The Alcohol and Health Puzzle

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Alcohol in any quantity may cause health problems, according to recent research. That settles a medical problem, but opens a behavioral one.

If alcohol is so awful, why has it been consumed by so many people since the dawn of history? Why are the most successful individuals, and nations, so dedicated to alcoholic excess? Why have we been reading so much about the moderate health benefits of moderate drinking?

Research about the effects of substances we consume is riddled with contradictions, ranging from vitamins to fats. For example, people at risk of heart disease are routinely warned off salt. That did not prevent one researcher from penning The Salt Fix (1), a book arguing that salt in the diet protects against heart disease.

The view that alcohol is always harmful encounters several plausibility problems, beginning with the fact that most members of some societies use alcohol regularly. If a drug is harmful, one would expect people to acquire resistance to it, whether via gene selection or learning.

Evolution and Dangerous Drugs

Excessive alcohol consumption is very bad for health and for family life. Farmers in rice-growing regions in Asia often had crop surpluses that they used to produce rice wine.

They evolved an intolerance to alcohol, and their descendants to this day have a low tolerance for alcohol that produces toxic reactions, such as a skin rash (2).

Evidently, alcoholic excess had compromised their ability to raise children. Evolved alcohol intolerance helped the affected people to stay sober and raise large families.

This raises the question of why alcohol intolerance is not more widely distributed around the globe, given the toxicity of alcohol.

The decline in cigarette smoking over the past half-century indicates a much more rapid rejection of a toxic drug via social learning than is possible through gene selection (3).

Why was natural selection so blind to the toxicity of alcohol outside of rice-growing regions? One possible solution is that social drinking provides countervailing benefits, at least for some populations, specifically those who are affluent, and those who are happy.

The Wealth Conundrum

The most affluent tenth of the population live substantially longer than the poorest tenth, a pattern that has received a lot of attention recently. The affluent are also heavy consumers of alcohol. How can they drink so much without doing serious harm to their health? Whatever protective factors derive from wealth must outweigh the alcohol damage. Possible influences involve virtually every facet of behavioral medicine.

One might point to better prenatal care and nutrition, better obstetric care, better nutrition and health throughout childhood, less parental conflict, and more and better education (that speaks to lifelong brain health and protection against senility).

The circumstances under which alcohol is consumed may matter, whether it is celebratory or used to dull suffering. For the wealthy, drinking often occurs in the context of an extended network of real-world friends and family who can provide emotional, and financial, support where needed.

Such networks favor occupational success. They are frequently the source of entry-level internships that make stepping stones to many good jobs. Elite contacts are also a source of customers and financing for new businesses.

There is none of the angst that torments those at the bottom of the occupational hierarchy who struggle to pay their rent, meet medical expenses, and put food on the table.

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So it is hardly surprising that most stress-related illnesses (including some mental illnesses) decline with rising income. These include obesity-related disorders that are a substantial source of early mortality (4). They also include drug addictions and, ironically, alcoholism.

Of course, the affluent are generally much happier and more optimistic about the future.

The Happiness Issue

Happiness is not the exclusive preserve of the wealthy, of course. In Europe's social democracies, all residents enjoy a good measure of financial security that has helped them to be quite open to the risk of starting new businesses. Denmark has more drinkers than any other country (95.3 percent women, 97.1 percent men).

Despite drinking a lot, Denmark has repeatedly come out at the top of the heap in surveys of happiness. A skeptic might retort that more Danes take the survey while actually intoxicated. Amusing as this explanation is, it seems far-fetched.

A more plausible explanation could be that the Danes, like the Irish, spend more time in pubs that play a central role in social networks in these countries. Another source of happiness in Denmark could be the very good quality of life that residents enjoy thanks to their affluence and the well-developed social democracy that minimizes inequality and alienation (5).

Many decades ago, when Ireland was a very poor country, residents scored high on happiness measures, coming in at the same level as the U.S., at that time a much wealthier place. Presumably, the Irish felt better integrated due in part to the social networks supported by local pubs that were also associated with alcoholism.

Conclusion

If wealth and happiness are correlated with heavy alcohol use, and if all alcohol use is intrinsically harmful as the research now suggests, then the issue of wealth and happiness being associated with heavy alcohol use and better health merits more attention.

Like everything else about human social life, the context in which alcohol is consumed may well matter more than the alcohol itself in terms of health outcomes. In any case, there is an unresolved conflict in the evidence that may reward further investigation.