Promoters of Ireland's official anti-drinking campaign aren't thinking straight.
Ireland appears to be in the grip of something of a panic about alcohol – a panic that seems to have displaced its preoccupation with illicit drugs.
A recent official report revealed a dramatic increase in alcohol consumption per head in Ireland, although it still lags behind many European countries. Binge drinking by young people, alcohol-related public disorder and domestic violence, and drink driving have all been the focus of intense public debate in recent months.
In the week of the Nice referendum in Ireland (see A not-so Nice referendum, by Brendan O’Neill), some of the insecurities underlying the panic about alcohol became apparent. Traditional forces for social order are in disarray. Leading figures in all the main political parties have been discredited by long-running inquiries revealing corruption on a scale that dwarfs any of Britain’s recent sleaze scandals. Yet more revelations of clerical sexual abuse and of the failure of the Catholic hierarchy to take decisive action against it are leading to demands for the resignation of Ireland’s leading prelate, Cardinal Desmond Connell.
All the pundits agree that the Celtic Tiger is now an endangered species. But while the Nice referendum revealed the contempt of Ireland’s political elite for the electorate, the relative economic prosperity of the past decade provides the elite with its last shred of legitimacy.
Underneath the elite’s concern about the drinking behaviour of the nation’s youth lies its anxiety about the breakdown of traditional sources of order and social control. Many who work in alcohol policy see the way forward in the promotion of more restrained drinking practices, particularly through the education system, but also through healthcare.
But the attempt to use GPs to implement the government’s anti-alcohol strategy – a key feature of public health initiatives in Britain as well as Ireland – is both illegitimate and destined to fail.
The Japanese eat very little fat and suffer fewer heart attacks than the British or Americans. The French eat a lot of fat and also suffer fewer heart attacks than the British or Americans. The Japanese drink very little red wine and suffer fewer heart attacks than the British or Americans. The Italians drink excessive amounts of red wine and also suffer fewer heart attacks than the British or Americans.
CONCLUSION: Eat and drink what you like. What kills you is speaking English.
It is easy to mock ‘risk factor’ epidemiology. Yet there is a real danger in the trend among promoters of public health to translate risk factors for disease into prescriptions for behaviour. Despite the lack of good evidence for any lifestyle advice beyond the recommendation to stop smoking, doctors have taken to advising their patients – often in a dogmatic and moralistic manner – about diet, exercise, sex and alcohol.
Of course, there are dangers to excessive alcohol consumption. It has long been recognised that acute intoxication sometimes induces violent or self-destructive behaviour, and that chronic excess consumption leads to cirrhosis of the liver and a range of other diseases. In the past, public concerns about the damaging consequences of alcohol excess were expressed in the temperance movement.
The anti-alcohol initiatives of the past decade have revived the puritanical spirit of the temperance movement, but in a modern, medicalised form. Alcohol dependency is now regarded as a disease – though one affecting a growing proportion of the population.
Whereas the old temperance movement was dedicated to rescuing the ‘habitual drunk’, the medical temperance movement shifted the focus of attention, first from the ‘alcoholic’ to the ‘problem drinker’, and then to the whole of society. The key to this transition in Britain was the adoption in the 1980s of the system of calculating recommended limits to alcohol consumption in units: 21 for men, 14 for women.
These calculations of alcohol consumption are highly arbitrary: there is no strong scientific evidence for any of these figures, which are simply based on extrapolating from studies relating levels of alcohol consumption to manifestations of disease among heavy drinkers to the rest of society.
There is a trend for alcohol limits to become tighter – a trend more related to the increasing sobriety of the wider political climate than to the emergence of epidemiological evidence justifying a more abstemious policy. And, according to the 21/14 criteria, more than a quarter of men and more than one in 10 women in Britain are drinking excessively.
In short, the medicalisation of alcohol has resulted in a dramatic inflation of the scale of the problem, justifying a more systematic intervention in the drinking habits of society.
In the Health of the Nation campaign in the early 1990s, the British government set specific targets to reduce alcohol consumption. It was the task of GPs to reduce the proportion of excessive male drinkers by 10 percent and that of female drinkers by four percent by 2005.
But public health campaigns about alcohol have been dogged by controversies.
One controversy surrounded the ‘population strategy’ advocated by the epidemiologist Geoffrey Rose. This strategy was based on the recognition that the pattern of drinking in society was unevenly distributed, with relatively small numbers at either extreme and the bulk of the population falling in the moderate middle ground.
Instead of following the traditional approach of concentrating on a few heavy drinkers, the population strategy set about shifting the whole pattern of drinking in society in a more moderate direction. The idea was that if everybody was drinking slightly less, then there would be fewer problem drinkers.
The fallacy of this argument is readily apparent: it is quite possible for many moderate drinkers to reduce their drinking to an even more moderate level, while a few hard drinkers carry on just as before or even increase their intake. The appeal of the population strategy to government is that it legitimises intervention in the personal behaviour of everybody, while avoiding the stigmatising character of any approach targeted specifically at problem drinkers.
Another controversy surrounds the fact that the relationship between alcohol consumption and life expectancy depicted graphically, is not linear, but ‘J-shaped’ (that is, although heavy drinking is bad for health, drinking a small amount seems to be beneficial).
In the 1990s, new studies showed that moderate drinking had a beneficial effect on health and longevity. According to a 1994 study by Richard Doll, the elder statesman of British epidemiology, drinking a couple of glasses of wine a day had a ‘cardio-protective’ effect, reducing the risk of coronary heart disease.
Doll’s paper was denounced by the director of the World Health Organisation’s (WHO) ‘programme on substance abuse’, who insisted that alcohol was a risky, addictive and toxic substance. The WHO was concerned that the publicity given to this study might encourage people to start drinking: ‘we are seeking to demystify the idea that alcohol is good for your health and to debunk the idea that to have a drink a day will keep the doctor away.’
Two leading epidemiologists posed the problem confronting health promoters in the area of alcohol consumption, as: ‘Is it possible to persuade older non-drinkers to drink a little for the benefit of their health, and is it possible to do this without increasing the number of people, especially teenagers, who drink at levels that are dangerous?’
This comment confirms both the remoteness of health promoters from the real world and the absurdity of the debate about alcohol and health. For the vast majority of people, whether they are teetotallers or drunks, or at some point on the wide spectrum in between, concerns about health are not a significant factor in their drinking behaviour.
People may drink alcohol in varying quantities (or may not drink at all) for all sorts of cultural, social and psychological reasons. In my experience, most habitual heavy drinkers are well aware that alcohol does not have a beneficial effect on their health, but reminding them of this does not inhibit their consumption. People who drink only occasionally or not at all have their own reasons, among which concerns about health are not likely to be prominent.
Only an epidemiologist could believe that either a middle-aged non-drinker sitting at home or a teenager going out on a weekend is going to be influenced by government propaganda advising them of the health benefits of ‘sensible drinking’.
Because heavy drinking is damaging to health does not mean that drinking alcohol is itself a medical problem. It is true that virtually every form of human activity, from playing football to watching football on TV, has consequences for health. It is arguable which is more dangerous: playing football, to joints and bones, or watching football, to the cardiovascular system (and both players and couch potatoes are at risk of alcoholism).
Some doctors seek to widen their professional remit to cover the entire range of human experience. A recent WHO report recommends treating violence as a public health problem, proposing a role for doctors in dealing with youth violence, child abuse, violence by intimate partners, abuse of elderly people, sexual violence, self-directed violence and collective violence. That should keep us busy.
But medical megalomania carries dangers for doctors and for patients. The expansion of medical practice into the regulation of behaviour carries doctors beyond their sphere of expertise and competence. When medical science is prostituted in the service of social control and political expediency – both significant trends under the New Labour government in Britain – both medicine and society will suffer.
If doctors assume the role of social worker, politician or even policeman, their relations with patients are likely to become more authoritarian and conflictual. If, instead of providing cure or care, doctors become intrusive and moralising, they will soon lose the respect of their patients.
When should a doctor intervene in a patient’s drinking? A doctor should intervene only when a patient requests help with an alcohol problem, or when a patient presents a clearly alcohol-related problem.
Otherwise, doctors should follow the advice of the great microbiologist Rene Dubos: ‘In the words of a wise physician, it is part of the doctor’s function to make it possible for his patients to go on doing the pleasant things that are bad for them – smoking too much, eating too much, drinking too much – without killing themselves any sooner than is necessary.’
Dr Michael Fitzpatrick is the author of MMR and Autism, Routledge, 2004 (buy this book from Amazon (UK) or Amazon (USA)); and The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA). He is also a contributor to Alternative Medicine: Should We Swallow It? Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)).
This is adapted from speech given to the ‘Alcohol, Ethics and Society’ conference in Dublin in September 2002, organised by the International Center for Alcohol Policy, Washington, DC and the National College of Ireland in Dublin. The conference was attended by representatives of the alcohol industry and people involved in alcohol policy and public health from around the world.
Why Irish eyes aren’t smiling, by Brendan O’Neill
Medicalising everyday life, by Dr Michael Fitzpatrick
spiked-issue: Drink and drugs
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