A patient was admitted to the Department of Medicine at a tertiary care hospital in northeast India with complications due to a damaged liver. This was his fourth admission in the past few years. Now, at the age of thirty-two, he suffered from end-stage liver disease.
The patient had to be kept restrained due to altered behaviour because of alcohol withdrawal. His young wife was attending to him and also looking after their newly born child.
“He drinks every day and beats me, and apologises for it the next day. At least he has a government job with a steady income. I am a middle school graduate. How will I fend for my child without him?” - His tearful bride would confide in us.
After a couple of weeks of intensive and expensive treatment, the patient was able to walk to the bathroom unassisted. We planned to discharge him for home care, but cautioned him against touching alcohol ever again. As it was, we were not sure how long he could survive with a rotten liver.
He needed liver transplantation, but that was not an option at our center, nor could the patient afford to travel to another center for the same. He meekly smiled and swore to turn over a new leaf.
The very same day, our evening rounds were interrupted by a commotion from the male ward. We rushed in to find our patient inebriated, vomiting fresh blood, and barely conscious. Having regained some strength, he had sneaked out of the ward and found some locally brewed liquor. His wife opted for a discharge against medical advice the following morning. All her attempts to treat her husband’s disease seemed to be thwarted.
The alcohol problem
With nearly one-third of the global population identifying as current drinkers, there is no denying that alcohol is ingrained deeply in our society. Food and drink have gone together since time immemorial. Effervescent ethanol, bottled over centuries and across miles in different forms, has been a natural accompaniment to cultures and civilizations.
Despite the sturdy body of evidence that underscores the ill effects of alcohol consumption, it continues to be one of the most socially accepted psychoactive substances.
Indians have a testy relationship with alcohol, differing widely in region, culture, and traditional beliefs. While local brews are a part of rituals and ceremonies for some Indians, others consider it taboo to drink at all. No one-size-fits-all generalization can be made about its use, but one fact remains: alcohol has steadily caused 60 to 70 percent of all liver cirrhosis in India in the past decade.
Cirrhosis is a late stage in liver disease when the healthy organ is replaced by scar tissue. The liver can regenerate, but progressive cirrhosis affects this drastically. It often requires a liver transplant to be treated definitively. We have over 2 lakh people dying of liver disease in the country each year, and nearly 1800 liver transplant surgeries happening annually. These numbers, however, have not discouraged the alcohol affliction.
A report in 2018 by the World Health Organization (WHO) found that alcohol consumption in India has increased by 38% in the past decade, and approximately 77 million people in India consume alcohol. In 2012, over a third of all road traffic accidents on Indian streets were attributed to drunk driving. The psychological, emotional, and financial impact of alcohol abuse is well documented. Why, then, is total alcohol consumption and alcoholic liver disease steadily on the rise?
Rising alcohol use
Selective regulations: While states like Gujarat and Bihar have completely banned the sale of alcohol (and unwittingly birthed the illicit liquor sale industry), Punjab and Haryana, which depend heavily on revenue from the alcohol industry for their state coffers, slash excise duties on liquor to keep prices significantly lower. Both extremes of regulations do the common man a disservice. Whether it is deaths due to hooch consumption or the easy access problem, these state rules end up costing the average Indian dearly.
COVID and alcohol: After the first set of restrictions eased during the lockdown in the pandemic, liquor shops were some of the first spots to reopen. After several incidents of overcrowding, alcohol sellers convinced some states to allow e-commerce sales, while sellers in other states began doing so furtively. Even as the WHO warned about the detrimental effects of alcohol use on immunity in COVID-19, the extent and prevalence of alcohol use were on the rise.
Not all alcohol is liquor: While liquor sales are placed under rules and regulations under law, the same laws don’t apply to non-allopathic medications. Homeopathic drugs are formulated in an alcohol base, as are several Ayurvedic concoctions. Not only are these drugs non-regulated, but they are also abused in lieu of alcohol. In the absence of monitoring, several cases of serious liver injuries due to these products have begun to come to the fore. What is even more concerning is that patients may not be aware of the alcohol-related risks associated with these drugs, and fall prey to the increasing alternative medicine market with no knowledge of the several hazards accompanying them.
Alcohol-harm paradox: The alcohol-harm paradox shows that people from lower socioeconomic strata are more susceptible to alcohol-related health issues than those from higher socioeconomic strata. This is hypothesized to be due to several factors: poorer nutrition and health status, scarcer access to health resources, and higher patterns of binge drinking. In India, the magnitude of the alcohol-harm paradox stands even more starkly, where most patients find out about their liver disease in advanced stages.
Social stigma: Our country has an ambiguous relationship with alcohol and with the disease of alcoholism. Alcohol addiction is recognized as a mental disorder, but is seldom treated that way. People suffering from alcoholism are often socially ostracised and do not find many sources of support. Rehabilitation centers and group meetings like Alcoholics Anonymous are mostly centered in urban areas, while government programmes for de-addiction are limited to medical colleges and tertiary hospitals. The availability of alcohol is universal; the treatment for its addiction, however, is hard to access.
No drinking is safe
In 2016, alcohol was estimated to be the seventh leading cause of death and disabilities worldwide. In people aged between 15 and 49, alcohol use was linked to 12.2% of male and 3.8% of female deaths. In the European region, alcohol has been linked to liver, breast, colon, and esophageal cancer, especially in mild to moderate drinkers.
Alcoholism is not the only risk attached to alcohol. The past belief that alcohol is safe “in moderation” has been debunked now. There is no safe limit to alcohol consumption; social drinking, “just this once”, and a half-glass of wine with dinner- all increase the risk of several diseases. This information, broadcast by WHO and disseminated by major health journals, has yet to reach public sensibilities. However, the writing has been on the wall for quite some time now.
There are recommendations to place health warnings on alcohol, as there are on cigarettes, for quite some time now. The evidence on the efficacy of health warnings meets stiff opposition from the alcohol industry worldwide. The sale of consumable alcohol is a trillion-dollar market, and its lobbyists fight all attempts to disincentivize alcohol consumption everywhere.
What can be done
One of the main issues with alcohol arises from its social acceptability as a mood-altering substance. Along with tobacco, it is one of the most contentious and unhealthy products allowed to be marketed legally. However, as the Prohibition Act in the United States and closer home in Bihar and Gujarat have shown, banning the sales of alcohol has not been a strong deterrent to alcohol consumption. Legislation, in the absence of public behavior change, has little effect.
Stigmatization notwithstanding, alcohol consumption is glamorized as a desirable social characteristic in popular culture representations and everyday lives. The very real and frequent ill effects of alcoholism, however, don’t find a real depiction in social situations.
Optimism bias keeps us believing that moderation will keep the ill effects of alcohol at bay, even though it has been proven to be untrue. Substance abuse legislation exists, but the implementation of alcohol reform practices is low on our health priorities. Community support for people suffering from alcoholism also needs to be supported by groundwork with grassroots involvement.
It is time we demand better for ourselves, from ourselves. We need stronger advocacy against imbibition, better policies to safeguard against underage drinking and drunk driving, and robust support systems to help those struggling with alcoholism. The answer cannot be found in a day’s work, but it is out there.
If you know anyone know needs help with deaddiction, you could reach out to Alcoholic Anonymous (Helpline number - +91 9022771011)
Edited by Parth Sharma
Image by Janvi Bokoliya
