Regional Workshop on Alcohol-Related Problems, Manila, Philippines, 8 - 12 August 1983 : report

(\;'P)l1NH/ICP /MNH/OO4

20 January 1984 EKGLISH ONLY

REGIONAL WORKSHOP ON ALCOHOL-RELATED PROBLEMS

Convened by the REGIONAL OFFICE FOR THE WESTERN PACIFIC OF THE WORLD HEALTH ORGANIZATION

Manila, Philippines 8-12 August 1983

Not for sale Printed and Distvibuted by the Regional Office for the Western Pacific of the World Health Organization Manila, Philippines January 1984

Wl',)fWPhO Llbhtdo." -/.n:JilH. rf:,llit-\t>ID•."·~

NOTE

The views expressed in this report are those of the participants in the Workshop and do no necessarily reflect the policies of the World Health Organization.

This report has been prepared by the WHO Regional Office for the Western Pacific for governments of countries and areas in the Region and for those who participated in the Regional Workshop on the Prevention of Alcohol-Related Problems, held in Manila from 8 to 12 August 1983.

CONT~NTS

1.

INTRODUCTION

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1

2.

SUMMARY OF GLOBAL AND REGIONAL TRENDS

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2.1 2.2

Global trends Regional trends Role of WHO

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2.3 3.

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2 3 6 6

NATIONAL POLICIES ON ALCOHOL-RELATED PROBLEMS SUMMARY AND DISCUSSIONS 3.1 3.2 3.3 ~ssential

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components of national alcohol polcies

6

3.4 4.

Collaboration and cooperation •....••.•••••••••••••••• Educational approaches •••.•••••••••••••••••••••••••.• Role of the health sector ••••••.•••.••••••.•••••••••.

8 10 10 11

FRAMEWORKS FOR NATIONAL POLICIES 4.1 4.2 4.3

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Framework A Fr amewor k B

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•

"

•••• "

•

"

"

"

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13

"" •• " " " " " •• " " • " ••• " " • " •••• " " " " •• " " • " " •••.•

20 24

National policies in developed countries

•••••••••••••

5.

CONCLUSIONS AND SUGGESTIONS FOR FUTURE ACTION 5.1 5.2 5.3 The formulation of comprehensive and integrated national policies on alcoho1related problems

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26

.•••••.........••...•••••••••••••••••

26

National and regional need for valid and accurate data on alcohol supply, alcohol consumption and alcohol-related proble~s ••••••••••••• Health manpower development for the prevention and control of alcohol-related problems •••••••••••••• 1 OBJ~CTIVES

26 26 29/30

ANN~X

OF THE WORKSHOP

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ANNEX 2

PROVISIONAL AGENDA AND SECRETARIAT

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31/32 33

ANNEX 3 - LIST OF PARTICIPANTS, TEMPORARY ADVISERS • • • • • • • • • • • • • • • • • • • • • • • •• • • • • • • . .

ANNEX 4 ANNEX 5 ANNEX 6

OPENING ADDRESS BY THE REGIONAL DIRECTOR COUNTRY PROFILES LIST OF DOCUMENTS

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37 39 81 83

ANNEX 7 - EVALUATION

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1.

INTRODUCTION

The Workshop on Alcohol-Related Problems was held from 8 to 12 August 1983 at the World Health Organization (WHO) Regional Office for the Western Pacific in Manila. Dr S.T. Han, Acting Regional Director, opened the meetiag and welcomed the participants on behalf of Dr Hiroshi Nakajima, who was absent on mission.

In his opening speech, the Regional Director drew attention to the alarming increase in the consumption of alcohol and in the magnitude of alcohol-related problems in many countries of the Region and pointed o~t that these problems are no longer the exclusive concern of developed countries but are becoming an increasingly important public health problem in many developing countries. He also noted that the World Health Organization, at both global and regional level, had expressed its concern about this issue and undertaken several measures directed towards the prevention and control of

alcohol-related problems. The Regional Conunittee for the Western Pacific adopted a resolution at its thirty-third session in September 1982 urging Member States to formulate comprehensive, continuous and long-term national policie. on alcohol-related problems and requesting the Regional Director to intensify WHO's programme on alcohol-related problems. The thirty-sixth World Health Assembly in May 1983 further requested the Director-General to continue and intensify WHO's programme on alcohol-related problems as an integral part of the strategy for health for all by the year 2000. The Regional Director therefore considered the organization of the workshop to be very timely and in line with the various resolutions which had been strongly supported by Member States. The workshop was attended by 11 participants from 10 countries and areas.

Dr Lina Manapsal of the Philippines was elected Chairman, Mr Venansio Alphons, Trust Territory of the Pacific Islands, Vice-Chairman, and Dr Susan Morey, Australia, Rapporteur. Dr~Sally

Dr Marcus Grant, Director, Alcohol Education Centre, London, and Casswell, Executive Director, Alcohol Research Unit, Auckland, provided support as temporary advisers in the preparation and conduct of the meeting. 1S

A list of participants, temporary advisers and secretariat Annex 3.

given 1n

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2.

SUMMARY OF GLOBAL AND REGIONAL TRENDS

2.1 2.1.1

Global trends Alconol consumption

Since the Second World War, major changes have taken place in global alcohol consumption, the problems associated with excessive drinking and the types of prevention and treatment systems used to respond to tnose problems. The most significant trend during the period has undoubtedly been the general increase in aggregate consumption. In most countries in the wodd, the upward trend in alcohol consumption has continued unabated for many years and any short-term fluctuations have been trifling in comparison with this impressive global surge. Some of the most spectacular rises in consumption have been in developing countries, which are also experiencing very rapid and wide-ranging social and economic changes. The alcoholic beverage industry, which is now dominated by a handful of transnational corporations, is becoming particularly interested in the growth potential of markets in developing countries. As alcohol consumption in some developed countries begins to level off as a result of the current economic difficulties, the beverage industry is intensifying its production and marketing efforts in the developing world. These changes in alcohol supply structures are likely to contribute towards further increases in consumption in developing countries.

As the econom~c aspects of alcohol have gradually Come to be recognized as having special importance, the trend has been to emphasize its special nature as a commodity with addictive properties and a potential for adverse social and health consequences. 2.1.2 Alcohol-related problams

Alcohol-related problems include damage to physical health, mental health, social relationships and working capacity. Increases in aggregate consumption in any country are associated with a growth in those problems that are most COmmon in that country. In many countries, including all the northern industrialized countries, despite some changes in drinking habits within the population, it is still adult males who constitute the vast majority of those with alcohol-related problems. Drinking by young people has sometimes risen more sharply than drinking by adults and is arousing special concern in some countries. Other issues that are of current interest in many parts of the world include the influence of mass tourism, the effect of increasing unemployment and the special problems of migrant workers and those who move from rural to urban areas.

- 3 -

2.1.3

Approaches to prevention and treatment

Of particular importance for the prevention of alcohol-related problems has been the emergence during the postwar period of a public health tren~ ~hat emphasizes two complementary approaches - namely, alcohol control ~ollcles and alcohol education. Having as their basis the proven aSsoclatlon between aggregate consumption and the prevalence of alcohol-related problems, alcohol control policies seek to influence availability through a variety of legal restrictions. These include taxation, licensing restrictions and regulations governing the production, distribution and marketing of alcoholic beverages. Alcohol education, either as a specific initiative or as part of a more general health promotion strategy, has increased in volume and intensity during this period in many countries, where it is seen as an important support for other control measures and even, in some cases, a prerequisite for them.

There has been a growing recognition of the essentially long-term nature of efforts to increase social awareness.

The predominantly medical response to alcohol-related problems has been modified during the last 15 years so that in many countries the treatment systems are now multi-sectoral in nature. Better integration between health, social and educational services remains an important goal for many countries. A WHO-coordinated project has listed a number of intervention policies that could be modified for use in many countries. Other international research has indicated that relatively low-cost interventions, if properly directed, could be just as effective as costly, highly technical specialist facilities. 2.2 2.2.1 Regional trends Alcohol consumption

The Western Pacific Region includes nations that vary greatly in population, resources and cultural background so that it is not surprising that their experiences in regard to alcohol and alcohol-related problems also differ widely. Per capita consumption varies greatly, ranging from less than one litre of absolute alcohol per annum (in some Pacific island developing countries) up to 10 litres in Australia. However, per capita consumption figures do not take into account differences in the distribution of alcohol within a population. In developing countries, the high proportion of children and those not substantially involved in a monetary economy drastically reduces the number among whom the available alcohol is shared. For example, it has been estimated that, at most, only 8% of the population of Papua New Guinea are regular drinkers. On that basis, the per capita consumption estimate for 1978 must be increased from 0.7 litres of absolute alcohol (based on total population) to 9.6 litres. Although the Western Pacific Region is currently of little significance in terms of the global alcohol market, Asia and Australasia/ Oceania recorded the largest increases in per capita consumption of alcohol in the period 1970-1977. Given the rapid social and economic changes taking place in the developing countries, the potential for a continued increase in alcohol consumption and alcohol-related problems in the Region is clear.

- 4 -

2.2.2

Alcohol-related problems

In the Region's developing countries, the problems perce~ved to relate to alcohol use include road accidents, criminal offences, marital breakdowns, impaired productivity, social disruption, vi~~:nce (both domestic and non-domestic) and public drunkenness. In Fiji, for example, over half the crimes committed in the period 1974-1976 were, according to the offenders, committed while under the influence of alcohol. Similarly, in Tonga in 1982, over 40% of assaults and acts of domestic violence were considered by the police to have been committed by people under the influence of alcohol. Solomon Islands recorded a 23% increase in major offences arising from the consumption of alcohol, as reported to the police, in the period 1975-1979. In some developing countries, the effects of alcohol on health have included not only the injuries caused by accidents and violence but also the effects of long-term consumption. In the Republic of Korea, for example, in recent years, 3-6% of psychiatric patients have been hospitalized for alcoholism and alcoholic psychosis. In West Malaysia, there was an increase of 32% in admissions for alcoholism from 1971 to 1980. There have been increases in alcohol-related problems in developed countries in the Region during the past two decades. Japan, Australia and New Zealand, all reported increases in hospitalization for alcoholism and in mortality from cirrhosis of the liver. Alcohol-related traffic accidents and morbidity were also considered significant in Australasia. 2.2.3 Production and marketing of alcohol

All governments in the region collect revenue from the taxation of alcohol and, in some countries, the government is also closely involved at the production stage. In those countries with developed market economies that were represented at the meeting, quasi-monopolistic corporations control the local production and marketing of alcohol. Among the developing countries in the region, examples of imports by transnational corporations and of local production under licence can both be found. Alcohol advertising and other forms of promotion are employed to increase the acceptability and status of alcohol use. Travel, including tourism, and improved communication technology have increased the international dissemination of lifestyles. Use of commercially produced and marketed alcohol is an important element in the Western lifestyle. Observation of tourist behaviour in developing countries may encourage the adoption of certain patterns of alcohol use, and this will be made all the easier by the availability of alcohol to meet the demands of the tourist trade. Strong positive associations between the images of alcohol and those of modernization and urbanization are also present in developing countries, reinforced by both expatriate and national models and by promotions by the alcohol industry. National controls on alcohol advertising have been eroded by the increasingly international communications network. Video cassettes watched in developing countries include alcohol advertising and the introduction of satellite television broadcasts may dramatically increase exposure to alcohol advertising.

- 5 -

2.2.4 Approaches to the control of alcohol-related problems . ~lmo~t all countries in the Western Pacific Region allow the sale and d1str1but1on of alcohol and many have only limited controls on its use No comprehensive national alcohol policies were reported. New Zealand ha; a ~ri~ten policy which ~alls for a reduction in per capita consumption, but 1t 1S that of the rat10nal advisory body and has not yet been endorsed by the government. No participating countries in the Region have policies for controlling the amount of alcohol produced or imported, except to ensure stable or increasing taxation revenue, but most of them do have controls on its distribution. In many countries, these regulations are not effectively enforced or else the only requirement is the payment of a licensing fee. The statutory regulations in existence commonly include the restriction of hours of sale and the prohibition of sales to minors. In the Republic of Korea, Malaysia and Japan this applies only to sales to minors for consumption on the premises. Local bans on sales of alcohol have been introduced (in Truk and temporarily in Simbu Province, Papua New Guinea) and, despite the existence of black markets, have had an impact upon availability and on alcohol-related problems. The promotion of alcohol is controlled at varying levels within the Region. Two of the developed countries, Japan and Australia, and at least two developing countries, the Republic of Korea and the Philippines, are by international standards, among those with the least restrictions on advertising. Other countries have SOme controls, such as a ban on direct alcohol advertising on television or radio (Malaysia and Solomon Islands) or a ban on certain types of alcohol advertising on television and radio (New Zealand and Fiji). In other countries, there are wider controls on other media, either by government regulation (Papua New Guinea) or by voluntary agreement (Samoa, Vanuatu). In most countries, some level of promotional activity, such as the distribution of paraphernalia advertising brand names and sponsorship, does exist. Many countries in the Region have legislation prOhibiting driving under the influence of alcohol. In the developed countries, this is enforced by means of breath or blood analysis and some developing countries such as Papua New Guinea are now considering similar steps. In developed countries, education campaigns use a variety of methods and tend to focus on promoting "moderate" or "appropriate" drinking. Other major educational efforts in Australasia have concentrated on discouraging drinking before driving. More recently, attention has focused on encouraging people to substitute non-alcoholic beverages for alcohol. In some developing countries, limited efforts at alcohol education have been made (Papua New Guinea) and in others, such as Malaysia and many Polynesian islands, religious education prohibits alcohol use. General lifestyle education programmes exist in some developing countries (the Philippines and the Trust Territory of the Pacific Islands and focus upon broader issues of health promotion.

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2.3

Role of WHO

During this period, WHO has become increasingly co~cerned about the adverse public health consequences of the upward trend 1n alcohol consumption throughout the world. The description of the alcohol dependence syndrome, the charting of existing preventive efforts by countries and of community responses and the encouragement of comprehensive national alcohol policies are all WHO initiatives that are essential for attaining the goal of health for all through primary health care. Through the research it has sponsored and through resolutions passed at the World. Health Assembly in 1979 (WHA32.40) and 1983 (WHA36.12) and by the Western Pacific Regional Committee in 1982 (WPR/RC33.Rl5), WHO has made its commitment to a strong and vigorous alcohol programme crystal clear. The commitment was reinforced by the Technical Discussions at the 35th World Health Assembly, which brought together evidence of concern from over 80 Member States, and served as a basis for discussions between them and WHO on the place of efforts to control alcohol-related problems in national health planning as a whole. What is essential now, as countries continue their efforts to develop their own policies, is that the results of those efforts should be consistent with the holistic concept of health. In the future, WHO can play an important part both by disseminating appropriate techniques and by supporting and encouraging comprehensive national alcohol policies and programmes as an integral part of the global and regional strategy of health for all through primary health care. Increasing alcohol consumption and increasing alcohol-related problems are certainly incompatible with achieving health for all by the year 2000.

3.

NATIONAL POLICIES ON ALCOHOL-RELATED PROBLEMS

3.1

Essential components of national alcohol policies

The Technical Discussions at the 35th World Health Assembly focused on the efforts of countries to formulate national alcohol policies as part and parcel of national health planning. The importance of this theme was reinforced by the resolution of the Regional Committee for the Western Pacific (WPR/RC33.R1S) later that year and by the subsequent resolution (WHA36.12) of the World Health Assembly in 1983. However, comprehensive national alcohol policies are, as yet, far from common and some countries

are less well prepared than others to begin the process of policy formulation. Tne main purpose of a comprehensive national alcohol policy is to acnieve a proper balance between economic and public-health interests. In the past, economic interests have dominated alcohol policy in most countries; efforts are now needed to formulate policies that will limit supply and demand and thereby reduce alcohol-related problems.

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3.1.1

Measure designed to limit the alcohol supply (a) Regulation of production by: - controlling commercially produced output; - controlling domestic and/or illegal output; controlling imports; - controlling agricultural supplies; - State control of the means of production.

(b)

Regulation of distribution by: - controlling the number and location of retail outlets; - laying down hours of permitted sale; - setting a minimum age for purchase;

- forbidding sale to intoxicated persons; - rationing sales;

- enforcing laws on illegal sales. (c) Taxation on: - production; - sale;

- imports; - advertising (by removing tax-deductible status). (d) International agreements: - on cessation of duty-free sales.; - against increasing access through trade agreements. 3.1.2 Measures designed to limit demand for alcohol (a) Regulation of advertising by: (b) a total or partial ban (possibly specific to some media); limitation to point of sale only; a statutory code of practice; control over sponsorship of sporting, cultural or other events;

International agreements: - to restrict cross-national advertising and promotion.

(d

Regulation of consumption by: - pricing policy (see 3.1.1); - provision of alternative (non-alcoholic) beverages.

(d)

Education of: - the general public; - specific high-risk groups; - professional workers; - opinion leaders.

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3.1.2

Measures designed to reduce alcohol-related problems (a) Reduction of acute problems by: preventing - preventing preventing - preventing - preventing (b) traffic accidents; other accidents; violent and non-violent crime; family problems; public drunkenness.

Reduction of chronic problems by: early. diagnosis and intervention; improved treatment at primary health care level; improved specialist treatment; improved referral procedures.

(c)

The training of: - health and social welfare workers; - law enforcement officers; - bar staff.

While these lists are not exhaustive, they indicate the main areas that need to be covered in a comprehensive national alcohol policy. Suggestions of programmes of action for many of these areas are included in the frameworks in Section 4 of this report. Not every country will choose to act in all the suggested areas; indeed, some measures listed above represent alternative approaches. Equally, the policy once developed, will not be immutable; as cirumstances change, so the policy will need to change with them. The process of developing a policy will, therefore, be a continuous one. not in any way static.

3.2

Cooperation

The successful implementation of a national alcohol policy requires cooperation between a variety of both governmental and non-governmental bodies. In the initial stages, it is necessary for those with an awareness of the extent of existing and potential alcohol-related problems to communicate that awareness to policy-makers in other relevant sectors in order to make it easier to draw up a national alcohol policy. Continuous intersectoral cooperation will also be needed for implementing and evaluating the national policy once it has been laid down. 3.2.1 Control of supply and demand

The design of measures to control supply and demand (3.1.1 and 3.1.2) will require collaboration between government departments with a responsibility for handling alcohol-related problems (health, social welfare, justice, education) and non-governmental organizations with 5

imilar c·)ncerns (such as welfare, religious and women's organizations,

consumer protection groups and voluntary organizations concerned with treating alcoholics). Collectively, they may be able to obtain cooperation from government departments (finance, trade, agriculture, employment and

- 9 -

tourism) with a role to play in establishing or mainta1n1ng controls on the availability of alcohol. In addition, a national alcohol policy will involve the business interests engaged in producing. importing. distributing and marketing alcohol. the media. the advertising industry and local retailers of alcohol. 3.2.2 Reduction of alcohol-related problems For example, countries with a

The reduction of specific alcohol-related problems (3.1.3) will al.o require cooperation between various sectors.

significant rate of alcohol-related traffic accidents may take steps to reduce their incidence in a variety of ways. such as the introduction of breath analysis for alcohol. the provision of alternative (non-alcoholic) beverages. the provision of alternative modes of transport. the improvement of roads and the education of consumers. These measures would involve the cooperation of agencies such as transport officers and police, retailers and caterers. the public transport industry, licensing authorities, civil engineers, trade unionists, employers, educationalists and those dispensing

primary health care. In co~ntries that assign priority to preventing male drunkenness. the methods debated might include determination of the optimal price for alcohol. payment of wages at shorter intervals. non-continuous and brief licensing hours. the sale of alcohol only with food. the training of bar staff and publicity campaigns to increase social intolerance of drunkenness and the consumer's awareness of its detrimental effects on health. prestige and financial status. The development and implementation of these methods would again require active cooperation between a variety of organizations. 3.2.3 Mechanisms for national collaboration and coordination

If a comprehensive national policy is to be devised. specific arrangements for continuously monitoring progress will be needed. such as the establishment of a national coordinating body. When such 3 body is being established. consideration should be given to its function (advisory or with specific powers). its funding (source. extent and stability) and its representativity (members from problem-handling agencies. government departments concerned with alcohol issues. the alcohol industry. the media and others with a role to play in specific strategies). An advisory body has been establiShed in New Zealand which is funded from a small additional levy on alcohol sales. It is under the jurisdiction of the Minister of Justice and includes representatives from the Ministries of Health and Social Welfare and the Treasury. Among the Government-appointed individual members is a senior representative of the alcohol industry. An alternative would be a regular meeting of government ministers chaired'by the prime minister or deputy prime minister. Whatever arrangements are made in a particular country, regular meetings are

essential. so that policies previously seen exclusively as matters of commerce. urban development, entertainment or tourism. can then be examined from the public-health viewpoint.

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3.2.4

Mechanisms for regional collaboration

Although comprehensive national policies must be designed and implemented ·with due regard to specific cultural features, regional collaboration is valuable in encouraging the development of prevention policies. Intraregional collaboration is useful in illuminating the similarities in regions with shared histories (such as the introduction of alcoholss part of the colonization process in the South Pacific) and the differences in ways of handling alcohol that have grown up in different cultural contexts.

3.3

Educational approaches

As alcohol-related problems increase in developing countries, the design and implementation of educational strategies that are relevant to the special problems of developing countries and take account of the high proportion of young people in the population becomes increasingly urgent. A clear idea of the most pressing alcohol-related problems in developing countries is therefore essential, so that programmes can be designed to try to solve them. Many of the priority problems for developing countries are those associated with acute intoxication. Drunkenness is itself a problem when it leads to violence, crime or accidents, especially traffic accidents. Although health problems take a longer time to develop, they are likely to become of increasing importance. Closely interlinked are personal problems, especially in relation to the family, economic problems related to overspending on alcohol and social problems, which may result in the rejection of the individual by the rest of the community. Although these problems may affect any member of society, adolescent drinking sometimes causes particular concern in developing countries. Both parents and teachers can provide good or bad examples of how to handle alcohol. If alcohol education concentrates only upon imparting information, it may not seem relevant to young people; facts need to be firmly rooted in experience. Education has a dual role to play: first, in creating and heightening social awareness and concern among people about alcohol-related problems and providing them with practical means of avoiding or alleviating those problems; and second, by influencing key decision-makers to look at policy development from the standpoint of public health. 3.4 Role of the health sector

Health professionals can playa vital role in prevention, early intervention and treatment with respect to alcohol-related problems. The majority of persons attending rehabilitation services have consulted health and welfare professionals over a period of many years regarding variety of alcohol-related problems that in general have not been recognized as such, so that no attempt has been made to influence and reduce alcohol consumption. Nevertheless, evaluative research has indicated that in the great majority of cases, a small amount of well-directed care given early produces results fully comparable with those of more intensive rehabilitation programmes at a later stage.

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Most of the care needed should be provided as part of routine health services by heath professionals who are not specialists in alcohol-related problems. If this is to be the case, greater emphasis must be placed on the concept, recognition and management of alcohol dependence and alcohol-related disabilities in the prequalification and postqualification training of all health professionals. Some professionals from a variety of disciplines, including medicine, nursing and social work, should be given special training in respect of alcohol-related problems. They would then be equipped to provide direct treatment services within the general health system, but more significantly to function as consultants and teachers for other health professionals. Professionals have a key role as community leaders working either as individuals or through their various professional bodies such as medical associations. They can help influence community attitudes towards the promotion of responsible drinking behaviour and the rejection of irresponsible or hazardous drinking. They can also help to create support within the community for the introduction of control measures that would allow maximum benefit to be derived from alcohol consumption of at least social and economic cost.

4.

FRAMEWORKS FOR NATIONAL POLICIES

The part1c1pants divided into two groups in order to draw up frameworks for the formulation of national alcohol policies for developing countries. In doing so, they followed the sequence of processes used to develop national health policies, namely: (a) Situation analysis

To discover what has been done, what is being done and what remains to be done in respect of alcohol-related problems in any particular country. (b) Broad Objective

To define the main purpose of a comprehensive national alcohol policy. (c) Detailed objectives

To translate the broad objective into a series of specific goals, possibly including actual targets that appear feasible within a specific time. (d) Master plan of action

To determine the priorities to be assigned to the different detailed objectives and to indicate the general policies that can be.adopt~d, including the main lines of action to be followed (but ~ Lnclud1ng specific activities).

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(e)

Programme of activities

To convert the master plan into a series of detailed programmes of activities specifying objectives and targets, indicating their sequence and the time required for their implementation. (f) Programme managememt and resources

To translate the programme of activities into operational terms, noting responsibility for management and for service delivery; to determine the resources (manpower, finance, expertise) necessary for implementation and to find out to what extent those resources are available. (g) Linkages

To determine the national and sub-national interest groups, both within and outside the government, that should be drawn into the formulation and implementation of a national alcohol policy, and to indicate ways of establishing linkages with them; to list, the relevant international bodies. (h) Monitoring, evaluation and indicators

To develop systems to assess the effectiveness of policies with a view to improving their impact and increasing their efficiency. The frameworks designed by the two groups for alcohol policies in developing countries are included here in full. The membership of the groups was as follows: Group A Dr Dr Dr Dr Dr Mr Dr

s. Morey, Australia M. Nishiyama, Japan C. Imako, Papua New Guinea L. Manapsa!, Philippines D.H. Lee, Republic of Korea s. Wolfgramm, Tonga (Chairman) M. Grant, Temporary Adviser

Group B Ms M. Rokosawa, Fiji (Chairman) Dr R.B. Ramlee, Malaysia Mrs E. Martillano, Philippines Mr S. Fangaria, Solomon Islands Mr V. Alphons, Trust Territory of the Pacific Islands Dr S. Casswell, Temporary Adviser Dr N. Shinfuku, Operational Officer

I

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4.1 4.1.1

Framework A Situational analysis

In developing health programmes and policies regarding alcohol-related problems, the current situation must be assessed taking into aCcount population, health status, health resources and ecological factors. This is especially important in order to obtain the necessary baseline information, much of which can usually be derived from reports. On the basis of that information, it may be possible to determine the current and expected problems together with their causes. It is therefore important to bear in mind certain demographic and other variables when planning such a programme. (a) population

It is important to study the composition and age distribution of the population, and especially the number of people aged 15-44 years - the most active group. High consumption of alcohol will certainly have an impact on extent to which they use the health services and health resourCes. It is also important to know the degree of urbanization, since larger numbers of people in the urban. areas consume alcohol than in the rural areas. (b) Mortality and morbidity

These are important crude indicators, especially with reference to certain diseases, such as cirrhosis of the liver. In morbidity statistics, however, problems do arise with regard to the accuracy of diagnosis. In some countries, hospital records may even fail to give the information required. (c) Socioeconomic status

Rises in the socioeconomic status of consumers lead to increases in

consumption. It is important to determine whether alcohol-related problems are prevalent in certain occupational groups or certain social strata. (d) Health status

Analysis and assessment of the present state of health of the population makes it possible to forecast future trends in mortality, morbidity and hospitalization by cause. (e) Traffic accidents

A high percentage of traffic accidents are caused by those who drink heavily. It may be necessary to deal with high-risk drivers as a priority problem in many countries. (f) ~

The country profiles (see Annex 5), especially from the developing countries, indicate that a significant proprotion of crimes are committed under the influence of alcohol.

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(g)

Social problems

Excessive drinking is an important factor in many social problems, such as marital disputes, assault and disorderly behaviour. (h) Religion

SOlne religious organizations play an important role in regard to alcohol consumption, particularly when their doctrine prohibits drinking. (i) Literacy rate

This indicator is essential for planning educational measures. Availability of alcohol As the availability of alcoholic beverages increases, so does the per capita consumption and, in many cases, in developing countries the percentage of the population consuming alcohol. It is therefore important to list all available information on the following topics: (a) (b) (c) (d) (e) (f) production - both commercial and domestic; imports and exports - total amount of all types of alcoholic beverages; marketing and advertising; taxation - any tax imposed on manufacture and sales, including imports and exports; alcohol outlets (illegal and legal) - any registration or licensing system; the history of alcohol control - any attempt to control alcohol consumption, production and distribution or to solve related problems.

Consumption Information on actual consumption, which is important for planning purposes, should COVer: (a) (b) (c) (d)

type of alcoholic beverages; content in terms of percentage of ethanol; consumption per head; age, sex and socioeconomic status in relation to consumption patterns;

(e)

drinking patterns.

- 15 -

Interest groups In developing any national programme, key interest groups should first be determined in: (a) (b) (c) the government; non-governmental organizations; international bodies.

The group agreed that, while not all of the above information would be readily available in many developing countries, the absence of Bome data should not be used as an excuse for lack of action in formulating a national policy. 4.1.2 Broad objective

To bring alcohol consumption to a level compatible with optimum health for the population and optimum socioeconomic development for the country. Five specific subsidiary objectives were also distinguished. 4.1.3 Determination of priorities among specific objectives

Essential in planning any programme is the setting of priorities, which requires clear judgements to be made. The group drew up criteria for ranking specific objectives derived from the bro~d objective. (a) (b) (c) (d) (e) Do effective techniques exist to reduce or control each of the alcohol-related problems listed? Are the techniques applicable in the particular country? Could they be applied in the localities? Does the multiplicity of effects of alcohol abuse lead to a need for wide-ranging action? Does a particular objective explicity express concerns important to the community?

On the basis of these criteria, the specific objectives were given the following order of priority:

Objective No.1 - To reduce acute alcohol-related problems (accidents, domestic violence, violent crimes, non-violent crimes). Methods (a) Road accidents (i) (ii) Compulsory breath testing or blood testing of drivers after accidents. Random breath testing of drivers.

- 16 -

(iii) (iv) (v) (vi) (vii) (viii) lix) (x) (xi) (b)

Introduction of legislation making wearing of seat belts compulsory. Enforcement of increased penalties for drunken driving convictions. Adequate licensing and testing for fitness of vehicles. Better design of roads. Reduction of driving offences by means of stricter enforcement of the law. Improved training of law enforcement officers. Provision of adequate alternative public transport systems. Improved systems for reporting the role of alcohol 'n traffic accidents. Educational programmes directed towards the general public and specific target groups, including teenagers.

Other accidents (i) (ii) Improved reporting of the role of alcohol in accidents at work. Programme to ensure early recognition of alcohol-related problems in the working environment.

(c)

Domestic violence (i) (ii) Improved reporting of the role of alcohol in domestic problems of all kinds. Community education programmes, emphasizing local support systems (both formal and informal).

(d)

Crime (i) (ii) Improved reporting of the role of alcohol in violent and non-violent crimes. Provision of counselling services during, or as an alternative to, the serving of prison sentences.

(e)

All acute alcohol-related problems (i) Training programmes, preferably on a multiprofessional basis, for primary health care workers, welfare workers, social workers, health counselling officers, teachers and law enforcement personnel.

- 17 -

Objective No.2 - To regulate the production and marketing of alcohol. Methods (a) Limitation of sales of alcoholic beverages (i) (ii) (iii) (iv) (b) Place of sale - to introduce legal and enforceable registration procedures. Time - to set specific hours of opening for all liquor outlets. To set a minimum age for purchasers. To introduce rationing systems to control consumption levels.

Taxation (i) (ii) To impose heavy taxes on manufacture, sale and importation, such taxes to be regularly reviewed. To increase prices under a public-heaLth-oriented pricing policy.

(c)

Limitations on advertising (i) (ii) (iii) (iv) Television and radio. Newspapers and other print media. Limitation of sports and other sponsorship by alcohol manufacturers. Inclusion of a health warning on the labels of alcohol beverages.

(d) (e)

Limitation of imports Strengthening of the responsible authorities and allocation of additional manpower in order to detect illegal production and illegal sales of alcohol. Review of any application from a local or forei~n body to establish a brewery or any other alcohol-production facility by an interministerial committee, which must include the Minister of Health as an active member.

(f)

- 18 -

Objective No.3 - To identify and reduce relevant alcohol-related problems. Methods (a) Emphasis should be laid on diagnosis and early intervention, with appropriate training of all health professionals, especially supplementary health workers at the peripheral level. In view of the dearth of trained psychiatrists special efforts must be made to increase training in mental health among auxiliary staff at all levels. Public awareness campaigns, spearheaded by health education officers, should be launched to increase understanding of the long-term health consequences of excessive drinking. Adolescent girls and pregnant women should be given adequate information on possible fetal abnormalities resulting from excessive drinking. Appropriate research should be initiated and improved reporting systems adopted so that trends can be monitored with a view to determining the priority health problems, especially in developing countries.

(b)

(c)

(d)

(e)

Objective No.4 - To ensure that greater weight is given to the public health implications in political decision-making. Methods (a) Establishment of an interministerial committee to consider matters relating to the production and importation of alcohol and to advise the government on matters pertaining to alcohol-related problems. This committee should be chaired by the highest possible person, preferably the Prime Minister or Deputy Prime Minister, and should also consider the possibilities of establishing a statutory national body. The proportion of the gross national product used for importing alcoholic beverages should be reduced. The help of professional bodies such as the Medical Association should be enlisted when aspects of alcohol policy are being discussed. The views of influential leaders in both urban and rural areas should be sought before decisions are taken. Government officials and members of parliament should be made aware of the issues.

(b) (c)

(d) (e)

- 19 -

Objective No.5 - To establish a maximum acceptable level of alcohol consumption. Methods (a)

Since it is difficult to propose any specific level of alcohol consumption that is acceptable to society and compatible with health, it is clear that this objective requires a variety of research activities, before approaches can be selected~ (i) A survey of drinking habits in order to define what 1S meant, in each country, by light, moderate and heavy drinking. Population surveys of consumer opinion, especially in relation to use of leisure. Research to determine the high-risk groups, possibly including teen-agers, drivers and the unemployed.

(ii) (iii) (b) (c)

Implementation of a range of long-term educational programmes. Mechanisms to coordinate the contributions of all the interest groups concerned. The involvement of religious groups should be sought in order to provide positive models of abstinence. Introduction of low-alcohol-content and alcohol-free beverages and the provision of safe drinking water.

(d) 4.1.4

Monitoring, evaluation and indicators

In order to assess the effectiveness of these methods, a number of indicators can be used for future planning~ (a) (b) (c) (d) (e) (f) (g) (h) Traffic accidents and accidents at work Domestic violence Violent crimes Non-violent crimes Relevant diseases and health problems Per capita consumption Political factors (consumers' associations, etc.) Commercial factors

These indicators should be expressed in numerical terms, so far as possible. Case studies on the history of the development of alcohol policies should also be undertaken. A narrative description of what has been done may be useful, both to the country itself and for the exchange of information and experience with other countries.

- 20 -

4.2 4.2.1

Framework B Situation analysis

Under this heading, the group discussed the issues of target population, the amount of alcohol consumed, alcohol-related problems, the availability of alcohol, and current attitudes and programmes. (a) Target population

In developing countries, the population pyramid is usually very heavy at the base, about 50% of the population being young. This factor needs to be borne in mind, because if young people drink to excess, their problems will have far-reaching and long-term effects on the country since they form such a large percentage of the population. The group also bore in mind the economic differences between areas, where most people work for wages or salaries (i.e. for cash), and rural areas where, with certain exceptions, people live by subsistence agriculture and cash transactions are relatively uncommon. Urban dwellers thus have more opportunities of purchasing and drinking alcohol than the rural population. (b) Consumption of alcohol

The rate of alcohol consumption in many developing countries is about 1 litre a year per member of the adult population. However, the general trend seems to be for consumption to increase steeply and becomes all the more marked if it is remembered that in develo~ing countries it is usually only a small sector (viz. the urban population) that is consuming the alcohol represented in national consumption statistics. Furthermore, although people in the rural areas cannot afford alcohol, they do make their own (for example, yagona, coconut toddy and samsu) and there is no information available either on the volume consumed or on the extent of the related problems. (c) Alcohol-related problems

In developing countries, the main problems caused by alcohol are family disputes, criminal offences, violence in the family and the community, medical problems and traffic offences. The group considered that serious medical problems arising from excessive alcohol consumption were a feature of the developed countries. Accordingly, while at the moment they do not warrant high priority in developing countries, their importance will probably increase as those countries develop. The developing countries should begin now to devise ways and means of dealing with these problems as they arise. Intervention in the early stages would be preferable.

lIn most developing countries in the Region, the urban popuLation represents between 20% and 30% of the total.

- 21 -

(d)

Availability (production, imports, distribution and marketing)

Increases in local production and/or imports are taking place. The transnational corporations are increasingly using the developing countries as dumping grounds for their surplus goods. There is little control over local retailing of alcohol. Although in most developing countries there are licensing boards to control distribution, in reality the lack of effective enforcement leads to abuses. Increased and effective advertising leads to increased sales of alcohol and raises the question of how much of the producers' budget is spent on advertising. (e) Current attitudes and programmes

The group considered the various developing countries in the Region from the point of view of the acceptance of drinking by society, programmes of education, programmes to control availability and programmes to control specific problems. There are varying degrees of acceptance of alcohol in developing countries ranging from Malaysia's bans, based on Muslim beliefs, to more permissiveness in other developing countries. However, most countries seemed to be concerned enough to have devised measures of control in the following fields: (i) Education - youth programmes and life enrichment programmes - religious education (Malaysia) - temperance movements (Fiji and the Philippines) government and private-sector counselling (Fiji and Solomon Islands) treatment: hospitals, health centres, mental health centres and Alcoholics Anonymous in most countries. (ii) Specific problems - drunken-driving laws (in most countries) - periodic bans on availability (during elections in the Philippines and Micronesia) legislation and regulations on public consumption and drunkenness (Fiji, the Philippines and Solomon Islands). (iii) Availability - controlling legislation exists in most countries but always enforced. - age restrictions advertising controls exist but are not always implemented or are not strong enough. lS

not

- 22 -

4.2.2

Objectives

Broad objective - the reduction and/or prevention of alcohol-related problems as part of the strategy of health for all by the year 2000. 4.2.3 Detailed objectives (1) (2) (3) (4) 4.2.4 Immediate stabilization of the production and importation of alcohol. Education of the public in good drinking habits and advertising of alcohol to a minimum. Reduction in mortality and morbidity from road accidents, violence and health problems considered attributable to alcohol. The launching of research to collect information on alcohol and related issues.

Master plan of action General

(1) Establishment by law of a National Committee to study, recommend, coordinate, and/or implement strategies to achieve the detailed objectives set 'and the attribution to the Committee of certain legislative powers to enable it to operate effectively. (2) Financing of the National Committee's activities by means of a levy on taxes on alcohol. (3) Inclusion in the National Committee of representatives of the government ministries responsible for the social services, trade and industry and of representatives of the private sector, especially the manufacturers of alcohol consumers and the community at large. To implement objective 1 (1) Stabilization of the number of licenses issued to manufacturers and distributors in accordance with the number of adults living in the area. (2) (3) Stabilization of the amount of alcohol produced on the same basis. Stabilization of the amount of alcohol imported.

(4) Study and monitoring by the international agencies of the production and distribution of alcoholic beverages in both developed and developing countries.

- 23 -

To implement objective 2 (1) Education of all groups to discourage excessive drinking.

(2) Counselling against excessive drinking dispensed by primary health care workers. (3) Encouragement by teachers, social workers, community leaders and other agents of sectoral participation in measures to curb excessive drinking. (4) Banning of advertisements by manufacturers and distributors of alcohol. (5) The monitoring by international agencies of advertising by transnational manufacturers.

To implement obiective 3 (1) Promotion of non-alcoholic beverages at affordable prices.

(2) Limitations on licensing hours and conditions of sale to encourage the consumption of food with alcohol. (3) Stricter enforcement of existing legislation to prohibit driving under the influence of alcohol. (4) (5) Introduction of compulsory breath-analysis. A review of penalties for offences against liquor laws. minors, the introduction drinking, including the use of liquor from automatic vending recreation that do not sell

(6) With a view to curbing drinking by and/or enforcement of laws against such identity cards, the banning of sales of machines and the provision of places of alcohol.

(7) Improvement of the condition of roads, road lighting and motor vehicles. (8) The training of bar staff to discourage them from serving alcohol to intoxicated persons. (9) Improvement of history-taking from patients suffering from alcohol-related ailments. To implement objective 4 (1) Determination by the National Committee on Alcohol of the types of information it will require for the proper exercise of its functions, followed by a request to the institutions concerned (e.g. breweries, distilleries, Customs, police, hospitals, etc.) to submit such information to it regularly.

- 24 -

(2) Mandatory submission of said information to the National Committee on Alcohol under the terms of the Act establishing the Committee.

(3) Analysis of the information, including determination of the social and economic costs of drinking to the individual, the family and the country. (4) Study of the role of indigenous alcoholic beverages in order to determine their contribution to alcohol-related problems. (5) Research by the National Committee on Alcohol into drinking habits in the country. 4.2.5 Programme management and resources

The group, while aware that each country must organize programmes in line with its own needs and the available resources, called for the following basic programmes: (1) Designation by the government of one of the social services ministries (health, education, youth, social welfare) to spearhead the programmes. (2) Where possible, integration of alcohol-related programmes into existing programmes. (3) The provision of finance, technology and export services, taking into consideration the stage of development and each developing country, by developed countries and international agencies. 4.2.6 Linkages

National and international exchanges of training materials, research results and manpower. 4.2.7 Monitoring, evaluation and indicators

Depending on the needs of each developing country, finance and expertise should be provided from developed countries and from international agencies to ensure continuous evaluation of the effectiveness of its programmes. 4.3 National policies in developed countries

Although the groups did not have sufficient time to formulate detailed frames for alcohol policies relevant to the needs of developed countries, the principal elements for such policies can be readily determined. Indeed, it is the similarities rather than the differences between the policies for developing and developed countries that are their most striking features. Two preliminary points, however, need to be made. Firstly, since many developed countries are major exporters of alcohol to developing countries, they must recognize in their policy formulation that they have international as well as national responsibilities. Secondly, since developing countries do not have the resources required to undertake

- 25 -

socio-behavioural and other research, developed countries should give special emphasis to such research efforts, which are likely to have a significant long-term impact upon global alcohol problems. Reviewing the list of essential components of national alcohol policies (3.1.1 - 3.1.3) and comparing them with Frameworks A and B makes it clear that developed countries also need to take action to restrict the alcohol supply, to limit demand and to solve specific alcohol-related problems. Since developed countries are not necessarily any further advanced in the formulation of public-health-oriented alcohol policies than developing countries, the same collaborative efforts are required to stimulate and sustain action. Thus, the main focus of policy formulation remains the same - namely, to undertake linked and coordinated programmes of activity in all three areas. Strategies to prevent alcohol-related problems require simultaneous measures to limit both supply and demand. Consideration of economic issues relating to the production, distribution and marketing of alcohol in developed countries requires to be balanced as in developing countries, by greater emphasis on the public-health aspects of the problem. There are, nevertheless, some important differences in emphasis in alcohol policies relevant to the needs of developed countries. First, it is likely that more extensive and more accurate data will be available regarding production, consumption and alcohol-related problems. The existence of such data should make it possible to determine the most important problems and trends and they can also be used to monitor progress. Similarly, since education and health care systems are likely to be more extensively developed, it may often be possible to integrate specific programmes of action into existing structures without putting undue strain on resources. A somewhat different pattern of response will be required from many developing countries, where acute problems dominate the picture. Although developed countries also experience these acute problems, they bear the additional burden of requiring more extensive treatment services to deal with chronic health problems resulting from prolonged excessive drinking. By contrast, in some specific areas, such as driving under the influence of alcohol, many developed countries may already have taken the very steps that were listed in both frameworks as being of urgent importance in developing countries. Perhaps the most striking difference with regard to alcohol policy formulation relates to the distribution of drinkers within the population. Although not universally the case, there is a tendency in many developing countries for the drinking to be done by a relatively smaller proportion of the population, particularly those in urban rather than rural areas. In many developed countries, drinking is more evenly spread amongst the majority of the population. This difference is an important reminder of the need to plan alcohol policies to meet the particular needs of particular countries as an integral part of national efforts to achieve health for all.

- 26 -

5.

CONCLUSIONS

The participants came to the following conclusions which could form the basis for national action as well as for WHO's collaboration at regional national levels: 5.1 The formulation of comprehensive and integrated national policies on alcohol-related problems

All the participants recognized alcohol-related problems as major public health and social problems requiring immediate national policies. Among the participating countries, very few have an integrated national policy on alcohol. In most of the countries, particularly in developing countries, economic interests were said to outweigh health considerations at governmental level. It is therefore essential to make politicians aware of the issues and enlist their support in the formulation of a well-balanced national alcohol policy. This can be done by Member States establishing multisectoral national coordinating bodies for the prevention of alcohol problems, including the prevention and control of alcohol-related health and social problems. 5.2 National and regional need for valid and accurate data on alcohol supply, alcohol consumption and alcohol-related problems

In many countries of the Western Pacific Region, some data are urgently needed on which to base the development and evaluation of alcohol policies and problem prevention policies. Some countries may require special help in designing and operating data gathering systems that are appropriate to their needs and their social and economic conditions, as well as offering opportunities for cross-cultural comparisons. 5.3 Health manpower development for the prevention and control of alcohol-related problems

Very few countries include alcohol-related problems among their targets for health for all by the year 2000. The involvement of health personnel in alcohol problems is sometimes limited to the treatment and rehabilitation of alcohol dependence in specialized institutions. There is a lack of training for health personnel, school teachers, law enforcement officers, administrators, etc. on the prevention and control of

alcohol-related problems.

- 27/28 -

Regional training courses on alcohol problems will be the most effective way of suggesting to administrators and health officers in developing countries where alcohol problems are arising means of reducing their seriousness. 5.4 Promoting social awareness of the problems of alcohol and discouraging excessive drinking

In many developing countries, the public is exposed to repeated advertising of alcoholic drinks. The drinking of alcohol, particularly beer, is considered in some cases to symboli~e social and economic status and a more sophisticated lifestyle. There are virtually no restrictions on alcohol advertising in developing countries. The public is not fully warned of the health and social ha~ards of alcohol. 5.5 Development of national and regional resources for behavioural research on alcohol-related problems

Alcohol drinking is causing various kinds of socio-behavioural problems such as violence, road traffic accidents, crime, marital disruption and mental health problems in children. In most of the countries of the Western Pacific, there has been very little research on psycho-behavioural aspects of alcohol-related problems. It was noted that the Regional Working Group on Alcohol-Related Problems in 1980 in Tokyo recommended the establishment of WHO collaborating centres in the Western Pacific Region for research, training, the promotion of prevention and exchange of information in the field of alcohol-related problems. Research activities could include the topics most relevant to the Western Pacific Region, such as the effects of rapid urbanization and tourism.

- 29/30 ANNEX 1

OBJECTIVES OF THE WORKSHOP

(1) To review the nature and magnitude of alcohol-related problems in countries or areas of the Region, the "resources already available for reducing their prevalence and impact, and the possible constraints to be overcome in establishing new programmes. (2) To prepare a framework for the design, implementation and evaluation of programmes, including the prevention, treatment and social integration aspects of the control of alcohol-related problems, as an integral part of the strategy for health for all through primary healtn care.

- 31/32 ANNEX 2

PROVISIONAL AGENDA

1. 2.

Opening ceremony Guidelines for the Workshop Presentation of country profiles Global and regional trends on alcohol-related problems National policies on alcohol-related problems Preparation of the framework Suggestions for future actions Review and adoption of the report Evaluation of the Workshop Closing ceremony

3. 4.

5. 6.

7. 8.

~

9.

10.

- 33 ANNEX 3

PROVISIONAL LIST OF PARTICIPANTS, TEMPORARY ADVISERS, OBSERVERS AND SECRETARIAT

1. AUSTRALIA

PARTICIPANTS

Dr Susan Morey Director Department of Community Medicine Royal Prince Alfred Hospital Sydney Ms Merewalesi Rokosawa Research Officer and Acting Assistant Director Social Welfare Department P.O. Box Government Buildings Suva Dr Masanori Nishiyama Medical Officer and Deputy Director Mental Health Division Public Health Bureau Ministry of Health and Welfare Japanese Government 1-2-2, Kasumigaseki Chiyoda-ku Tokyo 100 Dr Ramlee Bin Rahmat Acting Assistant-Director of Health Services (Health Education) Ministry of Health 'E' 3rd Floor Offices Complex Jalan Dungun, Damansara Heights Kuala Lumpur Dr Cyril Imako Medical Officer c/o Division of Health P.O. Box 635 Arawa North Solomons Province

FIJI

JAPAN

MALAYSIA

PAPUA NEW GUINEA

- 34 Annex 3 PHILIPPINES Dr Lina Manapsal Head Executive Assistant Ministry of Health Manila Ms Edita G. Martillano National Executive Director Philippine Mental Health Association 18 Eas t Avenue Que1;on City REPUBLIC OF KOREA Dr Dae-Hie Lee Neuropsychiatric Department 30-1, Choong-Kok Dong Sung Dong Ku Seoul Mr Samuel Fangaria Assistant Social Development Officer Ministry of Employment, Youth and Social Development P.O. Box G20 Honiara

SOLOMON ISLANDS

TONGA

Mr Sione T. Wolfgramm Health Planning Officer Vaiola Hospital Ministry of Health P.O. Box 59 Tonga Mr Venansio Alphons Executive Director Micronesian Bound, Inc. P.O. Box 326 Kolonia Ponape E.E. Is. 96941 2. TEMPORARY ADVISERS Dr Marcus Grant Director Alcohol Education Centre The Maudsley Hospital 99 Denmark Hill London SE5 8AZ Dr Sally Casswell Executive Director

TRUST TERRITORY OF THE PACIFIC ISLANDS

Alcohol Research Unit School of Medicine University of Auckland Private Bag Auckland New Zealand

- 35/36 Annex 3

4.

SECRETARIAT

Dr Naotaka Shinfuku (Operational officer) Regional Adviser in Mental Health and Drug Dependence WHO Regional Office for the Western Pacific Manila Mr H.S. Dhillon Chief Human Resource Development WHO Regional Office for the Western Pacific Manila

- 37 ANNEX 4

OPENING SPEECH OF THE REGIONAL DIRECTOR FOR THE REGIONAL WORKSHOP ON ALCOHOL-RELATED PROBLEMS MANILA, 8-12 AUGUST 1983

Distinguished Participants, Ladies and Gentlemen, It gives me great pleasure to welcome you today to the WHO Regional Office for the Western Pacific to take part in the Regional Workshop on Alcohol-Related Problems which is being held in this Office until 12 August 1983. As you are .well aware, there has been an alarming increase in the consumption of alcohol and in the magnitude of alcohol-related problems in many countries of the Region. Alcohol-related problems are no longer the exclusive concern of developed countries and are becoming an increasingly important public health problem in many developing count.ries. The World Health Organization both at global and regional level, has expressed its serious concern with this issue and has undertaken several activities directed towards its prevention and control. Among these, the Regional Working Group on Prevention and Control of Alcohol-Related Problems, held in Tokyo in 1980, made several recommendations to further strengthen the prevention and control programmes at regional and national levels. The Thirty-fifth World Health Assembly in May 1982 considered alcohol problems as the subject of its technical discussion. At its Thirty-third session in September 1982, the Regional Committee for the Western Pacific adopted a resolution urging Member States to formulate comprehensive, continuous and long-term national policies on alcohol-related problems and requesting the Regional Director to intensity .WHO's progranune on alcohol-related problems. The Thirty-sixth World Health Assembly in May 1983 further requested the Director-General to continue and intensify WHO's programme on alcohol-related problems as an integral part of the strategy for health for all through a primary health care approach. 1t. can be seen therefore that the organization of this workshop very timely and in line with the various resolutions which have heen strongly .qupported by our Member States. LS

- 38 Annex 4

II

" There can be no easy solution to alcohol-related problems, which are closely linked to socioeconomic conditions and culture-bound behavioural patterns. In some developing countries alcohol consumption is even considered to symbolize participation in a sophisticated modern lifestyle. The nature of the problem varies in fact greatly from country to country. Trauma resulting from alcohol-related violence and injuries related to drunken driving are new health hazards in some developing countries. In developed countries, alcohol-related ailments such as cirrhosis of the liver also show a sharp increase. Thus, the social dimensions of this problem need to be sufficiently taken into consideration in the formulation of an effective national policy. The participants in this workshop are drawn from those who are currently in charge of alcohol prevention and control programmes in their own countries or those who will eventually have that responsibility. Their main task will be to prepare a practical framework for the design, implementation and evaluation of programmes, including the prevention, treatment and social integration aspects of the control of alcohol-related problems, as an integral part of the health-for-all strategy. I am aware that this is quite a challenging task for most of you. However, I am sure that by drawing on the pool of expertise and experience that is available here, this meeting will be able to successfully achieve its assigned objectives. To conclude, let me extend my sincere thanks to the temporary advisers, Dr Marcus Grant, Director of the Alcohol Education Centre in London, and Dr Sally Casswell, Executive Director of the Alcohol Research Unit in Auckland, New Zealand, for their assistance in the preparation and conduct of this meeting. I wish you all an enjoyable stay in Manila.

,

- 39 -

ANNEX 5

COUNTRY PROFILES

AUSTRALIA

1. 1.1

General description of the society Demographic Population:

14 576 330 (1981) about 50% male, 26% under 15 years, 9% 65

Composition of population: years and over (1979)

Virtually 100% attendance at school between aged 5-15 years.

1.2

Social

Ethnically mainly Caucasian, about 78% born in Australia, 7.8% born in the United Kingdom or Ireland, 1.8% in Italy, 1.8% in Asia; 1.1% are Aborigines. Religion About 47% Protestant, 26% Roman Catholic, 3% Orthodox, 0.4% Jewish. Urbanicity

69.7% live in urban areas of 25 000 persons or over, 63% in urban areas of 100 000 persons or over. Distribution of the economically active population Agriculture 6%, m1nlng 1.4%; manufacturing 17.7%; electricity, gas and water 24; construction 6.3%; ~hol~sale and retail trade 17.4%; transport, storage 5.24; communications 2%; finance, property and business services 8.4%; public administration and defence 5.6%; community service 14.9%; recreation and other sources 5.2%. Political and Government structure Australia is a common~ealth comprising a federation of six states and territories. The states have considerable autonomy and are responsible for health services, primary and secondary education, law enforcement and licensing laws. The Commonwealth Government has major responsibility for financial matters, including excise policies. t~o

- 40 Annex 5

2.

Nature and magnitude of alcohol consumption

In 1981, Australia ranked 12th in the world for per capita annual consumpti.on of absolute alcohol, with a figure of 10.0 litres. Annual consumption of beer was 134.1 litres per capita (4th in the world), of wine 18.3 litres per capita (14th in the world) and of spirits 1.1 litre per capita (32nd in the world). There was a steady increase in total consumpti'lll from 1930 (approximately 2 litres per capita) to the mi.d-1970s and the level has remained fairly stable since that time. Thus beer accounts for about two thirds of alcohol consumed, wine for about 25% and spirits for about 13% of the total. Twenty-two per cent of Australian males and 11% of females drink alcohol every day. Nine per cent of males and 18% of females do not drink alcohol. Community surveys have indicated that approximately 4% of males and 1% of females can be considered. as high-risk or very-high-risk drinkers, with a further 10% of males and 5% of females considered intermediate-risk drinkers. Studies of alcohol use in schoolchildren from 12 to 18 years have shown up to 28% of males and 21% of females to be regular drinkers. Approximately 5.7% of personal consumption expenditure is used for alcohol (compared with 2% for tobacco, 17% for food and 6.5% for heal th) • 3. Major alcohol-related problems and trends Mortality FrOM 1969 to 1980 there was an increase of almost 20% in the number of alcohol-related deaths, from 2994 to 3660. The death rate from alcohol-related causes was 24.4 per 100 000 population in 1980. Alcohol-related deaths represented 2.8% of all deaths in 1969 and 3.3% in 1980. The male-to-female ratio is about 7.7 to 1. In 1980, alcohol-related deaths represented 4.8% of all deaths in children, 24.9% of all deaths in young adults, 5.7% of deaths in middle age and 1% of deaths in the eloer1y. Of all alcohol-related deaths in 1980, alcoholism was the cause in 9.6%, alcoholic cirrhosis in 18.8% (compared with 8.4% in 1969) and alcohol-related traffic deaths in 48.7%. Morbidity Studies have shown that up to 15% of all general hospital admissions are precipitated by alcohol-related problems and up to 33% of general hospital patients have an alcohol-related problem that mayor may not be the cause of the admission. As many as 25% of total psychiatric hospital admissions are thought to have alcohol-related problems. Alcohol is estimated to be an important factor in two out of every five divorces, 73% of violent crimes and 50% of serious crimes.

- 41 Annex 5

4.

National policy and control measures

A National Standing Committee on Alcohol has been formed to oversee national policy. This Committee reports to the Standing Committee of the Health Minister's Conference, which in turn reports to the Health Ministers' Conference. The Federal Government has some control over prices through sales tax and excise. Advertising of alcoholic beverages is regulated at a national level by a voluntary code supervised by the Media Council of Australia. A number of controls have been introduced by different states, such as random breath testing of motorists, immediate disqualification of drivers found to have a blood alcohol level greater than 0.05 or 0.08 g/100 m1 (it differs in different states) and compulsory blood alcohol testing of traffic accident victims. 5. Early intervention and education

A National Drug Education Programme is operated by the Australian Government. This aims to assist all sections of the community, particularly young people, to develop healthy and discerning attitudes towards all drugs, thereby reducing consumption of drugs generally in the community. Emphasis is placed on incorporating drug education into the wider context of health education, with particular attention to interpersonal relationships, lifestyle and adjustment in a complex society. Education programmes for professional groups in the community have also been provided under the Programme. The National Alcohol and Drug Dependence Industry Programme is funded by the federal government and conducted by the states. It aims at prevention, early detection and treatment of alcoholism and other drug dependence in the workforce. A number of national organizations, such as the Australian Medical Association, the various Royal Colleges and the Australian Foundation on Alcoholism and Drug Dependence, are active in developing training programmes for medical students and graduates. Initiatives have been taken to formalize a drug-and-alcohol curriculum for the training of nurses and some other professionals. The Australian Medical Society for Alcohol and Drug-Related Problems was formed several years ago to promote interest and expertise in the medical profession in the field of alcohol and drugs. A number of drunken-driver education programmes have been conducted for persons arrested for driving with a blood alcohol level above the prescribed limit.

- 42 -

Annex 5

6.

Prevention and management

A number of programmes designed to change customs and attitudes and to promote healthy lifestyles and awareness of responsible drug use have been conducted in the community. These include the "Life be in it" programme, a national media programme sponsored by the federal government and aimed at improving the overall health and fitness of the community; and the "Healthy Lifestyle Progralllllle" on the New South Wales Northcoast. This was a health promotion intervention which made extensive use of the media and commercial advertising techniques. A number of other pilot campaigns have been conducted by other groups, e.g. the Australian Medical Association organized a programme aimed at young males to reduce driving under the influence of alcohol. Efforts have been made to emphasize to the cOllllllunity in general and to professionals in particular that alcohol misuse should be seen as an ordinary health and social problem and be managed by ordinary health and welfare services. However, a number of specialized services do exist. The development of individual treatment programmes is primarily the responsibility of the states and territories. In some states, the health authorities have established special semi-autonomous alcohol and drug dependence facilities which provide specific treatment services. Inpatient alcohol rehabilitation progralllllles are operated in psychiatric and some freestanding hospitals, both public and private. A number of voluntary agencies, many with religious affiliations, offer residential services. Outpatient services are available from a number of general hospitals and many community health centres employ alcohol counsellors. A range of detoxification centres exists, some providing chemical support for withdrawal and others psychological support only. Some treatment programmes operate specifically for the Aboriginal community but there are few specific programmes for the migrant groups. Alcoholics Anonymous, Al-Anon and Al-Ateen are active throughout the country and many rehabilitation programmes concentrate on introducing patients to Alcoholics Anonymous. A number of specific drug-and-alcohol services have recently been established in large general teaching hospitals, particularly in New South Wales.

- 43 -

AnneK 5

COUNTRY PROFILE - FIJI Beverages that are potent ~nd contajn alcohol have been an .important part of the material culture of most human societies. In Fiji, the traditional potent and intoKicant (non-alcoholic) beverage is called 'yagona'; this was the forerunner of western alcoholic drinkR. The 'yagona' is served with stately traditional ceremonies which reinforce societal values, sanctions and position in the social structure4

The traditional chief drinks first to reinforce his 'ascribed' chiefly status.

It

is uncommon for women to partake.

The arrival of people from the West and with them their alcol"'l ic drinks, the drift from villages to towns, the changing lifestyle of local ·people, remunerative employment which enables easy purchase of alcohol have .all made their contributions to the change from 'yagona' to whisky, beer and other alcoholic drinks. What was lost in this process of beverage change was the socio-political element which used to reinforce traditional status and behaviour. In urban centres, anyone with money can buy alcoholic drinks for himself and his friends, and to some eKtent also buy himself the temporary "achieved" position of (liquor) chief. This in itself has some adverse effect, for it leads to eKcessive drinking and misuse of earnings to achieve status.

Nature ana magnitude of alcohol consumption During the colonial era in Fiji, local people who wished to drink liquor were required to apply for "permits", which were issued on the criterion of good characte,-. Permits have since been discarded and now anyone above the age of 18 years may buy liquor in a public place, eKcept that women ar<' still not allowed into public I>ars. Whilst on the natur.e of consumption, it is appropriate to mention here the existence and use in Fiji of other intoxicants, e.g. home-brew and

"toddy" made from fermented fruit juice, and benzine and glue sniffing by chi ldren. On the magnitude of alcohol consumption, three comparisons will illust.cate the degree of consumption in Fiji and the Pacific: (a) (1))

Rate of consumption of liquor per head of adult popUlation

% distribution of household eKpenditure between food, I>everages and tobacco, and

(c)

comparison of percentage household expenditure on alcoholic beverages in five Pacifi~

countries.

- 44 Annex 5

Table 1. (al Rate of consumption (in litres) per head of population Total Year

Consumption of spirituous drinks 1.5 1. 75

Consumption of beer 27.84 27.67 26.89 29.95 28.44 28.57 29.72

consumption

of 1 iquor 29.7 1,

1976 1977 1~78

29.42 28.43 31.45 29.34 29.44 30.39

1.54 1. 50

1979 1980 1981 1982

0.9 0.87 0.67 (Source;

Fiji Bureau of Statistics)

The above table illustrates that between 1976 and 1982, the consumption of local beer increased while the consumption of spirits declined, possibly because of high import taxes. Having said that, it is also clear from the third column that in total, the consumption of liquor has increased by 1.01 litre. per head.

Table 2. (b) Distribution of household expenditure on food. beverage and tobacco Alcoholic beverages Non-alcoholic beverages Tobacco Food (Source; 9.1% 5.4 6.3 - 79.2 100%

Fiji. Household Income and Expenditure Survey. 1977)

- 45 Annex 5

Table 3. (c) Cross-Pacific comparison (Household expenditure on alcoholi.c drinks as % of total household expenditure) Fiji New Caledonia (1968/69) Papua New Guinea (1970) Samoa 1971/72 Solomon Islands (1970) (Source, 8.2% (adjusted) 9.6% 11.34% 4.5% 3.0%

UN Compendium of Social Statistics, 1977 and Fiji Household Income Expenditure Survey, 1977.)

The time differential in the above tables renders them of only limited Nevertheless they are useful as a guide, particularly if allied with some local knowledge and eKperience. Thus, both Tables 2 and 3 above seem to indicate that expenditure on alcohol in 1976 (and by implication, the level of consumption) in the average Fiji household was moderate. However, since then, consumption has increased (see Table 1). Further, though household expenditure on alcohol was moderate in 1976, it was no cause for complacency since expenditure is one thing, and what liquor does to a people undergoing acculturation from an influerttial western culture, is another. As will be discussed later in the paper, expenditure may be moderate, out liquor increases people's anti-social behaviour if they are ignorant of its uncontrollable effects and ~ccordingly tend to abuse it. us~.

Major alcohol-related problems Like most social problems, the problem of drunkenness and alcoholism has a multifarious etiology and will need a many-pronged approach in order to determine its manifestations. In this paper, the writer will be looking only at the related problems of (a) criminal offences (b) road accidents and (c) marital breakdowns. (a) criminal offences

In 1975, the two related offences of "Drunk and Disorderly" and "Drunk and Incapable" were removed from the Penal Code and classified as Minor Offences. Below is a summary of cases dealt with by the police and the magistrates courts in Fiji between 1970 and 1977.

- 46 J,

Annex 5

I I

ii

II TABLE 3 Reported Year 1970 1971 1972 1973 1974 1975 1976 1977 cases Persons

Convictions for

arrested 2004 2555 2085 2079 3090 3355 4078 3757

drunkenness 1887 2261 1925 1876 2729 2683 3316 3138 ~

1911 2372 1902 1825 2735 2972 3489 3249 (Source~

Social Indicators for Fiji, 1977)

The above figures illustrate the increasing number of cases of drunkenness reported to the police, the number of people arrested and the rate of conviction. Over the period 1970-77, the number of people arrested had increased by 87%, while convictions had increased by only 66%. The difference may be due to cases in which people were arrested, locked in a cell overnight to sober up and then allowed to go home the next morning without being charged with an offence. Potent alcoholic beverages have been an important part of the material culture of most human societies. Quite apart from the above cases, which were directly linked to alcohol, there were other criminal offences which were reported to have been committed while the offenders were under the influence of liquor. A survey of Fiji prison records between 1970 and 1977 showed a high proportion of prisoners who claimed they committed the offences for which they were imprisoned whilst under the influence of alcohol. The findings as tabulated below showed that more than half the offences were attributable to liquor. Although it is easy to be suspicious of these figures and to say that prisoners readily resorted to liquor as a useful excuse for their deviant behaviour, local experience seems to suggest that there is plenty of truth in the figures below.

- 47 Annex 5 TABLE 4 Crime c01lllllitted under influence of liquor 60% 56% 56% (Source: Social Indicators for Fiji - 1977)

Year 1974 1975 1976

Crime committed while sober 40% 44% 44%

(b)

Traffic offences

Traffic offences in Fiji are on the increase. Granted account has to be taken of such factors as the increased number of cars on the road, the number of new drivers and so forth. It is also true to say that "Driving under the influence of alcohol" on its own, and as a component of "Careless Driving" and "Dangerous Driving" which often result in road deaths, together make a considerable contribution to increased traffic offences in Fiji and jointly form more than half of the traffic cases, as illustrated below: TABLE 5 Cause of accident Careless driving Dangerous driving Driving under the influence of alcohol Others (Source: Marital breakdown In 1980, surveys were conducted in 8 of 12 government Social Welfare Department offices in Fiji on their marriage guidance clientele. One of the questions posed attempted to find out what the clients thought was causing their matrimonial problems.

.!1ZQ 26.2% 4.3 1.5 68

1976 47.1% 10.9 3.1 38.9

1977 41.0% 7.9 2.5 48.6

Social Indicators of Fiji - 1977)

- 48 Annex 5

The table below illustrates the findings

% blaming District Suva

% blaming violence 13.6 3.0 2.0 21.4 8.5 N/A N/A 7.0

liquor 1.7 2.0 2.0 N/A 1.2 10.8 0.8

% blaming extramarital affairs 19.6 26.0 18.0 7.1 7.3 24.3 19.8 16.6 17.3

Lautoka Ba Nausori Labasa Savusavu

Rakiraki Sigatoka Mean average

2.7

9.2

(Source:

Social Welfare Department - Research Papers - 1981)

It is difficult to distinguish single causes of marital disputes and breakdowns since the dispute may have started from one cause e.g. excessive drinking, which led to extra-marital affairs, which led to wife-beating and assault. However, when the question was posed, it sought to elicit from the client the casual factor which was uppermost in his or her mind at the time of interview. As illustrated above in Table 6, drunkenness on its own contributed to only 2.7% of all marital disputes. However, it is also worth noting that the related causal factors of violence (9.2%) and extra-marital affairs (17.3%) are more frequently cited, and together, all three causes form one quarter of all causes of marital disputes. National policy and control measures Fiji appears to have no explicit policies on alcohol, except perhaps its economic policy, which encourages production of local beer as the second largest money-maker (next to sugar) in the manufacturing sector (Statistical News, 1979 and 1982 volumes). On the problems of alcoholism and drunkenness, there are no explicit policies. However, implicit policies are discernible in the legislation that created a Liquor Licensing Board to grant liquor licenses only to those who could be entrusted to sell with responsibility. The Solicitor-General of the country is Chairman of the Board.

- 49 -

Annex 5

Further, "Minor Offences" include "Drunk and Disorderly" and "Drunk and Incapable". The Juveniles Act stipulates that juveniles under 18 years of age may not be served or sold liquor in public places. The local police force do not hesitate to. arrest once the level of the inebriation is difficult to contain. Early intervention and management

The lp.gislation mentioned represents an attempt to control forcibly not only the distributi.on of liquor but also the resultant drunkenness. Intervention by persuasion used to be conducted by Alcoholics Anonymous, which is unfortunately now defunct. Similar functions have now been taken over by the Roman Catholic Church under the "Pioneer" scheme. This scheme, conducted by the church with the largest membership, has served about 5000 people in the past six years and the failure rate is claimed by the person in charge to be about 2%. However, most of those seeking "pioneer" assistance would be drunkards who are motivated by financial hardship to curb their drinking rather than by serious alcoholism. Counselling by the Social Welfare Department, priests, community elders and other voluntary social workers is also directed at early intervention to curb the habit of excessive drinking and reduce the related problems. Fiji has no special institutions for alcoholics. Summary Although consumption of alcoholic beverages in Fiji appears to be moderate (to judge by household expenditure on alcohol together with a cr.oss-country comparison in the Pacific), the level of related problems such as criminal offences, traffic offences and marital breakdown is relatively high. One explanation for this disparity is the novelty and resultant effects of liquor on a people undergoing western acculturation and subjected to a specific level of social and economic development not uncommon in third-world countries. Although there are no. explicit national policies to combat the problem of drunkenness and alcoholism, there are inbuilt measures of control and intervention. It appears reasonable therefore to state that if drunkenness is to be combated with a greater degree of success, the country needs to formulate explicit policies, and seriously plan policies for overcoming the problems.

- 50 Annex 5

COUNTRY PROFILE - JAPAN Since the mid-1950s, when the economy had fully recovered from the Second World War, improvements in wages and living standards have virtually kept pace with economic growth. Production gradually recovered and, as political, administrative and economic rehabilitation proceeded, the health administration, which had been destroyed, kept pace. n,is rapid expansion of the national economy gave the Japanese a dramatic increase in income, allowing them to enjoy unprecedented material affluence. At the same time, acute epidemics were quickly suppressed; the rlslng curve of mortality due to tuberculosis, which was previously a menace for the people, was drastically reduced. In the course of this growth, however, health was caught in a conceptual shift from a medical model for infectious diseases to a broader model for environmental and lifestyle sources of chronic diseases. Swiftly advancing pollution of the environment and increasing consumption of alcohol began to menace the people's health. A. Nature and magnitude of alcohol consumption

From olden times, Japanese were accustomed to drink and use alcoholic beverages for ceremonies and parties. They made an alcohol called "sake" from rice. Since the Second World War, the consumption of alcohol has dramatically increased, pari passu with economic growth, urbanization and industrialization. This is due to drinking among minors (although there has been a law since 1922 prohibiting minors from drinking alcohol) and also among women, who have recently taken to drinking alcoholic beverages. Almost 4.5 million people are estimated to drink, 90% of the adult male population and 50%-60% of the adult female population. Every year, the Ministry of Finance gathers data on the consumption

and production of a1.cohol. According to those data, the estimated per capita con6umption of alcoholic beverages in terms of 100% ethanol for ti,e populati.on aged 20 and over increased from approximately 6.3 litres in 1968 to 8.3 litres in 1980. Production is in private hands; however, the government regulates it to ensure stable tax revenue.

B.

Alcohol-related problems and trends

According to national data, alcohol-related problems can be divided into three categories, health, crime and accidents. Some other aspects of alcohol-related problems are family violence, child neglect due to excessive parental drinking, absenteeism and alcohol abuse in youth. Their prevalence cannot yet be determined, but they are believed to be on the increase and are a source of concern.

- 51 Annex 5

(1)

Cirrhosis of the liver

Mortality due to cirrhosis of the liver increased from 9 per 100 000 in 1955 to 14 per 100 000 in 1980. The rate of detection of fatty liver may have risen because gamma GTP can be easily tested in laboratories.

7000 6000 -7-- - -

14

5000 4000 3000 2000 (,c---.:~_ ~-~-

-

- -~

,-

12 10 8 6

(-) 1000 1955 (Data~

1960

1965

1970

1915

1980

From the Division of Statistics, Ministry of Health and Welfare) (x---x) (-)

Mortality rate by liver cirrhosis Alcohol consumption per annum

(2)

Number of heavy drinkers

The estimated number of heavy drinkers (defined by the WHO criterion as those drinking more than 150 ml pure alcohol per day) increased from 890·000 in 1965 to 1 870 000 in 1981. (3) Patients in mental hospitals diagnosed as alcoholics

In Japan. there are approximately 1500 mental hospitals with a total of 320 000 patients. The number of alcoholic patients with alcoholic psychosis and delirium tremens, alcoholic dementia, Wernicke-Korsakov syndrome,and the alcohol dependence syndrome increased from 14 000 in 1968 to 21 000 in 1982. There are no data concerning outpatients diagnosed as alcoholics. (4) Other health problems

Hypertension. cardiovascular disease. diabetes and other physical ailments have increased in number but the percentage caused by excessive drinking cannot be determined.

- 52 Annex 5

(5)

Accidents and drunken driving

The number of deaths caused by drunken driving was 300 in 1981 and the number of offences due to drunken driving decreased from 364 598 in 1977 to 175 751 in 1979, owing to the imposition of heavier penalties. Kowever, the number of offences had increased again to 277 929 by 1981. (6) Murder

The number of murders committed under the influence of alcohol was 71 from 1980 from January to August). (7) Social and family problems

Although systematic research in this field has not yet been carried out, many cases of divorce, separation and other family conflicts (child neglect, violence to wife and child) caused by alcoholism were reported in the Family Courts. Recently, alcohol-related problems in youth and women (referred to as kitchen drinkers) have been reported to be on the increase. C. National policy and control measures

A national health policy concerning alcohol-related problems and a national policy for trade in and the production, supply and taxation of liquor were promulgated in Japan after the Second World War. The Mental Health Division of the Ministry of Health and Welfare is responsible for the promotion of alcohol policies in the field of health. There are also some national, private and voluntary bodies concerned with alcohol-related problems. The Ministry of Finance is responsible for alcohol taxation policy. The Ministry of Trade is responsible for policy on trading, marketing and production of alcohol. In 1979, the Association for Health and Alcohol (AHA) was established, whose function is to promote educational programmes, research, preventive campaigns, etc.

The Japanese Mental Hospital Association, which is composed of some 1200 Directors of mental hospitals, is also promoting appropriate educational programmes and comprehensive community care for alcoholics. In 1983, an Expert Committee on Alcohol-Related Problems with Dr Hiroaki Kono as Chairman was organized by the Government to discuss and determine the future direction of the policy. Among voluntary bodies, the Japanese Sobriety Association and Alcoholics Anonymous have made much progress in their activities.

- 53 Annex 5

As for control policies, increases in the price of alcohol are supported by economic considerations~ revenue from taxation of liquor will continue to increase as the price of alcohol rises. D. Early intervention and education

The Government and other bodies provide training programmes for physicians; nurses, health workers and welfare officers on the prevention of alcohol-related problems. However, such training is not available for schoolteachers, law enforcement officers and administrators. Health workers and medical practitioners are consulted by those who drink too much; they play an important role in detecting high-risk drinkers. Undergraduate medical curricula include little on alcohol-related problems, only two to three hours being spent on the topic of alcoholism. Those who have committed murder under the influence of alcohol are taught in jail of some effects of alcohol and alcoholism. E. Prevention and management

New national data have shown widespread harm resulting from the increased consumption of alcohol. As a result, the Government is being impelled to take measures to prevent and reduce the consumption of alcohol, to develop intensive preventive programmes and to undertake additional measures for the management of such problems as may arise in relation to alcohol consumption. In view of the broad repercussions of alcohol problems, these programmes have important links with programmes on cancer, cardiovascular diseases, maternal and child health, occupational health and traffic accidents as well as with programmes on the strengthening of health services, health education and health manpower development. Alcohol policy and management had their origins in the Control of Inebriates Act, passed in 1961, which envisaged specialized wards for alcoholics. After the construction of specialized wards, the Government promoted community health care services which included prevention, early detection, treatment and rehabilitation. Measures to lessen alcohol-related problems were systematically divided into four groups as follows~

(1)

Normal drinkers

The Association for Health and Alcohol (AHA) provides many pamphlets and video-tapes to educate minors and normal drinkers, but minors

nevertheless, are very apt to drink. It is presumed that television commercials and campaigns by alcohol companies have encouraged this.

- 54 -

Annex 5

(2)

Heavy drinkers (high-risk drinkers)

High-risk drinkers suffering from hepatitis, fatty liver, hypertension and diabetes mellitus are required to consult health workers concerning their psycho-sociological problems. In 1979, an alcoholism counselling system started operation in Mental Health Centres. Health centres are also promoting mental health service programmes involving consultation and visiting care programmes for alcoholics. (3) Alcoholics

According to their physical and mental situations, alcoholics are treated in two ways as follows: (a) First phase (acute detoxification phase)

First phase treatment aims to promote recovery from delirium tremens, acute alcohol intoxication and alcoholic psychosis. (b) Second phase (release from psychic dependence)

Second-phase treatment aims to release alcoholics from psychic dependence on alcohol. Alcoholics are treated by group psychotherapy and day-care. (4) Recovery from alcoholism

Rehabilitation programmes and welfare services are provided by the Government and by private and voluntary agencies. Alcoholics must be taught to live without drinking alcohol in an environment where alcohol is available. The effectiveness of rehabilitation programmes is monitored. To summarize, it is necessary to promote: (1) (2) health planning at the national, regional and community levels, supported by effective health and medical information systems; education or re-education for physicians, nurses and health workers, together with schoolteachers and administrators, by establishing systematic educational programmes; screening tests for high-risk groups; establishment of National Institute of Alcoholism as soon as possible.

(3) (4)

- 55 Annex 5

COUNTRY PROFILE - MALAYSIA

A.

Nature and magnitude of alcohol consumption

In Malaysia today, alcoholism and problems related to it are not yet national public health issues as compared with drug addiction and communicable diseases. This is probably because Islam, the national religion, with its prohibition on the consumption of alcohol and other strong drinks, has resulted in less attention being paid to this area. In fact, there are no complete statistics available on the incidence and prevalence of alcohol-related problems. Problems do exist, as seen from sources such as hospital admissions, absenteeism, traffic accidents, rates of arrest, etc. For the present, the problem is still a very minor one and is not considered as priority for the public health services. In Malaysia, alcohol can be divided into two categories according to its cost and how it is produced. The first category, which is manufactured by licensed companies and factories, includes beer, whisky, brandy, stout, etc. To date there are only about five licensed manufacturers in operation. The licences are issued by the Ministry of Trade and Industry. As far as distributing and selling are concerned, individual retailers are required to obtain their licences from their local authority or municipality. All these licences are subject to compliance with certain sets of regulations, requirements and ordinances, failing which they are terminated or not renewed. There appears to be a tendency for the production of this category of alcohol to increase. In 1973, 55 million litres were produced and by 1977 this had increased to 76 million, while the total production in 1980 was nearly 120 million litres. In addition, large amounts are being imported. In 1978, alcohol worth 49 million Ringgit was imported and this figure is increasing yearly. It has been observed that Malaysia ranked as one of the world's largest consumers of brandy in 1980. The second category is the cheaper beverages, not manufactured by big companies but by local, small-scale producers. Included in this category are toddy and samsu. Toddy is a fermented drink made from coconuts while samsu is distilled alcohol. Both are very popular among the Indian community. Besiaes these categories of licensed production, the illicit production of toddy and samsu is also practised. For example in 1978, 27 000 litres of illicit samsu, 432 726 gallons of fermented mash, 165 stills and 970 litres of illicit toddy were seized in one state in WestAMalaysia. This illicit liquor may cause fatal poisoning. The magnitude of the illicit samsu problem can be assessed by the number of deaths that have occurred in the recent past owing to the consumption of this "killer brew". Between 1965 and 1977, 50 lives were lost in the state of Negri Sembilan alone. In the first half of 1981, illicit samsu claimed a further 20 lives. It can be stated quite confidently that the number of

- 56 Annex 3

deaths accuring through the consumption of illicit samsu is far more than is officially recorded. When death occurs, there is a flurry of activity but these tragic accidents are soon forgotten and life returns to normal except for the grief-stri.cken families. B. Major alcohol-related problems and trends Problems related to alcohol consumption can be divided as affecting Ca) (b) (c)

the drinker; the drinker's family; society in general e.g. ln their connexion with transport-road, rail, sea and air traffic; in the employment setting; in health and w~lfare services; and in specific age, sex and occupational groups. Drinkecs

(a)

Alcoholism undoubtedly brings in its wake a series of medical problems which include psychological problems, gastritis, pancreatic diseases, respiratory problems, heart attacks, obesity, cirrhosis of the liver and increased susceptibility to infection.

fhe liver is the main organ to be atfected by acute and chronic alcohol ism. These effects are termed acute yellow atrophy of the liver and degenc,."tion of the liver leading to cirrhosis. Th" number of alcoholics admitted to the various government hospitals tram 1971-1980 is given below~

Ail:·lISSlONS A."lD Or:.ATHS FROM ALCOHOLlS~1 1971-1930 GOVERN!".ENT HOSPITALS (WEST MALAYSIA)

1971

I

1972 DA

19-:3 DA

197:' JA

1975

i976 D)A:'IA

1977 DA

1978 D 1 ";

1979

198-) DA!D

AIQA

Alcoholism

455

5

523

:;;

549

2

531

i

587

3

630

5

556

7

614

4

571

5

688

!

2

Acute yellow a~rophy of ll.ver Degeneration of liver

16

i

9

I ! 18

;4

~4

i

41

3

12

1

I I l6

1

11

-

15,

i

1

15

1

87

20

93

22

80

36

90

23

41

10

51

9

22

6

14

-

39

11

36

4 ~

I Al coho1 ic

I General

pys~hosis

r

I

1

Hospital. lZuda Lu:npur

:jA

NA' NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

I I

!

J

:~A

~A

NA

NA

:H.

NA

NA

NA

1___To~al__ Source~

558

26

1625

26

647

42 \645

24

669

16

693

15

594

14

639

4 1625

17

739 ,_ 7

M~dical

Records Section

Total ad~issions~ Total deaths; 191

6~34

·~

Note:

A D SA

Ad~issions

Jea::hs :-;ot available

I:

- 58 -

Annex 5

There appears to be a gradual increase. This is also reflected in the number of cases diagnosed as acute yellow atrophy of the liver and degeneration of the liver. Among ethnic groups, the Indians form 90% of the cases, followed by the Chinese. Malays, rarely if ever, suffer from alcoholism, probably because Islam has a restraining effect, since alcohol and other intoxicating drinks are prohibited (haram). The sudden increase in the total number of deaths in certain years is due to acute poisoning episodes resulting from poisoning with illicit samsu. As far as alcoholic psychosis is concerned, the figures obtained are only from the General Hospital, Kuala Lumpur. As will be seen, there is no significant change over the last ten years. (b) Drinker's family

The marriage bonds of alcoholics do seem to be subject to some instability and risk of breakdown. Even though there are no concrete data on this, the trend is quite obvious from the histories of the patients admitted to the wards. (e)

Society in general (i) Traffic accidents related to alcoholism

From the records obtained from the Statistical Report on Road Accidents in Malaysia, in 1980, 0.19% of traffic accidents were due to intoxication (driver's fault); in 1981 the figure was only 0.14%. The figures for "Intoxication (pedestrian fault)" were 0.05% in 1980 and nil in 1981. According to the Traffic Division, these figures have remained the same for the last 10 years. One of the reasons given was that even though there is a road-traffic ordinance in relation to alcoholism, the charge brought in accidents due to alcoholism can only be based upon clinical reports by the attending physician. There is no .standard for the determination of alcohol level in the blood as in other countries. Thus if the clinical report cannot offer concrete evidence of the influence of alcohol, the charge will be "Disorderly Behaviour 1n Public". (i1) Occupational

Absenteeism and medical leave have been reported among known alcoholics, but there are no exact data on this.

- 59 Annex 5

C.

National policy and control measures (a) Assimilation of Islamic values

At present, the Malaysian Government is ~orking to~ards the assimilation of Islamic values and the Islamic way of life in all aspects of government machinery and in society. To give a fe~ examples, the practice of "toasting" at official functions has been abandoned. Drinking parties and social drinking are not encouraged in any government agency gatherings. (b) Advertisements and sales promotion

Advertisements for alcoholic beverages on radio and television have been banned for four to five years. This was possible because radio and television stations in Malaysia are run by a government agency. Advertisements in newspapers and maga~ines and on hoardings are still allowed but not encouraged. Ho~ever, alcohol advertisements in theatres and cinemas still dominate all other advertisements. (c) Licensing

Licences are issued and renewed if the manufacturers and retailers comply with the requirements and regulations, including those on sanitation of premises and the stipulation that drinking places must be secluded and not exhibited openly and should not be a source of public nuisance or disturbance. No more licences will be issued to toddy shops. (d) Legislation

There has been a great deal of legislation on alcoholism (i) Section 37 - Road Traffic Ordinance 1958 Part (1) states that: Any person who, when driving or attempting to drive a motor vehicle on a road or other public place, is under the influence of drink or a drug to such an extent as to be incapable of having proper control of such vehicle, shall be liable on conviction to imprisonment for a term not exceeding six months or to a fine not exceeding $1000 and, in the case of a second or subsequent conviction, to imprisonment for a term not exceeding 12 months or to a fine not exceeding $2000 or to both such imprisonment and fine. (ii) If the influence of alcohol cannot be established, the offender will be charged under Section 21, Minor Offences Ordinance No. 5/53 i.e. Disorderly Behaviour in Public.

- 60 Annex 5

(iiil

Eradication of Illicit Samsu Act, 1976. The sentence for trafficking in illicit samsu is ten years maximum and not less than four years, and the maximum fine is $20 000/=. The law also provides for a maximum sentence of two years

in jail for consumption of illicit samsu. produce or consume illicit samsu.

So far, there

is no evidence of consumers being charged in court.

However, the government has appealed to the public not to D. Early intervention and education

For ~uslims, information regarding the prohibition and effects of alcohol and other intoxicants is given very early, especially in the religious schools. The same is probably true for other religions like Christianity, Buddhism, Hinduism, etc. As far as Malaysia is concerned, at least in the case of children of primary school age, no parents ever teach or encourage their children to start drinking. Peer pressure is also a form of early intervention. At present, drinking alcohol is not really considered as a status symbol, as it was previo~ly. Furthermore, there is a possibility that drug addiction is taking the place of the drinking habit. E. h~s

Prevention and management

Besides the legislation described above, the tax on imported liquor also been raised. Whether this has any bearing on the consumption of expensive beverages or has resulted in more production of illicit liquor has yet to be discovered. As far as the patients are concerned, in the General Hospital in Kuala Lumpur, the psychiatric department has engaged a full-time social worker who will be organizing group dynamics and group discussions during the rehabilitation period. This is done regularly at least once a week for an unlimited time (usually more than a year). Group discussions were also arranged for the spouses at least once a month but the response generally was poor. This i. probably due to lack of interest, the breakdowns of the marriages or the spouses feeling that it was not their problem and that they had other more im portant things to attend to. As for voluntary organizations) there is only one active association -

Alcoholics Anonymous - operating in Kuala Lumpur.

Even then only 50% of

the members are Malaysian, the rest being expatriate.

- 61 Annex 5

COUNTRY PROFILE - NEW ZEALAND

Tne population of just over three million (2.4 million 15 years and over) is a largely urban one and includes 87% Pakeha (Caucasian), 9% Maori and 3% Pacific Islanders. Nature and magnitude of alcohol consumption Consumption of alcohol is amongst the highest in the Western Pacific Region. During the two decades 1955-1975, there was a 45% increase in adult per capita consumption but since 1975 consumption, though fluctuating, appears to have stabilized somewhat (a 2.5% increase 1975-1982) • Tanle 2. Estimated per capita consumption of absolute alcohol in New Zealand, 1955-1982 Per capita total population (litres) 5.4 5.3 5.8 6.5 8.0 8.1 8.1 8.6 8.4 8.6 8.9 8.6 Per capita population aged 15 years and over (litres) 7.9 7.9 8.6 9.6 11.4 11.5 11.5 12.1 11.6 11.8 12.1 11.7

Year 1955 1960 1965 1970 1975 1976 1977 1978 1979 1980 1981 1982

New Zealand nas traditionally been predominantly a beer-drinking and, to a lesser extent, a spirits-drinking nation. In 1955, beer comprised 73%, spirits 22% and wine only 5% of the total absolute alcohol consumed. However, there has been a trend towards wine consumption, somewhat at the expense of beer, and in 1982 beer accounted for 56%, spirits 22% and wine had risen to 21% of absolute alcohol consumed.

- 62 Annex 5

Distribution of consumption

Data from a national survey of 10 000 New Zealanders aged 14-65 (Casswell, 1978) indicated that just under 10% of the population are abstainers; 65% drink relatively moderate amounts of alcohol (an average of 20 ml or less of pure alcohol per day), and 9% drink 60 ml or more of pure alcohol per day. The survey showed that heavy drinkers are to be found 1n almost every category (sex, age, occupation, educational level, marital status and race).

Drinking patterns of men and women differ considerably: about 7% of men and 14% of women abstain from drinking, and 14% of men and 8% of females are considered heavy drinkers. For both sexes, however, the amounts of alcohol consumed on one

occasion rise rapidly after the age of 14, peak during the 18-23 years and drop gradually until age 55-65. Women drink less than men at all age levels, except 14 and 15. The survey also indicated that although Maoris and Pacific Islanders tenJ to drink more alcohol on anyone occasion than Pakehas, they drink less frequently; and more Maori and many more Pacific Island women abstain from alcohol than Pakeha women. Major alcol1ol-related problems and trends The alcohol-related problems which receive most popular attention are those associated with acute intoxication, especially alcohol's role in traffic accidents. Since 1970, there has been a 210% increase in alcohol-related traffic offences. (The introduction of the breath analyzer in 1969 considerably increased the detection of these offences, making earlier statistics not comparable). Other accidents, violent offences and social and marital disharmony are believed to be associated with acute intoxication but few reliable data are available. Alcohol-related adverse health consequences such as mortality from liver cirrhosis, alcoholism and alcoholic psychosis are documented and currently occur at the rate 6.8 per 100 000 aged 15 and over. There was a 300% increase in these mortality figures between 1955 and 1980. Alcohol is recognized as contributing to other illnesses but the relationship is less well documented. However, small-scale studies of hospital populations suggest that between 6 and 14% of admissions are associated with alcohol use.

National policy and control measures

A statutory body, the Alcoholic Liquor Advisory Council (ALAC) , was established in 1976 with funding from a levy on alcohol sales. Its budget in 1981-1982 was $2.4M, less than 1% of government revenue from indirect taxation on alcohol. As its name suggests, ALAC is an advisory body only

- 63 -

Annex 5

and among its statutory obligations is the requirement to promote moderation in drinking. ALAe's policy statements have recognized the need to stabilize or reduce per capita alcohol consumption and prevention measures to control the availability, price and promotion of alcohol are currently being developed. As yet there has been little real progress in the application of such policies, apart from an increase in taxation which has halted the previous decline in the real price of alcohol. Availability has risen dramatically over the past two decades and continues to do so, particularly in the licensing of sporting and other common-interest clubs. Alcohol advertising is allowed in the electronic media (subject to no use of brand names), in cinemas and print media, on hoardings and at point of sale. Legislation prohibiting public drunkenness was repeated in 1982. The prohibition on driving with alcohol level of 80 mg per cent (or the breath equivalent) is enforced; methods include the use of sporadic 'blitze', compulsory breath or blood analysis of serious traffic crash victims and breath analysis of those suspected of driving while under the influence of alcohol. Early intervention and education ALAe has funded mass-media campaigns during the past five years, which initially concentrated on warnings about the effects of alcohol on personal health; recently the campaigns have laid greater emphasis on the promotion of non-alcoholic beverages to prevent drunkenness and regular heavy alcohol consumption. A general alcohol awareness campaign carried out in 1982 attempted to raise public awareness of alcohol use as a public health issue and of factors encouraging or restraining the consumption of alcohol. School resources for education about alcohol, which often emphasize decision-making skills, are also distributed by ALAe. Prevention and management Until recently in New Zealand, efforts were focused on the tertiary prevention end of the continuum and the provision of adequate specialized treatment facilities was the priority. During the past two decades, admissions and readmissions for alcoholism and alcoholic psychosis have risen considerably; for example, there was a more than fivefold increase in psychiatric hospital admissions between 1960 and 1980 and in 1980 alcohol was responsible for one-fifth of all readmissions to psychiatric hospitals. More than three times this number are seen in non-psychiatric specialist institutions, some of which are government-funded through the Department of Health and some of which are operated by non-governmental organizations. During the past decade, funding of these non-governmental organizations has come in part from ALAe, thereby instituting a "user-group pays" principle for alcohol treatment.

- MAnnex 5

Recently, there has been more emphasis on early detection of people with alcohol-related problems and efforts have been made to set up employee assistance programmes and increase awareness of alcohol-related problems among deliverers of primary health care.

- 65 Annex 5

COUNTRY PROFILE - PAPUA NEW GUINEA

t.

Nature and magnitude of alcohol consumption

Generally speaking, nearly everywhere in Papua New Guinea, alcohol use is associated with leisure activities. For example, village drinking nearly always occurs in connexion with a party, ceremony or function during whi~h up to 25 people may on average, consume about 20 to 22 cartons of beer, with perhaps up to 5 or 6 bottles of spirituous liquors. Town people tend to drink more regularly (even daily) owing to the easy acce,S3ibility of alcohol outlets, the ready availability of money to buy al.cohol and possibly substantial job pressures (especially among young public servants in positions of responsibility). A survey in 1975-76 showed that on average, about six litres of alcohol are consumed per household per fortnight (at the cheapest rate of purchase). In Papua New GUinea, drinking is overwhelmingly a male activity and men seldom, if ever, drink with women. With the rapid increase in the equal and active participation of women in all forms of economic and social activity, the present position may change. lt is fair to say that the trend in Papua New Guinea is for alcohol ,;onsumption to increase, as shown by the following two tables (MacMarshall~ A macrosocial view of alcohol in Papua New Guinea, 1958-80). Note that while imports of beer are gradually declining, there is a marked increase in the domestic production of beer.

II

)! - 66 Annex 5

Domestic beer production and imports of beer for Papua New Guinea

in imperial gallons by year, 1959/60-1979/80 Year

Domestic production 438 000 528 000 543 000 705 000 1 047 000 1 412 000 1 859 000 2 376 000

Imports 423 000 483 500 532 500 824 600 601 800 451 200 367 600 372 000 493 200 355 500 712 200 1 124 900 1 071 300 646 800 142 400 81 900 55 000 1 n.d. 1 n.d. n.d.

Total 861 000 1 011 500 1 075 500 1 529 000 1 648 800 1 863 200 2 226 600

1959/60 1960/1)1 lq61/62 1962/63 1963/64 19b4/65

1965/(,6 1966/67 1967/68 1968/69 1969/70

2 748 000 3 068 200 3 361 500 4 299 200 5 458 900 5 115 300 5 815 300 4 996 900 5 711 900 7 685 000 9

2 575 000

3 (J06 000 3 587 000 i,

1970/71 1971/72 1972/73 1973/74 197[,/75 1975/76 1976/77 1977 /78 197$/79 1979/80

334 000

4 044 000 5 168 500 4 854 500 5 630 000 7 630 000

9 040 000 9 298 500

040 000

9 298 SOD 12 374 000 2 12 371 000

12 374 000 12 305 000

1

66 000

Ina data; information destroyed by Bureau of Statistics 2based on preliminary figures, January-April 1980

- 67 Annex 5

IMports of wine and spirituous liquors into Papua New Guinea 1975/76 and 1980 1n imperial gallons by year, 1959/60 Year 1959/60 1960/61 1961/62 1962/63 1963/64 1964/65 1965/66 1966/67 1967/68 1968/69 1969/70 1970/71 1971/72 1972/73 1973/74 1974/75 1975/76 1976/77 1977 /78 1978/79 1979/80 1980

~ 16 100 22 200 27 600 29 000 41 200 45 900 63 800 75 600 105 800 130 300 164 400 203 600 228 800 218 500 144 100 176 100 127 900 1 n.d. 1 n.d. 1 n.d. 1 n.d.

Spirit. 54 700 63 800 69 100 74 600 144 100 150 900 data incomplete 153 800 153 200 165 400 185 600 220 200 206 700 182 800 164 100 216 100 178 600 n.d. 1 n.d. 1 n.d. 1 n.d.

1

170 400

2

268 400 2

Ino data; information destroyed by Bureau of Statistics 2based

on

preliminary figures, January-April 1980

- 68 Annex 5

2.

Major alcohol-related problems and trends Among problems that are well recognized are; (a)

Motor vehicle accidents and pedestrian injuries. Although it is reported that road accidents in Papua New Guinea rose by more than 400% between 1968 and 1978 and that there are now over 13 times as many fatal road accidents per 10 000 registered vehicles as in Great Britain, there are no valid figures to determine

whether these accidents are related to alcohol use. About 14% and 16% of road accidents were attributed to alcohol use during 1981 and 1982 respectively. (b) (c) (d) (e) (f) (g) Crime and social disruption, which attention today. ~s

the problem commanding most

The impact of alcohol on family and work roles seems to be a substantial problem in some areas. Tribal clashes in the highlands - it is difficult to demonstrate whether alcohol is the sole contributory factor. Public drunkenness is largely a town problem. The short-term physiological consequences of drinking appear to present few problems at this juncture. The long-term physiological consequences of drinking (e.g. liver cirrhosis, chronic alcoholism) are negligible now but are sure to become increasingly important given Papua New Guinea's rates and patterns of alcohol consumption. Psychological and existential issues and problems which are difficult to estimate and which develop over time. Ingestion of methyl alcohol (e.g. March 1977 outbreak involving 32 young men).

(h) (i) 3.

National policy and control measures (1) (2) (3) Ban on liquor sales from bottle shops and licensed trade stores on pay days and public holidays. Total ban of liquor sales in troubled areas, e.g. three-month ban in simbu On all forms of liquor as a result of tribal fighting. Ban on the advertising of alcoholic beverages.

- 69 Annex 5

(4)

Impending legislation on the introduction of breath analysis equipment - on 15 March 1983, the Police Commissioner wrote to the Police Minister about the possibility of making legislative changes to accommodate specific breath-analyzing devices on road sides. Creation of a Ministry of Youth, Religion, and Women's Affairs.

(5) 4.

Early intervention and education

Educational materials in the form of posters and booklets are prepared by the Health Deparment in liaison with Dr Cliffor Smith and the Royal Papua New Guinea Constabulary. Emphasis is placed on social and physical problems and on traffic accidents related to alcohol use and abuse. 5. Prevention and management

Agencies along the lines of Alcoholics Anonymous may be useful in Papua New Guinea if properly adapted to local cultural realities. A detoxification centre - Bel lsi - which is now operating near Sogeri appears to be working well. Schoolchildren are given lessons on the dangers of alcohol between fourth and sixth grades. Provincial radio station programmes are particularly apt vehicles for disseminating information about problems related to alcohol use and misuse. References 1. 2. Milner, G., Assignment Report, ~O Regional Office for the Western Pacific, 1 July - 31 October 1979. MacMarshall, lASER Discussion Paper, May 1981.

- 70 Annex 5

COUNTRY PROFILE - PHILIPPINES

A.

Nature and magnitude of alcohoL consumption

Alcohol and alcoholic drinks, either indigenously prepared or commercially distilled, are part and parcel of the food intake of many families in the Philippines, both in the rt.1ral and in the urban areas. The farmers believe that a swallow or two of the indigenously prepared alcoholic beverages, such as coconut toddy (tuba) or nipa wine (lambanog) or sugar cane wine (basi), before they go out to the fields will provide them with the needed energy and body warmth for the performance of their farm chores in the morning. Another round of the same drink in the evening provides them with a good night's rest. Urban men, on the other hand, believe that drinking a glass of beer or a little wine before meals, particularly at the end of the day, will enhance appetite and ensure a restful night and bodily strength. Intake of alcohol and alcoholic drinks is not a monopoly of men. Women from urban and rural areas also take alcohol and alcoholic drinks for val·ied reasons: some to enhance appetite, others to counter menstrual

pains and the like and others again as a source of bodily energy. It may be mentioned in passing that the indigenously prepared alcoholic drinks from st.1gar cane, the basi, are available in two preparations "basing lalake", the basi preferred by men, and the "basing babae", the basi preferred by women. The Food and Nutrition Research Institute of the Philippines made a study of the mean per capita food consumption in the Philippines, both in the rural and urban areas, by island group in 1978. They found that the mean per capita consumption per year of alcoholic beverages is .4 kg per year, making 18 674 263.6 kg for 1978, and of coconut toddy (tuba, 1.5 kg per yearl, making 70 028 488.5 kg for 1978. There are no data available for the other indigenously prepared alcoholic drinks namely the "basi" made from sugar cane and "lambanog" made from the nipa palm. In the study by Dr Virgilio G. Santiago "A Survey on the Alcohol Dependence Syndrome and Disabilities Related to Alcohol Consumption in the Philippines - Phase I", it is reported that annual alcoholic beverage consumption among Filipinos on a per capita basis, increased from 18.67 litre. in 1971 to 28.58 litres in 1980. In terms of absolute alcohol, the increase was from 2.35 litres per person to 4.12 litres, an increase of 80 per cent. In the same study, Dr Santiago also reported that during a ten-year period (1971-1980), the importation of alcoholic beverages and distilled spirits rose by 182 per cent in volume and 1161 per cent in value. The reported figures on alcoholic beverages imported into the country may be considered lower than the actual supply, since some enters

the country through the military bases.

lThe estimated population for 1978 was 46 685 659.

- 71 Annex 5

B.

Alcohol-related problems and trends

In the Philippines, only very scanty documented data on alcohol-related problems are available; hence no figures and trends can be presented. We are aware, however, of serious adverse effects of prolonged alcohol drinking on the health of the drinker, affecting "virtually every organ system of the body". Among the major health-related problems observed are cirrhosis of the liver, cancer of the larynx, pharynx, liver, and other organs of the digestive system, alcoholic psychosis and delirium tremens. With regard to alcoholic psychosis and delirium tremens the latest figures for 1982 from the National Mental Hospital showed only one case of delirium tremens and that out of total admissions of 5857 mental cases for the year, about 1% were for alcoholic psychoses. Traffic accidents and work-related accidents are also among the major related problems involving either the drunker driver or the alcoholic pedestrian or worker. Accidents are among the leading causes of death in the Philippines, but whether they are alcohol-related or not is not indicated. Other occupational problems, such as absenteeism and the low productivity of the Philippine Labour force, could possibly be alcohol-related. Crimes, such as murders and homicides, are among the consequences of excessive alcohol drinking. Among married people, alcoholism is one of the causes of marital discord. In addition, alcoholism among parents results in poor parental examples being shown to the children. Among our youth, absenteeism from school, academic failures and vandalism are some of the problems that are influenced by alcohol abuse. C. National policy and control measures

Awareness of the problems that ensue from excessive intake of alcohol and alcoholic beverages resulted in the promulgation of: (1) Transportation and Traffic Code, Sec. 53

This code provides that no person shall drive a motor vehicle under the influence of liquor or a narcotic drug. The penalty for driving a motor vehicle while under the influence of alcohol or narcotic drugs is a fine of not less than 1200 or more than 1500 or an imprisonment of not more than three months or both at the discretion of the court.

- 72 Annex 5

(2) City or~inances which prohibit (1) the drinking of intoxicating . llquor or alcohollC beverages, bee; and wine on any public sidewalk, street, avenue or thoroughfare or ln plazas and parks which are not des~gnated f?r ~icnics, exc~rsion8 or health resorts; (2) the selling, bUYlng or drlnklng of any klnd of hard liquor in any sari-sari store; and (3) drunkenness or intoxication while in any public place or place open to public view or behaviour in a drunken, boisterous, rude or indecent manner in any place to the annoyance or inconvenience of another person.

The punishment for the violation of the aforementioned prohibition is either or both the payment of a fine or a prison sentence. The fine ranges from t25 to t200 and the imprisonment is for not less than 10 days to not more than 30 days. (3) There is a ban on the sale of alcohol two days before an election and on election day. (4) There is a total ban on military and police officers and men entering nightclubs, disco pubs, beer joints and other similar public drinking places. It may be noted that driving under the influence of liquor, according to the 1982 report prepared by the Constabulary Highway Patrol Group, led to 80 fatal traffic accidents, 697 non-fatal traffic accidents, 1215 accidents causing damage to property. This represents 4% of the total vehicular and traffic accidents, which totalled 54 467 in 1982. D. Early intervention and education

Early intervention in alcoholism has not been developed as yet in the Philippines. It is common knowledge that alcoholic patients rarely acknowledge their illness and usually do not seek treatment for alcoholism itself. Most of them consult the physician for Some physical complaint that appears to be aggravated or brought on by alcohol abuse. It may be observed, however, that family members, such as the mother or the wife or husband of the excessive drinker, provide what may be considered as "early intervention" by calling attention to the dangers. Unfortunately, more often than not, this results in nagging incidents which worsen the disharmony in the family and in turn cause the drinker to seek still more relief in drinking. Education on alcohol in the Philippines has been confined to articles printed from time to time in magazines such as Health and Home and in the press. Attempts to promote moderation in the consumption of liquor have been noted in the advertisement of certain locally distilled beverages which say "DRINK MODERATELY". The effects of such promotional undertakings as a method of education still need to be assessed. It can be said that there is no known planned educational programme of activities on alcohol to date being undertaken specifically by any particular health or service organization.

- 73 -

Annex 5

E.

Prevention and management of alcohol-related problems

Measures to prevent alcohol-related problems are limited to restriction of sale of alcoholic beverages to minors; restriction of operation of beer and public houses in the vicinity of university belts, and punishment of drunken drivers, which have already been discussed in Section C of this paper. Section D on early intervention and education describes the limited efforts at alcohol education through print media and advertisements. Other preventive programmes are being undertaken by public health, 'Dental health, welfare and social agencies, both government and private, which are directed to the strengthening of the family system, the enrichment of personality development, and maternal and child health programmes focusing on wholesome child-rearing practices. The management of alcohol-related problems is undertaken by medical centres with psychiatric units, regional hospitals with mental wards, the National Mental Hospital, mental hygiene clinics and mental health organizations. Treatment and rehabilitation centres for drug dependents also serve alcoholics. A local chapter of Alcoholics Anonymous operates actively in Metro Manila and certain cities outside Metro Manila.

- 74 -

Annex 5

COUNTRY PROFILE - TRUST TERRITORY OF THE PACIFIC ISLANDS (MICRONESIA)

Introduction Micronesia, meaning "tiny islands" consists of over 2000 small islands scattered in the Pacific Ocean. Geographically, they are those islands west of Hawaii, northeast of Australia and Papua New Guinea, east of the Philippines, and southeast of Japan. Though they span a distance the length of the United States, their landmass is less than that of the state of Rhode Island.

Politically, the Trust Territory is separated into four entities: the Commonwealth of the Northern Marianas, the Republic of Palau, the Republic of the Marshall Islands, and the Federated State of Micronesia (Yap, Truk, Ponape and Kosrae). The population of the Territory is approximately 130 000, of whom about 60% are under 25 years of age. The main foreign influence in these nations is currently American and Japanese, although Filipinos, Koreans and Hong Kong Chinese are now entering the islands. History of alcohol in Micronesia Alcoholic heverages are a Western contribution to Micronesia.

Before coming into contact with Europeans, the people of Micronesia possessed no alcoholic beverages, not even fermented coconut alcohol (tuba). In Yap, Palau and Saipan, the drug used Was betel nut and on Ponape it was kava (sakau). All of these drugs are still in use. When Micronesians first tasted lithe water that takes away one's wits" they

simply spat it out. However, as time passed, the people of Micronesia began to drink alcohol as more and more Europeans gave it to them as a token of good will. At the same time, Micronesians learned how to ferment coconut alcohol beverages and other home-made brews. Between the First and Second World Wars, the Japanese administration prohibited Micronesians from drinking alcoholic beverages. After the Second World War, the United States administration followed in the footsteps of the Japanese administration by continuing the prohibition. Even though both administrations prohibited any alcohol consumption by Micronesians, In one way or another they succeeded in acquiring alcoholic

beverages. Early in 1960, the legislature in the Trust Territory passed a law forbidding the brewing of any alcoholic beverages from coconut milk, yeast, or any man-made or natural chemical. beverages by Micronesians. Ironically, at the same time, a law alcoholi~

was passed permitting the importation and consumption of

- 75 Annex 5

A.

Nature and magnitude of alcohol consumption

As reported in "Youth Drinking in Micronesia" by Fr. Francis X. Hezel, between 1969 and 1977, the only years for which dollar figures of imported alcoholic beverages are recorded, consumption of beer and liquor increased steadily. Expenditure on alcohol rose from US$638 000 or 4.6% of the total value of imports in 1969, to about US$2 392 000 or 8% of the dollar value of imports in 1977, Table 1 shows the Trust Territory's imports of alcohol in thousands of dollars in comparison with the retail prices of other imported food. Table 1. Trust Territor of the Pacific Islands: (thousand) Alcohol as % of imports 4.59 5.07 6.48 6.41 6.46 7.35 6.11 8.14 D 8.00 im orts of alcohol

Year 1969 1970 1971 1972 1973 1974 1975 1976 1977 C B

Beer

Total alcohol 638.6

Per capita imports of alcohol

Real per capita imports of alcohol $13.49 18.25 27.73 20.20 14.84 14.79 15.45 34.04 34.04

$ 6.52 10.40 16.03 15.50 15.03 18.63 19.93 25.45 34.04

628.1 1 058.2 1 165.5

1 058.8 1 695.4 1 688.9 1 680.6 2 150.9 2 372.5 3 123.6 D 2 392.4

1 250.3 1 601.3 1 706.3 2 251.4

1 824.5

APrice index = weighted r.etail prices of rice, sugar, flour, canned sardines and canned corned beef. Base year = 1977. BThe 1969 data are marred by poor reporting. CI977 data include only the Marshalls, Palau, Ponape and Yap. DEstimated values. (Sources: Trust Territory reports to the Urtited Nations, 1969-1977 and Trust Territory Bulletin of Statistics Vol. 11.2)

- 76 Annex 5

Even with allowances made for inflation and population growth, the yearly per capita expenditure on alcohol during this period rose from about US$13.50 to more than US$34.00 according to the most recent data available. The per capita expenditure on alcohol in Yap and Palau has been considerably higher than that in other island groups. It is estimated that well over US$3 million a year is now spent on alcoholic beverages in the Federated State of Micronesia, Palau, and the Marshalls, and there is every expectation that this figure will increase in the future. Table 2 shows 1977 estimated expenditure on alcohol by island groups in thousands of United States dollars. Table 2. 1977 estimated expenditure on alcohol by district (thousand $) Per capita expenditure on alcohol $24.04 54.60 20.85 66.14

District Kosrae

Beer 494.0 556.4 297.1 477 .0

Total alcohol 651.5 738.2 441.8 560.9

% of total

expenditure 6.8 8.1 5.8 15.5

Marshalls Palau Ponape Truk Yap Totals or weighted averages

1 824.4

2 392.4

8.00

34.04

(Sources:

Trust Territory reports to the United Nations 1969-1977 and Trust Territory Bulletin of Statistics Vol. 11.2)

B.

Major alcohol-related problems and trends

In Ponape, the local "sakau" or kava is still a respected drink. The traditions surrounding sakau ritual have remained virtually the same throughout history, because its use is confined to the older generations, while alcohol has become the chosen drug of the younger generations. The other States, where alcohol use is more widespread, report a far greater incidence of alcohol-related problems among the adult population. Criminal behaviour in Micronesia is most frequently related to alcohol consumption. A statistical report for 1979-1981 from the State of Ponape revealed that in the two-year period, there had been 2096 arrests related to drinking: 591 arrests for disturbing the peace, 123 misdemeanours, and 1382 arrests for offences such as being a minor in possession of alcohol, possession of an open container of alcohol in public places, and similar infractions. The majority of those arrested were between the ages of 18 and 25.

- 77 -

Annex 5

Mahoney reported in his studies of youth drinking that between 1969 and mid-1973, the proportion of juveniles (under 18 years) prosecuted in the Republic of Palau increased steadily. The comparison between adults and juveniles is shown in Table 3. Table 3. Police prosecutions in Palau (1969-1973) 1969 Adults prosecuted Juveniles prosecuted Total prosecuted % Juveniles/total 83 23 L06 21.6% 1970 447 195 642 30.3% 1971 385 258 643 40.1% 1972 290 209 499 41.8% 1973 (seven months) 164 113 277 40.7%

(Source:

"Youth Drinking in Hie rones ian)

It is further recorded in "Youth Drinking in Micronesia" that 90% of all juvenile arrests were for alcohol-related offences, including illegal possession and consumption of alcohol, disturbing the peace while under the influence of alcohol, vandalism while under the influence of alcohol and burglary and larceny for the purposes of obtaining alcohol or money with which to purchase it. In addition, other social problems, such as committing public and private nuisance, marital problems, and family disputes can often be attributed to excessive drinking. Serious economic problems can also occur in families as a result of the tendency to spend whole pay packets on alcohol. C. National policy and control measures

National controls on alcohol consumption prohibit persons under the age of 21 from purchasing or consumpting any alcoholic beverage. However, there is little or no enforcement. In practice, anyone can import alcohol and will usually sell to anyone willing to buy, regardless of age. Each island group in the Trust Territory has its own policy. Kosrae has decided to prohibit alcohol consumption because of the strong religious beliefs prevalent there. It is, however, still possible to purchase alcoholic beverages in Kosrae. In 1977, Truk banned all alcohol beverages in response to public concern over bloodshed and other criminal acts which were seen to be related to alcohol. In Ponape, some of the municipalities have passed local legislation banning the consumption and sale of alcoholic beverages for similar reasons.

- 78 Annex 5

In Ponape, temporary prohibition was introduced in 1971 when all 27 bars were closed for a few months following two killings committed under the influence of alcohol. An Alcoholic Beverage Control Board (ABC Board) was established on many of the islands and drinking permits issued in an effort to control the sale of liquor to minors and to those most likely to abuse it. This measure had only a limited success because the permit system, which did not specify limits, was open to abuse. Indeed, revenue produced from the permits was insufficient even to support the ABC Boards. D. Early intervention and education

As appears to be the case in some other developing countries, Micronesians drink to get drunk. There is very little social drinking or drinking in moderation. Culturally, the drunken person can exhibit behaviour which would be deemed unacceptable if he were not drunk, but which is easily passed off the next day with the excuse of drunkeness. There have been very few successful attempts at education or alcohol abuse prevention programmes. Although missionary influence has had an impact on some of the smaller outer islands, this is hardly sufficient to combat what are seen to be alarmingly sharp increases in problems in the district centres. When Micronesia Bound was formed on Ponape in 1976, its purpose was to offer young people an alternative to delinquency and to rehabilitate troublesome youths. OVer the years, it has gradually included alcohol education as a major objective of its staff training. Although very successful in its programming, it has been able to reach only a minority of the young people across Micronesia. E. Prevention and management

Micronesia has few traditional controls over drinking, with the exception of public disgace in Kosrae. Because of the alcohol ban on Truk in 1977, crimes related to alcohol consumption are relatively fewer there. In places where alcohol is or has been made unavailable, people frequently resort to homemade concoctions of yeast or fermented coconut milk~ To date, public health centres and mental health programmes are ill-equipped to handle the reapidly increasing number of people with alcohol-related problems. There are some indications that problems of drunkenness are currently diminishing in Micronesia, although it is far from clearly why this is so. It has been suggested that, as people gradually become accustomed to alcohol, they learn to avoid some of the excesses of drunken behaviour. Alternatively, the growing popularity of marijuana among the youth and some adults may be responsible for a decline in the popularity of alcohol, or the traditional popularity of sakau may be reasserting itself.

- 79/80 Annex 5

What is most likely is that this reduction is a temporary phenomenon and that more people will drink alcoholic beverages as the islands' economy develops and expands. If, indeed, this happens, the future of the new Micronesian nations will be tarnished by an overwhelming dependence on imported alcohol.

- 81 ANNEX 6

LIST OF DOCUMENTS 1. Agenda/Annotated Agenda - WPR/Workshop/MNH/83.1 - WPR/Workshop/MNH/83.1(a) 2. Information Bulletins - WPR/Workshop/MNH/rB/1 - WPR/Workshop/MNH/IB/2 Information Bu11eting No. 1 'Provisional list of participants, temporary advisers, observers and secretariat

Provisional agenda Provisional annotated agenda

3.

Guidelines for the workshop Objectives of the workshop - (WP)MNH/rCP/MNH/004 Final Report: Working Group on the Prevention and Control of Alcohol-Related Problems, Tokyo, Japan - 27 May - 2 June 1980 Background Document for reference and use at the Technical Discussions on Alcohol Consumption and Alcohol-Related Problems: Development of National Policies and Programmes

- A35/Technical Discussions/l

- A35/Technical Discussions/l Addendum 1 - A36/Technical Discussions/6

Alcohol Consumption and AlcoholRelated Problems: Examples of National Policy Development Report on Technical Discussions Alcohol Consumption and Alcohol-Related Problems Development of National Policies and Programmes Alcohol as a Major Public Health Problem Alcohol Consumption and AlcoholRelated Problems: Development of National Policies and Programmes Alcohol Consumption and AlcoholRelated Problems: Development of National Policies and Programmes

- WPRiRC33. Rl5

- EB7l.R7 (Seventy-first session) - WHA36.l2 (Thirty-Sixth World Health Assembly)

- 82 -

Annex 6

4.

Country Profiles Australia Fiji Japan Malaysia New Zealand Papua New Guinea Philippines Republic of Korea Solomon Islands Tonga Trust Territory of the Pacific Islands Dr Ms Dr Dr Dr Dr Dr Dr Dr Mr Mr Susan Morey M. Rokosawa M. Nishiyama Ramlee Bin Rahmat Sally Casswell Cyril U. Imako L. Manapsal and Ms E. Martillano Dae Hie Lee S. Fangaria S. Wolfgramm V. Alphons

5.

Agenda No.4 WPR/Workshop/MNH/INF./l (Provisional agenda item 4.1) WPR/Workshop/MNH/INF./2 (Provisional agenda item 4.2) Global Trends in Alcohol-Related Problems (Dr Marcus Grant) The Minimization of Alcohol-Related Problems in the Western Pacific Region (Dr Sally Casswell)

6.

Agenda No.5 WPR/Workshop/MNH/INF./3 (Provisional agenda item5.1l WPR/Workshop/MNH/INF./4 (Provisional agenda item 5.2) WPR/Workshop/MNH/INF./5 (Provisional agenda item 5.3) WPR/Workshop/MNH/INF./6 (Provisional agenda item 5.4) Prevention of Alcohol-Related Problems in the Context of National Policy Development (Dr Marcus Grant) Community Approach (Dr S. Morey) Educational Programmes for Youth (Mr V. Alphons) Coordination and Collaboration of Different Sectors) (Dr Sally Casswell)

7.

Agenda No.6 WPR/Workshop/MNH/INF./7 (Provisional agenda item 6.1) Introduction to the Preparation of Framework

- 83 -

ANNEX 7

EVALUATION QUESTIONNAIRE Total number of participants: 11 persons Yes 1. 1.1 1.2 1.3 Educational gains Were the objectives met? Have new skills or concepts been learnt at the meeting? Can these skills and concepts be applied in your country? 11

No

11 11 (one participant answered both yes and no to this question)

2. 2.1 2.2

Process and outcome Were you able to express your ideas or problems at the meeting Was there enough opportunity to exchange knowledge and experience with other participants? Were you satisfied with all working papers If no, please explain for specific paper(s): The introduction to the framework required more time. There should have been a paper on high-risk groups.

10 11

1 (language problems)

2.3

9

2

2.4

Specify which of the working papers and background documents distributed for the meeting are the most useful for you: (a) Working papers Regional trends Prevention Global trends Country profiles Collaboration Community approach Education for youth Introduction to framework Final report (Casswell ) (Grant) (Grant) (Casswell) (Morey) (Alphons) 4 4 3 2 2 2 1 1 1

- 84 -

Annex 7 Yes (b) Background papers Tecnnical discussions (background and addendum) Tecnnical discussions (final report) Tokyo working group report 2.5 Did you have enough time to study the working papers? If ao, did you receive the working papers sufficiently in advance? 2.6 2.7 Were methods of introduction and presentation of different topics satisfactory? Were you fully satisfied with discussions (a) (b) 3. at the plenary session? at tne group session? 11

No

4 2

4

7

1

6

11

10

(time too short)

Organization of the meeting Were the duration and scheduling of different activiti~s - lectures, group discussions, etc. satisfactory? If ~,

10

please describe: 2

Group discussion sessions were too short

Country profiles should have been prepared further in advance 4. Administrative aspect Are orgaaization or administrative arrangements

10

1

for travel, accommodation, per diem, meeting room, and secretarial support satisfactory? If ~,

please describe:

WHO should send representative to meet participants at the airport. Advice on travel and working papers should be sent out much earlier.

'.

- 85 -

Annex 7 Yes No

5.

Your· overall conclusion Do you feel that (a) the suggestions for future action/ conclusions reflected the meeting consensus? II

(b) (c) (d)

such meetings should be held regularly? your attendance was worthwhile to you personally? your participation was worthwhile to your country?

11 11

11

Comments (if any): (a) (b)

There is much benefit to be derived from meeting others and sharing experiences Workshop style of meeting useful for health worker training need for continuing support of own government to maximize benefits l

(c) 6.

Is there any better way to achieve the meeting's Objectives? What follow-up activities, if any, would you recommend:. (a) (b)

7.

(c)

by your national government by WHO by other agencies (specify type)

9 9 2

Suggestions for future action by governments: Establish national body or forum Increase intersectoral collaboration Organize public meetings Hold country-level workshops Study size and nature of problem Research to monitor progress 3 2

J - 86 Annex 7

Suggestions for future action by WHO Regular regional training workshops Meeting of health ministers to implement national policies Provide developing countries with consultants Standardize data-collection systems Suggestions for future action by other agencies Professional organizations to become more active International bodies to provide funds and consultants All su 8.

4

estions for action included in both A and B) to be implemented. I

How many WHO meetings have you attended in your professional capacity in the past?

o=6

participants 1 6 participants 2 = 1 participant