Thursday, 15 September 2011

Alcohol in France – reflections in a Farmhouse near Uzes in Provence

Last time I looked, alcohol consumption in France had gone from about 21 litres a head (people aged 15+) a year to about 12. The question is why. There was no doubt that the high consumption in France went along with high levels of cirrhosis and cancers of the pharynx and oesophagus linked to alcohol (breast cancer too?). 

When I chaired the Academy of Medical Sciences working group that produced the report, Calling Time, we concluded that population levels of consumption were influenced by price, availability, and ...well, we didn’t quite say what, ... but it was culture, structure of short, all the other things that were likely to be important but were harder to nail down.

In response to our report, one distinguished physician (who had been described to me, decades ago, as a Thatcherite before it was fashionable) said that this was the Nanny-State-gone-mad. Now, there’s an original thought! In support of his argument against government meddling (in anything), he dwelt on our report’s graph of declining alcohol consumption in France, despite the low price.

The decline in alcohol consumption in France poses interesting questions. It is reasonable to say that one of the factors in the high alcohol consumption in France is the low price. But why has consumption declined? Robin Room had said that French agricultural workers were paid, in part, in alcohol. 

At table, in this glorious farm house (now bed and breakfast) near Uzes in Provence, amid copious jugs of locally produced red wine – from the farm’s own grapes – we discussed it. 

A former couturier, now consort of the woman who runs the B and B, said that locally, the workers who picked the grapes used to be given 5 litres of wine a day for personal consumption, and the supervisor, 8 litres. That may be only a few weeks a year, but I seem to remember Robin Room’s figure was 1.5 litres of wine a day to farm workers in general.

An engineer, another guest at the B and B, said that when he was growing up, post war, 60% of the French population lived rurally, presumably heavily involved in agriculture, and paid accordingly – a new understanding of liquidity; economists take note. Now, the French population is less than 20% rural. (In the UK, I think it is about 2% involved in agriculture. France has about the same population as the UK in a bigger land mass so presumably has more agriculture; plus, it was always said that one of the purposes of the EC budget was to subsidise inefficient French farmers.) Along with the decline in the proportion of agricultural workers was not just a decline in wine as a unit of wages, but a changed lifestyle. Going home for lunch in the middle of the day with alcohol, and a siesta, is going. In cities people are far more likely to work 9 to 5 (followed, it is rumoured, by ‘cinq a sept’ which is for other traditional French activities outside the home) – no home for lunch, no siesta, and less alcohol. A clamp down in drink driving may further have contributed.
Part of our argument on social determinants of health is that life style is important, but we need to address the social determinants of life style. Understanding reasons for alcohol consumption in different countries must be part of that. Volunteers for participant observation?

Monday, 12 September 2011

Riotous times

I have been citing Tottenham as having the worst male life expectancy in London, 18 years shorter than that in Kensington and Chelsea. What a coincidence that the riots should start in Tottenham, and not in Kensington and Chelsea. Gosh!

There is a close correlation between the geographical distribution of ill health and of crime. Not that one causes the other but that they have common causes. Go to your friendly neighbourhood prison (irony, this is irony) and you find that the inmates are highly likely to have a background of broken families, child abuse, low levels of education and literacy – all of which are linked to poor health, as well as crime. In Chicago, as Daly and Wilson showed, areas characterised by high income inequality had high homicide rates.
For some commentators, there is, of course, no link between poverty and urban unrest – didn’t one handler of stolen goods have a job, and another park his VW round the corner? – this was criminality pure and simple. To misquote Oscar Wilde, the riots were not very pure and their causes are certainly not simple. But poverty plays a role. The Guardian reported that of 1000 rioters going through the magistrate courts only 8.6% were in employment or training, i.e. 91.4% were not. Nationally, NEET is about 10%. No link between poverty and being hauled in for rioting?! In epidemiology we never get associations as big as that: 91% of rioters were NEET versus 10% of non-rioters.

There are exceptions, then, but it is a fair summary to say that people in jobs or education were not caught for rioting. I am being careful, here, just in case people with double firsts from Oxbridge were equally likely to riot but avoided being caught – young chaps doing what young chaps do, don’t you know.

Are you saying, asked one minister, that someone had his education maintenance allowance cut and so he nicked a pair of trainers? The implication is that if you answer “no” to that question you are somehow saying that there is no link between what government does and likelihood of being involved in law breaking. Which of course is garbage. This is not to argue that it is “the cuts”, pure and simple, that did it. Again, neither simple, nor pure. Given the association between NEET and rioting, we are dealing with long standing deep seated problems. The Prime Minister thinks it is slow moral decay, former Prime Minister Tony Blair thinks it isn’t, but the riots are all down to a criminal minority. I think they both had it right years earlier when they talked, not just of crime, but of the causes of crime. I don’t know how you measure moral decay, but we can measure NEET and show the strong link to civil disorder.

Of the riots, we have to ask why there, and why now? There, in Tottenham and the rest, because of long standing problems of deprivation, lack of education and jobs. But why the contagion spread to other areas is not straight forward. But a guess would say, that in these “secondary” areas it was again young people not in NEET who rioted. Why now? Apart from the precipitant of the police shooting of a local man, prospects for young people are getting worse. Living standards, according to the Governor of the Bank of England, will continue to decline; unemployment for young people is approaching the one million mark; in short, people in deprived areas have reason to feel little control over their lives and little prospect for the future. That explains a predisposition but not the exact timing. Prediction is difficult. As one economist said, his predictive models don’t even predict the past, let alone the future. That said, the riots are a strong reminder that the determinants of health and the determinants of other important social “outcomes” overlap. They need action.