Staggering Toward a Global Strategy on Alcohol Abuse
Science 16 May 2008: Vol. 320. no. 5878, pp. 862 - 863


David Grimm

Alcohol is about to get the type of attention usually reserved for AIDS and malaria. Next week, the World Health Organization (WHO) in Geneva, Switzerland, will take steps toward launching the first global assault on the harms associated with drinking. It’s a bold move, but it may not be bold enough. Although recent data indicate that alcohol abuse is a major killer worldwide, some experts feel that objections from member states and the involvement of the alcohol industry have weakened a resolution intended to kick-start a WHO-led offensive. Others wonder whether WHO has the resources to make such a strategy effective—or whether the agency should be focusing on other problems.

“A resolution is all very well, but it still takes a substantial commitment … for this to be translated into a substantial and lasting program of work,” says Robin Room, an alcohol policy expert at the University of Melbourne in Australia and a long-term observer of WHO.

This isn’t the first time WHO has flirted with an alcohol strategy. In 1983, the agency called on member states to strengthen their national alcohol policies—emphasizing a regional rather than global approach to the problem—but the words “fell on stony ground,” says Room.

“Alcohol has been a politically touchy thing for WHO to deal with,” Room notes, saying that the United States threatened to withhold funds from WHO in the 1980s if it pursued policies hostile to private enterprise. For a time, alcohol “dropped off WHO’s agenda.”

Then came WHO’s World Health Report 2002. Drawing on various studies, including WHO’s Global Burden of Disease project, the report concluded that alcohol was the fifth leading cause of death and disability worldwide. It beat out sanitation problems and high cholesterol and ranked just behind malnutrition and unsafe sex. Alcohol was as dangerous as tobacco, the report found—the source of up to 30% of various cancers and neurological disorders, and it had significant secondary dangers as well, leading to high rates of spousal abuse and homicide. Most devastating, however, was the conclusion that alcohol was the top cause of ill health and premature death in several developing countries, such as Brazil and Indonesia, and that—thank to rising incomes—things were only going to get worse. “It was a significant wake-up call,” says Peter Anderson, a public health expert previously with WHO, who currently advises the European Commission and other agencies on alcohol policy.

The report was the final straw for Finland. Having reduced liquor taxes to stay competitive with cheap Estonian imports, the country had seen a spike in alcoholrelated deaths. In 2005, Finland banded together with other Nordic countries, including Sweden and Norway, and presented a resolution to the World Health Assembly, WHO’s governing body, calling for a united effort to reduce alcohol-related health problems. “We wanted to see if a global strategy was possible,” says Bernt Bull, senior adviser at the Ministry of Health and Care Services in Norway and a member of the Norwegian delegation.

The resolution passed but quickly ran into trouble. The United States favored a voluntary strategy and called for more input from the alcohol industry. Thailand objected that the resolution didn’t go far enough and opposed industry involvement. And when WHO reconvened on the issue in May 2007, the drink trade had a new champion: Cuba. “The alcohol industry gives work and contributes to economic growth,” Oscar León Gonzalez of Cuba’s foreign affairs department told the Swedish newspaper Svenska Dagbladet at the time. He also said poorer countries had bigger problems: “Many countries cannot understand why [the Nordic countries] push the alcohol question so hard when people lie dying of AIDS, tuberculosis, and malaria.” The resolution died, but a few months later two of these poorer countries, Rwanda and Kenya, resurrected it in the form of a similarly worded resolution, effectively deflating León Gonzalez’s argument. “Alcohol causes a disproportionate burden of harm in poorer countries,” says Anderson, noting that people in these regions are likely to have more serious health risks and have less access to treatment. At the same time, the potential for harm is on the rise in countrie like India as people get a bit more money in their pockets.

“They’re going to start developing the same [alcohol-related] problems we had 50 years ago,” notes Ralph Hingson of the U.S. National Institute on Alcohol Abuse and Alcoholism in Bethesda,
Maryland. Hingson argues that WHO could help prevent a tragic repetition of this experience.

Buoyed by Africa’s involvement, the resolution won wide support from WHO’s executive board. Next week, member states are scheduled to vote at the World Health Assembly, and the measure is expected to pass. As written, the resolution directs the WHO director general to formulate a global alcohol strategy within 2 years. WHO’s final plan would not be legally binding but could include recommendations such as increasing alcohol taxes and banning certain types o liquor advertisements, as well as helping developed countries implement prevention strategies. A global approach is needed, says Anderson, because the alcohol trade crosses borders and because nations can learn from each other’s efforts. “You can’t just rely on a single country’s response.”

Despite its new momentum, however, the plan could run aground. Changes to the resolution, introduced recently by Mexico— and supported by Cuba and the United States—compel WHO’s director general to collaborate with the alcohol industry in shaping its strategy. And that could produce a “weak and feckless policy,” says Derek Rutherford, chair of the London-based Global Alcohol Policy Alliance. “The industry tries to play down evidence-based factors that reduce alcohol consumption, such as taxes and advertising bans, and instead focuses on education, eventhough there’s no proof that education works,” he says.

On the contrary, taxes are often ineffective and can even backfire, driving consumers to dangerous home brews, especially in poorer countries, says Phil Lynch of the U.S.–based spirits company Brown- Forman, a member of the Global Alcohol Producers Group, which is consulting with WHO. The industry is not opposed to regulation, he says, it just wants to see a comprehensive approach. “We understand the products better than everyone else, … and we deserve a seat at the table.”

WHO also must contend with limited resources. “WHO has a lot of irons in the fire,” says Room, noting that WHO’s investment in alcohol programs has been “extremely small in comparison with the size of the problems.” And Ramanan Laxminarayan, an expert on global disease priorities at the Washington, D.C.– based think tank Resources for the Future, says it may be hard for WHO—and poorer countries— to justify interventions aimed at curbing dangerous drinking. Such interventions “are not good value for the money,” says Laxminarayan, noting that malaria interventions are up to 100 times more cost effective.

Laxminarayan agrees with other global disease experts, however, that WHO is doing the right thing. “Developing countries don’t always have the foresight to see that alcohol will be a big issue for them,” he says. “WHO can be very influential in this regard.” Hingson says developed countries could benefit as well. He notes, for example, that the U.S. Surgeon General has released more than 30 reports on tobacco but only two on the harms of alcohol. “We may think we’re way ahead, but there are a lot of lessons we can learn.”

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