Dr. Daya Hewapathirane

About 9 million or an estimated 40% of the population of Sri Lanka consume alcohol and 99% of them are males. Those consuming alcohol daily amount to more than 4 million. The alcohol market includes pure alcohol such as hard liquor mainly arrack and beer and illicit liquor or kasippu. Illicit alcohol accounts for most of the alcohol consumed in the country. Studies done in 2013 reveal that illicit alcohol or kasippu accounts for as much as 65% of the total volume of alcohol consumed in Sri Lanka.

Considering only those who consume only pure alcohol, the per capita consumption amounts to 14.9 litres per annum.

Males          (age 15+)    –    18.9 liters

Females      (age 15+)    –      6.7 litres

Both sexes (age 15+)     –   14.9 litres

The annual per capita consumption of alcohol, both pure and illicit, by  males of Sri Lanka has been estimated to be a staggering 16.2 liters. This incidentally, is the highest per capita alcohol use among the SAARC countries (India, Pakistan, Bangladesh, Nepal, Nepal, Bhutan, Maldives,  Afghanistan). Alcohol dependence and abuse is a major health and social problem in the island often destroying our countrymen in the prime of their lives. About 23,000 alcohol related deaths occur annually in Sri Lanka or about 65 people die daily due to alcohol abuse.    Sri Lanka spends about Rs. 247 million per day on hard liquors. The total expenditure for patients with alcohol related health problems amounts to about Rs. 145 billion, which is affecting the country’s economy substantially. The leading cause of death among Sri Lankan males between the ages of 25 to 45 is alcohol related diseases. It is reported that about 48% of about 4000 of suicide deaths in Sri Lanka are directly related to alcohol abuse. NATA reports that the government spends an enormous amount of Rs.140 billion annually on treatment of patients suffering diseases owing to alcohol consumption. Drunk driving is a major cause of road  traffic accidents and related deaths and injuries.

A MALE PROBLEM

Alcohol abuse is an increasingly serious problem among a very large segment of the male population of Sri Lanka. This is not only having the effect of severely undermining their health and wellbeing, but also having increasingly harmful effects on the welfare and overall advancement of the country. The quality, competency, vitality and capability of the nation’s human resources are determining factors in overall development and prosperity of a nation. As the dominant component of the nation’s human resources, the male population of Sri Lanka is threatened with an increasingly serious alcohol abuse problem which calls for immediate attention on the part of the government.

The 2016 Global School-based Student Health Survey based on adolescent students of Sri Lanka revealed that the prevalence of alcohol consumption besides smoking and  other illegal substance abuse is an increasingly serious problem among male adolescents in the country. Studies have revealed that adolescents and young adults among males are highly vulnerable to the onset and continuation of the habit of alcohol use. Urbanization, westernization, and the availability and affordability appear to contribute to the upward trend in the sale of alcohol.

The National Authority on Tobacco and Alcohol (NATA) reports that alcohol consumption in Sri Lanka is associated with a huge expenditure for the drinking public. A small village with around 300 families spends an average of Rs. 400,000 (USA $2,446) per month on alcohol and tobacco. This menace is one of the primary reasons for the perpetuation of poverty in the island. The economic consequences of expenditure on alcohol can be significant at household level. Besides money spent on alcohol, a heavy drinker also faces other adverse economic effects. These include low wages (because of missed work and reduced efficiency on the job), lost employment opportunities, increased medical expenses for illness and accidents, legal cost of drink-related offences, and decreased eligibility for loans. The opportunity cost of expenditure on alcohol is most severe for the lower income category as well. The negative economic consequences on households, inevitably exerts a substantial burden on the national economy.

                                                                                                                                         Research has revealed that habitual drinkers among the Tamil  Estate community spend a staggering 40% of their income on alcohol. Alcoholism is a serious problem among the Tamil plantation community. Statistics from Sri Lanka Sumithrayo which is a government assisted charity, reveal that in the Tamil plantation community, one in every 10 school-going children drop out from school due to alcohol consumption in their respective homes. Also, for every alcohol consuming person, at least 10 other persons in the family including extended family members get adversely affected. It has been reported that Sri Lanka’s tea production is on the decline because of increasing alcohol consumption among the Tamil plantation community.

INCREASED CONSUMPTION IN RECENT DECADES

According to WHO studies, alcohol consumption in Sri Lanka shows a significant increase in recent decades, especially since the 1980s and most prominently from 2005 to 2016. In most low and middle-income countries, economic development is known to be a key factor associated with increased alcohol consumption. Sri Lanka’s economy picked up soon after the cessation of the armed conflict against Tamil terrorists, in 2009, and achieved middle-income country status in January 2010. The tourism industry, one of the country’s main income sources, started to flourish at the end of the armed conflict. During this period, most likely due to rising incomes, globalization effects, and making alcohol more available and affordable to people, Sri Lanka  experienced highly increased alcohol consumption. The so-called open economy” introduced to the country in 1978, led to the serious socio-economic problems  including the widespread proliferation of alcohol use and the aggravation of alcohol abuse in the country. Open economy resulted in increased relations and interactions with foreign countries, increased foreign investments within Sri Lanka and increased involvement of foreigners in Sri Lanka in various capacities, increased international travel and overseas employment of Sri Lankans and most importantly, the significant expansion of the tourism industry – all leading to  increased importation of foreign liquor and the expansion of local alcohol production and the expansion of the local alcohol market, the opening of the so-called wine stores” or liquor bars across the country, most often with the patronage of politicians.

EXPANSION DURING THE POST-CONFLICT PERIOD

During the post-conflict period, Sri Lanka’s alcohol industry expanded and there was increased availability of alcohol. Arrack and beer are the popular drinks of Sri Lanka and these are largely produced by two companies – The Distilleries Company of Sri Lanka (DCSL) is the leading arrack producer whereas the Lion Brewery (Ceylon) PLC,  is the market leader of the beer industry.  Both companies have seen market expansion since the end of the armed conflict. DCSL’s net profit increased from 2682 million Sri Lankan Rupees in 2009 to 6873 million Rupees by 2013, an increment of 156% (Distilleries Company of Sri Lanka PLC, 2014). Lion Brewery’s rapid market expansion increased its net profit from 88 million Rupees in 2009, to 1046 million Rupees by 2013, almost a 12-fold increment within 4 years (Lion Brewery (Ceylon) PLC).

                                                                                                                                       Rapid socio-economic development, expansion of the alcohol industry, weak law enforcement and lack of alcohol control strategies during the post-conflict period brought about a rapid increase in alcohol consumption among Sri Lankans. Weak law enforcement and lack of alcohol control strategies were  among other reasons for this rapid increase in consumption during the post-armed conflict period in Sri Lanka. Although the Sri Lankan government  from 2005 to early 2015 developed an alcohol control strategy and a new alcohol control Act, they continued to provide licences for new liquor sales outlets and registered more alcohol producers. Conversely, intensive raids on illicit alcohol brewers carried out by the Excise Department and Police Department in 2010 may have forced people to consume legally produced alcohol products which would have made a positive contribution towards the increment of recorded alcohol sales.

ILLICIT LIQUOR

Illicitly distilled liquor production and sales, especially kasippu, is widespread and is consumed mostly by those with low income. It was reported in the media that in 2015, the Sri Lanka Excise and Police Departments detected as many as 97,000 illicit liquor dens or hide-outs.  Controlling this menace has been severely hampered owing to the political patronage received by illicit liquor barons coupled with bribery and corruption on the part of Government agencies tasked with prevention and detection of this menace.

The difficulty in controlling the production, sales and consumption of illicit alcohol in Sri Lanka has been attributed to corruption in the enforcement agencies besides undue political interference. Those in the legal trade of pure alcohol argue that controls only serve to increase the consumption of illicit alcohol. Police involvement in connection with illicit liquor dens was mostly in connection with the range of crimes associated with these places. Illicit liquor is tied up with gambling dens and many other nefarious activities. Many acts of violence are committed at or in the vicinity of illicit dens. Media reports indicate that Illicit liquor barons are known to have close connections with the underworld. It has also been reported that crimes, including abduction, assault, robbery and murder have become a part of the process in auctions to win tenders for arrack taverns. In this situation, only thugs and illicit liquor barons have been in a position to take arrack taverns on rent. Illicit liquor barons have amassed enormous wealth and have become powerful and highly influential among politicians. They have been able to obtain large-scale contracts in many government projects across the country. A phenomenon observed in arrack business is the entry of unscrupulous business magnates into this business. They promote the sale of adulterated arrack, and often use the same push to pedal narcotics as well. This mafia is said to go all-out to sabotage any moves to combat its activities. This explains the huge amount of illicitly bottled arrack that finds its way to arrack taverns. Arrack business has always been big business and continues to get bigger and bigger.   

ALCOHOL USE BECOMING A NATIONAL PASTIME

In recent decades, consuming alcohol has become a widespread national pastime in Sri Lanka. It is distressing to note that it has become a practice that is widely and socially accepted. In Sri Lanka, both in urban and rural settings, most events, including funerals, some religious and cultural events are made into occasions to drink. In addition to recreation and fun with friends, alcohol consumption has become a panacea for everything – for joy and sorrow, for insomnia, for energy or laziness, for tiredness, for heat or cold, for courage or fear, or sometimes for no reason at all! 

For some people, consuming alcohol with others ‘for fun’, in social groups generates social ties and connections. To serve and consume alcohol is expected in certain settings, especially at popular events such as weddings,  Birthday parties, New Year celebrations etc. In fact, alcohol has become a necessary component in most household parties. In some quarters, social status is communicated and judged by the abundant amounts of expensive liquor served at social events.

SPIRITUAL VALUES

Alcoholism has led to a marked deterioration of moral and spiritual values and standards in Sri Lanka. It is a disgrace in a nation which claims to be founded on Buddhist principles. Refraining from alcohol and other intoxicants is the fifth precept of Buddhism and unfortunately, most Buddhist males appear to be ignoring this basic precept. The use of alcohol blunts the shame and moral dread and thus leads almost inevitably to a breach of the other precepts. One addicted to liquor will have little hesitation to lie or steal, will lose all sense of sexual decency and may easily be provoked even to  murder. Alcoholism is indeed a costly burden on our entire society. To indulge in intoxicating drinks is to deteriorate through all stages of morality, concentration and wisdom.

There is no evidence of alcohol consumption in Sri Lanka, prior to the arrival of European colonial powers. It was the Portuguese, Dutch and British that introduced and promoted alcohol consumption in Sri Lanka. In the late eighteenth century, it was the British who issued liquor licenses to open-up taverns all over the country. They increased state coffers by tax collections and promoted the drinking habit widely via the “Toddy act “of 1912.

MOTIVES FOR ALCOHOL USE AND ABUSE

Comprehensive studies have not been done on reasons and motives for alcohol use and abuse among people in Sri Lanka. It is possible that males, and different age groups develop different motivations towards alcohol use. These motivations may be influenced by varied factors, including genetic,  environmental and cultural factors. Genes that influence the metabolism of alcohol also influence the risk of alcoholism, as can a family history of alcoholism. Culture plays a significant role in motivating or de-motivating people toward various behaviors. Proper understanding of motives that direct people, especially young people to drink would help public health and education authorities to formulate effective public health policies and develop cost-effective measures to curb the alcohol problem.

Prominent among the varied domains of drinking motives are personal enjoyment, social pressure, and tension or anxiety reduction. The personal enjoyment motive perhaps is associated with heavy drinking whereas social pressure may be associated with lighter drinking patterns. Some say that drinks help them to relax, forget their worries and helps them to cheer up and feel good. Some young males in Sri Lanka appear to drink in order to become more prominent among peers and sometimes, especially in social gatherings, to attract the attention of others, especially females. To some, alcohol use symbolizes manhood, and thus, drinking behaviors are occasionally used to dominate others. Tension-reduction motivations appear to be an important social-cognitive factor in drinking behavior of many young Sri Lankan males.  Such motives are often related to solitary and excessive drinking. Among some members of the younger generation, in addition to the access to and availability of alcohol, the media, especially television and movies which glamorize alcohol use, appear to have a strong influence in  shaping of alcohol motives among the young. In-depth research is required to better understand the diverse psycho-social-cultural and environmental factors associated with alcohol use behavior among the younger generation of Sri Lankans.

Consumption of alcohol over a period of time leads to physical and psychological dependence and the development of tolerance. It is also addictive and psycho active like heroin. It is most worrisome to see that the country’s younger generation being  drawn into this despicable practice. As far as the adolescents are concerned, increased autonomy during this period in life, willingness to experiment, and peer influence/pressure create an environment encouraging high-risk decisions which influence adolescents’ health, such as substance abuse and smoking.  Seeking higher levels of sensation during the developmental stage among males compared to greater inhibitory control among females is evident. Thus, males are more likely to experiment with risky behaviors, and this could be one reason for the higher risk among males. Use of alcohol and tobacco by parents and seeing on television and media, popular movie stars, entertainers and sports celebrities consuming alcohol has increased the risk of alcohol consumption and smoking among the younger generation.

A research investigation in selected rural and sub-urban settings in Sri Lanka has revealed that there is a special group of males with a problematic drinking practice, who drink heavily in solitude on a daily basis. They often have the tendency to display embarrassing behavior in public, using unacceptable language, sometimes resorting to violent and anti-social behavior creating problems for others. Consumption of alcohol, specially binge drinking is associated with the development of “Dutch courage”. This leads many alcoholics to engage in violent behaviour and commit crimes that they would never had attempted in a sober state. Media often reports of tragic stories especially from rural and sub-urban areas where husbands come home drunk and physically harass and abuse their wives and children. Also, driving under the influence of alcohol often results in fatal road accidents. Some drunk drivers are overconfident and resort to reckless driving and excessive speed. Some suffer from fatigue and drowsiness under the influence of alcohol, and make wrong judgements leading to serious accidents.

HEALTH CONSEQUENCES OF ALCOHOL ABUSE

Medically, alcoholism is considered both a physical and mental illness. Alcohol use can affect all parts of the body, but it particularly affects the brain, heart, liver, pancreas and immune system and result in varied health ailments. Someone with a parent or sibling with alcoholism is three to four times more likely to become an alcoholic themselves. The magnitude of the increasingly severe problem of alcohol is reflected in the rising incidence of hospital admissions due to alcohol related diseases. Consumption of alcohol over a period results in fatty changes of the liver which later transforms to cirrhosis with liver cell degeneration, and accumulation of fluid in the abdomen followed by degeneration of the brain. Sri Lanka has the second highest incidence of cirrhosis in the world.

The Centre for Disease Control and Prevention (CDC) identifies 54 acute and chronic conditions associated with alcohol. Alcohol consumption causes degeneration of the heart muscle, and heart failure causing alcoholic cardiomyopathy. High blood pressure and increased cholesterol are also consequences of high consumptions. Also, acute and chronic gastritis and formation of gastric ulcers, and acute and chronic pancreatitis with endless abdominal pain and immense suffering are consequences of regular boozing. In addition, there is progressive degeneration of the brain leading to deterioration of intellectual functions social behaviour resulting in dementia.

The negative consequences of alcohol on people other than the drinker include injuries and deaths from road traffic accidents, harm from interpersonal violence, aggression and crime, harm to families that include psychological distress, pain and suffering from domestic violence, marital separation and divorce, child and household neglect, poverty, and, harm to the developing foetus. Apart from an unhealthy population with reduced productivity hindering the development of the country, a considerable proportion of national health expenditure must be spent to treat alcohol related diseases.

ECONOMIC IMPACT OF ALCOHOL CONSUMPTION

There is a paucity of published studies on the economic impact of alcohol and its related conditions in Sri Lanka, although there have been recent publications of social costs of alcohol use such as poverty. In 2015, a study was conducted by the National Authority on Tobacco and Alcohol, Sri Lanka Medical Association, Country office of the World Health Organization (WHO), and Health Intervention and Technology Assessment Programme, Thailand as part of the WHO SEARO initiative on introducing and capacity building on Health technology Assessments among South East Asian countries. The objective of the study was to estimate the economic costs of alcohol in Sri Lanka for the year 2015. In this study, among the overall direct health care costs included government expenditure and out-of-pocket private expenditures for outpatient and inpatient visits as well as clinic visits. The frequency of clinic visits per year and the cost borne by the government providing such services for each person were taken as the direct costs for outpatient care. Although the Centre for Disease Control and Prevention (CDC) has identified 54 acute and chronic disease conditions attributable to alcohol consumption, the 2015 study focused on 8 types of cancers and 19 noncommunicable diseases owing to the sparsity of data on the others. The costs of inpatient care considered the accommodation costs and the costs of pharmaceuticals, investigations, surgery and the costs of intensive care specific for each disease condition. The out of pocket expenses consists of the costs borne by the family of the patent during the hospital admission and clinic visits. The direct healthcare costs of alcohol-related cancers, which consist of the costs of inpatient care, outpatient care and private expenses were USD 25.67 million, which was 36% of the overall costs of alcohol-related cancers. The inpatient care costs contributed more than half (USD 14.96 million) of the direct cost. Private expenses were USD 9.98 million, which was nearly 40% of the direct cost.

Both morbidity and mortality were considered for calculating the indirect costs. The absenteeism cost was the lost income of the patients and the carers due to treatment seeking, hospitalization and recuperation at home following hospitalization. The indirect costs—the costs of absenteeism and premature mortality—consisted of 64% (USD 46.47 million) of the cost of alcohol-related cancers in 2015. The cost of premature mortality was USD 26.83 million, which was of 58% of the indirect cost. The cost of absenteeism was USD 19.64 million. Overall, the costs of cancers of the upper aerodigestive tract (lip, oral cavity and pharynx and oesophagus) was UDS 61.14 million, which accounted for 85% of the total cost of alcohol related cancers.

In the 2015 study, direct and indirect economic costs of alcohol related noncommunicable diseases and other conditions including different forms injuries, drowning and homicides were taken into consideration. Road injury costs was the most significant contributor to the total economic costs of alcohol related conditions other than cancer. It was USD 251 million, which was 30.8% of the overall cost of these conditions. Alcoholic liver disease, alcoholic gastritis and duodenitis, self-harm, alcohol use disorders and alcohol associated lower respiratory tract infections were the other significant contributors to this cost. The proportion of direct cost of ischemic heart disease and alcoholic gastritis and duodenitis were considerably high compared to their indirect cost component. This demonstrates the high economic burden imposed on the health care system by these conditions. The indirect cost of alcoholic liver disease was considerably high depicting the nature of high premature mortality with the condition.

TOTAL ECONOMIC COST OF ALCOHOL CONSUMPTION

The total economic cost of alcohol in Sri Lanka was USD 885.85 million in 2015. USD 388.35 million (44%) consisted of direct costs, while USD 497.49 (56%) consisted of indirect costs. The loss of productivity due to premature mortality, USD 388.86 million, was the highest cost category, accounting for 44% of the overall cost. The next highest cost was the inpatient care cost of USD 293.75 million, which was one third of the total cost. When specific disease conditions are considered, the economic costs of the cancers of the lip, oral cavity, pharynx and oesophagus amounted to USD 61.14 million. It reflects the fact that Sri Lanka has one of the highest incidences of cancers of the lip, oral cavity and pharynx. They  are commonest cancers among Sri Lankan males. Alcohol related cancers of the liver and colon cost USD 1.63 and 2.65 million. Therefore, addressing alcohol use should be a major aspect of prevention of cancers in Sri Lanka. Road injuries accounted for USD 251.28 million, which was 28.5% of the total cost. Preventing such injuries need cooperation of many sectors other than health. This underlies the importance of multi-sectoral involvement in addressing alcohol related harm.

Spending on purchasing alcohol, absenteeism and private expenses due to alcohol related conditions can exacerbate and perpetuate poverty. The impact of alcohol on poverty occurs through many mechanisms and is seen even in high income counties. In a study conducted in Sri Lanka examining the link between alcohol and poverty, some men revealed that their alcohol expenditure was greater than their income. Another study showed that the two lowest income categories spent more than 40% of their income on concurrent use of tobacco and alcohol. Therefore, alcohol use and its consequences should be a major dimension in developing and implementing policies for alleviation of poverty in Sri Lanka.

Sri Lanka provides free healthcare to all its citizens. People have the choice of seeking treatment in the government or the private sector for health services. The state sector is by far the largest provider of health services. The direct costs of in-patient care for alcohol related conditions, excluding private out of pocket expenditure amounts to about 40% of the recurrent health expenditure of the state health sector in 2015.  This is a substantial cost, which underlies the importance and the priority required for effective initiatives to prevent or minimize alcohol abuse in the country. In 2015, the government excise tax revenue from alcohol was less than the estimated total economic cost of alcohol to the government. In 2015, alcohol related conditions imposed a significant economic burden to Sri Lanka, with indirect costs (56% of total) exceeding the direct costs (44%).

Several types of costs were not included in the estimations. These include the opportunity costs of spending on purchasing alcohol products, costs of disease prevention and screening programmes, out of pocket expenditure by patients seeking services of the private sector, transport costs borne by the patient, enforcement and judicial costs and cost of property damage and insurance. Spending on drugs and devices which sometimes need to be purchased by the patients while obtaining treatment from the state sector was also not included in the estimate of out of pocket expenditure.

The economic cost of presenteeism (reduction in productivity despite working) due to alcohol related illness which has been taken into consideration in some studies was also not calculated. Furthermore, intangible costs of the effects of alcohol were not included in the analysis. Studies show that intangible cost may account for 20% to 27% of the total cost of alcohol. Recently, a study in Scotland found that the intangible cost accounted for 78% or the largest component of the total cost of alcohol use. The intangible costs in this study included costs of pain, grief and suffering to the casualty, relatives and friends, and, for fatal casualties, the intrinsic loss of enjoyment of life, excepting consumption of goods and services”. The costs of alcohol related violence, suicides too were not included.

SAVING THE YOUNGER GENERATION

Targeting adolescents and young adults is regarded as an important step to reduce the harm of alcohol abuse. Increasing the age at which alcohol can be purchased, the banning or restricting advertising of alcohol can be among alternative ways of reducing the harm of alcohol dependence and abuse. Credible, evidence based educational campaigns in the mass media about the consequences of alcohol abuse cane be useful.  Guidelines should be made available for parents to prevent alcohol abuse amongst adolescents.

Our young people should be informed that too much alcohol affects the central nervous system and how the brain functions. They should know that it affects perception, thinking, and coordination. It impairs judgment, reduces inhibitions, and increases aggression. Those who abuse alcohol are more likely than others to engage in high risk, thoughtless, or violent behaviors. Anyone who have developed alcohol related problem should be strongly encouraged to seek treatment.

An NGO titled Alcohol and Drug Information Centre (ADIC) in Sri Lanka, was established in 1990 and obtained Approved Charity Status in 1992.  ADIC drawing funds from many international and local sources, works for the reduction in demand for alcohol, tobacco and other drugs in Sri Lanka. It believes that through scientific and evidence-based research and investigations, and a participatory approach involving the community and all stakeholders, it is possible to make people realize that whatever drug, at whatever level is an impediment to human happiness. ADIC advocates for effective policy formulation for alcohol, tobacco and other drugs control. Its annual alcohol industry profile reports provide trend analysis of the Sri Lankan situation of alcohol consumption, sales, revenue and the industry in general.

A comprehensive approach is required in the development of well conceived, realistic short and long-term plans and programs to manage the problem, with the active involvement of the community at large, and all stakeholders connected with the problem. Such plans and programs should be based on in-depth research pertaining to alcohol use and abuse,  related motives and varied consequences. Enforcement of existing policies and formulation of new alcohol control strategies in Sri Lanka are vital. Saving the younger generation from alcohol abuse should be a high priority consideration in planning against alcohol abuse. Overall consequences of alcohol abuse, in particular its serious harm to the physical and mental development of the younger generation, should be a necessary component in school curriculum on social studies.

Future research should focus on identifying the individual-level characteristics of drinkers, their  average volume of total consumption, patterns of drinking such as binge drinking and alcohol use disorders among drinkers in the rural, semi urban and urban settings, and in places where alcohol related problems have shown an increasing trend in recent years. Problems encountered in implementing control strategies and alternative ways to resolve them are important considerations. Such information will facilitate the development of realistic plans initially aimed at minimizing the problem and eventually to contain this increasing serious national problem.   

Dr. Daya Hewapathirane