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Book Review
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Alcoholism in America.
By Sarah W. Tracy (John Hopkins University Press, Baltimore &
London, 2005, hb, ISBN 0-8018-8119-6), 357 pp.
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During
the nineteenth century, drinking in America changed. Industrialisation
required a reliable workforce and made workplace drinking a thing
of the past; urbanisation led to overcrowded living and working
conditions; and mass immigration (especially of Irish Catholics)
fed anxiety about urban disorder and public drunkenness. The latenineteenth
and earlytwentieth centuries saw the first attempts to medicalise
habitual drunkenness. This was not a simple exercise of medical
power, as it was driven by others besides physicians: the alcoholic
'rounders' who repeatedly ended up in prisons and hospitals were
a major problem; there was considerable social utility in a disease
diagnosis, especially one that separated drinkers from the insane;
and for drinkers themselves it was a means of reducing stigma.
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Medicalisation of inebriety was a
response to the problem of alcohol; a response that was an alternative
to temperance, and one that drew on the cachet of science, fitted
the growing mental hygiene movement, and was modelled on the medicalisation
of insanity. Between 1870 and 1920 over two hundred private and
public institutions were established across the United States. Some
patients were voluntary, most committed by the courts. Physicians
preferred the 'hopeful' cases; but too often the public institutions
were filled with 'incorrigibles,' resulting in overcrowding which
led to increasingly punitive and authoritarian treatment. Treatment
success—measured primarily by sobriety but also by social
functioning, in particular the ability to work—was vital to
ensure ongoing popular and state support for public institutions.
However, most institutions were privately run, so despite regular
calls for public inebriate institutions as a measure to relieve
overcrowding in jails and insane asylums, that situation remained
unchanged in most places. The introduction of national Prohibition
cut short efforts to treat alcoholism medically: if no one drank,
there would be no alcoholics (not that it turned out that way of
course).
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The
construction, experience, and treatment of alcoholism varied according
to gender and class. Alcoholism in women was variously attributed
to their peculiar physiology, their occupation (middle-class women
had too little to do, working class women too much, in addition
to the influence of the unsavoury elements they had to mix with),
the changing role of women (the influence of the 'New Woman'), and
consumption of proprietary medicines which notoriously contained
large amounts of alcohol. A poorly-run home was a cause of men's
drinking problems; and treatment for women was based on cultivating
domestic and maternal instincts. As bearers of morality, women inebriates
were more deviant than men, and as bearers of the nation's children,
female alcoholics were implicated in broader concerns about 'race
suicide.' Women drinkers thus signified a raft of social problems,
identification of which was used to drive reforms—although
not to benefit women themselves, as most institutions only treated
men.
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For
men, drinking was an opportunity to assert their masculinity, but
alcoholism also stripped it from them; male alcoholism was an expression
of a crisis of masculinity, linked to the threat from the 'New Woman.'
Almost universally, recovery from alcoholism was for men the recovery
of their manhood. Class mattered too, not just in terms of access
to treatment, but in how patients were accommodated—preferably
separated according to social standing. Middle-class women were
more likely to be diagnosed as dipsomaniacs, whereas working-class
women remained drunks.
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Alcoholism
in America is the first comprehensive work on alcoholism that
examines its medical, social, and cultural history during this early
period of medicalisation. It explores ideas about, practices in
relation to, and experiences of alcoholism and its treatment; Sarah
Tracy's aim is to capture the 'synergy among medical ideas, cultural
values, professional authority and policy making' (p. 5). Her account
is both specific to America—as a nation and culture that has
long had a fraught relationship with alcohol—and relevant
to contexts beyond the United States. The narrative of the book
moves from 'ideas to institutions to individuals' (p. 23). The first
two chapters analyse medical and cultural framing of inebriety as
a disease. The next four explore private and public inebriety institutions,
with two in-depth case studies of public institutions in Massachusetts
and Iowa. |
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The
final chapter uses patient correspondence from case files and published
patient narratives to examine how drinkers and their families framed
their condition. The conclusion looks at the fate of 'the disease
concept' since the repeal of Prohibition, and how 'social values,
political priorities and economic circumstances' continue to shape
'the definition and prevalence of pathology' (p. 291). The breadth
and depth of Alcoholism in America can be seen in Tracy's
account of the 'Foxborough experiment' in Massachusetts, which ranges
across 'unemployment, poverty, individual liberty, the power of
volition, state responsibility and the nature of disease' (p. 148). |
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How various players—physicians, the judiciary, politicians and public
health officials, and patients and their families—employed the 'disease
concept' is one of the book's main threads. Tracy argues that socially, culturally,
and medically, its lack of coherence (for what it meant then is as hard to
pin down as what it means now) was its strength, not a weakness. In this sense
alcoholism does not fit the dominant and reductionist ontological model of
disease as identical in each person. Her main argument is that 'a moral shroud
… cloaked the condition' (p. 39); that everyone understood alcoholism
as a medicomoral condition involving both biological determinism (often heredity)
and free will. Institutions treated both vice and disease—though there
was little in the way of specific medical therapeutics—and in contrast
to temperance narratives, patients framed their stories as medicomoral recovery
tales. |
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To the same degree, the book is specific to the United States framework—in
its emphasis on the 'disease concept,' which is central to addictions discourse
in the United States, while not to the same extent in other places; and similarly,
in its discussion on the level of the influence of the temperance movement
with its culmination in national Prohibition. But the book has a much bigger
story to tell, indeed one that establishes the social and medical history
of alcoholism. |
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CAROLINE CLARK
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TURNING POINT ALCOHOL
AND DRUG CENTRE
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