Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Shooting the innocent bystander
- Michael A Parsons (21 December 2007)
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The preventive paradox.
- Peter O'Loughlin, Beckenham BR3 3AT (23 December 2007)
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alcoholic myth!
- Dr Mohan devegowda (23 December 2007)
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harm reduction versus harm prevention and rationing of alcohol
- Kavita Singhal, Ankush Singhal (26 December 2007)
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Harmful Effects of Alcohol
- Javed Latoo (27 December 2007)
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Re: harm reduction versus harm prevention and rationing of alcohol
- Peter O'Loughlin (27 December 2007)
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Can't agree more with the author
- Tamseel Awan (27 December 2007)
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Alcohol - the elephant in the surgery
- Susannah R Harris (27 December 2007)
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Reducing the harms of alcohol World-wide
- Harald M Lipman (27 December 2007)
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Forced to be Free ?
- Michael A Parsons (29 December 2007)
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... to substantiate my support against alcohol
- Tamseel Awan (30 December 2007)
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Reduction of Alcohol consumption
- Christopher G Colenso-Dunne (30 December 2007)
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Re: Can't agree more with the author
- Michael A Parsons (30 December 2007)
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Alcohol and our responsibility in UK
- Sandip Raha, CF31 1RQ (31 December 2007)
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Re: ... to substantiate my support against alcohol
- Michael A Parsons (31 December 2007)
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tough measures:grasping the thistle
- Lesley J C Graham (31 December 2007)
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Re: tough measures:grasping the thistle
- Michael A Parsons (2 January 2008)
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alcohol harms public health
- Mike J McVicar (3 January 2008)
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Logic, honesty in statistics and the real issues
- stephen black (4 January 2008)
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Re: alcohol harms public health
- Michael A Parsons (7 January 2008)
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alcoholic liver disease is costly
- Susi R Harris (8 January 2008)
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Missed opportunities.
- Jessy Saini (8 January 2008)
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Free thiamine distribution - a new intervention?
- Marit Schou Hauger (12 May 2008)
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The elephant in the surgery
- Richard M. Lee (29 July 2008)
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Michael A Parsons, Retired lecturer Oxford College OX9 9EL
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Sir I admit I am a mere outsider with an interest in social sciences, but it strikes me that the excellent medical profession is being used as a shelter for an ever-growing band of self-righteous medlers. "Ordinary public" (that is: me) are at the receiving end of repeated attempts to control minorities by punishing all of us indiscriminately, using medical qualifications as grounds (child abuse being only one example). This latest drink price hike proposal needs squashing now:- the campaign has nothing to do with alcohol abusers, who can steal or afford it anyway. Because some people make the choice to drink "too much" ( by lab. standards) why should all of us be gunned down with yet more tax? We see the same self-righteous pattern with smoking (no private smoking clubs to be allowed)even though smokers already sustain huge swathes of the medical profession by their taxes. Other examples are plans to lower the drink-drive limit; or to raise the drinking or driving age; and so on. Yet filthy hospitals cause 90 000 plus admitted deaths a year, I am told - not to mention other crippling disease effects. There is no suggestion for fining unwashed doctors and nurses though! no policy of "physician heal thyself". I think the BMJ should take a stand against the non-judgmentalism of its self-righteous enthusiasts. Careless drivers, dirty medical environments, drunken slobs - these are the areas to be singled out and dealt with sharply. Otherwise you are reduced to the futility of the "ban guns" lobby, whose success had been followed by ever-rising tides of gun crime! Time to update your social views in line with your medicine: just as we try to administer a drug that, like a magic bullet, hits the disease process involved, so we should try to target the relatively few who actually cause harm. Life has a series of tragedies for most of us, and medicalising it does not mean it can be "cured". A little more humility would be welcome, alongside the noble and lofty aims of research and practice. We have a right to choose our own poison, after all. Not everyone wants a life chronically and for ever in doctors' hands. Competing interests: None declared |
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Peter O'Loughlin, Principal Eden Lodge Practice, Beckenham BR3 3AT
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First, I would like to thank the authors for their usual no rhetoric constructive views on reducing the harms caused by alcohol. Michael Parson's understandably takes the view that the majority of drinkers who are moderate in consumption, are to be penalised for the problems caused by others, a view that no doubt shared by many others. Unfortunately the paradox is that whilst it is true that those who drink the heaviest have the highest risk of alcohol related harm,those who consume less accrue most of the harm, simply because as a group, they are much larger. Evidence in support of that view comes from both Finland(1) and Switzerland (2). The former makes it clear that efforts to reduce the population harms of alcohol use, needs to reach the majority of drinkers, rather than the small proportion of heavy drinkers. The evidence from Switzerland is very revealing, inasmuch as it is able to conclude that moderate drinkers, who occassionally drink too much,are more likely to suffer an alcohol related injury, than chronic heavy drinkers. This conclusion is based on 8,736 emergency department patients who had been admitted to the hospital's surgical ward during an 18 month period. Whether one wants to regard alcohol related harm as a social, or medical problem is not really the issue, because in common with problems which has a major and adverse affect on society, we all have to pay, even those who don't drink at all. References: 1. Poikolainen K, Paljarvi T, Makela, P. alcohol and the preventive paradox:serious harms and drinking patterns. Addiction 2007;102(4) 571-578. 2 Medical News Today 26.02.06.citing, Gmel G, Degutis L. Alcoholism: Clinical and Experimental Research; February; Res30(3)2006. Competing interests: Alcohol and Drug Addiction Recovery |
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Dr Mohan devegowda, GP urban
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sir, The aggressive initiative shown for smoking should be shown towards alcohol also. Majority of doctors drink so we all qouote the safe figures endorsed by Journal and pyschiatirc associations! It is very sad indeed to advice patients to limit their consumption rather than discouraging them to do so. As a GP I feel it is our responsibility to enlighten the public the alocoholic impacts on ones life rather than telling 21 for men and 11 for women per week!! Competing interests: None declared |
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Kavita Singhal, Clinical observer Stevenage, SG1 4AB, Ankush Singhal
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We completely agree with the authors. Time has come to take some hard measures to control the damage. There is no doubt that alcohol significantly contributes to social problems (violence, abuse, other crimes, relationship problems, dysfunctional families, employment difficulties, socio-economic decline, accidents etc) as well as health problems (physical health consequences, trauma, psychiatric morbidities etc). It acts as a gateway substance (along with tobacco) which may lead to graduation to harder drugs of abuse. Alcohol is responsible for consumption of a significant proportion of NHS and social services resources, which otherwise can be used in a much better way. It is one of the most devastating social and health problems known to mankind. In our opinion, there is no way that one can reliably estimate the extent of direct and indirect effects of alcohol consumption across the globe. Mankind has tried to 'control' or 'reduce' the harms of alcohol for ages with few success stories so far. We believe, now we should think a step further. The solution probably lies in ‘preventing or stopping’ the harm altogether rather than trying to make alcohol 'safe'. Firstly, the so called 'safe limit' is not so safe (probably it is less harmful) and secondly, an alcohol dependent person, by virtue of this problem, is not likely to stay within safe limits for a significant period of time. Those who work with these people know how realistic such a goal is. It is usually a chronic relapsing and remitting problem which can not be treated forcefully. We are struggling to find cure for problems which are less devastating, but are not willing to cure this problem when we know the cure. Ideal long term cure would be a complete eradication of alcohol industry in a phased and planned manner, which sounds odd but is the only permanent cure. Practical short term measures may be as suggested by authors including more restricted availability, increased prices etc. We can not expect a society free from alcohol problems if a patient in A& E says that he does not have enough money to go back to his home by bus and to buy his medication, but is found drunk the very next day. We have to make alcohol ‘a luxury’. ‘Rationing’ (which is talk of the town for NHS at the moment) can be a good alternative. It means, interested and eligible people may be allowed to purchase a certain units (eg. 5 -8 units) of alcohol per week and this allowance should be cancelled for minimum 6 months if a person is found to be involved in any alcohol related crime. Competing interests: None declared |
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Javed Latoo, Specialty Registrar (ST4) Psychiatry and Honorary Clinical Assistant Neuropsychiatry Camden & Islington Mental Health & Social Care Trust, St Pancras Hospital, 4 St Pancras Way,NW1 0PE
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Dear Editor, It is important for government to implement effective policies such as increasing the price of alcohol (1), increasing the minimum age for buying alcohol, restricting the availability of alcohol including controlling the sales of alcohol by limiting hours or banning the sales in the supermarkets, lowering maximum blood alcohol level for drivers, banning advertising of alcohol and decrease in retail outlets found effective in other countries. It is only by introduction of social changes through legislation that can help to reduce harmful effects of alcohol on society. Failure to recognize the health and social costs of alcohol related problems by policy makers will continue to cost dearly to families, NHS and taxpayer. Dr Javed Latoo MBBS DPM MRCPsych Specialty Registrar Psychiatry Camden & Islington Mental Health and Social Care Trust Honorary Clinical Assistant Neuropsychiatry National Hospital for Neurology and Neurosurgery, Queen Square London. References; 1. Chisholm D, Rehm J, Van OM, Monteiro M. Reducing the global burden of hazardous alcohol use: a comparative cost-effectiveness analysis. J Stud Alcohol 2004; 65:782-93.[ISI][Medline] Competing interests: None declared |
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Peter O'Loughlin, Principal Beckenham BR3 3AT
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Kavita Singhal offers some interesting observations but, unfortunately there is no cure for addiction, perhaps the day will come when a 'magic bullet' eradicting it will arrive. In the interim period we need to understand and accept that no one sets out to become addicted, it is a process, which is not influenced by either quantity or frequency of use, but rather the vulnerability of the user. We also need to accept that once addiction is established it is irreversible, that the addict has relinqished the ability to control their intake; it is for that reason that 'harm reduction' whereby attempts are made to modify intake are futile. Unfortunatly since the National Treatment Agency, (NTA) declines to recognise the condition of addiction, Drug and Alcohol Action Teams, are obliged to offer 'harm reduction' via modification of drinking patterns, and clients are asked to keep a 'drinks diary'. Such superficial activities can only succeed in cases where addiction, or dependency, (a hoplessly inaccurate description) as it defined in DSM-1V, does not exist. Notwithstanding the gloomy prognosis that addiction is a chronic relapsing disease,recovery to the extent that the addiction is passive is more than possible. Those afflicted need to be made to understand that becoming alcohol and drug free is the inevetiable outcome of addiction, which will come to pass by death or choice. As a generalisation, addicts have a marked aversion to reality, and seek to avoid it, it is the therapist's job to bring them face to face with their situation. to bring them to the realisation and acceptance that they have a choice, to continue, or to become free. Unfortunately many addicts because of past experience of attempting to stop, or cut down and failing, feel they are unable to stop. Here again the therapist needs to work with them to the point where they can begin to believe that becoming drink and drug free is not just an option, but inevetiable, it is only a question of when and how. At that stage the 'Process of Change' has begun. Of course we fail more often than we succeed. We fail not because the addict is 'hopless', or helpless, but because he believes he is, or we believe he is. Where we fail it is because we have not found the 'key' to unlocking the belief in the addict that they can make a choice, but that does not mean someone else is unable to find it, therefore we should only quit when the addict has, by death or choice. Finally we also need to remember that mortality because of alcohol or drugs, is not uncommon in the medical profession, yet as the Medical Council on Alcohol point out, many do recover by attendance at AA or NA, without ever consulting another doctor or therapist. Needless to say all of the writers clients are urged to attend meetings on a regular basis. Competing interests: Alcohol and Drug Addiction Recovery |
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Tamseel Awan, GP BB11 2DL
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It is amazing to see how some people want to turn a blind eye to something so obvious. The author seems to have the correct credentials and has cited factual figures to support the arguments.
Mr Parsons' response "We have a right to choose our own poison, after all" made me smile. Although the title of his response is "Shooting the innocent bystander" he ignores the innocent bystanders who suffer due to alcoholics' actions (drink-driving leading to car accidents and innocent deaths, domestic violence etc.). Secondly if he, and other alcohol consumers want to poison themselves they should not be a burden on the NHS (which should cater for our "needs" and not "wants") and on the society. How about taking a private health insurance to cover the medical problems, an indemnity policy to cover all the social harms including deaths and another policy (if it exists) to tackle the psychological harm done to "innocent bystanders". I don't want to open another debate here but must mention that none of the original scriptures of any religion have ever promoted alcohol or other addictions. If we believe that those revelations were a "user guide" from our Creator, there must be some reason behind it. Competing interests: Trying to learn about other peoples' views about life in general. |
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Susannah R Harris, GP/Clinical lead in Substance Misuse Whitehouse Centre, Huddersfield, HD1 5JU /Calderdale Substance Misuse Service, Halifax HX1 5ER
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As a puzzled onlooker for several years, I am heartened to see this cogent article, based on evidence, outlining a constructive way forward for alcohol policy. Having been a GP for many years, I now treat problematic drug users in a properly resourced community drugs team, working to a national strategy, performance managed to targets by a government agency (to which I am seconded) and scrutinised by national inpectorate answerable to parliament, In contrast, for many years, the problematic alcohol users I have encountered are lucky if they can access any support, there have until recently been vitually no dedicated reources, a strategy without targets, and no scrutiny of services. It has been up to local clinicians and service managers to show an interest, and work to get small pots of money to fund treatment for a lucky few. So a kind of nihilistic denial goes on - as GPs, we know people have probelmatic alochol use but we don't talk about it because we know there is nowhere we can point them for help - alcohol is the elephant in the surgery. As the authors highlight, it is well-established that a particularly cost-effective and effective solution is to implement case identification and brief interventions at primary care level. Yet recent changes in the primary care contract have mitigated against this - GPs are no longer funded to collect even the most basic data on alcohol consumption, and the cost of implementing the National Enhanced Service Specification for alcohol in the 2003 nGMS contract was prohbitive for PCTs, because of its undue focus on detoxification, hence NES alcohol services are virtually non-existent. Worse still, the effect of the NES specification has been to change the way alcohol work is viewed by GPs, as 'non-core' - and even if individual GPs were still motivated to engage in alcohol work, their representative Local Medical Committees may advise them to cease, because they are not being paid for it! For several years now, the Department of Health (DH) and others have submitted applications for Alcohol Screening and Brief Interventions (SBI) to Primary Care Contracting (PCC), the organisation which determines which indicators will be included in the Quality Outcomes Framework (QOF) for payments to GPs under the new contract. So far all have been unsuccessful. The new DH funded research to which the authors refer will inform future applications to PCC, but it is to be hoped that it will not cause any undue delay. Let us look forward to the day when an alcohol SBI QOF application finally succeeds: the potential benefits are huge. Competing interests: None declared |
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Harald M Lipman, Retired Senior Medical Adviser FCO London NW3 6NY
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Reducing the harms of alcohol World-wide Your editorial “Reducing the harms of alcohol in the UK” highlights very comprehensively the problems of excessive alcohol intake in the UK. It mentions the world-wide problem and looks at the value of measures employed to reduce it. Evidence quoted comes down strongly in favour of price increases, restricted advertising and reducing sales. The potential benefits of education and public information are relegated to being of marginal value, at best. Gorbachev’s restrictions on alcohol production and sales, in the USSR in the 1980s, is frequently quoted as an example of the benefits of reducing alcohol consumption. These benefits are well-established and not in question. However, the inherent weakness in Gorbachev’s approach was that, for many reasons, it was not sustainable. Deaths from alcohol and alcohol substitutes in Russia have soared during the last two decades.1,2 Let us look at comparable situations, such as tobacco smoking, social drug usage, prostitution and so on. Gradually, realisation has dawned that so long as public demand remains high, measures which merely restrict supplies, cannot, by themselves, significantly reduce usage on a sustainable basis.3 To achieve sustainability, social legislation and simultaneous, intensive, prolonged public education of present and future generations are necessary So far, no country has introduced combined measures on a long-term basis and few long-term trials have been undertaken to demonstrate the assumed potential benefits of such an approach. Turning again to Russia, such a project is being developed, by a British organisation, International Cardiac Healthcare & RiskFactor Modification, ICHARM, in conjunction with the National Centre for Preventive Medicine, Russia. In a selected region of Russia, a five-year pilot project will be undertaken to reduce the incidence of cardiovascular disease by combining post- graduate medical courses, for polyclinic doctors, in preventive cardiology, with simultaneous intensive and long- continued public awareness programmes. An integral part of project this will entail achieving a reduction in alcohol intake on a sustainable basis. It is expected that the regional Russian authorities will, simultaneously, introduce social legislation to support and enhance the effectiveness of the campaigns. Data from this project will enable the UK and countries World-wide, to better determine their alcohol, tobacco and other public-health policies and, at the same time, actively apply & assess evidence-based principles to reduce the incidence of CVD & alcohol intake 1. Shkolnikov V, Andreev Y Mortality increase in Russia in the 90s: Alcohol and other related contributions Report at the symposium “Alcohol Health “ Moscow 2007. 2. Leon D et al Hazardous alcohol drinking and premature mortality in Russia: a population case-control study Lancet 2007 369: 2001-2009 3. National Governors Association, Health & Human Services Committee Combating & controlling substance abuse and illegal drug trafficking 2006 Competing interests: Director International Cardiac Healthcare & RiskFactor Modification |
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Michael A Parsons, Retired Lecturer Retired from Oxford and\Cherwell Valley College, OX9 9RR
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Are the views of K. Singhal et al. in fact simple medicine? Perhaps we have just a Puritan religious response; or perhaps the dream of a "rational" harm-free society; or perhaps the desire to eliminate everyone with different tastes(nasty). But whatever it is, it should not be given medical excuses. If you really want a rational policy here it would be the establishing of separate facilities for drinkers (or smokers or loud music lovers or whatever) where they could enjoy their preferences to the balance of their felt marginal utilities.
We are back in this current submission to the Prohibition Lobby in the US of the 1930's - and the speak-easies, crime and killings that followed its temporary success.
If you want to establish a smoke-free or drink free or car-free commune that is interesting as a fact about you, and we would benefit from studying you to find out why. But it is not a medical prescription for a free society: it is an attempt to dominate by a "science based" tyranny - and whether the science is dodgy or not is irrelevant for sentiments of this sort, because the science is just used as an excuse.
Wilfredo Pareto's review of the social role of sentiments in his 'Treatise on General Sociology' should urge caution on the most enthusiastic believer in scientism; and Michael Oakeshott's 'Rationalism in Politics` (especially the essays on rational conduct, and on political education) should be compulsory reading for all dispensers of social nostrums and universal remedies today!
Dr.Th. Dalrymple writes very convincingly in his study of the British underclass about the dangers of medicalising a social problem: not least because this replaces the concept of perpetrator by that of victim and disempowers the people involved, condemning them to the futility of a life without meaningful choices.
So once again: I feel medicine must have defined limits, as all expertise must. If I want to travel by sea, I choose the best captain I can find for the task: but I also choose my own destination.
Competing interests: None declared |
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Tamseel Awan, GP BB11 2DL
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I mentioned in my original post above about different scriptures being against alcohol consumption. Here are a few examples:
Bible "Wine is a mocker, strong drink is raging; and whosoever is deceived thereby is not wise." [Proverbs 20:1] "And be not drunk with wine." [Ephesians 5:18] Qur'an many places including "O ye who believe! Intoxicants and Gambling, (Dedication of) stones, And (divination by) arrows, Are an Abomination – Of Satan’s handiwork; Eschew such (abomination), That ye may prosper." [Al-Qur’an 5:90] Prophet Muhammad's sayings - all authenticated by many independent historians "Alcohol is the mother of all evils and it is the most shameful of evils." Sunan Ibn-I-Majah Volume 3, Book of Intoxicants, Chapter 30 Hadith No. 3371. "Anything which intoxicates in a large quantity, is prohibited even in a small quantity." Sunan Ibn-I-Majah Volume 3, Book of Intoxicants, Chapter 30 Hadith No. 3392. "God’s curse falls on ten groups of people who deal with alcohol. The one who distills it, the one for whom it has been distilled, the one who drinks it, the one who transports it, the one to who it has been brought, the one whom serves it, the one who sells it, the one who utilizes money from it, the one who buys it and the one who buys it for someone else." Sunan Ibn-I-Majah Volume 3, Book of Intoxicants, Chapter 30 Hadith No. 3380. With thanks to Dr Zakir Naik who provided the information. Competing interests: Trying to learn about other peoples' views about life in general. |
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Christopher G Colenso-Dunne, Writer Far North Queensland, 4879
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I agree - we certainly need to do more to reduce alcohol consumption here in Australia, particularly amongst indigenous communities where alcohol fuelled violence is rampant, but also amongst non-indigenous Australians. If people want to drink themselves to death then in principle I agree with the libertarian precept that it should be up to them. However, the practise is another matter. Even without a modern health system in which all of us must pay for the weaknesses of our neighbour, it is rare to find a drinker who does not affect others by his or her self-indulgence. Recently three small children, whom my wife teaches at a local indigenous school, lost their father to alcohol. By all accounts he was a decent, caring man who had always loved his children whom he looked after alone - the children's mother having limited access to them on account of her drunken and violent behaviour to them. Unfortunately, the father too was a chronic alcoholic and had developed type ll diabetes. His kidneys had packed up and he was on dialysis several times a week. He was also in a wheel chair because both his legs had been amputated bit by bit as gangrene spread up them. Eventually there was no more to amputate and he died. I have been threatened and narrowly escaped injury in public places in Australia and in the UK on many occasions by complete strangers fired up on alcohol. Short of a registration system in which only licensed drinkers would be allowed to buy alcohol from outlets, increasing the cost of alcohol is the only solution proven to make a difference to social problems caused by alcohol consumption. Of course, the keen drinker can in most jurisdictions legally brew his own beer, ferment his own wine and in New Zealand even distil his own spirits. Therefore, the needy drinker need not go without if he has a mind to it. However, the drunken louts who presently make life hell for the rest of us on a Friday or Saturday night, kill and maim us on the roads, and the addicted alcoholic causing mayhem at home are unlikely to have the wit or patience to brew their own. They then will be forced by the increased cost of their vice to consume less. And a very good thing this will be for all of us – libertarian principles notwithstanding. Competing interests: None declared |
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Michael A Parsons, Retikred Lecturer (Oxford and Cherwell Valley College) OX9 9RR
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Difficult To Swalow This Argument
- unlike a pint of good ale! although asking a drinker "what's your poison" is an old joke I am glad it can still raise a smile!
In my defence I say the tax collected on alcohol consumption covers NHS costs (unlike the numerous week-end sports injuries)- if it did not then please refund it to pay for separate drink-related treatment centres. And all sorts of people crash cars and even fight at home - I believe wife-beating has a flourishing history in tea-total households,not so?
Suggestion: enforce the law against violence, bad driving or whatever. Don't try to use these things as an excuse for attacking a pleasure you do not share.
Better still: teach people to use alcohol wisely as an aid to civilised living instead of wasting it on barbarous binges. That might limit the harm done by ill-tutored minds.
Competing interests: None declared |
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Sandip Raha, Hospital Physician Princess of Wales Hospital, Bridgend, CF31 1RQ
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I agree that in recent years Govt. has made alcohol more readilty available by relaxing licensing laws and also price ( relative to inflation / duty). Uk as a whole seems to heading for being a booze centre of western europe ( evident every night in local towns and in supermarkets). Traders seems to be doing a roaring business with hundreds of offers of cheap alcohol and also channel ferry booze trips. We in NHS seem to pick up pieces. Why cann't we have similar level of tolerance as we have on smoking lately (since the Uk ban)? May be we need young and old being shown alcohol related problems we see in hospitals ( not only driving and crash). The very culture of alcohol as a social catalyst needs to be revisited and more so for next generation who are already destroying their liver as well as heart and nervous system. As responsible medical profession we need to stand together and make Govt. and other concerned listen. Competing interests: None declared |
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Michael A Parsons, Retired Lecturer (Oxford and Cherwell Valley College) PR9 9RR
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Mohamed?The Bible? Jesus turned water into wine to the great benefit of the wedding guests (drinking is not the same as being drunk). In 1 Timothy 3 we are told to take a little wine for the stomach's sake, which might be good medical advice for all I know. So what?
So what is clear is the hidden agenda involved here, one of assertions based on ideological or religious commitment masquerading behind health research - as I said earlier, alas.
Competing interests: None declared |
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Lesley J C Graham, Associate Specialist, Public Health (Public Health Lead on Alcohol) Information Services, National Services Scotland, Gyle Square, 1 South Gyle Crescent, Edinburgh EH12
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Ian Gilmore and Nick Sheron succintly highlight the harm alcohol causes and ask whether tougher measures should be taken, in particular by governments. Virginia Berridge, in her case studies of public health activisim exhorts the efficacy of advocacy groups constructing coherent, evidence based messages; forming wide alliances; harnessing the media and seizing the political moment (1). Here in Scotland, alcohol related harm has been recognised as a major, if not the most serious, public health problem facing us with, for example, alcohol related death rates for men double those than in the rest of the UK (2). One example of such recognition is the enshrining of the principle of protection of the public's health in the forthcoming Scottish licensing legislation due to come into force in 2009. The new Scottish Government, in particular, the Cabinet Secretary for Justice, Kenny MacAskill, is optimising that legislative framework with proposals to ban drink promotions both in off sales and well as on sales; restrict the display of alcohol for sale and adopting a 'polluter pays' approach. The medical community have also recognised the need for action. In 2006, the Scottish Royal Colleges formed an advocacy group, Scottish Health Action on Alcohol Problems (SHAAP) and has been putting into practice much of what Victoria Berridge describes. It has recently published Alcohol: Price; Policy and Public Health (3), a report of an expert group it convened. This comprehensively sets out the argument (including the prevention paradox) and the evidence on both price and tax on alcohol and outlines policy options at both Scottish and UK levels. 1. Berridge V. Public Health Activism BMJ 335:1310-1312 2. Baker A. Alcohol Related Deaths in the UK www.statistics.gov.uk/statbase/Product.asp?vlnk=14496 3. Alcohol: Price, Policy and Public Health www.shaap.org.uk/publications.php Competing interests: Member of Executive Group of Scottish Health Action on Alcohol Problems |
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Michael A Parsons, Retired Lecturer Oxford and Cherwell Valley College OX9 9RR
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Surely the public health concerns of the "medical community" reasonably relate to such tasks as: - checking the quality of beer on sale, monitoring the cleanliness of hotel kitchens, confirming the absence of sawdust from our bread or e-coli from our meat; or ensuring the sanitisation of public hospitals, the purity of drinking water, the quarantine of infectious diseases and dangerous lunacies and so on. All your grasping of moments and political scheming may go down well in Russia (or why not try North Korea?) but such draconian measures have no part in the framework of peacable choice and a free polity. The thistle of this presumption needs both grasping and rooting out.
Competing interests: None declared |
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Mike J McVicar, retired professor Cambridge Regional College CB4 2QT
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It would appear that the responsive Mr Parsons may be confusing Environmental Health Officers (whose activities he has reasonably accurately described above) with Public Health Directors who are concerned with any condition which affects the health of the public on a widespread scale. As a causative factor in disease, alcohol is second to none in its range, affecting as it does almost every system of the body, from nervous (peripheral neuropathy, Wernicke's encephalopathy, Korsakoff's psychosis, alcoholic dementia) to gastrointestinal (peptic ulcer, oral and gastric cancer, liver cirrhosis and cancer) cardiovascular (hypertension, cardiomyopathy, ischaemic heart disease) reproductive (increased risk of sexually transmitted disease, foetal alcohol syndrome) - to name a few - and it ranks equally highly as a factor causing illness in others - to remind Mr Parsons of the article to which we are all responding, I quote: 'Drinking alcohol is a factor in more than half of violent crimes and a third of domestic violence. Between 780 000 and 1.3 million children are affected by their parents’ use of alcohol—30-60% of child protection cases and 23% of calls to the National Society for the Prevention of Cruelty to Children about child abuse or child neglect involved drunken adults.' Competing interests: None declared |
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stephen black, management consultant london sw1w 9sr
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Certain groups within the medical community have a disturbing tendency to completely ignore critical issues in policy debates that fall outside their areas of expertise. There are several in the debate about alcohol. One is an astonishing tendency to ignore the implications of their proposals on individual freedom and responsibility. Yes we could impose draconian restrictions on peoples' ability to buy alcohol, but are such measures acceptable in a free society? Another is a wilful tendency to quote statistics in a way that undermines honest discussion and, for that matter, public trust in government statistics. I may have missed it, but in the above debate I saw no mention of the well- known fact that mortality is significantly higher in the UK for teetotalers than for moderate drinkers. Most statistics were quoted to attempt to illustrate that alcohol is unambiguously always bad and that its bad affects are enormous and large for society. There is also little discussion of the diversity of individuals' responses to alcohol: some tolerate it well and others do not. Australian aboriginals north american natives and many asians can't tolerate the stuff and should probably avoide it. Europeans from races who have had farming for a long time are ususally much more tolerant (but with high individual variability). So blanket advice to mixed populations will rarely be right. But the biggest error is one of logic. Yes, a lot of crime and social disorder is associated with alcohol, but is it caused by alcohol? The critical experiment is this: imagine it were possible to eliminate the supply of alcohol (even Saudi Arabia has never achieved that) would the rate of wife-beating, child abuse or violence actually go down that much (Saudis are not notably more friendly to their women despite the religious prohibition of alcohol)? I suspect they might go down a bit (say 10%) but not by the amount implied by the anti- alcohol brigade. An example: possibly the majority of crime (from burglary to GBH) has alcohol as a factor. But do we really think that normal people drink and then suddenly decide to burgle their neighbour? It seems a lot more likely that they decide to burgle and then drink because it takes the edge off their guilt or makes them bolder in committing their crime. The same is true for other social disorders. Perhaps we should tackle the problems that drive people to be violent and they will drink less as a side effect. Pinning the blame for a host of social problems on booze is passing the buck not addressing the real problems (and the debate is dishonest if it doesn't even acknowledge this as potential confounder of the reported statistics). But the killer statistics in the UK should be that alcohol consumption has slightly declined since we introduced more freedom in the licensing rules desite the jerimiads from the anti-alcohol bodies. Perhaps people do have inbuilt restraint after all and don't have to be told what to do by the nanny state. Competing interests: I'm drinking a lovely Australian Shiraz as I write |
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Michael A Parsons, Retired Lectutrer Oxford and Cherwell Valley College, OX9 9RR
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Environmental versus public health? a distinction without difference, surely. Combining the two groups to cleanse our hospitals might prevemt 30 times the supposed number of deaths due to drink driving each year, I am told, and seems a more profitable goal.
Professions naturally see slanted population samples - an obvious drink/illness link as a cause/effect for a medical man might be no more than the policeman's refusal to have children since they turn out badly - the ones he sees do at any rate. But seriously, a strong association between two variables does not prove a causal link; otherwise you will believe rings cause marriages, bad teeth cause low IQ, or Saturday causes crowding on the High. People with different diseases do many other things in common as well as drink moderately - and many other things differently:- overwork, different genetic backgrounds, different food in youth and so on. Their problems may well have complex multifactoral causes. Indeed, the presence of alcohol could be a self-medication for relief for some of them. Worse, given this claim for alcohol's ubiquity, it could be no more significant than walking or beathing is as a cause - both of which they all do. It is extremely difficult to demonstrate cause and effect unambiguously in biological science, because of the vast range of variables involved in living things. And statistical generalisation is not the same as repeatable laboratory demonstration of a causal link, even if the variability of living things allowed that. How do you run a person's life through again without the drink? Competing interests: None declared |
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Susi R Harris, clinical Lead in Substance Misuse Calderdale Substance Missue Service, HX1 5ER
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It is right to highlight the complex and conflicting issues in alcohol harm, but we need to grasp them and deal with them, rather than shrink away from logiical analysis. Moderate drinking may be less harmful than complete abstinence, but this debate is about hazardous and harmful drinking, ie levels of consumption and patterns of drinking that do have higher mortality than either moderate drinking or teetotalism. Another statistic to put in the mix; the UK now has a rising rate of liver disease, most of this attributable to alcohol. In all the other major Western European countries, the rate of liver disease is falling. The pro-alcohol lobby might be well-advised to consider the need to be careful not to appear as blinkered as it alleges the anti's to be. We may wish the nanny state not to dictate to us about our lovely alcohol, but we do also expect our taxes to be spent wisely, and with foresight. Alcoholic liver disease is costly, the costs are set to rise further, and we are all paying the price. Current alcohol policy initiatives are a long way from even envisaging the sorts of measures that are now widely accepted by the public to reduce smoking. The actions being advocated in the article to reduce alcohol consumption are not draconian, they are just cost-effective. Competing interests: None declared |
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Jessy Saini, GP Trainee Black Country VTS
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Such emphasis is put upon the cost of early intervention in the treatment of alcohol misuse but a simple chat about it costs nothing. As a training GP I was alarmed to hear the shocking statistic that 1 in 5 of the people I will see in a normal morning surgery may be excessive drinkers but surveys suggest that 65% of GP’s see only up to 6 excessive drinkers in a year! If a brief intervention lasting 5-10 minutes can reduce alcohol consumption by up to 20%, role on longer consultations! Competing interests: None declared |
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Marit Schou Hauger, Medical student 1570
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Some of the serious health effects due to excessive alchohol consuption are related to Thiamine defiency. I wonder if it might be a good profylactic intervention to distribute free Vitamine B to alcoholics - for instance at through the GP office, the soup kitchen or through the Salvation armee. VItamine B is quite a cheap remedy, and I have not registered that its use is assosiated with any serious side effects. I may like to promote this idea to the Norwegian Health Department, and are looking for information about similar invervention. Do any of you know if this kind of intervention has been tried or considered elsewhere? Regards, Marit Schou Hauger, Norway Competing interests: None declared |
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Richard M. Lee, Community Psyhiatric Nurse Options CSMS -- Alcohol Team, WORTHING W. Sussex BN11 1QP
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Dr Haris is right to a point. The scarcity or complete absence of specialist comunity alcohol services does inhibit the routine exploration of the role of alcohol in presenting problems because GPs fear that afterwards there will be no way of getting the worms back in the can & that they will be expected to do a difficult specialist job for which they aren't equipped.
This overlooks the fact that many people whose health is affected by their drinking do not need a specialist service & can make changes with relatively little input & for whom a doctor's advice can be supplemented by good online help. Whether patients require simple advice or referal-on, they have to be identified first & Prof Drummond's 2005 Alcohol Needs Assessment Review Project demonstrated depressing, but in my view avoidably, low levels of detection of hazardous & harmful drinking by GPs. In my limited experience of trying to interest both medical & non-medical workers in alcohol interventions, 2 things themes repeat themselves: 1. With some honorable exceptions, GPs' responses tend to be, a) We haven't got time but b) We'd like to be paid more to do it. 2. Non-medical workers have fewer inhibitions about embracing alcohol screening & brief interventions enthusiastically & are often genuinely puzzled that doctors seem so reluctant to do the same, especially when they can see the effects of alcohol on the health & wellbeing of the nation. Competing interests: I am a community psychiatric nurse working in an NHS alcohol treatment service |
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