Knowledge in the Time of Cholera (25 page)

Accepting the
Times
' evaluation, other cities followed suit and established their own municipal boards of health, as the Metropolitan Board of Health became the model for sanitary reformers throughout the country (Duffy 1990; Rosenberg 1987b). In these cities, the sanitary reforms followed a similar trajectory; spurred by the threat of cholera, a coalition of politicians,
physicians,
and social reformers agitated for and won reform. State boards of health were also formed, beginning with Massachusetts in 1869. Even a short-lived National Board of Health was created in 1879 (Smillie 1943). As reforms spread, the sanitary movement, formerly a hodgepodge of reforming physicians and concerned citizens, became organized. A collective identity crystallized among sanitarians and was formalized with the founding of the American Public Health Association (APHA) in 1872. Unlike the AMA, the APHA was not a professional association but “a body of informed persons of good will to facilitate the enlightenment of the public and promote the appointment of more competent health authorities” (Smith quoted in Rosenkrantz 1974, 58). It became the central node for a wide array of diverse actors in the growing national movement, facilitating exchanges between diverse local reformers. No longer isolated in particular communities, to be a sanitarian now meant belonging to a national community of reformers, a diverse community, but a community nonetheless. By the early 1870s, the public health movement was nationally popular and institutionalized.

A COOPERATIVE SUCCESS, A PROFESSIONAL PROBLEM

With their popularity and resources, boards of health became a key prize in the epistemic contest. One might surmise that given the initial support regulars displayed toward sanitary reform and the participation of elite, sanitary-minded physicians on the board that the regulars would view the boards as a positive occurrence, an opportunity to advance their professional and epistemic goals. This was not the case. To the chagrin of regulars, the public health movement was inclusive and ecumenical in nature. This framing, which had allowed sanitarians to overcome entrenched politicians, created unintended problems for allopathic physicians in their epistemic contest over disease with homeopaths and other sanitarians that hindered the professional agenda of the AMA and local allopathic societies.

Despite the widespread celebration of public health after the 1866 epidemic, the bulk of allopathic physicians developed ambivalence toward the boards and sanitary science in general. On one hand, the boards of health seemed to offer an opportunity to improve the public image of allopathy (Rosenkrantz 1974). In 1873, President C. R. Agnew of the Medical Society of the State of New York urged his colleagues to embrace public health in order to gain “a new and enduring title to the respect and the gratitude of the public” (Agnew 1874, 4). Sanitary-minded physicians appealed to no
bler
sentiments, pointing out that “the vocation of the medical man is not bounded by the narrow confines of curing the sick, but embraces a far nobler work—a work of illimitable extent—the prevention of disease, and the prolongation of life; a field of science ‘where the harvest is truly plenteous, but the laborers are few' ” (
American Medical Times
1860, 47). The
American Medical Times
(1860, 46) argued that to “defend and relieve our fellow men from the preventible [
sic
] causes of disease, is manifestly the highest mission and best service of medical science and skill.” According to sanitary-minded physicians, this “highest mission” of the profession required doctors to put aside professional concerns and work cooperatively to end disease and, in turn, put themselves out of business.

Not all allopathic physicians agreed with this noble sentiment. Cholera as filth demanded wide-scale reforms, ranging from the disinfection of tenement cellars to new ventilation systems, from water sanitation to street cleaning. Reformers lacked any means by which to weight the impact or relevance of one factor vis-à-vis any other. The embrace of public health, therefore, required the embrace of a nonhierarchical, cooperative spirit, precisely at the time during which regulars sought to distinguish themselves as possessing epistemic authority. Because “cholera should not be treated as a disease, but as a pestilence” (Smith 1869, 59), sanitarians embraced an ethos of intellectual ecumenism anathema to the professional agenda of the AMA, embodied in the no consultation clause. Regulars not directly involved in the sanitary movement balked at this ecumenism, for it inhibited the profession's claim of a privileged standing within sanitary science and precluded their attempts to control the definition of cholera. Medical knowledge was placed on par with other forms of knowledge.

This was all the more troubling given the demands the boards of health asked of physicians—they wanted physicians to forfeit some of their autonomy by reporting their own cases to the boards and turning over their cholera patients to board-controlled hospitals. Most rank-and-file regulars did not welcome nonmedical board members inserting themselves between them and their patients. Their dismay was manifest in their widespread hesitation, and often blatant uncooperativeness, in reporting cases of disease to the board (Hammonds 1999; Maulitz 1979). They feared that their patients would be taken away from them, removed to one of the cholera hospitals to be treated by another doctor or, even worse, a homeopath. In this way, the boards' demands were contradictory to the economic logic of allopathic medical practice, abhorrent to their self-interest. There was a class dimen
sion
to allopathic ambivalence toward public health. Most of the sanitary-minded physicians were wealthy elites from families with a historical commitment to moral reform and civil service. While their medical knowledge was valued in the sanitary movement, their participation was rooted in their standing as important members of the community, “less in scientific acumen than in responsible citizenship” (Rosenkrantz 1974, 58). Rank-and-file regulars felt that they could ill afford the luxury of participation, given their precarious professional and economic situation. Indeed, the AMA's professionalization strategy was to deny the legitimacy of control over medicine by anyone other than allopathic physicians themselves. The entire premise of their professional project was to gain control over disease, not to share it with others. And this is precisely what the sanitary movement was asking them to do. Therefore, while the elite, sanitary-minded physicians preached cooperation, the majority of rank-and-file regulars felt that the professional benefits of sanitary science could only be accrued if and when allopathy controlled the boards of health.

Professionalizing Plumbers?

In addition to their troublesome economic implications, the boards of health encouraged even more challenges to allopathic authority, as a variety of new actors began to assert their right to participate in the management of disease. By rooting disease in place, the idea of cholera as filth
extended
the contours of the epistemic contest beyond the bounds of medicine. Other “experts” had something relevant to say. This expansion was exemplified by the attempt of plumbers to improve their own standing through their association with public health. Prior to 1866, it would have been unthinkable for allopathic physicians to envision a challenge to their authority from plumbers. After 1866, it was the reality of the epistemic contest.

Like the sanitary reformers generally, plumbers justified sanitary reforms on apolitical grounds: “In order that it [the board of health] may be of benefit to the people and extend its usefulness to its full capacity, its complexion should not be characterized by any sort of partisanship. It should be composed of sanitarians, if the objects of the health board are to be attained” (Halley 1887, 241). Plumbers could better serve the people's trust because they had the requisite expertise and were immune to political corruption. And because sewers, cesspools, and inadequate internal plumbing contributed to disease, plumbers possessed valuable insights into the transmission of disease and the creation of cholera nests. As the “water supply of cities
and
dwellings, the sewerage of cities and house drainage, are some of the most important features of sanitary science” (Halley 1887, 243), plumbers' knowledge was needed to unearth the mystery of disease. And unlike the doctor, the plumber had both the skill and motivation to search out disease in its element:

No doubt he [the doctor] often speculates as to what may have produced the trouble he is striving to remedy, but when it comes to a careful, minute, scientific investigation to determine this cause, he usually has neither sufficient motive, time nor knowledge to make it. Is it a matter connected with defective sewage in relation to—suppose we say diphtheria? This involves questions of sanitary engineering, the work of the plumber, the composition of sewer gases, and tests for them. (Billings 1879, 125)

Possessing this requisite expertise, plumbers demanded their due recognition within public health, to argue that “we are not arbitrary” (Halley 1887, 245) when it came to sanitary science. William Halley (1887, 245), a master plumber from Ohio, drew on the link between disease and place to demand inclusion on the boards:

No one profession or calling is able to hold sanitary science in the hollow of its hand. It has been the impression among legislators that physicians alone are competent to serve as members of State boards of health. Not all physicians are sanitarians, and the best medical ability on earth is unable to compass the whole range of
practical
sanitation. It is granted that medical knowledge is indispensable to a health board, but it requires the learning and skill of other callings to complete the full complement of a thorough, practical, efficient sanitary organization. Sanitary science to be of value must be practical; and the varied aspects of sanitation cannot be reached by medical wisdom alone, but by the technical knowledge and skill of mechanical art.

As paragons of “practical sanitation,” plumbers demanded not only inclusion but also the authority to carry out their work autonomously, unquestioned by other, nonplumbing sanitarians.

While sanitary-minded physicians attested to plumbers' relevant sanitary knowledge, the bulk of allopaths ridiculed their aspirations. For regulars,
cholera
was a medical problem, and when dealing with disease, it seemed absurd that plumbers would dictate anything to physicians. T. Clarke Miller (1887, 109), regular physician and president of the Ohio State Board of Health, mocked the plumbers' attempt to assert themselves on the boards:

The plumbers have been making very commendable progress in the past few years; there are many of them who can be trusted to do safe work in their line; but some of them, by reason of having learned their trade well, have come to consider themselves commanders in the sanitary army, and to assume that the whole burden of practical sanitation rests upon their shoulders, and to felicitate themselves that doctors and architects have heartily joined with them, who have always done, and are still doing, everything that is necessary to do about the relations of plumbing to health. Physicians who kept themselves abreast with the advance of knowledge of the etiology of disease, and have been foremost in the detection of bad plumbing by a knowledge of its results, are not only unnecessary but meddlesome—they know how to cure disease—nothing about how to
prevent
it. . . . Indeed, we are in danger of having an army of trades seeking to place themselves in the sanitary priesthood. . . . The butcher who knows wholesome meat and furnishes it to his customers is likely to become the “sanitary butcher.”

Sarcasm aside, Miller was serious in his foreboding. The medical profession could not afford to ignore “the growing army of sanitarians in special lines” (Miller 1887, 108). Regulars might lose their uniqueness and distinction within the sanitary movement if every group professionalized in the name of public health.

The boards created an arena accessible enough, epistemologically speaking, to allow for challenges to allopathy that extended beyond alternative medical sects; plumbers and other “sanitary professions” entered the fray. The added competition complicated regulars' attempts to use the boards to promote their professional ends. This was not just frustrating; it was nearly incomprehensible. Regulars believed that medical knowledge should trump other forms of knowledge, for “it will be seen that one may be a good practicing physician without being a sanitarian, but no one can be a good sanitarian without being a good physician; the requisites for one underlie those for the other, as a foundation” (Griscom 1857, 110). Insofar as nonmedical
knowledge
was relevant, allopathy sought to relegate such knowledge to a secondary status and to assert its control over it. Either physicians should dictate how the complementary, but inferior, knowledge should be deployed or physicians should acquaint themselves with this knowledge and deploy it themselves. Thus, although allopathic physicians begrudgingly acknowledged the relevance of other knowledge, they sought to subordinate it and, in some cases, even to steal it. Allopathic physicians envisioned a system of public health to be managed by doctors and doctors only.

To the extent that plumbers were never able to gain equal standing to physicians on the boards, allopathic physicians were successful. In most matters, medical knowledge remained valued over knowledge of plumbing. Unsurprisingly, plumbers bristled under this situation: “Last and worse of all, in spite of these severe labors, the plumber is subject to general obloquy. No one appreciates his labors. His bills are usually disputed, and even when he has done his best he feels that it is a thankless task and that no one appreciates his efforts” (
Plumber and Sanitary Engineer
1879, 94). Still, plumbers were granted a place at the public health table as active members of boards of health. They were successful in their campaigns against irrelevancy and were able to prevent doctors from fully capturing their knowledge, retaining some autonomy from sanitary physicians. These efforts—along with similar efforts on the part of civic engineers, architects, and other sanitarians—ended up tainting the original promise of sanitary science for allopathy, as regulars were finding it more and more difficult to assert themselves among the cacophony of competing voices.