Public Health and the power to persuade: Are we winning the argument?

I often write on this blog about evidence-based policy, but I want to write this week about how I feel torn in relation to this issue.

I was reminded of the ‘evidence-based’ phrase as I saw responses to the Government’s new drug strategy and the release of the latest drug-related death figures.  Transform, Release, Alex Stevens and others stated that the government was ‘ignoring’ evidence.

But on a quick Google search, I can’t see that Amber Rudd or Sarah Newton particularly used this phrase.  I’m not saying they didn’t use it at all, or that they wouldn’t want to make this claim – Sarah Newton did challenge the idea of decriminalisation on the basis that: ‘When you look at all the other available evidence, we just don't agree.’  I’d just suggest that they weren’t quite using the same ‘evidence based policy’ frame for their arguments.

On the Home Office webpage launching the strategy, the only reference to ‘evidence’ comes from Paul Hayes, which probably says more about the discourses of lobbyists and policy commentators than politicians.  As Alex Stevens’ own research would predict, the politicians were more interested in appearing ‘tough’ on ‘dangerous drugs’, as Sarah Newton put it in that article for DDN.

I should of course make my standard statement that when people cite evidence, it’s usually in relation to one ‘outcome’ of concern – in this case, drug-related deaths.  There is indeed good evidence that things like purity testing, drug consumption rooms, prescribed heroin, retention in treatment etc all reduce drug-related deaths (DRDs).  The problem of course comes when you acknowledge that DRDs aren’t the only outcome policymakers might be interested in (and they’re not the only drug-related outcome we should be interested in).

Regardless of our feelings about them, policymakers have other legitimate concerns: for example they worry that certain initiatives might undermine the fall in young people using substances.  That is, that decriminalisation or drug consumption rooms, or pill testing might send out the ‘wrong message’.  Giving them the benefit of the doubt, this could be genuine concern regarding harm reduction, as much as appearing ‘tough’.

(As an aside, it’s interesting that many of those who campaign on alcohol policy in the name of ‘public health’ would prefer to see fewer people using alcohol on the basis of the population model of alcohol-related harm, whereas those who campaign on policy relating to other drugs under the same banner often see no issue with more people using, and focus entirely on ‘harm’.)

But, more importantly, this isn’t just about harm reduction and drug-related deaths.  It’s also about morality.  You might think it shouldn’t be, but all politics is about morality.  Housing policy, inheritance tax, unemployment benefit – we can use ‘evidence’ in these arguments, and use economic theory to argue that putting a pound in the pocket of someone on £20,000 a year will benefit the economy more than putting it in the pocket of a millionaire, but that can’t be the end of the argument.  There will still be a discussion about whether that person ‘deserves’ that money.  And this is an important and necessary debate – because no matter which side of the political fence you sit, there are times when the ‘evidence’ for some perceived positive effect simply cannot outweigh the moral distaste you feel for a position.  And there’s the broader slippery slope argument: even if you don’t oppose this specific measure, it dilutes a point of principle that makes later distasteful initiatives more likely.

Here, we can see quite quickly how this applies to all parts of the political spectrum.  Peter Hitchens is quite open that his position on ‘drugs’ isn’t simply about the objective ‘harm’ they cause; it’s that taking intoxicants is somehow ‘wrong’.  And for all that left-liberals often like to think they’re wholly swayed by evidence, the ‘evidence’ would suggest otherwise and in fact ‘the Labour Party is a moral crusade or it is nothing’.  Finally, libertarians like Chris Snowdon often make use of the slippery slope argument.  For perfectly legitimate reasons, we don’t simply judge individual initiatives by their specific impacts on one outcome.

And most commentators on drug policy accept this – or at least are resigned to it.

Now here’s where I feel slightly torn.  My view on this blog is typically that we should acknowledge the complexity of policymaking and evaluation, and even then not discount the importance of moral or political positions; policymaking can’t simply be technocracy (even if we wanted it to be).

But then when it comes down to it, this can make me feel uncomfortable.  That is, the whole point of this blog is to encourage careful, nuanced thinking, and question black-and-white thinking, when most of life is more complicated than that.  Unfortunately, a critique of the ‘evidence-based’ position can somehow lead to an equally absolutist position of ‘anything goes’.  That is completely at odds with the aim of ‘thinking to some purpose’, as anything goes requires no thought at all.

What I mean is: even if the root cause of your position is irrational, or personal, you need to be able to articulate and explain it, maybe by saying that a certain policy is just a moral red line for you, or it just feels wrong, and describe why.  That isn’t to devalue the point; just to explain it.

And this this can sometimes be difficult and uncomfortable.  That thinking process shouldn’t simply be about saying ‘I think it so it’s reasonable’; it’s about reflecting on why you react in a particular way, and explaining it to someone else.

But when we acknowledge that, as the New Yorker article I linked to put it, ‘facts don’t change our minds’, this can open a can of worms.

As a response by a communications professional to a recent Guardian article put it: ‘telling people you’re wrong doesn’t work’.  This is generally true (although often not in a professional context, where in my experience we all seem much happier to look at evidence and change our minds), but the complexity is illustrated by the fact that the author – Nicky Hawkins – gives examples of successful campaigns that actually did exactly that: telling people they were wrong.  She explains how drink driving campaigns persuaded people that the issue wasn’t simply about ‘drunk’ drivers as much as the fact that anyone with a certain blood alcohol level will have slower reactions and poorer coordination.  That wasn’t just a way to justify the campaigns; it was the actual aim.  Deaths on the roads aren’t just caused by ‘alcoholics’.

But here’s where the difficulty arises.  The other example given is the justification for the smoking ban, where the villain of the piece became (apparently) second-hand smoke, not smokers themselves.  I don’t want to go into this in too much detail, partly because plenty of readers will know this example better than me.  But suffice to say…

(1) the timing of this campaign made it easier: there were fewer smokers, with rates particularly low amongst affluent/influential groups, so that even if smokers saw this as a personal attack they weren’t a majority or in a great position to make their voices heard.  (Of course the tobacco companies were in a strong position, but the argument wasn’t framed in relation to them, and their credibility amongst the general public was pretty low at this point.)

(2) The apparently desirable effects weren’t just about second-hand smoke; they were about persuading current smokers to give up.

So this wasn’t simply a brilliant campaign; the context is crucial, and there was some selective truth-telling (if that’s a phrase) in the accompanying justification.

There are lots of examples of this in politics in recent years (and actually, forever), so it’s a bit odd for a communications professional to offer this as a great insight.  Two recent classic examples prompted me to start this blog: drug treatment isn’t actually about crime and blood borne viruses, and tuition fees aren’t actually about getting students to pay their own way.  (The latter one is particularly egregious, because the burden to the taxpayer is not reduced, despite the popular narrative.)

I’m not saying the smoking ban was a bad idea, but I think it’s a classic case of not ‘thinking to some purpose’.  If the aim was to reduce passive smoking, then there are all sorts of options other than a ban that would have been workable.

And it’s much easier to ask people not to harm others than it is to suggest they should behave differently to stop harming themselves.  Interestingly, the same applies to the drink driving campaign: the most powerful point is that you could hurt someone else, who is innocent or your ‘vice’.

Most of the key public health debates today, though, are about people’s own decisions.  Perhaps the best way to frame these is, again, in terms of the structure that shapes these decisions: licensing, labelling, regulation, pricing.  But if the communications is designed for the general public, to directly change their decision-making, then unfortunately ideas of ‘passive drinking’ and the like have proved much less convincing; the argument is still about stopping people doing harm to themselves.

I know I’d be mistaken in hoping for some kind of Habermasian perfect communication and debate, and that kind of unrealistic aspiration is exactly what I try to critique on this blog.  My issue, as usual, is where to draw the line when you’re faced with a sea of grey, rather two clear camps of ‘good’ and ‘bad’.

The reason this has particularly resonated with me in the past couple of weeks isn’t just the fact that these three releases/articles have occurred; it’s also that I heard in my professional capacity that, pre-figuring the words of the breastfeeding article, public health professionals need to change the way they communicate with the public.  This sounds reasonable, and personally I’m not a fan of the preaching or evangelical approach – not because of its manner, but simply because I don’t share its view of the ‘good life’.  My objection isn’t the means, it’s the ends (although I don’t think you can separate them neatly).

I’m now going to draw on two people more experienced and intelligent than me.

I remember discussing with one academic a time that doubt crept into their mind about public health and the power to persuade.  If public health, in its attempts to compete with, say, the tobacco industry in trying to shape people’s beliefs and behaviour, adopts their principle of ‘persuade at almost any cost’, what makes it better than them?  That is, we have to be very careful about defining what makes ‘social’ marketing ‘good’, and ordinary marketing ‘evil’, as Gerard Hastings might put it.

This was a personal epiphany, but the general point isn’t a new insight, and it has some broader – moral – implications, to bring the discussion back to where it started: that policymaking can’t just be about technocracy.

And so to reference the other wiser head: James Nicholls (amongst others) has previously drawn attention to the role of alcohol in liberal political thought.  So let’s lookmat the nineteenth-century debate between John Stuart Mill and TH Green.  (And apologies if I oversimplify or misrepresent.  Go read James’ work if you want proper political theory.)  While Green felt it was illiberal to allow people to ‘enslave’ themselves to alcohol, and therefore recommended banning the substance, Mill rejected this argument – despite having used it to justify the abolition of slavery.  Mill suggested instead that if we’re really concerned with people’s moral behaviour, we shouldn’t use prohibition to shape it.  Someone who is only prevented from doing something immoral by the lack of opportunity isn’t showing moral character; they’re in fact behaving a lot like they’re a slave to the system.  The real show of moral character comes in making the ‘right’ choices.

And this position is further strengthened by Mill’s ‘harm principle’ that state intervention is justified when people’s actions impinge on others.  Of course in reality this is impossible to identify: no man is an island.  But the principle stands, even if the reality is more complicated.  (I can expand on this, but I think that’ll do for the moment.  Let’s just say if I do something, it potentially increases the likelihood that you will, so my decision isn’t entirely free of effects on others.)

So taking those two academic insights together, I feel uncomfortable if public health is somehow looking to change its approach.

Presenting facts is reasonable: if you drink too much you’re more likely to die earlier.  And actually evangelising is reasonable too: I believe that a longer life, full of physical activity and clean living is more rewarding and morally more valuable than other ways of living.  (I actually don’t.)

But mixing the two together, and persuading people to do something for one reason (‘you’ll love it’, ‘it’ll make you happier’) when your real reason is something else (‘the evidence suggests people will live longer and costs to the NHS will be reduced’) is distasteful to me.

And as I outlined right at the beginning, distaste can be a reasonable argument for rejecting a position, if explained.  So here’s my explanation: my distaste is that getting people to do the ‘right’ thing for the ‘wrong’ reasons is patronising and, at the risk of sounding like Chris Snowdon, a ‘slippery slope’.  If the current approach of public health professionals, with either evangelism or emphasis on ‘the evidence’ is considered patronising, wouldn’t this be even worse?

Of course you could ask: if there are two likely effects of an intervention why wouldn’t you emphasise the more powerful one?  And there might be some moments when the evidence and the emotion neatly intersect and provide powerful arguments.  But I suggest we should judge any such intervention by a crucial question: have you actually won the argument?  If you don’t care about that question, I’m not sure we’re on the same side in any debate.