Alcohol's Underestimated Death Toll
By Caterina Mauri
For most of Belgium’s history, alcohol killed almost no one, at least on paper. While Zola’s L’Assommoir (1877) was laying bare the devastating human cost of drinking in working-class Paris, in Belgium, officially, alcoholism accounted for only 4 out of every 1000 deaths at its pre-war peak in the early 1900s.
Today, we know alcohol is responsible for many more deaths than just those that are directly due to alcoholism. This article explores the death toll, both historical and modern, of Belgium’s favourite drug.
What is Alcoholism?
What?
Alcohol (ethanol) is a psychoactive, dependence-producing substance linked to over 200 diseases and injuries, including liver cirrhosis and cancers. It increases premature death risk, especially with higher consumption.
Who does it affect?
Alcohol is consumed worldwide, but its harms are unevenly distributed. High-income countries drink the most, but deaths are higher in lower income countries. Men, young adults and disadvantaged groups are most affected.
Diagnosis and Treatment
Diagnosis of excessive alcohol use relies on clinical assessment, patient history, screening tools, and laboratory tests. Treatment ranges from brief counselling to medication and therapy, with relapse prevention key to long-term recovery.
Prevention and Control
Policies like taxes, restricted availability marketing limits, and drink-driving enforcement reduce harm. Individual interventions help risky drinkers before dependence develops.
History of Alcohol Consumption in Belgium
Figure 1: In Belgium, alcohol was woven into daily life
Throughout history, alcohol consumption has played an important role in social life, helping to foster social connections and bonding among people. Yet the harmful effects of alcohol, particularly when consumed in large amounts, have been known since ancient times. Pliny the Elder, a Roman author and natural philosopher, noted that many Romans were driven to death by alcohol, while Galen, an influential Greek physician, cautioned against its use among children.
In 18th-century Belgium, alcohol was woven into daily life in ways that are difficult to appreciate today. The dominant beverage was beer, consumed by men, women, and children alike — including at mealtimes. This was not mere indulgence: before reliable municipal water supplies, beer was widely regarded as safer to drink than water, and the thousands of local breweries that dotted the country made it the cheapest and most accessible staple drink. Alcohol content was low (1 or 2%) and consumption was considered normal. Table beer remained popular during a large part of the twentieth century but lost market share to soft drinks in the past decades.
By the second half of the 1800s, Belgium had a serious alcohol problem. What changed over the course of the century was the rise of distilled spirits. Industrial production made cheap, highly alcoholic spirits widely available, even to the poor (Vleugels, 2004). Drinking establishments were opening on virtually every street corner. By 1900, Belgium had the highest density of bars and cafés in Western Europe: roughly 1 for every 11 adult men. Annual alcohol consumption exceeded 12 litres of pure alcohol per person (compared with, for example, around 8 in the UK, 11 in Italy, and 16 in France), with distilled spirits alone accounting for close to 10 litres per inhabitant by the 1880s (Annuaire sanitaire, 1913). Nor was consumption restricted to adults: children drank alongside them, and it was only after 1887 that minors under 16 were legally barred from being served in public houses.
Meanwhile, doctors had begun keeping count. The word “alcoholism” was coined by the Swedish physician Magnus Huss in the mid-nineteenth century, to describe what happens to the body after years of heavy drinking. Doctors started keeping track of how alcohol made people sick and how it killed them. Already in the 1870s, some municipal death records mentioned alcoholic delirium (délire alcoolique) and drunkenness (ivrognerie). Since 1886, alcoholism is one of the causes of death systematically mentioned in Belgian vital statistics records, the Mouvement de la Population et de l’état civil. Death records recognised not only chronic alcoholism but also acute intoxication as causes of death but did not distinguish them in the records (alcoolisme aigu ou chronique). Only from 1957 do records distinguish between alcoholic psychoses and alcohol dependence syndrome.
Figure 2: In 1911, Belgium counted 17 anti-alcohol societies with over 110,000 members
Source: Annuaire statistique
Figure 3: Belgium's temperance societies spread their message through their own press, such as the Journal de la Ligue patriotique contre l'alcoolisme
With drunkenness everywhere in public life, the political debate was not far behind. In the early 20th century, public health concerns gave rise to temperance movements across Europe and North America. In 1911, Belgium had 17 organized anti-alcoholism societies across the country with close to 110,000 members (Figure 2) and one specifically for women. These societies promoted total abstinence pledges, organized lectures and educational campaigns, published pamphlets and many had their own journals (e.g., Journal de la Ligue patriotique contre l’alcoolisme – Figure 2 – or Clairière, a periodical by the Union des femmes Belges contre l’alcoolisme). They pressured government for regulation of alcohol sales. Although Belgium never adopted full prohibition like in the United States (1920–1933), worries about alcohol’s health and social harms led to new limits on making, selling, and drinking it.
In Belgium, a key milestone was the Vandervelde law of 1919 (officially lifted only in 1984!), which prohibited the sale of spirits in pubs. Spirits could still be purchased for consumption at home, in quantities of at least 2 litres. This affected such drinks as the previously popular genever (jenever), which contains generally around 50% alcohol by volume.
Incidentally, this may have contributed to the rise of the strong beers Belgium is now famous for, as the sale of beer in pubs remained legal. Dubbels and Tripels, beers that are generally between 7 and 12% alcohol by volume, were no direct substitute for genever, but much stronger than most beers. At the end of the First World War, under the new regime of alcohol restriction, the per capita consumption of liquor significantly declined.
What Historical Death Records Show
Figure 4: Alcoholism's share of Belgian deaths has fluctuated sharply over nearly 140 years
Source: based on data from STATBEL, IHME – Global Burden of Disease; State Archives Belgium, Mouvement de la population; The vertical line marks changes in the data sources.
Newly digitised death records let us trace alcoholism deaths in Belgium back to 1886. They were high and rising in the late 19th and early 20th century, then dropped sharply around the First World War, when records are unavailable (Figure 4). This drop stands out even more given how fast alcoholism deaths had been rising in the decades before. The Vandervelde Law likely helped drive the turnaround.
Modern Measurement: Alcohol Attributable Mortality
Figure 5: In 2021, alcohol was behind 3,6% of all deaths in Belgium, with cancer accounting for the largest share
Source: based on data from Sciensano – BeBOD, processed by the author.
We now understand much more about how alcohol affects health. Over 200 diseases and injuries have been linked to it. Some, like acute alcohol poisoning or alcoholic cirrhosis of the liver, are caused by alcohol alone. In many other cases, alcohol is one contributing factor among several, rather than the sole cause.
This matters for how we read the historical records, too. Belgian death registers from the 19th-century captured only a narrow slice of alcohol’s true toll — likely no more than 1 death in 10.
Nowadays in Belgium, most alcohol-related deaths are due to cancer. This makes sense, as alcohol is a well-established cause of several cancers, including those of the mouth, liver and bowels. Deaths officially recorded as alcohol use disorders (the modern medical term for alcoholism) — the red bar in Figure 5 — are only a small part of the total, confirming that official records capture only a fraction of alcohol’s true impact. Brussels and Wallonia have slightly more alcohol-related deaths than Flanders.
Inequality in Alcoholism and Alcohol-Attributable Mortality
Figure 6: In 1901, repeat offenders were consistently more likely than first offenders to have an alcohol link across all offense categories
Source: based on data from the Statistique Judiciaire de la Belgique 1901, processed by the author.
For alcohol, the gap between rich and poor is especially wide. Wealthier people tend to drink more on average, yet most alcohol deaths happen among poorer people. This is called the alcohol harm paradox: those who drink the most are not those who die from it the most.
Several things likely explain this. Among poorer people, many do not drink at all, but those who do are more likely to drink heavily and concentrated in few occasions. Richer people, meanwhile, tend to eat better, exercise more, smoke less, and have easier access to healthcare, all of which may soften alcohol’s harm to the body.
The idea that alcohol might have a different effect on different groups in society is not new. Already in 1886, the Commission de Travail was set up by the Belgian parliament to look into the lives of the working class, and it paid close attention to alcohol use. Drinking was seen as a moral failing, mostly blamed on factory and manual workers. Statistics on drinking and bars were often published alongside figures on vagrants, mendicants, the “mentally insane”, and criminals. Figure 6 shows the share of male convicts whose offense was linked to alcohol — meaning they had acted while drunk, had at least one earlier conviction for drunkenness, or both. Repeat offenders were consistently more likely than first-time offenders to have this alcohol link, no matter the type of crime, suggesting a clear association between alcohol and social marginalisation.
Per capita liquor consumption, the number of drink shops, hospital admissions for alcohol-induced insanity, and the population of the Colonies de bien-faisance all show high values before the First World War and lower values from 1919 onward. Whether this reflects the effect of legislation, the disruptions of the war itself, or other concurrent changes, is difficult to say. Yet modern evidence confirms that restrictions on alcohol availability can have substantial and long-lasting effects on both consumption and mortality.
Figure 8: Hospital admissions for alcohol-induced insanity, and the population of the Colonies de bien-faisance
Source: based on data from Racine 1930, processed by the author.
Writing in 1930, Aimée Racine, a researcher at the Solvay Institute of Sociology, offered a fervent defence of Belgium’s anti-liquor legislation. She reported on the number of alcohol-selling establishments, recorded cases of alcohol-induced insanity in Belgian hospitals, and the population of the Colonies de bien-faisance, concluding that restrictive legislation was ‘undoubtedly responsible for the progress of temperance in Belgium.’ The figures below (Figure 7 and 8) reproduce her data.
Figure 7: Per capita liquor consumption and the number of drink shops
Source: based on data from Racine 1930, processed by the author.
Figure 9: Deaths due to alcoholism represented an increasing percentage of deaths before WWI and regional differences were large
Source: based on data from the State Archives, Mouvement de la population, 1886-1955, processed by the author.
Alcohol mortality also varies from region to region. Areas with more unemployment, more manual workers, and weaker social ties tend to have higher rates, while cities tend to do better (Blomgren et al., 2004). Regional disparities in alcohol-attributable mortality are well-documented in modern Belgium (Sciensano).
Click the names of the provinces in the legend to in- or exclude them from the graph.
Figure 10: Geographical differences in alcoholism mortality are also visible in the maps
Source: based on data from the State Archives, Mouvement de la population, 1903-1959, processed by the author.
Gender gaps in mortality due to alcoholism are striking and persistent (see Figure 11 below). Men die from alcohol at far higher rates than women, largely because they drink more — a pattern found across virtually every country where data exist, and one that, while narrowing, stretches back at least a century.
Figure 11: Gender gaps in mortality due to alcoholism are striking and persistent
Source: based on data from the State Archives, Mouvement de la population, 1886-1955, processed by the author.
What the Records Miss and Why It Still Matters Today
Historical records that name alcoholism as the cause of death almost certainly capture only a small part of alcohol’s true toll. Even back in the 1880s, people noticed that alcohol hit poorer groups harder, and that gap is still wide today. Beyond how much people drank, things like who they lived with, how much money they had, and the conditions they lived in likely shaped how much harm that drinking caused.
This shows the limits of official death records. To get a fuller picture, researchers will need modern methods that can trace deaths from related causes — such as cirrhosis — back to alcohol.
The 19th-century mortality surge was fuelled by cheap, widely available spirits, and the response — legislation, civic mobilisation, public pressure — had lasting effects. Today, cheap alcohol is as accessible as ever, and the links between price, availability, and harm remain just as relevant.
Literature
- Blomgren, J., P. Martikainen, P. Mäkelä, and T. Valkonen. “The effects of regional characteristics on alcohol-related mortality: A register-based multilevel analysis of 1.1 million men.” Social Science & Medicine 58.12 (2004): 2523-2535. doi:10.1016/j.socscimed.2003.09.027.
- Mackenbach, Johan P., et al. “Trends in inequalities in premature mortality: a study of 3.2 million deaths in 13 European countries.” J Epidemiol Community Health 69.3 (2015): 207-217.
- Racine, Aimee. “Belgium’s anti-liquor law.” Current History (1916-1940) 32.4 (1930): 703-706.
- Scholliers, Peter. “Food Culture in Belgium.” The Oxford Companion to Food Cultures (2008).
- Vleugels, An. Narratives of Drunkenness: Belgium, 1830–1914. Routledge, 2015.
- World Health Organization. Global Status Report on Alcohol and Health 2018. World Health Organization, 2018.
Data Sources
- Sciensano, BeBOD – Belgian National Burden of disease: Risk factor attributable burden – Alcohol attributable burden, Health Status Report, 30 January 2025.
- Institute for Health Metrics and Evaluation (IHME) – Global Burden of Disease.
- STATBEL, mortality databases.
- State Archives Belgium, Mouvement de la population et de l’état civil, 1886-1976.
- Annuaire statistique de la Belgique, 1913.
- Statistique judiciaire de la Belgique, 1901.