Dr Justus Apffelstaedt: WHO alarmism, alcohol science and the lamppost problem

In 2018, a much-quoted research paper on alcohol burden appeared in one of the most influential medical journals, The Lancet. It formed the basis of the WHO’s rather alarmist statement that there is “no safe level of alcohol use”. The research was performed by an independent population health research organization based at the University of Washington School of Medicine, the Institute for Health Metrics and Evaluation (IHME) as part of the Global Burden of Disease study which is regularly updated and informs health policy world-wide. Eight authors are listed, but the list of collaborators and their affiliations is several pages long.

I wish to spare the reader even a summary of the complex statistics that were used but will have a look at the conclusions with a weary and critical attitude. Without questioning the monumental effort that goes into the Global Burden of Disease studies and without wishing to diminish the meritorious aspects of this particular study, some critical comments are in order.

Experience teaches that in science there is a trade-off between granularity of the data, i.e. the precision of the data recorded versus the quantity of the data. This means, that for a study like this, it is impossible to collect data on all individuals on the globe and record faithfully how much and what alcoholic beverages they consume. Therefore, assumptions have to be made.

In this paper to me the most questionable assumptions concern how much pure alcohol is consumed: It is estimated from sales of alcoholic beverages which seems a fair method, but then this estimated consumption figure is corrected for “unrecorded” alcohol production e.g. home brewing and distilling. A further modification is introduced to account for “tourist” consumption of alcoholic beverages. I find this difficult to follow. 

A further point of critique is shared with many studies in this field: In a study of this magnitude, it is nigh impossible to differentiate between types of alcoholic beverages consumed; research with smaller sample sizes where this information is available, indicates fairly consistently that not all alcoholic beverages are equal as to what concerns health outcomes. There is robust evidence that fermented beverages, principally beer and wine, are in moderation not significantly detrimental to individual health. While general “alcohol” consumption for national populations as estimated in this paper may be valuable for politicians for example for taxation purposes and curtailing of excessive consumption, for the moderate consumer, this is of little use for direction of individual health behaviour.

What the data suggest versus what is claimed

In looking in detail at the graphs presented and the accompanying text, there seems to be a discrepancy: The graphs show a decreased risk for diabetes and ischaemic heart disease (heart attacks) for both females and males with a maximum effect at about 2-3 standard drinks per day, but the authors nevertheless claim in the text that there is an increase in risk for any consumption.

A further weakness of the paper is that it does not differentiate between mortality caused by abusive vs moderate drinking. It remains my contention, that most alcohol related deaths occur due to abusive levels of drinking. This, however, is an entirely different issue and should be treated similar to other substance abuse.

Lastly, when analysing the maps of global alcohol consumption presented in the paper, one cannot help noticing, that more than half of the countries in the top twenty of countries ranked by life expectancy are also countries with a high average consumption. This seems at least counterintuitive to the authors’ assertion that alcohol consumption is a major cause of mortality and runs contrary to many more detailed studies in large populations with long-term follow-up.

These are only some but not all reasons why I do not regard the findings of this paper as supporting the alarmist and prohibitionist proclamation of the WHO of “no safe limit”. It seems rather, that on the contrary, the data indicate the while specific diseases increase even for moderate drinking, overall mortality is more likely to be lower in moderate drinkers than in teetotallers or heavy drinkers. Such data, however, are not presented. It seems to me here that Andrew Lang’s famous saying is applicable which I have freely adapted: Statistics are like lampposts: While they illuminate the way home for the sober, for the drunk they merely serve as support (irony intended).  

So, after sitting all afternoon working through the paper and cross-referencing the points and review literature supporting my arguments, it is time to do a bit for my health: Heading out for an hour-long brisk walk and afterwards preparing a healthy dinner to be enjoyed with a glass of Delaire Graff Botmaskop 2015. Cheers to that!

• Dr. Justus Apffelstaedt is a specialist in breast and thyroid health, leading Apffelstaedt & Associates in Cape Town and Windhoek. A surgeon with a specific interest in surgical oncology and researcher, he was Associate Professor of Surgery at Stellenbosch University (1994–2017) and Head of Surgical Oncology, managing 1,000-plus cancer cases annually. He has more than 50 publications, shaped South Africa’s breast cancer screening policy, and co-founded Breast Surgery International. A sought-after speaker, he has given over 100 international lectures. He also holds an MBA and a Diploma in Wine. Through Apffelstaedt & Associates, he continues to advance specialized, patient-centered care in Southern Africa.