Harm minimization

Abstract

The control of alcohol-related problems is an intensely political and contentious subject, involving a host of interests that often promote entirely different agendas. Some of the most hotly debated issues include such topics as the use of taxation and restrictions on the availability of alcoholic beverages [l]. In general terms, any policy intended to reduce the level of alcohol-related problems, such as public disorder, accidents, injuries, illness and premature death, could loosely be termed ‘harm minimization’. Indeed, as recently noted by Single [2], one individual has claimed that the ‘harm minimization’ of illicit drug problems included the incarceration of drug users. Many would view this as a drastic and unacceptable step. In fact, there has for some time been a clear division between what is currently termed ‘harm minimization’ or ‘harm reduction’ and a rather different, but equally legitimate, approach, which has been called the ‘public health perspective’ in relation to alcohol and its associated problems. It is a contention of this chapter that these two approaches are not in essence so very different, even though they have sometimes been presented as being ‘rival’ perspectives. Moreover, it is stressed that harm minimization and the public health perspective are neither mutually exclusive nor incompatible. Throughout the past two centuries, national and regional approaches to curbing alcohol-related problems have ranged from attempts to stamp out drinking completely (NB Prohibition) to measures designed to deal with specific manifestations of the harmful consumption of alcohol [3]. During the past 25 years there have been several publications that have attempted to set out a general theoretical and practical perspective on the vexed issue of ‘what to do about alcohol’. This topic continues to have considerable importance and is inevitably complex because alcohol, a hugely popular psychoactive substance, may be used harmfully or, in moderation, in a beneficial manner [4]. Bruun et al. [5] produced an important and influential report, Alcohol Control Policies in Public Health Perspective. This gave great emphasis to the assertion that, as noted by Ledermann [6], rates of alcohol-related problems, such as liver cirrhosis mortality, are associated with per capita alcohol consumption. Accordingly, the key to curbing rates of alcohol-related problems is to control alcohol consumption in general. This view was reaffirmed by Kreitman [7], who stressed a ‘preventive paradox’, namely the fact that there are far more light and intermediate drinkers than heavy drinkers. Accordingly, it is important to reduce the alcohol consumption of the majority who do not drink heavily to achieve any major impact on the general population level of alcohol consumption and in so doing to reduce problems. A broadly similar view has since been expounded by several other authors, such as Edwards et al. [8] and by the World Health Organization [9]. This approach has been light-heartedly called ‘draining the ocean to prevent shark attacks’ [10]. It may be useful at this stage to draw attention to a parallel debate in connection with policies to deal with illicit drugs, especially since the advent of HIV/AIDS and hepatitis C amongst injecting drug users. The illogic, racism. homophobia and other injustices of past drug and HIV/AIDS policies have been brilliantly reviewed by Schilts and Gray [11, 12]. Broadly, approaches to illicit drug use have polarized into a ‘zero tolerance’ or drug-use eradication approach and an alternative perspective, namely harm minimization or harm reduction. It is clear that attempts to eradicate drug use have not been successful; even ‘primary prevention’/health promotion, designed to discourage young people from trying drugs, has a very poor record of achievement [13].