The first Pan American Conference on Alcohol Public Policies and its significance for the region

Preventing alcohol-related problems is one of the major goals of the alcohol field, and there is strong evidence that alcohol-control policies are an effective way to achieve this goal (Babor et al. 2003). In May 2005, the 58th World Health Assembly (WHA) of the World Health Organization (WHO) agreed on a resolution on ‘Public health problems caused by harmful use of alcohol’ that urges Member States to develop, implement and evaluate effective strategies and programmes for reducing alcohol-related problems (World Health Organization 2005). In a follow-up to the WHA resolution, the Pan American Health Organization (PAHO), in partnership with the Brazilian Government, organized the first ever hemispheric conference on alcohol public policies in Brazilia, from 28 to 30 November 2005. The conference was attended by about 110 participants from 27 countries of the Region, including representatives from Ministries of Health, the United States National Institute on Alcohol Abuse and Alcoholism and the Inter-American Drug Abuse Control Commission. Also present were non-governmental organizations such as Mothers Against Drunk Driving (MADD), policy makers from different parts of Brazil, and key researchers from the Region. Presentations were organized in plenary sessions or round-tables, and were followed by discussion in smaller work-groups. A wide range of topics were covered, such as: the burden of alcohol in countries of the Region; production, trade and marketing of alcohol in the Region; youth and marketing of alcohol; alcohol, gender and culture; alcohol and violence; alcohol and traffic safety; alcohol and indigenous health; and the implementation of alcohol policies. At the end of the 3-day meeting, participants approved by consensus the Brazilia Declaration on Alcohol Public Policies (http://www.senad.gov.br and http://www.paho.org), including the following six recommendations: Preventing and reducing alcohol consumption-related harms should be considered a public health priority for action in all countries of the Americas. Regional and national strategies need to be developed, incorporating culturally appropriate evidence-based approaches to reduce alcohol consumption-related harm. These strategies need to be supported by improved information systems and further scientific studies of the impact of alcohol and the effects of alcohol policies in the national and cultural contexts of the countries of the Americas. A regional network of collaborators on the reduction of alcohol consumption-related harms, nominated by the countries of the Americas, should be established, with the technical cooperation and support of PAHO. Alcohol policies whose effectiveness has been established by scientific research need to be implemented and evaluated in all countries of the Americas. Priority areas of action need to include heavy drinking occasions, overall alcohol consumption, women (including pregnant women), indigenous peoples, youth, other vulnerable populations, violence, intentional and unintentional injury, underage drinking, alcohol consumption-related injury and alcohol use disorders. The sense of excitement that we shared with all other participants in this important conference can best be understood by taking into consideration some of the socio-economic characteristics, culture and history of alcohol research of the Region in which the conference took place. There are 48 countries and territories in the Pan American Region, which covers North America, Central America, the Caribbean and South America. The total population of these countries is almost 892 million people, of which about 330.5 million are in the United States and Canada. If these two latter countries are excluded, the Region’s population age pyramid has a relatively large base. In Latin American and Caribbean nations the proportion of the population 0–19 years of age is about 40% of the total; in North America the proportion is 28% (US Census Bureau 2004). Most countries of the Region are ‘developing’ economies. While gross national income expressed as per capita income in the United States is $37 870 and in Canada is $24 470, in the vast majority of countries in the Region it is between $2000 and $4000 (PAHO 2005). Also, although the region south of the United States is associated mainly with the Spanish-speaking countries of Latin America, these are only about half of all the countries in that area. The diversity of cultures, history and languages across these nations is therefore extraordinary. Many of the health indices for the Region are not strong. As a consequence of relatively weak public health systems and lack of access to medical care, general mortality, infant mortality, malnutrition and infectious diseases rate are high. For instance, the all-causes adjusted mortality rate (2002–05 data) per 100 000 population was 546.5 for North America (Bermuda, Canada and the United States) but 700.7 for Latin America and the Caribbean (PAHO 2005). The 2002 infant mortality was 7 and 5.4 per 1000 live births in the United States and Canada, but 24.8 for the countries of Latin America and the Caribbean. The adjusted death rate per 100 000 population (2002–05 data) for communicable diseases was 28.9 for North America but 78 for Latin America and the Caribbean (PAHO 2005). The population-weighted average per capita consumption in litres of absolute alcohol for the Americas is 8.9, well above the global per capita consumption of 5.8 l (Rehm & Monteiro 2005). Total alcohol consumption (recorded and unrecorded) also in litres of absolute alcohol and based on population-weighted averages for the three subregions of the Americas is: 5.1 for Region D (Bolivia, Ecuador, Guatemala, Haiti, Nicaragua, Peru), 9.3 for Region A (Canada, Cuba, United States), and 9.0 for Region B (all other countries in the Region) (Babor et al. 2003). The prevalence of alcohol dependence in the population 15 years of age and older in these same three subregions ranges from 5.1% to 3.2% (Babor et al. 2003). However, this average can hide higher prevalence rates. For instance, general population surveys in Brazil put the prevalence of alcohol dependence between 9.4% and 11.2% in the population 18 years of age and older (Galduroz & Caetano 2004). Other types of alcohol-related health problems are also a great concern in the Pan American Region, and contribute to the overall poor health of the population. The alcohol-attributable burden of disease in the two areas that include most countries in the Region, with the exception of Canada and the United States (WHO’s Americas ‘B’ and ‘D’), varies between 8.6% and 17.3% for men and 2.2% and 4.1% for women (Babor et al. 2003). As a comparison, the world burden from men is 6.5% and for women it is 1.3%. The burden of disease attributed to alcohol is likely to grow further. Several factors contributing to the growth of alcohol consumption in countries of the Region have been identified (Caetano & Laranjeira 2006): the Region’s economic growth, its youthful population, the intensive marketing of alcoholic beverages by corporations, the availability of alcoholic beverages and their low price, weaknesses in public health systems, the uneven enforcement of existing policies or the lack of implementation of the most effective ones all contribute to increase the threat posed by alcohol to the health of the population. With exception of the United States and Canada, most countries in the Pan American Region have not had adequate resources to fund alcohol research. Most of these countries are developing nations, struggling with unstable economies and the need to pay attention to pressing social and public health problems such as malnutrition and infant mortality, as mentioned above. However, most countries have sustained an interest in alcohol research throughout the years. Reviews of parts of the alcohol literature in the Region have been published (Caetano 1984; Caetano & Carlini-Cotrim 1993; Room et al. 2002). Briefly, in the last 60 years there has been a shift in research from a focus on alcoholism and treatment to a broader agenda that includes clinical research, studies of treatment effectiveness, studies with brief interventions, school-based and community surveys and the development of standardized instruments for data collection in epidemiological and clinical research. This change occurred for many reasons. Economic development has created more opportunities for research funding. A new generation of researchers, many of whom have sought training abroad, has come of age. These professionals took positions of leadership in university and governmental settings, widening interest and training in research. Opportunities for interaction at the international level have also increased. Researchers from countries in the Pan American Region besides the United States and Canada are increasingly present at international meetings, and are also participating in international work supported by the World Health Organization and the Pan American Health Organization. Finally, there also is a wider access to scientific information though printed and electronic media. Professionals working in the alcohol field in the Region are strongly interested in alcohol control policies. Research work on policy development and effectiveness is only just beginning, but there already are some outstanding examples of how effective these policies can be if implemented in conjunction with local government and the community. For instance, the city of Diadema, Sao Paulo, Brazil, has implemented and is strictly enforcing a ban on alcohol sales after 11.00 p.m. As a result, the homicide rate which averaged 108/100 000 inhabitants between 1995 and 2004 fell 46% in the 2 years following the policy implementation (2002–04). The rate of assaults on women fell 26% during the same time-period. There is a clear awareness that these policies are essential for the prevention of alcohol-related problems in the Region. There is also awareness that many of the policies already exist [e.g. minimum drinking age (18 years), legal blood alcohol content for driving, hours of sale, some level of taxation], but that most of them are not enforced or are enforced in an inconsistent manner. This conference provided an opportunity for professionals and a number of public health officials of the various countries of the Region to come together and discuss common interests in the area of alcohol policies research and implementation. New research data were presented for the first time in some sessions, reflecting the flourishing work now being supported in several countries. It also generated an important document that contains an outline of recommendations for future work in the area. This is the beginning, but it is not ‘just’ a beginning. Professionals from countries in the Region recognize that alcohol is not an ordinary commodity (Babor et al. 2003), and that the best approach to serve the public good (Edwards et al. 1994) and prevent drinking-related problems is the implementation of alcohol control policies in a public health perspective (Bruun et al. 1975). Because of the quality of presentations during the conference, the wide range of topics covered, the energy of the participants and its focus on alcohol policies, we think that this conference is a landmark in the alcohol field in the Pan American Region. Raul Caetano’s work on this editorial was supported by a grant (RO1-AA013642) from the National Institute on Alcohol Abuse and Alcoholism to the University of Texas School of Public Health.

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