Official representatives of manufacturing countries are frequently seen in earnest conversation with representatives of manufacturers, or the actual manufacturers themselves, whom they, presumably, consult as to the best, quickest, and most equitable means of limiting manufacture.
A. E. Blanco, on the Limitation Conference of 1931, in an Anti-Opium Information Bureau Communiqué.

An account of the international drug control system merely in terms of the influence of individual countries and persons can be seriously misleading. The activity of interest groups can have a significant influence on the decisions reached by governments and in international negotiations and must therefore be considered.

Formal access to the UN by interest groups is gained by becoming accredited as nongovernmental organizations (NGOs). NGOs have a statutory basis under the UN charter whereas under the League convenant they fell outside the constitutional framework and were therefore of an informal nature. Under the UN arrangement* formal consultation is virtually limited to ECOSOC and its area of competence. On the other hand, the form of consultation followed by the League with other international bodies ranged across the entire compass of the League's interest areas. The influence of NGOs on UN activities has declined over the years (Skjelsbaek, 1973), although their number has steadily increased. For example, it has risen from 216 in 1962 to 419 in 1970 (Yearbook of the UN, 1970: 622).

NGOs represent a great variety of interests, which in turn vary considerably in form, intensity, and scope. These interests can be classified in a number of ways but for our purpose we may distinguish between three broad categories. The first category is exemplified by religious, temperance, and antiopium movements. The second comprises professional interests, such as those of lawyers, doctors, and scientists, while the third embraces the field of industry and commerce. From the historical point of view of international drug control it is the first and third categories which are of particular interest; the first because it is from among its members that pressure for increased controls has mainly come, and the third because it includes the interests of the economy which these controls are intended to regulate. The second group has emerged as an important factor more recently and will be seen in action later in connection with the Vienna treaty (chapter 16).

What influence any of these groups has had on decision-making in international organizations is difficult to measure. To say that influence has been exercised one must be able to demonstrate that the decisions, orientations, and opinions of the targets of influence have been changed from what they would have been in the absence of influence. On the other hand, success or failure to bring about an outcome does not necessarily imply the presence or absence of influence: pressure group activity may shift the probability of an outcome without perceptibly bringing about the desired outcome.

In the absence of adequate measures of influence, one is reduced to describing attempts at, rather than the effects of, influence. Only rarely can one conclude, as Pickard does, in reference to the nonratification of the various pre-1914 international agreements on such matters as the protection of women, child welfare, the opium traffic, obscene publications, and slavery, that:

circumspect pressures from various organs of the League, plus the less prudent pressures permitted NGOs, notably national NGOs, effected the requisite ratifications in double-quick time.

He further notes that, while the NGO contribution in the above cases was clear, "there are doubtless other instances, less definable and measurable . . . where the NGO impact has also been effective" (Pickard, 1965: 47).

As pressure groups, by definition, work outside the system they seek to influence and as their efforts are difficult to describe, it is inevitable that our discussion will leave out a great deal. In what follows, we will be mainly concerned with two key groups— the antidrug manufacture lobby and the drug suppliers.

Earlier we saw that procontrol groups have worked hard throughout history to interest governments and international organizations in instituting controls over opium and alcohol. The temperance groups, as will be seen in the next chapter, gained little headway beyond Anglo-Saxon and Scandinavian countries. In contrast, it was the antiopium missionaries in the Far East who exercised the greatest influence in shaping American public opinion and in inducing the U.S. to play a leading role in the international effort against the opium trade (Taylor, 1969: 29-30).

After international opium controls were well underway, perhaps the most important, and certainly the most persistent, pressure for control over drug manufacture was that exerted by the Anti-Opium Information Bureau, a one-man operation set up by A. E. Blanco, who, it will be remembered, had once been with the League's Opium Traffic Section. Blanco fervently believed that the solution to the drug problem lay in the limitation of manufacture to the amount sufficient to fulfill medical needs, and it is clear from the numerous communiqués he released to the press, the Advisory Committee and other League organs, inveighing against the Committee, that he was highly suspicious of the motives of the members of the Committee, when they rejected plan after plan put before them for controlling drug traffic. His press releases, according to Renborg (1964), "caused great irritation to the older members of the Committee." Taylor notes that (1969:227) "Because of the glare of publicity which it directed towards the Opium Advisory Committee and other agencies of the League concerned with the drug question, the Bureau was not uninfluential."

Blanco was the author of the "Scheme of Stipulated Supply," designed to control manufactured drugs. Under the plan, each country was to state in advance its requirements of each narcotic drug and to stipulate the country from which it would purchase these requirements. The plan was presented to the Advisory Committee by a private American citizen, C. K. Crane, through the medium of the U.S. State Department. Blanco had to resort to this roundabout way of bringing the scheme before the attention of the Advisory Committee because his own attempt to introduce it through the secretariat had failed. The Committee rejected Blanco's plan (OAC: 12th, 1929: 288), but its rejection so incensed the consuming countries that they voiced their protests to the League Assembly, which then stepped in to call for action to limit manufacture and for the enlargement of the Committee to include nonproducing countries.

The scheme was presented as an alternative to a plan devised by the manufacturing countries of the Advisory Opium Committee in a private meeting in London in 1931. Their plan was based on a quota system whereby drug manufacture would be divided between the existing manufacturing countries. The system was open to the criticism that it would perpetuate the privileged positions of these countries and secure for them a monopoly of the drug industry (Pastuhov, 1945). Eisenlohr notes that Blanco was part of the opposition which finally demolished the quota system (Eisenlohr, 1934: 275).

In the League days, the fact that the furtherance of industrial interests was government sponsored (in the sense that it was often the interest of their national drug industries which the Advisory Committee members served rather than the avowed interests of the Committee) obviated the need for private pharmaceutical pressure-group activity. Unlike attempts to influence decisions in domestic politics, influence at the international level could occur without any activity on the international stage by the interest group concerned. At the Hague conference in 1912, the country most responsible for the dilution of a resolution on manufactured drugs was Germany, which was a major manufacturer of opium derivatives and which had a virtual monopoly of cocaine production. Its chemical industry had exerted much pressure on the German government not to attend the conference; thus the German delegation "was out to scuttle any strong measures that might jeopardize the favoured position of their manufacturers" (Taylor, 1969: 102).

While it is only relatively recently that commercial interests in pharmaceuticals have become visibly active at an international level in the drug control field, lobbying efforts by physicians and pharmacists at the domestic level have had a long history (see Musto, 1973). Vested interests in the alcohol field have also long been represented by such NGOs as the Permanent International Committee on Wine Growing, the International Committee on the Trade in Wines, Ales, Ciders, Spirituous Liquors and Kindred Industries, and the International Union of the Development of Grape-Cure Resorts and the Consumption of Grapes (White, 1951). As there has been no real attempt at international control of alcohol, the efforts of these groups can hardly have been tested.

International pharmaceutical associations were already active during the League period. Interest was shown, for example, in the 1924 Geneva Opium Conference by the International Pharmaceutical Federation, which sent a letter to the president of the conference asking that favorable note be taken of the recommendations which the Federation had arrived at during its meeting in Paris in November 1924. Some of these recommendations read as follows:

. . . it will be necessary that the law regulating the traffic in narcotics in the different countries shall not impose upon pharmacists administrative provisions which might prove a source of worry and annoyance and hinder them in the conduct of their business, while not proving effective to prevent drugtakers from obtaining these substances by fraud or from persons less conscientious than the pharmacists.

. . . the prohibition to supply these medicaments to customers without a medical prescription should not, however, prevent the sale of medicaments containing so small a quantity that there can be no question of abuse. It is not necessary to demand more than is laid down in Article 14(b) and (c) of the Opium Convention.

Provisions regulating the sale of narcotics in pharmacies, and any registers and lists that may be prescribed, should be as simple as possible and drawn up in agreement with the pharmaceutical profession before being enforced (Records, Second Opium Conference, 1925:332).

More recently, shared interests among pharmaceutical manufacturers have led them to form such joint organizations as the Groupement International de l'Industrie Pharmaceutique des Pays de la Communauté Economique Européenne (GIIP), established in 1959, and the Pharmaceutical Industries Association in the European Free Trade Area (PIA). hi 1968 these groups, together with their counterparts in the U.S. and Canada, formed the International Federation of Pharmaceutical Manufacturers Associations (IFPMA). IFPMA was admitted as an NGO to WHO in 1971 (see chapter 12). Individual drug companies appear to be members of several NGOs simultaneously. This is suggested by the fact that at the WHO standing committee on nongovernmental organizations which considered IFPMA's admission in January 1971, the International Pharmaceutical Federation, another NGO, was represented by a senior member of the management of the Swiss drug firm CIBA-Geigy who a year later appeared as an IFPMA representative in the WHO executive board's listing of NGOs (EB 47 SR 17:275).

Although ECOSOC has been careful about granting status to profit-making businesses, organizations seeking such status can, and do, register under nonprofit-making codes and gain admittance nonetheless. While not profit-making in the strict sense, such organizations may still pursue the furtherance of their members' commercial interests. On the other hand, a commercial body may be considered so useful to an organization that the profit factor is ignored. Pickard offers an example of this: "The World Health Organization, for example, because of a possible need for close cooperation with great pharmaceutical businesses, was careful not to include the non-profit making proviso among its criteria for the granting of official relations to an NGO" (Pickard, 1956:43).

Although the acquisition of consultative status gives interest groups opportunities for lobbying, the additional channel of informal contacts between their representatives and officials in the control administration is frequently used. Usually these contacts are personal and the parties involved have known each other over a period of time. It is said by some drug industry personnel that such contacts are cultivated for the advantages inherent in being able to approach the right official on the right subject so as to obtain a hearing and express views, rather than to influence decisions directly. However, the fact that these channels are informal and operate outside the public forum means that there is no way of knowing what these views are, or how persuasively they are being expressed. In contrast, the situation in the League period was clearer. It was officially reported, for instance, that de Vasconcellos, the chairman of the Opium Advisory Committee "had been personally approached by a representative of the Société industrielle de chimie organique of Paris with reference to statements in the Committee's reports that this firm had been implicated in the illicit traffic. The representative was extremely anxious to disprove the charges made against his firm, and offered every facility for a thorough inquiry" (OAC minutes: 15th, 1932:9).0

Inclusion of the representatives of private organizations on conference delegations is another familiar practice. A joint report by UNESCO and the International Institute of Administrative Sciences (1951) notes that some governments "notably the U.S., prefer to give certain nonofficial groups the opportunity to express themselves as delegation members. At the San Francisco Conference which created the UN Charter in 1945, representatives of numerous private organizations were invited to act as 'consultants' to the American delegation. For financial reasons this practice was scarcely feasible for overseas governments." Another example is afforded by the U.S. delegation to the International Health Conference, which created WHO in 1946. The representative of the American Medical Association (AMA) was ap integral part of the delegation. The AMA was opposed to any action by WHO which might promote "socialized medicine," and thought that the organization should not concern itself with "the care of the sick and the social organization related to the practice of medicine" (Cox and Jacobson, 1973:178). Yet another example is the inclusion in the Swiss delegation to the Vienna Conference in 1971 of the executives of the three largest pharmaceutical companies of Switzerland: Hoffmann-La Roche, CIBAGeigy, and Sandoz (although they were not listed as such), as well as the inclusion, among U.S. delegates to the 1970 drafting session of the Commission, of a representative of the American Pharmaceutical Manufacturers Association.

A well-known feature of the relation between large-scale private enterprise and national government is the interchange of high-level personnel between the two concerns. Senior civil servants often take up positions on the boards of private companies when they reach retirement age, and in the U.S., especially, the phenomenon of clientalism is well known (Grove, 1962:159). In the drug field one can cite several examples of international civil servants leaving the service to join the pharmaceutical industry, or vice versa. The late Gilbert Yates, a former director of the UN Division of Narcotic Drugs, became the director of the Association of the British Pharmaceutical Industry; Adolf Lande, previously secretary of the INCB, has been connected with the American Pharmeceutical Manufacturers Association; and Hans Halbach, a former chief of the WHO Drug Dependence Unit and director of the Division of Pharmacology and Toxicology, is now employed by the Swiss drug company Hoffmann-La Roche. An earlier example is that of Otto Anselmino, who upon leaving League narcotics control work, became an employee of a German drug firm. Herbert May, one-time president of the Board, was a partner in his father's drug business before he joined the international drug control body.

To what extent the pharmaceutical industry has been able to exercise influence in the drug control area is, of course, an open question. That its interests were a decisive factor throughout the development of the international drug control system is manifest in all the more systematic historical accounts of narcotics control (Eisenlohr, 1934; Musto, 1973; and Taylor, 1969). Moreover, one of the more visible effects of the controls applied during the League period seems to have been to wrest the prominent legitimate pharmaceutical firms from their deep involvement in the illicit trade (see chapter 15).

The effectiveness of the industry's attempts to influence decisions depends on a number of factors. The degree of susceptibility of the targets of influence is obviously one of them. Clearly, the ability to persuade also depends on the persuader's reputation and the resources at his disposal. We indicated in the last chapter that, among other factors, the economic capability of the U.S. has provided it with the basis for intense activity and leadership in the field of drug control. Like countries, pressure groups too are unequal in their resources, power, and access to centers of decision-making. Although such attributes provide a frail basis for an estimation of the power potential of the pharmaceutical industry, we offer below some indicators of the extent of the industry's resources and interests.

Pharmaceuticals are a branch of the larger chemical industry. The chemical industry is a dynamic sector of modern industrial economy; on the average, it has had a growth rate about two-thirds higher than that of the national economy as a whole. Except for the food processing and texile sectors, the chemical industry also expands faster than the average for all manufacturing activities (UNIDO, 1969). The value of world chemical production is given below:

Four regional blocs, namely Western Europe, North America, Japan, and Eastern Europe account for 95 percent of the world production of pharmaceuticals. Among the product classes psychotropics rank fifth, and on a world scale this class represents a group of high growth (Woodward, 1973). The three leading exporting countries of pharmaceuticals have been West Germany, the U.S. and Switzerland if one takes sales by branches abroad as an indicator (SOU 1969:24; Breckon, 1972:28). Among the world's ten largest companies in 1965 seven are in the U.S., two are Swiss, and one is Japanese (SOU 1969:42). In addition to the trend towards monopoly, the larger companies have developed, since the Second World War, a "multinational" nature, geared to the extension of markets and reduction of costs through the establishment of subsidiaries in countries providing favorable conditions for this purpose. A high price is usually paid by developing countries for this so-called technology transfer. A study has been reported in Columbia, for example, which calculates that, of the effective returns to the parent corporation of a sample of pharmaceutical firms investigated, overpricing accounted for 82 percent, the remainder being made up of reported profits and royalties (Vaitsos, 1970). The exceptional profitability of the pharmaceutical sector has been noted by a few investigations (Sainsbury, 1967; Monopolies Commission, 1973). It is more profitable, in fact, than industry as a whole. A comparatively large proportion of the profits is spent on drug sales-promotion and research. One also finds small sums being invested in influencing political decisions: Beecham and CIBA-Geigy, for example, donated £20,000 and 2,000 respectively to the British Conservative party in 1971.

Resources, therefore, may have at least potentially important political consequences, although using them to create influence involves varying degrees of risk, in that the outcome cannot always be guaranteed. For example, the organization under whose auspices this study was undertaken, the International Research Group on Drug Legislation and Programs, and of which we ourselves are members, was partially financed by a group of European drug companies. These companies supported some of the Research Group's work, hoping that "the widest possible dissemination of the knowledge that such a project is being undertaken may delay or impede ratification of the Vienna treaty by a significant number of states" (Letter from CIBA-Geigy executive to chairman of the group, 5 August 1971). Our belief, however, is that such hopes did not influence the final outcome of the group's investigations.

There are conflicting views on the industry's relationship with governmental agencies; one view sees the industry as being encumbered by excessive regulations, and another believes that the industry's power is such as to frustrate any attempt to prevent it from acting entirely in its own self-interest. Some pharmaceutical companies claim to be in favor of controls as such controls would debar their more dubious competitors from the trade. A licensing system would, for instance, create a vested interest of the authorized drug firms in the effective functioning of the control regime which accords them this privilege (Lande, 1970). Nonetheless, the close association of the industry with national governments would lead one to suppose that governments themselves—especially when it comes to a question of export trade and "balance of payments"—take an interest in the protection of industrial interests, and insofar as the individuals involved often assume double roles, private and public, the actual relationships between industrial concerns and the agencies supposed to regulate them are not at all clear to the outsider. Against this background, one would be chary of supporting the view that those affected by governmental regulations should have a say in their planning, since at present this is not made contingent on a public declaration of interests. In the absence of such declarations, there is no opportunity for the public to assess the industry's influence or to decide to what extent government decisions are affected by commercial interests. In many cases the latter do have a say in planning since governments are often anxious to know whether a particular measure will arouse opposition or support, so that by a process of mutual accommodation between the interests involved controversy may be avoided. The private concerns in turn provide technical expertise, contacts, and general support. Again, it is important that these relations be subjected to public appraisal.

Before we conclude this chapter, one last problem must be mentioned. This is the degree to which the practice of medicine is open to the influence of the commercial sector. Studies in Britain and -America have all pointed to the importance of pharmaceutical detail-men and drug advertising as sources of information used by physicians in determining the types of medication to prescribe (Worthen, 1973; Wilson et al., 1963). Recognition of this problem has led the Board to state in its 1967 report that: "Commercial advertisment of psychoactive drugs could bring serious danger to public health and should therefore be restricted or if possible prohibited" (PCB/DSB, 1967: 26). A WHO document likewise attributed the excessive consumption of drugs in a number of countries to pharmaceutical advertising (WHO, 1968: 4). In our view these aspects are not irrelevant to international drug control and deserve closer attention and investigation by the intergovernmental agencies.

SUMMARY OF PART II

1. The international drug control system cannot be evalutated on the basis of the writings of insiders alone; there is a need for analysis by outsiders.

2. Conceptions of the drug problem and the definition of the objectives of international control have evolved over the years to culminate in a system aimed at limiting exclusively to medical and scientific purposes the trade in and use of controlled drugs. The goals and means of drug control are dictated by national and bureaucratic interests, the range of feasible options, the place of drug policy in broader social policy, attitudes towards drug control, and the institutional framework of treaty-making.

3. The key international drug control organs are: the Commission on Narcotic Drugs and its secretariat, the U:4 Division of Narcotic Drugs; the INCB and its secretariat; the Drug Dependence and Mental Health Units of WHO (now merged) and their expert committees.

4. In terms of resources and priority, drug affairs have a low rating in the UN and WHO. The Fund for Drug Abuse Control has, however, sharply increased the resources committed to work on drugs (other than alcohol). The Division has benefited most from the new funds.

5. Although outside experts and political bodies have their share in shaping the control system, the importance of the international civil servant should be recognized. It is generally underestimated because, in accordance with role expectations, his influence is usually played down.

6. All the key organs have their forerunners in the League of Nations. The League's traditions are still strong, and the present system cannot be understood without knowledge of its antecedents.

7. WHO drug-dependence expert committees have been concerned with the evaluation of drugs for control. Their area of interest has widened without a noticeable widening of the range of expertise brought to bear on their work.

8. The INCB's main contribution has been the development of a nearly worldwide statistical reporting system. It is questionable whether the elaborate estimates system the INCB oversees still serves the purpose for which it is intended. In practice, the INCB has exaggerated its independence from governments.

9. The Commission has concentrated mostly on opium/opiates. Its membership has progressively increased but a permanent core group of countries exists.

10. The control system is dominated by the U.S., the U.K., France, India and, to a lesser extent, Yugoslavia, Turkey, and Switzerland. The USSR's presence as a countervailing power is more significant in the treaty-making process than in the operations of the control organs.

11. The most influential country has consistently been the U.S. American influence has shaped the goals of the system, the control apparatus, the range of drugs placed under control, the means used to achieve drug control, and the general international policy. Its superpower status and resources and its own drug problem have contributed to its leading role in the drug field.

12. Pressure groups have had a part in the development of controls: antiopiumists exerted much pressure in the 1930s to bring about increased controls, and during the last decade the pharmaceutical industry has organized itself internationally to enable it to safeguard its interests in the face of international controls.

* The criteria for selection of NGO candidates include the relevance of the candidate's activities to those of ECOSOC; the conformity of its aims and purposes with those of the UN Charter; the representative nature of the candidate within its particular field of interest, and authority to speak for its members. National organizations would not normally be eligible unless there was no international organization in that particular field or unless the national organization had special experience.

* The developed countries indicated are the members of the European Economic Community (including Great Britain), Norway, Poland, Sweden, U.S., and USSR; the Latin American countries are Argentina, Brazil, Chile, Colombia, Mexico, Peru, and Venezuela. (Source: UNIDO Monograph on Industrial Development, No. 8 [1969].)