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?

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.