Drink Tank

The future of public health

Dr David Jernigan looks at the big challenges and big opportunities for public health.

This is an edited extract of the Basil Hetzel Oration delivered at the Public Health Association of Australia (PHAA) 43rd Annual Conference held on Perth on 16 September 2014. You can watch this presentation in full at: http://webcast.gigtv.com.au/Mediasite/Catalog/catalogs/phaa-annual-2014.


I stand in Basil Hetzel’s shadow and am honoured to deliver this oration. Hetzel was described in The Lancet as a “progressive and a risk-taker in his medical and public health career” and that “…one of Hetzel’s great attributes is his ability to influence those in power.” He himself remarked “I’ve been very, very fortunate. You’ve got to be lucky.”

I consider luck to be a combination of preparation plus opportunity. That’s how I’d like to divide my presentation: to talk about being prepared for what we see as the major global and public health challenges that face us, and then some of the opportunities before us.

I’m going to focus on alcohol because that’s the area I work in, however this has applications to many other fields – tobacco, food, guns, pollution, global warming and so on.

Big challenges

My colleague Nicholas Freudenberg recently laid out ten things that corporations do that greatly influence the debates, the context, and the challenges we face in public health.

1) Make disease promoting products ubiquitous

Alcohol marketing embeds alcohol everywhere in our lives. The industry does this through so many media, including sports sponsorship, retail signage and street signage. It’s virtually impossible to watch a sporting program with your children and family without being encouraged to drink alcohol.

2) Encourage retailers to promote their products

For instance, on the blocks around my Melbourne hotel there are stores where there is not a single window that is not covered in wine or beer ads. It is impossible to pass these stores and not be told: ‘you need to be drinking now’. In some places, such as New York, the alcohol is packaged right next to the non-alcoholic beverages. This sends a confusing message to young people to say the least.

3) Supersize products

In the United States we have what we call supersized alcopops or ‘binge in a can’. Tilt, a product of Anheuser-Busch, has 23.5oz or 12 per cent alcohol. It contains as much alcohol in a single serving can as almost 6 cans of Bud Light. Basically a six pack in one package.

4) Target marketing to vulnerable populations

Alcohol advertising is primarily regulated through the industry’s own self-regulation. I could show endless examples demonstrating breaches of this and marketing exposing vulnerable demographics more effectively than legal-age audiences.

How many of you think the alcohol industry targets young people? Studies find that the more young people are exposed to alcohol marketing the more likely they are to start drinking, or for those who are already drinking the more likely they are to drink more.

But youth aren’t by any means the only group being heavily exposed. We see a lot of alcohol marketing towards racial and ethnic minorities.

When you look at the data by race and ethnicity you can see the differences in alcohol brands and consumption quite clearly differs between African American, Hispanic, and Non-Hispanic White groups.

When you sort data by gender you can see how differently men and women are drinking. Women and alcohol marketing is a deeply ambivalent relationship where products are often targeted at women as being ‘all natural’ and ‘organic’ and so on. And women’s exposure to alcohol marketing has increased substantially, especially on television.

5) Price unhealthy products to promote sale and use

In the United States, first the alcoholic energy drinks and now their successors the super-sized alcopops are priced even more cheaply than the non-alcoholic energy drinks.

This situation is partly because of our taxes. In the United States taxes are volumetric and they lose their value every year because they are not tied to inflation. While we pay taxes which are tied to our income, the industry does not. Each year in effect the alcohol industry gets a tax cut.

The result is if you go into a corner store in my hometown and you look for the cheapest liquid – it’s not the milk, the soda, the juice or even the water. It’s the beer. That’s a worrying message.

6) Create monopolies that reduce bargaining power of consumers and government

The top ten beer companies produce two-thirds of the world’s beer. The top ten spirits companies produce nearly half of the world’s spirits.

The total value of their global trade is about $1 trillion dollars ($494.8 billion for beer and $262.5 billion for spirits in 2010). And in 2010 the ten wealthiest companies had a total net revenue or turnover of $159 billion, and operating profits of $33 billion.

If these companies were a country, they would rank 58th among the world’s 190 odd countries.

7) Support candidates who oppose public health policies

Alcohol companies use their profits to produce more money for traditional marketing as well as “stakeholder” marketing – such as supporting political candidates who oppose public health and lobbying against laws that protect it.

In the United States, at least $4 billion is spent on traditional marketing each year, and there’s about one lobbyist for every two members of Congress.

The industry spent about $150 million (that we can count) on political donations to state legislators in the first ten years of this century (from 2000 to 2010).

8) Lobby against laws that protect public health

The World Health Organization (WHO) has identified the three things which are the most effective (and cost effective) at reducing alcohol harms. These “Best Buys” are outlined in the WHO Global Strategy to reduce harmful use of alcohol:

  • regulating commercial and physical availability of alcohol
  • using pricing policies such as excise tax increases on alcoholic beverages
  • restricting or banning alcohol advertising and promotions.

And what is the alcohol industry doing? They’re actively opposing and lobbying against these best buys.

The industry often says it wants to partner with us, but it’s important to understand the basic conflict of interest here.

For instance, in the United States our distilled spirits council (DISCUS) and Beer Institute both make it very clear that they discourage and oppose inappropriate or abusive consumption of their products. The funny thing is, they never define what ‘abusive consumption’ is.

Even if we limit ‘abusive consumption’ to the DSM-IV criteria, the abusive and dependent drinking market in the United States was valued in a 2006 study at $25.8 billion and the underage drinking alcohol market was valued at $22.5 billion. If underage and pathological drinking were eliminated, this would be a total combined loss to the industry of $48.3 billion, or 37.5% of their sales (Foster et al. 2006).

Essentially, if everybody in the United States drank in a safe and responsible way alcohol companies would face a market less than half the size of what we have today and would lost at least a third of their profits.  No publicly-traded company can intentionally lose this much of their market and survive.

The alcohol industry has a clear conflict of interest with safe and responsible drinking.

9) Threaten to take jobs out of communities that oppose their policies

When you talk about policy measures such as increasing alcohol taxes, industry frequently makes the argument that this will threaten jobs. But the truth is they are only looking at jobs within their own industry not within the greater community.

Yes if you increased the price of alcohol and consumption goes down, there would be fewer people employed in the alcohol industry. But those jobs will transfer from a relatively capital intensive industry (alcohol production) to an extremely labour intensive industry (government administration, social and health services and so on).

My colleagues and I have worked with leading economists to map what would happen across our states in this scenario, and it turns out that alcohol tax increases have a slight positive effect on jobs. Measures such as this create jobs across the economy, they don’t kill them.

10) Organize Astroturf groups to oppose public health policies

We use the term ‘Astroturf’ to describe fake grassroots groups. Many of these are founded by leading brewers and distillers, and they generally have a predictable set of key messages:

  • alcohol confers net benefits to society
  • the “problem” is the way a few people drink rather than overall consumption in a community or country
  • the cornerstone of policy should be to encourage responsible drinking (but without defining ‘responsible’)
  • marketing should be self-regulated by the industry
  • industry representatives should have an equal place at the policy table with other “stakeholders”.

Big opportunities

I don’t think of alcohol, tobacco, junk food and so on as ‘bad’ industries, I think about them as industries that are doing their job. These are people, they are doing their job and it’s up to us in public health to do our job.

We have already been doing that effectively when it comes to tobacco, but part of that progress is to recognise that there’s not just one industry opposing evidence-based public health policies and programs.

What it takes: Research

We can do this. But what it takes is more than what public health has traditionally done, at least in my country. Yes we need traditional evidence-based research. But it also takes the non-traditional research such as public opinion polling, focus groups, and relationship building. The network research that organisers do to figure out who has influence and how to reach them. The research that comes about from listening to the people who are suffering the worst from the problem. And of course, research into the tactics of the opposition.

What it takes: Advocacy!

This research can feed advocacy. Advocacy is not taught nearly enough in our schools of public health training. It requires its own specific set of skills: strategic communication, organising (both community and political) and legal expertise regarding existing policies and how to write new ones.

Advocacy takes a willingness to be controversial and to engage in public debate; a commitment to accuracy (and never overstating the problem); along with persistence, focus and rapid response; message discipline (staying on message); and organising and relationship building.

We can do this. We can organise, we can build coalitions and we can advocate for the change that needs to happen if we are prepared and open to the opportunities that are before us.

I’d like to close with a couple of parting thoughts. The great artist of the United States southwest Georgia O’Keeffe said “I’ve been absolutely terrified every moment of my life – and I’ve never let it keep me from doing a single thing I wanted to do.”

I’m also inspired by the Chinese writer Lin Yu Tang who wrote: “Hope is like a road in the country; there was never a road, but when many people walk on it, the road comes into existence.” This is our job in public health – we build roads. Roads of hope, roads that are better and safer and longer and healthier for our families and our communities.

The words of Margaret Mead are appropriate for us as well: “Never doubt that a small group of thoughtful, committed citizens can change the world.” Look at you, look at the people around you. Why shouldn’t it be you, why shouldn’t it be us? Why shouldn’t WE be that small group of committed people that can change the world? This is the mission of public health. Together we can make a difference.

David Jernigan

David Jernigan

Dr David Jernigan is the Director of the Center on Alcohol Marketing and Youth (CAMY) and an associate professor at the Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.

He has worked as an advisor to the World Health Organization (WHO) and the World Bank on alcohol issues. He has also authored numerous peer-reviewed articles and has trained thousands of public health advocates in media advocacy and alcohol-problems prevention.

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