PUBLIC HEALTH ASPECTS OF ALCOHOLISM

THE DETERIORATED ALCOHOLIC

Some alcoholics will not accept treatment. Others have been treated and the treatment has failed. The majority of both these groups continue to deteriorate mentally and physically and to become progressively disorganized socially. These people present a serious problem to the communities in which they live.

In many cities there are areas where down-and-out alcoholics gather. The Bowery in New York is perhaps the best known of the ‘ skid rows ’, a term used to indicate the slippery slope down which these alcoholics have fallen. Respectable citizens may not know the site of the skid row in their particular cides but the police are in no doubt. These areas are characteristically the cheapest lodging house areas of the city. The alcoholic spends his day in the street and, if he has the price of a bed, his night in the lodging house. If not, he sleeps under bridges or on derelict sites where he finds the company of fellows in the same state. Some clergymen offer such alcoholics nightly shelter in church crypts. Many of these men are meths drinkers. In skid row the alcoholic finds two desirable things: anonymity and the absence of society’s strictures against drinking excesses. Alcoholics do not get to skid row from choice, but once there they may appreciate what it offers them. This is the chance to abandon themselves to drinking, immune from the shame resulting from the criticism of people who object and relatively unmolested by the police. These areas are eyesores and a matter for distress to the civic-minded. Nevertheless, they serve a purpose T-f for society by providing a retreat for those who have extruded themselves when they gave up the struggle to remain socialized. Skid rows perform a function in the cities which generate them.

From any point of view skid row presents an important public health problem. Many people die there from the consequences of alcoholism. But even without this, since we now look upon alcoholism as an illness, these areas constitute reservoirs of ill people, in which affected men sink steadily and to which newcomers are constantly drifting. Skid rows cannot be dealt with by cleaning up the neighbourhood. Unless a more satisfactory solution is found for the individual concerned, the problem has not been tackled. Hostels are required, with sheltered workshops and energetic social welfare measures that might enable these men to return by degrees to health, cleanliness and self-respect. Without this, there is no hope.

Most communities do more than just tacitly providing a skid row area in their town. For alcoholics who will not make use of treatment services, for alcoholics who are irrecoverable, they provide some charity and care. This is generally through support for organizations which accept the challenge of helping seemingly hopeless cases, particularly those who are homeless and jobless. In Britain the Salvation Army must take most credit for this. Its hostels and its Officers have eased the existence of innumerable deteriorating alcoholics.

The Salvation Army has been impelled to enter the field of treatment as well. In a few places special homes have been set up, where alcoholics are accepted who show ‘a sincere personal longing for deliverance’. Contact is kept with the men who leave by periodical letters and a monthly magazine. What started as a charitable concern for the destitute, based on religious precept, still remains so. But the workers have learned that care and charity by themselves are not enough. They have evolved a treatment orientation.

Another measure which the community adopts to deal with alcoholics is imprisonment. Drunkenness is not itself an offence in Britain though people are still charged with being ‘Drunk and Incapable’ or ‘Drunk and Disorderly’. Alcoholics are also picked up by the police for loitering and for vagrancy. First offenders get small fines for such offences but when they are often repeated magistrates send people to prison. Alcoholics are to be found in large numbers in most jails. Some alcoholics regard prison as a place of refuge. Food and shelter are provided there, devoid of any moralizing, which they feel they get from the Salvation Army, and without their being considered as mad, which is the impression they are sometimes given in psychiatric hospitals.

A study of alcoholics in prison was made by Jones,1 who compared them with alcoholics who attended a clinic for alcoholism. The prisoners had much more unstable work records, poorer educational backgrounds and much more previous imprisonment. They had led impoverished lives devoid of gratification. Prison alcoholics were less commonly married and the marriages of those who were had not lasted.

Alcoholics often appear to have little wish to be treated2 and look on the condition as wrong behaviour rather than as illness. Prison alcoholics have little motivation for treatment even if it is offered to them. Imprisonment is useless as a treatment for alcoholism. It is quite ineffective. Alternative approaches will have to be devised if the community wishes these people to be helped. It is important to recognize that, although alcoholics in prison may also have served sentences for other offences than drunkenness, such offences are usually a thing of the past. Prison alcoholics are most commonly committed because of their abnormal use of alcohol rather than for any palpably criminal behaviour.

An American study of men who were imprisoned for drunkenness1 showed that on an average they had four noninebriate arrests in addition. These non-alcoholic offences had taken place in their younger days, and had stopped when convictions for drunkenness began. Imprisoned for crimes to start with, they were subsequently jailed for public drunkenness.

While our concern in this book has been the alcoholic who is capable of recognizing his need for treatment and of responding to it, we do not want the responsibility of the community towards the more deteriorated alcoholics to be overlooked. We hope that, as treatment services become more adequate, less alcoholics will deteriorate to levels of helplessness. At present the need is to provide alcoholics themselves with understanding of possible paths to recovery and to serve upon responsible authorities most definite intimation that the proper place for alcoholics, however deteriorated they may be, is neither the gutter nor the jail.

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