India is a vast country with the second largest population in the world in which a relatively small proportion drink alcohol. However, the amount of alcohol consumed by this fraction of the population is so large that even spread out across 1.3 billion people to calculate per capita consumption, doesn’t fail to reveal a grave and growing problem. It is one of the few countries where consumption per capita is actually on the rise. Where are we headed?
Let’s start with a short history lesson, one that is several centuries old. It’s a lesson that busts the myth of the ‘abstinent Indian culture’ and allows us to understand the truth about alcohol consumption in contemporary India. We will see how our perspective of alcohol has transformed through the passage of time; four horses, four directions, and an act of dismemberment that ends with the present reality of alcohol use in the country.
Several centuries ago, the consumption of alcohol was not only socially accepted but prevalent. Rules and behavioural expectations around alcohol use were codified to ensure that it was an enjoyable yet controlled activity (the kind of documentation, by the way, that does not exist in modern India today). Communities celebrated an open but socially regulated culture of drinking - the first horse.
Between the mid-eighteenth and the mid-nineteenth centuries, the British East India Company began to establish its supremacy until the British Raj planted its flag in the country. Amongst the many things the colonial rule overhauled, one was India’s ancient relationship with alcohol. The production of alcohol and the act of drinking went from being a culturally regulated practice to a highly commercialised one - the second horse. Before this could settle into the DNA of the country, we experienced another transformation during the independence struggle; the Gandhian Era and the dawn of a temperance movement that endorsed the moral superiority of abstinence.
The latter half of the 20th century was a time when the morality of consuming alcohol was deeply questioned. It threw cultures and practices that had lasted for several centuries into turmoil and with it, a large number of people into confusion - the third horse. All this while, however, borders were impervious, and globalisation hadn’t taken the world by storm. By the early 90s, India finally opened its economy to the world, and we were yanked in yet another direction. Suddenly, availability of and accessibility to alcohol surged along with household incomes. The country was plastered with global marketing messages about the pleasures of drinking. This was a recipe for yet another major change in drinking behaviour - the fourth horse. As we stepped into the 21st century, all four horses had moved forward in different directions, and we began to see the results of the dismemberment.
In many countries, especially in the West, you would find a large proportion of the population consuming alcohol and a small percentage of that number displaying problems with alcohol. In India, it is the opposite. We have a smaller proportion of people who drink, but a large percentage of them have alcohol-related problems. Majority of people who consume alcohol are also males who primarily drink spirits, drink alone, and consume large amounts in short periods with the goal of getting intoxicated. Our history has fragmented our perception of alcohol, and we straddle between questioning its morality and exploiting its accessibility and pleasurable effects. We have not evolved into a culture of drinking as a socially enjoyable activity that is spread out over time without inebriation being the goal. As a result, you will witness problematic drinking patterns in bars littered across the country; a formula for immediate adverse events such as road accidents and physical brawls, and longer term poor health and social outcomes.
Let’s now examine the spectrum of alcohol consumption patterns and the composition of drinking behaviours in India.
At its extreme, dependent drinking is not just psychological but physical as well. Alcohol withdrawals can involve experiencing shakes, nausea, vomiting, sometimes even hallucinations and seizures, and can be fatal.
Take a moment and imagine what comes to mind when you think about a person who drinks heavily? Perhaps you have pictured what most people do; an “alcoholic” man from a particular economic stratum, getting drunk alone every day, unable to find his way home and perhaps ends up sleeping on the road. In reality, this conjured image represents a tiny proportion of drinkers in the country. The very tip of the iceberg that is visible to all of us. But, the rest of the iceberg that we are blind to is what reveals the true picture on the ground. The larger problem is the significantly higher proportion of people who are managing to lead a semblance of productive and functional lives despite drinking problematically.
Herein lies the prevention paradox; do we focus on the large number of people who have a smaller risk or the small number of people with a much larger risk? Ironically, we have chosen to focus on the latter. We have invested heavily in programs that involve hospitalisation and detoxification but have barely broken the surface in making low-cost interventions available at scale to risky drinkers. We have geared up for this conjured image of the ‘alcoholic’ but we have not been able to effectively help the majority before they tip over into dependency.
There is no single explanation for what causes and sustains addictive behaviour.
Similar to physical illnesses such as hypertension or diabetes, alcohol-related issues involve several things coming together. These include genetic predispositions as well as psychological and social factors. So, while a family history of alcohol problems doesn’t destine you to the same fate, the lack of family history doesn’t save you from it either.
Although the volume of alcohol ingestion can indicate risky drinking, it is critical not to ignore the pattern of consumption. Let’s take an example; person A drinks one peg of whiskey every evening, and person B drinks five pegs only on one day of the week. Person B’s behaviour is much more harmful as they are inflicting a lot more damage to their body by drinking a large amount of alcohol in a short amount of time.
By understanding these fundamentals, we can become more responsible, whether we drink or not. Importantly, it can also help us educate our loved ones and communities about alcohol consumption and get them early intervention from appropriate health professionals if that is the need. Small steps such as this can help us construct a healthier society.
It may (and it should) seem strange that our country doesn’t have a consolidated alcohol policy that brings together various sectors which can potentially be involved in reducing alcohol related harms e.g. education, legal, and policing systems. Like our history, we’re coping with fragments, and this is far from sustainable. We cannot move forward without recognition of where we stand today. Perhaps it is time we look beyond the tip of the iceberg to the reality of alcohol consumption in India – while there is no silver bullet, open discussion and education is always a great starting point.