Berridge, V (2003) History and twentieth-century drug policy: tellingtrue stories? [Essay review]. Medical history, 47 (4). pp. 518-524.ISSN 0025-7273

Downloaded from: http://researchonline.lshtm.ac.uk/15848/

DOI:

Usage Guidelines

Please refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna-tively contact researchonline@lshtm.ac.uk.

Available under license: Copyright the publishers

Essay Review

History and Twentieth-Century Drug Policy:Telling True Stories?

VIRGINIA BERRIDGE*

Griffith Edwards (ed.), Addiction: evolution of a specialist field, Blackwell Science, 2002,pp. viii, 400, £27.50 (paperback 0-632-05976-1).

David F Musto and Pamela Korsmeyer, The questfordrug control: politics andfederalpolicy in aperiod of increasing substance abuse, 1963-1981, New Haven and London, Yale University Press,2002, pp. xxiv, 312, £27.00 (hardback 0-300-09036-6).

H B Spear, Heroin addiction care and control: the British system 1916-1984, ed. Joy Mott,London, Drugscope, 2002, pp. xiii, 362, £35.00 (paperback 1-904319-04-1).

Do a search on "drugs" and "history" and youwould be rewarded by many titles. But manytread an all too familiar path. The assassins andcannabis, Homer and nepenthe, the opiates inShakespeare, lead through to the nineteenthcentury, literary and popular use, opium smokingand beyond. Published new primary research hasbeen short in supply and texts often recyclefamiliar work and quotations. But there are signsof change. A crop of recent books oninternational drug policy showed the benefits ofan expansion of research in that area.' DavidCourtwright's Forces of habit has provided anexcellent analytical oversight of the rise andfall of drugs in history.2 But the more recenthistory ofnational UK orUS drug use and controlhave been relatively neglected, or considered

* Virginia Berridge, London School of Hygiene andTropical Medicine, London.

' Virginia Berridge, 'Illicit drugs andinternationalism: the forgotten dimension', Med. Hist.,2001, 45 (2): 282-8; William McAllister, Drugdiplomacy in the twentieth century, London,Routledge, 2000.

2David Courtwright, Forces of habit: drugs andthe making of the modern world, Cambridge, MA,Harvard University Press, 2001.

as part of other topics, for example the adventof HIV/AIDS in the 1980s.3 Research basedaccounts like the short paper by Carol Smart onBritish drug policy from the 1930s to the 1960s,published nearly twenty years ago, remain rare.4The changes in drug policies in the period

since the Second World War and in particular the1960s and 1970s were significant and continue toexcite debate in today's fluid situation. Thisreview assesses three recent publications whichthrow light on that period, in very different ways.Musto and Korsmeyer cover the changes in USdrug policy since the Johnson era in the 1960s upto the end of the Carter presidency in the 1970s.The collection of interviews edited by GriffithEdwards singles out some of the scientists,researchers and clinicians who collectively have

3Virginia Berridge, AIDS in the UK: the makingofpolicy, 1981-1994, Oxford University Press, 1996.

4Carol Smart, 'Social policy and drug addiction:a critical study of policy development', Br. J.Addiction, 1984, 79 (1): 3 1-9.

518

Essay Review

formed the "alcohol, drug and smoking field"over the past fifty years. The part historytext/part autobiography by Bing Spear covers thechanges in British drug policy that paralleledthose in the US, although his frame starts earlier,in 1916, and finishes in the 1980s. These are theresearch-based texts which are lacking in thefield.Musto and Korsmeyer's book builds on the

more general overview of US drug policy withwhich David Musto's name has been associatedsince the 1970s. The new book looks at thesixties and seventies in greater depth. Korsmeyerhas mined primary sources in presidentialarchives, the Library of Congress and elsewhere,while Musto's connections in the drug field haveensured access to the papers of key players likeNixon's former drug czar, the psychiatrist JerryJaffe, and Carter's adviser on drugs, PeterBourne. The period they cover was an excitingone for US drug policy. The era ofprohibition setin motion by the Harrison Narcotics Act of 1914,and which lasted into the early 1960s, fell apartunder the pressures of crime and civildisobedience; the war in Vietnam; and increasingconsumption of illicit substances. The oldwarhorses of prohibition, in particular HarryAnslinger, the commissioner of the FederalBureau ofNarcotics since the 1930s, disappearedfrom the scene. The Johnson administrationbegan a three part approach to the drug problemwhich was later carried through in theadministration of Richard Nixon, Johnson'sRepublican successor. Nixon's attack on drugsinvolved a stress on the close connection betweendrugs and crime (a connection which remainscontroversial). Foreign policy was a keycomponent-relations with Mexico and withTurkey were affected by policies of bordercontainment (Operation Intercept) and of cropsubstitution. Close connections between locallaw enforcement and the federal fight wereestablished through the Office of Drug AbuseLaw Enforcement. A White House based SpecialAction Office on Drug Abuse Prevention(SAODAP) under Jaffe's medical leadership,

5David Musto, The American disease: origins ofnarcotic control, expanded ed., New York, OxfordUniversity Press, 1987.

saw addicts able to obtain maintenanceprescribing from government sponsored clinicsfor the first time since the 1920s. The drug onoffer was oral methadone, a synthetic narcoticdeveloped in Germany in the 1930s. None of thiseffort was an unmitigated success and inparticular fell foul oftensions within governmentbetween different agencies. But some of theNixon era organizations survive even in the early2000s, albeit in different form.

Gerald Ford's period as president (1974-77),bedevilled by cost-cutting, introduced a moremoderate tone. The word "minimize" rather thaneradicate appeared in official policy documents,in particular in the White Paper on DrugAbuse, well received by a population cynicalabout the imminence of victory in the war ondrugs. This attitude developed further in Carter'spresidency, which, the authors note, marked thehigh point of the American public's relativeacceptance of some degree of recreational druguse. The mistake made by Carter, and by Dr PeterBourne, his influential drugs adviser, was inassuming that public mood was a fixed point.Drug use, and its public acceptability, were bothfluid. Bourne's careless prescription for one ofhis staffers, and allegations that he had usedcocaine at a party for NORML (NationalOrganisation for Reform of the Marijuana Laws)led to his downfall. The Parents' Movement wasin the ascendant while the heroin trade, from Iran,Pakistan and Afghanistan, began to expand. Theheady days of the 1970s consensus were over.

This book covers important events, althoughits tone is hardly exciting. The illustrations of'men in suits" discussing drugs in committeemeetings that pepper the pages seem also to haveaffected the writing style. (Although a photo ofKeith Stroup of NORML bears an uncannyresemblance to Austin Powers.) There arethickets of detail on US policy manoeuvringwhich, for a non-American readership, aredifficult to master. A summing up or concludingchapter or overall bibliography and listing ofthe primary sources used would have beenhelpful. The book has a rather unfinished air. Anovel addition is a CD of the documents usedto write the text, inserted in the back cover.This is valuable, but also adds to the sense of

519

Essay Review

"develop your own analysis". The tone iscircumspect and analytical themes are few.Those that are extractable from the text aresensible and founded on long experience ofthe US drug policy scene. Musto comments thatlack of long term perspectives in politics hasconsistently hindered balanced perspectives onwhat policy can produce. He considers that druguse ebbs and flows in cycles on which policy haslittle impact. For this assessment at least, anhistorical perspective is essential.

Edwards' edited collection has one unifyingidea-the post-Second World War evolution of aseparate "field" of addiction specialists. It alsoprovides, through its interview format, someof the raw material for other studies in drug,alcohol and smoking history. It is the secondbook to be published from the series ofAddictioninterviews which the journal has featured formany years. The current collection has scientistsfrom the USA and Canada. There are politiciansand practitioner policy-makers from Australia;pioneers from the smoking field like RichardDoll and Charles Fletcher and the less wellknown Ove Ferno, the originator of nicotinereplacement therapy. There are British drugsresearchers; policy makers in the US; scientistsin post-war Europe; community activists in theUS, and researchers and policy-makers fromScandinavia. Each section finishes with a briefpage or two overview from an expert in the field.With such a cornucopia it is impossible to dojustice to every interview. Some overlap withMusto's study, for example an interview withJaffe, and also one with Vincent Dole, the pioneerof methadone maintenance therapy in New Yorkin the 1960s, although Musto's book appearsnot to have used this resource.Can any general conclusions be drawn about

the growth of the "field"? Interviewees from the1950s talk of how small even the alcohol fieldwas at that stage and how much it had grown bythe time they left it. Everyone knew everyone,but later it was impossible to do that. The influxof refugees from Europe to America was a stronginfluence. Few, however, had the experiencesof Charles Lieber, an expert on the biologicalaspects of alcohol abuse, who describes war-timedisplacement in Europe, beset by all the warring

armies; this makes his later eminence all the morelaudable. In the US, the Federal narcotics "farm"at Lexington, Kentucky, which provided bothincarceration and treatment, was a formativeinfluence for many researchers. Internationalnetworks were important. Scientific meetingsbrought researchers together, as did the newlyestablished WHO, and collaborative publicationlike the famous alcohol Purple Book of the 1970sforged a strong esprit de corps.6 Researchersfrom the Canadian Addiction ResearchFoundation, the powerhouse of research,treatment and prevention in that country since the1940s, speak of the changes in research policywhich have seen funded research give way totime limited grants, from "blue skies research"to direct policy and practice relevance. TheAustralians tell of policy battles, of more recentattempts to liberalize drug policy or of the failedattempt to institute a trial of heroin prescribing.The Scandinavians offer a window into a verydifferent situation for research, with fundingcoming from the state alcohol monopoly-evenfor sociology. They outline the strong interest inScandinavian co-operation, in research onpolicy, and a cadre of drug researchers who alsomaintain reputations in their general disciplinaryfields.

There are vignettes which stand out. Here isReg Smart ofthe Addiction Research Foundationspeaking of E M Jellinek, the author of theseminal The disease concept of alcoholism:"Jellinek, as I remember him, was a short, sort ofstooped-over, overweight man, with little hairleft. Not at all a romantic figure, but he hadmarried several times and he spoke often abouthis relationship with a Spanish ballet dancer, aswell as his other romantic affairs. I rememberhim as a great rapporteur and teller of jokes.

"He was older when I met him and he had ahearing aid. If a meeting became boring he wouldturn the hearing aid off and go to sleep. Several

6K Bruun, M Lumio, K Makela, L Pan, R Popham,R Room, S Schmidt, 0 Skog, P Sulkunnen, andE Osterberg, Alcohol control policies in publichealth perspective, Helsinki, Finnish Foundation forAlcohol Studies, WHO Regional office for Europe,Addiction Research Foundation of Ontario, 1975.

520

Essay Review

times I saw people awaken him and ask him tosummarize the discussion. Usually thesesummaries were very good" (p. 109).The three interviews with characters of

importance in the history ofpost-war British drugpolicy were of interest from my perspective.These are with Joy Mott, a drugs researcher at theHome Office, Thomas Bewley, formerlyconsultant to the Ministry of Health on drugsand a key force in British drug policy changes inthe 1960s; and Raj Rathod, a psychiatristworking in Crawley New Town, who publishedsome of the earliest epidemiological research onthe spread of the new heroin epidemic outsideLondon in the 1960s. Bewley's interview carriesa humorous flavour of the man.

"Tooting Bec was the most central mentalhospital which accepted patients from anywherein London. In the 1960s I used to admit alcoholicsof no fixed abode and we had an alcoholismprogramme. One of my registrars described itas patients coming in for their 1000 gallon checkup ... A small number of heroin addicts werealso admitted as no one else wanted to have muchto do with them at that time. When I first wrote tothe Lancet I think I had seen about 20. I don'tthink anyone else in the country had seen morethan two then. This was how I became an'expert'" (p. 247).Bewley went on to become influential in drug

policy and a President of the Royal College ofPsychiatrists; Rathod, by contrast, was a pioneerwho remained a relative outsider.

This is a rich collection. Some interviewsare clearly better than others and someinterviewers more talented at extracting thetelling phrase or anecdote. One encounter withthe Australian premier, Bob Hawke, is a lesson inhow not to do it, with closed statements ratherthan open ended questions, eliciting predictablyterse responses from the politician. The texttells us little about how the interviews wereconducted or when, and about how they havebeen edited. They were intended for publication,with the constraints on speaking freely which thatimplies. The interviewers are key players orresearchers in the field, several ofwhom have notuncomplicated relationships with theirinterviewees. Such constraints on source

production should be borne in mind. My owninterviews with one or two of these "players",not for publication, have produced differentperspectives. As one of the commentaries sighs,we all know that they could have told us so muchmore. Nevertheless, this collection is ofvalue andthe editor to be credited for his foresight ingathering the interviews together.The first volume of Addiction interviews

contained one with the former Home OfficeChief Drugs Inspector, Bing Spear. Spear died in1995 but his history of British drug policy from1916 to 1984 has been edited and brought tofruition by Joy Mott, the former Home Officeresearcher who is herself the subject of anAddiction interview. Here people who are theraw material of history are both writing andediting it, although in a different way to theinterview format in the Edwards book. Spearhas long been a legendary figure to liberalizersin the drug policy field. Tales of how he knewevery addict personally on the London drug"scene" of the 1960s, and would take his nighttime walks down to Piccadilly Circus to visitthe all night chemists supplying addicts havebeen told and retold. His lustre amongliberalizers derives from his criticisms of the turnwhich drug policy took after the changes ofthe 1960s. Spear considered that the changes inprescribing policy and the management of drugaddiction that marked the implementation of the1965 report of the second Brain committeeamplified rather than reduced the problem.Specifically he argued that policy was driven bythe interests of a small group of psychiatristswho, until then, had had little interest in drugs,but who established a treatment orthodoxy thathad disastrous results. Prescribing was takenaway from experienced general practitionersand located in hospital-based drug dependenceunits. Here psychiatrists imposed policies ofno prescribing, or of prescribing only oralmethadone (the synthetic narcotic also beingused in the US at this time). The result, he argued,was the growth of a black market. Addictnumbers expanded as addicts turned away fromthe clinics in search of a less restrictiveprescribing regime. His hostility was directedin particular at Dr Philip Connell, consultant at

521

Essay Review

the Maudsley and adviser on drugs to theDepartment of Health. Spear's views haverecently been taken up and advanced withsome success by those who want reinstatement ofheroin prescribing regimes.

Spear had already produced a detailed paper onthe evolution ofthe drug "problem" in the 1950sand 1960s which has been widely used byanalysts of that period.7 In the book he takes thatstyle of writing further, using mainly HomeOffice papers, and articles in the medical pressfrom the time, as well as the review andreminiscence which has been published by othersin the field over the last thirty years. Spear tells ushow British drug policy evolved towards the"disaster" of the post Brain 2 period after 1965.Advice from the drugs inspectorate to the firstBrain committee in the early 1960s was ignoredand the committee produced a sanguine view ofthe rapidly deteriorating situation. Theinspectorate's further warnings triggered theappointment of the second Brain committee, butthe implementation of its conclusions wasdisastrous. The Ministry of Health delayed insetting up the promised treatment centres,obtaining its advice from "persons experiencedin the treatment of addiction", the psychiatristswhom Spear obviously regarded with contempt.The Ministry, he argues, lost control of thesituation to a clinical clique who excludedgeneral practitioners and others experienced inthe treatment of addiction. Changes inprescribing practice were carried throughwithout liaising with the street agencies whoknew the grass roots situation. At Bewley's clinicthe change to time limited oral methadoneprescribing was announced simply through anotice posted on the door. The subsequentmedical attack on private prescribing in the1980s arose out of the desire to impose clinicalorthodoxy, which the private sector did notaccept.

This is a well known critique in the drugsfield, which is here presented with some vigourand in detail. It is written as an historical analysis,

7H B Spear, 'The growth of heroin addiction inthe United Kingdom', Br. J. Addiction, 1969, 64:245-55.

but is a hybrid, a semi autobiographicalaccount written by an important player in drugpolicy in the sixties with the intention of arguingthe Home Office view and that of theinspectorate. It is valuable, but also frustrating.Time and again, I longed for Spear to break out ofhis report writing style and tell us what went on,with some direct "feeling." He gives sometantalizing leads, but goes no further. Why werethe junior inspectors "betrayed" by HomeOffice administrative officials and the ChiefInspector at the time of the first Brain Report(p. 104)? Having helped initiate the secondcommittee, what was his view ofthe report? He had argued for compulsorynotification, not in itself a liberal policy-did theinspectorate's pressure for the second committeerebound on them? What was going on in theinspectorate during the period of delay between1965 to 1968? The sections in which Speargives a personal view are valuable. But anopportunity to explore his personal involvementin depth and the history and role of theinspectorate has been lost. The text has beenheavily reduced for publication (it was originallymuch longer) but we have no editorial note onhow this has been accomplished. Maybe Ms Mottmight consider David Musto's CD idea for theunpublished material; this is itself an historicalsource.

Alongside clinicians, women academics suchas myself and Carol Smart were clearly particularirritants for Spear. The first chapter of hisbook, which deals with the period during andafter the First World War, is framed as an attackon my own analysis of drug policy. This is theperiod of flux between 1916 and 1926, whenclinicians and the Home Office negotiated thebalance that was to operate in drug policy in thelight of the requirements of intemational drugcontrol. Was policy to be primarily penal inorientation, as in the US, or were medical men tobe allowed to prescribe? These tensionsestablished the medico-legal alliance which wasto characterize drug policy for so long. Ifound this chapter, the vehemence and bias of itsattack on myself, puzzling, in particular since ourrelations when Spear was alive had beencordial; he had never voiced these criticisms to

522

Essay Review

my face. I related it to the general agenda of thebook, which is to defend Spear's view of theHome Office and to criticize "psychiatricimperialism" in drug policy. Spear consideredthat my interpretation of the 1920s castaspersions on the role of the Home Office and ofMalcolm Delevingne, the civil servant who laterbecame one of the "grand old men" ofinternational drug control. He saw my analysis asmaking the medical profession the "heroes" andDelevingne the "villain". This is not the case,and I do not write history in the "heroes andvillains" mode. The point I make is that theobjectives of the Home Office changed overtime. Delevingne came to realize that the role ofthe medical profession in the treatment ofaddiction had to be recognized. What resultedwas a medico-penal alliance within which thebalance of power could change to one side or theother. This balance operates in 2003 as much as in1926. Like Spear, I concluded that Delevingnerather than Rolleston was the major architect ofBritish drug policy. It is a pity that Spear'seditor did not check my writing on this topicwhere this analysis is made plain.8

In order to develop his attack, Spear disputesmy interpretation of the evidence. Pages areoccupied with detailed textual criticism. In areview of this nature it would be tedious for thereadership to redispute everything in return,although I would be happy to do this given thespace. Let me focus on a particular example.I argue that the medical and pharmaceuticalprofessions as well as the vets were outraged bythe Home Office's issue of regulations underthe Dangerous Drugs Act in the 1920s. Spearwrites that I over-emphasize this. The medicalprofession, he argues, should not have beenbothered by a few requirements for clinicalrecord keeping or by the circulation of a black listof doctors prescribing to addicts. But this isahistorical; the evidence which he producesshows that they were. The aim of historicalwriting is to attain critical distance, not to

8Virginia Berridge, ' "Stamping out addiction":the work of the Rolleston Committee, 1924-1926',in G E Berrios and H Freeman (eds), 150 years ofBritish psychiatry, 1841-1991, Vol. 11: The aftermath,London, Athlone Press, 1996.

comment from an interested perspective, asSpear does here. He writes as the Home Officeinspector. By the 1960s and 1970s, his ownperiod of key influence, the professions wererelatively used to the requirements of control. Inthe 1920s, these were new systems which seemedto undermine professional freedom as well asbeing excessively bureaucratic. Spear'scomments on the role of the Ministry of Health(p. 9) show that he is unaware of its history, thatthe Ministry was only recently established in theearly 1920s. It did indeed have to win a positionof influence in drug policy in contrast to thelonger Home Office track record.

There is a further aspect to Spear's attack. Atseveral points, he uses words selectively whichappear to represent my views. He refers (p. 32)to a Home Office "defeat" as if this is myanalysis and in order to criticize thisinterpretation of policy. The actual words Iuse present a different analysis. "In reality theoutcome was more complex than astraightforward defeat for the Home Office. Itwas recognition that narcotic policy could notsimply remain a matter of increasing state andpolice regulation, as had been the case since1916. It was henceforward to be based on someform of partnership between the professionalideology ofdoctors and the aims ofpolicy as seenfrom the Home Office."9 Spear's stance raisesissues of source/historian relationships which arealso of interest methodologically to those of uswho work in the contemporary history field. Thegeneral topic is worth a fuller piece.

These books give a sense of the richness whichawaits in the study of science and policy inthe drugs, smoking and alcohol field in the lastfifty years. Musto and Spear invite comparisonbetween events in the US and those in the UK inthose years as policy on both sides of the Atlanticmoved closer together, aided by travel andinteraction between key players. There are somestriking similarities, despite the oft drawncontrast between the "liberalism" of British

9Virginia Berridge, 'Drugs and social policy:the establishment of drug control in Britain1900-1930', Br. J. Addiction, 1984, 79 (1): 17-29.

523

Essay Review

policy and the American "war on drugs". Therole of doctor advisers-Connell and others inthe UK, Boume and Jaffe in the US, is oneparallel. The Federal location of drug policy inthe States contrasts, however, with thedepartmental interests and empires which havecharacterized British drug policy. The role ofthe inspectorate in the UK also needs to be setwithin the context of inspectorial regimes ingeneral. The books also raise questions of

sources, methodology and interpretation. Wecan reinterpret the US policy history usingMusto's document CD; Edwards' interviewsawait analysis; and Bing Spear's book providessource material for further study. Historicalanalysis does not deal in "true stories" or in"heroes and villains"; but these texts providerich material for the considered national andcross national analysis which recent drug policystill needs.

524