Thursday, 13 March 2014

A new kind of drunkenness and the future of Public Health?

On Wednesday afternoon I was at an event at Southampton University – ‘Big Alcohol, Big Tobacco, Big Influence.  New vectors for global diseases’.  The event was very much targeted at public health academics and professionals, thinking about how best to tackle the challenges seen ahead.  You can (at the time I’m writing) watch the whole thing here: (the event actually starts about 8mins 40sec into the video)

I’ve got two real themes I’m going to take up here.

One is (again) about the idea of a change in drinking habits in the UK in the past 25 years, prompted by Nick Sheron’s presentation.  I should admit an interest here: I am very much of the generation that was brought up in this apparently ‘new’ culture – it was as I finished my undergraduate degree that alcohol consumption in the UK began to decline; no mere coincidence.

The other theme is based on Gerard Hastings’ presentation, which made me wonder about what the discipline of public health is for (again).

There were some pretty big names there.  Don Nutbeam, Vice Chancellor of the university, has considerable experience of working in government as a public health advisor, and opened the event.  The chair was Sir Ian Gilmore, and the speakers were Linda Bauld, Geof Rayner, Nick Sheron and Gerard Hastings.  (Links to their work are on the event page.)

There was lots of (healthy) food for thought. The most useful section for me was Nick Sheron outlining some well-analysed stats relating to alcohol health harm.  Given that my working time is basically split between commissioning substance misuse treatment services and thinking about alcohol policy from an academic perspective, there was lots to chew over (to continue the clunky food metaphor).

Nick’s point was that much more than overall average alcohol consumption, we have to think about affordability and patterns of consumption within that, as overall figures don’t necessarily predict harm levels that well.  For this reason, relatively recent increases in spirits and strong beer consumption are worth thinking about.

However, I’m still sceptical about the idea of a ‘new’ kind of drinking or drunkenness – that’s just what Henry Fielding said about gin.  And the marketing might be different, but that’s not necessarily the primary cause of the change in drinking behaviour: the marketers are responding to a potential market.

It’s interesting that Nick accepted the Parker/Brain/Measham view of the 1990s change in drinking habits as being about the ‘industry’ being panicked by ‘rave culture’, and putting all its efforts into tempting young people (back?) into pubs by presenting alcohol as a psychoactive substance.  This doesn’t quite fit with his claim that there was no binge drinking when he was at university in the 1970s – or at least no spirits drinking.  If that was the case, why would the drinks industry suddenly be in crisis in the 1990s?  Surely young people not drinking much would be nothing new?  Certainly the trend data don’t seem to suggest a major decline in consumption in these years.

Sticking my neck out with some speculation, which I can do as this is a blog not an academic article, I’d suggest that actually rather than a crisis for the industry this was a great opportunity.  You can read commentators from the 1930s, 1940s or the 1950s worrying about young people not going to pubs any more – they go to the cinema, or coffee bars, or dances.

At the same time, however, plenty of young people were going to pubs and getting drunk (or ‘buggering off with the bloody port-wine’, as one young woman put it).  And, to be a bit cavalier and take fiction from a few years later as a source: ‘Can’t tek the drink, that’s what’s the matter wi’ yo’ young ‘uns.’

What’s different in the 1990s and since is the affordability of alcohol.  This isn’t, as Nick Sheron came close to suggesting a couple of times, a measure of the ‘real’ price of alcohol.  It also relates to how much money we’ve got to spend on alcohol.  And thinking of Nick’s point about his university drinking, students have more to spend, and alcohol is, relative to other consumer items, cheaper than it used to be – particular for spirits.

The spirits marketing from the 1970s and 1980s Nick displayed was appealing to middle-aged drinkers because they were the ones with the money to spend.  By the 1990s, young people had some of that too, due to a period of ‘extended adolescence’, as Rob Hollands puts it.

It’s not that deliberate drinking to drunkenness is new; it’s that it’s more prevalent, and public.

And the way to deal with this is partly to address marketing, but also to take broader measures to address affordability and availability of alcohol.

Of course, like much of the rest of the afternoon, all this sidesteps the crucial debates about liberty and competing policy priorities.  Do we want to reduce ‘binge’ drinking?  Why?

And here I come onto what I found the most interesting aspect of the whole event: Gerard Hastings’ presentation.

In a way, he was simply following Don Nutbeam’s injunction in his opening speech to ‘stand up for what we think is right’.  I strongly encourage you to watch it (starting at about 1hr 54mins).

His presentation was a self-conscious call to arms, to stir people to struggle for a particular vision of a better world.  I liked this presentation because it was openly, self-consciously political.  There was no dissimulation.

I agree with lots of his points – and even where I don’t, I think public policy should openly debate them.  Should we be aiming for constant economy growth, and if so why?  Is private industry the best way to allocate particular resources, and if so why?  Should marketing (especially to children) be seen as just a part of everyday life?  Should we be doing more to address climate change?

These are all important questions, and Gerard helpfully framed these, openly, as questions about what we think it is to be human.  They are necessarily political and moral questions.  And as such, the discussion of evidence-based policy that framed much of the afternoon seemed a little sideswiped.

I didn’t get the chance to ask some of the questions I had in mind, nor to raise them over food and drink afterwards, as I had to rush back to Dorchester.  However, I wanted to ask why this call to arms was something for public health professionals specifically, and whether the approach recommended would actually be helpful in pragmatic political terms.

We’ve just seen a report come out from the Health Select Committee that argues that PHE (and really the Department of Health more generally) should be more vocal in presenting the Public Health case.

Of course, people like Chris Snowdon disagree (for reasons I can’t entirely understand, despite a lengthy Twitter exchange).  However, I see this as a perfectly reasonable part of policymaking as a balance of competing interests and perspectives: we have to balance one set of (likely) consequences against another, and decide whether the action is worth it (even if the decision is implicit rather than consciously calculated).

I can therefore see why Geof Rayner referred to ‘our side’, but I don’t know that I’m really on any ‘side’ in that sense.  I certainly can’t square my practices, preferences and beliefs with that kind of a public health viewpoint.*
Compromise doesn’t have to imply conflict – in fact, it could imply quite the opposite.

However, what a sensible compromise does need is for all the relevant positions to be stated clearly, and there’s a role for all sorts of stakeholders and views in this – though their opinions perhaps shouldn’t be given equal weight.

This is very much in line with the description of actual policymaking given by Don Nutbeam at the beginning of the event – though the reality is of course not so ordered and open as a textbook flowchart.

My vision of Public Health is that, just like ‘industry’ stakeholders, it should be a voice round the table to be weighed up.  This weighing up depends on values and structures of thought (as I’ve written about what I call neoliberalism); you need some critieria.

And this is where Gerard Hastings’ presentation is relevant: it does make sense to have some debate about these values and structures of thought (by which I mean what we see as possible and even imaginable).

However, that’s a much broader debate, and not something that people should do as public health professionals, but rather simply as citizens.  It’s not about public health; it’s about having a strong democratic culture.

But it’s also important in terms of practical politics.  Hastings was clear that he wanted people to think seriously about genuinely shocking problems around the world – and the crucial next step was for people to actually do something about them.

But what exactly we do is up for debate.  And personally, I think that transforming public health agendas to fight business full stop would be unhelpful.  The key contribution of public health as a discipline is to put an evidence-based view about what policies would maximise public health.

It might be that that a communist society could be healthier than our (arguably) neoliberal environment today.**  However, you’d still need public health stakeholders around the table, making the case for that particular perspective – since there would continue to be other priorities and interests: providing people with more material goods, for example.

Therefore, it’s not a cop-out to argue that public health has to be something narrower and more specific than ‘good’ things (meant in the sense of ‘the good’).  In fact, it’s essential.

And more than this, I’d suggest that the more public health professionals talk in frothing terms about industry, the more likely they are to be ignored.  This is not to say that the dominant structures of thought should simply be accepted; but if someone really cares about public health, they should be thinking of an answer to the question Yvette Cooper asked Don Nutbeam when he was a civil servant working on health policy: “What can I buy?”

To persist in a metaphor he would no doubt find awkward – and revealing – I wasn’t sure what I could ‘buy’ from Gerard Hastings, or today’s event.

*I’d had some Walkers crisps on the train to the event, and later in the evening had a pint of Cornish Coaster - manufactured by a company owned by Coors.

**I mean something very specific by neoliberal, as discussed in detail here:

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