Knowledge in the Time of Cholera (45 page)

Despite these limits, the idea of epistemic contests could prove quite fruitful for the examination of other cases. Subsequent scholars should take the concept up and manipulate it to fit the needs of their case. Here I offer only a few suggestions of the ways in which the concept might be useful.

First, as a general rule of thumb, intractable debates with incommensurable positions are a good place to find epistemic contests. Because medical issues involve the experiential knowledge of the patient, the practical knowledge of the clinician, and the scientific knowledge of the medical expert, medicine is rife with epistemic contests. For example, the incorporation of Complementary and Alternative Medicine (CAM) into mainstream scientific medicine involves some real epistemic tensions, especially around issues of testing and evaluating treatments. CAM advocates argue that biomedical testing procedures fail to capture the essence of CAM's efficacy. How can CAM treatments be adequately assessed if the whole of the person is not taken into account? Biomedical advocates retort that they cannot be expected to use unproven remedies. An uncertain stalemate ensues, bogged down in issues of incommensurability. Similar issues arise in cross-cultural exchanges of medical systems, particularly between Eastern and Western medical traditions. As medicine becomes globalized, these incommensurable systems interact, and often clash, in interesting ways. For example, in his analysis of the pluralities of modern Chinese medicine, Volker Scheid (2002) describes a hospital pharmacy in which one half is dedicated to modern medicines, the other to traditional herbal Chinese cures. One side is the model of modern science, the other the picture of folk wisdom. The two reside in the same space in a situation of constant tension and negotiation. Studying these separate-but-equal arrangements can shed light on epistemic contests that, unlike the case discussed in this book, do not result in one dominant epistemology or achieve epistemic closure. Andrew Lakoff (2005) has identified similar cross-cultural issues that have arisen in the importation of the biomedical model of mental illness to Argentina, a country with a long tradition of psychoanalytic psychiatry.

Second, the concept might help shed light on the divisions between biomedical research and clinical practice that are prevalent among health
professionals
(see Freidson 1970; Montgomery 2006). Misconstrued as a technical problem, the tension between researchers and clinicians has deep roots. Rather than the specific exigencies of clinical practice, the salient issue is epistemological in nature. Quite simply, the divergent roles that clinicians and researchers serve in the profession lead to different orientations toward knowledge and competing models of what constitutes useful knowledge. The epistemological tensions between researchers and clinicians reflect a classic distinction, noted by Aristotle, between
episteme
and
phronesis
(Jonsen and Toulmin 1988).
Episteme
is what we now understand as scientific reasoning in which the goal is to illuminate universal and general rules, to uncover timeless Truth. Clinicians, in contrast, approach knowledge differently, adopting a more practical posture toward knowing (Montgomery 2006). Practical wisdom, or what Aristotle calls
phronesis
, addresses particular cases and specific quandaries, employing, not maxims or rules, but a network of considerations to be tested by trial and error. It operates in the realm of the concrete, the temporal, and the presumptive. While
phronesis
and
episteme
are not inherently opposed, their relationship can be contentious, as the generalizing tendencies of
episteme
can threaten to devalue an appreciation of the idiosyncrasies of the clinical interaction. Understanding the epistemological roots in the researcher/clinician divide may prevent us from misreading issues like clinician resistance to evidence-based medicine (EBM) as merely technical problems and focus our attention on how to translate between epistemological orientations.

Finally, the concept could prove useful in examining those marginal diseases, or “contested diseases,” like fibromyalgia, environmental illness, chronic fatigue syndrome, and sick-building syndrome (see Barker 2005; Dumit 2006; Kroll et al. 2000; Murphy 2006). Here the issue is a clash between the biomedical model and more experientially based knowledges. Unable to detect these diseases through conventional biomedical means, some medical professionals deny their existence. However, patient advocacy groups vie for recognition, and the resources (i.e., insurance coverage) that accompany recognition, by appealing to experiential knowledge. How these issues get sorted out in practice could be examined fruitfully by bringing these epistemological issues to the forefront of the analysis.

Epistemic contests are not confined to medicine; they proliferate in other areas of social life as well. The classic cases come from the perpetual disputes between religion and science. Indeed, the Catholic Church's censorship of Galileo and his heliocentric universe in the seventeenth century is in many
ways
the paradigmatic example of an epistemic contest. Galileo's insight was rooted in his telescope, the Church's in the Bible. Galileo drew his insight from his own eyes, the Church from its clerical tradition. The modern incarnation of this, the debates over evolution, repeats this age-old epistemic contest in many ways.
¹⁰
Other examples of contemporary epistemic contests are the debates over postmodernism in academia, local environmental disputes like controversies over fisheries that pit local experiential knowledge against environmental science (see Marlor 2010), conflicts between the collective memory of communities and the historical knowledge produced by historians (Whooley 2008), the various cross-cultural confusions that proliferate under globalization, and even talent evaluation in baseball front offices, where new, advanced statistical analyses clash with the traditional wisdom of the baseball scout (see Lewis 2004).

A final direction for future research into epistemic contests is to see whether the concept is useful when applied to cases at different levels of analysis via “analogical theorizing” (Vaughan 2004). While this book explores meso-level practices, there is no logical imperative to restrict epistemic contests to this level of analysis. Indeed, epistemic contests may be just as prevalent, or more so, at a micro-interactive level. Once again, medicine is a good place to find such micro-level epistemic contests. For example, there is research showing fundamental incongruity in understandings of mental illness that play out in the clinical interaction between psychiatrists and patients (Whooley 2010). Or one could examine the conflicts between the standards of scientific evidence and legal evidence in the courtroom through the lens of an epistemic contest (e.g., demanding an expert witness to claim 100 percent certainty when the standards of science cannot possibly allow her to do so). Such analyses might lack the ability to account for large-scale changes over time, but they would likely provide insight into the ways in which actors advocate for epistemological positions that are only visible at the interactive level.

Regardless of what form this research will assume, sociology stands to gain much insight by reorienting epistemology away from speculative thought experiments toward the everyday practices by which actors adjudicate knowledge claims. Epistemological issues are not just the province of ivory tower philosophers; they are practical problems that must be negotiated in social life.

Because of this, we can learn from the quacks, dreamers, and medical reformers of the nineteenth century.

APPENDIX

A COMMENT ON SOURCES

In researching this book, I examined a wide variety of historical documents, culling data from book manuscripts, professional journals, meeting minutes, newspapers, magazines, legislative documents, and even memoirs and diaries. I sampled documents from each of the relevant collective actors (i.e., orthodox physicians, homeopaths, Thomsonists, sanitarians) and organizations (i.e., state legislatures, professional societies, boards of health) involved in the epistemic contest. Using these source materials, I was able to index the changes in medical knowledge, reconstructing the history of cholera as an object of intellectual scrutiny so as to gain insight into the more general epistemic contest over medicine in the nineteenth century.

To provide a baseline for this history, I traced the debates over cholera as they took shape in two medical journals, the
Boston Medical and Surgical Journal
and the
Journal of the American Medical Association
. Not only do the pages of these two journals contain debates over cholera; they also include professional polemics as many authors used the journals as a forum to rebut claims of competing medical sects. Moreover, their continuity allowed me to follow the evolution of the debate for the entire time period under concern (roughly 1830 to 1915).

Having established this foundation, I conducted a more targeted investigation of additional archival materials, which included:

•
Public Documents of the Collective Actors Involved
. These documents—journal articles, pamphlets, and editorials—consciously address a public audience, and, thus, reveal actors' arguments, rhetoric, and frames regarding cholera, as well as the epistemic assumptions underlying these.

•
Meeting Records of the Collective Actors Involved
. Transactions of meeting proceedings by the relevant actors balance public documents by provid
ing
a window into actors' strategic deliberations, illuminating internal debates obscured in the more consciously public documents.

•
Institutional Records
. Institutional records (i.e., legislative documents, internal sanitary reports, etc.) provide insight into the efficacy of actors' arguments in particular organizational environments. Because epistemic contests occur within the institutions, institutional documents provide some sense as to the causes of success or failure of particular arguments. These documents include the institutional rationale for taking one side over another in the adoption of particular policies.

All told I analyzed and coded over one thousand documents in detail and read many, many more. I approached each document as a rhetorical object that reflected a particular position within the epistemic contest, situating it within the longer debate of which the document was a part. My analysis of the documents assumed a dual tack. First, when examining the debates over cholera, I attended to the manner in which actors made truth claims about the disease and understood the nature of medical knowledge, focusing on both the form and content of their arguments. I analyzed not only the specific claims about cholera but also the epistemological assumptions underlying these claims (i.e., the nature of the facts contained therein, the presentation of knowledge claims, the authorities drawn upon, etc.). Second, I drew on internal documents from relevant organizations to reconstruct the strategies that relevant collective actors employed in the epistemic contest. The epistemic contest did not only unfold on the pages of old medical journals; it encompassed a number of strategies, both cultural and organizational, by which actors sought to achieve epistemic recognition. In other words, these internal documents shed light on the professional strategies actors adopted. Furthermore, because institutions have their own epistemologies and cultural norms, I embedded my analyses of these strategies within their institutional context to account for their efficacy in specific institutions.

Most of these materials were located in seven archives: the Bobst Library at New York University, the Bradford Homeopathic Collection at the Taubman Health Science Library at the University of Michigan, the Butler Library at Columbia University, the New York Academy of Medicine, the New York Historical Society, the Parnassus Library at the University of California–San Francisco, and the Rockefeller Foundation Archive Center. Below is a list of key sources.

Orthodox
Medicine

• American Medical Times
(1860–1864)

• Boston Medical and Surgical Journal
(1828–1928)

• Journal of the American Medical Association
(1883–Present)

• Medical and Surgical Reporter
(1856–1898)

• New York Journal of Medicine and Collateral Sciences
(1843–1856)

• Transactions of the American Medical Association
(1848–1882)

• Transactions of the Medical Society of the State of New York
(1807–1925)

• Transactions of the New York Academy of Medicine
(1851–1903)

Homeopathy

• American Journal of Homeopathy
(1853–1923)

• The Homeopathic Examiner
(1840–1847)

• The Physician's and Surgeon's Investigator
(1880–1889)

• Transactions of the American Institute of Homeopathy
(1844–1908)

• Transactions of the Homeopathic Medical Society of the State of New York
(1863–1896)

Sanitarians

• Annual Report of the Metropolitan Board of Health
(later titled
Annual Report of the Board of Health of the Health Department of the City of New York
) (1866–1912)

• The Plumber and Sanitary Engineer
(1877–1880)

• The Sanitarian
(1873–1904)

• Selections from Public Health Reports and Papers Presented at the Meetings of the American Public Health Association
(1873–1907)