Dear Friends,
 
     It's always interesting to learn how different some things appear to
colleagues in other disciplines!  Indeed, that is one way we all stretch
our minds and (hopefully) invigorate our own thoughts and perspectives and,
derivatively, the debates that occur in our own disciplines (I write as a
medical anthropologist who specializes in alcohol and drug studies).  With
this in mind I have scattered some responses to Andrew Barr's recent post
below, not to "pick a fight" or claim "I'm right, he's wrong," but rather
to hopefully stimulate further debate and discussion on the ATHG list of
these important matters.
 
 
At 02:43 AM 4/29/98 -0400, Andrew Barr wrote:
>Very little has been published in anything other than statistical journals
>about the Ledermann theory, although I did mention it in the British
>edition of my social history of drink (pp. 315-6, 320, 323-4).
 
I'm not sure what is meant here by "statistical journals" (anything in
which statistics is used?  journals from the discipline of statistics?),
but there has been a good deal of discussion of Ledermann's argument in the
cross-disciplinary social science literature that deals with alcohol and
drug research, and also in epidemiological journals.  While his argument,
like any other, has come in for plenty of good old fashioned critique, it
has also been recognized as important and insightful in drawing our
attention to the fact that alcohol consumption occurs in a host of wider
contexts (e.g., political economy viewpoints, etc.) and that these both
influence and encapsulate individual-level drinking.  An understanding of
this is a necessary first step toward recognizing that there are public
health issues surrounding the consumption of alcoholic beverages, just as
there are health issues for some individual consumers, and that these
public health issues can be affected by policies that either encourage or
discourage excessive consumption.
 
 Formulated
>by a French statistician called Sully Ledermann, it posits (if that is the
>word) that there exists a direct statistical correlation between the
>average level of alcohol consumption and the amount of alcohol-related harm
>in any given society. This forms the basis of the "public health model"
>(which I think is the US term) or "population" model (the UK term) of
>dealing with alcohol problems, according to which alcohol-related problems
>are increased if average consumption increases and decrease if average
>consumption falls, i.e. alcoholism is not a disease that strikes
>individuals but a social problem affecting society at large.
 
While there are a few (VERY few) exceptions in the cross-cultural
literature on drinking, it does not take a rocket scientist to figure out
that risk factors for alcohol-related harm at both the individual level and
the "body politic" (public health or population) level will increase as
average consumption increases.  Clearly there is a threshold here (if
average consumption was 1 drink per month it would be a non-issue), but the
threshold is pretty low.  Given what we know about the distribution of
consumption in human societies that have been properly sampled, a
relatively small minority of drinkers accounts for a disproportionately
large portion of consumption, and this affects "average consumption"
calculations.  But despite this, and the harm many of these heavy drinkers
do to their own bodies, their families, and their wider communities (via
drinking driving crashes, fires, elevated health insurance premiums for
everyone, etc.), we also know that what passes for moderate drinking in
many societies (such as the United States, Canada and much of Europe)
routinely produces BALs that affect people's ability to drive safely,
operate other machinery without incident, and on and on.  Yes, "alcoholism"
(that much debated and ill-defined etiology) strikes individuals (setting
aside the vexed issue of whether or not it is a "disease").  The public
health model doesn't argue that such individual-level physical harm as
cirrhosis, alcoholic hepatitis, etc. doesn't happen to excessive drinkers
over time.  Rather, what the public health model DOES argue is that there
are wider social costs BEYOND THE INDIVIDUAL LEVEL that are exacted by
excessive alcohol use.  The way this relates to Ledermann's work is the
demonstrable fact that as aggregate levels of consumption increase,
alcohol-related harm at levels beyond the individual usually increase too
(i.e., in general, these two things are positively correlated).
>
>Obviously this approach has encountered some difficulty in getting accepted
>in the US because it conflicts with the disease theory of alcoholism
>propagated by Alcoholics Anonymous and (I believe) pragmatically adopted by
>the medical profession as a means of getting alcoholics into treatment.
 
This is an interesting statement.  If one reads the popular press in the
USA (let alone the professional research literature--as distinct from the
advocacy and treatment literature--in alcohol and drug studies) the public
health approach appears to be slowly but surely supplanting the disease
theory.  "Propagated" is the correct word to use for AA's advocacy of the
disease model, since that model has (literally) been taken as an article of
faith since the 1930s and "pushed" relentlessly.  Unfortunately, despite
AA's wide familiarity and "name recognition" it doesn't provide a solution
for more than a fourth or a fifth of those who attend (or are remanded to)
its meetings.  To be generous, as Professor Barr is being, one can claim
that the disease theory was "pragmatically adopted by the medical
profession as a means of getting alcoholics into treatment."  To be less
generous (somewhat cynical), but maybe even MORE pragmatic, as I am being,
one could also argue--as has been done in the literature--that physicians
took to the disease theory because it resonated with their preconceived
notions and because it allowed them to claim what Gusfield calls "problem
ownership" over "alcoholism," (and thus to reap some of the lucrative
financial rewards that come from dealing with "alcoholics" in clinical
settings).
 
>Nevertheless, the public health/population model is official WHO policy and
>is supposed to have been adopted by its member countries. It lies behind
>the target declared by the WHO some years ago of reducing alcohol
>consumption by 25 per cent by the year 2000, which the US government
>adopted in its "Healthy People 2000" report published in 1990. So it is
>very influential, even if it is wrong (I am no statistician, but I simply
>don't understand how it can apply uniformly to different societies with
>different drinking patterns, as it is supposed to).
 
Barr has identified a weakness in the Ledermann model here, but not a fatal
flaw.  Different drinking patterns (and please note that in many
contemporary nation states there are MANY different drinking patterns
within a single "society") need to be taken into account ALONG WITH the
basic insight Ledermann provided as we seek to understand how patterns and
styles of drinking relate to levels of risk for different sorts of
individual-level and public/population-level harm.
>
>But I do believe that its influence must be declining now that all the
>evidence about the health benefits of moderate drinking stands in the way
>of the efforts of the WHO and its member states to tell their citizens who
>drink moderately to cut down on their alcohol consumption for the sake of
>the national health.
 
Excuse me?  There is SOME LIMITED evidence to suggest a modest benefit for
cardiovascular disease risk factors from "moderate" (read, quite limited)
alcohol consumption.  While the alcoholic beverage industry (especially the
wine industry, since this benefit was initially thought to derive solely
from red wine) has jumped on this finding with great fanfare and spent a
good deal of money publicizing itself as a new health food, this really
begs the public health question.  The health BENEFIT from limited alcohol
use accrues to individuals; the primary PROBLEMS from alcohol in modern
nation states/societies lie in the public health/population arena.  So
we're really talking about different things here.  Reduced CV risk for
those individuals who drink moderately (by no means everyone, remember)
does not eliminate the public health costs of alcohol on the body politic
from those individuals who do NOT imbibe in only small quantities or
occasionally.
 
 That is why I was so surprised to read a report of the
>Irish Health Minister advocating precisely this policy - "Less is Better"
>being the WHO dictum to get moderate drinkers to cut down.
>
Less is better as "the WHO dictum" is not something specifically targeted
at "moderate drinkers;" on the contrary, its main target is "heavy
drinkers," but once again we enter the semantic jungle of imprecise words
used to label quite varied quantity/frequency combinations coupled to often
very different expectations brought to the set and setting of drinking.  It
may be that a "moderate drinker" in Ireland would be considered to be a
"heavy drinker" in Taiwan, for example.  But in any event, why SHOULDN'T a
Health Minister advocate for the public health (and please recall this is
not the same thing as individually focused health).
 
>The Alcohol in Moderation Conference at VINEXPO in Bordeaux last June, in
>which I was involved, was basically directed at debunking this approach -
>hence our title, "Is More Better?"
 
Please reveal to us who the financial sponsors were for your conference.
Given its location, the first thing that jumps to my mind is the French
wine industry.  Is the fox guarding the henhouse here?
 
 Unfortunately, not everyone who made
>speeches at the conference wrote them out and no one recorded them, so we
>have only a few transcripts. The speakers were Jancis Robinson, Thomas
>Stuttaford, Diederick Grobbee, Jacques Weill (a statistician who tried his
>very best to explain to a lay audience why Ledermann was wrong), Dwight
>Heath and myself. Alcohol in Moderation now has a web site at
>http://www.btinternet.com/~aimdigest, and can be contacted by email at
>[log in to unmask]
 
I do not know who most of these speakers are, so forgive my ignorance
(perhaps you might tell us something about who each person is).  I know
Dwight Heath, however, and while I respect Dwight's myriad contributions to
alcohol studies he has for some time been a vocal minority voice in the
medical anthropology of alcohol and drugs in regards to this debate about
public health.  He and I disagree on some basic and fundamental issues
here, and so perhaps it doesn't surprise me that he was a speaker at this
conference which seems (from the way you've described it) to be an effort
to trash public health approaches to alcohol.  Or was there a different
agenda that I've missed?
>
>
Mac Marshall