Throughout the nineteenth century the international sanitary order had relied on quarantine and the surveillance of travellers and goods. More than half a century of international sanitary conferences, in all twelve meetings from 1850 to 1912, can be summarised as leading to the establishment of sanitary cordons against all pestilences coming from the East and an attempt to control migration, in particular the great pilgrimages.

The First World War fostered a new type of interest in international health with the recognition of the devastating potentialities of epidemic agents on multitudes thrown together in a giant battlefield. The Balkan experience was crucial in that it exposed millions of men, coming from all countries in the world, to a wide range of epidemic hazards, including water-borne diseases, typhus and malaria.

Two kinds of considerations, political and epidemiological, rendered the sanctuarist view pointless:

The pacifist wave after the Treaty of Versailles led to the perception of public health as an ingredient of civilisation and a condition of international peace.

The problem of social medicine: radical reform or authoritarian interventionism?

The aftermath of the First World War saw a transition from the control of epidemic, infectious diseases to international endeavours promoting social medicine. It was hoped that international peace could be underpinned by alleviation of social deprivation and injustice: effective health and welfare services were intended to stabilise the existence of new states and modernise administrative structures. State administrations adopted ambitious plans to extend social welfare provisions; and a private sector that had been heavily engaged in war relief work attempted to shift the basis of voluntary care away from philanthropic aid, and towards tackling the scientific roots of poverty and disease. The new priority given to maternal and child health, and to the prevention of chronic degenerative diseases (notably tuberculosis and certain sexually transmitted diseases) was linked to a range of demographic and social issues. Visionary schemes promoted innovative concepts of positive health and diverse concepts of ‘social hygiene’, ‘social medicine’ and of a healthy ‘human economy’. Clinical medicine was to be ‘reconstructed through social science’, and the organisation of medical care was to be collectivised by state and municipal public health physicians superintending polyclinics and public hospitals.

Whatever the prevailing political system, there was an international consensus among public health experts that the collectivisation of health care should look to advances in biological and social sciences.

‘Without the devoted personal service, the disinterested counsel, and the co-operation of experienced nurses who went out from America to the Far East, Continental Europe, and Latin America, public health nursing could not have achieved the relatively high status it now occupies in these areas.’ Such was the confident conclusion of Rockefeller officials in 1938, after twenty-four years of Rockefeller interventions in nursing. In this chapter I shall consider the role of the Rockefeller Foundation (RF) in promoting nursing education in England during the interwar period. This episode in RF history was marked by the competitive interplay between a number of international organisations keen to influence the pattern of nursing education. Organisational rivalry and constraints on resources undermined attempts to establish an international infrastructure for nursing education. Moreover the low prestige attached to nursing by the RF circumscribed any investment the Foundation was prepared to make and ultimately the results that could be achieved.

Nevertheless the ‘imperial gaze’ of the RF ranged far and wide across the realm of nursing, scanning England and certain parts of Central and Eastern Europe for opportunities to invest. Scotland, Wales and Northern Ireland fell outside the RF's immediate scope of nursing vision. In spite of its emblematic status as the centre of the British Empire, England proved disappointingly barren territory for Rockefeller's expansionist ambitions.

An elite of biomedical and health specialists functioning through the League of Nations Health Organisation (LNHO) in the interwar decades contributed to the development of the public health profession. They served as a co-ordinating body — a sort of executive committee — for a worldwide biomedical/public health episteme that recently had acquired confidence in its ability to alleviate human suffering by reducing, if not eliminating, disease. This new confidence reflected new consensual knowledge about the aetiology and epidemiology of many diseases and the physiological conditions and socio-economic factors contributing to human illness. It stimulated their humanitarian instincts, leading them to devise the LNHO, a novel institution at the centre of the interwar health regime. This regime had the unusual quality of being largely self-transforming in response to new scientific knowledge developed within the episteme. It also led to the creation in various countries of new national health institutions.

Health co-operation before 1919

During much of the nineteenth century, little consensual knowledge existed about the causes of illness or how diseases are transmitted. The social devastation and fear generated by plague and cholera, nevertheless, induced some governments to seek protection against epidemics emanating from the Middle and Far East and Asia Minor. Diverse, arbitrary, and often contradictory opinions about these diseases prevented effective action.

what kind of image does the term ‘drug user’ generally bring to mind in today's society? Is the average response to a statement that someone is ‘taking drugs’ likely to be an inquiry about what type of illness he or she is suffering from and what medication is being used to treat it? Probably not, because for most people ‘taking drugs’ tends to have a connotation that links it with abuse rather than with medicinal use.

Yet the word ‘drug’ was not always so closely linked in the public mind with substance abuse. The definition of the noun drug in volume III (published in 1897) of the original edition of the Oxford English Dictionary (OED) is as follows: ‘An original, simple medicinal substance, organic or inorganic, whether used by itself in its natural condition or prepared by art, or as an ingredient in a medicine or medicament.’

The OED went on to discuss other aspects of the history and use of the term that need not be considered here. From the point of view of this essay, the key fact to note is that the noun drug is associated with medicinal or related use. There is no reference to recreational use or abuse of a substance in the definition.

INTRODUCTION

success in the international pharmaceutical industry today is built on the discovery of new and better drugs for the treatment and cure of disease and their introduction to markets across the world. New drugs must be sold worldwide, since no company can fully exploit a patented product, recouping its research and development costs solely in its own home market, even in the two largest national markets, the USA and Japan. The ability of any company to innovate successfully largely depends on its resources although there is also an element of serendipity in the discovery of new drugs. Successful penetration of world markets depends on the product and its skilful marketing to secure maximum returns which, in turn, will finance further research and development.

The history of the British pharmaceutical industry and the growth of its research and development capability, to take a not insignificant place in the international industry in the late twentieth century, can conveniently be considered in three periods since the late nineteenth century. The divisions are marked by the two world wars, each of which gave a stimulus to research and development as well as bringing significant technological and organizational change to the industry and to individual players in it.

broadly this contribution is concerned with drug regulation in Germany during 1871–1914, in particular with the interaction of the government and the chemical industry in this area. From its beginning the German chemical industry was not a uniformly organized industrial branch. Since the 1850s and 1860s, it was possible to differentiate between the heavy chemicals (primary) industry and the preparations (processing) industry. Whereas the interest and problems of the first lay in the production of soda, sulphuric acid, potash, and fertilizers (in conjunction with the rising coal and steel industries), the second pursued its own interests and as such was the first to come into contact with governmental health institutions. This distinct attitude of the preparations industry is further underlined by the founding of a body, in 1877, called the Verein zur Wahrung der Interessen der chemischen Industrie (Association for Safeguarding the Interests of the Chemical Industry).

Analysing the health policy of the Empire, our main interest will be the preparations industry. Its products fall into two large groups, coal tar chemicals and fine chemicals – both are closely connected with the pharmacy. The pharmacists, in Germany traditionally having the privilege of preparing medicines, developed also an interest in fine chemicals. The mid-nineteenth-century industrialization brought forth such firms emerging from pharmacists' shops as Schering, Riedel, and Merck. Since the 1880s the dye manufacturers began to develop medicines from waste products or by-products.

the regulation of the supply of drugs became the subject of a lively debate in Britain during the second half of the nineteenth century. The basic question underlying this debate was, who should determine the availability of drugs in society, consumers, producers, or officials? From these discussions, three distinct models of regulation can be constructed: consumer sovereignty, occupational control, and bureaucratic regulation. By adding a local/national dimension to these categories, a six-fold classification can be produced. Within consumer sovereignty, a distinction can be made between the nationwide, individualistic, free-market model of the classical economists and the local, popularist, communal model of the democratic radicals. The subtypes of occupational control are based on the difference between regulation by local guilds and that by national professional associations. Similarly, regulation by local and central government can be distinguished. This classification is not intended as an analytic, conceptual typology of drug regulation but merely as a rough-and-ready sorting device. Its aim is the understanding of specific historical events and conditions, not the creation of logical, rational, universal theories.

The practice of pharmacy by the apothecary from the mid-sixteenth to the mid-eighteenth century obtained its characteristic features from origins in the medieval urban economy. The guild system with its strict control over who might practise a given craft, who might be trained, how one was to be trained, and how the craft was to be practised, provided the framework within which the apothecary operated. Craft guilds have been subject to widely different assessments.

the non-medical use of drugs today is an example of how society, supported by the medical profession, constructs ‘problems’ and invents ‘diseases’ for which they then find ‘treatments’. Some pharmacological substances, for example alcohol and tobacco, are major causes of death, yet are permitted to be sold and even advertised, and are a major source of government revenue. Others are regarded as ‘ethical’, and require a doctor's prescription. Some of the less harmful drugs, for example cannabis and heroin, are made dangerous by myth, politics, illegality, and other social factors. Governments and doctors capitalize on collective fantasies. They publicize the drugs in a way to induce horror and fear. This policy costs governments and nations dearly, but it provides other political benefits, including to the medical profession. The dangers of these substances are both created and emphasized with zeal rather than evidence. Such evidence as exists is liable to be concocted and financed in order to exaggerate their dangers.

Illegal drugs are the subject of a ‘phoney war’, waged by governments for their own purposes that certainly have nothing to do with the ‘dangers’ of these substances. Governments who capitalize on public shock-horror have a splendid means of diverting public attention and anger from real issues and for interfering in the affairs of other nations, even to the extent of sending spies and troops.

INTRODUCTION

from the time of earliest contact, it has been observed that the beverage alcohol introduced by Europeans had devastating consequences on Native North Americans. High rates of devastation have persisted into the present, as Figure 1 indicates. The data displayed there show that the age-adjusted rate of alcohol-related deaths had declined among Indians since the late 1960s, but increased in the late 1980s and is 5.4 times higher than it is for all races in the United States. The category of alcohol-related deaths does not include accidents, which was the second leading cause of death among Indians and Alaska Natives in 1988 and occurred at slightly more than twice the frequency as among all races in the United States. Slightly more than 50% of accidental deaths of Indians involve motor vehicles, and at least half of these are estimated to be due to alcohol abuse. Clearly, although the long-term trend of deaths involving alcohol seems to be a convergence between Indians and non-Indians, the differences are still substantial.

There have been a variety of explanations for the high rates of alcohol-related problems among Indians, none of which necessarily excludes any of the others. Perhaps the oldest in one form or another is that Indians cannot hold their liquor because biologically they are unable to do so. This explanation continues to be the subject of empirical scientific investigation, and is based upon the assumption that there is some genetic mechanism that is a necessary cause of alcohol abuse: without such a mechanism Indians would not have the problems with alcohol that they do.

INTRODUCTION

from the late sixteenth to the early eighteenth century substances with addictive qualities such as tobacco, coffee, cacao, tea, and distilled liquor were introduced, found acceptance, and spread with remarkable speed around the globe. The near-simultaneity of the introduction and the similarity in the reception and dissemination of these psychotropic substances among the population of Europe and parts of America, Asia, and Africa is striking enough to invite comparisons. To draw such comparisons is the aim of the following discussion, which will consider the transformation of these five stimulants from curiosity and rarity to commonplace commodity in the context of a number of converging and intersecting economic, social, and political processes.

The first of these is the expansion of European horizons in the wake of the great maritime discoveries at the turn of the sixteenth century. Europe's exploration of the globe not just ushered in a commercial revolution, but simultaneously helped ignite a revolution in scientific and religious thought and practice that was to have a lasting impact on the world. While the Renaissance overturned the existing canons of science and philosophy and inspired a new focus on the physical and the material, the Reformation forced a new consciousness upon man, urging him to contemplate God individually and to conduct his life according to a new personal ethic. In the practical morality of subsequent movements such as Puritanism and Pietism the new stimulants became indices of individual responsibility, and were alternately denounced as emblems of moral rot and social degeneracy, or celebrated as the embodiment of sobriety and vigilance.

are drugs a spectre that is haunting the world at the present time? This is a question which arises of necessity on reading headlines in newspapers such as these:

AIDS, in its early years in particular was a disease surrounded by history. Historians actively sought to bring the ‘lesson of history’ into the public debates. Even more surprisingly, policy makers were often prepared to listen. This essay will examine the various stages of the historical consciousness around AIDS (from the initial stage of ‘epidemic disease’ to the current period of normalization), will analyse of what the historical input has consisted, and will analyse, too, why history was initially so important. This historical consciousness has not, so far as AIDS is concerned, been applied to drug policy. Drugs have in the past, been an historically conscious area of health policy. But the impact of AIDS on drug policy has tended, in contrast, to be viewed ahistorically, as if all developments were totally new. Why this has been the case gives some insights into the uses of history as a policy-relevant science. This essay will also argue that history has a role to play in the analysis of post-AIDS drug policy – not least in drawing out some distinct themes and continuities with the pre-AIDS situation.

AIDS AND HISTORY: THE EARLY YEARS

The initial historical input into AIDS was marked. In the late twentieth century, laboratory and clinical science appeared to have conquered infectious, epidemic disease. According to the McKeown thesis (which stressed the role of nutrition rather than medical technology in conquering disease), medical discoveries and therapies may not have caused the decline in mortality of the nineteenth century, but they did have a significant impact in the twentieth.

INTRODUCTION: A VIEW ON OPIUM THERAPY

in the course of the eighteenth century the therapeutic use of opium became increasingly popular in western medicine. The drug was prescribed in numerous preparations not only as an analgesic and narcotic, but also as a diaphoretic and as a remedy against diarrhoea, vomiting, and cough. Moreover, it was considered to be helpful in various nervous and mental disorders. During the late eighteenth and early nineteenth centuries opium therapy got a further boost from the Brownian system of asthenic and sthenic diseases. In his Elements of Medicine John Brown (1735–88) had recommended opium as the strongest and most diffusible stimulant, the powers of which surpassed those of ether, camphor, volatile alkali, musk, and alcohol. This recommendation rested partly on Brown's personal experience, since he had found opium to be an effective remedy against his fits of gout, which in his view resulted from debility or asthenia. He also referred to his own experiments with opium and the other five substances, that had suggested different degrees of stimulant effect. In consequence, the followers of Brown frequently administered opium preparations in order to raise the degree of excitement in states of asthenia, which – according to the system – characterized most diseases.

although opiates are among the oldest medicines known to human kind, they continue to spark new discoveries in the workings of the brain. And although they remain of interest at the cutting edge of pharmacological research, opiates continue to be mired in intractable social problems. This essay examines the attitudes of physicians toward opiates from about 1890 to 1940. As part of the larger effort to transform medicine into a powerful and self-regulating profession in this period, American physicians sought to increase their control over the distribution of medicines to the sick. In the late nineteenth century, the harm associated with the unregulated American drug market provoked reformers both within and without the profession to action. Opiates were a target of concern because of their prevalence in proprietary medicines, their centrality in therapeutics, their association with symptom-relieving rather than curative medicine, and the risk they posed for addiction. To gauge these concerns, I will examine two kinds of sources. First, charting the actions of the American Medical Association (AMA) shows the role of opiates in the public effort to transform medicine and shake off charges of iatrogenic addiction. Second, within the profession, more private concerns about opiates in medical practice can be traced by surveying textbooks and manuals of materia medica and therapeutics.

well known from earliest Greek history, the opium poppy (Papaver somniferum L.) occupied an important role in ancient pharmacy and medicine, and its use encompassed matters of dietetics as well as frequent employment as a soporific and general analgesic. Greco-Roman medicine and pharmacology incorporated a very succinct knowledge and command of the dangers and benefits in the use of the opium poppy, and actions of drugs were widely understood. Its harvesting, preparation, distribution, and application in general pharmacy and medical therapeutics all were sophisticated and as precise as was then possible. Our ancient sources attest repeatedly to this deep sophistication in the grasp and understanding of the opium poppy, and Hellenistic and Roman pharmacy had refined a lengthy and venerated tradition of multiple uses. Modern pharmacology and medicinal chemistry, of course, confirms much of this ancient expertise, even as we wrestle with the addictive effects of the major alkaloids commonly isolated and administered from the raw opium. One notes in the study of Hellenistic and Roman use of opium that the ‘natural product’ may have induced occasional addiction (and was certainly employed in suicides), but unlike the dangers explicit with the employment of morphine, codeine, thebaine, and other opium alkaloids in modern pharmacy and medicine, and ancients could presume their collected latex had benefits that far outweighed its dangers.