I met James Harvey Young, or Harvey as everyone called him, back in the early 1990s when he came to Pittsburgh to give two public lectures. Harvey Young was already something of a legend in my mind, having published The Toadstool Millionaires in 1961 and The Medical Messiahs in 1967. The former work served as the foundational historical survey of the American patent medicine business, the latter a remarkable survey of American health quackery. Not long before, Young had published what was at the time the definitive study of the fight for the Food and Drugs Act of 1906. I took the opportunity to attend both lectures and the chance to talk with him one on one. Harvey was an absolute delight, and very kind to me. He also, however, kind of bombed at the School of Pharmacy—more about that in a moment.
First, a word about Samuel Hopkins Adams. Back in 1955, a much younger Harvey Young, “spent several engrossing hours”[i] with Adams at his Beaufort, South Carolina home—almost fifty years after the launch of Adams’ famous series in Collier’s that exposed and condemned the patent medicine industry practices. Then, as now, Adams was understood to be one of the titans of progressive-era muckraking journalism, exposing corruption and dangerous practices among public and private institutions. Adams was then only just winding down decades of prolific writing[ii] and had cultivated an enormous network of friends and associates. Adams to Young to Spillane—if you know me, you are only three degrees from Adams. From Harvey’s footnotes we know he and Adams discussed Adams’ path into newspaper work and to Collier’s, his background interest in public health, and the details of his encounters with various patent medicine manufacturers.
Young and Adams were kindred spirits. Both absolutely believed that progressive reform could/did mitigate the worst practices of the patent medicine industry. Both absolutely believed that “Gullible America” would be led astray by peddlers of catarrh powders and soothing syrups. Both were struck by the fact that patent medicines enjoyed their greatest success at the very moment medical science was making significant breakthroughs; indeed, both argued that the very complexity and nuance of modern science ran against the “nature of man” (Toadstool Millionaires, p. 157) to search for certainty and for “things that cannot be” (Toadstool Millionaires, p. 253). Finally, both embraced the clear distinction between the ethical pharmaceutical industry and the patent medicine business.[iii]
Which brings me to Harvey Young bombing in Pittsburgh. What happened? The simplest version I can give is that many in the audience resisted his framing of consumers as dupes. When Adams and Young talked in 1955, Adams had no more faith in the consumer than he had fifty years earlier. And when Harvey Young arrived in Pittsburgh, his faith in the consumer was likewise no more robust that it had been thirty years earlier when Toadstool Millionaires appeared. But his student audience was growing up in the full flush of a de-regulatory impulse that was not merely the province of conservative and libertarian activists, but also of a generation of grassroots patient’s rights advocates that lobbied for broader access to medications, for the streamlining of the drug approval process, and for greater access to alternative medicines. Young’s traveling hokum show fell flat. When he started on nutritional supplements, in the words of the late Rick Nelson, “it was time to leave.”
I wasn’t buying it either. Peter Temin had blurred the formerly bright line between the ethical and patent medicine industries. Historians of consumer society were deploying new theoretical frameworks to explore consumer agency in ways theretofore unexamined. Lizabeth Cohen, one of my graduate professors, had explored the power of consumer behavior to help define collective identity and to challenge (admittedly with varying levels of success) the boundaries of conventional social structures. Perhaps the finest distillation of the revisionist line of thinking ever published was Paula Fass’ 1994 review of John Burnham’s Bad Habits: Drinking, Gambling, Sexual Misbehavior, and Swearing in American History. Fass attacked Burnham as “deeply unsympathetic, even hostile” (p. 411) toward the consumer, and Burnham’s “moral outrage” that echoed Adams’ “muckraking tradition” (p. 412). Not merely content to condemn behavior, according to Fass, “[Burnham] needs to demonstrate that a conspiracy of unsavory commercial interests gained significant material advantage from this transformation. This need to expose and uncover the seamy, tainted, money side, and track the conspiratorial is familiar to most people who have read populist-progressive literature and progressive historiography” (p. 413). “Like the good progressive,” Fass concluded, “Burnham would rather see the evil figures who manipulate and exploit behind the scenes…to save us from ourselves, especially those of us who have weak minds because we are ‘vulnerable non-middle-class people’” (p.413). In line with this way of thinking, I did not really buy the idea that cocaine consumers were dupes. They did not need the labelling rules of the Pure Food and Drug Act to show them cocaine in their catarrh cures—the cocaine was the reason for the purchase in the first place. Labeling rules simply made it more convenient for the would-be cocaine purchaser to identify the cocaine-laced brand they preferred. This revisionist perspective hung on for a while—the contributors to Andrea Tone and Elizabeth Siegel Watkins’ 2007 edited volume, Medicating Modern America, took a mixed approach to the consumer but it is not hard to spot the legacies of 1980s and 1990s revisionism.[iv]
Since then, drug historians have swung very hard back to the Adams-Young view of the victimized consumer. David Courtwright’s work on limbic capitalism shows him to be the true inheritor of the old Adams-Young formula, albeit in a newer and more sophisticated way. Courtwright shares their pessimism, observing in The Age of Addiction: “people face more, and more cunningly fashioned, inducements to harmful habits than at any point in history” (p. 206). Moreover, Courtwright adds a healthy dose of progressive virtue (itself rooted in Victorian moralism) to his analysis, calling for a renewed commitment to the principle of hormesis (a little is good, a lot is bad), and praise for “the faculty of impulse control on which social order depends.” These are sentiments which would have resonated with Adams himself, famously intolerant of over-indulgence (“Sam was puritanical and didn’t like overdrinking or coarse stories”[v] as one friend observed). This is work deeply embedded in cultural assumptions about the appropriate fulfillment of desire.
Adjacent to the Courtwright critique of limbic capitalism are resurgent histories of the consumer protection impulse and historical critiques of neoliberalism. In the former camp, David Herzberg explicitly highlights the Controlled Substances Act as the “inheritor of a tradition of pioneering food and drug safety laws.”[vi] I noted the same thing about twenty years ago, but back then chose to emphasize the extent to which consumer-protection-rooted scheduling could misunderstand the consumer. Herzberg is probably right that industry regulation rooted in consumer protection is a better and more rational approach than punitive prohibition, but it has never been that rational, and arguably understood the consumer little better than its punitive counterpart. As for the critique of neoliberalism, Kathleen Frydl’s important work on the origins of the opioid crisis speaks bluntly: “we can see that the American opioid crisis is a drug epidemic made, and made catastrophically worse, by neoliberalism.” In a world where industry pulls the strings, Frydl argues that “to rely on a physician’s judgment to make sense of an exploding market in prescription drugs was, in effect, to delegate medical decision-making to Madison Avenue advertising budgets.”[vii]
Courtwright, Herzberg, and Frydl are all outstanding historians, whose work I admire and which influences my own. So, now what? Is there any space in our current historical work to take the drug consumer seriously while still acknowledging the need for intelligent regulation and highlighting the dubious practices of industry? Maybe leaving on a question is a cop-out. I am hopeful, though, that we will consider what the revisionist histories of the 80s and 90s had to say, and work toward integrating these into the next wave of scholarship.
Endnotes
[i] James Harvey Young, The Toadstool Millionaires: A Social History of Patent Medicines in America Before Federal Regulation (Princeton: Princeton University Press, 1966), 266.
[ii] Indeed, four days before meeting with Young, Adams learned from Bennet Cerf that his latest book (Grandfather Stories) had been chosen by the Book of the Month Club as its midsummer selection. Samuel V. Kennedy III, Samuel Hopkins Adams and the Business of Writing (Syracuse: Syracuse University Press, 1999), remains an indispensable biography.
[iii] James Harvey Young, for example, observes the postwar rise in the marketing of tranquilizers in The Toadstool Millionaires, but only in passing as he condemned the shadowy enterprises that sold fake knockoff tranquilizers.
[iv] Tone’s perceptive work on tranquilizers emphasized the “unexpected trajectories of medical inventions and the social construction of consumer markets” (p. 157). More directly (p. 163) she observed that “to view the diffusion of Miltown as a top-down process turns patients into pawns and occludes instances of patient influence and negotiation that, as historian Roy Porter and others have argued, have always given medicine its dynamic character and shape.” Viewing this as a top-down process, according to Tone, also avoided “the difficult question of what made Americans anxious in this first place” (p. 167). Studies of the role of patient/consumers in drug diffusion goes back decades; see, for example, J.S. Coleman, E. katz, and H. Menzel, Medical Innovation: A Diffusion Study (Indianapolis: Bobb-Merrill, 1966). Tone was just one of many historians influenced by Roy Porter, “The Patient’s View: Doing Medical History From Below,” Theory and Society 14 (1985): 175-198. Along the same lines, from the same moment, see Catharine Riessman, “Women and Medicalization: A New Perspective,” Social Policy (Summer 1983), 3-18. For a broadly influential revisionist perspective on commodities and consumption, see Arjun Appadurai’s framework for discussing the different spheres of knowledge-productive, knowledge-circulation, and knowledge-consumption in “Introduction: Commodities and the Politics of Value” in Appadurai, ed. The Social Life of Things: Commodities in Cultural Perspective (Cambridge: Cambridge University Press, 1988), 3-63.
[v] Kennedy, Samuel Hopkins Adams, 125.
[vi] David Herzberg, “Between the Free Market and the Drug War,” in David Farber, ed. The War on Drugs: A History (New York: New York University Press), 274.
[vii] Kathleen Frydl, “The Pharma Cartel,” in David Farner, ed. The War on Drugs: A History (New York: New York University Press), 305, 311. For an excellent review of the critical literature on Big Pharma and their influence on medical practice and prescribing, see Howard I. Kushner, “The Other War on Drugs: The Pharmaceutical Industry, Evidence-Based Medicine, and Clinical Practice,” Journal of Policy History 19 (2007), 49-70.