Knowledge in the Time of Cholera (39 page)

CONCLUSION—DE-DEMOCRATIZING MEDICINE

By the end of World War I, the reforms of allopathic medicine were complete, and the organizational infrastructure and the modern medical epistemology we know today were more or less in place. The epistemic opening offered by the early cholera epidemics had closed. Regulars, with their labs, were now the unquestioned authority on disease. Per Shakespeare's vision, cholera became a disease identified via the laboratory and treated by allopathic means. While the victory's impact on cholera was minimal—1892 was the last time the disease threatened the United States—it had great ramifications for future epidemics and medicine in general. Regulars no longer had to compete with others over the ownership and definition of disease. Allopaths had achieved epistemic closure.

The process by which bacteriological reformers achieved epistemic closure was all the more impressive, given that it was accomplished outside the bounds of the state. By carrying out their reforms through philanthropic funding, bacteriologists replaced contentious debate with allopathic injunctions, sanctioned, not by public fiat, but by private philanthropic resources. In adopting this “strategy of non-dialogue” (Biagioli 1994, 216), bacteriologists removed medical debates from the public sphere and instead allied with a handful of rich philanthropists to carry out their reforms. In other words, tapping into these private resources allowed bacteriological reformers to circumvent the state and public institutions and to avoid the repeated pitfalls that followed their advocacy in these public institutions. Crucial decisions that shaped the future of medicine were made by elites without general public input. Regulars won the debate over disease by ignoring it, or at least containing the debate among friends in the Rockefeller Foundation boardroom. By 1929, the Rockefeller Foundation had contributed $129 million to medical education and research. Adjusting for inflation, this is equivalent to approximately $1.6 billion today. Alternative sects and resistant regulars simply could not compete with these resources. No one reform—education, public health, hospital, licensing—was decisive but when taken together, they made it extremely difficult for alternative sects to get any foothold in the new organizations of modern medicine. As the momentum for the reforms grew, as more and more organizations came
under
the rule of the laboratory, the state began to tacitly, if not formally, endorse allopathy. But these endorsements came largely after the fact. And when they were granted, legislators willingly “acceded to physicians' contentions that successful practice required freedom from lay control” (Katz 2002, 31). The technical complexity of the laboratory became a legislative rationale for allowing allopaths to continue their consolidation of American medicine without outside interference.

Because the public—as represented by state institutions—had no opportunity to give its input, the process by which allopathy achieved epistemic closure was problematic in a democratic sense. The successful silencing of medical debates and the consolidation of epistemic authority is all the more striking considering that allopathic consolidation of U.S. medicine went against the public will that had been asserted for nearly a century. Beginning in 1830, state legislatures and the American citizenry had resisted all attempts by allopathy to seize complete control over medical decisions and medical knowledge. They demanded recognition as legitimate knowers and assessors of this knowledge. Unwilling to forfeit these rights, they widely supported the democratized epistemologies of alternative medical sects. Ultimately, Rockefeller money and resources allowed regulars to establish a constellation of specific spheres of professional authority
outside
of state influence. With private support, regulars could avoid the
public
democratic institutions that had long given them problems. There was no need to debate the merits of competing medical epistemologies in the public sphere when a handful of elite physicians could convince a handful of elite philanthropists to fund their programs. The new medical epistemology insulated expert knowledge in a way that represented a challenge to the epistemology of democracy—an epistemology long shared by state legislatures and alternative medical sects like homeopathy which championed competition, open debate, and public participation in medical knowledge.

The allopathic program of de-democratizing knowledge was, in a sense, built into the very fabric of the epistemology of the lab. The laboratory provided regulars with what Steven Fuller (2002,182) calls a “socially protected space” set apart from the democratic process where they could control medical investigation. Knowledge in the lab is largely closed to public observation or oversight. The laboratory does not tolerate public meddling. This insularity of the laboratory is glaring, especially when contrasted to the “space” of bedside empiricism, the patient's own domestic environment, where patients had more power to dictate treatment and speak their minds.
When
removed to hospitals, patients, once treated as a source of valuable information about disease, came to be seen as an obstacle to diagnosis. Their words were devalued for scientific tests, their ailments objectified as technical problems to be solved by science. Their status diminished, patients' agency in shaping their treatment was reduced. It is important to note that this exclusionary model of elite knowledge mirrored almost exactly the arguments made by regulars advocating for a privileged professional recognition throughout the nineteenth century. The difference now, after 1892, was that they had the lab and had found an audience amenable to the lab's promise (i.e., rich philanthropists). Using Rockefeller money to reorganize the institutions of American medicine around the lab, they insulated these institutions from public scrutiny. The more professional and scientific medicine became, the less democratic it became. The laboratory provided regulars' long-desired autonomy. By controlling access to the privileged space upon which all of medicine had been reorganized, allopathic physicians controlled medicine.

In the end, the consolidation of allopathic epistemic authority reflected an inherent tension between expertise and democracy. As Eliot Freidson (1970, 336) argues, “The relation of the expert to the modern society seems in fact to be one of the central problems of our time, for at its heart lie issues of democracy and freedom and of the degree to which ordinary men can shape the character of their own lives. The more decisions are made by experts, the less they can be made by laymen.” This tension between democracy and medical reform based on expertise was not lost on reformers. In arguing for a dramatic decrease in the number of medical schools, Flexner understood that if his suggestions were taken up, it would result in a more elite profession as lower-class, female, and black students, like alternative physicians, would be locked out of the new system of medicine. But, he argued, restricting the freedom to practice medicine would lead to a net gain in liberty:

[The community's] liberty is indeed clipped. As a result, however, more competent doctors being trained under the auspices of the state itself, the public health is improved; the physical well-being of the wage-worker is heightened; and a restriction put upon the liberty, so-called, of a dozen doctors increases the effectual liberty of all other citizens. Has democracy, then, really suffered a set-back? Reorganization along rational lines involves the strengthening, not the weakening, of democratic principle,
because
it tends to provide the conditions upon which well-being and effectual liberty depend. (Flexner 1910, 155)

This was a vision for a different kind of democracy. Insofar as the model organization of knowledge shares a constitutive relationship with the model of the good society (Shapin 2008), the epistemology of the laboratory and its accompanying organizational structure offered a new vision of the good society, one that represented a shift from the raucous but open egalitarian democracy of the Jacksonian period to an expert-guided rational polity of the Progressive Era. The participation of the public in medicine (as in politics) would be restricted. Its new role was more limited. In this way, the consolidation of allopathic authority under the epistemology of the lab shaped, and was shaped by, the changing understanding of American democracy and the role of the citizenry in that democracy. Rather than advocating participation, the new vision of democracy, and medicine, coached deference to expertise. Gone were the days when the citizen/patient would be invited to take a more active role in the execution of policy and health. Allopathy had captured cholera—and epistemic authority—in the lab.

CONCLUSION

Medicine after the Time of Cholera

In 1921, a new hero of medicine captured the imagination of the American public—a hero that would have been unrecognizable in the nineteenth century. Although many doctors vied for the role, it was a fictional character that came to personify the ethos of the new epistemology of the laboratory. Martin Arrowsmith, the protagonist in Sinclair Lewis's Pulitzer Prize–winning novel,
Arrowsmith
, embodied the ideals of the burgeoning medical science, his own intellectual growth mirroring that of medicine generally (Fangerau 2006). Indeed, Lewis consulted with Paul de Kruif, a former microbiologist at the Rockefeller Institute, in writing his novel, the intent of which was to paint a satirical picture of turn-of-the-century medicine, while championing the laboratory as the escape from the backward and unenlightened practices of traditional medicine.
¹
Imbued with the idealism of the new scientific era, Lewis produced certainly the most popular, albeit saccharine,
²
account of the intertwined processes of epistemic change and professionalization, with the corresponding shift in the identity of regular physicians.

The novel recounts Arrowsmith's peregrinations through the turbulent waters of American medicine. His journey mirrors that of the profession generally over the course of the late nineteenth and early twentieth centuries. Arrowsmith was born in 1883, the year Koch announced the discovery of comma bacillus. His life unfolds in the context of great changes to American medicine, thus offering “the recapitulation in one man's life of the development of medicine in the United States” (Rosenberg 1963, 450). A Midwestern doctor motivated by noble ideals, Arrowsmith struggles with his calling; he wants to help his fellow Americans, but is unsure how best to go about it. Throughout his career, Arrowsmith encounters various potential role models, who serve as signifiers of particular eras and epistemologies in U.S. medical history. Doc Vickerson, a country doctor whom Arrowsmith assists during his youth, is the epitome of the gentleman doc
tor
outlined in the first chapter of this book. Though earnest, Vickerson's practice is limited by his provincialism and his ignorance; his “physician's library” contains only three volumes: “Gray's Anatomy and [the] Bible and Shakespeare” (Lewis 2008, 4). Admiring Vickerson's dedication but recognizing the limits of his hidebound know-how, Arrowsmith departs for medical school, enticed by the new advances in medical sciences. However, there he meets faculty and students who lack curiosity and are “simply learning a trade” (Lewis 2008, 24). Representing clinicians for whom medicine was an art, Arrowsmith finds his medical peers ultimately undignified, both too commercial in their goals and too dismissive of the new laboratory sciences. Upon graduation, Arrowsmith enters the world of public health, but finds the boosterism and the politicking beneath him. He is troubled by the way in which politics muddles, and often undermines, his quest for improving the health of the community. Disillusioned, Arrowsmith is once again set adrift.

Eventually, Arrowsmith finds his calling in research, completing his professional journey, like medicine generally, at the laboratory. Here his role model is Dr. Max Gottlieb, a German bacteriologist so devoted to science that he neglects all social niceties.
³
Lauding the “necessity of technique” (Lewis 2008, 33) and the “beautiful dullness of long labors” (Lewis 2008, 57), Gottlieb is the consummate laboratory scientist. It is in the voice of Gottlieb's thick German accent that Lewis (2008, 278–279) provides what is perhaps the most romantic statement of the scientific ethos underlying the epistemology of the laboratory:

To be a scientist—it is not just a different job, so that a man should choose between being a scientist and being an explorer or a bond-salesman or a physician or a king or a farmer. It is a tangle of ver-y obscure emotions, like mysticism, or wanting to write poetry; it makes its victims all different from the good normal man. The normal man, he does not care much what he does except that he should eat and sleep and make love. But the scientist is intensely religious—he is so religious that he will not accept quarter-truths, because they are an insult to his faith. . . . He wants that everything should be subject to inexorable laws. . . . He speaks no meaner of the ridiculous faith-healers and chiropractors than he does of the doctors that want to snatch our science before it is tested and rush around hoping they heal people, and spoiling all the clues with their footsteps; and worse than the men like hogs, worse than the imbeciles who have not
even
heard of science, he hates pseudo-scientists, guess-scientists—like these psycho-analysts; and worse than those comic dream-scientists he hates the men that are allowed in a clean kingdom like biology but know only one textbook and how to lecture to nincompoops all so popular! He is the only real revolutionary, the authentic scientist, because he alone knows how liddle [
sic
] he knows. . . . But once again always remember that not all the men who work at science are scientists. So few! The rest—secretaries, press-agents, camp-followers! To be a scientist is like being a Goethe: it is born in you.