Características de los crímenes de lesa humanidad

Alcohol describes a range of organic compounds. The type found in alcoholic beverages is known as ethanol, which comes from a process of fermentation of fruits, grains or vegetables. Alcoholic beverages are divided into three main categories of beer, wine and spirits (ICAP 2006, 1). The strength of an alcoholic beverage is measured by the proportion of ethanol, commonly known as alcohol by volume and expressed as a percentage. Today almost all countries use a minimum alcohol by volume percentage to determine whether a beverage is

defined as alcoholic but there are varying approaches. The WHO found that this ranged from 0.1% to 12.0%, with seven countries having no definition at all. In some countries beer is not considered an alcoholic beverage and not subjected to special regulation (WHO 2004a, 13).

Alcohol is a toxic substance with direct and indirect effects on a number of human organs and systems (Babor et al 2003, 20). The impact is complex. Alcohol is a depressant, although an initial dose can have stimulant effects and cause feelings of well-being. These feelings occur due to the release of a neurotransmitter in the brain, causing a similar effect to cocaine and amphetamines. After the initial high, alcohol has a similar impact to sedatives (Cook 2007, 84). As more alcohol is consumed, the concentration in the blood increases because

absorption into the blood stream usually happens at a much faster rate than the liver can break the alcohol down. The effects that the drinker may experience include: dizziness, clumsiness, nausea, and impaired perception and cognition. At a sufficient level of concentration in the blood, the drinker will lose consciousness. Some of the psychological effects during a drinking session include: a sense of warmth, numbing physical pain, easing anxieties, and blocking out conscience (Cook 2007, 85). Alcoholic beverages also have many positive social associations, as a means of socialisation and an instrument of hospitality (Babor et al 2003, 15).

By the time of the first written records, fermented alcoholic beverages were widely used (Musto in Plant et al 1997, 10). The first concerns about alcohol consumption were recorded in China in around 2200BC. The Bible contains numerous references to drinking and

drunkenness and the Old Testament made reference to the disgrace of drunkenness (Schrad 2007, 438). Alcoholic beverages were present in nearly every traditional society, except aboriginal societies in Oceania and North America (Room 1997, 8). The production of alcoholic beverages was heavily linked to agriculture and a variety of crops were used, depending on what was available locally and seasonally (Room et al 2002, 21; Anderson 2006, 489). Production relied on an agricultural surplus above the level required for

household and community survival, and most beverages (except wine) did not keep for long. Because of the intoxicating power and irregular production, they were regarded as a special commodity and consumption was often restricted to particular social groups and occasions (Room et al 2002, 21). It took on a “fiesta” pattern with irregular consumption, usually to intoxication, which lasted until the supply was exhausted (Room and Jernigan 2000, 525). The consumption of alcohol tended to be the prerogative of powerful members of society. It

was reserved for older males; women and children were forbidden (Room 1997, 8). Urbanisation, changing gender roles, breakdown of lines of authority and taboos related to age, and increased emulation of Western drinking have all change how people drink alcohol (Room et al 2002, 32).

Culture and social grouping have an impact on consumption. Established customs that determined where, when and how to drink have tended to break down in favour of individual drinker choice (Room et al 2002, 36). Those on lower incomes are less likely to use alcohol than those on higher incomes. While less likely to drink, they tend to drink in more harmful ways. In England, those in the lowest socio-economic groups have a 15 fold higher risk of alcohol related mortality than professionals (Anderson 2006, 493). Drinking is also linked to economic development, as citizens become wealthier alcohol consumption increases

(Anderson 2006, 498; Medina-Mora 2007, 1042). The choice of whether and how to drink is influenced by the social group, even the behaviour of individuals when they are intoxicated is the subject of cultural expectations. In northern Europe, drinking has been an intermittent activity and alcohol is regarded as a powerful substance that transforms behaviour. In southern Europe where daily drinking is common, drinkers are expected to display as few changes as possible in their behaviour (Room 1997, 9). Many of the world’s major religions have viewed alcohol as a barrier to the achievement of personal salvation. The rise of Islam from the seventh century provided a rapidly growing religious faith that forbade the use of alcoholic beverages (Musto in Plant et al 1997, 13). Most of the major religions urge abstention on believers. Christianity is the major exception, although a number of denominations require abstinence (Room 1997, 8).

The average level of consumption in a population is expressed as litres of ethanol per capita per annum (Babor et al 2003, 31). It is measured either by analysing statistics on production and distribution, or through sample surveys of the population. The survey method is

considered to be superior because it allows consumption patterns to be measured and related to individual characteristics (WHO 2004a, 22). Production and distribution statistics do not include alcohol that is produced at a household or community level, rather than by the alcoholic beverage industry. On the Indian subcontinent around two thirds of alcohol

consumption is from unrecorded sources, and about one half of consumption in Africa (WHO 2004a, 15). Average consumption ranges from 13.9 litres per capita per year in Eastern Europe to 0.6 litres in the Muslim countries of the Eastern Mediterranean (Babor et al 2003,

35-7). Even within regions there is variation, average consumption in Europe varies from 2.9 litres in Uzbekistan to 30 litres in Moldova (Rehm et al 2006, 1088). The statistics are

skewed by the level of abstainers within the population and the variance is not as pronounced when assessing average consumption per drinker (Babor et al 2003, 35-7).

There are discernible global trends with regard to levels of alcohol consumption. In the early and mid-nineteenth century, alcohol consumption was high in most countries of Europe and North America. From the late nineteenth century through to the period between the two world wars there was a marked decline (Edwards et al 1994, 33; Room et al 2002, 37). From the end of World War Two to the 1970s there was another sustained increase, with some countries approaching the peaks of the nineteenth century (Edwards et al 1994, 34; Bruun et al 1975, 54). From the last quarter of the twentieth century, many developed countries experienced a decline while countries in the developing world and Eastern Europe

experienced rapidly increasing consumption (Babor et al 2003, 38-40; WHO 2004a, 10). There are reasons why alcohol consumption changes over time, most often because existing drinkers either increase or decrease their consumption (Edwards et al 1994, 38). These changes can arise from government policies, market forces or changes in drinking customs (Bruun et al 1975, 54).

Average consumption indicates the overall exposure of the population to alcohol, whereas distribution yields information about the proportion exposed to very high levels. Research has confirmed the need for both total volume and patterns of drinking to better assess the role of alcohol in disease and social harm (Rehm et al 2006, 1087; Room et al 2005, 521).

Because individuals and their exposure to disease are complex and multi-faceted, the

attributable fraction is used to assess the proportion of a disease in the population that would not have occurred if the effect associated with alcohol was absent (Rehm et al 2006, 506). The attributable fraction associated with liver cirrhosis is very high as alcohol is the most important contributor, while the attributable fraction associated with cancers is small as there are other higher risk factors. The extent to which alcohol contributes to disease and harm is shown by the number of disability adjusted life years (DALYs) or years of life lost due to alcohol (Ritter 2007, 616).

The way alcohol is consumed within a population has a major bearing on the alcohol related problems. In developed countries there is a typical life cycle drinking pattern of heavy

sporadic drinking in young adulthood, giving way to more regular drinking in middle age with less bouts of heavy drinking, followed by much lighter drinking in older age (Edwards et al 1994, 45). A large proportion of alcohol consumed is by a minority of drinkers, in the United States 20% of the population consumes about 85% of the alcohol (Giesbrecht 2008, 604). In the developed world it has been estimated that the top 10% of drinkers consume more than half the alcohol (Cook and Moore 2002, 122). Whereas once a population would favour a particular beverage, the trend since the middle of the twentieth century has been for the dominant beverage to lose popularity. In Europe this has occurred in the traditional wine drinking countries of the Mediterranean, the beer drinking countries of Central Europe and the spirits drinking countries of Northern Europe. Despite this, distinctive patterns such as weekend binge drinking in Scandinavia persist (Babor 2002, 71).

For each individual, there are a number of different drinking patterns from abstinence to very heavy drinking. While the decision to abstain from alcohol may be an economic one, there are many other considerations such as health, pregnancy, religious beliefs, or a dislike for the taste or effects of alcohol (Cook 2007, 66). The WHO found a consistently higher rate of abstinence among females, and the consistent role of religion in shaping drinking habits (WHO 2004a, 24). A favourable drinking pattern is regular consumption of small to

moderate amounts of alcohol per occasion, often with meals (Rehm et al 2006, 507). In some cultures this pattern of consumption is common and can be beneficial to health (Chaloupka et al 2006, 23; Fairweather and Mosher 2003, 18).

Intoxication is a temporary state of impairment brought on by the presence of alcohol (Babor et al 2003, 22; Kerr et al 2006, 1429). Intoxication can be influenced by social and cultural forces, but the number of drinks it takes to reach this state is also dependent on genetic factors related to metabolism and level of tolerance built up through past drinking (Kerr et al 2006, 1428). Binge drinking is defined as drinking more than twice the recommended daily limits in one drinking session. Using this definition, Hughes et al calculated that more than 90% of males and females binged typically on a night out (Hughes et al 2007, 62). While a majority of older adults use alcohol responsibly, adolescents are more likely to engage in patterns of binge drinking (Copeland et al 2007, 1740). Alcoholism describes a small proportion of the population with a physical addiction to alcohol, the term changed from the late 1970s to “alcohol dependence syndrome” (Babor et al 2003, 24; Edwards et al 1994, 92). Estimates of the percentage of the population with alcohol dependence vary from around 5%

in North America and Eastern Europe to 0% in the Muslim regions of the Middle East and South Asia (Babor et al 2003, 35).

The WHO recognised that culture has a significant role in shaping drinking patterns and explaining differences between countries (WHO 2006, 6). Different drinking patterns have led to the definition of “wet” and “dry” drinking cultures. Wet drinking cultures have a high level of consumption and high exposure of the population to alcohol. Room et al argued that in a dry drinking culture where exposure to alcohol is small, it will be those with a high disposition who will develop a drinking problem. Conversely, in a wet drinking culture, even those with a moderate disposition may end up with drinking problems (Room et al 2002, 162). Edwards et al also argued that a drinker’s risk of becoming a heavy drinker will depend on the prevailing culture. Alcoholics are therefore not just predetermined to heavy drinking but are affected by environmental factors (Edwards et al 1994, 90). Studies have found that individual drinkers are strongly influenced by their social network. An individual in a dry environment will tend to be a light drinker, whereas the same individual could become a heavy drinker in a wet environment (Edwards et al 1994, 91). A small group of “wet” drinking cultures have a very high prevalence of binge drinking, including the countries of Scandinavia and the former Soviet Union. Studies of Swedish drinking have shown that because of the prevailing drinking patterns, an increase in overall consumption will lead to greater mortality than any other western European country (Norstrom and Ramstedt 2006, 1544). In southern Europe approximately one in ten drinking occasions leads to intoxication, whereas a majority of drinking occasions in northern Europe result in intoxication (Babor in Muller and Klingemann 2004, 33). In developing societies it is quite common for only a minority of adults to be current drinkers and the frequency of drinking is also much less (Room et al 2002, 99-101).

Drinking alcohol has substantial impacts on the individual, their families and others. Over 60 diseases and types of trauma are causally linked with the use of alcohol, including: liver cirrhosis, cancer, neuropsychiatric conditions, cardiovascular conditions, gastrointestinal conditions, maternal conditions, acute toxic effects, accidents, self-inflicted injuries and violent deaths (Giesbrecht 2007, 1345; WHO 2004a, 1; Babor et al 2003, 64). Alcohol can adversely affect nearly every organ in the human body; no other product that is sold for consumption has such impacts (Babor et al 2003, 21). In developed countries, alcohol accounts for 9.2% of all disease, with only tobacco (12.2%) and high blood pressure (10.9%)

causing more harm (Babor et al 2003, 71). Alcohol is responsible for 1.8 million deaths each year and the loss of 58.3 million disability adjusted life years (WHO 2004a, 1). Deaths from alcoholism or liver cirrhosis only reflect a small proportion of the total impact where alcohol is a contributory cause, most of the problem is the result of acute intoxication (Edwards et al 1994, 15; Cook 2007, 118). Prior to middle age, the acute risks of injury and death due to intoxication are the most significant factor (Cook 2007, 119).

There is a dose-response relationship between alcohol consumption and many diseases and causes of mortality. Higher consumption increases the level of risk (Anderson and Baumberg 2006, 18; Babor in Muller and Klingemann 2004, 34; Romelsjo in Holder and Edwards 1995, 135). At consumption of around 20g per day, the risks increase by: twofold for cirrhosis of the liver, 20-30% for cancers of the larynx, 10% for cancer of the oesophagus, 14% for cancer of the liver, 10-20% for breast cancer, and 20% for stroke (Anderson in Holder and Edwards 1995, 109). The volume and frequency of binge drinking impacts on the risk of injury and disease, even for light to moderate drinkers (Anderson and Baumberg 2006, 18; Stranges et al 2006, 1265). High consumption or dangerous drinking patterns do not guarantee any particular outcome at the individual level, but contribute at the population level. Alcohol often combines with other factors including: genetic disposition, smoking, diet, personal neglect or dangerous environments (Bruun et al 1975, 26). There is no way of determining how much alcohol can cause harm at the individual level, and it is also difficult at the population level (Babor et al 2003, 62). The relationship between alcohol and the condition or event make it impossible for the individual drinker to effectively calculate the probabilities associated with each extra drink (Edwards et al 1994, 42).

Cirrhosis of the liver is a progressive replacement of healthy liver tissue with scarring, leading to liver failure and death. Cirrhosis mortality rates have long been used as an indicator of the prevalence of alcoholism in the population (Cook 2007, 109). This is

because the causal pathway between alcohol consumption and cirrhosis is strong (Room et al 2002, 122). While the relationship between alcohol and cancer is not as strong as the link between tobacco and cancer, alcohol is causally related to many cancers (Edwards et al 1994, 54). Long-term heavy drinkers have a stronger relationship to these cancers (Room et al 2002, 125). Studies have shown that as drinking increases so does blood pressure, particularly in men (Room et al 2002, 124; Edwards et al 1994, 55). Stroke and coronary heart disease display the complexities of alcohol. Evidence has confirmed that alcohol

consumption at low to moderate levels can offer protection against the most common form of stroke (WHO 2004a, 40). Similarly, regular light to moderate consumption of alcohol will reduce the risk of mortality from coronary heart disease and also reduce the risk of mortality in general (Stranges et al 2006, 1265). However, this effect does not hold for heavier

drinking and intoxication (Edwards et al 1994, 55).

Alcohol has a significant impact on the risk of injury or death. The impact includes unintentional injuries or accidents, intentional interpersonal violence, and self-harm or suicide (Room et al 2002, 140). The specific mechanisms that make alcohol responsible for injuries are the impact on reaction time, cognitive processing, coordination and vigilance (WHO 2004a, 46). Alcohol makes the drinker clumsy and the greater the level of

consumption, the more clumsy they become. Alcohol is strongly implicated in a range of injuries and deaths (Edwards et al 1994, 57). Although chronic use leads to a higher risk, the acute effects of alcohol among inexperienced drinkers put these individuals at a greater short- term risk. Alcohol is implicated in between 20% and 30% of all injuries and the amount consumed is the critical feature in determining the risk of injury (Borges et al 2006, 993; WHO 2004a, 46). Room et al argued that the impact from alcohol overdose is greater than for illicit drugs in most societies but not as well documented (Room et al 2002, 127). There is also a relationship between alcohol and road traffic accidents, with a threshold effect at a blood alcohol concentration of 0.04% (Babor et al 2003, 70). The relative risk of being involved in a road vehicle accident increases as blood alcohol concentration increases (Cook 2007, 89). Although hard to demonstrate, the WHO argued that there is an association between alcohol and depression (WHO 2004a, 44). Alcohol dependence and heavy

consumption also substantially increase the risk of suicide (Babor et al 2003, 71; Romelsjo in Holder and Edwards 1995, 135).

Drinking can also impact on families, workplaces, neighbourhoods and the broader population. The impact of alcohol on social harm demonstrates that all the costs are not internalised, this is an important justification for government intervention and regulation through alcohol control policies. Applying the same level of scientific rigour to alcohol and social harm as for individual health is problematic because of the multitude of factors responsible for social harm. The role of alcohol in disease is far better understood than in causing social harm as the number of factors is varied and complex (Babor et al 2003, 81). There are a range of alcohol related social consequences including: violence and aggression,

crime, public disorder, domestic violence, workplace problems, and financial problems (Babor et al 2003, 76). The costs are often borne by others, and are largely due to

intoxication (Cook 2007, 150). A significant social impact from alcohol is aggression and violence, generally as a result of intoxication. There is an increased likelihood of injury or death from violence, whether as a perpetrator or a victim (Klingemann 2001, 7). Research shows that the public drinking establishment (bar, pub, and nightclub) is the most likely environment for alcohol related aggression (Graham et al 2006, 1520; Treno et al 2008, 75). Klingemann argued that the impact on the family was at least as extensive as the harm suffered by the drinker (Klingemann 2001, 4). Heavy drinking impairs performance as a parent, spouse and household contributor and the impact is felt by the drinker’s partner and children (Room et al 2002, 144; WHO 2004a, 60). Children are most at risk because they have no capacity to protect themselves from the consequences of parental drinking

(Klingemann 2001, 4).

The impact of alcohol consumption varies by gender and age. Because of the higher levels of consumption and more dangerous drinking patterns, the disease burden is higher for men in developed countries by a ratio of about 5 to 1 (Babor et al 2003, 73). Young people are far less likely to suffer chronic disease from long-term heavy drinking. However, higher levels