(WP)MNH/ICP/ADA/002
10 May 1985
~GIONAL WORKSHOP ON NATIONAL POLICY AND PROGRAMME FORMULATION FOR THE PREVENTION AND CONTROL OF ALCOHOL-RELATED PROBLEMS
Convened by the Regional Office for the Western Pacific of the World Health Organization Auckland, New Zealand ;-9 November 1984
Not for Sale Printed and Distributed by the Regional Office for the Western Pacific of the World Health Organization Manila, Philippines November 1984
NOTE
The views expressed in this report are those of the participants in the Regional Workshop on National Policy and Programme Formulation for the Prevention and Control of Alcohol-related Problems and do not necessarily reflect the policies of the Organization.
This report has been prepared by the World Health Organization Regional Office for the Western Pacific for the governments of Member States in the Region and for those who participated in the Regional Workshop on National Policy and Programme Formulation for the Prevention and Control of Alcohol-related Problems, held in Auckland, New Zealand, from 5 to 9 Noveaber 1984.
CONTENTS
1.
INTRODUCTION
........................ a
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
1
2. 3.
OSJECTIVES OF THE MEETING SUKKARY OF COUNTRY PROFILES 3.1 3.2 3.3 3.4 3.5
.................................................................... ................................................................
2 2 2 3 3 4
Consumption of alcohol •.•••.••.•••••••••••.••••••••••• Alcohol-related problems .•••••••••.••••••••••••••••••• Concern among the population ••••••••••••••••••••••••••
Policy to prevent alcohol-related problems •••••••••••• Mechanisms and constraints for the development of policy ........................................................................................ ..
4 5
4.
SOCIAL AND MEDICAL ASPECTS OF ALCOHOL-RELATED PROBLEMS 4.1 4.2 Social aspects Medical aspects
..........
................................................................................ .............................................................................. .. ...................................................................... .
5 6
5.
MECHANISMS AND CONTROL 5.1
7 7 10
5.2 5.3 6.
Alcohol supply and control ................................... . Education, early detection and care ................... .
Examples, models and constraints: New Zealand and Japan
Australia, 13 14
••..•••.••••••.••..••.•.••••..•.•
FIELD VIS ITS 6.1 6.2
.. ................................................................. .
Alcohol Research Unit, Auckland Medical School Community Alcohol Services, Carrington Hospital, Auckland
..............
14
............................................................................ ..
6.3 7.
Social detoxication centre
....................................................
15 15 16
DESIGN OF NATIONAL STRATEGIES 7.1 7.2 7.3
.
................................................ . ••••••
Introduction .......................................................................... .. Workshop framework and composition ••••••••••••••••••••
Summary sheets:
Design of national strategies
16 18 19
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8.
COIiCLilSIONS AND SUGGESTIONS 8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8 8.9
................................... .
26
Overall evaluation of the workshop ..................... Magnitude and trends of alcohol-related problems •••••• Nature of alcohol-related problems .••••••••••••••••••• Pattern of alcohol drinking ............................ Resources .. ......... ..•••• •.••..•••.• ...•••••••••••••••. Constraints . . . .. . . •.••. . ... . . . . . .. . . .. ......... . ..... ••••. ... Need for the development of a national policy and progrannne .. • . . . • . . .. . .. .. ... .. • • • .. • .. • • • .. .. .. .. .. . .. • • .. . • • • .. • .. • • • •
26 26 27 27 27 27 28 28
Need for continuous inputs from WHO .••••.•...••••.••.• Need for collaboration among international, regional and national resources, including those of nongovernmental and qU8si-governmental organizations 8.10 Need for impleaentation of previous recommendations of WHO • • • • • ••••• • • •• • ... • • • • • • .. • .. • ... .. .. .. • • ... • • .. • • .. ••• • .. .. A,~NEX
28 28
1 - LIST OF PARTICIPANTS
............................................
29
ANNEX 2 - OPENING SPEECH OF DR HIROSHI NAKAJIMA, REGIONAL DIRECTOR, WHO WESTERN PACIFIC REGIONAL OFFICE •• ••• •• • • ••• • • .. .. ... •• ... .. .. .. .... .. .... .. . . . 33 37/38
ANNEX 3 - AGENDA ANNEX 4 -
ANNEX 5 -
.......................................................................... TIMETABLE ...................................................................... COUNTRY PROFILES .........................................................
39
41/42
,
,
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1.
INTRODUCTION
The Regional Workshop on National Policy and Programme Formulation for the Prevention and Control of Alcohol-Related Problems Was held at the University of Auckland Hedical School, Auckland, New Zealand, from 5 to 9 November 1984. This was the first regional group educational activity to be organized by the World Health Organization in New Zealand. Dr N. Shinfuku. Regional Adviser in Mental Health and Drug Dependence, opened the meeting on behalf of Dr Hiroshi Nakajima, Regional Director of the Regional Office for the Western Pacific of the World Health Organization. In his opening speech, the Regional Director expressed his sincere gratitude to the Government of New Zealand for agreeing to host the regional workshop. His opening speech is given in Annex 2. Dr Ron Barker, Secretary-General of the Department of Health, New Zealand, welcomed the participants representing the host country. Dr David Cole, Dean of the University of Auckland Medical School, also expressed his gratitude that the WHO workshop was being held in the University. The workshop was attended by thirteen partlclpants from nine countries or areas of the Region, namely. Cook Islands, Fiji, Kiribati. New Zealand. Papua New Guinea, Samoa, Solomon Islands, Tonga, and the Trust Territory of the Pacific Islands. Four temporary advisers: Dr Basil James, Wellington, Dr Sally Casswell. Auckland, Dr Hiroaki Kone, YokoBuka, and Dr Sue Morey, Sydney, provided support in the preparation and conduct of the meeting. Dr Basil James, Director of the Mental Health Division, Department of Health, New Zealand, acted as national coordinator for the workshop.
Mr J.F. Robertson, Chairman, Alcohol Liquor Advisory Council of New Zealand, Hr Keith Evans, Director, Alcoholic Liquor Advisory Council of New Zealand, and Dr Richard Taylor, South Pacific Commission, attended the workshop as observers representing their organizations. A list of participants, temporary advisers, observers and secretariat is given in Annex 1. Hr Sione T. Wolfgramm, Tonga, was appointed Chairman, and Dr Toia Alama, Samoa, Vice-Chairman.
Dr Geoffrey Maxwell Robinson, New Zealand, and Dr Brother Andrew, Papua New Guinea, contributed as Rapporteurs of the workshop.
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2.
OBJECTIVES OF TIlE MEETING
The general objective was to il~rease national awareness and to strengthen capability to formulate and develop nati?usl poli~ies for the prevention and control of alcohol-related problems 1n countr1es or areas where alcohol is a serious problem. Specific objectives were to enable participants: (1) to update their knowledge and information on the nature and magnitude of trends in alcohol-related problems in the Region;
(2) to describe the social and medical aspects of alcoholrelated problems; (3) to review, at national and regional levels, existing and possible mechanisms and approaches for the prevention and control of alcohol-related problems, including technical cooperation among developed and developing countries; (4) to design practical national strategies for the prevention and control of alcohol-related problems which are relevant to the social, cultural and economic conditions of the countries or areas of the participants.
3.
SUMMARY OF COUNTRY PROFILES
3.1
Consumption of alcohol
None of the Pacific Island countries represented at the workshop had a tradition of alcohol use during the pre-colonial period. However, a number of countries now have an established practice of non-commercial production of alcohol made from local materials, for example, Kiribati's "sour tOddy", to wh1ch, in recent times, methylated spirits is being added. The extent of use of these beverages is unknown. In terms of commercial alcohol, frequently imported but sometimes locally produced, figures demonstrate that, when expressed as a per capita consumption of absolute alcohol, the developing countries in the Pacific Islands by and large have much lower levels of consumption than the developed countries. Host are between 0.5 to 2 litres of absolute alcohol per capita compared with New Zealand and Australia with more than 7 litres. However, some of the developing countries have shown quite dramatic increases over the past few years, for example Samoa with a threefold increase. Pa lau had a relatively very high per capita consumption of 6.3 litre. of absolute alcohol in 1983 and Kiribati also had a relatively high level of 4.4 Htres.
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In many of the developing countries the conversion of total alcohol consumed to a per capita measure is misleading since drinking is confined to a small proportion of the population. For example, in Solomon Islands this . . ' proportion was estimated to comprise 20% of wage earners, mostly men between the ages of 18 to 45 years who resided in towns. Many countries reported that alcohol use and associated problems were urban phenomenon and were related to major changes in life-style and traditional cultural patterns of control. In Papua New Guinea, where the rural sector can earn cash, for example, through the sale of coffee, alcohol use is also an issue. It was stated that, in Kiribati, the generally accepted attitude is that people drink in order to get drunk and much of the information coming forward from the other participants suggested this to be a common pattern elsewhere. Participants described 'binges' of drinking which continue until all alcohol, and sometimes all money, is gone. The incorporation of alcohol into traditional patterns of sharing of goods was noted. A further reason for alcohol use mentioned was the alienation of the youth. 3.2 Alcohol-related problems
The alcohol-related problems experienced tend to be those which accompany drunkenness, and the participants agreed that these "social" problems, which also have major consequences for ill health, were most cOIIEonly experienced. The Samoan participant emphasized the effects of ,lcohol on the family of the drinker. The association between alcohol and criminal activity, particularly Violent crime, was repeatedly mentioned. In Fiji, for example t a survey of prison inmates has shown that 50-60% of inmates committed crimes while under the influence of alcohol during the period 1974-1976. In the Marshall Islands, alcohol-related crimes have more than doubled in the period 1979-1982. The effect of alcohol on driving and the resulting accidents was also frequently mentioned. In Cook Islands in 1984 the police records demonstrate that 45% of motor vehicle accidents were alcohol-related and the police estimated that the majority of those accidents in which someone was admitted to hospital were alcohol-involved. A financial costing suggested that one such motor vehicle accident costs Cook Islands around NZ$5 500.
3.3
Concern among the population
The high levels of perceived alcohol involvement in crime and accidents are viewed with considerable concern in many countries. This is demonstrated by official requests to WHO and SPC for assistance in this area and also in a variety of activities undertaken by certain sections of the population, most commonly women, but also church groups, to attempt to reduce alcohol-related problems. In Palau in 1958 prohibition was achieved through the activity of women. In Papua New Guinea there are many examples of women repeatedly requesting local prohibitions.
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However, there were also various examples given of a considerable amount of ambivalence existin& within the societies. For example, drunk driving is not considered of suffic~ent imp~rtance.t~ e~sure.a:rest in Palau if the offender is "an uncle or a hlgh ranklng ofhclal. Slmllar examples of lack of enforcement of existing legislation suggest a combination of both ambivalence and lack of financial resources.
3.4
Policy to prevent alcohol-related problems
The most COllllDon method of sttempting to prevent alcohol-related probleu& is controls on the sale of alcohol. Many countries have bodies, such as the Liquor Board of Samoa, which can grant applications for licences and prescribe opening and closing hours. Cook Islands hss a similar board; in practice it was noted that any stores selling food can also sell alcohol. It was noted that, in the case of Cook Islands, the police have no power to revoke a licence, even where there are repeated breaches of the licencing sct. Other methods to control availability are similarly not enforced. For example, in Kiribati a system of rationing the sale of methylated spirits for domestic use only was introduced but drinkers were clearly evading the system. In the Marshall Islands a system of identification cards to prevent unde r-age drinking is in place, but again it was reported that insufficient enforcement means that it is not effective. The membership of such licensing bodies and other organizations set up co make recommendations concerning alcohol-related problems was discussed by several participants •. Problems related to the fact that these were political appointments, thst there was a fairly fast turnover membership, and that in the case of Papua New Guinea, a wide range of interests was represented by the membership, such that the conflicts of interest between those holding a temperance perspective and the alcohol industry made the <:ollllllittee ineffective. The Papua New Guinea solution has been to separate these incerests into different forums; for example, the Health Department is pursuing a specific policy relevant to its staff while a separate nongovernmental organization representing concern about alcohol is also
being establisbed. Traditional systems of control were mentioned as operating successfully
to control the availability of alcohol and related problems.
For example,
in Kiribati the "Unimane", the old men, were successfully enforcing a prohibition on alcohol in certain areas.
3.5
Mechanisms and constraints for the
develo~nt
of policy
It was noted several times chat a major constraint on the
implementation of effective policy was ambivalence towards alcohol and related problems, particularly regarding the government's role as a revenue collection agency. In most of the countries represented, a significant amount of revenue was collected by the government from sales of alcohol.
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Several participants mentioned the importance of education. Some proposed this a8 an acceptable alternative in the light of the lack of acceptance of measures to control availability or, as in the case of Tonga advertising of alcohol. ' Some participants felt that additional information was required in order to convince p~licy makers of the need to take action, such as surveys of alcOhol consumptlon and alcohol-related damage (e.g. alcohol-involvement in hospital admissions) and particularly the financial costs inVOlved. The lack of technical aids, such as those for measurement of alcohol levels in the body, reduced both the opportunity to assess the role of alcohol in problems such as driving and also the enforcement of the laws. A participant from Papua New Guinea felt that sufficient local evidence of alcohol-related problems was available and saw the establishment of effective organizations as an important mechanism in that particular situation.
4.
SOCIAL AND MEDICAL ASPECTS OF ALCOHOL-RELATED PROBLEMS
4.1
Social aspects
In considering the social aspects of alcohol-related problems, it is necessary to reqember that ethanol, the essential component of alcoholic beverages, is a depressant drug, which progressively inhibits neuronal activities as its concentration increases. At relatively low doses, it selectively dis inhibits behaviour, reduces the level of self-criticism and impairs psychomotor performance and coordination. Higher concentrations lead to increased disinhibition and impairment of psychomotor control, and at relatively higher doses there is anaesthesia and unconsciousness. The effects of alcohol are individuslly specific and context dependent. Tolerance does develop with constant exposure but, at high levels, death is invariable. The reasons for drinking are extremely varied and complex. Drinking Can be a socially cohesive activity or it can be socially disruptive within a subgroup, or it can have a different basis and effect, depending on the relationship between one's subgroup and the larger society. Intoxication becomes habitual due to expectations based on past experience varying with the person'. initial emotional setting and with the external pressures to which he/she is subject. Intoxication may allow the ventilation of feelings and expression in word or act of suppressed desires. Drunkenness is often seen as the cause of problems when it may only be used as an occasion to deal with issues which would otherwise be avoided. It is important, in considering social problems associated with drinking, and particularlY if one is attempting to develop prevention strategies, to remember the various types of causes, e.g. e •• ential, precipitating, contributory and sufficient, and to discriminate between association and causation.
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The social problems associated with alcohol use var~ with the t~pe of drinking and with the amount of alcohol consumed. Undesirable behavl0ural effects such as trauma and aggression are common with occasional heavy . dri.nk:'ng. whereas long-term regular heavy d:inking can result ~n personallty deterioration the appearance of alcohollC Jealousy and paranola. and economic emba;rassment. Examples of social problems associated with alcohol use are:
domestic disharmony. including separation, divorce and child abuse; criminal behaviour such as assault, murder; non-criminal violence such as suicide, accidental death from traffic accidents, death from immersion, shootings and burning;
industrial accidents, absenteeism and inefficiency. leading to falling work status and unemployment; impaired functioning of senior community personnel;
diversion of domestic finances from family needs. roe social costs of alcohol are enonnous, far exceeding its social or economic benefits. It is extremely difficult to put accurate figures to this equation, both sides of which need much qualification.
4.2
Medical aspects
The physical complications of heavy alcohol consumption are many, and lnclude cardiovascular, respiratory. gastro-intestinal, haematological, neuro'ogical and metabolic complications. Liver damage is one of the most common complications. Fatty liver, alcoholic hepatitis and alcoholic cirrhosis are typical forms of liver damage. It has heen demonstrated that healthy volunteers with an adequate diet will develop a fatty liver after two days with an ethanol intake of 270 grams per day, or after eight days with a daily intake of 154 grams. These changes are reversible with abstinence, but longstanding fatty changes are thought to be a cause of hepatitic fibrosis, eventually leading to hepatic cirrhosis. In Japan, aicoholic hepati.tis is less common than in Europe and the United States and has been found in only 10% of patients admitted for alcoholism. Alcoholic hepatitis is usually caused hy continuous heavy drinking bouts, and patients may have hepatomegaly) icterus, fever, ascites and bleeding tendency. Some may develop hepatic encephalopathy and the disease may be fatal. It has been reported that cirrhosis of the liver develops in 21% of persons with a daily intake of 160 grams for 10 years, and in 51% of persons with that intake over 15 years. Females are more likely to develop cirrhosis with a lower daily intake and over a shorter period than are men. Recent studies have indicated that this difference may he related to changes in the ethanol elimination rate and the blood acetaldehyde concentration during the menstrual cycle.
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Withdrawal symptoms may develop when someone with a regular, heavy intake of alcohol ceases drinking. Tremor, sweating, diarrhoea, fever and tachycardia are common. In severe cases, disorientation hallucinations autonomic dysfunction and convulsions may o c c u r . ' ,
Another biomedical marker found useful in Japan is acetaldehyde dehydrogenase. Many Japanese develop flushing, tachycardia, nausea and vomiting after drinking alcohol. The cause of these symptoms is a deficiency of low acetaldehyde dehydrogenase, resulting in the inability to metabolize acetaldehyde to acetic acid at low concentration. It has been shown that 41% of Japanese people do not have low acetaldehyde dehydrogenase and 98% of Japanese chronic alcoholics have low acetaldehyde dehydrogenase.
5.
MECHANISMS AND OONTROL
5.1 5.1.1
Alcohol supply and control Minimization of problems
It is improbable that long-term prOhibition of alcohol will be acceptable to many populations in the Western Pacific Region; therefore all of the countries in the Region will need to develop methods for dealing with alcohol-related problems. This will entail helping the people who are affected by alcohol in one way or another, but also, and perhaps more importantly, making sure that everything possible is done to minimize the experience of alcohol-related problems. In many industrialized countries where consumption has rapidly increased and problems have also increased, there is now greater awareness of the need to treat alcohol as a special commodity, and of the need for public health considerations to be taken into account. Indirectly, changes in industrialized countries (increased awareness of the potential of alcohol to cause problems and a stabilization of alcohol consumption) _y have illportant repercussions for developing countries. It is clear that, as it becomes more and more difficult to expand the market in industrialized countries, those involved in the production and distribution of alcohol will look for new opportunities for sales elsewhere; the current developments in the Western Pacific Region, 8S elsewhere, indicate the importance of the developing world in such a search for expansion. Specific solutions for 8pecific kinds of alcohol-related problems will be needed; however it is clear that countries can minimize whichever kind of alcohol-related problem they are most likely to experience by controlling the overall level of alcohol use in that country.
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5.1.2
Relationship of consumption to problems
After the Second World War, many industrialized countries experienced major increases in overall alcohol consumption. For example, in New Zealand in the decade 1965-1975, per capita consumption of alcohol increased by almost 40% and alcohol-related deaths more than doubled. The increase in problems which accompanies an increase in per capita consumption happens because it is not only the non-drinkers or very light drinkers who increase their consumption, but the moderate and heavy drinkers also. It is for this reason that the governments of many industrialized countries where alcohol consumption has risen quite markedly have decided to take steps to ensure that consumption rises no further. In this way the increase in alcohol-related problems should also be stopped. 5.1.3 Relationship of supply to consumption
The recent decade during which alcohol consumption increased in many industrialized countries was also the time when there were quite marked changes in the 9upply of alcohol to the population. The number and kind of places where alcohol is sold increased, the alcohol industry began to market its products with more sophistication and determination, and the real cost of alcohol (the price of alcohol relative to other commodities and to disposable income) fell, so that alcohol became easier to afford. It appears very likely that the supply of alcohol does not merely follow demand but has the effect of increasing demand. Controls over the supply of alcohol can therefore be expected to influence overall cons~tion and, in turn, the problems related to alcohol. This may happen by both changing the drinking behaviour of those already experiencing problems, but also by preventing the recruitment of new problem drinkers. 5.1.4 The supply system
The major way in which the ownership of production, importation or distribution is likely to affect alcohol consumption and probleWB concerns the conflict of interest between public health concerns and those who profit from alcohol production. In the Western Pacific Region, the production or importation of alcohol is largely in private ownership, much of it foreign. In 8~e areas the government owns shares in alcohol production companies but nowhere in the market economies of the Western Pacific Region are there exa~lea of state monopolies, where the production or distribution of alcohol is completely in government hands. Such government monopolies are the aoBt caaprebeQ8ive method of controlling availability and distribution. It is possible, aut by no means certain, that state monopolies will be more responsive to a public health perspective.
)
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A less comprehensive method, which has been substituted in many countries of the Western Pacific Region, is for the government to license private interests to produce and sell alcohol. The licensing system may influence consumption and problems, providing it is enforced, by restricting sales to certain hours and in certain drinking environments. Research on natural experiments such as strikes in the distribution system has shown that reduction in availability reduces alcohol problems. Licensing legislation exists in both industrialized and developing countries in the Region but is not generally operating to prevent considerable increases in availabil ity. Alcohol is not merely distributed by its producers, it is marketed. A particular image is created for alcohol, for example its suitability for use in particular situations and the kind of people who will drink it. Exposure to alcohol advertising has been shown to be related to more positive images of drinkers among young people and it seems likely that, over time, alcohol advertising will encourage a liberalization of attitudes towards alcohol. Marketing is important in developing countries, even where there is a virtual monopoly on the market. Sponsorship, for example, is common throughout the Region. Not only does sponsorship of sporting events by the alcohol industry increase an association between drinking and sport (and oy implication health) but sponsorship can also be seen as a form of corporate advertising in which the alcohol industry establishes itself as a responsible and philanthropic e.lement of the business community. Not all of the influences which go to create a positive image of drinking are paid for by the industry. Alcohol is increasingly seen as an integral part of an affluent, modern and exciting lifestyle in developed countries and this is disseminated in films and videa and by tourism within developing countries. There is clearly an association between modernization and alcohol in developing countries which encourages its use. However, unlike some influences, paid advertising by the alcohol industry is under government control and restriction on it is frequently seen as an important symbolic issue by those concerned about alcohol problems. Research has shown that sales of alcohol, like sales of other goods, are affected by its cost to the consumer and this in turn influences the problems associated with chronic heavy drinking. Controlling the price by taxation is therefore one way in which consumption and some problems can be limited. The role of non-commercial alcohol in each local situation will need to be taken into account. 5.1.5 Constraints on controls of Supply
Opposition to controls on the supply of alcohol will obviously Come most strongly from those who benefit directly from its sale. Those making profits from its production, distribution or marketing will tend to object to any controls which reduce or slow down an increase in alcohol
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consumption. For example, in many countries of the Region, including dl!veloping countries, alcohol is sold in small general trad ing stores and is an item of high profitability. This wide distribution of vested interest in a.lcohol sales means that opposition to any changes in tbe system is al~o widespread. Other sources of opposition to restraints on availabil,cy of alcohol come fTom those who see local production as an importanc source ot employment. The de_nd for alcohol by touriets is also fr<lquently cited as a reason for exl'anding alcohol availability, particularly in developing countries. The imbalance in alcohol availability between the urban areas and rural areas often found in developing countrles leads to accusations of unfairness if availability is not increased to a similar level in the rural area.s ..
Opposition to restrictions on promotional activities comes from the alcohol industry, and the advertising and media industries, who also stand to lose from any restrictions, will also be vocal in their opposition. With the increasing financial input by alcohol industries into a variety of sporting and cultural activities, those organizing and participating in such events will a180 tend to oppose any restrictions. opposition to price increases at a level which will stabilize or reduce sales comes from the industry, whose profits will be threatened. However, the government will benefit from increasp.d revenue) provided that the
increase in taxation is not offset by a drop in sales. For chis reason the government may be open to the suggestion of at least stdbilizing sales by means of increased taxation. The government may also stanG to "ainDY a reduction in alcohol-related problems. Overall, perhaps the greatest constraint to cO(Jtrols on supply of alcohol being adopted in either developed or developing countries in the Region is the lack of a public health input into decision-making about alcohol supply. During the post-war years, the liberalization "f attitudes towards alcohol has led to a tendency to ignore alcohol's pot~ntial to cause great harm, and to Clake decisions about alcohol supply based on purely co.mercial considerations.
5.2
Education, early detection and care
Education programmes aim to prevent or reduce problems assuciated with alcohol misuse anc abuse. Historically, a three-tier system has heen the focus for education programmes, namely, information gathering, attitude fonnat ion and behaviour change. Eva luat ion of the effec ti veness of such programmes is not well developed, which is usually due to the following; (a) (b) (c) lack of measurable objectives; cOlDplexity in trying to identify the relationships between infonBation, attitudes and behaviour; difficulty in showing changes in drinking behaviour a5 related to programme efficacy.
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Much more needs to be done to upgrade the evaluation tools used in education programmes. 5.2.1 Public information
In the past public information programmes have focused in the main on the unacceptable use of alcohol and problems of drunkenness, chronic health deficits and safety. The usual models used for disseminating such information have been: (a) (b) media announcements, and information campaigns as part of a community activity.
Information projects aimed at encouraging responsible drinking have had to deal with questions such as: (a) (b) (c) What is responsible drinking? How much is too much? Should we prescribe or proscribe alcohol use.
In the United States efforts have been made to dispel some of the myths related to alcohol and alcoholics in the belief that correct information will encourage people to make wise choices about alcohol. Alcohol experts have pointed out that we must target our population much more accurately if we are to successfully use the public information system. We must decide who we want to reach and aim directly at that group. The needs to sensible promoted traditional "health education to teach your way to sobriety" model be reconsidered and health promotion should be considered as a more approach. Healthy lifestyles should be encouraged, alternatives and affirmative action for personal and communal health encouraged.
As a passing thought, one should consider why it is that so many powerful interest groups such as the liquor industry support traditional education programmes. Could it be that they really just don't seem to work? It must be acknowledged that of itself a medical campaign is not a total prevention package. However, media strategies can be used to increase public knowledge and compliance with regulations/controls. For public education programmes to work, the following should be considered: (a) (b) (c) (d) (e) The target. The relevance of the information to the targets. Convey the message through suitable actions. Use the medium of most vslue to the targets. Make sure the target gets many exposures to the message.
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5.2.2
Intervention
At times intervention is very closely related to prevention, as in working with the children of alcoholics, and at times closely related to treatment, as in identifying problem drinkers in the general hospital population. It is particularly important to con8ider the plight of the children of alcoholics a8 an obvious target, who are clearly at risk and available for intervention. Early intervention via health professionals is very important. Far too many people are being missed by health professionals, which may be due to one of the following: (a) (b) (c) (d) (e) lack of sufficient alcohol education in the training of health professionals; refusal by health workers to seek out problem drinkers; tendency by underestimate alcohol problem rates; tendency of patients to hide alcohol problems; belief that treatment does not work.
Emphasis must be placed on the screening of problem drinkers in health settings. 5.2.2 Care
The predominant focus for responses to alcohol problems remains treatment for addicted people. The international tendency is towards providing more and more sophisticated, high cost programmes to ward off alcohol problems. It is known of ~ourse that only a very small proportion of the population ever get help from such facilities. Countries should take care not to repeat other health areas' mistakes. What is meant by treatment? Are traditional leaders and healers to be utilized in trying to combat alcoholism? Will any system succeed if it does not have the support of local decision makers? Cheaper is often better. Research shows that if we can intervene early and provide community care for the problem drinker, with emphasis on life after treatment, we will do much better than with mere esoteric long-stay programmes. Emphasis should be placed on the utilization of recovery alcoholics and particularly people who can relate well to the sufferers. Natural resources, namely, the community, should also be used. It is not just the alcohol abuser who needs help - often it is the entire society around that person that is sick and greatly in need of education and support. Treatment is just the beginning. Recovery is a life-long process. Countries must attend to the physical, psychological, social and spiritual
needs of their people - and ignore any of these at their peril.
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5.3
Ezamples, models and constraints:
Australia, New Zealand and Japan
The three countries from which illustrative examples were taken are all economically well developed; all have demoustrated a marked increase in national consumption over the last decade, and an increased level of concern regarding the rising level of associated physical, psychological and social problems. The need to address the problems has been demonstrated by the formulation of policies at national level but it is recognized that to be effective these policies need to remain conspicuous and lead to specific actions across a wide front. This was not always the case. One of the most successful examples of government action was the establishment of the Alcoholic Liquor Advisory Council in New Zealand, in 1976. Established by law, the Counc il is charged not only with advising government and government departments, but also with encouraging, promoting and sponsoring public education, programmes of treatment, care and rehabilitation, and research. Funds for Council activities are obtained by a levy on manufacturers and importers of alcoholic liquor, and the present budget is 3.2 million dollars. Its primary objective is the promotion of moderation in alcohol use, and reduction of the adverse consequences of misuse. It provides a potent focus for national endeavours in the field.
An expert committee on alcohol-related problems was established in Japan in 1983. The three contributors recognized that there is no one single answer to the problem, and that efforts need to be directed concurrently at many levels. Availability (i.e. distribution and price) is seen as a key factor. Australia has implemented an indexstion policy so that the price of alcohol remains constant in relation to average disposable income. In New Zealand, the alcohol price has fallen markedly over the last decade in relative terms. The numbers of marketing outlets are currently a matter of local concern rsther than national, but increasing awareness of the need for some vigilance at national level is reported. With regard to advertising, voluntary codes by the industry are in place in both Australia and New Zealand. In the latter, television advertising of alcohol is banned by law. Community education is active in Japan through the Association for Health and Alcohol (AHA), in New Zealand through ALAe and other agencies, and in Australia. Emphasis is given to public education, not only as a means of increasing individual knowledge and responsibility, but also in order to improve the acceptance of government measures such as taxation and legislation designed to control national consumption and minimize abuse. Education sustained over a long period raises public awareness and could lead to a demand for action. The education of professionals through government-sponsored training programaes is occurring in Japan, but insufficient input into professional curricula is reported in the other two countries. The desirability of improving the education of groups such as teachers and law enforcement officers was noted, but this tends to be sporadic and the result of local
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initiatives. School education programmes have been developed, but are described as inadequate and of uncertain effectiveness. With regard to treatment services, the trend is seen as away from inpatient units, and towards treatment in the community as an outpatient. Examples were given of a spectrum of approaches, through "social" (i.e. non-medical) detoxication, through alcoholics anonymous and other organizations, to the more specialized inpatient units. Research is taking place in the three countries. In Japan the National Institute on Alcoholism is active. The emphasis in Australia tends to be biological; in New Zealand it is directed more to social research, especially the impact of measures aimed at prevention. Legislative action is reported as follows: Japan has very strict laws with regard to drinking/driving, which enjoy wide community support. Random breath-testing is permitted in Australia and its acceptability is cited as an example of public education. In New Zealand a new law requires those who have twice offended within a five-year period to obtain a "clearance" from an Alcohol Assessment Centre before the licence is restored. Minority groups are the subject of concern in the Australasian countries, and as alcohol abuse in these persons is seen as symptomatic of demoralization, special efforts are being made in a wide socioeconomic front. Constraints on the implementation of policies and strategies are identified as: ambivalence to the problem at all levels; industrial and commercial interests, and electoral considerations, especially the perceived rights of individuals to make personal choices.
Improved information and its dissemination at all levels, sustained over a long period, are seen as major contributions to overcoming these impediments.
6.
FIELD VISITS
6.1
Alcohol Research Unit, Auckland Medical School
Dr S. Casswell, Director, addressed the group on the work of this unit, which is funded by the Medical Research Council, the Alcoholic Liquor Advisory Council and the Department of eo_unity Health, under whose aegis it functions at the Medical School. The staff include sociologists, an
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economist, a statistician, a psychologist and a political scientist. A wide variety of research has or is being undertaken, particularly on the issues of alcohol advertising, public knowledge and attitudes towards alcohol consumption, liquor availability and controls, health promotion education and community-drinking patterns.
t
Recent studies on the economic evaluation of costs due to alcohol abuse, and the effect of alcohol abuse on the Maori population were discussed. Studies and material were made available to workshop participsnts. A collection of television and press advertisements to promote moderation and responsible attitudes towards alcohol consumption was shown.
6.2
Community Alcohol Services, Carrington Hospital, Auckland
Mr R. Gaskel, Director, addressed the group at this outpatient assessment and treatment facility, which is currently seeing approximately 800 new client. per year. It is staffed by a small multidisciplinary team of health professionals, and has good supporting services, when necessary, from the social and medical detoxication facilities, general practitioners and residential alcoholism treatment programmes. There is emphasis on individual counselling and group treatment (e.g. women's and family groups) and on education for community groups, health professionals and industries to establish employee assistance programmes. Self-referral. are accepted and other principal referral sources are general practitioners, hospitals and the Justice Department services. Such units are considered cost-effective as a relatively small proportion of clients is referred for residential treatment programmes. Younger clients in the earlier stages of alcohol dependency are being increasingly seen at this centre. Funding i. provided by the Auckland Hospital Board. 6.3 Social detoxication centre
The group visited this eight-bed facility operated by the Anglican City Mission. There is support if necessary from a medical practitioner, ambulance and hospitals, but the 10% of "guests" who require treatment with drug medication are transferred to hospitals. Anyone seeking help for alcohol dependency is accepted, but in general this precludes non-motivated police "referrals". Evidence of alcohol intoxication or withdrawal is required for admission. Treatment consists of concerned, supportive care from the stsff (seven), wno include two nurses funded by the Alcoholic Liquor Advisory Council and the local hospital bosrd. Average stay is five days and patients are usually subsequently referred on to other alcoholism treatment facilities. The current annual running cost is approximately NZ$110 000.
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7.
DESIGN OF NATIONAL STRATEGIES
7.1
Introduction
Some components of a national strategy to prevent specific alcohol-related problem are addressed in this section. For example, drinking in public places, if this is not acceptable to local people, can be specifically outlawed without any attempt to reduce the amount people drink or even how drunk they become. Another specific problem, commonly addressed, is the use of alcohol in conjunction with driving or operating other machinery. Other more general measures may also have the effect of reducing several specific kinds of problems but do so by reducing the overall availability of alcohol. The availability of commercial alcohol depends on the number of places selling it, the number of hours they are allowed to sell it, the age at which people are allowed to buy, and the price for which it is obtainable. Apart from these practical influences on availability, the extent to which social occasions (ranging from government functions through to weekend parties> and recreational activities involve alcohol and fail to provide alternatives will also influence people's drinking. Another set of general measures frequently included within national strategies is intended to affect people'. attitudes towards drinking. This frequently takes the form of attempting to educate the population about the effects of alcohol and in this way persuade them to use alcohol more wisely than they would do otherwise. It is likely that education is more effective if it is specific and immediately relevant. Therefore education should deal with people's current experiences rather than future consequences or future use of alcohol, and should emphasize aspects which are important to them. Education is usually directed at the individual drinker, to inform him or her about the ways to minimize his own experience of problems, but it can also be used to increase awareness throughout the whole community of the effects of alcohol and the way in which these' can be prevented. Thus education can increase support for a national strategy to prevent alcoholrelated problems. Such attempts at education have to compete with the ideas about alcohol that people receive from watching films and videos in which drinking often assumes major importance, and from the images of alcohol which are promoted by advertising. Films and video are not usually regulated by governments whereas the advertising of alcohol more often is, in acknowledgement of its effect on shaping attitudes to alcohol. A further important issue is the spon80rship of sporting and cultural events by the alcohol industry.
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Other general measures which are frequently used to prevent alcohol-related problems are sanctions against drunkenness. These may be both foraal, as in the case of legislation penalizing drunkenness in public places or while in charge of a motor vehicle, or informal controls such as those exercised by the senior members of the drinking group. A national strategy to prevent alcohol-related problems could identify existing controls against drunkenness, examine their usefulness, and ways to encourage or enforce them.
Despite all attempts to prevent alcohol-related problems, those societies which do not completely and effectively prohibit the use of alcohol are likely to experience some problems associated with its use. These may take the form of sick people needing assistance from the health or welfare system, or those breaking law8, who tend to be dealt with by the police or courts. Alcohol-related problems tend to show similarities across a range of different countries. However, to some extent they may appear in different forms and the local resources available to prevent and deal with them will also differ. Every national strategy therefore requires individual development, depending on an analysis of the local problems and resources. Documenting examples of the problems being experienced locally and the way in which these are being either dealt with or ignored serves two useful purposes. One of these is to allow reasonable solutions to be isolated and the other is to draw people's attention to the extent of alcohol-related problems (which is often not fully realized until they are collected together in this_way). The analysis of alcohol-related problems and the resources available for their prevention and handling will lead to the identification of a wide range of interested partiea. In addition to the government representatives, ca.aercial interests and official care providers (primary health care workers, teachers and the police), there will usually be a vsriety of nongovern.ental oraanizations such as Church and women's groups who are also concerned and have a role to play in the development and imple.entation of a national strategy. The range of interested parties in relation to alcohol suggests the need for a forum st which such people can meet and reach a consensus as to the strategy to be pursued. Some developed countries have attempted thi., with varying degrees of success. The effectiveness of such a forum is likely to be influenced by the breadth of the representation involved and, depending on the type of strategies agreed upon, the level of financial resources available. Many of the general strategies available, such as restricting the spread of licensed places to sell alcohol or increasing its price do not cost money to iapleaent. Increased taxation on alcohol, one way of increasing its price, can in fact provide financial resources to allow other activities which do not cost money, such a8 educating the drinking population about alcohol, enforcing laws to prevent traffic accidents, and training primary health care workers and others.
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Countries' experiences with alcohol change considerably over time and it is necessary for policy to adapt accordingly. Furthermore, under typical circu.stances, ca.mercial interests will form an organized and effective lobby group whereas those experiencing and concerned about alcohol-related problems will not. For these reasons aome developed countries have set up ongoing organizations to develop and monitor national strategies on alcohol. 7.2 Workshop framework and composition
The participants agreed to use the following framework for small group workshops on the designing of nationsl strategies: (1)
Alcohol-related problems (in approximate order of priority) Existing mechanisms to prevent problems Recommendations for future action (a) Long-term objectives
(2) (3)
To establish a comprehensive national policy and effective national and local strategies which will result in moderation in the use of alcohol and reduction of the adverse personal, social and economic consequences of its misuse.
(b) (c) (d)
Medium-term objectives Approaches (steps to be taken) and mechanisms Facilities and constraints
The participants also agreed on the following grouping and the composition of each group. Each group consisted of the countries/areas where similar objectives and approaches were expected. Each group prepared a summary sheet as a result of the small group workshop:
Group A Australia (Morey) Japan (Kono) New Zealand Papua New Guinea
Group B Cook Islands Fiji Samoa
Group C Kiribati Solomon Islands Harshall Islands Palau R. Fisher
Tonga S. Casswell
B. James
K. Evans
R. Taylor
N. Shinfuku
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7.3 7.3.1
Su.Bary aheets;
Design of national strategies
Group A - Australia, Japan, New Zealand, Papua New Guinea (1) Alcohol-related problems (in order of priority) (a> Recent increase in availability and national consumption, especially by specific groups such as women, minority groups (b) Social problems - disruption of family and community life - cri_ inc luding domestic violence - road traffic accidents - effects on industry and productivity, including absenteeism (c)
lIealth problems - dependency syndrooaes - systemic disease - e.g. hypertension and heart disease, cirrhosia. brain damage etc. - malnutrition - lack of facilities for intervention
(2)
Existing mechani ..s to prevent problems (a) Expert committees and related bodies - especially ALAe (New Zealand) (b) Legislation, e.g. governing price and distribution, driving offences, coapulsory treatment (c) Cultural factors, especially socisl support system and coheaiveneu (Papua New Guinea) (d) (e) Community and professional education Social interventions, e.g. employee assistance schemes
(f) Social policies, e.g. voluntary advertising code, price indexing
(g) (3)
Research
Reca.Dendations for future action (a) LOng-term objectives
To establish a comprehensive national policy and effective national aad local strategies which will result in moderation in the uee of alcohol and reduction of the adverse personal, social and economic cOilaequence8 of misuse.
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(b)
Medium-term obiectives (1984-1989) (i) To prevent the further rise of per capita consumption of alcohol.
(ii) To reduce and min1mlze the disruption of family and community life arising from alcohol use. (iii) To reduce and minimize alcohol-related crime.
(iv) To reduce and mlnlmize the morbidity and mortality associated with alcohol and driving. (v) To reduce the adverse effects on industry and productivity, including abseenteeism. (vi) To reduce and minimize alcohol-related disorders of health. (vii) To ensure access for all individuals to an appropriate range of intervention facilities. (viii) To facilitate the means of early identification of individualS with alcohol-related problems. (c) Approaches (i) The development and promulgation of government policies relating to the supply, control, price and distribution of alcohol. (ii) The establishment of independent national bodies comparable to New Zealand's Alcoholic Liquor Aavisory Council, funded by government, and charged with advising
government and government depart.ments, with promoting,
supporting and sponsoring education and prevention, and the care, treatment and rehabilitation of those adversely affected, directly and indirectly, by alcohol; and with doing other such things to achieve the overall objectives of promoting moderation in the uSe of alcohol and minimizing the adverse consequences of its misuse. (iii) The ident iHeation of politica 1, professional, business and caa.unity leaders, and recruiting their assistance to improve attitudes to the consumption of alcohol.
(iv) The establishment of accurate data collection concerning the supply, control, distribution and price of alcohol, its use and misuse in the community, its adverse consequences and their cost. (v) The ongoing effective dissemination of such information.
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(vi) The enactaent and enforcement of laws concerning the use of safety belts, drinking and driving, licensing of liquor outlets. (vii) Resistance to lowering of the drinking age, where such an age bas been defined, and the introduction of age limits where these do not exist. (viii) The abolition of alcohol liquor automatic vending machines in countries where they exist, and resistance to their introduction into countries where they do not. (ix) Dialogue with the liquor industry, e.g. with regard to a voluntary code of advertising. (d) Facilities (i) (ii) (iii) (iv) (v) (e) C~nity
and leader attitudes.
Formerly afflicted persons. Cultural forces. Adequate funding. Provision and dissemination of information.
Constraints (i) (iil (iii) (iv) Negative leadership and professional attitudes to intervention. Strength and interests of the liquor industry. Government attitudes to liquor revenue. Lack of enforcement of laws.
7.3.2
Group B: (1)
Cook rslands, Fiji, Samoa and Tonga
Alcohol-related problems (in order of priority) (a) (b) Deaths and injury from motor vehicle accidents. Crime, mainly violence and robbery.
(c) Social problems. Family problems (marital disharmony, wife beating, divorce, etc.) and problems outside of the family (brawls, truancy, etc.).
(d) Health problems. Medical complications of chronic alcoholism and malnutrition in children due to income diversion.
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(e) (f)
Income diversion, leading to lowered standard of living. Cultural erosion.
(g) Excessive recurrent government expenditure on health, police, social services, etc. because of alcohol-related problems. (h) (i) (2) Absenteeism from work and loss of productivity. Drowning and suicide.
Existing mechanisms to prevent problems (a) Licensing regulations for the sale of alcohol.
(b) Permits to drink alcohol, which also specify amount to be purchased per month (e.g. Tonga). (c) Drinking and driving legislation.
(d) Kealth education and promotion activities by health and education departments. (e) Cultural and religious discipline which restricts consumption of alcohol in certain areas or circumstances. (f) Banning of alcohol from sporting tournaments (especially rugby and soccer matches). (g) (h) (3) Job and recreational opportunities. Alcoholics anonymous and similar organizations.
Recommendations for further action (a) LOng-term objectives
To establish a ca.prehensive national policy and effective national and local strategies which will result in moderation in the use of alcohol and the reduction of the adverse personal, social and econo~c
consequences of its misuse.
(b)
Medium-term objectives (1984-1989)
(i) To reduce alcohol-related injury, crime, health and social problems (It was not possible to quantify most of these objectives). (ii) Considering that approximately 50% of motor vehicle accident deaths are probably alcohol-related, to reduce road accident mortality by 50%.
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(c) (i)
Approaches and mechanisms Motor vehicle accidents
- Introduction of legislation defining the blood alcohol level above which it is an offence to drive a motor vehicle. - Introduction of breathaliser and blood alcohol testing for those involved in motor vehicle accidents. - Introduction of random breathaliser testing of driver. of motor vehicles. Public education concerning the dangers of drinking and driving. (i i)
crime
- Reducing alcohol availability through legislation. - Self-protection of per&on and property. - Increased enforcement of existing laws. - Counselling convicted offenders. (iii) Social problems - Reducing alcohol availability through legislation. - Individual counselling by health, police, social and other personnel. - Strengthening women's groups.
(iv)
Health problems Health promotion activities.
Improving health statistics. - Monitoring child growth. (v) Income diversion - Spouses to collect husbands' salary. (vi) Cultural erosion
- Enforcing existing legislation which incorporates traditional cultural values and norms. - Strengthening cultural and youth groups.
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(d)
Facilities Documentation of alcohol-related costs. Churches. Culture and women's activities.
Village life. (e) Constraints Liquor industry (profit motivated). Governments (taxation revenue). Perceived employment opportunities by the community. Permissive community attitudes towards alcohol consumption. 1.3.3 Group C: (1) Kiribati, Solomon Islands, Marshall Islands and Palau
Alcohol-related problema (in order of priority) (a) (b) (c) Traffic and other accidents. Social disharmony e.g. - erosion of traditional values - violence of self and others Domestic problems divorce family break-up spouse beating schoo I truanc y
(d) (e) (2)
Health problems of the alcohol abuser and also his family e.g. child malnutrition. Problems in the work place e.g. absenteeism.
Existing mechanisms to prevent problems (a) Legal - variety of regulations and control of production and distribution. (b) Social - alcohol-related problems e.g. sanctions by traditional and church groups; drunken-driving, disorderly conduct, and assaults carry legal sanctions. (c) Educat ional - a few media and schoo l programmes available. Health resources are marginally available for the alcohol prevention programme.
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(3)
Recommendations for future action (a) LOng-term objectives
To establish a comprehensive national policy and effective national and local strategies which will result in moderation in the use of alcohol and the reduction of the adverse personal, social and econ~c
consequences of its misuse.
(b)
Medium-term objectives
(i) To set up an organization and implement the above policy, such as that already established in New Zealand by the Alcoholic Liquor Advisory Council Act (1976). (ii) To reduce alcohol supply by:
- regulating the production and importation of alcoholic beverages (government should own controlling part of production source);
regulating distribution e.g. age, time, location; - taxing production, sales and imports; - pricing alcoholic beverages to facilitate moderation drinking; - ensuring beverage has regular alcohol content. (iii) To limit demand:
- by regulating advertising particularly to at-risk populations. - by public education focused on health promotion activities, especially people in authority (tradition and church leaders). (iv) To reduce specific alcohol-related problema:
- traffic and other accidents - immediate arrest and imposition of severe penalties;
- assistance for domestic problems from within traditional and church systems. capacity for early diagnosis and treatment. sp@cific assistance available with appropriate attention to the sensitivities of local cultures. - training of specific groups, e.g. policemen, social
workers, clergy, to help them deal with alcohol-related problems.
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(c)
Facilities (i) Adequate funding must be provided.
(ii) Need for community consensus on the definition of the problem and solutions. (iii) Involvement of groups in authority and interest groups including religious, traditional and women's groups. (d) Constraints (i) (ii) Pressures from the liquor industry for unlimited aCCe8!.
production t and
Political ambivalence.
(iii) Lack of adequate sound information on which to base policy decisions. (iv) Need for national and international cooperation.
8.
CONCLUSIONS AND SUGGESTIONS
8.1
Overall evaluation of the workshop
The participants found the workshop most rewarding and useful for the deve lopment of effective nat ional po ticies and progranunes on the prevent i on and control of alcohol-related problems in countries or areas of the Western Pacific Region. They affirmed with satisfaction that the four objectives of the workshop had been successfully achieved. 8.2 Magnitude and trends of alcohol-related problems
The participants noted the surprising magnitude and rapidly increasing extent of alcohol-related problems in most of the participating countries or areas and thus confirmed the relevance of the series of resolutions adopted by WHO in that regard (e.g. resolution WPR/RC33.RI5: Alcohol a8 a major public health problem, resolution WHA36.12: Alcohol consumption and alcohol-related problems: development of national policies and programmes). The participants noted that alcohol-related problems will become a great threat to the achieveeent of health for all by the year 2000 in many participating countries or area. unless the necessary measures ara undertaken immediately.
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8.3
Nature of alcohol-related problems
The participants found that drunk driving, violenc .. and injuries contribute to the main alcohol-related public health probl.ems. Attention was also drawn to the malnutrition of children, psychological distress of family members, abaenteeism, etc. a9 important 90cial problems caused by alcohol. Alcohol-related medical disorders such as slcoholic liver disesse pancreatitis, alcohol psychosis, etc. are less visible in most of the participating countries or areas. However, it current trends continue. theae problems will become more apparent and action is required to prevent this.
In reviewina the nature of alcohol-related problems, the participants noted that there exist hardly any reliable data in most of the countries ,,' areas in the Region. 8.4 Pattern of alcohol drinking
The participants found that the majority of alCOhol-related problems in the South Pacific are caused by 'bing~' drinking, i.e. periodic excessive drinking, often on payday: This 'hinge' drinking is deeply rooted in the traditional pattern of interpersonal relationships, the valu~ system and lif.styles of the Pacific Islands countries (e.g. generosity, friendliness) • 8.5 Resources
The participants identified family, chur.ch, women's movements and traditional local leaders aa major existing resources to combat alcohol-related problems. However, the rapid spread of alcohol drinking is contributing to the eroBion of the abovementioned indigenous support systems. In this context, the participants found pr.imary health care (community participation) to be a most appropriate strategy to prevent and contain alcohol-related problems in the Pacific Island countries or areas. 8.6 Conptr.ints
The participants found that the economic incentive (revenue through taxation> outweighed the heslth conc~rn of the government. This constitutes an t.portant constraint on effectively combating alcohol problems in most of the Pacific Island countries or areas. They agreed with the view that the government can never be neutral in relation to alcohol since it ulti_tely controls the availabil ity of alcohol to the population.
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8.7
Need for the development of a national policy and programme
The participants found that very few countries or areas have any national policies or effective strategies to prevent and reduce alcohol-related social or health problems. They agreed on the need to develop national policiss and programmes through the establishment of coordinated and multidisciplinary mechanisms to combat alcohol-related problems. Attention was drawn to the mechanism and functions of ALAe (Alcoholic Liquor Advisory Council of New Zealand) as a possible model to develop a camprehensive ani coordinated national policy. 8.8 Need for continuous inputs from WHO
In view of the complexity of the problems, the participants suggested that it is vital for the success of the prevention and control of alcohol-related problems in Pacific Island countries that WHO provide continuous Imd long-term support to Member States. Requests were expressed for technical cooperation from WHO in data collection on alcohol-related problems, in the use of measurement devices of alcohol in the body, in the prevention of alcohol-related accidents, in the organization of national workshops on alcohol-related problems, etc.
8.9
Need for collaboration amo resources, Hie lud!>ng those organizations
0
international re ional and national nongovernmental and quasi-governmental
In view of the scarcity of technical resources for the prevention and control of alCOhol-related problems, the participants emphasized that it is vital to have good coordination and collaboration among international, regional, and national resources, including those of nongovernmental and quasi-governmental organizations, and to maximize use of the available technical resources. 8.10 Need for i!elementation of previous recommendations of WHO
The participants found the recent recommendations by WHO on alcohol-related problems to be highly relevant and suggested that all the Member States, international organizations and nongovernmental organizations concerned should take into account these rec~endstions in future activities. The recommendations are contained in~
among others, resolutions
WPR/RC33.R15: Alcohol as a major public health problem, and WHA36.12: Alcohol consumption and alcohol-related problems: development of national policies and proarammes.
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ANNEX 1
LIST OF PARTICIPANTS
COOK ISLANDS
Dr Moeka Maeva Teariki Director of Hospital and Clinical Medicine Ministry of Health RarotOt\¥js Mr Dhana Segrsn Gounder Medical Officer, Pathology c/o Lautok~ Hospital Lautoka Mr Timoci Vakatawase Welfare Officer Class I c/o Social Welfare Department P.O. Lautoka
FIJI
KIRIBATI
Mr David Tyeeting Ministry of Home Affairs and Decentralization c/o WHO Country Liaison Officer Tarewa Dr Geoffrey Maxwell Robinson Director
NEW ZEALAND
Wellington Alcohol and Drug Centre 265 Adelaide Road Wellington PAPUA NEW GUINEA Father Joseph Mandres Director Alcoholic Recovery Centre P.O. Box 1013 Boroko Dr Brother Andrew Specialist Medical Officer (Psychiatry) P.O. Box 1239 Boroko SAMOA Dr Toia Alama Acting Medical Superintendent Western Samoa National Hospital Private Bag ~
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Annex
1
SAMOA (Cont' d)
Mr Max Wendt Police Officer Weatern Samoa Police Force ~ Mr Zephaniah Takonene Principal, Social Development Officer Ministry of Employment, Youth and Social Development P.O. Box 620 Honiara Mr Sione T. Wolfgramm Health Planning Officer Ministry of Health P.O. Box 59 V.iola Hoapita I TOnga Mr Russell N. Edwards Health Planning Marshalls Ministry of Health P.O. Box 16 Majuro RepUblic of the Marshall Islands 96960 Dr Antonio Polloi Acting Chief Public Health and Chief, Mental Health Bureau of Health Services P.O. Box 100 Koror Republic of Palau 96940
SOLOMON ISLANDS
TONGA
TRUST TERRI10RY OF THE PACIFIC ISLANDS
TEMPORARY ADVlSERS
Dr Sally Casswell Executive Director
Alcohol Research Unit School of Medicine University of Auckland Private Bag Auckland New Zealand
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Annex 1
Dr Basil James Director of Mental Health Head Office Macarthy Trust Building Lambton Quay P.O. Box 5013 Wellington New Zealand
Or Hiroaki Kono Director National Institute of Alcoholism Ku ri h Il'IDB Japan Dr Susan Morey Department of Community Medicine Royal Prince Alfred Hospital 184 Glebe Point Glebe 2037 Sydney, New South Wales Australia
OBSERVERS
Mr Keith Evans Director Alcoholic Liquor Advisory Council Aurora House 62 The Terrace Wellington New Zealand Nr J.F. Robertson Chairman Alcoholic Liquor Advisory Council P.O. Box 5023 Wellington New Zealand Dr Richard Taylor South Pacific Commission P.O. Box D5 Nou... _ Cedex New Caledonia
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Annex 1
SECRETARIAT
Resio nal Advis er in Kenta l Healt h WHO Regio nal Offic e for the Weste rn Pacif ic P.c. Box 2932 Manil a Phi lippin es
Dr Naota ka Shinf uku
II
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ANNEX 2
OPENING SPEECH OF DR HIROSHI NAKAJIMA, REGIONAL DIRECTOR WHO WESTERN PACIFIC REGIONAL OFFICE (Given by Dr Naotaka Shinfuku on behalf of Dr Nakajima)
Distinguished Guests, Dear Participants, Colleagues, Friends, Ladies and Gentlemen: It gives me great pleasure to say a few words, on behalf of Dr Hiroshi Nakajima, Regional Director of the WHO Regional Office for the Western Pacific, on the occasion of the opening of the Regional Workshop on National Policy and Programme Formulation for the Prevention and Control of Alcohol-Related Problems, which is being held at the University of Auckland Medical School, from 5 to 9 November 1984. First of all, I would like to express my sincere gratitude to the Government of New Zealand for kindly agreeing to host this Regional Workshop, which is the first regional group educational activity to be organized by WHO in New Zealand. I am very happy to be able to avail itself of the excellent technical resources of this country for the programme on prevention and control of alcohol-related problems.
As you know, New Zealand has well-developed alcohol prevention and control programmes which the participants of this workshop will have the opporLunity to hear more about and observe for themselves during the field visit.
Since New Zealand is traditionally a welfare state, it has considerable experience and resources available for its programmes on mental health and substance abuse. I sincerely hope that collaboration between New Zealand and WHO in the above-mentioned programmes can be further developed in the future to enable countries of the Region to benefit from these technical resources and expertise.
As you will know, there has been a tremendous increase in the consumption of alcohol and consequently in the prevalence of alcoholrelated problems. In fact, these have become a major social and medical concern in both developed and developing countries of the Region. lnspite of this, national policies and prograe.es for the prevention and control of alcohol-related problems are still inadequately formulated in most cases.
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Annex 2
l.ecognizing the above situation, the World Health Organization, both at global and regional levels, has adopted a number of important resolutions and developed various programmes for the prevention and control of alcohol-related problems. In 1982, the Regional Committee held in Manila, adopted a resolution on "Alcohol as a major public health problem" and urged Member States of the Region to formulate comprehensive and long-term national policies on alcohol-related problems, with prevention as a priority, as an integral part of their national health-for-all strategies. This resolution, proposed by the New Zealand government and adopted unanimously by the Member States, has given a strong impetus to the development of regional programmes. This workshop can itself be considered one of the outcomes of the 1982 resolution.
In August 1983, the Regional Office convened a Regional Workshop on Alcohol-Related Problems in Manila, which formulated a framework for national policies for the prevention and control of alcohol problems. In view of its success and impact on Member States, it was considered useful to organize a similar workshop to provide continuous inputs for the formulation of effective national policies and programmes on alcohol in the Region. It was also suggested that participsnts be invited from the South Pacif:c countries in view of the emerging alcohol-related problems that have arisen in the wake of rapid social changes and in view also of the relative lack of national control programmes. Four objectives have been set for this workshop. One of these is to enable participants to design practical national strategies for the prevention and control of alcohol-related problems that are relevant to the social, cultural and economic conditions of their home countries or areas.
This is by no means an easy task considering the short time at your disposal but you will be able to count upon the collaboration of our able temporary advisers. At the end of the workshop, I would like to receive your suggestions on how the World Health Organization can effectively collaborate with you in minimizing the various health and other problems caused by the excessive use of alcohol such as acute and chronic intoxication, violence, road traffic accidents, break-up of the family, economic hardship and so on.
- 35/36 -
Annex 2
In your own country or area, you will be a key person initiating and developing an appropriate national alcohol programme. To ensure the success of your programmes, you will undoubtedly need to obtain the collaboration of the various sectors of government involved such as education, law enforcement, and finance. You may rest assured tbat tbe World Health Organization will continue to collaborate with you in the fight against alcohol-related problems. In conclusion, I would like to extend my thanks for the contribution of so many persons, which has enabled this workshop to be held in Auckland. Special thanks are due to Dr Ron Baker, Dr Bryan Christmas, Dr Basil James, Dr R. Fisber, and Ms Sutherland, of the Health Department in Wellington; to Dr F. McDonald, Mr T. Hobbs of Carrington Hospital; and to Dr Sally Casswell and staff members of the Alcohol Research Unit In Auckland. I would like to extend our gratitude for the generosity of the Alcoholic Liquor Advisory Council (ALAC) of New Zealand for its financial support. I would also like to thank the four temporary advisers, Dr Basil James, Wellington; Dr Sally Casswell, Auckland; Dr H. Kono, Japan and Dr Sue Morey, Sydney, for their splendid technical contributions to the preparation and conduct of this workshop. I am also pleased to note that Dr Keith Evans, Director of ALAC, Mr J.F. Robertson, Chairman of the ALAC and Mr Richard Taylor, South Pacific Commission are here today as observers. I wish you all successful and fruitful discussions and a pleasant stay 1n this city of Auckland. Thank you.
- 37/38 -
AlQIEX 3
AGENDA
1. 2.
Openina ceremony
Guidelines for the worl<ahop CoulI~ry
3. 4.
profiles
Social end medical ••pect. of alcohol-related probleaa Mechanis•• , and appro.¢~ for the prevention and control of alcobDl-related problem. Field visits to relev.ut programaes and facilities Design of national strate,ies <small group workshop) Conclusions and ausae_tions Review and adoption of draft report Evaluation of the workshop CIo_ina ceremony
5. 6. 7. 8.
9.
lO. 11.
- 39 -
ANNEX 4
TIMETABLE
5 November. Monday 8:30 9:00-10:00 (Session 1) 10:00-10:30 10:30-12:00 (Session 2) 12:001: 30 Registration
1.
Opening cereaony
TEA/COFFEE BREAK
2.
Guidelines for the workshop Country profiles
3.
LUNCH BllEAK
1:30 - 3:00 (Session 3) 3:00 - 3:30 3:30 - 4:00 (Session 4)
3.
Country profiles
TEA/COFFEE BREAK
3.
Country profiles
6 November, Tue.day 9:00 - 10:00 (Session 1) 10:00 - 10:30 10: 30 - 12:00 (Session 2) 12 :00 1:30 3.2 Su....ry Discu •• ion8
Country profiles TEA/COFFE! BREAl<
4.
Social and Medical Aspects of Alcohol-Related Problems
LUNCH BRL\X
1:30 - 3:00 (Session 3)
5.
Mechanism. and approaches
3100 -
3130
TEA/coFFEE BDAK
3130 - 4:00 (Se.. ion 4)
5.
Mechani••• and approaches
- 40 -
Annex 4
7 November, Wednesday
9:00 -
4:00
6.
Field visits
8 November. Thursday
9:00 - 10:00 (Session 1) 10:00 - 10dO 10: 30 - 12:00 ( Session 2) 12:00 1:30
7.1
7.2
Introduction SlIIall group workshop
TEA/COFFEE BREAK
7.2
Small group workshop
LUNCH BREAK
1:30 - 3:00 (Session 3) 3:00 3:30
7.2
Small group workshop
TEA/COFFEE BREAK
3:30 - 4:00 (Session 4)
7.3
Presentation and synthesis
9 November. Friday
9:00-10:00 (Session 1) 10:00 - 10:30 10:30 - 12:00 (Session 2) 12:00 1:30
8. 9.
Conclusions and suggestions Review and adoption of report
TEA/COFFEE BREAK
10. 11.
Review and adoption of report Closing ceremony
LUNCH BREAK
- 41/42 -
AIOOIX 5
COUNTRY PROFILES
Annex 5.1 Annex 5.2 Annex 5.3 Annex 5.4 Annex 5.5 Annex 5.6 Annex 5.7 Annex 5.8 Annex 5.9 Annex 5.10
Cook lalands
Fiji Kiribati Marshall Islands Rew Zealand
Palau Papua New Guinea SolOlJlon Islands Tonga SalDoa
-. 43 -
ANNEX 5.1
COOK ISLANDS - COUNTRY PROFILE
Incroduction Although Rarotonga or Cook Islanders do not become readily addicted to alcohol, most local inhabitants believe alcohol or the over-indulgence in alcohol is the islands' increasing source of problems, not only to persons individually but to families, the community and to the country as a whole. The old saying that drinking has no moral qualities in itself, that it is wrong only when done by wrong people at the wrong time, in the wrong places with ulldesirable consequences, does not seem to be true today as greater proportions of the population have easy access to intoxicating alcoholic liquor at any time of the day or night. It is interesting to note, that with the introduction and establishment of Christian principals to our shores, the practice of the "Kava" ceremony was banned successfully. Uawever. because of a lack of means and modes of fostering the attitudes and feelings of comradeship and togetherness, which I believe is a cultural inclination, the "Bush-beer" practice has again flourished. Unfortunately, this practice always was, and still is, illegal. It will probably continue to flourish. especially now with the increased cost of the illlported "Bond" beer. 1. Hagnitude, nature and trend of a1cohol-re1ated problems
The Cook Islands police record of alcohol-related motor vehicle accidents in 1984 is as follows; Months January February Karch April May June Total No. 10 14
Alcohol-related 7 5 6
14 12 9 6
5 3 3
- 44 -
Annex 5.1
It is of interest that accidents somehow involve younger adults under 30 years of age. Police allege that 90% of motor vehicle or road accidents admitted to hospital are alcohol-related. Increasing percentages of crime cases are allegedly due to alcohol consumption. Teenage indulgence, increased court convictions and fines, and the increased teenage pregnancy rate are alcohol-related. There are increased hospital admissions as a result of accidents by driving uder the influence of liquor. The increasing disruption of homes and divorce, child abuse, rape and indecent assault are alcohol-related. There are increasing costs for alcohol-related costs admitted to hospitals. A case study is illustrated: cause~
Case study 1.
Patient Name: Hospital:
T.M.
Male:
35 years
2. 3. 4. 5. 6.
Rerotonga 28 September 1983 23 November 1983
Date of admission: Date of discharge:
Length of stay in hospital: 56 days Cause of admissions: (1) (2) Compound fracture R. Tibia and Fibular External causes of injury. Motor vehicle traffic accident due to loss of control, as X was under the influence of liquor.
7.
Hospital cost: The following are the costs involved for patient X for S6 days stayed in the hospital. 7.1 7.2 7.3 7.4 7.5 Board, meals, nursing and medical care As in-patient: $56.00 per day x 56 X-ray repeated $12.00 per one X-ray x 5 times Laboratory tests various Drugs cost + 50% $521.66 Surgical operation at $200.00 x 7 operations
$3 136 00 60.00 43.80 782.49 1 400.00 $5,422.29 ==::a====r:=
8. 9.
Average cost per patient per day $97.00 base on above costing. There is also the question of loss of earnings to this patient, and the hardship faced by family during this period of incapability.
- 45/46 -
Annex 5.1
Existing legislation and control measures on alcohol In the 1940-1950s the practice of obtaining a bottle of whisky spirit for medicinal purpose per permit was introduced. In July 1981 Parliament passed an Act to amend the Cook Islands Liquor Licensing Authority that the members and chairman shall be appointed by the Prime Minister.
,0
In terms of control measures the police allege that the legislation is weak in that they do not have the power to prosecute drunkeds and, where there are repeated breaches of the Act, that they do not have the power to revoke the licences. ,
I
Repeated poor responses from the Liquor License COllunittee causes disappointment to the staff performing their duty, eventually leading to poor control measures for alcohol consumption and increased alcohol-related morbidity in the community and country. There seem to be very limited control measures in terms of stopping the supply of intoxicating liquor to the country. There is conflict as to whether it is practicable to decrease importation in the face of revenues obtained from the sale of liquor. It would appear that some improvements in the control of the use of alcohol would result from prohibition to those below the age of 21 from premises where liquor is sold. Unfortunately any shop or store selling food is also licenced to sell liquor legally. It would appear then that the most effective, alternative method of control of over-indulgence in alcohol consumPtion and alcohol problems i. health education, which should be directed to the public and the teenagers at gras.root levels. The pros and cons of alcohol consumption and its effects on the health of individuals, families, community and country resources should be known. Perhaps with an educated public moderate drinking practices could become enjoyable and relaxing.
- 47 -
Anoex 5.2
FIJI - COUNTRY PROFILE
Alcoholic beverages have been an important part of the material culture of most human societies. In Fiji alcohol in various forms was introduced in the early 19th century by explorers, traders, whalers and to soae extent missionaries. During the Second World War, American soldiers introduced brewing and distillation with which the Fijian soldiers became familiarized. There is no record of evidence that the indentured labourers from India were responsible for introducing slcoholic beverages in any form to Fiji. During the Japanese invasion of the then Gilbert and Ellice Islands the natives were resettled in Fiji and brought with them certain alcoholic beverages, notably "Toddy". A westernized form of living has caught up rapidly in Fiji and to date many interesting and revealing facts about alcohol-related problems are being noted at various levels of our society which comprises native Fijians, Indians and a minority of Westerners, Chinese, etc. We outline the magnitude, nature and trends of alcohol-related problems in Fiji and present the legislation that exists at present. 1. Magnitude, nature and trends of alcohol-related problems in Fiji
There is no severe restriction on the sale of alcoholic liquor to those desiring it provided it is purchased or acquired within the prescribed hours each day from licensed premises and is made use of or consumed within the premises or in private hOGes or properties. Alcoholic beverages may also be purchased from licensed premises by people of a certain age. There is no specific legislation as to the consumption or use of alcohol but legislation exists to puniSh its abusers, public drunkenness and those offences ca.mitted through the influence of drinks, e.g. intoxication while in charge of motor vehicles. Although the abuse of alcohol has become various levels of society in this country and work done by individuals, these statistics do extent of problems related to the consumption a common day-to-day fact in figures are available from not truly show the actual of alcohol.
- 48 -
I
,
Annex 5.2
We quote figures of conviction made at the Magistrates Court at Lautoka between 1980 and 1983:
~ Minor offenses (drunk and disorderly, drunk and incapable) Liquor (methylated spirits) (drinking methylated spirits, drinking in public places, bootlegging) Driving a motor vehicle under influence of liquor Il2 122
lJ£ 77
1983 142
25
15
37
31
16
18
5
5
A survey done in 1982 by the Department of Social Welfare on marriage guidance client~le reveals the following: Causes % blaming alcohol Mean average
% blaming violence
% blaming extra-marital affairs 17.3%
2.3%
9.2%
These figures were derived from surveys done throughout Fiji. We stress that the figures are probably unrealistic simply because clientele may not have disclosed all information necessary. The extent of alcohol-related problems in Fiji may be appropriately categorized as being associated with alcohol abuse. As stressed earlier, Our figures do not give a realiatic view of these problems that are directly associated with the consumption of alcohol. In our society we have different forms of so-called "drinkers", namely, social drinkers, symptomatic drinkers and alcoholic addicts. In common with most other countries in the "free world" today. Fiji is experiencing a national epidemic of alcohol-related problems. The tip of the iceberg of the problem is being seen in the hospitals. the other 90% or more existing out in the community, where it is the legitimate concern not only in the medical profession and the social welfare workers but of other professionals, community leaders and various concerned individuals at both urban and rural levels. Probably the biggest concern is the symptomatic drinkers, who consume alcohol merely to get drunk.
- 49 -
Annex 5.2
Existing legialation in Fiii With regard to the Liquor Act, licenaing i8 quite explicit. The Fiji Liquor Act empowers the Central Liquor Board, a Government-constituted body, to consider and grant PTovisional approval for all new liquor licences - hotels, night clubs, taverns, off licences, private hotels, clubs and restaurants. The Divisional Liquor Tribunals which exist in all the four divisions grant all new licences to hotels, nightclubs, taverns, off licences, etc. as above. As said, all new liquor licences are applied for to the Central Liquor Tribunal and when approved applicants apply to the Division Liquor Tribunal. which grant licences. Overall, the Divisional Liquor Tribunals' functions involve general liceneing, policing of licensed premises and ensurigg that licensees are aware of their responsibilities for the particular licences they hold respectively under the Act. At the present time in Fiji, the law regarding drinking and driving is out of step with the known facts concerning this problem. This hea created considerable confusion for doctors who are asked to assess these people. Fiji's laws regarding the so-called drunken driver (more accurately described as one driving under the influence of alcohol as such drivers often do not appear to be drunk) bear little relationship to the known facts concerning alcohol conaumption and the safe driving of a eotor vehicle. As a result of this. it is evident that confusion often reigns ~n the courtroom, when individuals charged with an offence related to driving under the influence of alcohol, are tried. The outcome of such trials, although legally correct as the law stands at the PTesent time, frequently hears no relationship to justice, and is an embarrassment to members of both the Police force and medical profession who are involved. Furthermore, it offers little protection to the public from the drunken driver.
The medical officer is required to fill our an examination form provided by the Police. The medical officer in many cases cannot be certain that the individual cODCerned is in a drunken state, or sufficiently unfit to drive as a result of alcohol intoxication. To quote the law "any person driving under the influence of liquor to such an extent has not to be able to have s proper control of a motor vehicle." The doctor's dileama is underatandable. There i8 no legal limit of the blood or crime alcohol level, and no legal requirement to provide such specimens. With regard to criminal offences a survey done between 1970 and 1977 revealed fra. interviews with prison inmates that their convictions in
about 60% of cases was directly related to alcohol consumption.
II
- 50 -
I I
II Annex 5.2
Deaths from road traffic accidents have been steadily r1s1ng over the years. The number of motor vehicles on Fiji roads is in the vicinity of 68 000. Deaths directly related to alcohol abuse are in the order of 50%, which is on par with .oat of the westernized countries. Conclusion Fiji like any other developing country is experiencing various problems of major CODCern related to the use and abuse of alcohol. We have highlighted these in our discussion. The law makers of Fiji have a great task ahead of them with relation to existing legislation, which at present cannot be considered satisfactory. In addition alcohol-related problems cannot be considered in isolation and the emphasis should be put on how curbing its ill effects can make a better Fiji.
- 51 -
ANNEX 5.3
KIRIBATI - COUNTRY PROFILE
The Republic of Kiribati geographically is where the international date line crosses over the equator. Kiribati comprises of more than 30 small atoll islands "cattered over a territory of ocean of more than two million sq. km. The total land area itself is only about 820 sq. km. The population of Kiribati is around 60 000 with an estimated growth rate of 2%. Of this population about one-third is congested on Urban Tarawa alone, the capital island of Kiribati, whose land area is only 15.7 sq.m. Typical of urban centres, Tarawa is also faced with increasing socioeconomic problems related with the urbanization phenomenon. Alcohol drinking is relatively a new concept in Kiribati having been introduced by Europeans at first contact in the 18009. Because the Kiribati people were not culturally acquainted with alcohol drinking it became an addiction problem and over the years bad drinking habits developed as a result. Of particular concern to the authorities in Kiribati is the increasing habit among the drinking people to turn to other drinks more dangerous to health. These include methylated spirits (which is currently the commonest and most popular), inhalation of benzine (petroleum) gas and various forms of homebrews which usually contain methylated spirits. It bas been generally accepted among the authorities concerned that one _jor reason which led "drinkers" to turn to these other alternatives is the fact the price of beer has escalated in the past: yeare and "drinkers" have discovered it is so much cheaper to buy _thylated spirits, which requires only a SlllAll 8IIIOunt to get them drunk. In addition, it has recently been discovered by the authorities that among "drinkers" the taking of methylated spirit. has been somewhat rationalized by calling it "alcohol" i.,.tead of spirits. It has been discovered that people ask for "alcohol" at the local stores and not "methylated spirit s". This problem is aore alanaiag as more and aore of the younger generation (obviously confused) are turning to this drinking habit. The authority concerned is fully aware of this and is currently findings ways of tackling the problem.
- 52 -
Annex 5.3
recently the Liquor Licensing Authority for Urban Tarawa tried to co.bat this problem by regulating that all local scores selling methylated spirits required that purchasers obtain a licence from the office of the Teinainano Urban Council (TUC) , which is the Local Authority for Urban Tarawa. On the licence the amount approved to be purchased would be shown as well as the naae of the person approved for that purchasing licence. The issuing of licences is restricted only to adults who have to convince licensing officers of TUC that they are purchasing methylated spirits for legitimate purposes. Despite this control however, "drinkers" are still managing to evade the system somehow. A survey of prison inmates carried out in 1977 by the Government Community Affairs Department indicated that more than 90% of prisoners committed offences under the influence of alcohol. Similarly the Commissioner of Police in his 1982 report reported that almost invariably offences against the person and property were all alcoho1-re1ated. Generally speaking Kiribati's attitude towards alcohol drinking 1S that one drinks to get drunk. It is not generally accepted or taken as part of an everyday but is treated as something more than "ordinary drink". A lot of people take to drinking as an excuse to find courage to go against the standard nora of the community and this is probably one reason also why the prison statistics above have shown such a high percentage of prisoners with alcohol problems. The most common and moat popular beers in Kiribati are Carlton Draught and Fosters in 370 ml cans. These have an average alcohol content of about 4.97.. It has been speculated among the authorities that these brands of beer are too strong and that perhaps to have weaker types could solve many of Kiribati's alcohol problems. However actual steps towards this direction have not been taken. "Toddy", a weaker beverage (0.5% alcohol) is also consUlted. There are about 60000 cartons (more than a .. i1lion cans) of beer and about 13 368 litres of liquor (hot drink) imported into Kiribati annually. As for methylated spirits about 10 055 litres are imported yearly. The making and selling of liquor, including beer and any other form of alcohol, are regulated and governed by the Liquor Ordinance, Cap 50 of the "Laws of the Republic of Kiribati". Local councils (authorities) are appointed Liquor Licensing Bodies for their areas of authority, thus the Teinainano Urban Council (TOe) Liquor Licensing Committee is the Liquor Licensing Authority for Urban South Tarawa. The Police also sit on the Committee although only playing an advisory role.
- 53/54-
Annex 5.3
Recently however on many islands, the traditional "Unimane" (old man) system of decision making has started to tackle alcohol drinking problems. Although their methods are not always conventionally within law, they appear to be more effective than the accual law as legislated. In many islands and villages, any form of alcohol consumption has been prohibited by the traditional leaders (old men) of the village. Punishments vary from island to island and from village to village. However very high cash fines and punishment by the cane are the two most cormaon methods. There have also been cases where the "offender" is ordered out of the village, and although the law protects his constitutional rights, in the end he has to leave because of social pressures against him and for his own safety. As a result many islands now have heen declared dry with the importation into the island and sale of alcohol prohibited by the island councils acting on the pressure and support of the "Unimane u associations. This has resulted
in a much improved and orderly environment and the authorities in Kiribati are considering that perhaps this could be one effective way of controlling and preventing alcohol-related problems in Kiribati.
- 55 -
ANNEX 5.4
MARSHALL ISLANDS - COUNTRY PROFILE
Magnitude nature and trend of alcohol-related problems Alcohol abuse and alcoholism have become serious problems in the Marshallese com.unities. Based on sUbjective observations, it appears the increasing abuse of alcohol and increasing crime rate are due to young people misusing alcohol as an escape mechanism from boredom and the feeling that their lives are monotonous and insignificant. The underlying support system of the fmnily is disintegrating. Youth, as well as elders, have become disenchanted and alienated. With traditional customs and family relationship undergoing dramatic changes over the past years, kinship lines and responsibilities have become fragmented for most Marshallese families. The Marshallese perceive the increased use of alcohol as one of the most serious problems in the islands and see it as a contributing factor in the fragmentation of kinship ties and other destructive changes. Alcohol has a180 been the cause of increased car accidents and the alarming increase in suicide attempts throughout the Marshall islands. Secause alcohol plays such an important part in many social problems, the key to solving the problems of suicide and alcohol abuse is to encourage and enforce the law on alcoholism and related practices. In particular the law against competence of alcohol by m1nors should be enforced. The suicide figures for 1979-1982 indicate a similar trend. The data indicate that most victims are young male adults. Some of the victims become frustrated and commit suicide because of misunderstanding and disagreement with their parents. Perhaps the lack of job also plays a significant role in suicides by causing frustration and anxiety. Between 1978-1980, there was a totsl of 17 mental cases in the Marshall Islands including nine cases of schizophrenia and nine cases of drug abuse and four cases of alcoholism. The medical staff indicate that there is reaSon to believe that the schizophrenia case may result from drug abuse and alcohol abuse. The numbers appear relatively small, but are still a serious concern in the Marshall Islands. Statistics indicate a gradual increase in the number of alcohol-related crimes, cases of attempted suicide and accidents. The number of alcohol-related crimes according to Public Safety record is; 100(979); 249(980); 262(1982).
- 56 -
Annex 5.4
Overview of alcoholism and ita effects on the community Each year the Marshalls spend almost $916 015 on alcoholic beverages. Alcohol has become a serious problem amongst the young people, mainly the high school students who are getting drunk and in some cases committing serious crimea or getting involved in crimes such as housebreaking and stealing in order to get drunk. In the olden days, only males could be seen drinking alcoholic beverages. It was not an accepted practice for WOmen to drink. Today, girls may follow their boyfriends to a bar. Most of the crimes incurred in the Marshalls are cou~itted by those who have been under the influence of alcohol. Estimates of crimes committed either under the influence of alcohol or to get the purchasing power for liquor supplies, ran as high as 90% of all those for which persons were actually arrested. The overall view in this respect is that the problem is increasing tremendously. The elementary school students are beginning to be involved in such things and ties between parents and their children are beginning to deteriorate. Furthermore, marital difficulties are also eaerging as serious consequences resulting from alcohol abuse. Existing legislative and control measure on alcohol The law in the Republic of the Marshall Islands does not permit drug consumption (other than those prescribed by a physician). There were laws and regulations initiated to regulate the control of alcohol-related problems under Trust Territory Laws. However, there are also regulations and laws established under the new Republic of the Marshalls. These laws are as follows: 1. 2. 3. No minor under 21 years of age beverages of any kind. 15
II I I
permitted to consume alcoholic
No one is sllowed to enter any bar or purchase any alcoholic beverages without an ID card. Many of the outer islands in the Marshalls do not allow consumption of alcoholic beverages at all.
Furthermore, the Marshall Islands Division of Mental Health, Alcohol and Drug Abuse, have established such programmes as AI-Anon, A.A. and Ala-Teen, trying to stop the excessive drinking of alcohol amongst the teens or anyone otherwise.
- 57 -
ANNEX 5.5
NEW ZEALAND - COUNTRY PROFILE
1.
Alcohol consumption and alcohol-related problems
Alcohol is all pervasive in New Zealand (population 3.2 million) society being the rule of many family, social and sporting functions. The young are introduced to it at an early age and 85% of the population over 15 years drinks alcohol. In One recent large survey 9% of the adult population were estiaated to be drinking in excess of 60ml of absolute alcohol daily. Alcohol consumption has increased progressively over the last 25 years rising from 5.4 litrea per capita in 1955 to 8.7 litres in 1982 (56% as beer). Over this period the increase was principslly due to a 100% increase in spirits cODsuaption and a 500% increase in wine consumption. Grape vine plantings more than doubled between 1975 and 1981. In 1960 there were 1694 licensed liquor outlets (1;950 per capita over 15 years) compared to 5260 outlets (1:630) in 1983. Over the last 20 years to 1980 there was a 25% reduction in the price of alcohol relative to per capita disposable income. In 1982 the government revenue from alcohol tax was estimated at $394 million (15% of indirect taxation). The liquor industry employs 3% of the workforce. Excluding television, liquor advertising is widespread. The Health Department's Annual Report for 1977 estimated that there were 53 000 alcoholics in New Zealand and a further 50 000 to 150 000 hazardous drinkers. Between 1960 and 1980 admissions to psychiatric hospitals for alcoholism and alcoholic psychoses increased from 14.1 to 94.7 per 100000. By 1982 alcoholism accounted for 43% of all male first admissions to psychiatric~institutions. Deaths from cirrhosis per million population rose from 9.5 to 34.5 between 1960 and 1980. Since 1978 public hospital boards have established alcohol and drug assessment snd outpatient treatment centres which ssw over 5000 new clients in 1983 (at 20 centres). ApproxLaately 2000 others are treated annually by voluntary agencies. An increasing proportion of clients have mixed alcohol and drug problems (15% 1983). Females currently account for 25% of referral compared with 15% in 1971. There is no significant racial weighting. The unesployed are vastly over-represented being 24% of referrals (3% population census). There is a trend of presenting for treatment st a younger age.
- j8 -
Annex 5.5
Some legal associations with alcohol m1suse are illustrated by the following statistics: (a) (b) Offences for drunkenness and disorder 21 462 (1978) 37 300 (1980)
Research estimates are that alcohol is involved in 53% of fatal traffic accidents and injuries e.g. in 1977 there were 350 deaths and 8762 injuries. In 1976 there were 9.824 charges of "driving under the influence" A 1983 study showed that 84% of violent offenders had been drinking alcohol before the offence.
<c)
(d)
There is paucity of NZ data pertaining to the contribution of alcohol misuse to the spectrum of social problems, e.g. industrial accidents, absenteeism, marital breakdown, child abuse, property loss. 2. Legislative and control measures on alcohol
Since 1918 a nationwide licensing poll has been held in conjunction with the triennial parliamentary elections and provides for all electors to vote prohibition, or state purchase and control of liquor, or continuance of the present system. The Alcoholic Liquor Advisory Council Act 1976 provided for the formation of this body, charged with the duty of encouraging moderation in the use of liquor, to discourage and reduce its misuse, and minimize the
personal, social and economic evils resulting from excessive drinking. The mandate is for persuasion rather than direct intervention; however, the Council is authorized to make recommendations to the Government, to departments of state, to authorities in the fields of health and education, social welfare, industry and to public and private bodies and individuals in respect of all alcohol-related matters. The Council makes grants for research and treatment, prepares public education material, carries out information campaigns ~ia the media, runs seminar, and liaise. with a variety of interested groups in the community. It is supported by a special levy on all alcohol produced in New Zealand or imported from abroad. ALAe has produced a pre~ention policy statement. The Sale of Liquor Act governs the availability of alcoholic beverages in New Zealand, in that the licensing of outlets, hours of sale, age restrictions and standard of licensed premises are subject to the provisions of the Act. On a local scale, the public have the opportunity to intluence alcohol control policy relating to availability. The Licensing Control Commission decides after a public enquiry whether to issue or renew tavern or hotel licences, and a poll of residents must be
- '9/60 -
Annex 5.5
taken to determine whether there is a desire that a tavern or hotel be established in that community. The price of alcoholic bevera,es is influenced via taxation (Beer Duty, Customs and Excise Duty, Sale. tax) and limited price controls. The Ac , 1978 makes it an offence to drive with a breath a rograma (or 80mg per 100ml blood). Recent additions to thiB act require those drivers who have accumulated two convictions within five years (one with a blood alcohol exceed ina 200 . . %) to be seen at an assessment centre and treated as nece •• ery before return of the licence. Additional to the Mental Health Act the Alcoholism and Drug Addiction Act (A & DA) 1966 provides for the detention of alcoholics in certain t;;atment institutions. There are approximately 400 such admissions per year and of these about 50% are voluntary applications by alcoholics themselves. An infrequently ueed option of the Criminal Justice Act (Section 48A) allows offenders to be detained under the A & DA Act .s an alternative to other penalties. Individual prohibition orders are rarely utilized because of MOdern mobility and difficulty of enforcement. Following the 1981 Penal Policy Review Committee Report there has been increaeinl emphasis on the asse.ement and treatment of offenders with alcohol proble.s within the justice system. There ia a trend of increasing demands for assessment, deferments of sentences until completion of treatment or treatment imposed a8 a condition of probation. Through care programmes in prisons are being established by alcohol agencies. The Suamary Offences Act 1981 enables police to detain or to take to their place of residence or to a detoxication centre, any person found intoxicated in a public place.
- 61 -
ANNEX 5.6
PALAU - COUNTRY PROFILE
The Republic of Palau is the westernmost archipelago of the Caroline Island group in Micronesia. Palau haa approximately 170.4 square miles with population density of approxieately 70 persons per square mile. It is a tropical island and its average yearly temperature is 80DF with average humidity of approximately 80%. The population is approxi. . tely 12 116 of which approximately 50% is under 25 yeara of age. The Alcohol problem During the years immediately after the war. Micronesia was administered by the United States Naval Government which did a good job in eradicating yaws but brought in a lot of liquor. In 1962, President Kennedy ordered that the islands be helped somehow to iaprove themselves and be friendly with United States. It was about this time when the Accelerated Elementary School Construction Program (AESCP) was begun and the Hillburton Dispensaries were built, and the islands witnessed the importation of a lot of food, cars and alcoholic beverages. After the Pacific War, brewing sprung up of moonshine was called JJ by the U.S. Navy. Ju~ce. Though the U.S. Military brought in a on how .uch beer a soldier could take out for joined islanders in JJ imbibina spree •• all over Palau. Our version This stands for jungle lot of liquor. it had a quote a picnic. Thus soldiers
Alcohol has caused social erosion; family disintegration, fighting and sleepless nights for frightened children. Of all the problems warranting arreats, alcohol contributes the most. Palauan women filed a petition with the United Nations and the local US Administration. They aanaged to eatablish prohibition in 1958. For a while this worked until the newly elected Palauan congress was organized. The group threw prohibition out the window. JJ brewing was resumed. Then Puhlic Health came in and condemned the quality of JJ so effectively that local stores began to import beer and liquor from Japan, Philippines and Milwaukee.
- 62 -
Annex 5.6
In an attempt to control alcohol, an ABC Board was created. It haa not been very effective. There are alcoholics and acute alcoholic problems on fortnightly payday weekends. A lot of alcohol drink is still being imported into Palau. The drinking age used to be 18 years and up. 21 years. Cultural constraints
This has been changed to
There are only 12 000 of us. Over half of this population has moved into the District Centre. Taking away the non-drinking population, i.e. those below 15 years, those over 70 years, and most women, there is a small population that drank the 358 279 gallons of beer and liquor imported into Palau during 1983. A Policeman cannot or should not arrest his uncle if he is drunk and WOrse still, if he is a high ranking official in the government.
In the days of old and even today, a village chief or group of chiefs could pass a decree to keep their village dry. If anyone was found drunk or importing drinks into the village, he would be fined very heavily. This traditional control is being weakened as lawyers are busy contending that this measure impinges on human rights. The Palau constitution respects tradition but in case of conflicts, written laws supersede. Statistics
Our statistics show a rate of 1.6 alcoholics per 1000 population for those who have come to us. Arrests by the police for crimes related to alcohol keep on rising. Our outpatient and inpatient services have witnessed an increase in injuries due to accidents related to alcohol abuse. Increased divorces, suicides, homicides and burglary are also a
result of increased alcohol abuse in Palau. Public awareness program
Public health education is still sporadic. Efforts to include topics on alcohol and drug abuse in school curriculum are still in the discussion stage. A rally for public cooperation is also still in the infant phase. Alcohol has become a major cause of morbidity and mortality in the islands. What can we do individually as a small island nation? What Can we do as a group? What can WHO do to help as an expert adviser in this are? I came to learn from this forum.
, I
- 63/64 -
AnDex 5.6
TABLE 1.
IMPORTATION OF ALCOHOLIC BEVERAGES Iln'O PALAU
Yea r
ColDllod i ty
US Dollar $ 526 340 124 704 651 044 b16 360 100 545 716 905 795 663 110 182 905 84.5
Volume in US Gallons
1979
Beer Liquor
212 708 34
i 1980
p~ 2
I I , 1981
I
Beer Liquor Beer Liquor
$
i $
226 020 12 759 238 779 269 792 14 036 283 828
i 1982 1983 NOT AVAILABLE Beer Liquor
$
it
879 349 125 046 004 395
342 346 15 933 358 279
SOURCES:
Tax Office - Republic of Palau P.o. Box 100, Zip Code 96940
- 65 -
AMlIEX 5.7
PAPUA NEW GUINEA - COUNTRY PROFILE
Papua New Guinea is an independent state of the Commonwealth, now entering the tenth year of independence. The country has,a population of three million and is a Westminsterstyle d.".,cracy. This year Papua New Guinea invited H.R.H. The Prince of Wales to open the new Parliament House in the presence of a splendid gathering of Heads of States and other dignitaries of South Pacific and neighbouring countries. This was a180 tbe occasion for a session of the Coononwealth Regional Heads of Government Keeting. Together with this and many other indications of stability and progress, the country is facing with great concern extensive social problems which are usually grouped together under the appellation of the most conspicuous manifestation of the disorder, the "Law and Order Problem", a problem which Papua New Guinea shares with many other countries at this time. Two important reports have recently been published on the Law and Order problem. One was an official government report, the Morgan report (1) by senior Public Servanta, tbe second, the Clifford report (2) was by a joint investigating team of the Institute of National Affairs, an organization of Papua New Guinea private enterprise and commercial interests and the Institute of Social and Economic Research, a government statutory body. Both reports gave prominence to the role of alcohol use as an important contributory factor to law and order breakdown, both indirectly and interacting with and coaplicating other social and individual factors. The Clifford report was less specific and detailed in its recommendations regarding alcohol control. However, this report did emphasize that in some areas, particularly among women, there are very strong calls to consider total prohibition as an option. This report also comments on the non-implementation of the very well-supported recommendations of the lASER, 1981 Report(3). The Clifford report, therefore, while giving les8 prominence to the problems of alcohol use than the Morgan report, is nevertheless definite in identifying it as priority action by all concerned with the life of the country.
- 66 -
Annex 5.7
Both reports are specifically concerned with law and order and therefore canoot be expected to address themselves to alcohol-related problems which are not perceived as having a bearing on criminal activity and cGmmUnity disruption. Nevertheless both reports see that law and order cannot be measured solely in terms of convictions, law enforcement or
legislative action, and therefore recognize that alcohol use is a major, rhough not the only factor in a wide area of social distress, associated with the disruptive effects of the present pattern of alcohol use. The Morgan report concludes with two hundred recommendations, among which are eleven concerned with alcohol use. Among these 200 recommendations the report identifies thirty-nine, which it designates "central", While among the 39 central recommendations it identifies nine which are designated "vital". Of these nine, no less than three are concerned with alcohol use of which the report states, "A decrease in crime can be achieved by reducing alcohol consumption. Furthermore, indirect benefits, both to the public purse ~nd to the community, can be made by achieving a tighter control on drink."
The three recommendations concerning alcohol use included among the nine "tvital", otherwise called "key" recommendations are concerned with: i.a)
that the State should acquire a controlling share of the brewing industry. that a part-time "Council of Experts" should be set up within the Health Department, and this Council of Experts should consider ways of controlling the importation of alcoholic beverages.
(b)
(c)
The Morgan report was not generally available until the middle of this year. As early as mid 1983 the Health Department had set up a sub-committee to report to the Secretary for Health on matters relating to alcohol and drugs. This had representatives from other Departments and Non-Government Or,;ani sat ions. This committee recommended that a National body be set up which would not be a government committee. The non-government members were invited tu
do this.
- 67 -
Annex 5.7
The reason for this was two-fold. Firstly, it was felt that a non-governaent body would be able with less restriction to make its views known to the media, and that it would administer finances with less budgetary restrictions than within a government department. The Health Department would maintain a liaison offic~r with the organization and they could ask over departments to do the same.
Secondly, it was realized that the greater part of the recommendations of the lASER report, and most actions that needed to be taken to implement a sound alcohol policy, were outside the control of the Health Department. It was felt that other departments would take greater notice of recommendations of a public body than of another department. A small group, under the chairmanship of a non-ministerial member of Parliament, is now seeking active and interested and knowledgeable members, planning a Constitution, seeking affiliation and finance and taking over steps to set up a viable Nationsl Organization for research and study on alcoho 1. Meanwhile, a Health Department committee has continued to function to determine policies and programmes that fall within Health Department responsibilities:
The following areas were identified for immediate attention: (Ii Improvement in the conlent of teaching concerning alcohol-related health and other problems in all syllabi and teaching programmes for health workers at all levels and in community health education programmes. Cl~ar policies and programmes for the management of all levels of health workers who have alcohol-related problems; believing that unless the Health Department took a lead in these, other Departments, and the Public Service as a whole, would not take advice from the Health Department.
(2)
(3)
To set an example by the Health Department by establishing a policy that all official Health Department functions should festure non-alcoholic drinks st least as prominently as alcoholic drinks.
"As a matter of integrity the members of the Government should
consider the wisdom of consuming liquor at official receptions and other publicly funded functions." Morgan report, reco_ndation 117.
- 68 •
I
J I
Annex 5.7
II
Apart from dealing with acute and serious problems, the greatest concern for finding ways of dealing with alcohol-related problems still lies with voluntary bodies; government assistance has been given to these but a general policy has not yet evolved to ensure regular funding of voluntary agencies, and support by definite government action. The two most active organizations in the field are Alcoholics Anonymous and the Recovery Centre. Lifeline and other counselling and welfare agencies also do much in this area. Unfortunately many of their activities have, of necessity to be limited to attempting curative action. The Government of Papua New Guinea is at this time recognizing the urgent need for preventive and promotional programmes at all levels. The Health Department in particular, is looking for guidelines to assist in its planning and, through a National Alcohol Council, to make the country aware of the need of a National Alcohol Policy.
- 69/70 -
Annsx 5.7
IIEFI!RENCBS
1.
Committee to Review Policy and Administration on Crime, Law and Order Morgan, L R (Secretary, Department of Provincial Affairs), Chairman Department of Provincial Affairs, Waigani, Port Moreaby, Papua New Guinea. December 1983. Clifford, W. Criminologist, U.K. and Australia. Stewart, B, Judge, Canada. Morauta, Mrs Louise, (PKG Citizen) Institute of Social and Economic Research, Wai.ani, Port Moresby. lASER "Policy Recommendations on Alcohol" 1981, lASER, Boroko, Papua New Guinea "Through a gla88 darkly. Baer and modernization in PNG" Mac Marshall (ed.) Monoaraph 18 1982 lAIER, Boroka, rtlG
2.
3.
- 71 -
ANNEX 5.8
SOLOMON ISLANDS
Introduction Alcohol-related problems are one of the COncerns in Solomon Islands. Unfortunately the issue has never been studied and documented. Conse~uently, the unavailability of relevant and reliable facts and figures makes it extremely difficult to present a clear picture of the magnitude, nature and trend of alcahol-related problema in this country. However, a few date were collected which are made available as Annexes I, 2 and 3. Magnitude, natur! and trend of alcohol-related problaas Alcohol as a product was introduced by foreigners into Solomon Islands. Kava ia co.mon in Fiji and there are certain ialands in this country which have a root similar to the Kava used in Fiji. This is 80 in an island near Vani1ooro in T_otuProvince where the root was prepare.d and drunk 8 imilarly to Kav... The Polynesians, and especially the Micronesian Gilbertese in the Western Province and other islands in Solomon Islands drink fermented coconut toddy, which is similar to that found in South-East Asia. Apart from that a coaaon habit is betel nut, which in actual fact is not alcohol but used by the people to get a kick by mulching betel leaf, betel lime and betel nut and eometimes chewing tobacco. Alcohol in the proper sense of the word was not known in Solomon Islands until the introduction of Christianity and western ways. Christianity introduced wine drinking through the western influence of travellers from Australia, New Zealand and other European countries, beer became a common drink. The reason for beer drinking by the foreigners was the f~ar of drinking water which was considered not safe when they arrived in a new country. The SolQhOn Islanders, who developed the cultural heritage, traditions and customs from their own chiefs and within the framework of the "wantok" system (extended faaily ayatem), began to imitate westerners and western ways. Christianity, which westerners believed, also made them think that what was good for a foreigner was good for Solomon Islanders. Moreover, some other Solomon Islanders who were exposed through travel and contact with western people grew up like an elite drinking, eating and wearing clothes like the western man, and therefore his fellow country men followed his example. Through this, alcohol bellan to intrude into our society and our ceremoniee, so today the country is importing ranges of alcohol aa given in page 74.
- 72 I
Annex 5.8
The quantity and value of alcohol imported from 1978-1983 has gone ~p by 75%. The landing price also has risen to 50% and the rate of consumption per household in the Bame period increased from 3.5 - 3.8%. The total population of Solomon Islands in the 1976 National Census was 196 823 and the 1984 Provincial Projection was 258 190. About 20% of the wage-earnere mostly men between the ages of 18-45 years who resided in the towns took alcohol. The magnitude of the problem i. not as serious a9 in some Pacific countries or in tbe western world. Our people drink beer mainly on payday or at parties and ceremoniea. Alcoholism is not common in the Solomon Islands except for a few cases. In a way drinking beer in the Solomons helps to keep the kidney flushed in a aituation with hard water full of calcium. The intake of undistilled and unboiled water can result in bowel disease and deposits of calcium in the kidneys resulting in stone in the kidney. On the other hand in the urban areas this bas lead to traffic accidents, drunken driving, assaults, etc., especially on Fridays and 'Saturdays when people tend to have parties and drink beer until they are drunk. There are other related problems like fighting, theft by ganga in search of beer, breaking into houses of expatriates in search of beer, neglecting of families resulting in divorce, which is rare. This is due to the wantok system whereby each person in the tribe looks after one another. In Solomon Islands alcoholism i. not a big problem but is a growing problem due to use by certain individuals such as foreign investors who use beer and tobacco to get around landowners to get thp. rights of logging, fro~ reef-owners to get the rights for fishing, or from landowner. for the rights of mining. Generally our people are peace-loving people and the main problem ia an urban problem, situated mainly in Honiara. Page 75 gives crime statistics collected from police which indicate the prevalence of alcohol-based cri~8. Page 76 gives marriage and divorce statistics, which indicate the contribution of alcohol. Thus, alcohol is seen as an urban problem in Solomon Islands. Legislative and control measures At present the laws relating to alcohol are founded in the Liquor 'Ordinance Chapter 33 of our Legislative Enactments. There are beer licences issued under by-laws of local bodies. The total number of licences issued in 1983 was 182. Under the traffic Chapter 19 certain penalties like suspension of driving licences are imposed on trRffic offences due to liquor consumption.
II
II
i!
II j I
II 1i
II II
II II
- 73 -
Annex 5.8
In short, in Solomon Islands the problem of alcoholism is an urban problem aDd aD imported phenomena. A good educational programme through achools, churchea, radio, and utilizing the traditional chief system could help to alleviate this urban probl_ In the process of devolution the Government haa started to produce elpilitable distribution of developmenta to all parts of Solomon Islands, which could a180 sssist in significantly reducing this problem.
- 74 -
Annex 5.8
IMPORTS OF ALCOHOL BEVERAGE 1978-1983
Items Oitres)
1978 1 357 015 2 310 9
1979 1 931 171 2 422 25 002
1980 829 079 1 154 30 283 8 980 580 13 728
1981 1 9&8 735 1 521 25 657 7 922 1 118 12 254 2 872 43 800
1982 1 870 281 1 117 39 504 6 204
1983 2 321 581 894 43 638 3 509
Beer Brandy Gin Rhum Vodka Whisky Wine Wine for fresh grapes still Bitter alcoholic and cordial liqeurs Others
310
10 352 144 15 392 3 817 13111
10 188 985 16 588 3 145 51 130
1 004 9 473
152 3 144
4 059 45 257
3 468 38 186
3 821 42 857
716 1 289 1 413 456
773 956 2 042 360
1 088 1 434 935 642
659 1 031 2 065 569
717 922 1 970 876
1 146
627 2 421 369
Total
- 75 -
Annex 5.8
OFFENCES ARISING FIlDM CONSUMPTION OF LIQUOR REPORTED TO POLICE
FRC14 1975-1983
1975 Murder/man slaughter Serious assaults Other assaults Assault/obstruct police Threatening Fighting (affray) R·~bbery
1976
1977 2
1978 4 93 163 5 75 54 1 141 6
1979 1 104 190 13 77
1980 6 41 615 15 77
1981 5 28 518 15 74 132 5 266 17 105 554 98 396 793 379 3385
1982 5 36 469 11 73
1983 4 23 260 4 30 60 7 119 14 53 262
30 77
84 187 9 89 35 1 115 7
114 190 13 94 50 2 172 4 34 275 64 30 102 18 1164
15 44
36 3 53 5 16 317 32 10 74 23 735
51 2 129 6 21 369 74 30 163 36 1266
133 8 333 14 92 19 93 332 665 326
124 9 260 34 93 508 78 305 610 288 2903
Malicious damage
Rape Other indecency Drunkenness Other 1 iquor offences Drunken driving Other driving offences Traffic accidents Total
31 315 14 27 92 22 1028
20 295 34 24 170 42 1127
25 140 281 174 1456
2769
- 76 .-
Annex 5.8
CIVIL CASES ON LEGAl SEPARATION AND DIVORCE
1978
1979
1980
1981
1982
1983
1984
Family problem Divorce
2S 7
26 8
18 9
18 14
11
16 16
17 14
7
- 77 -
ANNEX 5.9
TONGA - COUNTRY PROFILE
Introduction The Kingdom of Tonga lies in the central South Pacific, east of Fiji and south of Samoa, straddling the international dateline. The total land area is only 670 sq. kilometres on some 150 islands of which only 36 are permanently inhabited. The estimated population at the end of the year 1982 was 100 069. It appears that 63.76% (63 803) of the population live on the main island. People between 15-44 years of age constitute about 45.87% of the total population. These are the most active group in the population, who are utilizing more health services, and if they are not prevented from alcohol-related problems, it will have a direct impact on hospital utilization and health resources. They are also the most important target group in the consumption of alcoholic beverages. An inevitable trend regarding the age distribution of the population of the Kingdom is that the tinder 15 years age group is decreasing by 0.83% in 1979 to about 1.1% in the year 1983. This indicates that the females at the bearing age are actively participating in the work force and one could assume that young women noW are drinking alcohol. This response suggests the changing role of women in present day society and new irresponsibilities; however they must also bear in mind that they are without relief from traditional obligations. The aging of the population in Tonga is very slow as the age group 65 years and above only constitutes about 3.4% of the population. This indicates a ahorter life span which I presume to be a contributory factor to less known alcohol dependence. Although there is no hard data as yet available concerning the consumption of alcoholic beverages in Tonga, it is evident that this is a major health problem, not to speak of its socioeconomic impact. There is a significant internal migration from rural areas to urban areas and this will also make it even worse when the number of alcohol consumers is increasing. This urbanization will continue to cause JDore
family disruption: there will he more slum areas, high unemployment and the problem on alcohol dependence syndrome will start to emerge among society.
- 78 -
Annex 5.9
Alcohol
cons~ption
It is believed that the per capita consumption of alcohol and the number of consumers are increasing. The main reasons for these increaaes are the readily availability of alcohol, social pressure, unhealthy lifestyle, increasing industrialization and urbanization. The controlling authority for intoxicating Liquor Act is the Minister of Police and all licences for the sale of liquor must have his approval first. Furthermore for the consumption of intoxicating liquor, a Tongan must first have obtained a permit from the Minister of Police. Such permit may either be limited or unlimited at the discretion of the Minister. Unfortunately thia act is not adequately enforced at liquor outlets such a. hotels and motels. In Table 1 slight decrease imposed on this other alcoholic the total quantity of beer imported in 1982 indicatea a but this may be because of an increase in the tax and duty commodity. Also, a similar trend is shown on the wine and beverages.
TABLE 1.
STATEMENT OF SELECTED ITEMS FOR THE YEAR 1982/1983
1982 Commodity ale, stout and ~orter, etc. ~eer,
1983 Value Duty Quantity Value Duty
Unit Total Litre
Quantity
1 462 756
907 213
581 786
12 323 593
822 778
608 452
!thers Wine still Other fermented beverage, cider,
Litre
18 043.4
35 270
13 048
28 322
69 752
29 071
perry, mead '. Spirits proof and overproof
Litre Litre
1 566
4 980
1 686
569 8 832.15
2 746
623
6 865.94
41 730
228
13 017
3 615
Spirits underproof Inc. vodks, whiskey Litre Total Litre
29 378
96 433
8 073
12 833.16
52 831
76 990
55 853.34 178 413
102 035
50 566.31
138 346 110 299
- 79 -
Annex 5.9
On the other hand, alcoholic beverages, despite their addictive nature and because of their potential for adverse social and health consequences, make an important contribution to the socioeconomic structure of the Kingdom. In 1981, the Government through imposing of tax and duty, collected T$684 821 in 1982 and T$718 751 in 1983. Therefore, it is important that the economic and political constraints on the imposition of controls be weighed against the expected advantages. An important factor to consider in the variation in the pattern of alcohol consumption in Tonga is the influence of the religious organizations such as the Seven Day Adventists Churches and the Churches of the Later Day Saints. The religious belief and cultural difference~ of developing countries are important variables in determining which method or approaches should be adopted to alcohol-related problems.
Alcoho l-re lated problems Alcohol-re lated problems inc lude a wide range of illnesses, e. g. cirrhosis of the liver, misadventures such as attempted suicide or road accidents, social disorders, e.g. crime and marital disturbances. It is unfortunate that the morbidity statistical recording in the Ministry of Health is very much lacking in infonuation on history of alcohol consumption. However, the information documented in this report was obtained from the criminal records of the Ministry of Police for the year 1983. Social problems It can be seen from the significant annual report of the Minister of Police that alcohol-related problems have social in addition to health consequences. Parti.cular offences, "hieh are closely associated with the consumption of alcoholic drinks, are assault and bodily injury, indecent assault and rape. Drunk in public places and incapable disorderly behaviour, abusive and obscene language, fighting and criminal damage were among the offences conducted under the influence of liquor. Most traffic accidents and damage to property arise from drunkenness. Many domestic disputes and some broken marriages have been traced directly to one or both parties over-indulging in liquor. The drunk cases for 1983 were 1284 as compared with 1150 drunk cases in 1982. Of all offences other than those recorded against the Criminal Offences Act and Traffic Act, 52.39% were drunk charges.
- 80 -
Annex 5.9
Conclusions Unless immediate action is taken with respect to their prevention, alcohol-related problems may eventually become a serious health issue and a serious obstacle to socioeconomic development in Tonga. Current preventive measures on legal restriction on the sale of alcohol and imposing of penalties are not all effective. Therefore, emphasis should be given to adequate educational progra1lllles. Such prevention programmes can include demonstrations through campaigns to raise awareness of the population about the consequences of excessive drinking. The message should be clear and should be well received by the public as well as the schools. The training of nationalS to improve their w0rking knowledge on alcohol-related problems should also be regarded as high priority. The training programme should give same attPntion to principles and practices related to prevention, treatment, early diagnosis, rehabilitation and research programmes. Every health worker should be familiar with common variables in drinking patterns, and the ,ange of common alCOhol-related problems and their interrelationships. They should he aware of accepted methods of dealing with physical aspects of alcohol-related problems. Adequate training of nationals is important to ensure proper interpretation of the data, formulation of policies and development of adequate prevention programmes. The health programme should have a health promotion approach e.g. demonstrations to target groups, introduction of low-alcohol content beverages, and the use of pricing policies and avoidance of victim-blaming approaches. There is also a need to e.tablish speciality services at institutional and co_unity level for early diagnosis, treatment and access of the public. They should be vested with sufficient Authority for assessing priority areas, evaluating programme impl~mentation
and fOn"nulating
national policy. The National Food and Nutrition Committee has advised the National Health Development Committee of the Ministry of Health on the advertising of liquor in Tonga which produces negative effects for the public, and simultaneously requested NHDC for advice on whllt should be done. However, NHDC had the impres8ion that this particular commodity, despite its health consequences, is a political matter and did not agree to stopping the advertisement. NHDC directed that the Ministry of Health should carry out intensive and continuous health education on all alcoholic liquors if the consumption continues to increase, then the matter would be reconsidered again by NHDC. The contribution of the duty imposed on importation of liquor to the socioeconomic development of the country was also taken into consideration by the Committee.
- 81 -
ANNEX 5.10
SAMOA - COUNTRY PROFILE
Introduction Inadequate recordings and an inherent tendency to withhold information related to alcohol consumption, particularlY in villages, makes it difficult to give an accurate assessment snd account of alcohol related problems. Heavy fines are charged through traditional village councils on families of those confirmed drunk. Such penalties incur heavy losses to family properties in the form of animal stock and crops. The Church also strongly condemns drunkennes8 and since the Church is a way of life in Samoa, condemnation from the Church is in itself a form of penalty. Hesitancy on the part of the family or friends to reveal or even report consumption of alcohol is therefore not uncommon. Available figllres however, and a general personal impression, suggest that alcohol-related problems are increasing despite attempts to prohibits its use through the above disciplines based on social and moral considerations. Perhaps this is to be expected since alcohol is now more readily available in general stores throughout the country. 1. Magnitude nature and trend of related problems (a) Physical affections These are seen mainly as consequences of acute episodes of heavy drinking. Impairment of function and control, aggressiveness extending to sssault, accl.dents including motor vehicle accidents and police arrests for drunkenness are the commonest consequences of drunkenness. A n\~ber of deaths have occurred following drunken brawls. Bodily harm and sometimes death of innocent people and damage of property are noted consequences to the community from these acute episodes. Long-term physical consequences of prolonged heavy drinking are not a8 evident but again are expected to be on the increase. (i) Liver cirrhosis and hepatoma Liver cirrhosis is not uncommon in Samoa and the majority of cases are thought to be secondary to infectious hepatitis. A definite history of prolonged heavy alcohol consumption, however has been obtained in a significant number of cases.
- 82 -
Annex 5.10
(ii)
Cardiac myopathy Alcohol has been implicated In a few cases.
(iii)
Malnutrition This is not evident.
(iv)
Pancreatitis This is rare in Samoa but of those diagnosed a significant number fall in the category of heavy drinkers.
(v)
Fetal alcohol syndrome This is not a problem and there is no ca.e recorded.
(b)
Social consequences The complete range can be seen in vary i.ng stages, affecting the drinker, the family and the community. (i)
The drinker Because of aggressiveness, he is liable to lose his wife or family and friends, or even his job and means of support. Drinking has been implicated in a number of broken homes and loss of jobs. This problem is more evident in the town areas. III health, impairment of working capacity and loss of self-esteem is already evident i.n a number of heavy drinkers who present to the hospital services.
(ii)
The family Broken marriages, spouse and child abuse, poor family health because of diverting funds to alcohol procurement and added consequences are evident again mainly in the town dwellers. The extent however is not known but detailed consultation of some psychiatric patients has hinted on the significance of the problem.
- 83 ..
Annex S.lO
(iii)
The community The consequences of prolonged heavy drinking and alcoholism and its affect on the community as a whole are not revealed in magnitude. Physical violence, unnecessary loss of life and property and thieving, are the main Acute consequences. Economic costs of services, mainly in health and compensation, is a serious problem that is now encountered. Output los see
for public servants are as yet difficult to assess but Bre already evident in the self-employed. (c) Psychological A few cases of alcohol dependence and alcohol psychosis have been seen as well as SOme cases of alcohol pathological jealousy and hallucinations. Resultant child neglect is probably contributory to juvenile problems and school dropouts that are seen in some of these victim's families. A significant number of young suicidal male patients seen in 1982 were alcohol-related. 2. Legislation and control measures in alcohol production and consumption
The Liquor Act provides for the control of the manufacture and sale of liquor. Under this act the Liquor Board has the power to control the manufacture and importation of liquor, liquor licence applications, control applications for licence, price regulation and opening and cLosing hours for licensed institutions.
Manufacture and importation of liquor Except for the Government-owned breweries, it is not lawful for any person to brew or manufacture liquor. A person of 21 years or over is
allowed to bring into the country one bottle of spirit for himself or members of his family.
- 84 -
Annex 5.10
Sales of liquor Custody of liquor is held by the Collector of Customs. offence: (1) (2) To sell liquor without being licensed. For a person under 21 years to drink any liquor in any ilotel club or resort used by the public or to have possession of any liquor therein. For any person to drink liquor in a public place or any licensed pub lie vehic Ie. It is an
(3)
SUMMARY
Alcohol-related problems in Samoa are mainly the short-term consequences of acute episod~s of heavy drinking. Those resulting from prolonged heavy drinking are becoming evident and are expected to be on the increase as times goes by. Detailed histories of psychiatric and suicidal patients have hinted at already existing significant long-term consequences of alcohol consumption. Legislation on manufacture and sale of liquor covers most of the control measures, but a review and tightening of controls are necessary.