The politics of drinking
            February 07, 2014

Drinking, smoking and inequality: the public health dilemma

 My morning potterings were stopped in their tracks on Tuesday by an interview with top epidemiologist Sir Michael Marmot on BBC Radio 4's Today programme that blew away all the nonsense on alcohol and public health*.

He was responding to the World Health Organisation's claim that we're facing a global “tidal wave” of cancer fuelled by smoking, obesity and drinking.

“I'm not quite sure I would have used the words 'tidal wave',” he said, calmly pointing out that the main reason more people are dying of cancer is that we're living longer.

He did agree, though, that stopping smoking, drinking less and managing our diets “would make a huge difference” in delaying the onset of the disease, but added that his main concern was “the causes of the causes”.

“It's close to useless to lecture people about living heathily, a waste of breath,” he said. “The causes of smoking and drinking and being overweight are very much related to where you are in society. Your chances of getting alcohol-related diseases follow the social gradient.**

“It's not just poverty, it's inequalities... and the persistence of inequalities must be tackled by taking action on those inequalities.”

There's more about this approach in the 2010 report Fair Society, Healthy Lives, better known as the Marmot Review.

Despite Marmot's standing in the health community, his solutions have been largely ignored by those with the power to do something about it. The government's response, Healthy Lives, Healthy People, published later the same year while accepting the inequalities ultimately sees health as a matter of individual responsibility, with or without 'nudging' people towards making the right decisions – of which the minimum unit pricing of alcohol is an example, I would argue.

Marmot's strategy is altogether different, costly and challenging, and flies in the face of the neoliberal orthodoxy. But as he says, it's the only real solution.

What I'm wondering is, where does the public health community stand on this question? Its priorities for dealing with the alcohol question, for instance, would seem to fall within the scope of the government's approach, even if it's more radical and nudging.

Yet it would be wrong to assume 'public health' has a single, homogenous will on this, despite the high degree of orchestration around minimum pricing and other policies to restrict the availablity of drink.

Take, for example, a report produced last October by the Scottish Public Health Observatory titled What Would it Take to Eradicate Health Inequalities.. ScotPHO is no maverick organisation. It's jointly led by NHS Health Scotland. But its study supports the "fundamental causes" theory of health inequalities in strong terms:

“If correct, the current strategy to reduce health in equalities in Scotland, which has largely focused on understanding and eradicating gradients in the proximal causes of inequalities, such as tobacco, will be ultimately futile. New mediators will inevitably emerge to replace any successfully eliminated threats...”

It also finds that the more preventable a disease, the greater the health inequality, suggesting that deprived communities lack the basic resources to resist them.

“With tobacco and alcohol-related disease, knowledge of harms, financial security, good quality employment, affirming environments and prevalent social norms can all be drawn upon to prevent initiation of drug use and/or rehabilitation from addiction.”***

It concludes that “Elimination and prevention of inequalities in all-cause mortality will only be achieved if the underlying differences in income, wealth and power across society are reduced”.

That's a pretty big ask in the current climate, and, rather oddly considering the overall thrust of the document, right at the end the authors give the smoking ban as an example of the “universal contextual change” they're looking for.

Their own arguments would suggest that if people in the lower deciles of deprivation are nudged by such measures to give up smoking and drinking “new mediators will inevitably emerge”. But I suppose public health has to be pragmatic about this sort of thing, otherwise what is it there for?

To answer my own question, perhaps it might focus its lobbying power on addressing socioeconomic inequalities rather than punting short-term solutions. But that, too, is a big ask.

*It's available on podcast for a few more days here.

** See here, for instance. 

*** More research into the 'alcohol harm paradox' is underway.

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