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Alexandra Arriaga: Welcome to a special episode of I AM GPH, where we are featuring a great conversation between our very own Dr. Diana Silver, Associate Professor of Public Health Policy and Management here at NYU GPH, and Dr. Adam Karpati, Senior Vice President of Public Health Programs at Vital Strategies. Here at NYU GPH, Dr. Diana Silver's research explores the impact of variation in the implementation, adoption, and repeal of state and local public health policies on health outcomes, particularly alcohol consumption, motor vehicle crashes, tobacco use, and food safety. At Vital Strategies, Dr. Adam Karpati and his team work to increase and improve the collection and use of health data and the development and promotion of policies and programmatic work to address threats to public health. So please enjoy this wide ranging conversation in which they discuss the number one leading cause of death and disability in the population 15 to 49 years old in the world, and that is alcohol consumption.
Diana Silver: Hi, I'm Diana Silver. I'm an Associate Professor of Public Health Policy here at NYU's College for Global Public Health. And I am thrilled, thrilled, thrilled to be talking today to Dr. Adam Karpati, who is at Vital Strategies. And I've known Adam for some time, so followed him from one job to another. I wanted to start, Adam, can you just tell us a little bit about Vital Strategies, and what that organization is, what they do?
Adam Karpati: Sure. Thanks Diana, and thanks for inviting me to be here with you today. It's really exciting for me. Vital Strategies is a global public health organization. We're based here in New York City, but we have offices in many countries around the world. And indeed, we work in dozens and dozens of countries, mostly low and middle income countries around the world, and we work on a variety of public health issues. Largely, we work by providing technical assistance to government public health agencies. Our mission statement of our organization is that we're working towards a world where everyone is protected by a strong public health system. So we are really about helping governments build strong public health systems. And by that, we mean having good policies, and laws, and regulations to protect public health, and good programs for public health practice around a variety of issues. We work primarily on topics related to noncommunicable diseases, like tobacco control, obesity prevention, cardiovascular disease prevention, and on injury prevention, things like road safety and overdose prevention. But even more than the specific topical programs that we work in, we help governments build strong public health institutions. And that means helping to strengthen the human capacity in government public health agencies, technical capacity around data, for example, around policy formulation. So we do a lot of institutional strengthening, always a lot of work on data and epidemiology, as the sort of one of the cornerstones of public health practice, and a strong communications and advocacy component. And it's that combination of skills and functions at public health agencies that really contributes to making a strong public health system. So we're a large organization, we work all over the world, and I'm really excited to talk about a particular issue today around alcohol policy, but we work on all kinds of stuff.
Diana Silver: Great. It really helps to understand how alcohol actually fits into that big of a portfolio. And I'm sort of struck by the enormity of the challenges that your organization has taken on. So let's talk a little bit about alcohol, and actually, maybe you can even tell me, how did you come to this? I know you're an MD. You're not a PhD. That's the unfortunate degree I got. But you got an MD, but you're not seeing patients, right?
Adam Karpati: Right. So I do public health, and it's a form of medical practice that isn't about clinical service, but it's about thinking about health at a population level, at the level of entire cities, or states, or countries. And there's a great pathway towards getting into public health that you can get to it from many different directions. I happened to get to it from the medical training, and I did my medical training, and actually did my residency here at NYU at Bellevue Hospital and NYU Medical Center. But after that clinical training, I went and got further public health training at the US Centers for Disease Control and Prevention, and then worked for many years at the New York City Health Department and before joining Vital Strategies. And so part of that experience working here in New York City, many of us at Vital Strategies also have experience working in city health departments, including New York City. And so another perspective that we have at the organization is that we're interested in urban health, not just at national levels in low and middle income countries, but also in the cities. And we can talk about why cities could be special places to do public health. So I came to it from this medical pathway, and there's many others, as you have a different pathway to your public health practice, but that's mine.
Diana Silver: So let's talk about alcohol, and I wonder if we can just talk about alcohol, and the global burden of disease, and the perspective that you guys have about that?
Adam Karpati: Sure. So alcohol is a very important issue in global public health and one that doesn't get as much attention, frankly, as other issues. The adverse health consequences of alcohol are considerable. The data tells us, science tells us that approximately three million people each year around the world die as a result of alcohol consumption, and many, many more millions suffer illness, disability related to alcohol consumption. This makes alcohol one of the leading causes of death and disability in the world. And indeed, when you consider all of the various health impacts of alcohol consumption, of excessive alcohol consumption in particular, which we can talk about, there's a range of health impacts. Alcohol, as I said, is one of the leading causes of death globally. It is the leading cause of death and disability in the population 15 to 49 in the world. This highlights even further that the burden of alcohol health impact falls greatest on younger populations.
Diana Silver: And now I noticed that you said, "Excessive alcohol consumption." And so there we're talking about health consequences, like everything from drunk driving accidents, to excessive consumption that puts people at risk of other kinds of injuries. There's always, of course, cirrhosis. But I wonder if you can talk a little bit more about that, and then maybe we should think about, is there a reasonable, moderate level of alcohol consumption, and how we think about those questions?
Adam Karpati: So this is a very important issue. Thanks for bringing this up. So the range of health impacts, health consequences, related to alcohol consumption, as I said, is quite broad. A huge component, a huge proportion of these, are so-called noncommunicable diseases, like liver disease, but also cardiovascular disease, hypertension, heart disease, and also malignancies, cancers. So that's about half. Half of that three million is noncommunicable diseases. Another quarter to a third of those three million deaths are attributable to injuries, so car crashes, interpersonal violence, whether that's suicide, homicide, interpersonal violence, domestic assault, and things like that. And there's also a substantial burden related to infectious diseases. Alcohol contributes both to the acquisition, but also to negative consequences of tuberculosis, of HIV, STDs. And so the range is quite a wide variety of health issues. And then when it comes to characterizing the level of risk, this is a big one that's often poorly understood. I did mention excessive consumption. And typically when we talk about excessive alcohol consumption, we refer to kind of two different patterns of drinking: one, the sort of chronic heavy alcohol use, the routine daily-or-so consumption of high levels of alcohol. And but more prevalent, more common, is what in the United States we call binge drinking. Globally, the term used is heavy episodic drinking. And this is the consumption of high volumes of alcohol, typically defined for different populations, four, five, six drinks in a single occasion of drinking at one time. And that heavy episodic or binge drinking, very common around the world. About 20% of the population, globally, engages in binge drinking. And that's another pathway. So heavy chronic and heavy episodic are the largest contributors to adverse health consequences. But I also want to make the point, even lower levels of consumption do increase health risks. The cancer risk from alcohol is not limited only to the highest levels of consumption. Alcohol consumption during pregnancy, for example, is not only about high levels of consumption. And so there have been, and maybe we'll get into this later, over the years, this sort of hypothesis, or this narrative even, around the benefits of moderate consumption of alcohol. What we're finding increasingly as more science emerges on this, is that on average, there really is no healthy level of alcohol consumption. And there are risks, much lower risks, of course it needs to be said, but the risks are not zero even at lower levels of consumption.
Diana Silver: Right. I know that at least here in the United States, in fact, binge drinking is a much more common behavior than heavy drinking, which is such an interesting thing because it suggests that some of it might be socially constructed, or that there are social influences that create circumstances in which binge drinking becomes acceptable. And I guess that leads me, and I want to think about that. It's also a sort of, what do you do? Like what are we doing about alcohol consumption? What's on the horizon of things that we know that work, and what are the barriers to making sure that people are doing those things, that countries are doing those things, that cities are doing those things, that make it easier for people to reduce their own alcohol consumption?
Adam Karpati: So as you say, a basic principle of public health, one that is true across many, many different issues, is that individual behavior, individual behavior choices, like to drink, or to smoke tobacco, or to eat unhealthy food, or whatever, those individual choices do not happen in a vacuum. And the social, environmental, commercial, cultural context is a huge influence on individual behavior. So what that leads us to, that insight, that knowledge leads us to what are the strategies to reduce the adverse health consequences of alcohol consumption? And fortunately, there are good interventions, there are good policies, and they all are policy-based, because what we're talking about here is strategies at the population level across an entire jurisdiction, or even a whole country. We know what works. The evidence is pretty strong, it's very strong, and we know what works. So the World Health Organization has recently issued a clear and concise set of guidance for governments to implement policies to reduce the adverse health consequences of alcohol. They call it SAFER, S-A-F-E-R. I encourage people to look that up on the web. But the five interventions ... And there are five interventions, each one corresponds to the letter of SAFER. But the five interventions are this. The most important policy to reduce consumption of unhealthy commodities is price. And so taxation, to raise the price of alcohol is the most important public health intervention that governments need to do. So tax is one. Governments need to regulate the availability of alcohol. This has to do with all the laws that we're quite familiar with around who can buy alcohol, when can alcohol be purchased, where is it sold? All of that regulatory framework around the availability, that's the second group. The third area of policy is around marketing and advertising, and I'm sure we'll talk more about that. The impact of alcohol industry marketing of alcohol is huge, and governments need to balance what industry does with strong regulations about limits on advertising, especially to vulnerable populations like children. The fourth area is clinical services for people who have problems with alcohol consumption. Governments need to make proven clinical services available, and these can be delivered typically in primary care settings. We're not talking only about specialized alcohol treatment programs. We're talking about what primary care doctors and nurses can do. So that's the fourth area. And the fifth area, a high impact policy area, is drunk driving prevention, so the enactment of strong drunk driving laws and strong enforcement of those laws. So those are five policy areas that all governments around the world need to do. They're clearly articulated, and they importantly are all evidence-based. And by that, we mean there's strong scientific proof that these interventions reduce mortality.
Diana Silver: Well, if we know what to do, I guess it gets us to that point of why aren't we doing it? And I wonder if you can talk a little bit about the work that you and your colleagues at Vital Strategies have done with governments around the world around looking at alcohol. And maybe there are some success stories. Maybe there is somebody we could look to. I just wonder if you could share some of these experiences, and tell us what you've run into as you've done this work.
Adam Karpati: Yeah. So the barriers to enacting good alcohol policy are the same kinds of barriers in general that governments face on enacting public health policies around a lot of other issues. There are some particularities to alcohol that we can talk about, but raising taxes is just a difficult thing for governments to do, even though they generate revenue. The biggest barrier I would say to enacting good alcohol policies is the influence of the industry. Commercial interests behind alcohol are huge, very strong, very powerful, and often employ the same tactics as the other industries, like tobacco, around miscommunicating the science, around distracting governments towards noneffective strategies, and in general promoting a narrative of individual responsibility rather than a policy-oriented strategy. So I'd say industry interference, industry opposition to policy, is probably one of the most important barriers. But many countries are doing good work on this. Many countries in Europe have enacted strong alcohol policies. And across the entire European group of countries, there's been very significant reductions in per capita alcohol consumption and binge drinking. There was a recent report from Russia that indicated that coincident with the enactment of strong alcohol policies, including bringing unregulated alcohol production into the regulatory scheme, was associated, or coincided with, very dramatic reductions in mortality for men and women. Really impressive results in Russia. The Baltic States, Estonia, Lithuania, Latvia, they are known for good alcohol policies. In the countries that we typically work with in lower income countries, like Sri Lanka, Thailand, Botswana, these are all places that have overcome the barriers and enacted good alcohol policies.
Diana Silver: How have they been able to do that? Was the industry less powerful there?
Adam Karpati: I think it's political will. It all starts from the strong leadership at either the national level, or it could be at the city level that values science, that takes a view of trying to protect the health of their populations. And so it starts with political leadership, but it's also supported by strong civil society advocacy, so nongovernmental organizations pushing the agenda and doing good advocacy. So it's that interplay between a strong interest, and a strong advocacy at the grassroots level, and a forward thinking, public health oriented government with good leadership. Those are the ingredients. And then the technical dimensions, what does it take to enact the law and the right way? There's a wealth of international expertise around that, that countries can draw on. And countries that do good policies often avail themselves of some of that international support.
Diana Silver: Right. I'm interested in this idea that there are some governments that are willing to take it on. I know that here in the United States where we've had various organizations that have advocated around alcohol and alcohol consumption, or changing driving behaviors, things like MADD or something, they've gotten actually some support from the insurance industry, right? Because in fact, some of the best data that we have about laws that are passed on alcohol comes from the insurance industry, which is really ... has a deep, deep self-interest in reducing drunk driving. I wonder, are there other partners like that that seem on the face of it, maybe don't come immediately to the forefront, and that you've seen active in kind of making policy, or being supportive in a way that sort of the kind of community mobilization folks are not the same?
Adam Karpati: Yeah. It's a very good point, because one of the other barriers to alcohol policy is that alcohol is not often perceived as a public health issue. There's this sort of other narrative about the health benefits of alcohol consumption. There's the sort of whole story about it's just about individual choice, not about public policy. And in general, I think it's poorly communicated and poorly acknowledged, this huge health burden that I was talking about before. And so that does get to this issue of who are the stakeholders? Who are the potential champions for this? And obviously, the drunk driving prevention advocates are one group, but there are many others. Alcohol is a huge ... is a development issue globally. It has a huge economic impact, the mortality, the morbidity, the human suffering, the social consequences of alcohol. And so people who care about economic development in countries should care about alcohol policy. But beyond that, people who care about violence prevention, especially violence against women and the empowerment of communities, should care about alcohol policy. In many countries, the informal alcohol market, the production of unregulated alcohol, is one that provides revenue and its source of revenue to quite marginalized populations, often women-run businesses. And so acknowledging that and identifying that as a sector to work with is very important around advocacy. Then there's the other health advocates around noncommunicable diseases, those people who care about the burden of cardiovascular disease, cancer especially. As the science continues to emerge around the impact of alcohol and cancer rates, that community needs to get involved, and is indeed getting more involved in alcohol policy. So these downstream health impacts, I think, bring in other stakeholders. And so indeed we need to sort of enlarge the group of interested advocates that we need to mobilize around doing this.
Diana Silver: We haven't been great at that in this country-
Adam Karpati: Absolutely. True. True enough.
Diana Silver: ... certainly, right?
Adam Karpati: Yup.
Diana Silver: It's not like you see health insurers, or you see the hospital associations, or health plans coming forward and saying they're concerned about alcohol. That is not where they are at. So it is interesting to sort of identify some of what potential stakeholders are as we went forward, who you might try and kind of peel off from some of those groups. It reminds me though, even as you think about this global burden of disease, and we talk about the cancer part, is of course, is that alcohol is ... Right? It's one of the risk factors for breast cancer, and there’s been a lot of marketing to women. And so then you talked a little bit about sort of women involved in this production, and at the same time being at great risk. I wonder when you are working in low and middle income countries, is this seen as a gender issue? Do people acknowledge it that way? Is that a problem to think about?
Adam Karpati: I think it's a perspective that we need to be bringing a lot more attention to. You mentioned the marketing. It's just so dramatic, and there's good documentation of it. There's a lot of research going on in this area to try to track the activities of the industry around this. And I think we haven't highlighted it well enough. I think you raise a very good point. It's not something that is brought up early in the conversation about it as the special impacts on women. As you say, we haven't done a great job at highlighting some of these issues.
Diana Silver: So tell me, what do you think cities can do? So in some ways, we've talked ... When we think about pricing, certainly in the United States where we have let localities in some place be able to price alcohol differently. Although we know that in the United States at least, real tax rates for alcohol have basically declined. It's just been in a downward slide for the last 30 years. So taxation is something, minimum pricing, I think there are other kinds of things, but what can cities do? And tell me how different levels of government might be involved?
Adam Karpati: So you're right. There's a lot of challenges, but there's also a lot of opportunities for city governments to do more on alcohol policy. So going back to those best practices around price, availability, marketing, clinical services, and drunk driving prevention, cities have a lot to say about those things. Often cities have a role in the regulatory framework around the approval of licenses, around the enforcement of regulations, around underage sales, around hours of sale and things like that. Cities have a lot of, if not the authority to impose those regulations, although some may have that authority, certainly to enforce those regulations, same with drunk driving. Clinical services are often at the ... Cities have a lot of discretion to promote that more. Advertising limitations, that's one often that cities, especially on city-owned property, that's something New York City has done, limit advertising or prohibit advertising of alcohol on city-owned properties. So cities, again, have creative ways that they can get involved. And then there's the role of cities as advocates. There may be, and it's a true barrier, is that in many states, cities are preempted from imposing alcohol policies that are stronger than the state laws. That's a problem, and states need to advocate for the authority to protect the health of their populations. But in the absence of that authority, they can certainly advocate to their state counterparts and to national stakeholders as well.
Diana Silver: They're preempted. The question is, of course, are they preempting localities from doing something that would be more restrictive around alcohol, or less restrictive? Right? So preemption in and of itself is not necessarily, a priori, a bad thing. I think in practice, however, it's meant that localities that might want to take action ... New York City has been a very active public health place for a long time. You were deputy commissioner. Did you find that you had difficulty sort of acting on alcohol because of the role of the state at the city level?
Adam Karpati: Yeah. Even in a place like New York City, where the government of the city has a fair amount of autonomy and fair amount of authority, there's still a lot of these issues that are state issues, like the imposition of taxes for example, and other things. So indeed, I think even in a place like New York, there are limitations on what the city can do. But as you said, a deep understanding of what the laws are, and an attempt on the part of city governments to seek out the strongest kind of authority that they have, and to be creative about that, that's what people should be doing.
Diana Silver: Well, you talked about Botswana and you talked about Sri Lanka, the sort of nations that are doing something. Are there cities that you've come across as you do your work around building capacity with localities around the world that come to mind around alcohol? Or ...
Adam Karpati: Not so much.
Diana Silver: Not so much?
Adam Karpati: I don't have at my fingertips great urban examples of alcohol policy, to be honest with you. A lot of the efforts that I mentioned, as you said, are more at the national level in lower income settings. And that is an issue with urban public health generally in lower income areas, where the authority at the locality level, and the capacity for public health practice may not be as robust as it is in wealthier countries.
Diana Silver: Right. And it's a much more history of kind of centralized authority at the national level, which I think has also meant that you're not building capacity at a local level, because there's not a lot to do. But it seems to me it's also ... Alcohol does compete with a whole range of other sets of problems that people may be focused on. And so it's a challenge to advocates to figure out how to raise it on the agenda, and I think this notion of coming up with some extra stakeholders to help might be part of that.
Adam Karpati: And combining and sort of including alcohol in other sort of broader agendas around healthy eating and drinking, or health issues that are determined or influenced by commercial interests. It's bringing it into those rubrics. So that means bringing it alongside tobacco control, and sugar sweetened beverage tax policy, and things like that.
Diana Silver: But ministers of finance might have a different attitude towards alcohol than they might have to other products, right? Because of the role of the industry and because-
Adam Karpati: Yeah.
Diana Silver: ... they are a big employer. Can you talk just a little bit about that in the last few minutes?
Adam Karpati: Yeah. There's been some good research on the sort of overall financial impacts of, for example, taxation in general. They are revenue generating for governments, so that might make them attractive, though they have to be imposed at levels that actually influence consumption, and not just for revenue. Industry advocates often try to distract from the core science around this by invoking job losses, or smuggling, and informal markets. In general, those considerations have not been found to be significant problems. And in general, on average, the revenue benefits and the benefits to health far outweigh any of those other considerations. And I would point people to the economic analysis that was conducted by Bloomberg Philanthropies. I think Michael Bloomberg and Lawrence Summers co-chaired a commission on this, and they produced a very good report that I would point listeners to.
Diana Silver: Great. Well, I want to thank you for today, but I want to ask you in your last couple minutes with us, what would you say to students who are finishing, starting, beginning, hopefully graduating, with a master's in public health and who are interested in doing some work on alcohol, or interested in the work of Vital Strategy? What are the skills that they should be building? What kinds of things should they be interested in? Do you have any advice?
Adam Karpati: What I'd say is that like with every public health issue, there are so many dimensions to this issue that people can approach it from lots of different directions. Those who are interested in the epidemiology, in the efficacy of interventions, or the quantitative perspective on it, the economics, and the health, that there's a whole set of work around that. Others might be interested in coming at it from the advocacy perspective, how to build stakeholder coalitions, how to combat industry marketing with public health marketing. So there's that angle. There's the policy angle, understanding the legal dimensions of this. So there's lots of different ways that students can chart a course around this. And it all starts with sort of learning the basics, but then finding the part of the issue that resonates most with your own interests and your own skills.
Diana Silver: All right. Well, thanks a lot for joining me today. I hope you'll come back again, and we'll check in on some more successes at some point.
Adam Karpati: Thanks very much.