Knowledge in the Time of Cholera (42 page)

First, and most broadly, the analysis in this book specifies the mechanisms that undergird the macro-cultural account of U.S. medical professionalization. It eschews the analytical laziness of labeling an era and calling it an explanation. By focusing on practice, it allows for the identification and explanation of the human action that comprises such macro-cultural shifts. Certainly the cultural changes that accompanied the Jacksonian era played a role in creating an environment conducive to the epistemic challenge mustered by alternative medical movements. And undoubtedly the burgeoning acceptance of expert knowledge during the Progressive period was favorable to the reform of American medicine through the laboratory, exemplified in the Flexner Report. But these general shifts are not sufficient enough to tease out the nature of professionalization, or even to understand its course. Macro-cultural arguments may provide some basic contours of the narrative, but their lack of specificity leaves much of the story untold. By moving to a meso-level analysis, this book shows how large-scale cultural shifts operate through specific practices in specific settings. Rather than making a broad appeal to the culture of the Jacksonian period, it shows the ways in which the types of epistemological visions proffered by homeopaths and Thomsonians resonated in certain government institutions. Culture, in turn, is no longer conceived as something external, hovering above social action that sets the context, but as something produced and reproduced in practice.

Second, this book stresses the essential role of alternative medical movements in the development of medical knowledge. Rather than mere curiosities or, worse, repositories of errors, alternative medical movements emerge from this analysis as crucial. In addition to any specific intellectual influences they had (e.g., convincing regulars to discard heroic therapies like bloodletting), by forcing regulars to legitimate their professional claims in
epistemological
terms, these movements drove changes in medical knowledge. In other words, because epistemological positions arose from contentious struggle, the influence of alternative medical movements was manifest in the outcome of the epistemic contest. The crucial role played by alternative medical movements has been woefully underestimated in the dominant histories; alternative medical movements drove developments in medical knowledge through their dynamic, magnetic relationship with regulars. This case, then, points to the potential of social movements to play a more substantial, if more subtle, role in influencing knowledge than is typically recognized. Research on “scientific and intellectual movements” reveals the important influence of movements in scientific-knowledge-producing institutions, like research universities and scientific disciplines (Frickel 2004; Frickel and Gross 2005). However, because it largely restricts its analyses to autonomous scientific fields in which activists are forced to conform to scientific epistemic standards so as to portray themselves as credible knowers (see Epstein 1996), this body of research overlooks the potential influence of social movements in fundamental epistemological debates. In less autonomous fields, like medicine, or in fields experiencing epistemological flux, social movements like homeopathy can engage in “knowledge advocacy” on fundamental epistemological grounds (Whooley 2008), offering “epistemic challenges” as they are less pressed to debate the issues on the field's own terms (Hess 2004). In other words, the analytical frame here allows for a wider recognition of the “cognitive praxis” (Eyerman and Jamison 1991) of social movements, one that penetrates to the level of epistemology.

Third, this book clarifies the nature of the alliance between elite philanthropies and medicine by revealing the epistemological affinity between the bacteriological laboratory and Standard Oil's incorporation of chemistry laboratories in its industrial operations to gain a competitive edge. Typically, the alliance is reduced to simple class terms. For example, according to the account offered by E. Richard Brown (1979), Rockefeller adopted medical science as his philanthropic cause both to improve his public image in the wake of damaging labor disputes and because the laboratory portrayed problems as technical issues amenable to expert intervention, rather than general social problems of inequality. These dimensions undoubtedly were at play, but they do not explain why Rockefeller chose medicine specifically, and they overstate the degree to which the alliance was forged on the basis of crass class politics. By illuminating corporate scientific practices, long neglected in the sociology of science (Penders et al. 2009; Shapin
2008
), this analysis transforms Rockefeller from a mere cunning capitalist into a cunning capitalist who pioneered the integration of laboratory sciences in industrial practice. His efforts to integrate the laboratory mirrored the efforts of bacteriological reformers, with whom Rockefeller shared an epistemic affinity. And it was upon this affinity that a mutual alliance between the AMA and private interests was built.

The final historical correction that this book achieves relates to this last point. Regular reformers were able to translate this affinity for the laboratory into an alliance that enabled them to circumvent state legislatures to acquire the sufficient funds for their professionalization project. The decision to build the laboratory with
private
resources allowed regulars to avoid the
public
institutions that had rejected their professionalizing impulses for decades. Indeed, the desire to circumvent the government institutions was evident as early as the 1870s, when regulars lamented, “Legislative enactments in the various States of this Union clearly show that no reliance can be placed on either the uniformity or permanency of any laws now relating to the practice of medicine” (Medical Society of the State of New York 1870, 39). The “melancholy illustration” (Hutchinson 1867, 56) of continual failures in its legislative agenda led the AMA to seek an alternative route to professionalization, one that skirted government institutions. In its very establishment, the modern U.S. medical profession expressed hostility toward government intervention and wariness of working through state legislatures. This points to an earlier emergence of the AMA's antigovernment sentiment—and its corresponding embrace of private interests—than is typically acknowledged in historical accounts of the U.S. profession. Most histories of the U.S. debates over health care trace the AMA's wariness of state intervention to the World War I period (see Numbers 1978); their histories start in 1915 (see Starr 2011). This finding is more than the mere dating of a phenomenon. I demonstrate how the antigovernment sentiment was present in the very founding of the profession and as such, institutionalized in its professional culture. Given that regular physicians achieved professionalization
in spite
of the state, the hostility toward government intervention was inscribed in the very DNA of the profession. The strategy of achieving their ends through private means became a tried-and-true one postprofessionalization, one with a history of success. Thus, the exceptionalism of the U.S. medical system in its rejection of government intervention, on display most glaringly in the AMA's persistent campaign against government-run
health
insurance, has its roots in the manner in which the epistemic contest over medicine played out in the nineteenth century.

To be clear, I am not suggesting that the entirety of the muddled and vitriolic history of health insurance reforms in the United States is solely the result of the epistemic contest; I am not offering a mono-causal account of the decidedly peculiar U.S. medical system. Health care politics in the United States are exceedingly complex, and to attribute the entirety of this complexity to a single factor would be audaciously reductionistic. A number of factors (e.g., a weak labor movement, an impotent socialist political party, the federal system, resistance from insurance companies, a cultural of individualism, etc.) contributed to the long-standing resistance toward government-led health insurance. Indeed, the AMA, with its suspicion of government intervention and its early alliance with private industry, played an important role in shaping this system, but it was only one interest among many (albeit an important one). Furthermore, the U.S. health care system has experienced a number of dramatic organizational changes (Scott et al. 2000), character redefinitions (Light and Levine 1988), and market shifts (Timmermans and Oh 2010) since World War II.

In recounting the “peculiar” history of health care politics, Paul Starr (2011) outlines a two-stage model of the politics of U.S. health care. During the first half of the twentieth century, the politics were driven largely by interests groups, especially the AMA, which rejected government incursion into medicine, often framing such oppositions in terms of anticommunist ideology. This early era established the “script” for health care debates for the rest of the century, as evidenced by the repeating tropes of “socialized medicine.” During the second period, dated roughly from the 1950s, politics were constrained by what Starr (2011) terms a “policy trap.” In other words, the debates of the last half century have been constrained by the original mishmash of policies from the first half. Rather than approaching the issue broadly, the terms of the debate narrowed significantly, making broad reform efforts increasingly impossible. Accepting Starr's two-stage model of the history of U.S. health care reform efforts, the legacy of the epistemic contest was felt most strongly during the first period, when the AMA established itself as a staunch opponent to government-led health insurance.
⁵
It was during this time that the AMA's wariness of the state—the legacy of the epistemic contest—dominated the rationale of the AMA. Only a few decades removed from the wide open medical market of the nineteenth century,
allopathic
practitioners were unwilling to cede any of their hard-won professional authority, especially to government entities that had repeatedly denied the legitimacy of this authority on democratic grounds. Of course the politics of the new era were different; the more sedate politics of the Progressive Era had supplanted the woolly democratic experiments of the Jacksonian period. But the wounds remained for regulars, and having achieved epistemic closure
in spite
of the state, the AMA was unwilling to let it back in and fought tooth and nail against such a fate.

Insofar as the AMA was one of the most powerful stakeholders that successfully defeated early reforms efforts (Quadagno 2005), which later set the script for health care debates, and insofar as this oppositional stance was born of the epistemic contest, we can see the long shadow cast by nineteenth-century epistemological debates inscribed in the modern U.S. health care system. By attending to issues of epistemology and investigating the professionalization of U.S. medicine as a case of an epistemic contest, this book offers a more exacting account of the history of the American medical profession—one that tells us as much about the present as the past.

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 vaccines
⁷
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.