FAS: the gestation of a dubious idea
It is moralism, not evidence, that underpins the advice that pregnant women should abstain from alcohol.
A new scheme, announced on Sunday, that will ‘train midwives to give pregnant women advice on the dangers of alcohol’ has provoked controversy because the drinks firm Diageo, whose brands include Smirnoff and Guinness, is reportedly stumping up £4million to fund it. But it is the content of the scheme, not the organisation that is funding it, that should be provoking comment.
UK public health minister Anne Milton has claimed the scheme is ‘a great example of how business can work with NHS staff to provide women with valuable information’. But some doctors have raised ethical objections to the involvement of the drinks industry in the scheme. Vivienne Nathanson, long-time advocate of complete abstinence from alcohol during pregnancy and head of science and ethics at the British Medical Association, has so far been the main voice of criticism arguing that there is a conflict of interest, ‘because it’s in the interest of the drinks industry for people to continue to drink and it’s in the interests of health for people to drink much less, and certainly not to drink in pregnancy or to drink really minimally’.
In reality, however, the scheme does not throw up any conflicts of interest. In general pregnant women are not heavy drinkers; promoting alcohol abstinence for this group is not going to dent sales. What it will do is to remove any doubt about Diageo’s willingness to embrace the state-approved mantra of ‘responsible drinking’. After all, what better way for Diageo to demonstrate its commitment to ‘responsible drinking’ than to make a great show of protecting the defenceless unborn baby, and ‘empowering women’ with information about having a healthy pregnancy? Diageo can be entirely relied upon to be ‘on message’.
Besides, arguments over the origin of the funding miss the point. What should really be at the centre of the debate are the ideas and claims about alcohol and pregnancy that midwives are going to be educating women about. The real scandal is that the Liberal-Conservative government now overtly authorises the ‘abstinence is the only true way’ message, and is funding an organisation called the National Organisation on Fetal Alcohol Syndrome (NoFAS UK) to train midwives to promote that idea. It raises important questions about the nature of health policy and the obsession with intervening in the ‘early years’ of a child’s life – which now seems to include pregnancy, too.
NoFAS UK is the London-based affiliate of a North American lobbying organisation, NoFAS, established in 2003. Hitherto its activities have included an annual ‘pregnant pause’ where people involved with NoFAS UK (including men with balloons up their jumpers pretending to be pregnant) stand perfectly still at London’s Victoria train station for nine minutes, at nine minutes past nine on 9 September, to show passers-by that ‘women only need to pause from drinking alcohol for nine months in pregnancy to ensure that their babies will be born without the alcohol-related brain damage known as Fetal Alcohol Spectrum Disorder (FASD)’. NoFAS’s website also features its ‘alcohol and egg’ video, in which someone breaks an egg into a glass, pours in vodka and invites the viewer to see the egg ‘cook’. These offerings may seem strange, but NoFAS now seems to be taken seriously enough to train the nation’s midwives.
The core belief of the organisation is that alcohol is a dangerous substance, and that any alcohol consumed during pregnancy can harm the developing fetus. In promoting this outlook, NoFAS is involved in what sociologists call moral entrepreneurship. The organisation’s aim is to foster high levels of concern about a hitherto unrecognised problem and ensure that the ‘wrong’ of drinking anything at all in pregnancy is taken seriously. As sociologists have noted, one distinctive feature of today’s moral entrepreneurs is that they increasingly present their claims in medical or scientific terms. In turn, the solution to problems becomes new codes of conduct for behaviour, apparently sanctioned by the authority of medical science.
In her informative book on the development of FAS as a social problem in the US, Conceiving Risk, Bearing Responsibility: Fetal Alcohol Syndrome and the Diagnosis of Moral Disorder, Elizabeth Mitchell Armstrong points to the rise of what she calls medical entrepreneurs, individuals with a powerful sense of mission regarding their assessment of ‘the evidence’ who seek to ‘impress their… vision on the rest of society’.
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A particular understanding of the relation between alcohol consumption and fetal development emerged in the US. Those who originally coined the term Fetal Alcohol Syndrome in the early 1970s (a term used to describe a rarely occurring set of distinct problems found in babies born to some alcoholic women) engaged in ‘subtle broadening of the problem’ from the outset. They commented, for example, that no case of FAS had ever ‘been reported in a human being with a negative maternal history of ethanol use’. In other words, the knowledge that consumption of high levels of alcohol in pregnancy was associated with developmental problems in the fetus was taken to mean that FAS could only be avoided for sure if no alcohol is consumed. This point has been made in another way by historian Janet Golden, who explains that abstinence advocates shifted the definition of the problem that needed to be addressed away from maternal alcoholism (a serious problem for individuals requiring careful treatment and specialist intervention) to consumption of alcohol as a substance (a general behaviour to which the response is public health campaigns promoting abstinence for all).
British medical entrepreneurs around this issue have a similarly broad attitude to evidence about FAS. For example, the psychiatrist Raja Mukherjee, routinely a key speaker at NoFAS’s training events, justified abstinence advocacy in a 2005 commentary subtitled ‘abstinence from alcohol is the only safe message in pregnancy’. His case for abstinence was made through reference to ‘emerging evidence’ of an ‘inconclusive nature’ (studies on rat brains, observational studies of children’s behaviour and unpublished evidence). Thus in a departure from conventional justifications for policy, it was the inconclusive nature of the evidence – what is unknown rather that what is known - that formed the basis for the argument for policy change.
Following this logic, NoFAS promotes the notion of alcohol harm as a ‘spectrum’ (called Fetal Alcohol Spectrum Disorder, FASD), with varying amounts of harm caused by different levels of alcohol consumption. According to advocates of FASD as a concept, alcohol causes a variety of problems including intellectual, memory, mood and attention disorders. It is also argued that often FASD goes ‘undiagnosed’, or is misdiagnosed, ‘for example as autism or attention deficit hyperactivity disorder (ADHD)’, or that autism and ADHD are in fact symptoms of FASD. Further, we are told that FASD, when undiagnosed, can lead to ‘secondary disabilities’ that can include loneliness, school expulsions, addictions, chronic unemployment, promiscuity, unplanned pregnancies, poverty, criminality, prison, homelessness, depression and suicide.
The starting point is a presumption that any alcohol is damaging. It follows that when we consider problems children have, we should work backwards to maternal alcohol-consumption as the cause. Hence if a child of any age has problems and the mother drank at all during pregnancy, the suggestion is that there is likely to be a causal connection.
In the US, the medical entrepreneurs’ idea that alcohol consumption explains pretty much everything that ‘goes wrong’ with children gained traction with policymakers very rapidly. The US was the first country where alcohol abstinence advocacy became the official approach (in 1981). For some years, this was widely considered an ‘American’ view. For example, a Guardian article in 1991 notes: ‘The case for abstinence is not based on evidence. It is based on the logic of better safe than sorry. It is tempting, especially for an expectant mother, to say that any risk, however small or theoretical, is too great. But that is absurd. Everything about light drinking during pregnancy makes it the kind of theoretical risk that Americans are unlikely to evaluate sensibly. Doctors are innately cautious and made more so by lawyers hovering overhead with malpractice lawsuits.’
By 2007, however, the English Department of Health (DH) decided to advise women to abstain from alcohol in pregnancy. As was noted at the time, the DH did so in contradiction to the findings of its own review of studies on the subject, which found no evidence linking ‘low to moderate’ levels of alcohol consumption with the sorts of problems that feature in descriptions of FASD.
There is no question that 2007 marked a turning point in official approaches to this issue. As was argued on spiked at the time, there was an official admission that there was ‘no new evidence’ to explain the revised advice and that the chief merit of the new policy was that it was ‘clear and unambiguous’ rather than truthful.
Not commented on at the time, however, was the fact that ‘evidence’ as defined by NoFAS was already incorporated into official thinking and cited in the new advice: ‘The National Organisation on Fetal Alcohol Syndrome [NoFAS] estimates for the UK as a whole that there are more than 6,000 children born each year with Fetal Alcohol Spectrum Disorder [FASD].’ No account of the origin of the statistic ‘more than 6,000 children born each year with FASD’ can be found on the NoFAS website. According to the NHS Information Centre, the figure was generated by extrapolating estimates of the incidence of FASD for ‘Western countries’ and combining these with the official estimate of 700,000 live births in Britain each year. In other words, it is a ‘guesstimate’ of the incidence of a condition whose existence itself is questionable.
Armstrong’s analysis suggests that whether or not medical entrepreneurs achieve their goals depends on whether their vision resonates with already-existing policy concerns. US studies argue that wider cultural conditions in that country explain why FAS expanded and why the case for abstinence made sense to policymakers from the early 1980s onwards.
The same is true for Britain more recently. An approach that has no basis in conventional understandings of evidence has taken root, from the mid-2000s onwards, in the context of an official view that the way to solve any and all social problems is to ‘intervene early’. Educating pregnant women about their behaviour has emerged as the ultimate exemplar of the belief that the way to ‘get to the causes of problems’ is to change the way parents raise their child (and to go further by extending programmes to modify parenting practices backwards to the womb).
It would be a real pity if the debate about the new training scheme for midwives stays stuck in its current groove about who should fund this drive to monitor and modify behaviour in pregnancy and parenting. Other questions entirely need to be raised about where we will end up if this evidence-lite, early-intervention policy is continued.
Ellie Lee is senior lecturer in social policy at Kent University and a director of the Institute of Ideas. She is the director of Parenting Culture Studies and author of Abortion, Motherhood and Mental Health, Medicalizing Reproduction in the United States and Great Britain. (Buy this book from Amazon(UK).)