Public health is not an innocent concept

In the Nordic countries, the framing of alcohol and drug use as a public health issue has grown increasingly strong during the last few years. The main Finnish and Norwegian research units, for decades independent institutes with broad socio-cultural-epidemiological agendas, are now located within large governmental public health institutes. In Sweden, the Centre for Social Research on Alcohol and Drugs (SoRAD) has this year been merged into a larger Department of Public Health Science at Stockholm University (within the Faculty of Social Sciences) while the Public Health Agency is responsible for the implementation of the government’s Alcohol, Tobacco, Doping, Drugs and Gaming Strategy. At the Nordic Welfare Center (the owner of Nordic Studies on Alcohol and Drugs), alcohol, drug, tobacco and other addiction issues now come under the banner of public health. As is so often the case, the Danish situation is somewhat different and research has primarily another institutional framing, as part of the Department of Psychology at Aarhus University. Icelandic research in the field is scattered and not well resourced. It is thus very timely to reflect on the possible implications of the public health framing from a Nordic perspective, as Alex Mold (2018) does for Britain in her essay in this issue of NAD.

The topic “public health and alcohol and drug issues in the Nordic history” is vast, with a wealth of relevant literature. With some remarks on its complexity and cultural specificity I hope to stimulate further discussions about the present public health framing. It is easy to agree with Mold that the public health approach to alcohol and drugs has varied over time and has had different meanings for different actors. Also in the Nordic countries, it has sometimes been used as an alternative to criminal control perspectives. From the policy point of view the public health perspective seems to have the benefit of combining the focus on health, which obviously benefits everyone, with efforts focusing on entire populations and with the scientific legitimacy of medicine. Based on Mold’s article and on my limited knowledge of British history there seem, however, to be some characteristic features of the Nordic public health and substance-use history that make it understandable that we are more critical towards public health framing than the Anglo-Saxon world.

The first feature is related to the different words used. The closest equivalent to “public health” in the Nordic languages is “folkhälsa – folkehelse – kansanterveys”, or “the people’s health”. This latter concept indicates a focus on the entire population from a national point of view (cf. the rather recently more popular English-language concept “population health”). One can find both institutional and economic-historic reasons behind the “folk”-perspective. Institutionally, Sweden and Finland (which I know more about) had since the 18th century to the end of the 1930s “province doctors”, appointed by a central medical body and paid by the state. Their responsibility was to supervise the public medical institutions, to provide medical treatment to citizens but also, from the early 19th century, to prevent epidemics. From the mid-19th century a number of these doctors were responsible for giving annual reports on the health situation in the region to the central medical authority (see for instance Huldén, 2014, http://fho.sls.fi/uppslagsord/4563/provinsiallakare/). In these efforts the “province doctors” were a part of a comprehensive central and local administrative system. The central level has been active in regulating and controlling efforts in all parts of the country in both Finland and Sweden. But the many municipalities have from the 1860s had important and independent roles (with independent taxation rights) for both the health and welfare of especially the poor population. The inclusion of prevention in the people’s health thinking, with an explicit link to social welfare, was institutionalised about the same time as in England, but possibly with a stronger central guidance (Encyclopædia Britannica, 1910–1911).

The Nordic countries in the 19th and early 20th centuries were very small, rural, culturally homogenous and, in comparison with colonial and industrialised Great Britain, poor countries. Historian Karin Johannisson, in her fascinating analysis of the early-20th-century people’s health movement in Sweden, describes how the predominant perspective on health, or lack of ill-health, varied in Sweden during the 19th century. The early 1800s saw an emphasis on ensuring population growth. Later, relative overpopulation, especially in the countryside, triggered a liberal emigration policy, as a way of reducing over-population in poorer areas. With the (relatively late) industrialisation and increasing militarisation from the turn of the 20th century, and a decrease in fertility, a perspective that combined quality and quantity was needed. A strong nation required strong workers, soldiers and mothers (Johannisson, 1991).

Bacteriology and epidemiology introduced a new societal view on diseases. This was a fact not only in the Nordic countries. The notion of society as a “social body”, became prominent all over Europe, including in Great Britain, from the 1830s (Berg, 2009). In this epidemiological conceptualisation, all members of society were interconnected with each other like the organs of a human body. Diseases had to be fought, not only as problems within individual bodies, but also in the relations between persons (Johannisson, 1991). Arto Ruuska (2013) has in fact pointed out how British – and continental – medical alcohol experts, such as Trotter, had already at the turn of the 19th century identified “the social embeddedness” of alcohol problems.

As statistics on health conditions started to accumulate in the 19th century, it became clear that poverty and ill-health were closely linked. When the “people’s health movement” started in Sweden, it was openly declared that a person’s health was not his or her private issue. It was a national matter. As a consequence of (a) the national perspectives, (b) the strong central-local administration and (c) the poverty experienced in the Nordic countries, the people’s health efforts became closely linked to control measures that entered the very private spheres of especially poor people. This is particularly obvious in the Swedish case. The public health project focused on changing people’s behaviour, in terms of better hygiene, healthier sexuality and food habits, and temperance. The project was clearly normative. In the Nordic countries, in contrast to Britain, addressing drinking behaviour became a natural part of these efforts (Johannisson, 1991).

The people’s health project was not politically neutral. As Johannisson (1991) notes, the idea of societal conditions as being at the root of individuals’ ill-health was potentially revolutionary. It could have implied concerted efforts to improve the living conditions of the working class. But the people’s health project was predominantly a top-down project, and rarely presented critique of the social order. Individual or separate group interests (especially of weak groups or individuals) were always subordinated to the national concerns. A culture of political consensus which prioritises the collective interest over the individual is still something Nordic, and again particularly Swedish.

From a Nordic point of view, it seems rather self-evident that public health views on alcohol or drugs have never excluded individualised control of “misusers”. Control has often been part of public health projects, at times accompanied by separate but simultaneous control efforts. Within public health framed projects there have been frequent and obvious clashes between collective interests and individual civil or social rights. This is true in the case of the restrictive alcohol policy, where alcohol monopolies and high taxes restrict all citizens' possibilities to purchase alcohol only at certain times and places, and where purchasing more or less depends on their economic resources. It was true at the time that Sweden adopted its drug-free society policy, and the psychiatrist Nils Bejerot argued for the physical isolation of drug users who contaminated the population with drug-use behaviour (Bejerot, 1968). It was part of the reasoning behind the particularly strict control of AIDS-infected persons in the 1980s in Sweden (Trägårdh & Svedberg, 2013). The protection of the population is the ultimate argument behind the currently persistent political rejections of de-criminalisation of drug use, most determined in Sweden, in spite of research pointing at how this could save lives among drug users. The people’s health argument may in fact also lie behind the recent change of the Swedish asylum politics. A year after the generous acceptance of refugees in 2015, the protection of Swedish society became a valid motive for decisions about individual refugees that seem to clash with international laws on human rights (this problem also applies to the current asylum politics in Finland and Norway).

Today we can see a medicalisation of the handling of drug and alcohol problems in Nordic societies. From the drug policy point of view this development has been met with some sympathy, in contrast to the previous heavy emphasis on criminal control. However, the change does not mean that we will move into a post-control period. Alcohol and drug use will always affect others in addition to the user. Thus, informal or formal social control will always be present. For this reason it is very important in the public health era to preserve research (historical, conceptual, ethnographic, policy research, as well as quantitative and experimental analyses) that critically and independently of governmental policy or new actors, such as Big Pharma, studies how control affects less well-resourced individuals and groups who use alcohol and drugs and other addictive products.