Knowledge in the Time of Cholera (21 page)

As cholera neared, the board intensified its efforts. It hired thirty temporary assistants to carry out a comprehensive sanitary audit of the city, ordering them to locate and then remove the most egregious offenses. A citywide cleaning effort got under way, a welcomed departure from the previous sanitary regime, politically connected and hygienically neglectful. By April 9, the
New York Times
was predicting that even if the board could not prevent cholera, it should at least curb its excesses (Duffy 1974). The paper also encouraged the board to maintain its nerve in the face of the “powerful and selfish interests which are trying to perpetuate the nuisances and causes of disease in our City” (
New York Times
, April 9, 1866, 4).

On April 13, cholera arrived. The board immediately lobbied the governor's office to proclaim a state of emergency and extend its already substantial power. Granted this unprecedented authority by Governor Reuben Fenton's poetically named “Proclamation of Peril,” the board, with the full assistance of the Metropolitan Police, carried out an ambitious emergency program. It eliminated so-called cholera nests, isolated affected individuals and establishments, strengthened and maintained a quarantine system, and cleaned up the city's sewers, tenements, and other nuisances. Medical care was organized around house-to-house visits. Once indentified, the sick were transported to one of the board's six dispensaries or cholera hospitals estab
lished
specifically for the epidemic (Duffy 1974). Never had the city coordinated such an extensive medical campaign.

Cholera arrived and departed with little more than a whimper as it was largely contained to the port. Only six hundred New Yorkers died out of a population of over eight hundred thousand. The board had passed its first test with aplomb. This is not to suggest it was easy or without controversy. The board faced stiff local resistance in every neighborhood in which it sought to establish a cholera hospital. Still, despite these moments of public outrage
during
the epidemic, assessments of the board were almost universally complimentary
after
it. The final verdict came a year later, when the
New York Times
(March 31, 1867, 3) concluded, “It ought to be permanently remembered to the credit of the Board, that having to deal thus early with the epidemic, they succeeded in checking its progress.” Regardless of whether it was actually the sanitary reforms that led to the decreased mortality or simply a milder form of the disease, the Metropolitan Board of Health of New York City received the credit. It had tamed cholera, and, in doing so, offered other cities and communities a blueprint, which many began to implement shortly thereafter. With their proliferation throughout the country, boards of health became the new front in the epistemic contest over medicine, as multiple actors salivated over their extensive resources and power.

FRAMING EPISTEMIC AUTHORITY

The establishment of the Metropolitan Board of Health was a watershed moment, both in the U.S. experience with cholera and in the history of American medicine. Not only did the board usher in a period of interventionist sanitary reforms that would eventually conquer cholera; it also embodied a shift to a new secular conceptualization of disease, marking the date when cholera became a “social” rather than “spiritual” problem (Rosenberg 1987b). Cholera as a scourge from God could not be combated by mere human measures; cholera as filth could. The arsenal against the disease now included more than just prayer.

Yet the understanding of cholera as a
social
problem did little to mute the
medical
debates surrounding the disease. An important event, the establishment of the boards of health did little to resolve the epistemic contest. In fact, it stoked the epistemic contest by introducing a new type of organization with resources and power to fight over. As the boards of health became
the
main organization body that responded to cholera, they became an alluring prize to be won for allopathic physicians desiring to promote their professional goals. And the public esteem granted to the boards in the wake of the 1866 epidemic sweetened their allure.

The boards also introduced some complicating factors into the epistemic contest for allopaths. Prior to the boards' establishment, regulars focused mainly on ensuring homeopaths' marginalization. The boards, and the sanitary reform movement that underwrote their establishment, brought new players into the epistemic contest, all of whom sought the recognition to speak authoritatively on cholera and disease in general. A motley group of reformers, the “sanitarians” included influential community members, civil engineers, plumbers, progressive politicians, and physicians from all sects (Rosenkrantz 1974).
¹
The new actors each staked a claim to defining cholera in order to achieve different ends. Politicians sought patronage and potential kickbacks that accompanied a new institution with significant resources. Political reformers sought to use the boards as a model for their program to introduce rationality and integrity into municipal government. Homeopaths and other professionals (e.g., plumbers) sought inclusion on the boards and recognition for their essential contributions to the elimination of filth. And regulars tried to harness the boards to achieve professional and epistemic authority by taking credit for their sanitary successes. With all these competing actors and interests converging in the boards of health, the boards became not only the primary organizations to deal with cholera; they also became important sites for the epistemic contest over medical knowledge, ownership over the understanding and definition of disease, and the means by which society was to intervene. The boards became contentious arenas in which diverse actors asserted their status as privileged knowers and claimed epistemic authority.

This chapter investigates the consequences that the establishment of local boards of health, specifically New York City's Metropolitan Board of Health, had for the epistemic contest. During the 1860s, opinions about cholera (allopathic, homeopathic, and lay) converged around the notion of cholera as filth, to be eradicated through municipal reform. A coalition of lay elites and sanitary-minded physicians led the calls for sanitary reform. In the process, they framed epistemic authority in terms of its disinterested, apolitical nature, juxtaposing it to corrupt city politics. Expertise was seen as emanating from a particular ethos toward knowledge. As such, the boards promoted
a
type of “intellectual ecumenism” when it came to knowledge on cholera, one that encompassed not only medical knowledge but also a whole host of other forms of relevant knowledge.

As discussed in the introduction, epistemic authority can be justified along a number of interrelated but distinct dimensions.
How
actors frame their arguments for epistemic authority matters, as it delineates the types of arguments that can be legitimately mustered in defense of knowledge claims and dictates the organizational responses to these claims. Among the many ways in which epistemic authority can conceivably be justified, three are most common. First, such authority can be grounded in the
content
of one's knowledge. Recognition as a privileged knower is seen as deriving from the possession of a specialized body of knowledge. Claims made by clergy, which are based upon their understanding of sacred texts and a special spiritual insight, typically assume this form; clergy
possess
spiritual insight unavailable to the laity. Second, epistemic authority can be claimed on
methodological
grounds. Science is often legitimated this way. Scientists cannot be granted authority on the basis of the factual knowledge they possess, for the body of scientific knowledge is forever evolving. Rather, they claim epistemic authority based on their ability to achieve knowledge through the scientific method. Methodological appeals can be made in the name of an abstract ideal, like the scientific method, technical acumen (e.g., IT personnel), an ability to gather and process information (e.g., journalists), or the capacity to translate knowledge into practical applications (e.g., engineers). Finally, epistemic authority can be justified along the lines of an
ethos
or orientation toward knowledge. In these cases, it is not in the mechanics of knowledge production or the final knowledge produced that epistemic authority is justified, but in the stance one assumes toward the production of knowledge. An ethos-based approach to epistemic authority tends to place great emphasis on the character or position of the knower.

Sanitarians justified their epistemic authority in this final fashion, grounding it in their particular orientation vis-à-vis knowledge. Specifically, they claimed a special accuracy for their knowledge on account of its disinterested, apolitical character. The first section of this chapter describes this framing strategy by sanitarians in New York City, showing how it enabled them to convince the New York State legislature to establish a permanent, politically independent board of health. The decision to frame their epistemic authority along the lines of an apolitical ethos emerged in part from their opposition to city politicians. Because sanitarians approached
sanitary
knowledge without any political stakes in the findings, they could produce sober assessments of the city and yield rational, effective interventions to combat cholera. They were disinterested and, thus, their knowledge was more accurate than that of politicians, who had incentives (i.e., political patronage) to produce faulty knowledge that masked the extent of sanitary problems. Both sanitarians and their opponents in the City Inspector's Office used similar methods to gain knowledge of disease, but sanitarians claimed that the knowledge they achieved through such methods was more trustworthy, not because they possessed superior technical know-how, but because they were untainted by political calculations.

This particular framing not only emerged as a reaction to corrupt politicians but also flowed from the nature of sanitary knowledge itself. The diverse nature of the content of sanitary science prevented sanitarians from making claims based on the
content
of any one specific body of knowledge. New techniques like dot maps, normal mortality ratios, and sanitary surveys linked cholera to place and, in turn, recognized the relevancy of different types of knowledge related to place. With disease framed broadly as filth, possible relevant knowledge was wide-ranging; sanitarians pooled insight from a variety of sources. Medical knowledge was important, but so was engineering, legal reasoning, architecture, and even plumbing. The broad manner in which disease was defined necessitated a sanitary science that was practical in orientation and ecumenical in nature. Appeals to epistemic authority on specific technical and methodological grounds were not possible when so many different forms of expertise were deemed relevant. Rather, the new boards of health were conceived as a reform movement that targeted political corruption through an appeal to a disinterested ethos toward sanitary knowledge.

In terms of the epistemic contest, the ecumenical nature of the boards was detrimental to regulars' professional goals as it frustrated their attempts to gain control over public health. The second section of this chapter discusses the internal struggles over control of the Metropolitan Board of Health first between regulars and other sanitarians, specifically plumbers, and then between regulars and homeopaths. Allopathic physicians could not exclude nonmedical experts because the broad framing of disease as filth required the input of a number of actors, everyone from civil engineers to plumbers. They also were unable to exclude homeopaths from the board, for the expansive understanding of relevant knowledge translated into a broad recognition of relevant
medical
knowledge. Compounding matters, every attempt
on
the part of regulars to control the boards was effectively discredited by opponents as crassly political and in direct opposition to the stated ethos of the boards. Regulars' attempts to justify their control of the boards were therefore hampered by the manner in which the epistemic authority of the board was framed. As a result, they failed to turn the boards to their professional advantage.

As such, allopaths developed an ambivalence toward public health generally. On the one hand, the popularity of the boards made them a potential resource for bolstering the prestige of allopathy. Insofar as the sanitary measures of the boards were seen as successful, regulars benefited from an association with them. On the other hand, the intellectual ecumenism of the boards, and sanitary science more generally, made it very difficult for regulars to control the agenda of public health. Allopathic physicians found it difficult to assert the superiority of their medical knowledge over other forms of relevant knowledge (e.g., engineering, plumbing, etc.) and, even, over medical knowledge itself. In the end, the boards became part of the problem, not the solution, for regulars' professional aspirations. Once seen as prizes, they became yet another government agency to be viewed with suspicion.

LOCALIZING CHOLERA AS FILTH

By 1866, the confused debates as to the nature of cholera persisted, but most groups vying for control over the definition of cholera had reached agreement over a single fact—cholera was somehow related to filth. Historians have tended to treat this as an indicator of an emerging consensus for the miasmatic theory of disease (Barnes 1995; Duffy 1990; Leavitt 1992; Mitman and Numbers, 2003; Richmond 1947, 1954; Rosen 1993; Susser and Susser 1996). But the convergence of opinion was in fact more complex. The etiology of the disease and its relationship to filthy conditions remained a point of contention. Did filth create cholera? Did it just facilitate its spread by providing a fertile environment for growth? Or did filth simply undermine the health of the inhabitants living in it, making them more susceptible to the disease? Despite these persistent questions about the mechanisms behind the localization of disease, there was a degree of interpretive flexibility inherent in it. Some medical thinkers undoubtedly equated cholera with filth, but most adopted the more modest interpretation that there was some sort of demonstrable relationship between the two. Cholera need not be caused
by
filth in order for it to be related. Filthy locales were dangerous (Humphreys 2002), but how and why need not be specified. Minimally, all that the association of cholera with filth demanded was an acknowledgment of
some sort
of connection between place and disease for a wide array of actors to close ranks around commonsense sanitary interventions And it was flexible enough to allow for the commitment to it from a variety of epistemological perspectives, but definite enough to provide a common ground for disparate actors to coalesce into a public health movement. The theoretical stakes were minimal, but the practical implications great.