by Owen Whooley
Regulars were not the only ones to undergo a change in identity. A similar narrowing occurred for cholera, as its long meandering journey through various identities came to a decisive resolution. Over the course of the nineteenth century, cholera was transformed from a truly heterogeneous thing into a single germ. Once understood as a supernatural scourge, then a cluster of particular manifest symptoms, and later an aggregation of environmental degradations, cholera was radically altered by bacteriology. In spite of the ambiguities of the bacteriological research on cholera, it was reduced to an S-shaped microbe, observable only through the microscope. The presence or absence of this particular microbe determined the presence or absence of the disease. Environmental factors, so crucial in determining the spread of the disease, were de-emphasized (Dubos 1987). Cholera, long a vexing puzzle that “mocked the calculations of man,” was apprehended in the laboratory, tamed in petri dishes, and exposed by the microscope. Doctors now knew, or believed they knew, their microscopic enemy and attacked it as such.
Thus, epistemic closure brought a narrowing in the meanings of what was a disease and who was a doctor. Both cholera and allopathy had come a long way since 1832. Arrowsmith, like cholera, had been captured by the laboratory.
This book explains how this epistemic closure was achieved—how regulars came to embrace the epistemology of the laboratory and reconstructed U.S. medicine accordingly—despite resistance from alternative medical movements and government institutions reluctant to grant professional privileges lest they undermine core democratic values. The cholera epidemics, beginning in 1832, created a medical crisis, as allopathic physicians labored impotently to quell people’s fears of the foreign disease. This crisis was seized by alternative medical movements, first Thomsonism and then (and more persistently) homeopathy, to reverse the professional privileges that regulars had accumulated in the early part of the nineteenth century. With the public reeling from cholera and wary of regulars’ heroic treatments, these movements mounted an epistemological challenge to allopathy. Whether through appeals to make every person his own physician or by demonstrating claims through statistical rhetoric, they proffered more democratic epistemologies that resonated in state legislatures undergoing their own democratic transformation. Alternative medical movements won the near universal appeal of licensing laws; the medical market was deregulated; and an epistemic contest was born.
Facing such a challenge, regulars were forced to articulate a new epistemological vision to replace the discredited rationalism of the past. In response to the successes of alternative movements, reformers within regular medicine sought to capture some democratic bona fides by embracing an epistemology of radical empiricism, derived from the Paris School of medicine. Defined in opposition to rationalism, radical empiricism derided all theorizing, hypothesizing, and generalizing. This left allopaths with a fragmented knowledge base of competing claims and no mechanisms to adjudicate between them; their knowledge on cholera devolved into a series of disconnected empirical observations. To address this problem of adjudication, regulars established the American Medical Association, instituting a no consultation clause that defined homeopathic knowledge as outside of the universe of legitimate knowledge. Regulars tried—and generally failed—to use the organizational leverage of the AMA to prevent the homeopaths from translating government recognition into tangible resources. Still, in the AMA, allopaths formed a united front against “quacks” by constructing an organizational infrastructure insulated from their influence.
With the establishment of boards of health in 1866, a coalition of doctors and sanitary reformers began to rein in cholera’s worst excesses. United around a common understanding of cholera as filth, this eclectic group of lay and medical reformers mobilized to prevent cholera by cleaning up the environment and instituting broad sanitary reforms. This was accomplished to great effect. Deploying new technologies like dot maps, the Metropolitan Board of Health in New York City—the board which became the model for other municipalities—was widely credited with stifling the 1866 cholera epidemic. Regulars sought to harness the popularity of the new boards to advance their professional agenda by seizing control of their management. However, with public health expertise framed in terms of its apolitical character and disease framed broadly as filth, this strategy was seen by legislatures as crass politics and contradictory to the ecumenical spirit of the public health movement. It failed; homeopaths and other sanitarians won inclusion on the boards; and public health, much to the chagrin of the AMA, remained an eclectic movement.
In 1883 Robert Koch announced his discovery of the cholera microbe, once again redefining the identity of the disease. The event of Koch’s announcement was folded into, and interpreted through, the ongoing epistemic contest in the United States. Initially, both homeopaths and regulars attempted to configure Koch’s research as a discovery that legitimated their system of medicine. Through discovery narratives, both sought to embed Koch’s research within the history of their respective sects, while simultaneously promoting its promise by depicting it as a pivotal break from the past. Regular physicians proved more successful along these lines. Their narrative provided the intellectual rationale for the construction of a network linked to German science. Bacteriological reformers, most notably William Welch, established enduring connections to Koch’s laboratory and, in turn, created a space within regular medicine in which an epistemology of the laboratory could be incubated. Once the discovery became associated with allopathy, homeopaths adopted an oppositional stance against bacteriology that would ultimately doom their popularity as the germ theory gained public acclaim.
With their ties to the German laboratory, bacteriologists embarked upon an ambitious program of medical reform. They sought to remake the entire medical system around an insular, expert-centric epistemology, located in the laboratory, manifest in the new science of bacteriology, and exemplified by the Johns Hopkins model of medical education. Frustrated by the politicized response to the 1892 cholera epidemic in which the dictates of the bacteriological lab were repeatedly ignored by officials, reformers reevaluated their professionalization strategy. Continuously defeated in government institutions on democratic grounds, the AMA circumvented these institutions by aligning itself with large private philanthropies in order to achieve professionalization. Its epistemology of the lab resonated with Rockefeller, who was also integrating the laboratory into the manufacturing processes of Standard Oil. By convincing philanthropies, especially the Rockefeller Foundation, to fund its program of scientific medicine, the AMA evaded state legislatures to construct an organizational infrastructure orbiting around the lab—an infrastructure under AMA control and purified of homeopathic influence. Leveraging their new organizational power, regulars then won special professional privileges from the state after these organizations were in place. The nearly century-long dispute over medical epistemology came to an end, as regulars achieved epistemic closure, and in the process, created the U.S. medical professional, unique to Western developed nations in its authority, suspicion of government intervention, and extreme embrace of a scientific-technological approach to medicine.
PROFESSIONALIZATION AND EPISTEMIC CONTESTS
This particular course of U.S. medical professionalization might lead one to mistakenly believe that in the end medical debates did not matter; the AMA in effect purchased its power, using the tremendous economic resources at its disposal. But such a belief truncates history, neglecting to acknowledge the history of defeats that led the AMA to this particular professional strategy. It erases the important contribution of alternative medical movements in creating an intellectual and professional crisis that begged resolution. And it fails to offer an adequate explanation as to how the odd alliance between the AMA and the Rockefeller Foundation came to be. If we want to understand the history of a particular institution—in this case the American medical profession—we must be willing to embrace history in all its messiness and avoid reducing the complexities of
the past to simple, monocausal explanations. The meandering course of U.S. medical professionalization was determined by the contours of an epistemic contest. Though waged through specific issues, like cholera, the competition between regulars and alternative medical sects revolved around basic debates over what constituted legitimate medical knowledge. Therefore, to understand the course of the American medical profession—and its unusual outcome—it is essential to recognize this basic epistemic dimension.
This book explores the professionalization of American medicine through the lens of epistemological change, so as to account for the emergence of the laboratory, the nature of epistemic closure in medicine in the United States, and the organizational infrastructure that such closure yielded. The power of professions is rooted in their claim to expert knowledge (Abbott 1988), which justifies a “market shelter” over certain specialized areas of work (Freidson 2001). Professional legitimacy demands a solid intellectual foundation. Given the centrality of knowledge in the establishment, justification, and logic of professions, the analysis of their emergence, and indeed their persistence, must maintain a focus on developments in knowledge. This is not to discount the relevance of other factors (e.g., organizational development, monopolistic work practices, cultural practices, class dynamics, political struggle, etc.) commonly explored in the professions literature. Indeed, these factors arise repeatedly in the analysis in the book. Rather, it is to recognize that, in this case, these factors were fundamentally determined by the underlying issues of knowledge debate and claims-making; to understand the professions and their concomitant organizational structures, political alliances, and labor practices, we must attend to issues of knowledge first and foremost. Because knowledge is the “currency of competition” (Abbott 1988, 102), an adequate sociology of work—and by extension an adequate sociology of professions—must also be “a sociology of knowledge” (Freidson 2001, 27).
The analytical implication of this is clear: the sociology of knowledge must be brought to bear on the study of professions. Unfortunately, the dialogue between these two subfields has been lacking. Given that the professions are the primary organizational form by which developed countries organize expert knowledge, the absence of such a dialogue is both puzzling and inexcusable. Perhaps it stems from the sociology of knowledge’s focus on scientific knowledge in the past few decades, one more attuned to issues of knowledge production that is somewhat divorced from practical work activities. Perhaps parsing the activities of scientists in the lab has distracted the research agenda away from more clinical and practical forms of knowing. Whatever the rationale for this lack of dialogue—whatever its practical disciplinary justifications—this collective research decision, conscious or not, is problematic. This book opens an analytical space for such a dialogue.
While professionalization is at root always about knowledge, it is not always about epistemology. To be clear: professional disputes—or “jurisdiction disputes” (Abbott 1988)—do not necessarily involve epistemological issues. They can revolve around ownership of a particular work task, where the issues center not on fundamental epistemological questions, but rather on the control of specific tasks or definitions of specific problems (Abbott 1988). For example, disputes between neurologists and psychiatrists in the late 1800s did not focus on questions of psychiatric knowledge—where there was quite an overlap between the two groups—but rather on who controlled the treatment over “nervous” disorders and where the locus (e.g., asylums) of such treatment should be (Rosenberg 1995). Likewise, epistemic contests need not involve the professions. For example, disputes between creationists and evolutionists do not revolve around the issue of professional authority, but rather on things like the composition of the school curriculum. Epistemic contests and professional disputes can overlap, but they are distinct.
This distinction becomes evident when comparing the process of medical professionalization in the United States to that of other national contexts. While claims to American exceptionalism are often rife with exaggerations and normative assertions, the American medical profession has in fact departed from its peers in other Western democracies. The most obvious—and politically contentious difference—is its approach to health insurance, where “the United States stands out for the virulence of its political battles over health care” (Starr 2011, 1). Prior to the passage of the Patient Protection and Affordable Care Act (PPACA) in 2010, the United States was the only advanced country to lack a government-mandated system for universal health care. And even the mechanism by which PPACA seeks to achieve universal coverage is unique in that it does so largely through the private sector. The country’s approach to medical insurance is in great part a reflection of the profession’s adamant opposition to government intervention in medicine.
The absence of some sort of government-backed mechanism to achieve universal health care coverage is not the only way in which the U.S. medical system diverges from other developed countries. The American medical profession is also exceptional in its focus on technologically intensive medical services, its commitment to specialization, and historically, its embrace of the germ theory. To an extent unusual in the early twentieth century, American medicine was built around the promises of technological fixes, a tendency that has been exacerbated over the years by the structure of U.S. medical economics, which favors expensive technological interventions (see Birenbaum 2002, Clarke et al. 2003).
I have labored to show that the U.S. medical profession’s embrace of the epistemology of the laboratory and its suspicion of government institutions—the source of much of its exceptionalism—resulted from the specific trajectory of the epistemic contest. This argument raises a critical question when teasing out the relationship between epistemological change and professionalization: if all Western countries eventually embraced the laboratory sciences, why did this epistemic shift yield such different organizational/professional outcomes in the United States? Doesn’t it undermine the significance of the relationship between professionalization and epistemic change if similar epistemic outcomes lead to different professional ones?
The answer, I argue, is not really. While it is beyond the scope of this book to offer a comprehensive comparative account of professionalization in different contexts, a few comments are in order. First, as the status of the United States grew in the world, so too did its medical influence over other countries. It became a major exporter of the epistemology of the laboratory, and its doctors global emissaries for the lab. The worldwide adoption of this epistemology resulted in part from the U.S. epistemic contest, which created a profession whose very identity hinged on the laboratory and offered a vision that was exported to other countries via philanthropic projects. Second, the epistemological similarity between different countries leads many to gloss over real differences in the extent to which physicians in other nations embraced the epistemology of the laboratory. My argument vis-à-vis the exceptionalism of the U.S. case is a matter of degree, not kind. All Western countries eventually adopted the epistemology of the laboratory, but none with as much fervor as the United States. The germ theory became “gospel” in the United States (Tomes 1998) to an extent unrealized elsewhere. This degree of commitment reflected the particular nature of the epistemic contest in the United States. The identity of the medical profession in the United States came to be built on the laboratory; this was simply not the case in other countries (e.g., England), where professional political dynamics differed. While other countries demonstrated a greater emphasis on public health, general medicine, and prevention, the U.S. medical profession poured its energies and optimism into scientific medicine, as the laboratory justified the profession’s power. Therefore, while there was overlap between national contexts (partially due to the fact that they were not isolated from each other), the trajectory of professionalization in each country contained its own idiosyncrasies that subsequently became inscribed in their medical systems.
Ultimately, the relationship between epistemic conte
sts and professionalization is a historically contingent one, not a necessary one. The exceptionality of the U.S. medical system emerged out of (and can only be understood as resulting from) the unique history of its epistemic contest. This epistemic contest—with a strong democratic culture resistant to professions, active challenges by alternative medical movements, and eventual consolidation through the unique system of U.S. philanthropy—meant that the epistemology of the lab became linked to a suspicion of government intervention. But this was a specific outcome, contingent on a specific confluence of factors.
The professionalization of medicine in other countries did not involve epistemic challenges of the same nature or intensity. Context matters. The way in which different constellations of actors intersected in the political, social, and cultural systems of various countries affected the degree to which bacteriology mattered for the organization of medicine.4 For example, in Great Britain, the medical profession evolved along class lines (Shortt 1983). Elite physicians shared a background with government elites and always had their support. Although initially questioned for geopolitical reasons, the germ theory was folded into the existing professional hierarchy that had long-standing support from the state. In France, the germ theory was embraced first by a strong central government, which, given its reach, brought reluctant doctors along (Latour 1988). Indeed, the process of medical professionalization in France was carried out through the state, occurring much earlier than in the United States (see Ellis 1990; Geison 1984; Goldstein 1990; Weisz 1978). In other words, the adoption of bacteriology and the epistemology of the lab in England and France did not have the professionally trans-formative character that it had in the United States. In fact, of the developed Western European countries, only Germany had a medical profession that demonstrated a similar wariness toward working with the state. This reluctance, however, was resolved during the nationalistic run-up to World War I (Kater 1985). In the end, although rigorous comparative research on the professionalization of medicine in different countries is needed to tease out the nuances of these differences and similarities, the history presented in this book demonstrates the unusual extent to which the professional politics of U.S. medicine were animated by basic epistemological issues. In no other country did medical professionalization involve either the same epistemic dimensions present in the United States and/or the same hostility from state institutions.
