The Creation of the
National Institute on Alcohol
Abuse and Alcoholism
Responding to America's
Alcohol Problem
BRENDA G. HEWITT
BRENDA G. HEWITT is
a special assistant to the director of the NIAAA, Bethesda, Maryland. This article is adapted from an article that was originally
published in Alcohol Health & Research World, Vol., 19, No.1, 1995.
Although they had founded their
own national society and their own treatment
program, people
recovering from alcoholism in the 1960's realized that Americans did
not recognize
the alcohol-dependent person's plight. Thus, a few dedicated individuals
set out
to establish, through Federal legislation, a nationwide effort to combat
alcoholism
KEY WORDS: government
agency, AOD abuse, AOD dependence, history; AOD-related (AODE) problems;
legislation
Twenty-five years ago, Congress passed and President
Richard M. Nixon signed the Comprehensive Alcohol Abuse and Alcoholism
Prevention, Treatment, and Rehabilitation Act of 1970 (Public Law [P.L].)
91-616). Referred to as the "Hughes Act" for
the pivotal role played by Senator Harold E. Hughes in its passage,
this law recognized alcohol abuse and alcoholism as major public health
problems and created the National Institute on Alcohol Abuse and Alcoholism
(NIAAA) to combat them. The
road to the passage and signing of this legislation was not easy. In
the end, it required the courage of a number of recovered alcoholics
"going public," the initiative and resourcefulness of a freshman
U.S. Senator (who persevered despite a lack of funding for his Special
Subcommittee on Alcoholism), and the intercession of three individuals
in the waning hours of New Year's Eve in 1970 to convince the President
to sign P.L. 91-616 into law. The story of P.L. 91-616's passage is remembered with
pride by those who were there and is deserving of retelling on this
occasion-the 25th anniversary of NIAAA.
AMERICA's ALCOHOL PROBLEM
From
the time the first colonists arrived in the New World
bringing their alcoholic beverages with them, Americans have had a problem
with alcohol. That problem is a historic inability to reach any kind
of a national consensus about the role of alcohol in American society.
Americans' inability to reach such a consensus, in turn, has led to
fits and swings in public perception and, consequently, in public policy
concerning how best to deal with the individuals whose use of alcohol
causes difficulties and the difficulties these individuals cause. As
observed by Selden E. Bacon, former director of the Center
of Alcohol Studies at Rutgers
University and eminent scholar
on alcohol problems in America:
This complex set of problems over the
past 150 years has been defined as a moral weakness problem and turned
over to the churches, defined as an economic problem and turned over
to market and price control authorities, defined as a youth learning
problem and turned over to educators, defined as a crime problem and
turned over to law enforcement and correction agencies (U.S. Congress
1970, p. 115).
Several major shifts have occurred
in the way Americans have perceived and responded to Alcohol problems
from the colonial era to the temperance era (including Prohibition)
and from the temperance and Prohibition era to the present (Moore and
Gerstein 1981; Jung 1994).
The Colonial Era: Alcoholism Is a Sin
During the colonial period in America,
alcohol was very much a part of a community's social life. Alcohol was
used widely as both a beverage and a medicine, generally being considered
a substance that was both enjoyable and healthful. Even drunkenness
was tolerated so long as it did not interfere with a person's livelihood
or religious observance. In the colonial view, the problem was not alcohol,
but the individual who used alcohol. Habitual drunkenness,
which kept people from working and praying, represented a weakness of
character and a sin against God and the church. Punishment was
colonial America's
response to such weakness, and the stocks (i.e., structures that confined
the arms and legs of social miscreants for public chastisement) were
the colonial era's equivalent of the alcoholism treatment facility.
The Temperance Era: The Demon Is Rum
During the mid - to late -19th century, attempts
to respond to alcohol problems shifted from trying to control the individual
to trying to control the substance. With the Nation's population transforming
from an agrarian to an industrial society, new social problems, such
as poverty and crime, began to emerge (Jung 1994). Each of these social
ills was seen as connected to alcohol use. In response, a social reform
movement was born that began to focus on eliminating alcohol use as
a means of eliminating social problems. Aggressive public information
and legislative activities of anti-alcohol groups, such as the American
Temperance Society1, the Women's
Christian Temperance Union, and the Anti-Saloon League, with their images
of "demon rum" and ax-toting women, helped change Americans'
perceptions of alcohol problems and caused them, in response, to consider
them, eliminating the substance. Moore and Gerstein (1981) note that
during this period,
... the excessive
drinker came to be seen as someone who was ravaged and transformed by
an alien substance. Otherwise decent people could be transformed by
drink to become dissolute, violent, or degenerate. Moreover, since alcohol
was an addicting substance, even the most moderate drinker flirted with
danger at the rim of every cup (p. 9).
Although alcohol-related health problems
generally were not a major consideration during the temperance era,
there is some historical evidence that even during the hey-day of the
anti-saloon leagues, some attention was given
to the social and health consequences of problems drinking. According
to medical historian Phillip J. Pauly:
In the early 1890's, Seth Low, a wealthy
businessman, president of Columbia
University and future mayor
of New York [City], led
the Sociology Group, an informal discussion circle of academic, commercial,
and religious liberals interested in urban problems. In 1893 the group
began to discuss alcohol, and became so persuaded of the need for knowledgeable,
moderate action that they expanded to become a formal organization.
The resulting Committee of Fifty for the Investigation of the Liquor
Problem proposed to sponsor fact finding reports on the legal, economic,
ethical, and ... physiological aspects of alcohol use (Pauly 1990, pp. 366-392).
Not much came of the Committee's efforts as the national
climate moved toward Prohibition, and 1919 saw the passage of the Volstead Act, ushering in the legal abolition of alcohol consumption.
Reaction and Inaction
Prohibition was both a success and a failure. According to the Cooperative Comn-ds.
sion on the Study
of Alcoholism,2 on the one hand:
... rates of
problem drinking ... decreased substantially during the early years
of Prohibition .... reported deaths from liver
cirrhosis also declined as did hospitalization for alcoholism. Arrests
for public drunkenness were much lower than earlier (Plaut
1967, pp. 132-133).
On the other hand, "Prohibition was experienced
as an intolerable abridgement of personal freedom by many Americans"
(Plaut 1967, pp. 132-133). Thus, although
Prohibition achieved the goal of reducing alcohol-related problems,
Americans found the loss of personal autonomy in the matter of alcoholic
beverages excessive and voted to repeal the Volstead Act in 1932.
The experience of Prohibition led next to an era, from
the 1930's through the 1960's, in which alcohol-related problems generally
were ignored. The Cooperative Commission aptly sums up the situation:
The unique place of alcohol beverages in American culture
is evidenced by the fact that only one Amendment to the United States
Constitution has ever been repealed; that was the Eighteenth, or Prohibition,
Amendment.... The Prohibition Amendment was an attempt to "legislate
morals"; repeal of the Amendment was taken as evidence that the
American people felt this attempt had not succeeded, or indeed, was
an example of the medicine's being even worse than the illness. The hostile and
apprehensive reaction to this particular means of regulation has unfortunately
been transferred to the general idea of a comprehensive approach [to
alcohol problems]. As a result, proposals to change drinking patterns-whether
by educational, legislative, or other means-are still likely
to evoke charges of disregarding the "lessons" of the Prohibition
(Plaut 1967, pp. 14-15).
Fortunately, although many Americans
tried very hard to forget about alcohol problems after Prohibition,
changes were taking place in science and medicine, among public and
private helping agencies, and, most importantly, among the group most
affected by alcohol problems-the alcoholics themselves-to redefine alcohol-related
problems as health problems.
THE
BEGINNING OF CHANGE
The
private and public sectors undertook actions that revitalized the national
debate about alcohol-related problems and laid the groundwork for Federal
legislation. In the private sector, both the founding in 1935 of the
fellowship of Alcoholics Anonymous (AA) and the growing acceptance of
alcohol abuse and alcoholism as health problems by scientific and medical
organizations were pivotal events in helping to reintroduce the national
policy debate on alcohol-related problems. The success of AA helped
to demonstrate that alcoholics could recover. The establishment in the
mid-1930' s of the Research Council on Problems of Alcohol at Yale
University and the initial
publication in 1940 of the scholarly journal Quarterly Journal of Studies
on Alcohol were instrumental in recasting the public perception of alcohol
abuse and alcoholism as problems that would yield to scientific solutions.
The National Committee for Education on Alcohol (later called the National
Council on Alcoholism), founded in 1944 by Marty Mann, the first woman
to recover through AA, and researchers and physicians from Yale University,
also helped to spread the word. By the 1950's major health care organizations,
such as the American Medical Association and the World Health Organization,
began to address the health care aspects of alcoholism and the discrimination
against alcoholics in health care settings. By the 1960's these groups
were joined by the American Psychiatric Association and the American
Public Health Association in declaring alcoholism an illness (Plaut
1967).
On the public side, by this time several
States, such as California
and Maryland, also had
begun to develop programs to provide treatment and other supportive
services to alcoholics, although these were often under- funded and
not coordinated with the general health care system.
Despite these activities, public opinion
was slow to move away from the view of alcohol abuse and alcoholism
as moral or criminal issues. Federal programs to combat alcohol problems
also were limited. By the 1960's the National Institute of Mental
Health (NIMH) in the U.S. Public Health Service had begun a very small
program of grants in the alcohol area, leading to the establishment
in 1965 of the National Center
for the Prevention and Control of Alcohol Problems. The Center, however,
had limited program authority and a limited budget. The situation with
research was even more dismal. As asserted by the Cooperative Commission
on the Study of Alcoholism in its 1967 report:
Additional information about the nature
and causes of problem drinking is urgently needed. Past research in
this area has been uneven and sporadic.... While special attention to
alcohol problems is currently required ... research in this field cannot
be developed in isolation from investigations of a basic science nature
and those on other medical and psycho-social problems (Plaut
1967, pp. 50 and 52).
There was a general feeling among
advocates that the only way to sway public opinion and to address comprehensively
alcohol abuse and alcoholism was from the national level through a highly
placed and therefore highly visible Federal organization. For
this, legislation was required, and it was to this end that the many
disparate alcohol-related organizations came together in 1968.
One person who was involved intimately
in the struggle for Federal recognition of and support for alcoholism
legislation was the late Thomas P. Pike, a wealthy businessman from
Los Angeles, California.
In his Memoirs of Thomas P. Pike (1979), Pike himself a recovering alcoholic, speaks of the man whose name
was to become indelibly linked to NIAAA's
creation:
Then, in 1969, I met an extraordinary
man in Washington (DC) who convinced me that it was entirely possible
to realize our "impossible dream" of reaching the many, sur-mounting the huge barriers of public ignorance and ultimately
changing societal attitudes and removing stigma from alcoholism ..... This was the Honorable Harold Hughes, recovered
alcoholic, former governor of Iowa,
then a freshman U.S. Senator (Pike 1979, p.237).
Immediately upon arriving in office, Senator Hughes
was determined to move quickly in developing legislation addressing
alcohol problems. To this end, he elected to take on the chairmanship
in 1969 of a newly formed Special Sub-committee on Alcoholism and Narcotics
of the Senate Labor and Public Welfare Committee, even though funds
were not available for its operation. Instead, Senator Hughes found
a growing body of volunteers to do the work and donated his fees from
speaking engagements to provide the necessary funding to bring the issues
of alcohol abuse and alcoholism before both Congress and the American
people.
The first hearing of the Special Sub-committee on Alcoholism
and Narcotics was held in Washington,
DC, on July
30, 1969. Among those testifying at this event were Mann
and Bill Wilson, one of the AA founders. According to Pike:
Bill Wilson's testimony before the Senate
Alcoholism Subcommittee was historic and it was electrifying. The members
of the Subcommittee listened to him with respect and rapt attention
as Bill sketched the history of AA, described alcoholism as only he
could, spoke of the desperate need for research and made an impassioned
plea for long overdue and desperately needed Federal legislation and
funding (Pike 1979, p. 240).
In 14 hearings held across the country during the summer
of 1969, the Special Subcommittee received testimony from scientists,
religious leaders, politicians, alcoholism treatment providers, and
recovered alcoholics-individuals of disparate backgrounds who came together
to tell the Nation that it was time to do something about the problems
of alcohol abuse and alcoholism.
Based on these hearings, on May 14, 1970, Senator Hughes introduced into the Senate S.
3835, a bill intended to provide a comprehensive Federal program that
would address the prevention and treatment of alcohol abuse and alcoholism.
At this point, the bill faced a long road to enactment. Not only did
it need to pass both congressional houses, but it also had to be signed
by President Nixon, whose Executive Branch opposed the creation of the
proposed NIAAA.
Public testimony on S. 3835 was held in the Senate
on May 21 and 25, 1970. Among those who testified were Peter Domick,
U.S. Senator from Colorado; Luther A. Cloud, president of the National
Council on Alcoholism; Maxwell Weisman, director of alcohol programs
for the State of Maryland; Marvin A. Block, of the Committee on Alcohol
and Drug Dependence of the American Medical Association; Morris E. Chafetz,
of Massachusetts General Hospital (and later the first director of NIAAA);
and Selden E. Bacon. The bill was passed unanimously by the Senate on
August 10.
House Approval
Despite this auspicious beginning, the timing of S.
3835's passage by the Senate late in the second session of the 91 st
Congress made final enactment even more uncertain. As the bill reached
the House floor, a crowded December calendar threatened to postpone
its passage. If the House did not reach a decision by the
end of its 1970 session, S. 3835 would have to begin the legislative
process over again in the coming year. However, with the behind- the-scenes
participation of a key Congressman, Pike managed to slip the bill into
position for a vote "in the nick of time" (Pike 1979). A version
of S. 3835 passed the House on December 15, placing the proposed NIAAA
within NIMH instead of granting it independent status. Senator Hughes
accepted the House version in the interest of time. S. 3835 had only
one more hurdle before reaching enactment.
Enactment
Once more poised on the brink of success,
those in the alcohol field were dismayed to learn that the new P.L.
91-616 might not become a "law of the land." According to
Pike, members of President Nixon's cabinet had advised him to veto the
bill. Pike, along with other influential participants in the movement
to pass the legislations, 3 joined
"in a concerted effort to persuade the President to sign this legislation
into law." On New Year's Eve in 1970, President Nixon signed P.L.
91-616, the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment,
and Rehabilitation Act of 1970. This legislation was called by Pike
"a landmark in Public Health Legislation ... (that) came to be
known as alcoholism's Magna Carta (Pike 1979,
p. 241).4
There was no public ceremony. Very
few people outside the nascent alcohol field were aware that history
was being made. Yet December
31, 1970, marked not a year's ending but an Institute's beginning.
P.L.
91-616: THE CREATION OF NIAAA
The
landmark legislation that created NIAAA represented to many in the alcohol
field the culmination of the United States'
attempts to deal with its alcohol problem. In his foreword to the First
Special Report to the U.S. Congress on Alcohol and Health issued in
December 1971, Secretary of Health, Education, and Welfare (HEW) Elliot
L. Richardson noted:
We have emerged from an era when alcohol
abuse and alcoholism were equated by the public with moral degeneration
and despair to the day in 1970 when President Nixon signed into law
the land mark Public Law 91-616.... This law followed a historical precedent
of bringing together diverse and often divided interests in our society
in support of a major public health measure (NIAAA 1973, P. V).
NIAAA's Mission
P.L. 91-616 established NIAAA as an organizational
component of NIMH and instructed NIAAA to
... develop and
conduct comprehensive health, education, research, and planning programs
for the prevention and treatment of alcohol abuse and alcoholism and
for the rehabilitation of alcohol abusers and alcoholics (P.L. 91-616,
p. 1)
In addition to creating NIAAA, P.L.
91-616 did the following:
- Required that alcoholism programs be made available
to Federal civilian employees.
- Authorized the appropriation of Federal funds to the
States via a formula grant mechanism to assist them in planning, establishing,
maintaining, coordinating, and evaluating projects for the development
of more effective prevention, treatment, and rehabilitation programs.
- Prohibited discrimination in the hiring and firing of
recovered alcoholics in non- security jobs.
- Authorized grants and contracts for education and training
purposes and for demonstration and evaluation projects that provide
treatment and prevention services.
- Required the admission of alcohol abusers and alcoholics
to any public or private general hospital receiving Federal funds
for alcoholism treatment programs on the basis of medical need, and
prohibited discrimination against this population solely because of
their alcoholism.
- Required that the records of patients in alcoholism
treatment be kept confidential.
- Established a National Advisory Council on Alcohol Abuse
and Alcoholism to advise, consult with, and make recommendations to
the Secretary of HEW on matters relating to the activities and functions
of the Secretary in the field of alcohol abuse and alcoholism.
Interestingly enough, particularly in light of NIAAA's present research mission and the testimony by many
in the alcohol field of the need for scientifically based knowledge
about alcohol abuse, alcoholism, and related problems, the original
law establishing NIAAA did not include a specific section relating to
research. This function, rather, was authorized through the broad research
authorities of Section 301 of the Public Health Service Act. It was
not until the passage of P.L. 94-371 in 1976 that NIAAA gained
a discrete research authority.
INDEPENDENCE
Members
of the alcohol movement who felt strongly that the needs of alcoholic
persons would not receive the national attention and priority necessary
to effect change if NIAAA remained under the mental health mantle continued
to push for NIAAA's independent status. Even
before P.L. 91-616 was enacted, many organizations supporting the law
had favored placing NIAAA on its own within HEW's
U.S. Public Health Service (Lewis 1988). Although Senator Hughes had
accepted the House's placement of NIAAA within NIMH in 1970, NIAAA's
autonomy had been his original intention in S. 3835. Thus, the stage
was set for yet another major event in NIAAA's
history its elevation from an Institute
of NIMH to a fully autonomous
Institute of the newly created Alcohol, Drug Abuse, and Mental Health
Administration (ADAMHA; figure 1).
In his preface to the Proceedings
of the Third Annual Alcoholism Conference of the National Institute
on Alcohol Abuse and Alcoholism, then NIAAA Director Morris Chafetz
noted that "This time the signing took place-not in the dark stillness
of the night- but in the bright ceremonial atmosphere of the Oval Office"
(Chafetz l974, p. iii), To many, the creation
of a separate, visible National Institute devoted to addressing comprehensively
the problems of alcohol abuse and alcoholism was the true ending of
the story that had begun some 35 years ago.
EPILOGUE
Since
the passage of P.L. 91-616 25 years ago, NIAAA's mission
has evolved significantly. Changes have occurred in its leadership,
its organizational home, and its primary program emphasis. True to the
legacy of P.L. 91-616, however, NIAAA's commitment
to discovering the best ways to prevent and treat alcohol abuse and
alcoholism in America still embodies the strong hopes and dedication
of those who fought for this Institute's creation and who helped to
define alcohol abuse and alcoholism, not as problems experienced by
a few but problems affecting us all.
FOOTNOTES
1 The early
temperance movement advocated "temperate," or moderate, use
of alcohol. This began to change to an anti-saloon message around the
1850's.
2 The Cooperative
Commission on the Study of Alcoholism was established by a grant from
the National Institute of Mental Health in 1961. It was the first national
body established by the Federal Government to assess what the country
was doing to respond to alcohol problems and to recommend ways to improve
existing alcohol-related policies and programs.
3 Members
of the movement who joined Pike in persuading the President included
James Kemper, of the Kemper Insurance Company: Brinkley Smithers, of the Smithers Foundation:
and Donald Kendall. of Pepsi Cola.
4 Author's
Note: In reading the personal accounts of the late Thomas Pike, who
participated in the Special Subcommittee hearings, and the record of
those hearings, this is the only reference I have seen to P.L 91-616
as the alcoholic's "Magna Carta."
Most of the witnesses who testified before the Special Senate Subcommittee
referred to P.L 91-616 as the "Alcoholics' Bill of Rights."
Given Pike's deep and abiding belief that alcoholics can be set free
from their dependency, perhaps the use of Magna Carta
as the quintessential basis for all human rights is the more appropriate
anology.
REFERENCES
CHAFETZ, M., ed. Alcoholism: A Multilevel Problem. Proceedings of the Third Annual
Alcoholism Conference of the National Institute on Alcohol Abuse and
Alcoholism. Department of Health, Education,
and Welfare Pub. No. ADM 75-137. Washington,
DC: U.S.
Govt. Print. Off., 1974.
JUNG, J. Under the Influence:
Alcohol and Human
Behavior. Pacific Grove,
CA: Brooks/ Cole Publishing Company,
1994.
LEWIS, J. Congressional rites of passage for
the rights of alcoholics. Alcohol
Health & Research World 12(4):240252,1988.
MOORE, M. H. AND GERSTEIN, D.R., eds. Alcohol and Public Policy: Beyond the Shadow of prohibition. Washington,
DC: National
Academy Press, 1981.
NATIONAL INSTITUTE ON ALCOHOL ABUSE AND ALCOHOLISM.
First Special Report to the U.S. Congress
on Alcohol and Health. Pub. No. HSM
(73903 1), Rockville, MD:
U.S.
Department of Health, Education, and Welfare, 1973.
PAULY, P.J. The struggle for ignorance
about alcohol: American physiologists, Wilbur Olin Atwater, and the
Woman's Christian Temperance Union. Bulletin
of the History of Medicine 64(3):366392,1990.
PIKE, T.P. Memoirs of Thomas
P. Pike. Pasadena, CA:
Grant Dahlstrom, The
Castle, 1979.
PLAUT, T.F. Alcohol Problems: A Report to the Nation by the Cooperative Commission on the Study of alcoholism.
New York: Oxford
University Press, 1967.