by Owen Whooley
This chapter investigates the consequences that the establishment of local boards of health, specifically New York City’s Metropolitan Board of Health, had for the epistemic contest. During the 1860s, opinions about cholera (allopathic, homeopathic, and lay) converged around the notion of cholera as filth, to be eradicated through municipal reform. A coalition of lay elites and sanitary-minded physicians led the calls for sanitary reform. In the process, they framed epistemic authority in terms of its disinterested, apolitical nature, juxtaposing it to corrupt city politics. Expertise was seen as emanating from a particular ethos toward knowledge. As such, the boards promoted a type of “intellectual ecumenism” when it came to knowledge on cholera, one that encompassed not only medical knowledge but also a whole host of other forms of relevant knowledge.
As discussed in the introduction, epistemic authority can be justified along a number of interrelated but distinct dimensions. How actors frame their arguments for epistemic authority matters, as it delineates the types of arguments that can be legitimately mustered in defense of knowledge claims and dictates the organizational responses to these claims. Among the many ways in which epistemic authority can conceivably be justified, three are most common. First, such authority can be grounded in the content of one’s knowledge. Recognition as a privileged knower is seen as deriving from the possession of a specialized body of knowledge. Claims made by clergy, which are based upon their understanding of sacred texts and a special spiritual insight, typically assume this form; clergy possess spiritual insight unavailable to the laity. Second, epistemic authority can be claimed on methodological grounds. Science is often legitimated this way. Scientists cannot be granted authority on the basis of the factual knowledge they possess, for the body of scientific knowledge is forever evolving. Rather, they claim epistemic authority based on their ability to achieve knowledge through the scientific method. Methodological appeals can be made in the name of an abstract ideal, like the scientific method, technical acumen (e.g., IT personnel), an ability to gather and process information (e.g., journalists), or the capacity to translate knowledge into practical applications (e.g., engineers). Finally, epistemic authority can be justified along the lines of an ethos or orientation toward knowledge. In these cases, it is not in the mechanics of knowledge production or the final knowledge produced that epistemic authority is justified, but in the stance one assumes toward the production of knowledge. An ethos-based approach to epistemic authority tends to place great emphasis on the character or position of the knower.
Sanitarians justified their epistemic authority in this final fashion, grounding it in their particular orientation vis-à-vis knowledge. Specifically, they claimed a special accuracy for their knowledge on account of its disinterested, apolitical character. The first section of this chapter describes this framing strategy by sanitarians in New York City, showing how it enabled them to convince the New York State legislature to establish a permanent, politically independent board of health. The decision to frame their epistemic authority along the lines of an apolitical ethos emerged in part from their opposition to city politicians. Because sanitarians approached sanitary knowledge without any political stakes in the findings, they could produce sober assessments of the city and yield rational, effective interventions to combat cholera. They were disinterested and, thus, their knowledge was more accurate than that of politicians, who had incentives (i.e., political patronage) to produce faulty knowledge that masked the extent of sanitary problems. Both sanitarians and their opponents in the City Inspector’s Office used similar methods to gain knowledge of disease, but sanitarians claimed that the knowledge they achieved through such methods was more trustworthy, not because they possessed superior technical know-how, but because they were untainted by political calculations.
This particular framing not only emerged as a reaction to corrupt politicians but also flowed from the nature of sanitary knowledge itself. The diverse nature of the content of sanitary science prevented sanitarians from making claims based on the content of any one specific body of knowledge. New techniques like dot maps, normal mortality ratios, and sanitary surveys linked cholera to place and, in turn, recognized the relevancy of different types of knowledge related to place. With disease framed broadly as filth, possible relevant knowledge was wide-ranging; sanitarians pooled insight from a variety of sources. Medical knowledge was important, but so was engineering, legal reasoning, architecture, and even plumbing. The broad manner in which disease was defined necessitated a sanitary science that was practical in orientation and ecumenical in nature. Appeals to epistemic authority on specific technical and methodological grounds were not possible when so many different forms of expertise were deemed relevant. Rather, the new boards of health were conceived as a reform movement that targeted political corruption through an appeal to a disinterested ethos toward sanitary knowledge.
In terms of the epistemic contest, the ecumenical nature of the boards was detrimental to regulars’ professional goals as it frustrated their attempts to gain control over public health. The second section of this chapter discusses the internal struggles over control of the Metropolitan Board of Health first between regulars and other sanitarians, specifically plumbers, and then between regulars and homeopaths. Allopathic physicians could not exclude nonmedical experts because the broad framing of disease as filth required the input of a number of actors, everyone from civil engineers to plumbers. They also were unable to exclude homeopaths from the board, for the expansive understanding of relevant knowledge translated into a broad recognition of relevant medical knowledge. Compounding matters, every attempt on the part of regulars to control the boards was effectively discredited by opponents as crassly political and in direct opposition to the stated ethos of the boards. Regulars’ attempts to justify their control of the boards were therefore hampered by the manner in which the epistemic authority of the board was framed. As a result, they failed to turn the boards to their professional advantage.
As such, allopaths developed an ambivalence toward public health generally. On the one hand, the popularity of the boards made them a potential resource for bolstering the prestige of allopathy. Insofar as the sanitary measures of the boards were seen as successful, regulars benefited from an association with them. On the other hand, the intellectual ecumenism of the boards, and sanitary science more generally, made it very difficult for regulars to control the agenda of public health. Allopathic physicians found it difficult to assert the superiority of their medical knowledge over other forms of relevant knowledge (e.g., engineering, plumbing, etc.) and, even, over medical knowledge itself. In the end, the boards became part of the problem, not the solution, for regulars’ professional aspirations. Once seen as prizes, they became yet another government agency to be viewed with suspicion.
LOCALIZING CHOLERA AS FILTH
By 1866, the confused debates as to the nature of cholera persisted, but most groups vying for control over the definition of cholera had reached agreement over a single fact—cholera was somehow related to filth. Historians have tended to treat this as an indicator of an emerging consensus for the miasmatic theory of disease (Barnes 1995; Duffy 1990; Leavitt 1992; Mitman and Numbers, 2003; Richmond 1947, 1954; Rosen 1993; Susser and Susser 1996). But the convergence of opinion was in fact more complex. The etiology of the disease and its relationship to filthy conditions remained a point of contention. Did filth create cholera? Did it just facilitate its spread by providing a fertile environment for growth? Or did filth simply undermine the health of the inhabitants living in it, making them more susceptible to the disease? Despite these persistent questions about the mechanisms behind the localization of disease, there was a degree of interpretive flexibility inherent in it. Some medical thinkers undoubtedly equated cholera with filth, but most adopted the more modest interpretation that there was some sort of demonstrable relationship between the two. Cholera need not be caused by filth in order for it to be related. Filthy locales were dangerous (Humph
reys 2002), but how and why need not be specified. Minimally, all that the association of cholera with filth demanded was an acknowledgment of some sort of connection between place and disease for a wide array of actors to close ranks around commonsense sanitary interventions And it was flexible enough to allow for the commitment to it from a variety of epistemological perspectives, but definite enough to provide a common ground for disparate actors to coalesce into a public health movement. The theoretical stakes were minimal, but the practical implications great.
Beginning in the 1850s, the association of cholera and filth was given a concrete form by three new techniques—dot maps, sanitary surveys, and the statistical artifact of “normal mortality.” In many ways, this association required no mean feat of investigation. The copresence of squalor, filth, and disease was apparent to all familiar with certain urban streets. The New York Times (June 25, 1856, 3) noted that just walking down the street was enough for someone to “consent that the sense of smelling itself is a nuisance.” What the new techniques offered sanitary reformers was the elaboration and systemization of such anecdotal, sensory observations. Less important as sources of new insight, they served to illustrate existing ideas, providing visual representations that could be rhetorically deployed in the advocacy of sanitary reform. And sanitarians used them to great effect.
Mapping Disease—Even though the perceived link between environment and disease was not new to the nineteenth century,2 doctors and sanitarians began to illustrate this link in the mid-1800s using maps. While most early maps of cholera were European (especially English) in origin, by the 1850s, Americans were involved in mapping disease (Barrett 1996). The growing prominence of medical mapping received great impetus from epidemic diseases that emerged during this period (Jarcho 1970, 138), especially cholera (Vinten-Johansen et al. 2003, 322). This interest in mapping epidemic diseases coincided with technical advances in printing, specifically the shift from copperplate to lithography, which allowed for more elaborate maps and more efficient dissemination of these maps (Koch 2005, 41). In this “golden age of medical cartography” (Gilbert 1958, 173), sanitary reformers adapted maps not only to make sense of cholera but also to illustrate particular arguments as to its nature.
During this period, two types of cholera maps were produced. The earliest maps were progress maps that traced the spread of cholera across large areas (Vinten-Johansen et al. 2003, 323), visually representing the movement of cholera through space. They emphasized the mobility of disease. As such, progress maps promoted a view of cholera more favorable to contagion theories. Temporality was an important dimension, as dates of outbreaks in specific areas were often noted along the routes that cholera took. However, because they covered wide geographical spaces, progress maps were limited by certain informational barriers; it was difficult to accumulate accurate information from disparate geographic locations. Since the United States lacked an adequate infrastructure for the collection and aggregation of vital statistics, the data behind progress maps lacked the requisite reliability, and as such, the maps had limited impact.
Of much greater importance were the dot maps, or spot maps, of cholera. In the mid-1800s, cartographers began to focus on the local circumstances of areas with the highest incidence of cholera. The most famous of these nineteenth-century dot maps was John Snow’s map of the 1854 cholera outbreak in London.3 Unlike progress maps, the intent of dot maps was to show the clustering of disease in space. Cartographers mapped out a geographical area, and then using “dots” or some other marking device, noted the incidence of disease. Clusters of disease reflected unhealthy local conditions.4 As techniques developed, they used more sophisticated techniques for “spotting” their maps, such as shading techniques to visually relate the incidence of cases to population density. Interpretively, dot maps suggested a robust correlation between place and disease.
Like all maps, the dot maps were not mere presentations of facts. They marshaled selected propositions into arguments about the nature of the disease (Koch 2005). In other words, the cholera dot maps were arguments in visual form, and the argument they sought to convey was that there was a relationship between disease and some local factor (e.g., nuisances, cesspools, inadequate sanitation). For example, Snow’s map linked disease to contaminated water sources, most famously the Broad Street pump (Johnson 2006). Indeed, it was this ability to visually convey information that was most alluring about the maps. Complex, poorly understood disease properties were reduced to dots on a map—dots when aggregated conveyed a pattern not readily “seen” otherwise.
For sanitarians maps performed the crucial tasks of simplification, reduction, and translation. And they interacted with the viewers in a seemingly transparent way. Knowledge claims were made visible and legible to the public. Like statistics for homeopaths, maps made arguments through demonstrations of knowledge, albeit in visual form. In this respect, they suggested a more democratic form of knowing, even if this democratic commitment existed more in appearance than substantively. Indeed, as arguments in visual form, the maps excluded and masked as much as they included and revealed. Still, they made knowledge seem transparent and open to public evaluation. It is the appearance of transparency, and the unconscious way in which maps insinuate arguments (Boggs 1947), that make them effective rhetorically. Dot maps took complex arguments about the nature of cholera and transformed them into simple visual representations, rendering them perceptible to all.
This dot map indicates every cholera case (represented as black boxes). Map of Lancaster, Kentucky, Showing the Location of Each Cholera Case in 1873. Courtesy of the National Library of Medicine.
This spot map illustrates the more advanced mapping technique of shading, showing the varying incidences of cholera outbreaks through shading (the darker the shading, the higher the incidence) in Nashville, Tennessee, from Ely McClellan, 1873. Map of the Cholera Epidemic in Nashville, Tenn., in 1873. Courtesy of the National Library of Medicine.
The message dot maps conveyed was clear: when it came to disease, place mattered. While neither inherently contagionist nor noncontagionist, dot maps fostered a certain localism by offering a static picture of cholera (Stevenson 1965). By encouraging an “inherently ecological” way of thinking (Koch 2005, 2), they focused viewers’ attention to the environmental context of disease. They established a spatial relationship of disease and some other local factor (a source of putrefaction, a ship or a pier), rooting a disease in place by relating it to fixed characteristics of the environment. Consequently, while the maps did not exclude any notion of contagion, these notions would have had to be actively read onto the visual representation. They were not inherently noncontagionist, but they made contagion more difficult to see.
Normal Mortality—A great obstacle for medical cartographers was gathering accurate knowledge to collate and fashion into useful maps (Osborne 2000). Maps were joined with and backed by vital statistics. Indeed, historically the emergence of medical mapping coincided with the development of medical statistics, as both shared a common intellectual base as part of the slow progression of medical science (Koch 2005, 8). But more than just gathering raw data, cartographers had to construct statistical techniques and measures to impose order on such data.
Sanitarians drew on statistics to support the visual arguments of the dot maps. It was not enough to show that diseases clustered in some areas more than others; cartographers also needed to show that this clustering was somehow exceptional. After all, people naturally had to die somewhere. To indicate the presence of preventable deaths, sanitarians developed a statistical artifact—the “uniform law of mortality” (Shattuck 1850, 95) or the “normal death-rate” (Smith 1911, 119). This measure was used to support the argument that certain sanitary locales were unnatural as they produced outcomes that violated the normal incidence of mortality. In essence, American sanitarians cobbled together the limited available vital statistics and calculated the mortality rate due to “inevitable causes,” like old age, accidents,
and endemic disease. This was deemed the normal death rate. Deaths from epidemic diseases fell outside the normal death rate, and, in turn, were by definition preventable. Through neat, obfuscating data management, sanitarians reframed deaths from cholera as aberrations to be prevented by the proper application of sanitary reforms, rather than part of the normal course of nineteenth-century living.
With the concept of normal mortality underlying their construction, dot maps became visual representations of nonnormal mortality that was linked to filthy local conditions. Rhetorically, this statistical ratio possessed all of the benefits—reduction, simplicity, and mobility—that the homeopathic statistics had. The measure effectively transformed the central message of the sanitary movement—sanitation could prevent unnecessary death—into a simple, seemingly transparent numerical ratio.
