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- Alcohol in Colonial America
- Temperance Movement
- Alcoholism as Disease—Early Treatment
- Modern Alcoholism Movement
- Alcoholism, Law, and Psychiatry
- Early Twenty-First Century
Alcohol holds a prominent place in U.S. history, playing a more central role in American culture than any other psychoactive substance. And where alcohol has been used, worries about its excessive consumption and harmful effects have not lagged far behind. From eighteenth-century fears of social disorder in the new republic to contemporary fears about fetal alcohol syndrome, concerns about alcohol’s ability to threaten social and personal health have motivated a wide range of reformers over the past two and a half centuries. At the same time, alcohol has retained its status as America’s most popular consciousness-altering drug.
This research paper traces the history of alcohol and alcohol abuse in the United States. It highlights alcohol’s role as both a staple commodity and one of the most significant sources of disease and disability, and examines alcoholism’s long-contested identity as a disease and social vice and the failure of the medical profession, clergy, or the judicial system to successfully manage this sociomedical problem.
Alcohol in Colonial America
As early as 1585, the first European settlers on Roanoke Island began to brew beer with maize they had obtained from Native Americans. Nearly half a century later, when the Arbella left England for Boston’s shores, its Puritan passengers packed three times as much beer as water and stored some 10,000 gallons of wine. For sixteenth- and seventeenth-century Englishmen and Europeans, drinking was a way of life, essential in societies where most sources of water were contaminated. Colonists imported this way of life to America, where alcohol was regarded as the “Good Creature of God.” Whether rum distilled from West Indian sugar, home-brewed beer, or imported wines from the Continent, alcohol was a staple of colonial life, while wine and opium were mainstays of colonial medical practice. In short, colonial Americans drank early and often—at pubs, barn and house raisings, weddings, elections, and simply to fortify their constitutions against the harsh elements of their everyday existence. The early settlers, however, drew a distinction between drinking and drunkenness, regarding the latter as the work of the Devil.
Although the first temperance reformers may have been American Indians attempting to curtail the damage colonials introduced to their people through alcohol, the American temperance movement is said to have begun with the physician and statesman Benjamin Rush, whose concerns about the young republic’s health led him in 1784 to write An Inquiry into the Effects of Ardent Spirits upon the Human Body and Mind. Fearful for his new nation’s future, Rush recoiled at the prospect of intoxicated voters shaping the country’s destiny—no small consideration at a time when elections often featured heavy drinking and annual per capita consumption of alcohol figured between 4 and 6 gallons (approximately twice the rate of the early twenty-first century). Rush was also the first “modern” to articulate the disease concept of intemperance. Yet, like many in the earliest days of the American temperance movement, he distinguished between fermented beverages (such as beer and wine), which he regarded as healthful, and distilled alcohol (such as rum and whiskey), which he deemed dangerous. Historical evidence, however, suggests that Americans consumed even more alcohol between 1800 and 1830. The efficiency and profitability of turning corn into whiskey, heavy frontier drinking, the spread of urban saloons, and the immigration of beer-drinking Germans and whiskey-drinking Irish all encouraged the nation’s alcohol habits.
By 1836, however, the American temperance movement, set in motion by Rush and the subsequent efforts of evangelical clergy, was picking up momentum and attracting the support of farmers, industrialists, and homemakers. That year, the American Temperance Society began to advocate total abstinence rather than eliminating distilled beverages alone. Indeed, in the early 1840s, Americans in record numbers thronged to temperance rallies, pledged their sobriety publicly, and lobbied to end the licensing of saloons. The Washingtonian movement, a grassroots total-abstinence campaign based on mutual aid among reformed drinkers, sponsored parades and speeches, offered new members financial and moral assistance in their fight for sobriety, and established boarding houses for reformed inebriates wishing to live in a “dry” environment. The Washingtonian movement gave way to better-organized temperance fellowships such as the Red, White, and Blue Ribbon societies as the dry wave continued to crest. And by the 1850s, eleven states had passed prohibitory liquor legislation. Most of these laws, however, were repealed before the Civil War.
Alcoholism as Disease—Early Treatment
It was in the middle of the nineteenth century that the term “alcoholism” was introduced to describe excessive, pathological drinking. Swedish physician Magnus Huss employed the term in his 1849 Chronic Alcoholism. A Contribution to the Study of Dyscrasias Based on My Personal Experience and the Experience of Others to describe the intemperate consumption of alcohol as a disorder with a spectrum of somatic and mental consequences. The term “alcoholism” was not widely adopted, however, until the dawn of the twentieth century. In general, physicians and others who viewed excessive drinking as a disease in the second half of the nineteenth century employed the terms “intemperance,” “dipsomania,” and “inebriety.” Indeed, the first “inebriate homes”— voluntary, urban, usually privately operated residences, where up to fifty inebriate men lived for short periods to recover from the immediate effects of their drinking—were established in Boston (1857), San Francisco (1859), and Chicago (1863).
In 1864, physician J. Edward Turner opened what he claimed was “the first inebriate asylum in the world” in Binghamton, New York, funded through his tireless subscription campaign and monies from the state legislature. With this asylum, Turner inaugurated a new era of treatment for alcoholism. Combining the disease concept of inebriety with the nineteenth-century asylum movement, Turner hoped to restore countless habitual drunkards to useful citizenship. But Binghamton was a troubled institution from the start. Turner was a strict disciplinarian, and hospital trustees objected to his management style. The Binghamton asylum was sold to the state of New York for a dollar in 1879 and converted into a hospital for the chronically insane. Advocates for the disease concept of inebriety, however, were just gaining their stride in the late nineteenth century, having founded the American Association for the Cure of Inebriates (AACI) in 1870.
Established in an era marked by the rise of professional power, the AACI was the first collective organization devoted to promoting the disease concept of inebriety and institutions and laws based on it. Although inebriety usually meant “alcoholic inebriety,” these early medical reformers often used the term more generally, describing “opium inebriety,” “tobacco inebriety,” and “coffee and tea inebriety.” The AACI contended that alcoholic inebriates lost control of their actions as their drinking progressed, and they required restorative medical and moral treatment.
Envisioning a new medical specialty to address this problem, AACI members and their sympathizers built hundreds of private institutions to treat habitual drunkards. California, Connecticut, Iowa, Massachusetts, Minnesota, New York, and a few other states and cities followed suit, creating public inebriate facilities with varying degrees of success. Only Massachusetts and Iowa created comprehensive and relatively long-lived programs for the medical reform of inebriates, between 1893 and 1920. Treatment at these large state institutions generally focused on restoring the inebriate to economic self-sufficiency as well as sobriety.
In the early 1890s, patent medicine or “proprietary” cures such as Leslie E. Keeley’s bichloride of gold remedy for alcoholic, opium, or tobacco inebriety also commanded the public’s attention. By 1893, there were 118 Keeley Institutes across the country, and Keeley’s exorbitant claims of 95 percent success in curing inebriates attracted a great deal of public attention. Although they were dismissed by the regular physicians as “quacks,” gold cure and other patent medicine proprietors had a tremendous lay following. Arguably, Keeley and his proprietary competitors did more to garner public support for the disease concept than the regular medical profession.
In the years immediately preceding World War I, however, the asylum model was falling out of favor in the realms of mental medicine and inebriate reform. Under the influence of neurology and the mental hygiene movement, psychiatrists were moving outside the asylum to treat their patients and address the psychopathology of everyday life. Short-term care at psychopathic hospitals was meant to intercede early in the course of mental illness, offering more hopeful prognoses for patients and for a psychiatric profession that had become mired in custodialism.
At the same time, the Anti-Saloon League’s innovative bipartisan lobbying strategy had secured prohibitory state legislation around the country, capitalizing on public support for dry reform that the Women’s Christian Temperance Union had nurtured since its founding in 1874. By early 1919, ratification of the Eighteenth Amendment had established America as a “dry” nation, prohibiting the manufacture, sale, and distribution of alcohol. Wartime prohibition and anti-German sentiment (German immigrants were seen as heavy drinkers) also lent support to the dry cause. Under these circumstances, support for specialized medical care for alcoholics dwindled, as well as for inebriate hospitals. The wartime labor shortage had provided employment opportunities even for hard drinkers. All but a handful of the private institutions for inebriates closed their doors with the enactment of the Volstead Act in 1920, prohibiting the sale, manufacture, and possession of alcoholic beverages.
Modern Alcoholism Movement
The second effort to define alcoholism as a medical problem, known as the “modern alcoholism movement,” dates from Prohibition’s repeal in 1933 to roughly 1960. During this period, according to addiction historian William White’s book Slaying the Dragon (1998), the alcoholic was transformed from “a morally deformed perpetrator of harm to a sick person worthy of sympathy.”
The modern alcoholism movement rekindled public interest in treating alcoholism as a disease. As in the early effort to medicalize habitual drunkenness, the number and variety of parties engaged in promoting the disease concept was impressive. Lay groups such as Alcoholics Anonymous (AA); research groups such as the Research Council on Problems of Alcohol (RCPA) and the Yale Center of Alcohol Studies, both of which had significant public outreach missions; medical groups such as the World Health Organization and the American Medical Association; and businesses such as Eastman Kodak and E.I. du Pont de Nemours, who were interested in assisting their employees, all participated in the drive to promote the disease concept. They were joined by municipal and state governments, and finally, in 1970, by the federal government, when Congress passed the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act (the “Hughes Act”) endorsing a sociomedical approach to managing alcohol problems, if not the disease concept itself. This law established the National Institute for Alcohol Abuse and Alcoholism (NIAAA), the first U.S. federal agency devoted to eradicating problem drinking. It also signaled the high tide of support for the disease concept.
Like the early alcoholism movement of the Gilded Age and Progressive Era, the modern alcoholism movement was characterized, first, by an essential tension between medical and social (often moral) conceptions of inebriety and, second, by an elusive quest for a mechanism to explain the origins of alcoholism in each of its victims. These two aspects of the movement were related, of course, for many researchers in both the early and the modern movements hoped that discovering the holy grail of alcoholism’s pathogenic mechanism would give the medical explanation of the disease the upper hand and allow for efficient and effective interventions for a complex medical and social condition. Until this day came, however, alcoholism specialists promoted a holistic approach in which both the medical and the social dimensions of the condition were essential to successful treatment.
Ironically, the initial drive to promote the disease concept of alcoholism arose within a lay, not a medical organization: Alcoholics Anonymous. In 1935, William “Bill” Wilson and Robert “Dr. Bob” Smith formed this legendary mutual aid association for alcoholics. From the beginning, an important principle of the AA program was that alcoholism is a disease, an allergy of the body to alcohol. Wilson adopted this perspective during a stay at the Charles B. Towns Hospital in New York City, one of the few institutions for inebriates and drug addicts that remained open after Prohibition. Although no allergy to alcohol has ever been scientifically recognized, Wilson’s physician at the Towns Hospital had provided him with a medical framework that both assuaged his guilt about his own alcoholism and provided him and others with a strong rationale to avoid alcohol. Support for the disease concept of alcoholism grew with the rise of Alcoholics Anonymous in the 1930s and 1940s. Asserting that some people were allergic to alcohol, AA promoted sympathetic treatment for the alcoholic within a framework that did not threaten the drinking practices of post-Prohibition America. The various organizations involved in the modern alcoholism movement made every effort to abandon the “wet-dry” divide that had characterized the Prohibition era.
As alcohol historians and sociologists have suggested, Alcoholics Anonymous was hardly alone in its efforts to transform public opinion about alcoholism and the alcoholic. Founded in 1937, the RCPA served as a sort of lodestone for attracting researchers, policymakers, and public relations experts interested in promoting the disease concept. Initially, however, the organization had difficulty attracting financial support because the alcohol beverage industry feared that the group might highlight the dangers of alcohol generally—a vestige of the old wet-dry divide. Turning its attentions exclusively to alcoholism in 1939, however, the group was able to garner unprecedented support by championing research on a condition that was rooted in the drinker, not the beverage.
The Yale Laboratory of Applied Physiology recruited several RCPA researchers in 1941; these individuals established the Center of Alcohol Studies at Yale in 1943. The Yale Center took a multifaceted approach to the study of alcoholism, but it also focused on ways to gather, synthesize, and disseminate vast quantities of literature on the condition. Here, in the 1940s and 1950s, physiologist Elvin M. Jellinek developed his multiple “species” of alcoholism model, based on a wide review of the alcoholism literature (1942) and taking into consideration the trajectories of a group of AA members (1960). Three central features of Jellinek’s “classic disease model” were tolerance, or the need for increasing doses to produce the same effect over time; physical dependence, or the occurrence of withdrawal symptoms once alcohol consumption is stopped; and loss of control, or the inability to cease drinking. Finally, the National Committee for Education on Alcoholism (NCEA) arose as part of the Yale Center in 1944, but became independent of the university in 1950. The NCEA’s mission was to educate the general public about alcoholism as a disease. Its leader, a reformed alcoholic named Marty Mann, proved an energetic public relations mastermind; she served 35 years as director, carrying the message throughout the United States and abroad.
William White highlighted more peripheral factors that also contributed to the rise of the modern alcoholism paradigm. Public health leaders such as Lawrence Kolb, the head of addiction research at the U.S. Public Health Service between World War I and World War II, strongly advocated the disease concept of alcoholism and replacing the term “drunkenness” with “alcoholism.” Likewise, he encouraged the construction of public hospitals to treat the disease. Within the mainstream medical community, interest in addiction medicine was also growing. The New York City Medical Society on Alcoholism, formed in 1954, eventually evolved into today’s American Society of Addiction Medicine. Besides medical organizations and industry-supported employee assistance programs, the church became involved with alcoholism in 1949, with the formation of the National Clergy Council on Alcoholism and Related Drug Problems (NCCA), an organization established to guide the American Catholic Church in its ministry to alcoholics. State and municipal authorities also began to address the alcoholism problem once again, establishing outpatient and inpatient programs for problem drinkers, and launching initiatives to educate the public about alcoholism; between 1945 and 1955, 75 percent of state legislatures passed alcoholism initiatives.
All of these developments suggest a sea change in the way the public regarded alcohol in the three decades following repeal of Prohibition. The issue was not quite so clear-cut, however, in the realm of alcoholism research. Science appeared to raise more questions than it answered about the nature of the condition. Even Jellinek’s work was not without its critics. In fairness to the founder of “the classic disease concept,” Jellinek had voiced concerns about the utility of his multistage model to describe the wide spectrum of drinking problems he and Haggard observed. Researchers at the Yale Center of Alcohol Studies also rejected the allergy model in 1944, and they later failed to find a particular “alcoholic” personality profile, as posited by many psychiatrists in the 1940s and 1950s. University of Washington sociologist Joan Jackson, known primarily for her study of the dynamics of the alcoholic family, found the notion of a specific “alcoholism syndrome” extremely problematic in the late 1950s. And the findings of the 1972 RAND Corporation Report—that a significant proportion of individuals diagnosed as alcoholics could “recover” and drink normally, without losing control—also suggested that a strict definition of alcoholism as a disease might not be appropriate.
In the 1960s and 1970s, anthropologists and sociologists studying drinking practices demonstrated conclusively that the user’s mindset and context of use were key factors in shaping the consumption patterns of alcohol as well as other psychoactive substances. Finally, and important within today’s medical arena, no specific causal mechanism, save the consumption of alcohol, has ever been identified as being responsible for alcoholism. In hindsight, as William White has observed, the disease concept appears to have been more of a public relations success than a scientific one.
Alcoholism, Law, and Psychiatry
Outside the world of alcohol science, controversy continues. The Supreme Court cast doubt on the disease concept in the 1968 case of Powell v. Texas, letting stand a lower court’s decision that a chronic alcoholic was responsible for his conduct while under the influence; the court cited, among other issues, the lack of medical consensus on the disease concept of alcoholism. The American Psychiatric Association, which had recognized alcoholism as a personality disorder in its 1952 Diagnostic and Statistical Manual(DSM-I), reclassified alcohol problems in DSM-III in 1980, distinguishing between “alcohol dependency” and “alcohol problems.” Only the former was regarded as a disease, though both might benefit from medical attention.
This distinction echoed the World Health Organization (WHO) expert committee on alcohol-related disabilities’ 1977 findings, which drew attention to the incapacitating consequences of problem drinking, as distinct from alcoholism This observation had significant political implications, suggesting that reducing overall alcohol consumption in the general public could yield tremendous benefits—more than might come from addressing alcoholism alone. It remains unlikely that Americans would ever again pass a prohibition amendment, but public health officials hoped more headway might be made in addressing the overall harm that comes from alcohol consumption in the United States.
Indeed, the more encompassing “alcohol problems” approach that arose in the late 1970s subsumed alcoholism as but one of many negative consequences of alcohol consumption, and it has achieved tremendous currency within medical and public health circles in the past few decades. In 1990, for example, the Institute of Medicine of the National Academy of Sciences published Broadening the Base of Treatment for Alcohol Problems, reasoning that the term “alcohol problems” reflected the Institute’s belief “that the focus of treatment needs to be expanded.” Thus, “alcohol problems” is felt to be a more inclusive description of the object of treatment than such current alternatives as “alcoholism” or “alcohol dependence syndrome,” but it is nevertheless compatible with these widely used conceptual frameworks. The approach includes fetal alcohol syndrome (FAS), drunk driving, alcohol-related violence (including rape), unemployment, industrial accidents, binge drinking, and alcohol consumption among minors.
At the start of the twenty-first century, there is certainly reason to take these issues seriously. According to the March of Dimes, the national incidence of FAS in 2004 was approximately one out of every 1,000 births, with milder fetal alcohol effects (FAE) occurring far more commonly. Native American populations remain one of the most affected groups, with incidence levels in some tribes several times the national average. Likewise, the National Highway Traffic Safety Administration reported that in 2002 alcohol-related traffic fatalities accounted for about 40 percent of all moving vehicle fatalities nationwide. Approximately one-third of Americans will be involved in an alcohol-related crash at some time in their lives.
In 2000, the Substance Abuse and Mental Health Service Administration reported that most binge drinkers and heavy drinkers are between 18 and 25 years old. Not surprisingly, then, alcohol was implicated in 40 percent of all academic problems on college campuses across the United States in 1998, with 28 percent of college students dropping out because of their alcohol consumption. About one out of every five students on college campuses in 2000 was estimated to be a binge drinker, totaling about 7 million young adults nationwide. These statistics provide a sense of the magnitude of alcohol problems in the United States.
Ron Roizen, specialist sociologist, has emphasized the importance of interpreting the expansion of the alcohol problems domain in the context of late twentieth-century politics and policies. Focusing on individual consumption rates across society (and their negative social and medical consequences) may suggest government needs to play a stronger role in assisting individuals whose lives are adversely affected by alcohol, particularly if state and federal governments are seen as beneficiaries of taxes from the sale of ethanol. Other policy experts have interpreted the growing cries for action against alcohol abuse as an effort to redress the supply-side policies and reductions in federal and state human services that characterized the Reagan era—more state and federal funds for treatment are necessary not just for individuals with alcoholism, but for myriad individuals with alcohol problems.
Still, the rapid growth of addiction treatment facilities in the 1980s suggests that any decline in government assistance was offset by the rise of private care facilities, employee assistance programs, and the insurance industry’s recognition of addiction as a condition worth treating. It is certainly possible that the transition from alcoholism to alcohol problems that gained momentum during the Reagan years is a part of the rising tide of cultural conservatism in America, part of a larger “neotemperance” movement attempting to rein in a host of behaviors perceived to be morally questionable and potentially damaging to both individuals and society at large.
Finally, it is also possible to see the “alcohol problems” approach as a return to the sociomedical perspective of the early alcoholism movement and the holistic orientation expressed by Jellinek and Haggard in Alcohol Explored. This broad-based public health approach may counterbalance the growing focus within alcoholism research on genetics and neuropathic mechanisms. Regardless, one is left to wonder what the consequences of the changing paradigm will be for the alcoholic person. Will he or she be regarded as just one of many problem drinkers who warrant medical and social attention, or will association with drunk drivers and drinking mothers-to-be demonize the alcoholic once again?
Early Twenty-First Century
One of the most interesting developments regarding alcoholism at the start of the twenty-first century is its consideration in relationship to other psychoactive substance addictions. Roughly one century after the unified theory of “inebriety” was abandoned for “alcoholism,” “opiate addiction,” and other specific intoxications, pharmacological researchers are proposing a unitary theory of addiction in which a variety of psychoactive substances are seen as triggering similar neurochemical responses. The policy side of drug use preceded this development by a few decades with championing of the terms “chemical dependency” and “substance abuse,” but the new “dopamine hypothesis” appears to be gaining attention. It is worth noting, however, that even in the world of neurochemistry, culture, social behavior, and learning are key elements in mediating drug response. To quote a cover article from a 1997 issue of Time magazine devoted to the dopamine hypothesis, “Realistically, no one believes better medications alone will solve the drug problem. In fact, one of the most hopeful messages coming out of current research is that the biochemical abnormalities associated with addiction can be reversed through learning.” Whatever alcohol and alcoholism’s futures, they appear to be tied intimately to both culture and chemistry.
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