Monday, 29 April 2013

Alcohol policy and the industry

I feel that my previous post was a bit like weak academia, but what I hope to do with this one is illustrate how some elements of the model I proposed for understanding policymaking might be useful.

One of the debates I mentioned in my last post was about the role of the alcohol industry in policymaking.  This has been in the news, as a result of a report by Jim McCambridge, Ben Hawkins and Chris Holden which argued that the alcohol industry misrepresented research evidence in its submissions to the Scottish Government’s 2008 alcohol policy consultation, which included proposals for minimum unit pricing (MUP).

A lively debate followed (I found John Holmes on Twitter particularly interesting), and in one case strayed into a semantic discussion of the nature of ‘evidence’.*

The headline of a blog on the Guardian website presented the wider debate in stark terms: “Should those with a vested interest comment on minimum alcohol pricing?  This headline is itself a misrepresentation of the clear summary of the research Suzi Gage that followed.  The specific suggestion of the researchers is that ‘industry actors’ shouldn’t be involved in ‘the interpretation of research evidence’.

Thinking back to my previous post, this specific wording by McCambridge and colleagues really amounts to a claim that the alcohol industry isn’t the expert in what I posited as the second stage of thinking about policy: ‘what works’.  The gripe of McCambridge and colleagues is that the industry downplays strong evidence and promotes weak evidence or unevidenced conjecture in its place.

There is a statement in the article that ‘policy making is not a purely rational process, informed only by evidence.  It is by definition political and thus subject to a wide range of influences’.  I would take issue with this.  Policy cannot be solely informed by evidence, because evidence without aims is meaningless.  The decision on what these aims might be is certainly political, but that does not mean that it is by definition ‘not … purely rational’ – or more precisely that this somehow contrasts categorically with discussions of evidence.

What’s happening here is a prime case of the sort of problem L Susan Stebbing (the original thinker-to-some-purpose) was concerned to highlight.

It seems to me almost self-evident that the alcohol industry should be permitted to express its views on government policy, rendering the Guardian blog headline a bit of a straw man.  What’s at issue is quite how this should happen.  If we understand the injunction from McCambridge and colleagues as being that the alcohol industry shouldn’t get too involved in the ‘what works’ part of the policymaking process, this doesn’t rule out it contributing to the more fundamental question of ‘what is the problem’ (and what would be legitimate actions to address this).

This really hit home with me last November, when I was attending the DrugScope conference and felt that, regardless of my personal position, I could probably make the industry’s case better than Mark Baird was doing.  This is partly about not being so confrontational with those coming from a public health perspective, but it’s also about shifting the debate to ground where there is genuine uncertainty – and in fact there can never be certainty, because in this sense the decision is a political and moral one, rather than being simply about effectiveness.

The industry has a perfect right to sit at the policymaking table, but only as a stakeholder if it is being the industry.  If it’s trying to be a commentator on research evidence, you’re probably better off asking someone else (like McCambridge, or any number of other people).  The industry might commission research – but then you’d want to ask the actual researchers about the detail of that, rather than an industry representative such as Mark Baird (particularly given his slightly unusual definition of what constitutes ‘evidence’).

So, if I’m recommending shifting the debate to an earlier, more fundamental stage in that policymaking cycle, why, and what difference would that make?

Well, my first point is that all this industry ‘misrepresentation’ of research evidence isn’t a genuine debate about efficacy or effectiveness.  It seems fair to assume that the industry will continue to oppose intervention, even if in my view some explanations of why this is so (the shareholder imperative) are potentially a little simplistic in terms of their understanding of modern capitalism.**  Evidence can’t really change the industry’s position on intervention, because it’s based on economics and politics.

This applies not just to the alcohol industry’s position on alcohol policy, but to the issue itself in general.  The public health evidence can show that an intervention like MUP might reduce health harms across a population, or perhaps for a specific group; what it can’t show is whether this is a desirable aim, or (assuming health understood in these terms is a ‘good’ we want to promote as a society) how this balances against other potential ‘goods’ such as the pleasure of intoxication or the principles of liberty and autonomy.

L Susan Stebbing would probably argue that the industry should just come out and make this position clear, for reasons of transparency and so that we can have a constructive dialogue and genuine debate.  I’m tempted to think that, as well as this – in policymaking or public health circles perhaps – being open in this way would actually improve the industry’s standing.

Personally, I’m not sure that MUP would actually be an infringement of individuals’ (or corporations’) rights, but these sorts of arguments can’t be entirely undermined by predicted public health benefits.  When McCambridge says (in the radio link on the BBC article) that MUP would ‘benefit’ society at the expense of the industry, he’s assuming a particular view of the ‘good life’ and a particular conception of ‘society’ as opposed to ‘industry’.  These assumptions are not incontrovertible truths; they are particular ways of understanding the world.

If, in the mind of the public (or policymakers specifically), liberty and the pleasures of intoxication and taste trump living longer, that’s it – the argument is over no matter how effective a potential intervention might be.  And this would be without questioning the reliability or validity of the public health evidence.

In a sense, this is what McCambridge and colleagues are saying – as I quoted above, what they actually say is that ‘industry actors’ shouldn’t be involved in ‘the interpretation of research evidence’, and taking my model this would mean the industry wouldn’t have much of a role in the second stage – the ‘what works’ stage – but it might feed into the first: defining the problem.

However, I’m not sure how this could work out in practice.  I can’t really see the industry changing tack and being more open about their interests and objections.  (This is at a time when unfavourable comparisons with the tobacco industry are being made by McCambridge and colleagues.)  On the other hand, this doesn’t matter so much if we have policymakers and a wider public who are able to see the issues for what they are and consider them critically.

This idea of a public more willing and able to engage critically with public policy issues and cut through the rhetoric is at the core of L Susan Stebbing’s book, alongside the hope that politicians and other policymakers themselves might be clearer in their thinking and rhetoric.  Given that today, almost 75 years after it was first published, the arguments of Thinking to Some Purpose still seem directly relevant, it’s easy to be defeatist about the nature of public debate.  For the moment, though, I’m happy just to keep trying to follow Stebbing’s advice that ‘we should develop in ourselves a habit of sceptical inquiry’.

* Holmes also cited several other similar articles or findings.  One that’s quite informative is the discussion in response to this article in the BMJ.  I’m particularly interested in Don Shenker’s analogy with the car industry, where marketing a car on the basis of its safety record was apparently ‘anathema’ in the 1960s and 1970s.  (The discussion, under the tab ‘Read Responses’, seems to be free to non-subscribers.)
** On this front I immediately think of JK Galbraith’s idea of the technostructure, but there’s plenty of other work that critiques this sort of modelling of industry actors.

1 comment:

  1. Interesting stuff. I wonder if you've seen this set of papers from the PAHO, which I've found useful in understanding how policy makers could grapple with evidence (or the lack of it) when considering options for improving health.