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The Cholera Stigma and the Challenge of Interdisciplinary Epistemology: From Bengal to Haiti

2012; Taylor & Francis; Volume: 21; Issue: 4 Linguagem: Inglês

10.1080/09505431.2011.652082

1470-1189

Christopher Hamlin,

Zoonotic diseases and public health

Abstract For a century and a half cholera has been a stigmatizing disease. That the entire world was susceptible to it seemed merely to accentuate its association with Asia, and particularly with Bengal and its people. The recent epidemic in Haiti suggests that cholera still carries stigma. That stigma is the product of epistemic practices within an interdisciplinary and orientalist cholera science that took shape in the 1860s and 1870s, which have, without renewed scrutiny, prevailed largely uncontested until recent decades. Those practices involved an over-interpretation of the historical epidemiological work of John Macpherson by his colleague N. C. Macnamara. Recent research, recognizing the wide distribution and genetic instability of Vibrio cholerae, offers an alternative context for appreciating Macpherson's insights. This new program of interdisciplinary cholera research seems largely free of stigmatizing representations, but nor does it offer (or seek) a single and simple program of cholera prevention. The cholera case study invites reflection on the little-studied problem of epistemic accountability in interdisciplinary research, alerts us to questions of how disciplines are (and might be) made to cohere in policy-driven inquiries. The chief maxim is toward more explicit inclusion of the concept of multiple working hypotheses. Keywords: CholeraIndiaBengalstigmahistorical epidemiologypublic health policyHaitiinterdisciplinary epistemologyJohn MacphersonNottige Charles Macnamaramultiple working hypotheses Notes Propinquity and history were important; outbreaks in Africa, or from floods in the Indus valley, had had no such impact. Such views are found generally in medical references, histories of cholera, and popular encyclopedias. See http://www.britannica.com/EBchecked/topic/114078/cholera/253249/Cholerathrough-history. While this paper will not explore the cholera stigma in terms of social theory, it may be an especially insidious one, for it links in a relation of mutual amplification the three distinct forces (race, lesion, and madness) identified by Goffmanian stigma theorists: despised race or group was joined with overt pathology (the horrifying bluish and shrunken cast of late-stage cholera victims); its most conspicuous manifestation (uncontrollable defecation) would otherwise demarcate severe mental incompetence or the most egregious violation of societal norms. Other factors often recognized are cholera's deadliness, the suddenness of its striking and rapidity of its course, and the inability to perceive the immediate sources of the threat—which then can readily be embodied in some 'them'. And yet, one may note that other diseases (e.g. smallpox, tuberculosis, or dysentery), which combine similar elements of grotesqueness and dangerous social contact, have not acquired similar stigma. Nor, in places where it was endemic or regularly epidemic, was cholera particularly stigmatized (see Goffman, 1963 Goffman, E. 1963. Stigma. Notes on the Management of Spoiled Identity, Englewood Cliffs, NJ: Prentice-Hall. [Google Scholar]). Although biomedical modes of differentiation were central in emerging orientalism in the eighteenth and nineteenth centuries, Said does not focus directly on epidemiology or disease experience, though he does recognize an insidious medicalization in the origins of orientalism. Other interdisciplinary impositions on Asia were founded in French utopianism (which ultimately was biomedical), the classificatory enterprise (anthropological and biomedical), or the anatomical-evolutionary paradigm (with Geoffroy as exemplar) (see Said, 1978 Said, E. 1978. Orientalism, New York: Random House Vintage. [Google Scholar], pp. 78–79,114, 119, 142–144, 150). Remarkably neither Pollitzer nor his predecessors had evinced much concern that the terms used in ancient and modern Asian languages to include ostensible cholera usually did not refer to cholera exclusively. In their view one could expect to find (and infer from) descriptions of symptoms but did not expect concepts or terms. Howard-Jones (1974a) Howard-Jones, N. 1974a. Cholera nomenclature and nosology: a historical note. Bulletin of the World Health Organization, 51: 317–324. [PubMed], [Web of Science ®] , [Google Scholar] would add to this foundation Jan Semmelink's (1885) Semmelink, J. 1885. Geschiedenis der Cholera in oost-indië vóór 1817, Utrecht: C H E Breijer. [Google Scholar] Geschiedenis der Cholera in oost-indië vóór 1817. Though Semmelink also drew on Macnamara (and on Raoul Henri Scoutetten, indirectly one of Macnamara's key sources), he supplemented the record with early eighteenth century hospital records from the Dutch East Indies. His tentative conclusion was of an emerging disease that differed from those the first explorers had met. Appearing in the midst of the rethinking of cholera in light of Robert Koch's discoveries, Semmelink's work had little impact on what was becoming the standard account of Macnamara. By 1892, the list had expanded to 66 (Macnamara, 1892 Macnamara, N. C. 1892. Asiatic Cholera: History up to July 15, 1892, Causes and Treatment, London and New York: Macmillan. [Google Scholar], p. 1). British intransigence has been explored most closely by Howard-Jones (1974b) Howard-Jones, N. 1974b. The scientific background of the international sanitary conferences, 1851–1938. 3. WHO Chronicle, 28: 369–384. [PubMed] , [Google Scholar], Harrison (1994) Harrison, M. 1994. Public Health in British India: Anglo-Indian Preventive Medicine 1859–1914, Cambridge: Cambridge University Press. [Google Scholar], Baldwin (1999) Baldwin, P. 1999. Contagion and the State in Europe, 1830–1930, New York: Cambridge University Press. [Crossref] , [Google Scholar], and especially Watts (2001) Watts, S. 2001. From rapid change to stasis: Official responses to cholera in British-ruled India: 1860–c.1921. Journal of World History, 12: 321–374. (doi:10.1353/jwh.2001.0047)[Crossref], [PubMed], [Web of Science ®] , [Google Scholar], who finds the stance indefensible on the grounds that questions of cholera's nature and transmission should have been closed by the 1870s. In his view it was kept open artificially, to serve a political and ideological agenda. It is here that modern research on cholera impacts our historical judgment. If we take the view that there was, and is, legitimate uncertainty about these matters, we are apt to recognize the British position as defensible, if still self-serving. Remarkably, after isolation of the cholera bacillus went so far in vindicating his position, Macnamara moderated his views. In his 1892 follow-up he thought the colonial authorities had handled a cholera outbreak among Hindu pilgrims as well as they realistically could do, but criticized their public relations. That outbreak led to the cholera of the 1890s, however. Although it is not evident in his 1872 work, Macpherson too was involved in the controversy as a defender of British policies. In an unsigned 1867 Quarterly Review article, he referred to dubious views emerging from the International Sanitary Conferences that were contrary to 'our interests' (Macpherson, 1867 Macpherson, J. 1867. The cholera conference. Quarterly Review, 122: 29–55. [Google Scholar], p. 31). His concern was with potential international intervention in the Ganges valley, 'as the source of the disease—and this touches us very closely indeed; it involves many questions connected with the internal arrangements of India, and with the regularity of the transit through Egypt, so essential to our interests. As we believe that a review of the early history of cholera in India may help us very materially in judging of the value of some of the views of the Conference, we do not scruple to lay before the public a sketch of a subject, which has not hitherto been treated in the detail which it deserves'. Oddly, in concluding that the goddess proved the antiquity of cholera, Macnamara cited Macpherson, who, in turn, had cited Macnamara's earlier formulation of the argument. Anderson (2004) Anderson, W. 2004. Natural histories of infectious disease: ecological vision in twentieth-century biomedical science. Osiris, 19: 39–61. (doi:10.1086/649393)[Crossref], [PubMed], [Web of Science ®] , [Google Scholar] has explored the return of a broader biological agenda in the work of Macfarlane Burnet. In the Pasteurian tradition it remained important. For traces within the Kochian tradition see Mendelsohn (2002) Mendelsohn, A. 2002. 'Like all that lives': biology, medicine and bacteria in the age of Pasteur and Koch. History and Philosophy of the Life Sciences, 24: 3–36. (doi:10.1080/03919710210001714293)[Crossref], [PubMed], [Web of Science ®] , [Google Scholar]. By contrast, earlier in the nineteenth century there had been a good deal of interest in the geography of cholera within Asia. There was interest both in endemicity and in the triggers of pandemics (see Creighton, 1894 Creighton, C. 1894. A History of Epidemics in Britain, Volume II. From the Extinction of Plague to the Present Time, Cambridge: Cambridge University Press. [Google Scholar]). For a few it has led to renewal of interest in nineteenth-century data (see Glass and Black, 1992 Glass, R. I. and Black, R. E. 1992. "The epidemiology of cholera". In Cholera, Edited by: Barua, D. and Greenough III, W. B. 129–150. New York: Plenum. [Google Scholar]; Pascual et al., 2002 Pascual, M., Bouma, M. J. and Dobson, A. P. 2002. Cholera and climate: Revisiting the quantitative evidence. Microbes and Infection, 4: 237–245. (doi:10.1016/S1286-4579(01)01533-7)[Crossref], [PubMed], [Web of Science ®] , [Google Scholar]). Earlier Macpherson (1866) Macpherson, J. 1866. Cholera in its Home. With a Sketch of the Pathology and Treatment of the Disease, London: J. Churchill & Sons. [Google Scholar] had emphasized cholera picked up in port, but noted also that it tended to break out in passage up the Hoogley (cf. Shakespeare, 1890 Shakespeare, E. O. 1890. Report on the Cholera in Europe and India, Washington, DC: GPO. [Google Scholar], pp. 347–349; Drasar, 1996 Drasar, B. S. 1996. "Problems of the epidemiology of cholera and the ecology of Vibrio cholera". In Cholera and the Ecology of Vibrio cholera, Edited by: Drasar, B. S. and Forrest, B. D. 333–347. London: Chapman & Hall. [Crossref] , [Google Scholar], p. 342). The appropriate priority of vaccine development is probably the most visible issue of tension in the previous half century. Some who have celebrated the emergence of a multifaceted biological approach to cholera have seen the emphasis on vaccination as a narrow and ultimately unsuccessful response to global diarrheal disease (Barua and Merson, 1992 Barua, D. and Merson, M. 1992. "Prevention and control of cholera". In Cholera, Edited by: Barua, D. and Greenough, W. B. III. 329–349. New York: Plenum. [Google Scholar]). Vaccine developers in turn have sometimes been critical that the broad agenda is too little concerned with the immediate problem of cholera control.