A Case for the Inclusion of Awareness-Raising as an Integral Part of Alcohol-Related Public Health Policy in Sri Lanka

Abstract

The public health policy space can be one fraught with contention driven by historical tensions, individualistic ideologies, and corporate interests. This is nowhere more true than in the case of alcohol-related public health policy formulation in Sri Lanka. This means that the country struggles to reap the benefits of its own evidence-based alcohol policy: the National Authority on Tobacco and Alcohol Act. The following essay uses examples of the country’s public perception of alcohol to argue that raising awareness on alcohol harms should be an integral element of policy efforts to address alcohol as the public health issue it is.

Introduction

Conflicted histories with local temperance movements and the modern preoccupation with liberty and individuality mean that alcohol policy is typically viewed as governments’ way of conflating public interest with individual freedom. Hiding in the power struggle that ensues are the machinations of the alcohol industry itself that confound research (Stafford et al., 2020) and manipulate the political process (Movendi International, 2024) for its own narrow profit motives. The ultimate losers are the general public, who suffer both the direct and indirect costs of the alcohol industry. The struggle to formulate and implement meaningful alcohol policy, therefore, should be positioned in the sphere of public health policy, instead of the domain of economic considerations. However, it is not enough that these alcohol control policies leave the public they seek to serve is left out of policy discourse entirely. It is important that alcohol policies protect the public against false narratives by driving public awareness of the issue.

Discussion

Sri Lanka is a useful case study for this point. A small island, Sri Lanka’s conservative culture remains relatively free of the West’s strong alcohol norms. Strong legislation, namely the National Authority on Tobacco and Alcohol Act of 2006 (NATA Act) ensures that such normalisation has no space to materialise, by ‘assessing and monitoring of the production, marketing, and consumption of tobacco products and alcohol products with the ultimate goal of ‘discouraging persons especially children from smoking or consuming alcohol, by curtailing their access to tobacco products and alcohol products’ (National Dangerous Drugs Control Board, 2006, pp.i). Significantly, it also places alcohol policy firmly in the sphere of public health. This Act limits alcohol accessibility, and explicitly forbids alcohol promotion of any nature, putting the country in the best possible position to curtail alcohol harm.

These legislative measures ensure that outside forces do not introduce an alcogenic culture into the country, and existing alcohol norms are actively discouraged, resulting in 97% of the Sri Lankan population perceiving alcohol as a ‘problem’ (Alcohol and Drug Information Centre, Sri Lanka & Vital Strategies, 2023, pp.4). While 86% of abstainers believe that alcohol and alcohol consumption is a ‘problem’, even 61% of the alcohol-consuming demographic believe that alcohol is problematic (Alcohol and Drug Information Centre, Sri Lanka & Vital Strategies, 2023, pp.4). And yet, Sri Lanka’s alcohol-related public health burden remains high.

In 2017, the National Authority on Tobacco and Alcohol, the World Health Organisation, along with a few other stakeholders published a study that estimated the economic and social costs of tobacco and alcohol in Sri Lanka. The study found that the amalgamation of direct costs of diseases caused by alcohol was equal to LKR 52,429.6 (National Authority on Tobacco and Alcohol et al., 2017, pp.24-26). On the other hand, the indirect cost of alcohol was LKR 119,651.2 (National Authority on Tobacco and Alcohol et al., 2017, pp.24-26). This might make it appear as if there is less of a case to be made for alcohol policy to be included in the public health policy domain.

However - there are a few qualifying factors to be considered.

Alcohol is a causal factor for 200 health conditions, which include liver diseases, cancers, cardiovascular diseases, tuberculosis, HIV/AIDS, road injuries, violence, and suicide. The study however only takes 30 diseases and health issues into account (World Health Organisation, 2018, pp.vii). Additionally, the indirect costs of alcohol that the study considers are also costs that are indirectly related to health issues: costs related to absenteeism and premature mortality.

This said, the non-health-related costs of alcohol are difficult to quantify, given that the category includes the wider societal trauma, deprivation, environmental degradation (Movendi International, 2023), and interference into the political process (Chung et al., n.d.) that the alcohol industry and its products represent. Alcohol’s negative impact on those who do not even consume it - to children, significant partners, loved ones, and members of the wider community - can take the form of violence (Barret et al., n.d.), child abuse and neglect (Culbreth et al., 2020), gender-based violence (Swahn et al., 2021), and financial impact (Nyakutsikwa et al., 2020). These issues also have the potential to manifest themselves in the form of health issues that are rarely connected with their history with alcohol. It is safe to assume that the real health costs of alcohol are understated in this study.

Perhaps one reason for this high alcohol-related healthcare burden is the lack of public awareness of alcohol as a public health issue. According to the Public Opinion Survey cited above, the health harms of alcohol rank far down in the list of the factors affecting the public’s perception of alcohol. In a poll that allowed respondents to select multiple options, 54% of the people who answered viewed alcohol negatively due to its causal relationship with violence (Alcohol and Drug Information Centre, Sri Lanka & Vital Strategies, 2023, pp.5). 40% disapprove of alcohol due to the manner in which it diverts household income from essential goods, and 36% disapprove of alcohol’s wider impact on society in general. This is despite the fact that alcohol accounts for the loss of the lives of 4,000 individuals per 100,000 people each year from NCDs and injuries, suggesting that “the health costs of alcohol consumption are relatively more hidden compared to the other harms of alcohol consumption (Alcohol and Drug Information Centre, Sri Lanka & Vital Strategies, 2023, pp.5).”

Policy Implications

Considering the nature of the problem, it is therefore important that alcohol-related public health policies contain legislation that addresses the government’s responsibility of providing equal and equitable access to information that empowers people to make the decisions that are in their best interests.  In this interest, policy initiatives to do so should move beyond awareness campaigns. It is the task of the government to mainstream this understanding by introducing the relevant information to school and higher education curricula.

Conclusion

To conclude, there is a clear and urgent need to include awareness-raising as an inherent part of national alcohol policy in Sri Lanka. The country continues to struggle with alcohol harm despite robust legislative measures - the National Authority on Tobacco and Alcohol Act of 2006 - to curb the same. On the other hand, the underestimation of alcohol’s health burden - compounded by social issues that share a causal relationship with alcohol - further underscores the need for enhanced public awareness of alcohol as a public health issue, rather than a social one. Policy initiatives that address alcohol’s burden to the nation therefore should both prioritise awareness campaigns and institutionalise education on alcohol and alcohol harm within school and higher education curricula. This empowers the country’s citizenry to make informed decisions about both what they choose to consume and the policies they need legislated to protect public health and wellbeing.

References
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Author’s Bio

Theruni Liyanage is a graduate of the University of Colombo Faculty of Arts, with a BA in English Language and Literature. Since graduation, she has worked in non-governmental organisations addressing important social issues such as corruption (Transparency International Sri Lanka - TISL), and alcohol harm prevention (Movendi International) Her professional achievements include contributing towards the organisation of TISL’s National Symposium on Anti-Corruption (2022) and presenting, on her organisation’s behalf, at the Global Alcohol Policy Conference (2023).