NIH Says, “Look Out, You Have Fallen Off a Cliff”
We can all agree that falling from a height is bad for one’s health.
Imagine, then, a lovely green field, at one end of which is a cliff. There are signs that say, “DANGER! Beware of the Cliff.” The local paramedics are well-trained and prompt. It is explicitly a crime to push someone off the cliff. With all that understood, if someone is, say, running to catch a football and topples off that cliff, shouldn’t we be screaming, “Why is there no fence?”
A fence along a cliff is a form of prevention—not treatment, not enforcement, but prevention. Keeping someone from falling off a cliff is always preferable to putting them in an ambulance and investigating whether or not they were shoved. Yet when it comes to so many other policies for mitigating the harm of alcohol and other drugs, prevention comes as an afterthought. This has never been so stark as it was last week, as the United States Department of Health and Human Services slashed funding, infrastructure, and staff dedicated specifically to preventing harms.
The losses, both financial and technical, to those working in alcohol-related disease and harm are immediate. The STOP Act, dedicated to preventing underage alcohol use, is in limbo. The National Survey on Drug Use and Health has been completely de-staffed, a staggering loss of institutional knowledge. The alcohol epidemiology team at the Centers for Disease Control has been cut loose; these scientists provide the baseline understanding of national alcohol harms that every single advocate, researcher, and educator relies on. These are just some of the alcohol-centered resources that are gone, and alcohol-related harms are just one of the many toxicants, conditions, and diseases that have been left to run wild.
The loss, we must stress, goes far beyond the specific functions served by the abovementioned staff and projects. It threatens to decapitate—or, perhaps, desiccate—the country’s ability to address harms broadly and efficiently. Within the field of public health, there is a concept of interventions as points along a stream.
The Stream of Public Health Interventions
“Downstream” interventions are more direct to impacted individuals, stopping them at the point of harm, punishing them for causing it, or healing them once they’ve experienced it. Examples of downstream harms include refusing to serve intoxicated bar-goers, arresting people who drive while dangerously intoxicated, or funding “drying out” rooms for individuals who are acutely over-intoxicated.
“Upstream” interventions, on the other hand, passively affect a large swath of the population. These include price controls, restrictions on availability, limits on marketing, and proactive integration of non-alcoholic environments. These upstream options serve as the fence. Rather than knock a drink out of someone’s hands, or pick up the pieces once they’ve experienced acute or chronic harms, upstream prevention strategies keep people from ever coming close to the edge. The most smartly planned alcohol environment goes beyond a fence, to… well, to not building on the edge of a cliff in the first place.
NIH Cuts Leave U.S. Weak and Inefficient
The advantages of upstream prevention are not just philosophical. Research comparing different types of alcohol prevention strategies demonstrates that price controls are more than three times as cost-effective as dangerous driving interventions, and fully 14 times more cost-effective than interventions with problem drinkers. But there is a catch. Widely effective upstream interventions must be pursued at scale. A price increase at a single liquor store does little to change consumption. Banning alcohol ads only on, say, the 44 O’Shaughnessy MUNI route and no other public transit barely moves the needle on youth intention to drink. To pursue prevention strategies at that scale requires being able to understand alcohol harm at that scale—and that, in turn, requires the investment in resources and expertise that the U.S. Health and Human Services just obliterated.
By blindly slashing spending, the government has cost prevention efforts hundreds of millions, and very likely seeded the ground for thousands of preventable deaths.
There will be other opportunities for effective and widespread prevention. As long as there is a call to reduce the burden of alcohol-related morbidity and mortality, there will be pressure to maintain life-saving funding and resources. But for today, we mourn the hole in the fence that weakens us as a community and country. We fear for those who might fall through. And we, as both a professional field and a nation, must work to restore trust, understanding, and the embrace of prevention.
— Carson Benowitz-Fredericks, MSPH
READ MORE about the need for solidarity in addiction medicine.
READ MORE about California’s legislation prevention failures.
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