Harmful use of alcohol—the prime gateway drug to other addictions—is also a problem in Cuba, even though the National Program for Prevention of Harmful Use of Alcohol includes the most effective measures used in analogous programs around the world.

As a participant in the program’s committee and empirical observer of its accomplishments and unaccomplished goals, I draw attention to the community’s attitude of tolerance toward intoxication manifested by the lack of proportional consequences, and I insist on the need to broaden the community’s understanding of the risks of non-social drinking, which in Latin America is practically limited to alcoholism and its complications. This undervalues the damage wreaked by unpredictable and dangerous behavior under the influence, as well as the suffering of codependents and other “passive drinkers,” and the adverse effects of even social drinking.

KEYWORDS Alcohol abuse/prevention and control, alcohol consumption, alcohol drinking/culture, alcoholism, drinking behavior, behavior and behavior mechanisms, social determinants of health, social reinforcement, mass media, communication, Cuba

Twenty-five hundred years ago, Hippocrates bequeathed a set of ethical precepts that emphasized the social transcendence of the practice of medicine and the profound commitment of physicians to serve patients and their families selflessly and with a pure heart.[1]

Traditionally, small-town medical practice facilitated spontaneous interpersonal relationships between family doctors and nurses and their patients. Later, however, centralization of health services in large medical complexes, an explosion of technology not always wisely deployed, litigiousness, tabloid journalism and commercialism in health service provision have created conditions that are, to say the least, less than propitious for optimal satisfaction on the part of patients and families. In my view, this has been accompanied by a dangerous devaluation of clinical skills, of medicine as a vocation, and by deterioration in the relationship of physicians and other health professionals with patients and their families.

Popular belief has it that alcohol, particularly red wine, protects against atherosclerosis and associated cardio- and cerebrovascular conditions. That presumption motivates this paper, which describes the mechanisms underlying the J-shaped risk curve for alcohol use, with benefits for vascular disease risk at low consumption levels and harmful effects—both directly on the user and indirectly on the bystander—at higher levels. The importance of further exploring alcohol use in patients with cardiovascular risk factors and of intervening to modify non-social use of alcohol to prevent serious adverse health consequences is also addressed.

KEYWORDS Alcohol-related disorders, burden of illness, atherosclerosis, atherogenesis, vascular disease, risk factors, Cuba

In light of the World Health Organization’s declaration that non-dependent drinking contributes more to the global burden of alcohol-related disease than does drinking by those who meet diagnostic criteria for dependence, this paper argues that clinicians, researchers and decision-makers need to consider microsocial and macrosocial impacts of alcohol use, not just addiction and clinical effects on individuals meeting diagnostic criteria at the extreme high end of the alcohol-use spectrum. It suggests some qualitative dimensions to further define social or low-risk drinking and proposes that all drinking beyond that be described as harmful, because of its impacts on personal, community and population health.

KEYWORDS Alcohol-related disorders, burden of illness, International Classification of Diseases