The process of launching a diagnosis in order to launch its cure...has a name--disease mongering--bestowed by the same media that monger the diseases. It is a predictable, if perverse, outcome of a health-care system that bestows enormous rewards on drug makers, doctors, hospitals, and universities, but only for treating specific diseases. Disease mongering is...the bastard offspring of the marriage between science and the free market, which we trust to be almost as neutral as science in its determinations. Science names our maladies as diseases, and the free market provides the cures. Some of our most venerable diseases are the handiwork of public relations experts.
Before the Quarterly Journal of Studies on Alcohol ran his article “Alcohol and Public Opinion,” Dwight Anderson had never written for a scientific journal. He was a marketing man, the chairman of the board of the National Association of Publicity Directors. Unlikely as it seems, however, Anderson’s article played a seminal role in creating the disease we now call substance dependence. It was 1942, Prohibition was less than a decade gone, and doctors everywhere were dismayed by the failure of their profession to find effective treatments for what at the time was still called inebriety. They were even more dismayed at their difficulty in attracting public attention to the need for medical research into the problem…. Some of these doctors formed the Reasearch Council on Problems of Alcohol to figure out how to get recognition as the go-to guys for alcohol problems, and they turned to Anderson for some advice. A recovered alcoholic, he rendered a quick diagnosis: the doctors had failed to make sufficient hay of the idea that chronic drunkenness was actually a physical disease. In his article, Anderson laid out the case for the diagnosis:
"What are the ideas of the least common denominator concerning alcohol which can be most easily established…? The first is that the 'alcoholic’ is a sick man who is exceptionally reactive to alcohol…. Sickness implies the possibility of treatment. It also implies that, to some extent at least, the individual is not responsible for his condition. It further implies that it is worthwhile to try to help the sick one. Lastly, it follows from all this that the problem is a responsibility of the medical profession, of the constituted health authorities, and of the public in general…. When these ideas have been fully accepted by a large number of people...the 'yes response becomes automatic, uncritical, and on the emotional level...and only by this means can the required approvals be gained for changing existing situations, for the creation of new institutions, for the formation of groups to DO THINGS without which science remains inter."
Anderson proposed using the principles of modern marketing to solve the problem of chronic drunkenness: convince consumers that their suffering is related to a deficiency that only the client’s product can relieve. To judge from the subsequent success of the disease model of alcoholism, this was brilliant advice.
Anderson was hired to write his article by Elwin Morton Jellinek, a statistician who was preparing a monograph for the research council that it hoped would demonstrate the grave threat that inebriety posed to the public health. It’s not surprising that Jellinek turned to someone who had never before written a scientific treatise. His own life had prepared him to understand the limits of facts, to know when invention was necessary. Born in New York and raised in Budapest…, Jellinek was nearly fifty years old when he joined the nascent Research Council in 1939, and his only experience with alcohol to that point was whatever drinking he had done (and never said how much that was and tending to friends during their binges. He did have some academic experience--studies at Leipzig and Grenoble--and spoke or read twelve languages, but [did not hold] the master’s and doctoral degrees that he claimed Leipzig had awarded him, he never fully explained why he had disappeared from Budapest (where, according to his daughter, he did something related to foreign currency) and surfaced in Sierra Leone as business man with the name Nikita Hartmann, and he couldn’t quite account for his sudden move from there to Honduras or how he convince United Fruit that he could research plant biology for them. But when he left Central America, he landed a job--perhaps on the strength of his doctorate from the University of Tegucigalpa, which he had added to his resume and which also turned out to be bogues--at Worcester State Hospital as a statistician and an editor of a professional journal. When he went to work for the Research Council, it was explicitly for his editing skills, but it was his capacity to navigate the political and social landscape of drinking that ultimately served the organization (and Jellinek) best.
Six years after Prohibition was repealed, the tortured politics of wet and dry were still making coherent social policies about alcohol nearly impossible. Americans could not agree on just what kind of a problem inebriety was, and they never had…. Benjamin Rush--a signer of the Declaration of Independence, a doctor to the Continental Army, and a proponent of a constitutional guarantee of the right of medical freedom (lest health care become the entitlement of the rich)--announced in 1810 that “habitual drunkenness should be regarded not as a bad habit but as a disease...a palsy of the will….” Rush believed that abstinence was the best thing [because he thought] the problem was not spiritual but physical, not moral but medical, not a matter of right and wrong but of sickness. Alcohol, he argued, infected the soul, incapacitating the free will that all men in good health naturally possessed…. “Palsy of the will...” was in the body that was now the province of the doctors…[and] a public health problem...so grave, Rush thought, the the pathogen should be immediately banished. A century later, temperance groups, which claimed Rush as their founder, succeeded in fulfilling his dream of Prohibition.
The spectacular failure of Prohibition...forced mandatory abstinence into disrepute. The doctors at the Research Council, however, believed that abstinence was the only answer for the inebriate, and since 1935, they had at least two allies. Bill Wilson and Bob Smith…, [the founders of AA].
AA started small…, but Wilson and Smith had larger ambitions. They also face major obstacles to getting out the word that their was hope for chronic drunks. Not only did they favor abstinence, but they were an offshoot of the Oxford Group, an evangelical Protestant Organization (which eventually changed its name to Moral Re-Armament) that advocated “Four Absolutes: honesty, purity, selflessness and unbounded love. Its confessional prayer groups were the model for the AA meeting…, [a]n ascetic Christianity that favored abstinence. But then [they got an important break] when they met Sally Mann, a journalist who claimed to be the first woman who achieved sobriety through AA and who made it her life’s work to spread the AA gospel, met...Jellinek.
By then, Jellinek’s work at the Research Council had earned him the ultimate ticket to respectability: an appointment to Yale, where he joined the staff of the Laboratory of Applied Physiology in 1941 and became the managing editor of Quarterly Journal of Studies on Alcohol, two institutions that led the way in research and treatment of the new disease. And Mann was ready to spread the word about just what kind of disease inebriety was. It was all spelled out in chapter of Alcoholics Anonymous: “A Doctor’s Opinion,” written by William Silkworth, the physician who ran the upper-crust drunk take where Wilson had detoxed. In it, Silkworth brought Rush’s ideas into the twentieth century, opining the ineebriety was alcoholism, a word the doctors had previously used used to refer to the effects of chronic drunkenness, and drunkards were alcoholics, who had an “allergy” to alcohol and thus “cannot use liquor at all, for physiological reasons.” The fault, Silkworth said, was not in the bottle but in ourselves, at least in those selves unlucky enough to inhabit sick bodies. Alcoholism is the cause, rather than the effect, of inebriety, something over which the will had no control because it originated elsewhere; chronic drinking was the outcome of a “law of nature operating inexorably.” Alcoholism, in other words, was a disease in the most modern sense of the word, and modern man--that is to say rational man--will “accept the situation...and shape his policy accordingly” by abstaining from alcohol. And a rational society, Silkworth thought, will put alcoholics in the hand of the men with stethoscopes and give doctors the resources to find the best way to help patients achieve sobriety.
Silkworth’s disease and Mann’s tireless advocacy of it were exactly what the Research Council had ordered--a way to avoid the wet-dry culture war while still getting the message out about chronic drunkenness. By taking alcoholism entirely out of the moral realm and into the medical, the allergy model at a single stroke offered reassurance to all interest parties: alcoholics would get treatment in place of moral condemnation, drys could maintain that there was still something wrong with drinking (albeit only for some people), wets could argue that there was a place for alcohol in American life, clergy could still exhort (some) people toward (physician-assisted) abstinence and open their church basements to AA groups, and the newly reinvigorated brewing and distilling industries, which were pleased to help fund the the Research Councils research, could claim that science proved that alcohol didn’t kill people; alcoholism did.
Jellinek’s section of the laboratory eventually became Yale Center for Studies of Alcohol, which in turn started the Yale Summer School. In 1944, Jellinek helped Mann to start the National Education on Alcoholism in order to inform America of “two momentous discoveries”:
"FIRST, that alcoholism is a sickness, not a moral delinquency. SECOND, that when this is properly recognized the hitherto hopeless alcoholic can be completely rehabilitated."
Jellinek threw his Ivy League weight behind these ideas, Mann campaigned tirelessly on their behalf, and AA gathered members in their wake. By 1949, twelve state were sponsoring alcohol treatment programs, all of them run by graduates of Jellinek’s Yale Summer School and operating on the belief that alcoholism was a chronic disease for which AA attendance and lifelong abstinence were the treatment. Many more programs would follow. The “yes” response, as Anderson had predicted, was becoming automatic.
BUT THERE WAS ONE CATCH. The disease model may have been brilliant public relations, but it was not very good science... In what sense is alcoholism a disease? What exactly is wrong with people who can't control their drinking (other than the fact that they can't control their drinking)? What is the mechanism of this "allergy"? Jellineck struggled with these questions and found himself up against the triumphs of modern medicine. Smallpox, syphilis, diabetes: these and other signal discoveries had raised the bar for establishing a valid diagnosis. In each case, a single pathology--a virus, a spirochete, a malfunctioning pancreas--proved to be the underlying cause of illness and led to a cure: inoculation, antibiotics, insulin injections. To call something a disease was to imply that something physical would be discerned with a stethoscope or its modern equivalent and found responsible. But proponents of the allergy model abandoned it in 1952, and the pioneer neuroscientists of that decade failed to find the kind of biochemical indicators for alcoholism they the were finding for depression and schizophrenia. Nor did endocrinological or nutritional or cellular studies discern the kind of differences between alcoholics and the rest of the population that could definitively be called causes, rather than effects, of drinking. The disease model was turning out to good to be true.
By 1960, Jellinek had to acknowledge the difficulty when he spelled out his theory in The Disease Concept of Alcoholism. He defended the flaws in the concept by arguing that it was a mistake to insist on finding an underlying pathology before accepting that a particular condition was a disease. “The fact that doctors are not able to explain the nature of a condition does not constitute proof that it is not an illness,” he wrote. “There are many instances in the history of medicine of diseases whose nature was unknown for many years.” Absence of evidence, Jellinek claimed, was not evidence of absence, and not because future findings might finally turn up the pathogen, but because disease itself wasn’t really something in nature after all. “It comes to this,” he announced in italics, “a disease is what the medical profession recognizes as such.” It seemed that the physician’s authority to say which forms of suffering were diseases could be cut free from the science that justified it….
In 1965, the American Psychiatric Association voted to admit alcoholism to its nomenclature, and a year later, the American Medical Association followed suit. The National Institute on Alcohol Abuse and Alcoholism was founded in 1970. By 1973, all fifty states had programs to treat alcoholism, as did most hospitals, and insurance companies paid for inpatient treatment, nearly all of which was based on the allergy-abstinence model. Research dollars flowed, as scientists increasingly focused on what they saw as the disease mechanism that was central not only to alcoholism but to other drug problems, and eventually to behaviors like gambling and sex: addiction, the disabling of the will. And American increasingly came to see their compulsions, their difficulties in moderating no only their drug consumption but their eating, gambling, shopping, having sex, working--indeed nearly any activity--as symptoms of this new illness.
But while scientists have unveiled some of the genetic and neurochemical correlates of addiction and developed some drugs that help to block cravings and other withdrawal symptoms, no one has yet discovered the pathogen, the “law of nature operating inexorably,” that Silkworth thought lay behind addiction. Alcoholism, addiction, substance dependence--these terms perhaps sound more scientific than “inebriety” or “palsy of the will,” and present-day doctors can talk knowledgeably about dopamine metabolism and other mechanisms that Benjamin Rush may only have dreamed of, but the idea that there is something in the body that afflict certain peopl and renders them incapable of exercising their free will over alcohol remains just that--an idea, a fiction.
That hasn’t stopped the disease model from becoming the conventional wisdom about addiction, the reason the most of the $5.5 billion a year we spend on treating addiction goes to doctors and hospitals. Perhaps this is because its such a good idea, and in a way that neither Jellinek nor Anderson knew. The idea that addiction is an illness for which sobriety is the cure helps us to negotiate some of the vast confusions that have always haunted American life: our ambivalence about pleasure (especially drug-induced pleasure), for instancc, of the uncertainties about the limits of free-will and self-determination, a culture thrash that started before...Benjamin Rush and continues today. These questions threaten to emerge whenever we see a person in the throes of addiction; but with the disease model, we have a ready-made answer, on that has the imprimatur of science: addiction isn’t wrong, it’s sick; abstinence isn’t virtuous, it’s merely healthy, and then only for those with the affliction. And when you tell a person that he is drinking too much, you aren’t exercising a moral judgment. You’re simply telling him that he has a disease.
There can be no doubt that the disease model has helped millions of people. If a made-up disease can be of such immense value, then we must consider the possibility that the truth is not all it’s cracked up to be. Perhaps in the republic of medicine, the fiction that addiction is a disease is a noble lie….
The disease model...fits American society like a glove on a hand. It helps all of us, addicts or not, to understand ourselves ins ways that make living here easier; we don’t have to fight about about whether the addict is a sinner or what it means that free will can be subverted so easily….
The line between illness and health will always change with new knowledge and improved technology and even with shifting fashion…. Jellinek had it right: diseases are what the medical profession says they are.
There are better diseases and worse diseases…. But diagnoses will always be fashioned according to prevailing notions of the good life and the good person, of what kind of people we ought to be. To give suffering a scientific name is not to remove it from the hurly-burly of human history, much as we might wish…. There are no diseases in nature. The activist philosopher Peter Sedgwick has put this beautifully:
The fracture of a septuagenarian’s femur has, within the world of nature, no more significance than the snapping of an autumn leaf from it its twig; and the invasion of the human organism by cholera carries with it no more the stamp of “illness” than does the souring of milk by other forms of bacteria (“Illness--mental and otherwise,” Hastings Center Reports 1 : 30).
There’s plenty of suffering in the human world, but none of it matters until we give it a name. Once we’ve done that, we can put our doctors and the vast apparatus at their command to work to relieve it. To have a disease is to have claim on those resources which, enormous as they are, are still limited.
(pp. 10-23, 218)
Some pertinent references:
-AA's Own Stats Show Slow Demise
-Alcoholism: a disease of speculation
-Addiction: A Disorder of Choice
-Alcoholics Anonymous and the Disease Concept of Alcoholism
-Coming Clean: Overcoming Addiction Without Treatment
-Disease Concept of Alcoholism
-Diseasing of America: How we allowed recovery zealots and the treatment industry to convince us we are out of control. Peele, S. (1989, 1995). Lexington, MA/San Francisco: Lexington Books/Jossey-Bass.
-Documents concerning AA Web Site Inc.
-E. Morton Jellinek (author of The Disease Concept)
-"G.I. Heroin Addiction Epidemic in Vietnam,” New York Times, 5.16.71
-History of Alcoholics Anonymous
-Oral History Interviews with Substance Abuse Researchers
-Orange Papers (Re: AA’s financials)
-Remission From Drug Abuse Over a 25-Year Period: Patterns of Remission and Treatment Use
-Sociological Aspects of the Disease Model of Alcoholism
-The Fix: Solving the Nation's Drug Problem
-The Rebirth of the Disease Concept of Alcoholism in the 20th Century
-The William Griffith Wilson (Bill W.) Estate & Lois Burnham Wilson Estate
-Twelve Things That Alcoholics Anonymous Doesn't Want You to Know
-When AA Doesn't Work For You: Rational Steps to Quitting Alcohol by Albert Ellis
-Vietnam veterans' rapid recovery from heroin addiction: a fluke or normal expectation?