The following is a guest post by Merlin Chowkwanyun.
I admire greatly Daniel Goldberg’s critical writings on common assumptions in contemporary medical and public health practices. His most recent blog entry continues that reflexivity by provocatively considering the place of intellectual history in the history of medicine and public health. But while his post is valuable for reflecting on where the scholarship is going, its central premises are ultimately shaky and baffling, so much so that they risk mischaracterizing the field.
Goldberg declares that the “vast majority of historians of medicine and public health write mostly social and cultural history.” He wonders whether a gatekeeper effect might be at work against intellectual historians in the field like himself, who are in the “somewhat peculiar position of writing an entirely different genre of history from the dominant methodologies. (italics added)” Goldberg partially bases these statements on journal referee reports he has received, which suggest to him that the history of medicine and public health subfield operates with standards of evidence different from those in intellectual history. This state of affairs poses a considerable burden for people like himself. It would also be a detriment to the history of medicine and public health, foreclosing a fruitful plane of analysis.
If true, that is. But is it? I don’t think so. I want now to explore two questionable claims: 1) the supposed dominance of social and cultural historians in the field and 2) the sharp dualism the essay erects between “social and cultural history” on one hand and “intellectual history” on the other, one that I find false. I’ll conclude by stepping back from the history of medicine and public health entirely and ponder what it is we are doing when we say we are a certain kind of historians and what the pitfalls of that self-typologizing might be.
Most historians of medicine and public health would probably self-classify as “social and cultural” historians. But that doesn’t mean intellectual history is marginalized or excluded. Actually, it’s the exact opposite. At least for the past 50 years, intellectual history has been a central part of the field. Why this is so is, to some extent, commonsensical. An overarching goal of the field, after all, is to de-stabilize common categories that many take for granted as transhistorical and unchanging entities. This entails asking questions like what exactly has constituted “medicine” and “public health” in the first place; how certain signs and symptoms became recognized as “diseases” (and others not); and ways perceptions of human anatomy varied by time and region. Careful reading of texts and a rigorous command of what ideas are circulating – from rarefied and elite to popular and mass spheres – are necessary starting points to answering these and many other questions. People in the field may not call themselves “intellectual historians,” but most are certainly doing the same analytic work of people who do embrace that label.
To get more concrete, I thought I might look at a few influential bodies of scholarship that have emerged in the field. I briefly mentioned one of them above: the study of how diseases come to earn their labels and the narratives that emerge around them. This is a diverse literature, but its unifying inquiry is effectively captured in Charles Rosenberg’s introduction to Framing Disease: Studies in Cultural History, a 1992 volume co-edited with Janet Golden. In what has since become one of the most quoted passages in the field, Rosenberg wrote:
But ‘disease’ is an elusive entity. It is not simply a less than optimum physiological state. The reality is obviously a good deal more complex; disease is at once a biological event, a generation-specific repertoire of verbal constructs reflecting medicine’s intellectual and institutional history, an occasion of and potential legitimation for public policy, an aspect of social role and individual – intrapsychic – identity, a sanction for cultural values, and a structuring element in doctor and patient interactions. In some ways disease does not exist until we have agreed that it does, by perceiving, naming, and responding to it. (emphasis added)
The essays in Framing Disease, along with many monographs that appeared before and after it, examine how this process unfolded for a number of conditions we understand as “diseases.” Want to know about the contention and disagreement that occurred on the way to “chronic fatigue syndrome” and “Lyme disease’s” coalescence into seemingly discrete and tidy categories? Check out Robert Aronowitz’s essay in Framing and his Making Sense of Illness: Science, Society, and Disease. Along the way, he illustrates how a number of wider developments, like the emergence of patient advocacy and resistance to it by parts of the medical profession, affected the disease framing and naming that he traces.
You might then turn to Gerald Markowitz and David Rosner’s essay and their Deadly Dust: Silicosis and Politics of Occupational Disease in Twentieth-Century America, which explain how silicosis, a brutal respiratory disease experienced by coal miners, went from something widely recognized in the early twentieth century to something almost forgotten in the post-WWII decades. Like Aronowitz, Markowitz and Rosner situate the career of silicosis within broader historical currents that influenced it, in this case the consolidation of anti-labor politics and the growing ability of industrial firms and insurance companies to thwart disability claims. Just as intellectual historians are constantly showing us how many of our keywords – “human rights,” “democracy,” “liberty,” whatever else – in fact are malleable and historically fluid, these historians do the same for disease categories. Rather than separate intellectual and social and cultural history from one another, these authors fuse them together.
Two of my favorite more recent books, Nancy Tomes’s The Gospel of Germs: Men, Women, and the Microbe in American Life and David Barnes’s The Great Stink of Paris: the Nineteenth Century Struggle Against Filth and Germs, are offshoots of this literature. They historicize the emergence of what is now commonly referred to as the germ theory of disease – that is, defining and explaining the cause and spread of diseases in terms of microbes and pathogens. That differed enormously from predominant etiological beliefs beforehand, when into the last decades of the nineteenth century, “nearly all medical observers agreed on the fundamental causes of disease: heredity, climate, miasmas, immoderate lifestyles,” and advocated a program of behavioral modification, cleanliness, and sanitary infrastructure to address them.
There’s a twist, though. It comes in Tomes and Barnes’s finding that the transition to germ theory was hardly something clean-cut. What occurred wasn’t so much a neatly linear transition to a germ theory epoch as it was a drawn-out hybridization of many disease etiologies at the time. “The germ theory of disease,” Barnes writes, “changed everything and nothing at all.” The end result was what he calls a “sanitary-bacteriological synthesis (SBS),” which “made possible a new way of understanding, explaining, and combating disease in society by integrating the old concerns of the sanitary movement (filth and contamination, cleanliness and morality) with a new germ-centered focus on the danger of contact with potentially sick bodies and bodily substances, tests for the presence of microbes, and the promises of their control through laboratory science.”
Consequently, many practices of the sanitary era – public disinfection, infrastructure for waste disposal – remained, and well into the present day, the SBS persists. (If you’ve ever cleaned mounting gunk off your kitchen countertop, like I did this morning, without even really knowing exactly what microbes you’re trying to eliminate – but with the hope that you’re killing something – you’ve SBSed. If you’ve ever lived in a municipality with a garbage ordinance passed on public health grounds – you’ve been SBSed. Indeed, we are all SBSers now.) Identifying the precise subtleties of this shift in ideas about disease causation required these authors to conduct exacting and forensic reading of texts penned by both elite figures and ordinary people, in scientific journals and in popular pamphlets.
In other parts of their books, Tomes and Barnes place this (not quite) pre/post story in specific national and regional contexts. These etiological developments occurred in the Progressive Era United States and Third Republic France, where various figures behind new public health institutions, polices, and campaigns incorporated “germ-consciousness” into their work, fueled by a parallel societal push for scientific rationalization, social reform, “civilization” of marginal populations, and administrative centralization. Tomes and Barnes also bring readers to the ground, with thick descriptions of how these etiological transformations were understood and transformed at the local level and in everyday life. Tomes explains this approach to understanding the diffusion and “popularization” of disease concepts as follows: “… I prefer to think of popularization not as a hierarchical, top-down process where the focus is on what the public gets ‘right’ or ‘wrong,’ but as a dynamic where ideas and images are traded among different audiences, including laboratory scientists, practicing physicians, hygiene reformers, and interested lay people (italics added).” I highlight this passage because it points to diversity of sources used and multiple levels of thought traversed. It shows, too, the importance of understanding the historically specific social and cultural contexts in which transmission and transformation of ideas about disease occurs. Once again, stark oppositional categories separating “intellectual history” from “social and cultural history” don’t accurately capture the work these books do.
That’s the case with another body of scholarship I really admire, on the history of race, medicine, and health. These works examine how racial ideologies and politics affected medical science and public health practice. Keith Wailoo’s Dying in the City of the Blues: Sickle Cell Anemia and the Politics of Race and Health and How Cancer Crossed the Color Line look at the growing social and medical recognition of these diseases in African-American populations and how they turned into political metaphors and condensation symbols in tandem with mounting civil rights activism. In case studies of San Francisco, Los Angeles, and Baltimore, respectively, Nayan Shah, Natalia Molina, and Samuel Roberts show how turn of the century public health discourses stigmatized immigrant and black populations as volatile disease vectors and cauldrons of illness, providing a rationale for destructive urban renewal projects and residential segregation. Susan Reverby’s Examining Tuskegee: The Infamous Syphilis Study and Its Legacy investigates how racial biology underpinned the Tuskegee study, which sought to explore if and how syphilis developed differently in black people. Lundy Braun’s new Breathing Race into the Machine: The Surprising Career of the Spirometer from Plantation to Genetics analyzes how the science of spirometry and respiratory medicine was used to defend claims of black inferiority and white supremacy on biological grounds in a number of settings, ranging from the antebellum South to the mines of South Africa to elite New England colleges. Mike Yudell’s forthcoming Race Unmasked: A 20th Century Struggle to Define Human Difference is an exhaustive account of scientists’ century-long commitment to fixed, biological conceptions of race and how they responded to challenges within and outside of formal scientific orbits.
These works on race cover a lot of different ground, but it’s obvious they all take ideas very seriously, focused as they are on prevailing racial ideologies and how they became manifest in the discourses and practices described above. After reading this literature – or any of the other examples mentioned above – I’m confused about how anyone could claim there exists a band of “social and cultural historians” with a vested interest in marginalizing “intellectual history” and its methods and types of evidence. Like any field, the history of medicine and public health has its pathologies. But lack of analytic and methodological holism – stemming from tightly bounded and policed discourse communities – is not one of them. In fact, it’s one of the major strengths.
From the examples above, it’s clear that intellectual history is integral to many influential scholars’ work in the history of medicine and public health. So why does the original post in question suggest a tension between the two? I can’t speak to the content of the referee reports that Goldberg references (and from which he seems to infer much about the state of the field). But his perceptions also may be influenced by historiographic lore about the field’s development. According to this account, a parochial field, once heavily populated by M.D.’s who wrote narrow and hagiographic Great Doctor History, confronted (and resisted) an influx of social historians trained in the 1960s and 1970s. There’s a lot that’s right about this tale, and it resulted in some vicious intra-field academic battles in the late 1970s. But in the end, the entry of new ways of doing history into the field didn’t dislodge intellectual history at all. It just meant doing it in new and vibrant ways, exemplified by the books surveyed here.
Perhaps Goldberg is working from a constricted definition of “intellectual history,” one which takes its primary task as the analysis of writing by Great Men in medicine and public health. It’s true that few can get away with this kind of work today, particularly if one proceeds in an insular and internalist vein that fails to connect the ideas under scrutiny to the historical world out of which the text emerges. But this aversion is discipline-wide and hardly unique to the history of medicine and public health. The evolution of the history of religion and history of law is instructive. Both once focused narrowly on doctrinal change, but in the past few decades, have evolved enormously, with scholars now analyzing such changes in relation to concurrent historical developments. If the work of the regular writers here is any indication (on the S-USIH blog and in their scholarship), the intellectual history field itself has undergone the same transformation as well.
I want to conclude by thinking about the question of field labeling more generally, beyond the history of medicine and public health and intellectual history. Why do we embrace the academic identities we do? Why do we draw boundaries between them? Why do we sometimes push further and try to institutionalize them (as the creators of this blog did with the Society for U.S. Intellectual History)? What are the pros and cons?
I have to admit that when I first saw S-USIH existed, I was skeptical. Was there really a need for more sub-disciplinary niche building? Shouldn’t historians just try to answer questions at hand and use the analytic approaches (intellectual, social, political, economic, transnational, and others) that are most appropriate and effective, rather than get obsessed over labeling themselves? But the blog quickly put my skepticism to rest. In their posts, the authors were doing just that. The blog and the organization simply helped people with certain analytic proclivities – which we all have – come together, even as they consistently demonstrate that they work on multiple interpretive registers. I’ve been impressed with how well all the blog regulars place ideas front and center while never getting lost in just the ideas themselves. (Robert Greene II’s work on black political thought and conceptualizations of “the South” is one example.)
There’s a flip side, however, to labels. At worst, for those who take them a little too seriously, they can encourage fetishization of taxonomies that, at most, should serve as loose indicators of one’s approach, not hard-and-fast boundaries sharply demarcating fields. The latter can encourage practitioners to self-balkanize and pledge allegiance to a certain mode of thinking over others, rather than read widely to try and synthesize a diversity of approaches. This tendency is especially dangerous with early-career scholars or graduate students, who should be feeling out as much analytic, methodological, and substantive terrain as possible. Here, I’m reminded of the political theorist Ian Shapiro’s question: “Why plump for any reductionist program that is invariably going to load the dice in favor of one type of description?” Shapiro contrasts this – what he calls “method-driven” and “theory-driven” research – to “problem-driven” inquiry that simply “endeavor[s] to give the most plausible possible account of the phenomenon that stands in need of explanation.” This means using the modes of analysis that most effectively answer our questions, labels be damned. I believe the best historians in the field under question – and more generally – recognize and instantiate this, bridging approaches instead of viewing them as “entirely different genre[s].”
It may be best to close with a meditation by the late Eric Hobsbawm, whom many of us no doubt reflected upon when he died. His breadth, depth, and ability to identify processes, large and small, over multiple scales, large and small, is probably the signature feature of his work, and why we all admired it so much. I recently re-read a 1971 Hobsbawm essay, entitled “From Social History to Societal History,” which takes stock of social history’s emergence, its relationship to the social sciences, and the pliability and nebulousness of the label. He concludes the essay by sketching out what a “history of society” might look like. One paragraph stuck out to me, and I think it’s germane to this discussion:
But the social or societal aspects of man’s being cannot be separated from the other aspects of his being, except at the cost of tautology or extreme trivialization. They cannot, for more than a moment, be separated from the ways in which men get their living and their material environment. They cannot, even for a moment, be separated from their ideas, since their relations with one another are expressed and formulated in language which implies concepts as soon as they open their mouths. And so on.
His gendered language excepted, Hobsbawm was right, and historians of medicine and public health have largely heeded these words. Indeed, the current generation of historians and their students were raised on them.
Further Recommended Reading:
Aronowitz, Robert. Making Sense of Illness: Science, Society and Disease. New York: Cambridge University Press, 1998.
Barnes, David S. The Great Stink of Paris and the Nineteenth-Century Struggle Against Filth. Baltimore: Johns Hopkins University Press, 2006.
Braun, Lundy. Breathing Race into the Machine: The Surprising Career of the Spirometer from Plantation to Genetics. Minneapolis: University of Minnesota Press, 2014.
Hobsbawm, Eric. On History. New York: New Press, 1997.
Huisman, Frank and John Harley Warner, eds. Locating Medical History: The Stories and Their Meanings. Baltimore: Johns Hopkins Press, 2004.
Molina, Natalia. Fit to Be Citizens? Public Health and Race in Los Angeles, 1879–1939. Berkeley: University of California Press, 2006.
Reverby, Susan. Examining Tuskegee: The Infamous Tuskegee Syphilis Study and Its Legacy. Chapel Hill: University of North Carolina Press, 2009.
Roberts, Samuel K. Infectious Fear: Politics, Disease, and the Health Effects of Segregation. Chapel Hill: University of North Carolina Press, 2009.
Rosenberg, Charles and Janet Golden, eds. Framing Disease: Studies in Cultural History. New Brunswick: Rutgers University Press, 1992.
Rosner, David. “Tempest in a Test Tube: Medical History and the Historian.” Radical History Review no. 26 (October 1982): 166-171.
Rosner, David and Gerald Markowitz. Deadly Dust: Silicosis and the Politics of Occupational Disease in Twentieth Century. Princeton: Princeton University Press, 1991.
Shah, Nayan. Contagious Divides: Epidemics and Race in San Francisco’s Chinatown. Berkeley: University of California Press, 2001.
Shapiro, Ian. The Flight from Reality in the Human Sciences. Princeton: Princeton University Press, 2005.
Tomes, Nancy. The Gospel of Germs: Men, Women, and the Microbe in American Life. Cambridge: Harvard University Press, 1998.
Wailoo, Keith. Dying in the City of the Blues: Sickle Cell Anemia and the Politics of Race and Health. Chapel Hill, NC: University of North Carolina Press, 2001.
—. How Cancer Crossed the Color Line. New York: Oxford University Press, 2011.
Wright, Paul and Andy Treacher, eds. The Problem of Medical Knowledge: Examining the Social Construction of Medicine. Edinburgh: Edinburgh University Press, 1982.
Yudell, Michael. Race Unmasked: A 20th Century Struggle to Define Human Difference. New York: Columbia University Press, forthcoming, Fall 2014.