There but for the grace of God

Over the past few weeks, and in my previous blog post, I’ve been debating how we can best think about the support our sector tries to offer.  Sometimes this is about structures of oversight and how different services are divided up, but I’m frequently reminded of the possibly trickier issues of funding and stigma.  In this post I want to suggest they’re all potentially linked.

As I say, I’ve been thinking about targeted support and stigma a lot recently.  It’s the old issue of how you can offer targeted support to those who need it most, without creating a perception of them somehow being less than ‘normal’ people – a perception that will quite possibly make people less likely to seek out that support, as doing so would identify them as ‘in need’ or ‘at risk’.

This is a standard social policy issue, applied to school meals, university fees, child benefit, and so on.  In general terms, the argument would be that since the 1980s we have seen a move away from these approaches to something more targeted.

While there are potentially issues with this ‘targeting’ approach, the logic makes sense, and to a certain extent it’s unavoidable.  If we have limited resources, we have to ask how we can prioritise different issues or individuals.  This might seem to have become more severe during a period of austerity, but it’s not an issue that goes away: if we get an increase in funding, there will always be more worthy causes and good ideas than it can support.

But I’ve been conflating two ideas here: targeting issues and targeting people.

We will always have to balance up different initiatives or issues.  For example, are we more concerned about TB or measles as infectious diseases at the moment?

Think of this as comparable to when you move house.  You might well debate whether to redo the bathroom or kitchen first – or perhaps at the time it’s more of a priority to repaint a few other rooms.  Most of us don’t have the time or money to do everything at once.

That happens in all departments and policy areas.  We live in a finite world.

So why am I worried about stigma?

Well, targeting issues is not the same as targeting people.  (And even targeting issues can cause stigma if we see those issues as only relating to certain people.)

Let’s compare the attitude to prevention for measles and cervical cancer.  Both are prevented through vaccination, and there have been issues with ensuring coverage of both – but for quite different reasons, I would suggest.  The MMR scare has been well-documented.  The issue there is seen as being in the vaccination itself.  Some people perceive it as risky.

The issue with the HPV vaccine (though it doesn’t seem to be talked about much anymore) was that this was a sexually transmitted virus and so there was some concern that admitting to needing it was an acknowledgement that you, or perhaps more accurately your daughters, were likely to have unprotected sex.

The framing of this as a population issue helped get us over this: the vaccination is just something that health professionals recommend for everyone, to reduce our risk at a population level.  This is framed as leading to ‘community immunity’ as some people call it (to avoid thinking of people as a ‘herd’).

So what’s this got to do with alcohol?  Well this is again that old issue of whether ‘the problem’ resides in the substance (alcohol is ‘no ordinary commodity’ – a carcinogen, a toxin or a poison) or the person (‘I am an alcoholic’).  I’ve written about this before, and my usual get-out is that there are as many problems related to alcohol as there are individuals experiencing them.  We therefore shouldn’t search for a single diagnosis or solution.

But this doesn’t really help policymaking in lots of contexts.  Saying ‘it’s complicated’ (or more likely in policymaking circles ‘complex’, ‘multifactorial’ or ‘wicked’) doesn’t get us very far.  What are we going to actually do about that complexity?  (Actions speak louder than words.  You talk, we die.)

This is particularly acute when we know that, even controlling for the total amount of alcohol consumed, different groups of people experience different levels of harm.  This is partly due to certain protective factors and differences in patterns of consumption, but it’s also because risks don’t seem to just add together, they multiply.  Drinking and smoking and low levels of physical activity combine to make a particularly toxic combination for a range of health risks.

I say ‘different’ groups of people.  I mean class.  People from more deprived areas face higher levels of alcohol-related health harm even though, on average, they’re drinking less.

What can we do about this?  And what can we do about the fact that dependent drinkers are not a particularly popular group, and people find it hard to say ‘there but for the grace of God go I’?  Is this difficulty in identifying with ‘alcoholics’ partly due to the Alcoholics Anonymous approach of defining ‘alcoholics’ as a distinct, tightly defined group of people?  If we want public support for treatment or prevention, we need people to identify with those facing issues – unless we want to resort to the ‘mad, bad and dangerous to know’ approach that justified funding drug treatment in the 2000s.

Kettil Bruun and others solved this by suggesting that interventions should address a whole population (the HPV and measles approach), whereas Michael Marmot, thinking about wider public health issues, proposed something called ‘proportionate universalism’ in an attempt to square the circle: support is universally available, but targeted and made accessible for those most in need or traditionally least likely to make use of it.  Both represent a response based on the understanding that we live in a class society, which shapes both material resources and status.

So what does this mean for us today?  What are the burning issues in alcohol policy where this is relevant?

Well I’ve been thinking recently about two popular ideas.  One is labelling of alcoholic drinks, and the other is their idea of improving funding for alcohol treatment – perhaps through a ‘treatment levy’ as Alcohol Change have suggested: a specific addition to alcohol duty that is ringfenced to support alcohol treatment in the UK, which is still in some senses the ‘poor relation’ of drug treatment, which is not exactly affluent itself.

I think these two approaches (albeit slightly tweaked) have much in common, and can provide the best of the Marmot and Bruun approaches – which in themselves are attempts to get round that knowledge that, yes, alcohol is a potentially problematic substance for all, but perhaps we’re not all equally at risk.

Labelling is not simply about individual level decision-making on a specific occasion.  If we model it in that way, there’s a danger that (thinking about calories, for example) someone might choose to have a few vodkas rather than just one glass of wine, and end up drinking more alcohol.  For me, the point is more to create that general perception that for everyone alcohol is no ordinary commodity, and has risks attached.  That can then shape decision-making and culture in the longer term, both at an individual and population level.

I don’t want to overstate the potential of this.  More fundamentally you could ask the question why this information is displayed on other drinks but not ones containing alcohol.  But there is a neat dovetailing with the need for funding for alcohol treatment.

This levy is designed to specifically improve alcohol treatment, which supports people with the most serious problems but perhaps doesn’t do as much as we might hope.  In England, treatment services engage more than 50% of all people estimated to be using heroin, whereas they manage about 15% of people drinking dependently, which itself is a narrow definition of having a problem.

Specialist treatment, then, is focused on those most in need.  And here we return to the example of HPV.  If we think of the treatment of cervical (or other) cancers, debate tends not to focus on the fact that many of them are linked to ‘lifestyle’ factors such as smoking, drinking, diet, exercise, sexual behaviour (in terms of virus transmission).  Cancer is seen as a lottery and people should be treated.  Alcohol dependency is not viewed in the same way.  As in the HPV example specifically, it was seen as being linked to individual personal choices.

And this is where the idea of an alcohol levy, though logical, has some challenges.  It is an addition to alcohol duty, designed to support services that only serve a minority of the population.  I think that, rather than a levy, a more achievable idea is a broader ‘rationalisation’ of alcohol duty.  There is some appetite for this – and from organisations like the IFS, not just alcohol specialists.  From a political perspective, as I’ve noted elsewhere, there’s an opportunity to frame this kind of change as a positive of Brexit; something that I imagine politicians will be keen on (if this ever goes ahead).

The other advantage of this framing is that it feels less like a targeted tax all drinkers pay for people who have problems they don’t.  Of course this is the basic principle behind taxation and public services, but that doesn’t mean it’s an easy sell when this discussion is only about a particularly challenging issue.  If this allocation is contained within broader alcohol taxation (and I still support the idea of a hypothecated tax to produce a ringfenced budget) then that debate about the principle of ‘who pays’ is less at the forefront.  This is potentially a virtuous (or vicious) circle.  If we believe general taxation is for issues that affect us all, and alcohol treatment is funded in this way, then perhaps we might start to see alcohol treatment less as something that is for a special category of people.

And this links with the idea of labelling, which presents alcohol as a substance that comes with certain risks.

Crucially, though, this is different from the total consumption / whole population model of alcohol harm.  It acknowledges that alcohol is not all about risks adding up and leading to harmful health conditions, or even the slightly more subtle point that if we all drink more at a population level there will be more dependent drinkers.

The point is that there is, to some extent, a special category of people who are facing bigger challenges than the rest of us.  Their issues aren’t simply hangovers, ‘presenteeism’ at work and failing to fulfil some imagined potential.  But also, as with most other health or social issues, we can’t perfectly predict who they will be.  The point is to generate not just sympathy but empathy for those who need treatment.  ‘There but for the grace of God…’