Updated: Aug 30
Editor’s Note: We’ve been very pleased to post a series of responses to David’s Courtwright’s essay on addiction, history and historians. Now that Nancy Campbell, Alex Mold, Daniel Bradburd, and Samuel Roberts have all had their say, it seems fitting for David Courtwright to offer a brief reply to their thoughtful responses. For Points readers not familiar with David, he is currently Presidential Professor of History at the University of North Florida. He’s also the author of several books, including Dark Paradise: A History of Opiate Addiction in America (updated edition, Harvard University Press, 2001), Forces of Habit: Drugs and the Making of the Modern World (Harvard University Press, 2001), and No Right Turn: Conservative Politics in a Liberal America (Harvard University Press, 2010).
Addiction Neuroscience, the Progressive Implosion of Pathology, and Historical Explanation.
The U.S. National Institute on Drug Abuse (NIDA) claims to support “over 85 percent of the world’s research on the health aspects of drug abuse and addiction.” The figure may be a stretch, as it is unclear which health aspects, which drugs, and which addictions the research covers. As Alex Mold notes, NIDA has no monopoly on scientific investigation. Yet I do not doubt that NIDA’s current brain disease paradigm commands the high ground of funding, prestige, and publicity. Should NIDA and the National Institute on Alcohol Abuse and Alcoholism merge to form a new National Institute of Substance Use and Addiction Disorders, the unifying brain-disease model will become even more dominant. NIDA Director Nora Volkow puts the Grand Unifying Theory succinctly: “Addictions tend to move together, sharing many triggers and a great deal of biology.”
Historians and social scientists do not necessarily regard these developments with equanimity, as the Points responses and other comments on my work make clear. Dan Bradburd captures the worried mood by likening the brain disease paradigm to a head on the aroused Hydra of reductionism, and by suggesting that, in their own ways, Charles Murray and Nora Volkow are bent over the ancient oars of naturalized and problematized difference. Why, then, do I remain guardedly hopeful that there is something positive for historians in addiction neuroscience?
Let me introduce a line of thinking that I did not have space to develop (along with much else, apart from representative examples of U.S., British, and Chinese drug historiography) in “Addiction and the Science of History.” It is the idea that whenever medical investigators acquire increasingly specific, micro-level understandings of disease processes, everyone eventually benefits, historians included. Let’s call this process “the progressive implosion of pathology.”
Consider medical understanding of internal diseases. Physicians in the age of Hippocrates (466-377 B.C.) began to describe diseases naturalistically, as a consequence of imbalances in the body’s humors (black bile, yellow bile, blood, and phlegm) brought on by changes in environment and diet. Elements of this broad theory of pathology persisted until the late eighteenth century, when Giovanni Morgagni demonstrated that diseases were situated in particular organs, whose lesions an autopsist could catalog and correlate with premortem symptoms. In the early nineteenth century Marie-Franҫois-Xavier Bichat and René Laennec situated diseases in particular types of tissues; in 1858 Rudolph Virchow situated them in the disordered functioning of cells. Over the next four decades investigations by Louis Pasteur, Robert Koch, and others showed that, for many common diseases, specific microorganisms caused the pathological changes observed in the cells, tissues, and organs of their unwitting hosts.
The implosion of pathology and the discovery of the mechanisms of infection engendered a progressive revolution in surgery and public health and entered popular consciousness as “the germ theory of disease,” a phrase in common use by the 1870s. Granted, these same developments also led to germophobic obsessions and etiological rigidity. Joseph Goldberger, who suspected that pellagra was of dietary origin, went so far as to eat the excreta of pellagrous patients to prove that the disease was not infectious. Thanks to the work of René Dubos and others who explored the role of nutrition, social conditions, and environmental stressors, researchers gained a more nuanced understanding of infectious disease by the mid-twentieth century. That understanding is still maturing, most recently in the Darwinian medicine that has married bacteriology and virology to evolutionary principles to produce new insights into symptomatology, virulence and the role that infection plays in many chronic diseases.
Historians like William McNeill and Alfred Crosby (and some humanistically inclined scientists like Hans Zinsser) took advantage of this ongoing pathological revolution to offer fuller and more convincing accounts of key historical events, such as the European conquest and colonization of the Americas. Far from being mindless applications of reductive medical principles, the best work in this field combines economic, political, and cultural explanations in balanced syntheses, of which Charles Mann’s 1493: Uncovering the World that Columbus Made provides a recent example. Historians may be, as the philosopher Carl Hempel suggested, “borrowers” of general laws formulated and tested by other researchers. But no one ever said that they had to limit their borrowing to one sort of scientific principle or ignore the role of agency, contingency, and cultural variation in their narratives.
The scientific study of drug abuse and addiction in the late twentieth and early twenty-first centuries bears a close resemblance to the study of internal disease a century before. Both fields were characterized by paradigm-shifting micropathological discoveries linked to advances in scientific instrumentation; gross oversimplifications and premature claims as well as lasting breakthroughs; and, initially, few practical therapeutic applications. These would come later for infectious diseases, and may yet come for drug abuse and addiction. Should the equivalent of penicillin for addiction materialize, it seems likely that the policy balance (and much else about psychoactive drugs) would finally and decisively tilt toward medicalization.
Meanwhile historians can avail themselves of the new addiction science to throw light on various phenomena. Knowing how drugs act on the brain can help—repeat, help—explain such things as the commodification, globalization, and transcultural popularity of dopamine-augmenting substances; the strong positive correlation between proximity to drug supplies and rates of use and addiction; the shape and degree of flexibility for different drugs’ demand curves; the commercial and social pairing of mutually reinforcing drugs like alcohol and nicotine; the frequency with which abstinence-oriented treatments have failed, or, conversely, why methadone and buprenorphine have produced superior clinical results in a variety of cultural settings.
Addiction neuroscience is useless, or worse than useless, in trying to explain many other historical puzzles. Why did Australians and Americans ban opium smoking before they regulated morphine? The answer has much to do with culturally specific attitudes toward Chinese immigrants and definitions of vice and nothing to do with the relative toxicity or brain effects of the two opiates. (Otherwise morphine would have been banned first.) Sam Roberts offers other examples of phenomena better understood through social analysis than neuroscience. But historians make these sorts of judgments all the time. They carry about in their heads a carpenter’s box of explanatory tools. The trick is to match the tool to the job.
Another way to say this is that the language and insights of neuroscience will confer credibility on historians only when they use them appropriately, in a way that advances understanding of the particular problem at hand. The same principle applies to GPS, radiocarbon dating, the analysis of variance, and a dozen other science- or math-based techniques. It’s not the bright new tool that makes a good carpenter. It’s what he does with it.
Of course, things do not work out so neatly in the contested world of historical scholarship. One of the peculiarities of graduate education in history, and of social science generally, is that that it encourages beginning scholars to restrict themselves to those explanatory tools currently in disciplinary or political fashion. Seminars, like drugs, reshape the brain. Students learn which kinds of explanations will win approbation, and which will work on a career like Kryptonite on Superman. You can almost see the green glow emanating from the NIDA brain disease paradigm.
For white-coated addiction researchers “in the grip of scientific fascination,” as Nancy Campbell puts it, the bias cuts in the opposite direction. History and sociology and ethnography seem epistemologically soft, irrelevant, a waste of time. For many problems of a technical nature, they doubtless are. But they are not for others, and certainly not for those involving policy and social behaviors. This I take to be Sam Roberts’s point.
Whether my views reflect a balancing disposition, excessive politeness, or naïveté about scientific claims of objective knowledge, I cannot say. Personally, I suspect they derive from writing a world history of drug use, where necessity proved the mother of catholicity rather than of invention. What matters are less my inclinations than those of entire disciplines—of entire fields of knowledge—where the tendencies toward methodological exclusivity, boundary maintenance, and political defensiveness are marked and, in some contexts, counterproductive. When all you have is a hammer, as the saying goes, everything looks like a nail. But when you have access to other tools, and you ignore them, all you look is stubborn.