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How does the nation's 'alcohol problem' change from era to era? Stalking the social logic of problem-definition transformations since RepealAn edited version of this paper may be found in Sarah Tracy and Caroline Acker (eds.), Altering the American Consciousness: Essays on the History of Alcohol and Drug Use in the United States, 1800-2000, Amherst: University of Massachusetts Press, 2004, pp. 61-87.
The paper was originally presented at the conference titled "Historical Perspectives on Alcohol and Drug Use in American Society, 1800-1997," sponsored by The Francis Clark Wood Institute for the History of Medicine of the College of Physicians of Philadelphia, 9-11 May 1997. Research and preparation supported by National Institute on Alcohol Abuse and Alcoholism Grant No. AA09623. I thank Kaye Fillmore for helpful comments on an earlier draft.
Alcohol stood considerably higher on the American political and cultural agenda in 19th- and early-20th-century than it has over the two-thirds of a century since Repeal, in 1933. Why its decline? Over a century of heated conflict about alcohol -- and perhaps especially the drawn-out and fractious debate over Repeal -- exhausted the nation's patience and interest in the subject.1 Lingering cultural images of the great controversy and national prohibition's "failure"2 still operate in effect as historical brakes on alcohol's cultural politics. Moreover, the nation's post-Repeal political plate was full -- taken up with the continuing Great Depression, the emergent threat of rising fascism abroad, and, before very long, World War II.3
The New Alcoholism Paradigm and Problem De-politicization:
Within what Carolyn Wiener (1981) termed "the alcohol problems social arena" itself, the post-Repeal era soon saw the emergence and successful development of "the modern alcoholism movement" -- whose vigorous advocates, led by Mrs. Marty Mann and her National Committee for Education on Alcoholism (NCEA),4 argued that alcoholism, not alcohol, was the nation's most important alcohol problem and that alcoholism was a disease requiring greatly expanded treatment and research efforts, enterprises quite unlike the political agendas familiar to generations of Americans over the long course of what Selden Bacon (1967) called the Classic American Temperance Movement. The modern alcoholism movement split cultural "ownership" (Gusfield, 1996:249-250) of the alcohol problem domain between, on the one hand, Alcoholics Anonymous (AA), a voluntary fellowship devoted to the rescue and spiritual renewal of fellow alcoholics,5 and, on the other, a mainstream scientific enterprise devoted to promoting the importance of research in addressing the nation's alcohol problems.6Both interest groups viewed the dry-wet axis of controversy as diversionary and counterproductive -- and, especially within the first two or three formative decades following Repeal, struggled hard to distinguish their new agendas from the temperance tradition. In more recent decades, the "war on drugs" and a sustained assault on tobacco have become the focus of heated political exchange in the U.S., thus also displacing alcohol from its pre-Repeal station as the nation's original and deeply controversial "drug problem" (Levine, 1978).
Alcohol's low post-Repeal political profile also had an intentional component -- and may also be regarded as the product of what Paul Schrecker (1948:12-18) called historical "work." In the first decade after Repeal, before alcoholism became the consensus theme, a cohort of post-Repeal alcohol activists and enterprises -- including for example Luther Gulick and his Institute of Public Administration at Columbia University (whence came influential policy studies by Fosdick & Scott  and Harrison & Laine ), Everett Colby's "Council for Moderation" (Roizen 1991a & b), the Research Council on Problems of Alcohol (Roizen 1991a), and an emergent alcohol science center at Yale (Roizen, 1993a) -- quite deliberately sought ways to depoliticize the alcohol problem, thus wresting it from the country's dry-wet tug of war.7a Each of these enterprises offered its own thematic route to a new neutrality: Gulick suggested his public administration movement's domain assumption that apolitical, purely administrative solutions could be found for formerly political issues (see Gulick ; Roberts ); Colby suggested that a new normative consensus around moderate drinking would forestall or obviate renewed dry activism in the future; the nascent scientific organizations at first defined the nation's alcohol problem as either (a) a problem of distorted information (stemming from the long propaganda struggle between wets and drys) (Roizen 1991a:Ch. 7) or (b) the failure to adopt an adequately scientific approach to the immense complexity posed by the nation's multifarious alcohol problems (Roizen 1993a).
The American alcohol problem, as these observers saw it, lay less in alcohol, per se, than in the worn out positions of the dry and wet parties still defining the debate's terms and scrambling for post-Repeal influence. Would-be new players in the post-Repeal arena were particularly mindful of alcohol as an "historical" problem, too -- and searched for conceptual and policy tools with which to end the nation's seemingly ineluctable and senseless historical alternation between periods of dry and wet political dominance (Fosdick & Scott 1933; Reports 1938). Their image of pointless historical cycling and wasted political energy doubtless resonated with a larger sense of historical victimization and impotence occasioned by the Great Depression -- a social catastrophe widely regarded as the product of an ill understood boom-and-bust historical mechanism in capitalism not subject to adequate control by actors on the ground.7b
Institutionally speaking, both AA (with its tradition of nonparticipation in "external" matters and its privatist, spiritual orientation to alcoholism) and contemporary modern science (whose advocates emphasized its high premiums on disinterestedness, objectivity, and empiricism) nicely fit this spirit of de-politicization. The disease-alcoholism theme, when it came along, inherited this aspiration and managed to provide -- almost by accident, as it happened (Roizen 1991a:Ch. 8) -- a remarkably adept symbolic vehicle and problem focus for its realization. The disease idea also offered destigmatization to the alcoholic and a measure of new symbolic legitimacy for beverage alcohol itself -- which, in the new paradigm's lens, harbored little more responsibility for alcoholism or alcohol-related troubles than did sugar for the disease of diabetes. An astute dry critic, Ernest Gordon, got little general attention with his compliant that the new neutralist science looked pretty wet to his tutored eye (Gordon, 1946).
Not the least remarkable feature of the modern alcoholism movement was that it in effect represented a trial run for the proposition that modern science could and should take charge of a major American social problem. If Prohibition had been a "noble experiment" in grand-scale, legislatively-imposed social uplift, then the modern alcoholism movement represented a bold test of a new, would-be, post-Repeal scientific hegemony. And although it was not science at all, but AA's spiritually oriented approach, that provided the new movement's all-important evidence that alcoholics could in fact be helped,8 the disease concept's message of medicoscientific naturalism defined and premised the new cultural sensibility and spawned the considerable research and treatment enterprises that would emerge over the remainder of the 20th century.9
Origins, Rise, & Faltering of the Alcoholism Paradigm:
For all of its high scientific and cultural promise, the actual history of the disease concept's emergence as the new movement's ideological centerpiece reads like a history-of-science shaggy-dog story. In fact, neither AA nor the new science halves of the movement had begun with a disease-concept emphasis. AA -- as evidenced for example in its "Big Book" (Alcoholics Anonymous 1939) and a famous article published in the Saturday Evening Post by columnist Jack Alexander in 1941 -- had stressed instead the group's program of spiritual renewal and its members-help-members approach.10 The new scientific agenda (as noted above) initially focused on misinformation (in the RCPA) and inadequate appreciation and tools for handling complexity (at Yale). It was the alcoholism focus and the disease theme, however, that provided a crucial bridge, or "boundary object" (Star & Griesemer 1989),11 between the otherwise quite different institutional halves of the new movement. AA was of course committed to helping the alcoholic from the start. On the science side of the movement, however, the alcoholism focus emerged via a gradual evolution driven by the search for a symbol that would capture the new approach's essence and generate much needed funding (Roizen, forthcoming).
The new scientific enterprises -- both at the Research Council on Problems of Alcohol (RCPA) and at the Yale center -- faced a perplexing structural problem: Their neutralist message about alcohol -- attractive as it may have been to a great many middle-of-the-road Americans -- was ill-suited to inspiring money support from traditional research and/or alcohol patrons (foundations, wealthy individuals, and, perhaps most of all, John D. Rockefeller, Jr. and his philanthropic establishment). It happened that only the beverage industry -- distilling interests in particular -- were impressed enough by the new group's orientation to inquire about offering support. RCPA scientists initially shied away from such offers, fearing derived stigma and charges of biased research. Facing financial collapse, however, RCPA leadership -- in a move I've elsewhere described in more detail and dubbed "Bowman's Compromise" (Roizen 1991a:Ch. 8) -- voted in October, 1939 to accept beverage industry funding so long as all future research was devoted solely to the research problem posed by alcoholism.
RCPA Executive Committee chair, Karl M. Bowman, pointed out in a memo to the group's membership (see Roizen 1991a:Ch. 8) that traditional research focuses on alcohol -- research, for example, addressing alcohol's relation to ill-health, crime, poverty, etc. -- would inevitably generate results that would redound either to the benefit or the disadvantage of the beverage industry. Especially beneficial outcomes would be problematic where industry funds had been used and would immediately raise suspicions of bias. Research focused on alcoholism, Bowman observed, harbored no such daunting prospect. This odd aspect of alcoholism-focused research, Bowman concluded, implied that the RCPA might ethically accept offers of financial support from major distillers so long as alcoholism provided the main focus of its future research agenda.
In 1942, public relations specialist Dwight Anderson (1942) further developed this alcoholism theme by suggesting that the idea afforded an excellent symbol with which to clarify the differences between the new scientific approach to alcohol and the dry and wet mindsets. Two years later, in October, 1944, E.M. Jellinek and Marty Mann sought to conjoin Anderson's disease concept focus with what the Yale science group regarded as an emergent human resource in AA's potential for rapid, national growth. The Yale-based group's idea was to use the disease concept theme as a means for organizing a national, grassroots organization that would offer information and referral, advice to alcoholics and their families, and -- not least importantly -- generate financial support for new scientific research. AA, and particularly the families of AA members, would thus provide a resource for the emergent alcohol science not unlike the relationship between American Cancer Society (or other single-disease-advocacy organizations) and cancer research.12
Mann's NCEA began life as an integral and wholly supported element of the Yale science group -- and would remain so for the first five years of its existence. But although Mann proved quite successful in broadcasting the disease concept message to what seemed an enthusiastic American audience, her enterprise was remarkably unsuccessful in generating revenues for the parent Yale group, which lead finally to NCEA's separation from Yale in 1949. But Mann persevered, and her search led to a denouement of sorts five years later when her disease theme was embraced by a very wealthy and generous patron -- IBM-stock heir, R. Brinkley Smithers -- who welcomed the de-stigmatizing aspect of the disease conception in its own right and was willing generously to support both Mann's public education campaign as well as alcohol science on its behalf. Smithers' support ultimately consolidated a profound change that the disease concept campaign had wrought upon the alcohol science endeavor. Mann's great enterprise had in effect converted the disease-concept theme from a promotional slogan into a field-defining master concept -- a transformation that in due course would expose the new movement to the liabilities of over-selling the disease concept's scientific credentials and utility.
Virtually from the start, research directed at the disease idea proved unfavorable. Aside from two useful scientific contributions from E.M. Jellinek -- a phased symptomatology for alcoholism (Jellinek, 1952) and the prevalence estimation formula that bore his name (Jellinek, 1951) -- alcohol science created more difficulties than support for this central idea. Whether it was Haggard's (1944) early empirical rejection of AA's allergy hypothesis, Jackson's (1958) disconfirming analyses of the alcoholism syndrome, Syme's (1957) negative review of the prospects of discerning an alcoholic personality, or -- perhaps most disturbing of all -- the scientific evidence for the possibility of controlled-drinking among alcoholics (see Roizen, 1987), the alcohol science that blossomed into existence at least partly because of the success of the disease concept as a public relations enterprise proved hostile to the idea's various empirical test-points.13Even the Supreme Court -- in Powell v. Texas (Fingarette, 1970) -- could not quite bring itself to ratify the disease concept when it got the opportunity in 1968.
By the mid-1970s the Jellinekian disease concept's scientific liabilities finally caught up with the modern alcoholism movement. A controversial report out of the RAND Corporation, based on outcome data drawn from the U.S. National Institute on Alcohol Abuse and Alcoholism's (NIAAA) demonstration treatment projects around the country, reported that a significant fraction of diagnosed alcoholics were drinking normally at follow-up (see Armor et al. 1976, Roizen 1977 & 1987). Growing unease over the traditional alcoholism diagnosis' conceptual and scientific liabilities prompted Edwards and Gross (1976) to fashion the diagnostic criteria for an "alcohol dependence syndrome" -- which exercise, despite its own considerable conceptual and empirical difficulties, redefined alcohol addiction as the symbolic property of conventional psychiatry and distanced the diagnosis from the Jellinekian tradition of a discrete, freestanding disease entity with a determinate symptomatology and natural history.
In faraway Finland, a 1969 liberalization of alcohol control policies resulted before long in a sufficiently great increase in popular consumption that Finnish alcohol researchers took the occasion -- in combination with a panel of World Health Organization experts -- to question whether the alcoholism paradigm's well known indifference to nonalcoholic drinking, regardless at what level, was truly warranted from a public policy standpoint. The resulting publication (Bruun et al. 1975) brought Ledermann's (1956) provocative "single-distribution" model to greater scientific attention. Stateside, Cahalan and Room (Cahalan, 1970; Cahalan & Room 1974) began familiarizing a larger scientific audience with the theoretical and policy implications of new survey studies of drinking-related problems. By the mid-1970s, moreover, Robin Room had begun publishing a series of pathbreaking essays articulating a new "problem minimization" perspective on alcohol-problems prevention (e.g., Room 1972 & 1974).14
Yet, just how much or how little impact the alcoholism paradigm's accumulating scientific woes may have had on the modern movement is not easy to say. The paradigm's troubles probably had more currency in the worlds of alcohol science and professionally-offered treatment, where the disease concept had never held strong sway, than in the world of AA and AA-based lay treatment approaches, where alcohol science was regarded with no little suspicion in any case.
And what happened to Alcoholics Anonymous? It grew and grew (see Room and Greenfield, 1993) -- and, to a surprising extent, remained a separate and stable estate in the alcoholism social arena. But AA's diffusion also occasioned changes outside its institutional borders. Its famous 12-step approach and disease language become secularized, routinized, and hypostatized in a derivative tradition of proprietary and state-sponsored treatment enterprises, which included by more recent decades a burgeoning involuntary treatment system -- representing an increasing overlap between the substance abuse and the criminal justice establishments. AA's philosophy and institutional structure were also appropriated and adapted to many new territories of perceived excesses in American life -- from narcotics addiction to overweight to excessive sexual activity or preoccupation. The result was a widening swath of cultural salience for AA, which in due course introduced more and more Americans to the group's program, special language, and moral coordinates. Widening relevance, however, also attenuated the original philosophy -- comingling its thought in the public mind with ideas of co-dependency, "inner-child," and other personality-theory perspectives drawn from a crowded arena of pop psychology and "alternative medicine."
Rise of a Competitor Public Health Paradigm:
Since about 1975, however, the alcohol problems social arena has once again shown signs of re-heating and re-politicization. Perhaps the defining characteristic of this transformation is a re-problematization of alcohol, per se. The new trend is by no means a fait accompli, and significant segments of the alcohol problems domain remain seemingly un- or little affected. For instance, biological and genetic alcoholism research and treatment outcome studies -- research agendas still very much set by the modern alcoholism movement -- remain high priorities at NIAAA (since its creation in 1970, the most important source of funding for U.S. alcohol research). The nation's alcohol treatment capacity actually expanded dramatically over the decade of the 1980s (see Weisner et al.  and Schmidt and Weisner ) even as the nascent re-politicization emerged -- though significant signs of trouble and contraction in treatment were evident by the commencement of the 1990s (U.S. House of Representatives, 1991).15
Yet, clear evidence of the re-heating change are visible at a number levels -- in popular culture, in the appearance of a new or redefined array of alcohol-related "moral entrepreneurial" interest groups, and in alcohol science and policy.16 Though the proportions of drinkers and abstainers in the U.S. adult population (roughly a 2:1 ratio, respectively) -- have remained relatively stable over at least the past 50 years (see Room 1991:Table 10.1, p. 156), per capita alcohol consumption began a long, slow slide downward in the early 1980s -- after a rising trend that increased consumption by about 40% from 1962 to 1980. National survey data indicate that interpersonal friction over alcohol went up instead of down in this post-1980 era of downward-drifting consumption (Room et al., 1994) -- a finding suggesting that declining consumption may have co-occurred with an even greater relative tightening in drinking norms and associated informal social controls. Signs of a "new temperance" popular sensibility were palpable enough by the mid-1980s to be made the focus of cover stories or feature articles in Time, Newsweek, and Fortune as well as draw op-ed or news analysis articles in major newspapers -- e.g., in the Washington Post (Luks 1983), Wall Street Journal (Musto 1984; Heath 1985), Los Angeles Times(Keppel 1985), and New York Times (Goldberg 1987).17
The emergence of a new array alcohol-related problems and associated moral-entrepreneurial interest groups also signaled the re-heating shift18 -- as well as reflected something about the problem focuses, social roots, and value coordinates of the new sensibility. Fetal Alcohol Syndrome (FAS) -- the first in the series of new alcohol-related preoccupations -- was named in 1973 and came to wider public attention in a May 31, 1977 NBC Evening News broadcast with the introduction of "Melissa," a victim of the condition (Golden, 1996). MADD (Mothers Against Drunk Driving), RID (Remove Intoxicated Drivers), SADD (Students Against Drunk Driving) and others (see Marshall and Oleson 1994:55) launched grassroots campaigns against alcohol-impaired driving in the late 1970s and early 1980s. Though both FAS and MADD activists initially framed their public appeals in terms not uncongenial to the modern alcoholism movement -- i.e., stressing the need for more social control of the alcoholic mother-to-be and the alcoholic driver (see Golden, 1996, on FAS; Marshall and Oleson, 1994, on MADD) -- both endeavors' one-problem concentrations and get-tough dispositions were archetypal of the new sensibility.19 The Center for Science in the Public Interest (CSPI), an offshoot of Ralph Nader's consumer movement, attacked alcohol in the consumerist idiom -- promoting increased taxation, reduced alcohol advertising, and monitoring of the beverage industry -- and gave rise to Project SMART (Stop Marketing Alcohol on Radio and Television) and CCAA (Citizens Coalition on Alcohol Advertising) (Pittman 1991).
Even the National Council on Alcoholism (NCA) -- Mann's celebrated champion of the modern alcoholism movement in an earlier day -- redefined itself in preventionist terms over the 1980s, dropped industry representatives from its Board, and in 1990 renamed itself the National Council on Alcoholism and Drug Dependence (NCADD) in tune with alcohol's redefinition as "a drug" and the trend toward conflating alcohol, illicit drugs, and tobacco into a single "substance abuse," "chemical dependence," or "ATOD" (alcohol, tobacco, and other drugs) problem definition. Alcoholics Anonymous' thought also may have widened its salience into a more general asceticism in the American public's eye -- thus repositioning the pioneer fellowship with a recast sensibility for the era of the new public health approach. Tightening norms around the American definition of moderate drinking also indirectly marginalized AA's traditional focus on the farthest reaches of the deviant drinking spectrum.
New temperance enterprises also found support in a variety of institutional venues -- e.g., in philanthropic foundations (e.g., the Robert Wood Johnson Foundation, the Pew Charitable Trusts, the Kaiser Family Foundation, the Rockefeller Family Foundation, and the Buck Fund [which supports the California-based Marin Institute]) (Mosher & Jernigan 1989), in the "parent's movement" (Marcus 1989), in anti-drug advertising, and in a school-based prevention movement. Even an emergent "adult children of alcoholics movement," sparked by Janet Woitiz's (1983) bestseller (Rudy 1991:717), may be regarded as part of the wider ideological shift to the extent that its perspective tended to re-vilify the alcoholic -- at least as parent.20,21 Governmental and quasi- governmental agencies also played important and at times also problematic roles in the movement's diffusion (see Mosher and Jernigan's [1989:252-254] useful roster) -- sometimes testing the boundary between the protection of the public's health and political advocacy. Alcohol's increasing salience to the discipline of Public Health, the growing frequency of alcohol-related articles in the American Journal of Public Health, and new alcohol-related deliberations of public health policy groups also bear note (Mosher and Jernigan 1989:255). Not surprisingly, the emergence of anti-alcohol interest groups prompted the reinvigoration or creation of industry organizations aimed at countering alcohol-control measures and promoting their own approaches to prevention and research. These include the Distilled Spirits Council of the United States (DISCUS), the Beer Institute, the California Wine Institute, the American Vintners Association, Winegrape Growers of America, the Licenced Beverage Information Council, the Alcoholic Beverage Medical Research Foundation, the American Wine Alliance for Research and Education (AWARE), The Century Council, and the International Center for Alcohol Policy (see Marton, n.d.).
The appearance of new problem focuses -- notably, those aiming popular attention and opprobrium toward FAS, drunk driving, youthful drinking, and alcohol and violence -- redirected the nation's gaze away from the alcoholism movement's focus on the alcoholic. They also reshaped cultural perception of the alcohol-problems domain in subtle but important ways: (1) by redefining "the victim" in the alcohol-problems scenario -- moving the victim definition from the misunderstood and wrongly stigmatized alcoholic (i.e., the deviant drinker him- or herself) to the innocent casualty of someone else's drinking (the neonate with FAS, the child run over by a drunken driver, etc.) ; (2) by removing the necessity of an intermediating presence of alcoholism in the causal chain leading to the alcohol-problem -- meaning that drinking, per se, and not necessarily an alcoholic's drinking, might lie behind alcohol-related FAS, crash fatalities, and so on; and (3) by re-problematizing alcohol, per se -- thus granting new relevance to alcohol control measures as means for addressing such problems via public policy. At the symbolic level, the change was perhaps best reflected in the introduction of federally mandated warning labels in 1989 and the emergence of the problem-redefining slogan that "alcohol is a drug."
New scientific conceptualizations of alcohol problems also appeared on the scene -- most coming from alcohol epidemiologists. These came in a number of conceptual forms deriving from different disciplinary or empirical backgrounds and thus afforded a variety of conceptual options rather than a single, new paradigmatic monolith. Theory names such as the "disaggregation or alcohol- problems model," the "single-distribution model," the "agent-host-environment model," the "harm reduction model," and the "new public health approach" entered the alcohol policy discourse. Unlike the alcoholism model and focus that preceded them, however, these various designations were unlikely to be widely recognizable to the person on the street -- for one reason, because they reflected conceptual developments taking place in a relatively obscure scientific context and had no great campaigning agency (no Marty Mann or NCA) to carry their new message to the public -- though new volumes appeared from time to time which appeared to be aimed at a policy-making readership (e.g., Moore & Gerstein  and Edwards et al. ). The new conceptualizations focused policy attention once again on drinking, per se, and by extension on aggregate or per capita alcohol consumption. The change also expanded the orbit of new alcohol-related policy options -- which now stretched beyond the expansion of alcoholism treatment and newly encompassed for example: increased taxation, warning labels, reduced numbers of outlets, hours of sale, advertising restriction, counter-advertising, and server liability (for a fuller elaboration, see Walsh 1990; Mosher & Jernigan 1989).
Interestingly, the conceptual odyssey that took alcohol science from the "A" of an indifference alcohol control policy to the "B" of a keen interest therein appears to have traveled across roughly four steps. Consider, for example, the paradigmatic salience of a control measure such as increased taxation: According to the alcoholism paradigm, taxation was a useless and even unjust exercise because its impact would be felt only on nonalcoholic drinkers -- the ones who were not causing the alcohol-related problems. The very idea of alcoholism implied someone with a taste for alcohol that was unlikely to be tamed by mere tax increases. Other sorts of alcohol control policies were rendered similarly ineffectual by the alcoholism paradigm. Next came renewed attention to Ledermann's (1956), single-distribution model -- with its intriguing implication that the rigid J-like or lognormal shape of the distribution of consumption in human populations implied that downward shifts in mean consumption should also result in significant declines in the population's proportion of heavy drinkers. At this evolutionary stage -- roughly where the argument lay when Bruun et al. (1975) was published -- tax measures could be reintroduced into the orbit of legitimate alcohol policy options. Notice, however, that the policy's focus remained, as in the alcoholism model, on the heaviest alcohol consumers.
Next into the theoretical picture came the disaggregationist model, based on new survey studies of the distribution of drinking problems in general populations. Survey studies reported that alcohol-problems indicators did not comport well with the alcoholism paradigm. Instead of finding a few "alcoholics" who accounted for all the problems in the sample and left everybody else more or less problem-free, the survey data showed that lower level problem scores were commonplace; indeed they were so common that reported problems among less-than-the-heaviest drinkers actually outnumbered those of candidates for the alcoholism label. This finding became known as the "prevention paradox" (Kreitman, 1986) -- because it suggested that rational prevention policy might actually aim its controlling efforts at the population layer that did not drink the most but nevertheless amassed the greatest aggregate number of alcohol problems. This implication was buttressed along the way by evidence that even the most serious alcohol-related tragedies (e.g., traffic fatalities) more often occurred among nonalcoholic than alcoholic drinkers. Notice that the rationale and focus for alcohol control policies has by now moved away from both the alcoholism model's and even the Ledermann (1956) model's concern with the heavy end of the drinking spectrum and has settled instead on drinkers in a middle range.
The final step in the progression came with the growing salience of dose-response curves -- i.e., statistical profiles showing that increasing alcohol intake was associated with increasing levels of risk for one or another sort of alcohol-related problem. Curves with relatively steep slopes at low levels of alcohol intake suggested that drinking, if indulged in at all, should be kept to an absolute minimum. This was roughly where the argument had arrived with the publication of Edwards et al. (1994). The policy-span traversed in this evolution is remarkable -- taking public health conceptualization from virtual indifference to popular consumption levels to a paramount concern. From the risk-factor vantage point, any alcohol whatsoever poured into the flow of national consumption represented a step upward along one or another risk curve for some drinker somewhere. Only the nettlesome existence of epidemiological evidence of moderate drinking's favorable mortality effects (see Nestle 1996) has kept alcohol's transit from covering the full symbolic distance from benign "social condiment" (as Haggard and Jellinek  described it) to a toxic substance.
Why Transition from Alcoholism back to Alcohol?
How should we account for the transition, or would-be transition, from the de-politicizing period of the modern alcoholism movement (1935-1975) to the re-politicized period of the new public health approach (1975-)? Interpretive possibilities abound. We might view the emergence of the new public health perspective as a kind of long-overdue shucking-off of the early alcohol science's diversionary and self-promotion-based preoccupation with alcoholism -- in other words, as a belated expression of alcohol science's intellectual and institutional maturity and independence.22Then again, it might be more accurate to characterize the shift as a sign of the new maturity and independence for alcohol epidemiology, in particular, and a telling measure of alcohol epi's differentiation from the rest of alcohol science via the development of its own distinctive theoretical perspectives and, perhaps, the emergence of an international scientific community of alcohol epidemiologists as facilitated by the Kettil Bruun Society.23
Then again, one might fashion recent changes into a scenario in which the alcoholism paradigm is deeply imperiled and on its way out in alcohol science as a whole -- no longer fitted along a variety of dimensions to the nation's more problematized view of alcohol. And yet, it is also possible to read the same changes as suggesting that the alcoholism paradigm simply at some point accomplished its long-term purposes -- persuading the public that alcoholism was an illness and building a substantial treatment and research establishment embodying those commitments -- and thus obliged alcohol activists to move onward, and outward, into the prevention of a wider orbit of alcohol-rated problems. In this sense, the emergence of the public health paradigm may be regarded as an extension (rather than replacement) of the alcoholism paradigm's action agenda. Finally, it might even be suggested that the public health approach's return to (a) a focus on alcohol, per se, and (b) the promotion of political and popular responses reminiscent of a dry sensibility suggest the expiration or retreat from the post-Repeal dream that modern science would somehow find esoteric and powerful conceptual and policy tools for minimizing the nation's alcohol problems -- both in terms of the societal burdens and the wasted and divisive political energy such problems formerly attracted.
The unlikely story of the modern alcoholism movement's origins, with its strongly social-constructionist character and flimsy science base, invites our attentions to the relationship between alcohol science and the wider society. The alcoholism movement's story appears to have been framed in externalist social coordinates: notably, in the search for a de-politicized definition of the nation's alcohol problem, in the felt need to establish moderationist drinking norms (which the disease concept indirectly supplied by defining excessive drinking), and in the desire to test modern science's promise in addressing social problems. This social-constructionist account of the emergence and rise to hegemony of the modern alcoholism movement should probably in turn focus our attention on changes in the external social environment that may have occasioned the alcoholism movement's loss of influence and the rise of the new public health approach. The behind-the-scene's significance of the modern alcoholism movement's search for funding also quite naturally invites us to ask if and how the same needs may have remained one of the guiding forces in the emergence of the new public health approach. Room (1978), for instance, characterized the impact of increasing governmental involvement in the alcohol social arena as a problem-widening force:
At a deeper and more speculative level, research and policy attentions focused on per capita consumption may have had the symbolic subtext of proffering a subtle moral claim on a share of governmental revenues from alcohol sales, which revenues are of course geared to actual consumption. On the other hand -- and in light of the alcoholism movement's money-strapped, Depression-era origins -- it is also possible to view the new public health approach as in effect a liberation from the money-trail preoccupations of its paradigmatic predecessor. Perhaps time (and a future generation of alcohol historians!) will tell. The alcoholism-to-public-health shift roughly coincided with the commencement of the Reagan years and, as Wagner (1997) has argued, may best be regarded as part of the era's general cultural retrenchment. More recent public interest in the substance abuse problem domain also undoubtedly partly derived from the Soviet Union's collapse and the "cold war's" demise -- thus allowing for more national attention to be lavished on domestic issues.
As the [alcoholism] movement increasingly became a pressure group for greater governmental effort and funding for alcohol-specific programs, a strong interest developed in underlining alcohol's role in the broadest possible range of problems -- particularly those in the forefront of public attention, which concomitantly often carry considerable stigma. To emphasize alcohol's role in a broad range of problems is seen as the primary mechanism for raising alcohol's position on the societal agenda, and also creates a larger negative balance in arguments for the cost-effectiveness of alcohol...[programs]. (Room, 1978, p. 195)
The particular set of alcohol-related problem focuses that emerged over the 1970s and early 1980s also harbored important clues to the alcoholism-to-public health shift's social sources. MADD's angry acronym, for example, hints that the alcoholism paradigm may have failed to provide adequate social voice to the victims of alcohol-related harm and for the symbolic expression of their opprobrium or desire for vengeance.24 Similarly, the emergence of public concern over youthful or underage drinking harbors hints at another kind of cultural failure re the alcoholism paradigm. Though the disease concept engendered an enormous growth in the American formal social control system for alcoholic drinking, it tended to domesticate or normalize all non-alcoholic drinking (Levine ; Beauchamp ). This feature ill-equipped the alcoholism paradigm re the crucially important symbolic task of providing adequate symbolic foundation for our longstanding proscription of youthful drinking. An alcoholism-paradigm-based school pedagogy (which finally became fully articulated and available in McCarthy and Douglass's Alcohol and Social Responsibility ) never fully fit that symbolic desideratum. Indeed, the alcoholism paradigm -- with its "alcoholism can strike anyone," democratic ethos -- also offered few cultural supports for the maintainence of traditional status-based differentiations in drinking norms. David Pittman (1991) has shrewdly observed that the new temperance movement's targeting of drinking by youth, by pregnant women, by women in general, and by ethnic minorities in effect re-establishes a traditional hierarchy of status privilege re access to alcohol -- i.e., by omission placing the white, middle-class male at the top of the status-access heap.
Ironically, the disappearance of drys from meaningful influence in the alcohol social arena also played a crucial part in the alcoholism-to-public-health transition. At least part of the alcoholism paradigm's rhetorical appeal lay in its capacity to steal the alcohol issue from the clutches of drys and their alcohol-focused temperance paradigm. One cannot read the literature of the early alcoholism movement without being struck over and over again by the persistent references to the fact that the new movement was neither dry nor wet, took no political stand on alcohol, etc. -- and, in fact, that the new scientific approach was under siege by the old voices in the alcohol social arena (see, e.g., Haggard, 1945). In this way, drys offered a valuable focus and counterpoint for the new alcoholism movement -- allowing the new movement to define itself at least as much around what it was not as around what it was. Social movements benefit greatly by defining disfavored enemies, and the drys in particular fit this bill perfectly for the emergent alcoholism movement. But drys in due course disappeared from meaningful participation in the alcohol social arena -- depriving the movement of a valued adversary and, ironically, thus also providing occasion for the reintroduction of a new dry sensibility.
This background change in the alcoholism movement's rhetorical environment had a number of important consequences. For one, it loosed the rhetorical brake that the alcoholism movement had imposed on itself in order that its problem claims not sound too alarmist, too problem-emphasizing, or, in a word, too dry. With drys gone from the scene, however, the alcoholism paradigm could enjoy a new freedom in expanding the borders of problem definition it proffered. David Robinson (1972) insightfully characterized this new expansionism as an alcoholism movement that had "lost control" over its own ideology in the early 1970s. Room (1978) saw quite clearly how the expanding perimeter of the problem domain claimed by the alcoholism movement also thinned the salience of the movement's paradigm, thus also inviting competing "post-addiction" models (as Harry Levine  termed it) of a widening span of alcohol-related problems. Of course, a drying trend in popular sentiment might take a welcoming disposition to this newly re-heated alcohol-problems rhetoric. Moreover (and as Room  noted above), the emergence of NIAAA in the early 1970s shifted the pay-off matrix strongly in favor of problem amplification -- as NIAAA itself required as wide a problem domain as possible to justify its own budget and existence in the context of a great many other social problems competing for Congress's largesse.
Alcohol's shifting moral valence can have far-reaching consequences on problem-definition, scientific conceptualization, and public policy. To take just a single example of this sort of connection in moral architecture, consider the link between alcohol's perceived moral valence and alcoholism treatment's perceived appropriateness as public policy. Alcohol, in the early-post-Repeal era, was widely touted as a benign commodity, both in the popular (see, e.g., Wickware 1946)25and research literatures (see Katcher 1993). The alcoholism paradigm lent support to this moral coloration for alcohol by emphasizing that only the unfortunate few (i.e., the alcoholics) would get in trouble because of their drinking. These few, however, could thereupon lodge credible demands for benevolent handling (i.e., treatment) from society, given that the prevailing cultural definition of alcohol (i.e., as benign) had invited and justified their drinking in the first place. On the other hand, in a society where alcohol's moral valence grows darker -- in other words, where "prevention" messages increasingly warn the drinker of a variety of untoward or dangerous consequences of drinking -- the moral foundations for the provision of treatment are commensurately undercut. That which society warns one against, is that which society also bears less responsibility to treat benevolently when citizens ignore the warning (Roizen, 1993b). (It is interesting in this connection to see recent efforts to redefine the societal case for the provision of alcoholism treatment in terms of minimizing alcoholism's social harm [i.e., the harm alcoholics cause others] instead of helping the alcoholic [see McLellan et al. 1995]).
The old rhetorical themes of the modern alcoholism movement have undoubtedly lost a measure of their resonance in new sociocultural environment. Heroic allusions to the all-conquering potentials of modern science and scientific method undoubtedly gained a hollower ring as promises of new scientific understanding -- perhaps too often packaged in a "just around the corner" timescape -- repeatedly proved overly optimistic. Any scientific enterprise -- and especially science addressed to a social problem -- lacking a core of powerful and esoteric theorywill be specially susceptible to exogenous influences. Clearly, the alcohol problems arena has shifted cultural ground in recent years -- to cultural preoccupations with health-and-fitness, consumerism, the anti-drug and anti-tobacco enthusiasms, social order, and even, perhaps (as Pittman  noted), the partial retrenchment of traditional status relationships. What was once a great call for the genius of modern science to shed a problem-fixing enlightment and esoteric technological fix on America's alcohol problem has more recently seen alcohol shift to a life-style issue.
The new public health paradigm emerged from a number of credible scientific critiques of the alcoholism paradigm. There is a lively tradition of epidemiological thought and research behind the new paradigmatic contender -- ranging from Ledermann's (1956) daring single-distributionist generalization, to Skog's (1991) hypotheses about how the herd-like implications of Ledermann's model might be understood at the level of group and individual drinking behavior, to Cahalan and Room's (1974) survey-based effort to reinterpret problems that were once subsumed under the alcoholism label into a series of more discrete problem phenomena. The presence of this record of research enterprise gives the new public health paradigm a scientific "past" that the alcoholism paradigm in effect lacked in the 1930s and 1940s (putting aside a nascent psychiatric tradition of speculation on alcoholism). But even good scientific credentials do not, of course, obviate a connection between the scientific and the popular realms in the alcohol-problems domain. Perhaps a Darwinian image of that relation is best -- namely, a view of alcohol science that sees it as providing society with an array of paradigmatic choices (and their associated symbolic subtexts) from which to select the emphases that best suit current concerns and trends. Such a perspective may help us understand how alcohol scientists can quite accurately see themselves as following out the dictates of a perfectly scientific, internally driven research course while an externalist perspective on that same science offers ample suggestion of social construction.
Forward into the Past?
The Sixty-Four-Dollar Historical Question in all this is of course: Should we regard the current drift away from the de-politicizing alcoholism paradigm and toward the new, re-politicizing public health approach as historical progress or retrogression? In other words, does the new paradigmatic direction truly offer a better understanding and truer grasp of something called our "alcohol problems" -- at last cutting through the alcoholism paradigm's limits -- or are we kidding ourselves and the new public health approach instead is simply providing an apt scientific vehicle for a new dry-direction swing of the same old American historical pendulum, the one that that Fosdick and Scott (1933) and the early RCPA (Reports, 1938) warned us about? Does the public health approach really embody better science, or does it instead reflect a different value orientation to alcohol -- one, say, more in tune with the times?
Remarkably, the alcohol problems domain has by and large retained its cultural integrity over the years since Repeal: the alcoholism movement's designation of alcoholism as a disease did not result in alcoholism (much less alcohol-problems) becoming melded into the nation's mainstream or general health and mental health institutional systems; similarly, a more recent designation of alcohol as a drug has not (yet, at least) resulted in alcohol becoming fully subsumed within a new "substance abuse" problem definition. Alcohol problems have for the most part remained a recognizably separate department of life and society in the full post-Repeal era. Jack Blocker (1989) has suggested that the post-Repeal era reflects another (the fifth, to be more precise) revolution of an ongoing saga in which temperance cycles move from benevolent to coercive dispositions before they restart.
We might also profitably characterize the story alcohol's post-Repeal American experience as an exercise in historical forgetting in the nation's alcohol problems social arena. That first generation of post-Repeal analysts I spoke of at the beginning of this paper set their sights on understanding and, ultimately, reducing the amplitude of the historical arc of the nation's dry-wet-dry pendulum swings. Two successive generations of alcohol imagery -- the modern alcoholism movement and the new public health approach -- have in effect displaced and downgraded that historical problem with their own particular problem focuses. To the extent that new-public-health advocates increasingly concentrate their analytical attentions once again on alcohol, per se, their conceptual viewfinder returns the nation's attention to the very topic and problem-source claim that both post-Repeal de-politicizers and the alcoholism movement sought to displace and retire. If the new public health trend continues -- with its risk-factor sensibility setting the empirical, analytical, and policy-related agenda -- we as a nation will have less and less reason to expect a wider historical sensibility to emerge from the cultural elites to whom we entrust our best informed thought on the matter. Not knowing whether what we're seeing of late in alcohol science, in alcohol-related interest groups, and in popular sentiment is progress or retrogression is partly a byproduct of losing touch with the important place of the historical dynamic in our studies of this very American terrain. As the focus returns to alcohol,per se, our scientific elite and interest groups tacitly invite us to a vision in which history and society represent little more than the battle ground for a war between preventionist and industry perspectives on alcohol use. If that sounds familiar, well...
1 For the great Repeal debate, see especially Kyvig (1979), Jones (1960), and Merz (1930).
2 Compare Burnham's (1968) trenchant critique of the notion of national prohibition as a "failed experiment."
3 Recall, however, that World War I actually energized the dry campaign for the 18th Amendment. (See Jay L. Rubin's  superb study of the differences between WWII and WWI re alcohol in America.)
4 Later better known as the National Council on Alcoholism (NCA), and, since 1990, named the National Council on Alcoholism and Drug Dependence (NCADD).
5 AA has generated an immense historical literature, much of it by grateful members (see Bishop & Pittman 1995). The definitive history remains Ernest Kurtz's Not-God (1979).
6 The literature on the history of post-Repeal alcohol science is very thin -- comprising two dissertations (Room  and Roizen [1991a]), Carolyn Wiener's monograph (1981), and a variety of reminiscences by long-time Journal of Studies on Alcohol editor, Mark Keller (e.g., 1975, 1979, & 1991). Bruce Holly Johnson's (1973) dissertation remains the starting place for historical examination of the combined AA-and-science movement.
7a The search for a neutralist idiom for the post-Repeal handling of alcohol-related problems and alcohol's symbolic relegitimation began even before Repeal itself, with the "dilutionist" and "carbon monoxide" metaphor offered to Congress by Yale physiologist Yandell Henderson (see Pauly's  wonderful account).
7b Appendix A presents a visual represention of the "vicious circle" of dry-to-wet-to-dry historical cycling as offered in a draft Research Council on Problems of Alcohol brochure ("A Major Public Health Problem Not Being Systematically Attacked: The Misuse of Alcohol," n.d. [1938?]). The brochure's special notice in the canted-box on the brochure's title page reveals how eagerly the group sought to distinguish itself from dry and wet interests and as well how much it stressed its own objectivity and disinterestedness vis-a-vis alcohol research.
8 See Keller's (1972) commentary on this curious "capitulation" of alcoholism's treatment to AA (also, Room 1978:138-139).
9 Lynn M. Appleton (1995) has recently offered a welcome and on-target critical review of the tendency among American sociologists (as in Conrad and Schneider's Deviance and Medicalization ) to regard the modern alcoholism movement's disease campaign as a paradigmatic case of medicalization; "folk medicalization," argues Appleton, offers a better characterization of the actual social history. My sense is that the disease-alcoholism case requires that the issue "medicalization" be distinguished from that of "scientific ownership" and the growth of research. For the de-politicizing aspects of disease designations, see Gusfield (1967) -- recently made conviently available in Gusfield's (1996) new book.
10 Interestingly, Miller & Kurtz (1994) have recently pointed out that the most familiar and standard form of the disease concept (as available, for instance, in Ketchum and Morris ) was neither borrowed from nor central to AA thought. Kurtz (1979:212ff) noted that AA co-founder William Wilson, harbored serious reservations about the disease idea. Jack Alexander's AA article appeared in the Saturday Evening Post's 1 March 1941 issue.
11 I thank Caroline Acker for pointing out this very useful paper.
12 Incidentally, one of the reasons Mann's (1950) book on alcoholism addressed its narrative primarily to the families of alcoholics. A "Q&A" format article, titled "How can I help an alcoholic?" (1954) -- and undoubtedly authored by Mann herself -- describes the NCA in just these terms. The response to a question about the differences between AA and NCA reads in part: "The National Committee on Alcoholism, on the other hand, is a voluntary health agency, like the TB Association, the American Cancer Society, the American Heart Association. Its Board members are professional and lay citizens, mostly non-alcoholic" ("How," 1954, n.p.).
13 Fingarette (1988) brought this nether-side of science's relationship to the disease concept to a wider public audience.
14 If I may add a personal observation at this point: In retrospect, these various happenings certainly both undercut the reigning alcoholism paradigm and laid important foundations for the emergent competitor paradigm, the "new public health approach" (NPHA). Nevertheless, if you had asked me in 1975 -- or, for that matter, in 1980 or even in 1985 -- whether they represented serious challenges to either public perceptions or interest-group conceptualization of alcohol problems, I would have most assuredly said "no." The public health perspective was -- as far as I knew, at least -- a little known challenger deriving from a little known research specialty (survey research, redubbed "alcohol epidemiology" in part to improve its appearance in a field dominated by a medical or quasi-medical sensibility) whose main purpose was to waffle on answering the important question it was sent forth to answer: how many alcoholics were there? I recently asked my good friend and colleague, Robin Room, whether he had the feeling when Bruun et al. (1975) was being published that a shift in alcohol's popular paradigm was underway; he said "yes." This means I (who did not travel much or discourse with the alcohol research elite) and Robin (who did) might be separated by as much as 15 years (1975-1990) in our estimate of when the NPHA began to exert a meaningful influence on policy and popular thought and practice.
15 I thank Lynn Appleton (personal communication) for pointing out this reference and providing a useful synopsis of proprietary alcoholism treatment's troubled condition by the early 1990s.
16 Alcohol and temperance historians have themselves been going through a revisionist transformation in recent years -- sparked by John C. Burnham's (1968) seminal paper and carried forward in the work of Clark (1976) and Blocker (1989).
17 Time article appears in its May 20, 1985; Newsweek article, December 31, 1984 issue; Fortune article, March 18, 1985 issue (Sherman, S.P., "America's New Abstinence," n.p.a.). See Room (1991:149 et seq.) for more coverage of shifts in popular culture. Sociologist David Wagner's (1997) insightful monograph, The New Temperance: The American Obsession with Sin and Vice, locates changing sentiment toward alcohol within a broader new asceticism comprehending illicit drugs, sexuality, smoking, and fitness.
18 Walsh (1990:59-60) notes the remarkable frequency of such changing interest-group ownership of the alcohol problem in our U.S. historical experience.
19 Marshall and Oleson (1994) examined the internal evolution of MADD from an alcoholism to a NPHA focus. Musto (1984) early on placed the new anti-drunk-driving initiative at the heart of the new temperance shift. His Wall Street Journal discussion began: "For the second time in this century, a serious, effective and popular temperance movement is gathering force in this country. However, it is not a campaign for prohibition but for realistic efforts to curb the harmful effects of alcohol, especially the damage wrought by drunk drivers" (n.p.a.). Interestingly, the new grassroots movement was not sparked by increased in the nation's traffic crash fatality rate. In fact, this rate (per 100 million vehicle miles driven) has fallen steadily and substantially over the entire post-WWII era, and enjoyed a particularly sharp decline in the 1970s (see Graham, 1993:515-516), i.e., in the decade just before MADD et al. came on the scene. According to Graham's (1993:516) five-year averages (as offered in his "Table 1"), the U.S. traffic fatality rate (per 100 million miles of travel) fell by 20.62% from 1965-69 (during which period, the rate was 5.47) to 1970-74 (4.34) and by another 21.57% from 1970-74 to 1975-1979 (3.40). The rate of decline slowed in the 1980s: from 11.47% from 1975-79 to 1980-84 (3.01) and 11.87% from 1980-84 to 1985-89 (2.47).
20 Rudy (1991:717) cites a Newsweek cover story (January 18, 1988) on the adult children of alcoholics movement, the associated illustration offered "a shattered family portrait with a spilled booze bottle and the caption 'Growing Up with Alcoholic Parents Can Leave Scars for Life.'"
21 Notable for their absence from the list of active players are the Woman's Christian Temperance Union (WCTU) and the Anti-Saloon League, though occasional newspaper reports note an approving disposition toward the new temperance by group representatives (e.g., "Temperance," 1985).
22 Such a view might draw a relatively straight developmental line from Haggard and Jellinek's (1942) articulation of an "alcohol problems" paradigm, through the reassertion of that scientific perspective in the Cooperative Commission report published the mid-1960s (Plaut, 1967), to the recent ascendancy of the the new public health approach. It is interesting in this connection, however, that the original formulation of an "alcohol problems" perspective at Yale was intended to take attention away from a preoccupation with alcohol, per se -- which preoccupation was viewed as a dry fixation. The plural form, "alcohol problems," was deliberately intended as marking a sharp divide from the dry focus on "the alcohol problem," a singular form and focus on alcohol (see Roizen, 1993a). Indeed, a striking historical puzzle and clue may be said to reside in the fact that current advocates of the new disaggregationist, public health approach wish to restore alcohol, per se, to causal significance in "alcohol-related problems" whereas the early formulators of the "alcohol problems perspective" at Yale had quite the opposite goal in mind -- namely, distancing alcohol problems from alcohol, per se!
23 The Kettil Bruun Society for Social and Epidemiological Research on Alcohol -- named for the Finnish sociologist, Kettil Bruun (1924-1985), who pioneered many areas of alcohol social research -- serves several purposes in the international alcohol epidemiological community, including sponsoring an annual meeting.
24 For an analysis of MADD's emotional topography, see Marshall and Oleson (1996).
25 Wickware (1946:68), in Life, for example wrote: "Of the estimated 50,000,000 drinkers in the U.S., all but a fraction use alcohol moderately and more or less regularly because it makes them feel better and more appreciative of themselves and their fellows. It also gives them better appetites, since it is an excellent condiment. Taken for purposes of social relaxation or as a gustatory adjunct, alcohol never has damaged anyone. Even when taken in fairly large amounts over a long period of time, the purely physical effects of alcohol by itself are almost negligible."
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APPENDIX A: VICIOUS CIRCLE PAGE & TITLE PAGE OF A RESEARCH COUNCIL ON PROBLEMS OF ALCOHOL DRAFT BROCHURE [1938?]