If you remove something as complex as consuming alcoholic beverages from its cultural context, the knock-on effects are remarkable.
Consider the fact, recognized broadly even by some of the most ardent advocates of the population health epidemiological approach to distorting health effects of drink, that people of higher incomes tend to have better health outcomes in general than those of lower socio-economic status (SES).
This relates to something we call the Social Determinants of Health (SDH). These are a variety of factors that affect our health, but are not directly related to biology: income level, housing quality, employment opportunities, access to decent food, social services, etc.
These things all affect our health but they are normally out of our control. Someone who has a low income can’t just magically get a great job. Someone with limited education can’t just magically have a better education (especially if they’re working 60 hours a week just to get by). And on it goes.
This has been widely recognized by health bodies around the world. It has also led to some remarkable progressive efforts to equalize the conditions that can be addressed, such as eliminating “food deserts” in cities and advocating for food programs in schools, improved social housing, etc.
Now when you strip away considerations of social class, economics, and so on from things like the health outcomes of drinking, you get a highly distorted picture (and I’d argue a mostly theoretical picture) of the impact of drinking on health. All of those social determinants of health are ignored or at least seriously marginalized while theoretical models of health outcomes based upon theoretical individuals who theoretically all all in the same context.
So for example, a poor person and a rich person could drink the exact same quantity in the same patterns, and their health outcomes could be different because of those broad SDH factors and many of these cannot be managed (or “controlled”) statistically.
Even if you could control for every cultural factor that goes into an individual individuals risk for certain harms related to alcohol, even if the relative risk increases at the same rate, the overall risk (we usually call this “absolute risk”) of them developing certain conditions or falling victim to certain unfortunate outcomes related to alcohol is significantly different. It is not, however, captured in most of the alcohol harm research and such complexity is hardly ever included in public health anti-alcohol messaging.
Alcohol researchers recognize cultural context, but do their best to eliminate it. For example, when Zhao et al published their article claiming to have proven there is no benefit to moderate drinking, they did it by eliminating any data about abstainers because abstainers are a complicated bunch. Some of them are lifetime abstainers, some stop because they are sick, some claim to abstain but do not.
So instead of digging into these complications, they eliminated them. They decided that people who claim to drink very little (itself a cultural factor) could be a “proxy” for abstainers (even though they do not abstain) and then ran their numbers until they had results that showed no statistically significant effect of moderate drinking compared to this group of [non-]abstainers. Cultural considerations were intentionally erased to get cleaner (and for anti alcohol researchers, more satisfying) results.
Along with being just another way context is dismissed, what does this type of culture scrubbing do?
I would argue that by dismissing Social Determinants of Health, culture scrubbing opens a door for a much more virulent form of paternalism: arguments about Commercial Determinants of Health
See, marginalizing SDH, which are something on which I’d argue governments should (and could) act to allow people to live in a reasonable level of healthfulness, opens the door for arguments about the “Commercial Determinants of Health” to take hold. This idea that people are surrounded by commercial forces that undermine the individual’s ability to be healthy is appealing to governments and progressive public health advocates.
We see such arguments in statements about advertisements for sugary drinks and ultra processed food, all of which rest on an assumption– or even an assertion — that the industry behind this is determined to ruin people’s health, or at least is not bothered about issues of health. This then leads to arguments that, with such predatory bad actors out there, governments need to crack down on all these things that hurt people’s health. (Ban advertising, label everything that even seems unhealthy, and so on)
I’m no supporter of the big food industry–I prefer locally sourced, home made, and so on, and to be clear I have the income that allows me the luxury of acting on that preference–but I do see such arguments as problematic for a few reasons.
- They are deeply paternalistic: they do not accept that people make their decisions for purchasing food for all sorts of reasons, and many of them are entirely reasonable based upon the context (for example, fast food is quick and easy for parents who are rushing from one job to another to make ends meet; some people simply enjoy it). This is called “agency” and CDH arguments generally deny it to the “victims” of CDH.
- They distract from the Social Determinants of Health: maybe people would make healthier choices if they had the time, money, and access to better food, and if they didn’t have to work 60 hours a week to make ends meet.
- They reiterate a classic narrative of some predatory outsider going after unwitting innocents for personal gain. Although this is not entirely fictitious (if you think capitalism and profit are toxic predatory factors, then it’s entirely reasonable to think all these bad actors are just in it to profit on the misery of others).
The Commercial Determinants of Health are peak paternalism. They deny agency of these poor victims who would never go for fast food or a cola if they were not forced to do so by the predatory corporations. They allow these public health researchers to position themselves as heroes protecting the victims, while allowing governments to ignore the very considerable social factors that put many people in this vulnerable state.
(Ironically, some researchers squeeze millions of dollars out of governments to pursue their CDH agenda. I wonder what those millions could have done if redirected to healthy food programs, education, or housing.)
Just to be clear, I am not denying that companies and industry lobby governments to get preferential treatment. But that is very different than what CDH arguments advance as the insidious effect of commerce on individual health.
What does this have to do with drink? Well quite a bit actually. If you remove social context, generate data that does not consider cultural factors, and make big dumb statements about how the industry is out to kill everyone, then you’ve ceased to be a reasonable scholar or a reasonable health advocate, and you’ve become a zealot.
And yet… these arguments are the ones we hear. Partly this is because if an industry group says it, then it is framed as just self-interested, but if public health or health researchers say it, it is framed as disinterested public service. Notwithstanding the millions of dollars of funding that flows into this research.
This leads us to one final issue: the unbalanced research environment. People who seek to undertake more balanced research, and those who may find benefits in things like moderate drinking, have far fewer funding opportunities, and may risk becoming labelled as “industry apologists.” They may be (and some have been) black listed within the health research community.
This is a silencing that is skewing research and distorting our understanding of the health effect of drinking.
Silencing voices leads to ignorance not enlightenment.
While culture scrubbing limits the ability to discuss the complexity of everyday life and behaviour.
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