Drug Abuse

Health promotion, drugs and the moral high ground

Christopher Wibberley BA, PGCE, MSc, PhD Lecturer in Health Studies Manchester Polytechnic & Sandy Whitelaw BSc, PGCE, MSc Senior Health Promotion Officer Trafford District Health Authority Greater Manchester

It could be claimed that with the advent of AIDS, central government has had radically to rethink its approach to health promotion in such areas as sexuality and illicit drug use; and that such a rethink has led to the abandonment of an approach assuming a certain moral ascendancy, resulting from a framework based on individualism and ‘victim blaming’. Such a rethink would be commensurate with a move from a narrow approach based on health education to a broader health promotion approach (comprising health education, preventive services provision and health protection - see Tannahill 1985). In this article we attempt to explore whether such a claim can be sustained or whether health promotion in these areas still takes place within a dominant ‘central framework’ enshrined in government documents since the re-emergence of health education/ preventive medicine in the 1970’s- an area renamed for the 1980’s, in such documents, as health promotion. In so doing we will concentrate our efforts on the area of health promotion concerning illicit drug use.

This article will initially examine a range of conceptualisations or ‘types’ of health promotion before considering what makes up the ‘central framework’ for health promotion. Following this the practice of health promotion as it relates to the area of drug use, and the way that HIV/AIDS has affected policy concerning drug use will be discussed.

Finally conclusions will be drawn about the extent of any change in central government's approach to health promotion in this area.

Types of Health Promotion and the Central Framework

The 'central framework', noted above, is considered to be the way in which the various conceptualisations of health promotion are interpreted and subsequently represented by central government, and other concerned centralist bodies, to provide what can be considered as guidelines for action. Such interpretation and representation results from a selective process which acts to 'screen out' approaches which are at odds with the perceptions of those setting out the central framework. This 'screening' takes place from a range of conceptualisations of health promotion, which can de considered to fall into three main 'types' (see Wibberley 1989).

The first 'type' consists of approaches which essentially view health promotion as a collective term for various traditional activities relating to health education, preventive medicine and social engineering, resulting in a better coordination of pre-existing services. Such approaches will inevitably place a strong reliance on traditional areas of interest and traditional techniques. Services will be under the control of various professional groups - with the traditionally more powerful professions (such as a medical profession) exerting the most influence. Subsequently there will be a strong emphasis on the responsibility of individuals for their own health through behaviour modification (see Ringen 1979) - hence initiatives will be orientated towards the individual as opposed to the state or corporate bodies

The second ‘type’ can be seen to view health promotion as a form of revitalised/progressive health education of which two separate forms can be identified: a hard sell approach and a ‘self empowerment approach’. Both forms require developments from traditional health education, but the developments involve different emphases.

The emphasis of the ‘hard sell’ approach may involve high profile techniques, including the use of the mass media and is likely to concentrate on positive aspects of health, as opposed to restrictive practices. Whilst the messages produced might be more attractive to the target audience, the message itself will still be predetermined to a large extent by ‘expert professions’, attempting to produce prescribed changes in individual behaviour.

The ‘self empowerment’ approach is, like the ‘hard sell’ approach, orientated towards the individual; it differs however, from the ‘hard sell’ approach in that it seeks to promote independence of action. It can thus, at least superficially, be regarded as non-authoritarian in nature.

A central theme of the third type of health promotion, is that health is not solely a matter of individual concern, but that there are important social/political/economic/ cultural constraints which affect health. Three forms of this more ‘radical’ approach can be identified - two of which can be regarded as being either ‘top down’ or ‘bottom up’ in approach.

The ‘top down’ approach is based on professionals promoting health on behalf of individuals; however it is not orientated towards the individual, as in Kennedy’s words it constitutes a structural approach to health promotion (see Kennedy 1982) - aiming to promote health through initiatives aimed at the state and corporate bodies.

In comparison the ‘bottom up’ approach attempts to involve the community in the planning of initiatives and thus is not ‘expert led’; there is an inherent acceptance of factors beyond individual behaviour as being important determinants of health, however the involvement of the community in identifying their own needs means that initiatives may focus on the individual and/or on the wider social/economic/political arena.

A third approach which can be considered as bridging the gap between the former approaches involves the development of a strong research and development base upon which to build. Whilst expertise is required in order to decide upon initiatives, the types of initiatives arising should reflect the ‘consumer view’ of what is required. Such an approach should not be limited to actions aimed at individual behaviour, but should also include action by the state and corporate organisations as required/dictated by the situation. The ‘central framework’ itself provides a relatively narrow and restricted view or health promotion, the two recurring themes within this view being that individuals are responsible for their own health and that economic benefits will accrue from the adoption of preventive and health promoting strategies. In addition it can be noted that central government policy has, in the past, been punctuated by a action or calls to action over politically expedient issues (perceived as requiring a response from central government - these have recently included issues such as drug misuse and AIDS) .

Concentrating on the issue of individual responsibility for health, the recurring nature of this theme can be demonstrated by reference to a number of government and government sponsored documents and reports produced since the mid 1970s. 1976 saw the publication of ‘Prevention & Health: Everybody’s Business’ which noted that:

"a recurring theme of this paper is how much, today, prevention depends on the attitude of the individual to his own lifestyle" and that "much of the responsibility for ensuring his own good health lies with the individual" (DHSS 1976 p.95).

This precedent is continued in a report by the ‘Expenditure Committee’ on preventive medicine and a White Paper produced in response to this report. So the ‘Expenditure Committee’ Report stated that:

"we believe firmly that people must take more responsibility for their own health ... hard facts must be bluntly put, so that no-one can escape their force, and they must be skilfully presented. We regard our recommendations about publicity as being of special importance" (Expenditure Committee 1977 para 307).

In the White Paper ‘Prevention & Health’ it was stated that:

"while the Government and other agencies can help by fostering preventive poiicies, responsibility for his own health rests largely with the individual" (DHSS 1977 para 257).

Subsequent documents have, on the whole, reinforced this emphasis on the responsibility of the individual for his/her own health, and ignored the wider socio-political aspects of health promotion. ‘Care in Action’ which is a policy and priority document published in 1981 contains a section on prevention. The section begins with the following statement:

"The prevention of mental and physical ill-health is a prime objective and an area in which the individual has clear responsibilities. No-one can wholly escape illness or injury, but there are plenty of risks to health which are within the individual’s power to reduce or avoid. Too many endanger their health through ignorance or social pressures. Public action can give people the information they need to make sensible decisions about personal health, and encourage in the community a responsible atitude towards health matters (DHSS 1981 para 2.1).

Such an approach is reiterated in the Annual Report on the Health Service in England for 1984 which stated that:

"The changing patterns of disease have altered the relative responsibilities of the individual on the one hand and the Government and health agencies on the other. There was relatively little that individuals could do to reduce their chances of contracting some of the major diseases of the past. But today there is much that they can do to reduce the chances of ill-health and self-inflicted harm" (DHSS 1985 para 2.5).

This statement is reproduced verbatim in the ‘Report by the Comptroller & Auditor General - National Health Service: Preventive Medicine’ produced in 1986.

Thus in terms of the three ‘types’ of health promotion outlined above, the approach advocated through central government documents would seem most closely to approach ‘hard sell’ health promotion. Whilst the emphasis is not placed explicitly on positive aspects of health within the documents, it is intimated that a high profile approach to the provision of health information attempting to produce prescribed changes in individual behaviour is the way to proceed in health promotion. This is perhaps best exemplified by the quote already noted from the ‘Expenditure Committee’ report concerning hard facts being bluntly put and skillfully presented. This restricted ‘central framework’ tends to be translated to work carried out at both national and local levels within health promotion. For example as Rodmell & Watt state:

"It is certainly the case that a number of health education officers hold a theoretical critique of a lifestyle approach. The point to be made, however, is that in practice they find it difficult to work against the dominant ideology" (Rodmell & Watt 1986 p.4).

Such a situation has been confirmed by research carried out at a local level by one of the authors of this paper, although a ‘hard sell’ approach could be viewed as being delivered, at a local level, through a ‘collective’ medium (see Wibberley 1989).

The practice of health promotion in the issue of drug use

In practice, then, health promotion has equated to an approach which is individualistic in nature, centring on the need for behavioural conformity to pre-defined social norms with an inherent opportunity for its sponsors to capture the moral high ground. Embodied within this approach is the belief that individuals should behave in a decent, self respecting and dutiful manner as defined by society. For example, there exists an expectation that individuals should adhere to behaviour commensurate with their sex and social standing, and embrace fully the work ethic. Illicit drug use falls clearly outside such behavioural/social norms. Drug use and drug users are thus perceived as inherently bad by politicians and the media, and as posing a threat to the status quo. As Chalmers notes, drug users in the 1960s: "with their amorous arrangements, their music, their drugs and exacerbated individualism, dared to put in question the very touchstone of the rest of society's own sense of reality: the work ethic, the nuclear family, reciprocal obligations between the "citizen" and the state; in sum the ‘rational’ and normal rules of everyday life" (Chalmersl985p.102).

Additionally Edwards identifies class interests operating within such a perception of drug usage, suggesting that it is based on: "fears about ‘luxurious’ (recreational) use among industrial working classes" (Edwards 1981 p.6). MacGregor also notes that with respect to drug use: "the views that have been extensively quoted are those of the middle-aged and, generally, the powerful. These are the groups most threatened if sizable numbers of the young reject the values which legitimate the existing order" (Macgregor 1989 p.11), continuing:

"thus while the numbers engaging in illicit drug-taking are small by comparison with those who over-drink or are dependent upon tranquilizers, what fuelled the concern of the 1980s was the seemingly rapid rise in the numbers involved, and the unacceptability of the associated style of life" (ibid, emphasis added). \

Traditionally health promotion interventions concerning illicit drug use have responded within such an approach, accepting drug use and drug users as inherently bad and so is posing a threat to society. Thus campaigns have been launched highlighting the deleterious nature of drugs (as exemplified by the ‘Heroin Screws You Up’ Campaign in 1984). Similarly, media responses to the issue of drug use have employed a scaremongering approach, often exaggerating both the extent of the problem and the effects of drug usage (as exemplified by reporting of both ‘Ecstasy’ and ‘›rack’ during the late 1980s). Additionally attempts have also been made to provide schoolchildren with the skills to ‘say no’ to offers of drugs, both within the school curriculum, and with the help of the media. The consumption has been that the only appropriate response to the issue of illicit drug use is to pursue a goal of total abstinence. Whilst workers in the field may have desired a more flexible approach, in the face of political hostility at the thought of going soft on drug users, such flexibility has been difficult to achieve.

HIV/AIDS and policy concerning drug use

During the 1980s, as AIDS emerged as an issue warranting government attention, it has been suggested that there has been a change in central government actors’ attitudes towards drug issues. This has resulted in changes in proposed policy as evidenced by a report by the Advisory Council on the Misuse of Drugs (ACMD) which stated that:

"we have no hesitation in concluding that the spread of HlV is a greater danger to individual and public health than drug misuse. Accordingly, services which aim to minimise HlV risk behaviour by all available means should take precedence in development plans" (ACMD 1988 para 2.1).

The report included in its recommendations that:

"we must be prepared to continue to work with those who misuse drugs to help them reduce the risks in doing so"(para 2.2); "further syringe exchange schemes should be set up" (para 5.16);

"community pharmacists should be encouraged to sell injecting equipment at reasonable cost to injecting drug misusers"(para 5.17);

"prescribing can be a useful tool in helping change the behaviour of some drug users ... the range of acceptable goals towards which drug users might move with the help of prescribed drugs should include: the cessation of sharing equipment; the move from injecting use to oral use; decrease in drug misusers; abstinence" (para 6.2 - 6.3).

Certain commentators have suggested that these changes represent distinct, and possibly radical, shifts in policy (see for example Edwards 1989; Stimson 19903. Comment has also included criticism from the right that any such a shift is counter productive in terms of:

"destroying the very morality needed to avoid AIDS and social degeneracy" (Anderson 1988 p.17). The relevance and extent of these shifts for health promotion practice concerning drug use will be judged (for the purpose of this article) initially in terms of models of drug use, before considering their relevance and extent within the broader context of health promotion ‘types’. The importance of utilising models of drug use in interpreting the way in which such policy and practice is shaped has been implicitly noted by MacGregor who states that:

"the very way the problem is defined and perceived sets the framework within which the lines of policy and practice will be developed. It is therefore important always to look at the context within which social responses are worked out, to consider the way the social problem itself has been constructed" (MacGregor 198’ pp.17-18) .

De Haes has provided one breakdown of the way that drug use can be viewed, based on four models. These are -

"The moral-legal model. Drugs are prohibited by law, thus drug use is a crime and users and sellers have to be prosecuted.

The disease or public health model. Drugs are harmful to the body, people using them have a kind of illness, they need medical treatment.

The psycho-social model. People using drugs have personality disturbances or personal problems. They need psychotherapy or help with solving their problems.

The socio-cultural model. People are the victims of a badly organised and unjust society. Society has to be changed: people have to be more equal and have more power over their lives. In a ‘just society" there will be no drug problems." (De Haes 1987 p.437).

De Haes also notes that:

"all four models contain some truth. Therefore it seems to be more realistic to say that only a view that takes the four points into account is a ‘balanced’ view . (ibid) . Discussion above, noted that traditionally it has been assumed that health promotion interventions concerning illicit drug use should be framed within an approach based on the goal of total abstinence - ie based on a moral-legal model of drug use. Policy as exemplified by the ACMD report of 1988 moves beyond such a model, the quotes already noted above falling into the disease/public health model (for further discussion on this see Stimson 1990).

However, such policy does not extend to initiatives within the socio-cultural model. In fact any such policy shift has perhaps been detrimental, the disease model of drug use becoming dominant, and resulting in the restriction of developments such as those based in the community and centring on such issues as employment, housing and welfare rights, which could be considered to fall within the socio-cultural model.

So it could be argued that there has been a significant shift in policy within the context of models of drug use (away from a moral-legal model towards a disease/public health model); however, within the broader context of health promotion ‘types’ (identified above), such a shift is not so evident. The changes in policy noted from the ACMD report represent in essence a widening of the range of ‘acceptable’ behaviour. Illicit drug users are no longer outside of society - merely at its outer edges and should be helped to move towards the mainstream of society: acceptance is no longer reliant on abstinence. However, the emphasis of initiatives is still individualistic in nature. Additionally whilst it is inherent in the ACMD report that there needs to be a widening of ‘acceptable’ behaviour in the statement that:

"we must be prepared to continue to work with those who misuse drugs to help them to reduce the risks in so doing" (ACMD 1988 para 2.2), it is still perceived that behaviour needs to be changed:

"in general, publicity and outreach combined with syringe exchange and advice and counselling services are the best means of reaching and influencing the behaviour of non-opioid users" (ACMD 1988 para 6.16 emphasis added) and, in fact, there is still a strong reliance on elements of traditional health education:

"a campaign of education and information is needed both nationally and locally. In the long run we believe that sustained publicity and education will prove to be the most immportant influence on changin behaviour" (ACMD 1988 para 5.27 emphasis added).

Conclusions

It was stated at the beginning of this paper that it was intended to explore the claim that with the advent of AIDS, central government has had radically to rethink its approach to health promotion in such areas as sexuality and illicit drug use; alternatively, health promotion in these areas could be considered still to take place within a ‘central framework’ based on individualism and ‘victim blaming’ and assuming a certain moral ascendancy. Our discussion has suggested that there has not been a radical rethink in the government’s approach, and that the changes that have occurred, (with respect to the widening of ‘acceptable’ behaviours, and so ways that illicit drug users are treated) are prone to reversal.

Such a reversal may well occur if the threat of AIDS is perceived to be lessening - events occurring towards the end of 1989 would suggest that this is already happening. In September the Special Cabinet Committee on AIDS was disbanded, and Government funding of a national survey of sexual behaviour (linked to research on AIDS) was vetoed; in October/November the Health Education Authority’s television campaign concerning AIDS was postponed ‘indefinitely’ (see NAT 1989). This reversal may also be accelerated by periodic media interest in the issue of drugs - for example in the weeks leading up to the ‘World Ministerial Drugs Summit’ various programmes explored the ‘controversial’, nature of prescribing drugs to users (see for example Open Space BBC 2 Feb 1990, Up Front ITV April 1990, World in Action April ITV 1990).

What we are arguing then, is that towards the end of the 1980s there was a greater acceptance of drug using behaviour within society at a policy level, but that this did not represent a shift in practice in terms of ‘types’ of health promotion. Health promotion concerning drug use was still based on individualism - targeting the individual and trying to alter behaviour towards that which is more acceptable.

Furthermore, because there has been no radical shift, there is clearly a danger that there will be a reversal in terms of the acceptability of behaviour. In fact with the launch early in 1990 of the latest campaign against drugs - with its use of fear as a motivator and its slogan of ‘drugs: the effects can last forever’ such a reversal may already be considered to be upon us.

Additionally, changes in treatment, which can be regarded as a more distinct change in terms of models of drug use, may also be transitory - as they have benefited from practitioners being able to take advantage of an environment created by political expediency, and the need to ‘act’ against the threat of AIDS. If it becomes more politically expedient to act against illicit drugs and drug users, then the pendulum will inevitably swing back, to the detriment of those who use drugs, in whatever way, and society in general.

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