Sunday, 25 September 2016

What is Public Health?

Recently, I’ve been thinking a lot about what people mean by ‘Public Health’.  This is mostly in light of going to the Public Health England annual conference a couple of weeks ago.

(As I write about this, I’m aware that I haven’t read or written as much about public health as many people, and I’m probably making some pretty basic arguments and missing some crucial points.  Even so, I think it’s helpful to have this discussion and spark some debate.  And the points I’m making are as much about the politics and practicalities of doing public health work, which I’d suggest I’m perfectly capable of commenting on, having worked in a local authority for 5 years.  Let me know your thoughts in the comments section.)

There are many potential public health issues on the horizon, from dementia and cardiovascular disease, type 2 diabetes and so on, to childhood obesity and alcohol misuse.  But the epidemiological data is astonishingly clear (echoing the alcohol harm paradox that I’ve mentioned before): these diseases and ailments are, above all, correlated with socioeconomic status.

Slide taken from Susan Jebb's presentation at the PHE Conference, available here.

Now the response of some people I’ve mentioned this to (notably not part of the public health community, and not on the left politically) has been, on childhood obesity, to lament that parenting skills just aren’t distributed equally across society.

But the response of the public health community would be to argue that it’s environmental factors and ‘choice architecture’ that structure the choices of parents and children in an unhealthy direction.

And the soft sociologists amongst you might add that class is not just about wealth and income, but culture, and so particular patterns of behaviour are transmitted that may or may not have been positive adaptations in the past, but are now potentially ‘maladaptive’ (to use a word that makes me hugely uncomfortable).

But however we look at it, there’s no doubt that housing, local amenities, education, employment opportunities, diet, and so on are all affected by who our parents are and where they live.  They are associated with locality and socio-economic background – or class, to put it bluntly.  And all those factors influence our health in the long term.

So therefore, one ‘public health’ argument runs, public health needs to be about changing the way housing, local amenities, education, employment and so on are provided.  If the job of public health professionals is to influence health inequalities – as the Coalition Government stated quite plainly – then it has to be about wider socio-economic inequalities.

This where those on the right politically, or those who are more libertarian, start to suggest that public health these days is more about political campaigning than direct health interventions.

And there’s some truth to that.  Gerard Hastings isn’t just opposed to marketing for alcohol; he’s opposed to marketing for all consumables.  The ‘Future Public Health’ (framed as a successor to ‘the new public health’) is all about saving the planet for future generations.

And indeed saving the planet was the topic of the keynote address at the PHE conference.  Of course there are health issues associated with climate change – it will affect where malaria and other diseases are prevalent, and it will cause migration that will affect disease transmission.  But if the issue is preventing (or reducing) climate change, is this a ‘public health issue’?  What is it that PHE or local public health teams can or should be doing on this?

There is a case to be made that climate change is an extreme example, which was really included at the conference as a bit of background and scene setting as an interesting talk before dinner.  And not all public health professionals or academics are (thankfully) like Gerard Hastings.  Indeed, Duncan Selbie is a great example of a political pragmatistalthough this does frustrate many of his professional colleagues.

But the issue doesn’t have to be so huge as climate change for the point to still apply.  If housing is a public health issue, what is the public health intervention?  We know what ‘good’ housing looks like – and if there’s any debate about this, it’s likely to be amongst architects, town planners and engineers rather than people with a master’s degree in public health.

Are public health professionals well placed to argue about what ‘works’ in relation to employment strategies, local economic growth, or education policy?  I’m not sure they are – and local and central government, not to mention the private and third sectors, have plenty of able individuals already well qualified to lead on these issues.

So what is the public health contribution?  Well let’s think about the classic example of the Broad Street pump.  The reason cholera spread in Soho was primarily the poor quality of housing and drainage.  This was particularly bad in this area of London because the people were much poorer.  Richer areas had much better and more hygienic facilities.  So the health of the public was improved by better housing and could possibly have been improved earlier by a more equal distribution of wealth and resources.

But that required a political solution in terms of housing and social policy, as well as the simple macro-economic trend of increasing wealth and income.  But I’d argue the public health intervention is about the water supply and sewerage.

This is, in a way, tinkering at the edges: it’s a safe bet there will continue to be more diseases, even now, and that they will hit the poorest hardest.  That might not always be true, but as I say, it’s a pretty safe bet when we look at Ebola and other outbreaks.

So there is a public health point to be made that if you want to avoid these, certain improvements in housing and so forth would be beneficial, but the public health contribution is the evidence and advice to the politicians and officials who actually determine and implement housing policy.

In fact, that’s even the case in relation to improving the water supply.  It’s not the public health department who would necessarily enact something new, it would be the water board or its modern equivalent.

But the public health contribution, in all these cases, is to focus attention on the health of the public and how this might be affected by wider factors.  It has a role in contributing to the debate.

Take the example of alcohol guidelines.  There was much debate about these, but the key point is that they offer guidance to people who can then make their own decisions about how much alcohol to drink, if any.  The guidelines – perfectly justifiably – only refer to health risks.  You’d have to factor in your own thoughts about taste, intoxication, sociability and so on.

And this, rather than being a failing of the guidelines, is actually a strength.  As soon as public health somehow becomes about wider flourishing – with that worrying word ‘wellbeing’ – it is in the domain of ethics and politics.  And as Katharina Kieslich reminded the PHE conference, fair-minded people will not all agree on the priorities of any department or organisation, even in public health.  Despite the attempts of philosophers through the ages, we haven’t agreed what universal human aspirations and aims should be.  Wellbeing does not look the same for everyone, and is not as easily defined as disability-adjusted life years, which can only be a partial measure of happiness, fulfilment or wellbeing.

Yet there is this tendency for the domain of ‘health’ to expand and include various wider value judgements.  This is to some extent unavoidable, given the blurred boundaries between structure and agency, and the spectrum from choice to coercion.  And we should be more open about these grey areas.

Part of the reason that wellbeing seems like an apolitical area is that politics has been emptied of these fundamental philosophical, ethical debates.  In taking forward agendas clearly underpinned by certain ideological and ethical assumptions, successive governments from Thatcher to Cameron have sought to suggest that they are only introducing ‘efficiency’, and managing the machinery of the state more ‘effectively’ than their opponents.  If politics is simply the domain of securing economic prosperity and opportunity, while managing the neutral state apparatus effectively, then other areas – such as health and wellbeing – can reasonably be understood as being outside of politics.


So once the discussion of ethics is removed from politics, it becomes harder to see where ‘health’ ends and ‘politics’ starts.  Of course this isn’t a clear dividing line, and drawing it anywhere it arbitrary, but my fear at the moment is that it is not drawn at all, and that makes it difficult to identify what domain and responsibilities belong to ‘public health’ professionals at all.  Is it everything or nothing?  I’m certainly not an expert in everything, and no-one wants to be told they have a remit for nothing.  I think public health would flourish best with a smaller scope, but more clearly and carefully defined knowledge and responsibilities.  So before we celebrate what PHE does, it might be worth coming back to that question: ‘what is public health?

Saturday, 3 September 2016

When clear thinking can be muddy

One of my most common requests at work is for people to think clearly and consistently, and follow this up with a definite decision.  But when I write on this blog, I’m often calling for people to think not in terms of ‘bright lines’, but messy nuance.

I’ve been wondering about this possible inconsistency recently, and then a story has come out that has put things into focus for me.  The simple, and slightly trite answer, is that we can think perfectly clearly and openly, with consistent principles, but sometimes these come into conflict with each other, or meet complex problems were a perfect – or even neat – solution is impossible.


I was originally going to write something making the point that there are straightforward, but painful, choices for the public sector to do in the next few years, as predicted ‘demand’ increases for a range of reasons (mostly demographic) while funding from central government decreases – to zero, in the case of local authorities.  When systems are having to generate savings of 50% or more, talk of efficiencies is not just irrelevant, but potentially misleading and unhelpful.  Although the NHS hasn't been cut in the way that local authorities have, the reason there is increasing interest in tying health and social care together is that they are inextricably linked – not just for the patient or service user, but in terms of costs.  ‘Savings’ in social care, if not planned and delivered in partnership with the NHS, will simply lead to the balloon bulging elsewhere, in hospital admissions and length of stays, for example.

How are the choices ‘straightforward’ then, if funding is falling, demand is rising and the costs are shared between a whole range of organisations?  Well, the decision boils down to the fact that if the current spectrum of services are to be delivered, even if in a more ‘efficient’ way, there won’t be the budget to offer them to everyone – so they will be more ‘rationed’ in the terms of the article about NHS treatments.

That is, organisations will do less for some people, but maintain a stronger (or cheaper) service for others.  This does indeed undermine the principles of the NHS, but it’s the way local authorities and other elements of government have always operated, using means testing and targeted support, even where it’s not immediately apparent.

The only real alternative is to do less for everyone.  My gut feeling is that this would require a change in our attitude to the NHS, which can sometimes be seen as a universal service as delivering support not only to everyone, but for everything.  (Of course there is one alternative, which is to change the funding envelope.)

But what about my calls for ‘irrational policy’ and ‘compromise’?  The reality is that while you can accept a clear principle, there are no simple answers about what that means in practice.  What do you stop doing?  Why?  Who do you target?  Why?  How?  What are the consequences?

And that’s where the thinking is sometimes muddled, or there’s a reluctance to take the decision between those two very clear options.  There’s reluctance to draw a line because it’s seen as too definite.  Some people might say that it’s too difficult, or inappropriate, to draw lines like this.  We’re on a slippery slope by making a dent in universalism.

But universalism is drawing a line too.  It’s just that the line is either at one extreme or another, and is therefore can appear very simple.  It’s this simplicity that brings together self-styled defenders of the NHS – like Laurie Penny – and those who would prefer a market-based solution – like Chris Snowdon – in attacking the decision of the Vale of York CCG.  They’re at one extreme or another, but highlighting the inconsistency.

The thing is (and I should acknowledge this is where the opposition of people like Chris to the NHS is perfectly coherent*): with a fixed budget there is always a trade-off between those same ideas of doing less for everyone, or targeting particular groups.

The NHS is a classic example of this.  We need NICE and CCGs to make decisions about what treatments are available, because they can’t offer everything.  And with a fixed budget that principle has to apply even if those decisions apply equally to all users of the system.  (And the budget is inevitably fixed to some extent; it is not infinite.)

There are good reasons to maintain that absolute principle of universalism in the NHS, but we mustn’t be under any illusion: this equally requires the ‘rationing’ of services through CCGs and NICE.  And those ‘rationing’ decisions can’t be straightforward.

This all sounds a bit academic, and perhaps even a case of semantics.  But let’s see how it can work in practice, and how point about complexity is exactly how we go through our lives – not just for better or worse, but for better.

David Seedhouse, Professor of ‘values-based practice’ at the University of Worcester, wrote in the Guardian that just as hospital sites have gone ‘smoke free’, they should go ‘meat free’ too, as both meat and tobacco are carcinogens.

By taking this consistent position, it’s suggested, we can avoid ‘stunning inconsistencies’ such as this form of Orwellian ‘doublethink’:

“Either it’s OK to allow free choice or it’s OK to prevent ‘unhealthy behaviours’, but you can’t have it both ways … If you don’t ban meat, then you can’t ban smoking.”

Perhaps unsurprisingly, Chris Snowdon swiftly congratulated this reasoning.  (Although it wasn’t planned, it’s no coincidence we both chose to write about these two articles together, from quite different perspectives.)

In fact, the decision isn’t simply a choice between ‘free choice’ and preventing ‘unhealthy behaviours’.

First, on a technical point, health isn’t a binary.  Substances and behaviours – and particularly patterns of behaviour – can’t solely be described as ‘healthy’ or ‘unhealthy’.  The category of carcinogen depends on a causal link between the substance and cancer, not the probability or level of risk.  That is, someone whose published academic work focuses on health promotion makes exactly the mistake that has frustrated many who are interested in the new alcohol guidelines.

Meat might have some similar attributes to tobacco or smoking, but it’s not the same.  And that’s before we even get started on the fact that most people, if they had to choose one category, would probably classify meat as a food (a group of things essential for life), rather than as a carcinogen, while tobacco would be an intoxicant (something of a luxury, if perhaps essential for a functioning society).

What’s more, freedom isn’t a neat binary of ‘free’ and ‘unfree’, as politics, philosophy, theology, psychology, sociology, neuroscience and any other area of human study will tell you.  False consciousness, structure and agency, predestination – all these concepts and more are attempts to cut this Gordian knot.

But we know all this intuitively already.  That’s why the reaction I saw this article receive on Facebook and Twitter was ridicule, without even having to enter into an extended period of intellectual reflection.  We see the world not in black and white, but in infinite shades of colour.

Of course Seedhouse would respond that it’s revealing that those Twitter and Facebook comments didn’t involve much reflection:

“So long as we see the world in disconnected chunks, we can avoid serious thought, and preserve the status quo. We need more opportunity to think deeply for ourselves.”

In fact, he’s the one who is thinking in a superficial, simplistic way.  He writes that “Illogical beliefs appear compatible if their true connections are disguised.”  But the point is that things that are connected are not identical.  It’s easy to make a connection; more difficult to specify precisely what the nature of that connection is.  I’ll say again, meat and smoking are not the same.

The point is that all issues are on a slope, which means that libertarians fear the ‘slippery slope’ and others like David Seedhouse want everything to slide down to the bottom as quickly as possible.  But the fact is that not all slopes are or should be slippery.  It’s more likely the best solution is somewhere along the slope rather than at the top or the bottom.  If you find yourself at either end you’ll soon discover there’s another slope available.  Personally I think individuals and society are better served having a bit of stability rather than constantly sliding up or down the endless slopes that exist in the world.

But let’s bring the discussion back to me, this blog and my personal frustrations.

What all this means is that even if the principles are clear, and a decision is taken, we still have to face a messy reality.  So let’s not be afraid of making decisions and drawing lines, but equally let’s not imagine that act of drawing a line will simplify and make everything follow.  It won’t make things simple; it will only make things transparent.  But I’d say messy clarity is better than messy confusion.



*I have much more to say about this, and how insurance and purchasing schemes don’t really avoid this trade-off, but I’ll save that for another day.

Thursday, 9 June 2016

The good old days of the NTA?

Over the past few months, I’ve been working on two key projects as part of my role at Public Health Dorset.  First, we’ve been developing a joint strategy for alcohol and other drugs that applies across the three upper-tier local authorities of Bournemouth, Poole and Dorset.  Second, we’re starting work reviewing our existing treatment services and thinking about what we might put in place when we need to recommission in the next year or so.

Both of these projects have really brought home to me two points: there’s a huge range of ‘problems’ and ‘solutions’ that can be ascribed to alcohol and other drugs; and without the NTA and centrally-dictated policy, locally areas have a huge amount of autonomy in defining and pursuing these problems or solutions.

Neither of these points will be much of a surprise to regular readers of this blog, as they’re themes I often mention.

Now there are definite positives in this new environment of local autonomy: rural areas without any significant level of crack use don’t have to spend valuable time and energy writing a dedicated crack strategy, for example.  But that process of trying to identify ‘what is the problem’ and ‘what are we going to do about it’ isn’t simple.

We can sometimes think that ‘evidence’ or ‘needs assessment’ are going to provide the answers about what we should do locally, but that’s to overlook the fact that the only reason that was the case under the NTA was that they’d already set not only the terms of the debate, but also the answer.  The debate was set in terms of how we can best reduce crime and blood borne virus transmission, and the answer was methadone maintenance treatment for a sustained period of time (with a bit of emphasis later on completing treatment).

Now, because there are myriad problems that relate to substance use, and no single organisation dictating the answer, neither the aims nor solutions are clear.  And it can be a challenge to bottom out all those discussions.

As I say, there are positives.  It means a genuinely joint approach can be taken to commissioning and policymaking locally, which is what our strategy in Dorset is all about.  And commissioners of substance misuse treatment services are less likely to try to do everything in isolation from other areas (though that’s partly down to financial imperatives).

But going through that process isn’t just challenging; it’s time consuming – which means resource-intensive.  And those discussions then have to take place in all the 150 or so areas that commission services in England, not just in Whitehall.  And those discussions about whether this was an issue worth investing in just weren’t on the agenda at all.

I’m not saying it’s a bad thing one way or the other, and as well as opening the possibility of better local policymaking the change could be said to make policymaking more democratic and accountable to local residents.

But I do want to highlight how complacent it was possible to be, and how easy it was to demonise Paul Hayes for making a bargain with the government to get funding that was dependent on stigmatising drug users.  (As he put it, ‘Because you are seen as a threat, the government is prepared to spend money on drug treatment.’)


I wonder how many of those former critics would like to go back to those simpler times now?

Thursday, 21 April 2016

Addiction or false consciousness?

I recently read an article about gaming addiction, which inevitably got the usual questions bubbling around my head.  What might this person mean by 'addiction'?  What does this sort of issue have in common with 'drug addiction'  or 'substance misuse'?

If we take the DSM V definition of a substance use disorder, then it's certainly possible to identify that people can play games to the detriment of family and wider relationships, personal finances, career and so on.  And that the activity chosen at some level gives some kind of pleasure or release - even if by the point of dependence that's tinged with guilt or shame, or only amounts to feeling 'normal', not excited, euphoric or 'high'.  That's why I'm never surprised by (or interested in) academic studies or media stories identify how particular activities, or a new substance (such as cheese), stimulate the same receptors as heroin or cocaine.  That's just the body's way of saying you're getting something out of the activity.

So why bother writing about gaming 'addiction'?

Well, the key for me was this article linked this type of addiction with neoliberalism - a brilliant coming together of my two academic interests.  I wouldn't disagree with the writer that lots of people in today's society or economy don't get a sense of meaning, purpose or achievement from their work or wider life.  And that sense of purposelessness doesn't necessarily cause addiction or particular patterns of behaviour, but it can give less of an incentive to break them.  I've just been reading Geoffrey Pearson's The New Heroin Users, and that ends on the note that it's hard to address heroin use in an neighbourhood where use of the drug is widespread and there is mass unemployment.

That unemployment of Lancashire and Yorkshire in the early to mid 1980s could be seen as a direct (even deliberate) consequence of public policy (and let's set aside the fact that the economic policy specifically might be better labelled monetarist than neoliberal).  But it's not immediately clear that 'gaming' addiction is rooted in conditions or policy analogous to this form of (apparently problematic) substance use if the underlying issue is meaning (whether as a result of an unrewarding job or no job at all) or social/community and family connection.

There is certainly a tendency in social policy and related academic fields to say that Thatcherism ripped the heart out of communities, and to link this with close community identity.  And such an interpretation fits with the idea that addiction is a response to a lack of purpose caused by 'neoliberal' economic policy.

The thing is that the image of close-knit communities, held together by work, didn't operate in the same way in all places.  Mining villages were always exceptional in having a single employer, and even the dominance of Raleigh in Nottingham, or Ford in Dagenham didn't represent the life of most people in work under the postwar 'consensus' supposedly destroyed by Thatcher.  There's a reason academics felt the need to conduct ethnography of mining villages, and the idea that 'Coal is Our Life' was a striking title for a book.

This isn't peculiarly 'neoliberal', and might have more in common with the concerns of social commentators and academics in the nineteenth and early twentieth century - people losing their community and social ties (and mores) by moving to cities to take industrial work.  Think of Dickensian tales of London, or Marx's idea of alienation, or Durkheim's idea of anomie.  These were seen to some extent as originating in the division of labour and the loss of traditional community purpose and solidarity particular vocations had given, along with direct, personal, mutual interdependence.  The idea that interactions are based on the nexus of cash owes more to the era of Adam Smith than that of Friedrich Hayek and Milton Friedman.

And this rings true if we think about the history of addiction or substance use.  Public panics about drunkenness were often tied up with broader concerns about the lawlessness of developing industrial cities, and alcohol had a starring role in Engels' description of the hopelessness of life in industrial Manchester.

Misuse of alcohol and other drugs plays a starring role in plenty of literature of the pre-neoliberal world too, notably (though much later than Engels) in the work of Thomas Hardy (at least it's notable for someone who lives in 'Casterbridge').  And computer games hadn't been invented, so we can't find many characters 'addicted' to those.  But we can find people, as in George Eliot's Silas Marner, where a key plot point revolves not so much on a person's dependence on alcohol as what might be called a 'gambling addiction' in modern parlance.  Dunsey's gambling debts as much as his drinking lead him to deception and theft.

And the problems described in literature, media, or medical reports of the period don't sound so different from our own today.  I wouldn't deny that public policy affects the prevalence of misuse, the harmfulness of the consequences, and how easily people can 'recover'.  In fact, I've written about how neoliberalism as an ideology limits the way we approach issues of substance misuse.  But if we label 'gaming' as an addiction, which I might be able to agree with, we can't really see it as a consequence of 'neoliberalism'.  If we do, we risk failing to identify useful, practical solutions.

I have no doubt that many people could live a life more full of 'meaning' - and that, as shown by plenty of addiction treatment programmes, might be achieved as much through religion or philosophy as changing government economic or social policy.  Perhaps it might also be solved, as Marx envisaged, by a communist revolution.  Or perhaps by a return to small, self-sufficient communities as envisaged by the 'Diggers' in the seventeenth century or more recent utopian groups.

But whether that is more desirable than remaining engaged in society as we find it, tweaking our own relationship with it perhaps, and being aware and somewhat detached and cynical is a personal and philosophical question, not one where the causes of addiction are particularly relevant.  (You can perhaps guess where my natural sympathy lies.)

Addiction is more a human failing than one of neoliberalism.  I'm not convinced this search for meaning is something we particularly suffer with under 'neoliberalism'.  In fact, neoliberalism's most vocal critics wouldn't argue that people fail to find meaning under neoliberalism; they just argue that people find it in the 'wrong' things, like consumer products.  And if you're frustrated or sad that people are finding meaning in computer games or trainers, that's not an 'addiction' problem; that's a political or moral problem.  It's when people aren't finding meaning or connection that we can should be talking about 'addiction' rather than false consciousness.

Wednesday, 6 April 2016

Disunity as strength

The government recently published its ‘modern’ crime prevention strategy.  Apart from the bizarre title, given that modernism makes me think more of 1916 than 2016, there’s been some concern expressed that this signifies the end of any joint alcohol strategy.  It seems that alcohol-related crime will now be addressed through this crime prevention strategy rather than something covering alcohol issues as a whole.  And separately HMRC has just published its own alcohol strategy in relation to tax.

As usual, what I want to do here is raise the possibility that this actually might be a more positive development than it at first appears.  The fear from some in the field is that without an overarching strategy for ‘alcohol’ there will be no clear vision for action on alcohol from different government departments.

But why did I just put ‘alcohol’ in quotation marks?  It’s not just because our understanding of this topic is socially constructed – banal as that point is.  It’s that actually we group together issues under the banner of alcohol that don’t necessarily have a lot in common.  I’m not convinced by this banner as a unifying term.

Regular readers of this blog will be bored of me stating that there is a myriad of problems associated with alcohol.  And often that’s all they are – associated with, rather than caused by, the substance.  Those who frequently attend hospital emergency departments often have alcohol misuse disorders, but these are generally amongst several other problems where the line of causality isn’t obvious.  The same applies to many people in alcohol treatment.  It’s not just that seeing them as having an ‘alcohol’ issue is an incomplete picture, it can actively be unhelpful to dissociate alcohol from the other factors in their lives – just think of ‘dual diagnosis’ where substance misuse and mental health teams fail to work together because they see the problem as being rooted in the other discipline.  Recovery from substance misuse in lots of ways isn’t about the substance itself so much as the ingrained behaviours associated with it, and making sure people have the full range of appropriate resources (‘recovery capital’, if you will) to make effective and lasting changes to their lives.

But more fundamentally, even if we were to accept alcohol as at some level the root cause of certain problems, the way in which this happens – and the way in which the people affected understand this – varies hugely.  We know that people are very good at dodging the definition of problem drinking, and this is partly because it’s always easy to point to an ‘alcohol problem that you don’t have, and therefore you can’t be a ‘binge drinker’ or ‘problem drinker’ or ‘risky drinker’ or ‘alcoholic’.

Think of my research, where I was told by a group of people who had been drinking for more than seven hours straight that their drinking wasn’t an issue because they weren’t about to ‘kick off’ like some people would after two pints of ‘Stella’.  Or those who said they weren’t ‘binge’ drinkers and behaved responsibly, but admitted in the same conversation that on the way home from a night out they had set fire to several bins in a park.

This isn’t to condemn these types of drinking, but there’s no question that they would be deemed problematic from certain perspectives, and yet drinkers are able to dodge that classification by pointing to others who are the real ‘binge’ or ‘problem’ drinkers.

I’d suggest this is the curse of thinking about ‘alcohol’ problems.  As I’ve written about addiction before, we can sometimes try to pin down an almost infinite number of problems into one definition.  In the case of alcohol, I don’t think anyone is trying to get that kind of elusive single definition of ‘alcohol’ problems, but the discussion can still have much the same effect.

As John Holmes has persuasively suggested, assuming that the aim of policymakers isn’t abstinence from alcohol or prohibition, public policy would benefit from a debate about what desirable drinking might look like.  There’s a fundamental problem with that idea in this context, though.  An instant liberal (or libertarian) response might be that it isn’t for government to prescribe what desirable behaviour would be; instead it should proscribe activity that is undesirable, defined as being harmful to others.

But in fact, if we’re trying to set strategic objectives, it could be seen as being (unusually for policy) harder to define what is undesirable than what is desirable.  The problem is that even if we could define a single ideal of drinking (and mine might well look different to yours), there would be an infinite number of ways to deviate from this.  It doesn’t get us any closer to understanding that (a) drinking ‘risky’ amounts for health, (b) alcohol dependence, (c) ‘binge’ drinking, and (d) something that might be called ‘alcoholism’ can all be different issues, with different causes, different effects and different solutions.  That’s by no means an exhaustive list, and each individual will have unique circumstances, making the ‘problem’, ‘cause’ and ‘solution’ unique.

But more importantly for my original question of whether it’s worth grouping issues together under the banner of ‘alcohol’, I’m not convinced there’s a great deal to be gained by looking at dependency issues alongside the public health concerns of drinking a bit more than guidelines, alongside alcohol-related violent crime.  These involve different agencies, and different ‘solutions’.

At the risk of repeating myself, that approach offers us an all-too-welcome way of avoiding admitting the problems we might have: at least we don’t have that alcohol problem; which means, of course, that we don’t have an alcohol problem at all.  And that goes for towns, cities and government departments, as much as individual drinkers.  With that in mind, maybe there is some merit in having a crime strategy, a public health strategy, and a substance misuse strategy.  They should all address alcohol-related issues, of course, but maybe there’s a certain strength in disunity.  I’d rather try addressing the ‘alcohol harm paradox’ by thinking about smoking, drinking, diet and physical activity together, than by trying to link up alcohol-related violent crime, recommended drinking guidelines and what should be prescribed for detox.

Friday, 1 April 2016

What do we mean by 'drugs'?

Last week I was at a really interesting conference on psychoactivity and drug policy at Warwick University, and was surprised and honoured to be speaking on the same programme as the likes of Stuart Walton and Toby Seddon.

(Unusually, I was also genuinely impressed by the publicity they included in the conference pack – there’s some great work in the humanities going on there.)

The theme of the conference was prohibition, particularly in response to the Psychoactive Substances Act, which may or may not be implemented in the next month or two.  Given the media coverage of the Act this week, I think it's timely to comment on some of the discussions we had.

(Personally, I can’t see the government not implementing this.  Just because a ‘go live’ date hasn’t been set yet doesn’t mean the policy has been abandoned.)

The position of most people at the conference was opposition to ideas of prohibition, whether from a libertarian or harm reduction perspective.  For me, this debate centred on the concept of ‘drugs’.

Fundamentally, many people’s opposition to current drug policy is rooted in a feeling that it is unjust to have some substances legal and others illegal, when there isn’t a great deal to choose between them in terms of their inherent chemical or pharmacological properties.  Why is alcohol legal and MDMA not?  Chocolate and tobacco, but not cocaine and cannabis?  Julian Buchanan is a particularly vocal exponent of this position, using the phrase ‘drug apartheid’ to describe how some substances are considered consumer products (tobacco, alcohol, etc), others medicines (methadone, morphine, sativa), and others ‘drugs’ (heroin, cocaine, LSD).

At the conference, Toby Seddon suggested that, if we try to understand what that last category of ‘drugs’ means, the only thing these substances have in common is the way they are regulated.  They don’t have similar origins, histories or effects (in terms of either mind-alteration or health harm).  He suggested that any attempt to prompt a rethink of drug policy would need to question that concept of ‘drugs’, which currently simply reinforces the ‘apartheid’, as Julian Buchanan would put it.  If people keep referring to ‘drugs’, then they’re using a category that only functions as a tool to maintain regulatory distinctions between substances – precisely the distinctions they want to question.

An interesting presentation came from Kojo Koram, who offered a reminder of how these distinctions can be entrenched.  The 1961 UN Single Convention on Narcotic Drugs uses the word ‘evil’ multiple times in its preamble (p.23 in the pdf here) – a word that doesn’t appear in the comparable sections of conventions on slavery, or even genocide.  It is this moral framework around ‘drug’ use that helps maintain the status of certain forms of use (whether classified as pleasure-seeking, self-medication, addiction or anything else) as problematic.

Stuart Walton argued that what is required is a public challenge to these assumptions and this framework.  Those in positions of influence should speak and act in accordance with their beliefs while they are in a position to change things; not simply afterwards, once they have safely retired or changed jobs.  And people regardless of their power or influence should be open about their use of substances past and present – as also encouraged by Carl Hart – to help break that association between ‘drug’ use and ‘evil’.

My presentation was somewhat different, but focused on the same ideas: that the concepts we use to understand policy are hugely influential.  Given the tone of the event the night before and the conference itself was strongly against what was defined as ‘prohibition’, and highly critical of the Psychoactive Substances Act, I wanted to present some thinking that might be not simply critical, but constructively critical (thinking of the ever expanding list of rules of drug policy and Robert Maccoun’s suggestion that “Experts like to have it both ways; we hold the government to higher standards of proof than we apply to our own policy opinions”).  I wanted to ask whether there could be a sympathetic interpretation of the Act.

I’m not sure I entirely believe my own case, but I wanted to offer a bit of nuance to the claims being made.  My point was relatively simple: ‘psychoactivity’ has replaced ‘harm’ as the concept by which drug policy in the UK is justified.  ‘Psychoactivity’ might not be easily definable, but it is potentially more transparent and realistic than ‘harm’.

Before the Act, UK drug policy was structured around the concept of ‘harm’, and this is still the organising principle for much reform activity – the claim that we should legalise and regulate, or at least decriminalise, ‘drugs’ in order to reduce the harm to users.  The Advisory Council for the Misuse of Drugs (ACMD) was there to offer the government expert opinion about the relative harms of different substances, which would consequently be controlled to varying degrees using the classification system (Class A, Class B, Class C).

The Act replaces ‘harm’ as a way of regulating substances with ‘psychoactivity’.  Substances would no longer be assessed based on their likely harm to users; they would be banned regardless of harm if they were being bought or sold as having a psychoactive effect.  Of course this would in principle ban alcohol, nicotine and caffeine (not to mention several other substances) so explicit exceptions have to be made.  Originally, I thought this might open out discussion to consider why those substances are allowed and others aren’t – and this has happened in public debate, but the government’s position hasn’t changed.

But my argument in the conference paper was that this position might actually be justifiable based on research from history and the social sciences.  First off, the idea of ‘harm’ from substance use is hugely complex.

It could be harm to others, through use of the substance itself, as in passive smoking, or more indirectly through what Liam Donaldson called ‘passive drinking’.  It could be harm to the user directly – but this could take a variety of forms.  It could be that there’s a risk of death, or perhaps a risk of disability or sickness.  And these risks could be from chronic exposure to the substance, or from particularly severe or problematic acute exposure, or particular patterns of use, or through combination with other risky substances or behaviours.  (Here I'm mostly paraphrasing the discussions about alcohol harm at the recent Alcohol Research UK conference.)  Interestingly, when we think about drug deaths we tend to think about overdoses, while alcohol deaths tend to be seen as due to chronic diseases, the result of heavy use sustained over several years.

So you can see that any attempt to compare the potential harm of different substances is fraught with difficulty.  It will inevitably mean looking at a whole range of factors, and weighting them against each other – as you can see from this attempt by David Nutt and colleagues.  Just look at the sheer number of colours there have to be to identify all those potential harms.

A further complication is that these harms aren’t guaranteed.  As the Police are fond of pointing out in relation to new psychoactive substances, using certain substances might be described (if you’re prone to more than a little exaggeration) as ‘Russian Roulette’.  The key to this is the idea of ‘risk’, the problem being that we humans aren’t terribly good at understanding risk – as shown by the confused debate around the recent new alcohol consumption guidelines.  All this means that it’s difficult to put a single number on the harmfulness of a substance.  And that shouldn’t be a surprise to any historian or sociologist of drugs - though for a slightly different reason.

Think of Howard Becker writing about learning to get high from marijuana; Mary Douglas talking about ‘constructive drinking’; Norman Zinberg talking about drug, set and setting; MacAndrew and Edgerton talking about ‘drunken comportment’; or Dwight Heath on the anthropology of alcohol use.  All these authors note the importance of patterns of consumption and the culture or learned behaviour around substance use in determining both practices and harms.  Of course this isn’t to deny what might be called ‘objective’ effects or harms of substances; the point is that how these translate into harms isn’t straightforward.  When considering the likely harm of a substance in a given society, we should be thinking about the norms around its consumption.

This isn’t an original or blinding insight, but it is worth remembering, as it means that policy can’t – or rather shouldn’t – really be made on the basis of a purely scientific assessment of a substance’s properties.  But what’s that got to do with psychoactivity?  Well, the way that concept is applied in the Act is precisely how Toby Seddon or Julian Buchanan would identify ‘drugs’ in policy discussions: it means all those things that are illegal (or we want to be), since it explicitly excludes alcohol, nicotine and caffeine from the category.

And maybe that’s justifiable, given the evidence around harm and social context.  There’s a legitimate argument that given a society’s history and present circumstances, different substances with ostensibly similar pharmacological properties shouldn’t necessarily be regulated in the same way.  This is the thinking behind dividing societies into ‘wet’ and ‘dry’ in relation to their attitudes to alcohol.  Some societies have developed stable ways of dealing with well-established substances, but might not be able to have the same social control over a new substance.  I think this is a simplification of the different ways in which we relate to alcohol, but it's a pervasive model, and there should certainly be some acknowledgement of the importance of social context to harm.  The point is, policy based on the sociological and historical research on intoxicants wouldn’t necessarily apply a single standard to all relevant substances.  And a scientifically determined concept of harm, based on the inherent properties of a substance, wouldn’t be able to make these distinctions.

If people have quite different understandings of two very similar substances, it’s reasonable to acknowledge those understandings as misguided or irrational – but it would also be rational to control the substances in different ways to take account of the different way people react to them.

In practice, this is how the Government is using the concept of psychoactivity: to designate substances the government thinks, rightly or wrongly, we're not in a position to safely legalise, due to the social context.  (Or perhaps I should say, they're not in a position to safely legalise, due to the political context.)  And based on the scientific, historical and sociological evidence, there is a sense that psychoactive substances have dangers (even alcohol is ‘no ordinary commodity’), and, because of cultural factors, we can’t treat all substances that have the same apparent level of psychoactivity or toxicity in the same way.

This doesn’t mean that the UK government is right to ban MDMA, LSD, nitrous oxide and a myriad of other substances.  But it does make the apparent inconsistency a coherent position.  It is partly historical accident (and as Virginia Berridge and others would point out, a relatively recent historical accident), but there’s no avoiding the fact that currently illegal substances occupy a distinctly different position in our society to those longstanding legal substances such as caffeine, alcohol and nicotine.  Of course the fact that other substances have been legal – or differently regulated – in the relatively recent past suggests that it’s not unrealistic to imagine such a situation could be instituted again.  And that might not be a bad thing.  I’d hoped that those ‘disruptive innovations’ of e-cigs and NPS might prompt a rethink of current drug policy, and to a certain extent it’s disappointing they haven’t.

But to rail against the Psychoactive Substances Act as being incoherent, inconsistent or hypocritical is not only to subscribe to a naively rationalist view of policy, but also to neglect the hugely valuable contribution of history and social science to the study of intoxicating substances.  We can't – and perhaps more importantly shouldn't – rank substances according to some apparently objective, unchanging, ahistorical notion of harm.

That's perhaps an oversimplification of what Nutt and colleagues, and various campaigners have been trying to do, but I'd still suggest that's the frame by which they justify their approach.  And it's not only unrealistic; I'd suggest it's actually undesirable as an ideal.  If alcohol isn't an ordinary commodity, new psychoactive substances are even less so.  So perhaps ‘psychoactivity’ in the new Act is simply a synonym for ‘drugs’ as colloquially understood, as reflects the continuing influence of ‘drug apartheid’ – but we should be careful of extolling the benefits of a pure, objective, rationalist drug policy: there’s plenty of social research that suggests this wouldn’t fit with how we actually understand and use different substances.

It may not be a perfect policy, but let’s not be too quick to dismiss the Act as unthinking or arbitrary.  Maybe the Act, for all the critique, actually presents a more coherent approach to drug policy than ‘harm’, which simply points to an apparent inconsistency between legal and illegal substances.

Update 06-04-16:
You can hear me discussing some of these issues with Steve Harris of BBC Radio Solent on their 'Breakfast in Dorset' programme on the day the Act was meant to be introduced - but wasn't - here.

Friday, 18 March 2016

Individuals, society and desirable drinking

I spent a great day on Wednesday at the annual Alcohol Research UK conference.  There was a huge amount of evidence on show, and discussion about the nature of evidence-based policy, how research can produce impact and shape policy.

The discussion really boiled down to whether there could be a common language, and genuine communication between researchers and policymakers.  There was consideration of all the usual themes of academics being cautious about their conclusions, and working over long timescales, where politicians want the 'killer' study that gives them a definitive answer to a policy problem.  In fact, there's a point to be made that researchers too are looking for that perfect answer.  We isolate factors, control for variables, and try to identify causes.

Tom Parkman got to the heart of things in the final session, raising the question of whether alcohol was the cause of various problems, or whether the drinking was the result of (for example) housing, employment or relationship difficulties.  He described this as the 'chicken or egg' conundrum, but that's really a shorthand for the fact that these issues are mutually reinforcing – as he suggested, once problems are established and chronic, is there any value in identifying which came first?  It might be more helpful just to get on with an intervention that addresses problems as they stand now.

And actually researchers aren't great at this.  We can trot out 'complexity', but still don't often manage to move constructively beyond that to conclusions or suggestions that are relevant to policymakers.  It's no good responding that things are more complicated than policymakers would like, unless we can offer an alternative interpretation or proposal.

How do we represent that complexity?  Often a quantitative study identifies the specific contribution of alcohol to a 'complex' problem, as if then a controlled intervention can singly address the alcohol issue, while some other intervention or organisation deals with the bit that relates to housing, or employment, or whatever else has been controlled for in a regression analysis.

Qualitative studies often conclude by metaphorically throwing hands in the air and suggesting (correctly, but not always helpfully) that 'it's a bit of everything'.  The problem is 'complex' or 'wicked'.  And we tend to invent our own terms to try to make sense of things.  There's any number of typologies of drinking patterns – but how have these been translated into interventions or policy?

Here's where the fresh eyes of a more quantitative team were helpful.  John Holmes described some new work from the famous Sheffield Alcohol Research Group analysing drinking diaries to identify particular forms of drinking occasion, offering much-needed contextual data (but in a systematic way) to the overall consumption data that tells us only amounts and frequency.  I can see their typology of drinking occasions being genuinely useful – taking the work of Mark Bellis' team to the next level.  It's an example of acknowledging the situation is complex, and can't be accurately addressed with a single 'killer' answer, but still providing something that you can imagine being communicated to a policymaker.

But John closed his presentation by raising another key issue.  We know that 'harm' isn't easily defined, and we know that even if we do define it very tightly, we can't make a totally straightforward link between consumption and that harm.  We need that contextual information, about quantity per occasion, and other factors such as whether food was present, family or friends, and so on.  That is, harm isn't simply dependent on consumption levels; it's affected by drinking cultures.

So if we're not going to simply aim for prohibition or zero consumption of alcohol – if we're prepared to accept, as most people in the room seemed to be – that there could be positive, or neutral alcohol consumption, we need to define what a 'desirable' drinking culture might be.  What 'should' policy be aiming for?

And in the context of references to sociology and social anthropology, that makes complete sense.  There is no doubt that drinking 'cultures' affect harm, as well as simply consumption levels.  Sociologists by definition are interested in studying society, as much as individuals.

But policymakers aren't all sociologists.  The analysis doesn't simply translate into policy, as we heard so often during the day.  In this instance, it's because of a frame that defines what is appropriate for government to do.  We could argue over what a desirable drinking culture might look like, but that's a second order question.  First we'd need to have agreement that government be in the business of fostering 'culture'.  This would sit at odds with Margaret Thatcher's reasonable (and selectively quoted) statement that 'there is no such thing as society'.  This plain statement was actually very sensibly qualified by the observation that there are individuals and families.  This is really a claim about the appropriate unit of sociological and policy analysis: should we look at groups of people (who are only 'latent' classes, to use the terminology of John's paper) or should we look at the individuals themselves.  (I'd quibble with Thatcher's assumption that families are not a concept that needs unpacking, but that doesn't challenge the overall approach.)

It is an unavoidably political discussion not just to define what an acceptable drinking 'culture' is, but to even suggest that government should be thinking at the level of 'cultures'.  Much as I'm sceptical of the utility of the term (although it's been very useful in getting me publications in academic journals), this is a questionable claim while (if?) we live in a neoliberal political environment.  According to that orthodoxy, the unit of analysis is the individual.

And in fact, that's an appropriate place to end and bring this post full circle.  An individual, as Bauman pointed out, originally means something that is indivisible.  And that individual, as Tom Parkman's research suggests, can contain plenty of interacting factors (housing, employment, physical health, personal relationships, mental health, drinking practices etc etc).  But they are indivisible.


And, echoing Wulf Livingston from Tuesday's symposium, perhaps that's where we should start and finish: what does desirable drinking look like, not to policymakers, or public health professionals, or academic researchers, but to drinkersand the wider public themselves.