Regions, Networks and Fluids: Anaemia and Social Topology

Social Studies of Science

Volumn 24, Issue 4, 1994, Pages 641-671

  Mol, Annemarie ^a   Law, John ^b  

^a MAASTRICHT UNIVERSITY   (Netherlands)

^b KEELE UNIVERSITY   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

EID: 0028534738     PISSN: 03063127     EISSN: 14603659     Source Type: Journal    
DOI: 10.1177/030631279402400402     Document Type: Article

References (42)

1. D. Werner, Where There Is No Doctor: A Village Health Care Handbook (London: Macmillan, 1978), 125.
2. C.R. Schull, Common Medical Problems in the Tropics: A Clear Comprehensive Guide (London: Macmillan, 1987), 182.
3. An example of an extreme version of regional social thought would be that of Jurgen Habermas, where he seeks to separate ‘life world’ from ‘system’, and sort out all the concomitant subdivisions (for instance, power versus money, or morality versus ethics). For the most recent substantive step in this project, see Jurgen Habermas, Facultat und Geltung, Beitrage zur Diskurstheorie des Rechts und des demokratischen Rechtsstaat (Frankfurt am Main: Suhrkamp, 1992). But there are many other examples - see, for instance, Erving Goffman, The Presentation of Self in Everyday Life (Harmondsworth, Middx: Penguin, 1971). For an example of network theorizing, see Bruno Latour, Science in Action: How to Follow Scientists and Engineers Through Society (Milton Keynes, Bucks.: Open University Press, 1987).
4. One could say that anatomy is a topography, a map-making practice. Like geographical topographies, it localizes its objects within a set of coordinates, taking these coordinates as tools, rather than as an object of reflection. For an analysis of the spaces of geography, see Francois Dagognet, Une Epistemologie de VEspace Concret: Neo-Geographie (Paris: Vrin, 1977); and for the relation between the spatial tradition of anatomy and that of geography, see Dagognet, Faces, Surfaces, Interfaces (Paris: Vrin, 1982).
5. This movement is inspired by the work of Michel Serres. Serres brings to the fore the implicit spatial notions in a range of theories and other texts. See especially: Michel Serres, Le Passage du Nord-Ouest (Paris: Les Editions du Minuit, 1980), and Serres, Statues (Paris: Editions Francois Bourin, 1987). For the transportation of this strategy to science studies, see Annemarie Mol, ‘Topografie als methode van kennisonderzoek: Over het naast elkaar bestaan van enkele bloedarmoedes’, Kennis en Methode, Vol. 15 (1991), 314-30.
6. Susan Leigh Star, ‘Leaks of Experience’ (personal communication).
7. The term comes originally from the writing of David Bloor, Knowledge and Social Imagery (London: Routledge & Kegan Paul, 1976). See its extension by Michel Callon, ‘Some Elements of a Sociology of Translation: Domestication of the Scallops and the Fishermen of St. Brieuc Bay’, in John Law (ed.), Power, Action and Belief: A New Sociology of Knowledge?, Sociological Review Monograph No. 32 (London: Routledge & Kegan Paul, 1986), 196-233; and more recently by Law, Organizing Modernity (Oxford: Blackwell, 1994).
8. Joost Zaat, De macht der gewoonte: Over de huisarts en zijn laboratoriumonder-zoek (Amsterdam: Thesis Publishers, 1991). Each of these numbers is generated by superimposing epidemiological data-gathering on the work of general practitioners. In the Dutch system, access to a general practitioner is easy: for most people, and for all on lower incomes, an unlimited number of visits is included in their healthcare insurance. With the exception of emergencies, patients can only see a specialist if they are referred.
9. David Weatherall and Prawase Wasi, ‘Anemia’, in Kenneth Warren and Adel Mahmoud (eds), Tropical and Geographical Medicine (New York: McGraw-Hill, 1990), 55-65.
10. Calling a disease ‘tropical’ attributes its incidence to climate or geographical location, while calling it ‘nutritional’ stresses lack of food and other resources.
11. Aaron Eben John Masawe, ‘Nutritional Anaemias’, Clinics in Haematology, Vol. 10 (1981), 815-42.
12. Iron is a crucial component of the haemoglobin molecule: in anaemic patients the iron supply of the body is usually depleted.
13. Edward Kasili, ‘Malnutrition and Infections as Causes of Childhood Anemia in Tropical Africa’, The American Journal of Pediatric Hematology I Oncology, Vol. 12 (1990), 375-77.
14. This relates to the old discussion as to whether international relations should be discussed in terms of the North-South distinction or that of social class. Does it make best sense to distinguish the Western world and the ‘local upper class’ on the one hand, and the ‘local poor’ on the other?
15. The production of a norm for any population by drawing a gaussian curve through a series of highly variable haemoglobin levels is in itself an activity which produces regions. All the differences between individuals are suppressed in order to end up with the mean, the median and the lowest acceptable haemoglobin level for ‘the population’. This population may map on to a geographical region (for instance that of a nation) or on a social one (for instance people with low incomes). For the many contingencies involved in the production of statistics, see Aaron V. Cicourel, Method and Measurement in Sociology (New York: Free Press, 1964); Harold Garfinkel, Studies in Ethnomethodology (Englewood Cliffs, NJ: Prentice-Hall, 1967); J. Maxwell Atkinson, Discovering Suicide: Studies in the Social Organization of Sudden Death (London: Macmillan, 1978); Ian Hacking, The Taming of Chance (Cambridge: Cambridge University Press, 1990). For the shift in social medicine from geographical to social regionalism, see Eddy Houwaart, De hygienisten: Artsen, staat en volksgezondheid in Nederland 1840-1890 (Groningen: Historische Uitgeverij, 1991).
16. We leave open the question about what follows from the production of such regions. But note there is a range of possibilities. From indifference, to medical concern, from hard work by tropical doctors, to an easy association between ‘Africa’ and ‘disease’ - which can be mobilized to depict both black bodies and the continent as unruly, decaying, chaotic and hopeless. For a historical analysis of the latter association, see Jean Comaroff, ‘The Diseased Heart of Africa’, in Shirley Lindenbaum and Margaret Lock (eds), Knowledge, Power and Practice: The Anthropology of Medicine and Everyday Life (Berkeley, CA: University of California Press, 1993), 305-29.
17. Saadiya Aziz-Karim et al. ‘Anaemia in Pregnancy - A Study of 709 Women in Karachi’, Tropical Doctor, Vol. 20 (1990), 134-35.
18. J.A. Dorward, J.K. Knowles and I.M. Dorward, ‘Treatment of Severe Anaemia in Children in a Rural Hospital’, Tropical Doctor, Vol. 19 (1989), 155-58.
19. The argument is developed in a number of locations. See, in particular, Bruno Latour, ‘Drawing Things Together’, in Michael Lynch and Steve Woolgar (eds), Representation in Scientific Practice (Cambridge, MA: MIT Press, 1990), 19-68; for a witty and interesting recent study of three cases, see Joseph O'Connell, ‘Metrology: The Creation of Universality by the Circulation of Particulars’, Social Studies of Science, Vol. 23 (1993), 129-73.
20. The network character of machines is considered in Madeleine Akrich, ‘The De-scription of Technical Objects’, in Wiebe E. Bijker and John Law (eds), Shaping Technology - Building Society (Cambridge, MA: MIT Press, 1992), 205-24.
21. An inter-topological effect occurs where the operational rules of one space interfere with those of another: see Robert Cooper, ‘Formal Organization as Representation: Remote Control, Displacement and Abbreviation’, in Mike Reed and M. Hughes (eds), Rethinking Organization (London: Sage, 1992), 254-72.
22. What counts as a low haemoglobin level isn't unambiguous, even in the Netherlands. For an analysis in which the statistical approach to this question (the subject of the present paper) is contrasted with a pathophysiological and clinical alternative, see Annemarie Mol and Marc Berg, ‘Principles and Practices of Medicine: On the Co-existence of Various Anemias’, Culture, Medicine and Psychiatry, forthcoming.
23. The use of computers for file-keeping in general practice circumvents even the forms. What now becomes essential is the software that allows the retrieval of epidemiologically interesting data. With the pharmaceutical industry now giving computers free to general practitioners who are willing to take part in clinical trials, the development of research-friendly software is certain to follow quickly.
24. Even so Dutch epidemiologists complain. There are currently almost 200 (!) different methods of assembling epidemiological facts about death and disease in the Dutch population of less than 15 million. Since individuals have no ‘health care identification number’ it is almost impossible to link the various outputs of these systems. Moreover, upon closer inspection ‘just adding a form to work-as-usual’ is a gross simplification of what happens when practitioners are asked to gather epidemiological data. Categories used for one activity do not overlap with those used for another. For an insightful analysis of this, concentrating on the case of social medicine, see Nicolas Dodier, Vexpertise medicale: Essai de sociologie sur Vexercise du jugement (Paris: Metailie, 1993).
25. Here the word ‘laboratory’ is not the place where new knowledge is made, the location of science in action. In common medical usage ‘the laboratory’ is the collection of machines (from blood test to CT-scans) that is used in the daily assessment of patients. Thus, a small device such as a simple Hb-meter is not taken away from ‘the laboratory’ in order to raise a world: it is a laboratory. Throughout this article, we will use the term ‘the laboratory’ in this way.
26. For several examples of networks that failed in the attempt to cross the ocean from the West to another region, which also show that the missing link is usually something nobody knew to be a link in the first place, see Madeleine Akrich, Inscription et coordination socio-technique: Anthropology de quelques dispositifs energetiques (Paris: These Ecole de Mines, 1993).
27. Elizabeth Topley, ‘Testing Degree of Anaemia’, Tropical Doctor, Vol. 16 (1986), 3-8.
28. In his classical discussion about the relation between laboratory and clinic in medicine, Georges Canguilhem, in Le Normal et le Pathologique (Paris: Presses Universitaires de France, 1966), stresses the fact that clinical knowledge is older than that of the laboratory. He does so in order to defend the systematic primacy of the clinic. It is, he tells us, only through people's experience of suffering that laboratories ever came into being in the first place. It is only through suffering that we got to know about disease.
29. This quote is a typical compromise between the older clinical method that saw anaemia as a degree of whiteness and the newer laboratory method that measures haemoglobin levels. For what happens is that the doctor talks about seeing’ this or that haemoglobin level: a 15, a 10 or less. This is a good example of the way new techniques aren't simply added to older ones, but also lead them to change. Observing eyelids didn't stay the same after the start of haemoglobin measurements, for in addition to being a ‘sign of anaemia’ a white eyelid also became a possible indicator of a ‘low haemoglobin level’. For a good example of the way clinical diagnosis was altered by new machines, see Bemike Pasveer, ‘Depiction in Medicine as a Two-way Affair: X-ray Pictures and Pulmonary Tuberculosis in the Early Twentieth Century’, in liana Lowy (ed.), Medicine and Change: Historical and Sociological Studies in Medical Innovation (Paris: Les Editions Inserm, 1993), 85-106.
30. Though numbers, it shouldn't be forgotten, also have variable degrees of precision and fluidity. For the argument that ‘around ten o'clock’ may be a more appropriate number in a lot of contexts than ‘10.03h.’, see Michael Lynch, Method: Measurement-Ordinary and Scientific Measurement as Ethnomethodo-logical Phenomena’, in Graham Button (ed.), Ethnomethodology and the Human Sciences (Cambridge: Cambridge University Press, 1992), 77-108.
31. To further complicate this: many Dutch patients do not simply talk about anaemia-related complaints, but also come to their doctor with a medical story: ‘Doctor, I am so tired, I think I have anaemia, can I have my haemoglobin level checked?’ According to current clinical epidemiological wisdom, the haemoglobin levels of such patients are no lower than those of control groups, and are thus no more likely to need haemoglobin measurements. According to current social psychological wisdom, however, a ‘negative lab finding’ makes it easier for a general practitioner to discuss the events that led to the patient's tiredness. For an analysis of this double bind, based on interviews with Dutch general practitioners, see Annemarie Mol, ‘Van wie is de theorie? Bloedarmoede en de metapositie’, Gezondheid, Vol. 1 (1993), 5-16.
32. ‘The clinical gaze’ is a common expression among doctors for their clinical diagnosis, whether this is made by looking or listening. It comes in a variety of forms, many of which do not map on to the clinical gaze Michel Foucault talks about in La Naissance de la Clinique (Paris: Presses Universitaires de France, 1963). Foucault pointed at the way in which ‘modem medicine’ links signs and symptoms on the surfaces of the body to the lesions pathologists find in the organs when they open up a corpse. Modem medicine, however, has many alternatives. Sometimes pathology is part of them. Sometimes it isn't. In medicine's dealings with anaemia, pathology is marginal. It would be possible for a pathologist to differentiate between the deformations of red blood cells in a range of variants of anaemia. In practice this differentiation is rarely made and if it is, then it is done by a haematologist. Deformed red blood cells are certainly not a fundamental or even necessary part of the definition of anaemia. And neither are the deformations pathologists may find in the corpse of someone who died from anaemia. They may be relevant to the question of the death certificate, but they don't link to the diagnosis and treatment of living patients.
33. Interviews with Dutch general practitioners reveal an impressive variation in the extent to which they believe in and/or find themselves capable of observing paleness. Some build on it whereas others never even try to look at eyelids. And while some (white) tropical doctors told us that anaemia is easier to ‘see’ in patients with a white skin than in patients with a brown skin, general practitioners who haven't practised outside the Netherlands never mention the ease of such observations.
34. It is a standard claim of contemporary social theory that ‘the person’ is not coeval with the body. But the distinctive feature of fluid space is the unpredictability of the link between person and body.
35. Marilyn Strathem has pointed out that the family resemblance metaphor may be fused with a notion of kinship that is paramount in Western societies: a genetic one. This entails the idea that there are traits which can be isolated from one another, like genes, and combined in whatever way. Strathern reproaches Clifford for incorporating this genetic notion in his ideal of mixing cultures, trait by trait. See Marilyn Strathem, Reproducing the Future: Anthropology, Kinship and the New Reproductive Technologies (Manchester: Manchester University Press, 1992).
36. The faltering of regional boundaries and the instability of network elements amount to the same thing if stable elements are understood as entities with clear boundaries. Steve Woolgar explores this, contrasting rounded things with a fluid metaphor, that of the flux of varying viscosity: see Steve Woolgar, ‘Configuring the User: The Case of Usability Trials’, in John Law (ed.), A Sociology of Monsters: Essays on Power, Technology and Domination (London: Routledge, 1991), 58-99.
37. For this, see also Marc Berg, ‘The Construction of Medical Disposals: Medical Sociology and Medical Problem Solving in Clinical Practice’, Sociology of Health and Illness, Vol. 14 (1992), 151-80.
38. Some of the doctors interviewed said that for them giving iron was also a way to draw patients into Western medicine. The discussion about the place of Western medicine between other resources that African patients draw upon, falls outside the scope of this paper. But see, for instance, Didier Fassin, Pouvoir et maladie en Afrique (Paris: Presses Universitaires de France, 1992).
39. This points to a relationship between fluid topology and the tradition in sociology that, following the work of Wittgenstein, insists on the flexibility of rule-following. Pointing out the differences between instances time and again, is one possible expression of a fluid topology though there are many others. See Ludwig Wittgenstein, Philosophical Investigations (Oxford: Blackwell, 1953).
40. Networks may achieve robustness by means of syntactical substitutability where one equivalent set of links does the work of another and the syntax is sustained. If we might call this ‘centred redundancy’, then fluids perform ‘decentred redundancy’, except that the notion of ‘redundancy’ is closely linked to that of network.
41. A somewhat similar argument, turning around the notion of ambivalence, is developed by Vicky Singleton in her study of the British cervical screening programme: see Vicky Singleton, Science, Women and Ambivalence: An Actor-Network Analysis of the Cervical Screening Programme (unpublished PhD thesis, University of Lancaster, 1992); and Singleton and Mike Michael, ‘Actor-Networks and Ambivalence: General Practitioners in the UK Cervical Screening Programme’, Social Studies of Science, Vol. 23 (1993), 227-64.
42. Blood vessels themselves (or should we say: the stories histologists tell about them?) suggest another interesting way to be both a region and a fluid. In some measure vessels are well-bounded regions that keep their constituents inside them. Large arteries have solid walls. But the small hair vessels in most organs (except the brain) are permeable to endless chemical substances and many cells - a form of imagery that suggests that the network metaphor is taken from the technology it is used to talk about, while we tap biology's body for fluid metaphors.