By Arthur G. Nikelly
McKinley Health Center University of Illinois at Urbana
JOURNAL OF ALCOHOL & DRUG EDUCATION Spring 1994, pp. 1-12
Precapitalist societies did not experience severe problems with alcoholism as they exist today. The broad parameters associated with alcohol abuse have not been explicitly investigated by alcohol educators and researchers. Instead, they focus on group influences and stress individual responsibility to curtail alcohol abuse. Seeking the causes of alcohol abuse within the person diverts attention from the invisible economic, political, and social parameters that promote the lucrative industry of alcohol production and consumption. Advertising earnings and tax revenue from alcohol consumption are dominant economic motives that overlook the social costs. The remedy has been to treat the victims of alcohol abuse rather than to challenge the strong economic and political incentives that promote alcohol consumption. The proposed solution is for economic and political interventions to take precedence over individual education and treatment, making alcohol a highly taxed, and a less “visible” and available commodity. Educational institutions can create environments in which alcohol becomes less important in the lives of students.
Ethnographic observations of primitive societies suggest that the consumption of alcohol was controlled by sanctioned social customs, that the pathological consequences of alcohol abuse were infrequent, and that the consumption of alcohol had ritualistic, medicinal, and religious uses (Singer, 1986). Although primitive societies produced alcohol, no pathological consequences were associated from its consumption because drinking occurred within a stable social structure and was socially controlled and ritualized. A case in point is African nations that did not experience serious problems with alcohol abuse until the introduction of western alcoholic beverages and their promotion by the mass media. Even earlier, however, colonialism fostered a cash economy that destroyed indigenous subsistence economies and created a large unemployed population that lost dignity and self-esteem. Brewing originally took place in family settings and was a traditional ritual, culturally sanctioned and socially controlled. Post-colonial systems made alcohol available through profitable commercial outlets. Thus, the economic system encouraged social and economic stratification. Producers and distributors enjoyed financial gains and the traditional mode of regulation was destroyed.
Multinational enterprises seek to penetrate and “westernize” underdeveloped countries by promoting consumer products that are not related to such basic needs as nutrition, education, health care, and housing. Moreover, these enterprises often cultivate a single crop for export, thus depriving the local people of the opportunity to raise traditional staples for their own diets. Having lost their arable land, they became low-paid wage earners who were forced to buy imported food from other countries (Elling, 1981). Foreign corporations that seek to make a profit in Third World countries often establish economic domination and create poverty, deculturation, social stratification, and the dissolution of community cohesiveness–ideal conditions for increased alcohol consumption (Singer, 1986).
The situation in pre-industrial England was not so different from the circumstances in underdeveloped countries today. In the easy-going household workshops and cottage manufacturing of pre- industrial England, drinking meant friendship and sociability. With the advent of the industrial revolution, however, a new class of working people was created, apart from the wealthy owners of the large industries, and their heavy drinking was, to a large extent, associated with their subordinate and exploited status and to the cheaply produced and readily available distilled spirits (Sennett & Cobb, 1972). Alcohol abuse occurred in England during the industrial revolution when workers were alienated from the products of their labor and the unemployed were living in poverty. Under these conditions alcohol was consumed to obtain relief from stress and oblivion from misery (Jacobson, Hacker, & Atkins, 1983).
The spread of capitalism, often in the service of “God and profit,” forced workers to concentrate in urban industrial centers and fostered the emergence of a working class. These populations subsequently became vulnerable to social instability and economic fluctuations (Wolf, 1982). Thus, the industrial revolution transformed people’s lives by expanding commodity markets to alcoholic beverages. Dependency on alcohol promotes consumerism and enhances profits. For the same reasons North American and European conglomerates today admit to seeking new markets for their products among women and Third World countries (Jacobson, Hacker, & Atkins, 1983).
OBSTACLES TO THE CONTROL OF ALCOHOLISM
Solutions for alcoholism are sought according to how alcohol abuse is defined. Alcoholism is generally studied as the manifestation of either a personal or social problem that often involves family conflicts, personality characteristics, or interpersonal problems. The emphasis has been on the individual alcoholic, as if the rest of the world that produces and promotes alcohol did not exist.
The suggested remedy for the addictive use of alcohol has been, for the most part, to teach healthier life styles. The compelling influence of advertising and the devastating effects of social stress and economic pressures that bring on or are associated with alcohol abuse are rarely mentioned as etiological variables. Instead, most persons assume that illness aggravated by the social environment should be solved on a case by case basis by “professional” medical intervention or through individual actions. As a result, a collective assault on the causes of alcoholism–which are social–is way laid. Thus does the medical profession, perhaps unwittingly, serve the interests of those in power and strengthen the status quo (Sanders & Carver, 1985)?
Medical practices are currently based on the assumption that problem drinkers must learn to adapt to an environment that is often the primary cause of their alcohol abuse. Therapy groups, for example, are formed to accommodate students raised with alcoholic parents; yet no measures are taken to alter the economic conditions that in all likelihood are associated with problem drinking. The result has been an increase rather than a decrease in problem drinking (Hasin, Grant, Harford, Hilton, & Endicott, 1990).
The focus on diagnostic techniques and consultation and the emphasis given to counseling, psychotherapy, re-education, and rehabilitation fail to recognize the real issues–the endemic economic structures that support alcohol consumption. Indeed, the mental health professions have been little concerned with economics, focusing instead on the individual and overlooking the importance of the socioeconomic structure. Unwittingly, for the most part, these professions attribute the responsibility for change to the individual, yet, the conditions that increase pathology, stress, maladjustment, and alienation are part of a wider political and economic system (Lerner, 1973; Goldenberg, 1978).
Consider, for example, the following incident: Alarmed over increasing alcohol abuse among students at a large academic institution, officials with the aid of health advocates and educators initiated awareness programs, prevention workshops, and peer education. When the city’s mayor and bar-owners were asked to cooperate in the prevention of alcohol abuse, all agreed in principle with the alcohol awareness and prevention program but asserted that it was the responsibility of the consumer to decide on the amount of alcohol intake. The mayor argued that curtailing the consumption of alcohol would deprive the city of valuable tax revenues. The response to such inconsistencies has been mainly autoplastic, that is, the individual is expected to change, to cope, and to adapt; health is considered to be a personal rather than a structural issue.
Western society tacitly propagates a self-contained individualism that gives impetus to an acquisitive drive that leads to economic exploitation. In the business world, for example, misleading and confusing information is often used to win consumers without considering the effects of the product on the health of the user. Alcohol advertising, for instance, is countered by warnings from the health professions, but the individual is expected to sort out the contradictory information and make a rational decision. Attempts to undertake prevention programs against alcohol abuse are often met with resistance from those who hold power in the society. Still another inconsistency inherent in the free enterprise system is disdain for those who cannot postpone immediate pleasures for future rewards. At the same time, an endless array of goods that urge wasteful spending and the surrender to hedonism are paraded that encourages immediate gratification and the deferment of less selfish goals.
THE POLITICS OF ALCOHOLISM AS A DISEASE
The notion that alcoholism is a disease has serious limitations because it implies treatment for an illness and absolves any blame for being “ill.” Alcoholism as a disease presupposes that medical intervention will effect a cure (Kendell, 1979). The accepted procedure, therefore, is to confront the alcoholic with diagnosis, treatment, re-education and rehabilitation, rather than punishing the abuser with fines and incarceration (Park, 1983). Thus, the “sickness” model commodifies treatment, creating a market that enhances the growth of the health industry. When alcoholism is defined as a medical issue, politicians are provided with an excuse not to make electorally unpopular legislative decisions, such as levying higher taxes on the sale of alcoholic beverages or restricting their availability. Further, politicians can rationalize their reluctance to forbid the advertising of alcohol because such regulation would violate the spirit of competition and free enterprise. Thus, the false impression is conveyed to consumers that normal persons who enjoy drinking are not likely to become alcoholic, and the alcoholic beverage industry is given free reign to produce, distribute, and promote its products without admitting to the public the potential dangers.
The evidence for alcohol abuse and dependence as due to metabolic disorders, physiological abnormalities, or heredity is generally inconclusive; rather, it is the prolonged and excessive use of alcohol that produces biological dependency (Kendell, 1979). These predispositions are likely to be the result of, rather than the cause of, heavy alcoholic consumption (U.S. Department of Health and Human Services, 1980). In addition, biological vulnerability to alcohol abuse is compounded by such overwhelming social factors as stressful life events and emotional conflicts. Vulnerability can also be reinforced through parental modeling and peer pressure and through repeated exposure to advertising (DeFoe & Breed, 1979; Singer, 1986). It should be emphasized that not all persons who are exposed to these circumstances will become alcoholics and that some may become alcohol abusers without experiencing any of them.
All alcoholics are not the same, and the causes of drinking are multiple. Inherited predisposition to alcohol is only one factor, and drinking patterns vary, often in terms of the social context and ongoing stress. Labeling alcohol dependency a “disease” does not absolve the abuser from moral responsibility. Thus, by assigning to the alcoholic a medical debility and moral weakness, the problem is privatized. In turn, the medical professions profit by offering their professional skills and the alcohol industry is absolved from blame and continues to market its products. The outcome: alcohologists become absorbed in the genetic pathogenesis of alcoholism on the one hand, and with the conflicts, stresses, traumata, personality structure, and ego defenses on the other. Thus, the victim is treated and may be changed, but the profiteering multinational alcohol-manufacturing complex is accepted as the normal condition of the society (Singer, 1986).
THE OVERLOOKED SOCIAL AND CULTURAL FACTORS
The consumption of alcohol is often associated with success and sophistication, it portrays the social norm, and it constitutes the “right” thing to do (Jacobson, Hacker, & Atkins, 1983). The production of alcohol is not only a lucrative venture but a manipulative strategy to placate people who are stressed and unemployed and who live in the margins of society (Kendell, 1979). Research shows a marked comorbidity between anxiety disorders and alcohol problems; the anxiolytic effects of alcohol reinforce drinking behavior which, in turn, has the potential to promote anxiogenic consequences from pathological drinking (Kushner, Sher, & Beitman, 1990). Heavy alcohol consumption that leads to serious behavioral problems that are beyond personal responsibility is best understood within the context of often overlooked “invisible” economic and political forces. These forces are associated with the dramatic increase in the incidence of alcoholism along with its secondary physical illnesses and its strong association with socioeconomic, cultural, and consumer values. However, even when alcoholism is the outcome of social, economic, and political forces, it does not make the alcoholic entirely blameless.
The correlation between the rising incidence of alcoholism, on the one hand, and mortality from hepatic cirrhosis alone can serve as an independent reliable index for alcohol consumption (Kendell, 1979). Describing trends in the field of mental health, Redlich and Kellert (1978) report that during the 25-year period between 1950 and 1975 there was a significant shift of diagnoses from schizophrenia to alcoholism, which has become a major nosological category that includes 46% of the inpatients in state hospitals, and this category also had the highest readmission rates.
The inexpensive process of distilling and brewing alcohol created an abundance of a cheap commodity available to working people. Consumption soon became heavier among the lower socioeconomic classes, as documented from the larger number of hospital admissions and police arrests. However, a closer examination reveals that persons among the poor classes are more apt to experience problems with alcohol intake because the outcome of their drinking is more visible to the public (Park, 1983). Class divisions have been used to show that alcoholism causes poverty, thereby exonerating an economic structure that exploits workers and maintains social and economic inequality.
The amount of alcohol and the manner in which it is consumed are largely shaped by cultural contingencies. For example, despite the associated stresses of industrialization, modernization, and technological progress in Taiwan and Korea, both Asian countries with the Confucian moral ethic of moderation and temperance, the prevalence of alcoholism in Korea is three times higher than it is in Taiwan (Helzer, Canino, Yeh, Bland, Lee, Hwu, & Newman, 1990). The difference is that Korean culture not only tolerates but encourages alcohol consumption; cultural support is shown by the public display of drinking that symbolizes male mastery, strength, and domination. On the other hand, not only is drunkenness disapproved of in Taiwan, but it denotes degeneration and personal weakness. A similar parallel is observed in the U.S. where alcohol consumption among students living in Greek-letter social organizations is higher than it is among the male college population in general. The explanation lies in peer-reinforced behavior supported by a subculture within the infrastructure of the fraternity system–a finding that has been confirmed by previous studies (Tampke, 1989).
THE ECONOMICS OF ALCOHOLISM
The study of patterns of alcohol consumption focuses mainly on naturalistic observations of drinking, on the sociological variants, and on the associated individual cognitive processes. Anthropologists have concentrated their study in isolated cultures and have related problem drinking with normative drinking which, in turn, is referred to the drinking pattern typical of the culture. But alcohol consumption is not a static phenomenon. Rather, the larger, insidious economic and political forces endorse the sale of alcohol as a lucrative commodity and influence consumption. Left out is an important aspect of the political economy that connects and integrates the consumption of alcohol with broader political and economic forces. Individual drinking behavior is best understood in terms of a broader commercial perspective, one that is defined by the relationship between capitalist production and consumption and by the expansion and hegemony of monopolies. The transnational character of the alcohol market and its vast promotional drive creates a $170 billion a year alcohol sales enterprise (Singer, 1986); over one billion dollars a year is spent in advertising campaigns in the U.S. (Jacobson, Hacker, & Atkins, 1983).
DeFoe and Breed (1979) randomly examined college newspapers and found that alcohol advertisements accounted for half of all advertising. These advertisements suggested that those who drink were smarter and happier than those who abstain, that beer can be a substitute for learning, and that alcohol relieves the pressures of college life. Alcohol advertisements exploited the frustrations and stresses of higher education and offered ephemeral escape without making any substantial contribution to the basic goals of education. The alcohol industry claims that its advertising in college newspapers is designed to switch drinkers from other brands to their own product. Compared with the Midwest, however, campus newspapers in the South carried nearly three times the amount of advertising, in a region that has the lowest per capita alcohol consumption. The alcohol industry obviously wants to solicit more consumers, especially those who are experimenting with alcohol and may choose a brand to consume for life. During the last thirty years, millions of university students established drinking patterns that will persist throughout their lives. These investigators contend that the same trend can be expected in the next three decades.
A similar study seven years later showed that the national advertising of alcohol had declined but that the volume of local alcohol advertisements remained the same and encouraged heavier drinking. More emphasis was given to the quality and taste of alcohol and to sponsoring cultural events and sports activities. Attempts were made to form a friendly alliance with students and to make the college environment more accepting of alcohol. Although skepticism exists over the direct influence of alcohol advertising on drinking behavior, constant exposure to advertising of alcohol consumption can reinforce beliefs about drinking behavior in young persons (Breed, Wallack, & Grube, 1990).
The consumption of alcoholic beverages has risen steadily since World War II, and drinking begins at an earlier age (Walsh, 1989). The steady increase in alcohol production and consumption is related to the broader growth of commodity production in industrialized societies in which alcoholic beverages are consumed in tandem with other new forms of commodities and foods (Single, Morgan, & Lint, 1989). In modern industrial economies, alcohol consumption is a significant source of tax and advertising revenue. Despite these economic developments, the tacit role of the state in the logistics of alcohol has been grossly overlooked (Makela, Room, Single, Sulkunen, & Walsh, 1981). The state condones the use of alcohol as it does the consumption of other beverages and foods; however, current policies place restrictions on the consumer rather than curtail the availability of alcohol. Problem drinkers are treated or punished, but the economic interests of the alcohol industry are rarely examined. Moreover, those directly engaged in treatment are not strongly interested in the economics of alcohol consumption. Similarly, those responsible for the production, promotion, and distribution of alcoholic beverages have little interest in prevention. Because alcoholic beverages can be produced cheaply and in large quantities, there is strong pressure to prevent saturation of the market and to expand it in order to assure continued profits.
Economic gains, however, have not been evaluated against social costs. If the government controls opiates, prescription drugs, controlled substances, and harmful food additives, why not alcoholic beverages? One obvious answer is that the control of alcohol in the interests of public health will be strongly resisted by the producers and retailers who have a vested interest in the production and sale of alcohol.
The state plays a significant role in promoting the alcohol industry because it supports the manufacture of a highly taxable commodity that benefits the economy. On the opposite side of the coin, the alcohol industry has the political means to influence the government, to sway it to adopt legislation favorable to the industry. The pro-wine industry of California, for example, is involved with agribusiness, which combines state and private power, and supports the monopoly of the grape owners by forcing small farmers to go out of business (Bunce, 1979).
The Bank of America, one of the largest assets in the U.S., consolidated the wine industry by financing California wine producers and threatening to withdraw lines of credit from producers who did not join the monopoly. Yet, the economic incentives of financial institutions that expanded the market for alcoholic beverages have not been cited as determinants of alcohol consumption in our society in general and on college campuses in particular. For instance, in 1947 the four largest alcohol producing companies controlled 26% of the industry; by 1972 their control had doubled to 53% (Bunce, 1979). The merger of brewing, soft drink, and distilled spirits manufacturers into “multiple beverage conglomerates” (Singer, 1986, p. 121) emerged in the 1980s and granted them the power to target their advertisements to specific groups. With strong control over the wine industry and a large capital investment in vineyards, wine consumption doubled in the 1970s.
Many educators have lost touch with the larger social and economic problems of which the alcohol abuse of the individual is only a small part. Counselors concentrate on treatment rather than tackling social issues or challenging a system that fails to provide non-pathological alternatives to drinking. The dilemma has been whether to concentrate on economic reform that leads to a permanent solution or to provide educational or psychological assistance–a temporary remedy. The outcome of the prohibition era indicates that economic and political solutions are difficult to implement in a “free” society. More often than not, the approach has been to educate or to treat the victims of alcohol rather than to indict the political and economic incentives that promote the consumption of alcohol.
The causes of alcohol consumption and abuse are availability, commercial promotion, and weakening of social and legal restrictions, and class stratification (Singer, 1986). The vast majority of recommendations for the prevention of alcoholism, however, have been individualistic remedies that overlook the “big picture,” i.e., the social, cultural, and economic underpinnings of alcohol abuse. For instance, Tampke (1989) proposes that alcohol abuse can be curtailed through education: resistance to social pressures, enhancement of self- esteem, learning to cope with stress, and making responsible decision. On the other hand, Kendell (1979) argues that alcohol abuse is a political issue that requires, in large part, economic and social rather than medical or psychological solutions. He cites the dramatic increase in alcohol use and abuse during times when social sanction against consumption are reduced, when alcohol is readily available, when intense advertising campaigns are under way, and when lower prices prevail. By analogy, Kendell maintains that to reduce the excessive use of alcohol through medical and psychological interventions, is like trying to prevent war by offering better medical services to the wounded. The remedy he proposes is to influence the government to take legislative actions to make alcohol less available, highly taxed, and a less “visible” commodity of consumption.
Urging students to “say no” to alcohol constitutes a hollow solution that blames the victim. Neither does raising the drinking age eradicate alcohol abuse (Davis & Reynolds, 1990). Instead, counselors in colleges and universities need to become advocates for social change. Instead of “treating” students, they must establish a level of intellectual and emotional communication that relieves tension; they must encourage administrative flexibility and constructive change; they must foster respect for individual uniqueness (race, sex, ethnicity, class) and, most important of all, they must give students the opportunity to participate in decisions that enhance their self- esteem and promote personal responsibility.
Raising political and economic awareness, promoting social equality, ensuring student participation in the educational process, reinforcing feelings of solidarity with the academic community, and fostering peace with the physical environment– these are the broader and more pervasive responses to alcohol abuse. The logical conclusion is that treatment must focus on the dynamics of the free market that reflects a hierarchy of class and enslaves many in a patriarchal economic structure from which they cannot escape and for which relief is sought in alcohol abuse. Seeking the causes within the person lessens social dissent, directs attention for the social and economic underpinnings of alcohol abuse, and serves the interests of the market system (Baer, 1989).
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Please address correspondence to author at: University of Illinois Health Center 1109 South Lincoln Avenue Urbana, IL 61801