I hope 2019 has begun well and that the year ahead proves a good one for you all. Despite the ongoing political uncertainty in the UK and increasing strain on budgets, with little hope of improvement in the near term, I remain surprisingly upbeat. It may be the result of what seems to have been a successful London Christmas alcohol campaign, once the data firms up I shall certainly share more. It could be the prospect of the forthcoming City Health International Conference in Liverpool on 22 March, which promises some great speakers. Possibly it is a result of small, but welcome, signs of a willingness to explore new ways of thinking and working to reduce health inequalities in relation to mental health and hepatitis. Perhaps it’s having just secured funding to update our Safer Nightlife guidance, which aims to reduce drug related harms in the night time economy. I am sure the money has helped, you could say it has incentivised me.
There is nothing new about governments taking a view on the desirability, or otherwise, of the use of certain products or activities. This has often influenced tax or tariff rates. Government’s need revenue, income with a feel- good factor can seem particularly attractive. More recently we have seen an increase around the world of penalties in the form of taxes and charges to discourage or encourage particular behaviours. These are often part of, or packaged as, being part of a public health approach. The “stick” is for our own or societies good. The use of “carrots” is less well established.
This use of the “stick” is not a new thing. While the UK introduced a sugar tax on soft drinks in April 2018 there was a Sugar Act in 1764, which itself succeeded the Molasses Act. While this 18th Century legislation was mainly about protecting existing British industry from foreign competition the likely impact on reducing alcohol consumption within the American Colonies was welcomed. The beneficiaries of this revenue raising, sobriety boosting scheme were less than grateful to their masters in Westminster as it proved to be a significant contributory spark which would lead to war and the creation of the USA. I can’t see the disgruntled Irn Bru drinkers of Britain breaking out into armed revolt. However, the response to a mooted “pudding tax” do indicate that this might be taking the use of the stick beyond political acceptability.
Personally, I think it a good thing when we can take public opinion with us. Surely, we should be reflecting their concerns and priorities. Through involvement in drug policy and more recently community safety I have spent years working alongside the police. In Britain one of the underlying principles of law enforcement is “policing by consent”, that is having the approval and support of the public for what they do. This may not always be achieved but it is an admirable ambition. Work to improve the health of the populations we are meant to serve would surely benefit from a greater understanding of people’s views and concerns.
This is not to say we need to be reactive or, indeed, inactive. We have some good examples of where community engagement and good public messaging have helped create an environment where work to counter HIV enjoys overwhelming support. Needle exchanges are recognised as valid and important, drug and alcohol treatment, mental health services all enjoy support (although preferably not located in their own neighbourhoods). Smoking is far less common or socially acceptable. This has yielded tremendous gains, although it seems to be the one area where stigma is seen as a valid tool. It also an area where our progress is almost stalled and highlights some worrying failures to help those most vulnerable.
London, like many urban areas, is working to reduce emissions from vehicles and is looking to further encourage people to use public transport, walk, cycle. There are sticks being used here in the form of the congestion charge and the soon to be introduced Ultra Low Emission Zone. It would be fair to say that there is considerable opposition but in general the public mood seems supportive, wanting to see air quality improve as understanding and concerns about the health imp. Clean(er) air is a fairly attractive carrot, especially as most Londoners will not directly, experience the additional costs/penalties.
Rewards, or Contingency Management, to support behaviour change or engagement has a long track record and evidence base in drug and alcohol services. From encouraging people to complete their Hepatitis B vaccinations (needing three injections) to rewarding regular attendance at therapeutic sessions we can demonstrate efficacy. It doesn’t guarantee 100% outcomes, some approaches work better than others (cash is generally more attractive than vouchers - who knew?), but it is a valuable approach. And yet it has significant obstacles. It has been criticised as a reward for bad behaviour, it being unethical to pay people for what they “should do”, doubts cast over its long-term benefits (although these seem generally solid, with testing and vaccination benefits clearly being of ongoing benefit). When resources are scarce it can seem hard to justify giving £20 to those who are often on the margins of our communities. However, the efficacy of this kind of approach should be promoted and considered more widely.
Which brings me to the ice cream. I have no idea of the opposition faced, or indeed of its effectiveness but the approach by Bologna should attract the interest of the world. To encourage cycling, walking and the use of public transport citizens are rewarded with incentives such as ice cream, cinema tickets and even beer. It makes use of an app to see how people are travelling, which may seem an imposition, but for an ice cream, or a beer, I am sure I would adapt my behaviours. Let’s hope it helps Bologna achieve its air pollution goals, proves popular with its residents and so encourages fresh thinking in other cities about how to engage with our citizens. The carrot, or ice cream, may be mightier than the stick.