The problem of excessive alcohol consumption in Russia is well known; but there is a tendency to exaggerate it, which is evident for inside observers. The exaggeration aims at disguising shortcomings of the healthcare, with responsibility for the relatively short life expectancy especially among males shifted onto patients, that is, self-inflicted diseases caused by excessive alcohol consumption. During the anti-alcohol campaign (AAC) that was launched by Mikhail Gorbachev in 1985 and ended with a failure by 1988-1989, a mass consumption of non-beverage alcohol was observed: perfumery and technical fluids such as window-cleaner. Considering the large scale of the window cleaner sales in some areas e.g. in Siberia, it was knowingly tolerated by the authorities. The drinking of alcohol-containing technical liquids and perfumery decreased abruptly after the AAC, when vodka, beer and other beverages have become easily available and relatively cheap [1]. The alcohol consumption predictably increased after AAC. This facilitated economic reforms of the early 1990s: workers did not oppose privatization of factories, performed not always in accordance with the law, thanks to mass drunkenness. Following the abolition of the state alcohol monopoly in 1992, the country was flooded by alcoholic beverages of poor quality, sold through legally operating shops and kiosks. During the 1990s, ethanol was massively transported to Russia from Georgia; the author observed a long line of tank trucks queuing at the border. It was used for production of vodka and other beverages including wine and beer. The Caucasus has been known as a nationwide source of cheap alcohol. Alcoholic beverages sold in Russia with special reference to quality and toxicity were reviewed by Jargin [2]. It is well known in Russia that legally sold alcoholic beverages often caused intoxications up to lethal ones. The incidence of fatal poisonings with legally sold beverages increased considerably in the early 1990s [3]. The following absolute numbers of lethal poisonings with alcohol-containing fluids were reported: 1998 - 21,800, 1999 - 24,100, 2000 - 27,200; another upsurge was in 2006 [4]. In 2006, an outbreak of toxic liver injury was reportedly caused by disinfectant Extrasept-1 sold in vodka bottles in different regions of the Russian Federation [5]. Apart from ethanol, this liquid contained diethyl phthalate and polyhexamethylene guanidine hydrochloride (PHMG). The reported number of poisonings with marked jaundice during the period August-November 2006 was 12,611 cases, among them 1189 lethal ones [6,7]. Unrecorded figures were certainly higher. Histologically, “cholestatic hepatitis with a severe inflammatory component” was described [7]. However, PHMG and related polyhexamethylene biguanide (PHMB) are not particularly hepatotoxic. Both substances are used worldwide for disinfection of swimming pools [8]. As for diethyl phthalate, its acute toxicity is low. Apart from PHMG, “chloride compounds” [9,10], i.e. organochlorides have been discussed as possible causative factors. Of note, the “victims had yellow eyes” [11]. There is a suspicion that carbon tetrachloride, used in the dry cleaning, could have caused mass liver injury; there were rumors about it. Importantly, the toxic liquid was legally sold in shops and kiosks in vodka bottles [6], which has been veiled by some writers creating an impression that consumers deliberately bought the disinfectant: “This outbreak was caused by the consumption of antiseptics with chloride compounds due to the deficit of other non-beverage alcohol” [11]. Note that there was not the “deficit of other non-beverage alcohol” [11] but a temporary deficit of vodka caused by the elevation of excise duties in 2006 [12]. The shortage was compensated by surrogates sold in vodka bottles [6]. The quality of alcoholic beverages was improving after approximately 2006; but at the third year of the Ukraine war (2024) beer smells technical alcohol more often again. The technical ethanol has been added to beer, wine and other beverages. Its astringent taste is known as it has been stolen from some factories and scientific institutions, and was often used for drinking especially during AAC. Exaggeration by some authors of “unrecorded” alcohol consumption shifts responsibility for poisonings onto consumers, who allegedly prefer to drink surrogates [13]. The concept of unrecorded alcohol is not directly applicable to Russia without a comment that ethanol from non-edible sources, diverted from the industry or imported, has been used for production of beverages sold through legally operating shops [14, 5,3,15], thus being formally recorded. This occurred generally with the knowledge of authorities. In fact, “most vodka and liquor consumed by the population is purchased in the official retail stores” [9]. The Internet trade has been “typically for bulk orders only” [16]. The consumers are usually unable to distinguish by sight between branded and counterfeit vodka as it is sold at the same shops and looks identical or almost identical. In the 1990s, slanting labels and lax closures were known as attributes of falsified beverages. Today, bottles with falsified beverages are “in good accordance with the original products” [16]. Remarkably, the rate of suicides without measurable blood alcohol concentration (BAC) slightly increased in Belarus after the start of the AAC (1985 - 6.25; 1988 - approximately 6.6 per 100.000 of residents), then decreased to 6.1 after the AAC, which coincided with the peak of optimism at the beginning of the economic reforms around 1991. Thereafter, both the BAC-positive and BAC-negative suicide rates increased considerably, the latter up to approximately 10.4 in 2003 [17]. These figures indicate that dynamics of suicides depend not only on the amounts of consumed alcohol, but also on social factors. It can be reasonably assumed that the increase in the suicide rate after 1991 has been partly caused by deterioration of the social assistance, when many unemployed people were abandoned in a desperate condition.

Alcohol-Related Vs. Cardiovascular Mortality

After AAC, the average life expectancy in Russia decreased especially in men. For the period 1993-2001, this figure was estimated to be around 58-59 years [18, 9, 19]. Among the causes of the enhanced mortality have been limited availability of modern health care, chronic diseases often left untreated, late detection of malignancies, offences and crime against alcohol-depended people resulting in homelessness and premature death. The cause of the relatively high registered cardiovascular (CV) mortality in the former Soviet Union, and of its further increase after 1990, is evident to pathologists and other medical specialists. There is a tendency to overdiagnose CV diseases both at autopsies and in people dying at home, not undergoing autopsy. If a cause of death is not entirely clear, one of the standard post mortem diagnoses is “Ischemic heart disease with cardiac insufficiency” [63]. Furthermore, the irregular treatment of arterial hypertension [20] and diabetes mellitus contributes to the CV mortality. Not surprisingly, the deterioration of quality in pathology and other healthcare services in the 1990s coincided with the increase in CV mortality [21]. This could be indirectly confirmed by the following citation: “Increases and decreases in mortality related to CV diseases… but not to myocardial infarction, the proportion of which in Russian CV mortality is extremely low” [18]. Indeed, the diagnosis of myocardial infarction is usually based on distinct clinical or morphological criteria, while ischemic or atherosclerotic heart disease with cardiac insufficiency is sometimes used post mortem without strong evidence. Furthermore, the overdiagnosis of CV diseases is compatible with the “absence of any substantial variation in mortality rates from neoplasms, including those related to alcohol, during the period 1984-1994” [22] because cancer is rarely diagnosed without evidence. Characteristically, the mortality from lung cancer (requiring X-ray or autopsy for the diagnosis) in males decreased by 17% over the period 1998-2007, while that from breast cancer, rarely remaining undiagnosed, “increased considerably” [18]. Certain Russian authors exaggerate the cause-effect relationships between alcohol and CV mortality e.g. [23], thus depicting the high mortality as largely self-inflicted by alcohol; reviewed by Jargin [64]. This tendency is relatively new. An epidemiological study from 1977 reported that the prevalence of CV diseases including hypertension was not significantly higher among men who drank excessively than in the general male population [24]. Furthermore, the heavy binge drinking was discussed as a determinant of the increased mortality in Russia [25]. Without denying the harm from this hazardous pattern of alcohol consumption, it should be noted that the heavy binge drinking has been continuously declining in Russia [26,27]. Unlike the 20th century, it is difficult to meet a heavily drunk person today even among marginalized people. The drinking of vodka and fortified wine has been partly replaced by a moderate consumption of beer. As for young people, many of them adopt a moderate alcohol consumption style from the beginning.

Invasive Procedures with Questionable Indications Applied To Alcoholics

The following treatments were applied to alcoholics: prolonged intravenous drip infusions, sorbent hemoperfusion, pyrotherapy with sulfozine. Intravenous infusions were recommended for patients with alcoholism including moderately severe withdrawal syndrome: 7-10 infusions daily, sometimes combined with intramuscular injections [28-35]. The intravenous detoxification was regarded to be “indicated to nearly all alcohol-depended patients, especially to those with prolonged withdrawal syndrome” [28], also in the absence of (severe) intoxication [36]. Recommendations of intravenous infusion therapy of alcohol intoxication and withdrawal syndrome with both crystalloid and colloid solutions can be found also in recent instructive publications [37-39]. Apparently, the infusion therapy has been overused not only in alcoholics but also generally. Recent publications suggested a decrease in volumes of intravenous infusions [40]. Many cases with symptoms of excessive infusions, fluid overload, pulmonary or generalized edema have been reported [41]. In particular, certain dextran solutions (polyglucin, rheopolyglucin) were broadly used in Russia before adverse effects have been more fully appreciated [42,43] Some methods were patented e.g. infusion therapy and transcerebral electrophoresis of magnesium as a treatment of alcohol withdrawal syndrome [30,44-46]. As per the Cochrane review, there is no sufficient evidence to decide whether or not magnesium is useful for the therapy of alcohol withdrawal syndrome [47]. Excessive intravenous supply of magnesium can cause adverse effects. Fatal intravenous overdoses of magnesium in alcoholic patients were recorded [48]. Besides, various intramuscular injections were recommended: magnesium sulphate, sodium bromide and thiosulphate, subcutaneous infusions of saline and insufflations of oxygen; extracorporeal ultraviolet irradiation of blood, Unithiol, Dimercaprol, sorbent hemo- and lymphoperfusion etc. [49,50,36,35,51-53]. Other treatments disagreeing with the international practice have been applied, e.g. antipsychotic drugs (phenothiazines, haloperidol) for alcohol dependence in the absence of psychosis [54,55]. Among contraindications, synergism between certain antipsychotic drugs and alcohol, potentially aggravating liver injury, should have been considered [56]. The recommended duration of the intravenous detoxification was 5-12 days, or even 14-25 days according to some instructions [28,57,36,58]; a more recent publication recommended 2-3 days [37]. This is generally at variance with the international practice. Alcohol and its metabolites are eliminated spontaneously while rehydration can be usually achieved per os. Long-lasting drip infusions are uncomfortable; some patients regarded them as torture. Apparently, ideation of punishment coupled with irresponsibility has played a role in some personnel. It was known that the attitude to alcoholics was less responsible with lower procedural quality assurance than for other patients. Repeated infusions, endovascular and endoscopic manipulations lead to a transmission of viral hepatitis, which is unfavorable especially if combined with alcohol-related liver damage.

Among patients with alcoholism, biopsies were taken from kidneys, pancreas, liver, lung, salivary glands, stomach and skin also for research, repeatedly in some cases [59,60,33]. It was concluded on the basis of a series of renal biopsy studies that a generalized cytoskeleton abnormality with accumulation of filaments of intermediate type in macrophages, epithelial and other cells is typical for the cell damage by ethanol or the “alcoholic disease” [59,60]. It is known that Mallory bodies, seen in alcoholic hepatitis and some other liver conditions, contain filaments of intermediate type; however, generalizations as per Lebedev and Serov (cited above) have never been confirmed by other researchers. In any case, the cytoskeleton can be studied in experiments or post mortem. Another example: renal biopsies were collected from patients with chronic alcoholism and nephritic symptoms, whereas “intracapillary proliferative glomerulonephritis” was diagnosed in all cases. In a later study by the same researchers, the histopathological findings in 40 from 43 patients with alcoholism and nephritic symptoms were morphologically classified as membranoproliferative (mesangiocapillary) Gn; while in 29 from 31 patients with nephritic symptoms without alcoholism “fibroplastic” Gn was diagnosed [61]. The striking difference between the two groups is indicative of the data trimming. Other invasive procedures (celiacography, endoscopic cholangiopancreatography etc.) were applied in alcoholics without clear indications by Makhov et al. [33]. In the author’s opinion, repeated biopsies from different organs, doubtful morphological descriptions and interpretations, call in question the indications for biopsies and other invasive procedures at least in a part of the researched patients. An ethical problem has been the overuse of surgery in patients with tuberculosis (Tb) in the former Soviet Union, reviewed by Jargin [62]. According to official instructions, indications for surgery were ceteris paribus broader in alcohol-dependent than in other Tb patients [50]. In case of alcoholism, the surgical treatment was recommended to be implemented earlier, after a shorter period of medical therapy (Pilipchuk et al. 1974). Perelman et al. [58] insisted on early surgery in Tb patients with alcohol dependence, and operated them also in the absence of demonstrable Tb infection (e.g. a series of 49 patients with tuberculoma plus 41 with cavernous Tb, whereas micobacteria were demonstrated in 55 cases). At the same time, it was noticed that alcoholics have more frequent post-surgery complications [58]. Bronchoscopy was applied in cases with bronchitis [28], the latter being frequent among alcoholics in Russia due to smoking and the risk to sleep down at a cold place. Along with other complications, vocal cord injuries were observed after repeated bronchoscopies sometimes performed in conditions of insufficient procedural quality. It was noticed that vomiting triggered by apomorphine as aversive therapy of alcohol dependence provoked hemoptysis in patients with Tb [28]. Rudoi et al. (1994) reported that ~60% patients of a “phthisio-narcological” institution for compulsory treatment broke out; over 50% of them were returned by the police. The duration of stay in such institutions was a year or longer [28]. The compulsory treatment has been rooted in laws and regulations [28,65]. In 1974, chronic alcoholism was officially declared to be a ground for enforced treatment; the regulations were made stricter in 1985, making compulsory hospitalization and therapy of chronic alcoholics independent on their anti-social behavior. This practice was found in the 1990s to be contradictory to human rights. Nonetheless, some writers recommended restoration and further expansion of the compulsory treatment system [66]. According to a survey, 62.6% of specialists in addiction medicine supported compulsory treatment of alcoholism [67]. Enforced therapy of socially dangerous alcoholics is stipulated by Articles 97 and 98 of the Criminal Code of RF; besides, there is a legal mechanism enabling compulsory treatment of alcoholics in prisons [68]. One of the motives to overuse invasive procedures has been the training of medical personnel, also with the objective of readiness for war. Note that military and medical ethics are not the same. The comparatively short life expectancy in Russia is an economic advantage as it necessitates less healthcare investments and pensions. Furthermore, among factors contributing to the use of invasive procedures with unproven efficiency have been the partial isolation from the international scientific community, insufficient consideration of the principles of professional autonomy, informed consent and scientific polemics, as well as paternalistic attitude to patients. Ethical and legal basis of medical practice has not been sufficiently known and observed in Russia. Considering shortcomings of medical practice, research and education, governmental directives and increase in funding are unlikely to be sufficient for a solution. Measures for improvement of the healthcare in Russia must include participation of authorized foreign advisors. As far as we know, the Soviet and post-Soviet rulers, the party and military nomenklatura [69], did not allow the use of invasive procedures without indications on themselves and their relatives [70]. Alcoholics from their milieu have not been compulsorily treated by drip infusions days on end being infected with viral hepatitis; neither have they drunk technical ethanol sold in vodka bottles through legally operating shops. Military functionaries and their relatives will become more dominant thanks to the Ukraine war. Those participating in it, factually or on paper, are obtaining the veteran status and privileges over fellow-citizens. War veterans enjoy advantages in the healthcare and everyday life; there are, however, misgivings that the status has been awarded gratuitously to some individuals from the privileged milieu. Being not accustomed to hard and meticulous work, some of the functionaries’ protégés have been involved in professional misconduct of different kind [64]. The “ultra-rapid” (one session) psychotherapy of alcoholism, popular in the former SU and known as coding, should be briefly commented. This method was started during the anti-alcohol campaign [71,72]; it was criticized as incompatible with medical ethics because of mystification, verbal intimidation, spraying of the throat with ethyl chloride, massage of trigeminal nerve branches, forceful backwards movements of the patient’s head etc. [73]. The latter may be dangerous for patients with latent vertebral abnormalities. Nevertheless, it continues to be used [74]. Finally, it must be mentioned that conditions in Russian homes for the aged and psychiatric facilities lag behind their Western analogs. Experience of foreign countries must be studied in this field. Improvements of professional skills and remuneration of personnel in Russian homes for the aged and psychiatric hospitals is necessary, whereas the question of patients’ rights in such facilities should not be forgotten. The society must care of its unprotected members, including those suffering of alcoholism and alcohol-related dementia.

After all, the conclusion is cautiously optimistic: the heavy binge drinking and overall alcohol consumption are declining in Russia. However, there is still a need to prevent offences against people with alcoholism and alcohol-related dementia, aimed at appropriation of their residences, other properly, to improve the healthcare and public assistance. Unfortunately, it is hard to disagree that alcoholics in Russia have sometimes been those “who can be disdained, rejected, hated and persecuted, legally and without sense of guilt”[75]. Among the causes of the relatively low life expectancy is the limited availability of high-quality healthcare as well as toxicity of some legally sold alcoholic beverages?

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