A drug is defined in the Oxford English Dictionary as a medicinal substance, used alone or as an ingredient. But you could also think about a drug in a whole range of different contexts. Consider these four statements:
- A drug is something that pays the mortgage.
- A drug is a substance that helps restore bodily, biochemical balance.
- A drug, digoxin, is contained within Lanoxin tablets.
- Need for a drug is a political battering ram to remove barricades around British fuel refineries.
Which is correct? The second and third seem to match the dictionary definition most closely but they all are correct, depending upon which perceptual spectacles you wear. The same statements can be written in a more understandable way, which will be explored in this article.
- Drugs generate wealth.
- Drug action can be explained by theory.
- Drugs, to be proper, require special characteristics.
- Drugs matter for political control.
I have borrowed the thinking of the philosopher and historian Michel Foucault (1926–84) to explain what a drug is. He winkled out the curious from history and showed how things may not be as they initially appear; what is considered rational, systematic knowledge changes, abruptly, over history.
For example, in the 19th century, physicians, who could only observe patients’ external symptoms, explained disease, confidently, by particular ideas. Then, physicians collaborated with pathologists, who dissected dead bodies. Doctors realised that changes in corpses and diseases in the living bodies were connected. Suddenly, what a disease was, changed.1 Historical references in this article are mainly from Holloway2 and Matthews.3 For simplicity, the word “drug” embraces “medicine”.
First, let me consider who has generated wealth from drugs. Academics, apothecaries, booksellers, chemists, doctors, herbalists, industrialists, lay people, quacks, sovereigns — and pharmacists — have, over history, jostled for a slice of the profit.
The quack peddling secret remedies in the medieval marketplace made a profit. That traveller paid a licence fee, to the sovereign, who permitted the quack’s activities; the Crown profited. Later, Parliament, instead, profited, as stamp tax; an official paper strip sealed the drug and displayed payment. The quack championed remedies available at the local bookseller, who profited. Later, the newspaper said about a drug: “Get it from your chemist.” The stamp tax only ceased in 1941; prescription charges were introduced in 1952 and remain today.
When the public visited the apothecary in the 17th century, they expected a drug. They generally received it, for the apothecary was, before 1815, legally only permitted to charge for the drug but not for advice. From 1911, the public paid in advance, in taxation, through National Health Insurance.
In the 19th century, a drug was often something collected from the doctor. After 1911, for the wealthy, who retained private medical care, a drug remained something collected from the doctor. For the majority, especially following creation of the egalitarian National Health Service in 1948, a drug suddenly became something which pharmacists handed over to the patient. Pharmacists extracted the profit from those drugs from the 94 per cent of patients living in the urban areas; doctors, from the 6 per cent living in rural areas. That position remains, broadly, today.
In the 17th century, retail chemists found that drugs generated more profit when compounded in bigger batches at the back of their shops. Batch sizes increased. The pharmaceutical industry was born. Companies could carry a monopoly and so charge more. Drug distribution was limited to knowledgeable specialists: the pharmaceutical chemists. Those chemists, and their industry, benefited from each other’s prestige, which allowed each to increase their profits. Academic pharmacologists benefited as a drug became something which, injected into a rat, produced a paper; career progression in academia profits from publications.
Alternative legal healers, such as herbalists and aromotherapists profit from drugs. So do illicit drug pushers for pleasure drugs. Many, suddenly changing, groups took their cut. Presumably, changes will continue, related to who gains most power. Will more dispensing doctors return, for example? Or, will some group, only obvious with hindsight, become dominant, suddenly?
The theories explaining how drugs work have also changed over time. Drugs banished demons; drugs were an adjunct to divine power; drugs producing symptoms like a disease cured that disease; drugs rebalanced bodily equilibriums and drugs repaired the malfunctioning bodily chemical machine.
In ancient times, disease was believed to be caused by demons that had entered the body. The demons could only be removed with supernatural help. Later, foul-tasting remedies assisted; they disgusted the demons, which fled from the body. Until the early middle ages, prayers increased the potency of drugs. The use of most charms had ceased by the 15th century.
Paracelsus stimulated interest in homoeopathy: like cures like. A drug became something which was like the diseased organ; for example, the plant “eyebright” had eye-like flowers and was used for eyewashes.
Another ancient theory about a disease was that the body’s internal equilibrium was unbalanced. In a wet patient, for example, a drug such as a leech corrected the balance of humours.
The theory which has recently become dominant is a modification of the humoral viewpoint. Instead of intangible humours, modern humours can be seen, felt, tasted, smelled and heard. They are called “chemicals”. In the diseased body, they are out of equilibrium; a drug has become a repairer of the biochemical balance of the diseased, bodily machine. Before that could be imagined, healers had to perceive the body as a collection of chemicals. That demanded the belief that chemistry applied to living things and humans. Only then could people imagine, for a sample, that both parasites and human bodies were chemicals and that some chemicals, such as arsphenamine, combined with and destroyed the parasites instead of human chemicals, so restoring the normal predominance of human chemicals. This was a revolution in theory, so that questions such as about demons, became more difficult to ask. That sudden switch in perception, for drugs, was perhaps as important as the insight of Copernicus, who first realised that the earth revolved round the sun and not vice versa, for astronomy.
Just as medical theory changed when doctors of the living started talking to doctors of the dead, pharmaceutical theory, and the number of effective drugs, exploded when the clinical doctors started talking to non-clinical pharmacologists to and pure chemists.
A drug became an engineered product of Western biomedicine: a targeted, chemical “bullet”. Technologies, such as double-blind trials, reduced subjective bias. Doctors and pharmacists fortified their faith that their perception offered the true explanation of how a drug worked; their understanding was stencilled from experiment, the real, not from an ancient text. Their gaze became more assured.
What changes do the future hold? We expect some; science, by its nature, challenges existing theories until they are proved “wrong”. After that revolutionary period the previous questions become more difficult to ask.4 Perhaps today’s drug armamentarium will become obsolete once drugs that can modify genetic inheritance become available. Or, will a truly multicultural, British society embrace Ayurvedic and other medicines?
Just what characteristics does a proper drug possess? For example, we recognise aspirin as a drug today. It is usually within an aluminium strip in a cardboard carton; the citizens of Shakespeare’s age would recognise an earthenware pot containing seeds, but not the other way around. The language used to understand how to distinguish what is a drug, and what is not, has changed. This outline considers the changes in drug names, quantities, formulations and quality.
Consider names: a later generation would seldom recognise an earlier generation’s drugs. The opposite, describing a modern drug, such as lisinopril, to an earlier generation, would be incomprehensible because the physical artifact had not been invented. Even within one lifetime, names change as fashion changes. Only some drugs are common to British National Formulary editions two decades apart; the physical drug may be connected with many descriptors such as chemical, pharmacopoeial, and trade names and a pictorial, structural formula. Lavoisier made the system of language a transparent instrument: for example, instead of a traditional name of the substance “litharge”, the name “lead oxide” should include its component elements.5
The recognised reference quantities for weights, and the words describing them, have changed. “Two pennies” is an Anglo-Saxon example. The law buttressed introduction of the imperial, and later, the metric system. My cohort of pharmacy students was taught both “grains” and “grams”, so straddling old and new worlds. Later, a domestic spoonful was deemed too variable; only an authorised “5ml spoonful” became proper. As quantities became smaller, new words, such as “microgram”, were required. Drugs were formulated into many types of medicines. Some novel forms were so superior to the old that the old, such as cachets, became relics while the new, like tablets, now seem so familiar that they seem to have always been there — another example of abrupt change in pharmacy.
Considering quality, examples are Boyle’s early use of density, then pharmacognostical microscopy followed by contemporary instrumentation which can detect “stardust”. Within the European Union, a medicine became only legitimate if produced by one group, analysed by another, released by a Qualified Person and overseen by government scrutiny. The makers, distributors and dispensers were observed always, as were the inmates in the panopticon prison first described by the politician Bentham.6
We can only speculate what drugs and surveillance will become proper in, say, the 22nd century. To us, their warehouse may seem magical.
Mentioning that, today, high quality drugs demand close surveillance suggests the importance of control; those associated with the patient, sovereign and law are now outlined.
Perhaps, in early times, parents told children about healing drugs. They grew wild, could be searched for, and, later, cultivated. The individual then ingested the drug. There were seldom communication problems, or language difficulties, because the whole process occurred within one person possessing one mind. Control was complete.
In the 18th century, the gentry chose to take their recipes to specialists such as chemists and druggists who procured and prepared the drug. It became something that those patients could not completely control; the healers partially controlled those drugs. The common people copied the gentry. The monarch exerted control; power diffused downwards through institutions like the Royal College of Physicians. It had authority to inspect drugs sold by, for example, grocers. If those drugs were deemed substandard, they were burned, flaunting the sovereign’s power, before the shop door, in the stage of the street. The crowd saw, and, and helped to make true the falsehood of those drugs.
There was a public panic over the high rate of death by drug poisoning. The monarch’s power, through Parliament, produced, suddenly, the first legal control over drugs: the Arsenic Act 1851. Shortly, special rituals such as membership of the Pharmaceutical Society controlled the supply of similar drugs.
The drug may be something which seldom immediately kills, yet remains abusable, so is controlled by law. The first such diffusion of the monarch’s power occurred in 1914–18 when Britain was implicated as a centre for dealing in certain drugs. Some drugs are internationally recognised as needing legal control, such as the anabolic steroids misused in Olympic sports. Individuals who, through the use of such drugs, exceed the upper limit of normal muscle development are deemed to be an “out group” (“them”, who are feared) compared with our “in group” (“us”, who are trusted).7Which brings me to the fourth of the statements at the beginning of this article. Recently, during the petrol crisis, the British Government suddenly used the need for drugs to help justify the removal of barricades from oil refineries.
Control in the future is difficult to predict. However, if the future is like the past, those winning control will rewrite the historical account.
In summary, various sudden changes have been discussed, seen through four sorts of spectacles. The Talmud, a medieval religious text, puts it succinctly: we do not see the world as it is, but as we are. As we change our ways of looking, the world changes, sometimes suddenly; we then judge that new world.
Malcolm Brown is a pharmacist from Beccles, Suffolk
7. Bauman Z. Thinking sociologically. Oxford: Basil Blackwell; 1990. p41.