Addressing Alcohol Abuse in Mongolia

1. Addressing Alcohol Abuse in Mongolia Sean Armstrong Coordinator – Mongolia Medecins du Monde

2. Description of the talk • What is alcoholism? • What is the scope of the problem in Mongolia? • Alcohol-related harm, what is it and its impact. • Strategies for addressing alcohol abuse and related harm. • The effect of the Mongolian context

3. What is alcoholism? • Definitions please…

4. Alcohol Abuse DSM IV • A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period: • recurrent substance use resulting in a failure to fulfill major role obligations at work, school, home (e.g. neglect of children or household) • recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile while impaired by substance use) • recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct) • continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication) DSM IV

5. Alcohol Dependence DSM IV • A maladaptive pattern of substance use, leading to clinically significant impairment or distress, manifested by three (or more) of the following, occurring at any time in the same 12-month period: • Tolerance: • a need for increased amounts of the substance to achieve intoxication • markedly diminished effect with continued use of the same amount of substance • Withdrawal • Characteristic withdrawal syndrome for the substance • The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms • The substance often taken in larger amounts or over a longer period than was intended • A persistent desire or unsuccessful efforts to cut down or control substance use • A great deal of time is spent in activities to obtain, use or recover from effects of the substance • Social, occupational or recreational activities are given up or reduced • Substance use is continued despite knowledge of a persistent/recurrent physical or psychological problem (e.g., continued drinking despite recognition that an ulcer was made worse by alcohol consumption) DSM IV

6. So What is Alcoholism? • The medical versus the behavioral • There is agreement that later stages of the disease are definitively disease-like • However, screening tools (Callahan) developed by Sociologists are stronger while those developed by doctors (DSM III) are more sensitive • Over time, drinking habits change!!!!

7. Jellinek’s “Types of Alcohol Abuse” • Symptoms and psychological but no dependence = Alpha • Medical symptoms but no physical dependence = Beta • Symptoms and physical dependence = Gamma • Physical dependence but no symptoms = Delta • Binge drinking = Epsilon • Over time, drinking habits change!!!! Jellinek, EM. (1960). The Disease Concept of Alcoholism

8. What is the scope of the problem in Mongolia • Drinking problems are compared internationally on the basis of several key indicators: Total consumption (L/year), Consumption among the top quartile of heaviest drinkers, Percent abstaining, Type of alcohol consumed, Percent binge drinking (weekly) • These comparison approach the issue from the medical perspective

9. What is the scope of the problem in Mongolia • Total consumption: 9L / per person over 15 years of age (or 2 as listed on WHO website) • Recorded versus unrecorded? Most former Soviet countries underreport by almost half • Consumption among top quartile of drinkers: 86% of alcohol • Percent Abstaining: 38.2% of the population versus 20.8% in Russia (Means 17L / Drinker, among 10 highest internationally)

10. What is the scope of the problem in Mongolia • Type of alcohol consumed: In Mongolia over 70% of the market is vodka, as opposed to Russia where it is 50% • Percent binge drinking weekly: 18% of men, 6% of women (higher than in Russia and with Latvia among highest in world) • Mongolia is at risk for several “Types of Alcohol Abuse”

11. Alcohol Related Harm: What is it and what is its impact • Alcohol is related to disease • Alcohol is related it social problems • The cost to society can be determined using statistical models • Demographic changes often have their root in alcohol related issues as well

12. Alcohol Abuse and Disease • Binge drinking, common in Russia, leads to increased cardiovascular disease (CVD) mortality, particularly sudden cardiac death (scientific evidence indicates that alcohol abuse can injure the myocardium and cause a dangerous arrhythmia) (Leon et al.2005). • Many Cancers, such as Liver Cancer, Stomach Cancer, are significantly correlated to Alcohol abuse. • In terms of morbidity, the prevalence of mental disorders in heavy users is twice as high as in the general population. • Among other behaviors that compound the alcohol problem in Russia are drinking alcoholic substances not intended for consumption, such as perfume and medicine, and days-long binging (McKee 2005). Sources: McKee M. Suzcs S. Sarvary A. Adany R. Kiryanov N. Saburova L. Tomkins S. Andreev E. Leon DA. The composition of surrogate alcohols consumed in Russia. [Journal Article] Alcoholism: Clinical & Experimental Research. 29(10):1884-8, 2005 Oct. Malyutina S. Bobak M. Kurilovitch S. Gafarov V. Simonova G. Nikitin Y. Marmot M. Relation between heavy and binge drinking and all-cause and cardiovascular mortality in Novosibirsk, Russia: a prospective cohort study. [Comparative Study. Journal Article. Research Support, Non-U.S. Gov't] Lancet. 360(9344):1448-54, 2002 Nov 9.

13. Alcohol-related harm • An examination of the many factors involved can demonstrate an effect on: crime, disability, absenteeism, family, violence, injury, neonatal, infectious disease (sexual behavior and immunosuppression), traffic accidents, NCDs/health care, and poverty

14. Alcohol–related HARM: the cost to Europe Total tangible costs – €125bn • Report on Alcohol in Europe (Anderson and Baumberg), June 2006

15. Life expectancy at birth for men fell by over 6 years in Russia between 1989 and 1994. Data from the World Health Organization (WHO) show that it is working-age mortality that has led reductions in life expectancy Russian adults also experience lower healthy life expectancy Russian women live approximately 11 years longer than Russian men. In 2003, cardiovascular diseases, cancer, and injuries accounted for 78 percent of deaths The Affects on Life Expectancy

16. Strategies for addressing alcohol related harm • Pricing and Taxation • Regulating the Physical Availability • Modifying the Drinking Context • Drinking-Driving Countermeasures • Regulating Alcohol Promotion • Education and Persuasion Strategies • Treatment and Early Intervention Services

17. The effect of the Mongolian context • Major difference between males and females in mortality rates (12.49/10,000 versus 9.64/10,000) is due to injuries/violence (25% versus 8%) • Over 60% of all domestic violence and almost 50% of all divorces are alcohol-related • 80% of those in prison are there for alcohol-related issues • 1 Point of Sale for every 270 people in Mongolia, the most in the world

18. Alcohol Consumption Among Young People in Mongolia And yet the legal drinking age is 21! Mongolian Ministry of Health. (2006). EPIDEMIOLOGICAL STUDY ON PREVALENCE OF ALCOHOL CONSUMPTION, ALCOHOL DRINKING PATTERNS AND ALCOHOL RELATED HARMS IN MONGOLIA