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On their first encounter with alcohol, novices or those who are not accustomed to the substance, would generally report feeling dizzy, nauseous, drowsy, and thirsty and may suffer from a lack of coordination. All of these unpleasant experiences are results of the actual chemical effects of alcohol and other depressants. Some social drinkers may not experience these reactions if they take alcohol in small quantities. This is because the amount of alcohol consumed is insufficient to produce any measurable physical effects. For alcohol or ethanol to have any reinforcing effect, a measurable amount of it must reach the brain.

Once consumed, alcohol is absorbed and distributed throughout the body through the blood stream. The concentration of alcohol in the blood indicates the extent to which alcohol has been consumed and absorbed into the body. This is reflected in the concentration of alcohol in the brain as well.   To maintain a high blood-alcohol concentration, alcohol intake must be at a rate that exceeds the rate at which it is metabolized.  The depressant effect of alcohol depends on the amount of alcohol present in the brain. Studies have shown that even small amounts of alcohol cause dysphonic effects such as cutaneous flush, nausea, drowsiness and dizzy spells. Although it is traditionally said that alcohol induces “euphoria”, many do not feel joy or comfort when drinking alcohol. They are however, compelled to refrain from expressing their true experience in a group setting where alcohol is being consumed with veneration.

Alcohol is a Depressant

Ethanol is a depressant that reduces activity of the central nervous system. The neurotransmitter receptors are generally insensitive to ethanol (Hunt 1985).  However, ethanol has been reported as a specific and powerful substance that affects the function of at least two particular types of neuronal receptors; Gamma –Amino Butyric Acid (GABA) receptors and glutamate receptors (Koob et al., 1998).  GABA and glutamate are chemical neurotransmitters that account for much of the inhibitory and excitatory activity in the brain.  When the terminals of one cell release GABA into receptors on the next cell, that cell becomes less active and when glutamate lands on a glutamate receptor, that cell become more active.  It is in this way that many circuits in the brain maintain the delicate balance between excitation and inhibition.
Alcohol increases the activity of the neurotransmitter GABA (Ticku & Burch 1980; Davis & Ticku 1981).  Since GABA inhibits neuron activity, enhancing GABA functions reduces the excitability in many neural circuits.  As alcohol increases the inhibitory activity of GABA receptors and decreases the excitatory activity of glutamate receptors, having consumed alcohol, users would experience drowsiness and many other sedating effects (Hanson & Venturelli 1995). When imbibed, ethanol is metabolized predominantly in the liver where an enzyme called alcohol dehydrogenase or ADH breaks ethanol down into acetaldehyde, which in turn is broken down by another enzyme called acetaldehyde dehydrogenase in to acetate, which is ultimately metabolized to carbon dioxide and water.  The intermediate product, acetaldehyde, is a toxic chemical that induces a “flushing response” characterized by facial flushing, nausea and vomiting.  This reaction occurs as a consequence of high blood acetaldehyde concentration.

 

 

Fig.1: Psychosocial Factors that Make Alcohol Attractive

Alcohol use is usually initiated and continued because of the perception that it is fashionable, rewarding and attractive, even if there is a price to pay. This notion holds that the consumption of alcohol, like many other acquired human behaviors, is a learned behaviour and is usually performed in a social context.  There are many socially acceptable reasons and occasions for alcohol use. Various social rewards for the use of alcohol as well as famous personalities or role models that engage in drinking behaviors result in a wide variety of alcohol related practices being integrated into day to day life. Drinking alcohol typically has a social function, involving two or more persons interacting with one another and reacting to some social stimulus.
Alcohol is usually consumed on occasions such as parties, festivals, at the end of examinations and on holidays, all of which share certain common features such as;

• A spirit of happiness and cheer

• The friendly gathering

• A relaxed atmosphere

The attribution of the increased feelings of joy and goodwill to alcohol on special occasions could be explained through the two learning processes, classical and operant conditioning, and through social learning. Conditioned responses play an important part in day to day life. Although human behavior cannot be explained solely through conditioned responses as human beings are able to think, plan, believe, expect, and anticipate individuals are by no means passive responders to stimuli.  Conditioning and thoughts represent different levels of learning and reciprocally influence each other.  Conditioned responses can be made and unmade by thought, while thought can be influenced by conditioning. Humans can unlearn what they have learned using their cognitive abilities so that the strength of the conditioned responses changes over time.  During extinction, the strength of the Conditioned Response (CR) decreases as more trials occur in which the Conditioned Stimulus (CS) is presented without the Unconditioned Stimulus (UCS); eventually the Conditioned Response (CR) will disappear. This can be utilized as a prevention strategy to unlearn what has been wrongly learned about alcohol.
For some individuals, arriving home after a hard day’s work may be a “cue” – a signal or stimulus – for using alcohol before dinner.  Others might learn to enjoy taking alcohol with a meal. Some individuals who learn to associate alcohol with being carefree or vivacious at a party soon begin to associate the joyful mood of a celebration with alcohol use and on arriving at a party might head for the place in which drinks are served at the first opportunity. At any social event, there are probably as many learned cues for alcohol use present as there are alcohol users, both of which may motivate individuals to use alcohol at these events. However, some respond to a greater number of cues than others, and some stimuli are rare while others are pervasive. One of the long term results of learning to associate alcohol with positive factors leads to an extreme dependency on the substance. On the one hand an alcohol user who has learned to associate the use of alcohol with a large number of pervasive cues will be most frequently tempted to use alcohol.  Such people are more likely to find it difficult to change their patterns of alcohol use.  On the other hand, those who have learned to rely on alcohol for creating the desired moods or behaviour gradually have their range of enjoyable occasions, or their ability to relax and enjoy themselves, restricted. With the passage of time, occasions on which alcohol is available become the only occasions experienced or interpreted as enjoyable or relaxing. When this state of reliance on alcohol is reached, the pleasure gained from life becomes restricted or reduced.
What is noteworthy is that alcohol is usually consumed on occasions that are already characterized by happiness and a sense of freedom. It is easily assumed that the presence of alcohol is the cause for the feeling of happiness or relaxation. However, the reality is that if alcohol is used on such occasions, over a long period of time with the belief that it is the cause of the enjoyment, the users begin to gradually associate their feeling of pleasure with alcohol use. Alcohol then acquires the aura of being fun-filled and pleasurable through a process of classical conditioning.

Classical Conditioning

Classical conditioning, also known as “Pavlovian conditioning” or “respondent conditioning”, was the first type of learning to be discovered and studied within the behaviorist tradition (Huitt and Hummel, 1997). It refers to the behavioural technique of a pairing a naturally occurring response to a particular stimulus with another stimulus. It is expected that after repeated pairing of the two stimuli, the response to the first stimulus would be shown when exposed to the second. The major theorist in the study of classical conditioning was Ivan Pavlov, a Russian scientist trained in Biology and Medicine, who discovered the learning process somewhat accidentally while studying the digestive system of dogs (Huitt and Hummel, 1997; Horvath, et al., 2013). In other words, classical conditioning involves the repeated pairing of a stimulus that produces a natural response in an individual with an unrelated stimulus that does not naturally produce the response to the first. This eventually to the individual learning to connect the two stimuli, eventually showing the natural response to the former when exposed to the latter. Classical conditioning can thus be called a form of “learning by Association”.

The Study of Classical Conditioning: Pavlov’s Classic Experiment
Phase I: Before conditioning

 

 

Fig.2: The process of Classical Conditioning

As discussed above, classical conditioning was first studied in Pavlov’s celebrated experiment conducted in 1927 in which he observed the natural reaction of salivation in dogs. Pavlov’s experiment involved studying the natural process of salivation (Unconditioned Response) in dogs when presented with food (Unconditioned Stimulus), and when paired with the tone caused by the sounding of a tuning fork (Non Stimulus). By sounding a tuning fork a few seconds before the meat powder was given to the dogs over a period of time, the dogs began to salivate (Conditioned Response) at the tone of the tuning fork (Conditioned Stimulus) even when food wasn’t given. This process is briefly shown in the diagram above.
Alcohol may come to evoke the feeling of pleasure in a similar manner as shown below.

Fig.3: Application of the Classical Conditioning Process to Alcohol Use

Through classical conditioning, alcohol can become a symbol of pleasure and happiness, even though in reality, the chemical effects of alcohol are unpleasant and the experience of using it, uninteresting.  When in a social context, individuals learn to rely on alcohol to relax and enjoy or as a performance enhancer following the repeated association of alcohol with the mood they strive to achieve in the given context. With the passage of time, alcohol gradually becomes a necessary condition for reaching the desired mood.
Conditioning plays an important role in human behavior. For instance, while the aroma of newly baked bread, a stimulus that is directly connected to food, is likely to cause hunger in most individuals, stimuli that are not directly connected to a specific activity, may evoke the relevant response too, for example sexual arousal is conditioned by a variety of stimuli other than those directly involved in sex, and the sight of the hands on a clock indicating the nearing of the time at which one usually drinks tea or coffee can produce a thirst for those beverages.
The symbolic association of particular images or objects with certain situations colour the individual’s subjective perception of the world. Symbols are valuable tools for evoking desirable emotions and moods. For example, the presence of a Christmas tree greatly contributes to creating a festive mood, a phenomenon that cannot be explained by analyzing the botanical characteristics of pine trees alone. Similarly, coloured pieces of fabric are very much able to influence the moods of people, evoking feelings of patriotism and national pride if those pieces of fabric happen to be national flags, especially if hoisted on occasions that evoke feelings of patriotism and national pride.
Symbols are not always recognized as symbols. While it is well known that the festive feelings brought about by the presence of a Christmas tree are by no means the results of the inherent properties of pine trees, the symbolic function of alcohol and other drugs are not generally recognized in the same manner. In other words, it is unlikely that the feelings of pleasure and goodwill believed to be evoked by these substances would not be thought of in isolation from their chemical properties.
The many symbolic effects of alcohol come into effect at its very sight, smell, and taste even before it is consumed. For example, two friends in the act of “having a good time with a glass of beer” do not wait for the alcohol to be absorbed in to their bodies and reach their brains in order to experience the feelings of happiness, goodwill, and comradeship. In fact their mood peaks at the very first sip of beer or even at the mere sight of the unopened bottles. Thus, the glass of beer brings about the feelings of happiness, coziness, goodwill, and comradeship because it has come to be symbolic of these feelings and not because it has any inherent properties that could create them.
People who use alcohol to “ease fatigue” are generally those who are engaged in demanding jobs and are in the habit of taking a break for a quick drink at the nearest bar. For them, the feeling of relaxation they experience from their visits to the bar is more a result of the intermission in the strain of monotony of their work than of the drinks they consume. The rationale behind this is the same as that behind having intervals at schools and intermissions at a theatre or cinema.
The most frequently used symbolic function of alcohol is its function as an indicator to mark the distinction between the monotonous daily routines and well-deserved leisure time. It is natural for an individual to feel a sense of achievement and self satisfaction following the completion of a task. Those accustomed to use alcohol after completing a job, however, begin to attribute their sense of satisfaction and feeling of well earned rest to the alcohol and not to the completion of their task. Alcohol then becomes to them, the indicator of relaxation. Other similar perceptions of relaxation among those not in the habit of using alcohol may be centered on a cup of tea or on changing from work clothes to the more casual and comfortable clothing worn at home. Thus, for an individual who continuously associates alcohol with rest, it becomes a symbol of relaxation, just as a cup of tea or a change of clothes.
The use of alcohol is often perceived as a symbol of adulthood. Many teenagers demonstrate the use of alcoholic beverages deliberately, to project an image of reaching a certain degree of maturity. Furthermore, alcohol is often used as a sign of exclusiveness or as a status symbol. It is known that the alcohol industry use these perceived images of alcohol to their benefit, as a means of marketing its products. Phrases such as “the feeling, the flavour” for instance, that are used to promote alcohol indicates a sense of exclusiveness associated with the substances despite the fact that the harmful potential of both is commonly known and there is a sense of taboo associated with both. For instance, alcohol use is an anathema for sporting persons although certain brands of beer actively promote rugby tournaments and other sporting events.
Some people, particularly youth, tend to use alcohol, tobacco, and other drugs as a means of rebelling against the traditional values and norms of society. Teenagers may experiment with alcohol for the sheer thrill of exploring something that is considered taboo or ‘venturing into forbidden territory’, deriving from it a sense of enjoyment. Young boys may see alcohol as a symbol of ‘manliness’, using it to feel ‘macho’ or to develop a heightened sense of masculinity. Among women and young people, alcohol is more likely to be perceived as a symbol of independence and liberation with many initiating the use of the substance as a way of breaking away from the traditional expectation of women. From this perspective, society’s intense fear of alcohol may be the very cause of its attraction to a daring few in the manner that other thrill-seeking activities such as mountain climbing and sky diving are sought after for the mixed feelings of joy and fear that they evoke. This taking of risks or ‘living on the edge’ enables those who engage in them to achieve status in their respective peer groups.
The use of alcohol and other drugs usually involves special rituals. For example, decorated bottles and ornate glasses are often used when storing and serving alcohol. These factors add glamour to alcohol use and become as important to the users as the alcohol itself. It could be expected that drinking wine in a plastic cup would not have the same effect as drinking it out of a specially designed glass. Rituals such as these, so ardently followed by those who use alcohol and drugs, gain so much significance so that these substances are not merely consumed but are held in high esteem or reverence. The ways, in which the alcohol is brought to the selected location, the seating arrangements of the group are made, the alcohol is served, the group commences drinking, and the glasses or cans used, are all seen as special and very different from drinking other “ordinary” beverages such as water, fruit juice, or soda. Rituals such as these and drinking behaviour are learned since childhood.  This is supported by a study that involved showing pictures of events that occur in day to day life, some of which depicted individuals drinking various liquids, to a group of children. The children were then asked to describe the pictures and name what they thought the adults in them were drinking. It was found that children as young as three years of age were able to recognize which of the adults in the pictures were drinking alcohol.

Membership of a Group

In his famous statement, “Man is, by nature, a social animal”, the great thinker Aristotle describes the innate need human beings have for meeting, interacting and maintaining relations with each other. Communicating with others is essential in day to day life. It is common among peer groups to meet occasionally in a particular location to engage in friendly conversation and share in good humour. More often than not, such meetings take place along with the sharing of food and drink. While alcohol is one of the items shared in this way at casual meetings, in some groups the use of alcohol is compulsory. The passing around of the bottle of alcohol or the toasting and raising of glasses contribute to the feeling of togetherness and solidarity that strengthens the bond between the members of the group. Eventually, alcohol becomes symbolic of this feeling of solidarity as well as of one’s membership in the group and as the aim of many who aspire to enter the group is to be accepted as an equal member, they too would initiate the use of alcohol when with the group and may continue the use simply to escape being cast out. This implies that alcohol dependent individuals are less dependent on the alcohol than they are on the peer group.
When looking at the larger social context, alcohol use is most often seen at private events within the family and larger social events that normally take place either during times of leisure and festivity or simply during times of relaxation when there is no festive occasion in particular. Individuals, both young and old, sometimes drink at family celebrations and at meetings with peers that give acceptance to alcohol use in social settings.

Sanction to Break Rules

There is a tendency in many societies to pardon alcohol induced misconduct pardoned or view to it with tolerant permissiveness. As a result, alcohol and other drugs are often used as alibis by those who engage in unacceptable behaviour in order to gain special privileges from family members and from society in general. Some may occasionally use this social sanction to intimidate or physically assault others who continue to pardon them believing that the abusive behaviour was unintentional. Thus, it is the alcohol rather than the alcohol user that is blamed for the abusive behaviour and all other shortcomings.  Following a violent episode, users may resort to statements such as, “I had too much …………..”, “I can’t remember a thing ………………”, and “I was under the influence of it ……………..” in an attempt to escape blame for their actions.
Studies on wife abuse and rape in general reveal that, the perpetrator is blamed less if proved to have been intoxicated at the time of the crime, and more if proved to have been sober. It has been widely observed that following the use of alcohol or other drugs, individuals tend to engage in offensive and abusive behaviours that they would not dare to attempt when sober. These observations show that the use of alcohol or drugs is believed to be the direct cause of unacceptable and/or violent behavior. The belief that alcohol reduces inhibition is shared by medical professionals and legal professionals and is widely accepted in their fields as well.
Contrary to the popular notion that alcohol inhibits the individual’s capacity to think rationally and causes them to show uncharacteristic behaviour, recent research suggests that people’s mental capacity is in no way hindered following the use of alcohol (Critchlow, 1986; Bodini, 1986; Islieb, Vuchinich, and Tucker, 1988; Higgins and Harris, 1988). The so called alcohol induced behavior is often a mere performance and those who engage in such behaviour are well aware of their actions. For example, a man who beats his wife following a bout of drinking does so knowing that he would not be held accountable for his actions the following day. People who use alcohol to harm others in order to gain the false strength and courage that they thrive on usually choose as their targets victims whom they see as weaker than themselves. It has been observed that those who behave abusively following the use of alcohol usually do so only with those who are weaker, less powerful, more vulnerable, or more tolerant and permissive and that they immediately weaken if and when accosted by those who possess more strength and power such as a police officer.

Pardon for Bad Performance

People naturally strive to behave in a way that would ensure that they are perceived as competent and intelligent. It is generally accepted that there are certain exceptional circumstances to which inadequate behavior and poor performance are generally attributed: fatigue or illness, unfavourable environmental conditions, faulty equipment, immaturity or oversensitivity, over-exertion of the mind and body, or lack of effort. Alcohol or drug use is occasionally categorized by some users as an exceptional circumstance such as these and presented as an excuse for poor performance so as to avoid criticism. By consuming alcohol, individuals believe they could feel free to perform badly at tasks that they have no confidence to perform and escape or mitigate negative feedback. This is a part of the more general notion that alcohol or other drugs are used by individuals to escape having to take responsibility for their actions. It trades on the public assumption that alcohol and other drugs generally interfere with or disrupt performance. This assumption paves the way for what is called self-handicapping strategies. Those who handicap themselves deliberately, in this case by consuming alcohol, may not find their failures or inabilities as embarrassing as they would have had they been sober. In this case, people take refuge in the subjective belief that their failure or poor performance is not due to their inabilities but is due to their use of alcohol thereby increasing their levels of self confidence and relieving their anxiety.
While some may consume alcohol believing that they would have a ready excuse should they fail to succeed in an activity they attempt, there are others who may attribute their failure to not having consumed alcohol before attempting the activity, despite the availability of evidence proving the contrary. For instance, an individual who is unable to dance as well as others may claim that he would have put on a better performance had he consumed alcohol prior to his attempt. This statement is paradoxical in that it is well known that alcohol impairs rather than enhances the co-ordination of the arms and legs.

Expectancies

The physical and mental changes generally attributed to alcohol and other drugs are often contradictory. For example, after consuming alcohol some people report feeling happy while for others the mood changes to sadness, some become more pleasant and amiable while others become hostile, some are aroused, becoming more passionate or aggressive  while others become calm and docile, and some fall silent while others become more talkative. Alcohol, viewed from this perspective, takes on the perceived properties of a magic elixir. This biphasic response to alcohol and other drugs cannot be explained by the chemical or pharmacological effects of such substances. Other considerations, such as psychological factors, the individual’s learning, and the environment help to shape the behaviour related to alcohol and other drugs.
It has been found that the beliefs and expectations of the individual regarding the effects of alcohol and other drugs on behaviour and social functioning play a pivotal role in substance use (Goldman, 1999). These expectancies, learned through social processes, are powerful predictors of behaviour as they transmit information about alcohol and drug related behaviours and their consequences. Both, adolescents and adults have consistent sets of expectancies about the effects of alcohol on behaviour. An active area of research that has developed over several years involves investigating expectancies on the effects of alcohol. In an early investigation of alcohol’s effects on emotions (Russell and Mehrabian 1973), a small group of subjects were asked to describe how they would feel after having consumed two alcoholic drinks and after having consumed six or more alcoholic drinks. It was found that most subjects expected an increase of pleasure, arousal and dominance after two drinks, and a decrease in all three feelings following six or more drinks. The study shows that the expectations on alcohol are common among many people, or that there is a commonly accepted set of expectations regarding alcohol prevalent in society.
Two studies conducted by Isaacs (1977, 1979) investigated the expectations of a group of adolescents and young adults, seventh grade school children and college students respectively, on the effects of the use of alcohol on the behaviour of adults who are dependent and not dependent on alcohol. It was found that among both groups there was the general expectation that adults under the influence of alcohol become hostile, loud, aggressive, and unpleasant. The stereotype of alcoholics presented by both groups was more extreme than that of social drinkers. Among the college students, social drinkers were expected to become kinder, more interesting and sociable, aggressive, louder, more relaxed, and carefree whereas alcoholics were rated as crueler, more aggressive, less interesting, less relaxed, and less carefree than social drinkers.
The findings of Brown et.al (1980) and Christianson, Goldman and Inn (1982) and a number of other studies indicate that the general population holds a number of common expectations about the general behavioural and emotional effects of alcohol. Children who had not yet begun using alcohol showed a very high degree of positive expectancies regarding the substance, indicating that children already “knew” what to expect from alcohol even before they were able to gather any pharmacological knowledge on the actual effects of the substance. Beyond these general expectancies, it is possible to observe an immense diversity of feelings and behaviour displayed by individuals after having consumed alcohol.
In his the paper titled Alcohol, the Magic Elixir, Alan Marlatt (1987) compares two alternative hypotheses about the reinforcing effects of alcohol: tension – reduction vs. arousal enhancement. Marlatt argues that the outcome expectancies of the alcohol depend on the person. The perceptions on alcohol may vary between two extremes, one that views alcohol positively as an extremely powerful and magical substance, and the other that views alcohol negatively as extremely harmful, dangerous, and even evil, regardless of the objective evidence of its actual effects.
The way in which alcohol is evaluated and labeled in society as either negative or positive (negative and positive outcome expectancies) determines much of the behaviour towards it. For instance non-alcoholic placebo drinks, when presented to a group of subjects as real alcohol (via experimental deception), would cause those in the group to display typically drunken behaviour after having consumed it, confirming that much of the effects of alcohol are actually learned expectancies. Outcome expectancies are themselves determined by a multitude of factors. Expectancy effects for alcohol are presumably influenced by the following factors.

• Cultural and personal beliefs about alcohol and its effects that vary from one society to another. (Mac Andrew C, Edgarten RB: Drunken Comportment 1969)
• Personal experience with alcohol and past and present use of alcohol habits, often counted in the form of post – hoc attribution about alcohol as a cause of various psychological and physical outcomes. (Marlatt-1987)
• The setting or situation in which alcohol is consumed- individuals drinking alone, for example, evaluate the effects of alcohol differently compared to when they are drinking in an interpersonal setting. (Pliner P, Chappell H-1974)
• The “set” or expectancy about beverage content (alcohol vs. placebo) and dosage level (amount of alcohol believed to be in the drink)

Individuals experience the effects of alcohol differently in various situations. Laboratory research on the effects of alcohol and other drugs on social behavior have shown that many of the behavioural effects thought to be the result of alcohol and other drugs are not due to the effects of these substances but due to the expectancies that have risen through cultural learning. Expectancies on the effects of alcohol on social behaviour present at a cultural level could be learned by any individual in society before s/he takes his/her very first sip of alcohol.

Images from Advertising

Alcoholic beverages are promoted in a variety of ways. Such promotions include advertising, sponsorship, and multiplicity of marketing strategies. The extent of this activity is such that the promotion of alcoholic beverages and tobacco products has become part and parcel of everyday life. Perhaps to an extent that many promotional strategies are subtle and almost unnoticeable.
These advertisements glamorize alcohol use and sensitize people towards unconsciously being drawn to these substances. In most of these advertisements, there is an attempt to link the brand or product with desirable images. Alcohol is then, associated with social or sexual success and with rich and sophisticated lifestyles. Advertisements usually include visual examples of attractive people engaged in exciting and pleasurable activities, depicting alcohol use as being uniformly beneficial, with no indications given of the potential harmful effects of their use. The repeated association of alcohol with positive images, just as with the classical conditioning approach, serves to create over time, a sense of attraction towards these substances among the general public, especially children and youth. Furthermore, the widespread penetration of these advertisements into the general social mindset, ensure that alcohol and cigarettes are “normalized” making them more or less, ordinary consumer products.

 

Challenging Alcohol Expectancies

As discussed in the sections above, many of the reasons people may give for their use of alcohol are based on psychological factors such as the forgetting of problems, for relaxation, for increasing enjoyment, and as an appetizer, rather than on the pharmacological effects of alcohol itself. In order to be successful, prevention programmes should then focus the people and their reasons for alcohol use, rather than on the pharmaceutical effects of the alcohol. As none of the reasons for alcohol consumption are based on the pharmacological or chemical effect of ethyl alcohol, it is important to discuss how individuals falsely identify that alcohol use is beneficial, and then gradually work towards deconstructing those falsely held social beliefs and understanding them more realistically.

Shakya Nanayakkara

Secretary General, Healthy Lanka

+94 773786788

shakya@healthylanka.lk