Mental Health Reform: Alcohol and the Impact of Decisions
"A city where there is health, safety, and solidarity. Diadema: A city for everyone." Thus reads the title on the official website of the municipality of Diadema, a city of 400,000 located some 17 km. south of downtown São Paulo, Brazil.
Diadema, however, is more than a typical large district on the outskirts of São Paulo. It has taken a place on the world stage and for some years now, it has been an important subject for study by lawmakers, public health experts, and decision makers.
In the 1990s, anyone who referred to Diadema as a healthy and safe city would have risked becoming the target of satire during Carnival. In 1999, there were 102 homicides per 100,000 residents. However, 2 years later, in 2001, the rate had fallen to 65. And by 2004 it had dropped to 34.
Several steps taken by the Diadema municipal government have contributed to this surprising decline in violence and homicide rate. But falling crime stats are not the only improvement; there are other indicators of similar trends. Since 2002 for example, the number of reported traffic accidents has fallen by 30%; the number of assaults on women declined by more than one-half, and emergency-room admissions directly related to alcohol use have fallen by as much as 80%.
"The alcohol industry's overwhelming presence in the socio-cultural fabric of many countries in the Region is so powerful that it is virtually impossible to compete with it."
Dr. Maristela Monteiro, Regional Advisor on Alcohol and Substance Abuse (PAHO)
Efforts to understand the 1990s spiraling violence included studies done by the city's prefecture. And it was found that most homicides occurred between 11 PM and 4 AM. This finding led the city mayor to adopt two concrete measures whose implementation and monitoring appear to have made Diadema once again a healthy and safe city for all. A citywide program for citizens to surrender their firearms was launched. On July 15 2002, legislation was passed to forbid the sale of alcohol at the city's estimated 5,000 bars between the hours of 11 PM and 6 AM. (Excluding underage individuals, nondrinkers, and the elderly, the number of bars in Diadema averaged one establishment per 30 residents).
The Brazilian city began to reap the benefits of these measures almost overnight. Diadema began to record a decrease in violence, in injuries, and in deaths; the town gained greater safety. Residents felt a more harmonious society. And a steady rise on investment and urban development started to take place.
Not long after the new statistics began to make headlines in the local, national, and international press, at least 120 Brazilian municipalities, as well as the entire State of Pernambuco, drafted and approved similar measures in an attempt to replicate the good news from Diadema.
Dr. Maristela Monteiro
Signs of Progress
Speaking from her office at the regional headquarters of the Pan American Health Organization (PAHO) in Washington, D.C., Dr. Maristela Monteiro says these signs of progress have an undeniable validity and transcendence. They do provide important lessons not only for Brazil but for the rest of Latin America and the Caribbean, she said.
As PAHO Regional Advisor on Alcohol and Substance Abuse, Monteiro recalls that the institutional mandate of the organization is to cooperate and assist Member States in effectively implementing public policies and improve services. And that includes making alcohol a public health issue, as has been the case in Diadema and other places.
In Latin America and the Caribbean, however, implementing policies to reduce and control the access to, availability of, and advertising for alcohol, and to increase its price, should be as important as strengthening services," Dr. Monteiro explained. She said that unlike the case of tobacco (where major battles are being won in several countries of the Region) the struggle against alcohol dependency and the consequences of its use, abuse and availability, particularly among young people, are still at a very early stage. The exceptions are some areas of the United States and Canada and in singular, notable cases such as Diadema, in Brazil.
"We don't want to ban alcohol. It is part of our culture. What concerns us is that our very culture is perhaps being altered or undermined by the overwhelming influence of the industry and the authorities' lackluster efforts to restrict the almost boundless availability and accessibility of alcohol and its out-of-control advertising in the Region."
Dr. Maristela Monteiro, Regional Advisor(PAHO)"
"The alcohol industry's overwhelming presence in the socio-cultural fabric of many countries in the Region is so powerful that it is virtually impossible to compete with it," Dr. Monteiro said. "We don't want to ban alcohol. It is part of our culture. What concerns us is that our very culture is perhaps being altered or undermined by the overwhelming influence of the industry and the authorities' lackluster efforts to restrict the almost boundless availability and accessibility of alcohol and its out-of-control advertising in the Region. Furthermore, these industries dominate the industry in several countries and sub-regions, such as Brazil, Mexico, and the Caribbean." Alcohol manufacturers are very important sources of much-needed tax revenues for governments, she said, while the same governments are the ones shouldering the cost of excessive consumption, which eats up most of the revenue they receive.
Dr. Monteiro noted that the problem of alcohol goes far beyond the dependence it produces in so many people. In the specific context of mental health reform in the Americas, the problem is also that its effects and consequences are not directly related only to the group at the greatest risk. "The problem of alcohol is that it is not so much the people who are dependent but those who are not dependent."
Alcohol as a public-health issue has two basic components, she said. One is injuries, whether intentional or unintentional, resulting from its use, particularly among young people. And the second is abuse and dependence.
Intentional and unintentional injuries resulting from alcohol use account for approximately 60% of all deaths related to alcoholic beverages, and almost 40% of the total burden of the resulting illnesses.
"Young people have little experience with, and tolerance for alcohol. And they drink a lot. They are the ones in society who should be the healthiest, but they use alcohol during a period in their lives when they are also beginning to drive motor vehicles, practice sex, and use drugs," she said. "Their brains are still being formed, and alcohol can interfere with normal brain development."
The Regional Advisor noted that according to the World Health Organization (WHO) publication Neuroscience of Psychoactive Substance Use and Dependence (2004), an estimated 200 million people worldwide use some type of illicit drug, compared with 1.2 billion who consume alcohol.
"Only a small portion of drinkers develop clinical dependence. Nondependent people, who drink to excess only occasionally and who account for a much larger proportion of the population, represent a greater cost for society overall, since alcohol leads them to make greater use of medical care, have higher accident and injury rates, and be involved in more acts of violence (interpersonal, domestic, against women and children). It also lowers their labor productivity."
A 2005 study whose findings were published in PAHO's Pan American Journal of Public Health, estimated that more than 30 million people in Latin America and the Caribbean met the diagnostic criteria for alcohol-related disorders and that more than 75% of them were receiving no care or treatment.
"The Region is hampered by a heavy stigma against alcohol dependence that comes from the societal tendency to say that alcohol-related problems are linked to 'low moral values' and the failings of 'weak people' who could stop drinking if they wanted to. "
Dr. Maristela Monteiro, Regional Advisor (PAHO)
"Alcohol dependence today is considered a chronic, recurrent illness characterized by relapses and is part of a disorder whose recovery requires a long-term, on-going treatment," Dr. Monteiro said.
Nevertheless, she warned that treating what is commonly known as alcoholism without parallel policies to control its use and without laws, will not produce the desired results. She said that unfortunately, current services and legislation in most Latin American and Caribbean countries have dramatic shortcomings.
Burden with a Stigma
"The Region is hampered by a heavy stigma against alcohol dependence that comes from the societal tendency to say that alcohol-related problems are linked to 'low moral values' and the failings of 'weak people' who could stop drinking if they wanted to. And also from doctors themselves, she added, since it is still common to hear them say things such as: 'this isn't my problem; this is for a psychiatrist'".
Dr. Monteiro underscored that the mental health reform called-for in the 1990 Caracas Declaration emphasizes the need for a change of thinking at public health institutions. Primary-care services need to have the experts and the capacity to treat these diseases in a structural, regular, integrated and decentralized manner that guarantees respect for the human and civil rights of patients.
"Work with respect to alcohol and other psychoactive substances is sprinkled by similar challenges also seen in the mental health field per se: stigma, discrimination against patients and their families, violations of their human rights, the institutionalization of patients in deplorable and inhumane conditions; isolated treatments rather than integrated into the primary health care, lack of human and financial resources, shifting policies, unsatisfactory laws and the need for a civil society pledge to achieve the appropriate responses."
With regards to practical recommendations for decision-makers in Latin America and the Caribbean, Dr. Monteiro listed some of the best practices that governments can develop to comprehensively address alcohol-related problems.
The recommendations are based on evidence and studies by international experts as compiled in WHO's Alcohol: No Ordinary Commodity, published in 2003:
- Establishing a legal minimum age for buying alcoholic beverages
- Restricting days or times for selling alcohol
- Restricting the points of sale density
- Controlling alcohol production and sales (with emphasis on legal action against clandestine production)
- Raising alcohol taxes
- Controlling or prohibiting alcohol advertising, whether directly or indirectly
- Lowering the legally permitted blood alcohol level for driving
- Suspending the licenses of people who drive under the influence of alcohol
- Gradual licensing methods for new drivers
- Instituting brief interventions for problem drinkers, and
- Setting up a system to address and treat alcohol-related problems (dependence and others) that is fully integrated into the primary health care system.
"Perhaps we could then speak of an Americas for all where there is truly a much better health, safety, and solidarity", Dr. Monteiro said, -just as in Diadema.