SEVEN
Health, harm and risk
Introduction
Chapter Six identified efforts to morally regulate drinking within law and public discourse relating to crime and disorder in the late 20th and early 21st centuries, and found that these efforts were/are, to some degree, shaped by Victorian temperance attitudes. Along with crime and disorder, the other major social problem associated with alcohol in contemporary society is ill-health. Alcohol is consistently connected to a variety of health problems, including liver disease, heart disease, pancreatitis, foetal alcohol spectrum disorder (FASD) and certain types of cancer. Such forms of harm are associated with any forms of excessive consumption but especially with alcoholism, whose sufferers are usually defined by their habitual, compulsive or uncontrolled drinking. To deal with some of these problems, there has been: a promotion of abstinence from alcohol for young people under the age of 15;1 experiments with bans on super-strength beer and cider;2 demands for forceful clampdowns on the number of licensed premises entirely in so-called âbinge townsâ;3 calls for a total ban on all alcohol advertising and sponsorship;4 enhanced monitoring of patientsâ drinking by GPs;5 and most prominently, persistent campaigns for the imposition of a minimum unit price to reduce the affordability of alcoholic drinks.
The significance and prevalence of alcohol-related health problems has been a magnetic topic for public debate and regulatory projects in recent years. Interestingly, public discourse on alcohol and health has been increasingly shaped by a variety of campaign groups, including public health organisations and professional medical bodies. Minimum unit pricing (MUP), in particular, has been tirelessly promoted by such groups.6 The prominence of doctors, surgeons and epidemiologists within this health-focused discourse might imply that a more evidence-based approach to the social problem of alcohol, disconnected from the moralistic attitudes of the past, is emerging. Such a transformation would be consistent with the apparent triumph of the harm-based libertarianism of Hart over the legal moralism of Devlin in the 1960s, described in Chapter Five. It would also resonate with the macro picture of social change painted by sociologists Ulrich Beck and Anthony Giddens, in which the rise of a social order dominated by rational, secular assessments of catastrophic risk serves to sideline more traditional moral considerations.7 In regards to alcohol, to what extent is this accurate? Does this new public health coalition espouse a historically novel, scientific approach to alcohol? Have projects to morally regulate drinking been altered by these issues of health, harm and risk?
This chapter examines the development of drinking as a health problem from the 18th century onwards. It includes sections on health broadly as well as alcoholism specifically. Although sometimes characterised as a moral, social or psychological condition, it is usual in current parlance to frame alcoholism as ostensibly a health problem of some form. Its discursive development also tends to run parallel to the construction of wider alcohol-related health problems in the sense that two significant shifts have been identified in their recent histories. These are, first, the replacement of traditional and explicitly moral understandings of drink problems with medical ideas in the mid-20th century and, second, the emergence of a public health-oriented approach to governing drink in the late 20th century, which concentrated on total per capita consumption.8 With an intensive concern for developments in the 1960s and 2000s, this chapter examines the changing construction of alcohol as a health problem through time.9
Drink, health and moral health until the 1960s
Historians and social scientists studying health discourse related to alcohol tend to identify a new approach that has developed since the mid-20th century. The âvalue-based moralityâ of the temperance movement is seen to have been replaced by medical or scientific understandings of alcohol-related health problems.10 Thom examines how the medically inspired âdisease modelâ of alcoholism attained dominance over the older âmoral modelâ during this period.11 Nicholls further describes how âthe moral argumentationâ of temperance activists was replaced by the apparently âmorally neutral language of scienceâ in which the consequences of drinking are awarded primary importance.12 Sulkunen argues that consensus on what constitutes the moral âgood lifeâ, as well as the legitimacy to promote this through public regulation, has been overridden by a process of ânormative neutralizationâ.13 He claims that the saturation of contemporary Western societies with the principle of universal individuality has fatally weakened efforts to impose morals, including healthier lifestyles, on others. Do these developments indicate that, by the 1960s, the projects to morally regulate drinking had weakened?
The emergence of public health
The âulcer in the social bodyâ
For much of history, alcoholic drinks were regarded as healthy. In part, this was because beer provided a safer alternative to water. The reasons water was often unsafe only began to be understood when Dr John Snow linked the outbreak of cholera in London in 1848â49 to the contaminated water supplied by the Broad Street Pump. But, as Barr describes, people all over the world had been aware that drinking water was potentially hazardous long before Snowâs research.14 Alcoholic drinks were not just safer beverages, they were also widely regarded as possessing certain health too. Whisky, for example, was believed by many to ward off influenza until at least the early 20th century15 and beer was seen as an âarticle of dietâ,16 a normal foodstuff, for much of the 19th century. Burnett provides some support for the latter idea by calculating that, in the 17th century at least, beer provided 20 to 25% of an average personâs required calorie intake.17 Alcohol, beer particularly, was healthy and nutritious; the brewers were not, therefore, discordant with many peopleâs opinions when they claimed that beer is a âfood beverageâ and âpart of the strength of Britainâ18 during the First World War. Chapter Four noted that it became common to refer to teetotallers as âpussyfootsâ after the visit to Britain of US prohibitionist William âPussyfootâ Johnson in 1919. While the term might literally mean cautious or stealthy, it was commonly used pejoratively to imply indecision, timidity or fear.19 Drinkers, by implication, were strong, brave and decisive.
Nevertheless, alcohol has also been connected to a variety of health problems since at least the 18th century. In 1729, the London Journal discussed how excessive consumption of meat or drink wasâpernicious to the Health and Vigour of any Person, in the Discharge of the Offices of Lifeâ.20 Later in the century, a letter from âSetaymotâ in the Public Advertiser reiterated these beliefs, stating that health of the body and mind could be improved with âsobriety, gentleness, and temperance in meats, drinks, and exercisesâ.21 These habits of cleanliness and sobriety, Setaymot continued, bestow virtue upon the observer; it is through this âinward principleâ that such persons âare not subject to indispositions, nor molested with fevers; their heads are not dulled with fumes, nor their stomachs oppressed with fainting fits, or windy gripping humours; they rise fresh as the morning sunâ.22 It was common for excessive drinking to be connected to such broad, ill-defined health complaints, although some commentators were more specific about the ailments they associated with alcohol. On the subject of drink in 1710, the Athenian News asked:âHow many Diseases flow from that vitious [sic] fountain? How many are fed and nourished by it?â, before specifically identifying gout, which can âbring Pain enough with it, so as to make a few Years seem an Ageâ, as one such disease.23 The Athenian News, however, pointed out that gout was a âDanger of Drunkennessâ and a product of intemperance. The good and bad properties of alcohol were thus mediated by the concept of âtemperanceâ, defined as restraint or balance in personal diet and lifestyle.
In 1754, the Public Advertiser noted that âhealth is, more than is commonly thought, in a Manâs own Powerâ and the reward of temperance is that âone immediately feels its good Effectsâ.24 If general personal restraint improves wellbeing, then health (and ill-health) is in the hands of the individual. Writing in World, âAcademicusâ elaborated further:
The thinking part of man being allowed to be a modification of matter, it must be supposed to be a part of the bodyâŠ. Hence it will indisputably follow, that all powers of the mind, even the moral faculties, are inseparably connected with the temperament and habit of that body, of which she is part. Insomuch that prudence (the foundation of all morality) as well as justice, fortitude and temperance (the other cardinal virtues) and their opposites entirely depend upon the constitution. It will therefore become the province of the physician to extirpate the vicious habits of mankind, and introduce the contrary; to suppress luxury, and create chastity; to make the foolish prudent; the proud humbleâŠ. And all this is easy to be done, by the assistance of alternative medicines, and by a properly adapted regimen, that shall be perfective of each virtue, and repugnant to each vice.25
The body and mind were inseparable and morality of the body, expressed through the âproperly adapted regimenâ, was believed to improve the virtuosity of the mind. Individuals were responsible for their own physical and mental wellbeing; a virtuous life led to good health and, by inference, an intemperate life led to ill-health. Either way, health was fused to moral health.
The virtuous practice of temperance mediated between the purported good and bad effects of alcohol in the 18th century. To an extent, this approach continued to be evident in the 19th century. In 1830, the Derby Mercury recognised alcoholâs two faces by attacking the Beer Act on the grounds that it would discourage working men from taking beverages home to their families where they would be consumed as a âbodily nutrient, and not a moral poisonâ.26 But the rise of the temperance movement and the turn to teetotalism in the 1830s signified a hardening in attitudes as alcohol became associated with a larger number of often serious conditions. Some of these aetiological connections, such as the Morning Chronicleâs statement that a manâs consumption of spirits would âruin his health by destroying his liverâ,27 are now clinically established. Others have been discredited, as Barr highlights by describing how in t...