"Kettil Bruun, 1924-1985: An Appreciation,"

By Robin Room, The Drinking and Drug Practices Surveyor, No. 21, pp. 1, 42-49, (August) 1986.

Kettil Bruun died suddenly, hard at work and full of plans, on December 16, 1985. Those who knew him well miss him deeply -- for his probing mind, for his capacity for asking the unthinkable and for organizing ways to answer it, for his commitment to collegial work in a community of scholars and to putting knowledge to use in the world, and for his warmth, humour, modesty and good sense. The wider world will miss the work he still had to do, but will long honor, appreciate and use the wide-ranging and decisive contributions he made to knowledge and action.

Kettil's published work ranged over such a breadth of questions and methods in alcohol and drug studies that no single scholar can do it justice. Nor was his work confined to the alcohol and drug fields; at the time of his death, for instance, he was slated to [end of p. 1/begin p. 42] direct a study of the "burning and delicate question", as he put it, of language rights for Finnish-speaking children in the Swedish school system -- a project for which his own background as a Swedish-speaking Finn, from a country with entrenched minority language rights, in itself made a point. What is attempted here is simply a brief description of many of Kettil's studies and papers -- some of them hidden in antipodean conference proceedings, some in what he once called "our secret Scandinavian languages" -- which might, I hope, tempt many readers to discover or revisit the breadth, originality and pleasure of his work.

K. Bruun and J. Sääski, "The effect of relaxed liquor sales control in Tampere", Alkoholpolitik 18: 115-116, 1955. This is the English summary of an experimental study in alcohol control published in Swedish in the same journal. Along with Pekka Kuusi's classic study of the Alcohol Sales Experiment in Rural Finland (1957), the Tampere study represented the first fruits of a Finnish tradition of experimental studies of the effects of alcohol control changes, already under way before Kettil joined the Finnish Foundation for Alcohol Studies in 1955, which has made crucial contributions to the literature. Such experimental studies are still a novel idea in many countries with strong traditions of alcohol research.

Drinking Behavior in Small Groups. Helsinki: Finnish Foundation for Alcohol Studies, 1959. Papers from this study, Kettil's doctoral dissertation in sociology, were also published in the Quarterly Journal of Studies on Alcohol (v.20, 1959, pp. 53-64) and in Society, Culture and Drinking Patterns (ed. Pittman and Snyder). Along with Finnish sociology at the time, this study was deeply influenced by the U.S. literature -- in particular, by the small-group studies and methods of Robert Bales. Kettil's study pioneered the application of such methods -- with meticulous recording and coding of conversation, interaction, and drinking -- to alcohol studies, using as material a series of drinking sessions arranged to involve foursomes of male acquaintances -- they were not already drinking partners but worked in the same establishment. Kettil's study has never been surpassed in this genre, and I have found that many scholars agree that there would be much to be learned from new studies in its tradition. One remarkable sidelight of the study concerned group pressures on drinking: while Kettil observed many instances of drinkers urging companions to drink up and not get behind in their drinking, there was not a single instance of pressure to slow down or drink less. As I understand it, the study materials have found a new lease of life in Finnish linguistic studies, since the tape-recorded conversations of the drinking groups are among the earliest such recordings of everyday Finnish conversations. Perhaps they may eventually make a contribution also to linguistic studies of the effects of alcohol on the content and production of speech -- an interesting but, so far as I know, untapped area.

K. Bruun, E. Koura, R.E. Popham and J.R. Seeley, Maksakirroosikuolleisus Alkoholismin Levinneisyyden Mittarina. Tutkimukia ns. Jellinekin Kaavan [begin p. 43] Soveltuvuudesta Alkolistien Määrän Arviointiin Suomessa. (Liver Cirrhosis Mortality as a Means to Measure the Prevalence of Alcoholism. Studies on the Applicability of the Jellinek Forinula for the Estimation of the Number of Alcoholics in Finland). Helsinki: Finnish Foundation for Alcohol Studies, 1960. This macaronic volume -- in Finnish and English -- was the firstfruit of a continuing collaborative arrangement between the Finnish Foundation and the Addiction Research Foundation of Ontario. Kettil had previously visited ARF during his 1957 stay at the Yale Center; the book resulted from a stay by Popham in Helsinki which inaugurated the institutes' exchange program. Applying a trend analysis similar to Jellinek's to estimate the proportion of Finnish cirrhosis due to alcoholism (the P value of the formula) yielded a value of .85, at that time considered "incredible" (we would not be so sure about this now), while an attempt to derive the value directly, from records of deaths reported in 1954-55, yielded much lower proportions. The results of the formula with P set by these lower values was compared with and found lower than direct estimates from sampling techniques of the number of alcoholics in Helsinki. The study's findings contributed to the first wave of skepticism about the Jellinek Formula, which had been almost universally adopted as a means of estimating the prevalence of alcoholism. Kettil's later advice about how to deal with the policy demand for a number to answer the question of "how many alcoholics?" may be found in the first issue of the Surveyor (1970):

"I think one way to avoid the negative effects of the black-white thinking easily introduced by the dichotomy alcoholics/non-alcoholics is to try to use not only one but two or three measures thereby indicating the vagueness of our definitions. And I think we should not manipulate these measures to coincide - rather it would be nice to introduce operations giving different results. This will force the users to discuss what is behind these measures. In addition I think it is important to always give the actual distributions before using dichotomies." (p. 6)

Kettil Bruun and Touko Markkenen, Onko alkoholismi parannettavissa? (Can Alcoholism Be Cured?). Helsinki: Finnish Foundation for Alcohol Studies, 1961. This volume reports the results of a pioneer study summarized in English as: Kettil Bruun, "Outcome of Different Types of Treatment of Alcoholics", Quart. J. Stud. Alc. 24:2, pp. 280-288, 1963. In 1954, the Finnish Foundation for Alcohol Studies created a new outpatient treatment system for alcoholics on an experimental basis. In part drawing on the experience of the Yale Plan Clinics in the U.S., these "A-clinics" used a disease concept of alcoholism, a psychotherapeutic approach, and a professional staff of nurses, social workers and psychiatrists. Male patients between 26 and 55 were randomly assigned to an A-clinic or to a hospital outpatient clinic, where the main treatment was the prescription of disulfiram (Antabuse) by psychiatrists. During the study, A-clinic patients made an average of 32 visits, while those assigned to the hospital clinic made an average of 10 visits. As it turned out, about half of the patients in each sample were given disulfiram. A "normal group" of males matched by age and marital status was drawn at random from the Helsinki city register; of the 402 such respondents, 58 were adjudged as alcoholics by two raters guided by characteristics which most clearly distinguished patients' drinking behavior from general-population drinking behavior. Respondents were followed up 3 1/2 years after the initial interview (unfortunately, the general-population follow-up data does not seem to have been published in English). There were no significant differences between the two treatment samples in the rates of "cure?" (abstention or drinking only in accordance with the patient's subculture) or of "change" (a composite measure including social participation, style of drinking, and personality factors). Kettil's discussion of the results notes that the "enthusiasm over the establishment of the A-clinics in Finland" may have led to an exaggeration of their differences from previous treatment methods, and that "in a small homogeneous community like Helsinki it is difficult to prevent a popular attitude such as the disease concept of alcoholism from spreading from one treatment agency to another." Nevertheless, he adds, there were differences in the actual operation of the two treatment systems, and the lack of difference in results was unexpected.

From the perspective of the 30 years since this study's inception, it must be seen as a remarkable contribution. Random assignment to treatment is still rare in treatment evaluation studies, as is the study's attention to the fact that the treatment episodes under study do not exist in isolation - that the patients were often subjected to "extraneous therapeutic influences such as religion, institutions, medical care, and the like". The idea of comparing problem drinkers in the general population with clinical samples was not picked up elsewhere for a decade, and I know of no other study which has included in its design collecting follow-up data on both a treatment sample and a general population sample. The study's finding that treatment had a small effect on drinking behavior (about 1/5 were "cured" at follow-up), but that different treatments had little differential effect, unpalatable as it was then and is now, has since become a standard finding in the literature. Kettil's discussion even points to what is still the major unturned stone in seeking to escape the implications of this finding -- that differential results might be due not so much to treatment methods as to "some other factors such as therapist personality. . . . It turned out that one psychiatrist was responsible for a larger proportion of cured and changed patients than others, and this seemed to be due to personality factors".

Pekka Kuusi and Kettil Bruun, "Some Comments on the Use of Experimental Methods in Finnish Alcohol Research", presented at the Fourth World Congress of Sociology, Milan, 1959. In an interview published in the British Journal of Addiction last year (80:4, Dec. 1985, pp. 339-343), Kettil mentioned that Pekka Kuusi, a sociologist who headed the control and sales department of the Finnish State Alcohol Monopoly, and later headed the whole monopoly, "was very much impressed by Stuart Chapin's Experimental Sociology." [begin p. 44] The Milan paper was in fact a comment on a paper by Chapin, discussing methodological issues in the program of experimental studies in the alcohol field then under way in Finland. Problems with using matching procedures for control groups were illustrated with Lanu's study of the effects of the Monopoly's buyer surveillance program, which controlled alcohol sales to individual deviant drinkers. Matching on 13 characteristics not only almost exhausted the available cases but also meant that the effects were being tested only on a skewed subsample of the original cases. This experience, pointing to the superiority of a random-assignment procedure, underlay the researchers' insistence on random assignment in the treatment outcome study discussed above.

"This experimental design was accepted only after long discussions with people in charge of treatment. They felt that patients should be sent to different clinics according to their needs rather than on the principle of randomization. However, our arguments ran roughly, as follows: We do not know much about the efficacy of different treatments and the type of treatment in fact is seldom chosen on the basis of irrefutable knowledge. Furthermore, patients do not in general seek a particular type of treatment but just any treatment. . . . It was still impossible to obtain approval to leave a group of patients without any treatment, which would have been necessary for an ideal experimental design."

The paper ended with a ringing endorsement of experimental sociology for any "nation with a rational and empirical outlook on social problems." In the alcohol field in Finland,

"the policy has been that no permanent change in the administration of the alcohol trade should be introduced without first determining the effect such a change would bring about in the behavior of the people. For this reason, we have carried out changes with uncertain effects [in] limited local areas [before deciding on making the changes nationwide.] Thus, what mistakes we have made, we have made on a small scale."

In the 1985 interview, Kettil looked back on these statements as reflecting "a very naive and optimistic view". In the 1959 paper, the authors had in fact added a cautionary note: even in Finland "the experimental method is under general suspicion. Thus, suggestions for an experimental legislation bearing upon alcohol policy have been met with stiff opposition". From the perspective of 1985, Kettil nevertheless felt that "although I am not now as optimistic about the impact" of experimental studies, "there is something here that we have lost. There is still I think a place for experimental studies in sociology".

"Alcohol Studies in Scandinavia", Sociological Inquiry 31:1 (Winter 1961), pp. 78-92. At one level, this paper is a description for an American sociological audience of the substantive findings of Nordic, and particularly Finnish, sociological alcohol research in its three major areas of work: studies of "drinking habits and their social functions in different cultures", studies of "deviant behaviors . . . . especially of alcoholism, its treatment and control, and of relationships between crime and alcohol, and studies evaluating "the effectiveness of certain policies concerning the use of alcohol". At a second level, the paper describes the research institutions and the social background of Nordic alcohol research. At this level, the paper might be compared with a much more recent paper: Kettil Bruun and Pia Rosenqvist, "International Review Series: Alcohol and Alcohol Problems Research. 3. Nordic Countries", British Journal of Addiction 80:3 (Sept. 1985), pp. 245-253. The relatively sparse and recent research effort outside Finland recorded in the 1961 paper contrasts dramatically with the situation in 1985, and a substantial expansion in the range of interests and work is also evident among Finnish researchers. Connecting the national traditions in 1985 is a well-established and dense network of joint studies, both within and outside the Nordic countries, and an active Nordic Council for Alcohol and Drug Research. What is missing from the 1985 article is any notice of the pivotal role Kettil played in the organization, encouragement and building up of this community of researchers and institutions, not only in Finland and in Sweden (where the occupied a university chair in alcohol studies in 1981-1984), but throughout the Nordic area.

Kettil Bruun and Ragnar Hauge, Drinking Habits among Northern Youth. Helsinki: Finnish Foundation for Alcohol Studies, 1963. This pioneer international collaborative and comparative study of drinking patterns in a general population was the first project of the "Northern Committee for Alcohol Research" which had been formed by the Nordic Council in 1959. The impetus for the study came from the political level, and Kettil noted in 1985 that he had been "more or less ordered to run the study". The study, of 14-, 16- and 18-year-old boys in Helsinki, Copenhagen, Stockholm and Oslo, found greater differences in consumption between age groups than cross-nationally. Nevertheless, drinking was considerably more common in Copenhagen, and less common in Helsinki, than in the other cities. The study concluded that informal controls, particularly by parents, seemed to have a greater influence than the legal systems of age restrictions on drinking. In a follow-up study, the 14-year-olds from 1960 were reinterviewed as 18-year-olds in 1964, and the results reported in: Kettil Bruun, "The Drinking Habits of 18-Year-Old Males in the Northern Capitals, 1960 and 1964", Alkoholpolitik 4/1965, pp. 3-12. Compared to the 18-year-olds in the 1960 study, the 18-year-olds in the younger cohort were more likely to drink and drank more frequently, except in Oslo. In Helsinki, Stockholm and Oslo, both drinking at all and drinking spirits as a 14-year-old predicted more frequent drinking than otherwise as an 18-year-old. That this was not true in Copenhagen was seen as reflecting that "the psychological significance of whether one drinks and what is drunk is less than in the other towns, and that this most immediately reflects the general [liberal] attitude toward the use of alcohol".

These studies, which constituted Kettil's most sustained effort as a survey researcher, set a pattern for a tradition of Nordic collaborative research which continues today, and also established traditions of [begin p. 45] regular youth surveys which continue at least in Norway and Finland. The follow-up study was of course also an early example of the genre of longitudinal survey research studies which soon became established in the U.S. and elsewhere.

Juha Partanen, Kettil Bruun and Touo Markkanen, Inheritance of Drinking Behavior: A Study on Intelligence, Personality, and the Use of Alcohol of Adult Twins. Helsinki: Finnish Foundation for Alcohol Studies, 1966. This large and complicated multidisciplinary study had its inception in discussions among Finnish biological and behavioral scientists in 1956 about future lines of research, discussions which ended in focusing on the relative contribution of nature and nurture to drinking behavior and to alcoholism, and thus pointed to a study of heritability. 902 Finnish male twin pairs aged 28-37 years, and 160 matched control pairs consisting of one twin and a brother within 6 years of the twin's age, were interviewed and the zygosity of the twins determined. The twins interviewed constituted about two-thirds of all the eligible pairs in Finland. As the authors noted, studies of genetic inheritance had gone out of fashion in the preceding decades for essentially political reasons, and the study must be seen as initiating the modern era of large-scale genetic studies on general human populations. Perhaps due to the involvement of a sociologist, the study collected a wider diversity of information on drinking patterns, contexts and problems than usual in the genetic literature; the results were accordingly complicated, with findings of heritability for some aspects of drinking -- e.g., abstention and frequency of drinking -- but not for others -- e.g., social consequences of drinking -- and with a mixed picture for indications of alcohol dependence. The study epitomizes Kettil's abilities to organize and bring to a successful conclusion complicated collaborative enterprises: besides a four-person research team and a cadre of interviewers, 23 co-workers on various aspects of the study are listed.

"Alcohol, Narcotics and Other Drugs", Alkoholpolitik 3/1967, pp. 3-8. In this essay, an early foray into the field of drug policy, a new set of research agendas to which Kettil would turn in the following 15 years can be seen appearing in embryo. In the essay, as consistently in his later work, he insists on treating all drugs in the same conceptual framework, including alcohol, tobacco and psychoactive medicines as well as illicit drugs. Dangerousness, dependence potential, and control status, he points out, often do not go together. Implicitly, he takes the view that researchers have a duty to lean against the assumptions of public opinion; thus he is skeptical of a Swedish investigatory committee's accepting the concerns of public opinion without question as its starting-point. Among the conclusions, he notes the high rate of use of psychoactive medicines in Finland, and suggests "a more restrictive attitude could be adopted in the approval of new medicines".

Nils Christie and Kettil Bruun, "Alcohol Problems: The Conceptual Framework", pp. 65-73 in: Mark Keller and Timothy Coffey, eds., Proceedings of the 28th International Congress on Alcohol and Alcoholism, vol. 2. Highland Park NJ: Hillhouse Press, 1969. This much-cited paper probes the "great confusion in words and definitions" in the alcohol and drug fields, pointing out along the way that "the major hunt within the field of alcohol has been for what is common among the bad users while in the drug field it has been a hunt for what is common in the bad substances". Posing the question why is "so much energy put into big, fat words" like dependence, addiction and habituation, Christie and Bruun respond in functional terms, using three headings. The function of "preservation of the status quo" is exemplified by the hunt for "bad users" of alcohol: "if the bad drinkers can be identified, the good ones can continue in comfort and peace". Under the heading "language and power", the authors remark that "words have social consequences"; WHO's adoption of a dependence concept reflected that ''the need for one hat" under which all controlled substances would appear to fit "was even greater than the need for clarity". Under the heading "some functions of vagueness", Christie and Bruun lay out a classic critique of the medicalization of social problems:

"Who said the alcoholic should be combated by punishments? The poor alcoholic is a sick person. He ought not to be punished, he ought to be treated. Treatment is a help. Consequently, considerations of justice do not apply, and the homeless man can be placed for a considerable length of time in an institution intended to give treatment or help, even though the building sometimes is the same one as that used earlier for punishment."

On balance, Christie and Bruun pronounce themselves in favor of "the extermination of 'fat words'":

"Within our field, technical problems which call for technical advice, and ethical problems which call for political decisions, where we all have a voice, are unusually interwoven. Conceptual refinement is one way of giving to the experts what belongs to them, and to us all the decisions on ethics which belong to all of us."

"Social Control and Drug Policy", pp. 279-290 in: Folk Sjoquist and Malcolm Tottie, eds., Abuse of Central Stimulants, symposium arranged by the Swedish Committee an International Health Relations, Nov. 1968. Stockholm: Almquist and Wiksell, 1969. In this presentation to a medical and pharmacological audience, Kettil gently insists that "one of the main topics of sociology is social control, informal as well as formal", and suggests the applicability to drug policy problems of the Finnish tradition of experiments with control systems. "Research has been able to introduce more rational choices between different alternatives of social control. I do not intend to say that moral issues are solved but only that there is a hard core of fact which cannot be neglected when alternatives are discussed." The paper includes an early statement of the "problem-minimization" formulation of policy aims: "manipulation of one's psychic situation is a universal phenomenon, and the aim of control is to channel this human need so as to minimize the negative consequences and maximize the positive".

[begin p. 46] "The Actual and Registered Frequency of Drunkenness in Helsinki", British Journal of Addiction 64:1, 1969, pp. 3-8. This report drew on the Finnish data from a collaborative Nordic study of drinking among general-population mates aged 30-44 in the capital cities, carried out in 1964, to examine what was the risk of arrest for intoxication, i.e., what was the ratio between the number of intoxication occasions and the the number of arrests for intoxication. From respondents' reports of their drinking occasions in the week prior to the interview, Kettil estimated that 15% had reached a blood-alcohol level of 0.15%, and that those thus defined as having been intoxicated had been so an average of 1.3 times. Comparing the result with police statistics on arrests, it is calculated that the risk of being arrested on any given intoxication occasion is less than 3 in 100. The article ends by noting the usefulness of such a methodology in comparisons of cultures with very different police practices and alcohol cultures. To my knowledge, this article represents the first effort to use survey responses to estimate blood-alcohol levels, and one of the first efforts to treat discrepancies between survey data and official statistics as quantifiable and substantively interesting.

"Alkoholihaitat mahdollisimman vähäisiksi" (the minimization of alcohol damage), Alkoholipolitiikka 35, 1970, pp. 185-191. (Also in Swedish in Alkoholpolitik 33, 1970, pp. 99-103. English abstract in Drinking and Drug Practices Surveyor 8 (August 1973), pp. 15, 47.) Kettil notes that the new Finnish liquor law defines the primary aim of alcohol policy to be the minimization of damage due to alcohol, and lists the 7 most important kinds of damage caused by alcohol: reduction of lifespan, other damage to health caused by alcohol, the effect of alcohol on the crime rate and on public order, the effect of alcohol on work efficiency and on absence from work, the effect of alcohol on family life, the effect of alcohol on traffic safety, and economic loss. In the words of the abstract, "alcoholism is excluded from the classification because the damage caused by alcoholics already appears in the above classes. Many times alcohol is seen to be an addictive state. Neither this state nor the use of alcohol can be classified as damage". This formulation was influential as the "disaggregative" approach to alcohol problems prevention was developed in the U.S. in the early 1970s.

"Implications of Legislation Relating to Alcoholism and Drug Dependence: Government Policies", pp. 173-181 in: L.G. Kiloh and D.S. Bell, eds., 29th International Congress on Alcoholism and Drug Dependence. Sydney, Australia, February, 1970. Australia: Butterworths, 1971. Distinguishing between "law in books and law in action", Kettil opens by emphasizing the importance of understanding how government agencies controlling alcohol problems actually function. Reviewing Lemert's typology of societal strategies for controlling alcohol problems, Kettil proposes an alternative schema:

"social control could be thought of as primarily orientated towards different phases of the use of alcohol: towards the phase of choice, of use or of consequences. . . . The control could be orientated towards minimizing the number of situations in which an individual chooses to use alcohol, towards manipulation of the way alcohol is used, or towards a manipulation of the consequences of use. "

After discussing Finnish agencies of control in terms of this schema, Kettil argues that there are clear historical examples where government actions have influenced the rate of alcohol problems: "clearcut evidence is available that changes in the consumption level might influence the prevalence of at least some types of alcoholism". Arguing that strategies which affect the "general situation of the alcoholic" should not be obscured by "slogans that the cause of alcoholism is in the man", Kettil adds that "from the point of view of successful manipulation, I would stress the utility of the old temperance view that alcohol is the cause of alcoholism". While "this statement is not to be interpreted as a stand on the etiological discussion about alcoholism", in Kettil's view, "rather than etiological research, there is a need for studies of the actual and potential effects of governmental action".

Kettil's schema of types of control was adopted in essence by the 1981 U.S. National Academy of Sciences report, Alcohol and Public Policy. His paper's emphasis on the connections between controls, consumption levels, and rates of consequences foreshadows the 1975 volume on Alcohol Control Policies in Public Health Perspective, discussed below.

"Finland: The Non-Medical Approach", pp. 545-559 in: L.G. Kiloh and D.S. Bell, eds., 29th International Congress an Alcoholism and Drug Dependence: Sydney, Australia, February, 1970. Australia: Butterworths, 1971. We have used this deceptively-titled paper in alcohol and drug courses at Berkeley ever since its appearance. In part it is a summary presentation of and commentary on work by Siegler et al. on models of drug addiction and of alcoholism. In part, it presents a synthetic account ot the history of shifts in Finland between different models for dealing with alcohol problems, with special attention to "the trend towards the medical model", and in this regard can be seen, like Gusfield's article on "Moral Passage: The Symbolic Process in Public Designations of Deviance" (Social Problems 15:2, 1967, pp. 175-188), as a forerunner of sociological "constructivist" approaches. My favorite line in the paper is a capsule theory of how governing images or models of intractable problems change: "the consistent frustrations concerning the relative lack of success in fighting alcoholism made us move compulsively from one model to another".

Jellinek Memorial Lecture, 16th International Institute on the Prevention and Treatment of Alcoholism, Berlin, 28 June 1971. The lecture is organized around three domains: the act of drinking, the consequences of drinking, and controls on drinking, and includes a clear statement of the linkages between them: "changes in availability and prices exert an influence upon drinking and its consequences". Kettil calls particularly for "studies concerned with the total control system" in a cross-national perspective, and [begin p. 47] adds that one aim is to find "a basis for an international control policy in regard to alcohol", mentioning particularly that cheap access to alcohol is likely to increase consumption among diplomats and tourists: "I have in mind all the international airports in which alcohol seems to be the most important item of consumer goods. This is a field which requires attention on an international level - by WHO or some other agencies." Along the way, he takes a swipe at "the hundreds of studies focused upon either the causes of drinking, or upon the individual traits of deviant drinkers. Frankly speaking, I feel that we have reached a point at which we should admit that these studies have in general very limited value indeed." Kettil draws on Törnudd's analogous argument on the "futility of searching for the causes of crime": "the search for causes is influenced by the medical and biological sciences, and the idea that crimes have stable observable causes that could be eliminated." But knowledge of causes, even if it exists, "does not always prove of assistance in social actions. In the social sciences, alternative causal explanations are always apparent, and the choice of alternatives is far more a question of values than one of knowledge". Kettil adds that:

"in regard to studies concerned with clients or alcoholics, I think that investigations relating to the reaction towards the alcoholic are of much greater importance than studies of the alcoholic himself. This view has as its basis the assumption that it is much easier to change reactions towards the alcoholic than to change the alcoholic."

"Dilemmas in Drug Control Policy", Fifth Leonard Ball Oration. Melbourne: Alcoholism Foundation of Victoria, 1972. The oration was published by the Foundation in a pamphlet including photos of Kettil at the podium and posing (slightly uncomfortably) with the Australian organizers. The first "dilemma of control" discussed is the choice between focusing on alcohol or on alcoholism; Kettil concludes that "government control cannot be limited to alcoholism only; a definite need exists for a systematically-planned alcohol policy". Noting the "seemingly conspicuous absence of discussions on the importance of economic interest" in alcohol production and distribution, Kettil's second conclusion is that "in countries which are trying to develop an alcohol policy, an awareness should exist of the importance of controlling the economic interests connected with production and sale, along with discussion of the practicability of abolishing the right to advertise, and to control prices and availability." The contrast with stringent opium and cannabis controls, applied mainly to developing countries, is noted. In regard to a third dilemma, concerning control measures directed against the individual alcoholic, Kettil argues against "measures that are in conflict with individual rights to freedom. Manipulation of the situation of alcoholics should be a matter of general social policy". Lastly, in a brief discussion of the dilemmas of the "combined approach" to alcohol and drugs, Kettil argues that "on an international level the same general principles of control should he adopted, irrespective of the type of psychoactive substance"; this would represent a change from a situation in which "international policy has been dominated by a nationalistic and moralistic Western approach".

Alkoholi: kääyttöö, vaikutukset ja kontrolli (Alcohol: its use, effects and control). Helsinki: Kustannuso-sakeyhtiöö Tammi, 1972. [Also in Swedish as Alkohol i Norden (Alcohol in the Northern Countries). Stockholm: Bokforlaget Aldus/Bonniers, 1973.] The three long chapters which occupy 270 pages of this book are entitled "patterns of consumption", "consequences of alcohol misuse", and "control systems". They are followed by chapters on "misuse, consequences and control", and on "reforms". As the Swedish title implies, the book is heavily oriented to Nordic material and policy issues.

"Social Research, Social Policy and Action", pp. 115-119 in: The Epidemiology of Drug Dependence: Report on a Conference. . . . Copenhagen: WHO Regional Office for Europe, EURO 5436 IV, 1973. This paper takes a more skeptical view of the relation between research and action than Kettil's earlier discussions. "Research results are applied selectively", Kettil notes; Finnish studies which had often been cited as determining policy could be seen as simply providing arguments for policy directions which were already set.

"Research could be seen as a modern instrument of debate on policy, primarily on alternative means derived from the same basic values, rather than alternative goals. . . . Social research produces arguments . . . rather than logical conclusions regarding policy and action. . . . In areas relevant to policy and action, I question the accumulation of knowledge. Given this, the big decisions will always be taken primarily on the basis of values -- the small, but still important ones might, however, be improved by social research."

In discussing "research and power", Kettil mentions not only the relevance of identifying "those with the power to formulate research problems" but also the ability of the powerful to keep research results -- including marketing research -- secret. Anticipating one of his future projects, Kettil notes that "it has been impossible to obtain data on the consumption of medical drugs in Finland because of the economic interests involved, and, oddly enough, considerable research is carried out to obtain information that already exists". Concerning epidemiological studies, Kettil takes the view that "studies on the activities of the control agencies are . . . important complements" to studies of population characteristics.

"Such a combination, however, is not common, partly because control agencies do not like to accept the role of research object. And to go further and question the reliability of the information which they give seems almost insulting. Yet the question of reliability is always legitimate in research and no-one would object to its being raised in connexion with information supplied by users and addicts. In view of this reluctance to be investigated it is no surprise that policy recommendations are more likely to be produced and accepted when they relate to [begin p. 48] the behaviour of individuals rather than to the actions of control agents. Yet the behaviour of the latter is often easier to change than that of the former. "

Kettil Bruun, Lynn Pan and Ingemar Rexed, The Gentlemen's Club: International Control of Drugs and Alcohol. Chicago and London: University of Chicago Press, 1975. This landmark study can be seen as the first substantial product of a number of research agendas and orientations Kettil had been pointing towards in the papers of the preceding five years -- and also reflected his renewed interest in historical studies, in which he had received some early training. It is a study of the control system, designed to balance the studies of those controlled; it involved piercing walls of official secrecy, which are particularly dense for international agencies -- even if Kettil in theory had the right to see minutes and memoranda as an official delegate of his country. As the title implies, the book took a critical stance towards the history, operation and results of the international drug control machinery, paying careful attention to whose interests it served. Civil servants in international agencies read the book avidly but unofficially; incredibly, there is no copy of it in the headquarters library of the World Health Organization. The chapter on international alcohol control and the attention to alcohol in the conclusions furthered Kettil's agenda of putting consideration of all psychoactive drugs on a common footing. "The ultimate purpose of any social policy is presumably to reduce human misery; a drug control policy inspired by this end might therefore be primarily directed at minimizing the harmful effects of drug use. In preferring to address the harmful effects of drug use, we are underlining the need to specify, with some concreteness, what these effects might be." In this perspective, "alcohol gives rise to more problems than any of the other drugs" (pp. 287, 286).

A later article carries the book's story through the succeeding five years: Lynn Pan and Kettil Bruun, "Recent Developments in International Drug Control", British Journal of Addiction 74:2, June 1979, pp. 141-160. In their conclusions, the authors note some incremental changes, including a willingness to discuss alcohol in association with the other drugs with "far less resistance than would have been thought possible in 1973", but also note that the system "does not adapt itself expeditiously to change", and "is still used as a means whereby the wishes and perspectives of the dominant Western powers on the drug question are transmitted and imposed upon countries not sharing these wishes and perspectives".

Kettil Bruun, Griffith Edwards, Martti Lumio, Klaus Mäkelä, Lynn Pan, Robert E. Popham, Robin Room, Wolfgang Schmidt, Ole-Jørgen Skog, Pekka Sulkunen and Esa Österberg, Alcohol Control Policies in Public Health Perspective. Helsinki: Finnish Foundation for Alcohol Studies, 1975. This book, known in some circles as the "purple book" from the color of its cover in the English-language edition (it has appeared also in Finnish, German and Swedish), has attained an unusual prominence in the literature, becoming the basic citation for its fundamental argument, as that argument has gained increasing acceptance: "changes in the overall consumption of alcoholic beverages have a bearing on the health of the people in any society. Alcohol control measures can be used to limit consumption: thus, control of alcohol availability becomes a public health issue." In the interview in the 1985 British Journal of Addiction, Kettil briefly described his catalytic role in the project, and its background in the shock to liberal Finnish views on alcohol policies delivered by the effects of the liberalization of 1968/69. As a latecomer to the project, I had not realized, until in writing this appreciation I read over Kettil's papers from the preceding years, how much the conceptual frame of the book -- its concern with consumption, with consequences, with controls, and with the relations between them -- had been established well before the project began in 1973. Reflecting Kettil's pragmatic and incremental approach to building research institutions and teams, the substantial work done for the project in Finland served to recruit to alcohol studies two younger researchers who have gone on to make sustained contributions to the field.

Alcohol Policies in United Kingdom, a report by the U.K. Central Policy Review Staff, May 1979. Stockholm: Studies in Swedish Alcohol Policies project, Stockholm University, 1982. This report, which is marked "confidential" and had been suppressed by the Thatcher government, was published by Kettil, beyond the reach of the U.K. Official Secrets Act, when it came into his hands. It was an effective step in his continuing guerrilla war against attempts to keep research material secret: the spectacle of British researchers writing off to Stockholm for copies of the report helped the report receive the prominence in Britain that it deserved. In his foreword, Kettil justifies his publication of the report as part of the international background for the project, "Studies in Swedish Alcohol Policies", carried out while he was a professor of alcohol studies in the Sociology Department at Stockhom University (see below). He points particularly to the discussion of the diversity of government interests in alcohol policies -- that in Britain "sixteen departments have major policy interests in alcohol" -- and to the attempt by the report's authors to relate economic and health issues.

Kettil Bruun, ed., Controlling Psychotropic Drugs: The Nordic Experience. London and Canberra: Croom Helm; New York: SL Martin's Press, 1983. This book, originally published in Swedish in 1982, was the outcome of a joint Nordic study, involving 10 authors from Denmark, Finland, Norway and Sweden, as well as Lynn Pan (in the role of translator and clarifier she took on several times for Kettil). Kettil played a key role in the organization of the project, which started in 1977; it carried out his longtime agenda of studying the interaction between the pharmaceutical industry and government control agencies and policies, particularly with respect to psychoactive drugs. While the focus is on the Nordic countries, some attention is paid to the larger international context -- for instance, to the way in which the New Zealand system of national health insurance influences prescription [begin p. 49] drug use patterns. The aspects of the book described in the "Foreword" by Griffith Edwards might serve as a general characterization of the style of Kettil's work from about 1970 onwards:

"'We urge' say the authors in their concluding chapter 'the opening of a public debate on medicines policy'. There could not in fact be a better opening to that necessary debate than this scrupulously researched and carefully argued book. . . . If we agree that there have to be controls, then it becomes vital to understand how those controls actually work, in whose interests they really operate, the extent to which they achieve their purpose and the ways in which the intentions of the control apparatus are in actuality frustrated. It is to a dispassionate examination of those and many similar questions that this book promises so singularly to contribute.

"This is not though a book which flaunts a great apparatus of theory, but in terms of an important tradition of much Scandinavian social science enquiry - a style of research where Kettil Bruun has in previously published studies shown himself to be a master -- it deals largely in plain and carefully gathered facts. . . .

"This book . . . does indeed succeed in delineating the totality of a policy: it does not rest at describing the bits and disjointed pieces of social action, or the separate roles of individual agencies, institutions and interests, but insists that formal and informal control policy can only be understood as the interactions and tensions between all these elements and factions. . . . It is a book of scholarly interest, but also one which dares to make very practical policy recommendations. "

The book includes an appendix on "grappling with data inaccessibility", including a full account of the battle with the most recalcitrant source, Hoffman-La Roche. Kettil saw it as important to deal openly with the issue of secrecy: as he put it in the 1985 British Journal of Addiction interview, "if struggles for data are themselves secret you will never get a clear idea about what are the rights of the researcher. Norms cannot be developed in secrecy."

Kettil Bruun and Per Frånberg, eds. Den Svenska Supen: En Historia om Brännvin, Bratt och Byrakrati (Swedish shots: a history of liquor, Bratt and bureaucracy). Stockholm: Bokförlaget Prisma, 1985. Seven researchers formed the team for this project examining the interplay of alcohol consumption and control in Swedish history, carried out while Kettil was at Stockholm University. Kettil's contributions focus particularly on "Bratt's breakthrough" -- how the ideas of a turn-of-the-century Swedish doctor, Ivan Bratt, resulted in a rationing system for alcohol that lasted for four decades, and in an eventual centralization of the alcohol monopoly system -- on the functioning of the central alcohol control administration, and on gender and class distinctions in the application of the rationing system. Drawing on the work of the project, Kettil also prepared a short summary of the Swedish control history for publication in a W.H.O. document: "Sweden", pp. 114-119 in: Marcus Grant, ed., Alcohol Policies. Copenhagen: World Health Organization Regional Office for Europe, WHO Regional Publications, European Series No. 18, 1985.

Nils Christie and Kettil Bruun, Den gode fiende: Narkotikapolitikk i Norden (Suitable enemies: drug policies in the northern countries). Oslo: Universitets-forlaget, 1985. Also in Swedish - Stockholm: Raben and Sjöögren, 1985. This attempt by Nils and Kettil to bring some sense back into discussions of narcotics policy in the Nordic countries created a storm of controversy. Besides the illicit drugs, psychoactive medicines, alcohol, tobacco and caffeine were included in the book's analysis, the basic argument being that there is a gross disproportion between the harm caused by illicit drugs and the problems they create, when compared with the problems created by licit drugs. Only the book's discussion of the "unsuitable enemies" has yet appeared in English, in a temperance magazine published in Oslo: Kettill Bruun and Nils Christie, "Unsuitable Enemies". The Globe 2/1985 (June), pp. 18-20. The interests supporting tobacco, alcohol and coffee consumption are strong, the authors argue. "They occupy central positions both nationally and internationally. They are met with sympathy in wide circles. And they are capable of carrying on an offensive fight against everyone that wants to get them under control". For the state, then, "they are strong enemies, dangerous enemies, unsuitable enemies". The control of medicaments is likewise compromised by the power of the pharmaceutical industry. If "perhaps 2-3,000 of the 6,000 participants" in a World Psychiatry Congress "have their participation funded by the pharmaceutical industry", it is no wonder if the meetings are oriented towards medicinal approaches. "What gastronomical societies are for the wine industry, medical societies are for the pharmaceutical industry." Pointing to the profitability of the pharmaceutical industry and its concentration in six powerful industrial countries, the authors conclude that "it is not very surprising that the pharmaceutical industry is not easily defined as an enemy and that the products continue to be marketed and sold in far-away countries long after a united medical opinion has condemned them at home."

The range and reach of his work is extraordinary, and yet it may be hard to gather from it the affection and respect which Kettil inspired in those who knew him. One expression of this that found its way into print can be found in the "Acknowledgements" of Lynn Pan's Alcohol in Colonial Africa (Helsinki: Finnish Foundation for Alcohol Studies, 1975). Lynn, a historian originally from Malaysia who was to help Kettil on several later projects, wrote that "my greatest debt is to Kettil Bruun, who suggested the study in the first place, and for the pleasure of working with whom alone, I would almost be prepared to endure another winter in Finland". Whatever the season and the place, for many of us it will not be the same without him.

- Robin Room
Alcohol Research Group
Berkeley, California