I usually have a lot of time for Bernard Keane’s analysis. His is a voice of sanity in an otherwise dull, predictable and partisan public debate. But his critique on Monday of what he calls “preventative health wowsers” was way off the mark. It needs a response, not just because of this one article, but because vested interests and ideologues use many of the same facile arguments and too often are left unchallenged.
Bernard argues that the “the medical profession and the preventive health industry are engaged in a constant campaign against basic rights in the name of forcing Australians to become healthier”. He primarily draws on the responses to alcohol abuse, but also refers to smoking and gambling. He infers that the problem of alcohol abuse is overstated and that responses to health issue is “always to ban, to tax us and to use surveillance”. Bernard’s central thesis is that health professionals are simply social elites who want to control behaviours that they disapprove of.
On the first point that alcohol consumption is overstated, Bernard is being a little tricky with the numbers. Per capita consumption of alcohol is high by world standards with Australia ranked in the top 30 highest alcohol-consuming nations, and ahead of countries like Greece, USA, Italy Japan and Sweden. While it might be true that countries like France and Spain have higher per capita use this is only half the story, because average drinking patterns in those countries are healthier. Compare that to Australia, where one in five Australians (20.4%) drink at short-term risky/high-risk levels at least once a month (with the number rising among young adults). The burden of disease directly attributable to alcohol is uncertain but the number is probably somewhere around 5%. Between 1992 and 2001, more than 31,000 Australians died from alcohol-attributable injury and disease with over half a million hospitalisations over a similar period.
None of that might matter if you take the view that every individual has the right to drink or smoke themselves to death. However things are a little more complex than that. Foetal Alcohol Spectrum Disorder is now widely recognised as one of the most common preventable causes of birth defects and brain damage in children. It occurs when expectant mums consume alcohol during their pregnancy, many of them blissfully unaware that alcohol is harming their baby. What about the child’s right to be born free from damage? In Australia almost half of all perpetrators of assault are intoxicated before the event and it’s often innocent bystanders that get hurt. And there is the question of whether people really have a choice when they are in the grip of an addiction.
Then there is the cost. The total social cost of alcohol abuse is estimated at up to 30 billion dollars annually, with billions in costs such as crime, health, lost productivity and traffic accidents. Whenever someone ends up in a hospital or in trouble with the police it’s the community and not the individual that bears these costs. It’s ironic that some of the strongest opponents to pricing externalities like the costs of alcohol abuse, or air pollution for that matter, like to think of themselves as champions of the free market.
This brings us to the question of what sorts of intervention are appropriate. As far as Bernard’s concerned anything that smacks of a ban, tax or surveillance has no place. He outlines a long list of proposals such as banning adults from drinking alcohol at school functions to the licensing smokers. He uses this as evidence of the futility of any form of public intervention. It’s the classic straw man argument. As it happens, I agree with him that many of the suggestions in his piece are bad ideas and I suspect that some of my medical colleagues would agree. That’s because there is no “preventative health industry”. Health professionals don’t get together late at night to dream up ways to kill people’s fun.
Most of us follow the evidence and there is very good evidence of what works and what doesn’t.
Just look at the clear evidence around tobacco control to see that price, restrictions on advertising and sponsorship, labelling and public awareness campaigns have all played an effective role in reducing smoking rates. And fewer people smoking means fewer hospitalisations, which if nothing else means a reduction in the costs of funding a universal health system that we all pay for.
When it comes to alcohol reform many of the same lessons apply. When some cask wine is cheaper than bottled water it’s no wonder that problem drinkers who want to maximise their alcohol intake at the cheapest price choose that product. The evidence is clear that pricing beverages to reflect their alcohol content is an important lever to reduce problem drinking. The good news is that it’s also an effective industry measure. Taxing wine on value rather than alcohol content creates perverse incentives to drive production towards high volume low value product rather than the quality reputation on which the Australian wine industry depends. It’s why some parts of the wine industry are calling for change. Ken Henry, the former head of Treasury, recognised that the taxation of alcohol is a dog’s breakfast and called for a “volumetric” tax on all alcoholic beverages for these reasons.
Just like the tobacco example, there is also a place for alcohol labels that warn people that drinking while pregnant harms the foetus and for further restrictions on sponsorship and advertising, particularly targeted at young children.
I agree that we need to be much more careful about surveillance but the simple truth is that surveillance of drink drivers through random breath testing is one of the primary reasons we have seen a significant decrease in the road toll. Evidence shows that prohibition, on the other hand, is rarely successful and most public health advocates don’t support comprehensive bans. On this point Bernard is simply wrong. It’s for this reason that the suggestion to ban tobacco being sold to new users has not gone anywhere.
Ultimately the objective of public health policy is to balance the tension between the rights of the individual while minimising the costs to the community. Bernard’s nanny state, wowser argument is lazy andunsophisticated. I hate to disappoint him but I enjoy a drink and in my younger days I smoked the odd cigarette. I have no interest in stopping anyone’s fun. I share his libertarian instincts and agree that ultimately all adults have the right to drink and smoke themselves to an early grave. However when those choices affect others, both directly and through the public purse, the state has an obligation to act.