You don’t have to be poor to be hooked on drugs or alcohol but it helps

Dry January ought to be the season to talk about drunks. According to what passes for the public health debate, unfortunately, most of society thinks there’s little to say.

If you drink yourself to death, while taking care along the way to abuse your family, friends and unlucky strangers who cross your path, that’s your fault. You believed Ernest Hemingway when he said “a man does not exist until he is drunk”. No one has the right to be surprised that the drink has finished you – as it finished Hemingway – least of all your own pickled self. Stay too long at the bar, and you must expect to hear last orders called.

We have telethons and sponsored tests of endurance for every conceivable ailment. The charitable raise money to combat poverty in developing nations, cancer and heart disease. But I have yet to hear of a marathon run to save alcoholics from marathon binges or a public appeal on behalf of drying-out clinics. There’s no money in public health. Or votes either.

What applies to drink, applies to drug addiction, sexually transmitted diseases and obesity. In each instance, arguments you hear are filled with a mixture of denial and blame. The discourse is inherently conservative because it affirms that public intervention is pointless. People who cannot get through a week without a drink or a Saturday night without getting plastered are by any reasonable standard addicts. I speak from experience when I say that no heavy drinker agrees with this diagnosis. A line separates wild men on park benches from you and me having a good time. Britain’s tipsy culture won’t say where the line is for fear too many would find themselves on the wrong side. Never doubt that when you have crossed it, you alone will bear the blame.

In this climate of punitive neglect, addiction and obesity are dismissed as diseases of choice, which to use that most class-bound of Tory insults, the “nanny state” cannot cure. It’s true that breaking free from heroin, alcohol or sugar requires an effort of individual will. It is equally true that it is easier to summon the strength to quit when others are on hand to help. These truths ought to be self-evident. But they are not evident in Britain. Virtually everyone who is running to fat has at one time or another denied the results of body-mass index tests that report they are obese. The index would find that Olympic sprinters are overweight, we say, in our defence. So it would. Yet how many of those who say it have the muscles of Usain Bolt?

To be fair, dieting is discussed to excess – unlike alcoholism and drug addiction. But the conversation is dominated by fad diets that always disappoint. When even the BBC, promotes obscurantist delusions about fasting, the favoured weight-loss strategy of medieval mystics, there is an urgent need for the state to foster public health.

The state is failing because the Conservatives have got away with a great, shining lie. Journalists who think themselves speakers of truth to power rarely notice the fabrication. Opposition politicians who bellow about the depth of their hatred of “the Tories” allow ministers to escape without criticism. The lie is that the government has ring-fenced health spending from cuts. The argument about health spending has thus been an argument about the government’s failure to allow the NHS to keep up with the costs of an ageing population and advances in medical technology.

Few spotted that, with a magician’s sleight of hand, the government removed public health from health spending in 2013, and – hey presto! – public health was no longer defined as health. This playing with names, these accounting tricks, have allowed ministers to pretend they are not cutting health spending at the very moment they cut it. The King’s Fund described how the con went down. There were good reasons for giving local authorities control of public health. Councils regulated pubs and fast-food restaurants. Of course they should be responsible for alcoholism and obesity. If Britain is ever to catch up with the rest of Europe and encourage people to walk, run and cycle, the bulk of the work would fall to local authorities. Once again it made sense for them to take the lead on fitness.

For a few years all went well. Then in June 2015, the Treasury clawed back £200m from the public health grant. Local authorities took on responsibility for childhood obesity. The money they received for the extra work hid the scale of the cuts. But not for long. The last spending review announced a reduced income in real terms of £600m a year until 2020-21. Services to help men, women and children stop smoking and to control the spread of sexually transmitted diseases including Aids are already a mess. Meanwhile, I’ve interviewed drug and alcohol workers with scores of clients on their books they cannot begin to help. Their one relief is the sight of rich junkies because they know that all they want is methadone and will get what counselling they need privately.

Speaking of the rich, one cannot overlook the class element in the government’s trickery. You don’t have to be poor to be drink or drug dependent. But it helps. Michael Marmot’s great work on inequality in health shows how it is determined by the wider inequalities of society that deny access to education and decent housing. This is another truth which ought to be self-evident, particularly in Britain where the poor and working class are twice as likely to be obese than their better-born peers.

Obesity costs Britain £20bn in NHS spending and lost working days, and that is before you count the human price of lives shortened by diabetes and heart disease. But as I started with booze let me finish with it. Public health is not separate from the national health. You can’t hide it in a corner and strangle it in the dark. Alcohol contributes to 60 illnesses from mouth cancer to depression. A man who abuses a woman is likely to be driven by drink. A driver who runs you down is likely to be drunk. Alcohol consumption accounts for more than one million hospital admissions a year and over half of all violent crimes.

That the government should lie when it says it has protected the health budget is bad enough. That it can get away with lying is astonishing. Alcoholics Anonymous describes alcohol as “cunning, baffling and powerful”. So it can seem. But it has nothing on the Conservative party.