Hans Olav drew a direct connection between the
"disaggregationist" findings of early U.S. alcohol
survey epidemiology and the emergence of calls for
policy efforts to reduce per capita consumption. In
this post I'm going to try to explain why the link
Hans Olav posits is in fact highly problematic. I begin by defining
"disaggregationism."
1. When U.S. alcohol survey researchers first braved
to ask their general population samples about
alcohol-related problems--i.e., ask respondents (Rs)
questions about frictions with friends, relatives,
and workmates connected with drinking, illness
connected with drinking, heavy alcohol intake,
evidence of alcohol dependency, etc.--the findings
that came back from the field did not mirror the
reality that an "alcoholism paradigm" might have
predicted. Instead of finding that drinking problems
were distributed into two distinct subpopulations--
one large normal group (with no or very low problem
scores) and the other smaller group of alcoholics
(with high problem scores)--the survey data brought
the message that drinking problems were distributed
in a smoother and more unimodal fashion: Lots of Rs
reported positively on no problem measure at all or
only one measure; but then quite a few other Rs
reported positively on 2 problem measures;
somewhat fewer, but still a significant number,
reported 3 problems; and so on up the problem scale.
2. This simple finding had a number of corollaries:
For one, it implied that individual problem measures
were not highly correlated with one another. For
another, it meant that prevalence estimation of
something called "alcoholism" was going to be
difficult to do with survey data because the unimodal
distribution along the drinking-problems scale made
the question of where one drew the line between
"normal" and "problem" drinking essentially
arbitrary. Survey data also revealed two additional
embarrassing findings with respect to the then-prevailing
alcoholism paradigm: (1) it was young men in their
20s (and not the middle-aged men populating most
alcoholism treatment samples) who reported the
highest rates of alcohol-related problems, and (2)
longitudinal research conducted on these general
population samples showed that such problems
were often highly transitory over time, which ran
counter to the image of high intractability that had
grown up in clinical samples of alcoholics. Survey
research, in short, painted a picture of
alcohol-related problems sharply different from that
derived from "clinical alcoholism."
3. I'm sure it was Robin Room who first coined the
general term "disaggregation" to refer to this
survey-based alternative picture of alcohol-related
problems. To "disaggregate" is, of course, to unpack
or separate out things that were once packaged in a
single unit ("alcoholism") into a series of
dissimilar (or potentially dissimilar), separate
units ("drinking problems"). In a little 1972 paper
that I've always regarded as the point of
conceptual/policy departure for the
"disaggregationist," "alcohol problems," or "public
health approach" to alcohol problems (Room, "Notes on
Alcohol Policies in the Light of General-Population
Studies," _Drinking & Drug Practices Surveyor_,
6:10-12, 15, 1972), Robin elaborated a list of ten
(listed "a" to "j") main implications and
prospects of these simple but portent-laden
survey-research findings. Robin produced a series of
seminal papers further exploring the implications of
this new perspective for alcohol-problems prevention
(which he preferred to call "minimization") over the
1970s.
4. Item (b) on his 1972 paper's list read in part:
"Our studies suggest that when the traditional
unitary notion of 'alcoholism' is disaggregated,
there are differences in correlates of different
aspects of it....This suggests that a first
requirement for any social policy having to do with
alcohol is to define with some exactness what the
target of the program is, since shooting at one
target does not guarantee hitting all others" (p.
10).
5. Granting separate conceptual & policy status to
individual "alcohol problemS," with an emphasis on
the plurality of "problems," was one of the most
important seeming implications of these survey
findings. But it was not an entirely new finding and
implication. For one thing, Harold Mulford was at
about the same time contemplating similar survey
data in his Iowa-based and national survey studies--
and coming to some similar conclusions. Moreover,
Tom Plaut had elaborated a similar conceptual/policy
perspective in in an influential report tellingly
titled "Alcohol Problems [_n.b._]: A Report to the
Nation by the cooperative commission on the Study of
Alcoholism_ (Oxford, 1967). Plaut's dedication of
this report to E.M. Jellinek--the celebrated scientific
"father" of the modern disease conception of alcoholism
--was entirely fitting not only because Jellinek had died
while at work on the project (in 1963) but
also because the alcohol problems perspective it
articulated was in fact a re-expression of the
framework Jellinek had worked out years before in the
context of Yale's famous Center on Alcohol Studies
in Howard Haggard's Laboratory of Applied Physiology.
6. There is something deeply intriguing about this
continuity in scientific paradigms--from the
Jellinek-crafted version of the "alcohol problems"
paradigm of the early 1940s to its
re-definition out of survey research findings in the early
1970s. My hunch is that it reflects some kind of
deep, underlying, but tacit, affinity between
Benthamite, secular, utilitarianism and the default stance
of modern science when it is invited to
address any complex social problem. Be that as it
may, there is a single interesting feature of
Jellinek's "alcohol problems" paradigm that I'd like
to draw attention to here, namely: in Jellinek's
hands the _plurality_ of alcohol problems provided a
simple but effective rhetorical device for arguing
against the Dry disposition to speak instead of "the alcohol
problem"--i.e., in the singular--in making reference
to temperance sentiment's chief problem focus, namely
alcohol, per se. The late Mark Keller once recalled
about this orientation: "We did believe in 'The
Problems of Alcohol'--that was the title of Lecture
2, by E.M. Jellinek [to the Yale Summer School on
Alcohol Studies]....It parted from older conceptions
of 'the alcohol problem' which had filled the
historical problem-oriented literature dominated by
the temperance-antialcohol movement. We now were
invited to consider not that alcohol was THE problem
but that there were many problems in which alcohol
was involved in a variety of ways" (quoted in Roizen,
"Paradigm Sidetracked...," 1993, p. 16ff).
7. My point must be evident by now, Hans Olav:
Ironic, isn't it, that the "same" alcohol problems
perspective--with its pluralist and disaggregative
approach--was _in Jellinek's hands_ an argument for
_getting away from_ a focus on the control or
proscription of alcohol and alcohol consumption
whereas a half-century later and in the hands of
public-health-model advocates, the "same" alcohol problems
perspective provides the conceptual basis FOR
refocussing attention on alcohol consumption and
per cap consumption?! Indeed, how can such a
circumstance be accounted for?
8. The answer to this puzzle, I think, is
delightfully simple--it goes like this: It does
not matter so much what the content or substance of
the alcohol problems model is; it matters more what
paradigm the alcohol problems paradigm is regarded as offering
an alternative to at the time. In Jellinek's day, of
course, the alcohol problems model was doing battle
with the temperance paradigm (one that emphasized
alcohol/alcohol consumption above all else) whereas
in the early 1970s the alcohol problems model was
doing battle against the alcoholism paradigm (one with a
seemingly remarkable indifference to alcohol
consumption in the nonalcoholic segment of the
population). The important lesson in this, I
believe, is that there is nothing inherent
in the alcohol problems perspective that leads to
great attention, interest, and policy focus on
alcohol consumption and/or per cap alcohol
consumption.
9. In fact, the alcohol problems model was very
open-ended in this regard. Yes, it seemed in the 1970s to
undercut the alcoholism model of alcohol-related
problems (though even that simple assertion, in fact, was
and is open to considerable argument!)--but beyond
that, the disaggregationist perspective lent itself
to a great many interpretive directions and
possibilities. Even Robin, himself, may be credited
with exploring and writing-about insightful
analytical possibilities that LEAD AWAY FROM attention to
alcohol, per se, consumption, or per cap consumption.
E.g.: Robin elaborated an
interesting interpretation of regional variations in
alcohol problems in the U.S.--in which he argued that
low-consumption normative contexts tended to produce
lots of social disruption around alcohol but
on the other hand relatively fewer long-term health consequences,
whereas high-consumption normative contexts
conversely tended to produce higher health
consequences and lower social-disruption
consequences. When it came to alcohol-problems and
their relation to consumption, in other words,
culture could take its choice! One of the most
memorable of the lines of analysis that Robin (and
others) explored in the early 1970s suggested that
many of the things we had regarded as
alcohol-related problems might actually be reduced by
developing policy responses that would make the world
"safer" for heavy drinkers. Robin's articulation of
this perspective in a 1972 conference drew an
unforgetable response from Griffith Edwards, who
likened Robin's suggestion to (I paraphrase and
approximate here, because I don't have the conference
report handy) passing out earmuffs in Bedlam
so as to muffle out the screams of the sufferers.
To be sure, the same Robin Room went on to become one
of the co-authors of the famous Bruun et al. report
(_Alcohol Control Policies in Public Health
Perspective_)--which we always called, simply, "The
Purple Book"--in 1975. This work offered the
foundation case for re-focussing attention on per
capita consumption in coming years in the alcohol
problems/policy arena--and a highly problematic
argument it was, IMHO. The purple book's argument--with its
emphasis on high-end alcohol consumers--looks
somewhat dated nowadays. It was not an argument
that relied directly on the disaggregative
implications of the U.S. survey research findings.
10. The disaggregative survey implication offered still
more conceptual possibilities, some of which lead
even farther away from alcohol, per se, consumption,
or per cap consumption as causal agencies in our minds. Some of
these possibilities led in the direction of trying to hook-up
with applicable or potentially applicable
sociological theory. For example, two papers I wrote
during this period offered basic attempts to come to grips with the
theoretical possibilities of our
survey data's disaggregationist patterning. The
first was a paper with the unlikely title, "Deviance,
Dogpounds, and Drunks" (_Drinking & Drug Practices
Surveyor_ 7:21-25, 1973). In it I employed the
metaphor of the problem of "stray dogs" to cast into
sharp relief the differences between a
structuralist/environmentalist model of "deviance"
(in this case "problematic straying") and the
individualist perspective proffered in models like
the alcoholism paradigm (which would denote the "strays" problem in an
individualist idiom, as "strayism"). My point was that it came quite
naturally to us to explain the "stray dogs" problem in
structualist terms, but came equally naturally to us to explain
problems like "alcoholism" in individualist terms.
The paper, then, tried to offer the metaphor of
strays as a heuristic device for seeing what a
structualist model of alcohol problems would actually
look like. This, I note, was a model that tended to
de-emphasize the factor of alcohol consumption, per
se, and emphasize instead (for instance) the
normative mismatches between the drinking norms of
temporally adjacent social situations (e.g., the
situation of a "party" followed by the situation of
"driving home from the party"). (Not everybody in
the office, incidentally, was altogether keen on
publishing this strange, maybe even vaguely
undignified-sounding analysis in our house
journal--and I still admire its then-editor [namely,
Robin] for braving to put it in nonetheless!)
11. In 1975 I presented a paper in Finland, the
purple book's spiritual home, that used longitudinal
data to explore the question of whether, and to what
extent, we may actually have misnamed our "drinking
problem measures" as these were used in alcohol
surveys. My argument was that if the conceptual
"glue" of an addiction model was, in fact, subtracted
out of the conceptual rationale for drinking problem
measures, then it wasn't altogether clear anymore why
these problem measures deserved the name "drinking
problems." I wrote, "many problematic behaviors
which were labeled 'drinking' problems in alcohol
surveys could be classified under many different
headings by different observers: so, for example, a
respondent who 'spends too much money on drinking'
might be seen as mainfesting a 'budgeting' problem,
an 'income' problem, a 'guilt' problem, or a problem
finding other things to spend his money on" ("Drinking
and Drinking Problems: Some notes on the ascription of
problems to drinking," p. 3). I examined the
longitudinal association between changes in drinking
and changes in one drinking-related problem ("spouse
problems") to examine the possibility of more _independence_
between actual drinking and this drinking-problem measure
than our nomenclature at least tacitly implied.
12. There were other possibilities raised too:
including that our lower-level problem scores were
bascially trivial and unimportant--survey research
"noise" obscuring the important "signal" of a rare
few really problematic drinkers buried in our
samples. Genevieve Knupfer, the intellectual source
of much of the good thinking that went on in the
early days of the Berkeley group, in recent years
even painstakingly constructed an analysis addressing
the altogether plausible possibility that top-group
heavy drinkers in survey research studies were simply
not drinking enough to really represent clinical
alcohol dependence. She addressed this problem by
aggregating the samples of many survey studies into a
single super-sample that allowed her to look at the
problem profiles and correlates of a very top-top
group.
13. So, yes, Hans Olav, there is--and there was--a
considerable leap between the basic disaggregationist
implication of early survey studies of problem
drinking and the (seemingly, according to your
argument) derivative coceptual/policy interest in per
capita alcohol consumption! Indeed, as I have mulled
over your wonderful question when I had the chance
over the past few days, I have come up with several
additional points to offer you. For example,
keep in mind that AS SURVEY analysts the variable
"per capita alcohol consumption" would have been
quite difficult for us to introduce into our
analyses--for one thing, BECAUSE it was an aggregate
measure and therefore wouldn't have fit well into the
analytical habit we were familiar with. No, the
purple book's consumption agenda--and its legacy of the
Edwards et al. (Alcohol and the Public Good) volume
in our own day--involves a much more complicated
social history (and social construction) than the
simple three-part argument your post
presented. I hasten to add, Hans Olav, that it is
you, rather than I, who is closer to conventional
wisdom in this exchange. That's one of the reasons I'm
frustrated with the current hegemony (or wouldbe hegemony) of the
public health approach these days. There are a lot of
critical shots that this new paradigm and the
argument for this new paradigm really need to be
peppered with. Thanks for providing a venue for
suggesting just a few!
Sorry this is so rambling & long--but it's late and
I'm going to post it anyhow.
Ron
--
Ron Roizen
voice: 510-848-9123
fax: 510-848-9210
home: 510-848-9098
1818 Hearst Ave.
Berkeley, CA 94703
U.S.A.
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