Binge Drinking Alcohol Behaviors, and Alcohol

A dear friend and colleague, Jim Dolan, and I have been arguing for years about the inherent value (or lack of value) of alcohol in our society. Usually, we have these discussions as we care for an adult medicine service brimming with patients with alcohol-related illness, most often complications of alcoholic cirrhosis and alcohol withdrawal. These patients are terribly sick, sick enough to be hospitalized. We have had patients on our service as young as 21, and, not uncommonly, dying patients under age 30. We may concurrently have a patient in his late 60s or even 70s, who has been drinking heavily their entire life, and only now is it causing serious illness. That very week, you may catch us chatting over lunch about taking visiting friends to local breweries or wine tastings and attending house parties where alcohol is flowing. It is all very confusing.

The center of Dolan's argument that alcohol is "good" and maybe even "necessary" is that alcohol allows for a level of ease and social interaction that would otherwise be impossible, and that the very social connection that alcohol fosters is the key to human survival. He asserts that he would not have the deep conversations and resulting relationships he has without alcohol. While I absolutely agree with Dolan that humans are social beings, and that we require social connection to be well, I question how vital the alcohol is in sewing that social fabric.

The center of my counter-argument (I'll out myself here as a child of a family of alcoholics, thankfully not my own mother, but close enough that I have long held a healthy skepticism of the benefit of alcohol) is the terrible toll it takes on families. It is a toll I cannot exaggerate. This includes the medical toll, the social toll, and, ultimately, the death toll. My kind cousin, Bobby, died young of complications of alcoholism two decades after his beautiful mother, my aunt, died of the same. I remember a young, highly educated winery employee in her mid-thirties who lay dying in front of me and in total denial of her illness. Another young mom who was so depressed after her own mother's death that she started daily drinking, and whose belly was so swollen I was worried we may have missed a late term pregnancy. A former car salesman, now homeless, who had lost literally everything. The list is endless.

Is alcohol inherently good?

Is it inherently bad?

Living in the land of sugarcane, bananas, and binge drinking, I find myself again asking these questions. Whereas in the US, excessive drinking is often, though not always, a private endeavor, in rural Ecuador, like so much of life, drinking is a public affair. Not only is the purchase public (there are a few stores to purchase beer and/or hard alcohol), but also because social life happens in the streets, everyone knows exactly who is drinking, how much, when and where. It is not uncommon on Saturday and Sunday mornings to see people, usually men, who were up the night prior partying, staggering around still drunk and/or sleeping if off on the side of the road. Having just celebrated the town's annual fiestas, more people than I would like to admit were stumbling around the party and the next day completely blasted.

One La Josefina single dad, who I have known since he was a young child, shared with me that his ten-year-old son was being taken from him by the Ecuadorian equivalent to Child Protective Services because of his drinking habits. He is drunk literally every weekend. Several times in the last few months, as he has drunkenly stumbled toward me, I have reminded him that I do not want to talk to him unless he is sober. It is clear that a good portion of his family has alcohol use disorder; I remember his father drunk in the streets two decades ago. The young father was visibly distressed when we met, frantically calling CPS, looking for a way to contest the ruling. Unfortunately, just a couple of days later, he was stumbling around drunk at a quinceñera.

When the Okura-Baileys came to visit La Josefina last month, I bought a bottle of Pilsner for Pat. I know he likes a cold beer now and again, and I wanted to be a good hostess. One of the local boys saw Paul and Pat pouring cups for themselves and immediately tensed, "I didn't know that Pablo drinks," he said to me, a worried look on his face. I tried to reassure him that Paul would nurse his one glass for the remainder of the night and that there would be no drunken stagger, but he was clearly stressed by the consumption of an afternoon beer. It makes sense, if all he ever sees are people who start drinking and then don't stop until they are falling down drunk.

At last weekend's baptism party, Paul, Lucia and I were repeatedly offered alcohol. The push is hard. People wander the party with a bottle of beer or sugarcane alcohol and a communal cup, essentially handing out shots. It's a cultural norm. Alcohol comes out after the sopa, hornado and yuca are served, and it literally doesn't stop. Until the next morning. The same was true for the town fiestas the last few days. My friend, Lucia, is committed to being dry because her youngest daughter has struggled with drugs and alcohol and now proudly boasts two years sober. I decline because I don't like to drink, but it is also very difficult to consume alcohol in moderation here. Back home, I very occasionally drink a beer or a glass of wine with friends, but it is rare that I drink more than a gentle buzz-worth.

I do think that -- unlike many of my patients and some of the binge drinkers I see in this community -- the large majority of people I encounter drinking in my social networks do so responsibly and in moderation. I do not fault anyone for wanting something to loosen up. Don't we all want to be able to relax? To present our best selves? To connect? As I have written before, I also do not think there is something inherently wrong with indulgence. I just worry, really worry, about those who do not self-regulate and those who, for a wide range of reasons, cannot drink moderately. Whether due to cultural norms or trauma or mental illness or screwed up neurotransmitters -- when moderation is not possible, what is our duty as family and community and social creatures?

Ultimately, I wonder how we can build and maintain social connection, deep relationships, and ease of being for everyone (plus or minus the beer)?