Here is a little window into how the medical literature can get biased by controversial opinions disguised as ‘systematic reviews’

Here is a little window into how the medical literature can get biased by controversial opinions disguised as ‘systematic reviews’ for anyone interested. I’ll walk you through an example. Take this highly cited review article in the flagship @jsexmed

It purports to show that the “highest quality studies suggest that medical male circumcision has no adverse effect on sexual function, sensitivity, or satisfaction.” Okay, how was the quality of studies rated, who did the rating, and is that what the studies actually show?
First, just notice that the authors report “no conflict of interest.” Which is weird because the first author is co-founder of a pro-circumcision lobbying organization called the Circumcision Academy of Australia, several of whose board members derive their primary incomes from
See: patents.google.com/patent/WO20131…. But no matter. Even if they didn’t actually report their glaring conflicts of interest, perhaps they took care to build in strict precautions in their assessment of the available evidence to guard against any potential biases?
Unfortunately not. Although they nominally used the SIGN criteria for assigning levels of evidence (guiasalud.es/egpc/traduccio…), they failed to employ a “carefully assembled multidisciplinary group” as the guidelines for proper use of the criteria require. As @JennBossio et al. note
“It appears the two authors alone composed the group who rated the articles. According to the SIGN criteria they used, would their entire review in question not warrant a rating of ‘low quality’ based on the ‘high risk of bias’ introduced by the authors’ well documented,
unconditional support of the practice of circumcision?” (ncbi.nlm.nih.gov/pubmed/25761651). But as I explain in “The Unbearable Asymmetry of Bullshit” (healthwatch-uk.org/images/Newslet…) such letters to the editor are MUCH less visible than original “systematic reviews,”
so the latter continue to get cited (111 times since 2013 in this case), while the former are rarely noticed and tend 2 have little impact (6 citations to the Bossio et al. letter, 4 of them in articles by me). In another paper, Bossio et al. (

) note

that the big headline conclusion that male circumcision has no negative impact on sexual function, sensitivity, or satisfaction does not even line up with the evidence actually presented in the review by Morris & Krieger, but is more their “interpretation of trends” (see below).
Another author has argued (again, in a much less visible publication), that the ratings of study quality by M&K have more 2 do with the *results* of the study (whether it favors their conclusion or not) than the actual quality of the study (see screenshot) file.scirp.org/pdf/ASM_201503…
Nevertheless, this “systematic review” – with its headline conclusion that is not even supported by the evidence presented in it – continues to be referenced as the ‘final’ word on the subject in key sources used by unsuspecting doctors like @UpToDatelittlesproutings.com/wp-content/upl…
And because it is so much harder (not to mention time-consuming) to get a proper rebuttal of such biased reviews into the same flagship journals that initially published them, you get an “asymmetry of bullshit” situation as noted here healthwatch-uk.org/images/Newslet… (credit: @ziobrando)
As for the issue of sexually-relevant effects. Circumcision removes the most sensitive parts of the penis to light-touch; so penile sensitivity is *necessarily* affected by circumcision (see my discussion here

). Whether that amounts to a sexual harm is …

complicated but @RobDarbyCanberr and I have a lengthy discussion of the concept of sexual harm as it relates to the available evidence here: papers.ssrn.com/sol3/papers.cf…
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Ritual mutilation, human consumption, and contemporary insulation

https://traditionsofconflict.com/blog/2018/6/19/visceral-insulation

Until you have used a sieve to find the finger bones of a newborn baby in ploughsoil it is hard to explain how small they are – Timothy Taylor, The Buried Soul – How Humans Invented Death, 2002.

There are many dimensions of human behavior, and quite a few of them are unpleasant or inconceivable to modern, western eyes. One stares repulsed or uncomprehendingly at acts that likely would have been much more commonplace across cultures throughout our history. Consider the mourning practices of the Gebusi forager-horticulturalists of New Guinea. Anthropologist Bruce Knauft recounts the aftermath of the death of a man named Dugawe;

The following morning, Dugawe’s body was grossly bloated. His swollen limbs oozed corpse fluid, and his peeling skin exposed putrid yellowgreen flesh. His belly and even his genitals had swelled with the gases of decomposition. The stench was unforgettable; it burned up my nose, down my throat, and into my brain. Equally powerful were the actions of Dugawe’s female kin. With unearthly sobs, they draped themselves physically over the corpse, lovingly massaged its slime, and drew back its skin. They rubbed their arms and legs with the ooze of the body. Corpse fluid on one’s skin is a tangible sign of grief, of physical as well as emotional connection to the deceased—making one’s own body like the corpse. Seeing this, Dugawe’s departing soul was said to know how much they cared for him and ease his anger at having died, at least a little (Knauft, 51).

Knauft describes his own reaction to viewing this behavior; “Prior to fieldwork, the only dead body I had seen was the sedate face of a friend of my parents at an open-casket funeral. Now I was shocked and repulsed by the events surrounding Dugawe’s death. It seemed hideous that his corpse was allowed to decay and that our women friends wallowed in its stench.”

The Gebusi also previously had a practice of killing, cooking, and eating those suspected of committing sorcery. Knauft tells the story of a woman named Mokoyl, who was killed after being accused of sorcery, “Her body was summarily buried in the forest, but villagers from another settlement, knowing she had been killed as a sorceress, dug up and cooked and ate parts of the body before it decomposed. In doing so, they indicated their own support for the killing.”

Traditions of cannibalism often revolve around attempts to control the violent and unpredictable elements of life, as well as the afterlife. In Divine Hunger: Cannibalism as a Cultural System (1986), anthropologist Peggy Sanday writes that,

In many reports, the events associated with cannibalism refer not to hunger but to the physical control of chaos. For example, the victim is cast as the living metaphor for animality, chaos, and the powers of darkness – all those things people feel must be tamed, destroyed, or assimilated in the interest of an orderly social life. Cannibalism is then associated with a destructive power that must be propitiated or destroyed, and the act of propitiation or destruction is directly tied to social survival (Sanday, 6).

As anthropologists Kim Hill and Ana Magdalena Hurtado note of the Ypety Ache of Paraguay, after the death of a particularly hated individual, or if the death was especially violent, they “simply ate the cooked flesh of such cadavers and broke open the skulls to liberate the vengeful spirit rather than cremating the body completely.”

Anthropologist Fitz John Porter Poole described the funerary rites of the Bimin-Kuskusmin horticulturalists, also of New Guinea, writing that, “The wife of a deceased man, if she is still within her childbearing years, is expected to eat a tiny, raw fragment of flesh from her dead husband’s penis.” Notably, however, there is good reason to think many Bimin-Kuskusmin themselves found these practices quite unpleasant. “Indeed, most Bimin-Kuskusmin consider this mortuary act to be particularly degrading and disgusting.” Poole considers – but does not necessarily endorse – the idea that “some expressions [of disgust towards these rituals] were shaped by the knowledge that Europeans (government officials and missionaries) were strongly against such practices.”

Other Bimin-Kuskusmin rituals also showed a strong connection to bodily fluids in ways that are largely incongruous with modern western sensibilities. Buried tubes of menstrual blood were used in ritual fertilization of crops considered to be “female” (cultivated by women), such as sweet potatoes. In taro gardens, which are cared for by men, “tubes of semen are placed there to strengthen the finiik spirit believed to inhabit the tubers.” Men of the Arunta foragers of Australia would drink some of each other’s blood under the belief that it would make them stronger and prevent treachery. Anthropologists Francis Gillen and Walter Spencer wrote that, “If [a man] refused to drink the blood, then, as actually happened in one case known to us, his mouth would be forced open and blood poured into it, which would have just the same binding influence as if the drinking had been a voluntary one.” Gillen and Spencer also discuss practices of treating sickness with blood, adding that,

When a woman is very ill and weak, one of her male Umba, to whom she is Mia alkulla – that is, he is the son of one of her younger sisters – may volunteer to strengthen her with his blood, in which case all the women and children are sent away from her. The man draws a quantity of blood from [his] sub-incised urethra, and she drinks part of it, while he rubs the remainder over her body, adding afterwards a coating of red ochre and grease. [italics added]

Beyond funerary cannibalism, and the particular attention given to viscera and bodily fluids in rituals and social practices, cultures the world over have practiced forms of extreme body modification. In Captain James Cook’s journals describing his voyage to the Polynesian Islands, he described the amputation practices of the people of Tonga;

When I first visited these islands, during my last voyage, I observed that many of the inhabitants had one or both of their little fingers cut off; and we could not then receive any satisfactory account of the reason of this mutilation. but we now learned, that this operation is performed when they labour under some grievous disease, and think themselves in danger of dying. They suppose, that the Deity will accept of the little finger, as a sort of sacrifice efficacious enough to procure the recovery of their health. They cut it off with one of their stone hatchets. There was scarcely one in ten of them whom we did not find thus mutilated, in one or both hands; which has a disagreeable effect, especially as they sometimes cut too close, that they encroach upon the bone of the hand which joins to the amputated finger (Cook, 403).

Among several Xhosa-speaking populations, there was another ritual mutilation practice involving fingers, known as ingqithi, which was described by the superintendent of a mission hospital in South Africa in 1964;

The ingqithi custom is a ritual mutilation among several Xhosa-speaking tribes, usually performed upon children of pre-school age, in which the last portion of one of the fingers is amputated. The word is derived from the verb ukuthi qithiqithi, which means “to separate”. Separation, anatomical as well as psychological, is an important element in this custom…The whole family witnesses the ceremony, no outsider being present…the mutilation is not medically an amputation, but an exarticulation. The joint between the middle and the distal phalanx is crossed, the knife not cutting the bone… Special attention is paid to concealing the amputated portion of the finger. A burial place is chosen in the wall of the hut, at the top of which a little hole is made, and the phalanx is wrapped in cow-dung and plastered into that hole. This secrecy is exercised to prevent witches or evil spirits from detecting the piece of finger, as this would be fatal to the child. People say that if witches found it, the wound could swell and become septic.

Among 677 patients at Dr. Jensen’s hospital in 1964, 225 (33 percent) had ingqithi.

In a previous article, I described numerous historical traditions of extracting and displaying human heads, both during warfare and for ritual purposes. Heads would be severed, either in war or after the death of a relative, then in some cases organs would be removed, parts would be eaten, the head would be treated with chemicals and stitched, or defleshed, and prominently displayed. Such traditions have existed all over the world.

Head-hunting, extreme body mutilation, sorcery killings, cannibalism, human sacrifice; these were very real components of many human societies throughout history.

Heads taken by the Iban people of Borneo. From  The pagan tribes of Borneo  (1912) by Charles Hose

Heads taken by the Iban people of Borneo. From The pagan tribes of Borneo (1912) by Charles Hose

Anthropologist Timothy Taylor writes that the concept of ‘visceral insulation’ “describes the way in which the necessary specialization of the modern world screens or insulates people from ‘visceral’ things – bodies, blood, death screams, screams in in childbirth, excessive grieving…” He argues that this insulation has its genesis in the development of civilizations with substantial economic specialization;

Within civilizations, dirty and distressing jobs were delegated to people who could become habituated to them. The viscerally immersed specializations of slaughterers, tanners, butchers, embalmers, grave-diggers, and refuse collectors free others to become insulated enough to specialize in the arts and sciences. Without visceral insulation there would have been no Johann Sebastian Bach and no Marie Curie (Taylor 279).

Occupational specialization combined with modern infrastructure, sanitation systems, and medicine leads to most people in wealthy, industrialized societies – most of the time – having a degree of insulation from the violence, death, and disease that has been substantially more common throughout human history. Taylor adds that, “Visceral insulation, in prehistory and history, has led to the creation of a series of increasingly distinct and exclusive comfort zones.”

Being shielded from the violent, the horrifying, and the disgusting elements of life leads to a perspective of human existence that is fundamentally alien to the beliefs and social practices that have come before. Eating the body parts of a hated enemy or a loved one, collecting severed heads, cutting off fingers, or drinking the blood of a relative to cure a sickness, are behaviors that can only make sense among people familiar with the visceral. People who saw one-third of their children die in infancy, who had to regularly hunt, kill, and butcher animals themselves for food, where less than half of children made it to adulthood, and warfare was often fundamentally personal and endemic.

In sanitized environments, the visceral is kept hidden – and represents a much-maligned intruder – yet many cultures had to acclimate to its frequent appearance. If their practices seem strange, it is only because we inhabit societies that have been constructed precisely to shield us from this reality.

Cannibalism in Iberia

Trouble in early Mesolithic Iberia
Humans may have dined on other humans during the Epipalaeolithic-Mesolithic transition in Iberia, according to a new paper at the Journal of Anthropological Archaeology.

If true, I wonder if this had anything to do with the spread of the so called Villabruna cluster across Europe at around that time? I’m not suggesting that Villabruna forager bands ate most of the other European foragers, but rather that they coped best with the stresses associated with the Epipalaeolithic-Mesolithic transition.

The paper is behind a pay wall, but the figures can be viewed here.

Abstract: The identification of unarticulated human remains with anthropic marks in archaeological contexts normally involves solving two issues: a general one associated with the analysis and description of the anthropic manipulation marks, and another with regard to the interpretation of their purpose. In this paper we present new evidence of anthropophagic behaviour amongst hunter-gatherer groups of the Mediterranean Mesolithic. A total of 30 human remains with anthropic manipulation marks have been found in the Mesolithic layers of Coves de Santa Maira (Castell de Castells, Alicante, Spain), dating from ca. 10.2–9 cal ky BP. We describe the different marks identified on both human and faunal remains at the site (lithic, tooth, percussion and fire marks on bone cortex). As well as describing these marks, and considering that both human and faunal remains at the site present similar depositional and taphonomic features, this paper also contextualizes them within the archaeological context and subsistence patterns described for Mesolithic groups in the region. We cannot entirely rule out the possibility that these practices may be the result of periodic food stress suffered by the human populations. These anthropophagic events at the site coincide with a cultural change at the regional Epipalaeolithic-Mesolithic transition.

Morales-Pérez et al., Funerary practices or food delicatessen? Human remains with anthropic marks from the Western Mediterranean MesolithicJournal of Anthropological Archaeology, Volume 45, March 2017, Pages 115–130, http://dx.doi.org/10.1016/j.jaa.2016.11.002

Dills & Miron found that “national Prohibition reduced liver cirrhosis deaths — a commonly used proxy for all drinking at the time — by 10 to 20 percent.”

https://www.vox.com/the-highlight/2019/6/5/18518005/prohibition-alcohol-public-health-crime-benefits

Prohibition worked better than you think

America’s anti-alcohol experiment cut down on drinking and drinking-related deaths — and it may have reduced crime and violence overall.

Carry Nation burst into a Kansas bar one morning in February 1901. Six feet tall and dressed in black and white, she was armed with a hatchet. As a well-known member of the Woman’s Christian Temperance Union at the time, Nation had earned coverage as far away as the New York Times for her activism in favor of Prohibition — and was widely seen as a threat to bars and saloons across the country.

“The bartender ran towards me with a yell, wrenched my hatchet out of my hand and shot off his pistol toward the ceiling; he then ran out of the back door, and I got another hatchet,” Nation recalled in her autobiography.

Nation went on to wreck the place. She smashed the bar and alcohol bottles. She threw the cash register. She tore up the slot machine, the refrigerator, and the kegs. Beer flooded the property, leaving Nation “completely saturated,” she wrote.

This story is emblematic of how many Americans today see Prohibition: Driven by extremists, the country was pushed into an extreme experiment — to ban the sale, production, and transportation of alcohol in the US in 1919 through a constitutional amendment, the 18th. The policy was a political failure, leading to its repeal in 1933 through the 21st Amendment.

There’s also a widespread belief that Prohibition failed at even reducing drinking and led to an increase in violence as criminal groups took advantage of a large black market for booze.

“‘Everyone knows’ that Prohibition failed because Americans did not stop drinking,” historian Jack Blocker wrote in the American Journal of Public Health. He summarized what’s now the conventional wisdom: “Liquor’s illegal status furnished the soil in which organized crime flourished.”

But there’s a lot wrong with these present-day assumptions about Prohibition.

People like Nation, as extreme as they were, were driven by real problems caused by excessive drinking, including alcohol-induced domestic violence and crime as well as liver cirrhosis and other health issues. This was perceived as a widespread problem, at least in popular media: George Cruikshank’s 1847 series of drawings, The Bottle, portrayed a father spending all his family’s money drinking and, eventually, killing his wife by attacking her with a bottle. And as historian David Courtwright documented in The Age of Addiction, per capita alcohol consumption increased by nearly a third from 1900 to 1913, largely due to advancements in brewing that helped make beer much cheaper.

Portrait of American temperance reformer Carrie Nation (1846-1911) holding an axe and a bible. She wears a long dark dress, a dark veil, and a purse around her waist.
Carry Nation gained national notoriety for going to saloons and bars and, while dressed in black, destroying the establishments with a hatchet as she recited Bible verses.
 American Stock/Getty Images

Contrary to the conventional wisdom, the evidence also suggests Prohibition really did reduce drinking. Despite all the other problems associated with Prohibition, newer research even indicates banning the sale of alcohol may not have, on balance, led to an increase in violence and crime.

It’s time to reconsider whether America’s “noble experiment” was really such a failure after all.

Alcohol is still a problem in the US today

The perception of failure, experts argue, is one major reason America has not taken much action on alcohol in recent decades, even as booze is linked to more deaths each year than any other drug besides tobacco.

“The legacy of Prohibition and the interpretation that was given to the Prohibition experience was that alcohol control policy and controlling the availability simply did not work, so the focus should be on the individual abuser rather than the availability of alcohol,” Philip Cook, a public policy expert at Duke University, told me.

America continues to be plagued by alcohol-related problems. There are 88,000 deaths linked to alcohol each year — more than drug overdose deaths, car crash deaths, or deaths from gun violence. There are policies that could reduce the number of deaths, such as a higher alcohol tax. But there’s been little reception to these kinds of policies, as Cook told me: “I’ve spent much of my career documenting the benefits of higher alcohol taxes. And for the most part, I think that’s fallen on deaf ears, politically.”

He said that’s driven, at least in part, by the failure of Prohibition, which drove people to see alcohol control overall as ineffective. I’ve seen this in some of my own work: After Vox published my case for raising the alcohol tax, a fairly common response from readerswas represented by this comment: “This would be ‘Prohibition Lite.’ We know how Prohibition turned out.”

Protesters march in the streets of New York against Prohibition around 1933.
Protesters march in the streets of New York against Prohibition around 1933.
 Imagno/Getty Images

Advocacy groups and think tanks have similarly cited Prohibition to argue against alcohol control. As Christopher Snowdon in 2012 wrote for the Adam Smith Institute, a neoliberal think tank:

Ever since prohibition was discredited in the 1920s, reformers have been attracted to sin taxes as a means of discouraging an activity without making it illegal. By allowing people to indulge their sin, albeit at a higher cost, campaigners hope to avoid the crime, disorder and ill health that comes from outright criminalisation. This is wishful thinking.

In other policy areas, the failure of Prohibition has been used as evidence against the war on drugs. The American Civil Liberties Union, for one, cited Prohibition’s failure in its case “against drug prohibition.” The ACLU argued that prohibitions of drugs “did not mean, however, an end to drug use” but “that, suddenly, people were arrested and jailed for doing what they had previously done without government interference,” and that prohibitions “meant the emergence of a black market, operated by criminals and marked by violence.”

It’s in this context that the effects of Prohibition deserve another look: If banning alcohol wasn’t as much of a failure as people generally think, perhaps the other, related policies aren’t as ineffective as some assume.

Prohibition reduced drinking

For Carry Nation, the battle against alcohol was personal. Her first husband, Charles Gloyd, drank to excess. Pregnant, Nation went back to her parents, knowing that staying with “a drunken husband” would leave her “helpless” and with “no means of support.” Six months after Nation gave birth, and a mere 16 months after their wedding, Gloyd died of “delirium tremens or from pneumonia compounded by excessive drinking,” according to Fran Grace’s Carry A. Nation: Retelling the Life.

Prohibition meant to address these problems by reducing drinking. On that metric alone, it succeeded.

This is not controversial among experts. When I asked Courtwright, a drug historian at the University of North Florida, whether Prohibition led to more drinking, he responded, “No well-informed historian has believed that for 50 years.”

Courtwright’s The Age of Addiction has the statistics: “Per capita consumption initially fell to 30 percent of pre-Prohibition levels, before gradually increasing to 60 or 70 percent by 1933.” That suggests a 30 percent reduction, at a minimum, in consumption — although that was less than the initial effect, as people figured some ways around the law.

Some experts give lower estimates. A 2003 study from economists Angela Dills and Jeffrey Miron, a libertarian critical of prohibiting alcohol and other drugs, found that national Prohibition reduced liver cirrhosis deaths — a commonly used proxy for all drinking at the time — by 10 to 20 percent.

Prohibition agents aboard the Coast Guard cutter USS Seneca examine barrels of alcohol from a “rum runner” boat.
Prohibition agents aboard the Coast Guard cutter USS Seneca examine barrels of alcohol from a “rum runner” boat.
 Library of Congress/Corbis/VCG via Getty Images

Even the lower estimate, though, indicates that national Prohibition and state-level bans led to a reduction in drinking. (In this sense, it might be worth referring to “prohibitions,” plural: Some states enacted their own prohibitions before 1919, and some kept prohibitions after national repeal — Mississippi’s was the last to go in 1966. So the exact cutoff for when prohibitions started and ended can be messy, but nationwide Prohibition had its own effect since it was so big.)

Why did drinking fall? In short, prohibitions increased the price of alcohol and difficulty of getting it. The monetary price itself increased — “when the nation’s 1,300 breweries could no longer legally produce full-strength beer, urban prices rose between five- and tenfold,” Courtwright wrote in The Age of Addiction. To get alcohol, people then had to find out how to make it themselves or develop connections with people who had a source of booze. The quality of the alcohol, too, was often worse than when it was legal.

With lower consumption came benefits, historians have found. Courtwright, again:

Asked why her husband, a shipyard worker, was drinking less, a New Jersey housewife replied simply that it was due to liquor’s poorer quality and higher cost. Across the Hudson River, in Manhattan, the number of patients treated in Bellevue Hospital’s alcohol wards dropped from fifteen thousand a year before Prohibition to under six thousand in 1924. Nationally, cirrhosis deaths fell by more than a third between 1916 and 1929. In Detroit, arrests for drunkenness declined 90 percent during Prohibition’s first year. Domestic violence complaints fell by half.

There were costs too, Courtwright told me: “The iron law of prohibition is you will have fewer consumers, but each one will, on average, be worse off and more disruptive than consumers in a legal market.”

For example, the remaining drinkers were more likely to drink more potent forms of alcohol — it’s easier to smuggle one bottle of whiskey than multiple bottles of beer. More potency meant more intoxication for individuals, which meant more negative effects among them. (Not to mention the booze was more likely to be poisonous, due to misguided federal regulations.)

Still, in the end, overall alcohol consumption really did fall, with some benefits to public health and safety.

Prohibition may not have increased crime after all

Even if Prohibition did lead to less drinking, what about Al Capone and the St. Valentine’s Day Massacre? Surely the big increase in these types of crime wasn’t worth the benefits.

But it’s not clear Prohibition really did cause, on net, more violence.

Prohibition did lead to more violence in some places, particularly big cities where a black market and organized crime took off. But as Prohibition reduced drinking, it also reduced alcohol-induced violence, like domestic abuse. So the increase in organized crime may have been offset by a drop in more common, and less publicly visible, types of violence driven by alcohol.

Alcohol is known to induce violence. In modern times, the National Council on Alcoholism and Drug Dependence estimated alcohol is a factor in 40 percent of violent crimes, and the Centers for Disease Control and Prevention calculated that alcohol contributed to 47 percent of homicides.

A woman gets into a US Bureau of Prohibition car in 1930.
A woman gets into a US Bureau of Prohibition car in 1930.
 Keystone-France/Gamma-Keystone via Getty Images

Domestic violence was of particular concern in the early 20th century, especially for the women leading the charge on Prohibition. The movement for Prohibition was closely linked to women’s suffrage, with Susan B. Anthony herself advocating for stronger alcohol laws and Prohibition.

So what were Prohibition’s overall effects on crime? Emily Owens, an economist at the University of California Irvine, analyzed the effects of national Prohibition and state-level prohibitions in studies published in 2011 and 2014.

She found, contrary to popular perceptions about Prohibition and crime, that prohibitions were associated with lower murder rates — as much as 29 percent lower in some cases. Where crime did increase, it wasn’t always prohibition but other factors, like the swift urbanization that was occurring in the era, that were mostly to blame. Once you control for other factors, she told me, fluctuations in homicide during the 1920s “appear to be more closely connected to these [non-prohibition] changes.”

The Roaring ’20s were a wild time, with rapid urbanization, improvements in mass communication and transportation, and general social rebellion. All of that likely led to more violence, including organized crime, than there would have been otherwise. So Prohibition alone can’t be blamed for more organized crime — and it potentially reaped benefits with reductions in other kinds of alcohol-related violence, such as domestic abuse.

The Trans-Lux Theatre in Broadway in New York City in 1929.
The Trans-Lux Theatre in Broadway in New York City in 1929.
 Irving Browning/The New York Historical Society via Getty Images

“The public perception that creating this illegal market for alcohol opened up an opportunity for organized crime to earn a lot of revenue, that’s something that’s not disproven. That could still definitely be true,” Owens said. “However, it doesn’t outweigh the less sexy, less movie-friendly story about alcohol and violence, which is that it affects family members, it affects kids, it affects violence that happens inside someone’s home.”

Some research, such as a 2015 study by economist Brendan Livingston, produced similar findings to Owens’s studies, suggesting prohibitions — both capital P and lowercase — were linked to reduced crime and violence, at least temporarily.

Miron, the libertarian economist, is skeptical. He pointed out that the crime and death data from the time is unreliable; indeed, economists like Owens are still analyzing and publishing new interpretations of crime data from the early 20th century today in part because it’s taken experts a long time to make some sense of all the messy evidence. Miron also voiced skepticism that state-level prohibitions could have much of an effect on their own, as Owens’s research suggests — since people could cross state lines and continue to buy alcohol.

He also cited other harms linked to Prohibition: the reduced ability of people to drink for pleasure (impinging on civil liberties), the government revenue lost from invalidated alcohol taxes, the corruption fostered as organized crime paid off police and politicians, and the delegitimization of government more broadly as people flouted the law.

But on crime and violence, he said, “I agree that we don’t have slam-dunk evidence about alcohol prohibition.”

America may have overcorrected after Prohibition

There’s evidence that setting a higher alcohol taximposing a minimum price on alcohollimiting the number of alcohol outlets in a given arearevoking repeat alcohol offenders’ right to drink, and much more could help reduce drinking and its risks. Crucially, the evidence suggests these policies would affect not just casual or moderate drinkers but heavy drinkers, too. Experts say this could be achieved without the risks and downsides Prohibition presented.

But lawmakers and the public have not been amenable to these kinds of policies. The last time Congress took up the alcohol tax, in 2017, lawmakers cut it (with support, of course, from the alcohol lobby). The tax hasn’t increased since 1991, lagging behind inflation with every passing year.

The National Liberal Alliance gathers petitions to loosen restrictions on alcohol during Prohibition.
The National Liberal Alliance gathers petitions to loosen restrictions on alcohol during Prohibition.
 George Rinhart/Corbis via Getty Images

Cook said, and elaborated on in his book Paying the Tab: The Costs and Benefits of Alcohol Control, that this neglect of alcohol policy doesn’t match the evidence. But Prohibition has skewed the public’s and lawmakers’ perceptions of such policies.

Alcohol policy “needs to be considered in light of an accurate interpretation of the history of Prohibition,” Cook said. “Instead of saying that Prohibition was a failure so alcohol control is a nonstarter, turn that around and say that Prohibition on its own terms was successful to some extent. And there’s no reason to reject this overall approach [of alcohol control] just because of a misread of history.”

There’s a balancing act to strike. Prohibition had benefits when it came to health and some areas of crime and public safety, but it had a negative impact on pleasure, freedom, and other areas of crime and safety. That’s true in general for alcohol and other drug policy: Policies can impact freedom, pleasure, health, crime, safety, or a combination, but almost always with downsides in one or more of these categories as well — with different effects depending not just on the policy but the type of drug, too. Maybe a higher alcohol tax or some other approach would achieve a better middle ground than Prohibition did.

So we don’t have to go as far as Carry Nation. But we should acknowledge that restrictions on things some of us like can curtail misuse and related public health and safety problems. The question is how far we as a society want to go before taking a hatchet to America’s bars and liquor stores.