By Yangchen Dolkar MD
(with input from John Lambert MD)I was a medical officer at the DTR Hospital in Mundgod Settlement for one year from August, 2004 to August, 2005. It was a time of great learning, trying to understand the intricate life lines of my own community. I left with a feeling that there is still much left to be done in the fields of public health and medical care in spite of the many health clinics and the various health awareness programs, the latter through the Department of Health based in Dharamsala. My first big brow-furrowing experience was the age-old social problem of alcoholism. The Scene
Some of the people at the Elderly Home (EH), in Mundgod, buy a local brew from the local Indians who sell the brew from one of the tiny windows of their dwellings on the outskirts of camp 3, right adjacent to Pema-Tsal, the hostel for the cream of the CST school children in Mundgod. The brew comes in small 100ml plastic packs measuring 8 by 8 cms and costs 11.50 rupees per pack. The brew is prepared by local Indians who supposedly have government issued licenses. An elderly Tibetan man (let me call him the carrier guy) gets the brew from the local seller and takes it to the EH people.
I was witness, one evening, to such a business transaction. As I was sitting on the steps of the EH eatery waiting for my food order to get ready, I saw an elderly woman walk towards an elderly man, the carrier guy, who just entered the EH gate. The carrier guy had a shoulder bag and the woman had a plastic handbag. They met at the gate (the eatery is just ten steps from the gate and the first thing you see as you enter the EH) and chatted for a couple of seconds.
The usual EH gate-crowd was there, an elderly monk, an elderly man (the only one with a modern walker and who keeps his seat even on rainy days with a plastic cover over his head and shoulders), a mentally challenged woman who is not yet 65 but stays at the EH because she can not take care of herself, and a diabetic elderly man who once offered me a mango. The EH gate-crowd, I guess, are used to this illegal transaction and they were enjoying the transaction scene as usual. The elderly monk even gave a slight laugh but returned to his barely audible chant and rosary.
The lady, who runs the EH eatery, was sitting with me on the steps and she explained to me about what was going on right then. I laughed as she explained because I found the story amusing.
The elderly woman appeared to be talking, but was doing so in a discreetly low tone and the carrier guy was nodding inconspicuously. Then she moved sideways and held out her hand. The carrier guy pulled out a square white plastic pack from his shoulder bag and handed it over to the woman. The woman took it without looking at him and then she passed, in a tight fist as a way of slipping into his hands, the sum of money which she owed him. It was most interesting. So much secrecy out in the open with so many witnesses!
One among the gate-crowd shouted something to the woman as she took the white plastic pack from the carrier guy. The carrier guy left the gate when the transaction was over. The woman looked around in our direction. She said nothing and kept walking.
My companion lady said that both the woman and her man drink that brew and then she told me the name of the brew: kyakpa arak
(shit drink). I laughed out loud but after the initial surprise, thought seriously about the whole thing. A Closer Look
It is no laughing matter. A number of people in the Elderly Home and the community consume this local brew. The name sounds bad already but how much worse is the effect on the consumer? How many of the elderly who visit the hospital are daily or occasional consumers? How was this alcohol interacting with their medications? Something to think about, knowing that more than 50% of the daily OPD (out-patient) visits to the DTR Hospital are from the EH residents. What about the rest of the population?
One day I set out to find out more about the brew. Apparently, it is made from sugar cane as per the Indian man whom I chatted with outside the brew-seller’s house. The sugar cane syrup is boiled and ‘spirit’ is added to it.
“Just spirit,” he said.
Well, there are all kinds of spirit.
He did not know more than that.
I bought a plastic pack of the drink that day for inspection. The inscriptions on the pack were in the local Indian language as one can well imagine. There was some kind of a seal, incomprehensible though. I could decipher the numbers: 100ml; dated 24/08/04 and then on the side a potential expiration date of 04/09 which I assumed was the 4 th of September. It could not be 2009! It seems it had been packed and expired already. It was the 19 th of September that day. All kinds of thoughts about the safety of the beverage occurred to me at that time.
I met a Tibetan man in his late 40s on the way to the brew seller’s that day. I asked him where he was heading and he said, “Just strolling.” He asked me about my destination and I said, “to the brew shop.” He smiled and said he was heading there also.
“Do you take the brew daily?”
“Yes,” he said.
“When did you start drinking it?”
“Two months back,” he continued.
“Why did you start?”
“It helped me forget everything.”
“Yeah, it is very strong.”
“Do you know what you are drinking?”
“Don’t you want to know what you are drinking?”
“I don’t care.”
“How did you come to know about this drink?”
“A lot of Tibetans drink this stuff.”
I told him it is likely the drink has a bad kind of substance in it unlike the traditional alcohol that you buy in shops and, it can make you blind besides other bad things alcohol does to your body.
“Whatever it is this stuff has, it is very strong. I take one pack in the day and it kicks me out completely. I get up only the next morning.”The Culprit and It’s Crimes
From what I understand, kyakpa arak
has methanol as an additive and it is dirt cheap, maybe that’s why it has such a telling name. If methanol is truly the ‘spirit’ they add to the sugar cane syrup (nobody would tell you though), then it is serious stuff.
Local consumers are mainly elderly, both at the EH and in the settlement, but young people, especially young men in the settlement also drink it as they fall easy prey to the cheap price and the potency of this illicit drink.Ethanol Compared to Methanol: What is Alcohol?
Ethanol and methanol are the two most commonly used alcohols in the world. Traditionally, ethanol is used for consumption and methanol for industrial use. Ethanol
is the alcohol we talk about when we refer to legal and commonly sold liquor such as beer, wine, and hard alcohol. From a health perspective, ethanol is a poison causing all manner of negative health problems. Ethanol in the body is broken down to acetaldehyde and then to acetic acid in the liver. When one drinks a lot of alcohol at a time, the liver is not able to completely break down the alcohol and the acetaldehyde level increases. Acetaldehyde is toxic to the liver cells and causes liver damage. Ethanol binge drinking can cause fatty liver which means the liver cells become replaced by fat cells and do not work properly.
A person who consumes too much alcohol at one sitting will, of course, experience a chung-ney
(hangover). This means they will complain of nausea, vomiting and headache, as well as a general feeling of malaise and dehydration the morning after. Though the liver will rebound from this short-term assault, more chronic ethanol intake will destroy the liver. The liver eventually becomes small and useless. The liver tissue can not recover under constant assault. Eventually you see permanent damage to the body: a big bloated abdomen, bloody vomit, hemorrhoids, jaundice, coarse hand tremor and increasing fatigue.
Alcohol use slows reaction times, so some activities (for example driving, swimming or crossing roads) will become more risky. Alcohol use can affect someone's ability to make rational decisions; it has been linked to sexual risk taking and the transmission of HIV and other sexually transmitted diseases. Regular use of alcohol can lead to tolerance (needing to take more alcohol to get the same effect) and physical dependence (someone who is dependent becomes ill if they don't take alcohol). Alcohol use has been linked to lots of social problems, including domestic violence and violent crime. The loss of inhibitions can lead to aggressive behavior. It might also lead to relationship problems - being drunk isn't much of an excuse if you say something to a friend you regret the next day.
Taking a large dose of alcohol can cause memory loss, so you might not even remember what you said or why. Long-term use of alcohol is known to cause many physical illnesses including liver damage (that we mentioned before), stomach cancer and heart disease. Alcohol causes the body to lose heat to the environment - the blood vessels dilate, bringing them closer to the surface of the skin. Alcohol should never be given to someone to 'warm them up' (it will make them feel warmer, but their body will actually cool down). Alcohol will also reduce a person’s sensitivity to pain. It's possible to suffer injuries and not realize until the alcohol wears off - burns, cuts, bruises and even frostbite might go unnoticed. Alcohol causes dehydration, so taking alcohol with other drugs that dehydrate is potentially very risky.
A large dose of alcohol will cause overdose leading to loss of consciousness and possibly even death. For a non-tolerant person (someone not drinking regularly) about 30 units (a bottle of spirits) would end in a trip to hospital and could be fatal. If someone is drunk, the only thing that will help them to sober up is time. The body breaks down alcohol at the rate of one unit per hour - it's metabolized by the liver, which only works at one speed. Giving someone black coffee, or a cold shower to sober them up won't make their liver work any faster. They'll still be drunk - their judgment will be all over the place - but they'll be wide awake.
Taking alcohol with other drugs that have depressant effects (like heroin, methadone and some prescribed medicines like temazepam, diazepam or valium and antihistamines) will increase the potential for overdose. If you are with someone who has been drinking and loses consciousness, make sure they are in the recovery position and try to stay with them. Even if they don't overdose, they could vomit while they are unconscious and choke, causing aspiration pneumonia. Calling for an ambulance will ensure that they receive medical attention should they need it. Also, certain other medications change the body’s ability to break down alcohol, so people who are in the habit of drinking alcohol should let their doctors know that they are consumers.
In light moderation, ethanol has been shown to have a very slight positive effect on HDL cholesterol levels. This has been good news for French wine producers, but it is a very modest positive bragging point compared to the long list of negative health consequences. People who drink heavy ethanol continuously will eventually develop malnutrition, loss of memory, and are at risk for esophageal cancer, stomach cancer, liver cancer and pancreatic cancer. Chronic ethanol intake is also associated with cancers of the mouth, throat, vocal cord, lung, large intestine and breast.
Women have a lower threshold for ethanol intoxication than men. Women who are planning to be pregnant or are currently pregnant should NOT drink alcohol as it will cause damage to the baby.
The blood alcohol content (BAC) that is considered ‘breaking the law’ in drivers is .08 in the U.S, .03 in India, zero tolerance in Nepal and .08 in Canada. BAC depends on the amount of blood (which will increase with weight) in your body, sex, the amount of alcohol you consume over time (the faster you drink, the higher your BAL because the liver can handle more or less one drink per hour and not more, like we said earlier), the kind of alcoholic drink you have taken and there are also individual variations depending on your nutritional status, medications and genetics. But in general, it takes only a few drinks of beer to get to the ‘drunk driving’ level of BAC. Wine has more alcohol than beer and hard liquor has still more alcohol than wine.
Also, if you are alcohol dependent (see screening questions below) and decide that you want to stop drinking, you should consult your primary care physician and work together because there are serious withdrawal symptoms associated with it. The body is not used to an alcohol free environment suddenly and it reacts to that change in a severe manner. There are certain drugs that minimize these withdrawal symptoms and the primary care physician will know how to help you.Methanol
is a deadly poisonous substance that is cheap and easy to come by as ‘wood alcohol’ often used in industrial processes. It is changed to formaldehyde and formic acid in the blood and these two metabolites are harmful to the retina. The retina is where the images are formed in the eye. If the retina is damaged, you become blind. Other symptoms of methanol poisoning are headaches, ear buzzing, dizziness, nausea, gastrointestinal disturbances, weakness, vertigo, chills, memory lapses, numbness and shooting pains in the extremities. Formaldehyde is a known carcinogen (one that produces cancer) and causes birth defects. If consumed on a regular basis, your kidney will be damaged too. Some people may remember methanol as the poison that has caused some "skid row" alcoholics to end up blind or dead.According to a WHO study, alcohol is responsible for 3.5 per cent of the global burden of disease. Alcohol use is currently the leading cause of disability among men in the developed countries and the fourth leading cause of disability in developing countries.
The following are a few examples of local brews found around the world as summarized from the WHO Global Status Report on Alcohol 2004
- Locally available cheap raw material like sugar-cane, rice, palm, coconut and grains are used to make country liquor and illicit liquor that can contain alcohol up to 56%. Some examples of local brew are; arrack
, desi sharab
Because there is no legal quality control checks, methanol adulteration of the local brews is quite frequent occasionally causing mass poisonings, irreversible damage to the eyes and loss of lives. Illicit liquor which is cheaper than licensed liquor is popular among the poorer sections of the society.Venezuela
- A Venezuelan tribe makes corn liquor during the corn harvest seasons. Corn liquor is made by fermenting corn mash in a hollowed out tree trunk. The alcohol level of the corn liquor is such that it causes intoxication after just two glasses.Malaysia
- Some indigenous people on the island of Borneo drink a homemade rice wine called tuak
on certain occasions. The rice wine is reportedly very potent. Uganda
- Some common banana varieties are used to make tonto.
Green bananas are ripened in pits lined by banana leaves and covered for several days. Then the pulp is mixed with spear grass and stamped with foot to squeeze out the juice. The juice is then filtered through grass in a funnel and diluted with water. The diluted banana juice is mixed with ground sorghum and kept in a covered wood container for further fermentation. The alcohol content of tonto
is between 6-11%. Botswana-
Raw materials like wild berries, wild pumpkins, wild roots, oranges, sorghum and maize are used in variable quantities to make the local brews bojalwa
Yeast, black tobacco, car battery acid etc. are added to give the brew strength.Ethiopia
- Barley, wheat, hops and spices are the raw materials used to make talla.
The brew is given a smoky flavor by adding brown baked bread and fermenting in a vessel which is smoked on the inside. Alcohol content varies from 2-6%.Egypt-
Wheat is used to make a thick, pasty yellow brew called bouza.
The alcohol content of bouza
is between 3.8-4.2%.Ghana
- Women are mainly involved in making a brew from millet called pito
all around the country. The alcohol content of pito
is between 2-3%. Kenya
- Sugar-cane and muratina fruit is used to make muratina. The fruit is cut, sun-dried, boiled in water, sun-dried again, added to a small amount of sugar-cane juice and incubated for a day, removed, sun-dried again, added to a barrel of sugar-cane juice and allowed to ferment for several days. The final product is a sour alcohol.United Republic of Tanzania - As many as 15 varieties of local brews were found with varying levels of contaminants like aflatoxin B1, zinc, manganese and fortified with caffeine. Alcohol levels of the different brews (distilled, non-distilled) ranged between 2.2-29.3%.Tibetans
- We have our own traditional brew called chung
which is made using any one of these raw materials- rice, barley, maize and millet sometimes. The raw material is washed, cooked and cooled. Yeast powder is added to it and a small amount of water is added to the whole content before it is transferred to a container and kept in warm temperature for several days. The juice is squeezed out after the fermentation period and drunk either diluted (with water) or directly, flavored with sugar/honey. The alcohol content in chung
is reportedly less than 5%. Social Consequences
One time in the OPD of the DTR hospital, I had a visit from a young woman who came for her own personal medical complaint, but started telling me about her husband and his selfish, self-destructive behavior right away. She was desperate to tell someone about her frustration. Her husband had beaten her just the previous night and had beaten her in the past when he had been drunk. I was taken aback when I realized that her husband was a young Tibetan raised in my generation. Alcohol makes a man lose his bearings and the woman suffers, the children suffer, the family suffers and the society suffers.
Old people often drink because they have lived the better part of their lives and now in their old age, it is hard to be sedentary, alone and unable to perform useful tasks. Drinking helps the elderly forget their age and its distresses which are many. Life can sometimes get tricky and I believe this is one such instance, but alcohol use among the elderly can also contribute to medical problems, cause medication side effects, and lead to dependency.
Teenagers and young people drink because life is not as interesting as they want it to be or as a means of escape from reality. Alcohol can make a person feel temporarily
much better about him/herself. It gives vent to one’s suppressed desires and frustrations. Exposure to modern culture (television, film, internet) with its allure of ‘the good life’ entices many, but there is a risk that simple experimentation will result in permanent negative changes in young lives. Many youth (teenagers and young adults) engage in excessive drinking and drinking without regard for consequences which takes a toll physically, mentally, and financially.
Risk factors for the youth alcohol/substance abuse include chaotic home environments (particularly in which parents abuse alcohol/substances), ineffective parenting (especially with children with difficult temperaments), inappropriately shy or aggressive behavior in the classroom, failure in school performance, affiliations with peers displaying deviant behaviors, and perceptions of approval of drug-using behaviors in family, work, school, peer, and the community environment.
On the other hand, protective factors in the Tibetan community are strong and positive family bonds, parental monitoring of children's activities and peers, clear rules of conduct that are consistently enforced within the family, involvement of parents in the lives of their children, success in school performance, strong bonds with institutions (such as school and religious organizations) and adoption of conventional norms about alcohol use.
In Mundgod and in many Tibetan settlements, what young people hope to make and save by leaving school and doing sweater business, driving jobs, opening shops and restaurants, they lose badly by drinking. And the end result is tragic: an ER call to the doctor who rushes to the hospital and finds a young man involved in an MVA (Motor Vehicle Accident), totally unconscious with strong alcohol breath and blood all over his body, his back rider with a broken leg and white with panic. The young man’s father, in a dirty shirt, grey strands of hair and thick lines from hard work on his forehead holding his hands together before the doctor and asking him/her to save his son’s life, eyes all wary and broken. The young man did not want that. The father did not want that. The doctor did not want that. Yet, we are all victimized because of alcohol. How can we help each other?Take Home Message
Alcoholism is a social problem, not unique to any single population. It is often present where there are socio-economic limitations. Tackling the problem requires more than an individual. It requires the whole infra-structure of the society to get involved.
Young people want something interesting and cool to do. Old people want to forget their plight of suffering. A wife wants her husband to come home at the end of the day and sit for a family dinner together. We all need love and respect.
The TGIE has not released statistics, to my knowledge, about the prevalence of the problem throughout the Tibetan diaspora, but as long as poverty and under-employment continue in rural areas and more and more youth are exposed to glamorous notions of a ‘fast’ lifestyle in both urban and rural areas the problem of alcohol abuse and indeed all types of substance abuse will continue to afflict Tibetans, wherever they may be.What makes you an alcoholic?
Alcoholism is also known as "alcohol dependence." It is a condition that includes alcohol craving and continued drinking despite repeated alcohol-related problems, such as losing a job or getting into trouble with the law. Alcoholism includes four symptoms:
- Craving--A strong need, or compulsion, to drink.
- Impaired control--The inability to limit one's drinking on any given occasion.
- Physical dependence--Withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety, when alcohol use is stopped after a period of heavy drinking.
- Tolerance--The need for increasing amounts of alcohol in order to feel its effects.
Simply speaking, if you answer yes to two or more of the following four questions, you have a problem and should seek help.
- Have you ever felt you should Cut down on your drinking?
- Have people Annoyed you by criticizing your drinking?
- Have you ever felt bad or Guilty about your drinking?
- Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover ( Eye opener)?
Link: Frequently Asked Questions about Alcohol