Commentary: Epidemiology in context
The Department of the History of Science, Harvard University, Boston, USA. E-mail: rosenb3@fas.harvard.edu
Accepted 7 October 2008
In the spring of 1948, Erwin H Ackerknecht, a physician-historian newly settled at the University of Wisconsin in Madison, regretted that he might not be able to attend the annual meeting of the American Association for the History of Medicine in Philadelphia. Two young children, shallow pockets, and chronic stomach problems made travel for the German refugee-scholar difficult and expensive. But he received a last-minute invitation to deliver the Association's prestigious Fielding Garrison lecture.1 That talk, on ‘Anticontagionism between 1821–67’ written hastily in the 2 months available to him, has since become something of a landmark—in the words of a distinguished practitioner, ‘one of the most influential essays in the history of epidemiology ...’2 In its article form, his argument has remained a reference point for debate. The issues Ackerknecht raised have retained their heuristic value, despite a variety of objections to his characterization of particular students of disease and the implementation of particular policies in particular places,3 e.g. or his perhaps overly schematized articulation of the etiological choices available to his protagonists.4
What was the burden of his argument? It turns first on an irony. Anticontagionism as a self-conscious doctrine—defined by its militant opposition to contagionism—flourished in the decades immediately preceding the articulation and ultimate triumph of germ theory. In terms of conventional medical history this was a kind of darkness before dawn. Contagionism (and especially that version of it presuming a living substance or thing) appeared to its antagonists not a progressive way forward but instead ‘old and obsolete’, an antique doctrine that had not been proven by epidemiological or experimental data. It had, in fact, been discredited by its association with centuries of failed quarantines and sanitary cordons and the authoritarian regimes that imposed them: ‘what to us appears a vanguard action’, Ackerknecht argued in reference to Jacob Henle's retrospectively much-admired contagionism, ‘impressed ... contemporaries rather as a rearguard action, the last gallant defense of a dead hypothesis’ (563).5 Second, as Ackerknecht examined the controversy, he sought to link etiological thinking with a particular policy history (opposition to quarantines and cordons) and a particular intellectual and social location: bourgeois liberals suspicious of traditionalism in medicine and the authoritarian states which enforced quarantines that seemed ineffective and economically destructive. It was a practice based on dogma and groundless lay fears rather than evidence. Ackerknecht developed his argument by examining the debates surrounding yellow fever, cholera, plague (and, more tangentially, typhus which was both difficult to diagnose and generally conceded to be contagious in certain well-understood pathogenic local circumstances such as ships, prisons, and military camps).
Ackerknecht argues that the terms of debate were set in the conflict over yellow fever at the end of the eighteenth and beginning of the 19th centuries. The controversy over transmission of the ‘black vomit’ was a focus for epidemiological and policy discussion before cholera moved center-stage in the early 1830s. And yellow fever was elusive. It certainly did not fit the smallpox paradigm—the model of a truly contagious disease, passed from person to person by a substance capable of reproducing itself in the bodies of sufferers; inoculation and then vaccination had made this undeniable. Yellow fever did not seem to be spread by personal contact, though outbreaks were often associated with ships arriving from ports ridden with the disease. Moreover, those caring for sufferers did not seem particularly vulnerable. And yellow fever was seasonal. Why would a disease passed from person to person by some material contagion be seasonal? It seemed more likely evidence of its environmental—and, to this generation, thus atmospheric—origin.
Cholera like yellow fever was difficult to prove contagious. It was hard to reconstruct a chain of transmission during local epidemics—while the cordons and quarantines that had been established to fend off its relentless spread from the east to Europe and the Americas had shown themselves repeatedly—and didactically—ineffective. Many of those strongly opposing a theory of person to person contagion were, Ackerknecht emphasized, critical, data-oriented scientists like Virchow and Magendie. In sum, the cumulative experience of medical science had, by the 1840s, failed to demonstrate that yellow fever or cholera were communicable from person to person. Ackerknecht was well aware that a large middle-group of moderates avowed neither an exclusive contagionism nor its polarized opposite; they embraced what contemporaries called contingent contagionism.6
But it was the centrality of quarantine in the policy arena, Ackerknecht contended, that made many physicians take sides (11–12). It was not just that that quarantines were ineffective: they exerted a debilitating effect on economic activity (and thus indirectly the health status of working people) In this sense, they predisposed the poor to the epidemic. And perhaps more importantly, they directed attention away from local improvement—the clean streets and ventilated rooms, the sewers and personal cleanliness that seemed in fact to protect a community against disease. Anticontagionism expressed and legitimated, that is, a positive and powerfully motivating activist component, as well as what might be termed a negative anti-quarantine and anti-authoritarian identity. The bottom line, in the words of a representative American sanitarian, lay in the ‘superiority of sanitary measures over quarantines’.7 The anti-contagionists were, as Ackerknecht put it, ‘more than mere mouthpieces of a ruthless and economy-minded bourgeoisie’ (14). Opposition to germ theory was in some minds a defense of environmental reform.
In retrospect, Ackerknecht's argument seems novel and has remained visible because it appears to prefigure a contextual style of argument—one embedding medical thought in a situated world of time-bound actors and not in a timeless aggregation of increasingly precise statements about the nature of nature—the trajectory of gradual revelation that still seems to so many of our contemporaries the appropriate framework for approaching the historical development of science and medicine. But Ackerknecht is far from a relativist, even if he can be characterized as what might—anachronistically—be called a contextualist. His analysis is based in fact on his retrospective understanding of yellow fever and cholera—ailments whose etiology and modes of transmission were clarified only after the 1860s. They were, he argues, a frustrating challenge to even the best-informed medical men in the first two-thirds of the 19th century. Epidemiological idiosyncrasy implied continuing controversy; neither contagionism nor anticontagionism could claim the explanatory high ground. ‘Intellectually and rationally the two theories balanced each other too evenly’, Ackerknecht argued. ‘Under such conditions the accident of personal experience and temperament, and especially economic outlook and political loyalties will determine the decision. These, being liberal and bourgeois in the majority of the physicians of the time brought about the victory of anti-contagionism’ (17, ital. in original). But social location and class orientation determined medical discourse only in that residual space created by the gap between perceived phenomenon—epidemics of yellow, fever, let us say, plague or cholera—and the learned world's ability to explain them. Once explained in terms of a world of mosquitoes, rat fleas, contaminated water and pathogenic organisms, the space for debate—and for the role of social and economic commitment—grew ever-narrower.
Ackerknecht was by no means a consistent relativist—but rather a socially aware positivist.8 Some ideas were wrong and others were right—closer to the natural world. Some scholarship was of value, in this sense of contributing to scientific knowledge; other academic work was more a reflection of prevailing attitudes, assumptions, and stakeholder interests. Ackerknecht's position may, from today's perspective, seem inconsistent but it is far from irrelevant. Understanding the relationship between the natural world and our construction of it remains a fundamental and elusive problem—for historians as well as philosophers and sociologists of knowledge. In medicine it is particularly intractable.
Born in 1906, Ackerknecht was trained as a physician, as a medical historian in Leipzig, then as a social anthropologist in Paris after fleeing Germany with Hitler's ascent to power in 1933. He was interned in a labor camp with the outbreak of war and managed finally to find his way to New York in 1941. And though his politics had changed, from Communist, to Trotskyist, to unaffiliated Socialist, to jaundiced witness to the Cold War and finally disdainful observer of the student movements of 1968 and its associated cultural skepticism, he remained committed like many of his German-trained peers to a notion that medicine was not simply an applied science, that it was a social function and deeply embedded in every aspect of human culture and social organization.9 Even the definition of what constituted a disease was determined culturally as well as biologically. ‘Disease and its treatment are only in the abstract purely biological processes’, he wrote in 1947. ‘Actually such facts as whether a person gets sick at all, what kind of disease he acquires, and what kind of treatment he receives, depend largely on social factors.’10
Ackekrknecht had been influenced not only by the intense politics of his Weimar youth, but more specifically by his Leipzig doctoral thesis (directed by Henry Sigerist). It was a study of medical reform in 1848 that focused on the youthful Rudolf Virchow and his influential investigation of a Silesian typhus epidemic.11 In Virchow's iconic formulation, the causes of the disease were social, economic, and institutional—and thus remediable. Virchow's anticontagionism assumes a rather different meaning in this context of social and necessarily political criticism. ‘Economic factors’, as Ackerknecht explained, ‘did not only determine the stand of many in the anticontagionism discussion. Economic factors were consciously used by many to give a causal explanation of epidemics’... in the middle-third of the 19th century. (18). His familiarity with Virchow's history as social reformer and witness to the conservative reaction following the revolutions of 1848 must all have influenced Ackerknecht as he sought to understand how a great scientist like Virchow could have been so firmly an anticontagionist at mid-century. Ackerknecht retained, nevertheless, the ability to keep his distance from a political position—disease as the consequence of remediable social conditions—that he found emotionally attractive. ‘The sociological theory’, he warned, ‘claiming a kind of "social epidemic constitution", suffers often from the same haziness that is so characteristic of the theories of telluric "epidemic constitution" ’.(9)
Medicine is particularly in the social world, both indicator and substance of that world. Like many of his generation on the left, Henry Sigerist, his teacher, e.g. and George Rosen, his friend, Ackerknecht, saw medicine as a part of society in all of its aspects. It is this sense that his discussion of the controversy over contagionism and quarantine is most obviously didactic—an example of the ways in which social and economic orientations are inevitably part of that set of practices and ideas we call medicine. This was in fact the central vision of Henry Sigerist's Institute for the History of Medicine in the 1940s (and one not always congenial to Sigerist's Johns Hopkins colleagues in clinical medicine). It is no accident that George Rosen's still widely-cited article ‘What is Social Medicine’, appeared in the Bulletin of the History of Medicine, the year before Ackerknecht's study of anticontagionism.12 Both reflect a broad, inclusive, policy-oriented—and potentially activist—understanding of medicine. Rosen even saw this broadly social approach to the teaching of medical history as a potential tool for the implementation of social change. ‘... a medical history which approaches medicine with an understanding that it has always been involved in a matrix that is at once social, economic, political, and cultural can be developed into a method that can contribute to the solution of urgent social problems of medicine’.13
But belief, no matter how benevolent or seemingly enlightened, was never to remain unquestioned. Ackerknecht ends his paper with a plea for an ethnographer-historian's humility. We are not immune to errors because we are intellectually or morally superior, because we are somehow wiser than our predecessors, because we have somehow transcended the quaint imperfections of past belief. We live with contingency, within assumptions and seeming certainties that are time and culture-bound—even if that culture is a subculture of science or medicine. Having barely survived the ruthless certainties of authoritarian politics, he sought to live with that disquieting irony. There is a liberating humility in the acknowledgement that we live in history and are its prisoners.
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1 Ackerknecht EH to Sigerist HE. Sigerist Papers (1948) Yale University. May 20.
2 Coleman W. Yellow Fever in the North. The Methods of Early Epidemiology (1987) Madison: University of Wisconsin Press. 187.
3 Baldwin P. Contagion and the State in Europe, 1830–1930 (1999) Cambridge: Cambridge University Press.
4 Hamlin C. Predisposing causes and public health in early nineteenth-century medical thought. Soc Hist Med (1992) 5:43–70.[Abstract]
5 Jacob Henle: on Miasmata and Contagia. Bull Hist Med. Translated by Rosen G. (1938) 6:907–83.
6 Pelling M. Cholera, Fever and English Medicine 1825–1865 (1978) Oxford: Oxford University Press.
7 Clark HG. Superiority of Sanitary Measures over Quarantines. An Address delievered before the Suffolk District Medical Society (1852) Boston: Thurston, Torry, and Emerson.
8 Cooter R. Anticontagionism and history's medical record. In: The Problem of Medical Knowledge. Examining the Social Construction of Medicine—Treacher Wright P., ed. (1982) Edinburgh: Edinburgh University Press. 87–108.
9 Rosenberg CE, Erwin H. Ackerknecht, social medicine, and the history of medicine. Bull Hist Med (2007) 81:511–32.[Medline]
10 Ackerknecht EH. The role of medical history in medical education. Bull Hist Med (1947) 21:135–45. 143.
11 Virchow R. Beitrage zur Geschichte der Medizinalreform von 1848 (1932) Leipzig: Barth.
12 Rosen G. What is social medicine? A genetic analysis of the concept? Bull Hist Med (1947) 21:674–733.[Medline]
13 Rosen G. The place of history in medical education. Bull Hist Med (1948) 22:625.
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