Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean [1 ed.] 9781280087950, 9780821351253

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WORLD BANK D I S C U S S I O N PAPER NO. 433

Copyright © 2001. World Bank Publications. All rights reserved.

Gender Dimensions o f Alcohol Consumption and Alco ho1- Re1a t e d Problems in L a t i n America and t h e Caribbean

Hnin Hnin Pyne

Mariam Claeson Maria Correia The WorldBank Washington,D.C.

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

Copyright 0 2002 The Intemational Bank for Reconstruction and Development/THE WORLD BANK 1818 H Street, N.W. Washington, D.C. 20433, U.S.A. All rights reserved Manufactured in the United States of America First printing M a r c h 2002 1234040302

Discussion Papers present results of country analysis or research that are circulated to encourage discussion and comment within the development community. The typescript of t h i s paper therefore has n o t been prepared in accordance with the procedures appropriate to formal printed texts, and the W o r l d Bank accepts n o responsibility for errors. Some sources cited in t h i s paper m a y be informal documents that are n o t readily available. The findings, interpretations, and conclusions expressed in t h i s paper are entirely those of the author(s) and should n o t be attributed in any manner t o the World Bank, to its affiliated organizations, or t o members of i t s Board of Executive Directors or the countries they represent. The World Bank does n o t guarantee the accuracy o f the data included in t h i s publication and accepts n o responsibility for any consequence of their use. The boundaries, colors, denominations, and other information shown o n any m a p in t h i s volume d o n o t imply o n the part of the World Bank Group any judgment o n the legal status of any territory or the endorsement or acceptance of such boundaries. The material in t h i s publication is copyrighted. The W o r l d Bank encourages dissemination o f its w o r k and will normally grant permission promptly. Permission t o photocopy items for intemal or personal use, for the internal or personal use of specific clients, or for educational classroom use, i s granted by the World Bank, provided that the appropriate fee i s p a i d directly t o Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, M A 01923, U.S.A., telephone 978-750-8400, fax 978-750-4470. Please contact the Copyright Clearance Center before photocopying items. For permission t o reprint individual articles or chapters, please fax your request with complete information t o the Republication Department, Copyright Clearance Center, fax 978-750-4470. All other queries o n rights and licenses should b e addressed to the World Bank at the address above or faxed t o 202-522-2422. ISBN: 0-8213-5125-7 ISSN: 0259-21OX Hnin HninPyne i s a Public Health Specialist in the Department of Human Development of the W o r l d Bank’s South Asia Region. M a r i a m Claeson is a Lead Public Health Specialist at the World Bank. M a r i a Correia i s a Lead Specialist in the Gender Sector of the W o r l d Bank’s Latin America and Caribbean Region.

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Cover Art: Shh!, 2000. Acrylic, linen. B y Anaida H e m h d e z . Private Collection. Reproduced with permission of the artist and assistance f r o m the World Bank Art Program Library o f Congress Cataloging-in-Publication Data has b e e n applied for.

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

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111

CONTENTS Foreword Abstract

...............................................................................................................

v

..............................................................................................

1

.. ....................................................................................................................

I

Introduction

I1

Alcohol Consumption, A Public H e a l t h Issue

111

Gender Dimensions of Alcohol U s e in L a t i n America and the Caribbean.

IV

Alcohol Policies in L a t i n America and the Caribbean

V

Recommendations

.........................................

....................................................................................

...............................

....................................................................................

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2 13

27 33

ANNEX I

36

ANNEX I 1............................................................................................................

39

...........................................................................................................

40

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41

ANNEX I11 References

TABLES Table 1: T a b l e 2: T a b l e 3:

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Table 4: Table 5: Table 6: Table A1: Table A2: T a b l e A3: T a b l e A4:

B u r d e n o f Disease a n d Injury Attributable to A l c o h o l Use. 1990 ...........3 Prevalence o f A l c o h o l Dependency. by G e n d e r ......................................... 4 Relationship between A l c o h o l a n d Traffic-Related Accidents a n d Fatalities in Some L a t i n A m e r i c a n Countries .............................................. 6 Selected H e a l t h Issues by A l c o h o l Attributable F r a c t i o n .......................... 7

Findmgs from E a r l y Community Based Studies o f E p i d e m i o l o g y

o f A l c o h o l U s e ................................................................................................. Legislative Efforts in L a t i n A m e r i c a .............................................................

Alcohol-related Projects in t h e H e a l t h Sector ............................................. Alcohol-Related Projects in t h e A g r i c u l t u r a l Sector ................................... International Finance C o r p o r a t i o n (IFC) Alcohol-Related Projects a n d Guarantees ................................................................................................ Multilateral I n v e s t m e n t Guarantee A g e n c y (MIGA) Alcohol-Related Projects a n d Guarantees ...................................................

18 31 36 37

38 38

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

iv

FIGURES Figure 1: Figure 2:

Figure 3:

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Figure 4-5

Cirrhosis Mortality ........................................................................................... 5 Per Capita Alcohol Consumption, by Country and Type o f Beverage ................................................................ 14 Consumption o f Pure Alcohol Qter per Capita) by Country ........................................................................................................ 15 L i f e t i m e Prevalence o f Alcohol U s e among Secondary Students in N i n e Brazilian Cities by Gender .................................................................... 19

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

V

Foreword O v e r t h e last decade, alcohol c o n s u m p t i o n has become a n increasing c o n c e m a m o n g p u b l i c health p o l i c y makers a n d international development agencies. A l c o h o l i s o n e o f t h e m a j o r causes o f g l o b a l disease, with m e n bearing most o f t h e b u r d e n o f alcohol related diseases. In developing nations, alcohol ranks as t h e fourth cause of disability a m o n g m e n . In a d d i t i o n to c o n t r i b u t i n g to illness a n d injury, excessive drinktng affects health by leadmg to r i s k y behaviors, i n c l u d m g unsafe sex practices a n d violence. A l c o h o l c o n s u m p t i o n i s particularly problematic in t h e L a t i n A m e r i c a a n d t h e Caribbean (LAC) Region. Worldwide, L A C has t h e highest percentage of t o t a l deaths attributed to alcohol - 4.5 percent c o m p a r e d to 1.3 percent for developed regions a n d 1.6 percent for developing regions.

With a v i e w to better understandmg some o f t h e gender issues that negatively affect m e n in t h e L A C R e g o n , t h e purpose o f t h i s study was to identify t h e r o l e o f gender in a l c o h o l c o n s u m p t i o n a n d alcohol-related problems in t h e L A C Region. Based p r i m a r i l y on published literature on alcohol research in t h e L A C Region, t h e study examines t h e p u b l i c

health rationale for addressing alcohol use issues; investigates gender differences in a l c o h o l c o n s u m p t i o n levels a n d pattems a n d t h e socio-cultural forces shaping those dlfferences; a n d b r i e f l y dscusses t h e l e g d a t i v e a n d p o l i c y responses in L A C to tackle alcohol-related problems.

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T h e paper concludes that a l c o h o l use a n d abuse are l t n k e d to men’s a n d women’s roles a n d expectations in society. M e n are m o r e l k e l y to drink heavily a n d excessively t h a n are women, a n d less llkely to abstain from a l c o h o l consumption. Furthermore, drinking norms are applied differentially a n d t h i s i s most evident in t h e case o f gender. M e n a n d w o m e n are subjected to d f f e r e n t expectations a n d meanings in their use o f alcohol, as w e l l as in t h e w a y they r e s p o n d to it. T h e study identifies a n u m b e r o f alcohol p o l i c y options for LAC, i n c l u d i n g l e v y i n g taxes, setting p r o d u c t safety standards, licensing production, promoting health a n d p u b l i c education, c o n t r o l l i n g advertisements, enacting drunk driving laws a n d “ u m - a g e l i m i t s , supporting p u b l i c education, providmg consumer information, a n d restricting t h e times a n d c o n d t i o n s o f beverage sales. But g v e n t h e study’s fmdmgs, i t also emphasizes t h e importance o f considering t h e gender dunensions o f a l c o h o l c o n s u m p t i o n a n d alcoholrelated problems. Prevention a n d injury r e d u c t i o n mechanisms, in particular, should focus on changing socio-cultural norms about gender a n d drinking, i n c l u d m g those t h a t p r o m o t e high-risk drinking behaviors a m o n g males. Mechanisms that socialize males a n d females a b o u t drinking a n d drunkenness - i n c l u d i n g t h e medra - should b e targeted.

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

vi Ths r e p o r t was w r i t t e n with t h e objective of stimulating discussion on a n i m p o r t a n t p u b l i c health issue t h a t has h i t h e r t o received relatively l i m i t e d attention. I t was also w r i t t e n to create awareness of the importance that gender roles play in t h e lives o f m e n . W e h o p e that these two goals wdl b e a c h e v e d in t h e p r o d u c t i o n of thrs report.

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G u i l l e r m o Perry Chief Economist L a t i n A m e r i c a a n d the Caribbean R e g i o n

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

vii Abstract

Ths r e p o r t examines the gender dimensions o f a l c o h o l consumption a n d alcohol-related p r o b l e m s in L a t i n A m e r i c a a n d t h e Caribbean (LAC). I t finds that alcohol use i s o n e o f t h e

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m a j o r causes of the global disease burden, r a n k m g as t h e fourth cause o f disabhty a m o n g m e n in less developed countries. I t also finds that m e n bear most o f the b u r d e n o f alcoholrelated diseases a n d that alcohol plays a n i m p o r t a n t r o l e in instigating unsafe sex practices a n d v i o l e n t behaviors, for example, domestic violence. Moreover, the r e p o r t shows t h a t m e n are m o r e l k e l y t h a n w o m e n to drink a l c o h o l heavily a n d excessively a n d t h a t drinking norms influence these gender differences in a l c o h o l consumption. As for alcohol policies in t h e L A C R e g o n , the r e p o r t finds that these focus overwhelmingly on c o n t r o l o f availabihty a n d access to alcohol; implementation a n d enforcement o f these policies, however, r e m a i n superficial. Finally the r e p o r t lays out p o l i c y options for L A C countries rangmg from imposing taxes, to putting in place public education campaigns. But i t stresses t h e i m p o r t a n c e o f establishmg policies a n d programs t h a t consider gender differences in a l c o h o l c o n s u m p t i o n patterns a n d alcohol related problems.

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

Copyright © 2001. World Bank Publications. All rights reserved. Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

I.Introduction

1

T h e issue o f a l c o h o l evokes impassioned debate a m o n g scholars a n d practitioners in m a n y d m i p l i n e s . E a c h dtscipline, whether economics, p u b l i c health, medicine, anthropology or p u b l i c health, offers i t s own perspective on the way a l c o h o l affects t h e w e l l b e i n g o f indmiduals, families, a n d communities, a n d asks how-and even if-problems related to drinking should b e tackled. E v i d e n c e i s mounting that public health a n d social concems a b o u t the problems associated with a l c o h o l c o n s u m p t i o n a n d the problems associated with i t are entirely justified. This paper also holds t h a t efforts to prevent a n d mitigate these p r o b l e m s need to consider t h e particular gender roles a n d gender socio-cultural context in w h i c h h k m g occurs-in relations. E v e r y society where a l c o h o l i s consumed has norms t h a t establish t h e rules for when, how, a n d who drinks. Gender plays a critical p a r t in shaping those rules. A l c o h o l research began about forty years ago, but t h e issue o f a l c o h o l c o n s u m p t i o n a n d p r o d u c t i o n emerged onto the agenda o f the World B a n k only withm t h e past t e n years. Work supported by t h e Bank, such as social capital research, t h e G l o b a l B u r d e n o f Disease a n d Voices o f t h e Poor studes, a n d numerous consultations with c i v i l society organizations a n d indigenous communities reveals that t h e poor in developing countries perceive alcohol use-particularly a m o n g men-as detrimental to their w e l l b e i n g a n d their efforts to b d d h u m a n a n d social capital (Murray a n d Lopez, 1996; Narayan, 1999; Delaney a n d Shrader, 2000). These findings have fueled m o m e n t u m within t h e B a n k to examine i t s r o l e in mitigating alcohol's negative effects. T h e y have also heightened t h e need to pay close attention to t h e sigmficant gender dimensions o f t h e issue. T h e reports a n d studies financed by t h e B a n k have highlighted t h e r o l e of alcohol p r o d u c t i o n a n d c o n s u m p t i o n in economic a n d h u m a n development by d e t a h g the social a n d economic costs a n d benefits o f alcohol. T h e y have also p r o v i d e d a n economic rationale for government's r o l e in the p r e v e n t i o n o f alcohol-related p r o b l e m s (Cercone, 1993, Velasco, 1998; World B a n k Group, 2000). Though thorough a n d far-reachmg in their analyses, t h e existing papers have p a i d little attention to t h e gender dunensions o f t h e issue. T h e current undertaking strives to fill that gap.

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T h e objective o f h s paper i s to enhance the knowledge base of t h e World B a n k on t h e gender dimensions o f alcohol c o n s u m p t i o n a n d alcohol-related problems in L a t i n A m e r i c a a n d t h e Caribbean (LAC), a n d to identify k e y areas for f u t u r e research a n d i n t e r v e n t i o n by the Bank. T h e i n f o r m a t i o n garnered for h s paper comes p r i m a r i l y from the published literature on a l c o h o l research in t h e L A C r e g o n . T h e paper i s dtvided into four sections. T h e f i r s t p a r t examines t h e p u b l i c health rationale for addressing the issue of alcohol use. T h e second p a r t investigates gender differences in drinking levels a n d pattems a n d drinking-related problems, particularly in LAC, a n d addresses the socio-cultural forces shaping those differences. T h e third p a r t b r i e f l y dtscusses the legislative a n d p o l i c y responses in L A C to tackle alcohol-related problems, a n d t h e f i n a l p a r t makes b r o a d p o l i c y a n d p r o g r a m m i n g recommendations a n d identifies areas in n e e d o f further research a n d operations.

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

11. Alcohol Consumption, A Public H e a l t h Issue

2

Ths section provides support for t h e p u b l i c health concern about alcohol c o n s u m p t i o n a n d

abuse. T h e discussion on the effects o f a l c o h o l on health a n d social w e l l b e i n g i s organized into two parts. T h e f i r s t p a r t focuses on the dseases a n d injuries associated with a l c o h o l use, a n d t h e ways i t s i m p a c t primarily falls on t h e individual. T h e second p a r t focuses on t h e effects t h a t extend b e y o n d the i n d i v i d u a l to t h e family a n d community, through violence a n d t h e risk behaviors associated with alcohol.

Effects o f Alcohol o n Disease and Injury T h e World H e a l t h Organization (WHO, 1999) has identified a l c o h o l use as o n e o f t h e m a j o r causes o f the g l o b a l disease burden. T h e G l o b a l B u r d e n of Disease' study estimated that, in 1990, a l c o h o l was responsible for 3.5 percent o f t h e world's t o t a l disability-adjusted life-years lost. Ths exceeds t h e tolls taken by tobacco (2.6 percent) a n d f i c i t drugs (0.6 percent) c o m b i n e d (Murray a n d Lopez, 1996). T h e adverse effects o f a l c o h o l c o n s u m p t i o n on dsease a n d injury characterized by steady heavy drinking a n d i n t o x i c a t i o n are w e l l documented in t h e scientific literature. Among men, a l c o h o l i s t h e leadmg cause o f d s a b h t y in industriahzed countries a n d ranks fourth in causing disabihties in developing countries (WHO, 1999). A l c o h o l also plays a significant r o l e in causing disability through neuro-psychiatric conditions t h a t i m p a i r t h e w e l l b e i n g o f indviduals, f a d e s , a n d communities. Moreover, a l c o h o l i s closely associated with acute as w e l l as l o n g - t e r m chronic conditions ranging from addiction, b r a i n damage, hgh blood pressure, a n d stroke to cancers a n d muscle a n d b o n e dseases (Edwards a n d others, 1995). Furthermore, a l c o h o l i s a trigger for violence, injury, a n d accidents. All these facts bear particularly acute importance in LAC, the r e g i o n ht t h e hardest by the m o r t a l effects o f alcohol: c o m p a r e d to other geographical regions, L a t i n A m e r i c a h a d the highest percentage (4.5 percent) o f t o t a l deaths attributed to a l c o h o l (see T a b l e 1).

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V i e w i n g alcohol c o n s u m p t i o n as a c o n t i n u u m from abstinence to addiction, WHO r e c o p z e s two m a i n patterns o f drinking t h a t have the greatest adverse effects on health: sustained moderate or heavy drinking over a n extended p e r i o d o f time, a n d single or repeated e p i s o d c intoxication. An episode o f i n t o x i c a t i o n resulting from a single dnnkmg occasion can i m p a i r a n individual's health, as w e l l as t h e social w e l l being, through accidents, assaults, a n d injuries. Steady heavy drinking i s associated with numerous chronic physical a n d m e n t a l health problems.

In analyzing the attributable b u r d e n d u e to alcohol, M u r r a y a n d L o p e z examined three dimensions: detrimental effect o n injuries; detrimental effect on disease; a n d protective effect o n ischaemic heart disease. (For discussion o f methodology f o r deriving t h e estimates, see M u r r a y a n d Lopez, 1996).

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

3

Table 1: Burden of Disease and Injury Attributable to Alcohol Use, 1990 Deaths

As YOo f

(ooos)

total

Years o f l i f e lost

A s YOo f total

deaths

(YLLs)

YLL

(000’s)

Years l i v e d w/ (disabihty

. I s YOo f total

YLD

Disability adjusted l i f e years

YLDs)

PSYS)

(000’s)

(000’s)

As YOo f total

DALYs

LAC

136.1

4.5

3,319

5.9

6,201

14.7

9,520

9.7

Industrialized regions

136.8

1.3

4,601

5.4

10,797

14.3

15,398

9.6

Developing

636.8

1.6

14, 868

1.8

17,603

4.4

32,289

2.7

773.6

1.5

19, 287

2.1

28,400

6.0

47,687

3.5

regions Total

Source: Murray, C. a n d Lopez,

A. 1996

Furthermore, a l c o h o l i s a psychoactive substance that can lead to addiction a n d dependency. T h e p u b l i c health a n d meQcal communities regard alcohol dependency, also referred to as alcoholism, as a Qsease.’ T h e DSM I V classification system classifies a l c o h o l use disorders as substance-related disorder^.^ These are d i v i d e d into two groups: substance use disorders, w h i c h include dependence a n d abuse; a n d substance-induced disorders, i n c l u d i n g intoxication, withdrawal, delirium, dementia, amnestic disorder, psychotic disorder, mood disorder, anxiety disorder, sexual dysfunction, a n d sleep Qsorder (see A n n e x 2 for m o r e detailed d e h t i o n s o f substance-use Qsorders) .4 A l c o h o l dependence a n d abuse-both characterized by maladaptive patterns o f use leading to clinically s i p f i c a n t i m p a i r m e n t or &stress a n d manifested by tolerance, withdrawal, inablllty to fulfill r o l e obligations, recurrent substance related legal problems, a n d social a n d interpersonal problems-are issues o f p u b l i c health concern.

WHO estimates a prevalence o f 9.7 to 35.6 percent heavy dnnkers in t h e L A C region..‘ Research in t h e 1960s a n d 1970s estimated that in L a t i n A m e r i c a a b o u t 1 0 percent o f t h e p o p u l a t i o n were excessive drinkers a n d another 5 percent alcoholics (Caetano, 1984). Table 2 inQcates the prevalence o f a l c o h o l dependency in B r a z i l a n d M e x i c o . Sex disaggregation highlights the dramatically higher prevalence rates o f alcoholism a m o n g m e n c o m p a r e d to w o m e n . In Mexico, for example, 12.5 percent o f m e n were found to b e alcoholics, compared to only .06 percent o f w o m e n (Medina-Mora, 1999).

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Alcoholism, though s i p f i c a n t , i s but o n e o f t h e m a n y health problems associated with a l c o h o l use. Cirrhosis i s a c o m m o n l y known disease that i s related to a l c o h o l abuse. ,

* T h e health a n d medical literature employs terms such as alcohol abuse a n d alcohol dependency that are based

on a disease model, placing the issue p r i m a r i l y in the realm o f medicine a n d psychiatry rather t h a n in the realm o f social science. A l c o h o l abuse i s defined as patterns o f heavy alcohol intake in nondependent persons in w h i c h health consequences and/or i m p a i r m e n t in social f u n c t i o n i n g are associated (US. D H H S , 1990, p. x i ) . A l c o h o l dependence syndrome i s defined as a severe disability in w h i c h dependence brings a b o u t a reduction in the individual’s ability t o c o n t r o l the drinking behavior. International Classification o f Diseases o f WHO a n d Diagnostic and Statistical M a n u a l o f M e n t a l Disorders differentiate alcohol abuse (a nondependent, p r o b l e m drinking condition) from alcohol dependence. T h e definitions a n d the differentiation m a d e b e t w e e n t h e two condltions are constructed primarily for clinical reasons;, treatment o f each c o n d i t i o n requires dlfferent intervention goals and approaches. DSM I V i s the f o u r t h edition o f the A m e r i c a n P s y c h a t r i c Association Diagnostic a n d Statistical Manual. i i m e r i c a n Psychiatric Association Diagnostic a n d Statistical Manual, Fourth Edition, t h e A m e r i c a n Psychiatric Association, 1994.

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

Because of a l a c k o f data on alcohol abuse a n d alcohol-related problems, cirrhosis o f t e n serves as a proxy for heavy drinkmg levels.

4

Table 2: Prevalence of Alcohol Dependency, by Gender Country/ City

Male

Female

Age

Diagnostic test

Rio d e Janeiro

4.9%

1.7%

18 a n d older

CAGE

Sao P a u l o

13.0%

3.0%

15-49

CAGE

Porto A l e g r e

16.0%

4.0%

18 a n d older

CAGE

Bahai

6.3%

0.9%

?

DSM I11

?

ICD-10

Brazil

12.5% 0.6% Source: C a r h i - C o t r i m , 1999, Medina-Mora, 1999.

Mexico

-

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Measuring cirrhosis m o r t a l i t y has i t s h t a t i o n s ; but i t possesses o n e great advantage: t h e data are w i d e l y r e p o r t e d a n d therefore allow for comparisons between countries. Figure 1 indicates cirrhosis m o r t a l i t y rates for some countries in LAC. N o t a b l y , t h e rates show stark gender differences. Interpretation o f these cirrhosis statistics, however, calls for a n o t e o f caution: age standardization based on E u r o p e a n populations was used, raising t h e m o r t a l i t y rates. I t should b e considered that 36 percent o f L a t i n A m e r i c a i s b e l o w t h e age of 15, as compared to 19 percent o f E u r o p e (Madngal, 1998). I t i s also i m p o r t a n t to n o t e that the proportion o f t o t a l cirrhosis deaths caused by alcohol varies a m o n g countries as a result of other environmental factors t h a t contribute to cirrhosis m o r t a l i t y . Poor living conditions a n d hygiene as w e l l as m a l n u t r i t i o n can cause infectious a n d degenerative l i v e r conditions, both acute a n d chronic, m e a n i n g t h a t alcohol i s only o n e o f t h e m a n y factors t h a t contribute to cirrhosis deaths. Essentially, however, i t i s i m p o r t a n t to n o t e that cirrhosis remains a significant health p r o b l e m in m a n y o f t h e countries in LAC, particularly a m o n g m e n . Cirrhosis i s o n e o f t h e t e n leadmg causes of death in Mexico. Among m e n b e t w e e n t h e ages o f 35 a n d 45, i t i s t h e n u m b e r o n e M e r (Madrigal, 1998, Medma-Mora, 1999). In M e x i c o , Venezuela R.B., Argentina, a n d T r i n i d a d a n d Tobago, cirrhosis deaths a m o n g m e n are as m u c h as three times h g h e r t h a n t h e deaths a m o n g w o m e n . This concurs with e p i d e m i o l o g c a l findings that reveal that higher proportions o f m e n in L A C are heavy drinkers c o m p a r e d to their female counterparts (see Section 10. A l c o h o l dependency a n d cirrhosis are far from t h e only p r o b l e m s associated with a l c o h o l use. T h e scientific literature has p o i n t e d out t h a t a l c o h o l i s associated with m a n y other diseases, injuries, a n d accidents, such as traffic-related fatalities, homicides, a n d suicides. W e i t i s i m p o r t a n t to recognize that socio-economic c o n d t i o n s , enforcement measures, a n d safety regulations (such as seat-belt laws) m e d a t e t h e relationship between a l c o h o l consumption a n d traffic accidents, some studies c o n d u c t e d in L A C justify t h e c o n c e m about h s relationship, as demonstrated in Table 3.

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

Figure 1: Cirrhosis Mortality

5

Deaths from Cirrhosis Per 100,000 in the Americas and the Carribbean among men and women (age standardized) 80.0 0 r v

70.0 60.0 50.0

..." 40.0 CU r

.-ln

30.0

g 20.0

E

6

10.0 0.0

'ource: E d w a r d s a n d others, 1995

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G e n d e r dfferences in alcohol-related p r o b l e m s were further highlighted by E d w a r d s a n d others (1995), who determined the degree to w h i c h a l c o h o l contributes to h e s s a n d injury by conducting a meta-analysis of scientific studles p u b l i s h e d since 1980. T h e researchers t h e n p r o d u c e d estimates t h a t were c o m b i n e d with the existing data on prevalence of a l c o h o l use a m o n g the Australian population. In 1998, a similar exercise was carried out for t h e C a n a d a n population. This methodology was employed to determine t h e f r a c t i o n o f each disease a n d injury attributable to alcohol. T h e attributable fraction was f u r t h e r disaggregated by sex. Some health conditions are, by definition, caused by alcohol, such as alcoholic poisoning a n d alcohol dependence, a n d would, therefore, b e designated with a n attributable fraction o f 1.OO. O t h e r conditions that h a d relatively high attributable fractions w e r e unspecific liver cirrhosis, chronic pancreatitis, r o a d injuries, fire injuries, drowning, suicide, a n d assault. T h e two s t u d e s h g h h g h t e d a w i d e range o f health p r o b l e m s caused by alcohol, includmg: 0

cancers (for instance, l i v e r or laryngeal)

0

heart diseases

0

maternal a n d c h i l d health p r o b l e m (for instance, low birth weight, or spontaneous abortion)

0

injuries (for instance, falls, burns, or work related)

0

accidents (for instance, water or auto transport)

0

violence (for instance, suicide, assault, or c u d abuse).

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6 Table 3: Relationship between Alcohol and Traffic-Related Accidents and Fatalities in Some L a t i n American Countries ~~

Country

Year

Percent o f drivers with positive blood alcohol content

Argentina Brazil

1980 1995 1974

20% o f drivers in Buenos Aires*

Chde

PAC)

30% o f drivers in Salvador**

70% o f male drivers" Percent o f accidents attributed to alcohol

Bo h i a

1990s 1990s 1990s 1972 1974

Brazil Ecuador Mexico Mexico

1gO/o** 25%** 33%** 7% nationwide* 17% in M e x i c o City* ~

Percent o f traffic Chde Colombia Costa &ca Peru Sources:

1970 1990s 1990s 1990s

fatalities attributed to alcohol

46% (male traffic deaths)*

6O%** 46%"" 50°/o**

(*) Caetano, 1984; (**) Madngal, 1998

A l c o h o l contributed to certain problems, such as fire injuries, chronic pancreatitis, a n d assault, to the same extent a m o n g w o m e n as a m o n g m e n in Australia a n d Canada. W h e r e there were gender dfferences in attributable fractions, however, alcohol played a greater r o l e (that is, was designated with a higher fraction) in causing illnesses a n d injuries a m o n g m e n t h a n a m o n g w o m e n F a b l e 4). For example, alcohol was estimated to cause 41 percent o f suicide cases a m o n g m e n in Australia, compared to only 16 percent a m o n g their female counterparts. Country dfferences were also evident. W e alcohol contributed to nearly h a l f o f r o a d injuries in both C a n a d a n m e n a n d women, i t was m o r e instrumental in causing r o a d injuries a m o n g m e n (0.37) in Australia t h a n a m o n g w o m e n (0.18). Copyright © 2001. World Bank Publications. All rights reserved.

.

These two studies, w h c h estimated the r o l e o f alcohol in causing illnesses a n d injuries among the Australian a n d Canadian populations, o f f e r a useful methodology. However, their findmgs cannot b e g e n e r a k e d to other populations, especially in the developing world. Three key reasons for exercising caution in interpreting the data for other populations are: levels a n d patterns of drinkmg vary greatly across d f f e r e n t populations, particularly between m e n a n d women; 0

0

the meta-analysis only included scientific studies published in t h e English language; a n d social a n d environmental conditions that interact with drinkmg v a r y greatly across different populations.

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7

Table 4: Selected H e a l t h Issues by Alcohol Attributable Fractions H e a l t h issue

Liver cancer

Australian

Canadian

Male

Female

Male

Female

0.18

0.12

0.29

0.16

0.03

Breast cancer

0.04

Unspecific liver cirrhosis

0.54

0.43

0.54

0.54

Chronic pancreatitis

0.84

0.84

0.84

0.84 0.20

0.04

Spontaneous abortion

Road injuries

0.37

0.18

0.43

0.43

Fall injuries

0.34

0.34

0.24

0.15

F i r e injuries

0.44

0.44

0.38

0.38

Drowning

0.34

0.34

0.30

0.23

Suicide

0.41

0.16

0.27

0.17

Assault

0.47

0.47

0.27

0.27

Source: E d w a r d s a n d others, 1995, Single a n d others, 1998

Gender-Differentiated Effects o f Alcohol W o m e n are affected differently by a l c o h o l t h a n are m e n because o f physiological differences ( N U , 1999 a n d 2000; G r a h a m a n d others, 1998; Schenker, 1997). Schenker (1997) reviewed t h e m e Q c a l literature a n d highlighted t h e following k e y issues affecting w o m e n : 0

0

Copyright © 2001. World Bank Publications. All rights reserved.

0

W o m e n o b t a i n a h g h e r concentration o f a l c o h o l in t h e blood for a s d a r intake o f a l c o h o l because o f the l o w e r t o t a l water c o n t e n t in their bodies. A l c o h o l enters t h e bloodstream in a m o r e concentrated form in women, because t h e stomach enzyme that breaks down a l c o h o l b e f o r e i t enters t h e bloodstream i s less active in w o m e n . Alcohol's effects vary accordmg to t h e m e n s t r u a l cycle, because, research suggests, t h e intensity o f a l c o h o l intake i s affected by monthly h o r m o n a l fluctuations.

These physiological Qfferences have i m p o r t a n t implications (for detailed description of mechanisms, see NIAAA, 2000): 0

W o m e n are m o r e susceptible to alcoholic l i v e r hsease. W o m e n develop alcoholinduced l i v e r disease m o r e rapidly-over a shorter p e r i o d o f t i m e a n d after consuming less alcohol t h a n m e n . Furthermore, w o m e n are m o r e hkely t h a n m e n to develop alcohol hepatitis a n d to die from cirrhosis.

0

Women's hearts exhibit greater sensitivity to t h e adverse effects o f alcohol.

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8 0

0

0

W o m e n t e n d to b e c o m e m o r e intoxicated than m e n w h e n they ingest t h e same a m o u n t o f alcohol a n d to experience m o r e sedation (measured by four visual analog scales a n d by choice reaction time), suggesting that women's brains have a greater sensitivity to alcohol. W o m e n who are heavy drinkers have a n increased risk o f breast cancer. W o m e n who drink during pregnancy can adversely affect t h e fetus, dependmg on the a m o u n t consumed, manner o f consumption, a n d t h e phase o f pregnancy).

M a t e r n a l c o n s u m p t i o n o f a l c o h o l during pregnancy increases t h e r i s k of h a v i n g children with birth defects. H e a v y a n d binge drinking i s t h e most hazardous drinkmg p a t t e r n during pregnancy, l t n k e d strongly to t h e birth o f chddren with Fetal A l c o h o l Syndrome. In t h e U n i t e d States, FAS i s considered t h e most c o m m o n nonhereditary cause of m e n t a l retardation ( N U ,2000). C h i l d r e n with FAS share a characteristic set of minor facial traits a t birth; suffer from growth deficiencies; a n d the damage to their developing brains affects t h e m throughout their l i v e s 5 FAS i s a n example of the intergenerational effects o f alcohol consumption-the consequences of drinking passed on by a m o t h e r to h e r infant.

Beneficial Effects o f Alcohol o n Health

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Alcohol's negative effects on h u m a n health are a w e l l documented, longstanding p a r t o f t h e scientific literature. However, o v e r t h e past decade seemingly paradoxical evidence has emerged that alcohol c o n s u m p t i o n m a y have a protective effect on o n e aspect o f h u m a n health: coronary heart dlsease. S t u h e s have shown that individuals who consume small to moderate amounts o f a l c o h o l are less likely to have a m y o c a r h a l i n f a r c t i o n t h a n those who do not drink. (For a r e v i e w o f t h e studies in t h e U n i t e d States on t h e h e a l t h benefits o f alcohol, see NIAAA, 2000). These studies, however, have b e e n challenged on two fronts: a p p l i c a b h t y o f t h e fmdings to women; a n d m e t h o d o l o g y (see detailed discussion in World B a n k Group, 2000). T h e m a j o r i t y o f participants in t h e studies were m e n . In those w h e r e w o m e n did participate, t h e protective r e l a t i o n s h p was not s o clear. Studies found that light c o n s u m p t i o n o f a l c o h o l (1.5 to 29.9 grams per day) protected older w o m e n (50 years o f age a n d over) from CHD; light c o n s u m p t i o n also conferred protective benefits on w o m e n with o n e or m o r e risk factors for CHD. . These benefits dld not hold true, however, for w o m e n with no C H D risk factors. Such w o m e n enjoyed no significant protective effects. Notably, w o m e n who drank m o r e t h a n 30 grams per day h a d significantly higher mortality, largely d u e to t h e i r higher risk o f death from breast cancer. T h e research on beneficial effects o f a l c o h o l remains inconclusive for women. Furthermore, w h e n hscussing t h e beneficial effects o f a l c o h o l on t h e risk o f CHD, it i s i m p o r t a n t not to i g n o r e t h e prevalence of C H D in a g i v e n developing c o u n t r y in relation to other health a n d social problems t h a t are caused or exacerbated by alcohol.

N L U i (2000) has conducted a n extensive review a n d analysis o f FAS p r e v e n t i o n research. Although research i s largely US-based, t h e review offers a valuable framework for developing p r e v e n t i o n programs.

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Effect o f Impurities in Alcohol on Health

9

A large proportion o f the alcohol consumed in t h e developing world comes from illicit p r o d u c t i o n . A n o t h e r p u b l i c health concern about drinking involves t h e effect of impurities

in alcohol, a n d illicitly p r o d u c e d alcohol i s t h e greatest culprit. For instance, some poisoning deaths from drinking illicitly m a d e alcohol have b e e n attributed to iron particles leachmg from t h e disalling barrels. In a small r u r a l c o m m u n i t y in Mexico, 49 people d i e d after drinkmg illegally m a d e 9 6 - p r o o f agztardienteb (Medma-Mora, 1999). I t i s i m p o r t a n t to n o t e that t h e a l c o h o l industry has cited t h e potential dangers of illicitly p r o d u c e d alcohol as a n argument for c o n t r o l l i n g h o m e b r e w i n g a n d for promotingindustrial production; most often, these a l c o h o l industry campaigns are waged on b e h a l f o f foreign-made imports. T h e scope a n d s i p f i c a n c e of the effects of alcohol impurities r e m a i n hghly anecdotal, however, a n d d e m a n d f u r t h e r investigation.

Effect o f Alcohol o n Risk Behaviors

A third d i m e n s i o n o f t h e p u b l i c health concern over a l c o h o l c o n s u m p t i o n involves the effect o f a l c o h o l on risk behaviors. As l s c u s s e d above, substantial evidence from t h e medical a n d h e a l t h literature supports the conclusion t h a t dtsease a n d injury are a m o n g t h e d u e c t effects o f a l c o h o l consumption. Drinking can also i n d u e c t l y affect health by encouraging risk behaviors, such as unsafe sex. T h e AIDS epidemic makes such concerns even m o r e u r g e n t a n d hghlights t h e need to examine t h e relationship between alcohol a n d HIV risk behaviors. A survey of sexual behaviors a m o n g l o w - i n c o m e youths in Barrios Altos a n d C a n t o Grande in L i m a , P e r u found that, after c o n t r o l l i n g for age, sex, a n d socio-economic status, h a v i n g a sexually transmitted dtsease (past a n d present) a n d a n u n i n t e n d e d pregnancy were significantly related to c o m b i n i n g sex with a l c o h o l a n d drug use. T h e U e l i h o o d that a girl’s &st sexual intercourse happened a t a n early age increased if she h a d consumed alcohol (Caceres a n d others, 1997).

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A n o t h e r study, w h c h examined risk factors for HIV i n f e c t i o n a m o n g Guatemalan soldiers o f indigenous backgrounds, revealed that a l c o h o l c o n s u m p t i o n was strongly associated with HIV infection. Drinkmg, along with poor c o n d o m use a n d sex with prostitutes, was found to increase by a factor o f 15.6 t h e soldiers’ risk o f acquiring sexually transmitted diseases (Flores a n d Arathoon, 1994). Studies o f AIDS in other countries, such as Thailand, i n l c a t e t h a t a l c o h o l c o n s u m p t i o n influences m a n y dunensions o f sexual behavior. O n e such study, w h i c h i n c l u d e d students, soldiers, a n d clerks in the sample o f 1,472 men, revealed t h a t heavy drinking increased t h e odds o f h a v i n g h a d sexual intercourse; increased t h e odds o f h a v i n g visited prostitutes; a n d decreased the odds of consistent c o n d o m use in sexual encounters with sex workers (VanLandmgham a n d others, 1993). In addition to t h e survey, focus group l s c u s s i o n s with m e n identified drinkmg as t h e most i m p o r t a n t precursor to visiting sex workers. T h e r e l a t i o n s h p b e t w e e n drinkmg a n d HIV risk behaviors, such as visiting commercial sex workers or h a v i n g sex without condoms, i s not o n e o f simple causality. I t has b e e n argued that drinking behavior co-occurs with other dangerous factors, such as risk-taking

Includes beverages made f r o m sugar cane alcohol and agaves, such as mescal and sotol. Aguardiente means

“burning water” ( M e h a - M o r a , 1999).

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10

personality traits, suggesting that those who drink are also those who are likely to engage in r i s k y behaviors. As demonstrated by t h e T h a i study, a l c o h o l use i s most hkely to b e a n excuse for, rather t h a n a cause of, unsafe sexual behaviors; additionally, alcohol use serves as a p r e d x t o r o f hgh-risk behaviors. Consequently, HTV p r e v e n t i o n efforts n e e d to consider t h e r o l e o f drinkmg in the spread o f t h e AIDS virus.

Effect of Alcohol U s e on Families and Communities U n d o u b t e d l y , a l c o h o l use has played a s i p f i c a n t a n d integral r o l e in m a n y cultural a n d religious events a n d has also facilitated social interactions throughout h u m a n history (Lomitz, 1973; Heath, 1974; Bunzel, 1973). Though dtfficult to quantify, m a n y qualitative studies, particularly ethnographies, have demonstrated t h e r o l e o f alcohol as a social lubricant. However, these studies o f traditional or indigenous societies also indicate t h a t t h e secondary effects of alcohol vary greatly depending upon t h e socio-cultural c o n t e x t in w h i c h dnnkmg occurs (see Section 19.T h e studtes clearly find that t h e beneficial effects on social interactions are m a r r e d by the negative social impacts A l c o h o l - i n d u c e d problems (such as dtsease a n d injury) are b o r n e not only by t h e i n d i v i d u a l who consumes t h e alcohol, but also by his/her family a n d community. A l c o h o l reportedly plays a n i m p o r t a n t r o l e in instigating v i o l e n t behaviors, particularly within t h e famdy. Such behaviors include c h d d abuse a n d partner violence, the m a j o r i t y o f w h i c h i s against w o m e n .

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H o w e v e r , t h e relationship between a l c o h o l a n d family violence i s not o n e of simple causality. Levinson’s exhaustive 1989 review o f t h e anthropological literature on 90 preliterate a n d peasant societies explored the issues o f family violence in a cross-cultural perspective. H e found that only seven societies indicated t h a t a l c o h o l use was a key c o m p o n e n t in t h e sequence of events leadmg up to wife-beating. In those societies, i n t o x i c a t i o n p r o v i d e d a n excuse for the v i o l e n t behaviors of men; w h e n a v i o l e n t m a n was not intoxicated, wives, f a d e s , a n d communities would not tolerate h s violence. M e n o f the Tzeltal p e o p l e o f Mexico, L e v i n s o n found, drank heavily during fiestas. During these social events, they o f t e n became physically aggressive t o w a r d o n e another, a n d c o m m o n l y t h e male aggression w e n t on to b e du-ected t o w a r d female partners. Child abuse was not i n c l u d e d in t h e study. Studtes conducted in the 1990s have also found that a l c o h o l plays a significant r o l e in domestic violence. For example, m o r e t h a n a quarter (26 percent) o f t h e w o m e n seekmg counseling services in the u r b a n areas o f M e x i c o r e p o r t e d t h a t their partners’ abusive behaviors were fueled by intoxication (Ramirez a n d others, 1992). In t h e Solomon Islands, 32 percent o f f a d y violence offenses w e r e related to p r o b l e m drinking (McDonald, 1995). E v e n h g h e r rates were found in South A f r i c a : 67.4 percent o f domestic violence cases in Cape Town a n d 76.4 percent in r u r a l areas i n v o l v e d a l c o h o l use (Parry, 1995). A n o t h e r form o f f a d y violence i s c h i l d abuse. In both Canada a n d Australia, 16 percent o f c h i l d abuse cases c o u l d b e attvibuted to alcohol. InJapan, 20 percent o f abused c h d d r e n h a d alcoholic parents, a n d in H u n g a r y 8.6 percent o f c h i l d abuse cases in 1994 i n v o l v e d a l c o h o l (Fekete, 1996). A l c o h o l has also b e e n associated with a high proportion o f c h d d abuse cases in t h e UK (30 percent) a n d N o r w a y (50 percent) (Moser, 1992). Physical abuse during c h d d h o o d has also b e e n found to b e t h e risk factor for b e c o m i n g a l c o h o l dependent as a n adult. Ths highlights t h e intergenerational effect a n d t h e c o m p l e x relationship between violence a n d a l c o h o l abuse. In a case c o n t r o l study o f t h e relationship between physical a n d sexual abuse during c h i l d h o o d a m o n g N a v a j o N a t i v e Americans,

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

a l c o h o l dependence was found to b e a n independent risk factor for b e i n g i n v o l v e d in domestic violence, either as a v i c t i m or as a perpetrator (Kunitz, a n d others, 1998).

11

Summary

Throughout h u m a n history, alcohol use has evolved m a n y profound meanings in culture a n d religion. Particularly a m o n g men, i t has served to fachtate social interactions.

A l c o h o l use i s o n e o f t h e m a j o r causes o f t h e global disease burden. Among m e n in t h e industrialized regons, a l c o h o l ranks as t h e f u s t cause of Qsabhty; in t h e developing world, it ranks fourth. Adverse effects o f alcohol c o n s u m p t i o n on disease are w e l l documented in t h e scientific literature. These range from acute maladies to a host o f l o n g - t e r m chronic conditions, a m o n g t h e m b r a i n damage, hgh blood pressure, stroke, cancers, a n d muscle a n d b o n e diseases-as w e l l as injury a n d i t s consequences. Evidence has emerged to indicate that alcohol c o n s u m p t i o n has a protective effect against coronary heart diseases in m e n above forty who drlnk in moderation. T h e evidence for such a protective effect against coronary Qseases in w o m e n remains inconclusive. M e d i c a l research carried out in industrialized countries has found that g i r l s a n d w o m e n have far m o r e biological vulnerability to alcohol-related problems.

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T h e L A C r e g i o n has the highest percentage o f t o t a l deaths attributed to a l c o h o l use. M e n bear most o f t h e b u r d e n o f alcohol-related diseases, such as alcoholism a n d cirrhosis. Moreover, a higher proportion o f Qseases a n d injuries a m o n g m e n are attributable to alcohol t h a n a m o n g w o m e n . I t i s also i m p o r t a n t to emphasize t h a t t h e i n d i v i d u a l who consumes t h e alcohol i s not t h e only o n e affected by it. T h e drinker’s family a n d c o m m u n i t y also bear i t s costs. In addition, alcohol plays a n i m p o r t a n t r o l e in instigating unsafe sex practices a n d v i o l e n t behaviors, particularly within t h e family. A p r i m a r y example i s domestic violence, m u c h o f w h c h i s du-ected against w o m e n a n d children.

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111. Gender Dimensions o f Alcohol Use in Latin America and the Caribbean

13

T h i s section examines alcohol c o n s u m p t i o n at the country level in LAC; dscusses findmgs from epidemiological a n d ethnographrc studes, particularly focusing on gender differences in a l c o h o l use; a n d examines socio-cultural factors influencing these gender differences.

Alcohol Consumption Data at the Country Level A l c o h o l c o n s u m p t i o n i s most o f t e n measured as a n arithmetic m e a n o f p e r capita consumption, o f t e n generated by data on production, sales, a n d import a n d e x p o r t alcohol beverages in a given country or region. Such estimates only consider a l c o h o l t h a t i s legally available on t h e market. T h a t is, t h e typical alcohol c o n s u m p t i o n data f a i l to capture i n f o r m a t i o n about a large share o f t h e alcohol consumed in t h e developing world-dlegal alcohol, i n c l u d m g h o m e brews, moonshme, a n d smuggled liquor. This data gap i s particularly s i p f i c a n t in LAC, w h e r e two-thrrds o f a l l fermented a n d distilled alcoholic beverages are dhcit (Coombs a n d Globetti, 1986, Cercone, 1993, Velasco, 1998). For example, h a l f the alcoholic beverages on t h e m a r k e t in B r a z i l c o m e from dlegal production. In Ecuador, illtcitly p r o d u c e d a l c o h o l accounts for three times the o f f i c i a l p r o d u c t i o n . In Chile, w h e n clandestine p r o d u c t i o n was taken into account, statistics a b o u t p e r capita alcohol c o n s u m p t i o n increased by 20 percent (Caetano a n d Carlini-Cotrim, 1993). However, despite i t s limitations, t h e m e a n p e r capita c o n s u m p t i o n indicator has b e c o m e a widely used measure o f alcohol c o n s u m p t i o n because i t enables researchers to standardize a l c o h o l c o n s u m p t i o n over a n d across t i m e a n d between different societies (Grant a n d L i t v a k 1997, Cercone, 1993).

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Variations in the level o f alcohol c o n s u m p t i o n a m o n g countries in L A C are considerable. Paraguay consumes on average t h e h g h e s t a m o u n t o f alcohol (liters p e r capita) in LAC, a t 9.7 liters, f o l l o w e d closely by A r g e n t i n a with 9.4 liters. Ecuador, with 1.6 liters, consumes t h e least (WHO unpublished data). F i g u r e 2 portrays not only t h e wide-ranging p e r capita c o n s u m p t i o n levels in t h e r e g o n , but also provides a diverse b r e a k d o w n o f t h e t o t a l by type o f alcoholic beverage-beer, spirits, or wine. In Argentina, Uruguay, a n d Chde, for example, w i n e i s t h e most popularly alcoholic beverage. Spirits, on the other hand, d o m i n a t e alcohol c o n s u m p t i o n in Haiti, Paraguay, the D o m i n i c a n Republic, Costa &ca, a n d Nicaragua.

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

14

Figure 2: Per Capita Alcohol Consumption, by Country and Type of Beverage Per Capita Consumption o f Pure Alcohol, 1996

~

11

I

10

I

il)

s .-a

Spirits Beer

8 E

Country

I

Source: WHO.

In t h e 1980s, w h e n t h e region was undergoing a n economic crisis, c o n s u m p t i o n levels in M e x i c o a n d P e r u remained relatively constant, whereas they d e c h e d s i p f i c a n t l y in Chde a n d Argentina (see F i g u r e 3). Interestingly, during t h a t p e r i o d B r a z i l a n d C o l o m b i a saw s i p f i c a n t increases in m e a n consumption levels. Cercone (1993) n o t e d that t h e dramatic changes in a l c o h o l c o n s u m p t i o n during the 80s c o u l d have b e e n caused by such factors as t h e increase in a l c o h o l p r o d u c t i o n or the decrease in i t s relative price. O t h e r researchers suggest that in B r a z i l h s trend, w h c h continues up to t h e present day, i s most hkely propelled by a n increase in the buying p o w e r o f t h e m i d d l e class, by national economic stabfity, a n d by a sharp d e c h e in tariffs on i m p o r t e d beverages ( C a r h - C o t r i m , 1999).

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Epidemiological Findings M e a n p e r capita c o n s u m p t i o n hides a n enormous variation in t h e distribution o f a l c o h o l c o n s u m p t i o n in a g v e n society. Epidemiological s t u h e s on a l c o h o l p r o v i d e insights into t h e distribution of drinkmg levels a n d patterns. T h e y also a f f o r d a glunpse into alcohol-related problems within a population.

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15

Alcohol Consumption

18 16 14 4.-

12

g

lo

3 2

6

1980

0 1985

0 L

1989

4 2

0

Country

Source: T h e Brewers' Society, cited in Cercone, 1993 Researchers have been studying a l c o h o l c o n s u m p t i o n in L A C for t h e past four decades. H o w e v e r , Caetano, who in 1984 reviewed t h e epidemiology literature on alcohol consumption in t h e region, found t h a t t h e s t u d e s were o f t e n sporadlc a n d n a r r o w l y focused. With t h e exception o f Mexico, Brazil, Chde, a n d Costa Rica, L A C countries have not shown a sustained interest in conducting c o n t i n u i n g s t u d e s o f a l c o h o l use.

In h i s review o f t h e literature, Caetano (1984) i d e n t i f i e d t h e following as t h e most c o m m o n l y u s e d operationalization: 0

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0

Abstainers: those who have never drunk alcoholic beverages or who have drunk less t h a n 100 cc o f straight alcohol on fewer t h a n five days in t h e year p r e c e d m g t h e survey.' Moderate drinkers: those who m a y drink often, but whose regular i n t a k e does not exceed 100 cc o f straight a l c o h o l a day, or who experience less t h a n 12 episodes of drunkenness a year.

0

0

Excessive drinkers: those who drink habitually (more t h a n three days a week) a n d who c o m m o n l y consume over 100 cc o f straight a l c o h o l a day, or who experience 12 or m o r e episodes of drunkenness a year.

Alcoholics: i n d v i d u a l s who lose c o n t r o l o v e r their drinkmg a n d who l a c k t h e a b h t y to abstain or stop.

'O n e h u n d r e d cubic centimeters o f straight alcohol i s equivalent to about n i n e drinks, each with n i n e grams o f

straight alcohol (that is, a h a l f pint o f beer, a four-ounce glass o f wine, or a one-ounce shot o f spirits). L l a r c o n i selected 1OOcc (80 grams) as h i s estimate to comprise a b o u t 20 percent o f daily calories required (3000 calories). H e determined that moderate drinkers should not exceed t h a t amount.

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

16 A breakdown of t h e drinking categories by sex shows vast differences in alcohol consumption between m e n and w o m e n in LAC. Accordmg to community-based studles conducted in the region in t h e 1960s and 1980s, a higher proportion o f m e n than women are heavy or excessive drinkers. W o m e n were found to b e m o r e hkely to abstain f r o m alcohol than were men. In Mexico, f o r example, t h e Second National Survey on Addictions found that 27 percent o f the m e n and 63 percent of t h e w o m e n h a d drunk no alcohol in the past year. About 14.2 percent o f t h e men and less than 1 percent o f the w o m e n were considered heavy drinkers (Medma-Mora, 1999). Moreover, in Argentina, although three quarters o f the w o m e n in the Buenos Aires metropolitan area were considered light or moderate dnnkers, only 1 percent drank heavily, as compared to 12 percent o f m e n (cited in Caetano, 1984). This pattern was repeated in all other countries in the region (see Table 5). Variations also exist within a country. A national survey o f alcohol consumption in seven regions in Costa f i c a conducted in 1981 showed that among w o m e n t h e proportion o f abstainers ranged from 34 percent in Limon t o 61 percent in Santa Cruz, compared to 12 percent to 22 percent respectively among m e n (Caetano, 1984). O n c e again, a very small proportion o f w o m e n were found to b e heavy or excessive drinkers, a n d a n even smaller proportion were identified as alcoholics. Gender also interacts with other variables, such as age, socio-economic status, region (urban vs. rural), and ethnicity, to affect consumption levels and patterns. In Argentina, among m e n residing in wealthy areas, 0.6 percent were found to b e alcoholics and 7.5 percent excessive drinkers. These figures were considerably lower than rates among m e n residing in poor areas, where 13 percent were found to b e alcoholics and 20 percent were excessive drinkers (cited in Caetano, 1984). Another study found that alcoholism was four times greater in t h e s l u m s than in higher income areas (cited in Caetano, 1984). In a study o f a n indigenous community in Ecuador, drinking was associated with being male, single, young, and having low socio-economic status (cited in Caetano).8

.Withrespect to age, the majority o f alcoholics and excessive drinkers in Argentina were between t h e ages o f 25 and 54. A m o n g moderate d w k e r s , however, there was no variation by age (cited in Caetano, 1984). Among men in Mexico, heavy dnnkers were concentrated within the 30-39 age group, whereas no s i p f i c a n t variation existed among w o m e n across age groups (Medma-Mora, 1999).

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The majority o f t h e community-based studies that illustrate the distribution o f alcohol use were conducted in the1970s. Accordmg t o Caetano (1984), a review o f alcohol studies in t h e 1960s and 1970s in the region faced a number o f dfficulties: the literature was widely scattered, often remained unpublished, and, w h e n published, appeared in joumals with h t e d and irregular circulation. Caetano highhghted t h e limitations of the studies as follows: 0

Studies focused only on severe forms o f drinkmg, based on a theoretical approach that considers alcoholism to b e a disease.

-

T h e relationshp between p o v e r t y a n d alcohol will not b e discussed in t h i s paper-such a discussion would demand in-depth analysis o f the very extensive literature, particularly that w r i t t e n in t h e U n i t e d States. But some research findings should b e m e n t i o n e d here. For example, in t h e U n i t e d States, the poor are m o r e likely to abstain a n d less likely to b e moderate or light drinkers, but are m o r e likely to r e p o r t alcohol-related problems. I n c o m e interacts with o t h e r demographic variables, such as gender, age, a n d race, supporting the hypothesis that these bear a c o m p l e x relationship t o drinking behaviors P f o s h e r , 1994).

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17 0

0

0

Studres focused on u r b a n a n d working class populations, largely ignoring h g h e r socioe c o n o m i c classes, marginahzed groups in u r b a n areas, a n d r u r a l populations. In contrast, studres o f indrgenous populations a n d their drinkmg practices have employed ethnography rather t h a n epidemiology. Studres focused on t h e epidemiology o f alcoholism a n d not on t h e epidemiology o f alcohol-related problems, such as injuries, traffic accidents, a n d violence. Studies o f t e n h a d methodological shortcomings. Among t h e m lack o f consensus on d e f i n t i o n s a n d operationalizing alcoholism, as w e l l as problems in sampling a n d data collection.

T h e past two decades, however, have witnessed dramatic improvements. T h e a l c o h o l studres t h a t were c o n d u c t e d in L A C in the 1980s a n d 1990s focused on t h e effectiveness o f a l c o h o l dependency a n d abuse treatments, development a n d testing o f standardized instruments for data collection for research, screening, a n d diagnosis o f alcoholism (the instruments are generally in E u r o p e or t h e U n i t e d States), a n d p s y c h a t r i c problems. Research continues to b e heavily based on the disease m o d e l (Monteiro, 1996), a n d assessments o f t h e social dimensions (both social impacts a n d socio-cultural patterns o f dnnking) are s t d l lackmg.

Trends in Alcohol Consumption A l c o h o l c o n s u m p t i o n levels a n d patterns change over time. Sex-Qsaggregated t r e n d data a b o u t these changes r e m a i n scant. A recent W H O - s p o n s o r e d study in B r a z i l provides a m e r e glunpse o f w h a t has b e e n occurring in LAC over the past two decades ( C a r h - C o t r i m , 1999). T h e survey, conducted in 1987, 1989, a n d 1993, l o o k e d a t l i f e t i m e prevalence o f a l c o h o l use a m o n g secondary students in n i n e cities.. I t found that dnnkmg a m o n g students in seven o f t h e cities increased significantly over t h e three study periods. I t also n o t e d strikrng Qfferences between males a n d females. For female students, a l c o h o l c o n s u m p t i o n rose s i p f i c a n t l y in eight out o f n i n e cities, whereas for male students, it increased in only three cities. In Salvador, in contrast, t h e l i f e t i m e prevalence o f a l c o h o l c o n s u m p t i o n a m o n g young m e n decltned s i p f i c a n t l y over the six-year period.

A s d a r study o f a l c o h o l c o n s u m p t i o n a m o n g h g h - s c h o o l students was recently carried out in M e x i c o City, w h c h generally reports a h g h e r proportion o f a l c o h o l intake t h a n t h e

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national average (Medma-Mora, 1999). T h e study revealed that, a m o n g m a l e students, t h e proportion o f boys engaging in alcohol use increased over t h e three t i m e periods, 1989, 1991, a n d 1993. T h e proportion of girls using a l c o h o l increased from 13 percent in 1989 to 19 percent in 1991, but t h e n declined slightly, to 17 percent in 1993.

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

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19 Figures 4-5. Lifetime Prevalence o f Alcohol Use among Secondary Students in N i n e Brazilian Cities bv Gender Lifetime prevalence of alcohol use among secondary students in nine Brazilian cities (Male)

100 95 90 85 *,

C

Q

$ n

80

H 1987

75

1989

70

1993

65

60 55

50

Cities

Lifetime prevalence of alcohol use among secondary students in nine Brazilian cities (Female) 100

95 90 85

g1987

80

1989

75

01993

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70 65 60

55 50

Cities

**

Source: Carluu-Cotrim, 1999 (*** Statistically significant at t h e 1 p e r c e n t level; Statistically Significant at the 5 percent level; Statistically significant at t h e 10 percent level; n s : not statistically significant)

*

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

20 T h e general p o p u l a t i o n cannot b e characterized by findings a b o u t dnnlung patterns a n d trends a m o n g students. However, the s t u l e s in B r a z i l a n d M e x i c o indicate that greater attention must b e p a i d to t h e possibility that alcohol c o n s u m p t i o n a m o n g adolescents, in particular girls, i s increasing. Thrs i s a critical matter, not least because o f females’ greater biological vulnerability to alcohol-related problems.

D r i n k i n g Norms in L a t i n America and the Caribbean

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E v e r y social grouping establishes norms a n d rules for who, where, when, a n d how to drink alcohol. Social norms vary not only between countries but also within countries. T h e variations in t h e w a y t h e rules are applied become most evident in t h e case o f gender. M e n a n d w o m e n are subject to different sets o f expectations a b o u t alcohol use. T h o s e include t h e w a y each gender consumes a l c o h o l a n d t h e way each responds. A n t h r o p o l o g i c a l research has c o n t r i b u t e d greatly to t h e knowledge on consumption patterns9 a n d norms (Heath, 1998; Harvey, 1994; Bacon, 1973; Bunzel, 1973). Ethnographic studies have enriched the l s c o u r s e by demonstrating cross-cultural variations, as w e l l as s d r i t i e s , in people’s drinking patterns. These studies reveal that deeply embedded meanings are placed on t h e act o f drinlung. T h e s t u l e s also emphasize t h e n e e d to understand dnnking behaviors a n d the consequences o f drinking within t h e socio-cultural context. I t i s socio-cultural forces that influence why, when, a n d how people drink a n d act out. In a d h t i o n , they shape how alcohol-related problems manifest a n d how people seek h e l p to resolve these problems.

L A C possesses a m u l t i t u d e o f drinlung cultures t h a t reflect such variations in c o n s u m p t i o n level a n d preferred beverage. Mexico, for example, i s o f t e n characterized as a dry culture-a society where daily c o n s u m p t i o n i s not a c o m m o n practice. A l c o h o l use there i s m a r k e d by infrequent, heavy b i n g e drinlung, occurring at times o f fiestas (Medina-Mora, 1989 a n d 1999). B r a z i l presents a v e r y l f f e r e n t dnnlung pattern. Drinlung begins early in life, c o m m o n l y involving farmly, a n d appears to b e integrated into everyday life. T h e f i r s t alcoholic dnnk frequently takes place within a famdy setting. A study of adolescents in t h e u r b a n area o f Porto Alegre reveals t h e family’s i m p o r t a n t role, not only in providing t h e f i r s t drink to boys a n d girls, but also in supporting c o n t i n u e d drinking (1999). (Carlini-Cotrim, 1999). Y e t in Brazil, occasions o f excessive dnnkmg are also c o m m o n , especially during Carnival, soccer games, a n d holiday celebrations. Carnival i s considered to b e a “time out in w h i c h rules a n d rites o f everyday l i f e are t u r n e d upside down” a n d “not a t i m e for m o d e r a t i o n a n d control” (Carlini-Cotrim, 1999, p. 16-17).’’ Social norms in t h e r e g i o n shape drinking patterns by stressing t h e circumstances o f drinlung a n d one’s drinlung companions, rather t h a n t h e v o l u m e o f drink o n e consumes (Medina-Mora, 1999). E t h n o g r a p h c s t u l e s depict drinking as a critical aspect o f social events. A l c o h o l facilitates social interactions, particularly a m o n g m e n (Heath, 1973, Coombs a n d Globetti, 1986). A l c o h o l consumption p a t t e r n pertains to h o w a n d where alcohol i s consumed, a n d in w h a t context the c o n s u m p t i o n takes place. Variables o f interest include t e m p o r a l rhythm o f drinking, settings a n d activities associated with drinking, drinking peers, a n d types o f beverages. T h e temporal rhythm o f drinking would b e operationalized as the n u m b e r o f occasions w h e n t h e subject consumed a large a m o u n t o f drinks in t h e past p e r i o d o f h e or the n u m b e r o f drinks consumed during t h e subject’s last drinking occasion. V e r y l i t t l e research has been conducted, however, t o determine how a n i n d v i d u a l decides w h a t a drinking occasion i s . T h e particular setting, such as a b a r or fraternity house, i s considered to b e a n i m p o r t a n t variable, because drinking in different settings i s related to different behaviors a n d risks. lo V i o l e n t incidents, injuries, a n d accidents are prevalent during Carnival. T h e r o l e o f alcohol in these incidents, however, has n o t been studied (Carlini-Cotrim, 1999).

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21 Supporting t h i s findmg, epidemiological studies indicate that m e n in L A C are m o r e llkely to consume a n d abuse alcohol a n d that w o m e n are m o r e likely to abstain.” Norms support, a n d in m a n y cases encourage, drinking a m o n g men, whereas they i m p o s e conditions a n d restrictions on drinlung a m o n g w o m e n . W o m e n o f t e n face strict social scrutiny about m a n y behaviors, drinkmg a m o n g them. In Mexico, for example, young u n m a r r i e d w o m e n are dtscouraged from drinlung in public, particularly in the company o f m e n (Medma-Mora, 1999). Men’s consumption o f alcohol transpires in t h e p u b l i c realm, whereas women’s m o r e o f t e n occurs in private. Group dlscussions with m e n in H o n d u r a s a n d with m e n a n d w o m e n in t h e southwestern p a r t o f M e x i c o City indicated that m e n o f t e n d r a n k in p u b l i c places, w h i l e w o m e n o f t e n d r a n k at h o m e (Caetano, 1984). Drinlung in bars a n d other p u b l i c places i s considered unsuitable for women. T h e exception: during festivals a n d celebrations. In a d d t i o n , m e n also drink in p u b l i c because they are presented with m o r e social occasions that p r o m o t e drinking, such as sporting events. Men, however, also are condltioned to recognize social distinctions b e t w e e n appropriate a n d inappropriate dnnking patterns. A study of the people living in Ocongate, a small town in Peru, hghlights t h e importance o f understandmg t h e meanings attributed to drinking behaviors a n d the norms a n d customs that d f f e r e n t i a t e acceptable drinlung from unacceptable drinking (Harvey, 1994). In Ocongate, drinking i s perceived as a means of maintaining good relationships. T h e acts o f o f f e r i n g a n d receiving drinks are v i t a l parts o f the social contract. I t i s expected that both m e n a n d w o m e n w d drink during agncultural, domestic, Catholic, a n d state festivals. Drinkmg also has a spiritual a n d sacred dimension. A refusal to accept a dnnk can imply lack o f t r u s t a n d a denial o f m u t u a l respect a n d affection. Socially accepted drinlung in Ocongate i s drinking as a social affair. I t i s characterized by two specific stages (Harvey, 1994). T h e f i r s t stage begins with a ritual, such as roofing a house. I t always consists o f drinking to “liven up.” Ths stage involves singing, dancing, talking, joking, a n d swearing. T h e second stage s i p f i e s a social duty successfully achieved; i t i s always m a r k e d by excessive drinking. W h e n a drinker does not abide by t h e two-stage norm, however, drinking i s seen as motiveless a n d unacceptable, for both m e n a n d w o m e n .

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A n o t h e r aspect o f drinking-intoxication-also exposes gender dlfferences in t h e application o f norms. B i n g e drinlung resulting in drunkenness, w h c h o f t e n characterizes alcohol c o n s u m p t i o n during festivals, i s a c o m m o n practice a m o n g L a t i n A m e r i c a n men. In general, intoxication of m e n i s m o r e socially acceptable t h a n o f w o m e n . Focus group discussions with m e n in H o n d u r a s (cited in Caetano, 1984) revealed t h a t m e n perceived that w o m e n tolerate male partners’ i n t o x i c a t i o n (that is, w o m e n are expected to understand that intoxication i s a natural c o n d t i o n o f manhood, undesirable yet acceptable). Behaviors brought a b o u t by i n t o x i c a t i o n are also gender defined. For example, t h e study o f the Ocongate c o m m u n i t y demonstrates that in t h a t particular society, a l c o h o l provides room a n d opportunity to stretch t h e boundaries o f appropriate behavior.

l1 Ethnographic literature asserts, however, that t h i s i s not a universal phenomenon. A cross-cultural study o f 113 societies revealed that in 109 societies, both w o m e n a n d m e n d r a n k (Bacon, 1973). Only in four societies was drinkrng restricted to o n e sex, a n d in each o f these cases, t h e m e n d r a n k a n d the w o m e n did not. \Where there was a gender difference, m e n always engaged in alcohol c o n s u m p t i o n to a greater degree t h a n w o m e n .

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

22 Drinking sessions represent a t i m e w h e n w o m e n m a y openly d~scussthe h t a t i o n s a n d difficulties o f b e i n g wives a n d mothers-getting drunk legitimizes the opportunity to c o m p l a i n a b o u t gender roles a n d p o w e r relations. Furthermore, these drinking sessions also signify a t i m e w h e n both m e n a n d w o m e n m a y express their sexuality. In Ocongate, for example, d r u n k e n m e n are o f t e n expected to express their heterosexual virility. W o m e n also associate dnnkmg with sexual activity. H a r v e y (1994) found t h a t f i r s t sexual experiences a m o n g w o m e n o f t e n occurred during drinking sessions. In a r e v i e w o f a n t h r o p o l o g c a l s t u l e s , H e a t h (1998) also found that in m a n y societies w o m e n who drank, in particular those who got drunk, were regarded as sexually promiscuous or sexually available.

Theoretical Perspective o n Gender Differences in Alcohol Use Prevailing explanations for the gender Qfferences in drinkmg levels a n d pattems i n c l u d e positional a n d status roles; gender r o l e identity; a n d gender r o l e stress. As in t h e Qscourse on gender a n d health, t h e theoretical perspective on gender a n d a l c o h o l i s dominated by social r o l e theory (Walsh a n d others, 1995), w h i c h claims that “certain positions in society are related to sets o f expectations, w h c h g v e d u e c t i o n to the behavior o f indmiduals a n d to societal reactions to t h i s behavior” (Neve a n d others, 1997).

Positional and Status Roles of Gender

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Gender can b e defined as both a status a n d a positional role, w h c h can affect drinkmg levels a n d patterns. Status r o l e refers to “social expectations based on characteristics t h a t t h e indrvidual cannot easily influence” (Neve a n d others, 1997, p. 1441). Positional role, in contrast, i s “expectations related to position in social networks such as work a n d family.” Women’s r o l e in society i s deeply embedded in nurturing activities a n d obligations. Thus based on concepts o f gender status a n d position, heavy drinkmg a n d i n t o x i c a t i o n would confhct with t h e idea o f the nurturing female. Some a l c o h o l researchers assert that, as m o r e w o m e n m o v e into t h e workplace a n d gender roles change, t h e gap between male a n d female drinkmg behaviors wdl narrow. W e are already witnessing h s in m o r e industrialized countries, where w o m e n entering f o r m a l e m p l o y m e n t outside their homes are m o r e likely to consume alcohol. Researchers o f f e r two possible explanations: as w o m e n take on a d u a l role, in farmly a n d in t h e workplace, t h e n e w stress in their lives leads to m o r e drinking; a n d as w o m e n break down t h e social barriers to f o r m a l employment, they gain greater f r e e d o m to engage in behaviors tradtionally associated with men, i n c l u d i n g drinkmg (Del Boca, 1994).

Gender Role Identity Differences between m e n a n d w o m e n in drinkmg levels a n d patterns have also b e e n explained by gender r o l e identity, w h c h asserts that t h e internalization o f c o n v e n t i o n a l gender stereotypes influences drinkmg behaviors. Drinking a n d drunkenness are m o r e o f t e n perceived to b e consistent with a traditional notion o f masculinity a n d inconsistent with femininity. Therefore, m e n who c o n f o r m m o r e closely to cultural norms are m o r e l i k e l y to drink, w h i l e the reverse i s true for w o m e n (Huselid a n d Cooper, 1992).

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

23 Gender Role Stress Related to t h e notion o f gender identity i s t h a t o f gender r o l e stress. Such stress arises w h e n w o m e n a n d m e n c o n f r o n t difficulties in fulfilling socially i m p o s e d a n d internalized gender expectations. A c c o r d i n g to h s hypothesis, m e n dnnk because they cannot l i v e up to their gender i d e n t i t y (Silberschrmdt, 1988). This hypothesis i s c o m m o n l y employed to explain drinkmg a m o n g m e n in communities that have experienced socio-economic a n d p o l i t i c a l upheavals. For example, colonization a n d commercialization transformed t h e traditional p o w e r structures within m a n y i n d g e n o u s communities, fostering alienation a n d frustration. Ths was particularly true a m o n g men, who found themselves unable to m a i n t a i n jobs a n d unable to support their households-that is, unable to l i v e up to t h e t r a d t i o n a l expectations o f b e i n g men. Drinlung eased their stress over t h i s transformation o f their lives.

Role o f Machismo

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M u c h of t h e empirical work testing t h e above three hypotheses i s based on populations in t h e U n i t e d States a n d other industrialized countries. Although t h e a p p l i c a b d q o f these explanations to t h e L A C r e g o n needs h t h e r exploration, a n examination o f gender roles in L A C has p r o v i d e d insight into how gender identity-in particular t h e r o l e o f machismeis constructed. Researchers in L A C recognize t h e importance o f sexualitymasculLnity/femininity-in shaping a l c o h o l c o n s u m p t i o n a n d related problems. W r i t e s d e K e i j z e r (1998): “It i s clear how d o m i n a n t (hegemonic) masculinity affects t h e lives o f w o m e n a n d children in t h e areas such as social a n d domestic violence, reproduction, a n d sexuality. I t i s not so clear, a t least to men, t h a t t h e same mascultne traits also affect our own lives causing dsease a n d early deaths because o f accidents, AIDS, a l c o h o l a n d o t h e r drugs, suicide, violence.. . . ”

A study in M m o n e s i a reveals how socio-cultural concepts o f m a s c h t y affect drinking a m o n g m e n (Flange, 1998). In Truk, Micronesia, young m e n consume excessive amounts o f a l c o h o l with t h e i n t e n t i o n o f getting drunk. Drinkmg excessively, as w e l l as getting drunk quickly, celebrates male courage a n d forges solidarity a m o n g male youths. Unleashing aggression i s also a n essential activity o f these dnnlung episodes. Young m e n are u n d e r great pressure, once drunk, to demonstrate their courage a n d their m a t u r i t y by e n d u r i n g physical c o m b a t a n d pain. B i n g e drinkmg i s t i e d to risk-takmg behaviors that are regarded as proofs o f strength a n d bravery: fighting a n d canoe voyages out onto t h e o p e n sea. Homicides, b r u t a l fights, a n d suicides are not considered acceptable behaviors in Truk; but w h e n these things happen in t h e context o f dnnking a m o n g young men, they are regarded as tolerable outcomes. T h e interesting findmgs o f t h i s Micronesian study suggest how a sirmlar study conducting inside t h e L A C c o u l d d u m i n a t e regional dimensions o f t h e idea o f masculinity.

A study conducted by t h e Costa R i c a n D e m o g r a p h i c Association hghlights t h e r e l a t i o n s h p

a m o n g macbistd, a l c o h o l use, a n d sexual risk t a k i n g (that is, unsafe sex) (Madrigal a n d Schifter, 1992). I t found t h a t a m o n g t h e general p o p u l a t i o n in Costa k c a , machista a n d h o m o p h o b i c attitudes were closely related to higher levels o f a l c o h o l consumption, in a d d t i o n to sexual risk takmg. Men, t h a t is, i n t e r t w i n e a l c o h o l c o n s u m p t i o n with notions o f sexual prowess a n d domination. Drinking, most o f t e n excessive drinking, i s o n e manifestation of t h e d o m i n a n t (hegemonic) masculinity t h a t i s p r o m o t e d in m a n y societies in t h e r e g o n (Smart a n d Medma-Mora, 1986; Medma-Mora, 1999). Studies appear to indicate

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

24 that m a s c u h i t y plays a s i p f i c a n t r o l e in explaining gender differences in alcohol use a n d alcohol-related problems in LAC. However, there are areas related to gender roles that need further investigation: T h e h e g e m o n y of masculinity needs to b e unpackaged. D o e s alcohol use, a n d i t s attached m e a n i n g to machismo a n d sexuality, vary across age, racial, a n d social class lines? Social expectations about the ways m e n a n d w o m e n drink n e e d to b e m o r e thoroughly understood. How does socialization links notions o f m a s c u h t y a n d femininity with particular drinkmg behaviors, values, a n d meanings, both at t h e i n d i v i d u a l a n d societal levels? T h e mechanisms that socialize males a n d females a b o u t drinlung also n e e d study. Thus far, examination o f the roles o f family, schools, a n d meQa in reproducing these values a n d norms in L A C has b e e n neglected. T h e m a n n e r o f initiation to dnnkmg also calls for attention. T h i s i m p o r t a n t dunension o f socialization varies tremendously withm the countries o f t h e LAC.

Summary

W i h LAC, there are large variations in the levels o f a l c o h o l c o n s u m p t i o n a n d t h e

preferred types o f alcoholic beverage (beer, wine, or spirits). Distribution o f a l c o h o l drinking levels a n d patterns, as demonstrated by e p i d e m i o l o g c a l studies, shows that m e n are m o r e hkely to drink heavily a n d excessively t h a n are women, a n d that w o m e n are m o r e hkely to abstain t h a n are m e n . Gender also interacts with other variables such as age, socio-economic status, a n d race to influence drinking levels a n d patterns. Variations a m o n g m e n by age a n d socio-economic status are greater t h a n t h e variations a m o n g w o m e n .

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Gender-disaggregated i n f o r m a t i o n on drinking trends i s scant. T h e l o n g i t u d i n a l studies o f secondary students in B r a z i l a n d Mexico, however, p r o v i d e a g h p s e o f w h a t m a y have b e e n occurring over the past two decades. A l c o h o l c o n s u m p t i o n a m o n g female students in M e x i c o rose in eight out o f n i n e cities, as c o m p a r e d to three cities a m o n g their m a l e counterparts. In Brazil, the proportion o f boys engaging in a l c o h o l use increased from 1989 to 1993, whereas the proportion of g i r l s increased but t h e n slightly decreased. Increased alcohol c o n s u m p t i o n a m o n g youths, in particular girls, demands closer attention.

Drinlung norms influence gender differences in a l c o h o l consumption. Drinking rules are

applied dfferentially a n d t h l s i s most evident in t h e case o f gender. M e n a n d w o m e n are subjected to d f f e r e n t expectations a n d meanings in their use o f alcohol, as w e l l as in t h e w a y they respond to it.

T h e socio-cultural forces influence why, when, a n d how people drink a n d act out. In a d d t i o n , they shape how alcohol-related p r o b l e m s are manifested a n d how h e l p i s sought to resolve these problems. This elucidates t h e n e e d to understand drinking behaviors a n d t h e consequences o f drinking within t h e socio-cultural context. Socio-cultural forces affect both m e n a n d w o m e n . In general, m e n are expected a n d encouraged to drink, whereas w o m e n face greater scrutiny in their drinking behaviors.

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

25 Although both w o m e n a n d m e n in L A C engage in dnnlung during festivals, binge drinkmg i s m o r e c o m m o n a m o n g men. In addition, m e n have m o r e opportunities to drink-they are p r o v i d e d with m o r e social occasions that p r o m o t e drinkmg, such as sporting events, t h a n are women.

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as positional a n d P r e v a h g explanations for gender differences in alcohol use-gender status roles, gender r o l e identity a n d stress-are largely based on empirical work a m o n g populations in t h e U n i t e d States a n d other i n d u s t r i a h e d countries. Gender studes in the r e g i o n have, however, identified gender roles, in particular t h e social construct of m a s c h t y , as c o n t r i b u t i n g to alcohol use a n d abuse a m o n g m e n . Drinking, most o f t e n excessive drinkmg, i s o n e manifestation o f the d o m i n a n t (hegemonic) m a s c u h t y that i s p r o m o t e d in m a n y societies in LAC.

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27

IV. Alcohol Policies in Latin America and the Caribbean T h e f r r s t section o f t h i s paper examined the effect o f alcohol on health (dsease a n d injury) and on social w e l l b e i n g at t h e global level as w e l l as in LAC. T h e second section highlighted t h e gender l f f e r e n c e s in alcohol use a n d t h e socio-cultural norms i n f l u e n c i n g these differences. This section focuses on t h e interventions that have b e e n i m p l e m e n t e d to prevent a n d mitigate alcohol-related problems.

High-risk drinlung a n d alcohol-related problems are prevalent in LAC. T h e y place a heavy b u r d e n on t h e w e l l b e i n g o f indwiduals, f a d e s , a n d communities, a n d they i m p o s e great costs on t h e h e a l t h care system a n d on society a t large. From a p u b l i c health perspective, such damaging a l c o h o l use demands that governments take action. From a gender perspective, m e n are b e i n g dsproportionately affected by alcohol abuse a n d alcohol-related problems, w h i c h h a r m not only physical but also psychological w e l l being. From a family perspective, t h e i m p a c t o f drinlung behaviors a m o n g m e n i s also b o r n e by w o m e n a n d children, not least because they m a y b e c o m e v i c t i m s o f violence a n d sexually risky behaviors. T h e socio-cultural context o f drinking, particularly in regard to gender roles a n d relations, i s critical in i d e n t i f y i n g t h e causes o f t h e problem, t h e n in formulating possible solutions.

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An i m p o r t a n t tradeoff i s inherent in govemments’ a l c o h o l policies. G o v e r n m e n t s look through t h e lens o f welfare economics, preferring not to b e c o m e i n v o l v e d in a n issue unless i t has p r o d u c e d m a r k e t failures. With respect to alcohol, t h e p r i m a r y m a r k e t failure i s t h e negative externalities brought on by drinking. Furthermore, interventions that target a m a r k e t failure m a y entail hgh transaction costs, w l d e interventions t h a t are untargeted (population based) m a y

result in l o s s o f welfare for some consumers. G o v e r n m e n t interventions, t h a t is, must balance t h e marginal social costs alongside t h e marginal social benefits. However, t h e welfare economics perspective n e e d not contradict the goals o f p u b l i c health a n d gender equality. W h a t actions should a government take in order to reduce a l c o h o l c o n s u m p t i o n to a socially efficient level? T h e r e are interventions that m a k e good sense from a p u b l i c health perspective, such as taxing alcoholic beverages a n d levying fines; but because these interventions m a i n t a i n hgh transaction costs t h a t m a y outweigh the social benefits o f a r e d u c t i o n in drinking, they m a y not b e justified from t h e welfare economics perspective. T h e decision a b o u t the type o f a l c o h o l policies a government adopts should b e based on effectiveness as w e l l as cost o f implementation. O n e k e y p r o b l e m t h a t h t s the a b h t y to formulate economically sound alcohol policies i s t h e dearth o f i n f o r m a t i o n on the effectiveness o f such policies in developing countries. E v a l u a t i o n o f a l c o h o l policies a n d programs has p r i m a r i l y b e e n carried out in industrialized countries. (The economics perspective has been w e l l presented in t h e previous B a n k reports a n d papers. See World B a n k Group, 2000, a n d Cercone, 1993 for detailed analysis. P o l i c y options a n d their tradeoffs are summarized in A n n e x 3.)

Types of Alcohol Policies A l c o h o l policies can b e classified by their objectives: preventing drinking a n d high-risk drinking behaviors; reducing h a r m on i n d v i d u a l consumers as w e l l as on families a n d communities; regulating avadabihty a n d c o n d t i o n s o f a l c o h o l use; a n d providmg treatment for i n d v i d u a l s with drinking problems.

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28 High-risk drinkmg behaviors m a y b e prevented by prompting individuals to change their behavior, through information, education, a n d c o m m u n i c a t i o n (IEC) a n d through dsincentives a n d punishment. T h e IEC approach provides p o t e n t i a l drinkers with i n f o r m a t i o n on the h a r m posed by alcohol, i n t e n d m g to p r e v e n t or a t least delay drinkmg, or to change t h e drinkmg norms (&IS was t h e approach taken by m a n y anti-tobacco campaigns). A n o t h e r prevention m e t h o d i s to put in place disincentives or punishments for irresponsible, risky drinking. For example, laws such as prohibition a n d penalties for drunk driving c a n act as deterrents. G o v e r n m e n t s have also chosen to put in place environmental interventions, such as creating alternatives to alcoholic beverages a n d developing recreational activities for youths that do not i n v o l v e drinking. These strategies focus on promoting a n e n v i r o n m e n t that supports abstention from or l i m i t e d use o f alcohol. T h e second area o f intervention can b e labeled h a r m reduction. I t aims not to stop any kind of dnnking, but to prevent dnnkmg’s negative consequences, such as drunk driving. Examples o f these interventions include t h e use o f designated drivers a n d t h e provision o f free p u b l i c transportation during festivals a n d holidays, both during a n d after regular transit service hours. T h e h d type of alcohol policy involves regulating t h e availabhty o f alcohol a n d i t s conditions o f use. Regulation can range from t o t a l prohibition to imposing taxes. A v a i l a b h t y i s affected by restricting production, requiring licensing o f sales outlets, restricting days a n d hours o f sales, r a t i o n i n g sales, h t i n g drinktng to specific designated settings, a n d luniting the n u m b e r o f places o f sale. O t h e r c o m m o n p o l i c y actions i n c l u d e setting a minimum age lunit for serving a n d buying alcohol, refusing to serve those already intoxicated, a n d regulating t h e advertising o f alcoholic beverages by private companies.

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T h e fourth area o f p o l i c y intervention i s providmg treatment for indmiduals who engage in p r o b l e m drinkmg. Such treatment m a y b e o f f e r e d by specific programs or m a y b e integrated into existing health a n d social services provisions. Some a l c o h o l researchers have criticized current a l c o h o l policies, m a i n t a i n i n g that a focus on t h e level o f consumption-often referred to as t h e a m o u n t o f a l c o h o l consumed as i n d c a t e d by m e a n p e r capita consumption-is insufficient a n d misleadmg (Grant, 1997 a n d 1999). These researchers have argued against t h e single distribution theory, w h i c h assumes that a m e a n level o f c o n s u m p t i o n i s closely related to t h e n u m b e r o f persons drinktng a t levels associated with a high risk o f developing alcoholism or alcohol-related problems. T h e y also criticize t h e epidemiological studies for focusing on quantity-frequency scales o f average c o n s u m p t i o n a n d on m e a n p e r capita c o n s u m p t i o n a t t h e societal level, claiming that t h i s focus inevitably leads to alcohol c o n t r o l measures rather t h a n to targeting those dnnkmg occasions that are most harmful. G r a n t a n d L i v a k (1997) point out t h a t e p i s o d c heavy drinking i s t h e problem, not moderate daily consumption. These researchers call for a focus on a l c o h o l c o n s u m p t i o n patterns, w h c h pertain to how a n d where alcohol i s c o n s u m e d a n d in w h a t context t h e c o n s u m p t i o n takes place-looking a t such variants as t h e t e m p o r a l rhythm o f drinkmg; settings a n d activities associated with drinking; personal characteristics o f drinkers; drinking peers; a n d type of beverages.

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

29 A large body o f evidence, however, supports a correlation between levels o f alcohol-related p r o b l e m s a n d levels o f p e r capita c o n s u m p t i o n in the society (World B a n k Group, 2000).

T h e m u l t i p l i c i t y o f factors influencing the rate of alcohol-related p r o b l e m s clearly i n d c a t e s that p o l i c y options need to consider p e r capita consumption, patterns of drinking, a n d other qualitative aspects o f the dnnlung culture.

Alcohol Legislation in LAC B e g i n n i n g in t h e 1960s, a f e w L A C countries formulated explicit national alcohol policies. T h e p r o p o s e d measures were d r i v e n by fiscal motives, rather t h a n by p u b l i c health concerns. T h e y concentrated on taxation o f p r o d u c t i o n a n d sales (Madngal, 1998). Religious a n d m o r a l arguments also propelled these policies (Smart a n d Medina-Mora, 1986). T a b l e 6 shows t h e types o f legslation that have been enacted in L A C to c u r b alcohol-related problems. C u r r e n t legislative actions primarily seek to lunit the availabfity of alcoholic beverages. A l c o h o l c o n t r o l measures take diverse forms: g o v e r n m e n t m o n o p o l i e s on p r o d u c t i o n a n d sales; special taxes on alcohol beverages; mini" age l i m i t s ; sales restrictions set by licensing outlets, r a t i o n i n g purchases, a n d h d n g times o f sale.

In Costa Rica, the government holds a monopoly over t h e p r o d u c t i o n a n d sale o f alcoholic beverages (Caetano a n d C a r h i - C o t r i m , 1993). In Paraguay, t h e state agency Paraguayan A l c o h o l A d m i t l l s t r a t i o n (APAL) maintains a monopoly on purchasing, &stributing, a n d quality c o n t r o l o f a l l alcohol products (Madrigal, 1998, p. 251). Moreover, m a n y L A C governments earn revenues from alcohol taxation (Madrigal, 1998; Caetano a n d Carlini-

Cotrim, 1993).

As shown in Table 6, a minimum drinking age i s the most c o m m o n restriction on a l c o h o l use. Almost a l l countries in the r e g o n have set 18 years o f age as t h e mini".Chile, where the dnnkmg age i s 21, i s the sole exception. Across t h e LAC, laws prohbit s e h g a l c o h o l to minors a n d prohibit minors from buying alcohol-but these laws are seldom enforced. A study in B r a z i l s h o w e d that 5 percent of children between t h e ages o f 9 a n d 11years o f age a n d 9 percent o f children between 15 a n d 17 d r a n k in bars (Carlini-Cotrim, 1999).

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T h e governments o f Chile, Venezuela R.B., a n d C o l o m b i a have restricted drinlung to certain times of day a n d h t e d i t only to specified venues. Venezuela R.B. additionally regulates drinking on planes a n d boats a n d in sports centers. B r a z i l i s t h e only c o u n t r y in L A C that levies penalties a n d fines to &scourage drinking in t h e workplace. Bans a n d restrictions on advertising have also b e e n adopted across t h e region. Costa Rica's N a t i o n a l Institute on A l c o h o l i s m a n d Drug Dependence has b e e n screening alcohol-related advertising since 1975. entirely bands alcohol advertising on r a d o a n d TV. El Salvador a n d Paraguay have enacted legslation regulating a l c o h o l advertising on TV a n d in movies; both countries also require alcoholic products to bear w a r n i n g labels. G o v e r n m e n t efforts to prevent a n d mitigate alcohol-related p r o b l e m s face a n u m b e r o f lirmtations:

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30 0

0

Legislation a n d policies generally are not enforced, due to a lack o f political a n d social will to v i e w either alcohol misuse or alcohol-related p r o b l e m s as a societal issue.

L A C governments have focused on regulation o f alcohol's availabhty, rather t h a n on h a r m r e d u c t i o n a n d on education campaigns. T h e r e are a v e r y f e w exceptions: Chde a n d C o l o m b i a have enacted legslation to prevent alcohol-related problems through IEC; in Colombia, bylaws exist that specifically call for educational programs at the s c h o o l level, as w e l l as preventive campaigns targeting tobacco a n d a l c o h o l (Madrigal, 1998).

0

Governmentally set standards for treating a l c o h o l dependency a n d r e h a b h t a t i n g alcoholics are h t e d by a lack o f early detection a n d care. Moreover, treatment or support services are not coordinated with p u n i t i v e measures, such as fines a n d arrests. These failures limit t h e effectiveness o f l e g s l a t i o n in such countries as Honduras, Ecuador, a n d Argentina (Madrigal, 1998).

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Ovenvhelrmngly, alcohol policies in the L A C r e g i o n focus on c o n t r o l o f availabhty a n d access to alcohol. T h e effectiveness o f these interventions has been d i f f i c u l t to assess because i m p l e m e n t a t i o n a n d enforcement r e m a i n superficial.

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T

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V. Recommendations T h e World B a n k has a s i p f i c a n t r o l e to play in t h e prevention a n d m i t i g a t i o n of alcoholrelated p r o b l e m s in t h e L A C region. T h e Bank-and t h e h u m a n development sector in particular-should increase i t s efforts to prevent a l c o h o l abuse in client countries that bear a heavy b u r d e n o f alcohol-related problems. T h e B a n k should i d e n t i f y a n d support effective policies to reduce t h e i m p a c t on h u m a n capital, especially in countries with high p e r capita a l c o h o l consumption, as o u t l i n e d in the World B a n k Group N o t e on A l c o h o l Beverages. T a x a t i o n policies are a m o n g t h e measures that should b e considered. O t h e r priorities should i n c l u d e increasing t h e knowledge base by supporting research efforts; developing indrcators to measure a l c o h o l c o n s u m p t i o n level a n d patterns a m o n g m e n a n d women, as w e l l as to measure t h e economic a n d social consequences of a l c o h o l use; systematically integrating questions o f a l c o h o l use a n d related problems in consultations with governments a n d c i v i l society organizations; a n d providmg investment l e n d m g where there i s adequate data a n d a p o l i t i c a l a n d social will to address t h e issue. T h e rest o f t h i s section offers policy a n d p r o g r a m m i n g recommendations a n d proposes further research for t h e region.

Policy and Program Interventions

Copyright © 2001. World Bank Publications. All rights reserved.

A l c o h o l policies should address t h e m u l t i p l e determinants o f a l c o h o l abuse by putting in place cost-effective, culturally appropriate, sustainable interventions; preventing alcohol abuse a n d dependency; a n d reducing alcohol-related risks to t h e individual, whether d n n k e r or non-drinker, as w e l l as to the society. T h e r e c o m m e n d e d p u b l i c health approach includes a focus on risk behaviors a n d the enabling a n d r e i n f o r c i n g factors i n f l u e n c i n g those behaviors, as w e l l as a focus on t h e individuals or populations a t risk. A l c o h o l consumption, use, a n d abuse i s a c o n t i n u u m . T h e economic a n d p u b l i c health perspectives on alcohol use are not m u t u a l l y exclusive. An ideal policy decision should i d e n t i f y t h e o p t i m a l strateges a n d i n t e r v e n t i o n points within a specific country context. A l c o h o l p o l i c y options for L A C include levying taxes, setting p r o d u c t safety standards, licensing production, promoting health education, controlling advertisements, enacting drunk driving laws a n d minimum-age h t s , a n d restricting t h e times a n d con&tions o f beverage sales. P u b l i c education c o u l d encompass s c h o o l health education programs, media campaigns, a n d educational approaches targeting pregnant women, commercial sex workers, a n d victims o f physical a n d sexual abuse. Consumer information, such as facts a b o u t t h e dangers o f d r i n h g during pregnancy, i s a n i m p o r t a n t p u b l i c h e a l t h tool. However, because t h e i n f o r m a l sector supplies a s i p f i c a n t proportion o f t h e alcoholic beverages consumed in LAC, a l l these measures a n d their tradeoffs have to b e carefully evaluated, especially t h e measures a i m i n g at r e d u c i n g access to alcohol (see also A n n e x 3). Currently t h e m a j o r i t y of a l c o h o l policies in L A C focus on c o n t r o h g t h e availability o f alcohol. At t h e very minimum, these policies n e e d to b e e n f o r c e d a n d their effectiveness evaluated. N o t e , however, that t h e existing policies neglect t h e stark gender dimensions o f alcohol c o n s u m p t i o n a n d alcohol-related problems. As indrcated by epidemiological a n d anthropological studies, L A C countries vary in levels o f a l c o h o l c o n s u m p t i o n but also in patterns of drinking. G e n d e r drfferences are acute. D e s p i t e t h e overwhelrmng representation

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

34 of m e n in alcohol-related problems, a n d the p r e v a h g norms that support a n d encourage drinking a m o n g men, no existing interventions in LAC explicitly consider gender.

Gender analysis of alcohol c o n s u m p t i o n a n d alcohol-related problems indicates that interventions, particularly in t h e areas o f prevention a n d h a r m reduction, ought to focus on changing socio-cultural norms a b o u t gender a n d drinkmg. I t i s especially i m p o r t a n t to focus on the norms t h a t p r o m o t e hgh-risk drinkmg behaviors a m o n g males a n d to target t h e mechanisms t h a t socialize both genders about drinking a n d drunkenness. Interventions should b e specific to t h e socio-cultural context in w h i c h drinlung occurs, i n c l u d m g gender roles a n d identity. In designing interventions, gender differences in a l c o h o l c o n s u m p t i o n levels a n d patterns should b e assessed along the following dunensions using appropriate quantitative a n d qualitative methodologies:

What: W h a t are t h e preferences o f w o m e n a n d m e n with respect to alcoholic beverages? A r e some types o f beverages considered acceptable or unacceptable for w o m e n or m e n ? When:W h e n do m e n a n d w o m e n drink?For instance, do certain occasions, such as festivals or soccer games, prompt drinkmg? How do these occasions shape t h e level a n d pattern o f drinking? Where:W h e r e do w o m e n a n d m e n dnnk?For instance, do they drink in bars, a t work, in school, a t h o m e ? How does a setting shape the level a n d p a t t e r n o f dnnking?

HONHow do w o m e n a n d m e n pace their drinkmg?W h a t o t h e r behaviors accompany drinkmg-for instance, i s there other substance use? Wzth whom: With whom do w o m e n a n d m e n dnnk?For instance, do they drink alone, or do they drink with family members, peers, or co-workers? How do drinlung companions shape t h e level a n d p a t t e m o f drinkmg? Why Why do w o m e n a n d m e n drink?D o they dnnk to l i v e up to social expectations, to cope with stress, to facihtate social interactions, to ease sexual inhibitions, to enhance

masculinity? D o they abstain?

Using these dunensions to understand gender differences in drinkmg behaviors would

Copyright © 2001. World Bank Publications. All rights reserved.

enhance the efficiency a n d effectiveness o f p o l i c y interventions t h a t a i m to reduce or prevent alcohol-related p r o b l e m s in t h e L A C r e g o n .

Research

To create alcohol i n t e r v e n t i o n policies, m u c h m o r e research in a n u m b e r o f areas i s necessary. Such research needs to consider t h e following: e

A l c o h o l research in t h e r e g o n i s uneven. W h i l e some countries, such as Brazil, Mexico, a n d Costa Rica, have p r o d u c e d studres that p r o v i d e insight into patterns o f drinking a n d socio-cultural factors, o t h e r countries in t h e region have r e m a i n e d unexplored.

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

35 A t t e n t i o n should b e p a i d to countries where consumption levels are hgh, such as Paraguay, Argentina, Venezuela R.B., Uruguay, a n d Chde, a n d where there i s l i m i t e d i n f o r m a t i o n on the patterns of alcohol consumption, in particular i t s gender dunensions. 0

T h e p u b l i c health literature remains largely entrenched in the medical “disease” model. I t s u l l lacks i n f o r m a t i o n on t h e social impacts p r o d u c e d by alcohol use through violence a n d sexual risk behaviors. L A C needs further studies o f gender differences in the social impacts o f alcohol on families a n d communities, i n c l u d i n g suicide, crime, a n d violence (among m e n as w e l l as against w o m e n a n d children).

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Alcohol’s i m p a c t on household dynamics also needs m o r e investigation. Such studies should include the i m p a c t o f drinking on i n c o m e a n d expenditures a n d i t s i m p a c t on gender roles w i h families. Such studies can b e achieved through analysis o f household data from surveys that are already supported by the Bank.

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Unanswered questions remain about gender roles. Though h t e d , studies on alcohol use a n d gender already have revealed that mascuhmty plays a significant r o l e in LAC’S gender differences in alcohol use. But a n u m b e r o f gender r o l e topics remain unexplored, i n c l u d i n g how alcohol use, interrelated with manifestations o f machlsmo a n d sexuality, varies across age, racial, a n d social class h e s ; a n d how males a n d females are socialized a b o u t drinking. W h a t are the agents a n d mechanisms o f socialization in L A C countries? How are drinking behaviors initiated a n d perpetuated? These should b e the topics o f further research. There i s no i n v e n t o r y o f current anti-alcohol interventions inside the LAC. Such a n inventory, listing who i s doing w h a t a n d evaluating the interventions governments a n d c i v i l society organizations in L A C countries are carrying out, needs to b e undertaken.

Copyright © 2001. World Bank Publications. All rights reserved.

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L o n g i t u d i n a l studies should b e considered. Such studes would p r o v i d e invaluable i n f o r m a t i o n on trends a n d patterns o f alcohol c o n s u m p t i o n a m o n g m e n a n d w o m e n a n d particularly a m o n g the young.

Pyne, Hnin Hnin, et al. Gender Dimensions of Alcohol Consumption and Alcohol-Related Problems in Latin America and the Caribbean, World Bank Publications, 2001. ProQuest Ebook

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