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Issue 2 1999

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National Alcohol Strategy - Challenge to Government

There has been a huge increase in drinking among women and teenagers and a comprehensive national strategy is essential if the problem is to be tackled.

Alcohol Concern in its newly published Proposals for a National Alcohol Strategy for England points out that 11 to 15 year old are consuming on average 8.4 units a week - an increase from 5.4 units between 1990 and 1996. At the same time women's consumption rose from an average of 5.4 units to 6.3 units a week.

At the launch of the report in the House of Commons, Don Touhig, MP, the joint chairman of the all-party alcohol misuse committee, stressed the need for a national strategy, especially since, at the moment, 12 separate government departments had some say in alcohol policy. Mr Touhig also said that it was important to involve all interested parties. A wide range of agencies and organisations contributed to the report, including the Institute of Alcohol Studies, but the Portman Group, which speaks for the drink industry, refused an invitation. The alcohol manufacturers are anxious to avoid any measures which might restrict their operation and hope to convince the government that the alcohol problem is confined to a small body of abusive drinkers. The Brewers and Licensed Retailers Association (BLRA), whilst declining to participate in the Alcohol Concern exercise, has made a submission to the Department of Health on what it calls a Strategy to Combat Alcohol Misuse. One of the main aims of this is to disparage the argument, accepted by almost every European government and by the World Health Organization (WHO), that a reduction in per capita consumption has a direct effect on the level of alcohol-related problems. Sources close to Tessa Jowell, the Public Health Minister, state that the present British Government is at one with the drinks industry on this.

Alcohol Concern's report, reflecting an awareness of this situation, treads carefully when discussing any lowering of the national level of consumption. One proposal is that there should be a "taxation trigger to prevent serious escalation in alcohol consumption and alcohol misuse: excise duties continue to rise broadly in line with inflation, but if consumption of pure alcohol rises substantially to more than 8 litres per head of the population, excise duties should be set at a rate designed to return levels of consumption to those existing at the introduction of the Strategy." The most recent figures show that the current rate of consumption per head of the population is 7.6 litres per annum (9.4 litres for those aged 15 and over). Clearly, Alcohol Concern's proposal for a taxation trigger set at 8 litres is extremely modest but, even so, it is by no means certain that it will find favour with Mrs Jowell whose public statements have echoed the vocabulary of the Portman Group and who is anxious, above all, to avoid the accusation of nanny-statism. There is no mention in the document of the WHO's first European Action Plan on Alcohol which envisaged a 25 per cent decrease in alcohol consumption starting from a base line of 1980, a target which most wine-producing countries have met. There has been some speculation as to why the UK has chosen to take a lone stance on this issue.

The report states that the "operational Aims which inform the whole Strategy are:

  • To reduce the level of alcohol induced ill health

  • To reduce the number of alcohol related injuries

  • To reduce the rate of alcohol related crime

  • To reduce the number of alcohol related road accidents

  • To reduce economic loss in the workplace due to alcohol misuse."

It is certainly difficult to see how these will be achieved without a reduction in overall consumption.

The Government is anxious to reform the Licensing Laws and in this context, the report says:

"Licensing continues to be needed to regulate the sale and consumption of alcohol because of its intoxicating and addictive properties, its potential to damage health and contribute to nuisance and disorder. Determining within a legal framework the ages, times and location of purchase and consumption, the three primary aims of licensing should be to protect the young, to prevent disturbance and disorder, and to control excessive consumption in the interests of health and safety."

The Home Office's proposals will be presented towards the end of the year and the key points made in Alcohol Concern's report will be taken into consideration. They see the aim of any changes to the licensing laws as needing to reduce "alcohol related assaults, criminal damage, nuisance, public disorder and underage drinking, and promoting health and discouraging intoxication through the following measures:

  • The creation of a system of two licences - a premises licence and a personal licence - to be granted by a trained licensing panel of locally elected councillors and magistrates.

  • The local authority membership to be responsible for the premises licence, linking licensing decisions with local plans made under the Crime and Disorder Act (1998) and with town planning. Decisions to reflect annual local licensing plans, developed within the parameters of national criteria which require that the drinking environment, management procedures and location of licensed premises promote the safety of drinkers and the public. Supported by the introduction of a national set of licensed premises conditions which provide options to enable local circumstances to be met.

  • Magistrates to have responsibility for the personal licence attached to the licensee and portable between premises. Affecting a person's character and livelihood, this will be a judicial decision made according to national criteria setting out standards of personal integrity, former management and retail conduct, experience, and training.

  • Introduction of obligatory training for licensees, encouragement of training of other staff through a requirement on licensees to draw up a staff training plan, and the obligatory registration of licensed premises' door staff.

  • National promotion of the voluntary 'Citizencard' designed to prove age when buying products with an age limit: the purchase or supply of alcohol on behalf of under 18s for public, unsupervised consumption to be made illegal."

ALERT Comment

Alcohol Concern has necessarily had to reconcile divergent views. It has succeeded in producing a coherent strategy which the government would be well-advised to implement. It is regrettable, of course, that the industry and the Portman Group chose to stand aloof and rely on their own influence to argue such case as they have to the Public Health Minister, Tessa Jowell. There is, of course, no absolute necessity for them to be involved in a national strategy if the government is willing to use legislation and has the resolution to do something effective about the alcohol problem. However, this is unlikely to prove the case. Already Mrs Jowell has called for public health organisations to work more closely with the drink industry.

The government, we are told, is against the per capita consumption argument. This in itself indicates that it is firmly on the side of the drink industry and against the weight of medical and scientific opinion. Mrs Jowell recently launched the product labelling initiative. As part of this, a new leaflet prepared by the Health Education Authority, Think About Drink, which promotes the sensible drinking message, will be distributed in 70 per cent of supermarkets and off-licenses in the United Kingdom. Retailers who have signed up to the initiative and will ensure that unit content will be displayed on alcoholic drink include Asda, Safeway, Sainsbury's, Tesco's, Unwin's, Oddbins, Marks and Spencer, First Quench, Budgens, Somerfield, the Co-op, and Waitrose. The industry's contribution is being co-ordinated by the Director of External Affairs of Seagram. Seagram, of course, is the company which has been particularly aggressive in its approach to liquor advertising in the United States and which has been generous in its funding of front organisations. The parent company will no doubt be delighted to see its influence being so effectively exercised in this country.

The Conservative Party has always been criticised for its indebtedness to the brewers, although in 'Health of the Nation' it at least attempted to achieve a more coherent alcohol policy than previous governments had managed. It will be ironic if the Labour government proves to be even more compliant with the alcohol industry than their predecessors.

Closely connected with licensing laws is community safety. According to the report, the aim should be to reduce alcohol related crime and disturbance in public places and around drinking places. Alcohol Concern suggests the following measures:

  • A requirement that alcohol misuse is addressed in local audits and plans made under the Crime and Disorder Act (1998).

  • Providing good practice guidance to local authorities and the police, with particular emphasis on prevention practice in relation to the management of the environment in and around drinking venues.

  • Developing proposals to enhance the role of public transport in preventing alcohol related disorder.

  • Introducing a toughened glass requirement and a ban on the sale of alcohol in glass bottles in on-licensed premises.

The industry and its agents dislike the phrase "alcohol related" and question the association, obvious to anyone else and clearly proved in numerous pieces of research, of alcohol with violence and crime. Speaking at the launch of Proposals for a National Alcohol Strategy for England, Chief Superintendent Martin Jauch, of the Association of Chief Police Officers emphasised the importance of adopting strategies for dealing with the variety of offences which are alcohol related. He also made the point that "enforcement alone cannot work. Changes of culture are needed." Drinking patterns needed to change. Superintendent Jauch pointed to the success of legislation in the case of drink driving. Thirty years ago prosecution for this offence tended to elicit sympathy whereas now it is regarded as the consequence of totally unacceptable behaviour. Dr O'Neill, representing the British Medical Association (BMA), said that he favoured the 50mg limit and random breath testing, but he also said that there should be a link between penalty and treatment.

In discussing drink driving, Alcohol Concern makes proposals to reduce the number of alcohol related road accidents through:

  • The permissible level of alcohol in the blood when driving to 50 mgs of alcohol per 100 mls of blood.

  • Introducing general breath testing powers for the police, with guidelines to prevent harassment. Developing proposals for public transport designed to reduce the incidence of drink-driving, with particular emphasis on late night provision.

  • Introducing a requirement that pre-sentence assessments in drink-driving cases include consideration of making a treatment order: increasing scrutiny of high risk offenders' drinking problems prior to their being regranted a licence.

  • Continuing public education in relation to drink-driving, to include an increased component within driving test training and alcohol education in schools."

Dr Bill O'Neill also emphasised the need for a change in society's attitude to alcohol when he spoke at the launch. He stressed the need to refer to alcohol as a drug. Dr O'Neill brought up the subject of advertising and marketing and the question of whom the industry is targeting. He was in favour of labelling, health warnings, and the education of licensees in their responsibilities and the dangers inherent in their trade.

Alcohol Concern addresses the subject of the promotion of alcohol in the report and says that alcohol publicity regulations should balance the right to freedom of speech with the need to protect the young and to provide the public with balanced information to enable informed choices to be made in relation to health and safety. Its proposals are intended to promote "a more balanced portrayal of alcohol consumption and its outcomes in the media, together with the protection of young people from product promotion or media influences which may encourage them to drink alcohol prematurely or to excess in later life, through the following measures:

  • Introduction of proposals to encourage a more balanced portrayal of alcohol and to reduce the volume of references to alcohol in broadcasting.

  • Proposals to reduce alcohol advertising in the cinema particularly in relation to films with certificates permitting under 18s to attend.

  • A review of the content and interpretation of the advertising codes in order to reduce the numbers of advertisements likely to appeal to young people; the establishment of independent monitoring and adjudication arrangements to regulate sponsorship, packaging and merchandising of alcoholic drinks, with a view to protecting the young.

  • Regular monitoring of alcohol promotion by trading standards departments nationally.

Allied to this are the measures suggested to help in a change of attitudes to alcohol. Here the aim is to enhance people's capacity to make informed choices about their drinking habits and to increase awareness of the full range of support facilities available, through:

  • An annual national campaign involving television and other media, posters and leaflets, supported by complementary local initiatives and tailored campaigns.

  • Government guidance to health and local authorities recommending the inclusion of alcohol misuse public education within Health Improvement Programmes and crime and disorder plans.

  • Strengthening alcohol education for young people through specific guidance to schools; the development of parent education initiatives; an audit and update of alcohol teaching materials; an evaluation of alcohol education methods and recommending of most effective practice; and enhancing the role of youth work in alcohol education.

  • Establishing a network of major employers to develop flagship alcohol education programmes, increase the number of employers with effective polices, and develop ways of accessing the unemployed.

  • A statutory requirement that the packaging and promotion of alcoholic drinks includes information on the unit content of the product, set in the context of the sensible drinking message.

Jean Coussins, the director of the Portman Group, said that the government should not "interfere unfairly with the responsible drinking majority." She was opposed to "blanket solutions" and was in favour of targeting those she described as "the minority who abuse alcohol," reflecting the drink industry's desire to narrow the definition of "alcohol abuse". The alcohol problem is an issue with far wider implications than those arising from addiction or severe abuse. Alcohol Concern's proposals do, of course, deal with the extremes of abuse. They make clear that those in need of support and treatment, whether they are in the early stages of the development an alcohol problem or are already dependent drinkers, should have access to appropriate and quality alcohol services. At the moment, provision is unco-ordinated and falls short of providing those in need with access to minimum core services. "Core services should include," says the report, "outreach work; screening for alcohol problems in primary care and hospital settings, minimal interventions and brief treatments within primary health care, hospital and alcohol service settings; longer term specialist remedial treatment, including detoxification and counselling services in supported and day care settings, or in residential units for severe cases where support is lacking; self-help support groups; support for the children and partners of problem drinkers."

One of the problems of the current situation is that the funding of alcohol services comes from a range of sources - local authorities, the health service, the probation service. The services are provided by a variety of statutory and non-statutory agencies and there is a pressing need for effective co-ordination.

The report's proposals are aimed at providing "access to core alcohol support and treatment services through:

  • Funding the additional costs of providing minimum levels of access to core services.

  • Placing a requirement on local and heath authorities to provide alcohol services, produce annual plans and establish joint commissioning arrangements.

  • Supporting this requirement with guidance recommending:

    1. The range of core services to be provided (services targeting hard to access population groups to be developed once core services have been established);

    1. The establishment of an alcohol co-ordinating resource in each area to facilitate delivery of packages of care which address multiple needs, including the interface with mental health, illicit drug use and social welfare problems;

    1. good practice in respect of dual diagnosis (mental health/alcohol) cases;

    1. a requirement that each general hospital has a strategy for detecting and responding to alcohol problems;

    1. the provision of stable core funding for services with contracts of a minimum three years duration;

    1. the promotion of minimum service standards;

    1. the inclusion of alcohol targets within Health Improvement Programmes, with targets set for each agency responsible for funding alcohol services, including the health authority and Primary Care Groups, social services and the probation service.

  • Ensuring that health authorities rather than Primary Care Groups have the principal planning role in relation to health service provision in order to prevent fragmentation.

  • Developing pump prime funding options for alcohol services in general hospitals and primary health care settings.

  • Expanding the courts' drugs testing and treatment orders to include alcohol.

  • Including alcohol support and treatment in the service specification of prisons.

  • Undertaking a review of specialist and generic training.

  • Ensuring that alcohol is addressed in all national and local strategic developments relating to health and social welfare.

Alcohol Concern, presuming that the government follows all the proposals, estimates that by the end of the strategy's first five year term there would be a 5 per cent reduction in the level of alcohol abuse and a consequent minimum annual saving of £542.7 million. The report concedes that 5 per cent is a conservative target but the sums involved indicate the vast cost alcohol abuse is to society and are a reflection of the burden of pain and despair on the individual.

The Government's white paper, Saving Lives: Our Healthier Nation, published on 6th July, 1999, states that the broad aims in tackling alcohol abuse are:

  • to encourage people who drink to do so sensibly in line with out guidance, so as to avoid alcohol-related problems

  • to protect individuals and communities from anti-social and criminal behaviour related to alcohol misuse

  • to provide services of proven effectiveness that enable people to overcome their alcohol misuse problems

The white paper echoes recent statements by Public Health Minister, Tessa Jowell. that there is a rôle for the drink industry in constructing an alcohol strategy. Consultation will begin later in the summer and and the strategy will be published early next year.

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Drinking Industry scoring with the young

Young men and women in the United Kingdom are among the heaviest drinkers in Europe according to a new survey of trends in nine countries consisting of the United States and eight from Western Europe. The present upward trend in youthful alcohol consumption will continue in all but three of these countries. Research carried out by market analysts Datamonitor suggests that by 2003 attitudes will have changed and it will become more fashionable to consume alcohol in greater quantities.

Drinking is an increasingly popular activity amongst the economically crucial twenties age group. 18 to 24-year-olds are they heaviest drinkers. On average they consume 15.6 units of alcohol per week each, which is expected to increase to 17.2 units a week by 2003. This level is second only to the young people of Germany who consume an average of 20.3 units a week.

Earlier this year the brewers Whitbread, eager to understand and profit from the young market, identified seven distinctive types of drinker, from the young "steamer" who goes out with the intention of getting drunk to the "adapter" who is anxious to order the right label or brand to conform with his peer group.

These figures are good news for the drinks industry. Total sales are expected to rise from 940.9 million litres last year to 1.2 billion litres in four years' time. Richard Robinson, Datamonitor drinks industry analyst, suggested that one reason for the rise in youthful drinking was a revulsion from the eighties' preoccupation with healthy living. "Many people now follow a 'debits and credits' system," he said. "This dictates that consumers feel that one session of 'being good', such as going to the gym, earns them an indulgence such as an alcoholic drink. The debit and credit system is being reinforced by the revival of the cocktail culture in the US and the UK."

Mr Robinson said that "all the key trends are compounded by what has been described as a frame of mind in which it has become fashionable again to be seen to be living an opulent, indulgent life. In this mindset, consumers may feel indulgence in short, controlled bursts can be offset by regular exercise and healthy eating." The analyst uses the term fin de siècle to describe this attitude.

Datamonitor goes on to make the point that young British drinkers are particularly important to the industry.

"It would appear that under the 'debit and credit' system consumers are less puritanical in their attitudes than they once were. However, they remain concerned about their health and change their consumption habits accordingly. "While the health benefits of this are very questionable, the impact of this mode of thinking is such that it is beginning to have a significant effect on indulgent food and drink products, including alcohol.

"Although the 'debit and credit' mindset may be more apparent in the US, the UK remains one of the most important young adult markets in the world for alcoholic drinks manufacturers. The high consumption rates amongst consumers in this age range are sufficient in themselves to attract the attention of marketers.

"However, the manufacturers are attempting to engender loyalty in the long run; it is becoming apparent that, since the baby boom generation, consumers have been loath to change their drinking habits as they grow older. People are no longer prepared to admit to themselves that they are ageing and use a continuation of the brand choices they developed in their youth as a defiant link to their younger days. Manufacturers will continue to concentrate on this age group in the hope of establishing life long drinking habits and brand preferences."

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Helping children of problem drinking parents

The Eurocare Report 'Alcohol Problems in the Family: a Report to the European Union' has helped to draw attention to the problems experienced by children as a result of parental drinking not only in the UK but across the European Union.

Here, Jane Livingston describes a special project to help such children being undertaken in Scotland.

The Alcohol Advisory and Counselling Service (AACS) based in Aberdeen, Scotland secured start-up funding for a child/family worker post in 1995, in order to develop ways of helping children living in households in Aberdeen City and Aberdeenshire where there were parental and or family alcohol problems.

AACS Director, Janis McDonald, who has twenty years experience in the alcohol field identified the need for such a post early on her career and had lobbied continuously to see it realised. In doing so she anticipated the recommendation made in the 1998 report Alcohol Problems in the Family that specialist alcohol agencies should designate a member of staff responsible for family and children's services.

Whilst start-up funding ceased in March 1998, Aberdeenshire Council agreed to fund the post part-time thereafter. The agency is currently in discussion with Aberdeen City Council to secure additional funding.

I took on the post in January 1997 and it quickly became apparent that parental drinking was a priority. In reports published in November 1997, Child Line and Alcohol Concern highlighted that there are nearly one million children in the United Kingdom who are likely to be living with a parent whose drinking has reached harmful or risky levels - just over 85,000 of those children live in Scotland. At a local level a progress report by the Grampian Alcohol Development Officer, Sally Wilkins, entitled `Impact of Alcohol on Public Services' noted that in August 1997, Aberdeen City Social Work Department cited 24% of childcare cases as having alcohol as the reason for referral.

I became particularly interested in the impact of maternal drinking on children and the challenge it poses for social services. This interest was heightened by the introduction of the new Children (Scotland) Act 1995 with its emphasis on support and preventative work, as it is an area of work which is made difficult by the stigma that surrounds alcohol problems.

In October 1998 I completed a research thesis in which I examined the experiences of eight young people whose mothers have a drink problem. As an agency AACS firmly believes that an individual will go through a number of stages in relation to their drinking, in line with Prochaska and Di Clement's Cycle of Change Model, within which they identity five stages, including relapse, that an individual will move through. Direct work with clients has highlighted that there is a general lack of awareness of these stages and that relapse is more often than not viewed as failure as opposed to an integral part of change.

When carrying out the research for my thesis, each of the young people interviewed vividly described their experiences of living with someone going through these stages and their deep frustration at trying to get other people to understand what it is actually like for them. It was clear that the quality of their lives revolved around the drinker and their behaviour: in effect they determined the tempo of family life. The study makes the key point that there are different ways of working with both a parent and their children throughout the Cycle of Change and that an environment must be fostered within which parents and children feel secure in asking for help at. difficult times, without fearing that the family will be split up indefinitely. Ideally a family should be asking for support as opposed to fearing that they will be found out.

Through carrying out the research and continuing to work at the agency, I have seen more clearly that the existing system does little to support the family who is living with a drinker. It is evident that there is a distinct lack of training for professionals in addition to very few clear alcohol policies and that this leads to a wide variance in the quality of help available for families.

Current childcare services take little or no account of the process an individual will go through before changing a drinking behaviour. It is disheartening to witness a drinking parent promising repeatedly at. a childrens hearing or child care review that they will not drink again. How much more productive it would be to have an open and supportive discussion on relapse prevention strategies, action plans for children which take account of the Cycle of Change Model and even to hear the fundamental question being asked how can we support you in changing your drinking behaviour.

The answer may be as basic as providing childcare to enable a parent to attend counselling. To simply demand that a parent must change without taking account of the process they are going through is doing a disservice to them and to the child. This is often justified as focusing on protecting the child. I would argue that it is short. sighted and more damaging in the long run.

AACS has addressed the recommendation in the 1998 report that agencies should ensure that adequate training is provided to staff in relation to child development and the family aspects of alcohol problems by developing a two day training pack which we are marketing both internally and externally. Our aim is to continue to work to improve services for families and we have a number of goals that we still wish to realise.

As well as working at AACS Jane Livingston also runs her own consultancy focusing on children who are affected by a family members use of alcohol.

Copies of her research are available for £8 (includes printing, postage and packaging). She can be contacted at
Tel/Fax 01224 709922

Email janelivingston@btconnect. com
For further information about the child family project or the training pack please contact Jane Livingston directly or Mike Hutchinson (Training Manager) AACS
Tel 01224 573887 Fax 01224 213479

Email info@aacs.co.uk
A report on the child family project 1995-1998 is available from the agency for £2.50 (includes printing, postage and packaging)

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Health benefits of alcohol debunked

Why are you four times more likely to suffer from ischaemic heart disease in the United Kingdom than in France? Researchers tell us that the major risk factors are no less present over the Channel than in these islands. The higher consumption of alcohol in France has been identified as the explanation of the soi-disant "French Paradox" and red wine has been favourite in the health stakes. For quite a few years the drink industry publicity machine has made sure that everyone knows that a steady intake of Chateau Margaux, as recommended by Dr Stuttaford of The Times, will keep heart disease at bay. Large sums of money have been poured into research by the producers of alcoholic drink. Recently the Scotch Whisky Association paid for a study which indicated that the occasional dram could be as effective as red wine in averting a stroke. There is no doubt that the medical research carried out was done so in good faith and the results were certainly plausible. It seemed that men of about 50 years of age were protected from cardiovascular misfortune by a moderate consumption of red wine and possibly a glass of Glenmorangie.

Health campaigners and those working in the field of alcohol policy were justifiably alarmed that the message received by the public would be one of encouragement to drink. Whatever caveats accompanied the assertions of the researchers, it was argued, the idea would be implanted that drinking was a healthy activity.

The picture may be changing, however, and important new research has cast doubt on the protective effects of alcohol. Two studies recently published in The British Medical Journal (BMJ) have opened up the whole question. In the first* the red wine explanation of the French Paradox is shown to be no longer an established fact. Professor Nicholas Wald and Malcolm Law, of the Wolfson Institute of Preventive Medicine at St Bartholemew's in London, suggest that the disparity in the incidence of heart disease is accounted for by their "time lag" hypothesis.

"We propose," say the authors "that the difference is due to the time lag between increases in consumption of animal fat and serum cholesterol concentrations and the resulting increase in mortality from heart disease similar to the recognised time lag between smoking and lung cancer. Consumption of animal fat and serum cholesterol concentrations increased only recently in France but did so decades ago in Britain."

The hypothesis put forward by Dr Law and Professor Wald is based on the fact that there has only been a similarity in the consumption of animal fat and serum cholesterol in France and the United Kingdom for the last fifteen years. "There must be a time lag between the increase in serum cholesterol concentration and the full effect of the resulting increase in coronary artery atheroma and risk of death from ischaemic heart disease."

It is true that in the higher wine consuming countries there is a lower mortality rate from ischaemic heart disease. However, the countries where there is a high level of wine drinking (France, Italy, and Spain, for example) are those where saturated fat consumption was previously low but now increased to levels comparable to places like the UK. "The low mortality from ischaemic heart disease," say Law and Wald, "reflects the earlier low levels of saturated fat consumption, for which wine is simply an indirect marker or confounding factor."

Dr Law and Professor Wald further point out that not all French heart disease deaths were classified as such which in itself could account for about 20 per cent of the difference between Britain and France. In addition, they say that all alcoholic drinks, not simply red wine, protect against harm from cholesterol but that there was no evidence of this making any great difference.

In the second study** a research team led by George Davey Smith, Professor of Clinical Epidemiology at Bristol, has cast further doubt on the claims for alcohol's protective effect against heart disease. Their research drew on the data provided by a large cohort of men (almost 6,000) from western Scotland who were 35-64 when first screened between the years 1970 and 1973.

It has been argued that the relation between mortality and heart disease is best represented by a J shaped curve. This indicates that the greatest risk is found among heavy drinkers, the least among moderate drinkers, and that non-drinkers face a risk somewhere between the two. The suggestion has been made that non-drinkers include those who may avoid alcohol because of ill health or as a result of having been a former abuser of the substance. Professor Davey Smith's study shows that "there was no relation between mortality from coronary heart disease and alcohol consumption once adjustments were made for potential confounding factors". As opposed to some other studies, the researchers found no strong evidence that alcohol consumption reduced all cause mortality for light and moderate drinkers.

Other key findings were that drinkers of over 35 units a week had double the risk of mortality compared with non-drinkers and that risk of all cause mortality was higher in men drinking 22 or more units a week. It is worth pointing out that the old "sensible" drinking limit, scrapped by the previous government, had a maximum of 21 units a week.

The researchers say that "the overall association between alcohol consumption and mortality is unfavourable for men drinking over 22 units a week and does not support the promotion of increased drinking for reasons of health."

It may be the end of the road for the drink industry's argument for the health benefits of alcohol. The debate over the alleged benefits of red wine drinking will no doubt become more vigorous now that there are other explanations for the French paradox, but the French government, at least, appears to be convinced that alcohol is a major health problem. Lionel Jospin, the Prime Minister, is reported to be about to classify alcohol and tobacco as dangerous drugs. The French Health Ministry confirmed that Jospin was about to include both substances in the remit of an inter-ministerial commission charged with dealing with drug abuse. It is estimated that the two legal drugs account for more than 120,000 deaths a year in France. Recent reports indicated that seven million French people were excessive or dependent drinkers. One quarter of all hospital admissions in France, say Law and Wald, are a result of alcohol consumption. The drink industry is very powerful in France and has managed to ensure that measures to combat the problems related to alcohol have been kept to a minimum. It is outraged at the prospect of its products being put in the same category as heroin. The United Kingdom government takes a more sanguine view than its French counterpart and continues to promote the health benefits of alcohol. Perhaps these studies published by the BMJ will give the Public Health Minister and her advisers pause.

*Why heart disease mortality is low in France: the time lag explanation, Dr Malcolm Law and Professor Nicholas Wald, Wolfson Institute of Preventive Medicine, St Bartholomew's and The Royal London School of Medicine and Dentistry, British Medical Journal, vol 318, 1999.

** Alcohol consumption and mortality from all causes, coronary heart disease, and stroke: results from a prospective cohort study of Scottish men with 21 years of follow up. Professor George Davey Smith et al., British Medical Journal, vol.318, 1999.

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Life Saver

The main thrust of the Government's white paper, Saving Lives: Our Healthier Nation, is to improve the health of all, especially those who are more vulnerable to disease and illness because they are socially and economically disadvantaged.

"We are putting forward the first comprehensive Government plan focused on on the main killers: cancer, coronary heart disease and stroke, accidents, mental illness." This is to ignore the last government's Health of the Nation which pioneered the setting of targets in relation to these very conditions and also health behaviours such as drinking and smoking. The white paper claims, however, that its targets are "tougher" than those of the Conservative administration.

They are:

By the year 2010:

CANCER: to reduce the death rate in people under 75 by at least a fifth.

  • CORONARY HEART DISEASE and STROKE: to reduce the death rate in people under 75 by at least two fifths.

  • ACCIDENTS: to reduce the death rate by at least a fifth and serious injury by at least a tenth.

  • MENTAL ILLNESS: to reduce the death rate from suicide and undetermined injury by at least a fifth.

If we achieve these targets, we have the opportunity to save lives by preventing up to 300,000 untimely and unnecessary deaths."

The base-line for these aims are the 1995/96 levels of mortality.

To achieve these ambitious targets the Government says it is:

  • "putting in more money: £21 billion for the NHS alone to help secure a healthier population

  • tackling smoking as the single biggest preventable cause of poor health

  • integrating Government, and local government, work to improve health

  • stressing health improvement as a key role for the NHS

  • pressing for high health standards for all, not just the privileged few."

Focusing on the social, environmental, and economic factors leading to ill health involves co-operation between a wide range of government departments and local authorities. This is emphasised by the number of ministerial signatories to the white paper. Besides the Department of Health, they come from Social Security, the Treasury, the Privy Council, the Home Office, Education and Employment, Trade and Industry, Agriculture, Fisheries and Food, Environment, Transport and the Regions, and International Development. The Prime Minister provides a foreword. It is clearly a flagship document and implies a huge co-ordinated government effort over the coming years.

The white paper acknowledges the background of the considerable improvements in health over many years - factors such as increased longevity, the disappearance of many infectious diseases, rarity of death in childbirth - and says that this trend can be maintained by the efforts of individuals. "People can improve their own health, through physical activity, better diet and quitting smoking." Part of this can be achieved by educating people:

"We are introducing new Healthy Citizens programmes to help make decisions:

  • NHS Direct - a nurse-led telephone helpline and Internet service providing information and advice on health

  • Health Skills programmes for people to help themselves and others

  • Expert Patients programmes to help people manage their own illnesses."

The Health Education Authority will be replaced by the Health Development Agency. The new body will have a wider field of activity, including "commissioning and carrying out evidence-based national health promotion programmes and campaigns which are integrated with the Department of Health's overall communications strategy and linked with regional and local activity." The Agency will have the responsibility of giving advice on the targeting of health initiatives on the most disadvantaged members of society. In addition, it will advise on the ability of those involved in public health to implement Ministers' strategy and on the education and training needs of the workforce.

The "community factors" which affect health, says the paper, are poverty, low wages, unemployment, poor education, sub-standard housing, crime and disorder, and pollution. It stresses the coherence of the Government's policies over the range of these issues and the expected tendency towards improved health.

Although communities, individuals, and many government departments will be involved in the achievement of the targets, the National Health Service will necessarily have a central rôle:

"We will reorient the NHS to ensure that for the first time ever, health improvement will be integrated into the local delivery of health care:

  • health authorities have a new role in improving the health of local people

  • primary care groups and primary care trusts have new responsibilities for public health.

  • Local authorities will work in partnership with the NHS to plan for health improvement:

  • health action zones will break down barriers in providing services

  • healthy living centres will provide help for better health."

At the beginning of the white paper the Chief Medical Officer, Liam Donaldson, thoughtfully provides the Ten Tips for Better Health displayed below.

To increase people's access to information about what is happening on the ground, the Government is establishing a database of practice - Our Healthier Nation in Practice - as part of the Our Healthier Nation internet site on www.ohn.gov.uk. where people will be able to find information of the progress of the various initiatives.

Ten Tips for Better Health:

Don't smoke. If you can, stop. If you can't, cut down.

Follow a balanced diet with plenty of fruit and vegetables.

Keep physically active.

Manage stress by, for example, talking things through and making time to relax.

If you drink alcohol, do so in moderation.

Cover up in the sun, and protect children from sunburn.

Practise safe sex.

Take cancer screening opportunities.

Be safe on the roads: follow the Highway Code.

Learn the First Aid ABC - airways, breathing, circulation.

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The morning after problem

The first report of the government's social exclusion unit* paints a shocking picture of this country's contemporary ills. It makes plain the complicated relationship between poverty, low educational achievement, and health. One of the issues raised is teenage pregnancy and the growing concern over the general question of sexual health among young people.

Writing in the British Medical Journal, researchers from the Communicable Disease Surveillance Centre point out there "there is substantial sexual ill health among teenagers in England and Wales". Between 1995 and 1996 there was a 34 per cent rise in the number of cases of gonorrhoea in 16-19 year old males and a 30 per cent rise among females. At the same time there were similar increases in the incidence of other sexually transmitted diseases.

In 1996 86,174 young women under the age of twenty became pregnant. Over 30,000 of these had abortions. The bulk of the terminations were in urban areas. Despite these facts, the teenage birth rates in England and Wales were the highest in western Europe.

The new white paper, Saving Lives: Our Healthier Nation, refers to the action plan of the Social Exclusion Unit which includes "a national campaign to mobilise every section of the community to achieve its clear goal to cut the rate of teenage conceptions by half in under-18s by 2010". There should also be "better prevention by tackling the underlying causes of teenage pregnancy through better education about sex and relationships, clearer messages about contraception and special attention to high-risk groups including young men".

Martin McKee, Professor of European Public Health at the London School of Hygiene and Tropical Medicine, writing an editorial on the subject in the BMJ, looks further for the causes of the increase in teenage pregnancy and sexual ill health. He comments: "What is especially worrying is that it is not only in sexual health that British teenagers to do rather worse than their continental counterparts". Indeed, at the end of 1998 the European Drugs Monitoring Centre reported that British teenagers were more likely to have used illicit drugs than their contemporaries in any other European Union country. In addition, a number of surveys show that the 15 year olds most likely to drink alcohol at least weekly are those living in Wales and Northern Ireland.

Saving Lives: Our Healthier Nation says: "Drug misuse is associated with poor health both directly, for example through the effect of overdoses and the spread of infection (specifically HIV/AIDS and hepatitis B and C); and indirectly, because of the link with social exclusion through homelessness, poverty, unemployment and criminal behaviour. And the problem is frighteningly widespread".

In themselves, each of these problems - sex, alcohol, and drugs - is alarming enough but together, Professor McKee argues, they suggest some "more fundamental malaise." The weakening of the family unit is one possible answer. More families live in poverty in the United Kingdom than anywhere else in the European Union and there is a complex but proven link between poverty and risk taking behaviour. British mothers and fathers work the longest hours in Europe and consequently families spend less time together. Moral imperatives which formerly were delivered by the churches or in schools as well as in families are often absent.

Education is an element in the problem. It is the case that a humane education plays a rôle in delaying pregnancy and surveys indicate that level of education has an effect on smoking. One beneficial effect of pre-school education has been shown to be a long-term reduction in harmful behaviours on the part of teenagers. The United Kingdom, however, whilst being amongst the leaders when providing for those at the top of the educational scale, has a sorry record of underachievement among the less gifted and underprivileged. In basic literacy and numeracy skills this country disputes bottom place with the United States.

Clearly there is a considerable amount of work to do in unravelling the factors involved in teenage pregnancy and sexually transmitted disease. Alcohol and other drugs are a factor but poverty and poor education appear to lie at the root. Many people involved in dealing with these problems will be looking to the translation of the government's words into deeds.

*Social Exclusion Unit. Bringing Britain together: a national strategy for neighbourhood renewal. London: SEU , 1998.

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Do not go silent...

Andrew Varley looks at Caitlin Thomas' memoir of her life with Dylan

When Caitlin Thomas flew to New York to be with her dying husband, she spent the first night in an asylum, laced into a straight-jacket. Dylan had collapsed on 5th November, 1953, after a bout of whisky drinking and was lying in a coma. Caitlin became hysterical in the hospital and threw herself, wailing, on top of the poet, almost extinguishing what life was left. Dragged off him, she continued to make a scene, conscious that Thomas' most recent American girlfriend was amongst those gathered at the deathbed. Later she melodramatically smashed a large crucifix. Through a drunken haze, she remained aware of her performance and gratified at its effect.

"Between sanity and insanity, it is aid, there is a very thin line. In my case there was no such tremulous line, I was perfectly sane, nowhere near insanity. But extreme amounts of alcohol can make its subject, the one who is subjected to it, play some very insane tricks. And those tricks can trick the beholders of them into thinking that it is the subject that is insane, when, in fact, it is the alcohol that is making the subject behave insanely. When the subject is sober once again, it automatically, if unhappily, becomes sane. And this is what happened to me when I was put in the Bellevue asylum. I automatically, if unhappily, became sane again."

In old age, in sobriety, Caitlin Thomas was able to write with this painful, raw honesty, but it is like seeing someone open a wound and sometimes it is necessary to put her book down and detach from the agony she is not so much describing as reinflicting. It may be different for people who have not been there. Double Drink Story: My Life with Dylan Thomas (Virago) is Caitlin's account of her marriage. Her marriage and her descent into alcoholism were one and the same thing. Of course, the poet did not make his wife an alcoholic - the predisposition and the habits of life were already there - but life with Dylan Thomas no doubt accelerated the process. They met in the Wheatsheaf in Fitzrovia, she was captivated by his talk (but emphatically not by his appearance), he was flattered by the attentions of a personable, attractive girl who went drink for drink with him, and they spent their first week together in an hotel at the unwitting expense of Augustus John, who had seduced her when she was a young girl. When they married they moved to Laugharne on the South Wales coast into a house rented for them by the wife of the historian A.J.P. Taylor. Dylan wrote in the mornings and then went to the pub. Caitlin joined him in the evenings. Unselfconscious sex was only possible after a lot to drink. The pattern of their life - boozing and sponging, drunken coupling - was established from the beginning. It changed little with the appearance of children.

"Dylan had an ancient, out-of-the-cave conception that his drinking prowess made him even more manly, more of a swashbuckling he-man, more of a superman among his fellow men." Caitlin records this common alcoholic misconception but points out that Thomas never fell for the favourite delusion of drunken writers that inspiration lies at the bottom of a glass. "He knew only too well that drunken writing when reread in sobriety was revealed as junk. And he knew also, only too painfully, that there was no easy way, no painless way, to produce good writing." But Caitlin never deceived herself that his art could ever stop Thomas drinking. Alcohol was his master and, although as far as his writing was concerned he "was totally lacking in competitive spirit", when it came to booze "he had a rampant spirit of competition."

Like most alcoholics, Caitlin had moments of shame and disgust when she dreamed of giving up the stuff but it was not possible until she had experienced a good deal more suffering. Many wives of great men pass self-effacing lives, content with or resigned to second place. Some find a rôle to play or a career independent of their husbands. The same may now be said of men married to great women. Caitlin Thomas found neither career, contentment, nor resignation. She raged against standing in the shadow and, fuelled by drink, hit out, often all too literally. Behaviour which was forgiven her husband was held against her: genius excused, misery did not. Edith Sitwell, an early patron of Dylan, gave a luncheon party some time after the war. Although both Thomases were fearfully drunk, it was Caitlin who was the target of disapproval and Dylan the recipient of sympathy. Admittedly, he was always the less aggressive of the two.

The grotesque events surrounding Dylan Thomas' last days were as much the making of his own alcoholism as they were of Caitlin's. They have been replicated to a greater or lesser degree at the deaths of countless drunks who lacked the poet's literary eminence. Caitlin's drinking career continued into widowhood. She ended up in Italy where she met her second husband, Giuseppe Fazio, a man equal to her fiercest outbursts. This marriage and the birth of their son, Francesco, gave Caitlin the purpose she needed to find sobriety. After many false starts she was able, through the help of Alcoholics Anonymous, to spend the last twenty years of her life in recovery. While still drinking she had written about her life with Dylan. What she had to say then was under the distorting influence of alcohol. In Double Drink Story Caitlin sees clearly what drink did to her life and what it did to the great poet who was her first husband. She speaks with the uncompromising honesty of someone who has stripped away all pretence. If her prose occasionally sounds a little like a pastiche of Dylan's tumultuous language, we can hardly complain when it celebrates the rediscovery of the joy of living.

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Government's Millennium proposals get half-hearted support

The Government has been given the go-ahead for its proposals for 36 hours continuous drinking during the Mill-ennium celebrations by Parliament's Deregulation Committees, but not without some serious reservations being expressed.

Both Committees, one for the House of Commons and one for the House of Lords, agreed that the Government's proposals should now proceed to the next stage and be laid before Parliament for final approval. However, the Government was criticised by both Committees, particularly the Lord's Committee which accepted the main points made by the Institute of Alcohol Studies in its submission on the issue. (see Alcohol Alert Issue No.1 1999)

The House of Commons Committee criticised the Home Office for giving the impression in its original press release that the proposals had already been made law, when all that had happened was that they had simply been laid before Parliamentary Committees for consideration. The Committee asks that in future all Government Departments ensure that such false impressions be avoided, so as not to prejudice the task of Parliamentary scrutiny.

On issues of substance, however, the Commons Committee accepted all the Government's arguments and proposals, even regarding restriction orders, the means proposed by the Government to avoid undue social disturbance and public order problems arising from extended drinking hours. On this, the Committee accepted, apparently without question, the Government line that the proposals would not increase public disorder and that the provisions for restriction orders were adequate to deal with potential nuisance at `problem' premises. The Committee's comments simply ignore the main criticisms levelled at restriction orders, for example, that as in practice they could only be brought into effect after the nuisance had occurred, the protection they offer to local residents is more apparent than real.

The conclusions of the House of Lords Committee are far more critical of the Government. Indeed, the Lords Committee recommends that the Government amend its proposals to apply only to the Millennium Eve and not to subsequent New Year's Eves. This is because Parliament does not have sufficient evidence to agree to the proposals for subsequent New years and it would be sensible to await the outcome of Millennium Eve before making final decisions.*

On the main issues regarding, public order, noise and social disturbance, the Lord's Committee state:

"The Millennium New Year period is guaranteed to be a noisy one, with or without any relaxation in the licensing laws. For example, large-scale firework displays are planned and many church bells are being renovated up and down the country so that they can be rung simultaneously on 1 January 2000. Whilst we have considerable sympathy for residents who may be disturbed, we take the view that they are likely to be disturbed on the Millennium New Year's Eve anyway, with or without the present deregulation proposal. The exceptional nature of the celebrations that are already planned for the Millennium leads us to accept that it is possible that no necessary protection will be lost if the proposed relaxation is allowed for that New Year. We would also see no need for "restriction orders" if the proposal is limited to that occasion.

"The maintenance of "necessary protection" through the licensing laws - or their deregulation - raises complex questions of the maintenance of public order and the operation of public services over the holiday period. We agree with the Institute of Alcohol Studies that, despite the responses which the Home Office received to its consultation document, the Government's explanatory memorandum on the proposal fails almost completely to answer these questions. The IAS said in its evidence that "presumably, the Government is convinced that its proposals will not result in additional disturbances on the streets or seriously ill people not being cared for properly in Accident and Emergency Departments because of intoxicated (and often abusive) revellers putting undue strain on the system. It would clearly be helpful for the Government to publish the information, evidence and advice on which it has arrived at these confident conclusions. In view of the possible impact on the health service, this should be done by means of statements by the Secretary of State for Health as well as the Home Secretary."

The Lords Committee concludes:

`In an unprecedented situation, it is difficult to come to a firm conclusion as to whether necessary protection would be maintained under the proposal. We have concluded that, in order to guarantee necessary protection, in so far as this is possible, that in laying the second stage deregulation order before Parliament the Home Secretary and Secretary of State for Health should justify the Government's claim that the emergency services will be able to cope with the likely effects of the deregulation order over the Millennium period.'

Delegated Powers and Deregulation Committee. 18th Report and Third Report Session 1998-99. 16th and 17th June respectively 1999.

*STOP PRESS It has been announced that the government has accepted the Lords' recommendation and the order will now apply for this year only.

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Czar quality

In his first annual report, Keith Hellawell, the Government's Anti-Drugs Co-ordinator, states that it will take at least ten years "to rid our society of the cycle of drugs and crime which blights so many lives." He has £217 million to help accomplish the task and, for the first time, access to the seized assets of drug dealers.

"The overall aim of the ten-year strategy," writes the Drug Czar in his Foreword to the report, "is to shift the emphasis away from dealing with the consequences of the problem, to actively preventing it happening in the first place." Mr Hellawell goes on to say that the intention to direct the bulk of the available resources into treatment and education will "make a substantial impact on the amount of drug-related crime committed and the severe misery that causes."

Mike Trace, Deputy Anti-Drugs Co-ordinator, was formerly director of RAPt (the Rehabilitation of Addicted Prisoners Trust) and the report draws attention to the importance of treatment programmes in prison which "can mean the difference between hope and a future, or the return to a life of crime. Drug Testing and Treatment Orders are now on the agenda and the hope is to "break once and for all the link between drugs and crime."

The report sets out the targets which are to be achieved by 2002. They include the intention that all Drug Action Teams (DATs) should have established integrated and comprehensive programmes in lifeskills approaches in all schools. One result envisaged is a reduction in exclusions from schools for drug-related incidents. Also as far as young people are concerned the aim is to delay the first use of Class A drugs by six months and to reduce by 20 per cent the number of 11-16 year olds using Class A drugs.

The report goes on to state the aim "to increase the participation of problem drug misusers, including prisoners, in drug treatment programmes which have a positive impact on health and crime by 100 per cent by 2008, and by 66 per cent by 2005".

A reduction in the use of drugs involves a reduction in their availability. The report states that its principle aim in this area "is to reduce access to all drugs amongst young people (under 25) significantly, and to reduce access to the drugs which cause the greatest harm, particularly heroin and cocaine, by 50 per cent by 2008 and by 25 per cent by 2005."

The report, for all its worthy aims, would have more impact did it not almost sink beneath the weight of its own jargon and ambiguity of expression. What are we to make, for example, of the intention "to develop plans for the introduction of supervised consumption of controlled drugs by pharmacists"? It was Mr Hellawell who recently said, "There's a myth that if we legalise a substance it would somehow take the illegality out of it".

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Doctors debate cannabis

The motion on medical use, tabled by the Scottish Regional Public Health Committee, was lost by just nine votes after a heated debate on the benefits of the drug. Last year, the conference voted for trials, to begin this October, into the possible medicinal benefits of cannabis. Some sufferers from conditions such as multiple sclerosis and arthritis have found relief of pain through use of the drug.

The proposer of the motion, Dr Stephen Kisely said: "We are not proposing that the corner shop should be able to sell marijuana to anyone who comes through the door, but neither are we promoting the blanket prohibition which is in place at the moment. The legal effects of cannabis are far worse than the medical and psychological effects. People who are prosecuted for possession of cannabis may have their livelihoods destroyed for the use of a compound which has less adverse consequences than alcohol and tobacco. The BMA should stand up and act to help its patients. Making them criminals does not help."

In contrast, Dr Joan Richards suggested that trials on the medical benefits should be conducted before the BMA made calls for legalisation. "We do not know enough about the possible benefits yet," she said. "We should wait for the evidence."

Dr Ian Bogle, Chairman of the BMA, urged the conference to reject the motion. "We have spent many years discussing how to get the public off cigarettes. We do not want to spend the next 20 years talking about how to get the public off cannabis."

Last year, the House of Lords science and technology committee backed the use of cannabinoids - chemicals in cannabis - for medicinal purposes.

(See Alert, no.3, 1998).

The annual conference of the British Medical Association (BMA) has narrowly defeated a motion calling for cannabis to be legalised for medical use. At the same meeting in Belfast, doctors threw out by a large majority another motion calling for the drug to be decriminalised for recreational use.

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Methodists to renounce ban?

The annual conference of the Methodist Church has agreed, by a narrow margin, to refer proposals to permit the selling and serving of alcohol on church premises and to use alcoholic wine at communion for general discussion among its churches. A final decision will be taken at next year's conference.

The report Methodist Attitudes to Alcohol claimed that allowing churches to offer alcohol would promote responsible drinking. The Reverend John Kennedy, Church and Society secretary, said: 'Methodist attitudes to alcohol have changed significantly in recent decades, from a widespread commitment to abstinence to one in which moderate, responsible drinking is more common.' Mr Kennedy added, "More people drink, more people drink responsibly, and more people abuse alcohol."

There was opposition to the move towards liberalisation. Stephen Murray, representing the youth executive, said that the report did not address the concerns of young people among whom there was a serious problem as regards drinking. He said, "We are not just talking about sixteen to twenty year olds but rather twelve to thirteen year olds.'" The Youth Conference had voted by 112 to 12 votes to maintain a prohibition on alcohol.

Nicola Jones also opposed lifting the ban. "Alcohol is the biggest and most acceptable drug in the West," she said. "The Methodist Church is one of the few places where people can have a good time without alcohol.'" The Reverend Marian Jones said, "I am not usually shocked while working as a prison officer, but when you get sixteen to eighteen year olds telling you they are alcoholics, it's upsetting. They need safe places where there is no alcohol when they come out."

Professor Peter Howdle, a consultant at St James' Hospital, Leeds, challenged information in the report on the medical evidence regarding wine and coronary heart disease. It was still debatable whether the beneficial effects were due to the alcohol or to something else in the beverage. In any case, he believed, the issue should not be debated on the grounds that alcohol was good for you.

The Reverend Barbara Bircumshaw also believed the report to be based on flawed information. She wanted to know on what evidence the statement 'that we are handling our drink better' was based. "Over the past ten years the number of females exceeding the limits for drinking has increased by 40%. There has been no reduction in unhealthy drinking among either males or females. The target set by the Government in Health for the Nation to reduce the number of women drinking over the limit from 11% of the female population to 7% has in fact gone the other way to 14% drinking more than is sensible."

Arguing for the lifting of the ban, Mike Wright said, "There's a distinction between the promotion and the consumption of alcohol. Coming from a small village our premises are widely used for events like weddings and birthday parties. It can be quite restrictive if alcohol is not allowed."

Methodist circuits have until the 1st March 2000 to send in their responses to the report.

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And so, farewell then, duty free

At the June Summit of European Union Heads of Government, Tony Blair, allied with the French Prime Minister, Lionel Jospin, and the German Chancellor, Gerhard Schröder, failed to postpone once again the demise of the traveller's perk.

Like some rich spinster aunt keeping potential heirs guessing, duty free has lingered on its death bed for years, rallying occasionally, until on 30th June, 1999, it passed away. Despite such powerful support these leaders of Europe could not achieve the necessary unanimity among their fellows to prevent the ban coming into force.

The existence of duty-free concessions within the European Union was seen as illogical by the Commission in Brussels and the decision to remove them was taken in 1991. Since then there has been intensive lobbying of governments by ferry operators, airport authorities, and other groups with vested interests in the continuation of the trade. In the United Kingdom it was argued that 30,000 jobs would be lost as a result of the ban and Mr Blair's government became one of the most vocal in calling for a reprieve. Germany, with the well-being of the Baltic ferries particularly in mind, also hoped to extend the life of duty-free. It is, however, necessary to have unanimity in these decisions and determined opposition from Denmark and The Netherlands made certain that the 30th June deadline remained in place.

The confusion which has been generated over the last few years was kept up to the last. Ferries over the last few days of duty-free were fully booked, with eager shoppers queuing early least they boarded the ship too late to buy goods which, in many cases, they could probably buy cheaper in their local High Street and could certainly do so in the hypermarkets clustered around the French channel ports. The last weekend of the 52 year-old exemption saw record numbers of people crossing the Channel simply to buy duty-free goods for the last time. Their hurry may have been misplaced, however, since ferry operators intend to subsidise many goods in order to keep their price down to the duty-free level. Besides, duty will now be charged at the rate levied in the country where the sea journey started. Shops at airports will, of course, miss out on this advantage.

The drinker who takes a short-term view will still be able to enjoy a cut-rate booze-up: purchases for consumption on board ferries and aeroplanes remain duty-free. Passengers will still be allowed to buy duty-free goods on journeys to destinations outside the EU.

There appears to be a certain degree of public confusion as to what exactly is happening.

The hypermarkets, on the other hand, are quite clear that they stand to increase their profits.

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Dealing with drink

Derek Rutherford, now the chief executive of the United Kingdom Temperance Alliance, was between 1972 and 1980 the Director of the principal Government-backed agency on alcohol misuse, then known as the National Council on Alcoholism. Before his days at the NCA, he founded and directed TACADE, and after leaving it he established the Institute of Alcohol Studies. He has thus been involved in alcohol policy for over 30 years.

Here, he reviews a new book charting the development of alcohol and social policy from the beginning of the 1950's to the present day.

It has taken Betsy Thom some ten years to complete this book and it has appeared whilst we await the Department of Health's new strategy on alcohol.

For those who wish to understand how attitudes and responses to alcohol and alcohol problems developed over this period, and the changing reaction of Governments to alcohol policy, this book is a must. Those currently involved in alcohol prevention and treatment services will learn that the struggles they experience are not new and also that much has been achieved since the barren years of the 1950s. Older hands, despite some disappointments, ought to feel a sense of achievement at the vast improvement in the range of services available to problem drinkers. All who read the book will realise that 'alcohol policy today is embodied in the past'.

At the beginning of the 1950s state supported services for people with alcohol problems were virtually non -existent. In 1951, the Ministry of Health refused permission to a psychiatrist to attend a WHO conference on alcoholism on the grounds that `as there was no alcoholism in England and Wales', the subject did not merit the expence. The British Medical Association and other bodies held similar views. People with drinking problems found themselves, as Thom points out, 'in the terrible back wards of mental hospitals'.

Today, these attitudes strike us as extraordinary. We have to remember that alcohol consumption in 1950 was at a historically low level of 4.5 litres per head of population and the level of alcohol problems was also very low compared with both earlier and later.

It was also a question of how alcohol problems were perceived and defined. Throughout the 1950s the Ministry of Health considered alcoholism as a symptom of underlying disease, not a disease in itself. However, due to Alcoholics Anonymous influence on a number of professionals there was to be a re-emergence of the disease concept. Lincoln Williams in 1951 was to describe alcoholism as "an illness every bit as real and compelling as any of the maladies generally recognised as such". Thom poses the question "Why did the disease concept appeal so quickly and so widely?" and gives three reasons:

First, medical involvement was legitimised by defining alcoholism as a medical problem. Second, viewing alcoholism as a disease and not a moral failing or a sin made it easier to gain public support.Third, it provided a bridge between different interest groups and facilitated interaction between lay and professional discourses.

It was the growing acceptance of alcoholism as a disease which provided the impetus for treatment services. However, having served its purpose the disease concept began to be discarded in professional circles. It was replaced by the concepts of 'dependence on alcohol' and 'alcohol related disabilities' which incorporated physiological, psychological and social dimensions. A new 'public health' view of alcohol problems emerged with emphasis on the consumption of alcohol in the population as a whole and the link between consumption and alcohol related harm.

Dr D. L. Davies, Dean of the Institute of Psychiatry was to play an important rôle in giving alcoholism an academic framework. Dr Max Glatt, the psychiatrist who was refused permission to attend the WHO conference, later established in the 1950s an alcoholism unit at Warlingham Park, Surrey, and became the 'clinical leader' in the field. Thom in assessing official correspondence feels that Davies' approach to alcohol treatment was more in line with government policy than Glatt's. He was a member of several influential governmental committees and was in a strong position to influence the Ministry of Health whilst Glatt was an outsider. Yet it was Glatt's model of special inpatient units which the Ministry of Health recommended to Regional Health Authorities in 'The Hospital Treatment of Alcoholism' in 1962. This was the first official statement regarding alcoholism treatment within the NHS. It was a response to a 1961 report by a joint committee of the BMA and the Magistrates Association on the problems of alcoholism treatment, of which Glatt was a member.

During the same period, under the influence of Griffith Edwards clinical and epidemiological studies of alcoholism, gathered momentum and these began to influence policy decisions. Edwards was to play a decisive rôle in the development of services and in prevention strategies.

Outpatient treatment was shown to be as effective as in-patient care. It was at this stage that D. L. Davies began to exert his influence. He always had doubts about the need for specialist units but kept quiet with regard to the 1962 memorandum because he believed it necessary to get the Government in some way to respond to alcoholism.

Emphasis began to be placed on early intervention strategies for people with drinking problems. The 1978 Advisory Committee Report on Pattern and Range of Services for Problem Drinkers confirmed the need for community based services and supported the drive for Community Alcohol Teams and a primary care response to identify and support problem drinkers.

The problem here was that the development of a primary care response was a 'top down' initiative. It came from policy makers and specialists and as a result there has been difficulty in selling it to primary care workers. However, Thom takes too bleak a view: she does not mention the way in which the Probation Service has developed programmes for offenders with alcohol problems.

Thom considers that the major service development emerging in the 1960s was in the voluntary sector. It matured in the 1970s when government funding was made available. Partnerships between the voluntary and statutory services were established through the creation of Councils on Alcoholism. The formation of the Camberwell Council on Alcoholism and the National Council on Alcoholism in 1962 provided a national focus point for the advocacy of alcohol policy and a community based response to alcoholism.
By 1972 the National Council had been able to encourage the development of six local councils on alcoholism. More could have been achieved had there been adequate funding. Thom makes the point that "it is a common observation about British political life that it works through who knows whom". This was the case for Davies, Glatt and Edwards. They were well equated with people who had political clout or who sat on the appropriate committee.

However, Thom fails to mention that behind the Secretary of State, Sir Keith Joseph's interest in alcoholism lay his uncle, Harry Vincent, who was the Chairman of Bovis and the NCA. It was through Vincent that Keith Joseph took the important step of funding the voluntary sector and the famous DHSS Circular 21/73 was issued. Sir Keith also sought out Sir Bernard Braine, who under Harold Macmillan had been a junior minister and had a real interest in health matters, to succeed his uncle as Chairman of the NCA. Keith Joseph promised Sir Bernard that if he developed professionalism in the NCA and succeeded in the tasks he set for it more money would be found. The difficulties for the NCA had been largely caused by lack of funds. Since its inception in 1962 it had relied mainly on a grant from the Rowntree Social Service Trust. From 1973, aided by Government grants, the NCA was able to support existing councils and by 'pump priming' grants able to establish a sustainable network of local councils with the support of health and local authorities. The success of the policy is evidenced from a 1990 Alcohol Concern report which stated that councils on alcoholism had become the largest network of services for problem drinkers within the voluntary sector with over ninety regional and local councils in the UK.

The value of this aspect of the work of the NCA after its forced closure by the Conservative government was the determined effort by the DHSS Alcohol Policy Group to make sure Councils on Alcoholism were seen as an essential part of the network of service: "We pushed very hard and got approval from ministers that one of the major roles of Alcohol Concern should be the promotion of new Councils on Alcohol". (Dr Warman from DHSS interview). Thom provides evidence of the fact that the alcohol policy group was somehow not trusted by Sir George Young junior minister of health at the time.

The reorganisation of the national voluntary sector was done without consultation with the group responsible for the implementation of ministerial policy: "...things happened over official heads....suddenly we were presented with a fait accompli....it was done without the consultation of the Alcohol Policy Group" (Wawman's interview).

Thom does not cast any light on why the minister was so distrustful of his civil servants in charge of alcohol policy. Sir George when he was a backbencher was closely associated with the Federation of Alcohol Rehabilitation Establishments. Was it because the group was pro-active in its advocacy of the consumption model, disliked by the drinks industry which we know for the 1980s was exerting tremendous pressure on the government.

Thom shows that conflicts over interdepartmental responsibilities for the problems relating to alcohol consumption existed as soon as government took an interest in services.

In 1960 the Ministry of Health, the Home Office and Prison Committee officials held meetings to address the many sided aspects of alcohol problems and departmental interests and responsibilities. Issues relating to 'drunkenness' and 'alcoholism'; prevention and treatment impeded co-operation between departments. When the Ministry of Health confined itself to the narrow medical aspects then the Home Office withdrew from any further involvement. This division of responsibility between these two important departments became a major issue in responding to habitual drunken offenders.

Further conflict between the DHSS and Home Office surfaced over the Department's Advisory Committees Report on Prevention. DHSS were champions of the consumption model and it became clear that there were those in the Home Office opposed this view. A Home Office report was prepared by Mary Tuck which was not only not in line with DHSS thinking but which was published without the courtesy of interdepartmental consultation.

Thom shows the importance during the 1970s of DHSS civil servants such as Dr Alan Sippert and Chris Ralph in promoting and developing alcohol policy. Dr Wawman, testifies to the latter's ability in getting Ministers to give the right message. "Patrick Jenkin ... he was made to say things like 'Alcohol abuse is of epidemic proportions. His having said that, we were able to say ..... "The Minister said that, but when Ministers will not do this, it takes away your ability to influence official policy".

But things did change. `Drinking Sensibly' was issued by the Government and although the consumption model had made some inroads, it was so watered down that the document was dismissed as 'facile and inadequate' by the public health lobby. Wawman admits that large chunks were written by other departments such as the Ministry of Agriculture and Fisheries and the Treasury. He confirms that the decision to publish the document was taken by the Cabinet. To Dr Wawman it was therefore Government Policy.

The Government set up in 1987 an Interdepartmental Group on Alcohol Abuse. Thom from an interview says that the intention of the Group was to co-operate with the Drinks Industry and to this end the Portman Group was established in 1989.

Thom also outlines changes and diversity in treatment approaches developed during the period. Controlled drinking was developed as a therapeutic goal. This did create tensions within the field. Anthony Thorley, who at that time was the consultant psychiatrist at Parkwood House in Newcastle (he later became a senior medical officer at the Department), is quoted as saying "that staff wanted to counsel people with controlled drinking as a goal. They were virtually sacked, or marginalised or kicked out".

This is not my recollection. I know of no director of a Council of Alcoholism who was sacked for holding and practising such views. What did happen was that the NCA set up a working party under the chairmanship of Dr Raj Rathod and with as a member Jim Orford, a clinical psychologist and a well known advocate of controlled drinking. The working party set out guidelines for counselling problem drinkers in relation to both abstinence and controlled drinking.

It is a pity that Thom omits some significant developments which had a lasting impact. In 1977 the NCA issued its working party report on Alcohol and Work. The report itself was written by Dr Sippert and myself. It did much to encourage the development of alcohol policies in the workplace and this was acknowledged later by the Health and Safety Executive.

Whilst a brief reference is made to voluntary counsellors, there is no mention of the fact that this was an innovative initiative of the NCA in 1975. In 1975 the NCA was able to get a grant from the Baring Foundation on condition it was matched by the DHSS to initiate a voluntary counsellor training scheme. Chris Ralph was sceptical and I am told he went into the interview determined to turn it down. I came away with approval of the scheme. Chris Ralph had been won over to at least an experimental trial. This was successful and showed that ordinary men and women could be trained to counsel problem drinkers. Use of voluntary counsellors is a feature of the service provision of many advice centres today.

There was also the Blennerhassett Committee which reviewed the working of the 1967 Road Safety Act. Alan Sippert tried to persuade the Committee to recommend the introduction of a high risk offender procedure. The DHSS urgently requested the NCA to prepare written evidence in support of Sippert's proposal. When the report was published a high risk offender category was in their recommendations. In road traffic debates in the House of Commons in the early 1980s a high risk offender procedure was raised by Sir Bernard Braine and eventually the Department of Transport introduced it.

Even in this excellently researched and written book there some errors. One such is the view that in their early days Councils on Alcoholism were linked to temperance networks. This is not correct. The mistake probably arises from a misunderstanding of the nature of the Church of England Temperance Society which supported the creation of the NCA. The CETS had long ceased to be part of the mainstream Temperance movement. Indeed, relations between the temperance movement and the new alcoholism organisations were characterised by mutual mistrust and dislike. Temperance organisations did not support the disease concept while the alcoholism organisations did not wish to be seen as against alcohol as such.

Thom is also wrong in claiming that the NCA gave evidence to the Erroll Committee on liquor licensing in 1972. Basing his view on the old fashioned disease concept, the then Director of the NCA agreed that, "alcoholism comes in persons not in bottles" and he saw no relevance of liquor licensing to the problem. He therefore declined to give evidence.

My congratulations to Betsy Thom for a very thorough review of the development of social policy during the last 40 years. It has much to teach us all today and perhaps government officials facing a rising tide of problem drinking among the young could learn some valuable lessons from the past. However, the leadership must come from their political masters for it is the lack of political will that has hindered the application of effective policy to control rising alcohol problems.

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Hancock's last half hour

Sometime in 1958 Tony Hancock spent a day drinking with Jeffrey Barnard. As night fell neither man was finding it easy to stand. Hancock had urinated in his trousers. Barnard, the famous habitué of Soho bars, was in slightly the better state and finally managed to find a taxi whose driver was willing to risk their presence in his cab. Inside, the comedian, who at the time was at the peak of his fame, slumped on the floor. Barnard managed to steady himself on the seat. He noticed that Hancock was fumbling ineffectually inside his pockets, eventually locating a visiting card which he passed to Barnard with the words, "If ever you need my help, just call me." "Why on earth should I want help from you?" "Because," said Hancock, "I think you might have a drinking problem."

The same story, mutatis mutandis, is told by a large proportion of recovering alcoholics. Sometimes they are the Barnard figure, horrified into the beginnings of recognition by sympathy from a person hitherto regarded as a hopeless drunk; at others, they are in Hancock's position, blind to their own situation, but more than prepared to warn others as to the error of their ways. I know an elderly Californian who tells of the occasion when he was in a bar in San José and was approached by a man known locally as Sam the Lush. Sam looked at the small beer in front of my acquaintance who explained that he was trying to cut down. "Good idea," said the town drunk. "If I put it away like you, I'd cut down."

Tony Hancock did not accept his alcoholism until the last two years of his life. He made some effort to give up drinking but his frequent spells in a variety of clinics were usually the result of emergency admission rather than any voluntary decision to undergo treatment. Of course, from much earlier in his life, there was overwhelming evidence that he had a severe problem. The incident with Barnard occurred in 1958 when Hancock's Half Hour was running and he was at the height of his powers. From the earliest days of his first marriage he had, when drunk, behaved violently towards his wife, Cicely. His second wife, Freddie, fared no better and made several serious suicide attempts, as did his mistress Joan le Mesurier. Although, for a long time, he avoided drinking when he was working, as soon as he first discovered the magic of idiot boards he lost all restraint. A minor car accident immediately before the recording of The Blood Donor resulted in concussion and a consequent inability to learn his lines. Autocues were used and Hancock hardly ever learned a line again. He was liberated to drink when he liked and thereafter few performances were unimpaired by alcohol.

Hancock was able to inspire affection and loyalty and he tested these to the extreme. He treated friends, colleagues, lovers, and wives with a cavalier attitude which often amounted to callous indifference. Any sustained application, from learning lines to fostering relationships, from enduring the rigours of a theatrical run to facing the consequences of his actions, was utterly beyond him. There was always something else to prove about himself. Like the sad inadequate from East Cheam whom he so gloriously created on the wireless and television, Hancock went out of his depth in most things he undertook. Dealing with emotions led to tragi-comedy; attempts at self-improvement quickly descended to the ludicrous. Kenneth Williams, a man of genuine intellectual interests, dismissed Hancock's obsession with a variety of fairly obvious philosophers as superficial. His fondness for aperçus from the like of Bertrand Russell and H.G. Wells and his delusion that collecting sayings from the wise might somehow show him the meaning of life, indicate shallowness rather than profundity.

Hancock was far from the working class boy who was not given the chance of a good education. His grandfather was a prosperous Birmingham businessman, his father an able entertainer and reasonably successful hotelier, and his mother competent and ambitious. He was sent to a good prep school and on to a minor public school. There was no want of opportunity. His intellectual posturing was part of his alcoholic grandiosity, just as his emotional immaturity was a facet of his addictive personality. Of course, that is no more to say that he was unintelligent than the latter implies a total lack of feeling.

In Tony Hancock there was a disastrous combination of the urge to self-destruction which is a part of the make-up of so many alcoholics with the melancholy and frustration common to a lot of the greatest clowns. He often spoke about suicide. The comedian Charlie Drake records a conversation during which Hancock suggested a pact. Drake was convinced that he was perfectly serious. Suicide remained a theme with Hancock, although he often expressed a horror of people who he believed to have an aura of fatality about them. He was haunted by his father's early death from lung cancer and, it appears, encouraged in a childish fear of spirituality by his mother's addiction to spiritualism. In the last days of his life, when the will to self-destruction was strong upon him, he consulted a medium who fed him trite and inconsequential messages from beyond. He asked for bread and was given a stone.

The variety of treatments to which Hancock was subjected, whatever their value, were hampered by the denial he sustained until nearly the end. He was detoxed numerous times, consumed a wide range of drugs, including enormous quantities of Antabuse, and examined by a succession of psychiatrists. (His first brush with therapy was by proxy and richly comic: he needed a psychiatrist's opinion that he was unable to continue with the run of a particular show; the consultant would not go to Blackpool and Hancock could not get to him so Dennis Norden lay on the couch and answered the questions - "Ah! so you have three cars but cannot drive. Interesting.") There was little hope of any progress without his accepting his powerlessness and the fact of his addiction. He never found his way to Alcoholics Anonymous nor was introduced to any coherent programme. His wives and lovers, enabling and co-dependent in the classic mould, contributed to the prolongation of the problem as much as they endeavoured to solve it. Cicely was not the first wife to decide that what she drank the boozing husband could not. She became an alcoholic herself.

In the midst of all this Hancock managed to be the most successful and best loved comedian of his time. Some of his routines have passed into legend.The performances drew on his own fear and insecurity. The pomposity of the potential blood donor - "Pure British this is...with perhaps just a dash of Viking" - and the gloom of Sunday Afternoon at Home ("Oh look, over the road's going out!") came from the depths of his own being and were transformed in the act of artistic creation. They were more than just character traits; they were essential parts of a doomed personality.

There is a wonderful, heart-breaking story waiting to be told about Hancock. The Life and Death of Tony Hancock (Century) by Cliff Goodwin is not that book. It has its good points. It is detailed and apparently meticulously researches as far as factual material is concerned. Mr Goodwin clearly admires his subject. Curiously, whilst there is no doubt that he wants us to love Hancock, he leaves us thinking him rather a swine, less deserving of our sympathy than those left in the wake of his path through life. There is no doubt that a lot of people loved Tony Hancock and were prepared to tolerate monstrous behaviour because of other qualities they had experienced but simply making assertions in the face of evidence to the contrary is not good enough. An abler and subtler writer than Mr Goodwin is needed to get this across. The book conveys little of Hancock's magic. There is too much of an assumption that everyone is familiar with recordings of The Lad Himself at work. Mr Goodwin, we are told, worked as a sub-editor on numerous newspapers and magazines. Given the standards of most publishing houses these days, he should have used his presumed skills on his own manuscript. I lost count of the times he used the redundant formula "For some unknown reason..."

Mr Goodwin, who repeatedly shows himself unaware of the meaning of the word 'disinterested', must have stood out as a beacon of credulity in the newspapers where he worked. What other explanation is there for uncritically and rather breathlessly including the account of an Australian medium of her meeting with Hancock on the eve of his suicide, an account which she allegedly kept to herself for twenty years? The spectre of Hancock's father in the last hours of his life is too tempting for Mr Goodwin as a key to his self-destruction.

Whatever the demerits of the book, Hancock's is the story of thousands of other alcoholics who were never in his more noticeable circumstances. The sad horror lies in Spike Milligan's epitaph:

 "One by one he shut the door on all the people he knew; then he shut the door on himself."

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Fathers and sons...

Andrew Varley reviews Frederick the Great by Giles MacDonogh, Weidenfeld & Nicolson

To the Whigs he was the Protestant hero, to the Romantics, he was the Philosopher king, to the victors of 1945, he was the Proto-Nazi, and to Hitler himself he was the architect of modern Germany whose portrait went down into the bunker with the doomed Führer. For a man with such a distinctive character, whose views and accomplishments are widely known, Frederick II, King of Prussia, has managed to take on a bewildering variety of guises during the last two hundred years. Perhaps this is because he was so emotionally frigid that what he truly believed has been left open to speculation.

Curiously, he has never become a homosexual icon. It could be argued that he was as much a martyr to his supposed sexuality as was Oscar Wilde. The Irish playwright may have been incarcerated but at least he did not have to watch the beheading of his boyfriend from a cell window. Perhaps military success does not go with gay stardom - though, of course, throughout history there have been great commanders who happened to be homosexual. There again, it is typical of Frederick the Great that his homosexuality cannot be taken for granted. In the publicity for this important new biography of the Prussian king, it is said that Giles MacDonogh tackles Frederick's sexuality head on. When dealing with practice rather than simply inclination, this is not really the case. He refers to rumour - assiduously spread by the malicious Voltaire - but often in such a coy way that the reader could miss the implication. Whatever doubts we and his biographer may have now, Frederick's father was certain about his sexual habits.

A key to Frederick's personality is his relationship with his father. Frederick William I was a remarkable character. In reaction to his own father's luxurious tastes, he turned Prussia into a military camp, abandoned most of the architectural projects already set in train, and sent the court artists and musicians packing. The army was exalted above everything and the position German officers enjoyed for the next two centuries was established at the beginning of his reign. It is a measure of Frederick the Great's own standing that Frederick William has received comparatively little attention, at least from historians writing in English. Mr MacDonogh shows that many of the successes achieved by the son were based on the foresight of the father and the legacy of the Prussian army provided Frederick with the tool he needed.

However, it was Frederick William's personality which was decisive in the formation of his eldest son. He was in many ways a pathetic figure. It is impossible not to feel some sympathy for a man who can shout "Love me! love me!" at the person he is belabouring with his cane. He was brutal, obsessive, parsimonious, controlling, insecure, and suspicious. He was capable of maudlin sentiment, uxorious to a degree (to a wife who loathed him), philistine, and, at times, apparently on the point of mental disintegration. Everyone knows the story of the Potsdam Grenadiers, the regiment of giants, recruits for which were sought throughout Europe. Exceptionally tall men were unceremoniously press-ganged: a scandal was caused when an Italian priest was dragged from his altar by Frederick William's over enthusiastic agents and when an Imperial diplomat was shanghaied. He even tried mating his Grenadiers with lofty women, a failed experiment which presaged the later Lebensborn programme of the SS.

Frederick William's relaxation lay in getting hopelessly drunk in the all-male gathering he called the Tabakscollegium. Surrounded by his military friends, vast quantities of wine and beer were consumed whilst the men smoked (or pretended to smoke) their pipes. The king enjoyed coarse, but not improper, humour. Gundling, his licensed jester, could insult the guests with impunity, although the evening often ended with his being thrown out of the window into the moat. On one occasion, not recorded by Mr MacDonogh, the revellers forgot that the water was frozen solid and Gundling bounced amusingly. At least he was made a baron in compensation. These occasions were a torment for Frederick, who was abstemious in alcohol, hated buffoonery, and was much happier playing his flute or delving into the volumes of the philosophes which he secretly bought.

Like many intelligent, sensitive sons of such a man, Frederick took refuge in mockery and covert opposition. Improbably, when his mother, George II's sister, was trying, against the king's will, to engineer English marriages for Frederick and his favourite sister, Wilhelmina, he convinced himself that he was in love with Princess Amelia of Great Britain. In the end Frederick William prevented the alliance. Understandably, as things turned out, Wilhelmina never forgave her father for ending up as Margravine of Bayreuth rather than Princess of Wales. Frederick William hated his brother-in-law and, reasonably enough, was unwilling to act as England's glorified mercenary. Any indication of pro-English sentiment was calculated to enrage Frederick William. He was perfectly capable of humiliating his son in public, pulling his hair, cuffing him, and commenting on his effeminacy.

It is difficult to avoid the conclusion that Frederick William showed a majority of the symptoms associated with the so-called "addictive personality" and Frederick those of a man brought up in a dysfunctional, or

alcoholic, family. Having stated that, there is something to be said for the argument that there were no dysfunctional families until our century, with its obsession with psychological hypotheses, invented the term. Those ambitious to categorise us all would point to Frederick's over-compensation in striving to receive his father's approval from beyond the grave by far outstripping him in military achievement. Frederick William might have admired Frederick's prowess as a commander but he would have heartily deprecated his amoral, and at times treacherous, foreign policy.

The vogue for medical history - the effects of haemophilia in the Romanov family; the influence of Napoleon's health on the outcome of the Waterloo campaign; Caesar's epilepsy; genetical deterioration among the intermarrying Hapsburgs - has, on the whole, neglected alcohol's rôle in shaping historical events. It would be foolish to argue that Frederick the Great as battlefield tactician, or even as master of realpolitik , was solely the product of his upbringing but his underlying characteristics which determined his approach to war or politics were formed in the turmoil of the relationship he had with his father. Like many children of alcoholics (or, at least, of men with personalities like Frederick William's), Frederick learned to dissemble, rely on himself, and mistrust.

All mutual irritation, misunderstanding, and antipathy between father and son pale into insignificance when compared to the traumatic days of 1730 when Frederick decided to escape from Prussia and what he had come to view as an intolerable existence. Foreign powers were, albeit passively, involved, and Prussian officers had compromised themselves in helping the Prince and so there was something to be said for the King's talk of desertion and treason. Frederick was imprisoned and interrogated; his friend, von Katte, executed. For a time, it appeared that there might be a re-enactment of the tragedy worked out between another alcoholic sovereign,

Peter the Great, and his son, Alexis. But the case was different. Frederick William was more constrained by civilized behaviour than Peter - it was difficult to be otherwise - and Frederick was vastly more intelligent than the Tsarevitch. He survived, but coming close to the block on the orders of one's own father was as great a constraint on normal family life in the eighteenth century as it would be in ours. If Frederick was a cynic, it is hard to blame him.

Mr MacDonogh takes the reader through Frederick the Great's life in tremendous style. He is witty and discerning and concerned, of course, with far broader issues than those on which this review had dwelt. There are curious and sometimes baffling turns of phrase; there is the occasional solecism such as referring to the splendid Mme de Pompadour insultingly as La Pompadour; but the book will remain an important text on Frederick.

Old Fritz, as he came to be known, is a fascinating candidate for psychological analysis-with-hindsight but in Mr MacDonogh's book he comes over as strangely unlikable. In an earlier study - one very different in nature - Nancy Mitford, drawing on her own acquaintance just as she had when describing Mme de Pompadour's royal lover, Louis XV, leaves us with the impression of a rather lovable old queen. Here Frederick, even when his strengths are being discussed, is deeply irritating. Many of his artistic tastes were second rate - he regarded Graun as a much greater composer than Bach; in his building, the pettiness of rococo replaced the grandeur of baroque; he held foolish opinions based on ignorance (that the German language has no rules, for example). Like many people with liberal opinions, he was intolerant on those who did not. Very few of his contemporary monarchs had happy childhoods - if that is not an anachronistic assertion - but few were so fitted our idea of the adult child of an alcoholic. A new variation of an old dinner party game might be to ask the question, "Would you rather have been a subject of Frederick the Great or Louis XV?" Stick to the latter.

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