Wednesday, 15 February 2017

Ideology or technocracy in drug policy reform in 2017

Last week Volte Face published a report called ‘Black Sheep’ written by Lizzie McCulloch that aimed to highlight how substance misuse treatment services could better serve cannabis users who need support.  The conclusions could be thought of as having two elements: first, that the whole issue would be easier if cannabis wasn’t illegal, but rather formally regulated; second, that even if we keep the current legal status, our services could do better.

They brought together a panel of experts, including Lizzie, to discuss this.  Paul Hayes, former head of the NTA and now with Collective Voice, was there, as was Chris Ford, who I’ve followed through her regular DDN column, and Zaki Solosho, who’s previously run into problems with his own use of cannabis (and tobacco).  The discussion was chaired by award-winning scientist and journalist Suzi Gage.  And then they asked me to be there.  I’m not sure why, but I’m not one to turn down an invitation, so I went along.

For a clear write-up of the report and the discussion, check out this piece by Rosalind Stone.  As usual, I’m going to take a slightly different tack in my reflections; if you want to know what the report itself says, it’s not too long and it’s well-written, so there’s no point me paraphrasing here.  Read it!

The debate on Twitter beforehand and the event itself were eye-openers for me.  As Paul Hayes joked, some people really do seem to think cannabis is the only substance known to humanity that has no possible ill effects.  Of course, one of the reasons that VolteFace is interested in this issue is that it has a political mission.  It’s trying to affect the terms of the public debate about drug policy, and add a bit of nuance to the general starting point of ‘drugs are dangerous and therefore should be illegal’.

Of course, some people’s political calculation is that the best way to do this is to challenge it head-on and say that issues related to cannabis are ‘largely mythical’.  But other campaigners acknowledge there are harms related to cannabis, and then to suggest that the current policy approach actually makes these worse.  By taking the second approach, campaigners can’t be hit (so easily) with the accusation that they don’t care about risk or harm, and the argument potentially becomes less moral (heard as ‘drugs aren’t bad’) and more technocratic (how do we minimise harm).

This is a reasonable tactic, and can be seen as underpinning the introduction of needle exchanges in the 1980s and the expansion of drug treatment in the 2000s, but I wonder how powerful it is in today’s political climate.

Without wishing to turn this into yet another ill-informed blog post about Brexit and Trump, I do have some concerns about trying to mobilise public opinion by suggesting drug policy reform as a technocratic solution (even if it’s one that could save lives).  And as Paul Hayes’ response suggests, it’s not even one that the technocrats will all get solidly behind.

I’ve written before about alcohol policy, and how frustrating I find it when people criticise the methodology and findings of research, when their actual concerns are about the political philosophy of a policy.  That is, people attack the research behind drinking guidelines rather than simply sticking to the fundamental principle that people should be free to drink how they choose.

And I’ve been thinking about whether the same point applies to drug policy debates.  Campaigners could acknowledge, yes, that (for example) opiates in themselves aren’t terribly bad for people physiologically, and the harms of addiction are probably heightened by the way in which we regulate them – but then make the broader, more fundamental point that drug policy is really a question of liberty.

The idea of a ‘rational’, ‘technocratic’ drug policy is a chimera.  The harm of drugs isn’t inherent in the substance, and it isn’t inherent in drug policy either.  The harm is a result of a myriad of factors, including genetics and the wider social context.  Just look at how people drink differently in different societies – and for all that talk of safe continental drinking cultures, for most of the 20th century the French might have been restrained while drinking, but their liver disease rates certainly weren’t.

I started this blog as an attempt to comment on how policy debates could be more open and honest, having experienced odd distortions in the two fields I’ve worked in: substance misuse and higher education.  But which is more honest: an appeal to people’s emotions and principles in an age of post-truth politics, by saying drug policy is about liberty, or an appeal to rationality by claiming that legalisation – sorry, regulation – is a harm reduction initiative that we should implement regardless of our views on the morality of intoxication?

And actually, which is more realistic?  For all that this is supposedly an age of ‘alternative facts’ and emotional politics, where it’s no longer about ‘the economy, stupid’, the path to legalisation in the USA has been one of incremental, technocratic change – which then resulted in popular support because the terms of the debate had been changed.

And here’s where Paul Hayes and VolteFace have something in common: they’re both realists.  I’ve written before about my discomfort with the ‘bargain’ Paul (and others) made with policymakers and government, gaining funding for drug treatment by branding users as dangerous.  This was, in a way, disingenuous: the reason most of us are involved in this ‘sector’ is (and I don’t think this is overly idealistic) because of a wish to help people and make the world a better place; not because we think drug users need to be controlled.  And I’d say that slightly disingenuous bargain is exactly what VolteFace is trying to do with Black Sheep: making all the reasonable and technocratic arguments to change the terms of the debate, and steering clear from an unproductive discussion about the rights and wrongs of altering one’s mental state.

But then they part company.  Paul’s scepticism and realism informs his views on legalisation: he’s worried big business would take control (if not immediately), and harms would increase, as with tobacco, alcohol or gambling.  His is a full commitment to pragmatism.  The VolteFace view is more interesting: they’re taking a realpolitik approach to achieve an idealistic change.

I’m not sure which I prefer, though there is something easier about Paul Hayes’ consistency.  But equally, my ambivalence is probably fitting, given how frustrated I was at the launch event that there were two ‘sides’ of this debate (as in alcohol policy) and the atmosphere seemed to encourage people to choose one or the other, rather than acknowledging that under whatever regime, as long as humans are involved (not to mention cannabis), the situation will be imperfect.

Perhaps I can just remain an interested observer.

Monday, 30 January 2017

Faulty by design: the state of think tank thinking

This month, the think tank Reform have published a report criticising public sector commissioning.  The title certainly doesn’t mince its words: Faulty by Design.

Long-term readers of this blog will know I’m generally pretty sceptical of these kinds of reports, and specifically the work of Reform.  Some of this is natural defensiveness.  When I read sentences that state ‘commissioners … do not possess the necessary skills’ (p.11) I feel attacked personally.  But what I want to suggest here is that part of my frustration at these sorts of reports is about something more fundamental.

(Before I move onto the fundamentals, though, I can’t resist highlighting out the oddity of some points in the paper – for example where they disapprovingly note that 72% of local authorities are planning to cut substance misuse treatment budgets [p.23].  I’d love to know what the other 28% are planning to do, when public health budgets are being cut by central government by 20% up to 2020, at which point funding will reduce to zero.  Or when they note that services to address homelessness are ‘commissioned by a plethora of providers’, when a provider is someone who is commissioned, not someone who commissions.)

One of the recurring themes on this blog is that while straightforward and honest thinking and writing – thinking to some purpose – should be the aspiration of all those involved in politics and policy, humans are complex, as is the world they make around them, and so we shouldn’t imagine there are neat, perfect solutions that don’t require compromise.

Without wishing to violate the first of those principles – that I should be straightforward in my thinking and writing – I’d suggest that the ontological model of the Reform writers is naïve.

There is a section entitled ‘Not knowing what works’, which is to misrepresent and simplify the mechanics not just of commissioning but public policy more generally.  Public policy is not as simple as identifying a problem and then implementing a solution.  Any issue will be fused with others, and any ‘solution’ will affect not only that one issue but those others too.

And in any case, it’s not that commissioners don’t know what works; it’s that this can’t be represented as an ‘intervention’, or even a set of interventions, that can be managed as part of contracts.  This model of ‘commissioning for outcomes’ imagines a world of unilinear causality (if that’s a phrase): somewhere we you can pull a lever somewhere in the machine that is society, and then monitor and note the effects.  But society isn’t a machine, and policies and interventions aren’t levers.

What ‘works’ in addressing substance misuse, for example, is a complex mixture of housing, employment, relationships, education, and any number of other factors that most people would simply refer to as ‘life’.  No one organisation, no one ‘policy intervention’ can produce the relevant ‘social outcome’, to use the language of the report.

To be fair to the authors, they acknowledge that part of the problem is that the social world is ‘extremely complex’.  But they still conclude the section by suggesting that there is a solution to this, and that it is ‘greater development of the knowledge base and better dissemination of existing expertise’, with the development of ‘what works’ centres seen as ‘a positive step’ (p.14).

That is, the problem is framed as one of ‘knowledge’: if only we did more research, we could develop the magic lever.

Instead, I’d suggest, we’d have better public policy if we realised that striving for perfect knowledge is futile as there are no magic levers, and the question we should be asking cannot be as simple as ‘what works’.

As such, the approach of this report and others can feel like a lament about the fact that the world doesn’t fit into boxes or categories, or that people don’t behave in easily modelled ways.  When the report complains of the reality of STPs (p.35), this isn’t the fault of the idea of STPs, and it’s not something that a policy or structure can address; it’s simply poor management and people not doing their jobs terribly well.  When, on the same page, the authors describe the tension between ‘what works’ and what the voting public want, we’ve got to the heart of the matter.  Policy isn’t, can’t be, and shouldn’t be, simply about ‘what works’.

And just as there no magic ‘intervention’ that ‘works’, there is no ideal structure for public services.  The report laments ‘the cost of fragmentation’ (p.20), but the fact is that the idea of seamless integration, or a definitive structure, is a chimera.  The cake has to be cut somewhere, and there are pros and cons associated with every option.  Anyone who has observed health policy for more than four years or so will notice the incessant back and forth of the size of administrative units.  The grass may always seem greener, but it’s as if people are actually hankering after flowers that even the greenest of grass won’t produce.

A case in point is public health.  The report complains that locating public health departments in local authorities ‘has stood in the way of integration elsewhere in the NHS’, but equally locally its ‘prevention’ function in the NHS would hamper its ability to shape key influences on health that sit within local authorities, like transport, housing, planning, licensing, schools, and so on.

There is simply no ideal policy on this, and yet the report uses the word ‘integrated’ as if it simply means ‘good’ when there will inevitably be choices of what and how to ‘integrate’, and there will be pros and cons to any approach.  Setting aside the fact that ‘the NHS’ doesn’t really exist as an institution for a department to integrate with, we’d have to acknowledge that public health departments can either be ‘integrated’ with local authorities or ‘the NHS’ – unless of course you’re planning ‘integration’ of the whole set of public services.  But rather than cutting the Gordian knot, this would create one, with different strands of complexity inextricably linked to one another.  And even in that extreme example there would be a dividing line: we’d still have to decide what elements of life are ‘public’ and what ‘private’.

But at points in the document it really does seem that the authors imagine a world without boundaries or departments – of otherworldly ‘integration’.  In fact the language is oddly spiritual, suggesting public services should ‘transcend’ current service boundaries (p.25).  I can only assume they are imagining an all-encompassing ‘service’ (or ‘intervention’?), ‘commissioned’ presumably by some overarching ‘public commissioner’ – a leviathan of the police, community safety, social care, healthcare, transport, and so on ad infinitum.

To go back to a cake metaphor, it might seem like I’m having my cake and eating it – that I’m asking the impossible of the report’s authors as I criticise them for failing to provide a solution to a problem I think is intractable by definition.  But that isn’t quite what I mean.  I’m criticising them for noting the complexity of the world, and criticising commissioners for simplifying it, before they go on to simplify it in their own way, which is no more intellectually or practically justifiable.

Life is complex, and can be understood and arranged in an infinite number of ways.  None of these ways is perfect, and the reality is simply hard work on the ground, not a magical policy or structure being delivered by government, policymakers or a think tank.

The report presents the idea of integrating health and social care (which is already an article of faith of STPs and the Better Care Fund) as if it is groundbreaking or will make all the difference, rather than focusing on the fact that this kind of development is simply difficult and requires hard work.  There is no structure or approach that makes it easy.

And this is where my real unease with these think tank reports lies.  They always feel like they are written by ‘policymakers’ or ‘wonks’, rather than people who actually have to commission, design or deliver these services.

There can be ‘integration’, but it won’t come from breaking down departmental boundaries or fiddling with commissioning budgets.  There will never be a single department or budget where savings across every social policy field can be identified and pooled.

Instead, integration must come from the inevitable ‘plethora’ of commissioners and providers sitting together around a table and talking about the multiple needs of individual people, or groups of people, at a range of geographical levels.  The levels and groups of people around a table will never be perfect, but there’s no need for a report explaining this.  There’s just a need for people to talk to each other and get on with the work.

Friday, 6 January 2017

Dry January and sponsored marathon running

On Tuesday, presumably to break me into my first day back at work gently, I was asked to comment on Dry January for Radio 5’s Drive Time programme.  I’d been asked because they were looking for a slightly sceptical viewpoint, and although I was a little concerned that this might not fit terribly well with my Public Health Dorset role, the team were actually supportive of me offering a bit of balance in the discussion, particularly as I’m more probably more moderate than many of the alternative commentators available.  Unfortunately for Five Live, this meant that the discussion perhaps wasn’t the most electric you might hear – though I did interrupt another contributor at one point, for which I can only apologise.

As I say, it’s might not be the most interesting 20 minutes of radio you’ll ever hear, but if you want to listen to it, I’ve copied it to my SoundCloud account here:

I don’t want to exactly re-hash the piece here, but I wanted to outline my thoughts a bit more fully and clearly, and encourage a more involved debate either here or on Twitter.  (And something of a higher quality than this bizarre article pointed out to me by James Morris.  If you want a slightly different - and better - discussion of Dry January, you couldn't do much better than listening to this piece, including a contribution from James Nicholls.  It starts at around 15 minutes in.)

The first point I’d make is that it’s good anybody is talking about the possibility of going alcohol free.  Personally, I enjoy drinking and I don’t think health should necessarily be people’s number one priority when choosing how to live their lives.  But I do think we sometimes default to drinking alcohol when there’s no real reason to, and it might be worth reflecting on that occasionally – even if we then choose to carry on regardless.  Dry January opens out that possibility even for those of us who aren’t signed up.  By other people around me mentioning they’re drinking less, or not drinking at all, I might think twice myself (for better or worse, but at least for variety, and for the simple benefit of thinking at all).  And as I’ve pointed out a few times on this blog, lots of research – including my own – can be crudely summed up as proving that we tend to be pretty good at conning ourselves that it’s other people’s drinking that’s problematic, not our own.

And there’s no doubt that Professor Moore was right when he stated on the programme that there are significant benefits for lots of people from giving up alcohol, even if just for a month.

My concern is twofold, really.  What happens in the longer term, and is this something public sector organisations should be spending time (and potentially money) encouaraging?

In terms of the longer term point, my fear is that a month off alcohol doesn’t really fir terribly well with the standard approaches to behaviour change.  Generally, you look for realistic, sustainable change, which tends to mean small, gradual movements.  It could be argued that this isn’t the case with more extreme problems, such as addiction, where physiological detox is the starting point – but that’s generally undertaken where the long-term aim is abstinence.  In any case, Dry January is explicitly not designed for people who are dependent on alcohol.  That doesn’t mean that some of the people doing it won’t be looking to give up alcohol completely in the long-term, but that’s unlikely.

And that’s where my concern comes in: if you’re trying to encourage yourself to develop more ‘moderate’ consumption habits, complete abstinence isn’t a great way to train for that.  I wouldn’t enjoy Dry January.  I would find it hard and frustrating.  But I think I could probably do it (and I don’t think I’m entirely conning myself on this one).  But I wouldn’t necessarily have learnt a great deal about how to drink fewer pints when I do go out on a Friday evening, or how to not finish off a bottle of wine when it’s open – which are going to be the more useful ‘skills’ or habits in the long-term.

And what’s the message that a Dry January sends?  It’s drawing on the longstanding tradition of having a bit of a ‘detox’ in the new year to try to counteract the supposed ‘excesses’ of the Christmas period.  And so there’s a danger it just reinforces that pattern of drink heavily, then make up for it later by having some time off.  In fact, it looks like patterns of drinking are important in determining how harmful a particular level of consumption is.  Spreading the same amount of alcohol over several days or weeks is less damaging to your health than cramming it into one or two ‘binges’ or ‘bouts’.  As I said in the radio piece, it would be safer to drink exactly the same amount over two months, but rather than having December be ‘wet’ and then January ‘dry’, make both of these ‘damp’ – don’t take a feast and fast approach.  (The idea of labelling something 'damp' comes from this piece on 'damp feminism' - though personally I think I'd prefer the more idealistic 'wet feminism'.)

Of course there is some evidence that people do make changes to their drinking behaviour in the light of Dry January, and I would never deny that this might be a good thing for some people.  At the very least, you’ll reap some of those health benefits Professor Moore talks about.

But who is most likely to make these changes?  Well, unsurprisingly, looking at the main evaluation of Dry January in terms of who participated and made long-term changes (rather than Prof Moore’s work on the direct and immediate health effects), the people most likely not only to have low levels of drinking, but to have changed their drinking, are those who were drinking least to start with.

This isn’t really surprising, and isn’t a condemnation of Dry January, but it is something we should be aware of if the campaign is being advocated as something that will achieve public health aims.  Most of us don’t drink more than health guidelines advise, so it follows that for most people, while Dry January might be helping at the margins, that’s not where energy should be focused.  It’s not clear it’s that effective for higher risk drinkers.  And that’s only looking at the people who participate – which is in itself a self-selecting sample.  Again – and for both of these points we simply lack robust evidence – it seems that those most in need of support are those least likely to engage.

And that’s where I have my biggest concern about the coverage given to this campaign.  Is Dry January something public health departments should be encouraging?  Well, this year PHE aren’t pulling out the stops to support it this year, and in fact our local health improvement service is more likely to be running a campaign in February.

Although it wasn’t universally acclaimed, I have a lot of time for the review of evidence on alcohol interventions PHE published shortly before Christmas – and I’d argue that if we’re going to do anything to address alcohol consumption beyond treatment for those with dependency issues, we should be focusing our time and energy on the actions they identify as being evidence based.

That doesn’t mean that individuals shouldn’t do Dry January, and I welcome the development as a potentially useful natural experiment, but it needs a lot more evidence and people undertaking it need to be clear about what they’re trying to achieve with it.  It isn’t a get out of jail free card for previous or future excesses, unfortunately.

But as soon as it’s thought of as Dryathlon, now that’s a different story.  The whole movement makes more sense when I think of it like sponsored marathon running: it’s an excuse to get people to give to charity; it raises awareness of an issue; it’s not really going to engender long-term behaviour change – it’s about undergoing a trial and proving something to yourself (and other people).

(Incidentally, Dryathlon isn’t run by Alcohol Concern.)

So if you’re thinking of giving up alcohol for January, or Lent, or any other time – go for it (assuming you’ve not got signs of dependency that would make it risky).  You can even ask me to sponsor you, and I’ll probably do it out of some form of guilt.  Just make your choice of charity a good one, and remember that I’ll be giving grudgingly as I don’t really understand the point of sponsored events in the first place.  I’m happy just to give to a good cause, without any fancy dress or test of physical endurance being undertaken.

Wednesday, 7 December 2016

Concern isn't research and reducing harm won't mean zero harm

This morning, the merger of Alcohol Research UK (ARUK) and Alcohol Concern has been announced.

I have some concerns about this, and they really hang on whether the two organisations do in fact have ‘virtually identical charitable objects’, as the press release suggests.

But I want to explain that in a bit more detail, and give some insight into the background and perspective I bring to this discussion, as I think that’s crucially important.  In commenting on this merger, I’ll be revealing my prejudices about Alcohol Concern, which are really twofold.

And I do mean prejudices: people and organisations come to alcohol issues with their own background and perspective.  One thing I’ve discussed with some people in the sector is the way in which people’s own views and experiences of drinking and drunkenness can shape their views of alcohol.  So people who don’t find alcohol or drunkenness particularly attractive or enjoyable will tend to take a view of indifference or bemusement to the drug, if not outright hostility – much in the way many people now do of tobacco, which I always think of one of the worst drugs around in terms of cost-benefit or risk analysis (and yet it’s still bizarrely attractive for all that).

My use of the ‘carnivalesque’ as a concept is deliberately positive and ‘constructive’ – as the standard sociological/anthropological approach to alcohol is.  If I could sum up my concern with the merger in one sentence, it would be that I don't think Alcohol Concern can comfortably take that approach of thinking of ‘constructive drinking’.  However, that might not be the role of Alcohol Concern/Research – or at least only insofar as we have to acknowledge the ‘real world’ of how people interact with alcohol.

But specifically, here are those two negative impressions of Alcohol Concern.

First, they have a particular reputation within the sector and the wider media, as a go-to organisation for ‘anti-alcohol’ stories.  I can see that some people would argue that we need that kind of contribution to the debate, given the way media discussions seem to be set up as adversarial (despite my personal discomfort with playing that game).

Second, and partly as a consequence, I worry about the accuracy and impartiality of their research and advocacy.  I’m still not persuaded on Dry January.  It’s not really a reminder of the health benefits of regular alcohol free days, and I worry that it encourages an on-off approach to alcohol that isn’t always healthy.  (See also the potential negative consequences of the Scottish drink drive limit leading to ‘strategically’ planned drinking.  If I'm ‘strategically planning’ my drinking, you can be confident I won't be drinking halves.)

When Alcohol Concern report on Dry January, which is a potentially important public health intervention to change drinking cultures, they’re not aiming to be the most accurate and impartial people in the discussion; they’re also thinking about boosting the numbers signing up for the next round.

Sometimes, I get the same impression I do of the police or the Amy Winehouse foundation going into schools to deliver things that are well-intentioned but potentially counter-productive – or at best inefficient.

So much for my concern about Alcohol Concern.  By contrast, I see ARUK as an organisation that has carved out a niche in terms of being relatively impartial and simply representing ‘the evidence’ (even if that itself is a questionable concept).

Now there are potential positives there, as ARUK could drag Alcohol Concern’s lobbying and advocacy to be more accurate.  If Dry January really is effective, great.  If it isn’t, the ARUK-style influence might push them towards other interventions.  And Alcohol Concern (and Dry January particularly) has a high profile, and ARUK does amongst a different group of people, so perhaps together there will be an organisation with a louder, more accurate voice contributing to the debate.

But the flipside is that potentially ARUK’s apparently neutral position to reduce harm (and of course nothing is ‘neutral’) could be tarnished.  Of course Chris Snowdon’s at this already.

Now it might be that this isn’t the case, and it’s certainly simplistic, but I fear that with people like (the other) Dave Roberts, Mark Baird, Chris etc already looking for holes in any alcohol-related research, this could dilute the influence attached to ARUK interventions.

Much as I like the idea of commentators having some kind of ‘skin in the game’, to reference Nassim Nicholas Taleb, I think this doesn’t look so good for commentators on ‘evidence’.  Public debate is still structured around this idea of independent evidence that can (or should) speak for itself.  I heard a PHE regional representative yesterday describe the alcohol evidence review in these terms, still talking very clearly in the language of ‘evidence based policy’.

Dave/Chris/Mark have started not only to attack the accuracy of the Sheffield model (which I think the ARUK-type voice could credibly counter), but also their very motivation – that they have a vested interest in claiming the model works, either as temperance advocates or because they’ve got economic and egoistic interests in being proved right.  Once you’re on that ground, there’s no need to even engage with the ‘evidence’ because of its source.

This is pretty close to my discomfort with the Alcohol Concern advocacy/research/campaign work (which is why I call it a bit of a prejudice). To be fair, though, alcohol and tobacco academic researchers do this with industry-related work – though this does mean that some commentators are, as so often, having their cake and eating it.

And this comes back to that point of the moral or personal preference baggage you bring with you, and why Alcohol Concern has rubbed me up the wrong way.  They seem to come from a position where alcohol consumption is bad in itself.

I challenged former Chief Exec Jackie Ballard at an event about alcohol use and older people where she suggested that we should be telling older people they’ll get cancer or other diseases if they drink at certain levels.  This wasn’t what the research we’d just been hearing about showed.  In fact, it showed almost the opposite: that there are plenty of people who drink at pretty high levels who don’t suffer harm.  That’s precisely the challenge in communicating risk.  We can’t offer a credible message that is apocalyptic.  Jackie’s response to me could have been read as not understanding the nature of risk, but I felt it was something more than that; it was wanting to be able to make the case that all alcohol consumption is harmful (or bad).  I’ve written before about how that makes me feel uncomfortable.

Although the mission statements of the two organisations are remarkably similar, I think this difference in approach is shown by just one word: ‘no’.  The press release announcing the merger notes that ‘Alcohol Research UK works to reduce levels of alcohol-related harm’ and ‘Alcohol Concern works throughout England and Wales towards our vision of a world where alcohol does no harm’.

Reducing harm is not the same as seeing the ideal as a world where alcohol does no harm.  Of course, there are arguments for setting unachievable aspirations – as in ‘outcomes based accountability’, for example.  But in relation to practical policymaking, it feels a little awkward and utopian.

More importantly, though, it suggests a genuine difference of approach between the two organisations.  Given the nature of risk, the only way to ensure Alcohol Concern’s vision of ‘a world where alcohol does no harm’ is to reduce alcohol consumption to zero.  This is not just a quantitatively, but qualitatively, different aim from ARUK’s ‘reduce levels of alcohol-related harm’.  Even if this zero consumption world will only ever be an aspiration, it makes for a very different approach, and betrays a very different fundamental approach to this multifaceted substance.  (It’s not quite, but nearly, back to that old debate of whether we’re concerned with consumption or harm.)

Some of this response to the merger is inevitably personal, but I think it’s no less important for that – and commentators in general could be a bit more open about their own perspective.  If I were to write about my gut reaction, it would be the same as this slightly intellectualised response to the words ‘no’ or ‘zero’: I feel ARUK are probably ‘like me’, where I don’t think that of Alcohol Concern.

Of course, it could be that the influence of ARUK overcomes my concerns on all of this, and I’d genuinely welcome that, because of the frustrations outlined above – but I think the merger will pose a significant PR challenge for the new organisation.

There will always be tensions in merging what could simplistically be described as a ‘doing’ organisation in Alcohol Concern – with its research, consultancy and advocacy – and a ‘thinking’ organisation in ARUK.  But maybe those distinctions are breaking down in a world where research must demonstrate ‘impact’ – and perhaps that’s a good thing.

Saturday, 3 December 2016

Identity? Culture? Economics? It's all about power

On this blog I tend not to write about politics directly, but it’s hard to ignore politics today – even discussions of cannabis regulation include a nod to Donald Trump. Although I’ve mostly focused on issues of alcohol and drugs on the blog, the original intention was to discuss any public policy issue where I felt there was a lack of openness or clarity.

This often means that posts are reflective, or detached, questioning the terms of an argument as much as the conclusions, and this post is no exception.  I’m not going to come up with my own analysis of ‘why Trump won’, or why people voted for Brexit; there are other people far more knowledgeable and intelligent than me to do that.  What I want to do is suggest that in the post-mortems of the past year’s political developments, we seem to be approaching the analysis with the same kind of superficial thinking that characterised debate and commentary in the lead up to both elections.

Much of the debate I’ve seen has focused on whether ‘the left’ took a wrong turn after the 1980s, eschewing materialist politics for identity politics, where the focus was on respecting minorities and cultural difference, rather than dealing with economic inequality.  (At this point, I just want to emphasise that this is by no means a new academic debate – I’m re-reading Redistribution or Recognition, which is well over 10 years old, and the issue felt a little stale even back then given all the political sociology on ‘post-materialist’ politics.)

On one side, people like Imogen Tyler have suggested that votes for Trump were precisely an embodiment of this kind of identity politics – only the identity was of white men, rather than the minorities this approach tends to be associated with.

Others, like Simon Winlow and Steve Hall responded to this position by suggesting that in fact if only politicians had taken working-class materialist concerns seriously, the voters would never have been seduced down the blind alley of identity politics.  These commentators are concerned that the white working class is being labelled as racist when in fact they’re concerned about their economic security, which has been undermined by decades of neoliberal social and economic policy.

(My choices of commentators are sociologists, because of my academic background, not mainstream commentators – but this mirrors the general debate.)

It won’t surprise regular readers of this blog to find out that I think this is too black and white a reading of the issue.

The neatest explanation of this I’ve seen is this one, which notes that racism, sexism, and any other form of discrimination have economic effects.  They are not simply about ‘identity’.  There is no pure market where people interact without identity markers, without prejudice, where they are only interested in the cash nexus.

But if this has all been explained so well already, what can I add in a blog post several weeks after the event?  Well, I want to suggest that this comes down to taking a nuanced, complex understanding of the world.

It can be argued that at the heart of any area of thought on human behaviour – whether sociology, psychology, politics, health, economics – there is a concern with power or control.  What happens, and why?  Who or what influences what happens?

And without being facile, power is a complicated thing.  As any student of political sociology will tell you, it’s even very difficult to define as a concept, let alone trace and understand in real life.

My contention, which again won’t be surprising to regular readers of the blog, is that power isn’t simply economic.  I’m not going to go into that in detail here, but suffice to say that not all people from the same ethnic or gender group are equal, but equally neither are all billionaires: their influence will be shaped by not only their wealth and income, but also wider social and cultural capital.

With this idea of power as something more than economics or identity, it’s useful to make what seems like a trivial statement: these elections were about power.  I don’t mean simply that the electorate exercised its voting power; I mean that that people were voting to experience (as much as acquire) power and control, and this is reflected in the result.

Whether it’s about culture, economics, identity, or something else, people really did want to ‘take back control’.  And to decide which of these factors it was all ‘fundamentally’ about is to debate whether the chicken or egg came first.  On top of that, when you think of voters themselves, we’re not looking at one chicken and one egg and thinking which came first; there is a never-ending cycle of billions of ‘chickens and eggs’ across the world.

To stretch this analogy to breaking point, we should probably simply accept that chickens lay eggs and eggs hatch into chickens.  Culture, identity, economics, social connections – these are all elements of life, whether political or not.  They’re not going away, and will continue to shape power relations and politics.

Let’s think of this idea of power or control in more practical terms.  Control is of course related to money, finances, or however we want to label economic capital.  But people on the same salary are not – and do not see themselves – as being identical, equal, or even similar.  And that means that ‘the elite’ is not simply about money so much as culture.  This could be seen as an issue of ‘identity politics’ or soixante-huitard politics, but that genie is well and truly out of the bottle.  Practical politics is shaped by the here and now.  And indeed, for all that post-materialist politics is seen as a post-war phenomenon, there’s never been a neat and perfect correlation between class and political behaviour – otherwise there would be far fewer jobs in political sociology, and books like The Ragged Trousered Philanthropists and Felix Holt wouldn’t exist, for example.

To some extent, it’s a bit facile to suggest that explanations should acknowledge that there were lots of voters, each with various interacting influences and motivations.  But if it is facile, it somehow still seems to need saying.

Nassim Nicholas Taleb has criticised what he calls the ‘Intellectual Yet Idiot’ in polemic, sarcastic fashion, but there is a germ of truth in his analysis, which suggests that many people have been too quick to leap to single overarching explanations or views.  So just as they could not accept that Trump or Brexit were possibilities, so they now leap to a single certain position of whatever caused those votes.

My particular concern with this way of thinking is that it perfectly chimes with my experience of university education, where the emphasis was more on having a clear, forceful, eye-catching argument, rather than being accurate or ‘correct’.  And this isn’t confined to undergraduates – just think of Niall Ferguson.

That is, those who should be most likely to lead us in careful, nuanced thinking – academics – seem to be led themselves into definite, eye-catching statements (remember the claims that the Brexit and Trump votes are fundamentally about neoliberalism and economics).

People and life are complicated.  This seems, again, a facile statement, but it’s a truth that is far from universally acknowledged at the moment.  If this blog post is anything other than an incoherent ramble of frustration, it’s an expression of my wish for that truth to be more widely acknowledged by academics, commentators, policymakers, voters and (most of all) politicians.

Interestingly, politicians acknowledge the complexity of the world in drug policy, by pretending that things are simple.  If there’s something positive for me to cling to in today’s make-believe, black-and-white world of politics, perhaps it’s that behind the simple stories, there’s some complex understanding.  If that was campaigning in poetry, perhaps the governing in prose will make more sense.  However, I’m yet to be convinced.

Tuesday, 25 October 2016

The pleasures of being a child

Recently I’ve been thinking a lot about ideas of drinking to excess – and not simply because I was out with work colleagues on Friday night; mainly because the drinking studies network has a research ‘cluster’ on this topic.

The particular context for me has been ideas of transition.  There have been a couple of articles that caught my eye describing a shift from drinking patterns identified as problematic to something more reasonable – specifically abstinence.  The theme of both articles was to question why drinking should somehow be seen as the norm, whereby people don’t recognise that relaxation or fun is possible without intoxication.

What grabbed me was the statement by one of the authors that the reason she was comfortable not drinking was that she ‘liked’ herself sober.  Initially, I tried to suggest this was in tension with ideas of Britishness – it’s not very British to admit you ‘like’ yourself.  But then I thought this was perhaps more personal; it’s a journey of change and self-acceptance I haven’t been on.

And discussion of drinking – particularly this idea of drinking to ‘excess’, whatever that might be – are often framed in these terms: that there is a ‘better’ way of drinking (perhaps not drinking at all) that is more sophisticated, more adult.

This isn’t just the tone of media commentary on ‘binge’ drinking and young people.  It’s also the tone of several academic commentaries on alcohol consumption.  I’ve recently been reading a collection of essays edited by Tom Thurnell-Read, Drinking Dilemmas, which comes out of a conference of that same drinking studies network.

The book has many strengths (as well as a few weaknesses), which I’ll be writing about elsewhere, but here I just want to focus on the argument of one author: Oliver Smith.  Smith argues that while we might tend to see the ‘night-time economy’ as the domain of hedonistic 18-25s, there are many older consumers – and perhaps an increasing number of these –who feel they can’t (or simply don’t want to) let go of this way of spending evenings.  This, he describes in the context of Slavoj Žižek’s idea of ‘cultural infantilisation’.

My problem with this is two-fold.  First, I’m not sure why some of the relevant markers are characteristic of ‘infantilisation’.  I take the point that drinking bottles of wine after work isn’t necessarily an example of the ‘café society’ (p.183), but equally I struggle to see how this use of alcohol (or intoxication) as a reward is childish or teenaged.

Similarly, I’m not sure why a 1980s themed nightclub is childish (pp.174-5).  The cultural markers (neon colours, references to Frankie Goes to Hollywood) say more about the decade than the age of any particular consumers.  And if the consumers we’re talking about were children in the 1980s, this could be seen as the opposite of infantilisation: perhaps they’re not struggling to rediscover or extend their childhood so much as to behave in a way that was characteristically ‘adult’ while they were growing up.

But Smith’s core point is more fundamental than this.  It is that these young (but ageing) people have been unable to claim ‘traditional’ markers of adulthood – such as stable employment, owning a home, or marriage – and therefore seek meaning in the night-time economy.  And this is not presented neutrally; there is an undoubted judgement in describing ‘the birth of the infantile narcissist’ fostered by ‘consumer capitalism’.

I struggle with the ahistorical nature of these comparisons, which seem to owe more to a direct comparison with a generation born in the 1950s than any long-term aspects of British drinking cultures or wider social trends.  You could equally look at the centrality of ‘having a laff’ (often practical jokes at work) to Paul Willis’ young participants, who were precisely being socialised into that modernist, class-based working culture.  Home ownership is a relatively new (realistic) aspiration for most working people, particularly amongst the working class, who would often live with parents even after being married.  There are plenty of examples of young (and not so young) people struggling to carve out identities in periods of high unemployment and full employment.

The account from Smith reminds me more than anything of the postwar novels of the ‘Angry Young Men’.  Young men struggling not with the accessibility of those ‘markers of adulthood’, but their value.  Using the night-time economy as a way of achieving status (even if that means drinking contests, falling down stairs and vomiting on well-behaved, more ‘adult’ drinkers).  The narrative arc of stories such as Saturday Night and Sunday Morning, A Kind of Loving and Room at the Top leads to the main character getting married (though sometimes still living at home – or with the mother-in-law) and possibly having children – but is the achievement of these ‘markers of adulthood’ really seen as success, or something desirable?  These aren’t happy endings.

Smith’s concern with these drinking practices seems to be that they are ‘almost entirely driven by the consumer economy’ (p.184) and somehow empty of meaning – apparently lacking, as they do, the ‘gravitas’ of workplace pranks.

And here we get to the nub of so many critiques of the night-time economy.  Calling drinking in the night-time economy infantile narcissism is really a critique of consumerist pleasure.  But what is better, and why?  What does becoming an ‘adult’ mean in this world of ‘consumer capitalism’?  Why is this any better than remaining ‘infantile’, if infantilism is pleasurable?  As so often, we’re back to an idea that somehow drinking ‘to excess’ is inherently wrong, or undesirable.  And as a recent article by Toby Seddon on the nature of ‘drugs’ makes clear, this is likely to involve stigmatising certain groups within society, and taking a view of pleasure and fulfilment that is far from universally accepted.

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?