Phil Mellows reviews the arguments around harm reduction for drinkers; the current dire situation under neoliberal capitalism in terms of harm done by alcohol to the poorest fifth of the population; and argues for a 'paradigm shift' - government policy to address poverty and deprivation, and encourage healthy drinking behaviours.

At a guess, most people must have been totally bemused at the storm that broke around Public Health England’s recent campaign suggesting drinkers take a break from the booze a couple of days a week.

What could possibly go wrong with such a modest and sensible proposal? Yet there was a fury of recriminations and resignations. Why? Because a public health organisation had chosen to collaborate on the project with the industry-funded Drinkaware. Whatever the rights and wrongs of this, the cataclysmic reaction was surely way out of proportion, and a well-meaning message totally washed away in the deluge of exasperated outrage that came from much of the health community.

The alcohol field is, as a leading player pointed out at a recent event, criss-crossed with such political tripwires. A well-intentioned policy-maker’s knee-jerk in one direction is more likely than not to tangle in a snare and leave them flat on their face in a cowpat. There is a good reason for this. The history of the drink question is long and convoluted, and anyone seriously thinking about getting engaged in alcohol policy would be well-advised to take a step back and survey the battlefield before wading into the mud.

But where to start? How about 1974, a year of global recession and stagflation when Keynesian economics began to give way to neoliberalism and, not by chance, the year the Lalonde Report initiated a radical shift towards the idea of people taking individual responsibility for their health.

The following year saw the publication of Alcohol Control Policies in Public Health Perspective, a spin on Lalonde written by a kind of super-group of specialists led by the Finnish social scientist Kettil Bruun. In Britain it became known, cryptically, as The Purple Book. Basing its argument on a 1956 paper on alcohol-related mortality by French statistician Sully Ledermann, the Purple Book asserted that the answer to the drink question was, briefly, to reduce the availability of alcohol, chiefly through raising the price and restricting the numbers and activities of outlets.

Over a couple of decades this idea overturned the orthodoxy that had prevailed among the medical profession since the 1930s – the disease, or alcoholism, model. Rather than focusing on the plight of a subsection of humanity stricken with alcoholism, Ledermann’s research seemed to indicate that alcohol harms could be addressed by reducing alcohol consumption across the whole population. Alcohol harm became seen as a continuum in which all drinkers are potentially on the slippery slope towards dependence and everyone is drawn into alcohol policy’s remit.

This hypothesis underlay a paradigm shift in understanding the drink problem. While most people still talk of alcoholism, the term has largely disappeared from medical discourse and has been replaced by a new orthodoxy that, for its similarities to 19^th moral campaigns against the demon drink, you might call medical temperance. It was, indeed, an approach that the residues of the prohibitionist arm of the Victorian temperance movement could buy into and it produced a coalition of scientists and moralists that straddles harm reduction and post-prohibitionism.

The Drinkaware dispute starts here. The alcohol industry, while it has for centuries operated profitably within the state-imposed strictures of licensing regimes, understandably lobbies against measures that might further impede trade among the broad population, including those previously deemed not to have a drink problem. Many in the public health community consider PHE’s dalliance with the industry body as such a serious error because it distracts from what they see as the ‘real’ solution – reducing availability.

Setting recommended drinking guidelines can be viewed as another aspect of medical temperance in that it tends to sweep a broader swathe of the population into the category of ‘risky drinkers’ and conveniently presents policy-makers with a ‘problem’ on a scale that demands action at a population level. In fact, a well-publicised paper in The Lancet that recently asserted there is no safe level of alcohol consumption might well have taken this strategy a step too far. As well as undermining the credibility of the guidelines as far as the drinking public is concerned, it has divided public health.

Public health is a far from homogenous body, but it formed an unusually strong consensus around minimum unit pricing, in place in Scotland since May with Wales to follow next year. The situation in England is a sensitive one since the government was accused of backing away from the measure, under pressure from drinks industry lobbying.

The irony is that the Scottish government’s move to minimum pricing only escaped European competition laws because, while it started out as a whole population measure, its advocates were able to show that it is, as it turns out, a policy that targets heavier, riskier, drinkers. The success of that argument has prised open the possibility that perhaps whole population measures are not the only answer, and this doubt has been given an urgent impetus by austerity.

In May a report from Alcohol Concern, newly merged with Alcohol Research UK, identified a crisis in treatment services – it almost called it a ‘meltdown’. It showed that only 20% of those in need of help with their drinking are getting it, and the figure continues to fall as services are starved of resources, with reports of cuts of up to 58%.

The lack of political will to repair the welfare state means there is no guarantee that the hypothecated tax Alcohol Concern is arguing for will be effectively spent on alcohol treatment - any more than the recent freeze on beer duty will save the pub, as the official industry pre-Budget lobbying somewhat disingenuously implied.

Under a left-wing Labour government, and in the context of a long overdue review of the structures of alcohol taxation, including VAT, it might turn out to be a good idea. However it’s done, though, restoring and improving treatment services has become an urgent task. Beyond that, there is no simple policy wish-list that can fully address the alcohol question (nor, indeed, the pub question). It can only be approached from a broad social perspective that steps out of the polarised arguments that rage ever more ferocious between the drinks industry and public health.

Both positions, it can be argued, have their roots in neoliberal capitalism. Lalonde’s concept of a ‘new’ public health was taken up in an, admittedly, idiosyncratic fashion by Bruun et al, yet like the industry’s attempts to restore the ‘alcoholic’ approach, the whole population approach is essentially an individualist perspective in which a constructed rational subjectivity, here with free will, there under pressure from price and scarcity, chooses a healthy lifestyle.

They are two sides of the same coin, and what we need is a new coin. Another paradigm shift is due that takes us away from the bankruptcy of the alcoholic, disease model, and towards something more like the ‘old’ public health in which conditions are created in which people might enjoy a drink, and even get a little squiffy, without slithering into difficulties.

Exactly why the positive benefits of social drinking that human beings have enjoyed for most of their existence – and still enjoy today – should, in the modern age, cause problems of excess for some individuals is not well understood. The pink elephant in the bar-room, however, is that mortality statistics consistently show that the poorest fifth of the population are six to seven times more likely than the wealthiest fifth to die an alcohol related death – despite drinking less.

Yet this ‘alcohol harm paradox’, as it’s known, is not a paradox at all. Health in general is socially determined, a matter of class and a matter of the political will to address poverty and deprivation, to create a healthier society for all. And that should include a regulated environment that does not simply restrict alcohol availability but encourages the healthy drinking behaviours that can enrich our lives and strengthen social bonds.