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Research paper
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Alcohol harm reduction in Brazil

M nica Gorgulho , Vera Da Ros 1 o

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Abstract

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Keywords: Brazil; Alcohol harm reduction

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Alcohol consumption is an important health issue in Brazil. According to the Brazilian Centre for Drug Abuse Education (Centro Brasileiro de Informacoes sobre Drogas Psicotr picas, CEBRID), almost 68.7% of the countrys geno eral population tried alcohol in their lifetime and 11.2% can be considered addicted to alcohol (Centro Brasileiro de Informacoes sobre Drogas Psicotr picas [CEBRID], 2001). o Social costs of harmful alcohol use are very high. Alcohol misuse is the third most frequently cited reason for absence at work, and data obtained from psychiatric hospitals and clinics show that alcohol is responsible for 90% of all hospital admissions due to substance dependence, ranging from 95.3% in 1988 to 84.4% in 1999 (Noto, Moura, Nappo, Galdur z, & o Carlini, 2002). An analysis of 2360 ofcial autopsies of trafc accident victims in the state of S o Paulo during the year a 1999 found that 47% of victims tested positive for alcohol ingestion (Leyton, 2002). A CEBRID survey of 2372 1265-year olds living in 27 large (over 200,000 inhabitants) cities in S o Paulo State estimated that 52% of domestic a

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Alcohol consumption is an important health issue in Brazil. This paper provides an overview of alcohol-related problems in the country and explores some of the initiatives employed to address these problems. Although the notion of alcohol harm reduction is relatively new in Brazil, much work has been done to incorporate it further into the countrys drug policy. The paper discusses some of the federal and state government efforts in the realm of alcohol harm reduction and provides examples of good practice from a variety of other actors, such as NGOs and universities. Looking forward, a number of challenges are outlined, such as providing better treatment to all in need of assistance, establishing a fruitful and consistent partnership between private and public sectors, measuring the size and consequences of illicit alcohol production, and addressing alcohol-related problems among Brazils indigenous populations. In general, there is a lack of national drug and alcohol data in Brazil. Further research related to alcohol consumption, therefore, is necessary in order to provide Brazils decision-makers with comprehensive and reliable data that could guide public health policies. 2006 Published by Elsevier B.V.

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Corresponding author E-mail addresses: monica@dinamo.org.br (M. Gorgulho), veradaros@hotmail.com (V. Da Ros). 1 Tel.: +55 11 4195 0335; fax: +55 11 4195 0335.
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violence cases were related to alcohol use (Noto, Fonseca, Silva, & Galdur z, 2004). However, despite the relatively o high consumption and social costs, alcohol is not perceived as a drug by Brazilian general population, making the adoption of effective public policies difcult. Demographically, Brazil is the fth largest country in the world, with more than 178 million ethnically diverse, mostly urban inhabitants (World Health Organization [WHO], 2005). Important regional differences exist within the country, mainly between a more developed South and a poorer North (for more information on Brazils geography, population, and economy, see the Web site of the Brazilian Institute of Geography and Statistics [IBGE], available in English and Portuguese: www.igbe.gov.br). Like in many other countries, it is believed that Brazils problem drinkers are often unemployed, poor, and less educated (Melcop, 2004). However, one should take care with such an assumption, since levels of alcohol consumption are also very high among Brazils middle class and well-educated young people. Alcohol consumption is deeply rooted in Brazilian culture. Sugar cane arrived in Brazil around 1540s, becoming an important element of the countrys agricultural history. In the 16th and 17th centuries, the production of cacha a, a spirit c

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made from sugar cane, led to the beginning of the regions participation in protable alcohol trade, with merchants using cachaca as currency to buy slaves in Africa (Monteiro de Barros, n.d.). Cachaca gained prominence in Brazilian cul ture over the years. Now, Brazilians are proud of the national alcohol drink, caipirinha, prepared with cachaca. Regarding alcohol production, Brazil is the fourth largest beer market in the world, after China, the US, and Germany. By volume, beer is the highest consumed alcoholic beverage in the country (Carlini-Cotrim, 1999; Vaissman, 2004). Although data published by the World Health Organization (WHO) show an increase of 74.5% in Brazils per capita alcohol consumption between 1970 and 1996 (Carlini-Marlatt, 2001), it is still far behind other large markets. Thus, an average Brazilian consumed 46.7 l of beer a year in 2001, while this gure was 123.1 l for Germany and 83.2 l for the US (Commission for Distilled Spirits, 2002). Given the complexity and variety of issues surrounding alcohol consumption in this country, Brazil was the host of the First International Conference on Alcohol and Harm Reduction, held in the city of Recife, Pernambuco state (PE), in 2002 (Buning, Gorgulho, Melcop, & OHare, 2003). Participants from 20 different mainly developing countries and experts from Australia, Canada, Italy, the Netherlands, Sweden, Switzerland, and the US gathered to discuss approaches to creating comprehensive alcohol policies, especially in the context of transition and developing countries.

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Brazilian drug policy

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Brazilian drug policy is based on international treaties and is carried out under responsibility of two main bodies within the federal government: the National Anti-drug Secretariat (Secretaria Nacional Antidrogas, SENAD) and the Ministry of Health. SENAD, like many other national anti-drug bureaus, is a complex organisation. Responsible for planning, executing, coordinating, supervising, and controlling drug use prevention activities, as well as initiatives related to treatment, recovery, and social inclusion of drug dependents, SENAD states its support for harm reduction approach, making it one of the stakeholders of the Brazilian National Anti-drug Policy. However, an examination of SENADs mission statement, posted on its ofcial Web site (www.senad.gov.br), reveals the following aims: to follow persistently the ideal of building a society protected from the illicit drug use and the licit drugs misuse; and even, to seek awareness among drug users and the general society of the fact that illegal drug use feeds criminal activities and organisations whose main nancial source is in drug dealing. SENADs main objectives also include the following, . . . the promotion of harm reduction actions and strategies, in the face of human rights principles and public health measures, must be developed aiming at the reduction of the risks, the adverse consequences, and the harms associated with alcohol and other drug use to the indi-

vidual, the family, and the society. Such ambivalence in aims does not communicate a clear message and creates some confusion regarding SENADs real position. The general feeling is that the organisation itself, despite its involvement in some harm reduction activities, has a stricter and more prohibitive intention. Nevertheless, harm reduction measures are supported thanks to the efforts of some of SENADs technical advisors. The other organisation involved in the Brazilian policy on alcohol and other drugs is the Brazilian Ministry of Health (National Programme for Mental Health). Its actions are more clearly based on the principles of harm reduction and social welfare. The Ministry of Health adopted harm reduction principles in the mid-1990s, when Brazil was deeply concerned with the spread of the HIV/AIDS epidemic among injection drug users. In 2002, the Ministry was a very important partner and sponsor of the First International Alcohol and Harm Reduction Conference in Recife. Also in 2002, a standard model of assistance to individuals with alcohol problems was created within the National System of Public Health: CAPSad, providing psychosocial assistance centres for clients addicted to alcohol and psychotropic substances. These centres emphasise social inclusion, based on psychosocial interventions, instead of focusing on hospitalisation. Staffed by multi-disciplinary teams, the centres provide detoxication services, individual and group therapy, home visits and treatment, as well as family assistance and community activities aimed at reintegration of alcohol- or drug-dependent person into the family, community, and the society at large. Since this model was adopted, a decrease in the number of alcohol-related hospitalisations has been observed. However, despite the merits of this undertaking, the scarcity of these centres means that there is not enough assistance for individuals who need it. According to the 2005 WHO World Health Report, only 7.9% of Brazils gross domestic product was spent on health in 2002 (WHO, 2005). In 2003, Brazils present government (Ministry of Health and other ministries) launched the Inter-Ministry Group for Alcohol and Other Drugs. The Groups goal is to promote a more comprehensive approach to alcohol and other substance abuse prevention and treatment programmes. Also in 2003, the Ministry of Health launched the Brazilian Health Policy for Integral Attention to Users of Alcohol and Other Drugs, based on the principles of harm reduction. In the beginning of 2005, the Technical Advisory Committee for Health Policy on Alcohol and Other Drugs was founded. And, on July 4, 2005, a harm reduction model of dealing with alcohol and other drug use was approved and regulated for the whole country. In addition, the Ministry of Health has worked with the media in order to promote responsible drinking messages among the general population and especially among the young people. Following the international trend, the National Council of Advertising Self-Regulation (Conselho Nacional de Auto-Regulamentacao Publicit ria, CONAR) adopted a a code, which encourages responsible drinking patterns and

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Alcohol-related problems in Brazil There is a lack of national drug and alcohol data in Brazil. As such, it is difcult to capture a complete picture of drug and alcohol problems in this country. Consequently, one has to rely upon partial and local surveys (CEBRID, 2001) in order to try to get a better view of the situation, running the risk of a signicant range of different data (see www.drauziovarella.com.br). Statistics about alcohol-related trafc crashes vary from 70% of trafc accidents related to alcohol, according the Brazilian Ministry of Health, to 60%, according to WHO (WHO, 2004). Different rates have also been reported. For instance, a regional survey found that 37.7% of drivers had ingested alcohol at the time of the crash (Nery-Filho, Miranda, & Medina, 1995). In general, trafc accidents are related to high blood alcohol levels, occur more frequently in the evenings and during weekends, and are likely to involve young, single men as drivers (Santos, 1978). It must be noted that, with few exceptions, the conditions of the roads in Brazil are poor, which could also contribute to motor vehicle crashes. Unfortunately, no data on the relationship between road conditions and motor vehicle crashes are available. About 25% of industrial accidents and approximately 15% of work absenteeism in Brazil are connected to alcohol use (Melcop, 2004). Furthermore, in general, a range of physical injuries, mental problems, and risky sexual behaviours (involving acquisition of sexually transmitted diseases (STD) and HIV/AIDS), as well as serious chronic diseases (e.g., ischaemic heart disease, cirrhosis of the liver, and mouth and oropharynx cancer) can be linked to alcohol abuse (WHO, 2004). In Brazil, Galdur z and Caetano (2004) recorded an o increase in the number of alcohol-dependent individuals from 6.6% of the studied population in 1999 to 9.4% in 2001. Another study, representing 27.7% of Brazils total population, showed that 48.3% of youths aged 1217 years had tried alcohol, mainly beer (Galdur z, Noto, & Carlini, 1997). o Of greater concern is the fact that 5.2% of adolescents in

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prohibits alcohol advertising to minors (for more information and for the text of the code, see http://www.conar.org.br). In accordance with the Code, alcohol advertisements may only be broadcast from 9:30 p.m. to 6:00 a.m. and should not appeal to individuals under 18 years of age, the minimum legal drinking age in Brazil. Moreover, advertisements must avoid exploitation of eroticism, representation or suggestion of immoderate drinking patterns, or portrayal of any positive association between the product consumption and driving. These rules apply to advertisements in all mediaTV, radio, cinema, newspapers and magazines, the Internet, and so on. A balance between the two approaches by SENAD and the Ministry of Health has been sought through a continuous debate involving the two organisations and other bodies active in this area.

the same study were alcohol-dependent (CEBRID, 2001). The study also found that around 11.2% (about 5,283,000 people) of the general population satised the criteria for alcohol dependence. However, out of those 11.2%, only 4% about 211,320 individuals had received treatment for alcohol problems. In addition, there was a signicant increase in heavy alcohol consumption (drinking at least 20 times in the month prior to the survey), with young people drinking more frequently in the past years (Galdur z et al., 1997). o Other concerns are related to alcohol misuse among medical school students (Andrade et al., 1997; Saldanha, Sangoi, Jornada, M ller, & Cogo, 1994) and street children (Noto et u al., 2002). A 1993 study carried out by the State of S o Paulo Feda eration of Industries (Federacao das Ind strias do Estado de u S o Paulo, FIESP) suggested that between 10% and 15% a of Brazilian workers tested positive for alcohol dependence and abuse (Duarte, 2003). Regarding violence, a study carried out between 1990 and 1995 analysed 130 homicide incidents, involving 279 persons: 141 perpetrators and 138 victims (Duarte & Carlini-Cotrim, 2000). Out of those incidents, 76% involved alcohol ingestion by either perpetrator or victim. In addition, the study revealed that 58.9% of the perpetrators and 53.6% of the victims were under the inuence of alcohol at the moment of the offence. Another important issue is the illegal production of alcoholic beverages in Brazil. In 1984, the Brazilian Association of Beverages (Associacao Brasileira de Bebidas, ABRABE) estimated that almost half of distilled drinks consumed in the country came from illegal production (Masur & Jorge, 1984). Both commercial and illegal forms of cachaca exist, with women and low-income drinkers as the primary consumers of the latter category (Vaissman, 2004). The matter of unrecorded alcohol production is also linked to the issue of alcohol consumption by Brazils indigenous populations, among whom local beverages remain popular (Vaissman, 2004). Despite the fact that there is no indigenous census in Brazil, some estimates have been made by the government agencies (e.g., Fundacao Nacional do Indio and Fundacao Nacional de Sa de), the Catholic Church (Mission u ary Indigenous Council, CIMI), and by Instituto Socioambiental (ISA). Those estimates are based on different information and report between 350 thousand and more than 550 thousand indigenous people across the country. Census criteria and data vary. There are groups about whom there is simply no information available, and very little is known about the indigenous people who live in towns (for more information, see: www.aids.gov.br/alcool indios/home.htm). Despite these discrepancies, alcoholism is still perceived as a signicant health concern for Brazils indigenous people from age 12 to adulthood. Alcohol misuse by the indigenous people whether living in their own native land, near villages, or in the cities is one of the leading causes of death among this population. Alcohol abuse among the indigenous groups also contributes to a host of illnesses and conditions, such as hepatitis, cirrhosis, high blood pressure, heart diseases,
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stomach diseases, depression, and stress, as well as to a range of injuries from trafc crashes, interpersonal and self-directed violence, and bad falls (Coimbra, Santos, & Escobar, 2003).

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Alcohol harm reduction in Brazil Adapting the harm reduction approach to Brazilian drinking patterns or even implementing it within the Brazilian drug policy is not an easy task, since the Brazilians, like others, have a strong resistance to perceive alcohol as a drug. Hence, the current debate around alcohol use and misuse has been a priority for the Brazilian Ministry of Health, as illustrated by the rst national TV campaign on reducing alcohol-related harm, which ran in 2002. With the slogan, If you drink, do not drive; and if you are going to drive, do not drink, the Ministry of Health focused the publics attention on something not previously recognised as an issue. This awareness campaign was successful in starting a edgling but sustained national debate regarding the place of alcohol among the list of drugs that need to be better addressed by society. It is in this context that the harm reduction approach has conquered its place within the Brazilian reality. At the same time, since the 2002 TV campaign, the federal government has not been able to develop a more concrete body of experience focused specically on alcohol harm reduction. Thus, the initiatives we describe below come from the nongovernmental actors, such as NGOs and universities.

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Carry a card with your address, telephone number, blood type, and any medical restrictions, and so on. People were also reminded to drink more water along with their alcohol intake and to avoid drinking on an empty stomach. Second, training programmes ware organised for employees of bars and restaurants. These programmes promoted responsible hospitality practices, such as calling taxis for patrons who had too much to drink and not serving alcohol to intoxicated customers. Healthcare teams also got special training in dealing with alcohol-related accidents and intoxicated victims. In addition, taxi drivers were encouraged to enforce the use of seat belts among their passengers. To further reduce the incidence of alcohol-impaired driving, public transport was free during the time of the Carnival. The main objective of all of these initiatives was to minimise harm for drivers, pedestrians, and the population at large during the festivities. The campaign has already brought some positive results. For example, the Expresso da Folia (Revelry Express, the public transport service) has exceeded all expectations, with more and more passengers each year: there was a 35% increase in the number of customers from 2003 to 2004, showing that the general population understood the objective of the proposal (i.e., to enhance the enjoyment of the festival, with less harm to everyone). This annual initiative has grown in popularity, and the municipality of Recife has been invited to train personnel in other cities wishing to replicate this programme.

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Regulating closing hours: the experience of Diadema In 2002, Diadema, a city in the state of S o Paulo, adopted a a municipal code that prohibited sale of alcohol in local bars and other establishments after 11 p.m. With a high rate of criminality in the city and 60% of the murders occurring between 11 p.m. and 6 a.m., close to areas with high concentration of drinking venues, the goal of this action was to prevent alcohol-related criminality and murders (Manso, de Ara jo Faria, & Gall, 2005). u The introduction of the code was accompanied by announcements in local media outlets (newspapers and radio) and by a large-scale distribution of booklets explaining the reasons for limiting alcohol trading hours. In addition, the municipal civil guard visited the majority of local alcohol retailers before the implementation of the changes. During these visits, the sellers were asked to sign a document testifying to their awareness of the new regulation and the consequences of its violation (largely of administrative nature, from ofcial warning to license revocation). A team at the US Pacic Institute for Research and Evaluation (PIRE), assessed the results of this intervention (Pacic Institute for Research and Evaluation [PIRE], 2004). The Institutes main ndings suggested that the initiative helped to make Diadema safer. According to PIRE, the municipality was preventing 11 murders each month as a direct result of its adoption and enforcement of the new alcohol policy
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Examples of good practice in alcohol harm reduction in Brazil Drinking and driving

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A pioneer in the area of initiatives against drink-driving in Brazil is Centro de Prevencao as Depend ncias, coordinated ` e by Ana Gl ria Melcop. Working together with the munico ipality of Recife, the state of Pernambuco, and the federal government, Melcop and her team developed some creative approaches to deal with this issue. One of their initial focus areas was the most popular Brazilian festival and an important symbol of Brazilian culture: Carnival, a celebration traditionally accompanied by a lot of music, dancing, and drinking. In order to mitigate some of the attendant negative consequences during this time, the Centro de Prevencao and the municipality of Recife created a programme called Mais Vida na Folia (More Life in Revelry, for more information, see: www.recife.pe.gov.br). Launched in 2003, the programme consisted of several components. First, informational booklets were distributed to the population, and a phone information service was advertised for those wishing to call in with immediate questions. The booklets provided concrete advice on minimising harm to self and others, such as, Do not drive after drinking alcohol, Ask your friend to drive you home, if youve been drinking,

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(PIRE, 2004, p. 4). Moreover, rates of assault against women [were] lower in the 2 years following adoption and enforcement [of the code] . . . with an estimated average reduction of 9 assaults per month (PIRE, 2004, p. 4). Overall, PIRE concluded, adoption of the new policy was reducing police calls for service, preventing other interpersonal acts of violence, decreasing hospital admissions, and increasing citizen perception of personal safety and community order (PIRE, 2004, p. 3). It must be noted, however, that there has been a steady improvement of public safety in the city since January 2000 and, therefore, a combination of factors beyond the adoption of code (such as expanded police activity) may have contributed to the improved situation (PIRE, 2004, p. 3). Harm reduction and the alcohol industry There is an important debate about the alcohol industrys involvement in the efforts to reduce harm from alcohol misuse. Some think that, because of its economic interests, alcohol industry should not take part in this discussion. However, others believe exactly the opposite: because the alcohol industry is an important part of the whole picture and because of its economic power, one should include this sector in the debate. The approach of harm reduction is known for its inclusive, non-judgmental, and pragmatic way of dealing with the harms caused by drug misuse. The international movement of harm reduction was the rst to invite drug addicts to discuss how they could contribute to the debate on public policies regarding this issue. In those days, many people believed that, because of their personal interests, drug addicts could not come up with feasible proposals. History showed the sceptics wrong. It seems that, at present, we are facing the same dilemma in the alcohol eld: is it true that the alcohol industry just wants to sell its products, without any responsible behaviour towards its clients? In Brazil, many believe that this sector has much to contribute. For example, the leading beer company in the country, AmBev, was instrumental in increasing the sellers awareness about the minimum drinking age through its national campaign, Ask for the ID Card (AmBev Corporate Communications Ofce, 2004). Launched in late 2003, the campaign also sent a good-humoured message to young people regarding the importance of respecting the laws and promoted responsible drinking through providing consumer guidance at national events sponsored by the brewer. In addition, the initiative was complemented by a large donation of breathalysers to various Brazilian states. Another AmBev initiative involved an awareness campaign for TV and radio stations, newspapers, magazines, billboards, electronic panels, and taxis. The campaign advised drivers to drink responsibly and call taxis if they had too much to drink. The centrepiece of the initiative was the 30-s TV advertisement that depicted a young couple at a dance club. As they decide to leave, the man gives his companion what

appears to be an engagement ring, but turns out to be the car keys. This ad was shown during the National Trafc Week, promoted by the Ministry of Transportation, along with other campaigns about responsible drinking, like the Friend of the Time initiative (also supported by the brewer) that encouraged drinkers to choose a designated driver prior to going out. Harm reduction at the workplace A good example of harm reduction in the workplace is the annual campaign carried out in the south of the country, since 1997. This strategy is part of a Brazilian companys programme known as Permanent Campaigns for Health Promotion (Duarte, 2003). The campaign aims to provide employees with a clearer understanding of some health topics that are important for productivity and quality of life. Alcohol and drug use are among the many issues widely discussed with the workers. After their participation in the programme, the employees are encouraged to share the information with their families and communities, thus becoming multipliers of acquired knowledge (Duarte, 2003, p. 78). In 1999, for example, the theme of the campaign was Passport for Fun, beginning on the Monday before Carnival. Every day of that week the employees who used the company computers received colourful messages regarding the history of Carnival, interesting facts and fun tips, all emphasising the campaigns theme of safety and health promotion. Among such messages was concrete advice on alcohol consumption. For example, In moderate doses, alcohol makes you feel good, relaxed and uninhibited . . . but with a few doses more . . . you begin to have problems with motor coordination, thinking clearly and, very often, aggressiveness. If you drink, drink moderately (Duarte, 2003, p. 80). The focus on internal control was strong and no message advocated abstinence. On Friday, after all the awareness-raising efforts, employees received their Passport for Fun. Alcohol harm reduction at universities Given the high level of alcohol consumption among university students in Brazil (Kerr-Corr a et al., 2001; Stempliuk e et al., 2005), some schools have adopted the harm reduction approach and carried out campaigns promoting responsible drinking patterns. One of the examples is the S o Paulo State a University (Universidade Estadual Paulista, UNESP) and its Projeto Viver Bem (Project Live Well). First implemented in 1997, the programme was based on Brief Alcohol Screening and Intervention of College Students (BASICS), a preventive initiative developed in the US and aimed primarily at at-risk youths aged 1824 years (Dimeff, Baer, Kivlahan, & Marlatt, 1999). The goal of the Projeto Viver Bem was to reduce negative consequences from alcohol consumption by promoting responsible drinking behaviour, rather than by calling for abstinence. Programme participants were motivated to examine their drinking habits in a judgementDRUPOL 590 18

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free environment and to develop skills to minimise risk in the future. Some practical measures were proposed, such as drinking beverages with lower alcohol content, drinking with food, or drinking slowly, limiting the level of intake. Other measures of protection promoted by the programme included always practicing safer sex; not mixing alcohol with medicines, driving, or operating machinery; and not drinking alcohol if there is a test next day. Alcohol harm reduction among secondary school students According to a national survey, 48.3% of youths aged 1217 years have already tried alcohol in their lifetime (Galdur z et al., 1997). In response to this situation, initiao tives were developed to prevent the harms and risks of alcohol use and abuse among secondary school students. Aware of the fact that alcohol is the most used substance in Brazil (CEBRID, 2001) and despite the law that prohibits alcohol consumption by young people under age 18, the State of S o a Paulo Secretary of Education has for the last decade implemented a programme called Prevencao tamb m se ensina e (Prevention can also be learned). This programme has been carried out with about 6 million students from the basic to medium levels of education (rst 8 years of school). The programme promotes a healthy way of life and aims to reduce young peoples vulnerability to teenage pregnancy, STDs, and drug use. The main objectives of the initiative are to train educators to develop strategies of STD and drug use prevention among the students and provide the schools with pedagogical material specically developed for this purpose; and to build communitarian spaces involving the students, the school, and the community (as well as other ofcial services, such as public health units, other schools, NGOs, and so on) to promote debate and nd solutions to the common problems regarding these issues. The programme starts with more general subjects, such as health promotion, social and physical differences between boys and girls, and school sports, moving towards more complex issues, such as HIV/AIDS and other STDs, the meaning of wealth and poverty, legal and illegal drug use, the importance of self-respect as the base of good relationships with others, and so on. In 2000, the State of S o Paulo Secrea tary of Health partnered with SENAD to provide training courses to 2000 teachers from the states public educational system. In 2001, the Anti-drug Bureau of the state of S o Paulo and a the Secretary of Justice and Defence of Citizenship offered a training course specically related to prevention of legal and illegal drug use. The course trained 539 school principals and coordinators and was based on the ideals of harm reduction. We had the opportunity to be involved in such training. Since 2001, the harm reduction approach has been used in training courses and activities among schools. Not only are students expected to have a more responsible relationship with drugs and alcohol, but so are teachers. Teachers are trained to be

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more pragmatic in their behaviour towards students with drug and alcohol problems. Another initiative addressing alcohol consumption among secondary school students has been developed by a private university (Catholic University of S o Paulo) and was carried a out in the city of S o Paulos public high schools (D a, dos a e Santos, Itakura, & Olic, 2004). Avoiding the attitude of rejection and exclusion, this programme proposed an approach that consisted of four steps. The rst step was diagnosis through an anonymous questionnaire about alcohol use. Second was an alcohol education segment that used a specic psychodrama technique, retramatiza ao. This procedure was c chosen to give the students the opportunity to express their ideas and conicts without having to rely upon verbal communication. According to Liberman (1995), this technique allows each person to see an individual facet and, like a kaleidoscope, be able to build a whole picture, a critical image of the phenomenon, illuminated by the dramatic scene (see also D a et al., 2004). The third step was a Virtual Party e that invited students to explore possible effects from alcohol intake by using a website (for an example in English and French, see: www.virtual-party.org). The fourth step was a feedback to the participants, who received personalised information about their individual limits and tolerance to alcohol, along with some concrete advice on reducing certain risks and harms, such as unsafe sex, domestic violence, and bad academic performance (D a, Itakura, & Olic, 2003). Always a e joint venture with educators from each participating school, the objective of the initiative was to develop an approach that is feasible and takes into account local realities and culture.

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Alcohol harm reduction among the indigenous populations The Brazilian Ministry of Healths STD/AIDS Programme has promoted some alcohol-related projects for Brazils indigenous populations (Ministry of Health, 2001). These projects aimed to develop a comprehensive approach by working with interdisciplinary teams and local community representatives and by avoiding the zero-tolerance model based on abstention. In one such project, the participants were rst asked to examine and describe their drinking patterns, as well as their general needs and concerns, leading to a broader discussion of issues related to health and well-being. The experts and the participants engaged in an open exchange regarding alcohol use and its consequences, helping to develop a model for similar sessions with young people in schools within the indigenous communities. These discussions resulted in preparation of culturally sensitive educational materials in the form of folders, booklets, and videos. This and other Ministry of Healths projects helped to outline some of the priority areas for tackling alcohol-related problems in Brazils indigenous communities. Among the priority areas is the need to recover and strengthen individual
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and social identity within these groups by helping to preserve the social and cultural fabric of Brazils indigenous life, assuring the respect of geographic limits of indigenous lands, and improving these communities sense of security. Various government sectors need to be involved in addressing different needs of indigenous populations, shifting the concept of problematic alcohol use from the individual to social and collective realms.

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Looking forward Brazil has made some important progress in addressing the issue of alcohol misuse. It is clear, however, that solutions still need to be found for some problems, such as providing better treatment to all in need of assistance, establishing a fruitful and consistent partnership between private and public sectors, and implementing the majority of the items proposed in the Brazilian Drug and Alcohol Policy, with participation from both SENAD and the Ministry of Health, as well as other stakeholders. Although a sensitive and complex issue, another important challenge is popularising the concept of responsible drinking patterns among the general public, since the risks of alcohol misuse are becoming increasingly apparent. The World Health Organization denes alcohol as a drug. Though this denition is a biochemical fact, alcohol is sociologically different from illicit substances because of its prominence in many different cultures. On the one hand, the perception of alcohol as a drug can help us focus on more responsible consumption patterns, aiming at minimising alcohol-related risks and harms. On the other hand, the plan can backre, provoking a movement that can result in prohibition of alcohol consumption in the future. Further research related to alcohol consumption, therefore, is necessary in order to provide Brazils decision-makers with comprehensive and reliable data that could guide public health policies. It is also essential to improve the governments partnership with reliable and committed media outlets, important allies in reaching the general public (Gorgulho, 2001, 2005). Another crucial issue, at present poorly addressed by Brazilian organisations (the government, the research community, NGOs, and others), is the illegal production of alcohol. Although more research is necessary to measure the size and consequences of this market, there is a strong feeling about its negative impact on public health. Brazil has clearly shown commitment to face these challenges. Incorporating the principles of harm reduction into the countrys national drugs and alcohol policy albeit sometimes just partially supported points to a general predisposition of Brazilian authorities to be more humanistic and tolerant regarding this issue. Clearly, there is a long way to go, but it seems that Brazil is on the right track. Recent adoption of the harm reduction approach at the federal level reveals broad recognition of the necessity to nd new and effective ways of dealing with alcohol use and its consequences.

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The diversity of the initiatives above from government programmes to efforts by NGOs and universities shows that Brazil is looking for the best way to tackle the issue of alcohol abuse. Drinking does not always result in problems. Alcohol has an important place in Brazilian culture and can play a positive role in many social settings, associated with pleasant and relaxing behaviour. Although the notion of alcohol harm reduction is relatively new in Brazil, much work has been done to incorporate it further into the countrys drug policy. Inevitably, this process of integration will be surrounded by continuous debate and evaluation. Such constant appraisal is necessary to assess the real contribution that harm reduction can offer in minimising alcohol-related harm.

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We would like to thank our colleagues from Dinamo, Telva Barros and Ernst Buning, and Maria Paula Magalh es de a Oliveira for their contribution to this work.

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