Knowledge in the Time of Cholera

by Owen Whooley

  DEMOCRACY, PROFESSIONALIZATION, AND EPISTEMIC CLOSURE

  By the 1920s, regular physicians, through the AMA, had achieved epistemic closure. This is not to suggest that alternative medical movements ceased to exist. Indeed, alternative approaches to medicine persevered through the twentieth century (Whorton 2002; Young 1967) and have made a comeback in the past two decades (Eisenberg et al. 1998), especially with the contemporary attempts to incorporate Complementary and Alternative Medicine (CAM) into mainstream medicine. Nevertheless, despite this dogged perseverance, the endurance of alternative medicine on the margins does not undermine what Magali Larson (1977, 37) calls the “exceptional character of medicine’s professional success.” Once epistemic closure was achieved, alternative medical movements were relegated to the fringes of medicine. At the center of the new scientific medicine was the laboratory, and by controlling access to the laboratory, regular physicians had reduced the epistemic threats of alternative medical movements to mere nuisances.

  On the whole, the laboratory revolution and the profession’s extreme embrace of a biomedical model proved quite productive, although it was not without its problems and blind spots. By the mid-twentieth century, the laboratory took medical science to important new heights, improving diagnosis and treatment. It goes without saying that one would much rather be a patient today or even in 1892, than in 1832 or 1866. The most dramatic benefits came from the investment of time and energy into vaccination, which followed directly from the epistemic closure around the laboratory. While a cholera vaccine never became widespread,6 bacteriologists did discover effective vaccines7 for diseases like rabies (1885), tuberculosis (1921), yellow fever (1937), polio (1950), and the measles (1963). In terms of treatment, the diphtheria antitoxin, developed by Emil von Behring in the early 1890s, was bacteriology’s first real triumph. Though diphtheria was not that prevalent, it became important symbolically for reform. Bacteriologists heralded the antitoxin as justification for laboratory science, and it would remain the major success story for nearly two decades (Hammonds 1999). Salvarsan, a drug for syphilis developed by Paul Ehrlich in 1909, represented another early victory for bacteriology. Still, it was not until the late 1920s and 1930s, with the introduction of antibacterial drugs, like penicillin, and synthetic sulfa drugs, that bacteriology really bore therapeutic fruit—three decades after Koch’s announcement of the discovery of the comma bacillus.

  More immediate benefits came in the form of antiseptics and diagnostic technologies. The germ theory provided the explanatory framework that justified sterilization techniques for surgery,8 which dramatically reduced deaths from sepsis, infections, and putrefaction (Starr 1982; Temkin 1977). As for diagnostic practices, laboratory diagnoses were a boon, in that they seemed to provide conclusive evidence of the presence or absence of disease. Once again this benefit was not immediate as it took awhile to catch on given the technical difficulties and an initial lack of standards in bacteriology (Gossel 1992). Nevertheless, these diagnostic tools solved one of the more persistent issues regarding epidemics—the frequent and destructive early debates over whether a given epidemic disease was present in a locale.

  Indeed, wielding the bacteriological model, modern medicine did conquer many infectious diseases, but this was accomplished long after the resolution of the epistemic contest, as these innovations did not become commercially available and widely adopted until after World War II. Between allopathy’s embrace of the laboratory and its therapeutic fruits lay nearly fifty years of sparse accomplishments in which the search for what Paul Ehrlich called “magic bullets” ran largely on the fumes of promise. Still, even if we acknowledge the fits and starts of bacteriology—which the truth-wins-out narratives fail to do—the record is impressive. Despite the delay, bacteriology achieved important medical advances. The early promise of bacteriology, while perhaps naïve in its optimistic vision of magic bullets right around the corner, was not misguided.

  Nevertheless, while experimental laboratory science led to important medical advances, it also created some real blind spots. In delimiting acceptable knowledge, an epistemology inevitably excludes and/or ignores knowledge that does not fit its standards. The laboratory defines disease in a limited way, reducing it to the presence or absence of a microbe. To understand the limits of this reductionism, we need look no further than the manner in which cholera has been approached in the century since epistemic closure. Public health measures built on the bacteriological paradigm prove problematic when encountering the disease outside of the laboratory. In their excellent analysis of the epidemic in Venezuela, Charles Briggs and Clara Mantini-Briggs (2003) expose the pitfalls of current public health interventions that have their roots in the bacteriological paradigm. In 1992, cholera arrived in the eastern Delta region of Venezuela, hitting its indigenous communities particularly hard. In response, the World Health Organization (WHO)—an organization financed in part by the Rockefeller Foundation—dispatched an impressive number of medical officials to the Delta. The WHO’s strategy was built on an understanding of cholera as a germ. They “imbued Vibrio cholerae with quasi-military agency” (Briggs and Mantini-Briggs 2003) and approached the epidemic as a problem of germs and individual patients, not as a collective or environmental issue. Determining that the indigenous could not be sufficiently educated to prevent the disease, these officials focused on treatment, dispensing an incredible amount of antibiotics and, to a lesser extent, oral rehydration therapies. In other words, officials attacked the epidemic through the microbe. Though these efforts served to curb the worst excesses of the epidemic, once the crucial period passed, the medical officials quickly departed, having killed off the bacteria. What wasn’t addressed by the WHO is telling. There were no improvements made to the inadequate sanitary infrastructure of the Delta, no long-term funding for staffing of medical clinics, and no policies to address the social and economic inequality that enabled the epidemic in the first place. In targeting the germ, officials ignored the environment, leaving the Delta just as vulnerable to future cholera epidemics as when they arrived. They gave pills and left. Compare this to the successful sanitary efforts in the United States 126 years prior, in which diseases like cholera were addressed through environmental improvements, and the limitations of a bacteriological model for public health becomes starkly evident. The more public health is understood solely as an extension of bacteriology, the more limited it is in addressing the underlying social and structural causes of epidemics (Dubos 1987). The limits of the germ theory along these dimensions represent in part an epistemological failure of imagination (Farmer 2001).

  In reaction to this reductionism, current research on cholera has sought to undo the rigidity of the bacteriological paradigm by embracing a more complex understanding of the disease. The laboratory has been “home for cholera for much of the twentieth century” (Hamlin 2009, 236), but researchers are now trying to replace the cholera-as-a-germ model with a much messier, more unstable definition, by examining cholera in situ. The ecological view of the cholera microbe and “biocomplexity” recognizes that cholera interacts with its surrounding environment in fundamental ways and its pathogenicity is an acquired state (Colwell 2002; Colwell and Huq 2001). In other words, rather than extracting cholera from its environment to study it, this new paradigm re-embeds it to better grasp its nature. This is a direct challenge to the laboratory. And it complicates the identity of the disease; as historian Christopher Hamlin (2009, 16) notes,

  No longer is it possible to claim with confidence to know cholera. With cholera changing and inchoate, the control in our social and historical experiments has vanished. What has seemed most solid about it, its microbe, has turned out (like other microbes) to be a repository for varying bits of rogue DNA, which together express toxicity under certain conditions. While we know vastly more about it, the general entity “cholera” is less fixed than at any time since 1830.

  Armed with this new (or perhaps old?) perspective, current researchers “wonder why
there has been so little work of what seemed obvious questions” (Hamlin 2009, 230); the answer is that the epistemology of the laboratory prohibited (or at least impeded) these questions from even being asked.

  This shift in perspective is dramatic, its implications significant. The parsimonious view of cholera as a microbe, inherited from Koch, is giving way to a much messier picture, one that recognizes “many varieties of Vibrio cholerae, gaining or losing pathogenicity as toxin-bearing stretches of DNA move in, or toxin expression is turned up or down in response to environment” (Hamlin 2009, 211). By reintroducing complexity, the blinders that the epistemology of the laboratory erected are breaking down and its power as a means to understand cholera is being questioned.

  Expert Knowledge in Democratic Cultures

  The manner in which epistemic closure was achieved by regulars not only had ramifications for the conceptualization and treatment of disease entities; it also raised more fundamental issues of professions and democracy. A recurrent theme throughout the book has been the tension between the epistemic/professional project of allopathic medicine and democratic ideals. Prior to the 1900s, the history of allopathic professional struggles in these government institutions was one of the continuous rejection of regulars’ claims to privilege and programs of exclusion. Insofar as the American public voted on these issues, through their representatives, their message was clear—openness in the medical market was a positive ideal. The epistemological logic underlying these outcomes was one that viewed debate, dialogue, and transparency as essential to the development of medical knowledge.

  Epistemic closure, however, was achieved outside the type of public institutions that facilitate and ensure democratic oversight. Allopathic physicians, wielding premature claims of certainty, won the epistemic contest by convincing elite philanthropists to back their program outside of state influence. Philanthropic resources allowed them to reorganize the medical system around the laboratory and create an infrastructure under their control, which they leveraged to kill off alternative challengers. They effectively purchased the professional privileges they could not win through argumentation. Making the laboratory central to medical knowledge foreclosed democratic debate and took the discretion over medical matters out of the public sphere.

  Grounding professional authority in the laboratory placed medical knowledge firmly under the control of regulars. Although the specific means by which this was achieved were particular to medicine, the desired goal to monopolize knowledge so as to gain a market advantage is the essence of all professionalization efforts. In this way, professionalization conflicts with democratic values. The manner in which communities organize the production of knowledge shares a constitutive relationship with the model of the good society (Shapin 2008). How knowledge is to be achieved—and its concomitant hierarchies—mirrors an understanding of how decisions should be made. In the United States, professions have become the primary means by which the marketplace deals with expert knowledge. Certain actors are provided autonomy from outside influence, a privileged insulation granted on behalf of their perceived expertise and their status as elite knowers (Freidson 2001). But expert formal knowledge is not part of everyday knowledge; it is an elite knowledge that by nature is not democratic (Freidson 1970) and therefore exists awkwardly in democratic cultures. Karl Mannheim (1992, 185) recognized long ago, “Democratic cultures have a deep suspicion of all kinds of ‘occult’ knowledge cultivated in sects and secret coteries.” Insofar as their knowledge is opaque and “occult-like,” professions represent a threat to democratic ideals in that they have a unique capacity to discourage, distract from, and limit democratic deliberation (Dzur 2004). They carve out a hierarchy of privileged knowers within an (ideally) flattened democratic culture. Knowledge production becomes the province of the few, undertaken in spaces like the laboratory that are closed to the public. Democratic political governance, on the other hand, posits a very different epistemology, emphasizing openness, transparency, and the participation of a general public. The two visions of knowledge that form the basis of democracy and professionalization are in an important sense discordant.

  This dissonance must be resolved in practice. In a sense, the entire epistemic contest over nineteenth-century medicine revolved around the struggle between allopaths’ promotion of a privileged hierarchy in medical knowledge and alternative medical sects’ promotion of more democratic forms of knowing. After nearly a century of coming out on the losing end of the democracy/profession tension, regulars were able to draw on philanthropic resources to circumvent government institutions, achieving their professional goals outside the bounds of the state. Only after they had consolidated organizational power did allopathic physicians and the AMA then turn to the state. They were then able to use their newly acquired organizational leverage to dictate the terms of medical legislation and ensure that the oversight of every facet of medicine would be in their control. The AMA’s effective resistance to state interventions established the condition for a highly privatized medical system, exceptional throughout the developed world (Krause 1996; Saks 2003). In the end, allopaths resolved the tension between democracy and professionalization by avoiding it altogether, convincing a handful of elite philanthropists, rather than a democratic populace or their representatives, that the laboratory was the only legitimate way to medical knowledge.

  The social order of knowing promoted by bacteriological reformers was not just the reflection of cold professional calculation; it was embedded in the very epistemology of the lab. The laboratory is not a democratic space. It rarely allows outsiders in and even if it does, the barriers to participation are so high that only experts can realistically speak to what goes on there. It restricts participation to the technologically elite, who are both the producers and judges of knowledge claims produced therein. The public record of laboratory practices—journal articles—obscures their messiness and ambiguity (Latour and Woolgar 1986). In terms of the universe of knowers, the laboratory offers a restricted, closed system. Those outside are asked to trust its claims even though they are neither allowed, nor able, to adequately assess them. For these reasons, the laboratory was alluring for allopathic professional reformers. Its exclusionary nature fit squarely in a legacy of exclusionary allopathy epistemologies, evident first in authoritative testimony of rationalism and later imposed, under radical empiricism, by the AMA.9 The difference was that the scientific aura of the laboratory won important allies like Rockefeller, who provided the requisite resources for professionalization through the lab. The democratic arguments against allopathy had not changed. They were not defeated nor repelled. They could simply be ignored because reformers had tapped into a vast source of private resources.

  This history has important ramifications for how we think about the role of professions in democratic societies. Because professions are the most common way that modern societies institutionalize expertise, there is a tendency to take them for granted as the natural outcome of living in an increasingly complex world. What this book shows is that rather than natural outcomes, professions are born from historical processes, central to which is the need to resolve the tension between professional claims and democratic cultural values (at least in democratic societies, that is). There is no ideal way to achieve this resolution; rather as professions research has long argued, we need to attend to the historical particularities out of which these tensions are resolved.

  The history recounted in this book thus raises difficult questions. What is the place of expert knowledge in democratic societies? How can we organize knowledge to preserve democratic values while still acknowledging the need for hierarchies in knowing? How can we calculate and justify such a trade-off? How can we ensure equality and patient participation, and prevent epistemic inequality, while maintaining patient protections, sensible regulations, and a functioning system of medical credentialing? These types of questions are not restricted to medical issues, as they permeate the heart of the democratic experiment;
they can be read into any debates that involve trade-offs between freedom and equality. They are the type of questions that resist neat, abstract answers, but instead are sorted out in the messy world of local practice, a world rife with struggle, capitulations, compromise, and “satisficing” (March and Simon 1958).

  To be clear: this is not to say that professions are antidemocratic in their nature. Rather it is to realize their inherent tensions with democratic ideals, tensions that must be negotiated in practice. For medicine, the awkwardness was dealt with via circumvention. Other professions may resolve it differently. But we must attend to this issue in our analysis if we are to understand the emergence and character of particular professions.

  The democracy/profession tension speaks to a broader issue of inequality that stems from epistemic closure. In achieving professionalization, professions are granted authority and control over the deployment of expert knowledge (Abbott 1988; Freidson 1970, 1986, 2001). This privileged epistemic authority is granted at the expense of others. As this book illustrates, epistemologies differ in the degree to which they are inclusive of outsider participation. The epistemology of the laboratory falls on the exclusive end of the inclusivity/exclusivity spectrum. As it became institutionalized as the way to achieve medical knowledge, this exclusivity was made manifest in medical organizations and practice. Some of this exclusion was intentional. Regulars wanted to ensure that homeopathy was marginalized. But other aspects of this exclusion were less explicit, perhaps less intentional. Epistemic inequality was overlaid by gender and racial inequalities, resulting in the systematic exclusion of certain groups from the universe of legitimate medical knowers. For example, the Flexner Report, in assessing medical schools on laboratory-based criteria, was particularly hard on medical schools that trained minorities and women, which lacked the resources of research institutions to establish such facilities (Starr 1982, 124). Medicine became more homogenous as the profession became even more dominated by white males.