Knowledge in the Time of Cholera Read Free

produce a medical profession unusual in the developed world. These changes were not just concurrent but intimately related, each contributing to the development of a medical profession widely recognized as exceptional among developed countries, in its steadfast—and successful—opposition to government incursions into medical practice (most evident in the AMA’s various campaigns against government-run health insurance), and its fixation on scientific and technological solutions. While physicians of many different countries eventually embraced the laboratory sciences, none did so with as much fervor as the U.S. medical profession.
    In this book, I explain how debates over medical professionalization in the nineteenth century—conflicts over issues like licensing, board of health composition, government recognition of alternative medical sects—
became
epistemological, in the sense that underlying these specific issues was the animating question of what constituted legitimate medical knowledge. Professional struggle was inextricably tied to fundamental intellectual debates waged on the level of epistemology, in which the very identity of what constituted a medical fact was at stake. Or more accurately, these professional debates were
made
epistemological through a confluence of broad social changes, which enabled epidemics like cholera, and alternative medical movements, which seized the opportunities afforded by cholera to force allopathic medicine to justify its expertise in epistemological terms. Cholera and quacks joined to foment epistemological angst for allopathic medicine. And the eventual character of the profession would be inscribed with their indelible marks, as the allopaths would have to solve their riddles to achieve professional authority.
    By emphasizing epistemological struggle and change, I provide a framework to better understand the professionalization of U.S. medicine and, in doing so, offer a more nuanced account of a key (if not
the
key) cause of the exceptionalism of the U.S. medical system. When professionalization is no longer viewed as flowing directly from medical discoveries, and instead is seen as evolving according to the vicissitudes of epistemic politics, a very different story of the professionalization of American medicine emerges. It is a story of missed opportunities, of intellectual roads not taken, and of significant contributions by alternative medical movements that have all but disappeared from our historical consciousness. It is a story of the recurrent failures of allopathic physicians to reconcile their professional aspirations with the democratic ideals of American culture, and the repeated acceptance and recognition of alternative movements by government institutions. It is a story of the consolidation of professional authority by allopathic physicians through a strategy that circumvented the state—and public oversight—by securing the financial support of private philanthropies. But foremost, it is a story about the long-standing tension between the logic of professionalization and the ideals of democracy out of which an exceptional U.S. medical profession was born—one that raises difficult questions about the role of professions in democratic cultures.
    HEROIC DISCOVERIES, MISLEADING STORIES
    Conventional accounts of U.S. medical professionalization link professional authority to improvements in medical knowledge without paying attention to the epistemological changes that underlie these “improvements.” In these narratives, the allocation of authority follows on the heels of scientific discoveries, properly meted out according to the merit of the knowledge attained. We can call these accounts, somewhat crudely, “truth-wins-out narratives.” The logic of these narratives, often referred to as the “diffusion model” (Latour 1987), holds that ideas, by their self-evident truth, force people to assent to them. Advocates