FASlink Fetal Alcohol Disorders Society

Russia's Curse

www.thelancet.com Vol 367: 197-198, Jan. 21, 2006

Putin urged to address "Russia's curse"

Wide availability of cheap vodkas and hard spirits is driving Russia's drinking problems

It wasn't hard for Boris Kuznetsov to find the drinks he craved. Any grocery store or roadside kiosk had just what he was looking for. Perfume, brake fluid, de-icer, methylated spirits, toilet cleaner, nail varnish remover: "I drank them all", says Kuznetsov, who is 53 years old. "Everything that burns."

Like many Russian alcoholics, the former laser specialist from a top Moscow physics institute slithered into his darkest drinking days during the turmoil of Perestroika. He gave up his prestigious job, was rejected by his family, and ended up sleeping on the floor of a filthy apartment without a stick of furniture. And when Gorbachev restricted alcohol sales he turned to the hard stuff. "I only survived because I got poisoned by some chemical cleaning agent quite early on and I couldn't drink it any more", he remembers. "After that I stuck to cologne."

An estimated 500,000 Russians die each year for alcohol-related reasons, a figure that covers 30% of all male deaths (including murders and accidents). Vodka and other hard spirits remain the swig of choice, encompassing three-quarters of official consumption, compared with less than a fifth in the UK. The average Russian drinks 12–15 L of hard spirits every year, whille poverty forces many drinkers to resort to the "surrogate" alcohols that sated Kuznetsov's thirst.

In his annual address last year, President Vladimir Putin described the heavy toll that alcohol is taking on his country, decimating "young men, who are breadwinners for their families". Even the old stalwart of anti-alcoholism, Mikhail Gorbachev, recently spoke up and voiced his concern. "We are approaching a catastrophically high figure of spirits consumption", he told one interviewer. "The country . . . is killing itself."

As President Putin takes over the presidency of the G8 industrialised countries this month, he is being urged to transform his concern into concrete action and tackle "Russia's curse". The World Bank called for action last month, finding alcoholism plays a major part in falling male life expectancy—already down to an alarming 58 years old.

Russia's fondness for drink is nothing new. Production—and cconsumption— of vodka first became common in the 15th century becausee of increasing grain yields brought about by the introduction of new crop rotation methods. Chronicles from the ensuing centuries show villagers swung between abstinence and wild drinking bouts that could last for days during festivals.

The Tsars recognised alcohol's damaging effect but were reluctant to hinder production: in the 18th and 19th centuries it provided a third to a half of the treasury's indirect tax revenue. Fast-forward to 2006 and little has changed. Alcohol is big business, with a spirits market worth an estimated £7 billion (US$12·3 billion) per year. Holidays such as New Year and Orthodox Christmas, this month, are still a traditional time for mammoth benders, or "drinking without drying out". Whole bottles of vodka are regularly downed around kitchen tables. And, all too often, poverty and stress push hard drinking over the edge into alcoholism.

With the help of a twelve-step recovery programme Kuznetsov is now in control of his illness. "I can manage, one day at a time", he says. Yet millions remain trapped by the disease and new research suggests worrying trends in consumption. A recent report by Russia's National Alcohol Association found an increasing chunk of market share is taken by cheap and potentially lethal "surrogate" alcohols.

The effects are apparent from the growing frequency of tragic stories in the Russian press. In November, 33 people were killed in Magadan by a single batch of drinks contaminated with methanol. Shops in Krasnoyarsk were recently forced to remove a bath-cleaning fluid from sale because so many people were drinking it.

The composition of surrogate alcohols consumed in Russia was examined in a paper published in Alcoholism: Clinical &Experimental Research in October, 2005. Researchers found a "significant proportion" of Russian men were drinking products that have either very high concentrations of ethanol, or contaminants known to be toxic.

"We found that home-made alcohol had about the same amount of alcohol as vodka, but also contained a number of more toxic alcohols that could cause damage to the heart and liver", says one of the authors, Martin McKee, of the London School of Hygiene and Tropical Medicine.

Medicinal substances (essentially tinctures containing herbal remedies) were about one and a half times as strong as vodka, the report found. A third group, including products such as aftershaves, was more than twice as strong.

President Putin highlighted the mounting danger in his annual address, pointing out that 40 000 people a year are killed by alcohol poisoning, frequently from drinking surrogates. He has promised to make health issues key to his G8 leadership.

Yet critics say legislation designed to battle the problem is ineffective or even counterproductive. Laws to limit advertising of alcohol and its consumption in some public places have been applauded but new regulations introduced on January 1 to improve excise labelling are unlikely to prevent illegal production, they say.

"There is a strong suspicion that much of the recent legislation was simply fixed to benefit big alcohol producers", says Alexander Nemtsov, a professor and one of the country's leading experts on alcoholism.

Last year, President Putin suggested imposing a state monopoly on spirits in an attempt to regulate the market more effectively but appeared to step back from the idea after lobbying from manufacturers. Taxation on alcohol remains low, with the cheapest bottles of vodka costing 30 roubles ($1) each. And production of over-proof moonshine vodka called Samogon is rife: an estimated four bottles are drunk in the countryside for every licensed one.

Meanwhile, there is a rising scepticism about the common methods of treating alcoholics.

Most state clinics rely on "coding", a method invented by the Soviet psychiatrist, Alexander Dovzhenko. Patients undergoing this treatment are scared using hypnosis or suggestion into believing they will die or be permanently injured if they drink again.

Some are given a placebo and told it is a drug that reacts violently with alcohol.

For many it is a swift, brutal method, that is rarely effective over a long period. "They gabble something at you, make a woo-woo sound in your ears and then tell you your testicles will fall off if you touch a drop", says Aleksei, a middle-aged alcoholic in Moscow who has been coded several times. "It never worked for me."

Some doctors argue in favour of coding because it is occasionally successful, and inexpensive. "There's been a lot of black PR for coding recently saying it's inhumane and dangerous but I think it's scaremongering by companies that sell cure-all pills", says the head of one state narcology clinic, who asked not to be named. Another doctor described it as cheap psychotherapy that helped some patients "radically".

Aleksei Chistyakov, chief doctor of Recovery, a private medical rehabilitation centre for drug addicts and alcoholics in Moscow, is sceptical. "Many doctors have a traditional point of view on alcoholism and use prohibitive methods like coding", he says. "They think a patient has to be punished, to be taught to work, but it's not effective. An alcoholic doesn't drink because he's a bad person and he doesn't fall ill because he drinks a lot. He drinks because he's ill."

Nemtsov, who conducts his research at Moscow's state scientific and research institute of psychiatry, thinks coding's time may soon be up. "Coding worked to an extent on the Soviet person because he was suggestible", he says. "Now, as we become more sceptical like people in the West, it's less and less effective."

Back on the rails, Kuznetsov believes only long-term group therapy can wean a person off drink for good. "Without that I would never have managed", he says.

However, Alcoholics Anonymous has less than 300 groups in the country (compared to 1500 in Poland) and only a few state clinics provide similar programmes.

Asked what is lacking in the state approach to reducing alcoholism, Nemtsov replies: "There is no approach. The leadership of our country has forgotten about this problem."

There is a simple answer to why so many Russians fall prey to alcohol, he says: it's cheap. Between 30–60% of alcohol is clandestinely made, andd therefore untaxed. A large quantity is run off on "night shifts" at licensed factories where state inspectors are bribed to remove tags on production lines at the end of the working day.

"Practically all this illegal production thrives on corruption", says the professor. "Every local policeman in the country knows the house where samogon is made. But he does nothing about it in exchange for his own free supply."