Pubdate: Tue, 13 May 2008
Source: AlterNet (US Web)
Copyright: 2008 NYU Press
Authors: Wendy Chapkis and Richard J. Webb
Note: Wendy Chapkis and Richard J. Webb are the authors of "Dying to 
Get High" by NYU Press, 2008.


The Fine Line Between Good Medicine and 'Dangerous Drugs'

A History of the Battle Between Politics and Science Over the Use of 
Marijuana As a Medicine.

The following is an excerpt from "Dying to Get High" by Wendy Chapkis 
and Richard J. Webb (NYU Press, 2008). Reproduced by permission of 
the publisher.

For many modern critics, the concept of "medical marijuana" is a 
contradiction in terms. Medicine is standardized, synthetic, and 
pure; marijuana involves the unrefined and promiscuous coupling of 
more than four hundred components rooted in the dirt. Medicine -- in 
its most powerful and privileged forms -- rests in the hands of men, 
while the most potent form of marijuana is found in the female 
flowering plant. Medicine engages in heroic battles against death. 
Marijuana claims only to enhance the quality of life.

Medicine presents itself as an objective science safeguarded by the 
ritual of the double-blind, randomized clinical trial. The 
therapeutic value of marijuana relies largely on the "soft science" 
of subjective experience and anecdotal evidence. From the perspective 
of its critics, then, cannabis is an effeminate interloper in the 
masculine world of real medicine, a dangerous drug pushed on a 
credulous public by illegitimate quacks.

But this story is too simple. The line separating regular doctors 
from snake oil salesmen, good drugs from bad, is as much the product 
of politics as it is of science. The dominance of politics in 
determining the value of marijuana as a medicine was first 
demonstrated in the 1930s when the federal government began to 
restrict the medical use of marijuana, against the recommendations of 
the American Medical Association (AMA).

The struggle between politics and science over the use of cannabis as 
a medicine continues. In the final decade of the twentieth century, 
the federal government threatened physicians with the loss of their 
license for recommending marijuana to patients, made criminals of 
patients who followed their doctor's advice, and actively blocked 
scientific research into the therapeutic value of cannabis, while 
insisting that it was an established scientific fact that marijuana 
is not a medicine.

During the opening of a 2004 congressional hearing on medical 
marijuana, this ongoing battle over cannabis was described by 
committee chair Rep. Mark Souder (R-IN) as a critical front in the 
War on Drugs and consistent with the modernization of medicine:

This hearing will address a controversial topic, the use of marijuana 
for so-called medicinal purposes. In recent years, a large and 
well-funded pro-drug movement has succeeded in convincing many 
Americans that marijuana is a true medicine to be used in treating a 
wide variety of illnesses .... Marijuana was once used as a folk 
remedy in many primitive cultures, and even in the 19th century was 
frequently used by some American doctors, much as alcohol, cocaine, 
and heroin were once used by doctors. By the 20th century, however, 
its use by legitimate medical practitioners has dwindled, while its 
illegitimate use as a recreational drug has risen.

Souder thus sets the stage for a morality tale populated by primitive 
practitioners and legitimate doctors, dangerous drug fiends and 
decent drug warriors.

Fox News personality Bill O'Reilly invoked a similar cast of 
characters in his 2004 discussion of medical marijuana with U.S. 
Deputy "Drug Czar" Dr. Andrea Barthwell. That year, voters in Oregon 
were to be presented with a ballot measure to amend their state's 
already-existing medical marijuana law. The proposed amendment (which 
ultimately failed) was intended both to increase the amount of 
marijuana a patient could have over the course of a year and to 
redefine which health professionals could legally recommend marijuana 
for medical use.

O'Reilly scoffed at the idea that licensed health practitioners other 
than physicians might be authorized to recommend the use of cannabis 
to their patients: "Even a shaman could grant permission for you to 
toke in Oregon. I mean, this is, you know, any health practitioner. 
So you're a shaman from the Amazon and you set up shop. Come on, I 
mean, everybody knows this is a ruse. Am I wrong?" Andrea Barthwell 
confirmed for viewers that O'Reilly's concerns were quite legitimate: 
"No, you're absolutely right, Bill. This is what we've been trying to 
make clear to people when they have these proposals presented to 
them. This is not about getting medicine to people who are sick and 
dying. This is about making marijuana legal."

While both host and guest shared the belief that the Oregon proposal 
was no more than a thinly disguised attempt to legalize marijuana, 
O'Reilly asked whether cannabis itself might not be a legitimate 
medicine if prescribed by a legitimate physician to a patient with a 
legitimate need: "But there is a legitimate issue here, Doctor. We 
had Montel Williams [another popular TV talk show host] on a few 
weeks back. He has MS [multiple sclerosis]. And I believe Montel 
Williams when he says, 'Look, medical marijuana helps me, helps me 
cope with this disease, cope with my suffering. There's no reason why 
I should be denied it.' And I agree with Montel Williams that if this 
is the case, if a doctor -- a doctor -- says that he needs it for his 
MS, he should have it. You don't disagree with that, do you?" 
Barthwell's response was uncompromising: "Well, I do, actually. There 
is nothing that tells us from the science now that smoked, crude 
botanical should be a medication. We have a process that has been in 
place for 100 years in this country that protects the sick and dying 
from snake oil salesmen. And just because something makes you feel 
better doesn't make it medicine."

In this short exchange, the terms of the debate for dismissing 
cannabis therapeutics are neatly laid out: medical marijuana is a 
ruse; cannabis is the modern day equivalent of "snake oil"; "crude 
botanicals" are not real medicine; licensed alternative health 
practitioners are not legitimate healers; marijuana is reduced to and 
synonymous with smoking as a delivery system; and "feeling better" 
isn't always therapeutic. Taken together, these claims create a neat 
division between marijuana and "real medicine," with medicine 
narrowly defined as that which is practiced by physicians prescribing 
pharmaceuticals to patients who will not necessarily feel better as a result.

The Rise of "Regular" Medicine and the Battle Against Botanicals

According to Dr. Raphael Mechoulam, an Israeli research chemist who 
performed much of the original work in the early 1960s isolating the 
active ingredients in marijuana: From ancient times to the early 20th 
Century, cannabis was used for a wide variety of medical purposes 
including the treatment of pain and swelling, depression, arthritis, 
impotence, kidney stones, hemorrhaging in childbirth, irregular bowel 
movements, cold sores, distending stomach, dropsy, headaches, 
diseases of the respiratory organs, hysteria, neuralgia, sciatica, 
tetanus, dysentery, fatigue, disorders of the female reproductive 
system, convulsions, cholera, delirium tremens, vomiting, spasmodic 
asthma, and a host of other ailments. Most of these therapeutic 
claims were either based on folklore or were anecdotal, but the use 
of cannabis as a therapeutic agent in the past provides an insight 
for future drug development. More recently, some of the historical 
therapeutic properties of cannabis have been verified with pure 
natural or synthetic cannabinoids; however, in several fields no 
modern scientific work exists.

In order to understand why marijuana, a promising medicinal 
botanical, should now be excluded not only from the modern 
pharmacopeia but also from much formal scientific study, it is 
necessary to ask why some drugs, but not all, get labeled "medicine"; 
why some healers, and not others, are "regular doctors"; why some 
effects, but only some, are understood as "therapeutic"; and why some 
risks are acceptable while others are prohibited under penalty of 
law. The answers cannot be found in a simple appeal to scientific 
standards. Instead, in order to understand what counts as 
"legitimate" medicine, it is useful to ask who, beyond the patient, 
might benefit from such distinctions. In our exploration of the role 
of organized medicine, state regulatory agencies, the courts, and the 
pharmaceutical industry in the demonization of marijuana, the intent 
is not to perform the reverse process, demonizing modern medicine. 
Over the past century, during which organized medicine consolidated 
its authority and cannabis was first marginalized and then removed 
from the pharmacopeia, astonishing medical advances have been made. 
Unquestionably, the public would be ill served by a return to a time 
of unregulated medicine practiced by poorly trained doctors with 
recourse to few effective drugs.

Nonetheless, it is also the case that the healing arts remain an 
impure science. The most striking difference between marijuana and 
"real medicine" is not the physical but the social effects the plant 
has on users and healers alike. Association with marijuana marks 
those it touches as illegitimate -- a distinction with deep 
historical roots. Prior to the professionalization of medicine, lay 
healers -- often women -- made extensive use of medicinal plants. But 
as modern medicine moved into the ranks of the professions, and into 
hands of men, botanicals were discredited along with the women who 
had used them. In their pathbreaking study of the rise of the male 
medical expert, For Her Own Good, Barbara Ehrenreich and Deirdre 
English note that, in the fifteenth and sixteenth centuries, anxiety 
over women's knowledge of medicinal botanicals contributed to the 
European witch hunts: charges against the accused often included the 
provision of herbs.

In Colonial America and the early republic, health and healing 
practices also rested largely in the hands of lay women practicing 
herbal medicine. Historian Carol Smith-Rosenberg observes that "women 
as midwives and as family nurses, women wise in the ancient herbal 
pharmacopoeia, had always cared for their own and neighboring 
families. A survey of cookbooks and women's diaries for the 
eighteenth and early nineteenth centuries shows that women collected 
and exchanged recipes for medicines as routinely as they did for pies 
and cookies."

By the nineteenth century, however, as medicine entered the 
marketplace, male physicians with little formal training claimed for 
themselves the designation "Regular doctor" while moving all others 
to the margins of the healing arts. In North America, midwives, 
bonesetters, and "root and herb" doctors were thus gradually 
displaced by the self-proclaimed "Regulars," not through the violence 
of witch burnings, as happened in Europe, but rather through 
professionalization. This challenge was, according to Ehrenreich and 
English, "at bottom, economic. Medicine in the 19th century ... 
[became] a thing to be bought and sold."

Professionalization required that the Regulars distinguish themselves 
from midwives and herbalists; they did so through "heroic medicine," 
a practice involving dramatic (though not necessarily beneficial) 
techniques such as bloodletting, blistering, purging, and the use of 
toxic mercury-based medicines. These interventions were intended to 
produce "the strongest possible effect on the patient." Though such 
therapies were not only dangerous and often ineffective, Ehrenreich 
and English observe that they gave "regular doctors something 
activist, masculine, and imminently more salable than the herbal teas 
and sympathy served up by rural female healers." In fact, despite the 
very serious risks of heroic medicine, Smith-Rosenberg notes that the 
Regulars insisted that it was they who were protecting "the lives of 
innocent citizens from ill-trained, irresponsible 'irregulars,' and 
hysterical midwives."

The Regulars prospered during the first two decades of the nineteenth 
century and succeeded in securing licensing laws in many states 
restricting the practice of medicine to those in their ranks and 
limiting membership to men. But growing dissatisfaction with the 
results of "heroic medicine," and populist misgivings about 
monopolies and elites, led to the temporary repeal of such laws 
during the 1830s. The "Popular Health Movement" of the period 
challenged the position of Regulars by emphasizing "self-help" 
(through better hygiene and healthy living) and by embracing the 
therapeutic approaches of alternative medical sects, including those 
advocating botanical treatments.

As sociologist Carol Weisman notes, under the banner of science, 
Sectarians or Irregulars "were attacked by mainstream physicians as 
'quacks,' although the therapeutics of the regular physicians were 
not generally more effective than those of the irregulars." The 
Regulars reinforced their claim that they, and they alone, were 
legitimate physicians by founding a national professional 
organization in 1847 -- the American Medical Association -- 
explicitly excluding both women and sectarian practitioners.

In the second half of the nineteenth century, economic competition 
intensified as both Regulars and their rivals -- now known as the 
"Eclectics" -- opened medical schools to train practitioners. The 
Eclectics, who advocated the use of botanical therapies, also 
represented a more populist and egalitarian politics -- for example, 
they admitted women to their medical schools. During this same 
period, in 1854, cannabis joined other herbal remedies in the 
national pharmacopeias and was freely prescribed for a large number 
of medical conditions ranging from insomnia to neuropathic pain. In 
the late nineteenth and early twentieth centuries, dozens of research 
papers were published on the various medicinal uses of marijuana.

This corresponds to a period in which Regulars began to consolidate 
the power of the newly organized medical profession, in part by 
absorbing Eclectics into their ranks. As Paul Starr observes in his 
landmark study, The Social Transformation of American Medicine, 
Eclectics "succumbed to quiet cooptation; they were only too glad to 
be welcomed into the fold." By co-opting much of the opposition, 
physicians were able to secure new licensing laws restricting the 
practice of medicine. But Eclectics paid a significant price; with 
the consolidation of control by conventional medicine, botanical 
therapies were increasingly marginalized by mainstream medicine.

The allopathic approach of the Regulars was not only dominant but 
also institutionalized in the early twentieth century when organized 
medicine completed its process of professionalization by gaining 
control over medical education, access to hospitals, and the right to 
prescribe drugs. The dominance of this paradigm was reflected in the 
growing strength of the American Medical Association. In 1900 the AMA 
had no more than eight thousand members, but by 1910 membership 
reached seventy thousand, and by 1920 the majority of physicians in 
the United States had become members. In fact, by 1931 only about 5 
percent of all cases of illness were handled by non-MD practitioners.

This exponential increase in the power and professional authority of 
regular doctors surprisingly did not rest primarily on the provision 
of more effective medicines; these were slow to be developed. 
Instead, doctors were forced to find other ways to assert their newly 
established social and cultural legitimacy. One strategy was to 
position themselves as experts in not only the physical but also the 
moral health of the nation. In the nineteenth century, condemnation 
of birth control and abortion, for instance, provided physicians with 
a clear moral platform that allowed them to denounce practices still 
largely in the hands of "irregulars." According to Carol 
Smith-Rosenberg, these efforts to limit women's reproductive choices 
became a key arena "in the war between the allopaths and the 
'irregulars' for patients and for power .... The 'irregular' 
physician and the 'irregular' wife, the 'regulars' insisted, 
conspired together against public order and national well-being." As 
Carol Weisman observes, this claim of medical and moral expertise 
"provided regular physicians with an element of social respectability 
and moral authority, which was enhanced by publicly criticizing the 
abortion practices of other practitioners and the crass commercialism 
of purveyors of contraceptives and abortifacients."

At the end of the nineteenth century, flush with its legislative 
success against abortion, the AMA turned its attention to another 
arena that neatly linked morality and public health: the provision of 
drugs. Physicians enhanced their professional authority by speaking 
out against the dangers of addictive drugs frequently found in 
"patent medicines" and available directly to the public. Because the 
formulae of proprietary medicines were secret, it was impossible for 
patients to judge the safety of those drugs. The practitioners of 
organized medicine thus joined forces with muckraking journalists to 
bring to the public's attention the possible risks of patent 
medicines. This important public service had a significant payoff for 
the profession as well, reinforcing a growing distinction in the 
public mind between good drugs (dispensed by doctors) and bad drugs 
(available directly to the public by unlicensed practitioners). 
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