The microbe is a social leveller. Germ socialism, whereby we are all bound together, rests on “the utilization of the power of all for the good of all,” one end-product of which is hygiene, i.e. the science of the prevention of diseases. Hygiene presumes the causal mechanism of diseases can be uncovered and to be broken. Furthermore, this disease picture presumes that nobody is safe unless everyone is safe. There is a close relation between the dominant diseases of a given period and the character and style of that period. …
羅海德為 COVID-19 進行的讀書報告之二。… 從「疾病的圖像」到「病菌的社會主義」：「病因學」設定病源定義疾病，發生和傳播假設了可被理解的因果機制，如是，「衛生」工作依照這邏輯就是截斷因果鏈、防止疾病發生的科學。我們看見疾病的科學理解帶著社會道德涵義。我們對傳染病的知識會帶來社會性的轉化和變動。因此，親和的社會環境是必須的條件，要不然合作共謀是不可能發生的；人人平等面對的基礎，假設建制以大眾的好處為取向，以至重新定位。生物學的事與社會的事是扣在一起的；一個時代的主導、流行疾病，與那個時代的個性和風格是息息相關的。我們可稱之為「疾病的文化形態」。這裡總結的疾病論述一直發揮著主導作用，組織著我們的認知和應對的活動。並不是簡單的對錯，反而是這種論述、這個疾病的圖像，於 COVID-19 出現的今天，有甚麼新提示，凸出了那些有關我們時代和社會經濟政治的特殊境況？又暴露了那些缺失？（中文摘要翻譯／黎肖嫻）updated 18 May 2020
/… continued from Framing Diseases 01: Disease Pictures
/ feature image: Deadliest pandemics in history [WHO-CDC]
Disease and the cooperative society
The modern picture of disease, which connects essence with aetiology, has been elaborated on in various ways. One important strand, which has been revived in discussions of the social implications of COVID-19, involves the assumption that our scientific understanding of disease has moral and social implications. Our knowledge of infectious diseases calls for a social transformation. This transformation involves, or ought to involve, greater cooperation. According to this picture, disease is a social leveller that demands a reorientation of our institutions towards the public good.
This modern picture of disease was closely connected to the concept and practice of hygiene. In a famous 1895 article entitled “The Microbe as a Social Leveller”, NYC health commissioner Cyrus Edson argued that the modern science of hygiene and our knowledge of infectious disease, which are intertwined with our knowledge of micro-organisms, demand a move towards socialism. What does Edson mean by “socialism”?
As Edson sees it, socialism involves interdependency and mutual aid. The prosperity of each person depends on that of other people in the community. He explains this notion as follows: “The germ idea of Socialism, that all members of the body politic are theoretically and should be practically joint partners in one great co-operative state, which should paternally look after the affairs of each and should, by supplementing the individual efforts with the aggregate of influence and wealth, thereby insure individual prosperity…” Edson goes on: “It is a fascinating idea, the community of interest and helpfulness, the utilization of the power of all for the good of all, the loyal service given by each to all, and the gracious protection and aid given by all to each.” (Edson, 421) How is this idea of socialism connected to our scientific knowledge of infectious diseases?
Edson considers the science of hygiene. “The science of hygiene is the science of the prevention of disease…” (423). He expresses a complete confidence in its ability to uncover the causal mechanisms of disease: “Its laws have been formulated and their operation is well understood.” (423) Thus Edson thoroughly subscribes to the aetiological picture of disease. More specifically, he stresses the role of micro-organisms in the causal history of any epidemic: “The discovery of the microbes and of the work they do has naturally resulted in the community preparing itself for the fight with these little enemies.” (423). In this situation, nobody is safe unless everyone is safe. He explains that “we may only fight diseases in a community by meeting it everywhere.” (425). And this means that we must be aware of the people as “being one whole” (425). Each person’s health depends on the health of others. Edson describes the “socialism of the microbe” as consisting in “the chain of disease, which binds all the people of a community together.” (425) We are consciously bound together into a community of shared interest and mutual aid in virtue of our scientific knowledge of disease. “We might call it the Moral of the Past, as seen through the Microscope.” (425).
Besides Edson, another key figure who stressed the social implications of our knowledge of disease was Henry Sigerist, a historian of medicine at the Johns Hopkins University. His work during the 1930s and 40s focused on the connection between science, disease, and what he called “the cooperative society.” In a 1943 study, he wrote: “The step will be taken from the competitive to the cooperative society, democratically ruled on scientific principles…” (Sigerist, 244) Sigerist’s arguments, like those of Edson, were influenced by the development of hygiene. He quotes, for instance, Max von Pettenkofer, who made important contributions to practical hygiene.
Sigerist’s principal point is that the history of medicine and the history of civilization are closely interconnected. We cannot understand disease in isolation from the social and historical circumstances in which it develops. There is a dialectical interaction between disease and civilization. Elizabeth Fee has summarized Sigerist’s thesis as follows: “health and disease were intimately related to wars, famines, and the fares of nations, and also to art, culture, religion, and philosophy”, so we cannot study disease without considering “the relation… between social and biological existence.” (Fee: 1989)
Sigerist noted that there is a close relation between the dominant diseases of a given period and the character and style of that period. Diseases express dominant features of the culture or period in which they occur. We can characterize this aspect as the cultural morphology of disease. Sigerist writes: “…there is a certain relation between the prevailing diseases of a given period and their general character and style. The Middle Ages was a period of collectivism and the dominating diseases were such collective diseases as leprosy, plague, or dancing mania that befell entire groups. In the highly individualistic Renaissance, syphilis was in the foreground, a disease that does not attack just anybody, but is acquired through a highly individualistic act. The Baroque period was one of tremendous contrasts and contradictions. . . . The diseases most frequently pictured were deficiency diseases such as hunger-typhus and ergotism, and luxury diseases such as gout and dropsy…” (Sigerist, 186)
The reason why disease expresses culture is that there is a causal interaction between the one and other. Different cultures shape, and are shaped in turn, by disease. The history of disease cannot be approached independently of social factors. The biological is essentially interned with the social. Disease is intimately related to sanitation, eating habits, clothing, housing conditions (ventilation, heating, water supply, sewage and clean water), unemployment, working conditions (e.g., industrial hazards), recreation, health exams, access to hospitals, the speed and extent of communication and transportation networks, etc. The mode of existence of a community, including its technical systems, partly determines the diseases to which its exposed are exposed. It also determines their disposition to diseases. Moreover, disease is not only influenced by, but also influences, social arrangements and cultural forms. He notes that the law, for instance, had to take sickness into account, and that many religious and philosophical systems had to account for the problems posed by disease.
An important question concerns the “genesis” of disease. Sigerist everywhere stresses the matter of origins. For instance, he argues that the introduction of machines changed the nature of famine and population growth. Prior to the industrial revolution, population increases were affected by geography, in particular, by the productivity of the soil. But industrial production and transportation “permitted an increase of population beyond the natural capacity of the soil” and from that time on, “famines were man-made, the result of mismanagement, war, and blockade.” (Sigerist, 10) The genesis of disease is now, at least partly, inextricably social. This understanding of the origin of disease as at once biological and social led to important views about the practice of hygienic intervention. Sigerist was keenly aware of the absurdity that arises from any attempt to disengage medical interventions from social facts. He wrote, for instance: “To immunize colonial people against disease with one hand and exploit them into starvation with the other is a grim joke.’’ (S236) He underscored the connection between colonial exploitation and disease in Africa. More generally, Sigerist argued that disease is often produced by social and economic arrangements, particularly economic inequality. “All such conditions are the result not of natural but of man-made catastrophes.” (12)
An important aspect of this framework is the contention that, even if micro-organisms are taken as defining causes of infectious diseases, they must interact with other causal factors in order to produce a disease. Someone being infected is the result not only of the action of an external pathogen but also of environmental and social conditions. The struggle against disease must be directed towards the transformation of those conditions. For instance, Sigerist called for the institution of universal health care.
Thus we see emerging a certain picture of disease, more specifically infectious disease, according to which our scientific knowledge has uncovered our shared predicament as a community of shared interest and mutual aid. This interdependency, moreover, requires conceiving of disease not merely as a biological phenomenon but also as a broadly social phenomenon. According to this viewpoint, disease is intertwined with political, economic, legal, and cultural arrangements. This broad understanding rests on the theory and practice of hygiene. Progress in the scientific understanding and practical treatment of infectious disease, pursued in large part for the sake of health, demands the transformation of those arrangements along the lines of democracy and cooperation.
I do not want to endorse or reject this disease picture. I only aim to describe it, and to show that it has again resurfaced in certain recent discussions of COVID-19.
(12 May 2020, Hong Kong)
Edson, Cyrus 1895: “The Microbe as a Social Leveller,” The North American Review vol. 161, No. 467 (Oct., 1895), pp. 421-426.
Fee, Elizabeth 1989: “Henry E. Sigerist: From the Social Production of Disease to Medical Management and Scientific Socialism,” The Milbank Quarterly vol. 67; Supplement 1. Framing Disease: The Creation and Negotiation of Explanatory Schemes, pp. 127-150.
Sigerist, Henry E. 1943: Civilization and Disease. Ithaca: Cornell University Press.
/… to be cont’d… “Framing Diseases 03: COVID-19 and the Cooperative Society,” 2020.05.18