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Negotiating the Place of Alcohol in Public Health:
The Arguments at the Interface

 
Robin Room; Addiction, 100(10), Page 1396;, 2005-10. Posted: 2005-09-26
[Identifier: http://www.doctordeluca.com/Library/AbstinenceHR/NegotiateAlcPubHealth05.htm]
[Related resources: http://www.doctordeluca.com/ABS-MOD.htm#SERIES:%20Peer-AbsMod]
[Source: http://www.blackwell-synergy.com/doi/full/10.1111/j.1360-0443.2005.01183.x]

See also:
[Abstinence as the Only Treatment Goal: New U.S. Battles by Robin Room, 2000]
 

[This Article in PDF print format]

At its meeting on 25 January, the Executive Board (EB) of the World Health Organization (WHO) adopted a resolution on 'Public health problems caused by harmful use of alcohol', and submitted it for consideration at the World Health Assembly (WHA) this May. This is the first WHA resolution specifically on alcohol since 1983 (WHA32.40).

Although in the end it was sponsored at the EB by about 50 countries, the resolution was the culmination of a two-year effort by the Nordic countries, formalized last October in a resolution by the Nordic Council (2004). That Iceland chaired this year's EB was undoubtedly important in the resolution's passage. What were described as broad consultations had occurred already before the EB session, so that the on-the-record discussions were of what was already a compromise text.

My focus here is not on the main substance of the resolution's text (see Room & Babor 2005), but rather on the issues on which the Executive Board was divided in its discussion. A main point of discussion already in the earlier consultations had been the choice of terms. The original title of 'Public health problems caused by alcohol' had become '. . . caused by harmful use of alcohol' by the time the EB met, but the issue continued to have resonance for participants, some of whom had wanted instead the term 'abuse'. Canada remarked that a sore point was the implication in the title that any and every use of alcohol might have harmful effects, and added that no consensus would be achievable on that. However, the representative noted, the revised wording was not ideal because of the tautology: if there were public health problems caused by use of alcohol, it must be because some uses were harmful. Ecuador felt that it was important to distinguish between use, misuse and dependence, and suggested 'hazardous and harmful use' in the title to cover the cases of pregnant women and drivers, whom Iceland had pointed out would not be covered by 'abuse'. Thailand, on the other hand, wanted 'harmful use of' dropped from the title, and Nepal suggested using both 'use' and 'abuse' in the resolution. The USA wanted a balanced approach, where WHO addresses the harmful use of alcohol without becoming involved in areas regarded as beyond its purview. On a related point, Ecuador, El Salvador and the USA all mentioned benefits from the moderate use of alcohol, although Sweden noted that as a matter of logic the resolution did not deal with the benefits of alcohol, but rather with its misuse.

As considered by the EB, the resolution included a request that WHO 'organize open consultations with representatives of industry and agriculture and distributors of alcoholic beverages in order to limit the impact of harmful alcohol consumption'. Tonga favoured deleting this; in the delegate's view, as in the case of tobacco, the alcohol industry should be given no place at the discussion table in view of its clear vested interest. In a similar spirit, Pakistan felt that strong action had to be taken against alcohol manufacturers. Guinea-Bissau, Australia and the USA spoke in favour of the draft section. The view of the USA was that it was not possible to tackle the problems concerned without talking to the alcohol industry- producers, wholesalers and retailers; WHO should engage in open, transparent dialogue with the industry.

Tonga's suggestion to drop another section, concerning 'transparency, impartiality, and balanced regional and gender representation' in WHO's selection of experts on alcohol, in the end prevailed, despite an argument in favour by the USA, and more ambiguous arguments by Thailand and France. As Tonga noted, the section read as though it had been included in response to a complaint about selection of experts, perhaps from the alcohol industry.

The EB discussion marked the emergence into the political arena of the idea of a Framework Convention on Alcohol Control. The idea of an international convention parallel to the new tobacco convention has been mooted for several years in alcohol policy discussions (e.g. Jernigan et al. 2000), but has been kept completely off WHO's policy agenda. Pakistan called for a strategy similar to that employed for tobacco control, and Thailand specifically proposed a Framework Convention, an idea which met with cautious approval from Russia. On the other hand, Bolivia felt a Convention would be premature, France felt there was no question of embarking on this, and the USA noted it would be strongly opposed to it-in the delegate's view, food and alcohol differed from tobacco.

While several countries spoke only on technical points, or simply gave general support to the resolution, there was a fairly consistent split in the discussion between those wanting a robust WHO approach on alcohol and those wanting the alcohol beverage industry to be at the table in any WHO effort to tackle the problems. Lining up for a robust policy were Pakistan, Thailand, Russia, Nepal, and Tonga. Those favouring a 'balanced' approach included Ecuador, Bolivia, El Salvador (speaking for the Americas); those insisting, beyond this, that the industry should be at the table were the USA, Guinea-Bissau, the Maldives and Australia. The USA, indeed, felt that the resolution's language on consultations with the industry was weak, and wanted assurance of WHO's willingness to engage the industry in a serious way on a partnership basis. The Director-General duly noted that engagement was necessary in dealing with the alcohol industry.

The discussion reflected the emerging situation of the last few years. While Nordic countries have continued to play a role in stimulating WHO action on alcohol, the support for a vigorous programme has become much broader. Meanwhile a major stumbling-block to an effective programme has emerged in the role of the USA as a principal paladin for alcohol industry interests. This is a reversal of the USA's earlier role in support of WHO's alcohol programmes, including extra-budgetary contributions.

The argument over terminology is also worth noting. Those arguing for 'abuse' were presumably hampered by the fact that the term is not in approved use in WHO practice (unlike in the USA, where it is a diagnostic term). On the other hand, harmful use is a WHO diagnostic term, but in that usage covers neither drinking which is merely hazardous nor the harm to others from someone's drinking. Using 'harmful use' in the resolution title is also, as Canada noted, tautologous. But settling on such a formulation suits well the alcohol industry's interest in avoiding usages that imply that their product in itself could play any causal role in harm.

References

Jernigan, D. H., Monteiro, M., Room, R. & Saxena, S. (2000) Towards a global alcohol policy: alcohol, public health and the role of WHO. Bulletin of the World Health Organization, 78, 491 499. http://www.who.int/docstore/bulletin/pdf/2000/issue4/bu0534.pdf

Nordic Council (2004) Declaration from the Nordic Council of Ministers, Ministers of Social Affairs and Health, Regarding Alcohol Policy. Copenhagen: Nordic Council of Ministers. 18 October, Journal no. 43001.15.002/04. http://www.norden.org/social/uk/Final%20declaration.pdf

Room, R. & Babor, T. F. (2005) World Health Organization's global action on alcohol: resources required to match the rhetoric. Addiction, 100, 579 580.

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Alexander DeLuca, M.D., MPH

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Originally posted: 2005-09-26

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