Many were comatose, and those who were conscious had bouts of nausea, vomiting, and hyperventilation. Scarier still, some experienced kidney failure and vision problems. A world that was once crystal clear now looked like they were watching TV on a station with bad reception. Then their sight failed completely.
When these patients began trickling into emergency rooms at hospitals across Iran in late February, doctors struggled to make sense of what was happening. But Hossein Hassanian-Moghaddam, a clinical toxicologist at Loghman Hakim Hospital in Tehran, had seen this before. Even as cases of the novel coronavirus tore through Iran, a second epidemic emerged in its shadow. By mid-March, an outbreak of methanol poisoning gripped the country.
As the coronavirus began to spread throughout Iran, so did a false rumor that drinking high-proof alcohol would kill the virus in the body began circulating. Desperate to protect their families, even those who normally disavowed intoxication started searching for ethanol, the typical ingredient in consumable alcohol. Strained supply chains dovetailed with the opportunity to make a quick buck, and Iran quickly found itself awash in poisonous booze.
It would become the largest—and deadliest—such event doctors had recorded, garnering 5,876 hospitalizations and at least 800 deaths between February 23 and May 2. Hassanian-Moghaddam says that even young children began showing up in hospitals with methanol poisoning, having been given contaminated alcohol by their worried parents in the hopes that it would prevent the coronavirus.
Iran isn’t alone. According to data collected by Médecins Sans Frontières, 2020 has already racked up nearly 7,000 cases and 1,607 deaths related to methanol poisoning—enough to make this year the deadliest on record. Knut Erik Hovda, a physician at Oslo University Hospital and the world’s leading expert in methanol poisoning, says that these cases likely represent only the proverbial tip of the iceberg.
“Methanol poisoning is an extremely under-recognized problem,” Hovda says, “and we also know that just a fraction of those ever get diagnosed.”
Soon, countries from Mexico to the Dominican Republic to the United States would all find themselves confronting methanol poisoning. Methanol, also known as wood alcohol, is used as an industrial solvent. Because it’s so cheap and mimics the properties of ethanol, unscrupulous manufacturers will often dilute costlier alcohols with methanol. The problem is most common in countries with lax regulations or those dependent on black market booze. Disruptions from COVID-19 have made adulterated ethanol even more common, which has led to a spike in methanol poisoning, both in bottom-shelf liquor and in products like hand sanitizer.
“Many of the alcohols on the market were contaminated,” Hassanian-Moghaddam says of the situation in Iran, “and there was no shortage of people eager to buy cheap alcohol.”
Chemistry of a poison
Methanol and ethanol are chemical kissing cousins. Whereas ethanol has two carbon atoms, methanol only has one. Both are clear liquids that can quickly evaporate, and they taste similar too. Drink them, however, and the similarity ends. Toss back a shot of high-proof ethanol, and most people get a pleasant buzz. Toss back an equivalent shot of methanol, and you could be dead by morning. Less than a tablespoon of pure methanol (10 milliliters) can kill you.
The liver uses enzymes, including one called alcohol dehydrogenase, to transform ethanol from a mild toxin into a harmless chemical called acetate. The liver also uses alcohol dehydrogenase to break down methanol—and that’s where the problems start.
Instead of becoming a harmless chemical building block, the body metabolizes methanol into toxic formic acid. Formic acid interferes with a cell’s ability to make energy. Over time, it can starve cells of the oxygen and energy they need, which is a major problem for power-hungry optic nerves, leaving many methanol poisoning victims with permanent blindness.
The breakdown of methanol also creates an imbalance in the tightly regulated levels of acids and bases in the body, explains Frank Edwards, an emergency room physician at Arnot Ogden Medical Center in Elmira, New York.
“In a case of methanol poisoning, that imbalance is created by the buildup of formic acid,” he says.
Although basic blood tests can often provide clues to methanol poisoning, making the diagnosis isn’t easy. Most contaminated alcohol is a mixture of methanol and ethanol, and alcohol dehydrogenase will break down all the ethanol in the body before it starts in on the methanol. Depending on how much ethanol a person has been drinking, it can take several days for someone to begin experiencing symptoms of methanol poisoning. Thus, an individual may not connect the dots between their current symptoms and their previous drinking, nor do physicians always figure it out, says Kemal Canlar, founder of SafeProof.org.
“In the United States, these incidents are automatically listed as binge drinking or alcohol poisoning,” Canlar says. “They don't try and decipher if it's methanol.”
Big Business of Bootlegging
Diagnosing methanol poisoning is difficult at best, often for cultural reasons. In Islamic countries like Iran, where alcohol is illegal, individuals are often loath to disclose that they have been drinking for fear of repercussions, Hassanian-Moghaddam says. So too for those who have deliberately consumed methanol-containing products such as windshield washer fluid. And since methanol poisoning often causes changes in consciousness, it can be impossible to ask a patient directly.
But if doctors can make a diagnosis early enough, treatment can be lifesaving. “As long as you come in early enough to my office, I will make sure that you can walk out,” Hovda says.
A prescription drug called fomepizole binds to alcohol dehydrogenase and prevents it from turning methanol into formic acid. If fomepizole isn’t available, doctors can treat methanol poisoning with ethanol itself. Both strategies allow the body to excrete the methanol before it’s turned into formic acid.
The idea that ethanol is a leading antidote for methanol poisoning is not only ironic, it’s also used as a justification for the adulteration by dishonest manufacturers, Canlar says. The bootleggers feel that as long as they leave some ethanol, it will neutralize the deleterious effects of the methanol. Others simply don’t know that methanol is toxic—or just don’t care, he says. Euromonitor International estimates that as much as 25 percent of the $1.6 trillion global alcohol market comes from illicit sales. Counterfeit alcohol can range from bottom-shelf swill being sold as top-shelf booze to mixing in toxic methanol.
“Regardless of how cheap you can produce your own alcohol, you can always get hold of cheaper industrial methanol. By mixing methanol into the liquor, you would be able to sell much more alcohol and make much more money from it,” Hovda says.
The issue drew media attention in recent years after tourists traveling abroad in Indonesia, Mexico, and the Dominican Republic became ill or died after drinking contaminated alcohol. In other countries where alcohol sales are banned, the only source for liquor is via the black market. Pure ethanol sold for industrial uses is also sometimes spiked with methanol, ostensibly to prevent its diversion for bootleg liquor. This makes adulterated alcohol a major problem in places like Iran, according to Hassanian-Moghaddam.
Despite this, no country routinely collects data on the number of methanol poisoning cases, due in large part because it mainly affects the most impoverished and marginalized citizens, many of whom also binge drink, Hovda says. They often can’t afford safer options and wind up vulnerable to contaminated liquor.
As a result, Hovda has to glean information about methanol poisonings from news reports, which he does on a shoestring budget with a handful of volunteer collaborators from Médecins Sans Frontières. The resulting document is a simple Google spreadsheet, but it’s the only source of data the world has on cases of methanol poisoning.
The Dirty Side of Clean
Even though the phenomenon is much rarer in America than in other countries due to more stringent regulations on alcohol sales and distribution, those impacted in the U.S. by methanol poisoning tend to also be disproportionately poor and from minority groups, says Susan Smolinske, director of the New Mexico Poison and Drug Information Center.
That’s what Smolinske found this May, when she received a call from her colleague Steve Dudley of the Arizona Poison and Drug Information Center in Phoenix, Arizona. Brooks had received reports from emergency room physicians across Arizona that a handful of people, mostly men in their 30s and 40s, had shown up at hospitals with methanol poisoning. After conducting a similar investigation in New Mexico, Smolinske, Brooks, and a team of epidemiologists from the Centers for Disease Control and Prevention identified 15 cases of methanol poisoning across the two states between May 1 and June 30. Four of these individuals died, and three were left with permanent visual impairments. In July, Smolinske says, four more people were hospitalized in New Mexico.
All the cases involved ethanol-based hand sanitizers manufactured in Mexico that were contaminated with methanol. As the pandemic diverted ethanol for hand sanitizer from already stretched supply chains, the lockdowns imposed in both states also made it more difficult for those with an alcohol dependency to find their normal drinks. What resulted was people—nearly all of them men between the ages of 21 and 60 with existing alcohol problems—drinking cheap hand sanitizer they could find at corner stores and gas stations.
The U.S. Food and Drug Administration has since issued warnings about a variety of hand sanitizer products due to contamination issues. Smolinske adds that the danger is primarily through the oral consumption of these sanitizers, given that skin exposure probably isn’t enough to cause major problems.
“Even with 100 percent methanol, it would take about six hours of complete immersion—like submerged—to get to a toxic methanol level,” Smolinske says, citing a 1980 study that measured how quickly methanol was absorbed through the skin. But use of the contaminated sanitizer could still lead to nausea, vomiting, and vision problems—not to mention that methanol is ineffective at killing microbes.
Although Iran’s devastating outbreak of methanol poisoning has slowed in recent weeks, according to Hassanian-Moghaddam, Hovda’s spreadsheet shows a surge in methanol poisonings elsewhere in the world, including Mexico, India, Indonesia, and the Dominican Republic. News reports gathered by SafeProof.org’s Canlar also reveal a rise in seized counterfeit booze, much of it contaminated with methanol, in places from Cambodia to Turkey to South Africa.
Hovda hopes these incidents raise the profile of methanol poisonings worldwide and potentially spur the production of cheap, reliable tests to test for contaminated alcohol.