Why is alcohol policy difficult?
Reflections of a bureaucrat
Jeff Rich
Introduction
This paper asks the questions why does alcohol policy so often fail, and what makes it difficult? Responses to these questions underlie how both researchers and policy-makers
both conduct and converse about alcohol policy research that aims to have an impact on policy. I reflect on some historical examples of failure and my own personal experience of failure. I draw out three explanations of policy failure - dominant interests,weak ideas, and wicked problems- from my interpretation of debates on alcohol policy.While each explanation contributes insights, ultimately I prefer a fourth explanation.The difficulty of alcohol policy is, rather in the tradition of Bernard Crick's defence of politics, the noble difficulty of politics. Good alcohol policies, then, require less evidence based-policy, and more just political compromises of freedom and responsibility. They require more help for the drinkers, and less control of the drink.
It is not a standard academic research paper, but rather the personal reflections of a former alcohol policy bureaucrat. In that role I read much research and thought deeply and daily on alcohol, the drink question, but the forms in which my thought and research found expression were very different to conference papers of the academic world. In the role, I also had the good fortune to work closely with Professor Robin Room. When I left the role, I said to him that perhaps I ought to write something about my experiences, and Robin encouraged me. I thank Robin and the organisers of the KettlBruun conference for accepting this paper, which is more personal essay than academic research paper, as a fulfilment of that commitment.
If not a conventional research paper, it is also not a conventional official's presentation. I have let go of dot points, and paragraphs of more than three sentences, and tried to make sense through reflection of some frankly difficult experiences. The views expressed here, I need to state, are my own. They are not the views of the organisation I work for or the Governments I have served. They are presented in my after-hours capacity as an "independent scholar" and citizen, rather than on behalf of my institutional affiliation. I no longer play any role in alcohol policy. Yet, I still speak without an academic's freedom of speech, restricted by the public service code of conduct and rules on disclosure of confidences,but not completely subservient to them. Moreover, these views are puzzled out while writing, and reflect my own deep uncertainty about the answers.
Temperamentally I am with Vaclav Havel who once said [Havel quote ] But framing these questions and essaying some answers, however partial, are essential tasks to bridging the unfortunate misunderstandings between the worlds of research and governing. Policy impact from alcohol research can only come by bridging those worlds through mutual respect for different manners of thought, not digging in with beliefs about "translating research into practice[1]."
The KettlBruun tradition of alcohol policy
In 1972 KettlBruun gave a lecture here in Melbourne,the same city hosting this conference. He was sponsored by the Australian Alcoholism Foundation, then chaired by Weary Dunlop, the celebrated doctor who lived through and helped prisoners of war at Changi and subsequently helped many ex-soldiers who struggled with the drink[2]. He spoke on the theme of how to conceive and prepare a good alcohol policy.
He outlined three dilemmas that needed to be dealt with in order to prepare a "systematically planned alcohol policy." I will discuss just the first dilemma, that is, should the object of policy be alcohol or alcoholism? Bruun argued in favour of the product and not the disease. To "talk about alcohol control instead of alcoholism represents an attempt to influence not only alcoholics and the coming rate of alcoholics, but the societal level of drinking, which may be manipulated by such factors as prices and availability[3]." But Bruun anticipated, if still making light, of the difficulty, the prospective failure in setting such an objective to control the production and sale of alcohol. Such attempts stood "in contrast to the Western world's ideology of free enterprise...so that in many countries the control seems to fall into line with the philosophy of controlling alcoholics rather than that of the economic interest [which he elsewhere says "endeavours to raise the level of consumption][4]." So he seeks to reawaken "the historical development of an advanced philosophy in regard to the importance of excluding private profit from the liquor business," as exemplified in the Gothenburg system of local government owned alcohol stories in [Sweden]. Intriguingly, he primarily makes his argument on the basis of principle rather than effect - or what we might call today evidence-based policy. "Specific control measures have not provided much evidence of effect" he admits, but takes consolation in a methodological argument - "the difficulty in singling out one particular detail of control[5]." Ultimately, his argument rested on a political point: "in countries which are trying to develop an alcohol policy, an awareness should exist of the importance of controlling the economic interests connected with the production and sale, along with discussion of the practicability of abolishing the hit to advertise, and to control prices and availability[6]." In other words, it is not a question of what works, but of who does what to whom.
I like to think Bruun's talk that night gave birth to the ideas that still shape modern public health policy arguments about alcohol. In the forty years since great scholars such as Robin Room have elaborated these early ideas, and pursued the philosophy of "excluding private profit from the liquor business" despite a world of ideas increasingly hostile to the political principles that underlay Bruun'sargument. While these ideas have on the whole struggled mostly in the political contest, they have generated a rich tradition of scholarship, with thousands of research projects detailing dimensions of the control philosophy.They have also steeled a growing public health lobbying industry who are committed to asserting that the way to solve the drink question is for governments to tax, restrict and ban[7].
For seven years, I worked by the long fertile river that flowed from KettlBruun's ideas, so many expressed so ably by Robin Room. There I ran the alcohol policy unit in the Victorian Government in one of those recurring times when the "drink question" spilled over from private drinking rooms to the political cabinets of the nation. Good and bad ideas were debated fiercely. Good and bad ideas were implemented both weakly and well. My seven years in that role could be seen as a more apprenticeship compared to the lifetime of research by KettlBruun or Robin Room. But my seven years were part of longer quarter century career as a policy bureaucrat, dealing with policy questions large and small, governments strong and weak, issues dull and contentious, ideas favoured and opposed. My time in alcohol policy was thus a period of active inquiry not only about alcohol issues but about the nature of governing. It was seven years in which I learnt from small, modest successes, but, more deeply still, from policy failures. It was a fruitful time for reflection not only on new ways of framing the "drink question," but also on how to govern well, and why it is difficult to do both well together. As I finished my time there, I said to Robin Room: perhaps I should write a book about what it all meant. So, this little reflective essay is a first public step towards that work.
I wonder today how KettlBruun might judge the success or failure of the program he laid out for alcohol reformers that night. A case could be made, with the greatest respect to the distinguished scholars who work in his memory, that his program has been a policy failure. If we look merely at Australia, few governments have adopted his ideas, notwithstanding the exuberant and never stilled chorus of the public health lobby. Indeed, they have generally adopted an opposing program, symbolically represented in Victoria at least by the liberalisation of liquor licensing laws through the Nieuwenhuysen review of 1986. Yet 42 years on from Bruun's program, despite decades unwinding the control model, with more advertising, more availability, lower prices, fewer regulatory controls and more integration of alcohol treatment into mental health care, Australians drink 25 % less alcohol. The wrong policies appear to be producing the better results. Indeed, for several years WHO debated setting a global target to reduce per capita alcohol consumption relatively in countries by 10 % by 2025. Between x and y Australia achieved x % of this target, and with growing evidence that fewer young people are drinking and drinking less, future falls seem likely prospects. This policy triumph has occurred deep opposition by public health advocates. Surely, in the world of healthpolicy,such amisdiagnosis counts as a failure?
2. Alcohol policy's history of failures
If Bruun's program were counted a failure, he would be in distinguished company.Alcohol policy has a long and distinguished history of policy failures, some tragic, some comic. By policy failures I mean attempts to change societies through public policy that lead to major unanticipated consequences or are defeated by ferocious resistance.The archetypal case of policy failure (perhaps in all policy, not just alcohol policy) is prohibition, and demonstrates both. Prohibition was no accident, no political whim. It resulted from decades of global campaigning, accumulation of evidence and passionate advocacy by the temperance cause. In Victoria,the Maine Law (an early predecessor of prohibition) was being debated in the Victorian Parliament in the 1850s. Yet despite good intentions, evidence and strong coalitions of support, prohibition had disastrous consequences. The USA's 1919 Volstead Act led perhaps to reductions in drinking, but more certainly to resistance and subterfuge (moonshineand corruption) and disastrous unplanned side-effects (crime and unsafe products).
The political history of alcohol contains many such examples.In my role I would study examples as an antidote to the historical ignorance of today's public policy discussions, in which a line graph of data for the last ten years is commonly the deepest reflection you get on the past. I would steel myself when planning education campaigns with the case of the 1950s French President/Prime Minister, Pierre Mendes-France. Mendes-France assembled all the evidence on the harms of liver cirrhosis and the costs of alcohol-related hospital admissions to the war-impoverished French taxpayer, and then launched a campaign to persuade the French to drink milk, not wine. He failed, and soon retreated from accusations of pandering to dairy interests and the sneers and cat-calls of every cafe on the left-bank. I would console myself when advising on arguments to change the drinking culture by raising tax on cask wine, with the tale of WilliamGladstone's attempts in 1882 [check] to change alcohol taxation rates. It was a time when alcohol taxation was a much larger share of government revenue than today, and Gladstone sought both to open the trade of wine with continental Europe and to encourage a civilised culture ofwine drinking. But he badly misread the mood of newly widely enfranchised public and its beloved drinking habits, and was so defeated at the 1882 election. Gladstone commented afterwards that "We were washed away in a torrent of beer and gin." There were many times in my seven years as an alcohol policy bureaucrat that I feared I would be washed away in a torrent of vodka and Red Bull.
The historical example of failure, however, that I paid closest attention was early closing hours and its consequences of the six o'clock swill on Australia's, especially Victoria's, drinking culture. Australia has had a long policy obsession with trading hours and outlet density. Victoria never introduced Prohibition, although the idea was first investigated in its first democratic Parliament in the 1850s as the "Maine Law[8]." In nineteenth century Melbournetemperance advocates knew well "the drinking bill" and all its hidden harms, and had public inquiries into the misuse of opium, but tobacco was mainly seen as a problem when it was used as a cheap adulterant for watered down beer. By the 1880s a rapidly growing, prosperous Melbourne had given birth to strong social reform movements - including temperance - leading to a petition for local laws to cap hotel numbers which attracted the signatures of 25% of the adult female population. In 1885 trading after 11.30 pm was stopped. Temperance conferences went onto debate the Gothenburg system of local government controlled supply of alcohol, and brewers organisedtogether in the early twentieth century a first minimum price for alcohol scheme, as part of the elimination of unhealthy competition when Carlton and United Breweries was formed. Soon after in 1906 the notoriously pure deal-making politician Thomas Bent succumbed to both temperance advocates and hoteliers' interests to establish a liquor licensing buyback scheme was established to reduce the number of hotels.Looking back, you would have to ask what social benefit was gained by spending public money in eliminating competition in the brewing and hotels industry as Victoria went through 40 lean years and public retrenchments.But it took the crisis of war and the sectarian divisions of conscription,for the last step in 1916, whensix o'clock was set as closing time. But even trading hours and reducing outlet density was not enough for the temperance advocates. Prohibition was the end game, and they secured an agreement to hold a regular referendum for prohibition or local laws every 10 years in Victoria. This regular referenda is the only one of its kind that I am aware of in the history of Victoria - proof perhaps that alcohol has long been a "whole-of-government" priority, but it never succeeded, and never really came close. The highest vote was recorded in 1932 with 3x% voting yes, inspired by the famous poster - Booze: a shadow over the land. [Insert image] But unwinding the world war one deal took decades and much political frustration - John Cain Senior removed the requirement for a referendum after World War Two. In 1956 freshly elected Henry Bolte, later Premier for 17 years - who according to legend would plot his strategies while sharing a good cigar and a bottle of whiskywith his closest advisers - tried but failed to convince voters at a referendum to remove six o'clock closing even if just for the 1956 Melbourne Olympic Games. The referendum on the matter failed x to y %. There was a time in Victoria when a"wowser" was feared, not ridiculed.It then took the Phillips Royal Commission at last to unwind 50 years of law creating the drinking culture of the crowded six o'clock swill, which surely was a great Australian ugliness. But advocacy had created its own monster. So Phillips commentedthat: "the issue of hotel bar trading hours seems to me to be one arousing great publicinterest. I formed the impression that defence of the existing situation had become, in some cases,an act of faith. Defeat on this issue was important, not so much because it would open the wayto an increase of specific social evils or accentuate existing ones, but because it would register defeatfor the forces standing for morality and victory for selfishness and self-indulgence. To " Stickto Six , was not solely a programme dictated by a weighing of sociological considerations, buta required resistance to the forces of darkness[9]. p 24
It was in the backwash of this debate - a mere six years after Phillips had defied the wowsers to propose a different dispensation of morals, freedom and responsibility to suit a 1960s Australia no longer chained tothe world view of the Protestantchurches and the Salvation Army -that visiting Finn, KettlBruun, issued his call to arms for advocates of government control of drinking supply. Today, you could see it as exquisitely badly timed, although great and fertile ideas are rarely timely. Alcohol consumption would shortly reach its post-war peak; there was fair reason for Bruunto be concerned, but from then it began a long decline. The intertwined market and social revolutions of the 1970s were making the world of politics, business and government culturally inhospitable for rekindling policy experiments of Nordic local governments from the nineteenth century. Briefly in the late 1970s a tiring Victorian State Government tried to protect hotel business interests against price cutting by supermarkets by introducing a minimum price scheme for beer, but it did not work and it did not last. Finally in 1986, under Premier John Cain Junior's leadership, and with a young Jeff Kennett supporting as Opposition Leader, John Nieuwenhuysen's review of liquor licensing finally laid to rest the great cause and noble policy failure of alcohol control. [Insert quote] To this day, public health advocates have neither understood nor forgiven him. Even the Victorian Auditor-General felt free to caricature his report without bothering to read it[10]. The battlefield of ideas had changed, but public health advocates were about to take their battle plans from a general fighting an earlier war. They would have done better to leave them behind, and,to echo another political phrase,declare themdead, buried, cremated.