The Politics of Addiction: Medical Conflict and Drug Dependence in England since the 1960s by Sarah G. Mars (review)

The end of the 1970s was a watershed in the history of illicit drug use in Britain. Fears of drug abuse were already mounting in the 1960s and early 1970s. But they seem to be of a different nature than the concerns about the explosion of an illegal heroin trade and of the estimated number of heroin users—two thousand in 1977, one hundred thousand in 1987. Since then the field of illicit drug use changed again and again: in the later 1980s the arrival of HIV/AIDS forced the acceptance of policies of harm reduction. At the end of the 1990s focus shifted again to the relationship of dependent drug use and acquisitive crime.

All these changes went together with changes in the medical treatment of dependent drug users and in the policies concerning these treatments. In 1984 the Department of Health and Social Security issued the first official guidelines in British medicine, setting standards for “good clinical practice” in addiction treatment. Seen by some as an example of the increase of state authority at the expense of medical autonomy, the detailed analysis of Sarah Mars, in her new book on the history of the decision-making process of addiction treatment in England from the 1970s till the present day, shows (inevitably) that the matter is much more complicated.

Mars wrote her thesis, upon which this book is based, under the supervision of Virginia Berridge of the London School of Hygiene and Tropical Medicine. The Politics of Addiction should be read in the context of other studies by Berridge, and by another Ph.D. student of hers, Alex Mold. These studies focus on decision-making processes in the drugs field and of the interaction among politicians, state bureaucracies, medical practitioners, and voluntary associations. Mars presents us with a detailed empirical description and analysis of how decisions on addiction treatment were made. She has used extensive archival sources of involved organizations and individuals. But the most important source deciding the outcome of her study seems to be the interviews that she conducted with twenty-seven doctors in the years 2000–2003, most important because these interviews have given Mars the “behind-the-scenes” glimpses that contribute to her conclusion that the history of addiction policy since the 1970s is also the history of a conflict of power between different factors of doctors—more in particular between London clinicians and consultants, well represented in the General Medical Council (the medical regulatory body) on the one hand, and private practitioners on the other. Reading Mars, we are once more forced to conclude that the history of drugs is a history of (attempts) to control. In The Politics of Addiction the contestation is about the way to do addiction treatments, and about who is allowed to prescribe drugs, a contestation that is lost by the private practitioners and their self-organizations, who have less influence in formulating guidelines and other policies than the London consultants. Mars explains this difference in power using the analytical concepts of the cultural theory of Mary Douglas. The private practitioners are a loosely connected group who cherish their autonomy and do not succeed in formulating alternative guidelines. The London consultants meet each other regularly formally and informally, and have good connections with representatives of state bureaucracies. The General Medical Council disciplines private practitioners. In Mars’s analysis the issue is not a case of strengthening state authority over the medical profession, but of the alliance of one part of the medical profession with an arm of the state to control the practice of a second group of doctors. Though after 1984 new developments reduce the importance of the London consultants, private doctors remain unable to influence policies.

Mars’s analysis in itself is convincing. Moreover, it helps us to address historical problems that transcend...