1 dri nkers i n t he sample was 293.16 hours,
the heavy dr i nker s' average was f i ve timee t hi e number. Mean annual
consunption f o r dr i nker s i n t he sample wa s 12.7 l i t e r e of absol ut e
al cohol , while f o r heavy dr i nker s i t wae 83.7 l i t e r e . Thi s allowe
f or t he consumption of 1 pi nt of s p i r i t e per day. Frequency of
drunkenness among heavy dr i nker s was once every 8 days, while 75
per cent of al 1 dr i nker s got drunk l e e s than once a year.
Mexico 1s one of t he Lat i n American count r i es where al cohol
probleme have recei ved conei derabl e a t t ent i on f rom resear chers, and
a nunber of s t udi es have been car r i ed out there i n both general
popul at i on and epeci al groups. Some of t hese have been reviewed by
Cabildo (1967), and t he i nformat i on below 1s taken from h i s review.
Three o t he i n t i t i a l et udi ee provi di ng i nf or mat i on about al cohol
probleme i n Mexico were c a r r i e d o u t t o aes es s t he preval ence o
peychi at r i c pat hol ogy i n gener al . As such, t hey focused on t he
di agnoei s o al cohol i sm onl y , wi thou t touching o t her dri nki ng
probl ene o r dri nki ng pat t er ns . The Di recci on de Salud Mental y
l l i recci on de Bi oes t adi s t i ca ( c i t e d by Cabi l do, 1967 ) eurveyed a
nat i onal sample and found t he r a t e of al cohol i sm was 0.55 percent .
Cabi l do (1967) s t udi ed employeee from t he Mexican government. uit
of a t o t a l popul at i on o 568,396 a 2 per cent eample w a s taken; t he
rate o al cohol i sm was 0.7 percent . The queet i onnai r e used i n t he
Cabi l do sur vey was ueed by Ayuso e t a l . ( c i t e d by Cabi l do, 1967 ) on
a eample (N=3,231) o mi l i t a r y personnel . The preval ence o
al cohol i sm was t he same 0.7 per cent .
Maccoby ( U7 2) c a r r i e d out a s t udy o al cohol i em among males
16 yeare and above i n a mest i zo a gr i c ul t ur a 1 community. Drinkere
were c l a s s i f i e d accordi ng t o Marconi ' e t ypol ogy o moderate,
exceeei ve, and al cohol i cs . But Maccoby di d n o t us e Marconi' s
opera t i ona l de i n i t i ons . Alcoholiem wae de termined by t he degree of
f a i l u r e t o me t s o c i a l obl i gat i ons . Exceesive dr i nki ng was def i ned
by dri nki ng beyond c u l t u r a l norme, e.g., l os i ng workdaye becauee of
dri nki ng. Moderate dr i nki ng was t h a t mode o i nges t i on which di d
no t i n t e r f ere w i t h s o c i a l r e s pons i bi l i t i ee. W i t h t heee de i n i t i ons
t he r a t e o al cohol i em among malee i n t he v i l l a g e wae 14.4 percent .
There were 13 per cent excessi ve dr i nker s , 52 per cent moderate
dr i nker s , and 16 per cent abet ai ner e. Another 4 per cent of t he men
were c l a s s i f i e d a s c ur r r e nt abet ai ner e. Heavy dr i nki ng wae
poe i t i ve l y as s oci at ed wi t h age. Of t he male popul at i on 40 years o
age and ol der , 32 per cent were al cohol i cs and 16 per cent were
excessi ve dr i nker s. Among t hose l e e s t han 40 yeare o age t he
pr opor t i on o al cohol i ce and excesei ve dr i nker e was 8 per cent and 12
per cent , r es pect i vel y.
Another et udy i n a r u r a l community l e t h a t descri bed by Smart
e t a l . (1980), and Natera e t al . (lY81, 1982) which u t i l i z e d t he
"informan t" me thod t o c o l l e c t i nf ormation on dri nki ng pa t t er ne .3
The community 1s l ocat ed eouthwest of Mexico Ci t y and has 5,198
inha- bi t a nt s . The i nve s t i ga t i on col l ect ed i nformat i on from 30
groups o 5 people each. The average da i l y consumption o di f f e r e nt
t ypes of a l c ohol i c beverages among t he male popul at i on was 1.5
l i t e r a o pulque, 2 bot t l e e o beer, and hal f a gl aee o d i e t i l l e d
e p i r i t s . Women r epor t edl y dr i nk most l y a t home and dr i nk l e e s t han
men, but have a g r e a t t ol er ance f o r men's heavy dri nki ng. Reasone
or dri nki ng, i n dect eaei ng or der o importance, a r e : "habi t , " " t o
br i ng f r i ende cl oeer , " "t o r e s t , " "t o calm d o n t he nervee, " "t o
make work eas i er . " Reaeone f o r n o t dr i nki ng, a l e o i n decreasi ng
or der o importance , ar e: "heal t h reasons, " "moral reasons , "
"e conomic reasone, " "af r a i d o t he coneequencee, " "f ami l y problems, "
"work problems , " " di el i ke t he t a s t e. "
More r ecent l y, t he I ns t i t ut o kkxicano de Pei qui at r i a (kkxican
Ps ychi at r i c I n s t i t u t e ) has car r i ed out a number of surveye of
dri nki ng pr act i ces i n sever a1 Hexican cides. The i nfonnat i on
srnnmarized here are from s t udi es of dri nki ng among t he popul at i on of
La Paz (Medina-Mora e t a l . 1978), San Lui s Pot osi ( De l a Parra e t
a l . 1980), and Xexico Ci t y (Hedina+ora e t a l . 1980). I n a l 1 t hree
eurveys t he eampling methodology, dat a col l ect i on proceduree, and
dri nl dng c l a s s i f i c a t i ons were the same. These s t udi es found
one-fourth t o one-t hi rd of malee, and one-half of t he women, were
abst ai ner s. Another one-third of both men and women were i nfrequent
dr i nker s, 1.e. drank les8 than once a month, but a t least once a
year. Drinking c l a s s i f i c a t i ons r e f l e c t e d a much lower l eve1 of
al cohol i nges t i on than i n ot her st udi es. For example, r egul ar
habi t ual dr i nker s were deecri bed a s those who dri nk t hr ee o r more
times per day a t l e a s t once or M c e a month, and consume f i v e or
more dri nks per occasion. Excessive dri nki ng and al cohol i sm were
no t l i s t e d a s i dent i f i e d cat egori es.
The moet r ecent , and cer t ai nl y t he most comprehensive, s tudy
of dri nki ng pat t er ns i n t he general populardon i n Hexico i s t hat
car r i ed out a s p a r t o t he HO st udy of coaununity responses t o
al cohol -rel at ed problems. Thi s st udy wa s car r i ed out i n two ot her
c ounui e s besi des Hexico -- Zambia and Scotland -- i n t he framework
of i nt er na t i onal col l aborat i on. The same i ns truments f or dat a
col l ect i on and t he same methodology were appl i ed i n each country.
Adherente t o t he agreed procedures was ensured by a series of
meeting8 which brought t oget her t he research teams and where t he
me thods were di scussed and agreed upon.
Complete r epor t s f o r t h i s st udy a r e forthcorning. Data from
Mexico have been descri bed both by Calderon e t a l . (1981) i n the
r epor t from t ha t count ry and by Roizen (1981) i n a cross-cul t ural
review of f i ndi ngs from kkxico, Zambia, and Scotland. According t o
Calderon e t a l . t he work i n Mexico began i n 1976 and the obj ect i ves
t o be achieved were: a ) t o st udy dri nki ng pat t er ns and alcohol-
r e l a t e d problems and di s a bi l i ties; b) t o s tudy community responsee
t o d r i n k i q and t he ways i n which t he coaununity i n general and i t s
speci f i c i n s ti t ut i ons handled a l cohol-rela ted problems. The two
coaununities st udi ed i n Mexico, one r u r a l and t he ot her urban, a r e
both i n t he v i c i n i t y of Hexico Ci t y and had a hi et or y of dri nki ng
problems. Subj ect s f o r t he st udy were s el ect ed by a two-step
eampling procedure from among t he popul at i on 15 years of age and
ol der . Because dri nki ng problems a r e more preval ent among t he male
popul at i on, i t was decided t o oversample t h i s popul at i on s o t ha t
two-thirds of t he respondents would be males.
Among males 22 percent were c l a s s i f i e d a s r egul ar dr i nker s
( dr i nk a t l e a s t once a week). Approximately 25 percent were judged
t o be i nt ermedi at e dr i nker s ( dr i nk between one and t hr ee t i m e s a
month) and anot her 30 per cent f e11 i n t he cat egory of occasi onal
dr i nker s ( dr i nk l e s s t han once a month but a t l e a s e once a year).
The preval ence of a bs t a i ne r s was 19 per cent . Among femal es t he
pr opor t i on of bot h r egul ar and i nt er medi at e dr i nker s wa s 9 percent .
Occasi onal dr i nker s and a bs t a i ne r s had preval ence r a t e s o 40
per cent and 42 per cent , r es pect i vel y.
h i z e n (1981) pr ovi des a de t a i l e d a na l ys i s o t he Mexican dat a
from the WHO st udy. Approximately 40 per cent o t he al cohol
consmed i n Mexico 1s est i mat ed t o come from d i s t i l l e d s p i r i t s
( e s pe c i a l l y t equi l a and rum). Beer and s p i r i t s t oget her comprise 88
per cent o t he t o t a l al cohol consumption. Aimost a l 1 t he r e s t 1s
s uppl i ed by pul que, a ferment ed beverage made from t he s ap of t he
maque y cact us.
The as s oci at i on of dri nki ng wi t h age 1s such t h a t middle-aged
men show t he l a r g e r percent age o dr i nker s (91 per cent ) , fol l owed by
young men (83 per cent ) , fol l owed by ol der men (76 per cent ) . Among
women t her e i s n o t much change i n t he percent age o dr i nker s i n
r e l a t i o n t o age. I n gener al 50 per cent of t he women, independent o
age, a r e dr i nker s. Dr i nki w a t l e a s t once a week 1s more f r equent
among men t han among women, among r u r a l t nan among urban respond-
e nt e , among t he o l d t han among t he young. Twenty-seven per cent o
wmen dr i nker s and 59 per cent of male dr i nker s g e t drunk l e e s t han
o r about once a month. Frequency of bei ng drunk a t l e a s t once a
week i e 7 per cent among male dr i nker s and 1 per cent among femal e
dr i nker s.
The most f r equent l y s t a t e d r easons f o r dri nki ng a r e a s
fol l ows: "a good way t o cel ebr at e" (rilen, 50 per cent ; women, 38
per cent ) , " l i ke t he f e e l i ng of ge t t i ng hi gh o r drunk" (rnen, 43
percent ; women, 27 per cent ) , "i t i s what most o my f r i e nds do"
(men, 55 percent ; women, 44 percent ). The hi gh pr opor t i on of
dr i nker s decl ar i ng a s reason f o r dri nki ng "get t i ng hi gh or drunk"
seems t o i ndi c a t e approval o dr i nki ng t o i nt oxi cat i on.
Norma r egul at i ng dr i nki ng by s ex i n t he communities a r e ver y
di f f e r e nt . While 27 per cent o t he sample would condone dri nki ng by
a man 21 p a r e o age, t wi ce a s many o r 53 per cent would not condone
i t f o r a woman t he same age. A man 40 years o l d shoul d dr i nk,
accordi ng t o 15 per cent of t he s ubj ect s ; 43 per cent disapproved o
dr i nki ng by a woman of 40.
Male dr i nker s r e por t hi gh r a t e s o per sonal problems:
55 per cent r e por t g u i l t over dr i nki ng, 55 per cent e l t t hey shoui d
c u t down o r s t op dri nki ng al t oget her , 36 per cent experi enced hands
shaki ng i n t he morning a f t e r dri nki ng. Male dr i nker s i n t he r u r a l
area r epor t ed approxima t e l y t wi ce a s many problems a s t h e i r urban
count er par t s.
The presence of problems or i gi na t i ng from adver se s o c i a l
r e a c t i one t o t he s ubj e c t ' s dr i nki ng was a l s o i nve s t i ga t e d i n t he WHO
st udy. The s o c i a l problems most of t e n r epor t ed by male dr i nker s
were: " f e l t e f f e c t s o a l c ohol a t work" ( 35 per cent of ur ban
dr i nker s , 49 per cent o r u r a l dr i nker s ) ; "f ami l y and f r i e nds
problems" (32 per cent o urban dr i nke r s , 41 per cent of r u r a l
dr i nker s ) ; "ashamed o what you d i d whi l e drunk" (28 per cent o the
urban dr i nker s , 45 per cent o t he r u r a l dr i nker s ) . Problema i n t he
workplace, wi t h pol i c e , and a c c i de nt s were r epor t ed by 1 per cent t o
6 per cent of t he male dr i nker s . Female dr i nke r s bot h i n t he urban
and i n t he r u r a l community r epor t ed fewer problems t han male
dr i nker s . However, t he t ype o s o c i a l problems r epor t ed most
r equent l y were t he same as t hose r epor t ed b jr men.
Although t he above pr ovi des some d e t a l l , i t does n o t
s u f f i c i e n t l y r e ve a l t he r i c hne s s o t he da t a provi ded by t he WHO
s tudy. Many o t hes e r e s u l t s acqui r e more s i g n i f i cance when t hey
a r e compared w i t h s i mi l a r da t a rom t he two o t he r count r i es i n t he
s t udy, Zambia and Scot l and. Roizen 1s i n a much b e t t e r pos i t i on t o
i n t e r p r e t t he Mexican da t a t han t h i s r evi ewer , and t h i s 1s what he
had t o say:
And what shoul d we make o t he Mexican ci rcumst ance,
where i n s p i t e of t he e xt r a or di na r y i nf r equency of
dr i nki ng , 8 ti11 suba t an t i a 1 al cohol - r el a t ed problems
a r e r epor t ed, even by ne a r l y abst emi ous women? I n
t he Mexican da t a one has t he d i s t i n c t f e e l o t he
pr esence o a n over r i di ng c u l t u r a l nega t i v i t y toward
al cohol : perhaps a r he t or i c a l di s pos i t i on s o
8 t r ongl y i n c l i n e d agai ns t dr i nki ng a s t o promp t
e xt r a or di na r y r e por t a o i ts e v i l doings. . . Thi s body
of ant i dr i nkng r he t or i c , t hen, may f unc t i on a s a
ki nd of w e l l o u t o which t hose who a r e n o t
per mi t t ed acces s t o dr i nk a r e obl i ged t o d i p their
l a dl e s . . .We have seen, i n t he Mexican case
e s pe c i a l l y, a ci rcumst ance i n which v e r y hi gh
pos1 t i ve r epor t 8 on i ndi c a t or s sometimes r egar ded a s
i ndi c a t i v e o a dependence on al cohol never theless
a r e q u i t e compat i bl e wi t h a ver y low f r equency o
dr i nki ng on the whole (Roizen 1981: 51-52).
The Per cep t i on o A l cohol-Problems i n La t i n America:
J e l l i n e k ' s Chi l ean Connection
From t he vant age poi nt of t he ' dos i t appear s t h a t t he 19%
v i s i t t o Chi l e by E.M. J e l l i n e k was t he most i mpor t ant f a c t o r i n t he
development of a l c ohol epidemiology i n La t i n America. Thi s 1s n o t
t o i gnor e t he f a c t t h a t by 1956 Chi l e a l r e a dy had a t r a d i t i o n i n
dl cohol r esear ch. J or ge Mardones, t o whom J e l l i n e k dedi cat ed h i s
book Tne Di sease Concept of Alcoholism, and who w a s a member of t he
WHO Exper t Committee on Mental Heal t h and on Alcohol wi t h J e l l i n e k
and o &er es wa s t he head of t he I n s t i t u t o de I nves t i gaci ones sobr e
Alcoholismo of t he Uni ver s i t y of Chi l e. Mardones had been a c t i v e l y
devel opi ng exper i ment al l y- or i ent ed r es ear ch on al cohol p r i o r t o
J e l l i n e k t s v i s i t . H i s work a t t he time was di r e c t e d towards
r esear chi ng t he a s s oc i a t i on be tweeu a l c ohol i nt a ke and v i tamin
def i ci ency, and i t 1s di scussed i n d e t a l l by J e l l i n e k (1960). Al so,
Var el a and Marconi (1952) had a l r e a dy publ i shed what pr obabl y i s t he
f irs t r e pl i c a t i on of J e l l i n e k ' s U46 s t udy of symptoms of al cohol i sm
( J e l l i n e k 19 46 ) .
Bu t a f t e r J e l l i n e k t s v i s i t epi demi ol ogi cal r es ear ch
f l our i s he d, and Marconi publ i shed h i s f i r s t paper on t he di s eas e
concept based on J e l l i n e k ' s work (Marconi 1959).4 Other papera
f ol l owed (Marconi, 1964, 1905, 1967b, 1 9 8 7 ~ ) i n which Marconi was
n o t onl y concerned w i t h f ur t he r i ng t he di s e a s e concept , but a l s o
w i t h de i ni ng al conol i sm a t a n oper a t i ona l l e ve l . These opera t i o n a l
d e f i n i t i ons , developed f o r us e i n epi demi ol ogi cal sur veys i n t he
communi t y, f ound enormous accep t ance among a l c ohol - epi demi ol ogi s t e
i n La t i n Ame r i can na t i ons , and became a s t andar d concep t a ppl i e d i n
a number of pr eval ence s t u d i e s i n Chi l e, Ar gent i na, Br a z i l , Peru,
hiexico, and Cost a Rica.
Athough Marconi subscr i bed e n t i r e l y t o J e l l i u e k ' s di s e a s e
concept , t her e a r e many poi nt s of s u b s t a n t i a l di f f e r e nc e between
their work. Thus, J e l l i n e k ' s d e f i n i t i o n of al cohol i sm 1s pur posel y
l oos e and vague. He under st ands al cohol i sm as :
. . .any use of a l c ohol i c beverage t h a t causes any
-
damage t o t he i ndi vi dua l o r s o c i e t y o r both
( J e l l i ne k, 1960:35) .5
Marconi de i n e s al cohol i sm as:
. . .a chr oni c di s e a s e char act er i zed by a fundamental
d i s t urbance of t he c e nt r a l nervous system whi ch
mani f est s i t s e l f i n a group of bodi l y symptoms and
s i gns t h a t gi ve a n i mperi ous char act er t o t he
concomitant de s i r e t o dr i nk al cohol . On t he
behavi or al l e v e l , t he di s eas e mani f est s i t s e l f by a
yri mary o r secondar y s t a t e of physi cal dependen- on
t he drug. The symptoms di sappear t empor ar i l y af ter
t he consumption of a c e r t a i n qua nt i t y of al cohol
(Marconi 1959:221).5
Marconi' s d e f i n i t i o n 1s more pr e c i s e from t he begi nni ng and
does n o t mention al cohol - r el at ed "damage" o r problema a s a pos s i bl e
i ndi c a t or of t he di s eas e. The absence of al cohol - r el at ed problems
from t he de f i ni t i ons of bot h excessi ve dr i nke r s and a l c ohol i c s i n
La t i n America i s one of t he major di f f er ences between dri nki ng
t ypol ogi es developed i n t he U.S. and La t i n America. Thus, t he U.S.
concept o "problem dr i nker " does n o t have a p a r a l l e l i n Lat i n
American epi demi ol ogi cal l i t e r a t u r e . Marconi' s excessi ve dr i nker i s
roughl y comparable t o t he heavy dr i nker cat egor y i n t he U.S.
l i t e r a t u r e , but even her e t he l i mi t e of i u e s t i o n may va r y wi del y.
The U. S. concep t o "problem dr i nker " encompasses bo t h excessi ve
dr i nker s and al cohol i ce a s def i ned by Marconi.
Marconi '8 de i n i t i o n char act er i zes al cohol i sm as a pat hol ogy
of t he c e nt r a l nervous system. Por him t h i s concept i on i s a n
unavoi dabl e conseyuence o char act er i zi ng al cohol i sm by t he
phenomenon o phys i cal dependence. Thi s i s how he put s i t:
. . . i ( phys i cal dependence) i s def i ned as t he
coexi st ence of a e t a t e o i nt ens e d i s t r e s s , us ual l y
one o anxi et y, and o s t rong de s i r e t o i n g e s t al co-
h o l i c beverages, we mus t pos t ul a te t he e x i s t ence o
c e nt r a l neurona1 c i r c u i t s capabl e o unchai ni ng
spont aneousl y o r under t he s timulus of small doses
o et hanol t hose phenomena coneci ousl y r e gi s t e r e d by
t he p a t i e n t (Marconi 1967 b:634).
Br i ef l y, Marconi (1965, 1967 b, 1971) and Marconi e t a l . (1965,
1310) pos t ul at e t he exi s t ence o two c e nt r a l nervous c i r c u i t s
l ocat ed i n the hypothalamus: one would r e gul a t e t he a ppe t i t e f o r
al cohol and t he second t he appearance of anxi et y. I n t he
"i nt ermi t t e n t" t ype o al cohol i c, whi ch Marconi (1959 ) descr i bes as
experi enci ng shor t per i ods (days o r weeks) of a bs t i nence, al cohol
i nges t i on d i r e c t l y s t i mul at es t hese c i r c u i t s , wi t h t he wnsequent
appearance o "physi cal dependence" a s evi denced by " i n a b i l i t y t o
s t op" ( l o s s o cont r ol ) . I n t he "continuous" t ype of al cohol i c,
def i ned a s t hoee dr i nker s who experi ence i n t e r v a l s o sever a1 hours
between one dr i nki ng occasi on and t he next , the mechanism t r i gger i ng
t he appearance o phys i cal dependence i s di f f e r e nt . I n t h i s cas e
the c e nt r a l nervous system c i r c u i t s a r e depressed by t he continuous
i nges t i on of al cohol , and i t i s t he abr upt r educt i on o r t he decrease
i n t he requency o al cohol i nt ake t ha t t r i gge r s t he pat hol ogi cal
r eact i on causi ng phys i cal dependence, which t hen appears as
" i n a b i l i t y t o abs t ai n. "
These two mechanisms expl ai n t he appearance o one o t he
forms o physi cal dependence. Thi e i s t he t ype o dependence which
i s a t t he foundat i on, as mentioned, o two o t he t hr ee c l i n i c a l
forme o al cohol i sm a s proposed by Marconi: t he "i nt er mi t t en t" and
t he "continoue" a l c ohol i cs. Using J e l l i ne k' s t ypology, t hes e would
be the "gamma" and t he "del t a" al cohol i cs , r es pect i vel y. A t h i r d
c l i n i c a l orm p u t orward by Marconi, t he "r emi t t ent " al cohol i c,
corresponds t o J e l l i n e k '8 "epsi l on", a f orm o al cohol i sm w h i ch
J e l l i n e k di d n o t i nc l ude wi t hi n t he boundar i es of the di s eas e
concept. Thi e t ype of a l c o h o l i c i s char act er i zed by Marconi (1959)
a s pr esent i ng l ong per i ods o e l t her abe t i nence o r modera te dr i nki ng
between per i ods of a ddi c t i ve dr i nki ng. I n t h i s case, t he physi cal
dependence appear s epont aneousl y w i thou t any a l c ohol i nges t i on.
Thi s pat hogeni c t heor y o al cohol i sm put a forward a
r e l a t i ons hi p between cause and e f f e c t which 1s d i f f i c u l t t o accept .
The mal unct i oni ng of t he c e n t r a l nervous s ystem neurona1 c i r c u i ts,
a s proposed by Marconi, 1s a t one t i m e t r i gs e r e d by t he presence of
al cohol , a t anot her time by i t s absence o r by a r educt i on i n a l c ohol
i nt a ke , and a t a t h i r d t i m e occur s spont aneousl y. Empi r i cal
evi dence i n s uppor t of t h i s t heor y 1s l adci ng a s of t oday and,
t her ef or e, Marconi ' 8 i de a s remain t e nt a t i ve .
How can wide accept ance o Marconi t e concept s by La t i n
American r es ear cher s be expl ai ned i n t he l i g h t o t h i s c r i t i c i s m?
F i r s t , Marconi 1s concerned n o t onl y wi t h f ur t he r i ng t he di eeaee
concep t , bu t a l s o w i t h def i ni ng al cohol i sm, modera te dr i nki ng , and
exces s i ve dr i nki ng a t a ope r a t i ona l l e ve l . It 1s pos ei bl e t hen t o
i de nt i f y two d i e t i n c t ( al t hough connect ed) themes i n Marconi 'S
papers. One i s eminen t l y neur ophysi ol ogi cal and 1s a s s oc i a t ed w i t h
h i s pat hogeni c t heor y of al cohol i sm. The ot he r l e epi demi ol ogi cal
and can be exemplif i e d by h i s concern wi t h l a yi ng o u t "obj ect i ve
i ndi c a t or e" of al cohol i em whi ch would al l ow o r t he i d e n t i f i c a t i o n
o t h i s condi t i on i n epi demi ol ogi cal sur veys. Alcohol epidemio-
l o g i s t s may w e l l have been u t i l i z i n g Marconi' s oper at i onal
d e f i n i t i o n s wi t hout ne c e s e a r i l y subscr i bi ng t o h i e pat hogeni c t heor y
of al cohol i sm.
Second, i n t he overwhelming ma j or i t y o cas es epi demi ol ogi cal
s t udi e s of a l c ohol i n La t i n America have been aut hor ed by
physi ci ans, and t he not i on t h a t al cohol i em per se coul d be
consi der ed a s a e p e c i f i c di s eas e was t her ef or e n o t s o f 0 r e i ~ n . 7
I n t he U.S. and i n some Scandi navi an count r i es , on t he ot he r
hand, s oc i ol ogi s t s have been ver y a c t i v e i n t he f i e l d of al cohol
r esear ch. Thi s i n t e r e s t seems t o have emerged from t he combination
o a ge ne r a l concern f o r a n i mpor t ant s oc i oc ul t ur a l t opi c ( al cohol
and i t s us e s ) and t he empi r i cal or i e nt a t i on o U.S. soci ol ogy, which
pr ovi ded t he knowledge and t he t ool s ( sur vey r eeear ch) necessar y t o
devel op r es ear ch i n t he s ubj ect . Thue, one of t he main poi nt s of
di f f e r e nc e be tween t he U. S. and ia t i n America wi t h r egar d t o a l c ohol
s t udi e s 1s t he i nvol vement of s o c i a l s ci ences and t he consequent
development of competing a l t e r n a t i v e s t o t he di s eas e model of
al cohol i sm.
Both i n t he U.S. and La t i n America, s uppor t er s of t he di eeas e
concept have been q u i d t o poi nt o u t t h a t t he under st andi ng o
al cohol i sm a s a di s e a s e hel ped t o change t he l a be l l i ng of a l c ohol i c s
as mor al l y degraded, and paved t he way f o r t he publ i c he a l t h
approa ch t o a l c ohol problems .
It i s a l s o yoi nt ed o u t t h a t t he di s e a s e concept hel ped t o
c r e a t e a new f i e l d of r es ear ch and t he r e f or e l e gi t i ma t e d t he
a s p i r a t i o n s o a l c ohol r e s e a r c he r s f o r career development, f unding ,
and pr of es s i onal r e s pe c t a bi l i t y. It br ought this new f i e l d under
t he w i q g of a n a l r e a dy powerful e s t a bl i s he d pr of es s i onal group --
medi ci ne -- t hus i nc r e a s i ng i t s chancea f o r r ecogni t i on i n t he
s c i e n t i f i c communi t y. W i t h t h i s new paradigm, a l c ohol s p e c i a l i s ts
became more or gani zed and developed i n t o a n e f f e c t i v e group.8
Undoubtedly, t hese poi nt s have v a l i d i ty. However, t he
wi despread accept ance o t he di s e a s e concept and of Marconi' s
oper a t i o n a l de i n i t i ons has no t been w i thou t consequences t o La t i n
American r es ear ch on a l c ohol problems. Cl ar k (1975) ha s di scussed
adequat el y some of t he i mpl i cat i ons of t he di s e a s e concept f o r
r es ear ch. I n La t i n America, t he f ol l owi ng consequences a r e r e a d i l y
i d e n t i f i a bl e :
1 ) General popul at i on sur veys i n La t i n America have been basi -
c a l l y concerned wi t h a s s e s s i w t he pr eval ence of al cohol i sm.
Even t hose who estimate t he pr eval ence of d i f f e r e n t t ypes of
dr i nker s do s o onl y secondar i l y, f ocusi ng t h e i r di s cus s i on and
a n a l y s i s on t he pat hol ogi cal dr i nl r er s ( excessi ve dr i nker s and
a l c ohol i c s ) . Once t he gener al popul at i on sur veys of t he l a t e
' 50s and ' Os were developed, and t he pr eval ence o al cohol i sm
was e s t a bl i s he d, epidemiologically-oriented r es ear ch j u s t
ground t o a h a l t i n many count r i es. However, l i t t l e can be
done w i t h such nose-count i nf or mat i on ot he r t han usi ng i t t o
pr ovi de a n adequat e number of hos pi t a l beds f o r t he di scover ed
al cohol 1 cs .9
2 ) As a c or ol l a r y o t h i s concent r at i on of e f f o r t s t o assess t he
number of exces s i ve dr i nke r s and a l c ohol i c s , s oc i oc ul t ur a l
f a c t o r s a s s oc i a t e d wi t h dr i nki ng have been l e t negl ect ed i n
t he La t i n American a l c ohol l i t e r a t u r e . Thi s i s not t o s a y
t h a t r es ear cher s have n o t under l i ned t he i mport ance o such
f a c t o r s f o r under st andi ng al cohol abuse. A number o aut hor s
(Negret e 1973, 1974, 1976a; Adi s Cast r o 1966; Heath 1974;
Mar i at eyui 1961 b, U87 c) have emphasized t he ne c e s s i t y o
paying a t t e n t i o n t o t hose c h a r a c t e r i s t i c s of t he s o c i a l
environment t h a t have a bear i ng on a l c ohol use. Y e t , when i t
comes t o st udyi ng t he phenomenon i n t he community, onl y t he
more s ever e forms o i nge s t i on are addr essed. The onl y
except i on t o t h i s seems t o be t he et hnogr aphi c s t u d i e s
developed amow na t i ve peopl es, some o which have been
mentioned her e. Ou t s i d e t hese popul at i ons, which a r e
concent r at ed i n s mal l towns and r u r a l a r e a s , l i t t l e i a known
abou t r easons o r d r i d c i w , dr i nki ng cont ex ts, norms,
a t t i t u d e s , and b e l i e f s a s s oc i a t e d wi t h al cohol us e i n La t i n
Ameri ca.
3) The use of i n d i c a t o r s such a s " i n a b i l i t y t o s t op" o r
" i n a b i l i t y t o a bs t a i n" al l ows f o r t he i d e n t i f i c a t i o n o a
group of dr i nke r s w i t h s ever e al cohol problems i n t he gener al
popul at i on and who may be i n need o hel p. Whether t hey have
a di s e a s e c a l l e d al cohol i sm o r n o t becomes secondar y i f t he
purpose i s t o i d e n t i f y and assess t he pr eval ence o t hese
dr i nker s . However, by usi ng onl y t hese i ndi c a t or s , al ong wi th
amount and f r equency of dr i nki ng, t o i d e n t i f y " a t r i s k "
dr i nke r s , t he broader range o al cohol - r el at ed problems
remains l a r g e l y unexamined. Cl ar k (1976 ) has a l r e a dy
demonst rat ed f o r t he U.S., a t l e a s t , t h a t " l os s o cont r ol "
does n o t c o r r e l a t e hi ghl y w i th s c a l e s t h a t a s s e s s problems i n
s o c i a l f unct i oni ng caused by dr i nki ng. Thus, l i t t l e 1s known
about t he a s s o d a t i o n between dr i nki ng and t he occur r ence o
problems i n a r e a s such as i nt e r pe r s ona l r e l a t i ons hi ps ( wi f e,
f r i e nds , r e l a t i v e s , working r e l a t i o n s , and l e g a l problems)
amo% t he ge ne r a l popul at i on i n La t i n ~me r i c a . 10
4 ) The maj or i t y of ef f o r t s t o pr event a l c ohol problems have been
concent r at ed i n Chi l e, a s r e f l e c t e d i n r e a d i l y a va i l a bl e ,
publ i shed r esear ch. These programe have been developed under
t he framework of t he di s e a s e concept and t hus aimed a t t he
pr event i on of al cohol i 8m (Marconi 1966, 1969, 1976 ; Feuerhake
e t a l . 1980; Mi nol e t t i and Demjean 1976) r a t h e r t han t he whole
gamu t of al cohol - r el a t e d problems.
Data from t he ge ne r a l popul at i on i n t he U.S. show t h a t t her e
a r e ba s i c di f f e r e nc e s i n c h a r a c t e r i s t i c s such a s age, s o c i a l class,
o ccupa t i ona l s t a t us, and mar1 tal s t a tus be tween c l i n i cal popula t i ons
and problem dr i nke r s i n t he community. Thi s s ugges t s t h a t t hose
di agnosed a s a l c ohol i c s a r e a d i f f e r e n t popul at i on from t hose wi t h
al cohol problems who have not reached t he c l i n i c door. Fur t her ,
problems i n t ne ge ne r a l popul at i on do n o t a t a l 1 resemble problems
i n d i n i c a l groups. I n t he ge ne r a l popul at i on problems a r e "di f f us e
and spor adi c, " and t he pr esence of a p a r t i c u l a r problem has onl y a
modest c or r e l a t i on wi t h t he presence of problems i n ot he r a r e a s o r
i n t he f ut ur e (Room 1979). Tnus, by i de nt i f yi ng a popul at i on of
a l c ohol i c s based on " l os s of cont r ol " and " i n a b i l i t y t o a bs t a i n, " o r
a popul at i on of exces s i ve dr i nke r s by t he amount and f r equency of
dr i nki i y, epi demi ol ogi cal sur veys i n La t i n America pr ovi de onl y a
ve r y lid t ed pi c t ur e of t h e t ar ge t popula t i on f o r pr event i on
s t r a t e g i e s and o t he ki nds of problems that shoul d be prevent ed.
The goa l s of pr event i ve e f f o r t s have remained l a r g e l y r e s t r i c t e d t o
l oc a t i on of e a r l y case and publ i c educat i on about t he dangers o
al cohol , w i t h t hes e educa t i ona l e f or t e concent r a t ed on t eachi ng t he
p u b l i c how t o r ecogni ze e a r l y s i gns o al cohol i s m. l l
Concl usi ons
The epi demi ol ogy of al cohol - r el at ed problems i n Lat i n America
goes back al most 30 years. During t heee yecirs onl y a few count r i es
were a b l e t o mai nt ai n a s us t ai ned i n t e r e s t i n al cohol s t udi e s a s
evi denced by t he l i t e r a t u r e i n t he f i e l d . Amo- t hose doing s o
were Chi l e and Cost a Rica. More r ecent l y, Mexico has developed
s t udi es on t he communi t y response t o al cohol - r el a t ed problems wi t hi n
t he f ramework of a n i nt e r na t i ona l col l abor at i on w i t h t he World
Heal t h Organiza t i on.
From a n o v e r a l l per spect i ve i t 1s pos s i bl e t o per cei ve t h a t
al cohol cons ti t u t e s a l egi t i ma t e sour ce of concern f o r r esear cher a
i n La t i n America. Thi s concl usi on t akes i n t o consi der at i on t he
e xt e nt t o which al cohol use 1s as s oci at ed wi t h everyday l i f e i n
La t i n America: dr i nki ng t akes pl ace " f i r s t t hi ng i n t he rnorning,"
duri ng t he day, i n t he eveni ng, duri ng weekdays o r weekends, a t
r e l i gi oua ceremonies , bap t i s ms , f uner al e, marri ages, s p o r t
a c t i v i ties, i n t oas t i ng one 'S heal t h o r t o promote s oci al i zi ng , t o
cel ebr at e r evol ut i ons o r t o mourn them, t o bri ng f r i e nds cl os e
t oget her; i t t akes pl ace because t r a d i t i o n t e l l s one t o dr i nk,
because t her e 1s l i t t l e e l e e t o do, and because dr i nki ng 1s what men
a r e supyosed t o do -- t o name j u s t a few reasons.
What emerges a r e mcirked di f f er ences i n t he norms a e s o d a t e d
w i t h al cohol us e by men and women and t he consequent cont r as t s i n
t he dr i nki ng pa t t e r ns of t he two sexes. Except perhaps among t he
upper s o c i a l classes, f o r which t her e 1s ver y l i t t l e evi dence,
exces s i ve dr i nki ng 1s a t e r r i t o r y occupi ed by males. The women's
domain i s t h a t of abs t ent i on o r moderate dri nki ng. Drinking t o
i nt oxi cat i on 1s agai n a male pr er ogat i ve, t ol e r a t e d by both men and
women a l i ke . Thi s c ont r a s t i n normal pa t t e r ns of al cohol us e 1s one
of t he f act or 8 expl ai ni ng t ne l a r g e r a t i o of men over women who a r e
re cognize d i n t he communi t y as having al cohol - r el a t ed problems and
a r e r e cei vi ng t reat ment f or them i n ps ychia tri c hospi t a l s .
Looking a t t he r e s u l t e acr os s count r i es , i t i s pos s i bl e t o see
major di f f er ences i n t he e xt e nt of excessi ve dri nki ng and t he
composition of al cohol - r el at ed problems. There a r e , f o r example,
consi der abl e d i f f er ences i n t he propor t i on of "cilcoholics" and
excessi ve dr i nker s. Among males, t he propor t i on consi dered
al cohol i cs r a ~ g e s from 5 per cent i n Argent i na t o 10 per cent i n
Colombia, and f o r exces s i ve dr i nki ng from 12 per cent i n Argent i na t o
23 per cent i n Chi l e o r 26 per cent i n some pa r t s of Cost a Rica. Data
from Costa Rica, Mexico, and Chi l e a l s o i ndi c a t e s i g n i f i c a n t
va r i a t i ons among r egi ons wi t hi n t hese nat i ons. A i l t hese
di f f er ences , pl us t hose i n choice of a l c ohol i c beverages, make i t
unwarranted t o i d e n t i f y one s i ngl e pa t t e r n of dr i nki ng a s t ypi cal of
La t i n America as a whole.
The s t u d i e s reviewed f o r this paper a l s o show di f f e r e nc e s i n
t h e per cept i on of a l c ohol us e and al cohol - r el at ed problems between
the urban s o c i e t y of La t i n America count r i es , wi t h i t s European
r oot s , and t he na t i ve peopl es of t he r egi on. Et hnogr aphi c s t udi es
s ugges t t h a t al t hough dr i nki ng and heavy dr i nki ng 1s common pr a c t i c e
amo* na t i ve s , t he r e seems t o be more t ol er ance f o r t he e f f e c t s of
t hese pr a c t i c e s and a lower r a t e o problems.
La t i n American s t u d i e s have concent r at ed on urban and working
c l a s e popula t i ons , w i t h li t t l e a t t e nt i on gi ven t o mar gi nal urban
gr oups, r u r a l popul at i ons, o r t he upper c l a s s e s . The dr i nki ng of
na t i v e popula t i ons has no t been i nves t i ga t e d epi demi ol ogi cal l y, but
o n l y wi t h et hnogr aphi c methods. As a r e s u l t a l c ohol s t u d i e s i n
La t i n America comyrise a n epi demi ol ogy of al cohol i em i n t he urban
working c l a s s r a t h e r t han a ge ne r a l epi demi ol ogy of al cohol - r el at ed
problems. The window i n t o t he community opened by t hese s t u d i e s 1s
t ner ef or e ver y narrow, and al l ows onl y a ver y p a r t i a l view o t he
na t ur e and c ha r a c t e r i s tics of al cohol - r el at ed problems.
Di f f er ences i n t he per cept i on o a l c ohol problems a r e e vi de nt
i n t he way i n which yrof e s s i ona l s go about s t udyi ng al cohol problems
and what may be s e e n a s t he publ i c per cept i on of t hese problems.
Uhi l e r es ear cher s under st and al cohol problems a s event s r e l a t e d t o a
condi t i on c a l l e d al cohol i sm, t he popul ar view seems t o s e e t he
dominant pa t t e r n o dr i nki ng a s s por adi c and t he problems of
i n t e r e s t a s occasi on- r a t h e r t han condi t i on- r el at ed; i .e., s e r i ous
a l c ohol problems a r e t hose more dr amat i c e ve nt s such a s r oad
a c c i de nt s o r vi ol ence. It 1s q u i t e t r ue t h a t l a & of money t o buy
pr ovi s i ons toward the end o the month may be a major problem t o
t hose f a mi l i e s where money i s bei ng epent i n heavy dr i nki ng by t he
head o t he household. However, her e we a r e making r ef er ence t o the
ge ne r a l popul ar view of a l c ohol problems and n o t t he view of t hose
a f f e c t e d by heavy dr i nki ng. These two ve r y d i f f e r e n t p r o f i l e s of
a l c ohol problems a r e of i mport ance i n r e - or i e nt i ng pr event i ve and
t r e a tmen t i nt e r ve n t i ons .
Given t h i s ge ne r a l panorama, t he f ol l owi ng recommendations can
be made:
1) A ba s i c r e q u i s i t e f o r t he s ucces s f ul or gani zat i on and
development o any r es ear ch pr oj e c t 1s a n assessment of t he
l i t e r a t u r e i n t he f i e l d . As mentioned i n t h i s review, t he
al cohol 11 t e r a t ur e of La t i n American count r i es 1s wi del y
sca t t er ed. Many j our nal s have l i m i t ed and i r r e g u l a r
c i r c ul a t i on, and e ubs t a nt i a l r es ear ch remains unpubl i shed a s
mas ter ' S o r doc t or a l d i s s e r t a t i ons. 1 t would seem t her ef or e
t ha t the or gani za t i on of a cl ear i nghouse f o r the s c i e n t i f i c
l i t e r a t u r e on a l c ohol 1s a necessar v s t e D i n f ur t he r i nx t he
development o a l c ohol r es ear ch i n - t he -regi on. The PAHO-
sponsor ed Bi bl i ot e c a Regional de Medicina (BIREME), l oc a t e d i n
Sao Paul o, Br a z i l , would be one of many pot e nt i a l sites f o r
s u& a cl ear i nghouse.
2 ) Met hodol ogi cal short comi ngs appear i n some of t he epidemio-
l o g i c a l s t u d i e s c a r r i e d o u t i n La t n America. The problems
encount er ed a f ect sampling pr ocedur es, da t a c ol l e c t i on, and
t he s t a t i s t c a l t r eat ment , o the dat a. It would seem t here-
f or e de s i r a bl e t o pr ovi de more t r a i ni ng oppor t uni ties f o r
r e s e a r c he r s i n t he f i e l d i n La t n America. Thi s coul d be done
e i t her by or yani zi ng r es ear ch semi nar s ( t he example o t he
s chool s of al cohol i sm s t u d i e s may be i nvoked he r e ) , o r , b e t t e r
ye t , by devel opi ng r es ear ch pr oj e c t s i n t he area, which would
pr ovi de on- the- j ob t r a i ni ng f o r research per sonnel . The WHO
S t udy o Communi t y Responsea t o Al cohol-Rela t ed Problems i s
one example of t h i s t ype of e f f o r t .
3 ) Epi demi ol ogi cal s t udi es i n La t i n A m e r i ca shoul d be re- ocused
t o i n d u d e a broad r ange of al cohol - r el at ed problems, n o t onl y
t hose a s s oc i a t e d w i t h s ever e forms o dr i nki ng. Research on
t he a s s oc i a t i on b e tween al cohol and r e l a t ed casual ties shoul d
a l s o be s t i mul at ed. A f i r s t s t e p i n t h i s di r e c t i on shoul d
i ncl ude a n at t empt t o des cr i be how l e g a l syst ems i n s e l e c t e d
c ount r i e s of t he r egi on handl e al cohol - r el at ed problema.
4) Pr event i on ef f o r ts shoul d a l s o be r e- or i ent ed and broadened.
These i nt e r ve nt i ons shoul d aim a t minimizing n o t onl y
al cohol i sm, bu t a l 1 t he al cohol - r el a t e d problems i n the
communi t y. Accordi ngl y, t he " t a r ge t" popula t i ons shoul d be
r eadj us t ed t o i ncl ude a l 1 t hose dr i nke r s who pr es ent problems,
and not onl y t hose midway t o t he c l i n i c door, a s happens wi t h
" e a r l y case f i ndi ng" procedures. Negl ect ed s t r a t e g i e s of
pr event i on shoul d be developed and implemented, and t he f or mal
and int' ormal r esponses o t he community t o al cohol - r el at ed
problems shoul d a l s o be t aken i n t o account when pl anni ng
pr event i ve i nt e r ve nt i ons . It may a l s o be more f e a s i b l e t o
pr event undes i r abl e event s t han undesi r abl e condi t i ons ,
e s p e c i a l l y when t h e condi t on, such a s i s t he case wlth
"al cohol i sm, " i s poor l y del i neat ed. Fi na l l y, t he evai ua t i on
of pr event i on e f f o r t s shoul d i ncl ude n o t onl y a n overview o
t h e i r i mpl ement at i on, b u t a l s o a measure of t h e i r e f f e c t s i n
the communi t y.
Acknowledgments: R. Room provi ded much us e f ul advi ce and " t i ps "
t hroughout t h i s r esear ch. G. Col l i ns provi ded e xpe r t e d i t o r i a l
a s s i s t a nc e . R. Alacon, G. Caetano, C. Campillo, W. Cl ar k, R.
Gonzalez, D. Heath, J. Mar i at egui , J. Masur, M.E. Medina-Mora,
H. A. Higuez, J. Moser, L. Ral st on and R. Roizen provi ded sugges-
t i ons and r e p r i n t s o t h e i r work and o col l eagues. Thi s r es ear ch
was p a r t l y suppor t ed by t he Na t i ona l I n s t i t u t e on Alcohol Abuse and
Alcoholism, Na t i o n a l Al cohol Resear ch Cent er Gran t (M-0559 5 ) t o t he
Al cohol Research Group, Berkel ey, Cal i f or ni a.
DISCUSSANT
Car l os Campillo-Serrano
I t i s, f o r me , a t r ue pl eas ur e t o have t he pr i vi l e ge of
commenting on t he work of Dr . Raul Caetano. He 1s a n o l d and dear
f r i e n d and a l s o , a col l eague s i nc e our days i n epi demi ol ogi cal
ps ychi at r y a few year s ago a t t he Ps yc hi a t r i c I n s t i t u t e of London.
1 now have t he g r e a t pl eas ur e of s eei ng him a s a pr of es s i onal and
r es ear cher i n the f i e l d of al cohol i sm.
Works o t he q u a l i t y t h a t we have j u s t hear d a r e seldom found
i n t he l i t e r a t u r e of La t i n America. Dr . Caetano pr es ent ed a n excel -
l e n t and de t a i l e d r evi ew of t he t opi c, gi vi ng u s a panorama o t he
problema r e l a t e d t o a l c ohol i n La t i n America and t aki ng t he occasi on
t o poi nt o u t met hodol ogi cal weaknesses t h a t e x i s t i n t he var i ous
publ i cat i ons . Bi s paper a l s o emphasizes t he l a& of dat a i n
s peci f i c and impor t a n t a r e a s , and e xpl a i ns why epi demi ol ogi cal
r es ear ch i n our p a r t i c u l a r r egi on has rather r i g i d l y adher ed t o t he
medi cal model, and di s cus s es the l i mi t a t i ons of t h a t approach.
Obviously, t h i s i s a work t h a t wi l l 111 a gap i n our bi bl i o-
gr a phi e s and one t h a t has been needed f o r q u i t e some t i me . We have
n o t had t h i s bef or e because, among ot he r r easons, of a l a c k of
t r a i ne d and capabl e peopl e i n our r egi on and, a l s o , because of t he
e x t e n t of e f f o r t needed t o compile bi bl i ogr aphi es from wi del y
s c a t t e r e d s our ces i n La t i n America. For a l 1 o t hese r easons 1
would l i k e t o most h e a r t i l y congr at ul at e Dr . Caetano f o r t he q u a l i t y
of t he work pr esent ed t o us.
H i s work can be di vi ded i n t o our pa r t s ; a ) a revi ew of he a l t h
i ndi c a t or s i n La t i n America; b) a review of the e f f e c t s of al co-
nolism: deat hs due t o he pa t i c c i r r hos i s , al cohol i sm, a l c ohol i c
psychoses, crime, s ui c i de , con inement i n ment al i n s ti t ut i ons ; c ) a
s tudy o a l c ohol consumption pa t t e r n s and al cohol i sm w i t hi n communi-
ties; and d) t he La t i n American per s pect i ve on al cohol - r el at ed
problems.
La t i n America - The Beal t h Per s pect i ve
W i th t he da t a t ha t Dr . Caetano has gi ven us , i t i s ve r y ciear
t n a t La t i n America 1s a r a t h e r het erogeneous r egi on wi t h g r e a t
di f f e r e nc e s between count r i es , but a t t he same t i m e s har i ng a series
of common characteris ti cs whi ch di f f e r e n t i a te i t f rom ot he r r egi ons
of t he world. As a gr oup, t he count r i es of La t i n America r e t a i n a
q u i t e s e pa r a t e i d e n t i t y from more developed c ount r i e s such as
Canada, t he ni t e d St a t e s , and t hose of west er n Europe. We are
r e f e r r i n g t o c ount r i e s t h a t ge ne r a l l y are e i t h e r poor o r a t a median
l e v e 1 of pr os pe r i t y, under-developed o r devel opi ng, where r es our ces
t o de a l wi t h domest i c problems a r e f r e que nt l y s car ce.
The mor t a l i t y r a tes from he pa t i c c i r r h o s i s , a l c ohol i c psycho-
si s, and al conol i sm, a e Dr . Caetano has poi nt ed out , are hi gh i n
La t i n America, predomi nant l y a f f e c t i ng men between 55 t o 5 year s of
age. I mpor t ant di f f e r e nc e s a r e shown between cities; t hese coul d be
expl ai ned by s oc i oc ul t ur a l f a c t or s , but we shoul d n o t di scount
c e r t a i n pr a c t i c e s i n medi cal di agnoses and f a c i l i t i e s , and
di f f e r e nc e s i n aut ops y procedures. The da t a t h a t Dr . Caetano ha s
pr esent ed a l s o s ugges t s t h a t t he t opi c shoul d be r esear ched f u r t h e r
s o as t o e xpl a i n more s a t i s f a c t o r i l y the d i f er ences be tween
coun t r i e s .
The da t a r e f e r e nc e s t o s ui c i de s , t r a f f i c deat hs, t r a f f i c
a c c i de nt s , and t he l i k e are more d i f f i c u l t t o i n t e r p r e t t han t hose
pe r t a i ni ng t o c i r r h o s i s of t he l i v e r . Exi s t i ng s t u d i e s a r e incom-
pl e te, i nconcl usi ve , and l i m i t themselves t o suppl yi ng s t a tis ti cs;
no r ef er ence 1s made t o t he complex r e l a t i ons hi p be tween a l c ohol
consumption and l e g a l r esponses t o t hes e problems i n t he r es pect i ve
count r i es . There 1s a l ack of adequat e methodology, a l s o , t o
compile da t a on u a f f i c acci dent e s o that, al t hough a c c i de nt s a r e a
s e r i ous problem, t her e 1s l i t t l e awareness of t he ne c e s s i t y of
s t udyi ns this matter. It 1s a t opi c t h a t has been r a t h e r shunt ed
a s i d e i n La t i n America, b u t one whose s i gni f i c a nc e merits g r e a t
a t t e nt i on. St udi e s of admi ssi ons t o ment al hos pi t a l s are even more
d i f f i c u l t t o e va l ua t e because q u i t e of t en t hey speak about t he
a v a i l a b i l i t y of f a c i l i t i e s and psychi a tri c t r eat ment r a t h e r t han t he
pr o blems r e l a t e d t o al cohol .
Community St udi e s on Al cohol Consumption Pa t t e r ns
Dr . Caet ano' s r evi ew has covered s t u d i e s undert aken i n e a & of
t he count r i es of La t i n America. IUs revi ew 1s de t a i l e d and i ncl udes
n o t onl y t he r e s u l t s obt ai ned, but a l s o a n e va l ua t i on of t he methods
used. A main poi nt 1s t h a t i n La t i n A me r i c a community sur veys of
a l c ohol consumption pa t t e r ns da t e onl y from t he 1950s. Ea r l i e r
statistics f ocused on mor bi di t y, mor t a l i t y, and acci dent s .
The f i r s t epi demi ol ogi cal s t u d i e s were i n i t i a t e d by O us i ng
Marconi 'S ope r a t i ve de f i ni t i ons , which a r e more pr e c i s e and objec-
t i v e t han t he c l a s s i f i c a t i o n proposed by J e l l i ne k. The ma j o r i t y of
s t u d i e s do have met hodol ogi cal weaknesses. There 1s a l s o a n absence
of da t a a na l ys i s . I n s ever a1 ways, t he r e s u l t s of t he s t udi es a r e
d i f f i c u l t t o compare. We f i n d wi t h t he Marconi c l a s s i f i c a t i o n , f o r
example , tha t s t a t i 8 ti cs f o r e i t he r exces s i ve dr i nke r s o r a l c ohol i cs
coul d correspond, al t hough n o t e xa c t l y, t o t he cat egor y of problem
dr i nker i n t he Uni t ed St a t e s . We do not e t h a t t he c ount r i e s w i th
t he g r e a t e s t t r a d i t i o n of r es ear ch i n a l c ohol a r e Chi l e, Cost a Ri c a ,
Per u, Ar gent i na, Br a z i l , and most r e c e nt l y Hexico.
Tne La t i n American V i e w of Alcohol-Related Problema
Dr . Caetano obser ves t h a t J e l l i n e k ' s work has been t he
g r e a t e s t i nf l uence i n t he s t udy of al cohol i sm i n La t i n America.
Dr . J e l l i n e k ' s concept of al cohol i sm a s a di s e a s e i s t he one that
ha s pr evai l ed i n t he regi on. The pr i nc i pa l proponent of t h i s poi nt
of view has been Marconi, whose oper at i ve de i n i t i ons have been ueed
widely. Research h a s been under t he s uper vi s i on of doct or s , wi t h a
l a c k of a t t e n t i o n t o s oc i ol ogi c a l concerns t h a t are s o t ypi c a l i n
t he ni t ed St a t e s .
The l i mi t a t i oi i s of t he medi cal approach r e s t i n t he f a c t t h a t
a t t e n t i o n goes al most e xc l us i ve l y t o t hose who a r e c l a s s i f i e d
"al cohol i cs. " However, t hes e are a mi nor i t y and have a low degr ee
of v i s i b i l i t y i n t he community. The medi cal r esponse a l s o i gnor es
eoci ocul t u r a l f a c t o r s fundamental f o r t he desi gn of pr event i ve
campaigns; i .e., t he r easons, cont ext , and be l i e f S, a t t i t u d e s and
s t andar ds a s s oc i a t e d w i t h a l c ohol use.
Fi na l l y, t he f ol l owi ng i s a most i n t e r e s t i n g concl usi on
pr esent ed by Dr . Cae tano, which 1 s t r ongl y suppor t: Epi demi ol ogi cal
s t u d i e s i n La t i n America, p a r t i a l l y due t o us e of t he concept o
al cohol i sm a s a di s e a s e , have examined onl y p a r t of t he problem and
a smal l per cent age of the popul at i on, pr i ma r i l y t he working cl ase.
They have n o t d e a l t adequat el y wi t h t he r u r a l popul at i on o r t he
hi gher s o c i a l c l a s s e s . They do show t h a t t he consumption of al cohol
i n La t i n America i s i nt i ma t e l y connected t o t he d a i l y l i f e o i t s
i nha bi t a nt s , and t h a t t her e i s a g r e a t di f f e r e nc e i n t he pa t t e r ns of
consumption of men and women.
We f i n d t h a t t he count r i es t h a t have c ol l e c t e d t he most da t a
a r e Chi l e, Mexico, and Guatemala. Avai l abl e da t a show t h a t dr i nki ng
pr a c t i c e s i n e a & count r y and r egi on a r e ver y d i f f e r e n t and as a
r e s ul t , r a t her di f i c ul t t o compare. Al so, resear cher s ' percep t i ons
of t he dimensions of a l whol - r e l a t e d problems of t en di f e r f rom
t hose he l d by me ge ne r a l popul at i on.
Mexican Par t i c i p a t i o n i n t he WHO Mul t i nat i onal St udy
Now moving on from t he vor k of pr evi ous r es ear cher s , 1 wu l d
l i k e t o b r i e f l y de s c r i be t he pr oj e c t i n which our i n s t i t u t e has
r ecent l y been i nvol ved and t o which Dr. Caetano and Dr. Rene
Gonzalez have r ef er r ed i n commenting on community response t o
al cohol -rel at ed problems. Thi s i s a mul t i nat i onal e tudy d r a m up by
t he World Health Organi zat i on and fi nanced by t he U.S. National
I ne t i t ut e on Alcoholiem and Alcohol Abuse. The count ri ee s t udi ed
were Scot l and, Zambia, and Mexico. The obj ect i ves were t o not e t he
nat ure, ext ent , and manner i n which t he comuni t y deal e wi t h
al cohol -rel at ed probleme i n t hree count ri ee w i th di f er en t degrees
o eocioeconomic developmen t.
The et udy l e a pa r t o a n ext ensi ve WHO program r e l a t i ng t o
al cohol which l e t o be car r i ed out i n vari oue st agee. I n t he i r e t
et age we compiled i nformat i on according t o a gui del i ne proposed by
the eponsoring or gani zat i on on production, di et r i but i on, l egi e-
l a t i on, economice, and programe of t reat ment and r e ha bi l i t at i on.
The r e s ul t e of t hi e par t i cul ar compila t i on have al r eady been
publ i shed i n a WHO monograph.
Next, i n order t o obt ai n more e pe c i f i c and more det ai l ed
i nformat i on, we examined reeponeee t o al cohol -rel at ed probleme
through community eurveye i n two ar eae t o t he sout h o Mexico Ci t y.
uie was r u r a l and one was urban. We researched pat t er ne o con-
eumption and norme of dri nki ng. We a l e o eurveyed agenci es and
agent e i n the community who deal w i t h t hese probleme, such a e t he
pol i ce, hoepi t al s , churchee, heal t h aut hor i t ee, e t c. We then
i de nt i f i e d a group o dri nkere recognized i n t he community a s having
al cohol probleme and ueed our e tandard comuni t y queet i onnai re f or
them al eo.
During t he whole pro j ect we had t he advi ce and eupervi ei on o
vari ous expert e i n t hi e par t i cul ar f i e l d. Speci al care wae gi ven t o
meeting t e chni cal requiremente, euch a s de termining adequate eample
ei ze, s el ect i on o thoee t o be eurveyed, cont ent of queet i onnai re,
and compilation o dat a. I n order t o aesure t ha t we would be abl e
t o make comparieone betweeen count ri ee, we hel d vari oue meetlngs
during which we were ver y car ef ul t o determine t ha t t he col l ect i on
of dat a and compi l at i on o que6 t i onnai r e r eeul t e would guarantee t he
pos e i bi l i t y o comparison.
Thi s pro j e c t was i n i t i a t e d i n 1976 and wae concluded i n 1980.
The prel i mi nary r e e ul t s were present ed a t an i nt er nat i onal meeting
i n Mexico Ci t y i n J u l y 1981; Mexican aut hor i t i ee comect ed w i t h
al cohol programe and gues ts o vari ous coun tries of La t i n America
par t i ci pat ed. Mt e r t he meeting we worked wi t h Mexican aut hor i t i ee
deal i ng with probleme of alcoholiem and took s t e p s t o ehare our
experi encee with our colleaguee i n Lat i n America i n order t o l e y t he
groundwork f o r f ut ur e col l aborat i on.
The l a s t phase o t he pr oj ect , now underway, i e t o t r y t o
i n i t i a t e concret e act l on i n one o t he communitiee s t udi ed i n order
t o demons t r a t e t o Mexican a u t h o r i t e e a t t he na t i ona l l e ve 1 that
pr event i ve a c t i o n s are f e a s i bl e . We w i l l a l s o work t o e s t a b l i s h
f or mal cont act wi t h ot he r col l eagues i n La t n Anterica s o as t o
i n i tiate j o i n t pr o j e c t s .
The i mport ance of t he pr oj e c t t h a t 1 have j u s t descr i bed i s
t h a t i n var i ous ways we overcame t he l i mi t a t i o n s out l i ne d by Dr .
Caet ano i n c ome c t i on wi t h pr evi ous s t u d i e s under t aken i n La t n
America. We responded t o some o h i s suggest i one f i r s t by abandon-
i ng t he r i g i d medi cal model of a l c ohol a s a di s eas e, and t hen by
l ooki ng a t s o d a 1 and l e g a l problems. We used t he advi ce o
s p e c i a l i s t s , and dur i ng t he cour se of t he i nve s t i ga t i on developed
and t r ai ned a team of r es ear cher e under t he di r e c t i on of t he
I n s t i t u t e of Mexican Psychi at r y.
Thi s s t udy made i t pos s i bl e t o consi der t he problems of
a l c ohol i n a wider per s pect i ve, w i t h the goa l o ollowing through
wi t h pr event i ve pol i c i e s . One advant age was t h a t t he pr e s t i ge o
WHO gave u8 a c c e s s t o Mexican a ut hor i t i e s . And 1 would l i k e t o
r e pe a t t h a t we now have a group of t r a i ne d r e s e a r c he r s t o cont i nue
work on t h i s t opi c. 1 be l i e ve t h a t t h i s s t udy cr eat ed a model that
i s worthy of being copi ed i n ot he r count r i es o t he r egi on.
Chapt er Notes and Referentes
Manif esta t i ons and P e r c e ~ t i ons o
Al cohol-Related Problems i n t he Americas
No tes
1. I n s t andar d comparisons of c i r r h o s i s mor t a l i t y r a t e s between
U. S. dt i e s , San Fr anci sco ehows t he highee t r a t e . However,
t h i s par t l y r e l e c t s t he hi ghl y pr of es s i onal deat h
c e r t f i c a t i o n proceduree and t he re8 t r i c t e d boundari es o t he
c i t y (Room 1372).
2. The cat egor y of c ur r e nt a bs t a i ne r s was cr eat ed by t he revi ewer
by combining ex- dr i nker s and ex-problem dr i nke r s , who, accord-
i ng t o t he r e por t s , were def i ned a s t hose dr i nke r s who had
been i n continuous abs t ent i on f o r a t least one year pr i or t o
t he survey dat e. hen added t o t he l i f e t i me abs t ai ner s , t he
new group narrows t he di f f erence f o r abs ten t i on r a t es be tween
the two sexes.
3- With this method t he i nformat i on on al cohol use and dri nki ng
pa t t erne 1s col l ect ed f r on severa1 groups of people assembled
according t o occupat i on and which meet t o di scuss pat t er ns of
al cohol use i n t he i r pr of essi onal groups. The di scussi on 1s
coordina t ed by a t r ai ned l eader who f ollows a pre-arranged
schedul e o t opi cs f o r di scussi on. The mat er i al from t he
groups 1s col l at ed and a pi ct ur e of al cohol use i n t he
conununity can then be formed. The "i nfonuant " method provides
a descr i pt i on o how a group of s el ect ed i nvi di dual s percei ve
the pl ace of al cohol i n t hei r cul t ur e, but whether this
percept i on corresponde t o t he r e a l positiom and use of al cohol
i n t hot cul t ur e 1s debatable.
4. It should be not ed t ha t t he di sease concept had al r eady found
acceptance among Chilean psychia tris t e. liorwi tz (1965),
al r eady i nt e r pr e t i ng t he i ncr ease i n a l cohol-related
admissions t o Chi l ean mental hospi t a l e af ter 1947 , ascr i bed
t hese changes t o a s hi f t i n physi ci ans' perspect i ves about
al cohol i sm t reat ment due t o t he di f f us i on of t he di sease
concept. Al ow w i t h t hi s shi f t came accept ance o t he ki nd of
c l i n i c-based t r ea tmen t programs developed a t Yale i n 1943.
5 . J e l l i ne k becomes more s pe c i f i c when he def i nes t he vari ous
speci es of al cohol i sm (al pha, be ta, gama, del t a, epsi l on) .
Also, i n J e l l i ne k t he r ol e of al cohol -rel at ed problems i n
char act er i zi ng al cohol i sm changes according t o t he type being
considered: t he r ol e 1s per i pher al i n gaama and del t a
al cohol i cs , s i nce t hese a r e i de nt i f i e d by "l oes of cont rol "
and " i na bi l i t y t o abs t ai n, " but i t has a more cent r al meaning
i n the al pha and bet a types. The al pha al cohol i c dri nks t o
r el i eve t ensi ons and t he "damage" 1s both or gani cal l y and
s oci al 1 y-rela t ed ( i nt er per sonal r e l a t i ons, work, e t c. ) . Beta
al cohol i cs a r e charact eri zed by t he presence of al cohol -
r e l a t ed or gani c problema (polyneuropathy, gas tri tls,
ci r r hos i s ) .
6 . In a l a ter paper, Marconi (1967 c) quot es t hi s same def i ni t i on
but s ubs t i t ut e s t he word i l l n e s s f o r di sease, among ot her
a l t e r a t i ons i n wording .
7 . The reasons why i t was l e f t t o physi ci ans t o publ i sh papers on
t he dis t r i but i on and pat t er ns of al cohol consumptlon i n t he
gener al popul at i on o Lat i n American nat i ons a r e complex and
i nvol ve such f a c t or s a s f unding pat t er ns , t he development of
medicine and ot her heal t h r el at ed pr of essi ons, and t he general
under st andi ng o what pr of es s i on 1s supposed t o t ake a n
i n t e r e s t i n what s ubj e c t s i n La t i n Americn s o d e t i e s . I n
La t i a America, a s i n many p a r t s o t he worl d, many psychia-
trists and psychoanal yst s have n o t embraced t he di s e a s e
concept. Among t he f or mer , many see al cohol i sm a s a symptom
of a n under l yi ng psychi a t ri c d i s t urbance. Among the l at t er ,
al cohol i sm i s a symptom of a n unr esol ved c o n f l i c t which has
r o o t s i n e a r l y phases of pe r s ona l i t y development. However, a s
might be expect ed consi der i ng t h e i r views o t he problem,
ne i t he r o t hes e groups has been a c t i v e l y i nvol ved i n al cohol
r esear ch; whi l e t h e i r pos i t i ons may have a bear i ng on t he
handl i ng o c l i n i c a l cases, i t has n o t i nf l uenced epidemio-
l o g i c a l s t udi e s . One advant age o Marconi ' s f or mul at i on and
of tne di s e a s e concept , i n gener al , over ps yc hi a t r i c or
psychoanal yt i cal views i s t h a t t he former does encompass
epi demi ol ogy and t he c ol l e c t i on of da t a on dr i nki ng pr a c t i c e s
i n t he ge ne r a l popul at i on.
d . Recent l y, t her e have been i ndi c a t i ons of a s hi f t i n t he way
a l c ohol problems a r e underst ood. Room (1981) has a l r e a dy
commented on t he WHO 1980 Exper t Committee Repor t, which does
n o t make referente t o al cohol i sm a s was t he pr a c t i c e i n t he
' 50s, bu t i s concerned i n s t ead w i t h " t he a l c ohol dependence
syndrome" and wi t n "problems r e l a t e d t o al cohol consumption."
I n Lat i n America t he s i gns of such a s h i f t a r e a l s o pr esent .
A l though t he r ecen t al cohol l i t e r a t ur e does no t make r ef er ence
t o t he "al cohol dependence syndrome," a n a s s oc i a t i on r e c e nt l y
cr eat ed t o l i n k r es ear cher s i n the f i e l d has been named
Asoci aci on Ibero-Ameri cana de E s t udi os de l o s Problemas d e l
Alcohol (Ibero-American Associ at i on f o r t he St udy o Alcohol
Problems) . Fur t he r , t he r e c e nt l y developed "Pl an o
Alcoholism" ( Pl an de Alcoholismo) o t he Chi l ean Mi ni s t r y o
Heal t h (Medina 1960) i nt r oduces t he concep t o "problem
dr i nker s" t o encompass "excessi ve dr i nker s " and "al cohol i cs. "
9. Research wi t h a framework d i f f e r e n t r on t h a t provi ded by t he
disease concept ha s been ve r y s c a r c e i ndeed. Vi dal (1967 b,
197 1 ) has done work on per eonal i t y c h a r a c t e r i s t i c s o
al cohol i cs . Sl uzki (196 7 ) i n i t i a t e d s t udi e s f ocussed on the
pa t t e r n of i n t e r a c t i o n s i n f a mi l i e s of al cohol i ce. Diaz
(1980), usi ng et hnogr aphi c methodology, has descr i bed t he
f unct i oni ng of a cl ub of a bs t a i ne r s composed o r ecover ed
a l c ohol i cs. Masur (1980) has been a c t i v e l y pur sui ng r e s e a r ch
which us es t he "problem dr i nker " approach developed by Cahalan
(1909) and h i s a e s oc i a t e s .
10. It shoul d be not ed, however, t h a t whi l e t he di s e a s e concept
undeni abl y f ocuse d t he a t t e nt i on o r e s e a r cher s on s e l e c t e d
problems i ndi c a t i ve of phys i cal a ddi c t i on t o al cohol , i t d i d
n o t ne c e s s a r i l y i mpl y i gnor i ng s o c i a l o r c a s ua l t y problems.
The WHO de f i ni t i on of al mhol i s m (UHO 1952), as w e l l a s that
proposed by Kel l er (1962), advocat es usi ng s oc i a l problems a s
i ndi ca t or 8 of al mholism.
11. It s eas t na t t he onl y cal 1 t o adapt prevent i ve act i on t o t he
type of problem present ed by t he dri nker was made by Sl uzki
(1962). Af t e r es t abl i s hi ng that a l mhol i c e i n di f f e r e nt
s oc i a l classecl and w i th di f f e r e nt l e ve l s of educat i on c a e t o
t reat ment w i th di f f e r e nt problems, Sl uzki suggest ed t ha t
prevent i ve campaigns whi ch f ocused on t hose problems would
st and a be t t e r chance of achi evi ng success than those which
aimed a t e a r l y case fi ndi ng. Thi s approach has s i mi l a r i t i e s
with t ha t propoeed by U.S. r eeear cher s, which t akes i n t o
account not onl y problems such as "l oes of cont rol " or
" i na bi l i t y t o abs t ai n, " but t he whole spectrum of al mhol -
r e l a t ed problems i n t he conununity. Unf o r tuna t el y, Sl uzki ' S
proposal was not pureued i n Lat i n America.
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d. Aarens, T. Cameron, J. Roizen, R. Roizen, R. Room, D.
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Addiction esearch Foundation (1978). S t a t i s t i c a l Supplement t o t he
Annual Report 1317 - 1976. Addiction Research Foundation,
Toron to.
Adis Cae t r o, G. (1966 ) . A l coholismo y enfermedad: concepcion popular
(proyect o para s u i nves t i gaci on). Acta Psi qui a t r i c a y
Psi col oi t i ca de America La tina. 12: 343-350.
Adi cl Cast ro, G. and 1. Fl or es (1967 ). Estado act ual de l a epidemio-
l ogi a del alcoholismo y problemas del al cohol e n algunos
pai ses de America Latina: Costa Rica. Pp.86-91 i n J. Horwitz,
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e n America La t i na. Buenos Aires: Acta.
Agui l l er a, A. (1967 ) Estado act ual de l a epidemiologia del alcohol-
ismo y problemas del al cohol e n algunos pai ses de America
La tina: Guatemala. Pp. 106-111 i n J.Horwitz, J. Marconi, G.
Adis Cae t r o , eds . Epidemiologia del Alcoholismo en America
Lat i na, Buenos Ai res: Acta.
Al me i d a , M. (1971). El problema d e l al cohol e n e l Peru. Anales d e l
11 Congreso Naci onal de Ps i q u i a t r a , Lima, Peru: 180-181.
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Chapter Four
HISTORICAL AND CULTURAL FACTOBS
AFPECTING ALCOHOL AVAILABILITY AND CONSUHPTION IN LATIN AHEBICA
DISCUSSANTS
Eduardo bkdina Cardenae
Juan Carlos Negrete
HISTORICAL AND CULTURAL FACTORS
AFFECTING ALCOHOL AVAILABILITY AND CONSUMPTION I N LATIN AMERICA
Dwigh t B. Hea t h
I t i e now ge ne r a l l y recogni zed t h a t al cohol i e t he peycho-
a c t i v e drug moet wi del y ueed throughout t he world, and t h a t i t i e
probabl y a l e o t he ol de e t i n cue tomary ueage. There a r e few ar eae of
t he world where a l c ohol i c beveragee a r e more common among di ver ee
popul at i one than i n Lat i n ~ m e r i a , ~ o r where t hey have more var i ed
meaninge and f unct i one, o r where we know eo much about t he i r
importance throughout hi et or y. For a l 1 of t heee reaeone, a br i ef
revi ew of h i s t o r i a l 2 and c ul t ur a l 3 f a c t or e a f f e c t i ng al cohol
a v a i l a b i l i t y and consumption i n Lat i n America ehould be ueef ul i n
hel pi ng t o provi de cont ext f o r our di ecueei on of approachee toward
t he underet andi ng and prevent i on of al cohol - r el at ed probleme.
Thi e pr es ent at i on begi ne wi t h an i nt r oduct i on t o t he
impor t ance of hi e t o r i c a l and c u l t u r a l f a c t or e t oget her w i t h an
out l i ne of major r el evant work t h a t has al r eady been acampl i ehed i n
t h i s connection. A br i e f di ecueei on of t he pre-Columbian per i od
deal s w i t h t he broad d i e t r i but i on of a l c ohol i c beveragee among
nat i ve popul at i one p r i o r t o cont act w i t h Europeane, and wi t h eome of
what we know of t he pat t er ne of behavior and aeeoci at ed meaninge.
I n r e l a t i o n t o t he col oni al per i od we examine new st andard8 of
behavi or and di f f e r e n t meaninge t h a t were i nt roduced, and how t he
f or c e of l aw sometimes i nt er vened i n var i oue waye. A eect i on on
c u l t u r a l va r i a nt s i n modern hi e t or y provi dee a sampling of t he r i c h
d i v e r s i t y t ha t has been found among sever a1 Lat i n American
popula t i ons duri ng t he ni ne t eent h and t went i et h cent ur i ee. It deal e
w i th some b e l i e f s and a t t i t u d e s about dr i nki ng a8 euch, and wi t h
some of t he ways i n which a l c ohol i c beveragee a r e i nt egr at ed wi t h
economic, p o l i t i c a l , r e l i gi ous , and ot her as pect e of t he c ul t ur a l
eystems. It a l s o i ncl udee r ef er ence t o et hni c, cl aee, and ot her
var i ant e wi t hi n nat i ons. A few t e nt a t i ve concl uei ons a r e of f er ed
t h a t may be hel pf ul i n broad des cr i pt i ve and a n a l y t i c terme, and i n
i dent i f yi ng some i mp l i a t i o n s f o r act i on.
Thi e workehop hae provi ded a n appr opr i at e and t i mel y occaei on
f o r r e v i e wi q a l a r g e and di ver ee corpue of l i t e r a t u r e from a f r e e h
out l ook, and t h i e revi ew of t he wi del y ecat t er ed mat er i al shoul d be
i nf or mat i ve and us e f ul even t o col l eaguee who have worked i n t he
f i e l d f o r many years.
We a r e aware t ha t , f o r eome time, t her e has been conei derabl e
ambivalence about euch broad l a b e l e as "Lat i n America" o r "Ibero-
America." L e t u8 remember t ha t a f t e r Lui s Al ber t o Sanchez publ i ehed
a n eeeay wi t h t he provocat i ve t i t l e "Doee La t i n America Exi et ?"
t her e vas onl y a br i ef r aeh of uncomfortable j okes i n reeponee:
"Yes, i n t he t a bl e of or gani zat i on of t he U.S. Department of St at e, "
o r "Yes, i n 30 d i f f e r e n t i n e t i t u t e e and r eeear ch cent er e i n European
and Nor th American uni ver s i t i ee. " But t ha t di d not las t 10%. When
Sanchez expanded t he eeeay t o a book he answered h i e own ques t i on i n
t he a f f i rmat i ve: "Among t he count r i ee of Lat i n American t her e a r e as
many di f f er ences a e among t he e t a t e s t h a t make up t he Un i t ed S t at ee,
b u t fewer t han thoee among t he nat i ons of Europe. " (1944: 10).
Other Lat i n Americans addressed t h i e concern i n t he uneaey
yeare i mmedi at el y f ol l owi ng World War 11, when i ndi vi dual e and
groupe throughout much of t he worl d were gr appl i ng wi t h newly
i mpor t ant -- and newly uncer t ai n -- i s s uee of i de nt l t y. Excerpt e
f rom sever a1 aut hor s i l l u s t r a t e t h i e soul -eearchi ng, which
i nva r i a bl y managed t o r ea ch beyond t he narrow na t i ona l i e ti c views
t h a t had r e c e nt l y eeemed t o become s o pa t e nt l y obeol et e. "Modern
La t i n Ameri can cul t ur e" mue t be cons t r ued a s " . . . t he cona t r u c t i v e
and c r e a t i ve s ynt hes i s of Europe and America, of Spani arde and
Indiane...a e p i r i t u a l eymbioeis which i s e t i l l i n f u l l evol ut i on"
(Alvarado U 52). Si mi l ar l y, but i n a more s t r i d e n t l y r egi onal l e t i c
tone: "I n t he t a c i t conspi racy agai net t he r ecogni t i on of our
e t h i c a l and c u l t u r a l uni t y a r e wr i t e r s , c a p i t a l i s t e , and eol di er e of
i mperi al i em. Cul t i vat ed Europe hae been accustomed t o judge us and
t r e a t us a s t he di eper sed remaine of a shipwreck" (Vaeconceloe n.d.:
11 ). Even t hose who pay a t t e n t i o n t o s i g n i f i c a n t di f f er ences t end
t o emphasize uni t y. For example, "The di f f er encee come, n o t from
di f f er encee i n h i e t o r i c a l e i t ua t i on, b u t from t he temperamente of
t he act or e" ( Pi con 1951:335-336), o r "Cent ral America and South
America belong, as do North America, South Af r i ca, Aus t r al i a and New
Zealand t o t he ' Western World' ; t hey form, t oget her wi t h Br azi l , a n
I b e r i c-Cri ol l o-Indi an Zone" (Basadre 1951: 3% ). Ariel (Rodo 1900)
remaine a v i t a l i n t e l l e c t u a l f or c e symbolizing Lat i n e p i r i t u a l i t y
and dynamlem, even whi l e caudi l l os f a n t he embers of xenophobia t o
eer ve t he i r pr i va t e purposee.
A North American ant hr opol ogi et who has l ong wr eet l ed wi t h t he
confusi on over uni t y and d i v e r s i t y wi t h r eepect t o Lat i n America a e
a r egi on o f f e r e a eucci nct summary of t he problem: "A baei c theme
. . . has been t he r i c h d i v e r e i t y of cul t ur ee and e oc i e t i e e throughout
contemporary La t i n America. The r e a l i t y of di f erence, however,
ehoul d no t obecure t ha t wideepread underl yl ng un1 t y which der i ves,
i n l a r g e p a r t , from t he I be r i a n her i t age. Lat i n Americane and
o t her s gener al l y agr ee on t he impor t ance of personal i emo, di gni dad
de l a persona, and machismo i n t he l i f e of i ndi vi dual e, and a
v a r i e t y of i n s t i t ut i one can be f rui tf u l l y i n t er pr e t ed a8 expreeei ng
t hese bas i c e t hos componen ts, even though t her e l e of t en a marked
di vergence between i de a l e and a c t i o n ... [and even though] t he
dominant na t i ona l pa t t e r ns a l s o s t and 1x1 marked cont rae t t o t he
views of t he I ndi ans who comprise a s i g n i f i c a n t por t i on of t he
popul at i on i n many of thoee coun tries" (Hea t h 197 4b:424).
With t h i s j ue t i f i c a t i o n of t he "ia t i n American" component,
l e t ' e b r i e f l y examine t he j u s t i f i c a t i o n f o r f ocusi ng on h i e t o r i c a l
and c u l t u r a l f act or s . It 1s gr a t i f yi ng t h a t i n r ecent decadee
v i r t u a l l y a l 1 who work i n any f i e l d r e l a t e d t o t he et udy of al cohol
and i t s r e l a t i o n t o human behavi or have accept ed t he gener al
pr opoei t i on t h a t s o c i a l and c u l t u r a l f a c t or 8 a r e r el evant , i n
combina t i on w i t h physi ol ogi cal , ps ychol ogi cal , and o t her f act or s .
I n eome i n s t ances , however , such accept ance may be r e l a t i v e l y
paasi ve and pro-forma, implying l i t t l e underst andi ng and even l e e s
commitment. For t h a t reason, a n extreme i l l u s t r a t i o n may deserve
a t t e n t i o n a t t he out set --t o show t h a t we a r e t al ki ng about real and
s i gni f i c a n t di f er ences r a t h e r t han si mpl y overemphaeizing minor
f eat ur es wi t hi n a narrow range of var i at i on. For t h i e reaeon, 1
s ugges t now t h a t we b r i e f l y consi der t he f a c t t ha t , among many of
t he I ndi an t r i b e s i n c e nt r a l Br azi l t he ver y a c t of i ngeet i ng --
whether e a t i ng s o l i d s o r dr i nki ng l i qui ds , wi t h no r egar d t o t h e i r
a l c o h o l i c cont ent o r s o c i a l o r economic val ue -- i e eubj ect t o
ex treme modes t y, accompanied by shyneee , bl ushi ng , hi di ng f rom t he
view of ot her e, and s o f o r t h -- 1x1much t he way t h a t some of us may
f e e l about de ecat i on, sexual i nt er cour ee, o r ot he r a c t i v i ties (von
den St ei nen l 894) . Thi e 1s n o t an appr opr i at e cont ext f o r t r yi ng t o
i n t e r p r e t o r aes es s i mpl i cat i ons of euch an a t t i t u d e . However,
si mpl e r ecogni t i on of t he range of c u l t u r a l f act or 8 t h a t ehould be
consi dered i n any at t empt t o i nf l uence pat t er ne of al cohol
consumption i n t h a t a r e a shoul d dr amat i cal l y underecore t he need f o r
and val ue of de t a i l e d unders t andi ng of l o c a l pat t er ns , which of t en
range f a r out ai de t he cat egor i es t h a t have become cuetomary even i n
s peci al i zed surve y-ins trumen t e , o r i n t he minds of r esear cher e o r
o t her s who a r e concerned wi t h heal t h.
Fortuna t e l y, s chol ar s from Lat i n America have been ex t remel y
progressi ve--i n comparison w i th col l eaguee i n o t her par t e of t he
world--in t h e i r recogni t i on and appr eci at i on of t he impor t ance of
such c u l t u r a l var i at i on. P a r t of t h i s der i ves from t h e i r e a r l y
i n t e r e s t i n hi e t o r i c a l s t udi es on al cohol - r el a t ed t opi ce (e.g.,
Herrero 1940, Pi ga 1342, F. Ro j ae 1942, Ruiz 1939, Mendieta 1939), a
t opi c t ha t onl y l a t e r became a f ocus of concern f o r a few echol ar e
i n ot her pa r t e of t he world.4 Another r eason f o r t he e a r l y and
broad accept ance of s o ci ocul t u r a l per s pect i ves i s t he recogni t i on
t ha t t he di ver s e popula t i ons wi t hi n each nat i on of La t i n A me r i c a had
di f f e r e nt viewe about al cohol , ueed i t di f f er ent l y, and s o were
di f f e r e nt l a l l y sub j e c t t o kinde and r a t e e of al cohol -rel at ed
probleme. Such a view ha8 become i ncr eaei ngl y wideepread i n r ecent
yeare, even among epeci al i et e i n t he bi ol ogi cal and medical eci encee
( eee, e.g., Ki sei n and Begl ei t er 1976, Medina 1978, Negrete 1974),
but our colleaguee i n Lat i n America were v i r t u a l pioneere.
One of t he beet known e a r l y cont ri but i one t o t he eyst emat i c
s t udy of al cohol had a e i t e focue "epidemlology" (Horwitz, Marconi,
and Adie 1967a), but i t l e noteworthy t ha t t he major a r t i c i e e i n
t ha t col l ect l on de a l t wi t h "eoci ocul t ur al f act or e" i n al cohol use
( J . Maria t egui 1967 ) , me thods and r e s ul t e of "epidemiological and
eocioan t hropol ogi cal i nvee t i ga t i one" (Marconi and Adle 1967 ) ,
"epidemiolog y and eocioanthropolog y of alcoholiem and
al cohol -rel at ed probleme" (Marconi, Horwitz and Adie 1967 ), and a
" f i na l commentary" t ha t wae l a r ge l y devo t ed t o eoci ocul t ur a l
var i at l on (Horwitz, Marconi and Adie 1967 b). The except l onal
breadt h and high qua l i t y of t he component essays make t ha t volume an
i mport ant mi l es tone i n t he et udy of al cohol use i n Lat i n America.
I n 1974, anot her s pec al i eeue of the eame per i odi cal wae
devoted t o al cohol , eervi ng a e both a complement and a n update of
t he 1367 monograph. I n i t , J. Mari at egui ' e (1974) i nvent ory of
et udi ee on t he epidemiology of alcoholiem i n Lat i n America l e f a r
broader and deeper than one might gueee on t he baei e of t he t i t l e
al one, combining car ef ul def i ni t i on of terme w i t h br i ef c o u n t r p b p
count ry euii~nurriee of r ecent f i ndi nge and commentary t ha t i nt egr at ee
ant hropol ogi cal dat a and perepect l vee i n a n e f f e c t l ve manner. An
out l i ne of eoci ocul t ur al perepect i vee on al cohol i n Lat i n America by
Heath (1974a) l e a br i ef but compreheneive i nt r oduct i on t o t he broad
raage of l i t e r a t u r e t ha t wae avai l abl e on t he eubj ect . A summary of
c ul t ur a l f act or e i n epi deml ol ogi cal e t udi ee of alcoholiem by Negre te
(19 7 4) eucci nct l y i nt egr at ee t he publ i c heal t h model w i t h
peychological and eoci ol ogi cal t heor i ee about why people drink.
Sugees t i one f or a n i nt er nat i onal comparative e tudy of alcoholiem and
al cohol abuse were of f er ed by Murphy (1974), ant l ci pat l ng eome of
t he methodological problems t ha t have been encountered i n t he
prel i ml nary at t empt e t ha t have ei nce been made. Brief not es by
Negrete on al cohol and t r a f f i c , and by Adie on mental heal t h and
alcoholiem ehow tha t, al t hough few i nveet l ga t or e were e tudying
al cohol i n La t i n America a t t ha t time, t he i r work wae r el evant t o
t he eame i eeuee t ha t occupied colleaguee eleewhere.
Thie i e not an appr opr i at e cont ext i n which t o vent ure a more
thorough review of the l i t e r a t u r e -- preeumably t he proceedinge of
t h i s conference w i l l col l ect i vel y eerve t ha t purpoee -- but i t 1s
i mport ant i n terme of our hi e t or i c a l perepect l ve t o not e t ha t t here
have been severa1 val uabl e cont ri but i one made by La t i n Americane
wi t h r eepect t o t he et udy of al cohol . It a l s o deeervee t o be
mentioned t ha t euch worke were wr i t t en by aut hore whoee di veree
na t i ona l and pro es s i onal backgrounde have ei gni f i c a n t l y enr i ched
our underet andi ng of t he e ubj e c t mat t er , and a t t he same t i m e
demone t r a t e t ha t t he material i e of broad impor t ance and rel evan-
f ar beyond mere academi c i nvee t i gat i on.
The Pre-Columbian Per i od
It i e of c r uc i a l i mport ance t o recogni ze that ever y cul t ur e i n
human hi e t or y has shown c l e a r evi dence of bot h cont i nui t y ( or , eome
would eay, e t a b i l i t y ) i n c e r t a i n r es pect e on t he one hand, and
change ( or , i n s oci ol ogi cal terma, dynamics) on t he ot her hand.
There e x i e t e no peopl e wi t hout t h e i r uni que hi et or y, and t he
euppoeedly "unchanged" l i f e of "pr i mi t i ve" popul at i ons onl y appeare
s o becauee t he rate of change i s s o r e l a t i v e l y d i f f e r e n t from our
-
own.
W i t hout a t temp t i q t o provi de anyt hi ng approaching a
comprehensive revi ew of t he evi dence f o r pre-Colombian uses and
meanings of a l c ohol i c beverages i n t he Americae, i t may be us ef ul t o
mention a few dat a t h a t demonst rat e t h e i r e a r l y di e t r i but i on and
importance i n eel ect ed i net ances t ha t eer ve t o i l l u s t r a t e c u l t u r a l
f a c t or 8 of enduri ng relevan-.
There a r e ver y few p a r t s of t he worl d where t he na t ur a l
procees of f er ment at i on wae not ver y e a r l y recogni zed and el abor at ed
by nat i ve people t o produce beere, wines, meada, and ot her typee of
homebrew. It remains a paradox t ha t moet of t he a r e a t h a t i s now
~n g l o - ~me r i c a 5 l acked i ndi genous a l c ohol i c beveragee ( La Barre
19 38, Dri ver 196 9). An i r o n i c s i de l i gh t i s t ha t t he siaall por t i on
of North America where I ndi ane di d dr i nk i n pre-Columbian times
happene t o coi nci de, t o a remarkable degree, wi t h t he e xt e nt of
cont r ol a chi eve d by t he Spani arde duri ng t he col oni al peri od,
i ncl udi ng what i e now Mexico a e wel l as t he s t a t e s of Cal i f or ni a,
New Mexico, Arizona, and Texae (Waddell 1980; Bruman 1940).
Ae a re inement beyond si mpl e f er ment at i on, t he technology of
d i s t i l l a t i o n need n o t be complex nor i nvol ve hi ghl y r ef i ned
mat er i al s . Nevert hel ess, t he t echni que seems n o t t o have been
i nvent ed by any of t he popul at i one i n t h i s hemisphere i n t he
pre-Columbian er a. There wae eome cont roverey duri ng t he e a r l y p a r t
of t h i s cent ury about whether d i s t i l l a t i o n had been known among a t
l e a e t a few groups i n pre-Conquest Mexico (Bourke 1893, 1894), but
t he tenuoue evi dence of f er ed i n suppor t of t h a t i dea i e unconvincing
(Bruman 1944, Dri ver 1969).
The most famoue pre-Columbian cul t ur ee i n Lat i n America a r e
unquee t i onabl y t he so- cal l ed "high c i vi l i z a t i ons " of Az t ec, Maya,
and I nca, ea& of which combined complex s o c i a l or gani zat i on,
ex t enei ve pol i ti cal and economi c cont r ol e, l a r g e ci t i e e , complex
networke of communication and t ranepor ta t i on, and an e x t remel y
eophi et l cat ed e c i e nt i f i c and t echnol ogi cal eystem. Each of them
a l e o produced f er nent ed beveragee tha t played a va r i e t y of i mport ant
eymbolic and economic r ol e s i n t he l i ve e of both l eader e (eome of
whom were thought t o be descended from the gode) and comnonere.
The Aztece of cent r al Mexico a r e beet known i n t hi e reepect ,
pa r t l y on t he baei e of documente t ha t eurvi ve from pre-contact tlmee
and pa r t l y on t he baei e of rereiniecencee r emr ded by Spaniarde
duri ng t he ei xt eent h century. Pulque wae t he predominant beverage,
and i t remaine i mport ant today. It l e f ermented from t he eap of t he
maguey (Agave a t r ovi r ene, al eo known var i ouel y a8 al oee, agave, or
cent ury-pl ant ), which l e a l e o an i mport ant eource of f i be r e ueed t o
make rope, eandal e, and t ext i l es . A remarkably det ai l ed anal ysi e of
t he bi bl i ography and iconography of maguey and pulque i n t he
pre-Columbian Mexican codicee has been compiled (Goncalvee de Lima
[ 19%] ) , but i t r eveal e l i t t l e about workaday behavior o r about
nonne and valuee. I n eymbolic t e me , i t eeeme importan t tha t pulque
wae t hoi yht t o have been i nvent ed by t he gode ( eepeci al l y Mayahuel,
a female f i gur e wi t h 400 breaet e, aeeocl at ed wi t h Tl al oc, t he
pr i nci pal "rain-god"), and t ha t acceee t o i t wae r e e t r i c t e d i n eome
regi one .
The epeci al relevan- of pulque i n Aztec cul t ur e has long been
remgni zed; i t wae deecri bed i n eome d e t a l l i n t he so-cal l ed
"Fl orent i ne ~ode x, ' 6 and has been br i e f l y eummarized by severa1
aut hor s i n r ecent p a r e (e.g., Calderon 1968, Paredes 1975).
Per i odi c dri nkl ng and drunkenneee were impor t a nt ritual a c t i v i t i e e
of t he nobi l i t y, and both pr i e e t s and t he e l de r l y were allowed
o ccaei onal l y t o d r i d t consi derabl e amounte. Bu t o t her conmonere
were eubj ect t o eevere penal t i es , i ncl udi ng deat h, i f t hey became
drunk, and even a nobleman could be ki l l e d f o r being dr udt a t a n
i nappr opr i at e t i me . Thie well-known account i e probably not
i naccur at e, having been compiled a e o r a l hi et or y by a pr i e e t and
pro t oe thnographer , Bernardlno de Sahagun, f rom i nf orman t e who had
been nobl es i n Tl at el ol co, near t he cent er of Mexica cont rol . But,
f o r t ha t eame reaeon, i t wae* probably no t r epr eeent at l ve of workaday
realitles i n moet of t he rest of t ha t far-fl ung and l ooeel y
organi zed "empire." It 1s unfort unat e t hat , f o r l a & of ot her dat a,
t hi e epeci al view has long been general i zed t o a l 1 of t he ar ea t ha t
ha8 become t he nat i on- et at e of Mexico.
Si mi l ar l y, t he a t ti tudee of ano t her unrepreeent a t i ve eample
have been gener al i zed i n an i nappr opr i at e but widely ehared view of
maee drunkenneee on t he part of Meldcan Indi ane during t he col oni al
period. The Relaclone Geograficae were compiled af ter two
generat i one of Indi ana had been eubj ect ed t o Spanieh domination i n
cent r al Mexico, and thoee informante descended from Aztec noblee
appear t o have been nos t a l gi c a bou t the l o s t preroga t i vee previ ouel y
enjoyed by their f ami l l ee, t he "uppityneee" of commonere who would
have been t he i r eubj ect e, and s o f or t h. It l e d i f f i c u l t t o di ecern
how much of t h i s char act er i zat i on l e a confuei on between "r eal " and
"i deal " cul t ur e -- i . e. , between what peopl e d i d and what t hey
ehoul d have done -- and how much may have been wi ehf ul t hi nki ng o r
eome o t her ki nd of d i 8 t or tion.7
A more pl aus i bl e view wae r e c e nt l y of f er ed, c a r e f ul l y and
i magi nat i vel y r econet r uct ed on t he basi e of a compreheneive review
of a w i d e r a we of unpubliehed documente from var i oue regi one of
bkxi co (Tayl or 1979). According t o t h i s i nt e r pr e t a t i on, t her e wae
consi der abl e va r i a t i on i n dr i nki ng pr act i cee and norms i n var i oue
communities--as l e t he case today. A common pa t t e r n wae t h a t of
ye r i odi c f i e e t a s , i n which most of t he a d u l t s drank t o t he poi nt of
i nt oxi cat i on--al so a common pa t t e r n i n t he a t e a today. Both
dr i nki ng and drunkenneee were e o c i a l l y approved i n t he cont ext of
vener at i on of major d e i t i e s , a e a n i n t e g r a l p a r t of e i gni f i c a nt
a g r i c u l t u r a l ceremonies, o r i n cel ebr a t i on of impor t a n t event e i n
t he l i v e e of l o c a l l eader e. We w i l l r e t ur n t o bot h of t heee poi nt e,
l o c a l va r i a t i on and epi eodi c eanct i oned gener al drunkennees, l a t er .
Nat i ve ferment ed beer s throughout much of South America are
ge ne r a l l y c a l l e d chi cha ( Cut l er and Cardenae 1947) des pi t e a wide
va r i e t y of i ngr edi en t e , mamers of prepara t i on, and o t her ki nds of
var i at i on. The word ha s come i n t o Engl i sh as meanlng "maize beer, "
t he beverage t h a t wae (and l e ) s t a p l e t hroughout t he v a e t Inca
"Dnpire, " which domina t ed v i r t u a l l y a11 of t he Andean hi ghl ande f rom
Colombia eou thward i n t o Chi l e.
Li ke pulque i n Mexico, chi cha 1s a n u t r i t i o u s beverage drunk
by peopl e of bot h eexee and a l 1 agee (Nicholeon 1960). Aleo l i k e
pulque, i t has syrnbolic val ue t h a t i s ver y d i f f e r e n t from i t e
economi c and food val ue. Excavatione a t maj or Inca f o r t e and ci t i e e
have unmvered v a e t breweri ee and st orehoueee of chi cha, which l end
eupport t o t he view t ha t i t wae a n eepeci al l y i mport ant medium of
exchange, r egul at ed by t he s t a t e . Presumably i t wae p a r t of a
complex s ys tem of r e d i s t r i but i on, whereby raw ma t e r i a l s were
col l ect ed i n t he name of t he I nca and f i ni s he d product e were t hen
d i s t r i b u t e d by I nca l eader e. Such pat t er ns of exchange occur
throughou t t he world, and ant hr opol ogi e t e have demone t r a t ed how
ef f e c t i v e t hey a r e i n mai nt ai ni ng s o c i a l e t r a t i f i c a t i o n and
i nt egr at i on. Cl ear l y t he val ue of a g i f t depende i n p a r t on who i e
gi vi ng i t , and a gi f t i n such a system i mpl i ee a cont i nui ng
obl i gat i on. No t onl y doee s u& a eyetem demonetrate t he benefi cence
of a l eader , but i t a l e o can e ube t i t ut e f o r markete and money.
Unl i ke pul que i n Mexico, which began a 8 a smal l -ecal e cot t age-
i nduet r y, chi cha i n Peru eeeme t o have been produced on a l a r ge
e c a l e by t he mamakuna, t he famoue "chosen women" of t he Inca, eome-
t i m e s r e f e r r e d t o as "Vi rgi ne of t he Sun" (Morrie 1979). I n euch a
cont ext , dri nki ng occur r ed as a n accompaniment t o work, a e a reward
f o r eer vi ce, and occaei onal l y as par t of a r el i gi oue f i e e t a , duri ng
which drunkenness was n o t onl y a c e p t a b l e but a c t i v e l y eought a 8 a
ki nd of t ranecendent al experience. We w i l l pay a t t e nt i on l a t e r t o
eome aepect e of t hi e pat t er n that have changed markedly, and t o
ot her e t ha t have ehoni remarkable consi et ency over f our cent uri ee of
t ranecul t ur a l cont act .
Among t he Mayae of Meeoamerica, we know l i t t l e about t he
de t a i l e of product i on and di et r i but l on, but both pulque and
maize-baeed chicha appear t o have had eymbolic i nport ance i n
r el i gi oue and p o l i t i c a l contexte. The h y a e a l e o had a di et i nct i ve
r egi onal beer ( b a l d e ) fermented from t he bark of a tree (Barrera
1941, Goncalvee al . 77) .
Brief deecr i pt i one of preeumably t r a di t i ona l dri nki ng pat t er ne
occur i n many of t he j ournal e of expl orere and conquietadore, and i n
r epor t e from mi eei onari ee and adml ni et rat ore who extended the
f r ont i e r e of European cont act throughout Lat l n America. However,
de t a i l e on euch dri nki ng a r e nowhere e l e e eo r i c h a s i n thoee ar eae
of pre-Columbian ci vi l i zat l on.
The Col oni al Peri od
The a r r i v a l of Europeane had a n enormoue impact on both the
c ul t ur a l and na t ur a l ecol ogy of t he Weetern Hemiephere. I n one
eenee, i t wae f a r from being a "New World," having al r eady been
occupied by homo eapi ene f o r more than t en mi l l enni a; evidence i e
mountlng t ha t euggee t e almoe t double t ha t t i me . I n anot her eense,
however, i t wae a "New World" f o r the Europeane, who encountered
nat i ve popul at i one t ha t di d not f i t their coemology, much l e e s t he i r
l e ga l and p o l i t i c a l eysteme. It l e not t ha t t here had been no pr i or
confront at i on w i t h c ul t ur a l di f f er encee o r w i t h t he knde of
pheno t ypi c var i at i on t ha t we c a l 1 "r aci al "; cont act e wi t h Af r i ca and
t he Ori ent had been many and var i ed during t he precedlng cent uri ee.
But Native Americane were di f f e r e nt i n a eenee t ha t wae
fundamentally i mport ant a t t ha t t i me . Not having r ej ect ed
Chr i et i ani t y, t hey were t o be pr ot ect ed and helped i n waye t ha t
pr act i t i oner e of ot her recognized r el i gi one were not . Of couree,
t he r e a l i t y of s oc i a l r el at l one i n a cont ext of i mperi al conqueet,
freeboot i ng a n expanding mi l i t a r y f r ont i e r , and at t empt e t o gai n
wealth and l e i e ur e from conqueet r eeul t ed i n wideepread
expl oi t at i on, br ut a l i t y, and ot her abueee t ha t diverged f a r from t he
ut opi an i deal . Nevertheleee, r eepect f o r Indi an cul t ur ee wae a n
i mport ant t hread throughout t he Conqueet, and i t l e cr uci al t o
recogni ze t ha t "t he Conqueet" wae a 10%-term proceee r at her than a n
event . Obviouely, t he confront at i on wl t h Europeane made t hi e a "New
World" f o r t he nat l vee, al eo, i n a va r i e t y of reepect e. I n eome
ar eae they were l i t e r a l l y enelaved o r maeeacred; i n ot her e t hey were
di epl aced from t he i r t r a di t i ona l homee, eometimes obl i ged t o work a t
unaccuetomed jobe o r t o l i v e i n unaccuetomed p r o x i d t y t o each ot her
and t o a l i e n people. New kinde of l i veet ock di et urbed t he ecology
t o which t hey were adapt ed, j u s t a e new di s eas es t o which t hey had
no r eei s t ance took a heavy t ol l among them. Ae more de t a i l e d
h i e t o r i c a l s t udi e s a r e being made wi t h r eepect t o l i mi t e d aepect e of
cul t ur e and focuei ng on s p e c i f i c r egi ons o r communitiee, 1 t l e clear
t h a t nei t her of t he o l d s t ereot ypee about t he conquest f i t s wel l .
The "bl ack l egend" t h a t char act er i zed t he Spani arde a e r ut hl es e
monst ers cont ai ns a s much fal eehood -- and a s much t r ut h -- a e di d
t he " of f i c i a l " image t h a t por t r ayed them as e e l f l e e e l y undergoing
extreme hardshi ps t o br i ng s al vat i on and enl i ght enment t o t he savage
hordes.
I n or der t o have an appr eci at i on of t he ways i n which some
c u l t u r a l f a c t o r s have p e r s i s t ed ei nce pr ehi s t o r i c timee and o t her s
have been a l t e r e d i n var i oue waye, i t l e i mpor t ant t h a t we t r y t o
undere t and no t onl y t he dynaml ce of colonialism--wi t h t he
pr es ent at i on of new behavi ors and a t t i t u d e e a e modele, t he
i mposi t i on of new l aws, some di s c r e di t i ng of o l d waye on t he one
hand, and some nos t al gi a f o r them o r t he ot her . It l e a l s o
i mpor t ant t h a t we t r y t o underet and t he h i s t o r i c a l and c ul t ur a l
f a c t o r s t h a t had al r eady shaped t he pa t t e r ns borne from t he
met r opol i t an cent er . We must not l oe e s i g h t of t he f a c t t h a t t he
I b e r i a ( n o t y e t even "Spain" and "Port ugal ") of t he e r a of t he
Conquee t was c u l t u r a l l y and e t h n i c a l l y di ver s e i n t he mame way tha t
t h e New World wae, and t h a t i t s o n i drinlring pa t t e r ns der i ved from
cen t u r i e s of cont act among many peoples. Ar chaeol ogi cal evi dence
shows t h a t t he c ul t i va t i on of gr apes and t he product i on of wine on a
smal l s c a l e had been i nt r oduced i n sout her n Spai n by 600 B.C. The
Romans f or bade bot h u n t i l 280 A.D., when v a e t pl ant i ngs were
aut hor i zed i n t he r egi on of Baet i ca ( r oughl y correspondl ng t o
contemporary J e r e z ) and product i on promptly expanded t o t he poi nt
where mi l l i ons of amphorae of wine were being export ed t o I t a l y each
year .
The sout her n s t r i p of I be r i a , i n which moet of t he
conquis t ador s had been r ear ed, ehared t he medieval Medi t er r anean
pa t t e r n i n which wine wae bot h a n everyday beverage i n normal us e
and some times a conse cra t ed medlum of Chr i s t i a n communion. Drinklng
was c e r t a i n l y n o t confused wi t h drunlrenness, a s when Alfonso X
l i e t ed " f e r t i l e l ands t o yl el d good wine" among h i s pri mary c r i t e r i a
f or choosing t he s i t e of a uni ver s i t y. The s t apl e d r i n h were what
we would cal1 a l c ohol i c beveragee; wine wa s drunk t o r e l i e ve t h i r e t ,
wi t h meals, and as a r egul ar refreehment , i n a l 1 of t he waye t h a t
cof f ee, t ea, water, o r eof t dr i nke a r e now ueed i n t he United
~ t a t e s . ~ For t h a t mat t er , f ew peopl e anywhere i n t he world duri ng
t ha t time would have recogni ze d t he term "al cohol i c beverages" as
any ki nd of meaningful cat egory.
Moderation was a t r a i t much r eepect ed i n t he men of I ber i a.
Ce r t a i nl y commente about t he a u s t e r i t y of Bernan Cort ez wi t h r eepect
t o drinlr have t he r i ng of pr a i s e about thern. Thi s l e a l 1 t he more
convincing be cauee t he eame paragraph, w r i t t e n by an adul a t or y
contemporary, i ncl udee r ef erence t o t he Conquie t ador ' e weakneee f o r
women, hi e guet o i n eat ng, and hi e e k l l i n ehooting di ce ( b p e z de
Conara 1954).
One wideepread mieconception about t he bureaucracy of I ber i an
col oni al i em l e t ha t of uni formi t y of law and of i t e admi ni et rat i on
throughout t he far-f lung empire. I n f a c t , t her e wae l i t t l e
uni formi t y and not even much correepondence between law and r e a l i t y
i n much of col oni al Iberoamerica. I n par t , t hi e r eeul t ed from t he
f al l aci oue at t empt , by people unfami l i ar wi t h t he ar ea, t o formul at e
a ei ngl e code t ha t would appl y t o t he di veree ei t uat i one found
throughou t t he di spar a te and of t en remo te dependenciee. I n par t, i t
r eeul t ed from t he admi ni et r at i ve and l ogi e t i c a l problems t ha t i nhere
i n any at t empt by a emall and di epereed group t o cont r ol l ar ger
groupe, eepec al l y i n d i f f i c u l t t e r r a i n wi t h l i m t ed meane of
conmunicaton. I n ehor t , the e f f e c t i ve cont r ol of t he government
di d not ext end f a r beyond t he eeat e of government. Another
importan t cont r i but ng f a c t or wae t he a t t i tude of t he admnie t r at or e
themeelvee, of ten e xpl i c t l y uncommi t t e d t o t he enforcement of lawe
and r egul at i one, a e e pi tomzed i n t he -11-known phraee, " l a l e ee
acat a pero no se cumple" ( t he law l e reepect ed but not
Nevertheleee. t he record of lawe t ha t remain and t he abundante of
' cl os el y r e Gt e d documente, euch a e t r anecr i pt e of t r i a l e and
pet i t i one f o r r e l i e f from eome r egul at i one o r f o r e tricter
enforcement of ot her e, make them val uabl e gui dee t o both "r eal " and
"i deal " aepect e of the cul t ur ee of remote timee. Although t he t e xt
of a law doee not te11 ue what people a c t ua l l y di d, i t r e f l e c t e what
a ut hor i t e e thought they ought t o be doing, and a nc i l l a r y documente
of t he ki nds mentoned above of t en shed l i g h t on t he ei ze and nat ur e
of t he gap beween thoee two ki nds of norme.9 Por theee reaeone,
l e ga l decreee and many ot her kinde of documente w i l l be c i t e d i n
t hi e diecueeion. *
The beginninge of grape-growing i n t he New World have not been
eyst emat i cal l y i nveet i gat ed t o date, but i t l e c l e a r l y poet-
Colurabian. I n t he e a r l y yeare of European expl or at i on and mi l i t a r y
i ncurei one throughou t t he Wee t er n Heniephere, t he i nt r oduct on of
t he vi ne wae encouraged. I n 1519, t he Spanieh Board of Trade
decreed t ha t ever y ehi p coming t o t he I ndi ee ehould bri ng grape-
vi nee, preeumably eo t h a t l oc a l production could l eeeen t he need f or
European wine, ehor t en eupply rout ee, and f r e e val uabl e ehipping
epace. Bu t i n l a t e r yeare t he me t r opol i t an cent er t r i e d t o r egai n
*This diecueeion of drinlring i n t he col oni al peri od r e l i e e heavi l y
on eourcee t ha t have not ye t been publiehed and t ha t 1 have wt
pereonal l y analyzed. Di r ect quot at i one and decreee t ha t a r e not
f u l l y referenced i n t he next eever al pagee a r e quoted i n and c i t e d
by Taylor (1979), Hernandez (1374), o r Belaecuain e t a l . (1981).
i t s monopoly on t he commerce of wines and l i quor e. I n a br i ef
h i s t o r i cal ske t ch t ha t deserves t o be s t reng thened w i t h more
d e t a i l s , Bel ascuai n and h i e col l eaguee (1981) c i t e 1551 as t he f i r e t
vi nt age i n Peru, wi t h Bol i vi a and Argent i na cl os e behind. Br azi l
and Chi l e fol l owed, but ot he r Lat i n American count r i es never di d
develop t he i ndus t r y i n any s i g n i f i c a n t degree.
Changes i n a t t i t u d e s appear i n broad h i s t o r i c a l per spect i ve,
al t hough we know l i t t l e of how o r when eome p o l i d e s were r ever sed
by var i ous i mport ant i n s t i t ut i ons. It i s, of course, a l s o l i k e l y
tha t appar ent l y i ncons i s t en t a c t i v i t i e s were i n f a c t si mul t aneousl y
c a r r i e d o u t by var i ous arme of s o l a r g e and di ver s e an or gani zat i on
a s , f o r example, t he Soci et y of J es us , o r t he Crown. The J e s u i t s
a r e cr edl t ed wi t h havi ng i nt r oduced t he c ul t i va t i on of gr apes t o
Argent i na, and t h e i r ext ens i ve vi neyards i n c oa s t a l Peru were
e conomlcally s i gni f i c a n t (Cushner 1980) i n suppor t of t he i r
so- cal l ed "Republi cs" i n t he cont i nent al hear t l and, hundreds of
mi l es away. The "Republice" i n t ur n gai ned some of t he i r fame and
f or t une from t he c ul t i va t i on and s a l e of yerba mate (sometimes
c a l l e d " J e s ui t t ea") , which was promoted a s (among ot her t hi ngs) a
heal thf u 1 sube ti t u t e f o r al cohol i c beverages (Ruiz 1939 ) . Whe t her
t he marketing of t hes e pr oduct s r e f l e c t s changed a t t i t ude e toward
dr i nk, o r si mpl y shrewd busi ness pr a c t i c e i n at t endi ng t o d i f f e r e n t
s e c t o r s of a worl d market , remains t o be s t udi ed.
Another uncl ear Corpus of evi dence r e l a t e s t o t he view t ha t
t he Spani sh admi ni et r at i on had wi t h r es pect t o t he product i on of
a l c ohol i c beveragee i n t he Indi ee. We have a l r e a dy not ed t h a t i t
was encouraged i n t he e a r l y years, presumably f o r l o g i s t i c a l
reasons. But, i n keepi ng wi t h a gener al pa t t e r n of concern f o r
balance- f - t r ade and domina t i on of marke t e, r egul a t i ons were l a t e r
i s s ued t h a t di sal l owed shipment of a l c ohol i c beverages from one
admi ni s t r a t i v e j ur i s di c t i on t o anot her w i t hi n t he I ndi es , j us t a s
ot he r s di sal l owed i mpor t at i on from s hi ps of ot her f l ags . Some of
t he i r r e g u l a r i t i e e i n t he f or c e of l aw a s a r e s t r a i n t on
a v a i l a b i l i t y of al cohol c l e a r l y r e l a t e d t o short -t erm l o c a l
exi genci es a s , f o r example, when a 10%-s t andi ng ban on t he s a l e of
coconut wine was l i f t e d i n or der t o provi de more income f o r t he
r egi on around Colima, Mexico, a f t e r i t had been devast at ed by an
eart hquake (Bruman 1945).
(Ale as pect of t he p a t e r n a l l a t i c a t t i t u d e toward I ndi ans wa s a
s e r i e s of decr ees t h a t were os t e ns i bl y i nt ended, i n t he terminology
of today, a s l e g i s l a t i v e approaches t o t he pr event i on of al cohol -
r e l a t e d problema. As e a r l y as 1523, Car l os forbade t he sale t o
I ndi ans of "adul t er a t ed pulque, " on t he bas i e t ha t t he preserva t i vee
"st upef y and e a s i l y k i l l . " I n 1594, Fel i pe 11 decreed that vi ne not
be s o l d nor even i nt r oduced t o "pl ace8 and puebl os of Indi ana. "
Fel i pe 111 forbade payment of wages t o I ndi ans i n wine, on t he
penal t y of a f i ne of 20 pesos i n 1609.
The experi ence of Mexico i e eepeci al l y val uabl e a e an
i l l u a t r a t i ve case et udy f o r a number of reaeone. It i e a l ar ge and
di ver ee country; cal l ed meva Eepana, i t wae nei t her t he f i r e t nor
t he l a e t t o be col oni zed, and t here i e r e l a t i ve l y r i c h hi e t or i c a l
documentation. I n t erne of our epeci al i n t e r e e t i n al cohol -rel at ed
probleme, i t ha8 a l e o been deecri bed by sever a1 aut hore a e a cl aeei c
i l l u e t r a t i o n of the anomic impact of conqueet and t he wideepread
breakdown of norma agai ne t dri nki ng and drunkenneee . I l l u e t r a t i ve
of t he view t ha t ha8 gai ned wideepread accept ance i n t hi e comect i on
i e t he ead parayraph wi t h which a t hought ful hi s t or i a n concludee hi e
det ai l ed et udy of t he Aztece under Spanieh r ul e: "What we have
et udi ed i e the det ar i or at i on of a nat i ve empire and ci vi l i zat i on.
...If our eourcee may be bel i eved, few peoplee i n the whole of
hi et or y were more prone t o d r u n k e ~ e 8 8 than the Indi ane of t he
Spanieh Colony" (Gibeon 1964:409). Even a n hi s t or i a n who ueual l y
paya meticuloue a t t e nt i on t o de t a i l e i n ot her par t e of the world
accept e t he ext r apol at i one t ha t eeem t o have grown out of t he
di eeat i ef act i one of t he diepoeeeeeed he i r e of Aztec noblee: "The
I ndi an people euf f er ed tremendouely f rom t he alcoholiem i n which
t hey were encouraged t o indulge. It would r e a l l y eeem a e i f t he
c i vi l i e a t i on of t he Mexican pl at eau, l oei ng i t e anci ent f ramework
and tabooe, abandoned i t e e l f t o a t ampt at i on which wrought havoc
wi t h i t a f t e r 1600" (Braudel 1973:177).
As we have not ed above, what has been i gnored i n t hi e widely
a c e p t a d view i e t he abundant evidence t ha t has onl y r ecent l y been
gl eaned from cour t recorde, e a r l y I nqui ei t i on t r i a l e , v i e i t or e'
accounte, aanl ni e t r at or e' repor t e, and s i mi l ar documente. They ehow
that the image of pre-contact pr ohi bi t i on (wi t h except i one onl y f o r
pr i eet e, noblee, and t he aged) wae not accur at e f or many comiuni t i e e
t ha t l a y on the peri phery of Aztec domination, but t ha t per i odi c
f i e e t a e w i t h heavy dri nki ng by coanonere were r out i ne (Taylor
1979 ~29-34)
It may ve11 be t ha t a maj or por t i on of t he alarm expreeeed by
Spaniarde i n r e l a t i on t o the i nebr i et y t hey deplored i n Indi ane
r e l a t e s t o fundamental di f f er encee i n viewe about how and why one
ehould dri nk i n t he f i r e t place. It may wel l be t ha t Indi ane were
no t dri nki ng exceeei vel y " t o f orge t t he i r eorrowe, " but r at her were
cont i nui ng t o dr i nk, f o r t he i r ueual reaeone and i n t he i r ueual
manner, and thue t he t r a di t i ona l pat t er n of dri nki ng wae offenei ve
t o Europeane who val ued eobri et y. An i nt e l l e c t ua l hi s t or i an has put
t he poi nt t hi e way: "That f eat ur e of t he Spanieh temperament t ha t
remaine moe t conet ant over t he cent ur i ee i e eobriety... Two
thoueand yeare, wi t h a l 1 t he racial modif i cat i one t ha t invaeione and
t he mixing of peoplee can bri ng, have done nothing t o bl ur t hi e
char act er i e t i c. . . " (Nenendez 19 59 : 33).
Such a view i e not eimply a wi ehful reconet ruct i on by a
Spani ard proud of hi e her i t age; i t i e i n cl oee conformity wi t h t he
medieval Chri e t i a n view t ha t emphaeized man' e uniqueneee among t he
cr eat ur ee of t he e a r t h, di et i ngui ehed by h i e r a t i o n a l eoul .
According t o t h i e view, reaeon et ande as t he l i n k between heaven and
e a r t h i n a n or de r l y chai n of r el at i onehi pe t h a t pervade t he
uni verse. Reaeon 1s t he di vi ne part --t hat by which human bei nge
know God (and t her eby accept t he Chr i et i an coemology). It i s
evi denced i n poi eed e t a t u r e , gr ace of habi t e, beaut y of epeech, and
-- c r uc i a l from t he poi nt of view of t heol ogy -- e t a b i l i t y through
vi r t ue . From euch a per s pect i ve, t he drunken pagan i l l u s t r a t e e t he
power of Sat an from wi t hout , and t he et r engt h of i r r a t i o n a l f or cee
wi t hi n -- e v i l t endenci as abroad i n t he world and a l s o i nher ent i n
man -- whi ch combine t o undercut one ' e v i r t u e , i f one doee no t have
t he Chri e t i a n moral e t r engt h t o r e e i s t. I n ehor t , t he
conqui et adore, t he f riars , and t h e i r European con t emporari es were
convinced t h a t pagana, l acki ng a " et at e of gr ace, " were e a e i l y
overwhelmed by t empt at i one and by t h e i r baeer i n s t i n c t e , of which
drunkennese wae bot h proof and a r eeul t . A good Chr i s t i an, by
cont r aet , would n o t gi ve way t o drunkenneee, which i n t e r f e r e s u i t h
Go d-g i ven reason.
I l l u e t r a t i v e of Spanieh viewe t h a t seem t o r e f l e c t t h i e
concern f o r moderation a r e t he fol l owi ng: "I f t he I ndi an drank
pul que t he way Spani ards dr i nk wine (which i e n o t t he case, nor ha8
i t been, nor l e t her e any hope of t h e i r ever doing e o) i t coul d be
permitted. . . but t hes e a r e Indi ane and i t l e proven t h a t t h e i r
cuetom i s t o g e t drunk, and i t i e f o r t h a t reaeon t h a t t hey dri nk. "
A l o r l e v e l Spanieh bur eaucr at complained t o t he e f f e c t t h a t
"Everyone knowe t ha t f o r them [ I ndi ane] dr i nki ng e timula t e e ga i e t y
and, i n gener al , t hey do n o t dr i nk wi t h appr opr i at e moderation.
From t hi e, undi gni f i e d a c t a , proa ti t ut i on, and crime r eeul t . "
Pr i e e t e, whether r e cognizing t ha t drunkenneee wae of t en i n t i mat el y
aeeoci a t ed w i t h t r a d i t i o n a l r e l i gi oue pr act i ces or f ear f u1 tha t
"t her e l e no manner of e i n t h a t w i l l n o t be committed by drunken
I ndi ane, " viewed i t a s a t h r e a t t o t h e i r charges, whom t hey a l s o
conei dered normal l y weak and po t e n t i a l backel i dere. Frequen t
r ef er ence t o "i nceet " as a e p e c i f i c abominable outcome of
drunkenneee almoe t c e r t a i n l y l e col ored by Spanieh unf a mi l i a r i t y
w i t h I ndi an s o c i a l e t r uct ur e.
I n e p i t e of t heee and s i mi l a r miegivinge t h a t were expreeeed
about I ndi an drunkenneee, t he provi ei on of pulque wae not even
r egul at ed u n t i l t he middle of t he eevent eent h cent ury. A crude
meaeure of i ncr eaei ng e a l e e ( a t a t i m e when monetary i n f l a t i o n wae
minimal) 1s t he r i e e i n t he val ue of t he f r anchi ee ( a s i e nt o) f o r
c ol l e c t i ng t he pulque t ax i n Mexico Ci t y. I t wae eol d a t 66, 000
peeoe f o r t he f i r e t year, 1668, and had r i e e n t o 92, 000 j ue t e i x
yeare l a t er .
I r o n i c a l l y, t he aeeoci a t i on be tween drunkenneee and di er eepect
f o r o f f i c i a l e t h a t i e mentioned i n gener al et at ement e by c i v i l and
r e l i gi oue epokeeman i e n o t r e f l e c t e d i n t he r ecor de of t r i a l e o r
var i oue r e l a t e d ar chi va1 mat er i al e t h a t have been combed i n a
c a r e f ul eear ch f o r jue t euch evi dence (Tayl or 1979 :44-45). Perhape
more e t r i ki ng i e t he f a c t t h a t t he aeeoci at i on poei t ed between
drunkennees and vi ol en t crimee i e e i mi l a r l y uneube t a nt i a t e d,
al t hough t he r ecor de a r e euff i c i e n t l y r i c h i n d e t a i l t o al l ow many
ot he r aeeoci at i one, eome of them q u i t e unexpected, t o be di ecerned
(Tayl or 1979).
Obviouely, n o t a l 1 o f f i c i a l t r aneact i one concerning a l c ohol i c
beveragas were negat i ve. Taxee on pulque and f e e e f o r l i cens ee of
pul quer i ae and t averne added ei gni f i c a n t l y t o t he income o s ever al
j ur i edi ct i one, eepe c i a l l y thoee w i th denee popul at i one .
Furthermore, pulque was recogni zed, even by t he Spani arde, t o have
val ue apar t r oa i t e q u a l i t y a s an i nt oxi cant . Amo- t he sever a1
medi ci nal ueee of pul que t h a t were mentioned f avor abl y i n col oni al
record6 o Mexican cour t proceedinge are t he cure of headache,
e tomach ache, and di ar r hea, a e d i u r e t i c , t o pr event lice, t o promote
l a c t a t i o n o r a r r e e t menet ruat i on, t o heal wounde, a e a pur gat i ve,
"f or pai n, " and "good f or any i l l nees . "
The pr ogr eesi ve i mpoei t i on o l e g a l cont r ol e on pulque
eugges t e admi ni s t r at i ve concern, whether f o r f i e c a l reaeone o r i n
terme o e o c i a l cont r ol . There were eucceeei ve at t empt e ( i n 1579,
1585, and 1586) t o l i mi t s a l e e t o a f e w e p e c i f i c e i t e e i n and around
Mexico Ci t y. I n lb08, i t wae decreed t h a t t her e ehoul d be no more
t han one l i c e ne e per hundred I ndi ans i n a neighborhood. Tax evaei on
may have prompted r egul a t i one ( i n 16 35 and 16 39 ) t h a t epeci f i ed t h a t
pulque coul d be brough t i n t o t he c i t y onl y duri ng t he day.
Nat i ve beveragee were n o t t he onl y onee avai l abl e. For a
whi l e t her e appear s t o have been a dr i ve t o encourage Indi ane t o buy
Spanieh wines and brandi ee. Thi s may have been p a r t l y a n at t empt t o
unl oad poor q u a l i t y goode on a n u n c r i t i c a l market , and/ or i t may
have had t o do wi t h i ncr eaei ng revenuee through cuetome dut ee and
ot her taxee. There i s no i ndi cat i on t h a t t h i e t r ade r epr esent ad any
de l i be r a t e at t empt t o e ube t i t ut e a more " ci vi l i zed" dr i nk f o r a
"eavage" one; i n f a c t , t he a l t e r n a t i o n of permi eei on w i t h per i odi c
pr ohi bi t i on ( a s , e.g., i n 1594, 1637, 1640) eeeme t o r e f l e c t
i ndeci ei on o r i nconei et ency.
Deepi t e a l 1 our caveat e agai net overeet i mat i ng or
miecone t r ui ng publ i c i ne br i e t y i n ei xt een t h-cent ury Mexico , i t would
be u n r e a l i e t i c t o i gnor e o r deny t h a t t her e doee appear t o have been
a n i ncr eas e i n per-capi t a coneumption of pulque. What had been a
f ami l y e nt e r pr i e e became rnarket -ori ent ed a e l a r g a numbere of Indi ana
were r el ocat ed i n new s et t l ement e o r depri ved of t he i r l and. The
c ul t i va t i on of maguey wae ei gni f i c a n t l y expanded t o eer ve t he
burgeoning urban popul at i on. Taxee on a l c ohol i c beveragee became
e i g n i f i c a n t eourcee of revenue f o r publ i c worke; l i ceneee t o s e11
became bo t h more numeroue and more val uabl e.
It i e al t oget her poeei bl e that a por t i on of t he i ncreaeed
coneump t i on of pulque may indeed have r eeul t ed f rom f r u s t r a t i on,
anomie, and ot her ki nde of et r eee t ha t accompanied Spanieh
domination. But we muet not i gnore a va r i e t y of ot her i mport ant
f act or e t ha t may have cont ri but ed t o i t . The pool of f r equent
coneumere i ncreaeed enormouely a s t r a di t i ona l eumptuary lawe broke
down; pulque, l i k e meat, cacao, and cer t ai n kinde of cl ot hee, had
been l i mi t ad t o t he nobi l i t y f o r da i l y uee, but euch t ul e s were
r api dl y eroded a e t i a di t i onal l eader e were repl aced by Europeane.
The Ca t hol i c cal endar i nt roduced addi t i onal f eae t-days. Miecege-
nat i on cont ri but ed a new s oc i a l category, meetizoe, who of t en grew
up wi t h l a x o r confused pat t er ne of eoci al i zat i on and many of whom
had a et ake i n nei t her Indi an nor Spanieh eoci et y or norme.
A number of t he e a r l y chroni cl ere -- and eome wr i t er e today
whoee obeervat i one a r e euper f i ci al and a t a conei derabl e di et ance
from t he r e a l rhythme of everyday Indi an l i f e -- have poi nt ed t o
drunkenneee a e eymp toma t i c of l azi neee, and renderi ng Indi ane
i ncapabl e of work. Anyone who pays cl oee and euet ai ned at t ent i on,
of couree, would recogni ze t ha t t he l e a s t ener get i c Indi an ueual l y
worke harder t han any euch obeerver i n t he couree of normal
subei et ence a c t i vi t i e s . The di f f er ence l i e e i n t he rhythm of work,
which tende t o be i nt ens i va during br i ef peake during t he
a gr i c ul t ur a l cycl e, w i t h i n t erveni ng peri ode when li t t l e can
conet r uct i vel y be done. Lei eure and drunkennees a r e accept ed and
even encouraged a t epeci f i c times i n moe t urban i ndus t r i a l cul t ur ee,
and both a r e depl orad "a t t he wrong time;" t he sama i e t r ua of most
Indi an cul t uree.
But when a r i o t t ha t devast at ed much of Mexico Ci t y i n 1692
wae blamed on "drunken Indi ane, " prohi bi t i on wae impoeed.
Enforcement wae l a x, however, and wi t hi n a few yeare t he pulque
t rade wae agai n a major enterprise--although cont r ol had ehi f t ed t o
a few s oc i a l l y e l i t e f ami l i ee who have continuad t o dominate i t
wherever t he popul at i on i e l a r ga enough t o aeeure a ei zeabl e and
r egul ar p r o f i t (Kicza 1980). I n squeezing t he Indi ane out from t hi s
l uc r a t i ve t rade, spanieh10 ent repreneure were r epl i cat i ng an
advantapeoue move they had made earlier wi t h r eepect t o maize and
cacao.
A epeci al commieeion comprising f our membere of t he audi enci a
of Mexico Ci t y made a det al l ad r epor t on pul queri ae and taverne i n
t he c i t y during t he l a e t quar t er of t he U t h century. Carl os 111
had ordered t he et udy i n reeponee t o repeat ed complainte from
pr i e e t e about murdere, thef t e, aeeaul t e on epoueee and chi l dren, and
o t her "indecencies" and "eacr i l eges" tha t were euppoeedly being
committed by drunken Indiane. They found 45 pul queri ae, moet o
them eervi ng both eexee, where t here ehould have been onl y 24 f o r
men and 12 f o r women. (The f a c t t ha t eo many epeci al dri nki ng
pl acee were provided f o r women i n t he f i r e t pl ace i e a curioue f a c t ,
gi ven t ha t i t f i t v i t h nei t her t r a di t i ona l Spanieh nor Indi an
pat t er ne. ) Regulatione epeci f ylng t ha t t hey were t o be smal l , open,
and unfurniehed were gener al l y ignored. ( bl y women vere euppoeed t o
be i n t he busineee, but few were. There were few pol i ce i n t he
ci t y , and enf orcemen t of unpopular lawe wae no t preeeed, eepeci al l y
ei nce moet of t he pul queri ae were owned by weal t hy and powerful
i ndi vi dual e who r ent ed them out or had eubal t er ne working t here.
The recommendation of t he commiseion, which wae eoon enact ed, wae
not t o i ncr eaee cont r ol e o r t o res t r i c t di et r i but i on o r coneumption,
but t o i ncr eas e t he t ax and eet abl i s h a r egul ar cat egory wi t hi n t he
aya teme of t axat i on and adminis t r at i on.
What happened wi t h r eepect t o chicha i n Peru during t he
col oni al peri od l e bo t h di f f e r e nt from and ei mi l ar t o what happened
wi t h r eepect t o pulque i n Mexico. I n 1556, a judge i n Cuenca
r e e t r i c t e d t he use of chicha and, i n hi e deci ei on, reveal ed much
about t he epeci al p o l i t i c a l and economic i mpl i cat i ons of t ha t
beverage: "Becauee e a i d chi ef e and l eader e ueed t o have ' t averne'
and pl acee where a l 1 who came t o them were gi ven chicha t o dri nk,
and i t i e the cause of drunkenneee of t he people, and i t occupies
many men and women i n making t he chicha, and i t i s a t hi ng of bad
example, and t he s a i d chi ef e epend exceesi vel y on i t ; i t 1s ordered
t ha t from now on t hey not have euch ' taverne' nor publ i c o r eecr et
pl acee f o r dri nki ng" ( ar chi va1 me, ci t ed i n Roetworoweki 1977 :241).
I n t hi e way, t he conquistadore were abl e t o undercut one of t he
pr i nci pal baeee of power t hat t he Inca nobl es had enjoyed, and t o
dr i ve a wedge between them and t he commoners who had benef i t e d f ron
t he t r adi t i onal r e di s t r i bu t i ve eya t em. I r oni cal l y, t hi e r eeul t ed i n
wide di epersi on of what had been r e l a t i ve l y concent rat ed production;
t he new cot t age i nduet r y of chicha-making wae more d f f i c u l t t o t ax
and di d not come under t he cont r ol of t he European e l i t e , i n eharp
con t r as t w i t h wha t happened t o pulque i n Mexico.
Although t he Andean ar ea has not been s o car ef ul l y et ud ed
w i t h r eepect t o what col oni al documente can r eveal about dri nki ng,
t here a r e eome ei mi l ar al l uei ons t o drunkenneee a e commonplace,
promp t i ng Indi ane t o vi ol ence, crime , l azi nes s , eacr i l ege , and eo
f or t h. The world-view of Spaniards col or s t he i r eet i mat i one i n t hi e
ar ea, a s i n Mexico. Amo- Indi ana, drunkenneee i s s a i d t o be
"congeni t al , " " i n t he blood," "worsened by t he burning cl i mat e of
t he t r opi cs, " and s o f or th. Pr ohi bi t i on was recomuended by Cl er i cs
and admi ni et ra t or s "f or t he i r own [Indi ane ' j good" (assuming weak
w i l l and chi l di eh i gnorance) and "f or the gr eat er gl or y of God." A
Chi l ean archbishop epel l ed o u t det al l ad r e s t r i c t i ons on t he s a l e of
"wine o r chicha" t o Indi ane, and t hreat ened vi ol at or e wi t h exwm-
munication, whipping, and exi l e. Among hi e epeci f i cat i one were t he
following: 10 per cent a8 maximum pr of i t , no cr edi t eal ee, no uee a e
wages, no more t han 2 r e a l e s worth a t a time, and no more i f a
customer has drunk eleewhere (eources c i t e d i n Lej arza 1941).
Par ent het cal l y, one cannot hel p but be et r uck by how ver y ei mi l ar
t heee r e e t r i c t i one a r e , i n some r espect e, t o l e gi s l a t i ve cont r ol s i n
many modern a t a te6 and provinoes.
A l though pulque was by f a r the moet popular al cohol i c beverage
i n col oni al Mexico, t hi e doee not imply t ha t d i e t i l l e d l i quor s were
unknown. Cor t ea himeelf i ns t a l l e d t he f ir8 t sugarmi l l a year af ter
h i e a r r i v a l i n Cuernavaca, and t he production of aguardi ent e (cane
al cohol ) followed eoon af ter. An hi s t or i a n who has pai d epeci al
a t t e nt i on t o t hi e (Hernandez 1974) euggeete t ha t economic
prot ect i oni em, wi t h epecl al concern f o r t he brandy i nduet r y i n
Cataluna and t he rum i nduet r y i n t he Canary and Caribbean i sl ande,
wae probably moe t impor t a nt among t he reaeone f or long-term
pr ohi bi t i on on t he manufacture and s a l e of aguardi ent e i n Mexico.
He chroni cl ee t he cont roversi ee, provi des eome evidence of
bootlegging , and ehowe how l egal i zat i on, wi t h heavy taxee, provided
a major new eource of revenue from U96 on.
The a va i l a bi l i t y and coneumption of al cohol i c beveragee were
a l e o a eource of concern during t he col oni al peri od i n t he ar ea t hat
l e now Colombia. Ambivalence l e evidenced i n teetimony by
phyei ci ans who hai l ed aguardi ent e a s a i nval uabl e pa r t of their
pharmacopaea, admi ni st r at or e who poi nt ed out t ha t chicha i ncreaeee
t he work-efficiency of Indi ane, and c l e r i c s who deplored t he
immorali t y tha t they f e 1 t wae caueed by drunkennese. I n t he f ace of
adml ni et ra t i ve i ndi f f erence, t he archbishop t here, too, impoeed hi e
own eanct i on, i ncl udi ng excommunication f o r thoee who made, eol d, or
bought aguardi ent e, f i nee f o r thoee who owned t he t r api ches
(normally "cane-preeeee, " but i n contex t presumably " e t i l l e " ) a s
wel l a s 20 l aehee f o r bl acks ( or e xi l e f o r whi t ee) who operat ed them
(unpubliehed documente i n Archivo General de I ndi as, Sevi l l a,
ext r act ed i n U. Ro jae 1960).
Lomnitz'e account of t he Mapuche i n Chi l e (1973) was a
pi oneeri ng at t empt t o t r ace t he changing meaninge and ueee of
al cohol through f our cent ur i es, and Medina (1978) ha8 provided not
onl y a e trong endorsemen t of my recommendation tha t more hi e t or i c a l
et udi ee of dri nki ng be done, but a l s o a ueef ul l i e t of appr opr i at e
eourcee wr i t t en by people who were eye-witneseee or good r epor t er s
i n La t i n America during t he col oni al period.
Throughou t t he e r a of expl or at i on and col oni za t i on, European
cont act s with membere of ot her r acee were i nt er pr et ed i n r el i gi oue
r at her than r a c i a l terme, and even today, al t hough di scueei one of
vari oue popul at i ons a r e of t en couched i n t he vocabulary of "race, "
the di et i ngui ehi ng c r i t e r i a that a r e i mport ant tend t o be s oc i a l and
c ul t ur a l r at her t han phenotypic or phyei ol ogi cal . Clothing,
language, r el i gi on, and ot her aepect e of cuetomary behavior tend t o
be t he char act er i s tic6 t ha t people use f o r i dent i f ying "race, "
r at her than physi cal char act er i s t i ce, and i t 1s widely recognized
tha t an i ndi vi dual can l e a r n new pat t er ne and thue move ( or "pase")
from one euch cat egory t o anot her. Obviouely, we a r e not deal i ng
her e wi t h ge ne t i c i nher i t ance; i f t he term "i nheri t ance" 1s
per t i nent a t a l l , i t i e i n terme of "l earned i nher i t ance, " t he
product of eoci al i zat i on by meane of vhi ch chi l dr en a r e encouraged
t o r e pl i c a t e t he bel i ef e, a t t i t udee, val uee, and ot her pat t er ne t ha t
t hei r el der e f i nd congenial.
Cul t ur al Vari ant e i n Modern Hi st or y
We have al r eady examined, i n t he i nt r oduct i on t o t hi e chapt er,
one ei de of t he d i a l e c t i c concerning cul t ur al uni t y and di ver s i t y i n
Lat i n America. A number of Iberoamerican aut hor s were c i t e d i n
euppor t of t he proposi t i on tha t, f or cer t a i n a na l yt i c purposes, i t
1s bot h ueeful and meaningful t o di ecuss hi e t or i c a l and cul t ur al
f act or 6 a8 having a degree of uni t y throughout Lat i n America. We
have a l e o eeen t hat r egi onal di f f er encee, i n bot h pre-Colombian and
col oni al timee, i ncl uded eome s i gni f i c a nt kinde of var i at i on wi t h
r eepect t o t he a va i l a bi l i t y and coneumption of al cohol i c beverages.
I n t hi e eect i on, we w i l l br i e f l y and eel ect i vel y examine
r e l a t ed f orces during t he ni ne teen th and twentie t h cent uree .ll
Such a n at t empt ehould i l l u s t r a t e a va r i e t y of conei derat i one t ha t
a r e i mport ant not onl y i neof ar a e t hey r e f l e c t t he di ve r s i t y of
e thnographic f a c t e but a l e o i ns of ar a e t hey provide hi nt s about
reaeone f or par t i cul ar dri nki ng pa t t er ns , meanings of par t i cul ar
al cohol -rel at ed problems, behaviore o r a t ti tudee t ha t appear t o be
s a l ut a r y with r eepect t o dri nki ng, ot her s t ha t a r e aseoci at ed wi t h
vari oue kinde and r a t e e of eoci al o r physi cal pathology, and 80
f or th. The experi ence of l e g i s l a t or e, adminie t r at or e, and a wide
range of persone who a r e engaged i n t he enhancement of publ i c heal t h
has demonetrated vi vi dl y, i n a l 1 par t e of t he world, t ha t a ttempte
t o preven t o r a l l e vi a te any ki nd of heal t h-rel a t ed problem ehould
t ake i n t o account vari oue aspect s of t he cul t ur ee of t he populatione
t ha t a r e t o be af f ect ed. Fai l ur e t o do s o has, almoet without
except i on, r eeul t ed i n t he f a i l ur e of euch programe, whether aimed
a t t he l eve1 of primary, eecondary, or ter t i a r y "prevention. "
W i t h r eepect t o t he s ubj ect rnatter of t hi e eect i on, a s wi t h
previoue onee, a number of i mport ant f act or e have al r eady been
diecueeed i n ot her cont ext s. Negra te's (1976 ) excel l ent and
eucci nct review of eoci ocul t ur al f act or e i n alcoholiem ni cel y
combinee br i ef summariee of i mport ant eoci ol ogi cal and anthropo-
l ogi c a l t heori ee wi t h not es on c l i ni c a l i mpl i cat i ons, ueing dat a
from throughout Lat i n America. The pi oneeri ng work of J. Mariategui
( l 967) , with s i mi l ar scope, hae al r eady been c i t e d a8 an i mport ant
cont ri but i on. Heath' e (197 4a) review of t he l i t e r a t u r e l e hel pf ul ,
and Medina'e ( Ul d ) hae t he addi t i onal val ue of euggeeting f r u i t f u l
new di r ect i ons f o r reeearch. Amar (1977) t r eat ed eever al t opi cs i n
depth, i ncl udi r y " t ypi cal urban l i f e, " "conf l i ct i ng r a c i a l
r el at i one, " "whi te immigration" during the l a s t 100 years, "t he
r el at i onehi p between town and country," and both formal and informal
"s oci al controle." A number of et hnographi c s t udi ee t ha t have
al r eady been r epeat edl y eummarized i n t he al cohol l i t e r a t u r a w i l l
not be diecueeed here i n de t a i l ; those who a r e not f ami l i ar with
euch baei c worke a s Bunzel (1940), Mangin (1957 ), Madeen and Madeen
(l 969), Heath (l 958), Simmons (1959, W60, 1968) and ot her e w i l l
f i nd t he i r pr i nci pal dat a and i nt er pr et at i one c i t e d i n vari ous of
t he review a r t i c l e e al r eady mentioned.
Among t opi ca t h a t a r e euf f i c i e n t l y impor t ant , but probably no t
ye t e uf f i c i e nt l y f ami l i ar t o many, a r e t he waye i n which di f f e r e nt
aepect e of cul t ur e a r e i nt i mat el y l i nked wi t h bel i ef e and behaviore
about al cohol , and t he impreeeive r a s e of euch pat t er ns t ha t a r e
not ed throughout Lat i n America -- o r even wi t hi n a s i ngl e nat i on --
when a t t e nt i on l e pai d t o di f f e r e nt kinde of "s peci al populatione"
(Heath 1381) euch a s e t hni c groupe, r el i gi oue s e c t s , t r i bee, and
socioeconomi c cl aeeee .
Moet eoci al e c i e nt i e t e i n r ecent yeare have tended t o be wary
of t al ki ng abou t "nat i onal charact er" or "bas i c pereonal i t y type, "
but euch a gr oes l eve1 of gener al i zat i on tends t o pl ay an i mport ant
r o l e i n t e me of popular i nt er pr et at i one about drinlring pat t er ne and
t he i r sequelae. Diecueeion of na t i onal charact er l e f r aught w i th
daryer, pa r t l y becauee of t he di f f i c ul t y of ext r apol at i ng from
i ndi vi dual s t o popul at i ons, and pa r t l y becauee of t he reeenanent
tha t t he a c t of e t ereot ypi ng almo8 t i nevi t abl y engendere.
Despi te t he f a c t t ha t people may r es ent e t ereo typee a t t r i but ed
t o them by out s i der e, they of t en ehare -- and even cheri eh --
et ereot ypee t ha t a r e el uci dat ed by members of t he i r own group o r
e oc i a l category. Thus, whi l e Angloe may be deri ded and ecorned f or
exaggera t i ng and c a r i ca t uri ng t he impor tance of par tying and
machiemo among Lat i nos, a Nexican poet , eeeayi et , and diplomat has
been l i oni zed f o r hi e penet r at i ng i ns i ght s about t he importante of
f i e s t a s : "Fi es t as a r e our onl y luxury. .. .During theee days t he
s i l e n t Mexican whie t l e e , ehoute, ei nge, ehoote of f hi e f ireworks,
di echargee h i e pi e t ol i n t o t he a i r . ... Thie i e t he ni ght when
f r i ends who have no t exchanged more than t he prescri bed cour t eei ee
f o r months ge t drunk t oget her, t rade con i dencee, weep ovar t he eame
t roubl ee, di scover t ha t t hey a r e brot here, and eometimee, t o prove
i t , k i l l each ot her " (Paz 1961:49). Si mi l ar l y, al t hough an out si der
would be viewed a e being a t l e a e t one-sided, and more l i k e l y
bi got ed, i f he char act er i zed "t he Lat i n" a s i r r eeponei bl e, wily, and
more concerned w i th worde than wi t h a ct i on, t he qui nt ees ent i al
clown-hero f o r two genera t i ons of La t i n Americane has unquee t i onabl y
been "Cantinflae" (Mario Moreno), a s l i g h t l y eeedy charact er whoee
combination of pe r e mi a l i r r eeponei bi l i t y, a b i l i t y t o confound
ot her e wi t h g l i b but noneeneical verbi age, and eeeni ngl y unconecioue
but i n f i n i t e l y gr acef ul dodging of a l 1 ki nds of obet acl ee make him
a n obj ect of eyapathy and emphathy a8 w e l l a e of guffaws. No one
would claim t ha t a clown i e t he "culture-hero" o r s oc i a l cynoeure of
an i nt er nat i onal s oci et y, but when t he val uee and act i one he
port raye e t r i k e a reeponeive chord s o deepl y and s o broadl y f o r eo
lo-, t her e muet be a n i mport ant element of t r ut h i n t he
char act er i za t i on.
Another ki nd of evidence beare on t hi e groee l eve1 of
peycho-hie t o r i cal anal p i s : a li t er ar y genre of cul t ur al
i nt r oepect i on i n which Lat i n Americane have long been vocal and
a r t i c ul a t e . According t o a preval ent view, t he Conquest wae a
profound "peychic trauma," a second "orgi nal s i n f or t he conquerors
and a a us hi ng def eat f o r t he vanquiehed, and i t e t i l l weighe
heavi l y on a l 1 t h e deecendante." A more vi vi d char act er i zat i on
r epr eeent s t he cr aes European male rapi ng t he nobl e American female,
and then i gnori ng t he hal f-breed ( 1 e . , meet i zo) of fepri ng.
Argwdas (1909) e a r l y ueed t ha t image t o expl ai n why Boliviana a r e
"a ei ck people"; cl os el y r e l a t e d viewe have been a r t i c ul a t e d by
Aramoni (W61), Gonzalez Pineda (1961), Paz (1961), Bodriguez Sal a
(l 965), Freyre (1956, 1966), and ot here.
(be by-product of t hi e i e "t he c r i ol l o outlook" deecri bed by
Simmone (1955) i n coaet al Peru. Soci abl e but as oci al , f u l l of
gui l e, excel l i ng i n ver bal f a c i l i t y and mental a g i l i t y , one ehould
be abl e t o l i v e wel l wi t hout apparent ef f or t and t o "get away with"
anything. Although euch a charact er may not be hai l ed a8 t he i deal
son-in-law, he i e l i k e l y t o be t he eubj ect of a t l e a e t grudging
admi rat i on, not onl y i n Peru but a l s o i n Argentina ( l i ke t he f abl ed
gaucho), i n Mexico ( cl oeel y r e l a t e d t o t he charro), and elsewhere.
J ue t a8 t here i e an i mport ant di a l e c t i c between uni t y and
di ve r e i t y wi t hi n t he va s t regi on we have been cal l i ng Lat i n America,
t here l e a ei mi l ar l y i mport ant di a l e c t i c between uni t y and di ver s i t y
wi t hi n each of t he component ecol ogi cal ar eas ( a s when geographere
epeak of "t he Amazon baei n, " "t he Chaco," "t he al t i pl ano, " et c. ).
The eame holde t r ue wi t h r eepect t o cul t ur al ar eae, baeed on
t r a i t-die t r i but i one ( a s when e t hnol ogi e t e epeak of "Tropical
Foree t, " "Circum-Caribbean, " "Marginal, " "Meeo-American, " o r o t her
t ypes of cul t ur ee) . It l e a l e o t r ue with r eepect t o moe t of t he
i ndi vi dual na t i on-e t a t e s which have become such appar ent l y uni t ar y
e n t i t i e e i n modern times, even though t he i r p o l i t i c a l boundariee
of t en do vi ol ence t o c ul t ur a l and hi e t or i c a l systeme t ha t a r e
i mport ant t o people a t t he praeeroot e l evel .
E thnographi c S t udi es
A major cont r i but i on t ha t ant hropol ogi st e have nade t o our
underetandinp of al cohol and i t e i nt er act i on wi t h t he human animal
has been t he deecr i pt i on of pa t t e r ns among i d e n t i f i a b l e l oc a l
communitiee. Thi s hae t he advant age of ehowing how t he pa r t e of a
c ul t ur e r e l a t e t o each ot her . It can a l e o ehow how h i s t o r i c a l
f a c t or 8 i nf l uence pr es ent choi cee (whether i n a s t a b i l i z i n g ,
c a t a l y t i c , o r des t r uct i ve eense). I n some i ns t ancee, i t can r eveal
much about t he range of i ndi vi dual v a r i a t i o n wi t h r es pect t o a
normative norm, o r wi t h r eepect t o a des cr i pt i va n o n . I n ot her
i net ancee, i t can i l l umi nat e how "r eal " c ul t ur e f i t e -- o r d i f f e r s
from -- t he "i deal " cul t ur e, r egar dl es e of whether t h a t i d e a l i s
epi t omi zed i n lawe, gener al i zed deecr i pt i ons , e t h i c a l o r r e l i gi ous
pr ecept e, t he r e s u l t e of a queet i onnai re-survey, o r eome ot her
eource t h a t i e removed from t he r e a l i t y of everyday l i f e . Por a l 1
of t heee reaeone, et hnogr aphi c et udi ee of al cohol uee have been
val uabl e, des pi t e t he f a c t t h a t few ant hr opol ogi et e ever e e t o u t
wi t h t he s p e c i f i c i n t e n t i o n of focusi ng on t h a t realm of
behavi or . l 2
Among et hnogr aphi c s t udi ee of Lat i n America, t her e a r e onl y a
few t h a t have no mention of dr i nki ng and drunkenneee; t h i s 1s t r ue
of both peaeant communi t i e e and r e l a t i v e l y i e ol a t e d t r i bee which
have had onl y deeul t or y cont act wi t h r epr eeent at i ves of Weetern
i ndue t r i a l i z e d cul t ur ee. I n the cont ext of t h i e workshop, a
r egi onal eurvey would be of l i t t l e val ue, but a broad sampling w i l l
demonetra t e t he i n t er pl ay of h i e t o r i c a l and c u l t u r a l f act or e a t
var i oue l e v e l e of contemporary e o d e t y , and enabl e ue b e t t e r t o
appr eci a t e t he v a r e t y of a t ti t udes and i n t e r e e t e t ha t a r e i nvol ved
i n t he a v a i l a b i l i t y and coneumption of al cohol i c beveragee .
One pa t t e r n of dr i nki r y t h a t has been remarkably conei et ent
through t i m e and t h a t i s wi del y di s t r i but e d throughout Lat i n America
i e t h a t of dr i nki ng boute, o r group bingee. Char act er i et i cs of t h i s
pa t t e r n a r e t h a t t he men dr i nk t o t he poi nt of s t upef act i on; t he
beverage hae no r e l i g i o u s connot at i on; and al t hough dr i nki qg i n a
group i e a s o c i a l i mper at i ve, s o l i t a r y dr i nki ng i e unt hi nkabl e. The
broad geographi c range of t h i s s t y l e i e char act er i zed i n Cooper
(1949), and Mandelbaum euggest ed i t wae pr ot ot ypi cal of t he a r e a
(1365). A few of t he de t a i l e d l o c a l et udi es where i t i s exempl i fi ed
r e f e r t o Chi l e (e.g., Lomni t z 1969a, b, Medina and Ptarconi 1970);
Colombia (Sayree 1356); Ecuador (Maynard e t al . 1965, Rodriguez
Sandoval 1945); Guatemala (Rei che 1970); Mexico (Maccoby 1965,
Wileon 1372); and Peru (Gomez 1966, Mangin 1957, Marroquin 1943,
Si mone 1968). Thi e wi del y di e t r i but e d pa t t e r n was preeumably what
J e l l i n e k had i n mind when he spoke of contemporary Lat i n America as
having "an al cohol i c cul t ur e. "
It i e probabl y a l e o t he pa t t e r n t h a t has prompted many
t went i et h cent ur y obeer ver s t o be outepoken i n t h e i r c r i t i c i s m of
dri nki ng and drunkenneee as i mport ant obs t acl ee t o moderni zat i on and
progrese. A Pr ot eet ant mi ssi onar y' s view i s perhape more s t a r k l y
phrased t han eome ot her e, but i t r e f l e c t e a wideepread a t t i t u d e
among urban i nt er nat i onal l y or i ent ad people i n U t i n America today:
"Nei t her Government nor t he RDman Cat hol i c Church hae done anything
t o cont r ol t he dri nki ng habi t s of t he people--habite which,
accordi qg t o many I ndi ani et ae, a r e des t royi ng more Indiane than any
o t her s i ngl e cauee" (Rycrof t 1946 : 12-7 3).
However , among t he i ndi geni s tas, whoee work cont i nues t o have
a ei gni f i cant impact on thinking about t hese eame Andean
popula t i one, t he dri nki ng habi t e a r e almoe t i nvar i abl y por t rayed i n
ver y di f f e r e nt tenue--f avorably, a e i nt e gr a l par t e of nat i ve l i f e ,
i mport ant f o r r el i gi oue reasone a e well a s f o r s oci abi l i t y. Thie
view i s not r e e t r i c t e d t o ethnographere, but i s ehared by t he
coemopoli t an li t e t a ti who cheri eh f ol k t r a di t i ons ae importan t par t e
of t he worldwide human her i t age. I n hi e famoue novel about
quaei-eerf dom i n hi ghl and Ecuador, Icaza (1937 ) doee not i gnore t he
vi ol ence t ha t eometimes eneuee, but a l e o shows t he immenee val ue of
men'e going on a binge t oget her. Writing about a cl oeel y r el at ed
y opula t i on i n highland Bol i vi a, Arguedas (19 19 ) caref u l l y por t rayed
drunkemees a8 eynbol i cal l y i mport ant and eoci al l y usef ul ; t he few
r e erences t o i t i n J. C. Maria t egui ' s (197 1 ) almoe t timeleee
char act er i zat i on of Peruvian r e a l i t y ehow al cohol -rel at ad probleme
a e more a r e e ul t of i nt e r e t hni c prej udi ce and domination than a
cauee. A s i mi l ar view wi t h r es pect t o Mexican Indi ans i e of f er ed i n
a cl aeei c i ndi geni et novel by Lopez y Fuentes (1937), and i n a
quaei-autobiography ( e .g . , Pozae 1968 ) , a e w e l l a e i n innumerable
e thnographic monographe and communi t y e t udi ee.
Thie emphasie on t he eoci al val ue of ehari ng dri nk i e by no
meane di e t i nc t t o La t i n America, of couree. Throughout t he world,
one of t he m08 t widely recognized val ues of al cohol l e t hat , i n
r e l a t i ve l y low concentra t i ons, i t of ten i ncreaeee e oc i a bi l i ty.
Si ni l a r l y wideepread i n geopraphi cal tenue, and even bet t er
documentad over a l ong span of hi s t or y, i s t he eynbol i c val ue t ha t
of t en at t aches t o t he a c t of dri nki ng t oget her. I n f a c t , i t i s
i r o n i c t ha t eo much concern has been devoted t o alcoholiem a e an
a f f l i c t i o n of l onel y people, o r on t he diminiehing eoci al networke
of dri nkere a e t hei r probleme i ncreaee. I n moet of t he world,
dri nl dng i e e e e e nt i a l l y a eoci al a c t , of t en t o t he poi nt t ha t
e ol i t a r y dri nki ng i s unknown and even unimaginable. It i e i mport ant
t o keep t hi e i n mind, becauee a t l e a e t t hat , among t he
al cohol -rel at ad probleme t ha t loom l a r ge e t i n eome par t e of t he
world, i e v i r t u a l l y abeen t i n many Lat i n American communitiee.
Without expl ori ng i n de t a l l t he r i c h f und of epecif i c de t a i l e
t ha t have been amaeeed by ethnographere concerning t he poei t i ve
eoci al funct i one of dri nki ng, a few of t he i r srunmary i nt er pr et i ve
et at ement e should hel p t o convey eome of the benef i ci a1 eenee t ha t
a c a u e e from dri nki ng -- and even drunkenneee -- i n euch a context.
Among t he Camba of Bol i vi a, f o r example, ". . . f i es t a8 cons t i t ut e
v i r t u a l l y t he onl y corporat e form of s oc i a l expreesion. Drinking
p a r t i e e predominate amory r a r e s o c i a l a c t i v i t i e e , and al cohol eervee
t o f a c i l i t a t e r appor t between i ndi vi dual e who are normal l y i e ol a t e d
and i n a o v e r t e d " (Heath 19%:507 ). On t he baei e of h i e work i n
eever al comiuni t i e e i n hi ghl and Peru, ano t her observar concluQd
t hat : "Where t he us e of i nt oxi cat i ng beveragee i e expect ed and
commonplace, t he i r s pe c i a l q u a l i t i e s a r e coneci ouel y u t i l i z e d a s a
devi ce t o e t r uct ur e and promote s o c i a l i nt er cour ee and t o f a c i l i t a t e
t he achievement of c u l t u r a l i deal e" (Doughty 1971: 188). Remember
t h a t bot h of t hese coment e r e f e r t o popul at i one of Spanieh-epeaking
peaean t e who par tl ci pa te i n t he nat i onal economy, and no t t o a emal l
i s ol a t ed t r i be.
I t i s n o t onl y i n Andean count r i es t h a t dr i nki ng i s of t e n
c i t a d as a n a c t t h a t has i mport ant val ue i n promoting s o c i a l
cohesi on o r convi vi al i t y. The same i s t r ue i n t he Caribbean (e.g.,
Yawney 1969, Pr i nce e t al . 197 2, Manning 1979, Abad and Suarez 197 5,
Beaubrun iY68), Cent r al America (e.g., Ar r i ol a 1965, Chaesoul e t al .
1973, Pr es t an 1975, Reiche 1970), Mexico (e.g., Pozas 1957; Kearney
1970, Kennedy U63, Madsen and Madeen 1969), and i n lowland a r e a s of
South America (e.g., Leacock 1964, Goldenberg e t al . 1965).
Drinking As R l t ua l Behavior
I n many of t he e t h n i c cul t ur ee throughout Lat i n America,
s o c i a l dr i nki ng i s s o i mport ant t h a t i t l e imbedded i n eequencee of
ver bal and ot her behavi or t h a t a r e s o f ormal l y pat t er ned a s t o be
c a l l e d r i t u a l s . The case o t he Chamula o sout her n Mexico hae been
more c a r e f ul l y anal yzed t han many: "Symbolically, t he drinlsing
r i t u a l achi eves a t l e a s t f our obj ect i vee. It emphaeizee t he
pr i nc i pl e of equal i t y, f o r ea& pa r t i c i pa nt r ecei vee an equal
amount. It emphasizes t he pr i nc i pl e of rank, f o r equal por t i one a r e
ser ved accordi ng t o rank order. ... It l i t e r a l l y producee and a l e o
symbolizes t he h e a t t h a t 1s consi dered deei r abl e f o r human
i n t e r a c t i o n wi t h d e i t i e s and wi t h ea& ot her . Fi nal l y, i t
symbolizes s o l i d a r i t y amonp t he par t i ci pan ts.. . " (Goeeen 197 4 : U 4).
The symbolism of dr i nki r y t oget her a e a n i mport ant
cont r i but i on t o s o c i a l u n i t y becomee even more dramat i c i n t hose
popula t i one where dr i nki ng pa t t er ne themeelvee are e x p l i c i t l y
re cognized a s i mport an t f e a t ur es t ha t di e t l ngui s h membere of one
group from t hose of anot her (e.g., Heath 1971, Vi quei ra and Palerm
19 54, Sir~mons 19 55). Ano t her usage r e l a t e s al cohol and drunkennees
t o i n t e r - e t hni c r e l a t i one , a theme of pervaei ve concern i n most
Lat i n American s oc i e t i e e . Vi l l ager s i n sout her n Mexico are gl ad t o
have drunken i ndi vi dual 8 pl ay a v a r i e t y of p o l i t i c a l l y and
dr amat ur gi cal l y s i gni f i c a n t r ol e s , en joyng a pecul i ar
permi sei veness t ha t l e t e them "speak t he unepeakable" (Dennie 197 5) .
Secul ar r i t ual e a r e not t he onl y onee i n which al cohol playa
an i mport ant eymbolic t ol e ; dri nki ng and drunkenneee a r e hi ghi y
val ued aspect e of t he f i e e t as t ha t accompany r el i gi oue obeervancee
of a e i gni f i c a nt por t i on of t he popul at i on of Lat i n America. Thie
r ef er e not oni y t o r el i gi one of abor i gi nal tribes, but al 80 t o Roman
Catholiciem a8 i t i e pr act i ced by t he f ol k of urban a e w e l l a8 r ur a l
comi uni t i ee i n many count ri ee. Thi s pat t er n i e eo f ami l i ar a8 not
t o r equi r e det al l ad documenta t i on i n t hi e cont ext ; ( i l l u s t r a t i ve
caees from vari oue ar eae i ncl ude Kearney 1970, Holmberg 1971, Owen
1905, Goeeen 1974, and ot her e) . Another ki nd of s yncr et i c r el i gi on,
combining t r a di t i onal non-Wee t er n w i th Chr i s t i a n elemen t e, i e
exempl i fi ed i n t he so-cal l ad "Afro-American cul t s , " where al cohol l e
of ten ueed both a s a n of f er i ng t o t he eai nt e and a e an adj unct t o
t he ece t a t i c r el i gi oue experi ence tha t i nvol vee a e p i r i t ' e
"poeeeesion" of a devotee (e.g., Bourgignon 1964, Leacock 1964).
Other groups i n whi ch al cohol i c beverages are thought t o be hi ghi y
eeteemed by super nat ur al beings and, hence, conet i t ut e val uabl e
of f er i ags , a l s o i ncl ude eome peaeante who pr act i ce l oc a l var i ant e of
folk-Catholiciem (e.g., Bunzel 1940, Wagner 1978, Maynard e t a l .
196 5)
I f de i t i e e appr eci at e al cohol a s a comodi t y, eo do i ndi vi dual
humn beinge i n workaday ei t uat i ons . The economic val ue of
al cohol i c beveragee a e a commodity, both i n terme of s a l e s and i n
tenue of t axat i on, i e not onl y widely recognized but has probably
been t he s ubj ect of more quant i t at i ve documentation than any ot her
aepect of al cohol i n eoci ocul t ur al perepect i ve. There ar e, of
couree, a number of ot her vaya i n which al cohol i c beveragee f i gur e
i n eyeteme of exchange t ha t a r e never considered by s t a t i e t i c i a ne o r
macro-leve1 economie te. The beverage i t eel f i s eometimee a medium
of exchange f o r paying wagee, f i ne s , o r taxee (e.g., Bodriguez
Sandoval 13 45, Pozas 19 57 , Mendieta 19 39 ) . As was t he case i n t he
Inca Empire, e t r a t egi c di 6 t r i but i on of al cohol i c beveragee can a l s o
be a val uabl e way of accrui ng pr eet i ge (e.g., Vasquez 1967, Lomnitz
l969a). One t heor i et went s o f a r a e t o euggeet t ha t beer i s of
car di nal impor tance i n l ocal -l eve1 pol i ti ca i n t he Amazon basin:
"The cr uci al mechaniem by which one Tr opi cal For est vi l l a ge could
achi eve o r mai nt ai n a pos i t i on t ha t would impreee i t e neighbors wae
t o gi ve a f i e s t a which l a e t e d l onger, expended more beer, and
unleaehed more drunken brawle t han any ot her f i e s t a i n memory"
(La t hrap 197 0:54).
One par t i cul ar economic use has recei ved epeci al a t t e nt i on
becauee of i t e i nt e gr a l aeeoci at i on wi t h s oc i a l et r uct ur e, namely,
t he provi si on of beer by t he l a n d o ~ e r i n s i t ua t i one of r eci pr ocal
l abor exchange, where teame of neighbors work j oi nt l y on each
ot her ' s pr oper t i ee by turn; t hi s pat t er n 1s i mport ant i n wi del y
ecat t er ed ar eae (e.g., Doughty 1 9 7 1, Kennedy 1963, Muratorio 1980).
I nci dent al l y, t he out si der e' view t ha t al cohol i nt er f er ee wi t h work
and such a c t i v i t i e e t urn i n t o drunken or gi ee has been t eet ed, and,
not onl y l e t he e o d a b i l i t y enj oyabl e, but i n t e me of thermo-
dynamice "t he beer work pa r t y i e a r e l a t i ve l y e f f i d e n t meane of
mobi l i zi ng a yr i c ul t ur a l l abor " (Gregeon 1969 ) .
J ue t a s out si der 8 of ten err i n t he i r negat i ve eval uat i on of
dri nki ng i n r e l a t i on t o work, they of t en a r e mietaken i n t hei r
judgmen t abou t t he ph yei cal impact of a l cohol i c beveragee .
I l l u s t r a t i v e of t hi e l e t he uneubet ant i at ed view t hat : "(bce t he
nobl e beverage of t he Incae, chicha i e now cl aseed by general
coneent, along u i t h coca, a s t he Indi ana' deadl i eet enemy. ...The
corn t ha t before had nouriehed s o wel l thue t urned t o poieon; what
wae a bl eeei ng before became a curse. For cent ur i ee now, unchecked,
i t has eapped t he v i t a l i t y of the Indi an people" (Tunon de Lara
19% : 19-20). The r e a l i t y l e ver y di f f e r e nt from t hi e biaeed
out ei der ' e i nt e r pr e t at l on. Nu t r i t l onal anal ys i e l eaves no doubt
t ha t t he maize e t i l l nouriehee; f a r from being a poieon, chicha i e
ext remel y r i c h i n B-complex and C vi t ami ns, and calcium, a l 1 of
which a r e gener al l y l acl dng i n t he balance of t he t ypi cal Andean
d i e t (eee, e.g., S t ei nkraues 1979). Phyeiciane and bi ol ogi et e from
abroad a r e not t he onl y onee who haet en t o poi nt out t hat , f a r from
sapping t he v i t a l i t y o La t i n American Indi an popul at i one, chicha
eeeme t o r ei nf or ce it. An el oquent Peruvian writer makee much t he
sama poi nt t ha t Paz di d wi t h r eepect t o Mexico: "In da i l y needs,
f r uga l i t y r ul ee. But t he gr e a t event of t he f i e e t a comes, and t here
l e drinlc, va r i e t y of di shee, dancing, and a community of happy
bel ags. The f i e s t a i e vol a t i l e ; under i t e i nf l uence, heavinees 1s
f orgot t en, and t he worth of being a l i ve experienced anew"
(Val carcel 1950: 1st of un-numbered pagee).
The cont raet i ng view eeeme t o have gai ned wider recogni t i on,
however. (be eource commonly ci t ed i e t he r epor t of a committee
eent by t he I nt er nat i onal Labor Orpanization t o i nveet i gat e aepect e
of eoci al r el at i one and heal t h t hat might a f f e c t pr oduct i vi t y i n t he
Andean region. Although nona of t he membere had t r ai ni ng i n any of
t he eoci al , behavi oral , bi ol ogi cal , or medical ecienoee, t hei r
pat r oni zi r y and et hnocent r i c conclueion ha8 f o r many yeare been
gener al l y accept ed by pl amer s : "The abuse of al cohol and t he
chewing of coca l eavee hel p expl ai n, i n eome measure, i r r e gul a r i t i e s
i n t he eoci al , economic, and heal t h realme t ha t of t en a f f e c t t he
I ndi an of t he Andean a l t i pl ano" ( Of i d n a I nt er naci onal de Trabajo
1953: L 4 ) . Another hi ghl y queet l onabl e view l e t ha t t he t ox c
eubetancee i n chicha a r e cumulative, s o t ha t t he peasante of
hi ghl and Ecuador a r e yr adual l y poieoning themeelvee by i ageet i ng a
dr i nk t ha t t hey coneider heal t hf ul (Maynard 1965).
For thoee of ue who have pai d cloee a t t e nt l on t o "fol k uiedom"
o r popular be l i e f s about nut r i t i on and heal t h, i t ha8 been
f as ci nat i = -- and even gr at i f yi ng -- t o eee t ha t Western e c i e nt i s t e
a r e eometimee re-discovering impor t a nt f act a t ha t our informants
knew a l 1 the t i me . Thie i e not to s ay t ha t we expect al1 "fol k
wiedom" t o be confirmed, nor t ha t pr act i t i oner e i n t he bi ol ogi cal
and medical eci encee make few or i gi na l cont ri but i one. But i t i e
et r i ki ng t h a t t he nut r i t i ona l val ue of fermented beveragee, long
preeumed and ext ol l ed by peaeant and t r i b a l peoplee around t he
world, ha8 r ecent l y been ent hus i as t i cal l y confirmed i n gr eat d e t a i l
by epeci al i et s from many di s ci pl i nes (Gaetineau e t al . 1979). The
food val ue of chi cha ha8 al r eady been c i t e d (St ei nkrauee 1979);
pulque i e eecond onl y t o t o r t i l l a s a e a eource of eeeent i al vitamins
and minerale i n t he d i e t of some populatione i n c e nt r a l Mexico (R.
Andereon et a l . 1946).
Furthermore, t her e a r e a l e o et udi es t ha t eupport t he
wideepread fol k-bel i ef t ha t al cohol i c beveragee ( especi al l y chi cha
a nd o t her f ermented homebrew) have medicinal propert i e e i n addi t i on
t o t he i r gener al nut r i t i ona l value. It may seem remarkable t ha t
t heee medicinal val ues a r e , i n many r espect e, t he eame ones
s i gnal l ed by phyei ci ans duri ng t he col oni al peri od: a s a di ur e t i c ,
a s a n a i d t o nureing mothere, and f o r t he r e l i e f of di ar r hea, a s
w e l l a e t he more gener al t oni c qual i t y (Gastineau e t a l . 1979).
It muet a l s o be admitted t hat not a l 1 of t hose who recognize
hi e t or i c a l and c ul t ur a l f act or 6 a8 important i nfl uencee af f ect i ng
t he a va i l a bi l i t y and coneumption of al cohol i c beveragee consi der
them appr opr i at e or advantageoue. Even w h i l e recognizing bo t h t he
t r a di t i ona l and contemporary c ul t ur a l ei gni f i cance of dri nki ng and
drunkennese among many Mexican Indi an popul at i one, a soci ol ogi et
concluded "t hat t he i nf l uence of alcoholiem i n t he economy of t he
indigenee of Mexico i e di eaet r ous, " c i t i ng, among ot her probleme,
t h a t "t he coet of i nt oxi cat i ng beverages occupi es more t han f i f t y
percent of t he fami l y budget"; alcoholiem provokee among them t he
commission of crimee agai nst t he pereon"; pol i t i ci ane buy vot es with
dri nke; l andl or ds pay pa r t i a l s a l a r i e s i n dri nk; and eo f or t h
(Mendieta 1939: 89).
The char act er i zat i on of ei gni f i cant di ferences among
"eubcul t ures" or "claeeee" has been an i nt e gr a l par t of t he
t r a di t i on of nat i onal -l eve1 descr i pt i one of al cohol use i n i a t i n
America, even before eyet emat i c s t udi es were made (Horwitz, Marconi,
and Mi e 1967a: 61-137). When surveys a r e conducted, "socioeconomic
cl as e" tende t o be one of t he major demographic var i abl es (e.g.,
Chaesoul e t a l . 1973, Tarnapolsky et a l . 1965). Some have expreeeed
eur pr i ee t ha t i t i e not neceesar i l y thoee of lower cl as e who dr i nk
more. In f a c t , i n vari oue regi ons throughout Br azi l Paetore (1965)
demonetrated t hat members of t he upper-clase dr i nk more. He al eo
euggeeted t ha t they can be expected t o i ncr eaee t he i r consumption of
al cohol i c beveragee, becauee dri nki ng eerves not only t o symbolize
f r i endehi p but a l s o becauee i t has become a meane of conepicuoue
coneumption and of demonetrating one' s "coemopolitanism."
Rural-urban di f er ences a r e s i mi l a r l y no t ed i n ms t nat i onal
surveys. Chi l e provi des an i l l u s t r a t i ve case where popular views
about drunkenness have remained s t r i ki ngl y di f f e r e nt i n r ur a l and
urban ar eas f o r sever a1 years (e.g., Marconi, Varel a, e t a l . 1955,
iiorwitz and Marconi 1965, Marconi 1969, Medna and Marconi 1970,
Medna [ i n pr ess] ). The dat a a r e nei t her s t a t i s t i c a l l y overwhelming
nor l ogi c a l l y compelling ( i n view of me t hodol ogi cal shor tcomings),
but i t i s noteworthy nonet hel ess t ha t t he r ecent UHO survey of
dr i nki r y pat t er ns i n Mexico reveal ed t ha t r u r a l people drank more,
drank more of ten, and s pent more time dri nki ng than those i n t he
c i t y (WBO 1981: 120 e t seq. ). Thi s deserves mention i f onl y because
i t cont r ad ct s a wi del y hel d view t ha t t he pressures of urban l i f e ,
w i th hi gh unemployment, crowdry, a l e n life-ways, and s o f or t h,
make f or heavi er dri nki ng i n ci ties.
Illici t Production
l
1
It i s widely recognized t ha t a s i gni f i c a nt por t i on of t he
al cohol i c beverages used i n many Lat i n American communities i s not
recorded i n t he s t a t i s t i c e t ha t would normally be used a s a bas i s
f or es tima t i ng per-capi t a consumption. Domes t i c production of
f ermented dri nks, s u& a s pulque i n Mexico ( m0 1981, Garci a 1972,
Roufs and Bregenzer 1968), or chicha i n t he Andean count ri es (e.g.,
Vasquez 1367, Muelle 1945) i s widespread and customary, s o t ha t
s i gni f i can t quan t i ties of them a r e drunk w i thou t l eavi ng any
record. The same i s undoubtedly t r ue of home-ade wines i n
Argentina and Chi l e, a s wi t h ot her l o r a l c o h o l beverages elsewhere.
Another por t i on of al cohol consumption t ha t goes uncounted i s t ha t
of i l l i c i t l y d i s t i l l e d aguardi ent e, a c ha c a , or rum. Such
product i on has no t recei ved t he sye t emat i c a t t ent i on of schol ar s i n
Lat i n American cont ext s a s i t has i n Anglo America; my o m work i n
Costa Rica remains unpublished because i t would be i ncri mi nat i ng t o
many f r i ends who were hel pf ul . I n t ha t same country, illicit rum
(guaro) has long been recognized a s posing a major heal t h problem
(Chassoul 1 9 7 1 , Escobar e t a l . 1974), and cl andest i ne d i s t i l l a t i o n
i s mentioned a s a n i mport ant economic a c t i v i t y i n a t l e a s t a few
peasant communi t i e s elsewhere ( e .g . , Reichel-Dolmatof f and
Reichel-Dolmatof f 1361, Bunzel 1340).
The reason t ha t home-di st i l l at i on i s i l l e g a l i n most ar eas
probabl y has l e s 8 t o do wi t h publ i c heal t h than wi t h publ i c wealth.
Di s t i l l e d al cohol i c beverages a r e us ual l y heavi l y taxed, s o that
"moonshining" r epr esent e major l os s es t o t he nat i onal t reasury. The
s i t ua t i on i n Costa Rica i s even more problematic, because d i s t i l -
l a t i o n i s supposedly a monopoly of t he s t a t e . It should not be
s ur pr i s i ng t ha t t he pot ent i al c onf l i c t of i n t e r e s t between the
government a s benef i ci ar y of t he l i quor busi ness on t he one hand,
and t he government a s benefact or i n at t empt i ng t o prevent
al cohol -rel a t ed problems on t he o t her, i s no t onl y recognized but
acut el y f e l t i n many Lat n American nat i one. I n informal
conversa t i on, concerned Chi l eans of t en a r e ambivalen t abou t t he
personal advantage of having l i quor s avai l abl e ver y cheaply -- a
r a r e i net ance of low t axat i on -- and t he publ i c disadvantages
r e f l e c t e d i n high r a t e s of ci r r hoei s from long-term heavy drinklng.
Si mi l ar1 y, eome Argen t i nes who en j oy excel l en t winee a t reaeonable
p r i ces a r e a l e o di 8 t r eseed tha t t he i r impoveriehed compa t r o ts can
buy mediocre wines f o r l e s 8 than they would pay f o r milk, coffee, or
eof t drinke. Another i mport ant f a c t wi t h r es pect t o t he beverages,
and al cohol -rel at ed problema, i s t he remarkable exer ci ee i n s oc i a l
epidemiology i n which i t was demonstrated, f o r Tri ni dad and Tobago,
tha t: "The ex t r aor di nar i l y cl oee r e l a t i onshi p ( r = -0.978 ) between
road acci dent e and t he r e l a t i ve pr i ce of rum suggest s t ha t t he
l a t t e r may be a be t t e r i ndi cat or of t r ue coneumption than t he
f i gur es obt ai ned f rom product i on and impor ts minue expor t e"
(Beaubrun 1977 : 49).
The l i nkage between acci dent s and dri nki ng r a i s e s t he queet i on
of diminished r eeponei bi l i t y when an i ndi vi dual 1s i nt oxi cat ed. I n
Uruguay, f o r example, drunkennese can be coneidered an ext enuat i ng
circume tance w i t h reepe c t t o cri mi nal r eepons i bi l i t y, although
publ i c i nebr i a t i on 1s punishable (Galeano 1367 : 130-131). Si mi l ar
ambivalence i e evidenced i n wideepread acceptance o "t he di sease
model of alcoholism" on t he one hand, and continuing st i gmat i zat i on
of problem dr i nker s a s l acki ng w t h r eepect t o willpower and
mor al i t y ( i bi d: 136) on t he ot her.
Cl oeel y r e l a t ed t o t he queet i on o r es ponei bi l i t y f or drunken
compor tmen t i s the ques t i on o appreci a t i on of dri nki ng i n pos1 t i ve
t eme, when su& appr eci at i on does not r e l a t e t o economic,
r el i gi oue, or ot her e t r uc t ur a l l y important valuee. The r e a l and
symbolic l i nkage between dri nki ng rum and ot her forme of "play" 1s a
major theme i n t he l i v e s of young Bermudan males (Manning 1979).
Another curi oue f i ndi ng i n t he r ecent WHO croee-national survey was
i de nt i f i e d by t he s oci ol ogi et who wae commissioned t o analyze t he
f i ndi ngs i n t e me of crose-cul t ural s i mi l a r i t i e s and di f erencee:
"The degree t o which Mexican reepondente s a i d no t o t he i dea t ha t
' having a dri nk i e one of l i f e f s pl easur eef i e something of a
mystery," and "I n t he Mexican dat a one has t he di s t i nc t f e e l o t he
preeence of an overri di ng cul t ur al negat i vi t y toward al cohol "
( I bi zen 1981: 18, 51) .13
Thi e view of cul t ur al var i ant e i n r ecent hi s t or y i s i nt ended
t o be nei t her encycl opedi c i n breadt h nor comprehensive i n depth.
The sampling o var i ant a t t i t ude s and pr act i ces wi t h r espect t o
al cohol i c beveragee i n r ecent times has been del i ber at el y di verse i n
t e me of eubj ect e, t o r e f l e c t t he pervaeiveness of cul t ur al f act or s
tha t shoul d be unders tood bef or e anyone a t temp ts t o formula t e pl ans
f o r prevent i on of al cohol -rel at ed problema. It has a l s o been
di veree i n terms of geographi c di 6 t r i but i on, t o demone t r a t e tha t
each nat i on and ea& regi on can cont r i but e val uabl e dat a and r a i s e
i mport ant que8 t i one i n euch connectlon.
Conclusions
I n t he cont ext of a workshop such a s t hi s , i t seems appropri-
a t e t hat one not f e e l const rai ned i n t he sense t ha t conclusions need
be based s ol e l y on evidence present ed i n t he body of t he paper. I n
f a c t , i t seems more appr opr i at e, i n addressi ng t he broad s ubj ect of
h i s t or i cal and c ul t ur a l f act or 8 af f ect i ng t he a va i l a bi l i t y and
consumption of al cohol i c beverages, t o draw on a number of impres-
s i ons t ha t a r e not eas y t o document i n a bi bl i ogr aphi c sense, a s
wel l a s on t he many and di ver se sources t hat have been ci t ed above.
For example, immersing myself agai n i n t he l i t e r a t ur e , 1 f i nd
a few new quest i ons ar i s i ng. 1s t here perhaps an i nt er nat i onal type
of "Caribbean rum-cul t ur e, " as s oci a ted w i th a complex of f e a t ur es
such a s per i odi c unemployment or underemploymen t, f emale-domina ted
households, t r opi cal clima te, a di e t high i n carbohydra t es , and some
ot her f eat ur es ? If s o, i s i t a l s o associ at ed wi t h a f a i r amount o
boast i ng and horse-play among dr i nker s, and few s oc i a l , psycho-
l ogi cal , o r economic problems t ha t could be blamed on al cohol ? 1s
t here perhaps ano t her t ha t migh t be cal l ed t he "highland-cargo-
cul t ur e, " combining par t i ci pa t i on i n a hi er ar chi ca1 r el i gi ous and/or
p o l i t i c a l system i n which men take t urns holding short-term publ i c
of i ce, a cl i mat e tempered by hi gher el evat i ons ( a t l e a s t 2,000
met er s) , with i nt ens i ve agr i cul t ur e, and a more var i ed di e t ? I f so,
a r e boast i ng and horse-play probably absent , and drunkenness on t he
job expected? I f t her e i s a " f r ont i er beer-cul t ure, " does i t t ypi f y
newly es t abl i s hed towns and i ncl ude a high l i kel i hood of f i ght i ng,
even t o t he death. 1s t here perhaps an "upper-class whiskey
cul t ur e" even more widely di spersed i n c i t i e s throughout Lat i n
America? I f s o, i s i t t he onl y "al cohol i c subcul t ure" i n which women
par t i ci pat e al most a s of t en a s men? I f any of t hese is, i n f a c t , a
meaniryful cat egory, then we would do wel l t o as k oursel ves why.
Bu t i t may a l s o be tha t they a r e not even use u1 cat egori es.
Some of t he cat egor i es t ha t have enjoyed some currency and
t ha t have al r eady proven t he i r worth f or a va r i e t y of a na l yt i c
purposes probably deserve much more at t ent i on. Negrete (1374) has
al r eady ef f e c t i ve l y addressed " types of al cohol use" and t hei r
i mpl i ca t i on.
The Conques t didn' t neces s ar i l y dr i ve t he Mexican Indiana t o
dri nk i n the col oni al peri od, any more than c i t y l i f e dr i ves t hei r
descendants t o dr i nk today. Pr ohi bi t i on appears always t o have been
d i f f i c u l t t o enforce and, except when imbedded i n r el i gi ous
precep t e, tends t o be shor t -l i ved. Though t f u l pl anners have
di f er ed about whe t her s a l e s of al cohol i c beverages should be
r e s t r i c t e d t o hol i days--or forbi dden onl y on hol i days. Si mi l arl y,
vari ous j ur i s di ct i ons i n La t i n Ameri ca have experimented wi t h
r equi r i ng t ha t dri nki ng pl aces be open t o publ i c view--or t hat t hey
be cl oeed from view. Some have favored development of pub-like
atmoephere, congeni al t o women or f ami l i es a s w e l l a8 t o mn ,
whereae o t here have i n s i e t ed t ha t publ i c dri nki ng pl acee ehould be
s t a r k l y bare and f o r men only. The deba t e over whether food should
be avai l abl e wi t h dr i nk has been resol ved i n di f f e r e nt waye i n
di f f er en t places--and i n di f f er en t ways a l s o a t di f f eren t times i n
some s pe c i f i c placee.
I f a man has been t aught t ha t he muet never acheit t o being
weaker than anyone o r anyt hi ng, he l e not l i k e l y t o be comfortable
w i th t he gui del i nes of A l cohol i cs Anonymoue, emphasizing r e aogni t i on
tha t "al cohol 1s e t ronger" and surrender t o "a hi gher power. " I f ,
however, eomeone f e e l s comfortable i n t he s ecur i t y of having a cl oee
personal r el at i onehi p w i t h a s a i n t o r a par t i cul ar mani fest at i on of
t he Vi rgi n mr y , then a pledge of abstinente devoted t o t ha t
r el i gi oue f i gur e may be t her apeut i cal l y ef f ect i ve.
But t here may not be s o much need f o r t hi s eol ut i on among
Lat i n Americane. One of t he moet i mport ant gener al i zat i ons t hat
emergee from an overview of my quart er-cent ury of watching, readi ng,
l i et eni ng, and ot herwi se paying a t t e nt i on t o al cohol use i n Lat i n
America 1s t he r a r i t y wi t h which "alcoholism" occurs.14 To be
s ur e, i t l e a s er i oue problem t hat few of t he aut hore defi ne what
t hey mean by "addi ct i on, " "alcoholism, " o r "al cohol i cs. " Never the-
l e e s i t 1s e t r i ki ng t ha t s o many i nveet i gat or e -- most of them
preeumably a t l e a e t f ami l i ar wi t h t he maj or cont roversi ee over thoee
terms -- expl i ci t l y make t he poi nt t ha t thoee phenomena a r e abeent
i n t he popul at i ons e tudied. Medina's (1978) recommendation tha t
more car ef ul a t t e nt i on be gi ven t o defi ni ng t he t e me a s they a r e
ueed i n vari oue reeearch pr oj ect s deeerves not onl y a eeaond but
a l e o a f o l l o r u p . It l e s t r i ki ng t ha t t hi e shortcoming occure not
onl y amo= s oc i a l s c i e nt i s t s . There a r e a t l e a s t a s high a
proport i on of peychia t r i c , epi demi ol ogi cal , and ot her e t udi ee f rom
Lat i n America i n which t he terms "al cohol i c" and "alcoholism" a r e
ueed v i thou t speci f i c a t i on, i ncl udi ng many where t he sub ject-matter
has no thing t o do w i t h losa-of -cont rol , dependency, w i thdrawal , o r
o t her al cohol -rel a t ed probleme tha t ueual l y a r e ci t ed a8 diagnoe t i c
o r def i ni ng char act er i s tia.
1 w i l l go a e tep f ur t he r and euggeet t ha t we may soon f i nd
oureel vee i n a si tua t i on where t he t i r e d ol d ques tion-"prevention
of what?" t akes on new and immediate ei gni fi cance. Thi s may occur
becauee ano t her impor t an t gener al i za t i on f rom Lat i n American
experi ence 1s tha t a l cohol-related probleme, l i k e " a l coholice" and
"alcoholiem," a r e rare--at l e a s t i n comparieon wi t h populatione i n
t he r e e t of t h i s hemisphere, and even i n comparison wi t h much of t he
r e e t of t he world. A few nat i one a r e except i ons t o t hi e, a e
evidenced i n Dr . Cae tano' s preeen ta t i on on epidemiolog y, bu t moe t
eurveye and communi ty-s t udi es sugges t tha t Lat i n Ameri cane, by and
l ar ge, seem t o f e e l t ha t t hey s uf f er few s er i ous problems t ha t can
be r e l a t e d t o al cohol use, e i t he r t he i r own o r on t he p a r t of
e i gni f i c a nt ot her s. Thi s i s a l 1 t he more s i gni f i c a nt when one
consi ders t ha t t her e i s, i n a very r e a l sense, some bi as toward
f i ndi ng probleme when one i e doing reeearch on al cohol use.
It i s even more ei gni f i cant when one consi ders t ha t t hese
s t udi es of t en r e f e r t o popul at i one among whom heavy dri nki ng occure
r egul ar l y and where drunkenness i s both f r equent and accept abl e. It
i s now gener al l y recogni zed t ha t cer t ai n al cohol -rel at ed problems
t end t o be as s oci at ed wi t h par t i cul ar pat t er ns o r s t yl e s of
drinking. One o t he bes t known i l l u s t r a t i v e cases i s French
a l cool i sa t i on, i n which t he al cohol dependence e yndrome, o ten
cal l ed phyei ol ogi cal addi ct i on, can develop among i ndi vi dual e who
have been const ant wine-drinkers over s ever al years, even i f t hey
have never drunk enough t o show a blood-alcohol concent rat i on of .O8
percent o r any r e l a t e d phyei cal or mental impairment (Ledennann
1956). It shoul d s ur pr i ee no one t hat t he epi s odi c binge-drinking
t ha t t ypi f i es l a r ge segmente o t he Lat n American population does
no t produce anyt hi ng l i b e al cool i s a t i on, nor f requen t ci r r hos i s , nor
damage t o ot her i nt er na1 organs. But i t may be eur pr i si ng t ha t
nei t her is i t l i nked wi t h hi gh r a t e s o acci dent s (wi t h a few
dramat i c l oc a l except i one), nor wi t h high r a t e s of crimes o
vi ol ence.
Ano t her s t r i ki ng cont r as t w i th al cohol -rel at ed probleme i n
ot her pa r t s of t he world i s t he r a r i t y o i ndi vi dual e who s uf f er
gr e a t l y i n terms of mental heal t h. The gui l t - r i dden s o l i t a r y
dri nker who i s s o commonplace i n Anglo-America i s f or t unat el y
miesing i n moet of La t i n America, where dri nki ng i s us ual l y done i n
a s e t t i ng tha t emphasizee eoci abi l i t y.
A st rong caveat i s i n order a t t hi s poi nt . It may wel l be
t ha t t he foregoi ng "conclueions" a r e based on inadequate evidente.
By t hat , 1 do not mean t ha t my comments di verge from o r i gnore t he
dat a t hat a r e avai l abl e. On t he cont rary, i t seems appropri at e t o
s t r e s s t ha t t he dat a -- r i c h and di verse a s t hey a r e -- st i l l l eave
much t o be desi red. One o t he gr eat es t shortcomings i s shared with
t he va s t maj ori t y o s t udi ee, wherever t hey may have been con-
ducted. As Medina (1978) not ed, i t i s unfort unat e t hat , deepi t e
i ncreasi ng ef f or t e toward t r anedi eci pl i nar y col l abor at i on i n r ecent
years, t here have not yet been cl os el y i nt egr at ed s t udi es o
dri nki ng t ha t combine epi demi ol ogi cal assessmente of t he eequelae of
dri nki ng w i t h diagnos ti c and psychoevalua t i ve measures andl or
anal ysee o r el evant s oc i a l and cul t ur al eat ur es. Various
popul at i ons have been S t udi ed by vari ous methods. It i s probably no
s ur pr i s e t ha t those r e l a t i ve l y smal l and i eol at ed " t r i ba l "
popul at i one t ha t have been analyzed i n et hnographi c terms have
r a r e l y been et udi ed i n terms o bi ol ogi cal and medical sci ences.
I r oni cal l y, i t i s a l s o t r ue t ha t the popul at i ons bes t known i n
bi ol ogi cal and medical terms have r a r e l y been s ys t emat i cal l y s t udi ed
i n ways t ha t behavi oral and s oc i a l s c i e n t i s t s would f i nd hel pf ul i n
understanding t he s ubj ect of al cohol use, i t s meanings, and
f unctions.
By poi nt i ng out t ha t many people dr i nk of ten and wi t hout
s uf f er i ng s er i ous problems, 1 do not i nt end t o t r y t o steer us away
f rom t he i mport ant cent r al theme t ha t has brought us t oget her. What
1 want t o accomplish, on t he cont rary, i s t o confront a l 1 o us with
t he pr act i ca1 i mpl i ca t i ons of t hi s h i s t or i c a l and cul t ur al di ver s i t y
t ha t we have a l 1 accept ed a s being i n some sense rel evant . Let us
br i ef l y expl ore, i n some wide-ranging and occasi onal l y unor thodox
ways, vari ous senses i n whi ch t he cul t ur al and h i s t or i c a l f e a t ur es
may be i nformat i ve and useful .
I n si mpl est terms, s oc i a l acceptance of dri nki ng and o
drunkenness throughout much of Lat i n American provi des an emotional
cont ext i n which both dri nki ug and drunkenness a r e l i k e l y t o occur,
and i n which they can e a e i l y be viewed a s unproblematic. But l i f e
i s r a r e l y s o simple, and we should begin t o experiment wi t h themes
and var i at i one, harking badc t o some of t he mscellaneoue
i nformat i on t ha t was di scussed e a r l i e r i n t h i s chapter. For
example, i n those instantes where dri nki ng is considered a r el i gi ous
a c t , and drunkenness a t ranscendant s t a t e , i t i s unl i kel y t ha t
i nt er per s onal aggresei on would be a common al cohol -rel at ed problem.
Uhere dri nki ng i s a normal acmmpaniment t o plowing, pl ant i ng,
weeding , harves t i ng , house-building , and o t her maj or work-pro j ect s ,
i t i s not l i k e l y t o be used a s a means of psychol ogi cal escape. But
i f a youth i s i ndoct r i nat ed t ha t t he measure o a man i e h i s
capaci t y t o dri nk, he i s not l i k e l y t o be temperate, es peci al l y i n
h i s e a r l y experi ment at i on with al cohol .
I n s e t t i ngs where al cohol i s of f er ed t o t he gods, o r l i t i g a n t s
dri nk t oget her t o s i gnal acceptance of a set t l ement ar r i ved a t i n a
di scussi on t ha t has been open t o a l 1 passers-by, t here may develop a
c e r t a i n eymbolic r eser ve concerning t ha t beverage, such tha t
i ncont i nent dri nki ng might seem di s r es pect f ul . I n s e t t i ngs where -
being drunk i s scorned a s br ut i s h behavior, and t ransgressi ons of
pr opr i e t y are not excused, regardl ees of one' s s t a t e of i nebr i e t y,
s oc i a l pressures may hel p keep people sober.
I n s u, t he val ue o a comparative hi s t or i c a l and
s oci ocul t ur al perspect i ve i s t ha t i t bri ngs t o our at t ent i on t he
w i d e raqge o "nat ur al experimente" t ha t have o ccurred among vari ous
h w n popul at i ons. To recognize t he di ve r s i t y o t he hunan
experi ence i s val uabl e i n i t e e l f . To understand t ha t i t can provide
examples -- bo th f avor abl e and unfavorable - can transform such
re cogni t i on i n t o a pot en t i a l l y val uabl e i nvent ory o opt i ons .
Thi s workshop has been a n i mport ant f i r s t s t e p i n bri ngi ng a
number of i nt er ee t ng and knowledgeable La t i n Ameri cans toge t her t o
exchange i deas w i th some i nt e r e s t ed and knowledgeable people f rom
ot her ar eas. It i s cr uci al t ha t those who bes t know and work wi t hi n
the ia t i n American eystems of pol i t i c a l , economic, and ot her s oci al
r e l a t i ons be t he ones who i dent i f y wha t ever a l cohol -rel at ed probleme
may deserve t o be addressed, and t ha t t hey f ashi on, from whatever
sources, t he aeans of prevent i on t ha t they bel i eve would be most
f r u i t f ul .
Acknowledgements: Thi s i s t he f i r s t i n a pr oj ect ed s e r i e s of papera
emphasizing t he i nt e gr a l r ol e t ha t s oci ocul t ur al f act or 8 pl ay with
r es pect t o publ i c pol i ci es , prepared i n connection wi t h the Center
f o r Alcohol St udi es a t Brown Uni versi t y. As usual , A.M. Cooper
provided us ef ul i deas and as s i s t ance throughout i t s preparat i on:
J os e Amor y Vazquez hel ped round out the h i s t o r i a l perspect i ve; and
t he coment e by Eduardo Medina Cardenas and Juan Carl os Negrete
(publ i shed elsewhere i n t hi s volume) a r e much appreci at ed.
Eduardo Medina Cardenae
The exi st ence of al cohol i c beverages and t hei r var i ed s oc i a l l y
prescri bed and proscri bed uses have probably been t he s ubj ect of
more concordant or conj oi nt a c t i v i ties by anthropology and medicine
than ot her ar eas of comaon i nt e r e s t t o t he s oc i a l and heal t h
sci ences. Thi s l i ki ng f o r et hanol and t he condi t i ons surrounding
i t s uses among a l 1 t he human groups of which we know, despi t e the
f a c t t ha t i t i s physi ol ogi cal l y unnecessary, has meant t ha t any
e thnographic i nqui r y f i nds something t o record and t o i nt er pr et ;
f urthermore, s i nce anthropology has advanced from t he st udy of
si mpl e groupe t o t he s t udy of complex modern s oci et i es , these
customs have t urned o u t t o be dynami al l y as s oci at ed wi t h such
vari ous as pect s a s communi t y developmen t, rural -urban mi grat i on,
miscegenation, soci ocul t ur a l change, developmen t and under-
development and s o f or t h. For i ts par t, medicine, i ns of ar as i t has
been gr adual l y showing a more prevent i ve than cur at i ve a t t i t ude t o
si ckness and a concep t i on of heal t h more r e l a t e d t o well-being and
qua l i t y of l i f e than t o t he absence of s peci f i ed di seases, has had
t o begin t o l ook a t i ts f i e l d of endeavor through new eyes. hi l e
appl yi ng i t e own corpus of knowledge, medicine has had t o l ear n from
o t her academic di s ci pl i nes and f r on di r e c t observat i one i n t he
groups i t seeks t o a s e i s t .
There i e no doubt t ha t t he probleme r es ul t i ng from t he
dri nki ng of al cohol i c beverages a r e somewha t more ext ensi ve and
complex than t he pharmacological e f f e c t o et hanol on t he l i vi ng
organiem o r t he vari oue i ndi vi dual phyei cal and psychopathological
phenomena as s oci at ed wi t h i t s chroni c and excessi ve use. Examples
a r e what can be consi dered normal or abnormal consumption o
al cohol i c beverages, t he i ndi vi dual and/or social-environmental
var i abl es af f ect i ng t he i r use, t he many negat i ve e f f e c t s o
i nt emperat e consump t i on, t he ques t i onabl e e ect i veness o eo many
heal t h programa des pi t e t he resources i nvol ved, and s o f or t h.
Furthermore, t o coneider addi ct i on t o et hanol a di sease --
al cohol i sm -- i s i n many respect a a flawed approach, ei nce the
medical model has not been abl e t o account f or , much l e s s i nfl uence,
the gr e a t many f a c t or s connected with t he use of and access t o
al cohol i c beverages .
I n s hor t , t he epi demi ol ogi cal approach o publ i c heal t h has
been subs t a n t i a l l y e nr i ched by t he f i ndi nge o anthropology
concerning dri nki ng and t he problema r es ul t i ng from excessi ve use o
s p i r i tuous l i quor s.
Despi t e t he s i tua t i on descri bed, t he convergence o
anthropology and medicine has s o f a r been due more t o personal than
t o i ns t i t ut i ona l i nt e r e s t s , more t o casual coincidente than t o
predetermined planning. Anyone who examines t he many plan8 and
programs o t he vari ous count r i es o r regi ons can confirm t hi s ; su&
an examination shows t ha t t hat convergence has been due not s o much
t o t he program i n t e r e s t o a par t i cul ar medical care i ns t i t ut i on i n
usi ng avai l abl e an t hropol ogi cal knowledge a s t o t he cl ear si gh tedness
o persons who have ant i ci pat ed t he demands o t hei r sphere o
endeavor and, by t he i r own e f f or t s , have expanded t he i r usual
prof es s i onal perspect i ve. When t hese persone a r e i n t he managemen t
of a s peci f i ed program, such a c t i v i t i e s show more s oci ocul t ur al
s e ns i t i vi t y; when t hi s has not been so, a c r i t i c a 1 review of t he
principies underlying t he use of t he heal t h reeources and of the
e xt e nt t o which i n i t i a l t ar get s were achi eved shows, i n hi ndsi ght ,
t ha t the lower l eve1 of ef f i ci ency vas due t o some ext ent t o t he
omission o key s oci ocul t ur al f act or s.
Accordingly, t he poe e i bi l i t y of improving t he ef f i ci ency of
t he reeources and t he ef f ect i veneee of a c t i v i t i e s designed t o
prevent excessi ve dri nki ng and alcoholiem st i l l appear t o depend i n
l a r ge measure on accees t o a body of s oci ocul t ur al knowledge t ha t 1s
r at her ecat t er ed, out of reach, and, f o r thoee not f am l i ar with
baei c ant hropol ogi cal concepte, even unusable. Oa t he ot her hand,
a l 1 e f f or t s t o f a c i l i t a t e and i ns t i t ut i ona l i z e t hi e meeting of minde
from two ver y di f f e r e nt f i e l d s deeerve t o be emphasized and
encouraged.
Dr . Heath deserves a s peci al pl ace among those who have helped
narrow the gap between anthropology and medicine i n t hei r approach
t o t he use of al cohol i c beverages. We who have known him, from h i s
pi oneeri ng e thnographi c a l wor c Drinking Pa t t erne of the- Bolivian
Camba t o hi e i n t er es t i nn l e c t ur e "Soci o-ant hro~ol oni cal Fact ors i n
-
- - - - - - - - -
t he Pathogeny of ~l coh&i s m, " have been abl er t ow l ar n from t he
r e s ul t e ok h i s f i e l d work, h i e t heori zi ng about dri nki ng, and h i s
ext ensi ve and probably unequalled knowledge of t he world l i t e r a t ur e
on al cohol and i t e pl ace i n t he cul t ur al environment.
" Bi s t or i c a l and Cul t ur al Fact ore Aff ect i ng Alcohol Avail-
a b i l i t y and Coneumption i n Lat i n America" appears i n circumetancee
worthy of mention. Indeed, from t he broad pi ct ur e 1 have j us t
out l i ned i t may be deduced t hat :
1 ) It conet i t ut es a new cont ri but i on toward narrowing t he gap
between anthropology and medicine i n t he i r approach t o the
s t udy of al cohol .
2 ) The well-deeerved pr es t i ge of t he aut hor guaranteee t he
qua l i t y of t he new cont r i but i on and enhances t he importance
of t hi s s c i e nt i f i c meeting even more.
3) By r e s t r i c t i ng t he anal ys i s t o t he Lat i n American regi on,
he i s a bl e t o gi ve more depth t o h i s expl anat i on of aspect s
t ha t a r e omi t t ed o r har dl y coneidered when more ext enei ve
e t udi es a r e at t empt ed ( f or example, t he importance of
speci f i e d socioeconomc, geographic, hi et or i cal , pol i t i c a l
and ot her f act or s ) .
4 ) It i s worthwhile commenting on eome f a c t e from t he eect i ons
e n t i t l e d "The Pre-Columbian Peri od, " "The Col oni al Period, "
and "Cul t ural Vari at i one i n Modern Hetory" t ha t a r e st i l l
t opi cal becauee they a r e t o eome ex ten t recurrent .
o Pre-Columbian s oci et i ee and groupe coneumed fermented
dri nke i n accordance wi t h more or l e s e e t r i c t t ul e s of
vari oue kinds. Al though Dr . Heath r i g h t l y f i nde t hat i n
t he avai l abl e account s of theee cuetome i t i s d i f f i c u l t
t o di f f e r e nt i a t e t he "r eal " from t he "i deal " cul t ur e, he
support s what has s o of ten been noted by o t her i nves ti-
gat or s about t he f e a s i b i l i t y of moderating consumption
onl y i f i t i e f unct i onal l y i nt egr at ed i n t o t he socio-
c ul t ur a l contex t t o which t he dri nker belongs.
The common, and s o d a l l y approved, pat t er n wae t o dri nk
t o t he poi nt of i nt oxi cat i on (ceremonial or r i t u a l
dri nki ng). Such a mode of consumption was normal wi t hi n
i t e own cont ext . Because i t was i nt egr at ed i n some way
v i th o t her custome, i t di d not gr e a t l y di s t ur b them.
o The nu t ri t i onal qual i ties of f ermen t ed dri nke were
important; although i t was not e xpl i c i t l y s pel l ed out
i n t hat peri od, t he chicha o r beer t ha t was consumed di d
r epr es ent a s i gni f i c a nt di e t a r y supplement. Thi s
undoub t e dl y euppor t ed those economi c, S ymboli c, and
p o l i t i c a l val uee t o which we now tend t o gi ve more
emphaeis, i.e., t he a t t r i but e s of fermented dri nks a e
t r ade goods, a s of f er i ngs t o de i t i e s , and a s products t o
be di e t r i but ed by t he cent r al aut hor i t i es , r e i nf or dng
t he i r domina t i on of t he s oc i a l e t ruct ure.
o The a t t i t u d e of t he col oni al aut hor i t i ee towards
dri nki ng by t he nat i ve popul at i ons i s anot her chapter i n
t hat ver y heterogeneous and dramat i c peri od of cont act
and a c a l t ur a t i on. The European e tandard of f requen t ,
al though modera te, dri nki ng came i n t o conf l i ct w i t h the
na t i ve cue t on o per i odi c bu t i n tempera te consump t i on,
now more f r equent and wi t h well-known negat i ve
consequences .
o Dr . Heath emphasizes t he at t empt of t he aut hor i t i es t o
i nt roduce prevent i ve l e gi s l a t i on w i thou t having a f u l l
knowledge of t he dyaamic f a c t or s a s s o d a t e d wi t h t he
dri nki ng of t he dominated population. I n addi t i on, t he
ambigui t y, i nconsi s tency, and/ or va r i a bi l i t y of such
r ul e s , more motivated by t he i nt e r e s t e of t he aut hori -
t i e s than by a r e a l concern f o r t he well-being of those
groups, a r e well-known.
o I n t h i s f i e l d a s i n o t hers t here was a s t r uggl e wi t hi n
the r ul i ng cl as s between t he busi ness groups, more
motivated by economic motives and t he des i r e f o r pr of i t ,
and ot her groups t hat sought t o pr ot ect , educat e, andl or
conver t t he na t i ve popul at i on t o Chri s t i a ni t y
(governmen t of f i c i a l s , pr i e s ts, e t c. ) .
o The s odoc ul t ur a l gap between t he r ul er e and t he r ul ed
or i gi na t ed f rom t he vari ous e ter0 types tha t f ur t her
di s t or t e d obj ect i ve understanding of those phenomena.
The en t i r e possi bl e range, f rom i nt e gr a t i ng ceremonial
consump t i on t o i ndi vi dual pa t hol ogi c a l dri nk ng , was
unders tood r at her a s manif e s t a t i ons of behavior t ypi cal
o decadent, exhausted, l azy, vi ci ous, andl or weak
popula t i on groups .
o The et hnographi c cont r i but i ons o vari ous anthropolo-
g i s t e who have i nves t i gat ed groups of Indiana andl or
mest i zos i n modern t i m e s a r e out st andi ng. Bet t er
understandng o t he s oci al r ol e of t he use of al cohol i c
beverages i s complemented by epi dem ol ogi cal s t udi es
car r i ed out by heal t h pr of essi onal s among low-income and
margi nal s t r a t a o t he population. The i nt egr at i on o
these s t udi ee has t o a cer t ai n ext ent guaranteed a
cor r ect unders tanding of t he f a c t or s af ect i ng t he
dri nki ng phenomena; furthermore, i t has a l s o provided a
bas i s or ext r apol at i ng t he var i abl es i dent i f i e d t o o t her
groups o r cont ext s i n our present complex urban s oci et i es .
A br i ef eummary of two of t he conclusione of Dr . Heath' s paper
i s warranted.
One conclusion i s t h a t t o continue t o at t empt t o char act er i ze
c e r t a i n s pe c i f i c groupe o r subcul t ur es on t he bas i s of t he i r pat-
t er ne of dri nki ng i s unhel pful a t pr esent , because of tendencies t o
r epeat descr i pt i ons of e a r l y s t udi es usi ng t h i s approach without
cont ri but i ng anyt hi ng t o a dynamic underetanding of them. It would
be be t t e r t o add depth t o t he comprehensive epi demi ol ogi cal
approach, t h a t i s, t he approach based on t he t r i a d "agent", "host",
"environmen t"; and i n addi t i on, t o conduct mul t i di s c i pl i na r y s t ud es
t ha t corabine compara t i ve research on preval ence w i th diagnos t i c and
psycho-evaluative measurements and r el evant s oci ocul t ur al
char act er i s tics.
The r a r i t y of al cohol i sm, des pi t e general i zed dri nki ng among
the adul t popul at i on, i s anot her i mport ant impression gi ven by Dr .
Heath. However, he f i nds alcoholism a vague concept, t o s a y t he
least, because of t he l ack of common, unambiguous concepts and
parameters a mos s chol ar s both i n t he s oc i a l sci ences and i n heal t h.
More comments could be made on t he excel l ent work of Dr .
Heath, es peci al l y s i nce t he s ubj ect i s v i r t u a l l y i nexhauet i bl e both
a s regards i t s academc as pect s and i t s i mpl i cat i ons f o r preventive
medicine. From a review of t hese aspect s, i t appears cl ear t ha t
speci f i e d soci ocul t ur a l circums t ances tend t o genera t e s pe c i f i c
pat t er ns of dri nki ng, o r i nver sel y, t ha t t o i gnore such determinante
of dri nki ng i n a group w i l l r e s u l t i n misunderstanding t hei r
si gni f i cance. 1 should now l i k e t o add a few ot her comments t ha t
t he paper euggest s t o a medical reader:
o Hodera te consumption obt ai ne onl y i f t he s oci ocul t ur al
envi r oment of f e r s a coherent cont ext . The s ecul ar i za t i on
of modern l i f e tends t o waken t he common r ul e s i n this
regard and, t heref or e, t o f a c i l i t a te ananalous behaviors;
f ur t het nore , t he low socioeconom c l e ve l , t he margi nal i t y,
and t he anani e of many urban popul at i on groupe w i l l generat e
grea ter i n temperante .
o The nut r i t i ona l cont r i but i on of nat i ve fermented drinlrs i e
probably i r r e l e va nt i n the modern urban cont ext , i n t ha t
t he i r consirmption i s due t o many di f f e r e nt reaeons. Today,
t he diet of a gr e a t many people i s determined by a l i mi t ed
monetary budget, which must be di et r i but ed among product s
t ha t can be acqui red i n t he market pl ace and whose purchase
i s of t en i nfl uenced by t he non-objective f a c t or of
adver t i si ng.
On the ot her hand, t he us ef ul nut r i t i ona l qua l i t i e s of
home-brewed fermented beverages a r e not found i n those
produced by modern i ndust r y, and much l e e s i n hard l i quor s.
I n t hese, onl y t he c a l or i c cont r i but i on of et hanol i e
s i gni f i c a nt and, t herefore, t hey a r e not a di et ar y
eupplemen t.
o The i n t e r e s t s of those t ha t benef i t from t he production,
di s t r i but i on, and marketing of these beverages and of thoee
who must f a c e t he adverse consequences of excesei ve
consumption are f r equent l y f a r a pa r t and even opposed.
Those who ear n inccwe from t he manufacture, t axat i on, o r
sale of al cohol f i nd i t hard t o understand, much l e s e t o
agr ee wi t h, t hose who must pr ot ect t he s oc i a l group from
t he r i s ks of drunkennees, from t he or gani c daouige of
al cohol i cs , and from t he many i ndi vi dual , fami l y, and
s oc i a l problems of chroni c excesei ve use.
o Many more i nt e r di s c i pl i na r y i nves t i gat i one by anthro-
pol ogi s ts and physi ci ans a r e neceeeary. Separa te e t udi es
by each di s ci pl i ne of custopis and mannere o r epidemio-
l ogi c a l dat a t oo of t en r epeat one anot her. Although they
may r e f i ne e a r l i e r cont ri but i one, t hey add no s i gni f i c a nt
new f a c t s t o t he body of knowledge avai l abl e .
Such j oi n t reeearch ne cees ar i l y preeupposes a pr i or
i nt e r pr e t i ve ef f o r t. Thue , t he basi c conceptual ca t egori ee
used by e c i e nt i s t s i n each f i e l d should be improved and
et andardi zed, t he methods used ehould be improved, and t he
i nformat i on obt ai ned should be c r i t i c a l l y exchanged. n t i l
such cont act s a r e i ns t i t ut i ona l i z e d, t h i s approach wi l l not
be easy.
hat ant hropol ogy al one can cont r i but e concerning t he
a v a i l a b i l i t y and consumption of al cohol i c beverages i n Lat i n America
cannot cover ot her critica1 f a c t or s t ha t a f f e c t t he physi ci an i n hs
preven t i ve and cura t i ve work. The f ollowing consi dera t i ons , whi ch
a r e of f er ed by way of eltample, a l s o suggest t he advantages of t he
j oi nt approach al r eady mentioned.
Fi r s t , t he st udy of consumption should be r ef i ned not onl y i n
r e l a t i on t o t he socioeconomic and/or cul t ur al cont er t e, but a l s o by
age group and sex. For t he physi ci an, t he pr esent i ncr ease i n
excessi ve dri nki ng by women and adol escent e is a noteworthy
phenaaenon.
Second, and eepeci al l y i n t he case of adol eecent s, t he pat t er n
of dri nki ng i s mixed w i t h t he use of o t her pe ycho t rophi c sube tances
such a s mar1 juana, st i mul ant s, and/or vol a t i l e eol vent s, i f not wi t h
hard drugs such a s cocaine and opi at es. Hard drugs e t i l l appear t o
be more widely used i n t he English-speaking count r i es than i n Lat i n
America.
Thi rd, t he many f a c t or s involved i n t he use of a l 1 t hese
subst ances shoul d not onl y be i nves t i gat ed by anthropology and
medicine, but a l s o wi t h t he as s i s t ance of ot her eci ences such a s
soci ol ogy, economics, psychology. Indeed, any aepect of complex
modern s oci et y shoul d be approached caaprehensively, even though t he
i nt e r di s c i pl i na r y approach i s st i l l f a r from easy.
Fourth, and 1 r et ur n t o my i n i t i a l comment, t he cont r i but i on
of anthropology has helped t o improve t he usual medical model f o r
prevent i on i n t hese areae. But i t must go beyond t h a t poi nt ; i t
must ensure t ha t t he body of knowledge obt ai ned a l s o reaches and
a f f e c t s t he deci si ons and act i ons of t he hi gher government aut hori -
t i es . A t our t echni cal and academic l e ve l , t her e are us ual l y no
impor t a nt di f f erences i n approach t o wha t a r e t he mos t appropri at e
ways of preventing excessi ve dri nki ng and alcoholism; t ha t i s a o t
neces s ar i l y t he case with government a ut hor i t i e s who a r e i nfl uenced
by ot her val ue judgements. That i s t o say, anthropology and t he
ot her s oc i a l sci ences can make a s i gni f i c a nt cont r i but i on t o t he
development of pol i t i c a l modele of prevent i ve heal t h a c t i v i t i e s
which, t oget her w i th epi demi ol ogi cal models, should be extended t o
i nt e r s e c t or a l and intracommuni t y a c t i v i t i es .
Fi nal l y, t he mere exchange of i nt er di s ci pl i nar y i nformat i on a t
al 1 leve18 improves t he ef f i ci ency of any system. Thi s workshop can
e f f e c t i ve l y cont r i but e t o t he prevent i on of al cohol i sm not onl y i n
that i t af f or ds t he par t i ci pant s an opport uni t y of e qa gi ng i n a
di al ogue, but a l s o t o t he ext ent t ha t i t s conclusions a r e accessi bl e
t o bo th the s eni or heal t h aut hor i t i ee and the profeesi onal heal t h
workers of our count ri es.
DISCUSSANT
Juan Carl os Negrete
Profeesor l i eat h' s review shows h i s ext ensi ve knowledge of t he
f i e l d and hi e f a mi l i a r i t y wi t h Lat i n American hi s t or y and et hnol -
ogy. Of course, he himself i s a pioneer cont r i but or on t he subj ect ,
from h i e or i gi na l f i e l d r or k i n Bol i vi a through h i s severa1 wr i t i ngs
on t he s oci ocul t ur al model of al cohol i sm t o h i s excel l ent c l a s s i f i e d
bi bl i ography on al cohol and cul t ur e publ i shed l a s t year. Wri t t en a s
i t i s by a n ant hr opol ogi st , t hi s paper ' s main emphasie i s on
or i gi na l nat i ve pat t er ns and t he changes wtiich have r es ul t ed from
t he e a r l y i nt er act i on between t he abor i gi nal popul at i ons and t he i r
European col oni zers. Professor Heath' s hi s t or i c a l a n a l p i e sheds
l i g h t , not onl y on t he gener al development of Lat i n American
dri nki ng behaviour, but a l s o on some of t he most r el evant s oc i a l
a t t i tudes and val ues which provide its cul t ur al frame of reference.
A l though t hi s review i ncl udee a s ect i on on "Cul t ural Vari ant e
i n Mo&rn Hi st ory, " cont ai ni ng val uabl e descr i pt i ons of some cur r ent
c ul t ur a l a a i t e , i t appears t o pay les8 a t t e nt i on t o cul t ur al
changes wrough t by urbani zat i on, i ndus t r i a l i z a t i on, t he i nput of t he
more r ecent immgrante, i ncr easi ng contamination by f or ei gn l i f e -
s t yl ee, and the pressure of a much more developed al cohol i ndust ry.
Soci al customs i n Lat i n America a r e b e i q subj ect ed t o a procese of
i nt er nat i onal homogenization. The e a s i e r and more i nt enei ve trane-
cul t ur al cont act s, a s w e l l a s growing access t o publ i c eourcee of
i nformat i on and t o t he i nt er nat i onal mas8 media, eerve t o expose
l a r ge s ect i ons of t he Lat i n American popul at i on t o t he same cul t ur al
messages t ha t a r e i nf luencing ot her s oci et i es . I n ot her worde,
La t i n Ameri can c ul t ur a l pa t t erne a r e constan tl y evolving and appear
t o be changing a t a much qui cker pace than ever before. Any
deecr i pt i on -de of them a t t hi s poi nt must acknowledge such a
dynamic procese.
Profeseor Heath, who has kept i n a c t i ve cont act wi t h Lat i n
America over the l a s t 25 years, propoees a di f f er ent i at i on between a
nuuber of al cohol use pat t er ns which he has eeen developing during
this time. Hie l i st i ncl udee t he so-cal l ed "upper cl aes whisky
cul t ur e, " which wel l i l l u s t r a t e s some of t he changes caused by
i nt er nat i onal c ul t ur a l di f f us i on i n r ecent years. Lat i n American
upper cl as s es a r e r e a di l y adopting what t hey bel i eve t o be sophis-
tica t ed l i f ee t yl e s pr eval ent i n l eadi ng f or ei gn s oci e ties. Women
dri nk almos t a s much a s men and t he choice of beverage 1s det ernl ned
by faehi onabl e t rends. Products avai l abl e on t he i nt er nat i onal
market a r e much pr i zed, and i ncr edi bl y hi gh markup pr i ces a r e pai d
f or them. To be abl e t o t r e a t guest s t o a n "imported" whisky ha8
become a s t a t u s symbol among the pr i vi l eged cl asees i n Lat i n
American soci et y.
One l ong-est abl i shed c ul t ur a l t r a di t i on wi t h a di r e c t beari ng
on al cohol a va i l a bi l i t y i n Lat i n America i s t he continued production
of home-brewed al cohol i c beverages. Dr . Heath a s s e r t e t ha t i t had
been pr act i ced by nat i ve popul at i on l ong before t he a r r i v a l of t he
f i r s t European col oni zere. He a l s o remarks t hat , curi ousl y, i t was
known most l y i n t he ar ea t ha t f e11 under Spanish cont r ol and not i n
what i s now Anglo America. I t would appear t h a t brewing techniques
were unluiown, al s o, t o t he s cat t er ed i nhabi t ant s of Patagonia and
t he Argentine pampas. The abeence of nat i ve al cohol i c beverages i n
e i t he r t he Ar ct i c o r sout hern Patagonia may e a s i l y be j ue t i f i e d on
t he basi e of t he unf avourabl e geo-clima t i c condi t i ons pr evai l i ng i n
those regions. However , sugary subs t ances were avai l abl e f or
gat her i ng or could have been grown f o r t he purpose of al cohol making
i n ot her pa r t s of North America a s w e l l a s on t he humid pampas, but
t he l oc a l nat i ve groups di d not do t hi s . A reaeon could perhaps be
found i n t he degree of development requi red. I n order t o master t he
technique of alcohol-making, a s oc i a l group must be abl e t o operat e
on a long-term bas i s , t o engage i n e f f or t e t ha t w i l l f r uc t i f y onl y
a f t e r a wai t i ng peri od. To make use of a psychol ogi cal paradigm,
t he capaci t y t o postpone gr a t i f i c a t i on i s a s much a s i gn of cul t ur al
development i n a group a s i t i s of peychological mat ur i t y i n an
i ndi vi dual . A pr act i ce such a s brewing i mpl i es a r at her s e t t l e d way
of l i f e with time and e f f o r t devoted t o growing, harveet i ng, pro-
ceesi ng, and preservi ng. These a c t i v i t i e s were not t ypi cal of the
less organized hunting and gat heri ng cul t ur ee which i nhabi t ed t he
alcohol-f r ee regions.
Home-brewing i s st i l l widespread throughout Lat i n Ame r i c a ;
homemade "chicha" and sugarcane beverages produced i n domestic
stills r epr esent a l a r ge proport i on of t he avai l abl e supply i n t he
cent r al Andes region. Pri va te, independen t and uncon t r ol l ed
product i on of "pulque," sugarcane d i s t i l l a t e s , wines and "pisco"
(grape aquavi t a ) i e cur r ent l y t aki ng pl ace throughou t most coun t r i e e
i n Lat i n America i n s i gni f i c a nt volune. The est i mat e i n Costa Rica,
f o r example, i s t ha t t he i l l e g a l production of sugarcane "guaro"
equal e t ha t of t he s t a t e l i quor monopoly. Underetandably, t hi s
cul t ur al pa t t er n grea t l y j eopardi zes publ i c prevent i on campaigne
aimed a t reducing al cohol a va i l a bi l i t y.
Ano t her major c ul t ur a l obs t acl e t o t he implementation of
prevent i ve meaeures i s t he t r a di t i ona l Lat i n American di eregard f o r
r ul e s and regul a t i ons; Prof es s or Hea t h, somewha t apol oget i cal l y,
suggest s t hat , indeed, t hi s may be a cul t ur al t r a i t throughout t he
region. His r ef er ence t o a Mexican folk-hero whose a b i l i t y t o evade
r e s t r i c t i ons del i ght ed audi ences throughout Lat i n America i s a
t e l l i ng example. I n Br azi l , a much admired personal a b i l i t y i s t o
have e i t o (knorhow), t ha t i s, t he a b i l i t y t o bypass r ed t ape and
b l e g a l ur les and have one' s way. I n Argentina, a gr e a t deal of
s oc i a l pr es t i ge i s accorded t o those capable of "beat i ng the
sya tem"; i n t he l oc a l sl ang , t hese i ndi vi dual s a r e cal l ed pi ol a s o r
cancheros. Thus, Professor Heath need not have hes i t at ed t o
underl i ne a c ul t ur a l char act er i s t i c t ha t i s cer t a i nl y preval ent
throughout Lat i n American socl et y. By a l 1 t he evidence, i gnori ng o r
ci rcunvent i ng es t abl i s hed l e ga l r e s t r i c t i ons i s not seen a s
neces s ar i l y immoral or even reprehensi bl e i n Lat i n America. Such
behavior i s percei ved r at her a s a j us t i f i a bl e r eact i on agai ns t " t he
au t hor i t i es . "
By and l ar ge, La t i n Americans t end t o di s as s oci at e themselves
from those i n power; one senses i n t he popul at i on a total l a & of
i de nt i f i c a t i on wi t h the aut hor i t i es , a s i f t he l a t t e r were a l e n t o
the s ocl et y under their r ul e. Thi s, of course, may be a s i t ua t i on
or i gi nat i ng from the days when t he government was i n the hands of
the European col oni al aut hor i ties and t he nat i ve popul at i ons had no
par t i ci pat i on i n it. Later on, and t o a l ar ge ext ent up t o t h i s
date, pos i t i ons of aut hor i t y have been reserved t o a pr i vi l eged and
smal l s ect or , qui t e di s t a nt from t he mass of the population. Ae
l ong a s t hese maese8 percei ve no di f f er ence between t he law and t he
a ut hor i t y imposing i t , t hey a r e unl i kel y t o s e e anything wrong i n
t he i r unwi l l i ngness t o comply.
ALthough poor obeervance of r ul e s and r egul at i ons l i mi t i ng t he
a va i l a bi l i t y of al cohol i s perhaps more preval ent among t he
peasant s, campesinos, and nat i ve popul at i ons, t h i s a t t i t ude i s by no
means confined t o such s ect or s of t he soci et y. Professor Heath
gi ves an account of t he i ncons i s t ent behavior exhi bi t ed during
col oni al times by t he Spanish themselves w i t h regard t o t he
r e s t r i c t i ons imposed by t he Crown on t he s a l e and use of al cohol i c
beverages. He quot es a n ol d Spanish sayng: "Laws a r e t o be
aolrnowledged but not observed." W t t l e wonder, then, t ha t t here a r e
pr a c t l c a l l y no e f f e c t i ve measures governing t he a va i l a bi l i t y of
al cohol i n Lat i n American s oci et i es . Beverages can be obt ai ned from
publ i c out l e t s a t any t i me and by anybody. Oa Sundays and ot her
daya on which s t or e s a r e t o be cl osed t o t he publ i c, f o r instante,
i t i s not unusual t o s e e chi l dr en purchasing l i quor through t he back
door. They a r e s e nt by t he i r el der s , who a r e most l i k e l y engaging
i n one of those day-long l i ba t i ons t ha t Professor Heath s o r i ght l y
descr i bes a s a t ypi cal La t i n American pat t er n.
Ano t her i mport ant madi t i onal f eat ur e i de nt i f i e d by Professor
Heath a s pa r t of Lat i n American cul t ur e i s t he frequency of
drunkenness and t he degree of s oc l a l accept ance t hi s behavior
enjoys. Hi s t or i cal evidence would suggest t ha t t hi s t r adi t i on has
i ts r oot s i n pre-Colunbian soci et y. Native groups then used al cohol
and ot her psychoactlve eubst ances f o r t he expresa purpose of
i nebr i at i on. Drunkenness was not onl y not avoided but , on t he
cont rary, pureued i nt ent l onal l y. Today a s i mi l ar a t t l t ude
i nf l uences t he al cohol use pat t er n of t he i r descendante. For a
l a r ge proport l on, t o dri nk 1s e t l l synonymoue wi t h get t i ng drunk.
I n f a c t , popular language of t en makes no di s t i nct i on between
dri nki ng and drunkenness. For i nst ance, when i t 1s s a i d of someone,
" e l bebe" (he dr i nks ) , i t 1s meant t ha t he dri nks t o excess. Thi s
par t i cul ar cul t ur al connot at i on of t he verb "t o dri nk" must be taken
i n t o consi derat i on when al cohol use i n Lat i n America 1s surveyed,
eepeci al l y amng t he l e e s educated.
The r ecent WHO gener al popul at i on st udy i n Mexico t o which
Professor Heath r e f e r s i n h i s review found t ha t more than one-third
of t he adul t s i nt ervi ewed r epl i ed "No" t o t he quest i on: "Do you
drink?". Anyone who has had t he opport uni t y t o observe t he same
popul at i on behaving spont aneousl y i n nat ur al s et t i nge must doubt t he
correct nese of such an answer. It wl l may be t ha t t he Mexican
respondente f e l t t hey were being asked whether t hey g e t drunk and,
senei ng a n i mpl i c i t cr i t i ci s m i n t he quest l on, gave a n answer which
t hey assrnned would pl ease t he i nt ervi ewer. It must be s a i d t ha t a
non- judgmental or l eni en t s oc i a l a t t i t ude towards drunkemess 1s
more t ypi cal of t he lower cl as s es and more widespread i n those Lat i n
American coun t r i e e wi th l ar ger concentra t i one of nat i ve and mes t i zo
(hal f-breed) popul at i ons. I n Argentina, Uruguay, and t he sout hern
par t of Br azi l , where r ecent European immigran t e con8 ti t ut e a
s i zeabl e maj or i t y, f r equent drunkenness i s c l e a r l y l e s e preval ent .
These immigrants, most l y from Spain, Por t ugal , and I t a l y , have
brought wi t h them a t r a di t i on of s obr i et y es t abl i s hed i n t he i r
or i gi na l cul t ur es. I n addi t i on, they found i n t he i r new environment
geo-clima ti c condi t i ons permi t t i ng them t o cont i nue w i t h t hei r
European pat t er n of dri nki ng wine, a s opposed t o t he 8 tronger
beverages ut l l i z e d elsewhere on t he cont i nent .
Perhaps because of pressure from an expanding l i quor i nduet ry,
t he l ar ge Amerindian and mestizo popul at i ons around t he Caribbean
basi n and i n some Andean count r i es have tended t o s ubet i t ut e
di 8 t i l l e d beverages f or their t r a di t i onal l o r g r a d e brews.
Fermented dri nks were, of course, m r e s ui t ed t o t hei r cul t ur a1
pa t t e r n of prolonged cel ebra t i on and f i e s t a dri nki ng , which a l s o
i nvol ves a high volume i nt ake. The switch-over t o d i e t i l l a t e s
changed t he cont ent but not t he f orm of t he i r habi ts and r es ul t ed i n
mu ch m r e sever e i n t oxi ca t l ons. Foreign v i s i t or s t o Cent r al
America, f o r example, may be a l i t t l e s ur pr i s ed t ha t patrona i n
publ i c dri nki ng pl ace8 of t en order dri nks t o t he i r t abl es such a s
whisky, rum or even cognac--not i n i ndi vi dual measures, but by t he
whole bot t l e. The comparative coneumptlon f i gur es i n Table 1
i l l u s t r a t e t he r egi onal tendencies j us t described.
Absolu te Alcohol Consumption*
and Beverage Cl ase Preferente**
COUNTBIES
Absolu t e Percent age di s t r i but i on
Year
Al cohol s p i r i ts beer vi ne
LATIN AMERICA
Mexi co 1967 4 .S8 27 .3 53.0 19.1 ( a )
c . ~mer ca(b) 1967 6 .O7 14.2 24.0 1.8
~ e r u 197 O 7 .22 78 .O 18 .O 4.0
Chi l e 1972 14.0 10 .8 10 .7 78 .5
Argent i na 1965 18.2 13 .5 3.6 82.9
Fi nl and 1968 4.12 50.0 34.0 16.0
Swede n 1968 6.96 49.5 38.0 12.5
U* Ki~lgdan 19 66 7 &O 15 -2 7 5.3 9 03
W. Germany 1966 13 .O4 21.3 60.4 12.3
I t a l y 1968 16 004 13.1 4.0 82.3
France 1966 26 O12 18 .O 12.7 69 .3
NORTH AMERICA
SOURCE: Negrete, J. C. (1976) Alcoholism i n Lat n America. Annals of
t he New York Academy of Sci ences 27 3:9-23.
*liters per pereon age 15+, i n one year.
**percentage cont r i bu t i on of ea& beverage c l a s s t o t he
t o t a l aanual abs ol ut e al cohol coneumption.
(a)i ncl udee "pulquew
(b)average of 6 count r i es , popul at i on age U+:
Gua temla , Hondura e, Nicaragua , El Sal vador,
Cos ta R ca and Panama
From t he e a r l y f i e l d observat i ons among t he Camba of Bol i vi a,
Prof eesor Hea t h concluded tha t frequen t al cohol i c i nt oxi cat i on, wtren
c ul t ur a l l y i nt egr at ed and e oc i a l l y approved, i e not neceeear i l y
aesoci at ed wi t h devi ant behaviour and &es not f i t t he concept of
alcoholism. I n f a c t , he not ed t ha t t he ver y not on of alcoholiem
wae a l i e n t o t he Camba. I n t hi e preeent review Dr . Heath a l s o
quo t ee s ever al o t her e t hnol ogi s ts who, af t e r S tudying nat ve
coaununitiee i n Lat n America, have concluded t ha t alcoholism 1s mt
a problem i n cul t ur ee where t he uee of al cohol eervee sucia poei t i ve
funct i one a s hel pi ng group cohesiveneee, s oc i a bi l i t y, and r ol e
def i n i tion.
Of couree, t he s oc i a l eci ent i et e' view of al cohol i sm l e one of
devi ant behaviour, t ha t i e , a form of al cohol use which &es not
conform wi t h es t abl i ehed and e o d a l l y accept abl e cul t ur al pat t erne.
However, al cohol dependence a e underetood i n bi ol ogi cal terme i e
unl i kel y t o be eeen a e not i ceabl y di f f e r e nt behaviour i n a mi l i eu
which provides eo much opport uni t y f o r eoci al l y approved i nebri a-
t i on. Profeseor Heath' e remark about t he need t o complement
et hnographi c obeervat i one of dri nki ng behaviour wi t h biomedical
e t udi ee i e very w e l l taken indeed.
A word of caut i on ehould be gi ven t o t he i ndi geni et e who tend
t o i de a l i z e pre-Columbian cul t ur ee and eee no wrong i n t he i r anci ent
pat t er ne. Thei r r eepect f o r the t r ul y amazing degree of e o d a l
or gani zat on a t t a i ne d by eome of t hese cul t ur ee ehould not obscure
judgement when i nt e r pr e ti= t he hi e t or i c a l evidence about dri nk ng
behaviour .
I n a l 1 f ai r neee, however , t he European col oni za t i on has
profoundly a l t e r e d t he meaning and pat t er n of al cohol uee among
nat i ve populatione. It hae a l e o i nt roduced a new and problematic
s oc i a l element -- t he meetzo popul at on -- whoee cul t ur al frame of
reference i e undefined and e t reeef ul .
An i nt er eet ng ethno-philoeophical anal ys i s of t hi e change
procese 1s found i n a paper by Pages i ar r aya (1976) on dri nl dng
pat t er ne among Chaco cul t uree. Thie aut hor deal e wi t h t he t ot a l
cul t ur al change undergone by t he abori gi nee through t hei r expoeure
t o European i nf l uence and eeee t he a l t e r a t on i n t he i r dri nki ng
habi t e a e onl y an epiphenomenon of accul t ur at i on. Pages Larraya
aeeer t e t hat al cohol i nt oxi cat i on took pl ace or i gi na l l y wi t hi n a
ceremonial context; i t was onl y a meane t o cause i n t he dri nker a
" t r aneubst ant i at i on, " a change i nt o a di f f e r e nt -- eomewha t
super nat ur al -- i de nt i t y i n order t o enabl e him t o par t i ci pat e i n
vari oue r i t ual e. Through t he teachinge of f or ei gn mi esi onari ee t he
nat i ve was induced t o a t t ach a meaning t o al cohol i t eel f ; he l earned
that i t was e v i l , and t her ef or e, dri nki ng wae an a c t of wrongnees.
Thie moral i e t i c view carne t o i nvol ve t he na t i ves ' whole uni veree and
bel i ef system. They l ear ned t o l ook a t t he whi t e man's world a s t he
good one and t o percei ve t he i r own a s s i n f u l and demoniacal.
According t o Pages Larraya, such a cat as t r ophi c sel f-percept i on l e d
t o the developmant of s el f - des t r uct i ve pat t er ns of al cohol use on
t he pa r t of t he nat i ves. (Of course, he was anal yzi ng groups l e s s
c ul t ur a l l y developed and s oc i a l l y organi zed than t he hi gher
c i vi l i z a t i ons of meso-America and the Andes). I n t ha t sense t he
Chaco abor i gi nes were perhaps more vul nerabl e t o t he del et er i ous
e f f e c t of f or ei gn i nfl uences. A comparative st udy on t he prevalance
of al cohol probleme among di f f e r e nt t r i b a l groups i n Olclahoma
( St r at t on U78) l ends support t o t he view t ha t t hose l e s s s oc i a l l y
organi zed were more af-fect ed by cont act wi t h t he white man.
Professor Heath concludes t ha t i n s p i t e of heavy dri nk ng
pat t er ns , t he frequency of al cohol i sm i s low i n Lat i n America.
Speci f i cal l y, he i s impressed by t he apparent s c a r c i t y of t he
s ol i t a r y, gui l t - r i dden al cohol i c s o commonly found i n l ar ge urban
cent er s of more i ndus t r i al i zed s oci et i es . He remarks t ha t
epi demi ol ogi st s i n Lat i n America f i nd hi gher r a t e s of problem
dri nki ng i n r ur a l popul at i ons than among urban dwel l ers, and
cor r ect l y not es t ha t an opposi t e tendency 1s t he r ul e elsewhere.
Urbani zat i on could perhaps be a di s r upt ve f a c t or f o r those r ur a l
popul at i ons whi ch pr esent a hi gh degree of s oc i a l organi zat on,
group cont rol , o r r el i gi ous i nfl uence; however, i t 1s l i k e l y t o have
a benef i ci a1 i nf l uence on t he behavior of i ndi vi dual e from ot her
r u r a l ar eas i n Lat i n America who f i nd gr eat er s oc i a l support i n t he
ci tles. Pover t y, unemploymen t, seasonal and nomadi c pa t t e r ns of
o ccupa t i on, and t he a bsence of organi zed s oc i a l resour ces a r e
f act or 8 t ha t f r equent l y make l i vi ng i n r ur a l regi ons more s t r e s s f ul
t han i n urban cent ere i n La t i n America.
Although i t 1s possi bl e t o agr ee wi t h Dr . Heath t ha t al cohol
causes l e s s s oc i a l di s r upt on or devi ant behaviour i n Lat i n America
than i n , f o r example, Anglo America, dat a on mor t al i t y from al cohol -
r e l a t e d causes i ndi cat e t h a t al cohol abuse cons t i t ut es an equal l y
maj or publ i c heal t h problem i n both regi ons.
Chapter Notes and lbleferenoes
Hi st ori al and Cul t ur al Fact or8
Af f ect i ng Al cohol Avai l abi l i t y and
Consumpton i n Lat n American
No tes
l. "Latin America" 1s here used t o i ncl ude not onl y Cent r al and
South America, but a l s o Mexico and t he i s l ands of t he
Caribbean zone.
2. "His t or i cal " perspect i ve i s r e l a t i ve l y deep, i ncl udi ng
r ef er ence t o pre-Columbian pat t er ns i ns of ar a s t hey appear t o
have i nfl uenced subsequent developments.
3. The tenn "cul t ur al " 1s used i n t he broad ant hropol ogi cal
sense , i ncl udi ng exi s t en t i a l , eval ua t i ve, e conomic, pol i ti cal ,
r el i gi ous , and ot her aspect s of t he complex syetems of bel i ef
and behavior t ha t di f f eren t i a t e human popula t i ons , one f rom
ano the r .
4. Por a wel l indexed bi bl i ography of s t udi es on al cohol use i n
h i s t o r i a l perspect i ve, i n a l 1 par t s of t he world, s e e Heath
and Cooper (1981); t o keep abr eas t of cur r ent work, s ee t he
Alcohol and Temperance H i s t or y Group Ne ws l e tter (occasi onal ,
s i nce 1980).
5. The term "Anglo-America" i s used here a s a convenient
shorthand l a be l i n keeping wi t h a popular convention t ha t
cont r ast e "Anglo-" wi t h "Latin America." It i gnores t he
"Franco" component of Canada and ot her l i n g u i s t i c and e t hni c
var i ant e, i n much t he same way t ha t t he "La tia" l a be l i gnores
"Anglo, " "Afro , " "Dutch, " and ot her componente.
6 Or i gi nal l y publ i shed i n 1569, t he encycl opedi c Hi s t or i a de l a s
Cosas de l a Nueva Espana has been met cul ousl y t r ans l at ed and
annot at ed (A. Anderson and Dbble 1950- ).
I . If 50 years seems a shor t time i n which t o encounter ma j or
h i s t or i c a l revi si oni sm, 1 sugges t people consi der event s i n
t hei r own nat i on' s r ecent hi st or y. 1 used t o bel i eve t ha t
c ul t ur a l t r a i t s were not e a s i l y l o s t , but observat i ons of what
happened t o s l i de- r ul es , wire-recorders, and ot her phenomena
have convinced me t ha t major i teme can e f f e c t i ve l y "disappear"
qui ds l y from even a l i t e r a t e cul t ure. Thi s i dea was most
f or cef ul l y brought home when L u d l l e Hanna, my former hi gh
echo01 t eacher , r e cant l y lamented t ha t the Roman Cat hol i c
Tr i dent i ne maes ( i n Lat i n) has v i r t u a l l y ceased t o have
meaning "wi t hi n hal f a l i f et me. "
8. Some may no t be aware t ha t t he f i r e t s e t t l e r s of Anglo-America
were s mi l a r l y accuet wed t o ueing beer, mead, and ot her
al cohol i c beveragee t o s l ake t he i r t hi r s t . The movemente
toward temperante, and l a t e r pr ohi bi t i on, were not begun by
the e a r l y eet t l er s- - not even by t he Pur i t ans, who were smail
i n nunbers and f a r more t ol er ant of dri nkl ng than i e us ual l y
bel i eved (Lender 131 3). A br i ef but e f f e c t i ve eumnary of t he
hi e t or i cal and c ul t ur a l f act or 8 a f f ect i ng t he a va i l a bi l i t y and
consumptlon of al cohol i n t he United St at es 1s avai l abl e
(Aaron and Mueto 1981); more det ai l ed anal yei s , i ncl udi ng
per i odl c est i mat i one of per-capi t a consumptlon, l e i n
Borabaugh (1979).
9. The word "norm" l e used i n severa1 di f f e r e nt senses i n t he
s o d a 1 e de nc e e , and t hi s i nconsi st ency l e not always
addressed i n works t ha t deal wi t h norms i n r el at i on t o
drinking. Brief di scuesi on of vari oue ki nds of norms 1s
of f er ed by Heath (1980).
10. For our pr esent purpose, t he word "Spanish" r e f e r s t o anyone
who might have been cal l ed "white." Although t he dl et i nct i on
be tween European-born peni nsul ar es and Ameri can-born c r i ol l os
was i mport ant i n c e r t a i n r espect e, the di s t i nc t i on t ha t i e
more ei gni f i cant and pervaei ve i n t e me of t h i s di scusei on l e
t ha t between bl ancos ("whites") and caet ae ( a l 1 ot her s ,
i ncl udl ng Indi ans , me8 t i zos, blacke , mula t t os, zambos, e t a l . ) .
11. Although 1 t wae convenient t o r e f e r t o t he s i xt eent h through
ei ght eent h cent ur i es a s "t he col oni al peri od, " i t eeeme more
appropri a t e t o ref er t o t he ni ne t eent h and twen t i e th cent uri ee
as "modern hi st ory. " Many of today' s Lat i n American nat i ons
were born i n 1825; a few won independence e a r l i e r , a few
later, and some ar eae s t i l l have a pr ovi nci al , col oni al , o r
analogoue r e l a t i onehi p wi t h ano t her na t i on.
We a r e f or t unat e i n having more thorough coverage of t he
an thropologi c a l con t r i bu t l ons t o al cohol e t udi ee than 1s
avai l abl e f o r moet f i e l d s of r e l a t e d i nt er eet . An hi e t or i c a l
perepact i ve 1s avai l abl e i n Heath (1975); a thorough review of
t he 11 t er a t ur e, organi zed i n conceptual and theore t i c terme
(Heath 1916) has r ecent l y been updated (Heath [ i n prese] ); a n
indexed bi bl i ography provi des eas y acceee t o t he 11 t er at ur e
(Heath and Cooper 1981).
13. The reason why Roizen views t hi e a s "something of a mystery"
l e preeumably because t he reeponee t o a s i ngl e multiple-choice
ques t i on, t r anel a t ed from ano t her language, i e i nconei st ent
wi t h a l 1 of t he ot her di f f e r e nt ki nds of evidence about
h x i c a n a t t i t u d e s toward drinking. Thi s may be an i nst ance
where a "curi ous fi ndi ng" i s, i n l a r ge par t , a n a r t i f a c t of
t he method.
14. Thi s st at ement i s del i ber at el y phrased i n ver y gener al terma.
The r ef er ence t o "alcoholism" i s i nt ended t o encompass a broad
range of t he sever a1 def i ni t i ons t ha t have been proposed by
pr of essi onal r esear cher s i n vari ous f i e l ds , a s wel l a s
"al cohol dependence eyndrome. " Al though r ef er ence t o " r a r i ty"
admi t t e dl y r ef l e c t s a soci ol ogi cal and ant hropol ogi cal
emphasis on dominant pat t er ns , i t seems not t o be
s i gni f i c a nt l y di scr epant wi t h those ot her ki nds of dat a which
r e f l e c t t he epi demi ol ogi cal emphasis on inciden--ratee of
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CHAPTER FIVE
THE ANATOMY OF ALCOHOL POLICY:
PREVENTIVE APPROACHES
De an Ge r e t e i n
DISCUSSANTS
Marilynn Ka t a t e k y
Irving Root man
INTERNATIONAL STUDY OF ALCOHOL CONTROL EXPERIENCES (ISACE):
COMMENTS ON 'RE FINAL REPORT
Jamee Moe he r
THE ANATOMY OF ALCOHOL POLICY:
PREVENTIVE APPROACHES*
Dean Ger s t ei n
Publ i c p o l i c i e s a r e i mpor t ant though not d e f i n i t i v e gui des t o
under st andi ng government a c t i ons and t h e i r e f f e c t s , i n much t h e same
way a s a handf ul of r e c i pe s may i nform t h e pr os pect i ve d i n e r but are
no guar ant ee of t he meal. Thi s di ct um a ppl i e s a s much t o pol i c i e s
r e l a t i n g t o a l c ohol a s t hose r e l a t i n g t o war, cr i me, banking, o r
farmi ng .
Thi s essay concer ns t h e f or mat i ve a s pe c t s of a l c ohol
pol i c i e s . In pa r t i c ul a r i t gi ve s de t a i l e d a t t e n t i o n t o pr event i ve
approaches i n c ont r a s t t o r e e t o r a t i v e ones. The di s c us s i on begi ns
wi t h t he concept of governi ng i deas , wi t h examples drawn from t he
hi s t or y of t h e United St a t e s . A s ket ch of t he var i oue e f f e c t s of
a l c ohol use f ol l ows, t he s e bei ng t he pr i nc i pa l s ubj e c t s of al cohol
pol i cy. At t ent i on i s t hen t ur ned t o t he a n a l y t i c , normat i ve, and
pragmat i c i s s ue s t h a t surround pr event i ve p o l i c i e s r e l a t i n g t o
a l c ohol , such a s : ha t ki nds of p o l i c i e s can be di scer ned? What are
a ppr opr i a t e r o l e s f o r government i n t h i s a r e a ? ha t a r e t he
i mpor t ant e f f e c t s of government programe concerni ng a l c ohol use?
The di ecuesi on i s meant f o r gener al a ppl i c a t i on; i t does not t r y t o
set t l e t he s e ma t t e r s i n r e l a t i o n t o s p e c i f i c pol i c i e s , but t o de f i ne
and i l l u s t r a t e t he ques t i ons and concept ual t ool e needed t o
underst and and e va l ua t e t he a l t e r n a t i v e s .
*This es s ay l e a ns heavi l y on Al cohol and Publ i c Pol i cy: Beyond t he
Shadow of Pr ohi bi t i on, t he r e por t of t h e Panel on Al t e r na t i ve
Po l i c i e s Af f ect i ng t h e Pr event i on of Alcohol Abuse and Alcoholism
(Moore and Ger s t ei n 1981). However, t h i s work depar t a from t he
pa ne l ' s i n a number of pa r t i c ul a r e , f o r which my col l eagues cannot
be hel d r eeponsi bl e. A paper by Mark Moore (n.d.) suggest ed t h e
t i t l e.
Governing Ideae*
In t he beginning of p o l i t i c a l di al ogue, t her e a r e governing
ideae. This i e not t o eay that euch i deae f a11 from t he eky; t hey
a r e alwaye hi e t or i c a l l y root ed i n product i ve s oc i a l and c ul t ur a l
e oi l . Rather, i t l e t o eay t h a t among people wi t h many and di ver ee
i nt er eet e, a t hought ful o r successf ul exchange on any ei ngl e
pol i t i c a l subj ect can proceed only i f t he di al ogue hae eome basi e
f or mutual understanding. Thi s must a r i e e from c l e a r ,
et rai ght forward, broadly-agreed-upon, though gener al l y unepoken,
conceptione t ha t def i ne t he di ecueeant e' understanding of t he
eubj ect .
There need not be onl y one, and no more t han one, of t hese
simple t a c i t conceptione regardi ng a gi ven s ubj ect ; t her e may be two
o r t hr ee o r eometimee -- r ar el y -- more of t heee i deae may operat e
a t a gi ven time i n a given soci et y. But i neof ar a s a governing i dea
def i nes what moet people view a s "pl ai n comon eenee" about a t opi c,
t hat i dea wi l l def i ne t he boundariee wi t hi n which pol i cy opt i one can
be exerci eed. I f any new act i on of government i s t o be undertaken,
i t muet be conei et ent wi t h t hat i dea. Moreover, while a l ar ge
pl ur a l i e t i c eoci et y may have i n it t he i ne t i t ut i ona l l egaci ee of
varying i deas t hat achieved dominante i n one o r anot her hi e t or i c a l
peri od, t heee l egaci ee w i l l be under et eady preeeure t o change. I f
et r ongl y competing i dea8 co-exi et a t a gi ven time, s oci et y w i l l
e i t h e r c r e a t e a cl ean di vi ei on of l abor between i ne t i t ut i ons t ha t
r e f l e c t t he di f f er i ng i deae, o r t heee i ne t i t ut i ons w i l l be caught i n
a continuoue i deol ogi cal t u g - o f r a r . Pol i cy makers w i l l t o a l a r ge
degree t a l k past one anot her - f a i l i n g t o comuni cat e -- i n
p o l i t i c a l di scueei on on t he t opi c of concern.
In anal yzi ng al cohol pol i ci ee i n t he United St at ee, a few euch
governing i deae can be di ecerned. Two of them reach wel l back i n t o
t he count ry ' e hi et or y; they have becorne st r ongl y entrenched and can
be br i e f l y char act er i zed and l abel l ed. Fi r e t i e t he col oni al view,
t ha t dri nki ng i e a valued eoci al cuetom, t ha t overindulgence i s a
fl aw i n moral char act er , and t ha t i f neceeeary a doee of publ i c
di eci pl i ne i e t he appropri at e reeponee (Rorabaugh 1979). Second i e
t he temperance view, that al cohol ( or a t l e a s t , et rong l i quor ) l e
baei cal l y an addi ct i ng poieon, t ha t e e l l i ng o r coneuming i t can
conet i t ut e a publ i c hazard, and t ha t uee of t he law t o r e e t r i c t
(perhape even ban) i t e s a l e i s t he neceeeary reeponee (Aaron and
Mueto 1981; Levine 1978; Guefi el d 1963).
*A8 a general background on t he r ol e of i deas i n col l ect i ve act i on,
eee Pareone (1937). For more epeci f i c appl i cat i one t o al cohol , eee
Boom (1974) and Levine (1978).
Each of t he s e i de a s ha s proven t o have s t a yi ng power,
s us t a i ni ng i n s t i t u t i o n a l suppor t i n programe that implement publ i c
pol i c y and i n pr i va t e b e l i e f s and pr a c t i c e s , even as t h e i d e a s have
matured w i t h sometimes di s a s t r ous l y misguided exper i ence, and
accommodated t o s h i f t i n g s o c i a l t i de s . A t t he same t i m e we can
i d e n t i f y some more r ecent i de a s whoae s t a yi ng power and a b i l i t y t o
achi eve a pos i t i on of long-term dominance have not ye t f i r ml y o r
convi nci ngl y es t abl i s hed.
The f i r s t of t he s e 1s t he per s pect i ve of al cohol i em as a
di s e a s e ( J e l l i n e k 1960). It hol ds t h a t w h i l e t h e causes a r e as ye t
unknown, al cohol i sm 1s a di s e a s e t o which a small mi nor i t y of t h e
popul at i on, pe r f e c t l y normal i n ot he r r es pect a, i s vul ner abl e.
Alcoholism can and c e r t a i n l y shoul d be t r e a t e d wi t h one o r more of
s e ve r a 1 proven -- though not of cour s e pe r f e c t -- t her apeut i c
methods ( c f . Wiener 1980).
Another governi ng i de a 1s t he view t h a t i t 1s i n s oc i e t y' s
i n t e r e s t s t o c ont r ol t he d i s t r i b u t i o n of al cohol . (Levi ne 1980;
Fosdi ck and Sc ot t 1933). Thi s concept i on was q u i t e s t r ong about t h e
t i m e of Pr ohi bi t i on' s r epeal , and l e d t o t he c ur r e nt U.S. syatem of
s t a t e and na t i ona l a l c ohol i c beverage c ont r ol . Alcohol 1s con-
s i der ed a comonly-sought and c e r t a i n l y non-suppressable commodity,
but one s ubj e c t t o e xpl oi t a t i on by c r i mi na l gr eed, s o t h a t i t s
market i ng needs t o be overaeen by a s t r ong r e gul a t or y watchdog.
The f i n a l (and c ur r e nt l y l e a s t commanding) of t h e governi ng
i de a s 1s t he publ i c he a l t h per s pect i ve, i n which al cohol l a viewed
a s beni gn when used i n ama11 q u a n t i t i e s , but i nc r e a s i ngl y damaging
and r i s ky t o he a l t h when drunk t o excess. I n t h i s view di scourage-
ment of exces s i ve consumption by s t r ong publ i c h e a l t h warni ngs, hi gh
t a xa t i on, and r easonabl e l i m i ts on a v a i l a b i l i t y a r e i mpor t ant
measures i n t h e i n t e r e s t s of publ i c he a l t h (Bruun e t a l . 1975).
The i d e n t i f i c a t i o n of governi ng i de a s out s i de t h e Uni t ed
St a t e s cannot be done a p r i o r i , but r e qui r e s c a r e f u l a n a l y s i s of
h i s t o r i c a l and contemporary ma t e r i a l 8 t h a t di s pl a y t he i de ol ogi c a l
f oundat i ons of s o c i a l and p o l i t i c a l movements r egar di ng al cohol , and
t e 11 us how w e l l t hes e i de a s have become ent r enched i n common
i deol ogy and i n s t i t u t i o n a l p r a c t i c e ( c f . Moser 1979; World Heal t h
Or gani zat i on 1981; Si ngl e, Morgan, and de Li nt 1982) -
It 1s c l e a r t h a t a s us t ai ned s t r a t e g y v i a l e g i s l a t i v e and
ot he r means f o r l i mi t i ng o r pr event i ng al cohol - r el at ed problema must
bui l d on t h e base of a governi ng i dea. An e s t a bl i s he d i de a may
conveni ent l y suppor t t he a va i l a bl e i nst r ument s of pol i cy; a newer
one may r e qui r e s us t ai ned work t o spread i t and persuade peopl e of
i t s v a l i d i t y .
It ehould be evi dent t ha t a governing i dea covere much more
t han government pol i cy. A governing i dea about al cohol pr i nci pal l y
concerns people ' e everyday aeeumpt i one and ac t i one , and onl y
secondari l y how t hey expect governmente t o behave. Theee
expect at i one of government w i l l be ehaped, al eo, by gener al
phi l oeophi ee of t he e t a t e ' s r ol e i n s oci et y, a s w e l l a s pr act i ca1 o r
hi a t or i c a l judgments about how ef f e c t i ve epecif i c klnde of programe
w i l l be o r have been.
What i s moet not abl e about a governing i dea i e t ha t i t can t i e
t oget her i n a penet rat i ng and convincing way a judgment about t he
nat ur e and ei ze of t he pr i nci pal e f f e c t of al cohol uee, a view of
t he appr opr i at e r ol e of t he e t a t e , and a epeci f i c i dea about t he
inetrument o r program which t he government, i f cal l ed upon t o a c t ,
ehould uee. It doee t hi e even though t he grounds f o r t yi ng t hes e
elemente t oget her may be l ogi c a l l y vague o r hi e t or i c a l l y f or t ui t oue
r at her than l ogi cal l y ri gorous or empi r i cal l y compelling.
The subeequent eect i ons of t hi e eseay cover t he baei c
cat egor i ea of e f f e c t e of al cohol use, t he main kinde of pol i cy
inetrinnents and normative concept i ons t ha t may be act i vat ed i n
prevent i ve al cohol pol i cy, and coment e on t he waye i n which pol i cy
i nt er vent i one may o r may not produce intended r es ul t e. No
pa r t i c ul a r governing i dea i e propounded, though t her e a r e remarke
r el evant t o sever al . I n s hor t , what followe is an out l i ne of t he
comparative anatomy of al cohol pol i cy, wi t h epeci al a t t e nt i on t o
prevent i ve approaches.
The Ef f ect e of Aicohol Use
Vi r t ual l y every known human eoci et y uees beverage al cohol .
There l e conaequently enormoue var i at i on i n how i t 1s ueed, what t he
eoci al l y vi e i bl e r eeul t e ar e, and how much concern o r i nt e r e e t i a
shown i n t heee r es ul t e. Theae var i at i one acrose eoci et i es a r e
reviewed i n d e t a l l eleewhere (e.g. Gaetineau e t a l . 1979; MacAndrew
and Edgerton 1969; Marshall 1980; Si ngl e, Morgan, and de Li nt 1982;
Sulkunen 1978; World Health Organi zat i on 1981). Since my i nt ent i on
here l e simply t o def i ne t he axes of var i at i on i n government
pol i ci ee, onl y a few echematic remarke need be made here about how
t he e f f e c t s of al cohol a r e conceived.
Theee e f f e c t s vary i n qual i t y and i n quant i t y. There a r e
t hr ee baei c dimeneione of qual i t y, t ha t l e , t hr ee t ypee of e f f e c t s :
moral, physi cal , and economic. Theee e f f e c t s can be poei t i ve a s
wel l a s negat i ve, and t hey a r e not mutually excl uei ve.
Moral e f f e c t s r e f e r t o changea i n personal s a t i e f a c t i on and
eoci al s ol i da r i t y (Cahalan, Ci si n, and Croesley 1969). On t he
pos i t i ve s i d e , a l c ohol use c a n gi ve rise t o r e l a xa t i on o r pl eas ant
s ens at i ons , can mark i mpor t ant event s , and can f a c i l i t a t e c omuna l
occaei ons. On t he negat i ve s i de , a l c ohol use can r e s u l t i n l o s s of
mot i vat i on t o l i v e happi l y o r s uc c e s s f ul l y, l eadi ng t o s ui c i de o r
depr essi on, w i t hdrawal f rom i nt i ma t e r e l a t i o n s , o r vi ol e nt
behavi or. Alcohol can demor al i ze peopl e who use i t unwi sel y o r
unf or t una t e l y , and can f u r t h e r demor al i ze peopl e who come i n t o
c ont a c t wi t h o r depend on such us er s . I f t h e moral e f f e c t s a r e of
pr i nc i pa l concer n, t h e f ocus of pol i c y debat e o r ot he r conmuni cat i on
t ends t o be a l c ohol ' s negat i ve e f f e c t s on f ami l y l i f e , o r i n
c ont r a s t , i t s pos i t i ve r o l e i n cementing ext r a- f ami l i a1 f r i ends hi ps .
Economic e f f e c t s r e f e r t o changes i n weal t h o r u t i l i t y . On
t h e pos i t i ve s i de , a l c ohol 1s a commodity t h a t i s o f t e n de s i r e d f o r
i t s e l f and t hus " c r e a t e s jobs" and "put s c a p i t a l t o work" i n i t s
pr oduct i on and d i s t r i b u t i o n . On t he negat i ve s i d e t he r e 1s
de s t r uc t i on of pr oper t y i n a c c i de nt s , poor management due t o
al cohol -i mpai red de c i s i ons , l o s s i n pr oduct i ve l a bor c a pa c i t y, and
di ve r s i on of l a bor and c a p i t a l from ot he r uses t o t he al cohol t r a de
( Ber r y and Boland 1977; Luce and Schwei t zer 1978). her e economic
e f f e c t s a r e gi ven p r i o r i t y , t h e negat i ves of j ob abeent eei sm and
unf i t ne s s wi t h consequent economic de c l i ne and dependency a r e
cont r as t ed wi t h t he s ubs t a nt i a l e i z e of employment and p r o f i t i n t he
a l c ohol i c beverage i ndus t r y, wi t h i t s r e s u l t i n g be ne f i t s f o r r e t a i l
t r a de and government t a x revenues.
Physi cal e f f e c t s i nvol ve he a l t h. The pr i nc i pa l pos i t i ve
e f f e c t of al cohol appear s t o be a s a s a ni t a r y c a l o r i e sour ce and
- -
pos s i bl y a p a r t i a l a nt i dot e t o at her ogeni c o r ar t er y- cl oggi ng d i e t s
( Nat i onal I n s t i t u t e on Alcohol Abuse and Alcoholism, 1981). The
negat i ve e f f e c t s on he a l t h a r e bot h immediate (hangovers, a ddi c t i on,
f a t a l overdosea, i nj ur y, and deat h due t o trauma) and chr oni c (organ
damage such a s l i v e r c i r r h o s i s , Korsakoff br a i n syndrome,
hyper t ensi on, and weakening of t he he a r t muscle). Focus on t he
negat i ve he a l t h e f f e c t s t ends t o be split between t he mor t a l i t y and
major d i s a b i l i t i e s a s c r i ba bl e t o di s eaeee of t he l i v e r and ot he r
p a r t s of t he body among ol de r heavy dr i nke r s o r a u t o c r a s h
f a t a l i t i e s among t he young. The c ont r a s t i ng not i on of a pos i t i ve
he a l t h val ence f o r moderate dr i nki ng r e l a t i v e t o abet i nence o r heavy
dr i nki ng has gai ned cur r ency ( c f . Schmidt and Popham 1982).
For each c l a s s of e f f e c t s , pos i t i ve and negat i ve, t he r e 1s a
ba s i c range i n qua nt i t y from small t o l ar ge. It i s pos s i bl e,
however, t o di s t i ngui s h f our s ubt l y d i f f e r e n t components of judgment
about t he ove r a l l s i z e of an al cohol e f f e c t . F i r s t i s judgment of
t h e c a us a l s i gni f i c a nc e of a l c ohol a s a gener at or of t he e f f e c t .
Alcohol may o r may not be consi der ed a key c a us a l el ement o For
example, i n some r egi ons a n a l c ohol i c beverage (e. g. wine o r beer )
i s a d i e t a r y s t a p l e a ki n t o bread o r cheese; and even though t h e
chr oni c drunkard l a consi der ed a s o c i a l nui sance and a n
embarrassment o r posei bl y a nightmare f o r hi e (very eeldom l i er)
-
fami l y, t he pr i nci pal problem i s viewed a s a def ect i n i ndi vi dual o r
fami l y char act er . Alcohol 1s no more blamed f o r t he drunkard' s
behavior t han gr avi t y 1s f aul t ed f o r making some chi l dr en
accident-prone. I n addi t i on, t he e i z e of t he e f f e c t -- be i t
benef i ci a1 o r damaging -- depende on a ) t he ext ent of t he population
" at r i s k" (how many people a r e pot ent i al l y eubj ect t o i t ) , b) t he
degree of i t s epi sodi c o r i ndi vi dual l i kel i hood (whether t he chances
of i t s happening t o any ei ngl e eubj ect i n t hi e popul at i on a r e hi gh
o r low), and c ) its i ndi vi dual impact o r s ever i t y when i t does occur.
For t he rnoet par t , t he degree of e f f e c t i s not cal i br at ed by
s c i e n t i f i c anal ys i s of t hese f act or e, but 1s r at her compounded from
t r a di t i ona l bel i ef s , p o l i t i c a l r het or i c, and t o some degree,
empi ri cal i nqui ry. The r e e ul t i s t ha t moet i nt er es t ed pa r t i e s
di s pl ay a c e nt r a l concern wi t h onl y one or two presumptively l ar ge
e f f e c t e eel ect ed from t he ar r ay of poes i bi l i t i es . The one or two
may be drunk dr i vi ng, medical sequel ae of chroni c addi ct i on, poor
job performance, i l l e g a l product i on, vi ol ence, o r revenue. I n t he
next s ect i on we w i l l conei der how t hese concerns r e l a t e t o ot her
concept i ons t o form a governing i dea.
Def i ni ng Alcohol Pol i cy
General Coneideratione
Some gener al and obvious axioms t ha t should be kept continu-
ousl y i n mind i n t hi nki ng about al cohol pol i cy ( f or i t i s remarkably
easy t o overlook t he obvious) a r e t h a t a ) pol i cy on one subj ect i s
always made w t h an eye t o pol i cy about ot her subj ect s; b) ar t i cu-
l a t i o n of pol i cy i s only one f unct i on of governments; and c ) govern-
mente a r e always a par t of a epeci f i c soci et y. A r at i onal e f o r
act i on which eeems powerful t o t hose whose concern 1s focused on a
s i ngl e subj ect may appear t r i v i a l o r even i nconcei vabl e t o ot her
pa r t i e s because i t c onf l i c t s wi t h an over al l di r e c t i on of government
a t t he time, r equi r es t he use of capaci t i es o r resources t ha t do not
e xi s t o r have ot her pr i or i t i e s , o r f l i e s i n t he f ace of powerful
cont r ar y eoci al i nt e r e s t s o r values. On t he ot her hand, pol i ci es
a r e of t en made possi bl e because, i n addi t i on t o st r ong i n t r i n s i c
argumenta i n t he i r favor, t hey happen t o be consi st ent with an
over al l t rend i n power, o r because an under ut i l i zed or e a s i l y
avai l abl e i ne t i t ut i ona l mane l e s cl os e a t hand, or because t he
argumente l i n e up neat l y wi t h a powerful extragovernmental s oc i a l
movement. Most of t en i n a pl ur a l i e t i c eoci et y with a degree of
decent r al i zed government, one f i nds t ha t any cogent pol i cy i dea can
imbue some pat ch of p o l i t i c a l l i f e .
With t hes e gener al axioms gr ant ed, i t l e t i m e t o ask: what l e
a governmental a l c ohol pol i cy? - I n t h e br oadest eense, a publ i c
pol i cy i s a concept i on of a n i d e a l form of c o l l e c t i v e o r aggr egat e
behavi or i n t he s oc i e t y ( o r i n t h e c a s e of "f or ei gn pol i cy", i n t h e
behavi or of ot he r s o c i e t i e s ) t h a t t h e government espouses o r wi shes
t o encourage. The de s i r e d behavi or may be i d e n t i f i e d poe i t i ve l y,
e.g. cont i nuous economic growth, o r pr oe c r i pt i ve l y, e.g. put t i ng an
end t o vi ol e nt crime. Theee concept i ons of t he de s i r a bl e can be
c a l l e d pol i cy i de a l s . In t he c a s e of al cohol pol i cy t h e i d e a l might
r ange from no a l c ohol use t o a s much a l c ohol us e a s peopl e wi sh, but
i n most i ns t a nc e s i t t a ke s t he ge ne r a l form: s t op al cohol abuee and
al cohol i sm.
Such i d e a l s a r e us ua l l y f a r from t h e l e ve 1 of day-to-day
government a c t i v i t y . Much c l o s e r t o t he s ur f a c e a r e what can be
c a l l e d i ncr ement al N, such a s an x-percentage i nc r e a s e i n gr os s
na t i ona l product (GNP) o r a sl owi ng of t h e i ncr eas e i n crime r a t e s .
I n t h e U.S., examples of a l c ohol pol i c y s t a t e d a s such goa l s a t one
time o r anot her have i ncl uded s t a b i l i z a t i o n of per c a p i t a coneump-
t i o n , i ncr eas i ng al cohol i sm t r eat ment " s l ot s , " r a pi d r educt i on of
i l l e g a l al cohol pr oduct i on, l a r g e r government revenues from al cohol
t a xe s , decr eases i n t h e number of drunk-dri vi ng de a t hs , and epr ead
of r es pons i bl e dr i nki ng pr a c t i c e s .
Yet t he most us e f ul way t o anal yze t h e range of pos s i bl e
pr event i ve al cohol pol i c i e s 1s ne i t he r i n terms of ba s i c a l l y
unr eachabl e i d e a l s nor per i odi cal l y- adj us t ed i ncr ement al goa l s , but
r a t h e r i n t erms of pol i cy i nst r ument s, t he s pe c i f i c mechanisms o r
programa used t o implement t h e pol i c i e s . Looked a t t h i s way, we can
qui ckl y r ecogni ze two fundamental di vi s i ons of al cohol pol i ci ee:
pr event i ve and r e s t or a t i ve .
Pr event i ve and Res t or at i ve Pol i c i e s
Pr event i ve p o l i c i e s meant t o a f f e c t al cohol - r el at ed problems
have been f u l l y def i ned a s f ol l ows:
They a r e a l 1 p o l i c i e s t h a t oper at e i n a non-
per s onal i zed way t o a l t e r t he s e t of cont i ngenci es
a f f e c t i ng i ndi vi dua l s a s t hey dr i nk o r engage i n
a c t i v i t i e s t ha t (when combined wi t h i nt oxi c a t i on)
a r e consi der ed r i s ky. . . . None of t he s e p o l i c i e s
dependa on a cont i nui ng per sonal i zed r e l a t i ons hi p
between a program and a dr i nker . I ns t ead, t hey
ope r a t e t hrough t he remote mani pul at i on of a
r e l e ve nt s e t of i nc e nt i ve s and cont i ngenci es: t he
terms and ci r cumst ances under which al cohol 1s
a va i l a bl e , t he a t t i t u d e s of peopl e sur r oundi ng t he
dr i nke r , and t he beni gni t y of t h e phys i cal and
s o c i a l environment toward drunkenness. [Such]
programe ope r a t e ge ne r a l l y t hroughout t h e s oc i e t y.
The i nc e nt i ve s and cont i ngenci es a r e e s t a bl i s he d f o r
everyone (Moore and Ge r s t e i n 1981:53).
in b r i e f , pr event i ve p o l i c i e s are non-personal i zed and gener al .
Res t or at i ve pol i c i e s , i n immediate c ont r a s t t o pr event i ve
ones, f i r s t i de nt i f y i ndi vi dua l s who have c r e a t e d o r s uf f er ed
problems t h a t a r e d i r e c t l y due t o dr i nki ng, and t hen begi n and
mai nt ai n f o r some per i od of t i me a cont i nui ng face-t o-face
r e l a t i o n s h i p between t hes e i ndi vi dua l s and a s e r vi c e o r
i n s t i t u t i o n . The r e l a t i ons hi p 1s based on t he i ndi vi dua l ' s having
m e t some f a i r l y narrow o r e x p l i c i t l e g a l o r c l i n i c a l c r i t e r i o n ; t h e
t er mi nat i on of t h i s arrangement 1s us ual l y based on a c r i t e r i o n of
t he i ndi vi dua l ' s performance o r r e l a t i o n t o t h e i n s t i t u t i o n . The
d i f f e r e n t v a r i e t i e s of agency-cl i ent s t a t u s i ncl ude "t r eat ment , " i n
which a pr ocess of medi cal o r psychol ogi cal heal i ng 1s i nvol ved;
" r e ha bi l i t a t i on, " i n which t h e r e i s t r a i ni ng i n c ogni t i ve o r
psychomotor s k i l l s and or i e nt a t i on; and "punishment," i n which t he
i ndi vi dua l i s penal i zed f o r engagi ng i n wi l l f u l cr i mi nal a c t i v i t y .
Si nce t h e f ocus of t h i s paper i s pr event i ve pol i c i e s , f u r t h e r
a na l ys i s of t hes e r e s t or a t i ve approaches w i l l be suspended, and we
w i l l t u r n t o t h e s ubdi vi s i ons of pr event i ve approaches.
There a r e t hr e e ki nds of pr event i ve pol i c i e s : a ) r e gul a t i ng
t h e t erms and condi t i ons of a v a i l a b i l i t y of bot h a l c ohol and pl aces
i n which t o dr i nk i t ( r e gul a t i ng suppl y) ; b) t r yi ng t o i nf l uence
peopl e' s dr i nki ng pr a c t i c e s d i r e c t l y t hrough pedagogi cal e f f o r t s and
l e g a l s t i p u l a t i o n s ( shapi ng dr i nki ng pr a c t i c e s d i r e c t l y ) ; and c )
making t he e xt e r na 1 environment l e s 8 h o s t i l e o r r i s ky s o t h a t
p o t e n t i a l l y damaging consequences of i nt oxi c a t i on a r e reduced
( r educi ng envi ronment al r i s k ) . These t hr e e t ypes a r e r e l a t e d t o
each ot he r qui t e d i r e c t l y . Supply p o l i c i e s t r y t o c ont r ol two of
t h e elernents t h a t a r e necessar y t o ever y al cohol - r el at ed problem:
a l c ohol i t s e l f and pl aces i n which t o dr i nk i t . Pol i cy on dr i nki ng
p r a c t i c e presumes t h a t a l c ohol and dr i nki ng pl a c e s ( publ i c and
pr i va t e ) are a va i l a bl e and tries t o i nf l uence how peopl e t ake
advant age of them, i n terms of how much, how of t e n, o r what
a c t i v i t i e s dr i nke r s p a i r wi t h consumption. Fi na l l y, a pol i cy
desi gned t o reduce envi ronment al r i s k presumes t h a t peopl e w i l l be
dr i nki ng, g e t t i n g drunk, and put t i ng t hemsel ves i n danger i n var i ous
ways; t he obj e c t of t hes e p o l i c i e s i s t o l i m i t t h e s e ve r i t y of t h e
consequences by amking t he environment less hos t i l e .
It shoul d be not ed t h a t each of t he t hr e e t ypes of pr event i ve
pol i cy can subser ve a number of governi ng i deas. But more pe r t i ne nt
t o our purpose her e i s t o obser ve t h a t each t ype of pol i c y subsumes
a number of pol i cy i nst r ument s t h a t f ol l ow t he ge ne r a l l ogi c
out l i ne d, but var y i n f or ce, emphasis, and s t y l e .
Va r i e t i e s of Pr event i ve Pol i c i e s
Regul at i ng Supply
Regul at i on of suppl y ge ne r a l l y has f o r i t s obj e c t s t he
s e pa r a t i on of c r i mi na l o r i r r e g u l a r el ement s from t he l e gi t i ma t e
t r a de ; t h e mai nt enance of c i v i l or de r and decorum i n dr i nki ng
pl aces ; t he l i mi t a t i o n of exces s i ve coneumption*; o r t he keepi ng of
al cohol e n t i r e l y away from c e r t a i n c a t e gor i e s of peopl e f o r whom ( a t
a p a r t i c u l a r h i s t o r i c a l j unct ur e) i t i s consi der ed e s pe c i a l l y
dangerous, such a s peopl e of a p a r t i c u l a r e t h n i c group, peopl e
occupi ed i n hazardous a c t i v i t i e s , o r chi l dr en. The most t y p i c a l
suppl y pol i cy i nst r ument s i nvol ve pr oduct i on c ont r ol s , r e gul a t i on of
t he ownership, number, l oc a t i on, and r e t a i l hours of o u t l e t s , pr i c e
c ont r ol s , and r e s t r i c t i o n s on purchase of a l c ohol i c beverages
cont i ngent on age, ' r ace, o r some ot he r qua l i f i c a t i on. The most
c ont r ove r s i a 1 of t he s e i nst r ument s a t t h e c ur r e nt t i m e i n t he United
St a t e s a r e pr i c e c ont r ol s and a ge r e s t r i c t i o n s .
Pr i c e s and Taxes Pr i c e s can be c ont r ol l e d e i t h e r by
admi ni st er i ng them d i r e c t l y by " f a i r t r ade" o r pr i c e suppor t pl ans,
o r by ensur i ng c e r t a i n minimum p r i c e " f l oor s " wi t h e xc i s e t axat i on.
The e s s e n t i a l p r a c t i c a l ques t i on t h a t t h i s ki nd of pr event i on pol i cy
needs t o a s k 1s: Do p r i c e c ont r ol s a f f e c t t he most de l e t e r i ous
dr i nki ng pr a c t i c e s , i. e. , chr oni c heavy consumption and per i odi c
s ever e i nt oxi c a t i on? I n gener al , t he wei ght of evi dence a f f i r ms
t h a t pr i c e s do a f f e c t heavy dr i nki ng pr a c t i c e s (Moore and Ger s t ei n
1981: 68-83; Cook 1981). But some ot he r argumenta a r e e qua l l y
r e l e va nt : normative obj e c t i ons t h a t a l c ohol t a xe s a r e unf a i r t o
l i g h t and moderate dr i nke r s , and t h a t exci s e t a xe s on consumer i t e m s
f a 11 most heavi l y on t he poor, who can l e a s t a f f or d them; p r a c t i c a l
i s s ue s concer ni ng t he r e l a t i v e weight of t axes on beer , wine, and
s p i r i t s ; and i n t he United St a t e s , p o l i t i c a l obj e c t i ons based on t he
uneasy f e e l i ng t h a t t he use of heavy t a xa t i on a s a pr event i ve r a t h e r
*Cr i t i c s and advocat es a l i k e t end t o f ocus he a vi l y on t h i s a s pe c t of
suppl y pol i c i e s , t o t he poi nt t h a t t he s e pol i c i e s have come t o be
c a l l e d t h e "cont r ol of consumption" approach ( Pi t t man 1981). They
might b e t t e r be c a l l e d t he "cont r ol of pr oduct i on and di s t r i but i on"
approach, s i nc e t h e main burden of a c t i v a t i n g t he s e p o l i c i e s f a l l s
on t he c o me r c i a l s e c t or r a t h e r t han t he pr i va t e consumer. The most
i n f l u e n t i a l advocat e of c ont r ol p o l i c i e s i n t h e l a t e Pr ohi bi t i on e r a
put t he cas e simply as : t ake t he hi gh p r o f i t s out of al cohol (John
D. Rockef el l er Jr., i n Fosdi ck and Sc ot t 1933).
t han e t r i c t l y a revenue meaeure beare t oo much reeemblance t o Vol-
e t e a di m, that l e , t ha t t h i e approach i e t ai nt ed by t he exceeeive
moraliem and di eaet r oue r e e ul t e of nat i onal Pr ohi bi t i on (implemented
under t he Voletead Act).
Thie domination of t he al cohol pol i cy pi ct ur e i n t he United
St at ee by t he ehadow of Pr ohi bi t i on i e probably not appl i cabl e t o
many ot her count ri ee. I n s i mi l a r faehi on, t he much l i g h t e r t axee
her e on beer and wine than on e p i r i t e have some par t i cul ar
hi e t or i c a l ant ecedent e. I n general , a prevent i ve pol i cy would be
moet e f f i c i e nt i f i t taxed quant i t i ee of et hyl al cohol equal l y,
whether packaged i n weak o r et rong eol ut i on. tiowever, a n i ncr eaee
i n any par t of t he al cohol t ax et r uct ur e would probably eerve
prevent i ve obj ect i vee r e l a t i ng t o exceeeive coneumption, though
eomewhat l e e s e f f i c i e nt l y. It ehould be noted t ha t t he hi ghl y
ca~nner ci al i zed, r e l a t i ve l y concent rat ed, and thoroughly regul at ed
nat ur e of t he manufacture of al cohol i c beveragee i n t he United
St at ee 1s more conducive t o c ol l e c t i on of an exci ee t a x t han would
be t he case i n a more di spersed, l e e s camnercial, o r l es e cl oeel y
regul at ed manufacturing economy.
The normative i e s we a r e twofold. Fi r s t , i e i t f a i r f o r a l 1
dr i nker e t o be taxed i f onl y eome dr i nk dangerouely o r exceeei vel y?
In pa r t , t he way t he queet i on l e phraeed misees t he poi nt : a high
prevent i ve t a x i e meant pr eci eel y t o keep people from dri nkl ng s o
much and thue put t i ng themeelvee a t gr eat er r i ek. Many people who
become exceeeive dr i nker e were l i g h t o r moderate dr i nker s a t one
t i m e , s o i t i e d i f f i c u l t t o s uet ai n t he not i on that t h i s group of
dr i nker e shoul dn' t be af f ect ed. It i e i n f a c t t he heavi eet dr i nker e
who pay moet of t he t ax, ei nce t hey dr i nk most of t he al cohol . I n
addi t i on, many of t he damagee from exceeeive dr i nki ng (e.8. i nj ur i e s
due t o as eaul t e and acci dent e) f a11 on people who were not dr i nki ng
exceeei vel y themeelvee but were unfort unat e enough t o be around
soPPeone who di d. Thus t he prevent i ve e f f e c t of t axee would benef i t
even t o thoee who dri nk eaf el y themeelvee.
The ot her normative i eeue 1s equi t y: t he bel i ef t h a t al cohol
t axee f a11 moet heavi l y on t he poor, and hardl y a f f e c t t he wealthy.
I n f a c t , econometric et udi ee euggeet t h a t hi gher t axes on al cohol i c
beveragee r eeul t i n moet people spending about t he same on drinlring,
but dri nki ng l es e; thoee who do i ncreaee t he i r expendi t ure appear t o
be l ar gel y thoee who can af f or d t o do 80 without f i nanci a1
di et r eee. Since weal t hi er people gener al l y epend conei derabl y more
on al cohol t o begin wi t h, a n i ncreaeed t a x would i n f a c t a f f e c t them
conei derabl y.
Age Reet r i ct i ons The debat e about age r e e t r i c t i one i n t he
United St at ee has not been over whether t her e ehould be any
r e e t r i c t i one , but whether t he r i ght t o purchaee al cohol i c beveragee
ehould be i ni t i a t e d a t 18 yeare of age or a t 21 years o r eomewhere
i n between. Complicating and domi nat i ng t h i s debat e a r e two
somewhat d i f f e r e n t i s s ue s : drunken dr i vi ng a c c i de nt e and dr i nki ng by
young peopl e under t he age of 18 (Wechsler 1980).
The downward movement of t h e minimum l e g a l dr i nki ng age f rom
21 t o 19 o r 18 year s i n roughl y hal f t he s t a t e s dur i ng t he e a r l y
1970s p a r a l l e l l e d r educt i ons i n t he minimum vot i ng age. These
r educt i ons , i n t ur n, were t he coneequence pr i nc i pa l l y of t h e V i e t
Nam war, when 18-year-old dr a f t e e s were c a l l e d on f o r a d i s t a n t war
of unc e r t a i n suppor t and l egi t i macy, wi t hout t h e f r a nc hi e e t o
p a r t i c i p a t e i n t he most fundamental r i t e of r e pr e s e nt a t i ve
democr at i c p o l i t i c s .
The r e c e nt t i d e of r e ve r s a l s i n t h i s r e l a t i v e l y s mal l
adj ust ment i n t he dr i nki ng age has occurred al most e xc l us i ve l y on
t h e grounds t h a t many 18, 19, and 20 ye a r ol d l i v e s a r e bei ng l o s t
i n drunken dr i vi ng a c c i de nt s , and t ha t t hes e newly e n t i t l e d
pur chaser s a r e t hemsel ves i l l i c i t l y i ncr eas i ng t h e a v a i l a b i l i t y of
al cohol t o even younger c hi l dr e n. The evi dence i n d i c a t e s t h a t
changes i n t he l e g a l pur chasi ng age do not g r e a t l y change t h e
ove r a l l qua nt i t y of a l c ohol t h a t t hos e d i r e c t l y a f f e c t e d consume.
There i s, however, a cons i der abl e e f f e c t on where t hey do t h e i r
dr i nki ng. When purchase 1s i l l e g a l , young peopl e of t he s e ages a r e
excl uded from ba r s and ot he r by-t he-dri nk s e r vi c e es t abl i s hment s ,
and t hus spend consi der abl y l e s s t i me dr i vi ng t o and from such
pl aces. I ns t ead t hey conf i ne t h e i r dr i nki ng l a r g e l y t o pr i va t e
homes. There i s t hen a measurabl e di f f e r e nc e i n a ut o c r a s h
f a t a l i t i e s i n t h i s age band (Dougl ass 1979-80). For t h e United
St a t e s a s a whole, t hes e di f f e r e nc e s e a s i l y add up t o hundreds of
l i v e s a year .
Although some a t t e n t i o n has been pai d t o t h e e f f e c t of
pur chasi ng age minima on pr ovi s i on of al cohol t o adol es cent s w e l l
below t he cont r over s i a1 age range, t he r e 1s r e a l l y no per suasi ve
evi dence t h a t adj ust ment s t o t h e age minimum have much e f f e c t on
dr i nki ng behavi or i n t h i s group.
Thi s i s s u e r a i e e s t o v i s i b i l i t y a n i mpor t ant dimension of t h e
pol i cy i s s ue s surroundi ng a l c ohol use. There 1s c l e a r l y a s t r ong
na t i ona l consensus t h a t Pr ohi bi t i on i n t h e 1920s was a bad mi st ake.
It f os t e r e d vi ol e nt cr i mi nal or gani zat i ons , cr eat ed open o r bar el y
di s gui s ed contempt f o r t he law, and f a i l e d t o e l i mi na t e
dri nki ng--al t hough t he consensus does g l o s s over t he f a c t t h a t
dr i nki ng di d r e t r e a t dur i ng Pr ohi bi t i on t o t h e l owest l e v e l e i n t h e
h i s t o r y of t he count r y, a t l e a s t one- t hi r d less and perhape onl y
ha l f a s much a s a t pr esent o r immediately bef or e Pr ohi bi t i on
(Warburton 1932, J e l l i n e k 1947/ 8). The gr e a t maj or i t y of peopl e i n
t h e United St a t e s st i l l c l e a r l y bel i eve i n t h e v a l i d i t y of
pr ohi bi t i ng al cohol t o a l a r ge por t i on of t he popul at i on, i ncl udi ng
some who a r e vot i ng c i t i z e n s , because t hey a r e t oo young. Thi e 1s a
cont i nued endorsement of p a r t i a l pr ohi bi t i on, and of measuree t o
implement i t which do not de s t r oy l e gi t i ma t e busi ness. Thi s
endoreement gi ve s dr amat i c evi dence of t he be l i e f t h a t a l c ohol i s
d i f f e r e n t from ot he r ki nds of beverages i n t h a t i t 1s t oo dangerous
t o be made r e a di l y a va i l a bl e t o t hos e not possessi ng t h e s k i l l s o r
judgment t o use i t s a f e l y and appr opr i at el y. But what i e s a f e and
a ppr opr i a t e use? hat i s bei ng done t o see t h a t t he necessar y
e k i l l s and judgment a r e i n pl ace by t he ei ght eent h o r s hor t l y-
f ol l owi ng bi r t hday? And what measures can o r shoul d t h e government
t ake t he r e a f t e r t o see t h a t t he s e us e f ul f a c u l t i e s a r e exer ci sed?
These a r e t h e prominent ques t i ons t h a t a r i s e i n consi der i ng p o l i c i e s
t h a t t r y t o shape dr i nki ng pr a c t i c e s d i r e c t l y .
Shaping ur i nki ng Pr a c t i c e s Di r e c t l y
Adul t s a r e on t he whole l e g a l l y l i cens ed t o dr i nk, but
powerful f or c e s c ons t r a i n t h e i r freedom t o e xe r c i s e t h i s l i cens e.
Undoubtedly t he most powerf u1 c o n s t r a i n t s a r e t he i nf or mal norms
that c hi l dr e n l e a r n e a r l y i n l i f e i n t he home, and t hen go on t o
test, modify, and t r ans mi t t o each ot he r a s a d u l t expect at i ons i n
f a mi l i e s , f r i e nds hi ps , and work r e l a t i ons . Whether governments
under t ake t o shape dr i nki ng pr a c t i c e s o r not , t he s e i nf or mal s o c i a l
and c u l t u r a l cont r ol 8 w i l l oper at e, and t hey a r e t h e major f a c t t h a t
any pol i cy i nt e r ve nt i on must t a ke i n t o account .
I f t he s t a t e t ri es t o c ons t r uc t a pr event i ve pol i c y focused on
dr i nki ng pr a c t i c e s , a number of d i f f i c u l t i e s a r i s e . F i r s t , a t t h e
l e ve 1 of i d e a l s , t he problem i s t o de f i ne t he ki nds of dr i nki ng
pr a c t i c e s -- amounts, f r equenci es, and occasi ons -- t hat a r e
consi der ed s a f e and a ppr opr i a t e , and c l e a r l y set of f t hos e t h a t f a 11
out ei de t he s e boundari es. The problem her e i s t h e s he e r va r i e t y of
dr i nki ng customs i n a s oc i e t y wi t h more t han a s i ngl e c u l t u r a l
heritage--and v i r t u a l l y a l 1 na t i ona l s o c i e t i e s a r e mul t i - et hni c. No
mat t er where t he boundary l i n e s a r e drawn, t he r e wi l l be uproar.
I ne vi t a bl y, a set of boundari es on a c c e pt a bi l i t y w i l l excl ude ways
of dr i nki ng t h a t s ubs t a nt i a l f r a c t i o n s of t he popul at i on w i l l
consi der t o be q u i t e normal and accept abl e, and none of t he
government' s busi ness. The same s e t of l i n e s w i l l a l s o permit
dr i nki ng pr a c t i c e s t h a t s u b s t a n t i a l f r a c t i o n s of t he popul ace w i l l
conei der qui t e out r ageous and unusual , l eadi ng them t o accuse t he
government of gi vi ng pos i t i ve a s s e nt t o behavi or t h a t t hey cons i der
f r i ght e ni ng, hazardous, o r wrong. The t a s k of drawing a s e t of
gui de l i ne s t ha t minimize i r r e c onc i l a bl e vi ewpoi nt s is not an
envi abl e one.
There a r e some ways i n which pol i cymakers can t une such
p o l i c i e s s o a s t o c r e a t e less di scor d. I n pa r t i c ul a r , not a l 1 l i n e s
need t o be drawn wi t h equal f or c e .
A l i n e defended by c r i mi na l s t a t u t e s must command
wi der compliance ( 1 . . , admit more of c ur r e nt
dr i nki ng pr a c t i c e s ) and be focused on behavi or t h a t
produces more adver se e xt e r na 1 e f f e c t s t han a l i n e
defended by weaker measures such a s economic
i nc e nt i ve s , c i v i l s a nc t i ons , advi sor y educat i onal
programs, o r exemplary a c t i o n s of government. Thi s
s ugges t s t h a t one might want t o e s t a b l i s h a v a r i e t y
of l i n e s wi t h var yi ng degr ees of f or ce. Cri mi nal
s t a t u t e s shoul d be s pa r s e l y used t o di scour age onl y
t he r a r e s t and most dangerous conduct. Ot her pro-
grams coul d be used more l i b e r a l l y and e s t a b l i s h
somewhat more c ont r ove r s i a 1 goa l s (Moore and
Ger s t ei n 1981: 57-58.)
The i nst r ument s out l i ne d here--8t at ut ory r e gul a t i on of
i ndi vi dua l conduct o r more si mpl y, t h e - law; educat i on, i nf or mat i on,
and t r a i n i n g programs under government aus pi ces conducted i n t h e
school s, mass media, and el sewher e, o r b r i e f l y , educat i on; and
a c t i ons of government meant t o set a good example f o r p r i v a t e
c i t i z e n s o r pr i va t e s e c t or i n s t i t u t i o n s , 1.e. symbolic act i on--are
t he ways i n which governments can t r y t o implement concept i ons of
s a f e t y and appr opr i at enes s i n dr i nki ng pr a c t i c e s .
Assuming t ha t consensus can be reached about which pr a c t i c e s
a r e s u f f i c i e n t l y hazardous o r devi ant t o merit one o r anot her l eve1
of a c t i on, t h e government must f ace t he count er vai l i ng c o n s i d e r
a t i o n s of e f f e c t i ve ne s s and of compet i t i on f o r r esour ces. I n t he
shapi ng of dr i nki ng pr a c t i c e s , t he r e w i l l be s t r ong r e s i s t a nc e t o
any e f f o r t t ha t t r i e s t o move very f a r beyond di scour agi ng what
i nf or mal norms al r eady condemn, o r approving what t he s e norms
al r eady esteem. I n or der t o e f f e c t i v e l y overcome such r e s i s t a nc e s ,
f o r example by s t r engt heni ng discouragement i n t o e f f e c t i v e
det er r ence o r backing appr oval wi t h e f f i c i e n t educat i on, t he
government must be prepared t o devot e i t s e l f t o t he s e t a s ks e i t h e r
a t t he expense of ot he r t a s ks o r a s a n a ddi t i ona l d i f f i c u l t job.
Drunk Dr i vi ng and t h e Law The handl i ng of drunk dr i vi ng may
s er ve a s a n example. I f t he problem i s t o pr event peopl e f r m
dr i vi ng drunk, i t i s i mpor t ant - t o r ecogni ze how l i t t l e- l l ke l i hood
t he r e 1s t h a t any i ndi vi dua l epi sode of drunkenness a t t he wheel
w i l l be det ect ed when i t occur s ( Bor kenst ei n 1974). The chr oni c
v i o l a t o r 1s c e r t a i n l y l i k e l y t o be caught sooner o r l a t e r , and
caught once, i s more l i k e l y t o be caught agai n. But most of t he
d r i v e r s r es pons i bl e f o r drunk dr i vi ng acci dent s a r e " f i r s t
of f ender s" i n terms of pr evi ous pol i c e detection--and de t e c t i on as a
r e s u l t of a n acci dent does not seem a powerful pr event i ve s t r a t e gy
(Ross 1981). Y e t major e f f o r t s t o l aunch e x t r a pol i c e on s p e c i a l
p a t r o l s i n t he l a t e ni ght dr i vi ng l a ne s where most s e r i ous drunk
dri vi ng acci dent e occur, e f f or t e t h a t can a t t r a c t media publ i c t y
wi t hout which t here w l l be l i t t l e prevent i va e f f e c t , a r e qui t e
expeneive (Levy e t a l . 1978; cf . Reed 1981). There a r e l i mi t e t o
how much of the pol i ce budget can be e hi f t e d i n t o drunk dri vi ng
det errence i f t he community i e not wi l l i ng t o forego o r reduce
pol i ce act i on on aeeaul t e , robberi ee , areon, drug t raneact i ons,
rapes, and s o f or t h. Ae i t et ands, of t he 10 mi l l i on a r r e e t e
annual l y recorded i n t he Federal Bureau of I nveet i gat i on c r i me index
f o r t he United St at ee, over 1 114 mi l l i on a r e al r eady f o r drunk
dri vi ng. Another 1 114 mi l l i on a r e f o r publ i c drunkenneee.
There i s consi derabl e sent i ment f o r i ncreaei ng t he drunk
dri vi ng penal t i es now on t he books, or f o r appl yi ng them wi t h f u l l e r
f orce i net ead of diepoeing of theee vi ol at i one eo f r equent l y wi t h
pl ea bargaine, di verei one t o t r ea tmen t, probat i on, and suspended
eentencee (Alcoholiem Report 1982a,b). But t her e a r e no empty j a i l
c e l l e awai t i ng drunk dri vere. J a i l cells a r e ecarce, expeneive
reeourcee t ha t t he j uet i ce eys t e m mus t marshal l car ef ul l y. Every
dec ei on t o imprieon eomeone f o r a l engt h of t i m e neceeear i l y meane
del ayi ng o r denying imprieonment f o r some ot her vi ol at or whose
convi ct i on could be eubj ect t o t hi e eanct i on. hen t he quest i on i s
whether we f r e e t he a r s o d e t o r t hi ef i n or der t o imprieon t he drunk
dr i ver , t he answer doee not come eaei l y.
Education, Alcohol, and Children. The ar ea of educat i on f aces
eomewha t s i mi l ar i e e we , but eomewhat di f f e r e nt onee a s well. The
rudiments of educat i on -- readi ng, wr i t i ng, and ar i t hmet i c -- a r e
t he pr i nci pal thinge that edi ool e a r e meant t o teach. The quant i t y
of educat i onal time t h a t can be devoted t o "heal t h and saf et y" i s
l i mi t ed. There i e l i t t l e doubt that t he s a f e and appropri at e use of
al cohol ehould be a n i mport ant pa r t of t hi e curriculum. The
queet i ons a r e what i s t o be t aught , and how?
What chi l dr en l e a n from t he i r t eachere i n echo01 i s l a r ge l y
how t o behave i n non-f a dl y- or i e nt e d envi r oment e, how t o work
eucces s f ul l y through a eer i ee of graded, progresei vel y more
d i f f i c u l t l eeeone, and how t o remember and make use of euch f a c t ua l
knowledge a s when Columbue landed i n t he New World. By e x e p l e ,
ca j ol er y, and di s ci pl i ne , t eachere t r a n mi t habi t e of though t , of
c i v i l i t y , and of i n t e r e s t i n t he pr act i ca1 world and i t s l eesons. By
eystem, t r i a l , and e r r or , par t i cul ar sldlls can be t rai ned. I n t he
cont ext of pr ohi b t i on f o r chi l dr en and detached profeseionaliem
among t eachere, what can eerve a s a l eeeon pl an i n eaf e and
appr opr i at e dri nki ng? I f o t her ar eae of curriculum a r e coneidered,
t he cont r as t becomes qui t e clear: i t i e not expected t ha t et udent e
w i l l l e a r n how t o mul t i pl y w i t hout pr a c t i cng mul t i pl i ca t i on t abl ee,
o r t hat anyone can l e a r n t o read wi t hout t ak ng booke home f o r et udy
and bri ngi ng homework i n f o r cr i t i ci em and prai ee? I f we wish
ctLil&en not t o dri nk a t al l , t hi e meesage can c e r t a i nl y be
t ranemi t t ed. But i f adul t e can t e11 chi l dr en nothing more than "not
u n t i l you' re ol der ", t h i s does n o t go ve r y f a r toward i nc ul c a t i ng
s a f e o r a ppr opr i a t e behavi or once t hey a r e ol der .
The most e f f e c t i v e b a s i s f o r educat i ng c hi l dr e n t o pr event
problems i n the us e of a l c ohol i s t o r ecogni ze that moet of them
wi l l have t o l e a r n f o r themselves, and what t hey need most
e s p e c i a l l y i s t he be ne f i t of a d u l t exper i ence and example i n gauging
t he t i me s , pl aces , amounts, and r i s k s i nvol ved i n dr i nki ng and n o t
dr i nki ng. Alcohol educat i on f o r s chool chi l dr en shoul d f ocus on
yr e s e nt s i t ua t i ons i n s t ead of t he d i s t a n t f ut ur e , and temper r e e pe c t
f o r l e g a l pr ohi bi t i on -- which needs t o be e t r e s s e d f o r i t s
pr o t e c t i ve s i gni f i cance (drunkenness i s a poor l e a r ni ng condi t i on)
-- wi t h r e s pe c t f o r t he r e a l exper i ences t h a t c hi l dr e n have, which
t hey must i n t e r p r e t and l e a r n t o c ont r ol f o r themselves.
Reducing Environmental Risk
Even t he most st r enuous e f f o r t s t h a t might be devot ed t o
reduci ng unsaf e o r i nappr opr i a te dr i nki ng pr a c t i c e s canno t be
expect ed t o e l i mi na t e o r r a d i c a l l y cur t a11 them. I f we a c c e pt t h i e
premi se, i t becomes s e ns i bl e t o expl or e pr event i ve p o l i c i e s t h a t a r e
desi gned t o reduce t he damage a s s oc i a t ed w i t h wha t ever dr i nki ng
pr a c t i c e s a c t u a l l y occur.
Thi s approach -- mani pul at i ng t he environment s o
t h a t r i s k s of harmful e f f e c t s a r e reduced even i n
the pr esence of drunken behavi or -- has been
char act er i zed a s "making t he worl d s a f e f o r drunks",
a c ha r a c t e r i z a t i on t h a t t ends t o evoke moral
uneasi ness o r even out r age i n some qua r t e r s , r oot ed
i n t he l ongst andi ng view t h a t drunkenness i s moral
e r r o r tha t shoul d ge t i t e j us t des er t a. . . . The
approach can be more a c c ur a t e l y, i f more awkwardly,
des cr i bed as "making t he world s a f e r f o r , and f r m,
peopl e who a r e a f f e c t e d by al cohol " (Moore and
Ger s t ei n 1981:lOO-101).
It i s n o t d i f f i c u l t t o under st and t he obj e c t i ons t h a t some
peopl e mi ght have t o p o l i c i e s t h a t do n o t seem t o a t t a & d i r e c t l y
t he causes of al cohol - r el at ed problems, b u t i n s t e a d seem t o t a c i t l y
a c c e pt exces s i ve o r 111-timed drunkenness and ar r ange t o make i t s
consequences les8 s t e r n. Aside from t he pr a c t i c a 1 poi nt t h a t '
depl or i ng a condi t i on does n o t make i t l e a s real, there are some
sound norma t i v e arguments de ending t h i s approach. Fi r e t,
pr ot e c t i on a ga i ne t t he coneequencee of drtinken behavi or i s
be ne f i c i a 1 n o t o n l y t o drunks. To s e l e c t a dr amat i c example: a n
i nt oxi c a t ed p i l o t , mechani c, bus dr i ve r , r a i l r o a d engi neer , o r
swi t ch ope r a t or menaces t he l i v e s of many o t he r s i n a ddi t i on t o h i e
o r he r own. Second, whi l e drunkenness may have a gr e a t e r vol unt ar y
component t han f a t i g u e , absent -mi ndedness, i r r i t a t i on, o r a pr evi ous
i nj ur y, t he r eeul t i ng i npai rment e and aesoci at ed r i eke of "human
er r or " a r e s i mi l ar . Meaeuree taken t o reduce t he harm of drunken
miehape w i l l reduce t he ha m of ot her niehape t o t he eame degree.
Fi nal l y, t here i e ample precedent i n ot her ar eae f o r
gover ment i nt er vent i on t o reduce diecomfort o r i l l ne e e w i t hout
epeci al regard f o r t he mor al i t y o r l e g a l i t y of cont r i but or y
act i one. Prevent i ve meaeuree a s w e l l a s t her apeut i c onee a r e used
t o cont r ol venereal di eeaee, wi t hout cavi l e o r ba r r i e r s concerning
mar i t al et at ue o r pa r t i c ul a r sexual pr act i cee. Nei t her ci gar et t e
enokere nor obese people a r e denied ot herwi ee-avai l abl e publ i c funde
f o r t reat ment of he a r t di sease, whi l e blood preeeure t eet i ng and
cardiopulmonary r es us ci t a t i on t r ai ni ng a r e encouraged even though
many -- indeed most -- su& vi ct i ms have been i ndul gent i n d i e t and
def i d e n t i n physi cal di s ci pl i ne.
The two pr i nci pal cat egori ee of envi r oment al r i e k a r e
i nt er per eonal hazarde and physi cal caeual t i ee. I n regard t o t he
f i r e t , t he most common impreeeion about drunkenneee and
i nt er per eonal c onf l i c t i s t ha t drunke endanger ot her s; ye t t here i e
nuch euggeet i ve evi dence t ha t i nt oxi cat i on l eade more of ten t o
vi c t i ni z a t i on of t he drunk than by t he drunk. "Rolling drunke" 1s a
eubet ant i al cri mi nal paetime; and a hi et or y of al cohol i sm can cos t
people i mport ant l i f e chancee regardl ese of t he i r cur r ent and
proepect i ve e t a t e of eobr i et y.
I n regard t o t he caeual t i ee, ei nce al cohol i nt oxi cat i on tends
t o make people ciumey and i nat t ent i ve, i t has been i mpl i cat ed t o
eone degree i n many Linde of trauma (Aarene e t a l . 1977 ): drownings,
burns, f a l l e , and nonentum i nj ur i e s , no t abl y motor vehi ci e
acci dent s. If everyday mat er i al e and nachinee were made l e e s l i k e l y
t o r i p , t r i p, bludgeon, o r burn people who might be l ee8 than f u l l y
e f f i c i e n t (whether due t o drunkenneee o r some o t her reason) ,
al cohol -rel at ed (and ot her ) caeual ties would be fewer. Furt her ,
"e i nce a l cohol-rela t ed caeual t i e e tend t o be concentra ted i n t he
noet severe cat egori ee -- dea t he and permanen t di s a bi l i t i e e --
e a f e t y improvemente w i l l a f f e c t al cohol -rel at ed i nj ur i e s moet
dramat i cal l y. " (Moore and Geret ei n 1981 :102).
The major example of e a f e t y t echnol ogi es t ha t can prevent a
l a r ge number of al cohol caeual t i ee a r e automobile eaf et y devi ces
t h a t i ncr ease t he craehworthiness of vehi cl ee wi t h r espect t o
occupant i n jury; e.g., aut omat i c res training-be1 t e ys teme
(lap-e houlder l oope) and "a i r bage" (i npact - t r i gger ed pneuma ti c
bar r i er s ) . There a r e , of couree, many craehes i n which no
re e t r ai ni ng devi ce would preven t mort al wounding , bu t i t would be
i n e u u c t i v e i f newe r epor t e of eeri oue t r a f f i c acci dent e i ndi cat ed
not onl y t he eobr i et y of t he dead and t he survi vore, but which were
wearing e e a t bel t e.
There are a number of ways i n which s a f e t y t echnol ogi es can be
advanced by government pol i cy: educat i ng consumers t o d e s i r e them,
sponsor i ng r es ear ch and development t o improve them, of f e r i ng
f avor abl e t a x i nc e nt i ve s o r c r e d i t s , r e qui r i ng t h a t manuf act ur er s
make them a va i l a bl e a s pai d opt i ons , o r r equi r i ng a l 1 aut omobi l ee t o
have them. A s i mi l a r range of pol i cy opt i ons 1s a va i l a bl e f o r o t h e r
s a f e t y devi ces (e. g. , household smoke de t e c t or s , "dead man"
c ont r ol s on t r a i n engi nes, s el f - ext i ngui s hi ng c i g a r e t t e s . ) There
seem t o be s u b s t a n t i a l grounds f o r t hose who a r e broadl y concerned
wi t l i pr event i ng al cohol problems t o t ake an i n t e r e s t i n s a f e t y
i s s ue s and pol i c i e s (Mosher and Mot t l 1981).
Conclusion
Thi s es s ay has out l i ne d a series of us e f ul a na l yt i c ,
normat i ve, and pragmat i c pol i cy concept s t h a t a r i s e i n connect i on
wi t h t he pr event i on of al cohol - r el at ed problems. The ef f e c t s o
a l c ohol t h a t come i n t o pl ay when consi der i ng t he s e p o l i c i e s have
been sket ched; t he na t ur e and s i gni f i c a nc e of governi ng i deas have
been descr i bed and i l l u s t r a t e d ; a scheme def i ni ng t ypes of p o l i c i e s
i n terms of t he i nst r ument s -- government programs o r mechanisms-
used t o achi eve them has been of f e r e d; and t h i s scheme ha s been
f i l l e d out wi t h some examples of pr event i ve pol i c i e s , cover i ng t he
pr i nc i pl e i s s ue s i nvol ved i n t h e i r s e l e c t i o n and i mpl ement at i on.
Cr eat i ng and car r yi ng out al cohol pol i cy w l l never approach
t h e pur i t y of ches s o r l abor at or y s ci ence, but p o l i c i e s do have
consequences which can be f o r b e t t e r o r worse. Well-organized
pr a c t i c a 1 t hi nki ng i s o f t e n pa r t of t h e di f f e r e nc e between b e t t e r o r
worse pol i cy r e s ul t s . It i s t he aim of t h e pr es ent pi ece t o a i d
such t hi nki ng .
DISCUSSANT
Mari l ynn Kat at sky
1 would l i k e t o t hank Dr . Ger s t ei n f o r h i s marvel ous, ver y
a r t i c u l a t e pr es ent at i on. Having r ead Alcohol and Publ i c Pol i cy
mysel f , 1 can appr eci at e j u s t how much work went i n t o d i s t i l l i n g t he
key concept s a nd- i s s ue s t h a t Dean hi ghl i ght ed f o r us today.
Bas i cal l y, 1 am he r e t o pr es ent t h e view from t he t r enches --
what i t i s l i k e out t he r e i n t he f i e l d -- and t o ask from t ha t
per s pect i ve whether t h i e paper has r el evance f o r t he c ount r i e s i n
t he Region of t he Americas.
Thi s whole di s cues i on of a l c ohol problems, as we have hear d,
shoul d be put i n t o t he cont ext of wh a t has been happening i n t he
a l c ohol f i e l d i n t he r egi on over , eay, t he pa s t 20 t o 30 year s . 1
would l i k e t o br i ng you up t o d a t e wi t h what has been happening i n
t h e p o l i t i c a l ar ena as we e e e it from t h e he a l t h s i d e , p a r t i c u l a r l y
where di s cues i ons on al cohol c ont r ol p o l i c i e s a r e j u s t begi nni ng t o
t a b pl ace.
It i s of i n t e r e e t t o not e t h a t i n J ul y, 1981 t h e Cent r al
American Mi ni s t e r s of Heal t h di scueeed t h i s i s s u e of al cohol and
al cohol c ont r ol , and Dr . Arroyo, who i s wi t h us t oday, pr esent ed a
revi ew of l e g i s l a t i o n i n t he Cent r al American i st hmus. I n that
review, he def i ned sme of t h e major i s s u e s that were p a r t i c u l a r l y
r el evant t he r e ; f o r example, t he f a c t t ha t t he r e was consi der abl e
emphasis on f i s c a l c ons i de r a t i ons i n t h e i r l e g i s l a t i o n . Many d i f -
f i c u l t i e s i n implementing t he l e g i s l a t i o n were di scuesed. Also,
Dr . Arroyo emphasized such problems a s t he l a c k of e va l ua t i on of
l e g i s l a t i o n and t he existente of a number of out dat ed and c onf l i c t -
i ng pol i c i e s .
As a r e s u l t of t he di s cues i ons i n Ce nt r a l America i n 1981, t h e
Ministers of Heal t h e e t f o r t h recommendations t o e s t a b l i s h i n t e r
di s c i pl i na r y, mul t i e e c t or i a l committees o r commissions which would
compile e xi e t i ng l e g i s l a t i o n , e va l ua t e i t e impact, and recommend
neceesar y l e g i s l a t i v e changes based on s c i e n t i f i c c r i t e r i a . Much of
what t hey recommended would be de e i r a bl e , but i t i s hi ghl y unl i kel y
t h a t t hes e c ount r i e s w i l l a c t u a l l y implement recommendations. One
recommendation wae l oweri ng of t he s p e c i f i c per cent age of al cohol i n
a l c ohol i c beverages a s a meane of reduci ng a l c ohol r e l a t e d problems.
Another wae t o promote t h e paesage of l e g i s l a t i o n t o r e qui r e
di esemi nat i on of i nf or mat i on on t he negat i ve e f f e c t s of a l c ohol
t hrough t he mas8 media and f or mal educat i onal system.
1 t hi nk t h e Cent r al American Mi ni s ter8 Conf er ence di s c us s i ons
r epr es ent a depar t ur e from t he t e nor and cont ent of pr evi ous
cons i der at i one of t h i s t opi c wherei n, f o r example, emphasis had been
pl aced on t he need t o do epi demi ol ogi cal r es ear ch on al cohol i sm, t o
adopt p o l i c i e s which would f a vor t r eat ment and pr event i on, and t o
devel op t he necesear y manpower
Cl ear l y t he change i n f ocus towarde al cohol - cont r ol - r el at ed
i e s w s i s i ndi c a t i ve t h a t r ecent HO i n i t i a t i v e s i n t h i s a r e a have
had some impact. Si mi l a r l y, t he Si xt h Meeting of t he Conference of
t i ni et er e Responsi bl e f o r Heal t h of t h e Caribbean Community, which
took pl ace i n Grenada i n J u l y 1980, r esol ved t h a t e f f o r t s " t o r educe
t he l eve1 of coneumption by per euaei on and educat i on a s wel l as
l e g a l and f i s c a l measures ehould be consi dered. " I n a ddi t i on,
conf er ence p a r t i c i p a n t s c a l l e d on t he me mb e r governments t o cons i der
banning al cohol a dve r t i s i ng i n t he mass media.
A t t h e na t i ona l l e v e l t he r e were a l s o some s t r ong i ndi c a t i ons
t h a t governments were moving towards c ons i de r a t i on of al cohol
c ont r ol pol i c i e s t h a t might reduce a l c ohol consumption i n t he
popul at i on, and concommitantly, t he r a t e of al cohol problems. 1
t hi nk we have seen i n Ar gent i na, f o r example, an i n t e r e s t on t he
pa r t of t h a t Government t o revi ew some of t he Uni t ed St a t e e and
Canadian exper i ence i n pa r t i c ul a r . It i s our under st andi ng t h a t
i nt r oduc t i on o some form of a l c ohol c ont r ol l e g i s l a t i o n 1s now
pending i n Argent i na.
While few c ount r i e s r e a l l y have looked ver y c a r e f ul l y a t
methods of c ont r ol l i ng t he a v a i l a b i l i t y of a l c ohol i c beverages,
s e ve r a l have i n s t i t u t e d programs t o i nf l ue nc e and r educe consumer
demand. There a r e a number of r easons why t he r e i s t h i s emphasis on
demand. F i r s t of a l l , i t i s something t h a t t he h e a l t h s e c t o r can
i nf l uence. It 1s something on which peopl e working i n t he Heal t h
Mi ni st r y and t he Educat i on Mi ni st r y can g e t t oge t he r and a c t u a l l y
have a n impact. They can devel op a program and set u t up, and i t
r e a l l y does not t a ke a whole l o t of coor di nat i on wi t h ot he r
s ect or s . Obt ai ni ng t he consensus of t he Mi ni s t er s i n a va r i e t y o
Mi ni s t r i e s , of cour se, would be d i f f i c u l t because you have a number
of competing i n t e r e s t s i nvol ved.
There i s one book 1 t hought 1 would mention i n passi ng si mpl y
because 1 l i ke d i t s o much, and 1 don' t know t ha t i t has got t e n a s
much pl ay i n t he di s cus s i on t oday a s i t shoul d. Thi s 1s t he
Addi ct i on Research Foundation book on Publ i c Educat i on and Soc i a l
Pol i cy, which 1 found very he l pf ul i n under st andi ng some of t he
f or c e s a t work i n Lat i n America. The book hi ghl i ght s t h e importance
of publ i c a t t i t u d e s i n t he pol i cy making pr ocess and o u t l i n e s some
of t he key i s s ue s very c l e a r l y.
While one es t i mat es a t i me l a g of about 20 t o 30 ye a r s i n t he
more developed c ount r i e s , such a s Canada, betweem c e r t a i n r esear ch
f i ndi ngs and subsequent changes i n publ i c a t t i t u d e s and pol i cy, t he
l a g 1s much l onger i n t he l e s s e r developed count r i ee. Publ i c
educat i on i n t he more developed c ount r i e s w i l l s hor t e n t h a t l ag.
However, t he obs t a c l e s , not onl y t o publ i c educat i on but t o a c h i e ~
i ng t he necessar y l e v e l of s ophi s t i c a t i on i n t he popul at i on, a r e a
l o t more formi dabl e i n t he less developed count r i es .
Another r eason why we a r e seei ng l e s s i n t e r e s t on a l c ohol
c ont r ol pol i c i e s and a g r e a t e r i n t e r e s t on i nt e r ve ni ng wi t h consumer
demand 1s t h a t i n La t i n America t he r e has been cons i der abl e empha-
sis on t he di s e a s e concept of al cohol i sm. Indeed, t h a t concept 1s
not f u l l y accept ed i n a l 1 c i r c l e s ; ye t i t 1s t h e most pr eval ent
concept t ha t we f i nd i n Lat i n America.
In our survey of publ i c a t t i t ude s about al cohol i sm and t he
causes of al cohol i sm gener al l y, people i n f i ve count r i es we eurveyed
were of t he opi ni on t ha t alcoholiem l e eol el y t he r eeponei bi l i t y of
t he i ndi vi dual . For t he maj or i t y of t hose surveyed, i f i t 1s not
eome t ype of moral queet i on, t hen i t 1s some s o r t of di sease
quest i on, but i t i mpl i cat ee t he i ndi vi dual a s opposed t o soci et y.
So, 1 t hi nk you have t o recognize and grappl e with publ i c a t t i t ude s
about alcoholism, because t hey s er i ous l y a f f e c t t he way a government
i s going t o formul at e pol i cy.
Another i s s ue we might mention l e that t her e a r e a l o t of
veeted i nt e r e e t e i n t he di eeaee model of al cohol i sm i n Lat i n
America. There a r e many people who have worked l ong and hard t o
make t he di seaee model of al cohol i sm more widely accept ed, and thoee
people de f i ni t e l y have much vest ed i n promoting t ha t concept. You
a l s o have Alcoholice Anonymous which represent e a very important
f or ce i n t he Region 1 t hi nk, i n terms of shaping publ i c a t t i t ude s i n
general ; t ha t group would cer t ai nl y not have very much t o gai n f r m
a s h i f t i n t hi nki ng on t h i s poi nt .
I n any case, i n looking towarde t he f ut ur e i n t h i s Region, 1
would l i k e t o say a b i t about what we might expect t o see i n terms
of f ut ur e l e gi s l a t i on and pol i ci ee. I n t he s hor t term, 1 don' t
t hi nk that we a r e going t o see any s i gni f i cant del i ber at e at t empt s
a t changing eupply. 1 t hi nk we can expect t o cont i nue t o see
emphasie on t he demand ei de, wi t h an i ncr easi ng number of educa-
t i onal programs. Costa Rica is one example of a country wi t h a very
ext emi ve educat i onal program on al cohol . 1 t hi nk we a r e going t o
continue t o s ee many of t hese.
We may begin t o eee a few governmente t aki ng s t eps i n t he
ar eas of t axat i on, reduct i on of al cohol cont ent , and s o on.
However, 1 don' t t hi nk t her e w i l l be any very eyst emat i c, broad-
based at t empt s a t reducing al cohol problems through goverment
i nt er vent i on.
1 must agai n i n s i s t t hat my remarks a r e t o t a l l y personal
opinione. 1 am not a pol i t i c a l s c i e nt i s t , and 1 have checked t he
background of everybody i n t h i s room t o make eure t ha t we di d not
have any pol i t i c a l s c i e nt i s t e here; t her ef or e, 1 f e e l t ha t my
p o l i t i c a l opinione a r e e nt i r e l y a s good ae anyone e l s e ' s guess. To
summarize, 1 j us t do not t hi nk t ha t we a r e going t o see a t rend
toward supply reduct i on s t r a t e gi e e and pol i ci es i n Lat i n America f o r
a very long time.
DISCUSSANT
I r vi ng Rootman
There 1s no doubt i n my mind t h a t t h e aim o Dr . Ge r s t e i n' s
e xc e l l e nt paper has been and w i l l cont i nue t o be achi eved. That is,
drawing on t he out st andi ng work of t h e Nat i onal Academy of Sci ences
panel on Al t e r na t i ve Pol i c i e s Af f ect i ng t he Pr event i on of Alcohol
Abuse and Alcoholism, it most c e r t a i n l y has ai ded us i n or gani zi ng
our pr a c t i c a 1 t hi nki ng about al cohol yr event i on p o l i c i e s and w i l l
a i d o t h e r s out s i de o t h i s room. 1 t hi nk t h a t we a l 1 owe Dr .
Ger s t ei n and t he ot he r pa r t i c i pa nt s i n t he panel , some of whom are
among us , a s i nc e r e vot e of t hanks f o r t h e i r e f f o r t s . They have
succeeded i n i l l umi na t i ng t he l andscape o pr event i ve al cohol
p o l i c i e s wi t h a l i g h t of unpar al l el ed i n t e n s i t y and c l a r i t y . I n
f a c t , 1 f i nd ver y l i t t l e i n t he paper which has been pr esent ed, o r
i n t he r epor t on which i t l eans , wi t h which 1 di s agr ee.
Having s a i d t h i s , however, 1 do have some concerne and
comments about t he paper and t h e r epor t which 1 would l i k e t o br i ng
t o your a t t e nt i on.
n i e f i r s t has t o do wi t h t he emphasis on government and i t s
r o l e i n devel opi ng and implementing al cohol pol i c i e s . While 1 would
be t he l a s t person t o deny t h a t government has a c r i t i c a 1 r o l e t o
pl ay i n t h i s f i e l d , 1 do f e e l t h a t governments a r e not t he onl y
bodi es t h a t can devel op and implement pol i c i e s f o r t h e pr event i on o r
management of al cohol problems. Such pol i c i e s can be and a r e
developed and implemented by a va r i e t y of u n i t s a t d i f f e r e n t l e v e l e
i ncl udi ng school s, t r eat ment agenci es, vol unt ar y a s s oc i a t i ons , work
or gani zat i ons , and community groups. It might even be argued t h a t
such bodi es a r e pot e nt i a l l y more e f f e c t i v e t han governments i n t ha t
t hey a r e c l os e r t o t h e s i t u a t i o n s of concern.
It was, i n f a c t , t h i s ki nd of t hi nki ng which st i mul at ed t he
development of t he WHO Community Response t o Alcohol Problems
pr oj e c t which 1 have had t he pr i vi l e ge o managing f o r t he pa s t two
and a ha l f year s. Thi s pr oj e c t was i n i t i a t e d wi t h suppor t rom t h e
Nat i onal I n s t i t u t e on Alcohol Abuse and Alcoholism i n 1976. To
da t e , t hr e e c ount r i e s -- Mexico, Scot l and and Zambia -- have
pa r t i c i pa t e d. Dr . Campillo pr esent ed some o t he f i ndi ngs o one
st udy c a r r i e d out a s pa r t of t he Mexican pr oj e c t . While t heee
f i ndi ngs a r e c e r t a i n l y i n t e r e s t i n g , t hey do not f u l l y expr es s t he
s i gni f i c a nc e o t he pr oj e c t . Its i mport ance i s pr i mar i l y t o
s t i mul a t e appr opi at e r esponses t o a l c ohol problems, i ncl udi ng t hose
of a pol i cy nat ur e, a t l oc a l , i nt er medi at e, and na t i ona l l e ve l s .
Aithough t he pr oj ect 1s e t i l l ongoing i n t he t hr ee count r i ee,
t her e a r e some s i gns t hat i t has al r eady eucceeded i n et i mul at i ng
reeponsee a t a l 1 of t hese l evel s . For i nst ance, i n Zambia, a s a
r eeul t of t he pr oj ect , Community Action Groupe have been eet abl i ehed
i n t he par t i ci pat i ng r ur a l and urban communities. These groups
d i f f e r i n t he i r compoeition, concerns, and approaches to' al cohol
problems. A l 1 of them, however, have t aken al cohol probleme
eeri ouel y and have attempted t o develop eol ut i ons t ha t f i t t he l ocal
circumstancee, drawing i n par t on t he i nformat i on obt ai ned a s par t
of t he community reeponse proj ect . As an example, a goal of t he
group i n one community was t o reduce home brewing. Thi s group
arranged f or addi t i onal e t a l l e a t t he market 80 t hat home brewers
could se11 ot her producte, t hereby removing t he economic neces s i t y
f or home brewing. We do not a s yet h o w whether t h i s act i on wae
euccessf ul , but i t i l l u s t r a t e s how a l ocal group can develop and
implement a prevent i ve pol i cy.
In addi t i on, i n both Mexico and Zambia nat i onal meetings have
been held which consi dered t he i mpl i cat i one of t he pr oj ect f or
nat i onal pol i ci es t o reepond t o al cohol -rel at ed problems. While not
a l 1 of t he recommended pol i ci es emerged di r e c t l y f rom t he completed
et udi ee, many di d, and t he pr oj ect served a s an opport uni t y t o focus
nat i onal a t t e nt i on on al cohol problems and yossi bl e prevent i ve
pol i ci ee. het her o r not such pol i ci es w i l l be implemented remains
t o be seen, but it should be noted t ha t not a l 1 of t he
recammendatione requi red government act i on. Same were di r ect ed t o
act i on by ot her bodies such a s vol unt ary organi zat i one and
i nduet ry. It may i n pr act i ce t ur n out t ha t more w i l l be
accomplished by t he pol i cy act i ons of euch i ns t i t ut i ons than by
government .
Thus, t he community responee pr oj ect suggest s t o me t ha t t he
development of pol i ci es t o prevent al cohol problems by non-
governmental bodiee i e possi bl e and des i r abl e. 1 am c e r t a i n t ha t
a l 1 of you can t hi nk of ot her examples t o eupport t hi e poi nt . It,
t her ef or e, would be a grave e r r or i f we l o s t s i ght of such
poe s i bi l i t i e e by a n excl uei ve focue on government. Fort unat el y,
most of t he principies and concepte a r t i c ul a t e d i n D r . Ger st ei n' s
paper can be appl i ed t o pol i cy development a t t hese ot her l e ve l s a s
wel l .
A second concern 1s t ha t most of t he experi ence descri bed i n
t he Nat i onal Academy of Science r epor t and cr yet al i zed i n Dr .
Gerst ei n' e paper 1s North American or European. Thi s probably does
not make much di f f er ence wi t h regard t o t he rel evance of t he
concept ual framework f o r ot her count ri ee. It may, however, be very
important wi t h regard t o t he rel evance of t he par t i cul ar pol i ci es
t ha t have been gi ven a s examples. A s Dr . Caetano c l e a r l y poi nt ed
out i n hi s paper, circumetances i n Lat n American count r i es ar e
s ubs t ant i al l y di f f er ent from thoee i n t he United St at es and Canada.
The community r esponse pr oj e c t demonst rat ed a s i mi l a r poi nt . Dr .
Smart ' s concl uei on t he r e f or e , t h a t "it i s ver y doubt f ul t h a t
r e s u l t s from t he more developed world can be appl i ed wi t hout change
t o La t i n American and t he Caribbean" must be h e a r t i l y endorsed and
emphasized.
It i s c l e a r t o me from Dr . Ge r s t e i n' s pr e s e nt a t i on t h a t he
a gr e e s wi t h t h i s poi nt of view, but ot he r s may not . It i s t hus
necessar y t o r e i t e r a t e i t whenever pos s i bl e and t o t r y t o ens ur e
t h a t i t s i mpl i cat i ons a r e recogni zed i n c ount r i e s t h a t may wish t o
devel op pr event i ve pol i c i e s .
One such i mpl i cat i on i s t h a t a c r i t i c a 1 s t e p i n development of
pr event i ve pol i c i e s by any count r y shoul d be a n e a r l y at t empt t o
de f i ne t he magnitude and na t ur e of t h e a l c ohol problems t h a t t he
count r y i t s e l f i s f aci ng. Recent WHO work i n t h i s a r e a , i ncl udi ng
t he community response pr oj e c t , may be he l pf ul i n t h i s r egar d.
Another i mpl i cat i on i s t h a t i t i s i mport ant t o e va l ua t e t h e
impact of pr event i ve p o l i c i e s t r i e d i n p a r t i c u l a r devel opi ng
c ount r i e s and t o make t he r e s u l t s a va i l a bl e t o ot he r devel opi ng
c ount r i e s . The est abl i shment of r e gi ona l c l e a r i ng houses a s
suggest ed by Dr . Caetano i s one mechanism f o r accompl i shi ng t hi s .
Another might be r e gi ona l workshops o r conf er ences on a l c ohol pol i c y
development which coul d be desi gned t o s har e not onl y t he r e s u l t s of
r es ear ch, but a l s o t h e exper i ences i nvol ved i n pol i cy development
and implementation.
mi s b r i ws me t o anot her concern a r i s i n g from Dr . Ger s t ei n' e
paper--namely, how does, o r shoul d, a government o r ot he r body
a c t u a l l y go about devel opi ng and implementing a l c ohol pr event i on
pol i c i e s ? Unf or t unat el y, Dr . Ge r s t e i n' s paper i s s i l e n t on t h i s
quest i on, but i t i s a n i mpor t ant one and i t must be addr essed i n
or der t o f u l l y underst and why al cohol pol i cy development can never
approach t h e pur i t y of chess o r l a bor a t or y sci ence. Perhaps t h i s i s
a t opi c which we might cons i der i n our di s cus s i ons , a s 1 am s ur e we
a l 1 have some pr a c t i c a 1 exper i ences t o br i ng t o bear on i t . Une
i de a which we may, i n p a r t i c u l a r , wi sh t o consi der i s t he val ue of
na t i ona l o r sub- nat i onal coor di nat i ng committees t o devel op al cohol
pol i c i e s .
A f i n a l concern which 1 have wi t h Dr . Ge r s t e i n' s paper has t o
do wi t h t he emphasis on al cohol . While such a n emphasis i s c e r t a i nl y
under st andabl e i n terms of t he mandate of t he Nat i onal Academy o
Sci ences panel , 1 wonder i f i t doesn' t t o some e xt e nt i n h i b i t our
c r e a t i v e t hi nki ng about yr event i ve pol i c i e s . Aiter a l l , we know
from our r es ear ch t ha t al cohol use c ova r i e s wi t h ot he r h e a l t k
r e l a t e d behavi our s such a s smoking, cannabi s use, n u t r i t i o n a l , and
sexual pr a c t i c e s . Thus, anot her pos ei bl e pr event i ve s t r a t e gy i s t o
at t empt t o i nf l uence al cohol consumption and a s s oc i a t e d consequences
by i nf luencing ot her health-comprieing or health-enhancing behav-
i oure. In t he terminology ueed by Dr . Gerst ei n, euch a et r at egy
might be descri bed a s "ehaping dri nki ng pr act i cas i ndi r ect l y. "
Al t er nat i vel y, one might r e f e r t o i t a s a "heal t h yromotion
et rat egy. " Such a et r at egy c e r t a i nl y has i mpl i cat i one f o r pol i cy
development .
This 1s not t o eay t h a t t he s t r a t e gi e e out l i ned by Dr . Cer et ei n
should not be pureued. They ehould however, be pursued wi t h due
regard t o circumetances and conei derat i on of ot her pos s i bi l i t i e e .
TIlE INTERNATIONAL STUDY OF ALCOHOL CONTROL EXPERIENCES (ISACE):
SUMHARY OF THE FINAL REPORT
Jamee F. Moeher
The I nt er nat i onal Study of Alcohol Control Experiencee
(ISACE), which was conducted wi t h t he hel p and coordi nat i on of t he
World Health Organi zat i on' e European r egi onal of f i c e , brought
t oget her al cohol -pol i cy reeearchere from eeven countriee--the United
S t at ee, Canada, I r el and, Finland, Poland, Swi t zerl and, and Holland.
Its purpoee wae t o study wi t hi n an hi e t or i c a l frame t he
r el at i ons hi pe between al cohol cont r ol pol i ci ee, dri nki ng pat t er ne,
and al cohol -rel at ed probleme i n di f f e r e nt eoci et al set t i nge. The
etudy extended from 1978 t o 1981; i t r eeul t ed i n a two-volume
r epor t , severa1 dozen reeearch papers, and a weal t h of hi e t or i c a l
and s t a t i s t i c a l dat a. For my pr eeent at i on today, 1 w i l l First
br i e f l y descr i be t he background t o t he etudy, i ncl udi ng i t s or i gi nal
goal 8 and methodology, and t hen w i l l r epor t i t e major f i ndi ngs and
conclueions.
To some ext ent , t he foundat i on f or t he ISACE pr oj ect was l a i d
by an e a r l i e r pr oj ect i nvol vi ng Fi nni eh, Canadian, Br i t i eh,
Norwegian, and U.S. reeearchere which cuiminated i n t he 1975 r epor t
Alcohol Control Pol i ci ee i n Publ i c Health Perepect i ve (known a s t he
Purpl e Book). That st udy documented two important r el at i onehi pe:
f i r e t , t he st udy found st r ong evidence t ha t coneumption i n a
popul at i on i nfl uencee t he r a t e of long-tenn physi ol ogi cal
complicatione from dri nki ng, euch a8 ci r r hoei s ; eecond, a
par t i cul ar popul at i on' s r a t e of coneumption wae found t o be
i nfl uenced by s oc i e t a l cont r ol e of al cohol a va i l a bi l i t y, notably
pri ce. The reeearchere concluded: "changee i n t he over al l
coneumption of al cohol i c beveragee have a beari ng on t he heal t h of
t he people of any soci et y. Alcohol cont r ol meaeuree can be used t o
l i mi t coneumption: thue cont r ol of al cohol a va i l a bi l i t y becomes a
publ i c heal t h i s s ue ."
The Pur pl e Book was wr i t t e n i n t h e cont ext of a worldwide r i e e
i n al cohol consumption dur i ng t he pr ecedi ng cent ur y and was a
r a d i c a l depar t ur e from t he wel l - est abl i shed d i s i n t e r e s t i n al cohol
c ont r ol pol i c i e s among most publ i c he a l t h policy-makere. The
di s eas e model of al cohol i sm, which ha s provi ded t he bas i c framework
f o r most pol i cy deci s i ons , has r e l i e d v i r t u a l l y excl uei vel y on
t r eat ment and educat i onal s t r a t e g i e s f o r deal i ng wi t h al cohol -
r e l a t e d problems. The r e p o r t ' s aim was q u i t e e x p l i c i t l y t o provi de
new a l t e r n a t i v e pr event i on approaches. The r es ear cher e s t a t e d:
"...it w i l l have ser ved i t s purpose i f i t s t i mul a t e e debat e and, i n
t he procesa, l e a ds t o a renewed i n t e r e s t i n t he pot e nt i a l importance
of c ont r ol pol i cy i n t he pr event i on of al cohol problems" (p. 12).
I n t h i s aim, i t may be consi der ed t o have been q u i t e succesef ul .
For i net ance, i n t he l a s t year e of t he 1970s a t t i t u d e s and
a c t i v i t i e s of t he World Heal t h Or gani zat i on i n t h e a l c ohol a r e a
s h i f t e d q u i t e dr amat i cal l y t o i ncl ude s u b e t a n t i a l a t t e n t i o n t o
a l c ohol consumption l e v e l s and al cohol c o n t r o l p o l i c i e s a s i mport ant
el ement s of a publ i c he a l t h approach. Thi s s h i f t cul mi nat ed i n a
1979 WHO Expert Committee r e por t , wi t h recommendations r egar di ng t h e
publ i c he a l t h a s pe c t s of c ont r ol pol i c i e s i n more sweepi- and more
d i r e c t l y p o l i t i c a l tems t han found i n t he 1975 r e por t . I n t he
United St a t e s -- a f t e r a l ong per i od o avoi dance on t he pa r t of t he
publ i c he a l t h est abl i shment -- s e r i oue di s c us s i on of t he i s s u e s
i nvol ved has r e c e nt l y emerged, i ncl udi ng t he r e c e nt Nat i onal Academy
of Sci encee panel r e por t t i t l e d Al cohol and Publ i c Pol i cy (Moore and
Ger s t ei n 1981).
The Pur pl e Book was onl y an i n i t i a l s t e p i n t h e under et andi ng
of al cohol c o n t r o l exper i ences from a publ i c he a l t h per s pect i ve-
Two i mpor t ant dimensions were most appar ent l y l acki ng i n t he 1975
st udy: t he r e l a t i ons hi p of cont r ol e, consumption, and s o c i a l ( a s
opposed t o physi ol ogi cal ) problems r e l a t e d t o a l c ohol ( dr unk
dr i vi ng, acci dent e, work, f ami l y l i f e , e t c . ) ; and a h i s t o r i c a l and
comparat i ve a na l ye i s of t he impact of c u l t u r a l , p o l i t i c a l and
s o c i e t a l f a c t o r s on t hese t hr ee key va r i a bl e s .
ISACE' s primary agendas concerned t hese two dimensione. Thus
i t s met hodol ogi cal emphasie was on under t aki ng comparat i ve case
s t u d i e s o na t i ona l ( or r e gi ona l i n t he i net ancee of Ca l i f or ni a and
Ont ar i o) exper i ences, c e nt e r i ng on t he per i od of worldwide r i s i n g
consumption from 1950 t o 1975. An ambi t i ous program o r es ear ch
da t a c o l l e c t i o n focused on a l c ohol c ont r ol s , consumption, and
consequences a s wel l a s p o t e n t i a l l y expl anat or y background informa-
t i on. As t he pr oj e c t pr ogr essed, t he unique h i s t o r i c a l exper i ences
found i n each s t udy s i t e became obvious. The p a r t i c i p a n t s t he r e f or e
deci ded t ha t t he f i n a l r e por t needed two volumes: one t o i ncl ude
t he seven i ndi vi dual c a s e s t udi e s , and anot her t o at t empt t o
i nt e gr a t e t he f i ndi ngs of t h e s t udy i n a comparat i ve frame.
Aithough ISACE served t o emphasize t he c u l t u r a l speci f i c i t y of
dr i nki ng pat t er ns , probleme, and al cohol c ont r ol pol i ci ee, many
uni f yi ng t r ends can a l s o be r epor t ed acr os s s t udy s i t e e . 1 wi l l
revi ew t he hi ghl i ght e very br i ef l y. There were shar p i ncr eas es i n
per c a pi t a consumption i n a l 1 pa r t i c i pa t i ng count r i es , wi t h t he
gr e a t e e t i ncr eas es occur r i ng i n count r i ee wi t h t he loweet
coneumption r a t e s a t t he begi nni ng of t h e s t udy period. Alcohol
became more i nt egr at ed i n t o fami l y and s o c i a l l i f e , and t he number
of dr i nki ng occasi ons i ncreased. These broad changee, however, di d
not r epl ace t r a d i t i o n a l dr i nki ng pat t er ns . The st udy s i t e s , de s pi t e
experi enci ng t h i e uni f yi ng t r end toward an " i nt er nat i onal " dr i nki ng
c ul t ur e , a l 1 mai nt ai ned t h e i r c u l t u r a l di s t i nct i venes s . The new
dr i nki ng occaei one, new beverages, and new dr i nki ng e t yl e e were
i ns t ead added ont o t he exi et i ng, t r a d i t i o n a l dr i nki ng cul t ur e.
Changing dr i nki ng pat t er ns , t hen, cons t i t ut ed one aepect of
t he broad changes i n l i f e e t y l e and c u l t u r a l pa t t e r ns t h a t occurred
i n t h i e peri od. The r a t e e of dr i nki ng problem i ndi c a t or s changed
si mul t aneouel y. ( 1 should her e di gr e s s f o r j us t a moment t o eay
ISACE used an "alcohol-probleme" approach, i n which s pe c i f i c al cohol -
r e l a t e d damagee were di saggregat ed. The pr oj ect deci ded not t o
at t empt t o def i ne "alcoholiem, " not i ng t he varyi ng approaches t o
t h a t concept . I nst ead we choee t o t r e a t al cohol i sm a s a s epar at e
al cohol problem.) The ISACE pr oj ect grappl ed, of t e n unsucceesful l y,
wl t h t he d i f f i c u l t y of i nt e r pr e t i ng problem i ndi cat or s , i ncl udi ng
t hose f o r al cohol i sm, acr os s c u l t u r a l s e t t i ngs . Aicohol problems
were viewed d i f f e r e n t l y i n each s oci et y, and t he methods of def i ni ng
them and recordi ng t h e i r ext ent made comparieons extremely
d i f f i c u l t . Even t he most r e l i a b l e s t a t i s t i c a l i ndi c a t or s --
al cohol - r el at ed c i r r h o s i s and t r a f f i c deat hs -- were not t r eat ed
uniformly acr ose st udy s i t e s . S t a t i s t i c s concerni ng t r ends i n t h e
r a t e e of al cohol i sm, t reat ment admi ssi ons , and publ i c drunkenness
a r r e s t a were t he l e a s t r e l i a b l e and t he moet l i k e l y t o r e f l e c t
changes i n t he s oc i e t a l handl i ng of al cohol problems.
The ISACE st udy documented t hes e d i f f i c u l t i e s and at t empt ed t o
use them t o t h e i r best advantage. Severa1 t r ends were di scovered:
a ) a l 1 st udy s i t e s di d r epor t i ncr eas es i n c i r r h o s i s deat hs and
al cohol - r el at ed t r a f f i c f a t a l i t i e s , al t hough t he i ncr eas es were not
d i r e c t l y pr opor t i onal t o i ncr eas es i n per c a p i t a consumption; b)
dr i nki ng problems became l e s e s t r i c t l y confi ned t o s o c i a l out cas t s
and v i e i b l y devi ant subgroups; c ) t h e s o c i a l handl i ng of al cohol
problems, a s w e l l as t he c u l t u r a l per cept i ons of t hes e problems,
changed r a di c a l l y dur i ng t he st udy per i od; d) t r eat ment f a c i l i t i e s
expanded r api dl y , and t h i s t r end i ncl uded a g r e a t pr ol i f e r a t i on i n
t ypes of al cohol - r el at ed ser vi cee, wi t h a concomitant decreaee i n
t he r o l e of pol i ce and s o c i a l a ut hor i t i e s . I nt e r e s t i ngl y, t hes e
t r ends were found t o a t l e a s t some ext ent i n a l 1 et udy s i t e s ,
al t hough t he pa r t i c ul a r mixee of var i ous problems found i n each s i t e
d i f er ed markedly. Those mixes remained d i s t i n c t i v e dur i ng t h e
et udy peri od deepi t e r a di c a l changes i n t h e i r composition.
ISACE descr i bed t he most r e c e nt t r end concerni ng problems
management a s a s h i f t of emphasis from " t he bot t l e " t o " t he man."
Alcohol problems became a ma t t e r def i ned i n terme of s p e c i f i c
i ndi vi dua l de f e c t s , which meant t h a t t he r e was no need t o c ont r ol
t he dr i nki ng of t he va s t ma j or i t y of dr i nker s . The t r ends
concerni ng c ont r ol s t r u c t u r e s i n t he s t udy sites r e f l e c t e d t h i s new
i n t e r p r e t a t i o n of a l c ohol problems. Cont r ol s t r uc t ur e s gener al l y
accommodated, o r a t l e a s t di d not i n t e r f e r e wi t h, t he l a r g e
i nc r e a s e s i n per c a p i t a l consumption and number of dr i nki ng
occasi ons. Because of t he wide v a r i a t i o n i n c o n t r o l e t r u c t u r e s
a c r os s st udy sites, t h i s accommodation took many d i f f e r e n t forms.
For example, i n Fi nl and r e t a i l expansi on r equi r ed major l e g i s l a t i v e
reforme, i ncl udi ng l aws per mi t t i ng s a l e s i n r e s t a ur a nt s and
off-premi ses r e t a i l shops i n r u r a l communities. I n Ca l i f or ni a and
Ont ar i o gr adual l ooseni ng of l i c e ns i ng r e s t r i c t i o n e occur r ed, whi l e
i n Swi t zer l and and Holland l i t t l e l e g i s l a t i v e a c t i on was neceesary.
Cont r ol s t r u c t u r e s , t hen, ge ne r a l l y responded t o economic
f a c t o r s r e l a t e d t o t he changes i n t he al cohol market i t e e l f . A t t he
pr oduct i on l eve1 t he al cohol i ndus t r y became i ncr eas i ngl y concen-
t r a t e d , a s l o c a l and smal l - scal e pr oduct i on became economi cal l y more
d i f f i c u l t . Agr i cul t ur a1 p r i o r i t i e s pl ayed a l a r ge pa r t i n de f i n %
t h e producing i ndus t r y' s r o l e i n t he economy, which us ua l l y r e s ul t e d
i n var i ous measures t o expand yr oduct i on. The r e t a i l s t r u c t u r e a l e o
wi t nessed dr amat i c changee. dew o u t l e t s emerged, a s al cohol became
a s s oc i a t e d wi t h var i ous new l i f e s i t ua t i ons . Lei s ur e i ndus t r i e s ,
r e s t a ur a nt s , s por t 8 and a r t e promot ers a l 1 became i nc r e a s i ngl y
dependent on al cohol s a l e s . A s t he number and s i z e of t hes e vest ed
i n t e r e s t s i n al cohol i ncr eas ed, s o di d t h e i r i nf l uence i n na t i ona l
a f f a i r s . Thus t he t r end toward i ncr eased pr oduct i on and di s t r i bu-
t i o n of a l c ohol tended t o f u e 1 i t s e l f , a s governments found i t much
e a s i e r t o open new o u t l e t s and manufact uri ng est abl i shment 8 t han t o
redepl oy e x i s t i n g ones.
A s t he s e f i ndi ngs i ndi c a t e , ISACE became i n p a r t a n e xe r c i s e
i n docurnenting di ve r s e economic, s oc i a l , p o l i t i c a l , and c u l t u r a l
f a c t o r s which i nt e r pl a y wi t h dr i nki ng pr a c t i c e s , problems, and
a l c ohol c ont r ol s t r uc t ur e s . The dr amat i c changes i n dr i nk ng
pr a c t i c e s r e f l e c t cor r espondi ng changes i n l i f e s t y l e s and l e i s u r e
a c t i v i t i e s ; t he emergence of t h e wel f ar e s t a t e had a profound impact
on t he d e f i n i t i o n and measurement of al cohol - r el at ed problems;
di ve r s e economic and h i s t o r i c a l f a c t o r s hel ped det ermi ne changee i n
t h e c o n t r o l s t r u c t u r e s i n r esponse t o an i ncr eased demand f o r
al cohol .
Thi s pi c t ur e t r a ns l a t e d i n t o consi der abl e uncer t ai nt y
r egar di ng t he r e s ol ut i on of ISACE's o r i g i n a l assi gnment . We found
t i i at a gi ven c ont r ol r e gul a t i on - minimum dr i nki ng age, r e t a i l
pr a c t i c e s , t a xa t i on pol i c i e s , e t c . -- had var yi ng i mpact s i n
d i f f e r e n t s oc i e t i e s . Although ISACE wae a bl e t o concl ude t h a t
r e l a t i ons hi ps di d e x i s t between dr i nki ng yr act i ces , problems, and
c ont r ol pol i c i e s , l i t t l e gui dance was fort hcomi ng concerni ng t hose
r e l a t i ons hi ps on an a b s t r a c t l evel .
Thi s canpl exi t y and uncer t ai nt y, however, d i d not mean t ha t
t he common experi ences that were found di d not provi de i mport ant
i mpl i cat i ons f o r prevent i on pol i cy. ISACE o f f e r s s i x bas i c
concl usi ons t o i t s i nt e r na t i ona l audi ence f o r cons i der at i on i n
devel opi ng al cohol pol i c i e s :
n i e s t a t e ' s dual r o l e s -- economic and he a l t h -- r egar di ng
al cohol have been c a r e f ul l y separ at ed duri ng t he l a s t t hr ee
decades. t i eal t h i s s ue s car r y l i t t l e weight i n t hose
agenci es det ermi ni ng economic pol i cy regardi ng al cohol , and
heal t h and wel f ar e agenci es gener al l y i gnor e economic
i s s ues . Because cont r ol measures do a f f e c t t he incidente
of var i ous dr i nki ng problems, even i f i n a complex and
c u l t u r a l l y speci f i c manner, t hes e two agency f unct i ons need
t o be combined i n pa r t i c ul a r s o c i e t a l s e t t i ngs .
2) Pr event i ve al cohol p o l i c i e s provi de a des i r abl e a l t e r na t i ve
t o t hose s t r a t e g i e s which t end t o s i ngl e out i ndi vi dual 8
f o r s pe c i a l handl i ng. Speci al handl i ng means l abel i ng
i ndi vi dual s a s devi ant s, and i n a peri od of decl i ni ng
r esour ces f o r s o c i a l wel f ar e may wel l be t r a ns l a t e d i n t o
puni t i ve r at her t han t her apeut i c responses.
3) Although t he i ncr eas ee i n consumption and problems duri ng
t he st udy peri od cannot be a t t r i b u t e d t o t he r el axat i on of
cont r ol s , most governmental responses r ei nf orced t hese
t r ends. Fur t her r el axat i ons shoul d, t her ef or e, be made
wi t h caut i on and wi t h a sense of experiment. As mentioned
e a r l i e r , i t i s very d i f f i c u l t t o r es ci nd a s t e p toward
r el axat i on once t h e vest ed i n t e r e s t s a r e i n pl ace.
4) Cont r ol and t reat ment responses appear i nadequat e t o deal
wi t h many event-based al cohol - r el at ed problems, such a s
t r a f f i c c a s u a l t i e s and violente. Use o governmental
powers t o mani pul at e t he environment of dr i nki ng i n or der
t o reduce t he adverse consequences of dr i nki ng ( wi t hout
neces s ar i l y reduci ng consumption o r changing dr i nki ng
pa t t e r ns ) should t her ef or e be c a r e f ul l y consi dered.
5) Governments shoul d r econsi der any f i s c a l o r ot her i ncent i ve
pr mot i ng i nvest ment s i n t he product i on and d i s t r i b u t i o n of
al cohol i c beverages. The prospect of i ncr eas i ng excess
capaci t y i n t he al cohol i ndus t r y r a i s e s t he i s s ues of
i nt e ns i f i e d i nt e r na t i ona l compet i t i on and of economic
pr es s ur es pushing al cohol producers t o conquer new market s
i n l e a s developed count r i es.
6) As suggest ed by t he f i f t h concern, new mechanisms a t t he
i nt e r na t i ona l l e ve 1 may be needed t o addr es s t he he a l t h and
s o c i a l c os t e a s s oc i a t e d wi t h al cohol . Export i ng count r i es
ga i n t h e economic be ne f i t e of t h e a l c ohol t r a d e wi t hout any
of t h e c o s t s a s s oc i a t e d wi t h domeetic consumption. The
World t l eal t h Or gani zat i on and ot he r i nt e r na t i ona l
or gani zat i ons shoul d gi ve c l os e a t t e n t i o n t o t r a de pol i c i e s
and arrangement s a f f e c t i n g t he i n t e r n a t i o n a l a v a i l a b i l i t y
of al cohol .
These concl usi ons were desi gned t o be r e l e va nt t o t h e i n t e r -
na t i ona l audi ence, but obvi ousl y t h e i r r e l a t i v e i mport ance wi l l vary
accor di ng t o t he p a r t i c u l a r ci r cumet ances of each s oci et y. 1
suggest t h a t , de s pi t e t he ver y l i mi t e d r e pr e s e nt a t i on i n ISACE, t hey
can pr ovi de some gui dance a s we d e a l wi t h t he i s s ue s of t h i e con-
f er ence. Perhaps an ove r a l l l ees on from t he yr oj e c t i s t he need f o r
c a r e f ul a t t e n t i o n t o s p e c i f i c c u l t u r a l , h i s t o r i c a l , and economic
f a c t o r s i n each s oc i e t y a s t hey a f f e c t al cohol pol i cy and dr i nki ng
pa t t e r ns and problems. Only wi t h c a r e f ul et udy and hel p from t he
r e gi ona l and i n t e r n a t i o n a l conmuni t i es can a n e f f e c t i v e ove r a l l
al cohol pr event i on pol i cy be developed.
Acknowledgment: Thi s r esear ch was p a r t l y support ed by t he Nat i onal
I n s t i t u t e on Alcohol Abuse and Alcoholism, Na t i o n a l Alcohol Research
Cent er Grant (AA-05595) t o t he Alcohol Research Group, Berkeley,
Cal i f or ni a.
Chapt er Notes and Keferencee
The Anatomy of Alcohol Pol i cy:
Pr event i ve Approachee
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Ch a p t e r S i x
THE IMPACT OF PREVENTION LEGISLATION:
AN EXAMINATION OF RESEARCH FINDINGS
R e g i n a l d Sma r t
DlSCUSSANTS
Mi c h a e l H. Be a ubr un
Ma r i a E l e n a Medi na-Mora
A SURVEY OF ALCOUOL-RELATED LEGISLATION
J a i me Arroyo S u c r e
THE IMPACT OF PREVENTION MEASURES:
AN EXAMINATION OF RESEARCH FINDINGS
Regi nal d G. Smart
The l a s t f i v e ye a r s have seen a remarkable t ur n away from an
excl us i ve emphasis on t r eat ment a s a pr event i ve measure f o r al cohol
problems and towards government c ont r ol s and r e s t r i c t i o n s . There
seems t o be gener al accept ance now i n many, but not a l l , a r e a s of
e a r l i e r r e s i s t a nc e t h a t governments shoul d he l p t o pr event al chohol
problems and t h a t c e r t a i n t ypes of pol i c i e s and l aws a r e more
he l pf ul t han ot her s . For a l ong t i m e i t was argued t h a t t h e main
r o l e of government was t o pr ovi de t r eat ment f a c i l i t i e s and t ha t
governments had l i t t l e t o do wi t h how many o r what t ype of al cohol
problems occur i n a s oci et y. Even World Heal t h Or gani zat i on r epor t a
(1980), which e a r l i e r emphasized al cohol i sm and t r eat ment needs,
s t a t e t he c a s e c l e a r l y f o r government p o l i c i e s r e l a t e d t o t he
pr event i on, not of "al cohol i sm, " but of a l c ohol problems. The
problem now i s t o d i s t i l l a l 1 of t he a va i l a bl e empi r i cal and
t h e o r e t i c a l st udy i n t o some c l e a r concl usi ons which can be t h e ba s i s
f o r pr event i ve programa. The aims of t h i s paper a r e t o come t o
t he s e concl usi ons.
Severa1 major revi ews of t h i s a r e a were made i n t h e pa s t
sever a1 year s , s t a r t i n g wi t h Alcohol Cont r ol Pol i c i e s i n Publ i c
Heal t h Per s pect i ve (Bruun e t a l . 1975) sponsored by t h e World Heal t h
Or gani zat i on. A book by Moser (1980), The Pr event i on of Alcohol-
r e l a t e d Problema summarizes da t a on c o n t r o l s from some 80
count r i es . A l ar ge- scal e st udy of al cohol pol i cy anii c ont r ol s has
r e c e nt l y been publ i shed by t h e Nat i onal Academy of Sci ences (Moore
and Ger s t ei n 1981). Two volumes a r e i n pr es s from t he WHO
I nt e r na t i ona l Study of Alcohol Cont r ol Experi ences (ISACE), which
l ooks a t al cohol c ont r ol s i n seven c ount r i e s (Makela e t a l . 1982).
I n a ddi t i on, t h e r e a r e many s mal l er papera on i ndi vi dua l c o n t r o l s o r
pol i c i e s . A l 1 of t he l a r ge s t u d i e s can be s a i d t o r each a roughly
s i mi l a r concl usi on -- t h a t govemments can reduce a l c ohol problems
by means of c ont r ol pol i c i e s .
With such a l a r g e amount of ma t e r i a l t o be consi der ed, some
s e l e c t i v i t y i s e s s e nt i a l . Thi s review concent r at es on empi r i cal , a s
opposed t o t he or e t i c a l , s t u d i e s and pays p a r t i c u l a r a t t e n t i o n t o
t hose a r e a s i n which t her e has been most r ecent work, namely:
o over al l s t udi es of a va i l a bi l i t y and consumption
o changes i n laws governing out l e t s and hours of s a l e
o pr i ce and t axat i on
o laws r e l a t i ng t o age of purchase and consumption
o adver t i si ng cont r ol s
The main aim i s t o deci de on warrant abl e as s er t i ons i n a l 1 of t hese
ar eas , and a secondary aim i s t o i ndi cat e t he needs f o r f ur t her
research, es peci al l y i n t he count r i es of t he WO Region of t he
Americas.
Overal l Avai l abi l i t y and Consumption of Alcohol
Aimost a l 1 government l e gi s l a t i on about al cohol ser ves t o
i ncr ease or decrease i t s a va i l a bi l i t y. Most emp ri ca1 s t udi es
di r e c t l y r el at ed t o al cohol a va i l a bi l i t y and consumption have been
concerned wi t h di s c r e t e changes i n al cohol cont r ol pol i ces o r
procedures. A ma j or problem i s t ha t usual l y " a va i l a bi l i t y" changes
slowly.
The t rend i n most count r i es over t he past 20 year s has been
f or a gradual l i be r a l i z a t i on i n al cohol cont r ol laws. However, few
s i ngl e changee can be expected t o have a det ect abl e e f f e c t on
al cohol consumption o r al cohol problems. For example, t her e have
been more than 30 l i be r a l i e a t i ons of minor aspect s of t he cont r ol
l a ws i n Ont ari o duri ng t he pas t 20 years. Si mi l ar changes occurred
i n ot her Canadian provi nces duri ng t he same time. hat proport i on
of t he i ar ge i ncr ease i n al cohol consumption could be a t t r i but e d t o
i ncreased a va i l a bi l i t y or t o any of t he i ndi vi dual changes? Liow do
we answer t h i s quest i on when severa1 changes were usual l y made a t
t he same time ami no changes appeared i n i s ol at i on? i ar ge i ncr eas es
i n af f l uence had a l s o occurred, t he soberi ng i nfl uence of t he
temperante movement had decl i ned, and adver t i s i ng of al cohol i c
beverages had i ncreased. Furthermore , people' S des i r e t o dri nk
grew. Methods f or i s ol a t i ng t he i nf l uence of each of t hese f a c t or s
do not seem a t hand.
Pol i t i ci ans who enact changes usual l y argue t ha t t hey a r e
merely keeping up with publ i c opi ni on, i . e. , t hat i ncreased des i r e
t o dr i nk precedes r at her t han followe i ncr eases i n a va i l a bi l i t y.
Current l y, i t is d i f f i c u l t t o di sput e t h i s proposi t i on. The report
of t he World Health Organi eat i on on al cohol cont r ol pol i c i e s (Bruun
et a l . 1975) concluded t ha t "t he a va i l a bi l i t y of al cohol 1s an
important f act or i n t he gener al l eve1 of consumpt i ~n. " A st at ement
of t he Addiction Research Foundation on al cohol pol i ci es (Addiction
Research Foundation 1978) s t a t e d t ha t "t he cumulative e f f e c t (of a l 1
t he i ndi vi dua l l i b e r a l i z a t i o n s ) ha s r epr esent ed a major a l t e r a t i o n
i n a v a i l a b i l i t y , and t he r e f or e , has undoubtedly cont r i but ed t o
i nc r e a s e s i n consumption and a t t e nda nt problems ..."
Unf or t unat el y, t he r e a r e onl y a few s t udi e s examining t he
t o t a l range of va r i a bl e s which may a f f e c t a v a i l a b i l i t y . Bacon
(1977) s t udi ed ni ne communities i n f i v e s t a t e s and concluded t ha t
va r i a t i ons i n a v a i l a b i l i t y had l i t t l e e f f e c t on consumption. There
appear t o be no s t u d i e s which have empi r i cal l y examined gener al
a v a i l a b i l i t y i n a v a r i e t y of c ount r i e s f o r e f f e c t s on consumption.
Smart (1977b) examined t he r e l a t i ons hi p between ove r a l l avai l -
a b i l i t y , pe r c a pi t a consumption, and al cohol i sm r a t e s i n t h e United
St a t e s . lie found t ha t t he c or r e l a t i on between per c a pi t a
consumption and a v a i l a b i l i t y was pos i t i ve and s i gni f i c a nt . iowever,
t he c o r r e l a t i o n between per c a pi t a consumption and urbanism was a l s o
pos i t i ve and t he c or r e l a t i on wi t h income was even gr e a t e r . P a r t i a l
c or r e l a t i ons showed t h a t much of t he s t a t i s t i c a l r e l a t i ons hi p
between per c a pi t a consumption and a v a i l a b i l i t y i s account ed f o r by
income and urbanism. Thus, changes i n a v a i l a b i l i t y may have l i t t l e
e f f e c t upon e i t h e r consumption o r a l c ohol problems i f changes i n
l eve1 of income o r degr ee of ur bani zat i on a r e not a l s o consi der ed.
Lat er s t udi e s by Harford (1979) and Colon (1981) have shown
t h a t a v a i l a b i l i t y i s not a s i n g l e dimension; s pe c i f i c a l l y,
di f f e r e nc e s between on-premise and off-premi se a v a i l a b i l i t y w i l l
have d i f f e r e n t i mpact s a s r egar ds l i v e r c i r r h o s i s . The ISACE st udy
by i4akela e t a l . (1982) concluded t h a t "whi l e t he o v e r a l l i nc r e a s e
i n a l c ohol consumption coul d not be a t t r i b u t e d t o t h e gener al
r e l a xa t i on of c ont r ol r e gul a t i ons i n t he st udy s o c i e t i e s , t h e pol i c y
approach t aken by most governments r ei nf or ced t he i ncr eas i ng
accept ance of al cohol i n t o peopl e' s everyday l i f e , and made way f o r
expanding t he supply. " The aut hor s of t h i s st udy put more emphasis
on gener al i nc r e a s e s i n a f f l ue nc e and ur bani zat i on and t he way
temperance i nf l ue nc e s have decr eased a s c a us a l f a c t or s . They a l s o
poi nt out t h a t al cohol has become more c l os e l y a s s oc i a t e d wi t h
l e i s u r e pur s ui t s and t h e i r commer ci al i zat i on. The a ut hor s a l s o show
t he i ncr eas i ng economic i mport ance of a l c ohol a s a commodity, a n
element i n i n t e r n a t i o n a l t r a de , and a n a gr i c ul t ur a 1 product .
A t pr es ent , e xi s t i ng anal ys es do not al l ow us t o a s s i gn any
gr e a t importance t o ove r a l l a v a i l a b i l i t y a s a f a c t o r i n i ncr eased
al cohol consumption. hiuch l a r g e r s oc i a l , c u l t u r a l , and economic
changes seem equal l y i mpor t ant and i n t he aggr egat e pr obabl y more
i mpor t ant i n some c ount r i e s .
Alcohol Out l e t s and Hours of Sal e:
Rel at i onshi ps t o Consumption and Problems
Vi r t ua l l y a l 1 c ount r i e s have numerous c ont r ol e on t he number
and t ype of o u t l e t s and t h e hours of s a l e f o r a l c ohol i c beverages.
Some i de a of t he va r i a t i on i n t ypes of c ont r ol on a world-wide ba s i s
can be gained from Moser's book (1980). We can make i nt er nat i onal
comparisons, a s wel l a s more l oc a l before-and-af t e r s t udi es, wlien
cont r ol s a r e changed. Most changes i n out l e t frequency or type and
i n hours of s a l e a r e small i n nat ure. Often t hey a r e l ocal and may
appl y i n a s i ngl e s t a t e o r provi nce o r even a smal l c i t y. Limited
var i abl es st udi ed i ncl ude t he s a l e of l i quor by t he dr i nk, t he
i nt r oduct i on of Sunday s al es , t he l engt heni ng of hours of s al es ,
et c. Broader changes examined i ncl ude pr ohi bi t i on and t he short ages
brought on by war o r ot her di s l ocat i ons of a s oci al nat ure.
Severa1 s t udi es (Mass Observation 1943; Popham e t a l . 1975)
found that cor r el at i ons between drunkenness r a t e s and out l e t s per
popul at i on base ar e negat i ve. I n any gi ven ar ea i t 1s l i ke l y t hat
publ i c t ol er ance f or drunkenness cor r el at es wi t h t he number of
out l et s . Also, cor r el at i ons between numbers of out l e t s and per
capi t a s a l e s a r e i ns i gni f i cant (Popham e t a l . 1976), but t he
var i at i on st udi ed has not been very gr eat . It seems unl i kel y t ha t
adding o r t aki ng away a few al cohol out l e t s makes much di f f er ence t o
most ar eas unl ess t he number drops t o zero.
Small Changes i n liumber of Out l et s and Hours of Sal e
Numerous sma11 changes i n a s i ngl e cont r ol measure have
cr eat ed l i t t l e ef f ect . For example, Bryant (1954) found no e f f e c t
on consumption wi t h t he i nt r oduct i on of l i quor by t he dri nk. Dewar
and Sommer (1962) found no e f f e c t from repl aci ng t he male beer
par l our wi t h a t avern servi ng both beer and wine t o bot h sexes.
Smart and Docherty (1976) f a i l e d t o f i nd t he expected e f f e c t s from
t he i nt r oduct i on of on-premise consumption on dri nki ng dr i vi ng
y roblems.
Popham e t a l . (1975) st udi ed t he i nt r oduct i on of lounges and
t aver ns i n Ont ari o, which pr i or t o 1947 had only dul l and
unat t r act i ve beer parl ours frequent ed mostly by men. The lounges
allowed t he s a l e of a l 1 t ypes of al cohol i c beverage by t he dri nk;
many provided ent ert ai nment and oppor t uni t i es t o dance and made
s peci al e f f o r t s t o a t t r a c t women and middle-class customers. Per
capi t a s a l e s i ncreased more i n Ont ari o t han i n neighboring Manitoba,
but drunkenness convi ct i ons and l i v e r c i r r hos i s deat hs i ncreased
more i n Manitoba. Of course, t h i s change di d not simply i ncr ease
a va i l a bi l i t y, but gr eat l y enhanced t he at t r act i venes s of on-premise
dri nki ng environmente.
Smart (1974b) compared s a l e s of al cohol i c beverages made i n
sel f - ser vi ce and cl erk-servi ce package s t or e s i n Ontario. In
s el f - s er vi ce s t or e s a l 1 al cohol i c beverages a r e di spl ayed, much a s
i n any grocery supermarket. I n t he cl erk-servi ce s t or es , customers
make s el ect i ons from a l i st and a c l e r k br i ngs t he purchase from t he
r e a r of t he s t or e. Di spl ays of beverages a r e smal l or
non-exi st ent . Customers i n sel f - ser vi ce s t or e s made l ar ger
pur chases t han t hose i n cl er k- s er vi ce a t or e s . They a l s o r epor t ed
more impulse buying and a hi gher aver age consumption dur i ng t he
pr evi ous week.
Numerous per i ods when l i quor s t o r e per sonnel were on s t r i k e
have a l s o been i nve s t i ga t e d. They pr es ent one of t he few
oppor t uni t i e s t o st udy r educt i on i n a v a i l a b i l i t y , a s most changes
a r e toward l i b e r a l i z a t i o n . The be s t known st udy i s one by Makela
(1974) of t he Fi nni sh Alko per sonnel s t r i k e . Thi s s t r i k e l a s t e d
f i v e weeks and a f f e c t e d r e t a i l o u t l e t s , but not r e s t a ur a nt s o r t he
s a l e of l i g h t beer (3.7 per cent a l c ohol o r l e s s ) . Ef f e c t s on
consumption by "average c i t i z e ns " were very -11; however, a r r e s t s
f o r drunkenness and di s t ur bance of t he peace decl i ned s u b s t a n t i a l l y .
Smart (1977a) s t udi e d two l i quor s t o r e s t r i k e s i n Canada.
They were f o r s hor t per i ods of t i m e ( f our and ni ne weeks) and
compl et el y a f f e c t e d onl y package s t o r e s a l e s , wi t h l e s s e r e f f e c t s on
h o t e l s and r e s t a ur a nt s . Nei t her of t he strikes reduced t he t o t a l s
f o r t r a f f i c a c c i de nt s , i mpai r ed dr i vi ng, o r t r a f f i c f a t a l i t i e s .
However, dur i ng one s t r i k e per i od a r r e s t s f o r publ i c drunkenness
s ubs t a nt i a l l y decreased. Thi s f i ndi ng shows, a s does da t a from t he
Alko s t r i k e per i od, t h a t per sons whose dr i nki ng i s exces s i ve and
beyond c ont r ol can be a f f e c t e d by al cohol a v a i l a b i l i t y . It i s known
t h a t most of t hose a r r e s t e d f o r drunkenness a r e t ypi c a l l y s o c i a l l y
de t e r i or a t e d o r skid-row a l c ohol i c s .
St udi es of s t r i k e per i ods i n Manitoba have shown s i mi l a r
r e s u l t s (Harper e t a l . 1981b), wi t h fewer admi ssi ons t o a medical
de t oxi f i c a t i on f a c i l i t y dur i ng a l i quor s t r i k e but no de c l i ne dur i ng
a beer s t r i k e . Over al l consumption was lowered onl y dur i ng t he
l i quor s t r i k e .
Brown (1978b) found a n e s pe c i a l l y l a r g e e f f e c t r e s ul t i ng from
a beer s t r i k e i n New Zeal and, where t ypi c a l beer consumption i s ver y
hi gh and ot he r beverages a r e not popul ar . The f o u r r e e k s t r i k e had
a major e f f e c t on drunkenness and ot he r al cohol - r el at ed of f ences, a s
we l l a s t r a f f i c acci dent s.
Some i n t e r e s t has been t aken i n changes of hours of s a l e .
They have been a f a vor i t e means of r egul at i on, but few cont r ol l ed,
e mpi r i c a l s t u d i e s of t h e i r e f f e c t s a r e a va i l a bl e . Shadwell (1923)
contended t h a t of a l 1 wartime measures i n Br i t a i n a f f e c t i ng
a v a i l a b i l i t y , s hor t e r s e l l i n g hour s were t h e most i mport ant .
However, such a l a r ge va r i e t y of changes were made t ha t t h e val ue of
any one i s d i f f i c u l t t o a s s e s s (Smart 1974a).
A pos i t i ve c or r e l a t i on between opening hours of beer par l our s
and a r r e s t s f o r drunkenness has been found i n s ever a1 s t u d i e s (e. g.
Popham 1962). However, t he same hour l y p a t t e r n of a r r e s t s occur s on
Sunday i n Toronto when beer pa r l our s are cl osed. Popham (1962) has
suggest ed t h a t "hours of s a l e r e f l e c t e d t he dr i nki ng p a t t e r n of a t
l e a s t one segment of t h e community r a t h e r t han t h e r ever se. "
Kaymond (1969) hae s t udi ed t h e change i n on-premise cl oei ng
houre i n Aus t r al i a. Tr adi t i onal l y, t aver ne cl osed a t 6:00 p.m. t o
al l ow workers t o dr i nk a f t e r work but s t i l l ge t home f o r di nner .
Thie l e d t o t he "6 o' cl ock ew l l , " t h a t i s, hur r i ed dr i nki ng from
about 5:30 onwards. When hours were extended t o 10:OO p.m. i n
Vi ct or i a, Raymond found no e f f e c t on t o t a l per sonal i nj ur y
acci dent e. However, t he peak hour f o r acci dent s changed from 6:00 -
7:00 p.m. t o 10:OO - 1 1 : OO p.m.
A t r i a l Sat urday cl os i ng of Alko s t o r e s i n Fi nl and was
eval uat ed by Sa i l a (1978). A chr oni c problem i n Fi nl and has been
publ i c i nt oxi cat i on, eepeci al l y on Sat urdays. Alko s t o r e s were
cl oeed on Sat urdays f o r ei ght months, st oppi ng off-premise s a l e s of
e p i r i t s and wine, al t hough l i g h t and medium beer was a va i l a bl e a t
gr ocer y et or ee. The cl os ur e reduced publ i c drunkenness and
al cohol - r el at ed violente, a s w e l l a s t o t a l consumption. There vas
no evi dence of a n i ncr eas e i n non-beverage al cohol o r i l l i c i t
al cohol consumption.
Numerous s ma l l t o medium changes have appar ent l y had no
epeci al st udy. Thi s would i ncl ude: opening hours f o r package
s t or e e ; Sunday s t o r e openi ngs; hol i day cl os i ngs ; cl os i ngs on vot i ng
daye; and i nt r oduct i on of beer and wine i n t o gr ocer y s t or es . This
i s unf or t unat e a s smal l changes a r e f r equent l y i nt r oduced, and t h e
al cohol r esear ch community of t e n has l i t t l e t o add t o t he pol i cy
deci si on-maki ng process i f no empi r i cal s t udi es have been done.
From t he s t udi e s di ecussed above, one might agr ee wi t h Popham
et a l . (1975) t h a t " var i at i on i n i ndi c a t or s of t he preval ence of
i ne br i e t y i s not dependent upon o u t l e t frequency. " Out l et frequency
a l e o does not appear t o govern average consumption. The e f f e c t s of
changes i n houre of s a l e on consumption a r e var i abl e from one st udy
t o anot her and d i f f i c u l t t o pr edi ct . I n s hor t , small changes i n
a v a i l a b i l i t y of t he t ype examined above t ypi c a l l y have smal l or
i ne i gni f i c a nt e f f e c t s on dri nki ng and dr i nki ng problems. However, a
major e f f e c t on consumption and problems of i nt oxi cat i on i s found
where s t o r e s can be cl osed f o r a whole day each week.
Some Large Changes i n Alcohol Ava i l a bi l i t y
Moet s i t u a t i o n s i nvol vi ng l a r ge changes i n a v a i l a b i l i t y
i nvol ve pr ohi bi t i on, wartime shor t ages, o r t he i nt r oduct i on of
s t o r e s t o previ ousl y dr y a r e a s , such a s i n Fi nl and.
The e f f e c t s of pr ohi bi t i on on dr i nki ng have been wel l st udi ed
i n t he United St a t e s (Warburton 1932), Canada (Popham 1956) and
Fi nl and (Bruun e t a l . 1960). In a l 1 of t hese, pr ohi bi t i on cr eat ed a
major r educt i on i n per c a pi t a al cohol consumption and i n such
al cohol problems a s drunkenness, l i v e r c i r r h o s i s , al cohol - r el at ed
deat h r at ee, and t he l i ke . To some ext ent t he changes were
temporary, a s t he l a r g e s t changes were e a r l y i n t h e per i od of
pr ohi bi t i on. Arguments made a ga i ns t pr ohi bi t i on, e s pe c i a l l y i n t h e
United St a t e s , were t h a t i t encouraged i l l i c i t t r a d e i n al cohol and
f os t e r e d t he development of ganga and c r i mi na l el ement s. A Nat i onal
Academy of Sci ences st udy ( Ger s t ei n and Moore 1981) concluded t h a t
" t he pr ohi bi t i on e r a ... l e f t a sour t a s t e on t he na t i ona l pal at e"
and l e d t o a r e j e c t i o n of c ont r ol measures and of a l c ohol pr event i on
i n gener al . Probabl y t hes e argumente have some v a l i d i t y f o r many
count r i es . It t he r e f or e becomee a mat t er of i ndi vi dua l judgement
whether na t i ona l pr ohi bi t i on w a s r e a l l y wort h t h e e f f o r t .
Limited pr ohi bi t i on has been i nt r oduced r e c e nt l y i n t o eome
nor t heni communities i n Canada i n reeponee t o s o c i a l problems
as eoci at ed wi t h ver y hi gh al cohol consumption. A st udy by Smart
(1979) showed va r i a bl e e f f e c t s on drunkenness, a s e a ul t , and impaired
dr i vi ng char ges. However, i n t h e most i e ol a t e d communities, where
pr ohi bi t i on was most s uccees f ul , t he r e was a s ube t a nt i a l r educt i on
i n al cohol probleme a f t e r pr ohi bi t i on. Such l i mi t e d pr ohi bi t i ons
might wel l be expanded t o ot he r na t i ve o r i s ol a t e d a r e a s o r t o t hoee
wi t h l o c a l opt i ons concerni ng al cohol .
Many d i f f i c u l t i e e e x i s t i n a s s e s s i ng t he cons i der abl e e f f e c t
of wartime r e s t r i c t i o n s on dr i nki ng. They pr es ent s i t u a t i o n s which
can never be dupl i cat ed a s p a r t of government pol i cy. Aleo, t oo
many ot he r va r i a bl e s occur dur i ng wartime t o be s u r e t h a t r educt i ons
a r e pr i ma r i l y r eeponei bl e f o r changes i n dr i nki ng pa t t e r ns .
The bes t s t u d i e s of wartime r e s t r i c t i o n s were probabl y t hos e
af f e c t i ng Br i t a i n dur i ng t he 1914-1918 war (Shadwell 1923; Smart
1974a). Shadwell concluded t h a t "excessi ve dr i nki ng can be
e f f e c t i v e l y checked and t he d i s a b i l i t y caueed by i t reduced by
appr opr i at e measuree. " He saw t he pr i nc i pa l meaeures t o be
cur t ai l ment of hour s of s a l e , l i ni i t a t i on of euppl y, and r a i s e d
pr i c e s . Aithough i mpor t ant , n e i t h e r t h e s e pa r a t e val ue of each
f a c t o r nor t h e i r combined val ue can be aseessed. A h i e t o r i c a l
a na l ys i s (Smart 1947a) shows t h a t t h e f ol l owi ng a l e o i n f luenced t h e
e f f e c t e of wartime r e s t r i c t i o n s :
1) During t he year s 1916 t o 1918 t he r e were r e s t r i c t i o n s on
beverage out put and i mpor t at i on.
2) Many peopl e had l i t t l e t i me t o dr i nk a s work l oads
i ncr eased up t o 60 hours per week.
3) Bombings, and bl ackout s made peopl e l e s s wi l l i ng t o move
out s i de t h e i r houses f o r dr i nki ng occasi ons o r of f - l i cens e
purchases.
4) A gener al wave of pa t r i ot i e m perhaps l e d some peopl e t o
reduce t h e i r dr i nki ng i n keeping wi t h t h e examples and
exhor t at i ons of na t i ona l l eader s .
5) The war probabl y i ncr eased pr ohi bi t i oni s t and moder at i oni st
f e e l i n g s which had e xi s t e d be f or e ' t he war. I n f a c t , per
c a p i t a consumption of al cohol and drunkenness convi ct i ons
had peaked around 1900 and were on t he way down a t t h e time
of t he war.
6) Shor t ages of policemen and physi ci ans made t he de t e c t i on of
drunkenness and l i v e r c i r r h o s i s deat hs l e s s l i ke l y.
Severa1 i n t e r e s t i n g s t u d i e s of a v a i l a b i l i t y have examined t h e
i nt r oduc t i on of a l c ohol o u t l e t s t o i s ol a t e d a r e a s of Fi nl and. As i n
Norway and Sweden, Fi nl and has had a l ong temperance t r a d i t i o n , a
low per c a pi t a rate of al cohol consumption, and a s pi r i t s - dr i nki ng
t r a d i t i o n . Access t o a l c ohol i c beverages i s st i l l d i f f i c u l t i n many
pa r t e of Fi nl and; l i quor s t o r e s a r e d i f f i c u l t t o f i nd and of t e n
crowded, al t hough beer is more avai l abl e. For many year s no al co-
hol i c beverages a t a l 1 were s ol d i n most r u r a l a r e a s and smal l towns
i n Fi nl and. A l i mi t e d number of s t o r e s were i nt r oduced i n 1951 t o
market towns. Numerous comparisons of dr i nki ng and drunkenness
pa t t e r ns were made between t hose towns and ot he r s which di d not have
s t o r e s (Kuusi 1957). The major f i ndi ngs were t h a t t he opening of
s t o r e s i ncr eased t he f r equency of dr i nki ng, e s pe c i a l l y of beer and
wine, decr eased t he use of i l l i c i t s p i r i t s , but had l i t t l e e f f e c t on
exces s i ve dr i nki ng o r dr unkemess.
Another Yinnish experiment i n t h e year s 1969-1970 i nvol ved
even l a r g e r changes i n a v a i l a b i l i t y (Makela 1972). Pr evi ous t o 1969
l i quor s t o r e s were not al l owed i n r u r a l a r e a s and l i c e ns e d r est au-
r a n t s were few i n number. Publ i c opi ni on f avor ed l i b e r a l i z a t i o n of
t he s e c ont r ol l aws s o t h a t : a ) t h e number of l i q u o r s t o r e s was
i ncr eased s u b s t a n t i a l l y (132 i n 1968 t o 167 i n 1970); b) t he number
of f ul l y- l i cens ed r e s t a ur a nt s was i ncr eased by about 80 per cent ; c )
some 17, 431 new medium beer o u t l e t s were i nt r oduced; and d) 3,000
medium beer ba r s were opened.
The aims were t o l i b e r a l i z e t h e e x i s t i n g laws and t o make
a va i l a bl e l o r a l c o h o l beverages which would s u b s t i t u t e f o r t he
f avor ed s p i r i t s . It was hoped t h a t t h i s would c ont r ol t h e expl os i ve
i nt oxi c a t i on r e s u l t i n g from t he r api d dr i nki ng of s p i r i t s s o t ypi c a l
i n Fi nl and.
As might have been expect ed, t o t a l per c a p i t a consumption
i ncr eas ed about 48 per cent i n t h e f i r s t year a f t e r t he changes.
Also, numbers of heavy us e r s i ncr eased pr opor t i onat el y. There was
l i t t l e s i g n t h a t beer-dri nki ng s ubs t i t ut e d f o r s pi r i t s - dr i nki ng a s
had been expect ed. Beer account ed f o r much of t he i ncr eas e, but
t he r e was no compensatory r educt i on i n s p i r i t s use. Of cour se, i t
i s unc e r t a i n whether t he f i ndi ngs from t h i s s t udy coul d be
gener al i zed t o ot he r c ount r i e s wi t h d i f f e r e n t dr i nki ng s i t ua t i ons .
Because of t he r a pi di t y of t h e change, i t i s ver y l i k e l y t ha t t he
i ncr eas ed a v a i l a b i l i t y cont r i but ed most t o t he i ncr eas e. It i s
d i f f i c u l t , however, t o be s ur e t h a t publ i c d e s i r e t o dr i nk more was
not a n i mpor t ant c ont r i but or i n t e r a c t i n g wi t h i ncr eas ed a v a i l a b i l i t y .
Governments ot he r t han Fi nl and have made at t empt s t o
s u b s t i t u t e one beverage f o r anot her , us ual l y beer o r wine f o r
d i s t i l l e d s p i r i t s . Not a l 1 e f f o r t s a t s u b s t i t u t i o n have been
eval uat ed, but some have. The i nt r oduc t i on of low and medium be e r s
i n Fi nl and ser ved t o i ncr eas e o v e r a l l consumption. The i nt r oduct i on
of l i g h t beer i n Ont ar i o was found by hi t ehead and Szandorowski
(1977) t o be most l y a s u b s t i t u t i o n of one a l c ohol i c beverage f o r
anot her . However, t he r e was some i nc r e a s e i n consumption wi t h t he
change t o l i g h t beer wi t h meals. There a r e some s i gns t h a t t he
una va i l a bi l i t y of one beverage ( a s dur i ng s t r i k e s ) l e a d s t o l i mi t e d
s u b s t i t u t i o n of ot he r s but a decr ease i n o v e r a l l consumption ( Si ngl e
1979). Thi s r es ear ch i ndi c a t e s t h a t most at t empt s a t s u b s t i t u t i o n
a r e l i k e l y t o f a i l unl es s a ppr opr i a t e changes i n p r i c e and avai l -
a b i l i t y a r e made a t t he same t i m e .
Government Cont r ol s and Alcohol Use i n t he Fut ur e
It i s wort h s pecul at i ng about what t h e f ut ur e may hol d f o r t h e
r e l a t i ons hi ps between a v a i l a b i l i t y and dr i nki ng. One approach i s t o
examine worldwide t r e nds i n dr i nki ng. Sulkunen (1976) r epor t ed d a t a
from t he World Alcohol Pr oj e c t (WAP) on al cohol consumption and
dr i nki ng pa t t e r ns i n more t han 30 c ount r i e s over a per i od of about
20 year s between 1950 and 1970. Unf or t unat el y, no d a t a were
gat her ed on t he l e v e l s of a v a i l a b i l i t y i n va r i ous c ount r i e s and
hence cr oss- nat i onal comparisons a r e not f e a s i bl e ; nor were many
devel opi ng c ount r i e s from La t i n America o r t he Cari bbean i ncl uded.
Never t hel ess, some of Sul kunen' s concl usi ons, pr ovi di ng grounds f o r
s pecul at i on, i ncl udi ng t he f ol l owi ng:
1 ) There has been a world wide r i s e i n al cohol consumption i n t he
ye a r s 1950-1970.
2) The r i s e has been g r e a t e s t i n c ount r i e s where s p i r i t s a r e t h e
pr ef er r ed beverage.
3) There i s homogenization of dr i nki ng I i abi t s t hroughout t he
world. That i s, beer i s becoming more popul ar i n
wine-drinking count r i es ; wine i n s pi r i t s - dr i nki ng c ount r i e s ,
e t c .
4) The homogenization 1s not a t t he expense of t r a d i t i o n a l
beverages, but i n a ddi t i on t o them.
There i s evi dence now from a va r i e t y of c ount r i e s -- f o r
example, Canada, The United St a t e s , Fi nl and , Poland, e t c ( s e e
iiakela e t a l . 1982 f o r a review) -- t h a t al cohol consumption has
s t a b i l i z e d o r has even s l i g h t l y decr eased s i nc e about 1975. Thi s
may be e i t h e r temporary o r a long-term t r end such a s t he "l ong wave"
of post war consumption i ncr eas e. The r eas ons f o r t h i s r educt i on
probabl y i ncl ude s t a b i l i z a t i o n of r e a l income, a new emphasis on
he a l t hy l i f e - s t y l e s and f i t n e e s , and changes i n t he demographic
composi t i on of t he popul at i on, f o r example, addi ng l a r ge numbers of
young l i g h t dr i nke r s t o t he dr i nki ng popul at i on. We can a s k what
e f f e c t t h i s s t a b i l i z a t i o n w i l l have on al cohol c ont r ol pol i c i e s .
W i l l i t mean t ha t governments w i l l i ncr eas e a v a i l a b i l i t y i n or de r t o
s t i mul a t e more dr i nki ng and hence more t ax revenues? W i l l t he r e be
decr eas es i n r e a l pr i c e s f o r a l c ohol i c beveragea?
There a r e sane l i mi t e d i ndi c a t i ons t h a t t h e g r e a t i nc r e a s e s i n
a v a i l a b i l i t y seen i n t he ye a r s 1950-1970 i n al most a l 1 c ount r i e s a r e
on t he wane. Many governments appear more c a ut i ous now t han
f or mer l y. Pr ohi bi t i on has been i nt r oduced i n Poland and Paki st an;
age l aws have been i ncr eased i n many a r e a s of Canada and t h e U.S.A.,
and a dve r t i s i ng r e s t r i c t i o n s o r out r i ght bans have been put i n t o
f or c e i n many count r i es . It may be t ha t a ge ne r a l l y more r e s t r i c -
t i v e approach i n government c ont r ol s i s t h e c ur r e nt z e i t g e i s t .
Pr i c e and Taxat i on
Vi r t ua l l y a l 1 governments set t h e pr i c e s of a l c ohol i c
bever ages, e i t h e r i n d i r e c t l y tlirough var i ous t a xa t i on schemes o r
d i r e c t l y by s e l l i n g t hrough government monopoly s t or e s . The ISACE
st udy (Nakela e t a l . 1982) found t h a t " t he pr opor t i on of t he f i n a l
p r i c e of a l c ohol i c beverages t h a t 1s a t t r i b u t a b l e t o t a xa t i on v a r i e s
g r e a t l y among beverages and among s oc i e t i e s . " Gener al l y, d i s t i l l e d
bever ages were more heavi l y taxed t han ot he r s and over ha l f of t h e
f i n a l p r i c e may be due t o t axat i on. Si nce governments cons t ant l y
a d j u s t a l c ohol pr i c e s i n r esponse t o economic and t a xa t i on needs,
t hos e concerned wi t h a l c ohol pol i cy might a l s o cons i der he a l t h
ma t t e r s when s e t t i n g p r i c e l e ve l s .
Pr i c e c ont r ol s Imve been a major recommendation a r i s i n g from
r es ear ch on d i s t r i b u t i o n pa t t e r ns of al cohol consumption. It has
been argued (Popham e t a l . 1975) t h a t bot h per c a p i t a c ons mpt i on
and al cohol - r el at ed problems, such a s l i v e r c i r r h o s i s , can be
reduced by s ubs t a nt i a l changes i n t he r e a l pr i c e of a l c ohol i c
beverages. Recommendations by t h e s i n g l e d i s t r i b u t i o n t h e o r i s t s
have us ua l l y been more moderate: a ) t h a t t h e pr es ent r e a l pr i c e of
a l c ohol i c beverages merely be mai nt ai ned and not lowered a s
i n f l a t i o n i ncr eas es ; and b) t h a t t he r e be a uni f onn p r i c e c o n t r o l
pol i c y whereby p r i c e s a r e based on t he amount of al cohol i n each
beverage .
Probabl y no c ont r ol f a c t o r has been s o o f t e n s t udi e d a s has
pr i c e . Severa1 e a r l y s t udi e s of d r a s t i c pr i ce- t axat i on i nc r e a s e s i n
Denmark and Belgium found s u b s t a n t i a l decr eases i n t h e consumption
of d i s t i l l e d beverages and a less marked dr op i n t o t a l consumption
( s e e revi ews of Sruun e t a l . 1975; Popham e t a l . 1975). The tax
i nc r e a s e s l e vi e d were much hi gher t han coul d now be done i n most
Western count r i es . For example, t h e t a x on d i s t i l l e d s p i r i t s i n
Denmark was r ai s ed by a f a c t o r of 11, c h i e f l y because of wartime
shor t ages.
Our knowledge of how pr i c e changes can a f f e c t consumption and
al cohol - r el at ed problems i s based on economet ri c anal ys es r a t he r
t han exper i ment al o r quasi -experi ment al st udy. Such s t u d i e s examine
how n a t u r a l l y occur r i ng f l uc t ua t i ons i n pr i c e r e l a t e t o per c a pi t a
consumption and al cohol problems, us ua l l y l i v e r c i r r hos i s . Such
s t u d i e s a r e decept i vel y e a s y t o do, but i n t he aggr egat e t h e i r
r e s u l t a have been d i f f i c u l t t o i n t e r p r e t .
The f i r s t l a r g e economet ri c s t udy was done by Seel ey (1960),
who examined time series da t a f o r Ont ar i o. He examined t h e r a t i o of
al cohol pr i c e s t o di s pos abl e income and found t h a t i t var i ed
i nve r s e l y wi t h both a l c ohol s a l e s and l i v e r c i r r h o s i s de a t h r a t e s .
Thi s prompted t he suggest i on t h a t i f r e a l pr i c e s were r a i s e d by 20
o r 30 per cent over s ever a1 ye a r s i t coul d be det ermi ned whether
t he r e was a r e a l e f f e c t on consumption and l i v e r c i r r hos i s . The
suggest ed experiment has appar ent l y not yet been done.
An i mpor t ant el ement i n t he argument about pr i c e s and
consumption i s t he ques t i on of t he e l a s t i c i t y of demand Eor
a l c ohol i c beverages. I f demand i s r e l a t i v e l y i n e l a s t i c v i t h r egar d
t o pr i c e s , t hen t her e i s l i t t l e any government can do s hor t of
i nc r e a s i ng pr i c e s t o phenomenal l e ve l s . Some pr oduct s, such as
bread i n Western c ount r i e s , have an i n e l a s t i c demand and few
s ubs t i t ut e s . I f pr i c e s a r e i ncr eas ed, t hen peopl e si mpl y spend more
wi t hout decr easi ng t h e i r consumption by a s i g n i f i c a n t amount.
Argumente about p r i c e i n e l a s t i c i t y f o r a l c ohol i c beverages a r e
now very t opi c a l . Popham e t a l . (1976) and Bruun e t a l . (1975) have
reviewed a l a r g e number of empi r i cal s t u d i e s and concluded t h a t
"when ot he r f a c t o r s remain unchanged, a r i s e i n a l c ohol pr i c e s has
ge ne r a l l y l e d t o a dr op i n t he consumption of al cohol . " The
Nat i onal Academy of Sci ences s t udy (Moore and Ger s t ei n 1981)
concluded that "an i ncr eased t a x on a l c ohol i c beverages has t he
p a r t i c u l a r e f f e c t of improving t he chr oni c he a l t h pi c t ur e " and
t he r e f or e recommended such i nc r e a s e i n conj unct i on wi t h pr event i ve
programe. Ot her s (e.g. Par ker and Harman 1978) have cl ai med t h a t
income, not pr i c e , i s t he main det er mi nant of al cohol consumption,
and t ha t demand f o r beer and s p i r i t s i s r e l a t i v e l y i n e l a s t i c and
hence not modi f i abl e by pr i c e changes. A review and r e- anal ysi s by
Or ns t ei n (1980) has shown t ha t n e i t h e r poi nt of view i s e n t i r e l y
c or r e c t ; t h a t i s, t he r e was no suppor t f o r t he view t h a t "income
e f f e c t s dominate pr i c e e f f e c t s , " nor i s t he r e " i n e l a s t i c demand f o r
s p i r i t s " ( a t l e a s t i n The United St a t e s ) . The main concl usi on of
Schmidt and Popham was suppor t ed; t hat is, consumpt i on i s s e n s i t i ve
t o pr i c e changes, but " t he s e n s i t i v i t y v a r i e s a c r os s beverages. "
Or ns t ei n concluded t h a t "demand e s t i ma t i on 1s a d i f f i c u l t and
i ne xa c t busi ness" and " t he r e s u l t s a r e s t r ongl y a f f e c t e d by t h e d a t a
and economet ri c t echni ques used."
Econometric anal ys es have not l e d t o very c l e a r concl usi ons
about what t ype of p r i c e i ncr eas e coul d be expect ed t o l ead t o what
decr ease o r change i n a l c ohol consumption o r problems. Demand f o r
beverages may vary consi der abl y a c r os s j ur i s di c t i ons and i n response
t o many f a c t o r s ot he r t han pr i c e , i ncl udi ng income. Heavy dr i nke r s
may not be much a f f e c t e d by p r i c e i nc r e a s e s , and cheaper beverages
can be s ubs t i t ut e d f o r t he more expensi ve. I n gener al , p r i c e seems
t o af f e c t consumpt i on but we cannot of f e r ver y def i n i t e suggest i ons
t o governments a s t o how t o change p r i c e s t o achi eve any de s i r e d
pr event i ve ef f e c t w i t hout undesi r ed l os s es .
Perhaps a l 1 that can be l ear ned from economet ri c s t u d i e s has
been l ear ned al r eady, and new exper i ment al appr oaches shoul d be
t r i e d . The o r i g i n a l paper by Seel ey c a l l e d Eor a l ar ge- s cal e s o c i a l
exper i ment , and t h i s i s st i l l needed today.
Another a r e a f o r t he exper i ment al st udy of p r i c e has been
opened up by Babor e t a l . (1978). They s t udi ed "happy hour"
condi t i ons i n a n exper i ment al bar s i t ua t i on. Male vol unt eer s were
gi ven a c c e s s t o a l c ohol i c beverages f o r a 20-day per i od. Some were
charged 50 c e nt s per dr i nk and ot he r s ( t h e happy hour group) 25
c e nt s dur i ng a three-hour per i od. Both c a s ua l dr i nke r s and heavy
dr i nke r s s i g n i f i c a n t l y i ncr eased t h e i r consumption dur i ng t h e happy
hours. However, heavy dr i nke r s i ncr eased much more t han di d cas ual
dr i nke r s . The happy hour consumption was not a s u b s t i t u t e f o r
consumption a t ot he r times.
Research of t h i s s o r t shoul d be ext ended i n t o ot he r s i t u a t i o n s
where cheap a l c ohol i c beverages a r e made a va i l a bl e , such a s c oc kt a i l
p a r t i e s , r ecept i ons , Okt ober f est s, and c e r t a i n ki nds o a i r t r a ve l .
Var i abl es as s oci at ed wi t h i ncr eased consumption, such a s di sposabl e
income and pe r s ona l i t y char ac teris t i c s , coul d a l s o be i nve s t i ga t e d.
The exper i ment al s i t u a t i o n al l ows a c ont r ol over va r i a bl e s which has
been d i f f i c u l t t o obt a i n i n economet ri c anal yses. Perhaps
governments coul d be persuaded t o decr ease t he number of s i t u a t i o n s
where al cohol i s gi ven away o r s ol d a t ver y low cos t .
A f i n a l problem wi t h c ont r ol l i ng a l c ohol problems through
r educi ng per c a p i t a consumption r e l a t e s t o t he s e l e c t i o n of t he
problems t o be cont r ol l ed. The best c or r e l a t i ons between
consumption and r e l a t e d problems are f o r consumption and l i v e r
c i r r hos i s . Much r es ear ch i n d i c a t e s t h a t a l c ohol problems and
consumption a r e not c ons i s t e nt l y c or r e l a t e d ( s e e Makela 1975) , and
hence a c t i ons c ont r ol l i ng one problem may not c ont r ol anot her .
Lat el y, r es ear ch has i ndi cat ed t he be ne f i c i a 1 e f f e c t s of smal l
amounts of al cohol (up t o two dr i nks per day) (Yano e t a l . 1977;
Bar bor i ak et a l . 1977) i n pr event i ng cor onar y he a r t di sease.
Cur r ent anal yses a r e i ndi c a t i ng (Popham 1982) t ha t t he pr ot e c t i ve
e f f e c t of al cohol may not peak a t two dr i nks , but i nc r e a s e wi t h t he
amount t aken. I n t h a t cas e, encouragi ng t h e popul at i on by what ever
means t o dr i nk l e e s may mean a l a t e r i nc r e a s e i n he a r t di sease.
J u s t how t h i s i s t o be bal anced a ga i ns t t h e expect ed r educt i on i n
l i v e r di s e a s e cannot be seen a t pr esent .
Changes i n t he Dr i nki ng o r Purchasi ng Age
f o r Ai cohol i c Beverages
Expect at i ons about t he consequences of r educi ng t he dr i nki ng
age var y i n accordance wi t h t he view gener al l y t aken about al cohol
c ont r ol pol i c i e s . For some i t i s s een a s a pr event i ve measure. For
example, Wilkinson (1970) argued a "f or bi dden f r u i t " t heor y i n which
a l c ohol becomes e s pe c i a l l y a t t r a c t i v e t o young peopl e because of i t s
i l l e g a l i t y . According t o t h i s view, dr i nki ng nonns devel op once i t
becomes l e ga l f o r young peopl e t o dr i nk, t hus l i el pi ng t o pr event
l a t e r problems. Wilkinson recommended l oweri ng t he dr i nki ng age t o
18 i n a l 1 j ur i s di c t i ons . On t h e ot he r hand, t hose i n f avour of t h e
" di s t r i but i on" t heor y ( f o r example, Popham et a l . 1975) argued t ha t
l i b e r a l i z a t i o n c ont r i but e s t o hi gher per c a pi t a consumption and
hence t o al cohol - r el at ed problems.
Some argue t ha t changing t h e law should have no e f f e c t on
consumption a t a l l . Si nce many young peopl e dr i nk bef or e t he l e ga l
age, l oweri ng t he age onl y l e g a l i z e s t h e s t a t u s quo. We a l s o know
t ha t many European c ount r i e s , such a s Br i t a i n, have always had low
dr i nki ng ages wi t h r e l a t i v e l y low per c a pi t a consumption and
al cohol i sm r a t e s . However, France and I t a l y a l s o have low dr i nki ng
ages and l ead t he world i n bot h al cohol consumption and i t s
problems. I nt e r na t i ona l comparisons may be of l i t t l e val ue compared
t o bef or e and a f t e r s t udi e s i n s i ngl e j ur i s di c t i ons .
Apparent l y no a s pe c t of al cohol c ont r ol l e g i s l a t i o n has been
s o o f t e n changed i n r ecent year s a s t h e l e g a l age f o r dr i nki ng o r
t he purchase of a l c ohol i c beverages. I n some j ur i s di c t i ons age laws
govern onl y t he purchase of a l c ohol i c beverages, but i n ot he r s , such
a s Ont ar i o t hey govern pur chase, possessi on, and consumption.
During t he ye a r s 1970 t o 1975, a l 1 10 Canadian pr ovi nces and 26 of
50 American s t a t e s decr eased t h e l e g a l pur chasi ng o r dr i nki ng age.
Smart and Goodstadt (1977), Wechsler (1980), and ot he r s have
summarized r es ear ch bear i ng on t h e e f f e c t s of t hes e age r educt i ons-
I n gener al , t he a va i l a bl e d a t a pr ovi de evi dence of : a ) i nc r e a s e s i n
yout hf ul dr i nki ng a f t e r t he age r educt i ons (Smart and Schmidt,
1975) ; b) i ncr eased admi ssi ons t o t r eat ai ent f a c i l i t i e s f o r young
peopl e (Smart and Fi nl ey 1975); and c ) s u b e t a n t i a l i nc r e a s e s i n
al cohol - r el at ed a c c i de nt s and f a t a l i t i e s bot h f o r t hose gi ven t h e
r i g h t t o dr i nk and t hose i n t he next lower age cat egor y (Williams e t
a l . 1974; Brown and i.laghsood100 1981; Vhitehead e t a l . 1975).
However, where l a r g e s t u d i e s have been done, t h e e f f e c t s of t he s e
laws have o f t e n been small and va r i a bl e from one j u r i s d i c t i o n t o
anot her (Douglass and Fi l k i n s 1974).
Af t er publ i c pr essur e, t h e dr i nki ng age has been i ncr eas ed i n
Michigan ( 18 t o 21); Maine, Massachuset t s and New Hampshire (18 t o
20); Iowa, Minnesota, Montana, Tennessee, Ont ar i o and Saskatchewan
( 18 t o 19) . We now lmve d a t a from a v a r i e t y of sour ces on t he
e f f e c t s of t he i ncr eas e i n t he dr i nki ng age i n Ont ar i o from 1 8 t o 19
year s ( Vi ngi l i s and Smart 1982).
Although i t seems c l e a r t h a t r educi ng t h e dr i nki ng age
i ncr eased yout hf ul dr i nki ng and dr i nki ngl dr i vi ng problems, i t i s not
c l e a r t h a t i ncr eas es i n t he age would decr eas e them s ubs t a nt i a l l y.
For one t hi ng, wi t h t he except i on of Michigan, a l 1 s t a t e s and
pr ovi nces which i ncr eased dr i nki ng ages di d s o by onl y one o r two
year s ( 18 t o 1 9 o r 20), whereas t he e a r l i e r r educt i ons had us ual l y
dropped t he dr i nki ng age t hr e e year s ( 21 t o 18). Ther ef or e, a
r e l a t i v e l y smal l er segment of t h e dr i nki ng popul at i on was a f f e c t e d
by t he i ncr eas es . Also, "gr andf at her " c l a us e s were of t e n i ncl uded
so t h a t t hose who had a l r e a dy reached t he lower age coul d l e ga l l y
cont i nue t o dr i nk when t h e age was r ai s ed.
Unf or t unat el y, d a t a on t he e f f e c t s of i nc r e a s i ng t he dr i nki ng
age a r e ver y spar se. Only a handf ul of s t u d i e s bear d i r e c t l y on t h e
quest i on. One i nve s t i ga t e d s chool o f f i c i a l s ' per cept i ons of
dr i nki ng problems among yout h; o t h e r s i nve s t i ga t e d t r e nds i n pol i c e
s t a t i s t i c s and acci dent r a t e s .
I n an anonymous st udy (Anon 1979) ques t i onnai r es were mai l ed
t o hi gh school pr i nc i pa l s i n Michigan a f t e r t he l e g a l age was
i ncr eased from 18 t o 21 i n December 1978. A maj or i t y of t h e
p r i n c i p a l s r epor t ed t h a t a f t e r t he age was i ncr eas ed t h e r e were
fewer al cohol - r el at ed problems i n t h e i r school ( 74 per cent ) , less
dr i nki ng among younger s t ude nt s ( 69 per cent ) , less dr i nki ng at
school f unct i ons (67 per cent ) , and l e s s dr i nki ng dur i ng school hour s
(79 per cent ) . It was concluded t h a t r a i s i n g t h e dr i nki ng age had
made a pos i t i ve di f f e r e nc e i n t he dr i nki ng of hi gh school s t udent s .
Roy and Gr eenbl at t (1979) conducted a comparat i ve st udy of
dr i nki ng- dr i ver def endant s i n Massachuset t s i n February and Oct ober
1979. Thi s r es ear ch was under t aken t o e va l ua t e t he e f f e c t i ve ne s s of
a new dr i nki ng law which r a i s e d t h e l e ga l dr i nki ng age i n Massachu-
setts from 1 8 t o 20 year s on Apr i l 16, 1979. When a n October sample
was compared t o an e a r l i e r sample in February, a 26 per cent i nc r e a s e
was found i n t he number of t eenager s (15-19 year s of age) who were
charged wi t h d r i n k i ~ l d r i v i n p of f ences , whi l e an 8 per cent decr eas e
was found i n t he number of 20-25 year ol ds who were charged wi t h
t he s e of f ences. Aithough t est s of s i gni f i c a nc e were not of f e r e d,
suf f i c i e n t i nf or mat i on vas a va i l a bl e f o r a na l ys i s . While t eenager s
comprised about 14 per cent of t he Pebruary dr i nki ngl dr i vi ng
def endant s, t hey accounted f o r over 17 per cent i n October. However,
t he o v e r a l l t o t a l s f o r bot h months were al most t he same. The
unexpected i nc r e a s e i n char ges coul d be due t o i nt e ns i ve pol i c e
enforcement and/ or yout hf ul di sobedi ence of t he law. The aut hor s
suggest ed t h a t yout hs might be dr i nki ng more i n car a because t hey
coul d not l e g a l l y dr i nk i n l i quor est abl i shment s. However, not
enough i nf or mat i on was a va i l a bl e t o det ermi ne whether enforcement
pr a c t i c e s had changed. Teenagers were a l s o found t o have a hi gher
t han expect ed frequency of mul t i pl e of f ences , i ncl udi ng oper at i ng t o
endanger, use of motor vehi cl e wi t hout a ut hor i t y, l eavi ng t h e scene
of an acci dent wi t h pr oper t y damage and per sonal i nj ur y, cr i mes
a ga i ns t pr oper t y , and publ i c or de r of f ences. Thus, t he r e s u l t s
demonst rat ed an i nc r e a s e i n of f ences r a t h e r t han t h e expect ed
decr ease.
Sever a1 s t udi e s of t he age l aw changes have been made i n
Michigan. Wagenaar (1980) c ol l e c t e d acci dent mor t a l i t y r a t e s based
on a 20 per cent random sample of a l 1 r epor t ed motor ve hi c l e c r a s he s
i n t he St a t e of Michigan from 1972 t hrough 1979. The t hr e e
dependent va r i a bl e s were: a ) pol i c e r epor t ed "had been dr i nki ng"
a c c i de nt s (HBD); b) pol i c e r epor t ed "had not been dr i nki ng"
a c c i de nt s (HNBD); and c ) l at e- ni ght , s i n g l e ve hi c l e wi t h male d r i v e r
a c c i de nt s (3FS). The t hr e e age groups i nve s t i ga t e d were: 18-20,
21-25, and 25-45 year ol ds. The r e s u l t s i ndi c a t e d a n i n s i g n i f i c a n t
downward t r end f o r non-al cohol -rel at ed acci dent s f o r a l 1 age groups,
and a s i g n i f i c a n t downward t r end f o r al cohol - r el at ed a c c i de nt s and
t he 3FS acci dent s f o r 18-20 year ol ds , but a s i g n i f i c a n t i ncr eas e
f o r t he 21-24 year ol ds i n t he HBD cat egor y and i n s i g n i f i c a n t
i nc r e a s e s i n t he remai ni ng cat egor i es . Wagenaar concluded t h a t
r a i s i ng t he dr i nki ng age was "an e f f e c t i v e countermeasure f o r t h e
major cause of mor bi di t y and mor t a l i t y among young people."
In Ont ar i o, t he dr i nki ng and purchasi ng age f or . a l c ohol i c
beverages was reduced i n J ul y 1971. Soon a f t e r , r e por t s from school
o f f i c i a l s i ndi cat ed t h a t d i s c i p l i n a r y problema i nvol vi ng s t ude nt s
had i ncr eased gr e a t l y. Data were a l s o wi del y publ i ci zed which
i ndi c a t e d l a r g e i ncr eas es i n al cohol - r el at ed a c c i de nt s among young
peopl e (Whitehead 1977). Ci t i z e n groups and a n a s s oc i a t i on of
school pr i nc i pa l s pe t i t i one d t he government t o r a i s e t he dr i nki ng
age. A government-appointed commission hel d a s e r i e s of publ i c
i n q u i r i e s about yout hf ul dr i nki ng, examined t he evi dence and
e ve nt ua l l y concluded t ha t t he dr i nki ng age shoul d be i ncr eased
( Ont ar i o Youth Se c r e t a r i a t 1976). The l e g a l age was i ncr eased from
1 8 t o 19 ye a r s a s of Januar y 1, 1979; t hose aged 1 8 bef or e January
1, 1979 coul d st i l l l e g a l l y dr i nk. The new l aw r equi r ed
age- of - maj or i t y c a r ds wi t h a phot o and i ncr eased pe na l t i e s f o r
s er vi ng underage dr i nker s .
A new st udy from t he Addi ct i on Research Foundat i on ( Vi ngi l i s
and Smart 1982) anal yzes f our t ypes of da t a r e l e va nt t o t he e f f e c t s
of t h e i nc r e a s e i n t he Ont ar i o dr i nki ng age. The d a t a a r e from:
o sur veys of dr i nki ng and dr i nki ng problema i n
l a r g e samples ( n = 4687 and 5794) of hi gh school
s t udent s ;
o a st udy of per cept i ons of 531 vi ce- pr i nci pal s ;
o a t r end a na l ys i s of young dr i nki ng of f ender
char ges; and
o a t r end a na l ys i s of dr i nki ngl dr i vi ng s t a t i s t i c s .
It was expect ed t h a t because of t he na t ur e of t h e change (one-
year i nc r e a s e onl y) t he e f f e c t s would be smal l but pos i t i ve . Si nce
r es ear ch on t he de t e r r e nt e f f e c t s of l e g i s l a t i o n has c ons i s t e nt l y
shown i n i t i a l pos i t i ve e f f e c t s of s hor t dur at i on, i t was pr edi ct ed
t ha t any e f f e c t s would be most v i s i b l e dur i ng t he f i r s t few months
of t he new law.
The r e s u l t e of t he f our s t u d i e s i ndi c a t e few s t a t i s t i c a l l y
s i g n i f i c a n t changes s i nc e t he r a i s i n g of t he dr i nki ng age. The hi gh
school sur veys found t h a t among t h e r e u l a r dr i nke r s , t he r e va s no
s i g n i f i c a n t change between 1977 and 1 d- i n t he pr opor t i on of ol der
ver sus younger s t ude nt s r e por t i ng occur r ences of s l i g h t i nt oxi c a t i on
o r heavi er al cohol use i n t h e p r i o r month. The vi ce- pr i nci pal st udy
found t h a t t he maj or i t y of vi ce- pr i nci pal 8 r epor t ed obser vi ng no
changes i n dr i nk- r el at ed behavi or s. The da t a on dr i nki ng- of f ender
char ges showed no s i g n i f i c a n t di f f e r e nc e s a f t e r t h e l e g a l dr i nki ng
age change. Si mi l ar l y, no di f f e r e nc e s were found f o r dr i vi ng
convi ct i ons o r f a t a l i t i e s .
There was some evi dence of minimal, though i n t e r e s t i n g ,
e f f e c t s o t he dr i nki ng law on t hose i n t he non-regul ar dr i nker
cat egor y. ' The hi gh school survey found a f t e r t he l aw change a
s i g n i f i c a n t decr ease among 18 t o 19 ye a r ol ds , but a s i g n i f i c a n t
i nc r e a s e i n t hose under 18 who r epor t ed dr i nki ng and g e t t i n g " t i ght "
dur i ng t h e p r i o r month. Addi t i onal l y, between 20 and 30 per cent of
t he vi ce- pr i nci pal 8 r epor t ed a decr eas e i n dr i nk- r el at ed behavi or s.
Charges a ga i ns t young dr i nki ng of f ender s have moved s l i g h t l y
downward s i nc e t he i nc r e a s e i n t h e dr i nki ng age; however, t h i s
t r end i s i n s i g n i f i c a n t and, wi t h no c ont r ol group, d i f f i c u l t t o
i n t e r p r e t . I n summary, t he s e f i ndi ngs t e n t a t i v e l y seem t o suggest
some minimal e f f e c t f o r 18-19 year ol d hi gh school s t ude nt s , but not
f o r t h e r e gul a r (once a week o r more) o r t he younger dr i nke r s .
The convi ct i on and f a t a l i t y s t a t i s t i c s a r e not s e ns i t i ve
enough a s measures; t hey seem t o show t ha t t oo few tiigh-accident-
and- ar r est - r i s k yout hs a r e changing t h e i r dr i nki ng pa t t e r ns f o r a
c a us e l e f f e c t r e l a t i ons hi p t o emerge. These r e s u l t e a r e cont r ar y t o
Wagenaar' s f i ndi ngs (1980) i n Michigan, where s i g n i f i c a n t downward
t r e nds i n f a t a l i t i e s di d occur. Iiowever, t he r e t he l e g a l age
i nc r e a s e was from 18 t o 21 year s of age. The minimal e f f e c t i n t h e
Ont ar i o st udy was pr edi ct ed, a s t he one year i nc r e a s e was not
s u f f i c i e n t t o cause a major impact on yout hf ul dr i nki ng behavi or .
There seems t o be a s mal l and s e l e c t i v e pr event i on e f f e c t from
i ncr eas i ng t he dr i nki ng age by one year and a g r e a t e r one from
i nc r e a s i ng i t by t hr ee. Research of g r e a t e r r ef i nement and wi t h
fewer met hodol ogi cal problems is needed t o v a l i d a t e t hes e
pr el i mi nar y f i ndi ngs.
Adver t i si ng of Ai cohol i c Beverages
A s ur pr i s i ng amount of energy has been expended on c ont r ol e on
t h e a dve r t i s i ng of a l c ohol i c beverages. I n t he pa s t f i v e year s
l e g i s l a t i v e debat es and di s c us s i ons have looked a t al cohol
a dve r t i s i ng i n Canada, t he United S t a t e s , England, Fi nl and, Mexico,
Honduras, Norway, Spai n, Swi t zer l and and Sweden ( s e e Moser 1980 f o r
a revi ew). New a dve r t i s i ng bans have been imposed i n Paki s t an,
Sweden, Norway, and Poland, but s t udi e s of t h e i r e f f e c t s have not
been found. There a r e l ong-st andi ng bans on a l c ohol a dve r t i s i ng i n
many I sl ami c c ount r i e s such a s Egypt, Saudi Ar abi a, and Kuwait, a s
w e l l a s i n I ndi a and Kussia. Aicohol a dve r t i s i ng seems t o be one
a r e a of l e g i s l a t i v e pr event i on i n which p o l i t i c i a n s and government
o f f i c i a l s i n a l 1 c ount r i e s a r e wi l l i ng t o a c t . There seems t o be no
count r y i n which al cohol a dve r t i s i ng i s not s ubj e c t t o government
c ont r ol a a s t o cont ent , time, and space.
Much of t he concern a t t he p o l i t i c a l and policy-making l e v e l s
i s about t he pos s i bl e impact of al cohol a dve r t i s i ng on a c t u a l
consumption, both immediately and a s i t af f e c t s t he younger
gener at i on. Probabl e sour ces of concern a r e t he s he e r volume of
a l c ohol a dve r t i s i ng r e l a t i v e t o publ i c- ser vi ce announcements f o r
moderat i on (McEwan and Hanneman 1974; Smart and Krakowski 1973) , t h e
use of l i f e s t y l e appeal s ( Jor dan and Goldberg 1977, McEwan and
Hanneman 1974), t he p o s s i b i l i t y of r e s or t t o subl i mi nal e r o t i c
appeal (Key 1976) , and t he i mpl i cat i ons of pos s i bl e i nf l ue nc e over
t he e d i t o r i a l and news t r eat ment of al cohol problems i n t h e media.
Repr esent at i ves of t he a l c ohol i ndus t r y t ypi c a l l y mai nt ai n
t h a t t h e i r a dve r t i s i ng does not a f f e c t ove r a l l consumption i n t h e
popul at i on a t l a r ge , but r a t h e r i nf l uences market -shares and brand
choi ces wi t hi n t h e i ndus t r y. Research t o da t e has not answered t he
ques t i ons of whe t h e r al cohol a dve r t i s i ng does i nc r e a s e aggr egat e
consumption ( t h a t is, consumption a c r os s br ands) , al t hough many
s t u d i e s seem t o suppor t t he i ndus t r y posi t i on.
Unf or t unat el y, t he impact of al cohol a dve r t i s i ng on
consumption i s a d i f f i c u l t a r e a t o r esear ch. Simon (1969) put i t
t h i s way: "The e f f e c t of l i quor a dve r t i s i ng i s among t h e har der
a dve r t i s i ng e f f e c t s t o measure . . . Liquor execut i ves commonly say
t h a t no one knows and no one can know t he e f f e c t s o l i quor
-
adver t i s i ng. " In pa r t i c ul a r , he poi nt ed t o two problems: a ) t he
d i f f i c u l t y of pi npoi nt i ng which s a l e s r e f l e c t which exposure t o what
adver t i sment s i n which media; and b) t h e pos s i bl e d i f f u s i o n and
cumul at i on o a dve r t i s i ng e f f e c t s over time. Blane and Hewitt
(1980) a r e s i mi l a r l y pe s s i mi s t i c about t he c ur r e nt s t a t e of
knowledge: "Examination of what i s known about a dve r t i s i ng i n
r e l a t i o n t o s a l e s and market i ng l e a ds t o no cl ear - cut concl usi on
concer ni ng i t s e f f e c t on consumption. " They p a r t i c u l a r l y emphasized
t h e d i f f i c u l t y o i n t e r p r e t i n g t he d i r e c t i o n of c a us a l i t y i n any
observed c o r r e l a t i o n between al cohol s a l e s and a dve r t i s i ng
expendi t ur es. That i s, i t seems j u s t a s l i k e l y t h a t i ncr eas ed s a l e s
v i l 1 s t i mul a t e a dve r t i s i ng expendi t ur es a s t h a t a dve r t i s i ng vil1
s t i mul a t e s a l e s . The f ol l owi ng s e c t i o n revi ews s ever a1 s t u d i e s t h a t
show t h e i r concern va s j us t i f i e d.
For t unat el y , t he pas t f i ve year s have seen a consi der abl e
development of empi r i cal s t u d i e s of al cohol a dve r t i s i ng. Research-
ers employed econometric and t r end anal ys es , quasi -experi ment al
s t u d i e s and exper i ment al paradigms.
Econometric Anal yses
Econometric anal ys es a r e e s s e n t i a l l y mul t i pl e r e gr e s s i on
anal ys es of s a l e s a s a f unc t i on o s ever a1 va r i a bl e s , i ncl udi ng
a dve r t i s i ng spending o r volume. A number of s t u d i e s have examined
al cohol s a l e s i n r e l a t i o n t o a pr e di c t or e e t which i ncl udes
a dve r t i s i ng (Bourgeois and Barnes 1979; Grabowski 1976; McGuiness
1979; Pe l e s 1971a, 1971b; Simon 1969).
Bourgeois and Barnes (1979) examined t he per c a p i t a
consumption of al cohol i n t he 10 pr ovi nces of Canada over 24 year s,
and conducted s epar at e a na l ys e s f o r beer , wine, l i quor and t o t a l
consumption of abs ol ut e al cohol . Thei r r e s u l t s were complex, t o put
i t mi l dl y. Beer consumption was r epor t ed t o be pos i t i ve l y r e l a t e d
t o pr i nt - adver t i s i ng expendi t ur es, but negat i vel y t o t hose f o r
br oadcast adver t i s i ng . Liquor , on t he ot he r hand , r e l a t e d nega-
t i v e l y t o p r i n t a dve r t i s i ng and pos i t i ve l y t o br oadcast a dve r t i s i ng
-- a s ur pr i s i ng r e s u l t s i nce t he r e i s no br oadcast a dve r t i s i ng of
l i quor anywhere i n Canada. Wine s a l e s r e l a t e d pos i t i ve l y t o
br oadcast a dve r t i s i ng onl y. f i n a l l y , t he r e was no s i g n i f i c a n t
impact of e i t h e r p r i n t o r br oadcast a dve r t i s i ng on s a l e s of t o t a l
al cohol . Presumably, t he c ont r a di c t or y e f e c t e on beer and l i quor
s a l e s cancel l ed each ot he r out . These somewhat i mpl ausi bl e r e s u l t s
may r e f l e c t sever a1 problems, t o r example: a ) onl y f i v e d a t a poi r i t s
were a va i l a bl e f o r a dve r t i s i ng expendi t ur es; and b) quest i onabl e
assumpt i ons had t o be made t o a l l o c a t e a dve r t i s i ng expendi t ur es i n t o
pr ovi nc i a l shar es.
Grabowski (1976), not i ng t ha t t he ques t i on of whether
a dve r t i s i ng pr i mar i l y a f f e c t e d s a l e s or vi c e ver s a va s a gener al
i s s u e i n economlc t heor y, examined h i e da t a f o r bot h ki nds of
i nf l uence. His r e s u l t s f o r a dve r t i e i ng' s e f f e c t on s a l e s were
negat i ve. However, he found, f o r al cohol a s w e l l a s ot he r product
c a t e gor i e s , t h a t s a l e s s t r ongl y pr edi ct ed a dve r t i s i ng expendi t ur es.
When companies have a popul ar product wi t h growing s a l e s , t hey tend
t o i ncr eas e a dve r t i s i ng .
McGuiness (1979) examined demand f o r a l c ohol i c bever ages i n
t he United Kingdom over t he per i od 1956-1975. He found s i g n i f i c a n t
evi dence t h a t a dve r t i s i ng had a modest impact on l i quor s a l e s , but
t he r e was no comparable evi dence of impact on t he s a l e s of beer ,
wine, o r ci der .
Pe l e s (1971a, 1971b) came t o t he concl usi on t h a t ge ne r a l l y
a dve r t i s i ng a f f e c t s market s ha r e s of beer s a l e s wi t hi n t he al cohol
i ndus t r y r a t h e r t han t o t a l beer s a l e s . He a l s o showed t h a t
a dve r t i s i ng does more f o r t he market s har e of l a r g e pr oducer s t han
of smal l producers. Pel es poi nt ed out t h a t adver t i ei ng does eeem t o
i nc r e a s e t he t o t a l demand f o r ot he r pr oduct c a t e gor i e s , e i t h e r
s t a b l y (e. g. c i g a r e t t e s ) o r t empor ar i l y (e.g. aut omobi l es, where
s a l e s i n a gi ven year a r e a t t he expense of s a l e s i n t he succeedi ng
year ) .
A pi oneer i ng st udy by Simon (1969) di d not bear on t o t a l
product -cat egory demand, but r a t h e r on market share. He found gr e a t
product l oya l t y, i ndi cat ed by annual r e t e nt i on r a t e e of 75 per cent .
He r epor t ed t ha t al cohol a dve r t i s i ng brought di mi ni shi ng r e t u r n s a t
each l e ve 1 o i ncr eased expendi t ur e. Fi na l l y, unl i ke Pe l e s ( 1971a) ,
he concluded t h a t t he p r o f i t r e t u r n s on a dve r t i s i ng a r e hi gher f o r
smal l er t han f o r l a r g e r a dve r t isers.
J u r i s d i c t i o n a l Quasi-Experiments
Campbell (1969) was t h e f i r s t t o advocat e quaei -experi ment al
s t u d i e s of t he e f f e c t s of l ar ge- s cal e s o c i a l changes. One ki nd of
s o c i a l change t ha t can be s t udi e d i n t h i s way i s t he e f f e c t of
i nt r oduc t i on o r removal of r e s t r i c t i o n s on al cohol adver t i s i ng.
Smart and Cut l er (1976) s t udi e d t h e e f f e c t of t he 1971 al cohol
a dve r t i s i ng ban i n Br i t i s h Columbia by comparing consumption f i gur e s
f o r B.C. and Ont ar i o, t he most comparable j ur i s di c t i ons . They
concluded t ha t t h e i r dat a" . . . l e n t l i t t l e suppor t f o r t he view
t h a t t he B.C. a dve r t i s i ng ban reduced al cohol coneumption" (p.20).
However, t he e f f e c t i ve ne s s of t he ban was compromised by cont i nued
exposure t o a dve r t i s i ng i n na t i ona l newspapers and magazinee, and
br oadcast a dve r t i s i ng from Al ber t a and t he s t a t e of Washington
a c r os s t he U.S. border.
More r e c e nt l y, Ogborne and Smart (1980) s t udi e d t h e 1974 beer
a dve r t i s i ng ban i n Manitoba. They r epor t ed t h a t beer consumption
showed a s i gni f i c a nt i nc r e a s e under t h e ban, comparable t o t h e
pa t t e r n i n Al ber t a (where t h e r e was no ban) over t he sanie i nt e r va l .
The same problem of cont i nued exposure t o out-of-province adver-
t i s i n g appl i ed her e a s i n t h e Smart and Cut l e r (1976 ) st udy. The
r es ear ch team a l s o found no s i g n i f i c a n t r e l a t i ons hi ps between t h e
comprehensiveness of a dve r t i s i ng r e s t r i c t i o n s i n t he va r i ous states
of t h e United St a t e s and measures of al cohol consumption o r
al cohol i sm.
Experi ment al St udi e s
Few exper i ment al s t udi e s of al cohol a dve r t i s i ng have been
done. Brown (1978a) assi gned 30 s o c i a l dr i nke r s t he t a s k o
es t i mat i ng t h e l i quor and mix cont ent of vodka and t oni c mi xt ur es of
var yi ng concent r at i on. The t a s k provi ded an oppor t uni t y f o r
measurabl e d i f f e r e n t i a l consumption of t he vodka. Subj ect s were
a l t e r n a t i v e l y exposed t o c i g a r e t t e and al cohol a dve r t i s i ng i n a
count er bal anced wi t hi n- subj ect exper i ment al desi gn. Subj ect s dr ank
s i g n i f i c a n t l y more vodka a f t e r exposure t o a l c ohol a dve r t i s i ng t han
a f t e r exposure t o c i g a r e t t e a dve r t i s i ng. Brown concluded t h a t
al cohol a dve r t i s i ng i nc r e a s e s t he subsequent consumption of avai l -
a b l e al cohol . iiowever, t he r e i s an a l t e r n a t i v e i nt e r pr e t a t i on:
pos s i bl y, t he al cohol a dve r t i s i ng hei gnt ened s u b j e c t s t awareness of
t he r ange of al cohol a l t e r na t i ve s . Because t oni c heavi l y masks t he
f l a vor of l i quor , and vodka i s e a s i l y masked i n t h e pr opor t i ons used
by Brown (0:10, 1: 9, 1:7, 1:5, and 1: 3) , t he s ubj e c t s might have
drunken more because t hey were t r yi ng har der t o i d e n t i f y t h e l i quor
i n us e, being i n a s t a t e of hei ght ened appr eci at i on of a l t e r n a t i v e
p o s s i b i l i t i e s .
Kohn, Smart , and Ogborne, i n an as-yet -unreport ed st udy
(1979), examined t he impact of two ki nds of p r i n t a dve r t i s i ng f o r
Hei nekent s beer -- s o c i a l cont ext o r l i f e s t y l e a dve r t i s i ng and
pr oduct - qual i t y a dve r t i s ng -- on short -t erm and long-term al cohol
consumption. Short-term consumption was measured by gi vi ng s ubj e c t s
a 5 d o l l a r food voucher t o e a t i n a l o c a l l i cens ed r e s t a ur a nt f r a n
which t he exper i ment er s obt ai ned feedback on s ubj e c t s ' a l c ohol
consumption. Long-term consumption was measured by a r e t r os pe c t i ve
t el ephone i nt er vi ew ( a t l e a s t s i x weeks l a t e r ) on consumption of
bot h non-al cohol i c and a l c ohol i c beverages. Experi ment al s ubj e c t s
were asked t o e va l ua t e e i t h e r f i v e soci al - cont ext adver t i sement s o r
f i v e produc t - qual i t y adver t i sement s i n a t ypi c a l marke t - r esear ch
manner. Cont r ol s ubj e c t s were quest i oned about t h e i r e va l ua t i ons of
t he shopping mal1 where t he d a t a were c ol l e c t e d and r ecei ved t he
same voucher a s exper i ment al s ubj e c t s . Although t h e d a t a a r e not
ye t f u l l y anal yzed, i t was found t h a t a dve r t i s i ng exposure had no
s i g n i f i c a n t e f f e c t on purchase of a l c ohol i c beverages a t t he
r e s t a ur a nt , ne i t he r when combining a l 1 c a t e gor i e s of al cohol ( i . e.
wine, domest i c beer , imported beer , and l i quor ) nor when consi der i ng
them s epar at el y. The t el ephone i nt er vi ewer s , a l s o , found no
long-term e f f e c t .
hat can be concluded about t he e f f e c t s of a l c ohol a dve r t i s i ng
on t o t a l consumption? It would be us e f ul t o have more s t u d i e s of
a dve r t i s i ng bans, e s pe c i a l l y t hos e i n Scandi navi a, as w e l l a s more
exper i ment al s t udi e s . Also, t he e f f e c t s of a dve r t i s i ng over a
l onger per i od of t i m e , a s f o r example a gener at i on, need t o be
examined. A t pr es ent , however , t he evi dence t h a t a dve r t i s i n g has
much e f f e c t on s pe c i f i c o r t o t a l s a l e s of a l c ohol i c bever ages 1s
very weak and i nconcl usi ve. It may wel l be t ha t al 1 t he l e g i s l a t i v e
e f f o r t s a t c ont r ol i n t h i s a r e a w i l l have l i t t l e impact. Ef f or t s
miglit b e t t e r be di r e c t e d el sewher e, f o r example towards pr i c e o r
a v a i l a b i l i t y c ont r ol s .
Research on Legal Cont r ol
i n t he WHO Region of t h e Americas
To da t e , t he s t udi e s o l e g a l c ont r ol s and a l c ohol problems
have looked a t Europe , Nort h America, and Aus t r al as i a. Si mi l ar
s t u d i e s a r e almost non- exi st ent i n Lat i n American and Caribbean
count r i es . Indeed, good d a t a on al cohol consumption over time seem
t o be almost unavai l abl e f o r many such count r i es . For example, t h e
World Alcohol Pr oj ect (Sulkunen 1976) cont ai ned d a t a on 33
c ount r i e s , but onl y Cuba and Per u were i ncl uded from t he l e s s
developed c ount r i e s of t he Americas. An e a r l i e r World Heal t h
Or gani zat i on r epor t (Moser 1974) developed d a t a on a l c ohol problems
and programs i n Chi l e, but no ot he r La t i n American count ry.
A more r ecent r epor t (Moser 1980) does, however, have a wide
va r i e t y of i nf or mat i on on a l c ohol consumption and c ont r ol s i n t he
r egi on. Probably many c ount r i e s now have s u f f i c i e n t i nf or mat i on t o
do s t u d i e s of l e g a l c ont r ol s and consumption. However, t he r e a r e
s t i l l v i r t u a l l y no Lat i n American o r Cari bbean s t udi e s of : a )
a v a i l a b i l i t y and consumption; b) t he working of i ndi vi dua l al cohol
c ont r ol s di r e c t e d toward a dve r t i s i ng, age, hours of s a l e , et c. ; c )
t he i nf l uence of p r i c e on consumption; and d) p r i c e e l a s t i c i t i e s
f o r va r i ous beverages. An except i on 1s t he work of Beaubrun (1977)
on t he c l os e c or r e l a t i ons between t he pr i c e of rum, consumption, and
a c c i de nt s i n Tr i ni dad and Tobago.
It 1s very doubt f ul t h a t r e s u l t s from t h e more developed
world can be appl i ed wi t hout change t o La t i n America and t he
Caribbean. Local consurnption ha bi t s and t he s oc i oc ul t ur a l mi l i e u
a r e s o d i f f e r e n t as t o make such a ppl i c a t i on ver y r i s ky. Perhaps a
few examples w i l l s uf f i c e . I n many a r e a s of La t i n America l o c a l l y
produced beverages, such as pul que, chi cha, and rum, a r e o f t e n not
c ont r ol l e d o r t axed by t h e government. Attempts a t p r i c e o r l e g a l
c ont r ol s of ot he r a l c ohol i c beverages may simply l ead t o a s h i f t
towards t he l o c a l l y produced v a r i e t i e s . I n many r u r a l a r e a s , t oo,
i t may be economic t o dr i nk a l c ohol i c beverages because t hey c ont a i n
c a l o r i e s and a r e cheaper , s a f e r , and more a va i l a bl e t han wat er o r
mi l k ( Negr et e 1976). Las t l y, such c ount r i e s of t e n have l a r g e a r e a s
where al cohol consumption i s i ncr eas i ng r api dl y, due t o t our i sm o r a
l a r g e i nf l ux of workers, a s f o r t h e pet r ochemi cal i ndus t r y.
Typi cal - l y , such s i t u a t i o n s a r e d i f f i c u l t f o r governments t o
c ont r ol and a l c ohol problems a r e o f t e n s ubs t a nt i a l .
Cl ear l y, t he r e is a need f o r s t u d i e s of pr event i on and l e ga l
c o n t r o l s i n La t i n American and Caribbean c ount r i e s . Such s t u d i e s
might be done wi t h t he a i d of t h e World Heal t h Or gani zat i on o r ot he r
i n t e r n a t i o n a l agenci es. A s t a r t ha s been made i n Mexico wi t h a WHO-
sponsored st udy of community r esponses t o al cohol problems.
However, t h i s st udy does not bear d i r e c t l y on t h e working of l e g a l
cont r ol s .
Concl usi ons
The a va i l a bl e e mpi r i c a l s t u d i e s al l ow onl y some t e n t a t i v e
concl usi ons about t he pr event i on of al cohol - r el at ed problems.
Research i n t h i s a r e a i s expanding qui ckl y and any concl usi on can
e a s i l y become dat ed. A t l e a s t t he f ol l owi ng can be suggest ed:
1 ) There is widespread agreement t h a t governments have a r o l e
i n pr event i on of al cohol problems which i ncl udes , but goes
wel l beyond , t he need t o pr ovi de t r eat ment f o r al cohol i cs .
That r o l e i s t o examine how c ur r e nt p o l i c i e s and laws
r es pect i ng a v a i l a b i l i t y , p r i c e , and a dve r t i s i ng of
a l c ohol i c beverages a f f e c t bot h s a l e s and a l c ohol problems
and t o seek me t hod s of reduci ng problems t hr ough government
a c t i on.
2) Over al l s t udi e s of a v a i l a b i l i t y show t h a t i t has i ncr eas ed
al ong wi t h a f f l ue nc e , ur bani zat i on, and t h e ge ne r a l accept -
a b i l i t y of al cohol i n s oc i e t y. Aithough a v a i l a b i l i t y of
al cohol has i ncr eas ed i n many c ount r i e s , i t s e f f e c t s on
consumption a r e i mpossi bl e t o s e pa r a t e from br oader s o c i a l
and c u l t u r a l changes.
Numerous smal l changes i n hour s of s a l e and numbers of
dr i nki ng es t abl i s hment s have no s i g n i f i c a n t e f f e c t on t he
amount of dr i nki ng. However, many l a r g e r changes i n
numbers of o u t l e t s , f o r example i n Fi nl and i n t he 196OVs,
do have a g r e a t e f f e c t . St r i k e s by l i quor s t o r e employees
and c l os i ng s t o r e s on Sat ur days have bot h af f ect ed
consumption and drunkenness. Pr ohi bi t i on, bot h t o t a l and
p a r t i a l ( a s i n nor t her n Ont ar i o) , ha s had consi der abl e
ef f e c t on consumption and problems. When governments wish
t o decr ease consumption t hrough changi ng a v a i l a b i l i t y ,
d r a s t i c measures w i l l us ua l l y be r equi r ed.
4) Per c a p i t a al cohol consumption seems t o have s t a b i l i z e d i n
many c ount r i e s over t he past f i v e year s. A t pr es ent we do
not have good expl anat i ons f o r t h i s phenomenon, nor do we
know what e f f e c t i t w i l l have on governrnent revenues and
t he tendency of governments t o c r e a t e new demand o r
i nc r e a s e a v a i l a b i l i t y .
5) There a r e some i ndi c a t i ons t h a t t he d r e a t i nc r e a s e s i n
al cohol a v a i l a b i l i t y s i nc e World War 11 may be ended, a t
l e a s t t empor ar i l y, i n many West e r n count r i es .
6) Both economet ri c and exper i ment al s t u d i e s suggest t h a t
s a l e s of a l c ohol i c bever ages us ua l l y behave much as s a l e s
of ot he r consumer goods. People buy more when t hey a r e
cheap and l e s s when t hey a r e a r e not . However, t h e exact
r e l a t i ons hi ps between pr i c e and consumption a r e va r i a bl e
and s ubj ect t o many f a c t o r s d i f f i c u l t t o c ont r ol and
st udy. Experi ment al s t udi e s of s i t u a t i o n s where p r i c e is
mani pul at ed may gi ve b e t t e r r e s u l t s t han pursui ng
l ar ge- scal e economet ri c s t udi e s .
7) Some s t u d i e s show t h a t al cohol use l ower s t h e r i s k o
cor onar y he a r t di s e a s e ; many show t h a t i t i nc r e a s e s t he
r i s k of l i v e r c i r r hos i s . Governments, i n s e l e c t i ng
a l c ohol c ont r ol p o l i c i e s , may be r equi r ed t o deci de
between t hese e f f e c t s .
8) bwe r i ng t he dr i nki ng age appeared t o i nc r e a s e con-
sumption, al cohol - r el at ed t r a f f i c acci dent e, and
admi ssi ons t o t r eat ment f o r t h e age group a f f e c t e d.
Rai si ng dr i nki ng ages has been shown t o decr eas e con-
sumption and, where t he change is s ubs t a nt i a l , decr ease
al cohol - r el at ed acci dent s .
9) Research on a dve r t i s i ng of a l c ohol i c beverages does not
i ndi c a t e t ha t i t ha s an i mpor t ant e f f e c t on s a l e s o r
consumption. Le gi s l a t i ve e f f o r t s a t pr event i on of a l c ohol
problems a r e mi sdi r ect ed i f focused on a dve r t i s i ng.
10) Kesearch on a v a i l a b i l i t y , pr i c e , consumption, and problems
i s needed i n La t i n American and Cari bbean count r i es.
Research from ot he r c ount r i e s cannot be e a s i l y gener al i zed
t o t hese count r i es .
The empi r i cal evi dence i n t o t a l s ugges t s t h a t pr event i on
of al cohol - r el at ed problems depends upon hol di ng
a v a i l a b i l i t y and p r i c e s const ant o r even r educi ng
a v a i l a b i l i t y , keepi ng acces s f o r young peopl e l i mi t e d and
hoping t h a t t he pr es ent t r end towards a pl a t e a u i n a l c ohol
consumption cont i nues where i t has begun. I n c e r t a i n
c ount r i e s i t may be pos s i bl e t o make l a r g e changes i n
pr i c e o r a v a i l a b i l i t y , but i n or de r t o have a s ubs t a nt i a l
e f f e c t t hey must be ver y l a r ge , probabl y l a r g e r t han most
governments w i l l consi der .
2 46
DISCUSSANT
Michael H. Beaubrun
It would be d i f f i c u l t t o di s agr ee wi t h t he o v e r a l l concl usi on
of Dr . Smart t h a t "t he a va i l a bl e empi r i cal s t u d i e s al l ow onl y some
t e n t a t i v e concl usi ons about t he pr event i on of al cohol - r el at ed
problems . " Yet, t he r e i s i nc r e a s i ng worldwide consensus t ha t
a v a i l a b i l i t y and p r i c e a r e everywhere c l e a r l y r e l a t e d t o consumption
and t o problems due t o al cohol , though s oc i oc ul t ur a l f a c t o r s modify
t he p i c t u r e consi der abl y.
It i s t r u e t h a t c o r r e l a t i o n s a r e not i pso- f act o evi dence of
caus at i on, and i t i s not easy t o s e pa r a t e t he va r i a bl e s i nvol ved-
However, t he sheer wei ght of t he i ncr eas i ng evi dence from
economet ri c and exper i ment al s t u d i e s s t r ongl y suggest s t h a t t her e i s
a cause and e f f e c t r e l a t i ons hi p, and t he r e a r e s uf f i c i e n t i ns t a nc e s
of " na t ur a l experi ment s" t o j u s t i f y our advocacy of some c ont r ol
s t r a t e g i e s aimed a t r educi ng a v a i l a b i l i t y , provi ded we r ecogni ze t h e
l i mi t s of such cont r ol s .
1 w i l l t r y t o avoi d goi ng over t h e ground covered i n t he
e xc e l l e nt revi ew by Dr . Smart of t he a va i l a bl e r es ear ch and w i l l t r y
i ns t e a d t o di s c us s some of t he i mpl i cat i ons of h i s f i ndi ngs and t o
r e l a t e them t o our Caribbean exper i ence.
"Supply Si de" St r a t e gi e s
D r . Smart f ound a s i gni f i c a nt , pos i t i ve c o r r e l a t i o n between
per c a p i t a consumption and ove r a l l a v a i l a b i l i t y i n t h e Uni t ed St a t e s
(Smart 1977b). Yet he not es t h a t t he c o r r e l a t i o n of consumption
wi t h income wa s even g r e a t e r , and t he r e was a c l o s e pos i t i ve
c o r r e l a t i o n wi t h ur bani zat i on.
Makela e t a l . (1982), i n t he ISACE st udy, a l s o emphasized t he
importance of a f f l ue nc e and ur bani zat i on, as w e l l a s l i be r a l i z e d
a t t i t u d e s and ot he r s oc i oc ul t ur a l f a c t or s . The concl usi on i s t h a t
i t i s i mpossi bl e t o s e pa r a t e a v a i l a b i l i t y from income and ot he r
s o c i a l and c u l t u r a l f a c t or s .
Economic Ava i l a bi l i t y A f i e l d st udy of dr i nki ng pr a c t i c e s i n
suburban Ki ngst on, Jamaica, conducted i n 1966 (Beaubrun 1968) showed
a very c l e a r c or r e l a t i on between dr i nki ng and s o c i a l c l a s s a s
def i ned by housing ar ea. Here, t oo, income seemed t h e most
i mport ant s i n g l e va r i a bl e . We have no s t u d i e s of t he e f f e c t of
l i b e r a l i z a t i o n of c ont r ol s o r of t h e e f f e c t of l i quor s t o r e s t r i k e s ,
but economic a v a i l a b i l i t y i n Jamaica seemed r e l a t e d t o heavy
dr i nki ng. I n most of t he Cari bbean i s l a nds , a l c ohol i s f r eel y
a va i l a bl e and can be purchased i n supermarket s, gr oc e r i e s and, i n
some pl aces, even i n vendi ng machines. The onl y r e a l cur b on
a v a i l a b i l i t y i s economic a v a i l a b i l i t y determined by income and pr i ce.
Ci r r hos i s mor t a l i t y rates i n t he Cari bbean bear a rough
r e l a t i o n s h i p t o t h e r a t i o between income and t he pr i c e of beverage
al cohol . Tourism c e nt r e s l i k e t he Bahamas, Puer t o Rico, Mar t i ni que,
Aruba, and t h e Vi r gi n I s l a nds have very hi gh r a t e s . There t h e pr i c e
of a l c ohol i s low and incomes r e l a t i v e l y hi gh by Cari bbean s t a r r
dar ds. Mor t al i t y r a t e s from al cohol - r el at ed causes a r e hi gher i n
t he Vi r gi n I s l ands t han i n any s t a t e i n t he Uni t ed St a t e s . (U.S.
Department of t i eal t h and Human Ser vi ces r epor t 1981)
Alcohol Out l e t s and llours of Sal e: Rel at i onshi p t o Consumption and
Problems It i s not s u r ~ r i s i n n t o f i n d t h a t smal l channes i n hour s
of s a l e and numbers of o;tletsWhad few s i gni f i c a nt e f f e Gs , but t ha t
l a r g e r changes di d. It would be i mport ant t o st udy not onl y t he
f r equency of o u t l e t s but t h e i r l ocat i on.
We have t he i mpr essi on t h a t t he l oc a t i on of bar s near t o
pl aces where men a r e pai d poses a d i s t i n c t hazard. I n t hose
Caribbean I s l ands where t he r e a r e o i l r e f i n e r i e s , s ugar f a c t o r i e s ,
and ot he r i ndus t r i e s , ba r s l oc a t e d near t he ent r ance of t h e work
pl ace do a r oar i ng t r a de on pay day, and even i n t he absence of
r es ear ch f i ndi ngs , we have gone on record as recommending t h a t no
bar shoul d be l ocat ed near t he pl ace where workers a r e pai d
(Beaubrun and Mahy 1980).
Pr i ce and Taxat i on The s i ngl e - di s t r i but i on t h e o r i s t s have us ua l l y
made pr i c e c ont r ol t h e i r major reconnnendation based on t h e c l e a r
r e c i pr oc a l r e l a t i ons hi p between r e a l p r i c e and consumption, which i n
t ur n i s r e l a t e d t o he a l t h and s o c i a l damage ( Seal ey 1960, Popham,
Schmidt and de Li nt 1975). The i nver s e r e l a t i ons hi p between p r i c e
and l i v e r c i r r h o s i s mor t a l i t y demonst rat ed i n Ont ar i o ha s s i nc e been
shown t o r e l a t e t o ot he r damage a s wel l . Hospi t al admi ssi ons f o r
al cohol i sm i n Scot l and showed a s i mi l a r i nve r s e r e l a t i ons hi p wi t h
r e a l p r i c e of al cohol (Semple and Yarrow 1974), and we have found i n
Tr i ni dad and Tobago an even c l os e r r e c i pr oc a l r e l a t i ons hi p between
r e a l pr i c e and road t r a f f i c a c c i de nt s (Beaubrun 1977).
I n t h e Tr i ni dad st udy, t h e c o r r e l a t i o n we obt ai ned between t h e
r e l a t i v e pr i c e and a c c i de nt s over t he 10-year per i od 1966-1975 was
s o c l os e ( R = -0.978) t h a t i t seemed unbel i evabl e. Subsequent small
changes i n t he f i gur e s put out by t he c e n t r a l s t a t i s t i c a l o f f i c e may
r educe t he l e ve 1 of t h i s c o r r e l a t i o n but i t st i l l remai ns hi ghl y
s i gni f i c a nt . hat i s most s i g n i f i c a n t i s t h a t br eaks i n t h e gr aphs
showing sudden decr eas es i n road a c c i de nt s i n 1968 and a ga i n i n 1973
were c or r e l a t e d wi t h s i g n i f i c a n t i nc r e a s e s i n t h e e xc i s e and
purchase t a xe s on al cohol r e f l e c t e d by r i s e s i n r e l a t i v e pr i ce. I n
each of t hose two year s, purchase t a x on rum was i ncr eas ed by 100
per cent . I n 1968, t he r e was a l s o a n i nc r e a s e of t h e e xc i s e t a x on
al cohol from TT 89.50 t o TT $12.00 pe r i mper i al proof gal l on. These
t a x i ncr eaees were i nt r oduced a s revenue ear ni ng measures, but t h e i r
e f f e c t on t he acci dent r a t e was dramat i c.
A c l o s e r l ook a t t h e acci dent st at i st i cs shows us t h a t most of
t hes e a c c i de nt s were caused by dr i ve r s under t he age of 25, who were
unl i ke l y t o be a l c ohol i c s a s ye t . A r ecent f i e l d s t udy of dr i nki ng
i n Tobago showed t he mean age of heavy dr i nki ng was 25 t o 34 year s
( Pa t r i c k and Pa t r i c k 1980). I ncr eas es i n t he p r i c e of beverage
al cohol a r e more l i k e l y t o be f e l t by young peopl e who have less
money i n t h e i r pocket s, and t h i s may be why p r i c e e f f e c t s on t h e
t o t a l acci dent rate a r e s o gr e a t .
These gr aphs were pr esent ed t o t he upper liouse of t he
Par l i ament of Tr i ni dad and Tobago i n December 1977 dur i ng a budget
debat e. I n January 1978, t he rum manuf act ur er s i ncr eas ed t h e p r i c e
of rum by 25 per cent and t he acci dent rate showed a correspondi ng
de c l i ne (Beaubrun and Mahy 1980).
One of t he major problems i n implementing c o n t r o l s t r a t e g i e s
i s t he problem of mobi l i zi ng t h e p o l i t i c a l w i l l . Po l i t i c i a n s w i l l
i n t h e main do what t hey f e e l t he vot e r s would want, and t h e be s t
approach t o them i s t hrough t he publ i c. But, t her e i s a l s o t he
problem of convi nci ng mi ni s t e r s of f i nance o r chancel l or s of t he
excheqwr t h a t s t r a t e g i e s proposed as a he a l t h measure w i l l not
i n t e r f e r e wi t h t a x revenue. It i s t he r e f or e i mpor t ant a l s o t o
conduct economet ri c s t udi e s which c l e a r l y i ndi c a t e what t ax
i nc r e a s e s a r e compat i bl e wi t h both improved he a l t h and improved
revenue. A r ecent economet ri c st udy by Duffy i n t h e United Kingdom
examined t h e i nf l uence of " pr i c e s , consumer incomes and a dve r t i s i ng
upon t he demand f o r a l c ohol i c dr i nk i n t he U.K." Among ot he r
t hi ngs , i t c l e a r l y showed t h a t t a x revenue coul d be i ncr eased and
consumption reduced qui t e s i g n i f i c a n t l y by r a i s i ng t h e r a t e s of
dut y, e s p e c i a l l y on s p i r i t s (Duffy 1981).
Another f i ndi ng of t ha t st udy s uppor t s t he concl usi on a r r i ve d
a t by Dr . Smart, t h a t s t u d i e s t o da t e i ndi c a t e that a dve r t i s i ng
c ont r ol s a r e a r e l a t i v e l y i n e f f e c t i v e way of r e s t r a i n i n g al cohol
consumption (Duff y 1981).
Changes i n t he Dri nki ng o r Purchasi ng Age Li mi t s The s t u d i e s
reviewed seemed t o negat e t he "f or bi dden f r u i t " hypot heei s
- -
(Wi l ki nson 1970). ~ower i & t h e dr i nki ng age i ncr eased consumption
and dr i nki ng/ dr i vi ng problems. I ncr easi ng t he dr i nki ng age seemed
t o r e s u l t i n fewer al cohol - r el at ed problems.
Our f i e l d stuciy i n Jamaica i n 1966 showed t h a t heavy dr i nki ng
was r e l a t e d t o t he age a t which Jamai cans s t a r t t o dr i nk. Thi s
f i ndi ng was s i g n i f i c a n t a t t h e .O5 l e v e l , suggest i ng t h a t any
measure which coul d del ay t he s t a r t of dr i nki ng might r e s u l t i n
fewer excessi ve dr i nke r s and, t he r e f or e , fewer dr i nki ng problems.
There may be ot he r ways of del ayi ng t h e s t a r t of dr i nki ng. We
have al r eady spoken of t he s t r a t e g y of pr i c i ng a l c ohol out s i de t he
r each of youngst er s. It is i mpor t ant t ha t t he pr i c e of beer be
c l e a r l y hi gher t han t h a t of a s o f t dr i nk l i k e Pepsi o r Coke. I n
some of our i s l a nds , however, t h i s i s not s o and we have even
encount ered s i t u a t i o n s where s o f t dr i nks would onl y be ser ved a s a
"chaser. "
Sometimes, t oo, t he r e a r e l e g a l age limits which a r e not
enf or ced a t a l l . I n most Caribbean c ount r i e s t he r e is a l e g a l age
l i m i t , but c hi l dr e n walk i n t o supermarket s and buy a l c ohol wi t hout
bei ng quest i oned.
Dr . Smart concl udes t h a t t he "empi r i cal evi dence i n t o t a l
suggest s t h a t t he pr event i on of al cohol - r el at ed problems depende
upon hol di ng a v a i l a b i l i t y and pr i c e s cons t ant o r even reduci ng
a v a i l a b i l i t y , keeping a c c e s s f o r young peopl e l i mi t e d, and hoping
t h a t t he pr esent t r end toward t he pl at eau of a l c ohol consumption
cont i nues where i t has begun."
With t h i s view 1 am i n complete agreement. There i s need t o
i ndex t axes and pr i c e s of beverage al cohol s o t h a t t he r e a l pr i c e
does not f a 11 i n r e l a t i o n t o income. And ye t , t h i s measure a l one
would not be enough, f o r each count r y has s oc i oc ul t ur a l f a c t or 8
which modify t h e pi c t ur e .
I n 1980, a meeting of t h e ministers r es pons i bl e f o r h e a l t h of
t he Caribbean community passed Resol ut i on 26 on t h e s ubj e c t of
al cohol i sm. That r e s ol ut i on adopt ed r educt i on of consumption a s a
goa l of he a l t h pol i cy, and member governments were urged t o adopt
S t r a t e g i e s aimed a t reduc i ng a v a i l a b i l i t y a s we l l a s s t r a t e g i e s
aimed a t reduci ng t he demand f o r al cohol . The a ut hor s of t ha t
r e s ol ut i on s t a t e d t h a t t hey wished t o draw a t t e n t i o n e s pe c i a l l y:
. . . t o t he f a c t t h a t t he most i mpor t ant s i ngl e
method of reduci ng demand i s p r i c e mani pul at i on by
t axat i on, a s wel l a s t o t he a s s e r t i on t ha t : "Alcohol
i s s o much a pa r t of our way of l i f e i n t he Carib-
bean t h a t i t would be a mi st ake t o at t empt t o reduce
consumption by t oo d r a s t i c a pr ogr ame of f i s c a l and
l e g a l measures. The aim shoul d be t o at t empt t o
lower consumption gr adual l y over t h e next decade by
a combination of educat i on about t he hazards of
al cohol use combined wi t h such f i s c a l and l e g a l
measures a s may be necessary t o prevent t he r e a l
p r i c e of al cohol from f a l l i n g , whi l e we at t empt t o
moderate our dr i nki ng l i f e - s t yl e . (Caricom Heal t h
Mi ni s t er s Meeting 1980).
Demand Cont rol Fact or s
A c r i t i c i s m t h a t might be made of t h i s revi ew i s t h a t i t s
scope was t oo l i mi t ed. It d e a l t excl us i vel y wi t h l e g i s l a t i o n
a f f e c t i ng a v a i l a b i l i t y , concent r at i ng on pr i c e mani pul at i on,
cont r ol s of market i ng, numbers of o u t l e t s , and age limits. I n a
suppl y and demand model t hes e would al 1 be "supply s i de"
s t r a t e gi e s . The onl y measure di scussed which might be seen as
a f f e c t i ng "demand" would be t he c ont r ol of adver t i s i ng.
The Br eat hal yser and Scandinavian-type laws have not been
mentioned, nor have compulsory d r i v e r educat i on programs f o r
"dr i vi ng whi l e i nt oxi cat ed" (DWI) offences. The f i n a l r epor t of t he
U.S. Department of Tr ans por t at i on on "Det errence of t he Dri nki ng
Dri ver: An I nt er nat i onal Survey" (Ross 1981) has been gi ven t o us
and i t would be appr opr i at e t o have mentioned some of t hes e f i ndi ngs.
I nt e r na t i ona l experi ence shows us t h a t i n t h e s hor t run
Scandinavian-type laws, e s pe c i a l l y i f coupled wi t h some res ons i bl e
Sh-r i m~l ement at i on. and hi nh v i s i b i l i t v . r e s u l t i n s i nni f i c a nt r e uct on
-
i n acci dent s and mor t al i t y but t ha t i n t he l o w run this det er r ent
e f f e c t t ends t o be l o s t cien i n a few year s , a s -publ i c percept i on of
t he t h r e a t of being caught recedes. Cer t ai nt y of det ect i on i s t h e
i mport ant var i abl e and not s e ve r i t y of punishment. Ce l e r i t y of
punishment has y e t t o be pr oper l y eval uat ed.
Even i n t he l i g h t of t h e tendency f o r e f f e c t s t o di mi ni sh i n
t h e l ong term, we cannot e a s i l y i gnor e t he tremendous savi ng of
himran l i f e represent ed by t h e e a r l y gai ns , which al one would j u s t i f y
t he l e gi s l a t i on. We must, however, cont i nue t o sear ch f o r b e t t e r
ways of enhancing t he percei ved t h r e a t of det ect i on.
As Dr . Heat h' s paper was concerned wi t h eval uat i ng e xi s t i ng
r esear ch, i t may not be appr opr i at e t o di s cus s pr event i ve l egi s -
l a t i o n which has never been t es t ed o r assessed. However, t he r e have
been some proposed measures, such a s l e g i s l a t i o n r equi r i ng a
t echnol ogi cal devi ce t h a t would r equi r e a c e r t a i n degree of
de xt e r i t y i n or der t o s t a r t a car .
One method of l e g a l i nt e r ve nt i on which, i f i t had been
suppor t ed i n t he Appeals Cour t , might have had a s i g n i f i c a n t e f f e c t
on drunken dr i vi ng was a Ca l i f or ni a cas e which ne a r l y became a
pr ecedent . Thi s was t he cas e where t he pr opr i e t or of a bar was hel d
t o be r es pons i bl e i n law f o r t h e acci dent i n which h i s drunken
customer became i nvol ved. Had t h i s judgement been upheld i t might
have made bar t ender s r e f us e t o s e11 dr i nks t o peopl e who were
becoming i nt oxi cat ed. 1 am t o l d t h a t f o r a whi l e i t di d have j us t
t h i s e f f e c t -- u n t i l t he c a s e went t o appeal .
Concluding Remarks
Cont r ol s a r e odi ous, p a r t i c u l a r l y i n democraci es where a hi gh
val ue 1s pl aced on per sonal freedom; ye t t he r e 1s some evi dence t o
show t h a t c ont r ol s a r e s t i l l t h e most e f f e c t i v e method a va i l a bl e t o
us f o r changing behaviour. Treatment and educat i on have done l i t t l e
t o d a t e t o stem t he t i d e of t h i s worl d-cl ass problem.
I n a n e a r l i e r l e c t ur e , 1 r e f e r r e d t o t he words of Shakespear e' s
S i r Toby Belch who, wlien chi ded f o r h i s drunken r e ve l r y, s a i d t o
Malvolio: "Dost thou t hi nk, because t hou a r t vi r t uous , t he r e s h a l l
be no more cakes and a l e ? " S i r Toby, l i k e t he rest of us, r es ent ed
havi ng h i s pl eas ur e cont r ol l ed.
DISCUSSANT
Maria El ena Medina-Mora
Using Dr . Smar t ' s e xc e l l e nt paper a s a poi nt of depar t ur e, 1
wi l l concent r at e my remarks on t he impact of pr event i ve measures i n
La t i n American count r i es . There 1s agreement t h a t some pol i c i e s o r
i nt e r ve nt i ons coul d have more e f f e c t t han ot he r s . The problem 1s t o
deci de how and under what ci r cumst ances t hey w i l l be e f f e c t i v e , t o
whom t hey shoul d be gear ed, and what s oc i oc ul t ur a l condi t i ons
f a c i l i t a t e o r l i m i t t he pr event i ve pot e nt i a l of t he d i f f e r e n t t ypes
of measures. Only t hen can we make concr et e reconnnendations.
The count r y of Mexico 1s a p a r t i c u l a r l y us e f ul example t o
st udy pr event i ve measures , because i t 1s r e pr e s e nt a t i ve of a number
o ot he r s wi t h s i mi l a r c h a r a c t e r i s t i c s such a s s t a ge of development,
socioeconomic change, c u l t u r a l norms and val ues, pgt t e r ns of
consumption, d i v e r s i t y i n t he e x i s t i n g l e g i s l a t i o n , and a l a c k of
r es ear ch t o suppor t pos s i bl e pol i c y recommendations. I n any case,
recommendations f o r pr event i ve measures must t ake i n t o account t h e
ge ne r a l cont ext , i ncl udi ng t he a v a i l a b i l i t y o r l i mi t a t i o n of
r esour ces, t he l e ve 1 of l i t e r a c y , c u l t u r a l ba r r i e r e , e t c .
The da t a reviewed by Dr . Smart c l e a r l y show that small and
i s o l a t e d changes i n c ont r ol s br i ng about onl y shor t - l i ved and
moderate changes i n consumption, and hel p di mi ni sh conf i dence i n t h e
judgement of t hose who proposed such changes. Any a l t e r n a t i v e
proposed must be a complete a l t e r n a t i v e , an adequat e one. It must
be eval uat ed from a l 1 poi nt s of view, i ns of a r a s pos s i bl e,
pe r t a i ni ng t o bot h t he economic and s o c i a l e f f e c t s , but a l s o t he
c o l l a t e r a l r e s u l t s t h a t coul d be der i ved.
I n many r egi ons i t might be economical t o dr i nk a l c ohol i c
beverages because t hey have c a l o r i e s and a r e cheaper , l e s s harmful ,
and more a va i l a bl e t han ot he r bever ages such a s wat er o r milk. I n
such s i t u a t i o n s it would be necessar y t o r a i s e t he st andar d of
l i v i n g si mul t aneousl y wi t h i nc r e a s i ng c ont r ol of a l c ohol a va i l -
a b i l i t y , o r e l s e s i d e e f f e c t s might become more dangerous t han
per mi t t i ng t he s a l e of al cohol .
Mexico ha s a l r e a dy had some exper i ences wi t h l i mi t a t i o n of
a v a i l a b i l i t y of a l c ohol i c beverages. The f e de r a l d i s t r i c t , f o r a
per i od of f i v e year s, begi nni ng i n 1950, pr ohi bi t ed t he r e t a i l i n g of
beverages wi t h al cohol cont ent g r e a t e r t han f i v e per cent . I n t he
s hor t term t h i s measure appar ent l y l e d t o a r educt i on i n a l c ohol
consumption and a decr ease i n t he numbers of problems as s oci at ed
wi t h dr i nki ng. The r e s u l t s i n t he l ong term were di sappoi nt i ng.
The met r opol i t an a r e a of t h e Mexican c a p i t a l i ncl udes a f r a c t i o n of
a nei ghbor i ng s t a t e , a n a r e a t h a t has s een development of some of
t he most i mpor t ant i ndus t r i e s i n t h e count r y. With l i mi t s on t he
a v a i l a b i l i t y of al cohol i n t he f e de r a l d i s t r i c t , t he r e was a
p r o l i f e r a t i o n a c r os s t he bor der of ni ght s pot s , package s t o r e s t h a t
were open 24 hour s, and pl a c e s where one coul d buy and dr i nk l a r g e
q u a n t i t i e s of a l c ohol i c beverages. Soon t h i s a r e a was known a s t h e
" be l t of di s s i pa t i on. " By 1955 t h e laws pe r t a i ni ng t o t h e s a l e of
l i q u o r i n t he f e de r a l d i s t r i c t were changed and l i be r a l i z e d,
al t hough t h e new code di d l i m i t t he c ons t r uc t i on of package s t o r e s
t o a di s t a nc e of 500 met er s from school s, work c e nt e r s , hos pi t a l s ,
e t c .
Ef f e c t i ve pr event i ve measures must a l s o t ake i n t o consi der a-
t i o n pur chasi ng pa t t e r ns , consumption norms, and val ues and
a t t i t u d e s connect ed wi t h use of al cohol . Research r e s u l t s show
d i f f e r i n g pa t t e r ns f o r t hose who buy i n s e l f - s e r vi c e supermarket s
and t hose who buy i n s mal l er s t or e s . Si nce i n Mexico a l c ohol i c
beverages can be bought i n supermarket S, one might reconnnend
c ont r ol s f o r t he s e p a r t i c u l a r es t abl i s hment s on t he t heor y t h a t
impulse buying i n s e l f - s e r vi c e s t o r e s i s r es pons i bl e f o r a hi gher
volume of s a l e s . owever, market i nf or mat i on i ndi c a t e s t h a t less
t han 20 per cent of s a l e s a r e made i n t he s el f - s er vi ce supermarket s.
Furt hermore, i n t hes e s t o r e s t h e cust omers a r e housewives of t he
hi gher economic c l a s s who come i n t o s t oc k up f o r t h e f ami l y and
us ua l l y buy imported l i quor s . I n c ont r a s t , i n t he -11 s t o r e s
cust omers purchase much l a r g e r volumes of l i quor , us ual l y f o r
i me d i a t e use (Rosovsky 1982). Customers of t he s mal l er s t o r e s a r e
ge ne r a l l y males from t he lower socioeconomic s t r a t a ; us ua l l y t hey
consume a moderate l eve1 ever y day, augmented on s pe c i a l occasi ons,
weekends, days of pay, hol i days , and t he l i k e (Cal deron 1981).
Thus, a measure t o di scour age i mpul se buying i n s e l f - s e r vi c e
supermarket s would a f f e c t j u s t a smal l pa r t of t he popul at i on, whi l e
a s t r a t e g y aimed towards t h e smal l es t abl i s hment s might be more
e f f e c t i ve .
Not onl y a r e t he p a t t e r n s of consumption and purchase
i mpor t ant , but a l s o t he c u l t u r a l f a c t o r s , norms, and val ues t h a t a r e
r e f l e c t e d i n t he pa t t e r ns of consumption. Si mi l a r pa t t e r ns have
been observed i n r egi ons t hroughout La t i n America ( Negr et e 1979) -
Dr . Smart s t a t e s t h a t on t h e ba s i s of c ur r e nt evi dence ge ne r a l
a v a i l a b i l i t y of al cohol does not appear t o be a n i mport ant f a c t o r
a f f e c t i n e consumption. The s o c i a l , c u l t u r a l , and economic changes,
when grouped t oget her , w i l l probabl y loom ever more i mpor t ant i n
some count r i es . For example, i n Mexico and ot he r c ount r i e s of La t i n
America where consumption of a l c ohol and drunkenness a r e consi der ed
pa r t of t he male r ol e , and where s t r ong s anct i ons e x i s t a ga i ns t
consumption of al cohol by women, one would not expect women t o
i nc r e a s e consumption i n pr opor t i on t o r e l a xa t i on of c ont r ol s . I n
February 1981, i n t he f e d e r a l d i s t r i c t of Mexico Ci t y, laws
pr event i ng women from e nt e r i ng t he cant eens o r bar s , and r e s t r i c t i n g
where t hey coul d buy l i quor , were r epeal ed. Although now women
coul d buy al cohol anywhere, no s i g n i f i c a n t change i n a l c ohol
consumption has occurred. Even i f a n i nc r e a s e i n consumption by
women i s measured event ual l y, r es ear cher s w i l l have t o l ook a t such
pos s i bl y a s s oc i a t e d f a c t o r s a s r e l a xa t i on of s o c i a l norms and
g r e a t e r e qua l i t y of t he sexes.
Exi s t i ng l e g i s l a t i o n shoul d be eval uat ed. There a r e a number
of l aws t h a t have been proposed t o r e gul a t e al cohol consumption i n
La t i n America. However, i n many c a s e s t he s e laws a r e not put i n t o
pr a c t i c e . They a r e not enf or ced because q u i t e of t e n t he law i s t oo
e l e va t e d, t oo l o f t y , and i s o l a t e d from r e a l i t y -- a consequence of
s oc i oc ul t ur a l di f f e r e nc e s between t h e few who a r e p o l i t i c a l l y a c t i v e
and t he ma j or i t y of t he popul at i on. Before consi der i ng new
measures, i t would be wise t o eval uat e e xi s t i ng l e g i s l a t i o n and t o
educat e t h e popul at i on about t h e he a l t h, s o c i a l , and economic
problems as s oci at ed wi t h al cohol consumption.
Three exauiples i l l u s t r a t e t he a p p l i c a b i l i t y o r l a c k t her eof of
c ur r e nt r egul at i ons :
o The law pr ohi bi t i ng t he openi ng of l i quor s t o r e s near
i n d u s t r i a l par ks, h e a l t h f a c i l i t i e s , o r s chool s has been
rendered moot by t he expl os i ve growth of Mexico Ci t y and
t h e p r o l i f e r a t i o n of t he s e f a c i l i t i e s .
o St r ong enforcement of one r e gul a t i on, whose obj e c t i ve 1s t o
c ont r ol a v a i l a b i l i t y of a l c ohol by l i mi t i n g t he s a l e of
al cohol t o 20 per cent of t o t a l s a l e s i n t h e smal l
neighborhood gr ocer y s t o r e s , would l ead t o bankruptcy of
neighborhood s t or e s . Due t o t h e c mp e t i t i o n on food pr i c e s
from t he l a r g e supermarket s, t h e small s t o r e s t u r n t o t he
s a l e of al cohol t o sur vi ve.
o I n t h e month of December 1981, a decr ease i n t he number of
acci dent e, a r r e s t s , et c. , occur r ed i n one Mexican s t a t e
t h a t c a r r i e d out a n experiment t o s e e i f a l c ohol consump-
t i o n would drop when s a l e of l i q u o r wa s l i mi t e d t o c e r t a i n
hour s and days of t he week. Aithough i t 1s t oo soon t o
eval uat e t he r e a l e f f e c t s of t hes e measures, t hey r epr es ent
a n i s o l a t e d example of i nnovat i on and exper i ment at i on.
We know t he r e a r e many i n t e r e s t s i n t he al cohol i ndus t r y t h a t
might be a f f e c t e d by meesures t o c ont r ol al cohol . One s ugges t i on
f o r count er i ng i ndus t r y pr es s ur es 1s t o e s t a b l i s h a government
monopoly c ont r ol l i ng pr oduct i on and sale of al cohol . However, i n
Cost a Ri ca, where such a monopoly e x i s t s and s a l e s of al cohol have
s t a b i l i z e d , t he r e has been a l a r g e volume of boot l eg a l c ohol
produced and s ol d i l l e g a l l y . Uruguay was a l s o not s ucces s f ul i n
r educi ng consumption wi t h a government monopoly ( Negr et e 1981).
Furt hermore, t he a l c ohol i ndus t r y does r epr es ent a
cons i der abl e amount of economic a c t i v i t y . Count r i es t h a t wish t o
promote t h e i r economic development w i l l have t o de a l wi t h t he
dichotomy t h a t al t hough t hey want t o reduce t he pr oduct i on of
al cohol , t hey a l s o have an i n t e r e s t i n i ncr eas i ng t a x revenues.
Quite o f t e n t h e i s s ue s i nvol ve more t han j u s t t he r e l a t i ons hi p
between publ i c and pr i va t e i n t e r e s t s . Wi t hi n t h e publ i c s e c t or , f o r
example, var i ous agenci es a r e concerned wi t h t he promotion and
r e s t or a t i on of he a l t h, and ot he r s a r e t r yi ng t o s t i mul a t e t he
economic development of t he count r y. Mechanisms t o coor di nat e
d i f f e r e n t governmental i n i t i a t i v e s might be benef i ci a1 i n s e t t i n g
congruent pol i c i e s .
To da t e t h e r es ear ch ha s been modest i n scope, and f u r t h e r
r es ear ch 1s r equi r ed. One recommended di r e c t i on would be towards
devel opi ng us e f ul i n d i r e c t i n d i c a t o r s t o measure t he e f f e c t s of
changing pol i c i e s . It would be us e f ul t o mount s t udi e s t o eval uat e
t h e measures al r eady i n e xi s t e nc e pr ohi bi t i ng t h e s a l e of l i quor on
e l e c t i o n days, on na t i ona l hol i days , e t c . Research on pa t t e r ns of
s a l e and consumption might l e a d t o devel opi ng and eval uat i ng new
i nt e r ve nt i ons i n or der t o di s cover t hos e p o l i c i e s which w i l l have
t he most be ne f i t i n c ount r i e s exper i enci ng r api d socioeconomic and
p o l i t i c a l change.
Fi na l l y, t he r e i s no que s t i on t h a t changes i n t he s o c i a l mores
pe r t a i ni ng t o al cohol a r e t aki ng pl ace and t ha t pr event i ve measures
cannot awai t t he r e s u l t s of r es ear ch t h a t i s g o i y t o come i n t he
f ut ur e . For t h i s r eason many of our pol i c i e s w i l l be based t o a
consi der abl e e xt e nt on t he exper i ence of ot he r count r i es . For t h e
moment we w i l l have t o consi der t he r e s u l t s s h o m from r a i s i ng t he
l e g a l age f o r dr i nki ng and t he e f f e c t s of massi ve educat i on programs.
STUDY ON ALCOHOL-RELATED LEGISLATION
I N CENTRAL AMERICA AND PANAMA
Jai me Arroyo Sucre
The use and abuse of a l c ohol i s pa r t of t h e c u l t u r a l t r a di -
t i ons of t he peopl es of Cent r al America and Panama. h i l e t he
adopt i on of a l i e n customs i n r e c e nt year s has l e d t o changes i n
consumption pa t t e r ns , t r a d i t i o n a l customs have remained subst an-
t i a l l y unchanged, and per c a p i t a consumption shows a n upward t r end.
The count r i es have recogni zed t he problems a r i s i n g from t hes e
ci r cumst ances on many occasi ons. Thei r st udy and di s cus s i on i s
always a mat t er of concern, not onl y t o he a l t h workers but a l s o t o
a l 1 prof e s s i ona l s and t he connnunity a t l a r ge . Because dr i nki ng
customs a r e s o i mport ant i n t he s o c i a l , c u l t u r a l , economic, and
r e l i gi ous l i f e of t h e community, t hey have been approached i n a
va r i e t y of ways, f r equent l y opposed and i n c o n f l i c t wi t h one anot her -
Pr i o r i t y has r a r e l y been assi gned t o t he he a l t h a s pe c t s of t he
problem and we pr of es s i onal s , and ot he r persons i nt e r e s t e d i n t hes e
t a s ks , have been unabl e t o pr ovi de s c i e n t i f i c and t e c hni c a l d a t a t o
suppor t passage of adequat e l e gi s l a t i on. The magnitude of t he
problem t o be f aced i s evi dent i f , i n a ddi t i on, we bear i n mind:
t ha t i n some c ount r i e s mor bi di t y and mor t a l i t y r a t e e suggest ot he r
p r i o r i t i e s ; t ha t t he economic s t r u c t u r e of t hes e c ount r i e s
encourages t he c u l t i v a t i o n of gr a i ns and t he pr oduct i on, market i ng
and consumption of al cohol ; and, e s pe c i a l l y, t h a t t he popul at i on a t
l a r ge and even he a l t h workers accept and t o l e r a t e t he s e habi t s .
Throughout t he hi s t or y of publ i c he a l t h, government a c t i o n has
been one of t he most i mpor t ant f a c t o r s i n di s e a s e c o n t r o l and h e a l t h
promotion. Po l i t i c a l de c i s i ons embodied i n laws a r e t h e ba s i s f o r
t h e i r execut i on. Le gi s l a t i on governi ng t h e dynamic bal ance of t he
e c ol ogi c a l t r i a d -- c a us a l agent/environment/susceptible hos t -
c o n s t i t u t e s a ba s i c i nst r ument f o r pr event i ng al cohol - r el at ed
problems.
Although t he c ount r i e s of t he a r e a r ecogni ze t h e s er i ous nes s
and magnitude of t h e problems r e l a t i n g t o al cohol consumption, few
of them have compi l at i ons of e x i s t i n g l e g i s l a t i o n on t h e t opi c. A t
t h e i r XXV Meeting i n 1980 t he Mi ni s t er s of Heal t h demonst rat ed t h e i r
i n t e r e s t when t hey c a l l e d upon t h e Pan American Or gani zat i on t o
pr epar e a st udy t h a t would c o l l e c t , anal yze, draw concl usi ons, and
make recommendations on e x i s t i n g l e g i s l a t i o n ( Resol ut i on V I 1 1 of t h e
XXV Meeting of t he Mi ni s t e r s of Heal t h of Cent r al America and
Panama). It was t h a t r e s ol ut i on t h a t gave rise t o t he document t h a t
i s t h e ba s i s of my pr e s e nt a t i on today.
PAHO Study: Methodology
The f i r s t s t age of t he i nve s t i ga t i on was devoted t o c ol l e c t i ng
t he i nf or mat i on a va i l a bl e i n Panama, Honduras, Guatemala, Ni caragua,
and El Sal vador. To obt a i n comparable da t a , a gener al ques t i onnai r e
was pr epar ed cover i ng l aws r e l a t i n g t o t he c a us a l agent , t he envi -
ronment, and t he s us c e pt i bl e host . The ques t i ons d e a l t wi t h t he
t ypes and c h a r a c t e r i s t i c s of a l c ohol s f o r consumption; pr oduct i on,
i mpor t at i on, d i s t r i b u t i o n , qua l i t y c ont r ol , s a l e , and consumption;
c ont r ol of pl aces of s a l e and t h e i r bus i nes s hour s; and t he age,
sex, and occupat i on of pur chaser s and/ or consumers. I n addi t i on,
s p e c i f i c a s pe c t s such a s t he oper at i on of motor ve hi c l e s , employ-
ment, educat i on, penal and c i v i l ma t t e r s were a l s o i ncl uded. A
s e pa r a t e ques t i onnai r e covered t h e promotion of a dve r t i s i ng f o r
al cohol consumption.
Given t he scope of t he problem, t h e ques t i onnai r e is, of
cour se, not exhaust i ve, but i t does r epr es ent a f i r s t at t empt t o
ga t he r i nf or mat i on on t h e e x i s t i n g l e g i s l a t i o n of t h e count r i es . It
needs t o be f l es hed out by na t i ona l sur veys desi gned t o obt a i n a
b e t t e r under st andi ng of t he problem and t o devel op b e t t e r pr event i ve
l e g i s l a t i o n .
The i nf or mat i on was obt ai ned t hrough i nt er vi ews wi t h o f f i c i a l s
desi gnat ed by t h e he a l t h a u t h o r i t i e s of t h e count r i es . I n most
c a s e s t he y had onl y a very ge ne r a l knowledge of t h e l e g i s l a t i o n , but
t hey a l 1 subsequent l y s e nt t he aut hor i nf or mat i on on codes, laws,
r u l e s and r egul at i ons . Uhen t he d a t a were compared, di f f e r e nc e s
were found between what t he o f f i c i a l s had s a i d and what t he laws
pr escr i bed.
The i nt er vi ews and t he que s t i onna i r e s t oge t he r gave us a n i de a
of what l e g i s l a t i o n e x i s t s i n t h i s r egar d, and of what was bei ng
enf or ced i n each count ry. Although di f f e r e nc e s were found between
t he s t a t u t e s on t he books and t h e r e a l i t i e s of t h e l e g a l system,
t he s e w i l l have t o be covered by s ubs eqwnt i nve s t i ga t i ons , which
obvi ousl y shoul d be c a r r i e d out by o f f i c i a l s o r r e s e a r c he r s wi t hi n
each count ry .
Le gi s l a t i on i n Cent r al America
A l 1 t he c ount r i e s of t he a r e a have comprehensive al cohol
l e g i s l a t i o n . Laws enact ed a t t he begi nni ng of independence a r e
st i l l i n f or c e and r e f l e c t t h e l e g a l system t h a t r ul ed our r e l a t i o n s
wi t h Spai n dur i ng t he c ol oni a l e r a . Le gi s l a t i on has been pr i ma r i l y
cent er ed on economic and f i s c a l mat t er s. The governments have
promoted gr a i n c u l t i v a t i o n and t h e pr oduct i on, d i s t r i b u t i o n ,
market i ng, and consumption of al cohol , t aki ng i n t o account t a x and
f i s c a l advant aees and t h e gener at i on of economic growth and expor t
a c t i v i t y . I n most of t he c ount r i e s t hes e a c t i v i t i e s , i ncl udi ng
qua l i t y c ont r ol , a r e t he r e s pons i bi l i t y of t he Xi ni s t r y of Fi nance,
and i n some of t he Mi ni st r y of Heal t h, a l b e i t onl y t a nge nt i a l l y.
Al cohol Tax Laws
The l e g i s l a t i o n on t h e pr oduct i on, i mpor t at i on, d i s t r i b u t i o n ,
s a l e , and consumption of a l c ohol i c beverages i s abundant. I n most
of t he c ount r i e s t he pe r t i ne nt l e g a l r u l e s a r e pa r t of t he t a x o r
commercial codea, o r of what a r e c a l l e d "al cohol decr ees o r laws."
The di f f e r e nc e s between what was s a i d i n t he i nt er vi ews and what t he
l aw pr e s c r i be s and t he d i f f i c u l t i e s encount ered i n obt ai ni ng copi es
o t he r el evant pr ovi s i ons showed t h a t t he l e g i s l a t i o n 1s s c a t t e r e d
i n many sour ces and t h a t , from t he poi nt of view of he a l t h, it i s of
l i t t l e use and r a r e l y appl i ed.
To overcome t h i s d i f f i c u l t y , one of t he c ount r i e s 1s st udyi ng
a d r a f t Nat i onal Alcohol and Alcoholism Code, which br i ngs t oget her
t he s c a t t e r e d l e g i s l a t i o n and w i l l f i l l t he gaps i n i t ( Newsl et t er
No. 6, Nat i onal Alcoholism I n s t i t u t e , San J os e, Cost a Rica).
Si nce t he Mi ni s t r i e s of Heal t h a r e r es pons i bl e f o r t he
well-being of t he popul at i on, t hey must have t he l e g a l means t o
perform t h i s f unc t i on a s i t r e l a t e s t o a wi del y consumed and ver y
harmful subst ance. I n most of t h e c ount r i e s , even t h e qua l i t y
c ont r ol of a l c ohol i c beverages i s i n t h e hands of t h e Mi ni s t r y of
Finance o r t he I nt e r na 1 Revenue Ser vi ce. The most i mport ant
chemi cal a na l ys i s i s t h e det er mi nat i on of t he a l c ohol i c s t r e ngt h of
t he beverages, but f o r t a x c o l l e c t i o n purposes, r a t h e r t han f o r
pr ot e c t i ne t he he a l t h of t h e consumer.
Al cohol i c Content
The amount of a l c ohol per mi t t ed o r i n some c a s e s r equi r ed i n
d i f f e r e n t t ypes of a l c ohol i c beverages i s similar i n t he var i ous
c ount r i e s of t h e ar ea. Surveys of dr i nki ng p a t t e r n s i n d i c a t e that
most dr i nke r s a r e more concerned about t h e qua nt i t y -- t h e number of
dr i nks o r rounde consumed. Accordi ngl y, pr event i ve measures s i mi l a r
t o t hos e used t o reduce t he per cent age of harmful eubet ances i n
t obacco pr oduct s coul d be appl i ed; t h a t l e , t h e a l c ohol i c c ont e nt of
t he beveragee coul d be reduced. Manufact urere i ndi c a t e t h a t t hey
can produce beverages wi t h a lower a l c ohol i c cont ent but wi t h t h e
same teste. Thi s t ype of measure would reduce pr oduct i on c os t e and
t hus enabl e some governments t o e x t r a c t more t a x d o l l a r s wi t hout
adver sel y a f f e c t i ng t he he a l t h of t he popul at i on.
Pr oduct i on and Ui s t r i but i on Cont r ol a
Al cohol pr oduct i on, which was i n i t i a l l y a s t a t e monopoly
t hroughout t he r egi on, has i n most c a s e s now been t r a ns f e r r e d t o
pr i va t e e nt e r pr i s e . Qual i t y c ont r ol i s f r equent l y t h e r esponsi -
b i l i t y of t he t a x agenci es, which di s r e ga r d t he p o s s i b i l i t y t l i at
a l c ohol i c beverages may cont ai n t oxi c subst ances. Thi s r i e k i s much
g r e a t e r i n t he c a s e of cont raband l i quor , but none of t h e l aws 1
have reviewed a ut hor i z e t he Mi ni s t r i e s of Heal t h t o t ake appr opr i at e
measuree i n t h i s r egar d.
The i mpor t at i on of a l c ohol i c beverages i s covered by many t a x
r egul at i one. With r egar d t o he a l t h, however, t he onl y requi rement
i e a r e g i s t r a t i o n wi t h t h e h e a l t h a u t h o r i t i e e which cont i nues i n
f or c e f o r a va r i a bl e number of year s . During t h i s per i od, v i r t u a l l y
no q u a l i t y c ont r ol a a r e c a r r i e d out f o r t he pr ot e c t i on of t h e
coneuming popul at i on.
The t a x r egul at i one of t he c ount r i e s do pr e s c r i be t h e t ypes of
cont ai ner and r e gul a t e t h e i r di e t r i but i on. Although my revi ew found
no a pe c i f i c r ef er encee t o t h e r o l e of he a l t h a u t h o r i t i e s , t he l aws
not onl y permi t but would f a c i l i t a t e c ont r ol di r e c t e d a t improvement
of he a l t h.
Regul at i on of Sa l e s and Consumption
The t a x r e gul a t i ons r a t h e r a c c ur a t e l y de f i ne t he scope of
sales. The pr ovi ai ons r e l a t i n g t o t he l oc a t i on of shops, t h e i r
c l a s s i f i c a t i o n , and- busi ness hour s imply mandates t h a t f a c i l i t a t e
t he execut i on of pr event i ve measuree f o r eome hi gh- r i ek groups.
However, i n t he opi ni on of t he persone i n t e n i e we d most euch
r e gul a t i ons a r e not observed, and t h e he a l t h a u t h o r i t i e s have no
l e g a l means of enf or ci ng them. I n t h i s r egar d a l 1 my i nf or mant e em-
phasi zed t h e l a c k of gui de l i ne s f o r e e t a bl i s hi ng necessar y
cooper at i on between government agenci es. Most of t he r u l e s were
enact ed t o pr ot e c t t he he a l t h of pur chaser s, e s p e c i a l l y wi t h r e s pe c t
t o age. According t o t he opi ni ons obt ai ned, t he pr ovi s i ons a r e not
obl i gat or y.
Almost a l 1 t he Cent r al American c ount r i e s have r e gul a t i ons on
t he consumption o a l c ohol i c beverages, al t hough t hey a r e sometimes
s c a t t e r e d throughout var i ous s t a t u t e s . Tax pr ovi s i ons de f i ne t he
d i f f e r e n t t ypes o a l c ohol i c beverages which a r e l e g a l l y per mi t t ed.
Nat i onal laws o r c i v i l , s o c i a l , pol i c e and ot he r r e gul a t i ons may
l i m i t consumption f o r r easons of age, t r a de o r pr of es s i on, o r i n
r e l a t i o n t o working hours. There a r e no s i mi l a r pr ovi s i ons based on
he a l t h grounds.
Although a l 1 t he c ount r i e s have s t andar ds f o r t h e hour s dur i ng
which a l c ohol i c beverages may be s ol d, t hey a r e not obl i gat or y.
According t o t he l aws, a l c ohol i c beverages may not be consumed i n
publ i c pl aces. Never t hel ess, t he per sons i nt er vi ewed were of t he
opi ni on t h a t t he t o l e r a n t a t t i t u d e of t he popul at i on not onl y
f a c i l i t a t e s but even encourages t h e ha bi t of dr i nki ng i n publ i c-
The r u l e s t h a t govern t h e pl aces i n which a l c ohol i c bever ages
a r e consumed f i nd t h e i r l e g a l ba s i s i n t h e he a l t h codes o r regul a-
t i o n s and a r e t he same a s f o r t he s a l e of food s t u f f s . These r u l e s
a r e us ua l l y appl i ed more f l e x i b l y t o shops t h a t s e r ve a l c ohol i c
beverages.
With t he except i on of t hose mentioned i n t h e f or egoi ng
paragraph, t he ot he r pr ovi s i ons a r e not embodied i n what i s us ual l y
consi der ed he a l t h l e gi s l a t i on.
Pr event i on of Al cohol - r el at ed Problems
I n most o t he c ount r i e s , r e gul a t i ons on t he ope r a t i on of
motor ve hi c l e s and al cohol i sm a r e pa r t o t he Tr a f f i c o r Pol i ce
Regul at i ons. The r o l e of t h e he a l t h s e r vi c e s i n det er mi ni ng blood
al cohol cont ent 1s not w e l l def i ned, and i n many c ount r i e s t he
Mi ni s t r i e s of Heal t h do not have t he necessar y r es our ces t o d e a l
wi t h t he problem.
Tr a f f i c educat i on and a l c ohol consumption programs do not come
under t he a ut hor i t y o f , and sometimes a r e not even coor di nat ed wi t h,
he a l t h a c t i v i t i e s . They a r e t he r e s pons i bi l i t y of ot he r government
agenci es. I nf or mat i on i ndi c a t i ng t h a t permanent educat i on programe
a r e coor di nat ed, promoted, and execut ed by t h e Mi ni s t r i e s of Heal t h
and Educat i on wi t hi n t he formal educat i on system 1s a va i l a bl e f o r
onl y one count r y i n t he ar ea.
Pr ovi si ons on employment problema a r e pa r t o l a bor l e gi s -
l a t i o n and cover t he employer/employee r e l a t i ons hi p when t he
dr i nki ng of al cohol i c beverages i s i nvol ved and dr i nki ng i s a cause
f o r di smi eeal . I n very few caees a r e r ef er ences made t o ot her
aepect s of t he problem.
I n gener al , per t i nent laws a r e aimed at s ol vi ng probleme
caused by t he use of al cohol . Few e s t a bl i e h t hose means of
pr ot ect i ng al cohol i cs t ha t would r e f l e c t modern knowledge of t he
t opi c.
Fur t her , i n most of t he count r i es t her e i s a l e g a l voi d i n
r es pect t o s o c i a l l e g i s l a t i o n on t he pr event i on and t reat ment of
al cohol i em and t he r e h a b i l i t a t i o n of al cohol i ce. I n one count r y, a n
a r t i c l e of a prel i mi nary d r a f t of t he Conet i t ut i on s e t s f o r t h
gener al gui del i nee f o r t he c a r e of al cohol i ce; i n anot her , a
prel i mi nary d r a f t of a code cont ai ns more s pe c i f i c gui del i nes f o r
deal i ng comprehensively wi t h t he problem.
Alcohol Advert i si ng
Awa r e of t he heal t h hazar ds i nvol ved i n t he use of al cohol ,
t he promotion of al cohol consumption i n t he media, t he existente of
laws f o r t he c ont r ol of adver t i s i ng, and t he need t o f ocus heal t h
educat i on programe on t hes e t oxi c subst ancee, t he Mi ni s t r i ee of
e a l t h request ed PAHO t o prepare a st udy.
The more knowledge i e avai l abl e on t h i s t opi c and t he more
c e r t a i n t he r i s k s caused by t he uee of t hes e subst ancee become, t he
more evi dent t he need t o cont r ol advert i sement e f o r them.
Plost of t he count r i es have laws t h a t cont r ol adver t i s i ng f o r
consumption of al cohol i c beveragee. Thi s cont r ol i e exer ci sed
through mul t i di s ci pl i nar y commissions appoi nt ed f o r t h a t purpose.
I n some count r i es , t he membere of t heee commissions a r e appoi nt ed
d i r e c t l y by t he Pr esi dent of t h e Republic; i n ot her s , t he l aw
s t i p u l a t e s t he pos t s whose incumbents w i l l be membere. I n a l 1
caeee, t he pa r t i c i pa t i on of he a l t h o f f i c i a l s is c e nt r a l .
I n many count r i es , cont r ol ext ends t o t he pr esa, r adi o,
t el evi ei on, pos t er s and bi l l boar ds , a s w e l l a s t o ot he r adver t i s i ng
media. It i s not appl i ed wi t h t he same e t r i c t n e e s i n a l 1 t he
count r i es , nor does i t a f f e c t a l 1 media uniformly.
Cont rol ext ends t o t he form, cont ent , pr eeent at i on, and
obj ect i ve of t he message, a s wel l a e t he a c t i v i t i e s i t promotes and
t he behavior i t f os t er e. The ef f ect i venes s of t h i s cont r ol should
be eval uat ed and, where neceesary, appr opr i at e changes i nt roduced.
I n most of t he count r i ee i t i s d i f f i c u l t t o e s t a b l i e h cont r ol s
of t he dur at i on of t he message, t he frequency wi t h which i t i e
r epeat ed, and t he hours a t which i t i s broadcaet , a l 1 of which would
i nf l uence whp t he r eci pi ent e of t he meseage a r e and what i t s impact
on them i s l i k e l y t o be. Thus, t he meesages cont i nue t o a f f e c t
chi l dr en and yout hs, who a r e l i k e l y t o be s us cept i bl e.
The l e g i s l a t i o n reviewed cont ai ned no pr ovi s i ons on t h e
censor shi p o f i l ms , comic s t r i p s o r ot her mas8 media i n which t he
heroes appear dr i nki ng, nor do any o t h e laws f or bi d o r l i m i t t he
adver t i s i ng of t hes e eubst ances.
Conclusions
1. The st udy showed t ha t t her e 1s abundant l e g i s l a t i o n on al cohol
use. Most of t he pr ovi s i ons a r e s cat t er ed and t he he a l t h
a u t h o r i t i e s a r e us ual l y unf ami l i ar wi t h them.
Recommendation: The count r i es t h a t have not al r eady done
s o should appoi nt an i nt er - di s ci pl i nar y committee t o
revi ew and compile t he e xi s t i ng l e g i s l a t i o n on al cohol
consumpt ion.
2. Many of t he laws and r gul at i ons i n f or ce a r e not heal t h
r e l a t e d, and some t ha t coul d be us ef ul a r e not appl i ed.
Recommendation: The above-mentioned committee shoul d be
r esponsi bl e f o r anal yzi ng t he r u l e s r e l a t i n g t o heal t h and
recommending gui del i nes f o r t h e i r b e t t e r appl i cat i on.
3. Acompar i eonof e xi s t i ng r u l e s a n d o f r u l e s de s i r a bl e f r o mt h e
poi nt of view of he a l t h would make i t pos s i bl e t o devel op
appr opr i at e gui di ng principies f o r new l e gi s l a t i on.
Recommendation: On t he bas i s of t he above-mentioned
review and anal ys i s , t he committee should make recommen-
dat i ons on appr opr i at e gui del i nes f o r amending o r r evi s i ng
t he l e g a l pr ovi si ons on t hes e as pect s .
40 Most of t he count r i es have l e g a l pr ovi si ons t h a t cont r ol
al cohol adver t i s i ng. Thei r enforcement has not been eval uat ed.
Recommendation: Programs f o r t he c ont r ol of al cohol
adver t i s i ng shoul d be eval uat ed.
5 . During t he survey, no laws or r egul at i ons were encount ered
enabl i ng t he mas8 media t o be used t o expl ai n t he adverse
heal t h e f f e c t s of al cohol use.
Recommendation: The a dvi s a bi l i t y of proposi ng laws t h a t
w i l l f a c i l i t a t e he a l t h promotion t hrough publ i c i t y on t he
adverse as pect s of al cohol consumption shoul d be examined.
Thi s l e g i s l a t i o n shoul d provi de t he necessary r esour ces
f o r ensur i ng t h a t t he qua l i t y and pr es ent at i on of t he
messages i s such t h a t t hey can compete wi t h commercial
adver t i s i ng.
6. The c l a s s i f i c a t i on of al cohol i c beverages according t o t he i r
al cohol cont ent i s eometimee r i gi d. I n a l 1 t he count r i es , t he
range of t he al cohol cont ent s defi ned by law 1s si mi l ar .
Recomnendation: The pos s i bi l i t y of reducing t he al cohol i c
s t r engt h of t he beverages ehould be st udi ed.
7. I n most of t he count r i es, t he qual i t y cont r ol of al cohol i c
beverages, whether produced l egal l y, smuggled, o r imported, 1s
not t he r es pons i bi l i t y of t he heal t h aut hor i t i es . The purpose
of qual i t y cont r ol l e t o determine t he amount of t he per t i nent
t ax r at her than t o pr ot ect t he consumer.
Recommendation : The par t i ci pat i on of t he heal t h
a ut hor i t i e s i n t he qual i t y cont r ol of nat i onal o r imported
beverages should be be t t e r defi ned.
8- The laws and r egul at i ons reviewed do not gi ve t he heal t h
a ut hor i t i e s cont r ol of t he heal t h aspect s of t he di s t r i but i on
of al cohol i c beverages and der i vat i ves o r of t he enforcement
of t he provi si ons r el at i ng t o t he i r s a l e ( l ocat i on,
r e s t r i c t i ons f o r reasons of heal t h, et c. ) .
Recommendation: The heal t h a ut hor i t i e s should st udy and
propose l egal meane t hat riould enabl e them t o par t i ci pat e
i n t he cont r ol of c e r t a i n heal t h as pect s t hat a r e not
covered i n t he di s t r i but i on and s a l e of al cohol i c
beverages.
9. Nat i onal s t a t ut e s do not def i ne t he r ol e of t he heal t h
a ut hor i t i e s i n programe f or t he prevent i on of t r a f f i c
acci dent e due t o al cohol use. Frequent l y, no resources a r e
al l ocat ed t o t hese programe.
Recommendation: The count r i es t ha t have not al r eady done
s o ehould st udy and c l e a r l y def i ne t he r ol e of t he heal t h
team i n programs f o r t he prevent i on of t r a f f i c acci dent s
associ at ed wi t h t he use of al cohol .
10. Most of t he count r i es do not have any l e ga l r ul e s permi t t i ng
t he conduct of educat i on programs on t he r i s ks of al cohol use
i n t he formal educat i on system.
Recommendation: The count r i es t hat have not al ready done
s o should review t h e i r l e gi s l a t i on wi t h a view t o t he
i ncorporat i on of a heal t h educat i on program on t he r i s ks
caused by al cohol consumption i n t he formal educat i on
syetem.
11. The laws deal i ng wi t h probleme caused by t he use of al cohol i n
l abor , penal , c i v i l and ot her l e ga l ar eas have not been
updated and omit as pect s of t he problem.
Recommendation: Some c ount r i e s shoul d revi ew t he
pr ovi s i ons on problems . caused by t he consumption of
al cohol i n l a bor , penal , c i v i l and o t h e r l e g a l f i e l d s .
12. I n many c ount r i e s t he al cohol i sm laws a r e not c ons i s t e nt wi t h
pr es ent s c i e n t i f i c knowledge.
Recommendation: The l e g i s l a t i o n on al cohol i sm should be
updated. For t h a t purpose, cooper at i on between t he
c ount r i e s andl or t e c hni c a l advi sor y s e r vi c e s by PAHo/WHO
and ot he r i n t e r n a t i o n a l agenci es would be advi sabl e.
13. During t he sur vey no l e g a l pr ovi s i ons r e gul a t i ng t he
coor di nat i on of t he a c t i v i t i e s of t he var i ous government
agenci es de a l i ng wi t h problems due t o al cohol use were
encount ered.
Recommendation: St r a t e gi e s shoul d be s t udi ed f o r
proposi ng l e ga l pr ovi s i ons on t he coor di nat i on of t he
var i ous government agenci es de a l i ng wi t h problems due t o
al cohol use shoul d be st udi ed.
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An Examination of Research Fi ndi ngs
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Appe ndi x A
CONSENSUS VIWJS ON DEVELOPMENT OF ALCOHOL POLICIES
Alternative Non-coneensus viewe
Appe ndi x B
LI ST OF PAETICIPANTS
APPENDIX A
CONSENSUS VIEWS ON
DEVELOPMENT OF ALCOHOL POLICIES
As noted i n t he Background and Overview of t he Proceedings, t he
fol l owi ng st at ement of consensus views 1s t he product of a del i -
ber at i ve process t h a t began t he l a s t morning of t he workshop. At
t hat time, par t i ci pant s m e t i n t hr ee smal l groups t o review a dr a f t
st at ement prepared t he previ ous evening by t he workshop rapport eur.
The dr a f t present ed t he r appor t eur ' s impression of t he consensus
t ha t emerged amo- t he par t i ci pant s duri ng t he f i r s t two days
regarding cur r ent underst andi ngs about al cohol -rel at ed problems and
prevent i on of t hose problems, par t i cul ar l y l egi sl at i vel y-based
approaches t o prevention. The dr a f t was based on t he s t udi es and
ot her empi ri cal evi dence cont ai ned i n t he papers commissioned f o r
t he workshop and t he pl enary di scussi ons cent er i ng on, but not
r e s t r i c t e d t o, t hose papers during t he f i rst two days. In reviewing
t he dr a f t , each of t he small groups suggested changes, del et i ons,
addi t i ons and r evi s i ons i n t he d r a f t t o more accur at el y r e f l e c t
t he i r own understandings. The chairmen of t he smal l groups report ed
t hes e r eact i ons a t t he f i n a l plenary s es s i on of t he workshop and
s hor t l y t her eaf t er submitted wr i t t en r epor t s t o t he IOM s t a f f .
Based on t hose comments, t he I OM s t a f f r edr af t ed t he st at ement
of t he consensus views and ci r cul at ed i t t o t he Advisory Committee
members f o r f i n a l review. Thei r comments were i ncorporat ed i n t o a
f i n a l st at ement t ha t was del i vered on Apri l 14 t o t he Offi ce of
I nt er nat i onal Health, (OIH), U.S. Department of Health and Human
Servi ces, f o r i t s use i n preparat i on f o r t he World Health Assembly
t echni cal di scussi ons on al cohol i n May 1982. It was emphasized
t ha t t he st at ement comprised a perceived consensus of t he maj ori t y
of t he par t i ci pant s , not necessar i l y t he views of each and every
one, inasmuch a s time had not permi t t ed a complete di s t r i but i on t o
a l 1 par t i ci pant s f o r review.
I n e a r l y May t he st at ement a s del i ver ed t o O I H was sent t o a l 1
ot her workshop par t i ci pant s l i s t e d i n Appendix B, wi t h a request
t h a t t hey review i t and s e d back any qual i f yi ng o r di ssent i ng
views. Several responses were hel pf ul i n f ur t he r cl ar i f yi ng t he
st at ement , although i t s basi c cont ent di d not change. l bo
non-coneensus views a r e r epr i nt ed i n t h e i r e nt i r e t y f o l l o w i ~ t he
consensus st at ement s. A l 1 ot her par t i ci pant s accept ed t he statement
a s di s t r i but ed t o them. The consensus st at ement t ha t appears next
t hus r e f l e c t s , wi t h two except i ons, t he views of a l 1 par t i ci pant s .
It must be emphasized agai n t h a t t he views expressed her ei n
r e f l e c t a consensus of t he workshop par t i ci pant s i n t h e i r i ndi vi dual
capaci t y. They do not represent t he pos i t i on of any government o r
count ry of a par t i ci pant , t he I ns t i t ut e of Medicine, t he National
Academy of Sci ences, o r t he Pan American Health Organzation.
1. I N THE COUNTRIES OF THE AMERICAS, THE MAJOR NEGLECTED BURDEN TO
SOCIETY OF ALCOHOL CONSUMPTION IS THE HEALTH, ECONOMIC, AND
SOCIAL COST OF PROBLmS ASSOCIATED WITH EPISODIC INTOXICATIONm
o Most s oc i e t i e s have i nt egr at ed pat t er ns of al cohol use i n t o
t he i r s oc i a l and c ul t ur a l norms of behavior. Episodic
i nt oxi cat i on, which may be i nt egr at ed i nt o t hose norms,
cr eat es very s er i ous and c os t l y problems and burdens f o r t he
i ndi vi dual fami l y and soci et y.
Whether o r not associ at ed wi t h chroni c heavy dri nki ng,
epi sodi c i nt oxi cat i on i s r el at ed di r e c t l y t o acci dent s,
par t i cul ar l y motor vehi cl e acci dent s, wi t h premature deat h
o r di sabl i ng i nj ur y bot h f o r t he i nt oxi cat ed par t y and
ot her s af f ect ed by t he acci dent ; vi ol ent andl or cri mi nal
behavior; fam l y di sr upt i on; c hi l d negl ect ; and impairment
of work capaci t y and at t endant l o s s of productive capaci t y .
Alcohol a l s o has been l i nked t o f e t a l damage when dri nki ng
occurs i n r e l a t i on t o pregnancy. Chronic heavy dri nki ng, i n
which i nt oxi cat i on occurs more f r equent l y, a l s o c a r r i e s a
hi gh r i s k of long term medical consequences f o r t he
i ndi vi dual , bot h physi cal (e. g., c i r r hos i s of t he l i v e r and
s us c e pt i bi l i t y t o cancer) and psychological (e-g.,
dependency o r l o s s of cont r ol ) , which i n t ur n can cause
f ur t he r physi cal and mental di s or der s and sui ci de.
I n addi t i on t o l o s s of l i f e and well-being t o i ndi vi dual 8
and f ami l i es , t he burden t o s oci et y of epi sodi c i nt oxi cat i on
and chroni c heavy dri nki ng 1s s ubs t ant i al i n l os t
cont r i but i ons t o economic product i vi t y and s oc i a l
development, a s w e l l a s i n t he use of scar ce resources f o r
r es t or at i ve and long term heal t h car e, and f o r
r e ha bi l i t a t i ve s oc i a l servi ces.
o Each count ry of t he Americae now neede t o aeeeee more
adequat el y t he epeci f i c nat ur e and ext ent of t he burden
t o each eoci et y of t he f u l l range of al cohol -rel at ed
probleme. Such a n e f f or t would i ncl ude hpr oved publ i c
record-keepiqg and r epor t i na systeme of al cohol -rel at ed
problems, epi demi ol ogi cal et udi ee, and t ar get ed case
et udi ee. Re eearch on al cohol -rel at ed problems should be
conducted i n t he cont ext of cuetomary and normative
dri nki ng behavior i n each eoci et y-
2- T U PUBLIC HEALTH AND HEALTH SCIENCES COEMUNITIES I N MOST OF
THE WUNTBIES OF THE AMERICAS, WILE WNTINUING TO IMPROVE
TREATMENT OF ALCOHOLISM I N INDIVIDUALS, SHOULD DEVELOP GREATER
INTEREST I N GROUP-ORiENTED HEASRES AMED AT THE PREVENTION OF
ALCOHOL-RELATED PROBLEMS
o Buildiqg on t he i ncreaeed f l ow o i nformat i on and t he
r e s ul t e of et udi ee i dent i f i ed i n I t e m 1 preceding, nat i one
i n t he Americas can t a r ge t pol i cy- or i ent ed research and
demonetration pr oj ect e on prevent i on e f f or t s - As par t of
t heee pro j ect e, empi ri cal eval uat i on should f ocus on both
intended e f f e c t s and "eide" e f f e c t s of par t i cul ar prevent i on
et r at egi ee.
o A s ubet ant i al accumulation of al cohol l egi el at i on i n many
count r i ee of t he Americae appeare t o be unknown t o present
day policymakere and l i t t l e enforced. There i s a need f o r
hi e t or i c a l reeaarch on al cohol -rel at ed l egi s l at i on,
i ncl udi qg t he reasone f o r i t e enactment, i n order t o
i de nt i f y l e gi e l a t i ve e f f or t e that have been ef f ect i ve or
i nef f ect i ve, o r t ha t have produced e f f e c t e paradoxi cal t o
t bose that were i nt ended- Such reeearch could suggest
f ut ur e l e gi e l a t i ve act i on, a s w e l l a e i de nt i f y exi et i ng laws
o r r ul ee t ha t mlght be enforced a e par t of a prevent i on
programe
3- AVAILABLE EMPIRICAL EVIDENCE SUGGESTS THAT A NWBER OF
PBEVENTION-OKIENTED, MOSTLY LEGISLATIVELY BASED POLICIES CAN
REDUCE THE BURDEN OF ALOOHOL-RELATED PROBLEWS.
o Caution i n General i zi ng. St udi es on t he e f f e c t s of
prevent i on-ori ent ed publ i c pol i ci ee a r e l i ml t ed i n number
and have been do& l ar gel y i n a few i nduet r i al i zed
count r i es. Por t heee reasone, gener al i zat i ons must be
caut i oue.
o Per capi t a Consumption. I nt er nat i onal experience euggests
that t he r el at i onehi p betueen t he growth o per capi t a
coneumption and t he &te of al cohol -rel at ed problems cannot
be ignored. Increases i n per capi t a consumption of al cohol
a r e associ at ed wi t h i ncreaeed frequency of epi eodi c
i nt oxi cat i on andl or i nci dence of chroni c heavy dri nki ng, and
t hese r e s ul t i n i ncr easee i n a t l e a s t some va r i e t i e e of
al cohol -rel at ed problems.
o Pr i ce t o Consumet. Alcoholic beverages, l i k e ot her
commoditie S, a r e pri ce-sensi t i ve; s i gni f i cant i ncr eases i n
t he r e a l cos t of al cohol , vi a t axat i on o r r el at ed pol i ci es ,
reduce average per capi t a consumption. I n many count r i es,
t he r e a l cos t of al cohol t o consumers has been dropping
because t ax r a t e s have not been adj ust ed t o r e f l e c t
i nf l at i on.
o Alcohol Avai l abi l i t y. While minor reduct i ons i n t he number
of s a l e s out l e t s o r cl osi ng hours do not appear t o
measurably a f f e c t consumption, major changes have had a
consi derabl e e f f e c t on per capi t a consumption. I n addi t i on,
pr ohi bi t i og accese t o al cohol f o r s peci f i c cat egor i es of t he
popul at i on (e.g., s i gni f i cant l y r ai ei ng t he l egal dri nki ng
age) demonst rat i vel y reduces al cohol -rel at ed problems, such
a s al cohol - r el at ed t r af f i c acci dent S, among t he cat egor i es
of people af f ect ed.
o Drudc-Driving Lawe. Short-run reduct i ons i n harmful
consequences of dr i vi ng whi l e i nt oxi cat ed t ypi cal l y occur
f ol l oi i ng t he i nt r oduct i on of new, s t r i oge nt l y enforced and
wel l -publ i ci zed laws; longer-term e f f e c t s appear t o depend
on cont i nuat i on of i nt ense enforcement and publ i ci t y.
o Environmental Int ervent i ons. Pol i ci ee that r e s ul t i n
reduciog t he problem consequencee of al cohol -rel at ed
behavior by reducing environmental r i s k a r e a promising
cat egory of i nt ervent i ons. Examples of such pol i ci es
i ncl ude i ncreased use of automobile s e a t bel t e t o reduce
passeoger/ dri ver f a t a l i t i e s i n motor vehi cl e acci dent e, and
t he use of smoke det ect or 8 t o reduce deat hs and di s a bi l i t i e e
f rom acci dent al f ires.
o Advert i si ng and Education. Evidence i s - not concl usi ve about
t he impact of adver t i si ng on dri nki ng pr act i ces and
problems, nor about t he use of t he school s and mass media i n
educat i onal ef f o r t s t o modif y present and f ut ur e del et er i ous
dri nki ng behavior; addi t i onal research neede t o be done on
t hese prevent i on s t r at egi es .
4. POLICY INITUTIVES TOWARD PBKVENTING ALCOHOL-BELATBD PBOBLW
SHOULD INTEGRATE HTBLIC BEALTE SECTOR BENBFITS AND COSTS WITH
TmSE BELATED TO ECONOMIC DWELOPXENT AND VALUBS IMPORTANT TO
THE SOCIAL, CULTUBAL, AND POLITICAL FABBIC OF THE SOCIETYa
o I n count ri ee where alcohol coneumption i e permtted, i t e
production andlor coneumption i e a eource of t ax revenue and
employment- I n count ri ee where t our i m is ei t her an
exi et i ng o r developing induetry, al cohol i c beveragee of t en
cont ri but e a eignif i cant port i on of aeeociated revenwe.
With reepect t o individual and eoci al uee of alcohol, t he
obvioue functione t hat have eupported drinking customs
throughout hietory ar e thoee phanuacological ef f ect s
accompanying moderate drinking , euch ae relaxation, a sense
of well-being, and mild t r anqui l i zat i on- A l 1 euch f act or e,
par t i cul ar l y thoee concerning increaeed revenue and
employment , cmpr i ee eignif i cant elemente i n a soci et y ' e
approach t o policy fonuulation on alcohol-related problema.
o In moet count ri ee t here i e a di et reesi ng l ack of
communication i n alcohol policy fonuulation between pereons
concerned with t he public heal t h aepecte of those pol i ci es
and othere concerned w i t h the revenue and
employment-producing r ol e of alcohol. To address t h i s
problem, t he public heal t h sect or i n each country needs t o
begin a dialogue with ot her mi ni et ri ee and i ns t i t ut ee of
finance, comnerce, j uet i ce, t raneport at i on and l a w
enforcement- The f act t hat alcohol coneumption pat t erns and
l evel e ar e relevant t o r at ee of alcohol problema mane t hat
alcohol production and avai l abi l i t y muet be t r eat ed
l egi el at i vel y and pol i t i cal l y ae a public heal t h concern, a s
wel l ae a f i s c a l and ecominic concern.
o There ar e ei gni f i cant i nt er nat i onal incentives and
conet rai nt e, both gl obal and regional, influencing nat i onal
alcohol policy fonuulation. In each country, t he views of
e nt i t i e e concerned with t rade agreemente and controle on
alcoholic-beverage-producing i nduet ri ee need t o be
coneidered i n diecueeione of public heal t h concerns r el at ed
t o alcohol coneumption. Such diecueeione mght be organized
on a regional baeie, with col l aborat i ve ef f or t s among
count ri ee i n appropriate geographic c ~ n f i g u r a t i o n s ~ WHO and
i t e regional of f i cee, including PAHO, could have an
i nport ant communication and coordination r ol e t o play i n
f urthering i nt er nat i onal col l aborat i ve reeearch.
5. WETHER OR NOT LEGISLATIVELY BASED, IMPLWNTATION OF EFFECTIVE
POLICIES POR PREVENTING ALCOHOL-RELATED PBOBLEWS MUST BEGIN
W I T H CREATION OF PUBLIC AND GOVERiWENTAL &ARE- NESS OF THE
ENORMOUS BURDEN OF THOSE PROBLEMS TO THE SOCIETY.
o b s u l t s of improved record+eeping and report i ng systeme and
expanded research, noted i n I t e m 1 preceding, can cont r i but e
s i gni f i c a nt l y t o t he development of a successful publ i c
awarenese s t r at egy. Such a s t r at egy w i l l have t o be aimed
a t showing t h a t problems r el at ed t o epi sodi c i nt oxi cat i on,
whether o r not r el at ed t o chroni c heavy dri nki ng, a t e n d
beyond t he problems of alcoholism, a r e j us t a e di et ur bi ng t o
t he i ndi vi dual s i nvol ved, t he i r f ami l i es , and soci et y, and
t her ef or e merit i nt enei f i ed nat i onal a t t e nt i on and act i on.
o Prevention pol i cy formul at i on i n t he al cohol ar ea may focus
pri mari l y on publ i c s ect or l e gi s l a t i on and act i ons a t
vari ous l e ve l s of governraent . I n many count r i es, however,
pol i cy formul at i on a l s o needs t o i nvol ve c r i t i c a 1 pr i vat e
s ect or i ns t i t ut i ons and groups such ae vol unt ary
organi zat i ons, l abor and i ndust r y, and r el i gi ous ,
educat i onal , s oci al , and community organi zat i ons.
6 . THE EXPERIENCE OF ONE COUNTRY FREQUENTLY CAN BE HELPFUL TO
OTHER COUNTRIES I N DEVELOPING ALCOHOL POLICIES. I N THE FINAL
ANALYSIS, HOWEVER, EACH COUNTRY'S PUBLIC AWARENESS STRATEGIES
AND PREVENTION PROGRAMS REGARDING ALCOHOL-RELATED PBOBLEMS MUST
BE SHAPED BY ITS OWN UNIQUE SOCIAL, CULTURAL, POLITICAL AND
ECONOMIC SITUATIONS.
Al t er nat i ve Non-Consensus Vi e ws
Eech par t i ci pant was gi ven t he opport uni t y t o submit f o r
publ i cat i on any disagreements wi t h t he coneensue st at ement s. Two
such st at ement s were received.
Harry Gene i evi ne: Like some ot her recent s t udent s of t he al cohol
f i e l d , 1 am i nt er es t ed i n t he way knowledge and f a c t e a r e produced,
promulgated and l egi t i mi zed (See a i s f i e l d 1981, Weiner 1981). h o n g
t he quest i one one can a s k ar e: Why t hese f a c t s and not ot her f a c t s ?
Why 1s knowledge present ed i n t h i s fonu? hy a r e t hese poi nt s
si ngl ed out and emphasized and not ot her s ? Why, indeed, i e t her e a
"coneensus" st at ement a t a l l ?
It 1s not c l e a r what t h i s i s a "consensue" of . 1s t h i s a
consensue of da t a and concl usi ons of t he papers presented a t t he
conference, o r of a l 1 t he st at ement s made? Or l e t h i s a consensus
of t he gener al opi ni ons of t he al cohol and publ i c heal t h pro-
f es s i onal s assembled a t t he conference r egar dl ess of whether
anyt hi ng was s ai d on t he subj ect a t t he conference o r not ?
The f i r s t poi nt of t he document makes a number of st at ement s
f o r which, i n my opi ni on, l i t t l e o r no evidence was preeented a t t he
conference f o r most of t he count r i es of t he Americas. There was
vi r t ua l l y no evi dence present ed on t he r el at i ons hi p of al cohol t o
"vi ol ent andl or cr i mi nal behavior; fami l y di sr upt i on; chi l d negl ect ;
and impairment of work capaci t y and at t endant l o s s of productive
capaci t y. . . . [and] f e t a l damage." There was no evidence t o support
t he st at ement that t he "burden t o s oci et y of epi sodi c i nt oxi cat i on
and chroni c heavy drinicing 1s s ubs t ant i al i n l o s t cont ri but i one t o
economc pr oduct i vi t y and s oc i a l development . " (On t h i s l a s t poi nt
my paper drew t he opposi t e concl usi on). Fi nal l y, t her e was no
evidence t o support t he statement t ha t t he count r i es of t he Americas
experi ence s ubs t ant i al l os s e s becauee of t he "uee of scar ce
resources f o r r es t or at i ve and long-term heal t h car e, and f o r
r e ha bi l i t a t i ve s oc i a l cervices" f o r al cohol problema. Indeed, t he
overwhelming t hr us t of t he di scussi on a t t he conference was t ha t
t her e 1s l i t t l e dat a avai l abl e on t he r el at i ons hi p of al cohol t o
s oc i a l problems f o r most of t he count r i ee of t he Americas.
The consensus st at ement a l s o gi ves t he impression t ha t chroni c
heavy dri nl dng and per i odi c i nt oxi cat i on a r e reeponei bl e f or , o r t he
cause of , t hese problems and "enonuous burdens" ( or a t l e a s t a
e i g d f i c a n t percentage of them). And i t gi ves t he impression t ha t
by doing something t o prevent al cohol problems -- pri mari l y by
s i gni f i c a nt l y r ai s i ug pr i ce and reducing a va i l a bi l i t y -- a count ry
can eave consi derabl e sums of money and reduce a number of major
s oc i a l problems. Thi s would t r ul y be a wonderful t hi ng i f i t were
t r ue. Unfort unat el y, i t i s not . Although this t ype of argument i s
of t en used t o publ i ci ze al cohol problems, and t o secure more funding
f o r research, t reat ment , and prevention, t her e i s no emprica1 dat a,
i n my opinion, t o support t he st at ement t h a t al cohol consumption
di r e c t l y causes t hese problems.
The consensus st at ement recogni zes t h i s i mpl i ci t l y by using a
terminology , common i n t he al cohol f i e l d, t o suggest caus al i t y
without saying s o di r ect l y. Thus t he st at ement poi nt s out t h a t
i nt oxi cat i on and heavy dri nki ng a r e "associ at ed wi t h, " "linked t o, "
and "di r ect l y r el at ed t o" t he vari ous problems and economic cost e.
While t he t one and s t y l e of t hese st at ement s eound s ubs t ant i al and
aut hor i t at i ve, none of t he phrases means t ha t dri nki ng o r i nt oxi -
cat i on causes t he problema.
Indeed , t he t erminology of "associ at ion" and "r el at i on" l eavee
t he di s t i nc t pos s i bi l i t y t ha t t he causal r el at i ons hi p could go t he
ot her way -- t ha t vari ous economic and s oc i a l problems cause harmful
dri nki ng and i nt oxi cat i on. Furt her, what i s l e f t of f t he l i st of
"al cohol -rel at ed problems" i e j us t a s i nt er eet i ng a s what i s
i ncl uded. Left of f ar e: poverty, i nadequat e s ani t at i on, poor di e t ,
unemployment, i nf a nt mor t al i t y, inadequate housing, war, urban
slums, oppresei ve work condi t i ons, recessi ons and depressi one, l ack
of medical cat e, and s o on. Li ke t he ot her problems, a l 1 of t heee
could be responsi bl e f o r heavy dri nki ng and i nt oxi cat i on a s much a e
t he reverse. However, t her e was no more evidence presented f o r
t hese al cohol -rel at ed problems t han f o r t he ot her s.
1 do not mean t o imply t h a t t he consensus statement i e t he
r e e ul t of i nt ent i onal f a l s i f i c a t i on. On t he cont r ar y, t h i s i s t he
work of c a r e f ul and caut i ous people using t he st andard r het or i cal
format and language of t he al cohol f i e l d ; c e r t a i n problems a r e
"nat ur al l y" l i nked wi t h al cohol , and ot her s a r e not . Thue, although
t her e was l i t t l e dat a, i n my opi ni on, f o r most of t he cl ai ms d e
under t he f i r s t poi nt of t he consensus st at ement , they could i n good
conecience be included because "everybody" knows t hey a r e t r ue. And
t h i s consensus st at ement adds i t s own b i t t o what "everybody knows."
The promise of t he consensue statement i s t ha t by following
what a r e cal l ed "group-oriented prevent i on measuree" -- pri mari l y
r ai s i ng pr i ces and reducing a va i l a bi l i t y -- major s oci al problems of
t he Americas w i l l be reduced. 1 t hi nk t h i s of f e r s a f a l s e sol ut i on
t o r e a l s oc i a l and economic problems. Even i f , f o r example, t he
al cohol consumption of t he count r i es of t he Americas was s i gni f i -
cant l y reduced, 1 do not t hi nk t her e would be s i gni f i cant
reduct i one i n vi ol ent o r cr i mi nal bahavi or, fami l y di erupt i one,
c hi l d negl ect , o r a n i ncr eaee i n ove r a l l e c o md c product i vi t y.
During t he 19208 i n t he United St at ee, f o r example when al cobol
consumption dropped very ei gni f i cant l y, t her e wae no reduct i on i n
major eoci al and economic probleme. Indeed, under Pr ohi bi t i on t he
U.S. experienced t he growth of organized crime, t he youth r ebel l i on
of t he f l apper er a, and t he woret depresei on i n America hi et ory.
Like automobile s a f e t y deeign, a i r and water pol l ut i on, i nf ant
mor t al i t y, c i ga r e t t e smoking, t oxi c wastee and environmental
hazards, al cohol consumption l e a l egi t i mat e and important publ i c
heal t h concern. Howeve r, over eel l i ng t he e v i l coneequences of
al cohol does not hel p publ i c heal t h. Furt her, although reducing t he
incidente of publ i c heal t h probleme br i ngs mat er i al and qual i t y of
l i f e improvemente f o r many people, i t w i l l not ueual l y produce
soci et al - l eve1 economic benef i t s. Deeigning s a f e r automobiles and
reducing i ndue t r i a l pol l ut i on, f o r example, save l i v e s but coet
money. Si mi l arl y, reducing al cohol consumption wi l l not produce t he
s oc i a l and economic bargi n t h i s coneensus statement promiees.
Marcelo Selowsky: My f i r s t obj ect i on t o t he etatement of consensue
views stems from t he f a c t t ha t t he workshop concent rat ed much t oo
heavi l y on l e gi s l a t i ve cont r ol e and pr ohi bi t i on on t he eupply
( a va i l a bi l i t y) of al cohol . The f a c t t ha t people a r e abl e t o
eubs t i t ut e t he t i m e and e i t e of purchaee, a e wel l a s t o swi t ch t o
ot her sources of al cohol (i . e. , i nformal o r domestic), was t hus not
c a r e f ul l y enough considered. Thie l e par t i cul ar l y important i n
r u r a l ar eae of developiqg count ri ee. Also, i t i e not c l e a r t ha t
from a broader wel fare poi nt of view, r e e t r i c t i one on t he eupply
s i de make people happi er (we a r e not i nt er es t ed i n bri ngi ng down
al cohol coneumption per e e but i n i ncreased wel fare). What ot her
behavi oral changes can we expect by r e s t r i c t i ng t he eupply of
al cohol i c beverages? The a l t e r na t i ve i nt er vent i on, on t he demand
s i de, which 1 bel i eve t o be more consi et ent wi t h t hese broader
obj ect i vee, should have been gi ven equal importance.
Second, 1 don' t t hi nk t he empi ri cal evidence on t he
ef f ect i venese of supply ei de versus demand ei de i nt er vent i ons 1s
st rong enough t o make some of t he st at ement s included i n t he
consensus st at ement s.
Third, t he r ol e of t axat i on l e di ecussed wi t h a very narrow
obj ect i ve, namely, agai n, t o bri ng down t he consrmiption of al cohol .
I f t he e f f e c t of al cohol t axat i on on low income groupe reduces t he i r
net r e a l income ( t he incone l e f t t o buy ot her comnoditiee), then t he
purchaee of ot her comodi t i ee, euch a s food, medicine, and,
cl ot hi ng, w i l l go down, par t i cul ar l y i f t hei r demand f or alcohol i e
i nel aet i c. i b w do we t ake t hi e i nt o account? Again, i t l e t he
r eeul t of looldng a t a very narmw obj ect i ve -- consmption of
alcohol -- inetead of a t t he general welfare of thoee income groupe-
e f erencee
Guefield, Joeeph R. (1981) The Culture of Public Problema: Drinking
Driving and t he Symbolic Order, Chicago : Univereity of Chicago
Preee.
Wiener, Carolyn L. (1981) The Pol i t i ce of Alcoholiem, New Brunswick,
New Jersey: Traneaction Booke.
WORKSHOP PARTICIPANTS, GUEST SPEAKERS, AND INVITED OBSERVERS
Workshop Par t i ci pant s
Jaime Arroyo Sucre
Prof. Medicina Prevent i va y Soci al
Univereidad de Panama
Panama, Panama
M i chael Beaubrun
Di r ect or , Caribbean I n s t i t u t e
on Alcoholism
Univerei t y of t he Wes t Indl ee
Por t of Spain, Tri ni dad
Linda A. Bennett
Center f o r Family Research
George Washington Uni verei t y
Medical Center
Washington, D .C.
Robert J. Blendon
Seni or Vice-President
The Robe r t Wood Johnson Founda t i on
Pri ncet on, New J er s ey
Raul Cae tano
Aseoci at e Professor of Peychi at ry
Federal Universi t y of Rio de
J anei r o (on l eave)
Research Analyst, Alcohol Research
Group
Bericeley, Cal i f or ni a
Charl es Chassoul Plionge
Di r ect or
I ns t i t ut o Nacional Sobre Alcoholismo
San Jose, Costa Rica
Carl os Campillo-Serrano
I ns t i t ut o Mexi cano de Psi qui a t r i a
Mexico C i t y, Mexico
Dean Gerst ei n
Assembly of Behavioral and
Soci al Sci ences
Nat i onal Academy of Sci ences
Washiag ton, D .C.
Un e Gonzalez
Regional Advisor i n Manta1 Heal t h
Pan Ameri can Health Organiza t i on
Washiag ton, D.C.
Berkley C. Hathorne
I nt er na t i onal Act i vi ties Of f i cer
Of f i ce of t he Administrator
Alcohol, Drug Abuse, and
Mental eal t h Administra t i on
Dwight B. k a t h
Professor of Anthropology
B ~ O M Uni versi t y
Providence, Rhode I s l and
Marilynn Katatsky
Regional Advisor on Alcoholism
and Drug Abuse
Pan American Health and Human Servi ces
Washington, D.C.
Harry Gene Levine
Professor of Sociology
Queene College
New York, New York
Eduardo Medina Cardenas
Mi ni et eri o de Salud
Sant i ago, Chi l e
Mari a Elena Medina-Mo r a
I ns t i t ut o Mexicano de Psi qui a t r i a
Mexico C i t y, Mexico
James Moeher
Alcohol Reeearch Group
Bericeley, Cal i f or ni a
Juan Carl os Negrete
Associ at e Di r ect or , Departppent
of Ps ychi at r y,
Montreal General Hospi t al
Montreal, Quebec, Canada
Robin Room
Sc i e nt i f i c Di rect or
Alcohol Research Group
Be rkel ey, Cal i f or ni a
I r vi ng Rootman
Chief , Heal th Promotion S t udl ee
Heal t h and Welfare Canada
Ottawa, Ont ari o, CAnada
Wolf gang Schmidt
Al coholism and Drug Addic t i on
Resear ch Founda t i on
Toron t o , Ont ari o , Canada
Marcelo Selowsky
Economi c Advisor
The World Bank
Washington, D.C.
Reginald Smart
Alcoholism and Drug Addi c t i on
Re search Founda t i on
Toronto , Ont ari o , Canada
Robe r t S t r aus
Prof es s or and Chairman, Deparment
o f Behavi oral S c ence
Col l ege of Medicine
Uni versi t y of Kentucky
Lexing ton, Kentucky
Leland H. Towle
Chi ef , I nt er nat i onal and I nt er -
governmental Af f a i r s
Na t i ona l I ns ti t u t e on Alcohol Abuse
and Alcoholism
Ro ckvi l l e , Maryland
Gues t Speaker8
k c t o r R. cuna
Di r ect or , Pan Americen Heal t h
Organiza t i on
Washington, D.C.
Pet er D. Be11
Pr esi den t
Inter-Ameri can Heal t h Founda t i on
Washington, D.C.
John H. Bryant
Deputy As s i s t ant Secr et ar y f o r
I nt er na t i ona l Heal t h
Department of Heal t h and Human Ser vl ces
Washing t on, D .C.
Thomas F. Malone
Forei gn Secr et ar y
Na t i ona l Academy of Sci encee
Washington, D.C.
Fr eder i dc C. Robbins
Pr esi den t
I n s ti t ut e of Medicine
Nat i onal Academy of Sde nc e s
Washington, D .C.
Norman Sar t or i us
Di r ect or , Di vi si on of Mental Heal t h
World Heal t h Organi zat i on
Geneva, Swi t zer l and
I nvi t ed Observers
George Al l eyne
Chief of Research, Promotion
and Coordi nat i on
Pan American Heal t h Organiza t i on
Washing ton, D .C.
Fabi o Arango
Economlc Advisor
Economic Commission f o r La t i n America
Washing ton, D .C.
Loran Archer
Act i ng Di r ect or , Na t i ona l I n e t i t u t e
on Alcohol Abuse and Alcoholism
Department of Heal t h and Human Ser vi cee
Washing ton, D .C.
Karen Be11
Board on Sci ence and Technology f o r
I nt er na t i ona l Development
Na t i ona l Academy of S ci ences
Washington, D.C.
N e i l Boyer
Agency Di rect or f o r Health and Naraot i cr
Bureau of I nt er nat i onal
Organization Aff a i r s
U.S. Department of St a t e
Washing ton, D .C.
Gordon B ~ O M
Di r ect or , Offi ce of I nt er nat i onal
Economi c Pol i cy
Bureau of I nt er nat i onal Or gadzat i on
Af f a i r s
U.S. Department of St at e
Waehing ton, D .C.
John Deering
Economlc Advisor
Pan American Heal t h Organization
Washington, D.C.
Abraham Drobny
Chi ef, Publ i c i i eal t h Pr oj ect e
Int erAmeri can Development Bank
Washington, D.C.
Paul Ehrl i ch
Depu t y Di r ect or
Pan American k a l t h Organization
Washington, D.C.
John Evans
Di r ect or , Population, Health and
Nu t r i t i o n Departmen t
The World Bank
Washington, D.C.
Barbara Fi l ner
I ne t i t ut e of Hedicine
Nat i onal Academy of Sci ences
Washington, D .C.
Mar t i t a Ma nt
S e d o r Program Offi cer
The Robert Wood Johnson Foundatin
Pri ncet on, New J er s ey
William Player
Adminis t r a t or , Al cohol, Drug and
Mental Health Admlnistration
Depar tment o Heal t h and Human Servi ces
Washington, D .C.
Al i ce M c G i l l
Offi ce of eal t h Promo t i on
Department of Health and Human Servi ces
Washington, D.C.
Lane Por t er
Norri s and Norrie, I nt er nat i onal
Lawyers
Bos ton, Massachuse tts
David Promisel
Army Research I ns ti t u t e
Arl i ng ton, Vi rgi ni a
Edward S. Sanda
S ci en t i f i c Research and
Education Di vi si on
Die t i l l e d Spi r i ts Council
of the U.S.
Mark Schneider
Of f i cer of Long-Range Planning
Pan American Heal th Organiza t i on
Washing ton, D .C.
Nancy Woli cki
St a f f , U.S. Senate Subcommittee on
Al cohol i m and Drug Abuse
Washing ton, D .C.
Alvaro Gomez
Secre t a r i a t of Legal Af f ai r s
Organi zat i on of American St at ee
Washing ton, D .C.