Commission on Security & Cooperation in Europe:
U.S. Helsinki Commission
Russian-U.S. Cooperation in the Fight Against Alcoholism: A Glass Half Full?
Dr. Margaret Murray,
Director, International Research Program,
National Institute on Alcohol Abuse and Alcoholism
National Institutes of Health,
Dr. Eugene Zubkov,
Co-Founder, House of Hope on a Hill,
Leningrad oblast, Russia
Ms. Heidi Brown,
New York, New York
The hearing was held from 2:00 to 4:00 p.m. in
2360 Rayburn House Office Building, Washington, D.C.,
Mark Milosch, staff director for Congressman Smith
at the Helsinki Commission, Moderating
Date: Tuesday, August 2, 2011
MARK MILOSCH: I’m here for Chairman Chris Smith. I’d like to welcome everyone
to today’s briefing on U.S. and Russian approaches to treating the disease of
alcoholism. My name is Mark Milosch, and I’m Congressman Smith’s staff
director at the Helsinki Commission.
As many of you know, the commission is mandated to focus on the human dimension
of the Helsinki process, but not so well known is that our own country is also
included in monitoring and review, and will be today.
The problem of alcoholism, and indeed addiction in general, knows no
international border and remains a major problem in Russia and in the United
States. Recently the Helsinki Commission held a hearing examining demographic
trends in the OSCE region.
Alcoholism is a major factor in the high mortality rate of Russian men. And
Russia is geographically the largest OSCE state. Alcoholism also seriously
affects the United States, the most populous OSCE state.
Chairman Smith chairs also the Global Health Subcommittee of the House Foreign
Affairs Committee, and has spent a long career in Congress advocating for the
human rights and dignity of those who have little or no voice in politics.
Certainly the suffering alcoholic, misunderstood and often blamed for failing
to sober up, deserves our attention.
The U.S.-Russian relationship is vast, complex and often troubled, but an
impasse on a key strategic question need not mean progress cannot be made in
other parts of the relationship. The bilateral presidential commission plays
an important role in addressing the panoply of interests and concerns, and
includes a health working group where questions of alcoholism and addiction are
It is our hope that today’s conversation can make a valuable contribution to
these worthy efforts, and particularly to stimulate the sharing of best
practices such as Alcoholics Anonymous. We have an expert panel to address
many of these points, and I will let my colleague, Kyle Parker, introduce our
Before doing that, I would just like to note that there were folks from HHS and
USAID who are directly involved in our bilateral dialogue on alcoholism who we
had hoped could participate but were unable due to the August vacation season.
As a courtesy, we also sought the participation of the Russian embassy, and I
believe we have some representatives here in the audience, and I hope they will
pose some questions to the panel.
Finally, we have some submissions from Russia for the record, which I will let
Kyle explain in more detail.
KYLE PARKER: Thank you, Mark.
The two submissions we have for the record are sitting out on the table.
Actually, no, we have three. Two of them unfortunately we just got and they’re
in Russian, so I put them out there understanding that I think some of you
probably do read Russian. For those who don’t, we’ll have those translated and
they’ll be on our site and become part of the formal record of today’s event.
One of them comes from Andrei Sitov, who is the bureau chief of ITAR-TASS, I
think, for the past 12, 13 years in Washington, has written extensively on this
story. As well, we have a submission from Leonid Nikitinsky at Novaya Gazeta
in Moscow, who has also covered this story based in Russia.
We also have a submission for the record from Dr. Marya Levintova, with the
National Institutes of Health, on alcohol policy. And, again, hopefully we’ll
have our third panelist, also from NIH, to speak.
A couple of quick words.
You know, this story is – I mean, it seems every week now for many months -- at
least that I’ve been paying a little bit of attention to this -- there’s two or
three major stories in the English language press and the Russian press about
alcoholism in Russia. A lot has focused recently on some of the law changes,
policy changes, the reclassification of beer, the way it’s advertised, things
that indeed may have some effect.
Today’s briefing, however, is going to sort of assume that despite our best
efforts, both Russia and United States’ efforts to, I guess, sort of head the
problem off at the pass and address these risk factors, you will have people
who will nonetheless get sick and be sick with alcoholism, and what can be done
What does the alcoholic who has a problem in, say, Peoria – what’s available?
How is that alcoholic treated? How is he viewed in society? What about in a
place like Irkutsk or Voronezh? What’s available? What are the treatment
paradigms? What’s working?
We will hear quite a bit today about the House of Hope – which is a video here
we had on and was unfortunately not playing correctly – situated in the
Leningrad Oblast, which I believe might be the only institution in Russia, or
certainly one of the major ones, that’s using – that’s treating alcoholism
based on the approach of the 12 steps of Alcoholics Anonymous.
With that, I’d like to jump right in and hear from our witnesses. We’ll start
off with Heidi Brown. And Heidi spent more than a dozen years covering Russia
for Forbes magazine, in the Far East as in Moscow, and became interested in
Russia’s alcoholism problem while studying in St. Petersburg, and has written
extensively on the House of Hope and alcoholism in Russia.
And we’re very glad to have you here today, Heidi, coming from New York City to
join us. She is currently a senior analyst at Kroll. And, Heidi?
HEIDI BROWN: Thank you so much. I also want to thank the Helsinki Commission
for getting this panel together to talk about this important issue, and
specifically Kyle Parker for working with me on my research the last year or so
while I’ve been putting an article together that came out in June.
Can you hear me OK? OK. I get a little nervous sometimes when I speak
publicly. Just a little bit of background about why – how I got involved in
this as a journalist.
In 1992, when I was studying in a language program at St. Petersburg State
University, it was a very chaotic time. And we were all very young. We were
living in a dormitory with Russian students and kind of not really
understanding how difficult things were for them, and sort of the historic
context that everything was taking place.
And, you know, they took away the subsidized bread. You know, a lot of things
changed for people. They were very angry and anxious. But when I look back I
realize that the main way people were dealing with this lack of clarity and the
anger that they had for all the changes in the country was through alcohol.
And we really saw it in the dormitory, living with the students.
I had two male dorm mates who were basically drunk all the time. And of course
we’ll all acknowledge that that’s sort of applicable here, too, to college
students in the United States, but it was to a very extreme degree.
One of my dorm mates would get so drunk that you couldn’t even tell whether he
was conscious or unconscious. He would just sort of stand there and sway back
and forth. And, again, I’ll say also, the Dartmouth kids were known for being
able to keep up with the Russians.
But, you know, once I moved on and I got a professional journalism job in
Vladivostok, again it was very clear how much alcohol played a role in helping
people cope with their problems.
And then when I was at Forbes I had lunch one day with a consular official from
New York, and he was complaining – which is very common when you talk to
Russians – that the Western media only wants to cover negative things about
Russia. We have this agenda; we always want to make things look bad.
And I said, well, you know, tell me something positive. I want to hear
something positive. I have spent a long time studying the country and its
people and I actually have a lot of faith in the country’s ability to pull out
of its problems.
And he said, well, there’s this clinic outside of St. Petersburg that’s doing
really amazing things. And it was begun by an American businessman named Lou
Bantle. And it’s struggling financially but I really think you should go take
a look. It’s doing really special things. And it’s the only clinic in Russia
that’s using the Alcoholics Anonymous method, that’s completely free, and it’s
treating families and patients all the time.
And so I went back to my editors, and they really liked the angle because there
was an American involved, there was a businessman doing interesting things.
And I think no one would argue with the fact that alcoholism is a theme that
touches everybody and it’s universal.
So I met Eugene Yubkov after that, and we talked a lot, and he gave me some
background and context, more than just the stereotypes that I had seen of what
alcoholism truly means to Russians and how difficult it is for them to really
fight this disease, and how few options they have for treatment.
So I went over and I visited the house, and I had very mixed reactions to it
because, you know, I pictured it as an American, going to a beautiful place on
a river where everyone is sort of strolling around and holding hands and it’s
very beautiful. And this place wasn’t like that. It’s a very kind of basic
It’s on this sort of treeless hill, and you walk up and you see a lot of people
who are really in pain. And as Eugene Yubkov explained it to me, these are
people who kind of are on their last stop in life. They’ve tried everything
else. And I’ll talk a little bit about the things that they tried.
But you see, when you go into the home and you meet with people, how grateful
they are to have an opportunity to do something completely different, which is
to really look at themselves and think about the way alcoholism has affected
them and their families, which most Russians don’t get the chance to do.
So I did the article, and then later, which is actually very recently, I did an
article for the World Policy Journal, which asked me to look at the issue a
little bit more deeply, more about the disease and not just the House of Hope.
And so I wanted to step back and, as a sort of introduction to the other people
who will be following me, just give you a couple of statistics and a brief
history of what’s happening with the disease in Russia and how it got to the
point where it is today.
In 1991 there were 150 million people in the country of Russia. Today the
population stands at 140 million, which is a huge drop. A boy who was born
today probably will not live past the age of 60. It’s been determined by
scientists that half of Russian male deaths are due to alcohol-related diseases
and accidents. Half a million deaths a year are alcohol-related.
And then, just as an aside, part of the problem with the consumption of vodka
in Russia is because of counterfeit vodka. And out of 2.3 billion liters of
vodka that are sold a year, about 700 million of them are counterfeit and very
So, just briefly a little history. We all think about Russians and drinking
and vodka as sort of this, you know, fun – you can’t picture Russia without
vodka. And the question kind of is, well, how did that happen? You know, are
Russians just intrinsically vodka lovers? Like how did it all get started?
Well, when Vladimir the Great, back in 982, decided to establish Russia as the
country that we know today, he wanted to convert his population to a
monotheistic religion. And he actually chose Christianity over the others
because it calls for and accepts the consumption of alcohol.
And from there, in the 1500s people started producing their own vodka. The
czars implemented monopolies in Russia to make sure that they could profit from
people’s consumption of vodka. And as we went through into the 19th century,
landowners were actually paying their surfs partly in vodka for their labors.
Later leaders tried to impose prohibitions to keep people from actually
drinking the vodka, but they turned to making their own. They made their own
moonshine and they often got poisoned. So, actually even Lenin tried to impose
a prohibition on consumption of alcohol but even he had to lift it.
So when Stalin came in, he imposed the monopoly again and the country was able
to profit from sales of vodka again. Brezhnev tried to stop it, imposing lots
of draconian rules. Gorbachev was the last leader to try to encourage people
to stop drinking, but his measures were so unpopular that he actually had to
So today, where are we? As Mark mentioned, the government is taking steps to
try to keep people from drinking again, and what it’s doing is raising taxes on
liquor. So, for example, a bottle of vodka which used to cost $3 is now going
to cost $3.50. And it’s actually going to make Russia having the most
expensive vodka in the world, if you can believe it, when you look at income
levels in Russia. But, unfortunately, this just encourages people to go and
try to get alcohol in other ways.
You know, other ways they’re trying to regulate – advertising. There’s a
narcologist who has been designated by Vladimir Putin as the head of sort of
the addiction problem in Russia, and he’s taking steps by sort of educating
people to drink better and to drink less.
So there’s not really an emphasis on treatment. You know, there’s a lot more
of an emphasis on deterring people from drinking. And that’s why, you know,
we’re looking at the House of Hope today, and other treatment methods, to try
to keep – to try to keep a focus on how to help people once they get sobriety.
How do they live with their sobriety?
MR. PARKER: Thank you, Heidi.
We’ll now move to Dr. Zubkov. Dr. Zubkov, glad to have you. And thank you for
making the trip down from the city today.
Dr. Zubkov was trained as a Soviet narcologist, I believe in the late ’70s; is
a practicing psychologist in New York; has been extensively involved in the
treatment of alcoholism in Russia as well as here, based now more than, I
think, two decades in the United States; is one of the co-founders of the House
of Hope in the Leningrad Oblast.
Let’s see, he went to medical school at the First Pavlov Medical University in
St. Petersburg, so is a Russian M.D., and works in the New York Counseling
Center currently, in Manhattan.
And, Dr. Zubkov, we’d like to recognize you for any remarks you wish to make.
DR. EUGENE ZUBKOV: Thank you. I would like to thank the commission for
inviting me, and Kyle Parker, who helped me to, you know, understand what I
need to talk about, and actually who provided me with the possibility to talk
about, you know, House of Hope and problem of alcoholism in Russia.
I actually would like to briefly describe the remarkable example of how one
man’s personal initiative could have a very dramatic international impact. You
know, Russia has a historically well-documented thousand years of relationships
with alcohol. And, you know, Russians continue to drink and the need for help
In 1999, American philanthropist and corporate executive Louis Bantle made his
first trip to Soviet Union. Visiting numerous treatment centers, he was
shocked at how alcoholism was treated. He started a small not-for-profit group
which was called International Institute for Alcoholism Education and
Treatment, which has saved thousands of lives in Russia and trained 300 Russian
professionals, including members of the clergy, doctors, high-profile
personalities – painters, singers, you know, rock personalities.
Lou wanted to help Russian society to leave the stigma associated with the
disease and to expose Russian treatment professionals to Western treatment
modalities. In 1996, the House of Hope on a Hill, which utilizes, loosely,
Minnesota model and is based on 12 steps’ way, was founded, then built. And
since then, 4,500 patients have gone through a 28-day rehabilitation process in
our 30-bed center near St. Petersburg in the small village of Petercula (ph).
Most of all, the key personnel at House of Hope were trained in best American
rehabs. And there are now 370 AA meetings, AA groups in Russia, and 40 percent
of those meetings were started by – initiated by the graduates of the house.
In ’96 there were seven AA meetings in St. Petersburg. Today there are 39.
And also, most of those meetings were initiated by the graduates of the house.
One thing I wanted to add, the rehabilitation at the house is absolutely free.
And I’d like to correct: There are quite a few rehabs which you utilize in
12-step model in Minnesota, but ours, the House of Hope, is the only free
rehab. It is completely free.
And I would like to add that we’ve had patients come over from 90 cities in
Russia, along from far east from Vladivostok, from Khabarovsk, Chechnya, you
name it. You know, we have a map with pins where, you know, people come.
And, as well, we have patients come from Brighton Beach area, from New York,
and they were accepted and they received treatment because Russian was their
first language, and from Greece, from Germany.
And I’m not talking about Ukraine and Belarussia and Estonia, but we have a
very diverse group of, you know, patients. And then when those patients return
back to their communities, most of them, they start – they start their own
For example, if somebody goes to, you know, to the village, a small city which
hadn’t been exposed to it, they start a meeting there. And that’s what
happened. I think out – yeah, 40 percent out of this 370 registered AA
meetings in Russia were started by the graduates of the house.
And through his death in 2010, the house was funded by Mr. Bantle. Several
Russian and American companies and individuals have supported House of Hope
almost since it’s inception as well, but there was a small trickle of money,
not a lot of input.
The city of St. Petersburg also twice made financial contribution to our
efforts. Usually it was connected somehow to the election campaign. But, you
know, that support was more a result of a personal context rather than the
result of the traditional fundraising efforts.
I would like to take a moment to acknowledge Robert Bantle, who is in the
audience today. This year marked the 15th anniversary of the founding of House
of Hope by Lou Bantle. Bob is now carrying on his father’s legacy, begun in
’96, and is continuing to fulfill his father’s commitment to help suffering
alcoholics in Russia.
And alcoholism is a very serious problem in Russia today in terms of both adult
mortality and lost productivity. As in the United States, alcoholism is a
profound drain on health care resources.
Russian narcology, which is sort of similar to our American addictionology, is
a different field, though probably Dr. Murray could better comment on the
research aspects and cooperation in the field. But Russian treatment methods
are largely very biologically oriented and sometimes strange.
For example, you know, one of the most popular modalities of treatment is
intramuscular or intracutaneous Antabuse implant. So Antabuse is being
implanted under muscular – and, you know, people pay a lot of money on this,
and this is still considered reliable method.
And after this, patient is basically – he is on his own. He doesn’t get any
therapeutic support. He doesn’t get any – he doesn’t go to any meetings. And
when he has a personal crisis, the easiest way for him to resolve it is try to
drink, and very often this could end in fatalities. You know, people die or
they become disabled.
And, you know, they have a lot of consequences. And, actually, the list of
famous people who died as a result of these Antabuse implants is long, is
numerous. A lot of Russians, you know, famous and high-profile personalities
in the 1970s and ’80s died as a result of this Antabuse implant.
Also there is – according – but if there – you know, there will questions, I’d
be happy to answer in more detail what are these methods are. And, you know,
12-step methods and, you know, Minnesota models, are frowned upon.
Doctors are mostly interested to establish direct contact with the patient and
sometimes, you know, exercise some kind of a control over the patient rather
than to let patient loose and do their recovery by himself, though certainly
there are some exceptions like Dr. Zakov (ph), for example, who is very
But, you know, the people who are really supportive of 12-step programs in the
medical community, they are very few. And generally, though, the method is not
endorsed and does not support it, and it’s not prohibited, but it’s not still
popular with the physicians and the church.
The United States and Russia share the program of treatment and defining not
only for alcoholism but substance as a whole, including tobacco, licit and
illicit drugs. Both countries have criminalized the disease of addiction for
both countries. Substance abuse is an 800-pound gorilla in the family room.
Denial runs rampant in both countries, and thoughtful discussion of practical
solutions, sad to say, is largely absent in the media.
Substance abuse is the largest preventable killer of both citizens of both
Russia and the U.S. There are 75,000 alcohol-related deaths in Russia each
year recently, and 23,000 from acute alcohol poisoning.
Russia has – according to the data of 2009, Russia has 2.7 million alcoholics
on the register, official register. It means probably three times that many
patients that are not registered. They’re over the register, in the official
number. You know, the supposed number of alcoholics could be five times
Both countries tax and tobacco directly and they tax drug use indirectly.
Just as Prohibition in the United States bombed, the criminalization of the
production and distribution of alcohol, high taxes on alcohol in Russia have
had a similar effect.
In Russia, at least one-third of 27 billions liters of water produced annually
is sold and taxed fraudulently, and one-third is sold in adulterated toxic
reformulation. In other words, one third of all alcohol in Russia is pure
illegal. Two-third is poison.
In United States, public awareness of the deleterious effects of substance
abuse was pioneered by individuals and groups like Surgeon General Everett
Koop, Betty Ford, Mothers Against Drunk Drivers, to mention a few, but the
impact of the effort has taken decades to impact American society.
Dr. Koop’s anti-smoking campaign took 20 years to take hold, and he was
resisted tooth and nail by the vested interests of the tobacco and alcohol
industries, as well as by both the print and broadcast media because of the
massive revenues generated by ads for these products.
Like the Brezhnev-era incarcerations of alcoholics, you know, sobering tanks
and, you know, prison for alcoholics, from ’64 to ’80, now the USA today jails
many of its alcoholics and addicts. And of those jailed for substance
abuse-related crime, only a tiny percent receive treatment, who are jailed for
their substance abuse: alcohol, tobacco, drugs. Substance abuse-related
incarceration is a growth industry dramatically more expensive than outpatient
And – three minutes more. And I wanted to say a few more words of House of
Hope. You know, the beauty of the House of Hope model, that it can be easily
reproduced across the former Soviet Union. Our method doesn’t require special
treatment or medication.
In recent years we have been approached by people from many regions of Russia,
Ukraine, Estonia and Belarus to help us train their staff or to start new
treatment centers. Often the only thing that stands in the way of the
beginning of a new clinic in another location is resistance from the ignorant
local official or local officials.
At the House of Hope, we face more than the obstacle of national addiction.
Our problems are larger than the low percentage of alcoholics who receive
treatment. We are struggling with the primitive state of philanthropy in
Russia. That means we get very few donations from the Russians.
The Bantle family has been essential to our existence, but we need to expand
our base of support in order to survive. For example, you know, all charitable
donations in Russia are taxed. Therefore people don’t want to donate. If they
donate, you know, a large amount of money, they basically say, I have extra
money. And, you know, this is not good for somebody who lives in Russia.
For years we have tried to raise funds from the Russians using our network of
political and business connections within the country, but we have been forced
to accept the fact that our community is not an attractive target for donors.
In Russia, corporations and philanthropists prefer to support high-profile,
socially acceptable organizations such as performing and visual arts, for
You know, when we approached one of the major businessmen, oligarchs, he said,
why should I support you? I would give 3 (million) or 4 million to Mariinsky
Theater and my name will be in the program. With you, same thing: We don’t
want ourselves to be associated with – you know, with a rehab. Though the
recent exception, for example, the brewery Baltika is continuously supporting
us for many years.
We also tried to approach many U.S. businesses operating in St. Petersburg and
in Leningrad Oblast. Leningrad region there are about 150 U.S. corporations.
They operate businesses in – you know, in the region. And we’ve had two
American interns who did – you know, they did a great job. They’ve done all
the letter-writing, you know, very nice letters, solicitation letters.
We received the list from the American Chamber of Commerce in St. Petersburg.
We hand-delivered the letter twice, 150 letters which were signed by our board
of directors committee, you know, which had all – you know, Yuri Shevchuk,
Mitsky (ph) and a lot of, you know, high-profile Russians. And we didn’t get
even a single response in writing, though, you know, we delivered to the
switchboard. The secretary signed that they received our mail, and it went
directly to the bucket.
So, in conclusion, I just wanted to say that both United States and Russia
socially isolate and neglect or incarcerate their addicts and drunks. As an
addiction expert from Russia living in the United States and having the
opportunity to observe the problems that are common in both countries, I can
see that there’s a lot of – there’s much opportunity to cooperate.
And in my opinion, the key here is to take an inspiration from people like Lou
Bantle and make the commitment. Thank you.
MR. MILOSCH: Thank you very much.
If you don’t mind, I’ll ask a couple of questions and then we’ll go to Kyle
with a couple of questions, and then we’ll go out to the audience. I guess
I’ll bundle mine together.
I’d be very curious to hear any thoughts that either of you might have on a
kind of question of national feeling. I mean, I confess here to an American
prejudice without knowing much about Russian methods of dealing with
alcoholism. I tend to think that the solution is Alcoholics Anonymous. Right
or wrong, this is how I approach the problem.
I’d like to hear your thoughts on how the fact that AA comes out of the United
States might be an obstacle to its progress in Russia because it may seem like,
well, this comes from a country that’s historically been our rival, or how
orthodoxy deals with the fact that of course AA comes out of a kind of American
secularized Protestant milieu and, you know, how do they deal with that?
Do they recognize that there’s nothing really in the AA program that’s hostile
to orthodoxy and try to make it their own, or does it always remain something
else? That’s the first thing I’ll throw out, orthodoxy and the Russian
I’d also like to hear about the implications of this problem, because it seems
that the implications of alcoholism in Russia are huge. We’ve already
mentioned demographics. Russia is in a demographic crisis, but it will even go
way beyond – way beyond that. You know, the problem is as serious as it is.
As I’ve read in the essays of Ms. Brown and Mr. Zubkov, it’s going to affect
relations between men and women deeply. What can one expect when one gets
married? The expectations are going to become low. How do the sexes relate to
each other? How do the generations relate to each other when you have so many
children raised in alcoholic households?
It just seems – it seems like a wound on marriage, childhood, social
development, something that is going to in fact go beyond the problem of the
person splayed out on the concrete, but it’s going to affect the mood and
social relations of everybody in the country because it affects their
expectations. So that’s just kind of a big thing I throw out, if you have any
comments on that.
Thirdly, it occurs to me that we’re also dealing with social attitudes here
that are very hard to change, in that the attitude that hard drinking, drinking
a bottle of vodka, you know, out-drinking your neighbor, the people who are
with you at the table, becomes a kind of test of Russianness, and that’s very
dangerous when a test of your patriotism becomes how much can you drink, or a
test of manliness.
And the social attitudes often react negatively to pressure. The more
campaigns you have to change them, then the more certain milieus will dig in,
and then it becomes an act of a rebellious spirit, of independence. It’s very
hard to attack these kinds of loaded attitudes without provoking a reaction
that doesn’t undo anything that you – any progress you make.
So I’m just throwing a lot out there. I would like to hear what either of you
have to say.
MS. BROWN: Sure. I think as Medvedev and Putin do a tandem answering of the
questions, you can jump in whenever you want.
So, I guess I’ll take the third one, the question about social attitudes,
I do think that their – and, again, you know, I will start my answer by saying
I am an outsider. I am not Russian. So this is – what I say has to do with my
observations over the years.
But in terms of social attitudes towards drinking, you know, when I observed my
own responses over there, I realized how much I had internalized stereotypes
about drinking in Russia, because after visiting the House of Hope, I went with
some friends out to dinner, and some of the people were – actually, most of the
people at the dinner were recovering alcoholics.
So here we were in a group at restaurant on Nevsky Prospect in St. Petersburg,
and we’re all sitting down to dinner and we’re all talking. And I’m sitting
there thinking, what’s missing? Here we are, we’re all meeting, we’re
celebrating. Oh, yeah, we’re not toasting.
Like, how is this possible? We’re sitting in Russia celebrating something and
we’re not toasting. Is this really Russian? Like, can you be Russian, can you
have a Russian cultural celebration, a funeral, a meeting, an acquaintance,
spend time together without drinking? Hmm, you know?
And I do think that right now that’s something that Russians are asking
themselves. You know, and you might disagree with me, but I think that as the
country starts to try to come to grips with why it can’t get out of its own way
in terms of improving the situation, really starting to tackle alcoholism and
move on, I think people are starting to say, you know, can we have Russian
culture without having vodka involved?
And, you know, again, I alluded to this narcologist who Vladimir Putin has
supported. His name is Yevgeny Bryun, and he’s – I interviewed him. He’s a
lovely man. But he supports the older method that Dr. Zubkov alluded to of
using medications to treat alcohol instead of therapy.
And I feel that his approaches, which are – you know, when you’re sitting at
the table drinking with your family and your friends and you’re getting drunk,
take a walk around the table and open the windows so you don’t get too drunk.
Or, you know, he said that he’s trying to improve policy by encouraging people
to drink other kinds of alcohol, like beer and wine and not just vodka.
So this is an educated, trained professional. And he wants to help people. I
mean, he admits fully – he doesn’t try to put under the rug the fact that
people have an alcoholism problem in Russia.
So I don’t know if that answers the question about social attitudes. I mean, I
just feel partly that, you know, it’s a kind of a two-part problem. There’s
the way Russians see drinking and there’s also the way we foreigners see
drinking in Russia, and it kind of goes together.
I will let Dr. Zubkov answer the question about families and alcoholism.
In terms of AA in Russia, I think you’ve really hit it on the head. I think
there is a lot of mistrust of Alcoholics Anonymous there because it is seen as
Western. And as much progress has been made in Russia, and as cosmopolitan
people have become and the traveling that’s been done, there are a lot of
people who still have sort of a nationalism or a resentment about methods that
have come from abroad.
Alcoholics Anonymous didn’t really come to Russia, I believe, until the 1990s.
Is that right, the early ’90s, late ’80s?
DR. ZUBKOV: Eighty-nine.
MS. BROWN: Yeah, and you can imagine in a country where there is no religion
except for the state, and Alcoholics Anonymous requires the belief in a higher
power, the government certainly doesn’t want you to believe in a higher power
other that the state. And it was very much discouraged and actually seen as a
I have a friend who told me stories about trying to smuggle in the AA book in
the ’80s and having customs officials rifle through her suitcase. You know, it
was medical supplies and AA books. She could have brought the medical supplies
in to sell at a high profit, but they left those in the suitcase and they took
out the AA books.
And, you know, in terms of the church, again, a really good point. What you
see today is the church probably has – and this is according to one priest that
I interviewed in Moscow – probably about a quarter of the priests in the
Orthodox Church are alcoholic. And it’s a very – it’s a very insidious disease
in the church because you have to use wine in your ceremonies.
So on the one hand, people can hide and they can continue their disease. On
the other hand, if a priest wants to overcome his alcoholism, it’s almost
impossible because he has to use wine in the ceremonies.
And the church, like many other large, established religious institutions in
other countries, keeps its secrets and encourages priests not to talk about
things publicly. Patriarch Kirill, who is very close, reportedly, with
Vladimir Putin and has his backing, has sort of nominally made comments that
Alcoholics and Anonymous and other therapy methods could be considered
But at the end of the day, he – I mean, just one example of the way that he’s
not really working with AA and other positive methods is that the priest told
me that he actually reversed an earlier rule. He had told priests that they
didn’t have to use wine in their ceremonies if they were battling alcoholism.
They could just use juice. And he has taken away that rule so that you have to
And, you know, again, in this country, in Russia, which is sort of starting to
find its religious identity again, you know, to have the head of its religious
– of the church not be fully behind every method that could possibly help
people, you know, that’s definitely questionable.
DR. ZUBKOV: I wanted to add a couple of words on orthodoxy and, you know,
relation of the orthodox iraks (ph). Two or three iraks made comments on 12
steps way, and basically they were, at the best, neutral. And they didn’t say
they endorse it; they say, well, you can use it if it’s under supervision of a
priest. And basically that was it.
But the bigger problem is that, you know, first, a lot of priests don’t follow
what their patriarchs say. There is a lot of – very often, you know, priests
don’t abide by – they’re ignorant of, you know, the opinions of their senior
And, second, it is – AA is still viewed, actually, as a Protestant invasion,
and this is the major problem. And, for example, you know, the infamous
Serbsky Institute, they have a physician who writes about AA. He wrote, I
don’t know, about a dozen very enflamed articles about, you know, how it is
negative for the Russian society, how it is absolutely unacceptable for the
Russian psyche. And one of his most recent topics links Satanism to AA.
So, it is completely – it is completely out of – and, you know, the doctor who
wrote this article was inspired by one of the senior priests in Moscow. So on
one end there’s a patriarch who said this is OK. On the other end, you know,
they read – you know, the huge amount – a huge number of priests which do say,
we don’t want to deal with it because it’s questionable, it’s Protestant, you
know, and those people do things by themselves, they do it without our control.
And so far relations are difficult, though there are priests who have – who
even started 12-step programs, but I would say then probably there are five or
six people altogether. There are not many.
MR. MILOSCH: That’s interesting because I think in the U.S. I’m not aware of
any associations between AA and being Protestant. I don’t think people in the
U.S. would make that connection.
MS. BROWN: But I think it’s the idea of Protestantism being Western.
MR. MILOSCH: Being American, yeah.
DR. ZUBKOV: Yes, but, you know, the Oxford Group, which actually gave birth to
AA, they were a Protestant group, a Protestant gathering of people. But still,
it was a business association, so what about – you know, Protestants have a lot
of excellent rehabs. You know, they charge money for it. I mean, sometimes
MS. BROWN: In Russia?
DR. ZUBKOV: In Russia, but they fund a lot of excellent rehabs.
And, you know, church views it as probably a subversive activity. They’re
always trying to link whatever Protestants to do the sects.
MR. MILOSCH: Do either of you have any thoughts on the far-reaching
implications of alcoholism for marriage, child raising, the social atmosphere
in the cities?
MS. BROWN: I mean, the only thing I’ll say is just based on a couple of
interviews I did with people who are recovering at the House of Hope.
One man, I think he was in his 60s, and he’s actually very typical of the kind
of – I mean, unless you would argue with me – typical of the kind of person who
has sort of reached the end of the road and, you know, come to the House of
Hope to give it one last shot.
You know, he’d taken the Antabuse dosage that Dr. Zubkov has described several
times. He’s been in and out of jail. And his pattern fits one of the patterns
of alcohol consumption in Russia, which is to go on what’s called zapoy, which
are extended binges that last for a week, two weeks.
And that – and it makes it very insidious in the family of an alcoholic because
they can convince themselves that the person is not an alcoholic because they
can go for weeks or months with being sober. And, again, Antabuse can
exacerbate that because you go for a long period of time being sober.
But the people who practice these binges, their families fit into the pattern
and they begin to expect when these zapoy are going to happen, and they know
how long they’re going to last. And so, this man told me about his pattern and
how his wife started to ask him, OK, well, when’s the next time you’re going to
start your binge, because you seem really unhappy.
And that was one of the reasons why he actually stopped his Antabuse
treatments, because he would go, you know, for three to six months without
drinking. And the Antabuse – unless maybe we haven’t made it clear enough, but
it doesn’t do anything about addiction. It just makes you not – it makes it
very uncomfortable to drink.
So there is nothing that’s actually happening in your family or in your own
ability to cope with sobriety when you’re on a medication like that. The wife
noticed: You know, you’re not drinking. You seem really unhappy. Let’s go
back to the pattern. Stop taking the Antabuse. Start your binges again.
MR. MILOSCH: Thanks very much.
MR. PARKER: Yes, thank you. And just a quick note. We will shortly be
joined, hopefully, by our witness from NIH. A little bit of confusion, but
she’ll be happy to give us the American perspective and the American model,
with some authority. She is well-credentialed over there at NIH.
And also, from the bios – I just grabbed a couple of things from your bio, Dr.
Zubkov. It’s a long and impressive résumé. And so, again, those are out there
on the table. I see people have availed themselves. There’s some other
The CRS memos I’d draw particular attention to because they’re not public.
They were created for the commission some months ago. And there’s an
interesting one there about sort of the effectiveness of AA.
I think the general conclusion is that it’s at least as effective as other
treatment models. And, again, hopefully Dr. Murray will be able to share a
little bit more about sort of American best practice in that regard.
A couple of quick questions I have, in no particular order.
First, where do Russian AA meetings happen? You know, over here in the United
States they’re all over the place. They’ve sort of become almost like Chinese
restaurants and burger – I mean, you can’t go to a small town that doesn’t have
one across the United States. In fact, they happen here on the Capitol campus,
indeed even in the Capitol building itself.
I know they happen in bars in some places, and they happen around the clock in
places like New York City. I’m just wondering, you know, it seems to be here
in the United States as sort of the church basement, it’s the community center,
and in a sense, when you look at the numbers in Russia where AA is, it’s there
but it’s not really there in terms of the numbers. They’re so small.
What stands in the way? Is it difficult to get the local community center, the
local, I don’t know, ubcom (ph) or gutespalcom (ph) or whoever has a room that
you can use to allow some drunks to drink some coffee, smoke some cigarettes
and tell some jokes once a week? So that would be one question.
The other question is, does sort of the Soviet memory or sort of the legacy of
informants, kompromats, sort of eavesdropping, does that affect in any way, or
do you see that affecting in any way the willingness of folks to come together
anonymously? At the same time, if you’re in a town, people do recognize
people, especially a small town.
You would imagine that – you know, again, I can imagine that here in the United
States it’s probably not the most natural thing to do to bare your soul to one
another in, again, not really a public setting but certainly not – you know,
not – it’s not a walk-talk, right? You’re meeting somewhere. How does that
affect – you know, how does that play out in Russia?
And, lastly, prisons – prisons, prereleases. What’s going on inside the
Russian prison system? I know there’s been a lot of work this past year on the
bilateral presidential commission, and it was recently, I believe,
institutionalized just a couple months ago in the creation of a new rule of law
A lot of great work has been done out at post by people like Tom Firestone in
Moscow; here in Washington Catherine Newcombe, who’ve worked with SYN (ph), the
Russian prison system, in looking at some of these types of rehab,
rehabilitation, job training, but how would treating alcoholism addiction fit
into that in SYN?
DR. ZUBKOV: Well, first about AA. AA is perfect for us. It works. The only
problem, that people are not often referred to the meetings. You know, two
major groups of professionals here who are confronted with a problem, you know,
who see a drunk, you know, they’re the priests and they’re the doctor, the
So, very often what they do, they try to reassure the patients. They either
try to make the patient their client and therefore continue professional
relations at the charge level.
And also the church, the church is trying, you know, to set up a network of its
own rehabs. And they get, definitely, preferential treatment from the state.
For example, GOS (ph) narcocontrol, you know, it’s the structure which is
analogous to –
MS. BROWN: The DEA?
DR. ZUBKOV: Yeah, DEA. They recently signed an agreement with the Moscow
patriarchate, you know, for the rehab organization, where the Russian Orthodox
Church claims it has 30 rehabs. Thirty rehabs is the number which definitely
doesn’t reflect the total number of the rehabs, you know.
And, you know, House of Hope and a couple older rehabs which are for 20 years
in existence, they have never been mentioned, even in this document. So there
is a preferential treatment.
And I think it’s the lack of the referral and, you know, the information. When
people get to the meetings you know, a certain percentage always stays, a lot
like here. It is about 30 percent, you know, who stay. And then some people
relapse and they come back, you know.
But there was an upsurge in the ’90s when the number of the meetings rapidly
increased, but then in the – you know, after the year 2000 there was sort of a
plateau, probably with 5 (percent), 10 percent annual growth.
And, you know, this informants thing, this is usually people who don’t want to
go to the meetings. I mean, they usually – this is like, you know, the usual
thing they say: We don’t want to be here because we’re afraid that there might
be an informant. But usually it’s just an excuse not to go to the meetings.
You know, the same people have to go in through the treatment at the house, for
example – you know, through the rehabilitation they pick up and they do
actually pretty well.
And as for the prisons, I could say, you know, they’re just starting to do it.
It’s pretty new. And, for example, the first prison program in the
penitentiary was also down by the International Institute by Lobentyl (ph) in
’97, if you are familiar with the special type hospital in St. Petersburg.
You know, the one, Fyngergergrienka (ph), you know, all of them were – all the
dissidents were there. It’s a huge hospital, a thousand beds. The first
program was started by the institute there, and it’s still in existence, still
doing good. It’s not really spreading. It’s still, you know, their inside
problem. And director of the hospital, Dr. Tashkin (ph), he was the first to
let somebody who was a patient in the hospital in. So he did let the inmate in
after he was let out.
MS. BROWN: And do you know where there meetings happen? I’m curious too.
DR. ZUBKOV: Well, you know, I see no problem with the meeting space. I mean,
very few meetings are going in the church – in the churches, where the priest
sympathizes, but usually when they want to start meetings, you know, they have
a space – you know, they have space immediately. They don’t –
MR. PARKER: Government buildings, universities?
DR. ZUBKOV: No. Usually they rent – it’s in an apartment or a studio. You
know, it’s some public space which they pay a small rent to upkeep. But
meeting space definitely is not a problem.
MR. PARKER: What about employee assistance programs? Is that something that’s
DR. ZUBKOV: I’m not familiar there’s a single one. You know, we offered to
develop it because Mr. Bantle had a use –
MR. PARKER: Have you spoken with people like Andy Somers at AmCham to see if
that could get it started with American companies or –
DR. ZUBKOV: No.
MR. PARKER: Would that be worthwhile? We could follow up with him as well and
DR. ZUBKOV: But I’m not sure that there is even one employee assistance –
MS. BROWN: Did you want to say something?
MR. PARKER: Should we move to public questions?
MR. MILOSCH: Yeah, sure.
MR. PARKER: Yeah, please.
Q: I just have a response that relates to your question. (Off mic.)
MR. PARKER: Thank you, Doctor.
Q: (Off mic) – employee assistance programs are actually –
MR. PARKER: There’s a microphone, just so the transcriber will catch your
MR. PARKER: That one over there.
Q: So, yeah, basically –
MR. PARKER: Say your name and your affiliation so –
Q: Sure. Sure. Marya Levintova, Fogarty International Center, National
Institutes of Health.
So the employee assistance programs are of interest to a lot of companies in
Russia. Many multinational companies have affiliations in Russia, you know,
Pepsi, Philip Morris, and you name it. And all of them are experiencing
various issues that they would like to resolve, and these programs are
definitely on their radar.
They have not, at this point – from what I know, they have not moved it to the
point of where they can actually say that these programs exist.
MR. PARKER: At this point we can, again, move to public questions. Please, if
you have a question, the microphones are on.
Q: Thank you very much. Ron McNamera with the Helsinki Commission.
I wonder if you could address the question, as it affects children with perhaps
a mom who is alcoholic, and trying to address that question.
I also, I guess, in listening to you, was wondering about young people and
trying to have interventions that try to affect, you know, the question of
drinking early in life. At the hearing that Mr. Milosch referred to, one of
the startling points that I took away from that is that the life expectancy of
a male in the Russian Federation is slightly lower than it was in 1961. So
that sort of really confronted this aspect that contributes to those statistics.
And then finally, certainly with regard to the question of corruption in the
Russian Federation, I’m sort of intrigued in terms of – and not – don’t get me
wrong. I’m not trying to, if you will, pick on the Russian Orthodox Church,
but I wonder if there’s sort of a little bit of a – a little bit of a conflict.
I don’t know – I know, for example, that the church is quite involved in terms
of the tobacco and cigarette industry or sales. And I wondered, to the extent
that the Russian Orthodox church itself might be involved actually in one way
or another in terms of alcohol as a commodity or product. So if – I wonder if
you could – might address some of those concerns or issues that came to my
mind. Thank you.
MR. PARKER: Thanks, Ron. Any others to go in this round?
MS. BROWN: I’ll take the last point, because I did some reporting on it. As I
mentioned in my intro, the counterfeit vodka trade is enormous. It definitely
helps to account for some of the health problems that are developing and have
developed in the health of the population. I can admit that I was a victim of
counterfeit vodka consumption when I was in Vladivostok. It’s a very strange
feeling. Luckily, none of us died, but my – the effect that it had on me was
fainting and hitting my head. And the bottle looked completely normal. It
looked like a regular bottle of vodka.
The production often happens in the south of Russia. They produce the vodka
using very cheap materials, and then they either – the bottle of vodka in
Russia, in an attempt to regulate it, every bottle that’s sold in stores has to
have a stamp that the producer pays a dollar for, or sometimes the retailer.
So a lot of times, of course it’s an organized-crime group or something
unofficial, where they produce the vodka in a plant that looks normal and very
modern. But they steal a stamp off the back of a truck, or they pay corrupt
officials less money for the stamp, and it just gets slapped on the bottle.
Again, you know, very nice-looking sticker. And what an expert on the vodka
trade told me is that it just – in order for the counterfeit-vodka trade to be
as widespread as it is – in other words, going from production to distribution
to sale at a retailer like a store or a kiosk means that probably people very
high up in the power structure are involved as well.
So, you know, I can’t name any names. I don’t have examples of specific
government agencies who are involved. But any time you have, you know, an
industry like the counterfeit alcohol industry, which accounts, again, for
two-thirds of alcohol or vodka sold in the country, you can assume that you’ve
got local police, city officials, regulators, perhaps tax police, others, also
either turning a blind eye or profiting from it. It’s just – it has to be.
And again, organized crime groups are involved.
And to be fair, also to point out that the tradition of making your own bathtub
gin, which is called samagan (ph), continues to this day very proudly. Some
people think that it tastes better. And they continue to give it out as gifts
or – as I mentioned, when the tax increases or when vodka sales are curtailed,
as they just recently were last year, people are happy to go back and get it
from other outlets and make it themselves or have friends make it for them.
MR. PARKER: Do we have other questions?
MR. ZUBKOV: I can also comment on the –
MR. PARKER: Sure.
MR. ZUBKOV: And I think I forgot to address one question about the importance
and impact of alcoholism. I’ve met with many politicians because, you know,
all of our fundraising is done, you know, on the – on the very personal level.
You have to meet with people. You have to convince them to do it. And, you
know, out of 25 meetings, one usually works. And I’ve met with some pretty
high-level politicians, and everybody admits that it’s a national disaster and
this is a national threat which could destroy country.
And at the same point – you know, at the same time, you know, one of the – one
of the very rich people whom I met, he said, so what? I mean, I’ll donate to
the women’s – (inaudible) – you know, hundred thousand dollars. But I won’t
donate to your cause. I mean, I’m not interested. And that’s – but everybody,
you know, in (church ?), in ministry of health, they say it is a problem,
And there is a program which is called Health of the Nation which allocated a
pretty significant amount of money and – but so far I don’t know what came out
of it. I don’t know if anything. And as for the church, you know, I think all
tobacco scandals expired in the ‘90s. the most recent tobacco scandal was in
‘96/’97. But the attitude in general, I think it’s about control, it’s about
establishing (merging ?) with the state and, you know, establishing control
and, you know, the concept of “Russki mir,” Russian world.
But even the rehabs – I mean, some of them, they have modified 12-step program,
which they modify and they call it orthodox steps of sober. But basically
these are transformed and changed, you know, 12 steps, away, even to the point
– but they don’t want to endorse something which is completely independent and
unaffiliated with them.
MS. BROWN: If – I was just going to really quickly add to the question about
corruption. You know, it’s – in a country like Russia, I’m sure you know,
where there’s very little transparency and a lot of incentive to not uncover
difficult truths by both journalists and other advocates, there’s been
discussion in the public sphere about how much of a role corruption plays in
the ongoing production of counterfeit vodka, but also this kind of – what we’ve
been discussing – inability to really get your – the government’s hands around
the problem and turn to steps like AA. And corruption often comes up as one of
So I just – I just want to put it out there. Unfortunately, you know, no one
has been able to actually identify, you know, what government official is
responsible or what ministry. But when you look at the problem and the way
that it’s not advancing, you have to – it’s just the elephant in the room.
Like, whose vested interests are there that are preventing, for example, the
counterfeit vodka industry from being dismantled?
MR. PARKER: Yeah, please.
Q: My name is Lawrence Avasian (sp). I am the director of the U.S.-Russia
Civil Society Partnership Program. And it’s the analog to the bilateral
presidential commission. There are working groups under this new program,
including public health. And we’re going to be very interested in talking to
you about how this might fit in under the public-health aegis.
My question is – are my glasses on? – twofold. One is, to what extent is this
a problem among women in Russia as well as – of course, we know it’s probably
dominated by men. But to what extent is this a problem among women? And on
the other hand, since we know alcoholism is a family disease and often an
alcoholic may not hit a bottom until the family confronts him or her, how
widespread is the growth of Al-Anon and the recovery of the family of the
MR. PARKER: Thank you. Please, have at it.
MR. ZUBKOV: OK. There are, in – I know in big cities there are several
Al-Anon groups, though I cannot give you the numbers. I don’t know how many.
But I know in St. Petersburg, there are five, probably, Al-Anon meetings,
probably. I just cannot give you the numbers offhand. I can look them up and,
you know, give it to you later. But I don’t have the numbers at once.
And, you know, the family – of course it affects the families. And, for
example, we have a family program which is 10 years old at the House of Hope
and which is very good, which is very efficient, almost, you know, hundred
percent of the families of the patients who are – if they have had –
(inaudible) – who are at the House of Hope, they subscribe to the family
program. And most of the rehabs – most of the rehabs, they do – you know, they
do have family programs.
As for conception of women, when I started to work – that was ’79 – I do
remember that the statistics we were provided, that ratio between male-female
of alcoholism in the Soviet Union was one to 10. I think by ’93 this ratio
changed by nine to eight. Current, nine to eight – I – one to eight, one to
eight. One to eight, yes. Unfortunately, I don’t know current numbers. I
don’t know today’s numbers. I just know numbers on the register, which
Minister Bolik (sp) provided on the register. But that numbers I do have.
MS. BROWN: I’ll just – if you don’t mind, I’ll just add. In the story that I
did for the World Policy Journal, there’s a statistic on fetal alcohol
syndrome, which obviously concerns consumption of alcohol amongst women. And
in the city of Murmansk, some American academics did a study of the children in
the orphanage and studied, you know, the percentage of those children who were
born with fetal alcohol syndrome. And they found that more than half were. So
obviously the people who end up having to turn to orphanages for help are in a
But another study that I looked at was from St. Petersburg. A group – I think
it was from Tufts – they surveyed women on the street, and I believe maybe in a
gynecology clinic, and asked them about what they knew about the effect of
alcohol on pregnancy. And basically 80 to 90 percent of them answered
questions about how alcohol affects you very accurately. But about one in five
said that they’d recently drunk heavily.
So it’s not just a question of lack of information.
MR. ZUBKOV: Also one comment on the prison system and the gravity of the
situation. We – our guest – we had Vitaly Mozikov (ph), who’s currently – he’s
working for the president’s administration in Moscow. But he was the DA for
the prison system in St. Petersburg, 20,000 beds, pretty big system. And he
provided numbers – I think that was ’97 or ’98 – that 82 percent in prison – in
prisons of northwest were there because they committed their crimes while being
under the influence of alcohol. Eighty-two percent alcohol – (inaudible). so
that was ’97.
MR. PARKER: Do we have other questions? Please.
Q: Pat Siraneks (ph) with the commission. Two questions. So when I was
reading about this topic, I came across an interesting statistic. During the –
at least in the ‘80s, when Gorbachev introduced the “end the alcohol” campaign,
a significant amount of deaths were attributed to the drinking of – I don’t
know if this – this might fall under your counterfeit alcohol – or rather vodka
– topic, but I think it’s industrial alcohol, as in, like, ethanol, or maybe
sometimes even perfume, like that people would be driven to drink this when
vodka wasn’t available. I was wondering if that’s still fairly prevalent
today, and also, like, what the government can do, if anything, to regulate
that in society, like regulate people drinking those industrial alcohols.
And also, how in the – in the Russian public is alcoholism viewed in, like,
comparison with, say, heroin addiction, which I know is – I think Russia is the
number-one country in the world in terms of heroin addiction? Is it viewed as
less, like, important? Because I know there’s been various efforts to stem the
flow of heroin from Afghanistan in recent years since the war began.
So it’s two questions: namely, how can they restrict industrial alcohol use
for drinking, and also how is alcoholism viewed in comparison with other drug
addictions. So thank you.
MR. PARKER: Ms. Bender (sp)? You had a question? Oh, we can take them in a
row that way. OK, sure. Sure, sure.
MS. BROWN: You’re absolutely right. That’s one of – the consumption of
substitutes for vodka is much more common in Russia, and I think it’s sort of –
when you hear about it, it’s quite shocking when you – when you hear about what
people put in their bodies, because they’re so desperate for alcohol.
Antifreeze is one of them, and cologne, like you mentioned, and medicines;
anything that has alcohol in it.
Now, it really depends upon who you talk to. The man who’s the expert on the
counterfeit vodka industry is one of the only people in the country who tracks
consumption numbers of vodka. But he also sells his statistics to people who
produce vodka to liquor companies. You know, unfortunately he’s not completely
But his position and of course the position of the alcohol lobby in Russia is
that when you make vodka too expensive, people turn to substitutes. So they
argue that taxes should be dropped or lowered on vodka. They think vodka
should be made more economically accessible. And I haven’t heard any other
argument or suggestion in my reporting about another way to prevent that,
unfortunately, other than to treat addiction; other than to help people cope
with their addiction to alcohol.
I can’t comment on the heroin issue. Genya (sp), will you comment on the
MR. ZUBKOV: Well, I think heroin addiction is much more communogenic in
Russia. Therefore, heroin definitely viewed different – definitely differently
than alcohol. And alcohol is almost – it’s a household phenomenon. People
don’t criminalize. I mean, they – you know, if you’re on a bus, I mean, they
might let you – the seat, they might let you sit if you’re drunk. They will
sympathize with you. There’s, you know, a lot of tolerance of drinking in
public, even the alcoholics.
And heroin addiction is very heavily stigmatized, and, you know, any addiction,
for that matter. And it also gets a lot of attention in the media recently
for, you know – as drug addiction, because a lot of – a lot of children or rich
people, they – you know, they get addicted. They get addicted to cocaine. And
therefore, you know, the campaign is spearheaded.
Even, you know, some officials from your – (inaudible) – ministry and, you
know, from the president’s administration, they have cocaine addiction, and
that’s very difficult to fight, and heroin addiction. And therefore there is a
lot of attention, official attention to the problem. Though it’s not a major
killer of, you know, people in, you know, of population in Russia.
MR. PARKER: Thank you, Dr. Zubkov.
We’re going to – pleased to be joined by Dr. Margaret Murray from NIH to give
us the U.S. perspective on how we treat alcoholism in the – in the United
States. Again, we’ve constructed this briefing to be a two-way street. And
one of the questions I do hope we can address is, we’ve heard a lot about the
problems in Russia. I’m wondering, what can we here in the United States – you
know, how can we benefit from Russia’s experience? What – are there – are
there treatment modes or things that are happening in Russia that we’re not
doing, things we can learn. And hopefully after Dr. Murray’s presentation we
can perhaps explore that a little bit.
We will set up a PowerPoint here, and while we’re doing so, I’d like to take a
moment and introduce Dr. Murray, who’s the director of international research
programs at the National Institute on Alcohol Abuse and Alcoholism at NIH. Dr.
Murray directs NIAAA’s efforts in international research collaboration,
spanning each of the institute’s priorities in biomedical, epidemiological,
prevention, and treatment research. And this includes serving on the U.S.
science and technology committees, NIH and government-wide initiatives in
global health, representing NIAAA to multilateral organizations such as the
World Health Organization and the National Academies of Science committees.
She’s primarily responsible for facilitating collaborative relationships at the
individual institute and scientist level; is well published on the subject.
And Dr. Murray, are you involved in the BPC health working group that we – that
we do have with Russia?
MARGARET MURRAY: Yes.
MR. PARKER: OK. And also involved in – as I had thought, in the BPC
And we can begin your presentation. I assume it’s pretty simple, and I will
click – OK.
MS. MURRAY: So you want me to cue you for the –
MR. PARKER: Yeah, sure, I’ll – we’ll work it out.
MS. MURRAY: I’m sorry I’m late, because I’ve been told before to visit this
program called the House of Hope. And I haven’t – when I’m – the last time I
was in Russia, I had absolutely no time to do so. But I will do it, I promise,
the next time I’m there, which is going to be in a few months.
The National Institute on Alcohol Abuse and Alcoholism is one of the 27
institutes that make up the U.S. National Institutes of Health. We can move to
the next slide. And basically our mission is to do research on every aspect of
alcohol. We say we – we cover everything from the cell to taxes, so tax policy
that has to do with the price, which we were just – I just heard a question
when I came in talking about, as well as what happens on the cellular level
when alcohol is ingested.
Next slide. So why do we have a special focus on alcohol? Whoops, we’re – we
can kind of rush through these, because – all right. Because alcohol – first
of all, it’s legal, widely used, easily obtained. And it’s part of the social
context of the United States as well as many other countries. Alcohol has both
beneficial and harmful health effects. It’s used by most people, actually,
without causing harm to themselves or others. So there’s not a huge number of
people that will become addicted from alcohol use.
However, because it interacts with the whole body and risky drinking produces
intoxication, even people who aren’t addicted can have problems from it. And
it’s the leading risk – a leading risk factor for morbidity and mortality
throughout the world.
This next slide shows alcohol consumption. This is from the World Health
Organization. It was published in Lancet a few years ago. And the latest
numbers from WHO don’t change it much. But you can see this is consumption of
alcohol in pure liters of adults aged 15 and older. You can see the – I don’t
know if the colors are coming through really clear. But with few exceptions,
it’s the high-income countries that have the most alcohol consumption. And
Russia is one of those – one of those exceptions.
Next slide. And of course, because of – is this the next slide? Yeah. OK.
Because of alcohol consumption, the disease associated with – the burden of
disease associated with alcohol is spread out in the same pattern, as you see
in this slide, also with data from the World Health Organization.
OK, next. So there’s two distinct patterns of drinking that we have to be
concerned about. One is binge drinking, which is drinking too much too fast.
And we define that in the United States as about five drinks for men and four
drinks for women over a period of two hours. And that’s because it raises the
blood alcohol level to – the BAC to about point – 0.8, which – or .08, which is
our legal intoxication limit in the United States. And that’s based on an
average BMI, so an average-sized man or woman. And of course there’s
variations in those.
This is a particularly prevalent pattern of drinking among young adults in the
United States. And it’s associated with a lot of morbidity and mortality. The
other part is heavy drinking, which is drinking too much too often. So it’s
the frequency of use. And we say if you’re drinking more than five drinks for
men and four for women in a day, and if you’re drinking more than seven drinks
in a week for women and 14 in a week for men, that your frequency of drinking
is too high. And it’s associated with all of the more chronic conditions that
can arise from alcohol use.
This next – the next slide shows the frequency of risk drinking in the U.S.
population. And because we define it that way – and that’s based on a
population study of 40 – more than 40,000 individuals that we do in the United
States. And we’re one of the few countries in the world – in fact, I’m not
sure of any others – that do a population study. In the past, we always study
treatment populations. You know, we looked at people who came in for
alcoholism treatment. And our understanding of the disease was based on that.
Now, because we look at a general population, we’ve had a very different view
and a very different picture of alcohol – problems in alcohol addiction. So 65
percent of the U.S. adult population are current drinkers, and about 59 percent
of those drinkers did not report risky drinking. So they’re not drinking over
You can see in the graph on the – well, OK, we’ll go on to the next slide.
(Off mic) – go back – you see the graph on the right: As you increase your
drinking, you also increase your risk for alcohol dependence. And that’s what
we’re talking about when we talk about the disease of alcoholism.
OK, next slide.
So what we’ve done in the United States, at least since 1990, when we had the
Institute of Medicine take a look at alcohol problems across the country, we
started to look at a continuum of problems and the chronic dependence, which is
around 1 percent of the population, is a very small portion, but that’s the
portion that we talk about when we talk about either inpatient or outpatient
Now, severe dependence – likely those – that group will be treated in
outpatient treatment. But the other groups, the mild to moderate group, that,
nowadays, we’re treating in primary-care settings. So these are people that
won’t even enter the treatment system. And we started doing that because only
a small percentage of people who meet the criteria for alcohol problems
actually ever go into treatment.
And the other important fact to remember is that people might recognize they
have a pretty heavy problem with alcohol. It might be 10 years before they get
into the treatment system. And it’s not because – well, it has to do with a
lot of things. Stigma is one. Another is that, you know, the – they – people
just – it interrupts their lives to such a point. So they have to – start
having problems with family and legal problems and work problems, and sometimes
be forced to get into that treatment system.
So we think that we have a better approach by starting to look at problems
early on when they’re in that mild and moderate phase. And we have
interventions that work very well when delivered by primary-care physicians in
hospital settings and in primary-care treatment, where an individual might not
even think they have a problem with alcohol yet, but they go in and they get an
OK. We look at alcohol-use disorders themselves. About 7 percent, little over
7 percent of the U.S. population currently would meet the criteria in the
Diagnostic and Statistical Manual for substance abuse or dependence. So those
people would have an alcohol-use disorder, we would say. They meet the
criteria. And of those, an awful lot have comorbid drug use and also
psychiatric disorders. So when we talk about treatment, we often have to talk
about treating all of these things at the same time.
We’ve done a lot of research over 40 years on different treatments. And I
think today we’re supposed – we’re focusing more on the behavioral treatments.
And if you see those listed here – the cognitive-behavioral therapy, the
12-step – what we call 12-step facilitation, which would be any program that’s
based on a 12-step method; motivational enhancement, community reinforcement,
and marital behavioral therapy. All these have been proven to be effective.
They all work.
We need to know more at this point about which patients do better with which
treatment. And that’s where we’re focusing our research today. But all of
them work, I would say, more or less equally well.
The other treatment I call – we have up here called “screening and brief
intervention,” that’s what we do in the primary-care settings. And that’s
actually got the strongest evidence base for it; that’s got the strongest
We can go on to the next one. The other area that we’re working on very much,
we’re very focused, is on medication development. And there are a few
medications that are approved currently. And I know they’re approved in Russia
as well. Vivitrol is approved in Russia. They’re not widely used by treatment
programs in the United States; I don’t know about Russia. I think there are a
number of reasons for that. And I think the biggest one is that our treatment
system is sort of based on a non-medical model in the United States, so we
don’t do enough with the current medications that we have.
But also, the treatment effects, while they’re good, and they work better for
some people than others, they’re not strong enough yet that we have a lot of
people convinced. So we’re continuing to look at new compounds based on what
we’re learning about how alcohol affects the receptor system in the brain and
how we can develop medications that can reduce craving and reduce that
continual desire or addiction to alcohol.
So in the U.S., when we look at residential versus outpatient care, most of our
treatment is outpatient, although about 27 percent of facilities offer
inpatient care. And there are insurance programs that will pay for inpatient
care in the United States, although the managed-care policies pretty much favor
the outpatient care. These are the 28-day programs that you hear so much
about. They also – they use a variety of the treatments that I went through
So in a – in a given facility, you would have 95 percent of them that offer
individual therapy and 89 percent that offer group therapy, and a little less
offer family counseling. So all these take place within the same facility.
You see that pharmacotherapy number is only at 42 percent, and that includes
patients who are getting help for their comorbid mental-health disorders, so
they might be getting antidepressants to treat depression or an anti-anxiety
medication. And only about 24 percent are using the medications that we
currently have available to treat dependence.
Alcoholics Anonymous has been an extremely important mainstay of treatment in
the United States. And most programs offer AA to patients who, while they’re
in the inpatient and outpatient setting, but also for – they provide the
aftercare that’s needed for most people. The – there’s been – you know,
because I’ve been in this field for a while and I’ve seen a lot of scientists,
especially the people working on medications, try to say, well, AA, what does
it really do, and, you know, there – you’ll see reviews in the literature;
especially Cochrane Review has a famous one where they say, well, you can’t say
that AA really helps or that it – or that it doesn’t help.
But that’s not really true. While there have not been studies that compare AA
to no treatment – and that’s because the Alcoholics Anonymous people don’t want
a study like that – they don’t want to have people not have the option to go to
AA, which I think is a good, ethical decision.
But when you compare it with other treatments, it’s actually showing that it
does have an effect and it does have a positive benefit. And those positive
benefits, it seems from researchers that are focusing on AA – and it took a
while to find people who were willing to, you know, research AA – it’s both the
social support for abstinence that AA provides, as well as enhancing an
individual’s spirituality, which we know is key to recovery for a lot of people.
So when we’ve actually looked at AA in studies in the way that it is ethical
that we can, we see positive benefits.
And the other thing is, AA is so accessible. There are some people who say
they never find a meeting that they, you know, can feel comfortable in. But
most people can find an Alcoholics Anonymous meeting where they don’t have to
miss time from work, they’re around people that they feel are their peers, they
like the anonymity and they like that social support that they get.
And there are meetings – I live right across from Grace Methodist Church in
Gaithersburg, Maryland. It’s one of the oldest AA meetings in Montgomery
County. There are three meetings a day in that church, and there have been for
almost a hundred years – or actually, I can’t say that, because AA – the church
is a hundred years old, but AA’s been around for 70-some years. And Christmas
Day, Thanksgiving Day. And it’s open, it’s accessible, and people can go, and
nobody has to know that they’re there. You know, they – you don’t have to tell
your employer, you don’t have to access your insurance program. Morning, noon,
and evening you can find an AA meeting.
So in spite of some of the – some of the scientists who say, well, we really
don’t know if AA’s effective or not, I would have to say that it is. And the
research that we’ve done shows that.
OK. NIAAA is 40 years old, so we try to take a look at the next 40 years. And
what we’re hoping is for a more complete repertoire of medications that will
actually be more effective than the ones we have now and reach those people
where current medications are not doing so much.
And finally, personalized treatment. Because there are so many treatment
options, we need to know about individuals and how they match up with
treatments and what would be the most effective treatment for people. So
that’s what we’re working on now, is to be able to say to an individual, you
know, based on your genetic makeup and, your – you know, your profile, we can
recommend this type of treatment. And that’s what we’re hoping to have
available from our research.
MR. PARKER: Well, thank you, Dr. Murray. That was – that was quite a
presentation and gives us a lot of meat to sort of chew on and discuss here.
I will start and then again turn it over if there are any questions here now
that we’ve had the full panel and seen a little bit about both approaches.
Again – and I would just mention here, we focus on the OSC region. And
alcoholism, of course, isn’t unique to Russia or the United States. And I can
recall some months ago the World Health Organization study had listed Moldova,
I think, as the highest consumption in terms of liters per capita of alcohol.
But of course Russia is the biggest country, and the United States has double
the population. And so I would hope that, you know, again, you get these two
heavyweights in their approaches, that there can be benefits beyond.
And I really hope that we can – again, if anyone has comments on what might we
learn, what might we take from sort of the Russian treatment model, one of the
things we haven’t discussed today much at all and I don’t know that we’ll have
the time to are all of these alternative treatments that are beyond the
medications we’re seeing, sort of the, you know, hypnotism and – and I know
often they get sort of the, you know, I don’t know, roll your eyes at this type
of alternative approach, although there have been recent reports, you know, in
our own media about alternative medicine in the United States being used
extensively and possibly working maybe because of placebo effect or whatnot –
but again, getting some result.
And there was a recent news report I saw in Russia that looked at Russians
accessing health care, so to say, and found that a lot of the health care they
were accessing was indeed the nontraditional health care that was often
provided by a primary-care provider who was a traditional doctor but was
offering something by way of acupuncture, herbalism, hypnotism, other types of
Just try and see if there’s anything else here I had. I think that’s about it.
Oh, and also, Dr. Murray, on the – on the BPC , one of the things that I heard
from colleagues at HHS was that, one, not a whole lot has been discussed in the
health working group on this at the BPC, and that some of what has been
discussed involves what seem to be sort of euphemistically termed “harm
minimalization” programs involving methadone clinics, possibly needle
exchanges, and noting Russian resistance to that approach.
You know, again, one of the reasons we sort of focus on the 12 steps here today
– apart from the big reason that they do work – is that, one, they don’t cost
anything. They don’t – they’re not nearly as controversial as some of the
other approaches. And also, interestingly enough, AA doesn’t really even take
a position on alcohol itself. It’s not a temperate society. It’s not aiming
to do away with or – you know, even tell people not to drink. It sort of seems
to be, you know, saying, if you’ve gotten sick, here’s what we have. And if
you like what we have, come and, you know, listen to what we do and, you know,
take what you need, leave the rest, as it were.
But I’m just wondering if you could comment a little bit on that. Again, what
does the U.S. have to learn from and benefit? How do we benefit in this
two-way relationship with our Russian partners?
MS. MURRAY: Well, NIAAA has done a number of collaborative research projects
with investigators in Russia over the years. While we haven’t focused on
treatment – and that – you know, that’s interesting that it’s an omission. I
was thinking about that on the way over. We’ve worked on, actually, an
interesting study in the ‘90s on the topology of alcoholism. And what we
basically found out – that alcoholism is the same whether you’re in the United
States or you’re in Russia or in any other country. We’ve also worked on
alcohol’s involvement in HIV epidemic, as well as we’ve done a lot of work in
fetal – probably the most work has been in fetal alcohol syndrome and
prevention of fetal alcohol syndrome.
I think there’s a lot that the United States can learn from methods of
treatment. And I know that Russian scientists are also looking at medications
to treat addiction. The fact that Russia has a medical specialty in narcology
that we don’t have in the United States – so it’s a branch of psychiatry – I
think that’s very important. We don’t have that. We’re starting – we do have
addiction psychiatry, and we’re working with the – some other groups of
physicians on developing a specialty in addiction medicine. But we don’t have
it currently, and Russia’s had it for a long time.
So Russia has always taken a medical view of alcoholism, whereas it took the
United States a long time to come around to that. Russia also, you know, has,
I would say, almost – at least, you know, when times are good, the treatment
system in Russia is good because it’s inpatient and it’s over a long enough
period of time.
The – one issue that I would like to explore, whether it’s a deterrent or not,
is the fact that alcoholics have to be registered in Russia, people who receive
a diagnosis of alcoholism. And I don’t know how much – how much that deters
people going into treatment. But I’d be interested in learning about that.
MR. : (Off mic.)
Q: A bit on the question that you had in regards to the bilateral presidential
commission and alcohol and other addiction-related activities. I’m actually
the person at NIH who coordinates the NIH activities on BPC, and you rightly
mentioned that there is perhaps a little bit more information on the drug abuse
activities because of SAMHSA’s part in the BPC , in the health working group,
because SAMHSA has kind of this whole separate activity that they’re doing with
So NIH being bottom-up – you know, scientist-to-scientist driven, a little bit
of a different approach in what we are able and are doing with Russian
scientists. So some of the activities that Peggy just described as far as the
collaborations with Russian scientists are the things that we’re doing. And
the needle exchange programs, they’re obviously not a research thing. They are
an – you know, they’re a programmatic question.
So there are studies that are evaluating their efficacy. But, as you know, in
Russia that is against the law, to do needle exchange. So a lot of those
programs had to be stopped in Russia.
The one thing that we’re doing actually together with NIAAA, we are organizing
a scientific forum, which will happen in Moscow this coming November. And
there will be a whole section on alcohol, mostly focusing on prevention and
other related aspects – not necessarily treatment, because again, NIH does more
research. So we could study the treatments but not actually provide them. So
that’s kind of a difference.
And I think some of these kind of discussions that we get into is that we’re
often asked, you know, why aren’t you supporting treatment programs in country
A or country B? Because that’s not what NIH actually does. We can study those
approaches that are used by these different methodologies, but not actually
provide the resources to fund them.
So – and Peggy will be going together with the director for NIAAA in November.
So hopefully we’ll have some more details to report after that meeting. But
MR. PARKER: Thank you. That’s very interesting. And I would just note,
SAMHSA, as you mentioned, you know, a recent report, which caught the headlines
I think just yesterday or the day before, singling out none other than the
national capital region for being I think the highest in terms of alcohol and
So this is, again, a topic and an issue that’s directly relevant right here,
even in this – in this town – especially in this town, as it were.
We are right up against the time that we have allotted. Are there any
last-minute questions to go into the record before – Mr. Bentle – before we
close the record?
MR. BENTLE: I want to thank the commission for including Dr. Zubkov and Heidi,
and in particular thank Dr. Zubkov for his tireless work over in Russia over
the last 20 years. My dad started that as a means of keeping himself sober.
And in addition to the 4,500 patients we’ve had there, we’ve had about an equal
amount go through the family program, which I think – you know, if we can break
the cycle of alcoholism for generation to generation, at least that’s a great
I’m also involved with Father Martin’s Ashley up in Havre de Grace, and we’re
working on a program with our returning men and women in the service. And the
drug and alcohol abuse in terms of our recovering vets is something that I
think is germane both to the Russian population and the U.S. population.
But I want to thank the commission, Kyle, Mike, and the rest of you for
bringing attention to this issue. The pharmacological and the other aspects,
working in the different facilities that I’m involved with, and it’s growing,
But at the end of the day, I think as long as you can get the recovering
alcoholic a sense of hope and that someone else cares, that’s what I found out
when I was over in Russia last month, putting my dad’s ashes in the ground over
there, is the sense of belonging and knowing that there’s someone else out
there that cares really makes a difference, and getting that person to make
that first step out.
And to anybody else in the room that has got ideas in terms of how to get EAP
programs going over in Russia, to help us with the children’s – the family
planning programs or make us better aware what other resources might be
available to ensure that the continuance of House of Hope is a beacon of help
for the Russian people and for a less – to be able to expand to the other
regions, as Dr. Zubkov had referred to – there’s a great need, there’s a great
Just given where philanthropy is in Russia, it’s very, very difficult to work.
And again, I applaud Eugene for 20 years not paying any graft, not paying any
takes, and working in a very difficult political-social-economic environment in
order to keep the house alive.
So thank you, Eugene, and thank you, commission.
MR. PARKER: Thank you for your perspective. Do we – do we have any
last-minute – any burning desires, as they – as they might say? I am glad you
mentioned the veterans aspect. You know, our chairman, Chris Smith, was
chairman of Veterans Affairs and had done some very interesting work on some of
these questions, particularly homeless veterans, which, again, you know,
alcoholism and drug abuse are issues that are around that milieu as well.
With that, I will thank everyone and turn it over to Mark for the last word.
MR. MILOSCH: Once in a while I get the last word. You know, I would like to
turn the last word into the last question. I was – I was reflecting on what
we’ve been doing here. And it seems that – this is a bit different from the
usual Helsinki Commission event. You know, usually we do something on a – on
something that has a clear U.S. foreign policy take, or hooks into a clear U.S.
foreign policy issue and is a foreign policy goal, affected. And, you know,
action items come out of our hearings and briefings.
And that’s a good thing. The commission was created for – to promote change,
and especially in human rights and humanitarian affairs. And alcohol –
alcoholism certainly fits in with the humanitarian concern.
This briefing is a little bit different. It’s not exactly so clear. If I were
to say, you know, where does Congress go from here on this issue, it’s really
far from clear. We’re, you know, very happy to provide a forum on this issue.
And I’m sure the congressman – the chairman strongly supports what each of you
are doing on this.
But – and – but before I close, I would like to ask you – answer this question
of, you know, what Congress’s role might be, where we might go from here. Is
there a – perhaps a programming element to what we’re talking about here?
Would some other sort of Congressional action be called for, other than the
forum that we’ve provided today? You know, it would be very helpful to hear
So one last question, and I’d like to hear from each of you, please. Thanks.
MS. BROWN: I don’t – I don’t think I’m going to comment on that. I mean, I’m
– I think this is a great start. We started the conversation here. You know,
before Dr. Murray came, we were talking about the benefits of therapy. You
talked about the benefits of pharmacological treatments. Seems like there’s a
lot more discussion that has to happen before we can talk about Congress taking
steps or making – taking any action, in my personal opinion.
MR. MILOSCH: Mr. Zubkov?
MR. ZUBKOV: I also think that this could be a beginning. Because we have a
lot of contacts and opportunities in Russia. And, you know, while I was
talking about the House, I wanted to say what initiative one person can do.
But if the recent organized group – you know, which will deal with the
situation – you know, the situation can be changed critically. I mean, one
person did what he did, you know? Thousands of people, you know, hundreds of
meetings started in the country. But this was an effort of one person alone,
You know, there’s a group cooperation, there’s a group effort. And, you know,
bilateral commission, a lot – many positive things could happen if it’s in the
focus of attention of two countries.
MR. MILOSCH: Thank you, Doctor.
MS. MURRAY: You know, it’s an interesting question, because I think that, you
know, Congress probably could do something to, you know, formalize some of the
– maybe some of the discussions that go on between the U.S. and Russia. We’ve
been working – trying to work together with Russian scientists and, you know,
Russian investigators that study alcohol over a number of years. But to have –
you know, and it is, as Maria explained, a bottom-up approach. But to have
some top-down to go along with that I think could possibly be helpful.
So even – you know, just some kind of a formal statement about, you know, the
encouragement of the two countries working together because we don’t have
enough scientists studying alcohol in the world. And so any place where we can
have groups working together, we’re going to get closer to getting better
MR. : Thanks very much. (Inaudible) – congressional caucus on substance
abuse and alcoholism. And we’ll be sure to get the transcript of our briefing
to them. I want to thank all of you for participating, and thank Kyle for
organizing this, and Josh Shapiro and everyone else for participating.
Thank you very much. We’re adjourned.