sorting things out by geoffrey bowker Sorting Things Out Inside Technology edited by Wiebe E. Bijker, W. Bernard Carlson, and Trevor Pinch J anet Abbate, ImJenting the Internet Charles Bazerman, The Languages of' Edison's Light Marc Berg, Rationalizing Medical Work: Decision Support Techniques and Medical Practias Wiebe E. Bijke1; Of Bicycles, Bakelites, and Bulbs: Toward a Theory of Sociotechnical Change Wiebe E. Bijker and John Law, editors, ShajJing iechnolo[,ry/Building Society: Studies in Sociotechnical Change Stuart S. Blume, Insight and Industry: On the Dynamics of' Technological Change in Medicine Geoffrey C. Bowke1; Scienre of' the Run: Injimnation Management and Industrial Ceo physics at Schlwnberger, I9 20-1940 Geoffrey C. Bowker and Susan Leigh St 327 References Name Index Subject Index 335 367 373 Acknowledgments This project has taken several years and spanned two countries and several institutions. We have, therefore, many people to thank, and in these few pages we will do those who we mention scant justice. None of the work below would have been possible without the support of the National Science Foundation (NSF EVS grant no. SBR 9514744). We would like to thank our colleagues on the Classification Project, University of Illinois: Stefan Timmermans, Niranjan Karnik, Laura Neumann, jesper Dopping, Theresa Chi Lin, and Randi Markussen for ongoing discussions and insight. Stefan and Laura assisted with the interviews at Iowa. The Graduate School of Library and Information Science at the University of Illinois gave us continual support-we thank all faculty members and doctoral students there for their unfailing intellectual generosity. We also thank the Advanced Information Technologies Group, University of Illinois, for project support for parts of the study, especially Robert Alun Jones. We are much indebted to the members of the Nursing Interventions Project at the University oflowa. In particular, joanne McCloskey and Gloria Bulechek provided many helpful suggestions during conversations. We would further like to thank the following Iowa team members who have graciously allowed us to interview them: Laurie Ackerman, Sally Blackman, Gloria Bulechek, joan Carter, Jeanette Daly, janice Denehy, Bill Donahue, Chris Forcucci, Orpha Glick, Mary Kanak, Vicki Kraus, Tom Kruckeberg, Meridean Maas, Joanne McCloskey, Barbara Rake!, MariLa Titler, Bonnie Wakefield, and Huibin Yue. Bill Donahue was a great support in facilitating access to the Nursing Interventions Classification (NIC) list-serve archives and in helping us during our trips to Iowa. x Acknowledgments Earlier versions of several of the chapters have been published as follows: chapter 1 " How Things (actor-net) Work: Classification, Magic, and the Ubiquity of Standards", in a special issue of the Danish philosophical journal Philosophia titled " Thinking in the World-Humans, Things, Nature", 25 (3-4), 1 997: 1 95-220; chapter 3 " The History of Information Infrastructures-the Case of the International Classification of Diseases", in Information Processing and Management, special issue on the history of information science, 32(1 ), 1 996, 49-6 1; chapter 4 "Situations vs. Standards in Long-Term, Wide-Scale Decision Making: the Case of the International Classification of Diseases", Proceedings of the Twenty-Fourth Annual Hawaii International Conference on System Science, 1 991: 73-81; chapter 5 Susan Leigh Star and Geoffrey Bowker. 1 997. "Of Lungs and Lungers: The Classified Story of Tuberculosis", Mind, Culture and Activity 4: 3-23. Reprinted in Anselm Strauss and Juliet Corbin, ed. 1 97-227, Grounded Theory in Practice, Thousand Oaks, CA: SAGE, 1 997; chapter 7 " Infrastructure and Organizational Transformation: Classifying Nurses' Work" in Wanda Orlikowski et al. (eds.), Information Technology and Changes in Organizational Work, London: Chapman and Hall, 1 996, 344-370; and chapter 8 "Lest We Remember: Organizational Forgetting and the Production of Knowledge", in Accounting, Management and Information Technology, 7 (3) 1 997: 1 1 3-1 38. Robert Dale Parker suggested several helpful references on the literary background of women and disease in the nineteenth century; Helen Watson Verran and Marc Berg gave us very useful comments on earlier drafts of sections of this book. Conversations with Kari Thoresen about the notion of texture in organizations were very helpful, as were ongoing conversations with the late Anselm Strauss about trajectory. The work of Mark Casey Condon on the nature of time morality in a men's homeless shelter was helpful in thinking through issues in the chapter on tuberculosis. For various parts of the argument, we received most helpful comments from Ann Bishop, Emily Ignacio, Bill Anderson, Susan Anderson, Howard S. Becker, Isabelle Baszanger, Nick Burbules, Kathy Addelson, Dick Boland, Chuck Goodwin, Chuck Bazerman, Cheris Kramarae, Donna Haraway, Linnea Dunn, Bruno Latour, JoAnne Yates, Gail Hornstein, Ina Wagner, Joan Fujimura, Alberto Cambrosio, Jiirg Striibing, John Law, John Bowers, Kjeld Schmidt, Kari Thoresen, Niranjan Karnik, Karen Ruhleder, Emily Ignacio, Joseph Goguen, Mike Lynch, Charlotte Linde, Marc Berg, Adele Clarke, Alice Robbin, Ole Hanseth, John Acknowledgments xt Garrett, Mike Robinson, Tone Bratteteig, Rogers Hall, Susan Newman, Susanne Bodker, Allan Riegenstreif, and Jean Lave. This raw list cannot do justice to their help. Benoit Malin was a constant source of inspiration. Ann Fagot-Largeault was a great guide through the material philosophy of classification, both in her magnificent book on the International Classification of Diseases (lCD) and in person. John King, Dick Boland, and Bill Turner provided a great deal of help in thinking through the wider implications of our work. Kay Tomlinson gave a careful and generous reading of the final manuscript. Brad Allen provided invaluable research assistance and a gift of energy. Doug Nelson provided support and healing. Xerox PARC provided us with office space and valuable collegial input during a sabbatical in 1 997-98; we are grateful to Lucy Suchman, Julian Orr, Susan Newman, David Levy, Randy Trigg, and Jeannette Blomberg. The United Nations and WHO archives both provided hospitality and materials; notably Liisa Fagerlund and Sahil Mandel gave of their time and energy. The South Africa collection of the Hoover Institution, Stanford University was most welcoming. The library at the University of Illinois, Urbana Champaign was a great treasure. The authors gratefully acknowledge the following for permission to use sources: • The South African Institute of Race Relations for perm1sswn to reproduce the information in tables 6. 1 and 6.2. From Muriel Horrell. 1 969. A Survey of Race Relations. • Institute for Operations Research and the Management Sciences (INFORMS) for permission to reprint material for table 1.1 from Susan Leigh Star and Karen Ruhleder 1 996. "Steps Toward an Ecology of Infrastructure: Design and Access for Large Information Spaces," Information Systems Research 17: 1 1 1-1 34. • Willem Struik of Kagiso Publishers, Pretoria, for permission to reprint the photograph in figure 6.3 from Bruwer, J., J. Grobbelaar and H. van Zyl. 1 958. Race Studies (Differentiated Syllabus) for Std VI, Voortrekkerpers, Johannesburg, and Alexander Butchart for providing a copy of the photograph. • Times Media Picture Library, Times Media, Ltd. of Johannesburg for permission to reprint the photograph in figure 6.2 . xii Acknowledgments • Bill Poole of Leco and Associates, Pittsburgh, for permiSSIOn to reprint their advertisement "monitoring the classification: the recovery room," figure 3.2. • The Hoover Institution for its help in locating and reproducing the photograph in figure 6.1. The photo was originally in a pamphlet in their collection, " The Fight for Freedom in South Africa and What It Means for Workers in the United States," produced by Red Sun Press Publications, nd. • Mosby Publishers, St. Louis, for permission to reproduce illustrations from the Nursing Interventions Classification, eds. Joanne McCloskey and Gloria Bulecheck, second edition, figures 7. 1 to 7.5. • The World Health Organization, Geneva, for permission to reproduce charts from the international classification of diseases, ICD-9 and ICD-10, figures 2. 1 and 2.2. • The picture of the Wilkinson's family (father, mother and two children) appears courtesy of Terry Shean/Sunday Times, Johannesburg. Envoi We would hate to have to assign a Dewey classification number to this book, which straddles sociology, anthropology, history and information systems, and design. Our modest hope is that it will not find its way onto the fantasy shelves. Introduction: To Classify Is Human In an episode of The X-Files, a television show devoted to FBI investigations of the paranormal, federal agents Mulder and Scully investigated a spate of murders of psychics of all stamps: palm readers, astrologers, and so forth. The plot unfolded thusly: The murderer would get his fortune read or astrological chart done, and then brutaly slay the fortune-teller. It emerged during the show that the reason for these visits was that he wanted to understand what he was doing and why he was doing it, and he thought psychics could help him understand his urges to kill people. Only one psychic, an insurance salesman with the ability to scry the future, was able to prdict his murderous attacks and recognize the criminal. When finally the murderer met this psychic, he burst into his impassioned plea for an explanation of what he was doing. "Why am I compelled to kill all these people," the salesman responded in a world-weary tone such as one might take with a slow child: "Don't you get it, son? You're a homicidal maniac." The maniac was delighted with this insight. He then proceeds to try to kill again. The salesman's answer is both penetrating and banal-what it says about classification systems is the topic of this book. Why is it so funny? Our lives are henged round with systems of classification, limned by standard formats, prescriptions, and objects. Enter a modern home and you are surrounded by standards and categories spanning the color of paint on the walls and in the fabric of the furniture, the types of wires strung to appliances, the codes in the building permits allowing t _ he kitchen sink to be properly plumbed and the walls to be adequately fireproofed. Ignore these forms at your peril-as a building owner, be sued by irate tenants; as an inspector, risk malpractice suits denying your proper application of the ideal to the case at hand; as a parent, risk toxic paint threatening your children. To classify is human. Not all classifications take formal shape or are standardized in commercial and bureaucratic products. We all spend large parts of our days doing classification work, often tacitly, and we 2 Introduction make up and use a range of ad hoc classifications to do so. We sort dirty dishes from clean, white laundry from colorfast, important email to be answered from e-junk. We match the size and type of our car tires to the amount of pressure they should accept. Our desktops are a mute testimony to a kind of muddled folk classification: papers that must be read by yesterday, but that have been there since last year; old professional journals that really should be read and even in fact may someday be, but that have been there since last year; assorted grant applications, tax forms, various work-related surveys and forms waiting to be filled out for everything from parking spaces to immunizations. These surfaces may be piled with sentimental cards that are already read, but which cannot yet be thrown out, alongside reminder notes to send similar cards to parents, sweethearts, or friends for their birthdays, all piled on top of last year's calendar (which-who knows?-may be useful at tax time). Any part of the home, school, or workplace reveals some such system of classification: medications classed as not for children occupy a higher shelf than safer ones; books for reference are shelved close to where we do the Sunday crossword puzzle; door keys are color-coded and stored according to frequency of use. What sorts of things order these piles, locations, and implicit labels? We have certain knowledge of these intimate spaces, classifications that appear to live partly in our hands-definitely not just in the head or in any formal algorithm. The knowledge about which thing will be useful at any given moment is embodied in a flow of mundane tasks and practices and many varied social roles (child, boss, friend, employee). When we need to put our hands on something,.it is there. Our computer desktops are no less cluttered. Here the electronic equivalent of "not yet ready to throw out" is also well represented. A quick scan of one of the author's desktops reveals eight residual categories represented in the various folders of email and papers: "fun," "take back to office," "remember to look up," "misc.," "misc. correspondence," "general web information," "teaching stuff to do," and "to do." We doubt if this is an unusual degree of disarray or an overly prolific use of the "none of the above" category so common to standardized tests and surveys. These standards and classifications, however imbricated in our lives, are ordinarily invisible. The formal, bureaucratic ones trail behind them the entourage of permits, forms, numerals, and the sometimesvisible work of people who adjust them to make organizations run smoothly. In that sense, they may become more visible, especially when To Classify Is Human 3 they break down or become objects of contention. But what are these categories? Who makes them, and who may change them? When and why do they become visible? How do they spread? What, for instance, is the relationship among locally generated categories, tailored to the particular space of a bathroom cabinet, and the commodified, elaborate, expensive ones generated by medical diagnoses, government regulatory bodies, and pharmaceutical firms? Remarkably for such a central part of our lives, we stand for the most part in formal ignorance of the social and moral order created by these invisible, potent entities. Their impact is indisputable, and as Foucault reminds us, inescapable. Try the simple experiment of ignoring your gender classification and use instead whichever toilets are the nearest; try to locate a library book shelved under the wrong Library of Congress catalogue number; stand in the immigration queue at a busy foreign airport without the right passport or arrive without the transformer and the adaptor that translates between electrical standards. The material force of categories appears always and instantly. At the level of public policy, classifications such as those of regions, activities, and natural resources play an equally important role. Whether or not a region is classified as ecologically important, whether another is zoned industrial or residential come to bear significantly on future economic decisions. The substrate of decision making in this area, while often hotly argued across political camps, is only intermittently visible. Changing such categories, once designated, is usually a cumbersome, bureaucratically fraught process. For all this importance, classifications and standards occupy a peculiar place in studies of social order. Anthropologists have studied classification as a device for understanding the cultures of otherscategories such as the raw and the cooked have been clues to the core organizing principles for colonial Western understandings of "primitive" culture. Some economists have looked at the effects of adopting a standard in those markets where networks and compatibility are crucial. For example, videotape recorders, refrigerators, and personal computer software embody arguably inferior technical standards, but standards that benefited from the timing of their historical entry into the marketplace. Some historians have examined the explosion of natural history and medical classifications in the late nineteenth century, both as a political force and as an organizing rubric for complex bureaucracies. A few sociologists have done detailed studies of individual categories linked with social movements, such as the 4 Introduction diagnosis of homosexuality as an illness and its demedicalization in the wake of gay and lesbian civil rights. Information scientists work every day on the design, delegation, and choice of classification systems and standards, yet few see them as artifacts embodying moral and aesthetic choices that in turn craft people's identities, aspirations, and dignity. 1 Philosophers and statisticians have produced highly formal discussions of classification theory, but few empirical studies of use or impact. Both within and outside the academy, single categories or classes of categories may also become objects of contention and study. The above-mentioned demedicalization of the category homosexual in the American Psychiatric Association's (APA) Diagnostic and Statistical Manual 3 (the DSM, a handbook of psychiatric classification) followed direct and vigorous lobbying of the APA by gay and lesbian advocates (Kirk and Kutchins 1 992). During this same era, feminists were split on the subject of whether the categories of premenstrual syndrome and postpartum depression would be good or bad for women as they became included in the DSM. Many feminist psychotherapists were engaged in a bitter argument about whether to include these categories. As Ann Figert ( 1 996) relates, they even felt their own identities and professional judgments to be on the line. Allan Young ( 1 995) makes the complicating observation that psychiatrists increasingly use the language of the DSM to communicate with each other and their accounting departments, although they frequently do not believe in the categories they are using. More recently, as discussed in chapter 6, the option to choose multiple racial categories was introduced as part of the U.S. government's routine data-collection mission, following Statistical Directive 15 in October 1 997. The Office of Management and Budget (OMB) issued the directive; conservatively, its implementation will cost several million dollars. One direct consequence is the addition of this option to the U.S. census, an addition that was fraught with political passion. A march on Washington concerning the category took the traditional ultimate avenue of mass protest for American activists. The march was conducted by people who identified themselves as multiracial, and their families and advocates. At the same time, it was vigorously opposed by many African-American and Hispanic civil rights groups (among several others), who saw the option as a "whitewash" against which important ethnic and policy-related distinctions would be lost (Robbin 1 998). To Classify Is Human 5 Despite the contentiousness of some categories, however, none of the above-named disciplines or social movements has systematically addressed the pragmatics of the invisible forces of categories and standards in the modern built world, especially the modern information technology world. Foucault's ( 1 970; 1 982) work comes the closest to a thoroughgoing examination in his arguments that an archaeological dig is necessary to find the origins and consequences of a range of social categories and practices. He focused on the concept of order and its implementation in categorical discourse. The ubiquity described by Foucault appears as an iron cage of bureaucratic discipline against a broad historical landscape. But there is much more to be done, both empirically and theoretically. No one, including Foucault, has systematically tackled the question of how these properties inform social and moral order via the new technological and electronic infrastructures. Few have looked at the creation and maintenance of complex classifications as a kind of work practice, with its attendant financial, skill, and moral dimensions. These are the tasks of this book. Foucault's practical archaeology is a point of departure for examining several cases of classification, some of which have become formal or standardized, and some of which have not. We have several concerns in this exploration, growing both from the consideration of classification work and its attendant moral dimensions. First, we seek to understand the role of invisibility in the work that classification does in ordering human interaction. We want to understand how these categories are made and kept invisible, and in some cases, we want to challenge the silences surrounding them. In this sense, our job here is to find tools for seeing the invisible, much as Emile Durkheim passionately sought to convince his audience of the material force of the social fact-to see that society was not just an idea-more than 1 00 years ago (Durkheim 1 982). The book also explores systems of classification as part of the built information environment. Much as a city planner or urban historian would leaf back through highway permits and zoning decisions to tell a city's story, we delve the dusty archives of classification design to understand better how wide-scale classification decisions have been made. We have a moral and ethical agenda in our querying of these systems. Each standard and each category valorizes some point of view and silences another. This is not inherently a bad thing-indeed it is inescapable. But it is an ethical choice, and as such it is dangerous-not 6 Introduction bad, but dangerous. For example, the decision of the U.S. Immigration and Naturalization Service to classify some races and classes as desirable for U.S. residents, and others as not, resulted in a quota system that valued affiuent people from northern and western Europe over those (especially the poor) from Africa or South America. The decision to classify students by their standardized achievement and aptitude tests valorizes some kinds of knowledge skills and renders other kinds invisible. Other types of decisions with serious material force may not immediately appear as morally problematic. The collective standardization in the United States on VHS videotapes over Betamax, for instance, may seem ethically neutral. The classification and standardization of types of seed for farming is not obviously fraught with moral weight. But as Busch (1995) and Addelson ( 1 994) argue, such long-term, collective forms of choice are also morally weighted. We2 are used to viewing moral choices as individual, as dilemmas, and as rational choices. We have an impoverished vocabulary for collective moral passages, to use Addelson's terminology. For any individual, group or situation, classifications and standards give advantage or they give suffering. Jobs are made and lost; some regions benefit at the expense of others. How these choices are made, and how we may think about that invisible matching process, is at the core of the ethical project of this work. Working Infrastructures Sorting Things Out stands at the crossroads of the sociology of knowledge and technology, history, and information science. The categories represented on our desktops and in our medicine cabinets are fairly ad hoc and individual, not even legitimate anthropological folk or ethno classifications. They are not often investigated by information scientists (but see Kwasnik 1 988, 1 991; Beghtol 1 995 ; Star 1 998). But everyone uses and creates them in some form, and they are (increasingly) important in organizing computer-based work. They often have old and deep historical roots. True, personal information managers are designed precisely to make this process transparent, but even with their aid, the problem continues: we still must design or select categories, still enter data, still struggle with things that do not fit. At the same time, we rub these ad hoc classifications against an increasingly elaborate large-scale system of formal categories and standards. Users To Classify Is Human 7 of the Internet alone navigate, now fairly seamlessly, more than 200 formally elected Internet standards for information transmission each time they send an email message. If we are to understand larger scale classifications, we also need to understand how desktop classifications link up with those that are formal, standardized, and widespread. Every link in hypertext creates a category. That is, it reflects some judgment about two or more objects: they are the same, or alike, or functionally linked, or linked as part of an unfolding series. The rummage sale of information on the World Wide Web is overwhelming, and we all agree that finding information is much less of a problem than assessing its quality-the nature of its categorical associations and by whom they are made (Bates, in press). The historical cultural model of social classification research in this book, from desktop to wide-scale infrastructure, is a good one through which to view problems of indexing, tracking, and even compiling bibliographies on the Web. In its cultural and workplace dimensions, it offers insights into the problematics of design of classification systems, and a lens for examining their impact. It looks at these processes as a sort of crafting of treaties. In this, a cross-disciplinary approach is crucial. Any information systems design that neglects use and user semantics is bound for trouble down the line-it will become either oppressive or irrelevant. Information systems mix up the conventional and the formal, the hard technical problems of storage and retrieval with the hard interactional problems of querying and organizing. Information systems are undergoing rapid change. There is an explosion of information on the Web and associated technologies, and fast moving changes in how information may converge across previously disparate families of technology-for instance, using one's television to retrieve email and browse the Web, using one's Internet connections to make telephone calls. Whatever we write here about the latest electronic developments will be outdated by the time this book sees print, a medium that many would argue is itself anachronistic. Conventions of use and understandings of the impact of these changes on social organization are slower to come. The following example illustrates the intermingling of the conventional and the local in the types of classificatory links formed by hypertext. A few years ago, our university was in the enviable position of having several job openings in library and information science. Both the authors were on 8 Introduction the search committee. During the process of sifting through applications and finding out more about candidates, the need arose to query something on the candidate's resume. We used the Alta Vista search engine to find the candidate's email address. (Of course, the first thing one really does with Alta Vista is ego surfing--checking one's own name to see how many times it appears on the Web-but ·we had already done that.) His email address and formal institutional home page appeared in about fifteen seconds on our desktop, but so did his contributions to a discussion on world peace, a feminist bulletin board, and one of the more arcane alt.rec Usenet groups. We found ourselves unable to stop our eyes from roving through the quoted U senet posts--category boundaries surely never meant to be crossed by a job search committee. Fortunately for us as committee members, we interpreted what we found on the Web as evidence that the applicant was a more well rounded person than his formal CV resume had conveyed. He became a more interesting candidate. But of course, it might have gone badly for him. In less than a minute we had accessed information about him that crossed a social boundary of de facto privacy, access, and awareness context (Glaser and Strauss 1 965). The risk of random readership had been there in some sense when he posted to a public space, but who on a search committee in the old days of a couple of years ago could possibly be bothered searching listserv archives? Who would have time? There are many ethical and etiquette-related questions here, of course, with the right to privacy not least among them. The incident also points to the fact that as a culture we have not yet developed conventions of classification for the Web that bear much moral or habitual conviction in daily practice. The label alt.rec does not yet have the reflex power that the label private does on a desk drawer or notebook cover. We would never open someone's desk drawer or diary. We are not usually known to be rude people, but we have not yet developed or absorbed routine similar politeness for things such as powerful Web search engines. We were thus somewhat embarrassed and confused about the morality of mentioning the alt.rec postings to the committee. As we evolve the classifications of habit-grow common fingertips with respect to linkages and networks-we will be faced with some choices. How standardized will our indexes become? What forms of freedom of association (among people, texts and people, and texts) do we want to preserve and which are no longer useful? Who will decide these matters? Investigating Infrastructure To Classify Is Human 9 People do many things today that a few hundred years ago would have looked like magic. And if we don't understand a given technology today it looks like magic: for example, we are perpetually surprised by the mellifluous tones read off our favorite CDs by, we believe, a laser. Most of us have no notion of the decades of negotiation that inform agreement on, inter alia, standard disc size, speed, electronic setting, and amplification standards. It is not dissimilar to the experience of magic one enjoys at a fine restaurant or an absorbing play. Common descriptions of good waiters or butlers (one thinks of Jeeves in the Wodehouse stories) are those who clear a table and smooth the unfolding of events "as if by magic." In a compelling play, the hours of rehearsal and missteps are disappeared from center stage, behind a seamless front stage presentation. Is the magic of the CD different from the magic of the waiter or the theater ensemble? Are these two kinds of magic or one-or none? This book is an attempt to answer these questions, which can be posed more prosaically as: • What work do classifications and standards do? Again, we want to look at what goes into making things work like magic : making them fit together so that we can buy a radio built by someone we have never met in Japan, plug it into a wall in Champaign, Illinois, and hear the world news from the BBC. • Who does that work? We explore the fact that all this magic involves much work: there is a lot of hard labor in effortless ease.3 Such invisible work is often not only underpaid, it is severely underrepresented in theoretical literature (Star and Strauss 1 999). We will discuss where all the "missing work" that makes things look magical goes. • What happens to the cases that do not fit? We want to draw attention to cases that do not fit easily into our magical created world of standards and classifications: the left handers in the world of right-handed magic, chronic disease sufferers in the acute world of allopathic medicine, the vegetarian in MacDonald's (Star 1 991 b), and so forth. These are issues of great import. It is easy to get lost in Baudrillard's (1990) cool memories of simulacra. He argues that it is impossible to sort out media representations from "what really happens." We are unable to stand outside representation or separate simulations from 1 0 Introduction nature. At the same time, he pays no attention to the work of constructing the simulations, or the infrastructural considerations that underwrite the images or events (and we agree that separating them ontologically is a hopeless task). The hype of our postmodern times is that we do not need to think about this sort of work any more. The real issues are scientific and technological, stripped of the conditions of production-in artificial life, thinking machines, nanotechnology, and genetic manipulation .... Clearly each of these is important. But there is more at stake-epistemologically, politically, and ethically-in the day-to-day work of building classification systems and producing and maintaining standards than in abstract arguments about representation. Their pyrotechnics may hold our fascinated gaze, but they cannot provide any path to answering our moral questions. Two Definitions: Classification and Standards Up to this point, we have been using the terms classification and standardization without formal definition. Let us clarify the terms now. Classification A classification is a spatial, temporal, or spatia-temporal segmentation of the world. A "classification system" is a set of boxes (metaphorical or literal) into which things can be put to then do some kind of work-bureaucratic or knowledge production. In an abstract, ideal sense, a classification system exhibits the following properties: 1. There are consistent, unique classificatory principles in operation. One common sort of system here is the genetic principle of ordering. This refers not to DNA analysis, but to an older and simpler sense of the word: classifying things by their origin and descent (Tort 1 989). A genealogical map of a family's history of marriage, birth, and death is genetic in this sense (even for adopted children and in-laws). So is a flow chart showing a hierarchy of tasks deriving from one another over time. There are many other types of classificatory principles-sorting correspondence by date received (temporal order), for example, or recipes by those most frequently used (functional order) . 2. The categories are mutually exclusive. In an ideal world, categories are clearly demarcated bins, into which any object addressed by the system will neatly and uniquely fit. So in the family genealogy, one mother and one father give birth to a child, forever and uniquely attributed to them as parents-there are no surrogate mothers, or What Are You ? To Classify Is Human 11 I grew up in Rhode Island, a New England state largely populated by Italian-Americans and French-Canadians that is known chiefly for its small stature . When I was a kid in our neighborhood, the first thing you would ask on encountering a newcomer was "what's your name?" The second was "what are you?" " What are you" was an invitation to recite your ethnic composition in a kind of singsong voice: 90 percent of the kids would say "Italian with a little bit of French," or "half-Portuguese, one-quarter Italian and one-quarter Armenian." When I would chime in with "half-Jewish, one-quarter Scottish and one-quarter English," the range of responses went from very puzzled looks to "does that mean you're not Catholic?" Wherein, I guess, began my fascination with classification, and especially with the problem of residual categories, or, the "other," or not elsewhere classified. -Leigh Star issues of shared custody or of retrospective DNA testing. A rose is a rose, not a rose sometimes and a daisy other times. 3. The system is complete. With respect to the items, actions, or areas under its consideration, the ideal classification system provides total coverage of the world it describes. So, for example, a botanical classifier would not simply ignore a newly discovered plant, but would always strive to name it. A physician using a diagnostic classification must enter something in the patient's record where a category is called for; where unknown, the possibility exists of a medical discovery, to be absorbed into the complete system of classifying. No real-world working classification system that we have looked at meets these "simple" requirements and we doubt that any ever could. In the case of unique classificatory systems, people disagree about their nature; they ignore or misunderstand them; or they routinely mix together different and contradictory principles. A library, for example, may have a consistent Library of Congress system in place, but supplement it in an ad hoc way. Best sellers to be rented out to patrons may be placed on a separate shelf; very rare, pornographic, or expensive books may be locked away from general viewing at the discretion of the local librarian. Thus, the books are moved, without being formally reclassified, yet carry an additional functional system in their physical placement. 12 Introduction For the second point, mutual exclusivity may be impossible in practice, as when there is disagreement or ambivalence about the membership of an object in a category. Medicine is replete with such examples, especially when the disease entity is controversial or socially stigmatized. On the third point, completeness, there may be good reasons to ignore data that would make a system more comprehensive. The discovery of a new species on an economically important development site may be silenced for monetary considerations. An anomaly may be acknowledged, but be too expensive-politically or bureaucratically-to introduce into a system of record keeping. In chapter 2, we demonstrate ways of reading classification systems so as to be simultaneously sensitive to these conceptual, organizational, and political dimensions. Consider the International Classification of Diseases (lCD), which is used as a major example throughout this book. The full title of the current (tenth) edition of the lCD, is: "ICD-1 0-International Statistical Classification of Diseases and Related Health Problems; Tenth Revision." Note that it is designated a statistical classification: Only diseases that are statistically significant are entered here (it is not an attempt to classify all diseases). The lCD is labeled a "classification," even though many have said that it is a "nomenclature" since it has no single classificatory principle (it has at least four, which are not mutually exclusive, a point developed in chapter 4). A nomenclature simply means an agreed-upon naming scheme, one that need not follow any classificatory principles. The nomenclature of streets in Paris, for example, includes those named after intellectual figures, plants and trees, battles, and politicians, as well as those inherited from former governments, such as Rue de Lutece (Lutece was the ancient Roman name for Paris). This is no classificatory system. Nomenclature and classification are frequently confused, however, since attempts are often made to model nomenclature on a single, stable system of classification principles, as for example with botany (Bowker, in press) or anatomy. In the case of the lCD, diagnostic nomenclature and the terms in the lCD itself were conflated in the American system of diagnosis-related groups (DRGs), much to the dismay of some medical researchers. In many cases the ICD represents a compromise between conflicting schemes." The terms used in categories C82-C85 for non-Hodgkin's lymphomas are those of the Working Formulation, which attempted to find common ground among several major classification systems. The terms used in these schemes are not given in the Tabular List but appear in the Alphabeti- To Classify Is Human 13 cal Index; exact equivalence with the terms appearing in the Tabular List is not always possible" (ICD-10, 1: 2 1 5). The lCD, however, presents itself clearly as a classification scheme and not a nomenclature. Since 1 970, there has been an effort underway by the WHO to build a distinct International Nomenclature of Diseases (IND), whose main purpose will be to provide: "a single recommended name for every disease entity" (ICD-10, 1: 25). For the purposes of this book, we take a broad enough definition so that anything consistently called a classification system and treated as such can be included in the term. This is a classic Pragmatist turnthings perceived as real are real in their consequences (Thomas and Thomas l 917) . If we took a purist or formalist view, the lCD would be a (somewhat confused) nomenclature and who knows what the IND would represent. With a broad, Pragmatic definition we can look at the work that is involved in building and maintaining a family of entities that people call classification systems rather than attempt the Herculean, Sisyphian task of purifying the (un)stable systems in place. Howard Becker makes a cognate point here: Epistemology has been a ... negative discipline, mostly devoted to saying what you shouldn't do if you want your activity to merit the title of science, and to keeping unworthy pretenders from successfully appropriating it. The sociology of science, the empirical descendant of epistemology, gives up trying to decide what should and shouldn't count as science, and tells what people who claim to be doing science do. (Becker 1 996, 54-55) The work of making, maintaining, and analyzing classification systems is richly textured. It is one of the central kinds of work of modernity, including science and medicine. It is, we argue, central to social life. Standards Classifications and standards are closely related, but not identical. While this book focuses on classification, standards are crucial components of the larger argument. The systems we discuss often do become standardized; in addition, a standard is in part a way of classifying the world. What then are standards? The term as we use it in the book has several dimensions: 1. A "standard" is any set of agreed-upon rules for the production of (textual or material) objects. 2. A standard spans more than one community of practice (or site of activity). It has temporal reach as well in that it persists over time. 14 Introduction 3. Standards are deployed in making things work together over distance and heterogeneous metrics. For example, computer protocols for Internet communication involve a cascade of standards (Abbate and Kahin 1 995) that need to work together well for the average user to gain seamless access to the web of information. There are standards for the components to link from your computer to the phone network, for coding and decoding binary streams as sound, for sending messages from one network to another, for attaching documents to messages, and so forth. 4. Legal bodies often enforce standards, be these mandated by professional organizations, manufacturers' organizations, or the state. We might say tomorrow that volapiik, a universal language that boasted some twenty-three journals in 1889 (Proust 1989, 580), or its successor Esperanto shall henceforth be the standard language for international diplomacy. Without a mechanism of enforcement, however, or a grassroots movement, we shall fail. 5. There is no natural law that the best standard shall win-QWERTY, Lotus 1 23, DOS, and VHS are often cited as examples in this context. The standards that do win may do so for a variety of other reasons: they build on an installed base, they had better marketing at the outset, or they were used by a community of gatekeepers who favored their use. Sometimes standards win due to an outright conspiracy, as in the case of the gas refrigerator documented by Cowan ( 1 985 ). 6. Standards have significant inertia and can be very difficult and expensive to change. It was possible to build a cathedral like Chartres without standard representations (blueprints) and standard building materials such as regular sizes for stones, tools, and so forth (Turnbull 1 993). People invented an amazing array of analog measuring devices (such as string lengths). Each cathedral town posted the local analog metric (a length of metal) at its gates, so that peripatetic master builders could calibrate their work to it when they arrived in the town. They did not have a wide-scale measurement system such as our modern metric or decimal systems. (Whether as a result of this local improvisation or not, Turnbull notes, many cathedrals did fall down!) It is no longer possible to build a complex collective project without standardized measurements. Consider a modern housing development where so much needs to come together from distant and proximate sources-electricity, gas, sewer, timber sizes, screws, nails and so To Classify Is Human 15 on. The control of standards is a central, often underanalyzed feature of economic life (see the work of Paul David-for example David and Rothwell 1 994-for a rich treatment). It is key to knowledge production as well. Latour ( 1 987) speculates that far more economic resources are spent creating and maintaining standards than in producing "pure" science. There are a number of histories of standards that point to the development and maintenance of standards as being critical to industrial production. At the same time, just as with classifications, these dimensions of standards are in some sense idealized. They embody goals of practice and production that are never perfectly realized, like Plato's triangles. The process of building to a standardized code, for example, usually includes a face-to-face negotiation between builder(s) and inspector(s), which itself includes a history of relations between those people. Small deviations are routinely overlooked, unless the inspector is making a political point. The idiom "good enough for government use" embodies the common-sense accommodations of the slip between the ideal standard and the contingencies of practice. In this and in many other ways, then, classifications and standards are two sides of the same coin. Classifications may or may not become standardized. If they do not, they are ad hoc, limited to an individual or a local community, and/or of limited duration. At the same time, every successful standard imposes a classification system, at the very least between good and bad ways of organizing actions or things. And the work-arounds involved in the practical use of standards frequently entail the use of ad hoc nonstandard categories. For example, a patient may respond to a standardized protocol for the management of chronic back pain by approximating the directions and supplementing them with an idiosyncratic or alternative medical classification scheme. If the protocol requires a number of exercises done three times a day, patients may distinguish good days from bad days, vacation days from working days, and only do the exercises when they deem them necessary. Classifications and standards are related in another sense, which concerns the use of a classification by more than one social world or community of practice, and the impact that use has on questions of membership and the taken-for-grantedness of objects (Cambrosio and Keating 1 995 ). Throughout this book, we speak of classifications as objects for cooperation across social worlds, or as boundary objects (Star and Griesemer 1 989). Drawing from earlier studies of 16 Introduction interdisciplinary scientific cooperation, we define boundary objects as those objects that both inhabit several communities of practice and satisfY the informational requirements of each of them. In working practice, they are objects that are able both to travel across borders and maintain some sort of constant identity. They can be tailored to meet the needs of any one community (they are plastic in this sense, or customizable). At the same time, they have common identities across settings. This is achieved by allowing the objects to be weakly structured in common use, imposing stronger structures in the individualsite tailored use. They are thus both ambiguous and constant; they may be abstract or concrete. In chapter 9, we explore in detail the abstract ramifications of the use of classifications by more than one community and the connection with the emergence of standards. The Structure of This Book To explore these questions, we have written a first chapter detailing some key themes of the work to follow. We have then divided the middle of the book into three parts, which look at several classification systems. We have structured these studies around three issues in turn: classification and large-scale infrastructures (part 1), classification and biography (part II), and classification and work practice (part Ill). Weaving these three themes together, we can explore the texture of the space within which infrastructures work and classification systems from different worlds meet, adjust, fracture, or merge. In two concluding chapters, we elaborate some theoretical conclusions from these studies. Part I: Classification and Large-Scale Infrastructures Classification systems are integral to any working infrastructure. In part I (chapters 2 to 4) we examine how a global medical classification system was developed to serve the conflicting needs of multiple local, national, and international information systems. Our investigation here begins in the late nineteenth century with another kind of information explosion-the development of myriad systems of classification and standardization of modern industrial and scientific institutions. In the nineteenth century people learned to look at themselves as surrounded by tiny, invisible things that have the power of life or death: microbes and bacteria. They learned to teach their children to To Classify Is Human I 7 wash their hands of germs before eating, and later, to apply antiseptic salve to a cat scratch or an inflamed fingernail. Company washrooms sprouted signs admonishing employees to wash hands before returning to work, especially if they worked with food served to others. In this period, people also learned how to perform surgery that would not usually be fatal and how to link gum disease with bacteria between the teeth. At the same time they learned these practices about germs, another ubiquitous set of tiny, invisible things were being negotiated and sewn into the social fabric. These were formal, commodified classifications and standards, both scientific and commercial. People classified, measured, and standardized just about everything-animals, human races, books, pharmaceutical products, taxes, jobs, and diseases. The categories so produced lived in industry, medicine, science, education, and government. They ranged from the measurement of machine tools to the measurement of people's forearms and foreheads. The standards were sometimes physically tiny measures: how big should a standard size second of time be, an eyeglass screw, or an electrical pulse rate?4 At other times, they were larger: what size should a railroad car be, a city street, or a corporation? Government agencies, industrial consortia, and scientific committees created the standards and category systems. So did mail-order firms, machine-tool manufacturers, animal breeders, and thousands of other actors. Most of these activities became silently embodied in the built environment and in notions of good practice. The decisions taken in the course of their construction are forever lost to the historical record. In fact, their history is considered by most to be boring, trivial, and unworthy of investigation. There are some striking similarities to our own late twentiethcentury historical moment in that faced by Europeans at the end of the nineteenth century. A new international information-sharing and gathering movement was starting, thanks to the advent of wide-scale international travel, international quasigovernmental governance structures, and a growing awareness that many phenomena (like epidemics and markets) would not be confined to one country. In the nineteenth century, for the first time people faced large numbers of bodies and their microbes moving rapidly across national borders and between large bureaucracies-and at an unprecedented rate. Especially in the case of epidemics, international public health became an urgent necessity. Attempts to control these passengers represent one of the first large-scale western medical classification schemes: ships that I H lnlmdur:tion Figure I. I Map indicating the geographical distribution of the sources or cholera and " the p rogress or cholera epidemics" by land and sea routes. The pro gression hy land is shown by the line with small vertical marks (I H23-l 1\47), by sea in I 1\65 via ship, and new progressions overland h·om I 1\92. Note the sea routes marked between Mecca and Marseilles. Source: A. Proust 1 892. called at ports on the way back fi·om Mecca had to f(>ilow a period of quarantine during which anyone inhx:ted would become symptomatic-thus emulating the slower timeline of horse or camel travel (see figure 1 . 1 ). After quarantine, one was given a "clean bill of health" and allowed h·eedom of transport. This was a costly delay !c>r the ships, and so a black market in clean bills of health appeared shortly thereafter .... The problem of tracking who was dying of what and where on earth became a permanent feature of international bureaucracy (see figure 1.2). Constructing such a list may appear to be to us a comparatively straightforward task, once the mechanisms t<>r reporting were in place. To Cfassz(y Is Human 19 lndi(lUill\t.la. ,Jist�ibulion fJtlogr�:tpllique DU llERCI!.AU IIU CIIOUi:RA [ DES£$ FO,YERS ENDiMowfPIDiMI{lU£� F.'l' l,.\�'tlli llES it>ml:m.s :»lll c.n:�Ri!l. For over 1 00 years, howevet� there has never been consensus about disease categories or about the process of collecting data. So one culture sees spirit possession as a valid cause of death, another ridicules this as superstition; one medical specialty sees cancer as a localized phenomenon to be cut out and stopped from spreading, another sees it as a disorder of the whole immune system that merely manifests in one location or another. The implications f(Jr both treatment and classification differ. Trying to encode both causes results in serious information retrieval problems. In addition, classifications shift historically. In Britain in I 650 we find that 696 people died of being " aged"; 31 succumbed to wolves, 9 to grief, and l9 to " King's Evil." " Mother" claimed 2 in I 647 but none in 1 650, but in that year 2 were "smothered and stifled" (see figure 1.3). Seven starved in 1 650 (Graunt 1 662), but by 1 9;)() the WHO would make a distinction: if an adult starved to death it was a misfortune; if a child starved, it was homicide. Death by wolf alone becomes impossible by 1 948, where death from animals is divided between venomous and nonvenomous, and only dogs and rats are singled out f()f categories of their own (ICD-5 1 948, 267). PATENTE DE SANTE �om da bil.timent . . .. w 0 z <( a: \ature du batiment .. Pavilion . .. . . . . . • . . . . . lL Tonneaux ... . . . . . . .. . canons . . . ... ... ... . . . . \ppartenant au port d Destination •... . ..... \om du capitaine ... . . �om du mCdecin . . . . . . f:quipage (tout compris) ... ... ... ...... . Passagers . . . ..•. •.. .. Cargaison . . . . . . .. . .. !�tat hygienique du navire ... . . . . . . . . . . .. . i:tat hygienique do !'equipage (couchago, vetements, etc.) .... Etat hygienique des passagers • ..• . • • . . \'ivres et approvisionnements divers ..... Eau . . ... ............ . f;tat S du port . ... . >anitaire� des environs Jl a ete constate dans lo port ou ses envi rons pendant Ia derniere semaine ecou!t\e : cas de cholera. cas de fievre j aune. cas de peste . Delivree le d du mois 189 a heure du Figure 1.2 w c w a: z < CJ) z 0 1- < a: 1- CJ) z REPUBLIQUE FRA:\'c,;AISE ADMINISTRATION S A NITA IRE PATENTE DE SANTE Nous, de Ia sante a l'ORT certifions que le batiment ci-apres design!\ part de ce port dans les conditions sui vantes, dtl.ment constatees : Nom du bil.timent .... . � Nature du batiment ... Malades a bard Pavilion ............. . Tonneaux · . · · . · · · · · · · · :Etat hygienique du na- Canoris. .. . . . . . . . . . . . . . vire . . .•.. . . . . ....... Appartenant au port d Etat hygicnique de !'aDestination . . . . . . . . • . • qui page ( couchage , !\om du capitaine . .... v�tements , etc.) . . . . . Nom du medecin . . . . . . Etat hygienique des ,., ) passagers ...... . . . . . "qui page (tout compris Vivres et approvisionPassagers . . . . . . . . . . . • nements divers . . ••.. Cargaison.. . . . . . . . . . . Eau . . . . . . . . . . ...... . . . Conformement aux articles 30, 31, 32 et 33 du regiemont, l'etat sanitaire du navire a ete verifie, Ia visite medicale a ete passee au moment de l'embarquement des passagers et il a ete constate qu'il n'existait a bard, a" moment du depart, aucun malade atteint d'affection pestilentielle ( cholera, fievre j aune, peste), ni linge sale, ni substance susceptible de nuire a Ia sante du bard. Nous certifions, en ontre, S du port est ....• . • . .. que l'etat sanitaire I des environs est . • ... et qu'il a etc con state dans le � ...•. cas de cholera port (ou ses environs) pendant ••. .. cas de fiiwre jaune Ia derniere semaine ccoulee . . . . . cas de peste En foi de quoi, no us a vans delivre Ia presente patente, a , le du mois d 189 , a heure du L'Exp8ditionnaire Sceau d6 l' A dministration, de Ia Paten te, LE DB LA SANTt, PRESCRIPTIONS EXTRAITES DU REGLEMENT GENERAL DE POLI CE SANITAIRE MARITIME Voi R AU VERSO. French bill of health. An original "clean bill of health." Source: A. Proust 1 892. To ClassifY Is Human 21 The first part of this book is dedicated to understandig the construction of the International Classification of Diseases (ICD) : a classification scheme with its origins in the late nineteenth century but still present today-indeed, it is ubiquitous in medical bureaucracy and medical information systems. The ICD constitutes an impressive attempt to coordinate information and resources about mortality and morbidity globally. For the background research for understanding international processes of classification, we went to Geneva and studied the archives of the WHO and its predecessors such as the League of Nations and the Office Internationale d'Hygiene Publique. Roughly every ten years since the 1 890s, the ICD has been revised. The UN and the WHO have kept some records of the process of revision; others are to be found in the file cabinets of individuals involved in the revision process. What we found was not a record of gradually increasing consensus, but a panoply of tangled and crisscrossing classification schemes held together by an increasingly harassed and sprawling international public health bureaucracy. Spirit possession and superstition never do reconcile, but for some data to be entered on the western-oriented death certificate, it becomes possible from the WHO point of view for a death to be assigned the category "nonexistent disease." One of the other major influences on keeping medical records has been insurance companies, as we discuss in chapter 4. As the working lives of individuals became more closely tied up with the state and its occupational health concerns, the classification of work-related diseases (including industrial accidents) became very important. Life expectancy measures were equally important, both for estimating the available labor force and for basic planning measures. Of course, occupational and nonwork related medical classifications did not always line up: companies might have been reluctant to take responsibility for unsafe working conditions, latency in conditions such as asbestosis makes data hard to come by; thus there may have been moral conflicts about the cause of such illnesses. In similar fashion, any classification that touched on religious or ethical questions (and surprisingly many do so) would be disputed. If life begins at the moment of conception, abortion is murder and a fetus dead at three months is a stillbirth, encoded as a live infant death. Contemporary abortion wars in the United States and western Europe attest to the enduring and irreconcilable ontologies involved in these codifications. The Years of our Lord Abortive and Stil-bom Aged Ague and F...,. Apoplex and Suddenly Bloac:h Blasted Bleeding Bloody Flux, Scouring and Flux Burnt and Scalded Calenture Cancer, Gangrene and Fistula Woll Canker, Sore-mouth and Thrush Child-bed Chrisoms and Infants Colick and Wind Cold and Cough Consumption and Cough Canvuls1on Cramp Cut of the Stone Dropsie and Tympany Drowned Excessive drinking Executed Fainted in a Bath Falling-Sickness Flax' and small Pox Found dead in the Streets French-Pox Frighted Gout Grief Hanged, and made-away themselves Head-Ach Jaundice {aw-fain mpostume Itch Killed by several Accidents King's Evil Lethargy Leprosie Liver-growu, Spleen and Rickets Lunatick Meagrom Measles Mother Murdered Overlaid and Starved at Nurse Palsie -tiPla�e Plague in the Guts Pleurisie Poisoned Purples and Spotted Fever Quinsie and Sore-throat Rickets Mother, rising of the Lights Rupture Scal'd head Scurvy Smothered and sti6ed Sores, lllcers, broken and bruised Shot (Limbs Spleen Shiagles Starved Stitch Stone and Strangury Sciatica Stopping of the Stomach Surfet Swine--Pox. Teeth and Worms Tiuick Thrush Vomiting Worms Wen Suddenly Figure 1.3 1 647 335 916 1 26o 68 4 3 I SS 3 I 26 66 161 1 J69 103 'm 1 85 47 8 3 ' 39 6 t8 4 9 12 II 57 l 75 27 27 3 53 12 . . 5 • 3 •5 27 3597 JO 145 14 I SO I SO 16 2 32 I S ,. 45 29 2 1 7 4 767 6z I 147 I 1648 1649 16sa 3•9 327 35 1 835 889 696 8134 75 ' 970 74 64 74 3 2 sJ I 176 289 6 10 5 I 29 Jl 19 8 28 54 42 ro6 1 14 1 17 1254 •o6s 990 71 ss a. 2200 2388 1988 491 530 493 I 2 I 3 434 42 1 saa 40 JO 27 • 1 7 29 43 • 3 400 "90 1 84 6 9 8 29 I S 18 4 I 5 12 9 lJ t6 7 10 l J 14 l ll 2 35 39 49 l 6 1 6s 59 I 57 39 94 26 22 19 4 2 4 I 46 56 59 18 6 " IJ 5 92 3. 33 7 •• 36 .1 21 19 20 6 1 1 67 '5 l 26 13 20 3 7 47 43 6s II 12 1 7 224 2 16 190 92 1 1 5 120 7 7 . 6 20 21 21 • 1 7 17 16 1 7 4 I 42 29 2& 29 JO 33 I J7 •36 1 23 4 3 597 540· 598 47 6 3 7 107 I DS 6; I I 165 1 389 78o IOJS lo6 7 6 3 SJJ II 31 68 2o6 . . � 2350 569 444 49 24 I s•s 7 21 3 7 1 7 9 41 3 So 47 22 4 6s 7 8 33 .a 2J 23 23 54 24 26o ' 34 7 I 29 26 so ss 104 709 4 ss The Table of C A S 1652 : 1 653 Jh I 3134 834 864 1212 i 282 � � � I 1 18 3 76: I 200 5 I 53 J6 51 53 213 1 58 128o IO� 102 41 2410 2286 653 6o6 I I ss6 617 so 53 12 '9 3 4 1 279 1 39 9 14 20 20 • 7 s 14 II 14 I S 2 6 43 57 105 79 4S 57 20 26 4 3 72 67 II 9 6 6 6z 8 I I 3 3 29 JO 20 29 t6 6 l iD 32 19 17 6o 75 20 18 329 229 1 38 1 35 16 7 43 41 32 2S I J 2 41 44 67 66 1 77 178 I 905 691 6 3 86 53 1654 ; r6ss ml 483 974 . � I J7 1 j 86 1 9• 4 2 7 386 168 7 10 I 37 73 72 44 192 177 '343 : la89 101 8; 36 21 2868 26a6 828 702 2 4 704 66a JO 43 .. 19 1 ". 4 812 1 294 4 3 20 29 I 6 8 17 10 9 14 6 71 6� 2 2 90 92 S8 S2 26 27 10 9 65 5• 1 2 6 14 3 S2 II 2 • J 9 ;8 18 22 16 8 � I 2<1 IO -, 89 s6 9 I S 372 1 78 347 166 I S II 2 44 IOJ 32 23 I J 38 49 107 94 212 128 4 2 IIJI 8o3 14 1 6s6 ! 16s7 1658 J �� ; � 467 . 1 1 76 I s75 I 999 !Sao 100 1 1 3 1 38 ' I s i 5 3 s 4 368 362 2JJ 5 7 4 3 i Jl 24 3 5 81 19 27 201 236 225 1393 n6:a 1 144 120 1 13 '79 l'e JO 31 2757 3610 1027 8o7 841 I 3 5 7o6 6 � ; 931 49 6o 22 20 1 8 3' I 8•3 SJ; 409 4 9 ll 23 2S 53 I 7 1 3 1 3 10 12 16 24 18 3 4 s 41 46 77 3 I 12% So 1 34 43 S2 47 24 23 28 4 6 I so J8 5 1 7 1 3 6 7 i 1 53 15 So 3 3 6 5 7 53 44 so 2J 20 .. 6 4 14 31 5 9 f 446 17 16 52 56 1 26 1 3 7 10 458 Jl7 476 212 20J 228 20 19 18 71 82 82 34 40 47 6 2 3 6 57 72 69 145 1 29 277 161 1 37 218 I I I 1 198 878 1036 57 66 27 16 19 ' Probably • ,..... for wail•=• ....U p The table of casualties, England in the seventeenth century. Source: J. Graunt 1 662. UA L TIE S. !659 42 1 909 2JOJ 9 1 3 7 346 6 63 73 226 8;8 1 !6 33 2982 742 6 646 57 4 1 523 2 5 1 14 ' 3 II 35 102 105 5 5 28 6 14 s 6 I 70 46 1 7 36 253 1 2 368 21 441 210 12 95 6! 7 7 I 7 .. 2 t 86 ::!02 2 8J9 I66o 544 1095 2148 67 2 25 1 6 ! 629 1 499 579 956 22 ' 3 s 44 � 20 I 68 6 194 I SO 1 1 23 2 596 ! 67 48 24 10 3414 1 827 I0,3 I 52 4 872 235 48 43 18 s 354 6 Jl 9 2 4 36 26 76 96 47 54 4 2 I 5 14 4 74 8 20 43 21 14 402 10 12 48 20 7 14 30 2 2 14 192 loo8 10 19 3 72 18 17 2 !8 8 47 10 58 54 t6 I 2 94 6 42 4 17 32 01 44 2 23 35 1630 439 7 1 2 1091 36 8 2 438 to 14 410 661 1 1 rs 10 5 352 7 23 4 4 ' 57 1 1 1 2 2378 2035 57 58 5 ' 19 10 171 3 87 18 252 279 33 29 13 10 40 33 12 5 20 8 59 16 76 55 25 12 II 10 23 1317 24 58 8 72 6 7 24 39 I ' 57 I 5c! I 12 23 4 31 59 1 2 7 ;8 20 12 3 22 6 35 IJ 73 47 1 8 � 24 3 3 IJ 1 7 274 26 58 6 99 4 9 20 149 . 4 335 14 1 7 I 28 I 37 ox. See Creli;hton, 1., -+6'1-+6J. 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The statistical committee discussed in chapter 4, assigned with determining the exact moment of the beginning of life by number of attempted breaths and weight of fetus or infant, cuts a Solomon-like figure against such a disputed landscape. At the same time, there is an element of reductionist absurdity here-how many breaths equals " life"? If not specified, another source of quality control for data is lost; if specified, it appears to make common sense ironic. This is an issue we will revisit as well in the discussion of nursing interventions, in chapter 7. Algorithms for codification do not resolve the moral questions involved, although they may obscure them. For decades, priests, feminists, and medical ethicists on both sides have debated the question of when a human life begins. The moral questions involved in encoding such information-and the politics of certainty and of voice involvedare much more obscure. Forms like the death certificate, when aggregated, form a case of what Kirk and Kutchins ( 1 992) call "the substitution of precision for validity" (see also Star 1 989b). That is, when a seemingly neutral data collection mechanism is substituted for ethical conflict about the contents of the forms, the moral debate is partially erased. One may get ever more precise knowledge, without having resolved deeper questions, and indeed, by burying those questions. There is no simple pluralistic answer to how such questions may be resolved democratically or with due process. Making all knowledge retrievable, and thus re-debatable, is an appealing solution in a sense from a purely information scientific point of view. From a practical organizational viewpoint, however, this approach fails. For example, in 1 927, a manual describing simultaneous causes of death listed some 8,300 terms, which represented 34 million possible combinations that might appear on the face of a death certificate. A complete user manual for filling out the certificate would involve sixty-one volumes of I ,000 pages each. This is clearly not a pragmatic choice for conducting a task that most physicians also find boring, low-status, and clinically unimportant. As we know from studies of work of all sorts, people do not do the ideal job, but the doable job. When faced with too many alternatives and too much information, they satisfice (March and Simon 1 958). As an indicator of this, studies of the validity of codes on death certificates repeatedly show that doctors have favorite categories; these are region- To Classify Is Human 25 ally biased; and autopsies (which are rarely done) have a low rate of agreement with the code on the form (Fagot-Largeault 1 989). Even when there is relatively simple consensus about the cause of death, the act of assigning a classification can be socially or ethically charged. Thus, in some countries the death certificate has two faces: a public certificate handed to the funeral director so that arrangements can be made quickly and discreetly, and a statistical cause filed anonymously with the public health department. In this case, the doctor is not faced with telling the family of a socially unacceptable form of death: syphilis can become heart failure, or suicide can become a stroke. For example, as we discuss in chapter 4, the process of moving to an anonymous statistical record may reveal hidden biases in the reporting of death. Where the death certificate is public, stigma and the desire to protect the feelings of the family may reign over scientific accuracy. Over the years, those designing the list of causes of death and disease have struggled with all of these problems. One of the simple but important rules of thumb to try to control for this degree of uncertainty is to distribute the residual categories. "Not elsewhere classified" appears throughout the entire lCD, but nowhere as a top-level category. So since uncertainty is inevitable, and its scope and scale essentially unknowable, at least its impact will not hit a single disease or location disproportionately. Its effects will remain as local as possible; the quest for certainty is not lost, but postponed, diluted, and abridged. With the rise of very-large-scale information systems, the Internet, the Web, and digital libraries, we find that the sorts of uncertainties faced by the WHO are themselves endemic in our own lives. When we use email filters, for example, we risk losing the information that does not fit the sender's category: junk email is very hard to sort out automatically in a reliable way. If we have too many detailed filters, we lose the efficiency sought from the filter in the first place. As we move into desktop use of hyperlinked digital libraries, we fracture the traditional bibliographic categories across media, versions, genres, and author. The freedom entailed is that we can customize our own library spaces; but as Jo Freeman (1972) pointed out in her classic article, " The Tyranny of Structurelessness," this is also so much more work that we may fall into a lowest level convenience classification rather than a high-level semantic one. In one of our digital library projects at Illinois, for example, several undergraduates we interviewed in 26 Introduction focus groups stated that they would just get five references for a term paper-any five-since that is what the professor wanted, and references had better be ones that are listed electronically and available without walking across campus. The lCD classification is in many ways an ideal mirror of how people designing global information schemes struggle with uncertainty, ambiguity, standardization, and the practicalities of data quality. Digging into the archives, and reading the lCD closely through its changes, reveals some of the upstream, design-oriented decisions informing the negotiated order achieved by the vast system of forms, boxes, software, and death certificates. At the same time, we have been constantly aware of the human suffering often occasioned by the apparently bloodless apparatus of paperwork through which these data are collected. Part II: Classification and Biography The second part of this book looks at two cases where the lives of individuals are broken, twisted, and torqued by their encounters with classification systems. This often invisible anguish informs another level of ethical inquiry. Once having been made, the classification systems are applied to individual cases-sometimes resulting in a kind of surreal bureaucratic landscape. Sociologist Max Weber spoke of the "iron cage of bureaucracy" hemming in the lives of modern workers and families. The cage formed by classification systems can be constraining in just this way, although cage might be too impoverished a metaphor to describe its variations and occasional stretches. In chapters 5 and 6 we look at biography and classification. We chose two examples where classification has become a direct tool mediating human suffering. Our first case concerns tuberculosis patients and the impact of disease classification on their lives. We use historical data to discuss the experience of the disease within the tuberculosis asylum. Tuberculosis patients, like many with chronic illness, live under a confusing regime of categories and metrics (see also Ziporyn 1 992). Many people were incarcerated for years-some for decades-waiting for the disease to run its course, to achieve a cure at high altitudes, or to die there. They were subjected to a constant battery of measurements: lung capacity, auscultation, body temperature and pulse rate, x-rays, and, as they were developed, laboratory tests of blood and other bodily fluids. The results of the tests determined the degree of free- To Classify Is Human 27 dom from the sanatorium regime as well as, ultimately, the date of release. Of no surprise to medical sociologists, the interpretation and negotiations of the tests between doctor and patient were fraught with questions of the social value of the patient (middle-class patients being thought more compliant and reliable when on furlough from the asylum than those from lower classes), with gender stereotypes, and with the gradual adaptation of the patient's biographical expectations to the period of incarceration. Thomas Mann's The Magic Mountain and Julius Roth's Timetables are full of stories of classification and metrication. We examine how different time lines, and expectations about those time lines, unfold in these two remarkable volumes. Biography, career, the state of the medical art with respect to the disease, and the public health adjudication of tuberculosis are all intertwined against the landscape of the sanatorium. Life in the sanatorium has a surreal, almost nightmarish quality, as detailed by Mann, Roth, and many other writers throughout the twentieth century. This sense comes precisely from the misalignment of a patient's life expectations, the uncertainties of the disease and of the treatment, and the negotiations laden with other sorts of interactional burdens. It is one thing to be ill and in the hospital with an indefinite release date. It is quite another when the date of release includes one's ability to negotiate well with the physicians, their interpretation of the latest research, and the exigencies of public health forms and red tape. We call this agglomeration torque, a twisting of time lines that pull at each other, and bend or twist both patient biography and the process of metrication. When all are aligned, there is no sense of torque or stress; when they pull against each other over a long period, a nightmare texture emerges. A similar torque is found in the second case in this section, that of race classification and reclassification under apartheid in South Africa. Between 1 950 and the fall of apartheid forty years later, South Africans were ruled under an extremely rigid, comprehensive system of race classification. Divided into four main racial groupswhite/European, Bantu (black) , Asian and coloured (mixed race)­ people's lives were rigidly segregated. The segregation extended from so-called petty apartheid (separate bus stops, water fountains, and toilets) to rights of work, residency, education, and freedom of movement. This system became the target of worldwide protest and eventually came to a formal end. These facts are common knowledge. What 28 Introduction has been less well documented or publicized are the actual techniques used to classify people by race. In chapter 6, we examine in detail some cases of mixed-race people who applied to be reclassified after their initial racial designation by the state. These borderline cases serve to illuminate the underlying architecture of apartheid. This was a mixture of brute power, confused eugenics, and appropriations of anthropological theories of race. The scientific reason given for apartheid by the white supremacist Nationalist party was "separate development"-the idea that to develop naturally, the races must develop separately. In pursuing this ideology, of course, people and families that crossed the color barrier were problematic. If a natural scientific explanation was given for apartheid, systematic means should be available to winnow white from black, coloured from black and so on. As the chapter delineates, this attempt was fraught with inconsistencies and local work-arounds, as people never easily fit any categories. Over 1 00,000 people made formal appeals concerning their race classification; most were denied. Although it lies at a political extreme, these cases form a continuum with the classification of people at different stages of tuberculosis. In both cases, biographies and categories fall along often conflicting trajectories. Lives are twisted, even torn, in the attempt to force the one into the other. These torques may be petty or grand, but they are a way of understanding the coconstruction of lives and their categories. Part Ill: Classification and Work Practice In part III, chapters 7 and 8, look at how classification systems organize and are organized by work practice. We examine the effort of a group of nursing scientists based at the University of Iowa, led by Joanne McCloskey and Gloria Bulechek, to produce a classification of nursing interventions. Their Nursing Intervention Classification (NIC) aims at depicting the range of activities that nurses carry out in their daily routines. Their original system consisted of a list of some 336 interventions; each comprised of a label, a definition, a set of activities, and a short list of background readings. Each of those interventions is in turn classified within a taxonomy of six domains and twenty-six classes. For example, one of the tasks nurses commonly perform is preparing and monitoring intravenous medication. The nursing intervention "epidural analgesia administration" is defined as: To Classify Is Human 29 "preparation and delivery of narcotic analgesics into the epidural space;" another common one, "cough enhancement," groups activities designed to help respiration. The Iowa NIC researchers built up their system of nursing interventions inductively. They created a preliminary list that distinguished between nursing interventions and activities, then nurtured a large grassroots network of nursing researchers. 5 This group narrowed the preliminary list of interventions to the original 336 published in NIC and further validated them via surveys and focus groups. Different interventions were reviewed for clinical relevance, and a coding scheme was developed. The classification system grew through a cooperative process, with nurses in field sites trying out categories, and suggesting new ones in a series of regional and specialist meetings. Since 1 992 the nurses have added over 50 interventions to their original list. We attended a number of these meetings, and interviewed many of the nurses involved. Caring work such as calming and educating patients, usually done by nurses, often cuts across specific medical diagnostic categories. The NIC investigators use their list of interventions to make visible and legitimate the work that nurses do. The idea is that it will be used to compare work across hospitals, specialties, and geographical areas, and to build objective research measures for the outcomes. NIC, although still relatively young, promises to be a major rallying point for nurses in the decades to come. Before NIC, much nursing work was invisible to the medical record. As one nurse poignantly said, "we were just thrown in with the cost of the room." Another said, "I am not a bed!" The traditional, quintessential nurse would be ever present, caregiving, and helpful-but not a part of the formal patient-doctor information structure. Of course, this invisibility is bound up with traditional gender roles, as with librarians, social workers, and primary school teachers. But as with the lCD, classifying events is difficult. In the case of �IC, the politics move from a politics of certainty to a politics of ambiguity. The essence of this politics is walking a tightrope between increased visibility and increased surveillance; between overspecifying what a nurse should do and taking away discretion from the individual practitioner. When discretion and the tacit knowledge that is part of every occupation meet the medical bureaucracy, which would account for every pill and every moment of health care workers' time, contradictions 30 Introduction ensue. This is especially true m the "softer" areas of care. Socialpsychological care giving is one of the areas where this dilemma is prominent. For example, NIC lists as nursing interventions "anticipatory guidance" and "mood management"-preparation for grief or surgery. Difficult though these are to capture in a classification scheme, one much more difficult is "humor." How can one capture humor as a deliberate nursing intervention? Does sarcasm, irony, or laughter count as a nursing intervention? When do you stop? How to reimburse humor, how to measure this kind of care? No one would dispute the importance of humor, but it is by its nature a situated and subjective action. A grey area of common sense remains for the individual staff nurse to define whether some of the nursing interventions are worth classifying. There are continuing tensions within NIC between just this kind of common sense and abstracting away from the local to standardize and compare, while at the same time rendering invisible work visible. Nurses' work is often invisible for a combination of good and bad reasons. Nurses have to ask mundane questions, rearrange bedcovers, move a patient's hand so that it is closer to a button, and sympathize about the suffering involved in illness. Bringing this work out into the open and differentiating its components can mean belaboring the obvious or risking being too vague. One of the battlefields where comparability and control appear as opposing factors is in linking NIC to costs. NIC researchers assert that the classification of nursing interventions will allow a determination of the costs of services provided by nurses and planning for resources needed in nursing practice. As the nurse above says, nursing treatments are usually bundled in with the room price. NIC is used in the development of nursing health care systems and may provide a planning vehicle for previously untracked costs. As we shall see, NIC can also be problematic for nurses. Like any other classification scheme that renders work visible, it can also render surveillance easier-and it could in the end lead to a Tayloristic dissection of the tasks of nursing (as the NIC designers are well aware). So-called unskilled tasks may be taken out of their hands and the profession as a whole may suffer a loss of autonomy and the substitution of rigid procedure for common sense. As in the case of the lCD, there are many layers of meaning involved in developing and implementing nursing classification. NIC might look like a straightforward organizational tool: it is in fact much more To Classify Is Human 31 than that. It merges science, practice, bureaucracy, and information systems. NIC coordinates bodies, impairments, charts, reimbursement systems, vocabularies, patients, and health care professionals. Ultimately, it provides a manifesto for nursing as an organized occupation, a basis for a scientific domain, and a tool for organizing work practices. Why It Is Important to Study Classification Systems The sheer density of the collisions of classification schemes in our lives calls for a new kind of science, a new set of metaphors, linking traditional social science and computer and information science. We need a topography of things such as the distribution of ambiguity; the fluid dynamics of how classification systems meet up-a plate tectonics rather than a static geology. This new science will draw on the best empirical studies of work-arounds, information use, and mundane tools such as desktop folders and file cabinets (perhaps peering backwards out from the Web and into the practices). It will also use the best of object-oriented programming and other areas of computer science to describe this territory. It will build on years of valuable research on classification in library and information science. We end this introduction with a future scenario that symbolizes this abstract endeavor. Imagine that you are walking through a forest of interarticulated branches. Some are covered with ice or snow, and the sun melts their touching tips to reveal space between. Some are so thickly brambled they seem solid; others are oddly angular in nature, like esplanaded trees. Some of the trees are wild, some have been cultivated. Some are old and gnarled, and some are tiny shoots; some of the old ones are nearly dead, others show green leaves. The forest is still wild, but there are some parks, and some protocols for finding one's way along, at least on the known paths. Helicopters flying overhead can quickly tell you how many types of each tree, even each leaf, there are in the world, but they cannot yet give you a guidebook for bird-watching or forestry management. There is a lot of underbrush and a complex ecology of soil bacteria, flora, and fauna. Now imagine that the forest is a huge information space and each of the trees and bushes are classification systems. Those who make them up and use them are the animals and plants, and the soil is a mix of the Internet, the paper world, and other communication infrastructures. 3 2 Introduction Your job is to describe this forest. You may write a basic manual of forestry, or paint a landscape, compose an opera, or improve the maps used throughout. What will your product look like? Who will use it? In this book, we show from our studies of medical, scientific, and race classification that, like a good forest, some areas will be left wild, or in darkness, or even unmapped (that is, some ambiguity will remain). We will show that abstract schema that do not take use into account-say, maps that leave out landmarks or altitude or how readers use maps-will simply fail. (That is, common sense will be seen as the precious resource that it is.) We intuit that a mixture of scientific, poetic, and artistic talents, such as that represented in the hypertextual world, will be crucial to this task. We will demonstrate the value of a mixture of formal and folk classifications that are used sensibly in the context of people's lives. 1 Some Tricks of the Trade in Analyzing Classification My guess is that we have a folk theory of categorization itself. It says that things come in well-defined kinds, that the kinds are characterized by shared properties, and that there is one right taxonomy of the kinds. It is easier to show what is wrong with a scientific theory than with a folk theory. A folk theory defines common sense itself. When the folk theory and the technical theory converge, it gets even tougher to see where that theory gets in the way-or even that it is a theory at all. (Lakoff 1987, 121) Introduction: A Good Infrastructure Is Hard to Find Information infrastructure is a tricky thing to analyze.6 Good, usable systems disappear almost by definition. The easier they are to use, the harder they are to see. ,-\s well, most of the time, the bigger they are, the harder they are to see. Unless we are electricians or building inspectors, we rarely think about the myriad of databases, standards, and instruction manuals subtending our reading lamps, much less about the politics of the electric grid that they tap into. And so on, as many layers of technology accrue and expand over space and time. Systems of classification (and of standardization) form a juncture of social organization, moral order, and layers of technical integration. Each subsystem inherits, increasingly as it scales up, the inertia of the installed base of systems that have come before. Infrastructures are never transparent for everyone, and their workability as they scale up becomes increasingly complex. Through due methodological attention to the architecture and use of these systems, we can achieve a deeper understanding of how it is that individuals and communities meet infrastructure. We know that this means, at the least, an understanding of infrastructure that includes these points: 34 Chapter 1 • A historical process of development of many tools, arranged for a wide variety of users, and made to work in concert. • A practical match among routines of work practice, technology, and wider scale organizational and technical resources. • A rich set of negotiated compromises ranging from epistemology to data entry that are both available and transparent to communities of users. • A negotiated order in which all of the above, recursively, can function together. Table 1.1 shows a more elaborate definition of infrastructure, using Star and Ruhleder ( 1 996), who emphasize that one person's infrastructure may be another's barrier. This chapter offers four themes, methodological points of departure for the analysis of these complex relationships. Each theme operates as a gestalt switch-it comes in the form of an infrastructural inversion (Bowker 1 994). This inversion is a struggle against the tendency of infrastructure to disappear (except when breaking down). It means learning to look closely at technologies and arrangements that, by design and by habit, tend to fade into the woodwork (sometimes literally!). Infrastructural inversion means recognizing the depths of interdependence of technical networks and standards, on the one hand, and the real work of politics and knowledge production8 on the other. It foregrounds these normally invisible Lilliputian threads and furthermore gives them causal prominence in many areas usually attributed to heroic actors, social movements, or cultural mores. The inversion is similar to the argument made by Becker (1982) in his book Art Worlds. Most history and social analysis of art has neglected the details of infrastructure within which communities of artistic practice emerge. Becker's inversion examines the conventions and constraints of the material artistic infrastructure and its ramifications. For example, the convention of musical concerts lasting about three hours ramifies throughout the producing organization. Parking attendants, unions, ticket takers, and theater rentals are arranged in cascading dependence on this interval of time. An eight-hour musical piece, which is occasionally written, means rearranging all of these expectations, which in turn is so expensive that such productions are rare. Or paintings are about the size, usually, that will hang comfortably on a wall. They are also the size that fits rolls of canvas, the skills of framers, Table 1.1 Some Tricks of the Trade in Analyzing Classification 35 A definition of infrastructure • Embeddedness. Infrastructure is sunk into, inside of, other structures, social arrangements, and technologies, • Transparency. Infrastructure is transparent to use in the sense that it does not have to be reinvented each time or assembled for each task, but invisibly supports those tasks. • Reach or scope. This may be either spatial or temporal-infrastructure has reach beyond a single event or one-site practice; • Learned as part of membership. The taken-for-grantedness of artifacts and organizational arrangements is a sine qua non of membership in a community of practice (Lave and Wenger 1 991, Star 1 996). Strangers and outsiders encounter infrastructure as a target object to be learned about. New participants acquire a naturalized familiarity with its objects as they become members. • Links with conventions of practice. Infrastructure both shapes and is shaped by the conventions of a community of practice; for example, the ways that cycles of day-night work are affected by and affect electrical power rates and needs. Generations of typists have learned the QWERTY keyboard; its limitations are inherited by the computer keyboard and thence by the design of today's computer furniture (Becker 1 982). • Embodiment of standards. Modified by scope and often by conflicting conventions, infrastructure takes on transparency by plugging into other infrastructures and tools in a standardized fashion. • Built on an installed base. Infrastructure does not grow de novo; it wrestles with the inertia of the installed base and inherits strengths and limitations from that base. Optical fibers run along old railroad lines, new systems are designed for backward compatibility; and failing to account for these constraints may be fatal or distorting to new development processes (Monteiro and Hanseth 1 996). • Becomes visible upon breakdown. The normally invisible quality of working infrastructure becomes visible when it breaks: the server is down, the bridge washes out, there is a power blackout. Even when there are backup mechanisms or procedures, their existence further highlights the now visible infrastructure. • Is fixed in modular increments, not all at once or globally. Because infrastructure is big, layered, and complex, and because it means different things locally, it is never changed from above. Changes take time and negotiation, and adjustment with other aspects of the systems involved.7 Source: Star and Rohleder 1 996. 36 Chapter 1 and the very doorways of museums and galleries. These constraints are mutable only at great cost, and artists must always consider them before violating them. Scientific inversions of infrastructure were the theme of a pathbreaking edited volume, The Right Tools for the Job: At Work in Twentieth-Century Life Sciences (Clarke and Fujimura 1 992). The purpose of this volume was to tell the history of biology in a new way-from the point of view of the materials that constrain and enable biological researchers. Rats, petri dishes, taxidermy, planaria, drosophila, and test tubes take center stage in this narrative. The standardization of genetic research on a few specially bred organisms (notably drosophila) has constrained the pacing of research and the ways the questions may be framed, and it has given biological supply houses an important, invisible role in research horizons. While elephants or whales might answer different kinds of biological questions, they are obviously unwieldy lab animals. While pregnant cow's urine played a critical role in the discovery and isolation of reproductive hormones, no historian of biology had thought it important to describe the task of obtaining gallons of it on a regular basis. Adele Clarke ( 1 998) puckishly relates her discovery, found in the memoirs of a biologist, of the technique required to do so: tickle the cow's labia to make her urinate. A starkly different view of the tasks of laboratory biology emerges from this image. It must be added to the processes of stabling, feeding, impregnating, and caring for the cows involved. The supply chain, techniques, and animal handling methods had to be invented along with biology's conceptual frame; they are not accidental, but constitutive. Our infrastructural inversion with respect to information technologies and their attendant classification systems follows this line of analysis. Like the cow's urine or the eight-hour concert, we have found many examples of counterintuitive, often humorous struggles with constraints and conventions in the crafting of classifications. For instance, as we shall see in chapter 5, in analyzing the experience of tuberculosis patients in Mann's The Magic Mountain, we found the story of one woman who had been incarcerated so long in the sanatorium that leaving it became unthinkable. She recovered from the disease, but tried to subvert the diagnosis of wellness. When the doctors took her temperature, she would surreptitiously dip the thermometer in hot water to make it seem that she still had a fever. On discovering this, the doctors created a thermometer without markings, so that she could not tell what the mercury column indicated. They called this Some Tricks of the Trade in Analyzing Classification 37 "the silent sister." The silent sister immediately becomes itself a telling indicator of the entangled infrastructure, medical politics, and the use of metrics in classifying tubercular patients. It tells a rich metaphorical story, and may become a concept useful beyond the rarified walls of the fictional Swiss asylum. What other silent sisters will we encounter in our infrastructural inversion-what surveillance, deception, caring, struggling, or negotiating? In the sections below, four themes are presented that require the special double vision implied in the anecdotes above. They frame the new way of seeing that brings to life large-scale, bureaucratic classifications and standards. Without this map, excursions into this aspect of information infrastructure can be stiflingly boring. Many classifications appear as nothing more than lists of numbers with labels attached, buried in software menus, users' manuals, or other references. As discussed in chapter 2, new eyes are needed for reading classification systems, for restoring the deleted and dessicated narratives to these peculiar cultural, technical, and scientific artifacts. Methodological Themes for Infrastructural Inversion Ubiquity The first major theme is the ubiquity of classifying and standardizing. Classification schemes and standards literally saturate our environment. In the built world we inhabit, thousands and thousands of standards are used everywhere, from setting up the plumbing in a house to assembling a car engine to transferring a file from one computer to another. Consider the canonically simple act of writing a letter longhand, putting it in an envelope, and mailing it. There are standards for paper size, the distance between lines in lined paper, envelope size, the glue on the envelope, the size of stamps, their glue, the ink in a pen, the sharpness of its nib, the composition of the paper (which in turn can be broken down to the nature of the watermark, if any; the degree of recycled material used in its production, the definition of what counts as recycling), and so forth. Similarly, in any bureaucracy, classifications abound-consider the simple but increasingly common classifications that are used when you dial an airline for information ("if you are traveling domestically, press 1 "; "if you want information about flight arrivals and departures . . . . "). And once the airline has you on the line, you are classified by them as a frequent flyer (normal, gold or platinum); corporate or 38 Chapter 1 Becoming an Irate Howard Becker relates a delightful anecdote concerning his classification by an airline. A relative working for one of the airlines told him how desk clerks handle customer complaints. The strategy is first to try to solve the problem. If the customer remains unsatisfied and becomes very angry in the process, the clerk dubs him or her "an irate." The clerk then calls the supervisor, "I have an irate on the line," shorthand for the category of an irritated passenger. One day Becker was having a difficult interaction with the same airline. He called the airline desk, and in a calm tone of voice, said, " Hello, my name is Howard Becker and I'm an irate. Can you help me with this ticket?" The clerk began to sputter, "How did you know that word?" Becker had succeeded in unearthing a little of the hidden classificatory apparatus behind the scenes at the airline. He notes that the interaction after this speeded up and went particularly smoothly. individual; tourist or business class; short haul or long haul (different fare rates and scheduling apply). This categorical saturation furthermore forms a complex web. Although it is possible to pull out a single classification scheme or standard for reference purposes, in reality none of them stand alone. So a subproperty of ubiquity is interdependence, and frequently, integration. A systems approach might see the proliferation of both standards and classifications as purely a matter of integration-almost like a gigantic web of interoperability. Yet the sheer density of these phenomena go beyond questions of interoperability. They are layered, tangled, textured; they interact to form an ecology as well as a flat set of compatibilities. That is to say, they facilitate the coordination of heterogeneous "dispositifs techniques" (Foucault 1 975). They are lodged in different communities of practice such as laboratories, records offices, insurance companies, and so forth.9 There are spaces between (unclassified, nonstandard areas), of course, and these are equally important to the analysis. It seems that increasingly these spaces are marked as unclassified and nonstandard. It is a struggle to step back from this complexity and think about the issue of ubiquity rather than try to trace the myriad connections in any one case. The ubiquity of classifications and standards is curiously difficult to see, as we are quite schooled in ignoring both, for a variety of interesting reasons. We also need concepts for under- Some Tricks of the Trade in Anal)'zing Classification 39 standing movements, textures, and shifts that will grasp patterns within the ubiquitous larger phenomenon. The distribution of residual categories ("not elsewhere classified" or "other") is one such concept. "Others" are everywhere, structuring social order. Another such concept might be what Strauss et al. ( 1 985) call a "cumulative mess trajectory." In medicine, this occurs when one has an illness, is given a medicine to cure the illness, but incurs a serious side effect, which then needs to be treated with another medicine, and so forth. If the trajectory becomes so tangled that you cannot turn back and the interactions multiply, "cumulative mess" results. We see this phenomenon in the interaction of categories and standards all the time-ecological examples are particularly rich places to look. Materiality and Texture The second methodological departure point is that classifications and standards are material, as well as symbolic. How do we perceive this densely saturated classified and textured world? Under the sway of cognitive idealism, it is easy to see classifications as properties of mind and standards as ideal numbers or floating cultural inheritances. But they have material force in the world. They are built into and embedded in every feature of the built environment (and in many of the nature-culture borderlands, such as with engineered genetic organisms). All classification and standardization schemes are a mixture of physical entities, such as paper forms, plugs, or software instructions encoded in silicon, and conventional arrangements such as speed and rhythm, dimension, and how specifications are implemented. Perhaps because of this mixture, the web of intertwined schemes can be difficult to see. In general, the trick is to question every apparently natural easiness in the world around us and look for the work involved in making it easy. Within a project or on a desktop, the seeing consists in seamlessly moving between the physical and the conventional. So when computer programmers write some lines of java code, they move within conventional constraints and make innovations based on them; at the same time, they strike plastic keys, shift notes around on a desktop, and consult manuals for various standards and other information. If we were to try to list all the classifications and standards involved in writing a program, the list could run to pages. Classifications include types of objects, types of hardware, matches between requirements categories and code categories, and metacategories such 40 Chapter 1 as the goodness of fit of the piece of code with the larger system under development. Standards range from the precise integration of the underlying hardware to the 60Hz power coming out of the wall through a standard size plug. Merely reducing the description to the physical aspect such as the plug does not get us anywhere interesting about the actual mixture of physical and conventional or symbolic. A good operations researcher could describe how and whether things would work together, often purposefully blurring the physical and conventional boundaries in making the analysis. But what is missing is a sense of the landscape of work as experienced by those within it. It gives no sense of something as important as the texture of an organization: Is it smooth or rough? Bare or knotty? What is needed is a sense of the topography of all of the arrangements: Are they colliding, coextensive, gappy, or orthogonal? One way to get at these questions is to take quite literally the kinds of metaphors that people use when describing their experience of organizations, bureaucracies, and information systems, which are discussed in more detail in chapter 9. When we think of classifications and standards as both material and symbolic, we adapt a set of tools not usually applied to them. There are tools for analyzing built structures, such as structural integrity, enclosures and confinements, permeability, and durability, among many others. Structures have texture and depth. The textural way of speaking of classifications and standards is common in organizations and groups. Metaphors of tautness, knots, fabrics, and networks pervade modern language (Lakoff and Johnson 1 980). The Indeterminacy of the Past: Multiple Times, Multiple Voices The third methodological theme concerns the past as indeterminate.10 We are constantly revising our knowledge of the past in light of new developments in the present. This is not a new idea to historiography or to biography. We change our resumes as we acquire new skills to appear like smooth, planned paths of development, even if the change had been unexpected or undesired. When we become members of new social worlds, we often retell our life stories in new terminology. A common example of this is a religious conversion where the past is retold as exemplifying errors, sinning, and repentance (Strauss 1 959). Or when one comes out as gay or lesbian, childhood behaviors and teenage crushes become indicators of early inklings of sexual choice (Wolfe and Stanley 1 980). Some Tricks of the Trade in Analyzing Classification 41 At wider levels of scale, these revisions also mean the introduction of new voices-many possible kinds of interpretations of categories, texts, and artifacts. Multiple voices and silences are represented in any scheme that attempts to sort out the world. No one classification organizes reality for everyone-for example, the red light, yellow light, green light traffic light distinctions do not work for blind people (who need sound coding). In looking to classification schemes as ways of ordering the past, it is easy to forget those who have been overlooked in this way. Thus, the indeterminacy of the past implies recovering multivocality; it also means understanding how standard narratives that appear universal have been constructed (Star 1 991 a). There is no way of ever getting access to the past except through classification systems of one sort or another-formal or informal, hierarchical or not. Take the apparently unproblematic statement: "In 1 640, the English revolution occurred; this led to a twenty-year period in which the English had no monarchy." The classifications involved here, all problematic, include the following: • The current segmentation of time into days, months, and years. Accounts of the English revolution generally use the Gregorian calendar, which was adopted some 1 00 years later, so causing translation problems with contemporary documents. • The classification of peoples into English, Irish, Scots, French, and so on. These designations were by no means so clear at the time; the whole discourse of "national genius" or character only arose in the nineteenth century. • The classification of events into revolutions, reforms, revolts, rebellions, and so forth (see Furet 1 978 on thinking the French revolution). There was no concept of "revolution" at the time; our current conception is marked by the historiographical work of Karl Marx. • What do we classify as being a "monarchy?" There is a strong historiographical tradition that says that Oliver Cromwell was a monarch-he walked, talked, and acted like one after all. Under this view, there is no hiatus at all in this English institution; rather a usurper took the throne. There are two major historiographic schools of thought about using classification systems on the past. One maintains that we should only use classifications available to actors at the time, much as an ethnographer tries faithfully to mirror the categories of their respondents. 42 Chapter 1 Authors in this tradition warn against the dangers of anachronism. Hacking ( 1 995) on child abuse is a sophisticated version that we discuss in chapter 7. If a category did not exist contemporaneously, it should not be retroactively applied. The other school of thought holds that we should use the real classifications that progress in the arts and sciences has uncovered. Often history informed by current sociology will take this path. For example, Tort's ( 1 989) work on "genetic" classification systems (which were not so called at the time, but which are of vital interest to the Foucaldian problematic) imposes a post hoc order on nineteenth-century classification schemes in a variety of sciences. Even though those schemes were perceived by their creators as responding solely to the specific needs of the discipline they were dealing with (etymology, say, or mineralogy), Tort demonstrates that there wa� a link between many different schemes (both direct in people shifting disciplines and conceptual in their organization) that allows us to perceive an order nowhere apparent to contemporaries. From a pragmatist point of view, both aspects are important in analyzing the consequences of modern systems of classification and standardization. We seek to understand classification systems according to the work that they are doing and the networks within which they are embedded. That entails both an understanding of the categories of those designing and using the systems, and a set of analytic questions derived from our own concerns as analysts. When we ask historical questions about the deeply and heterogeneously structured space of classification systems and standards, we are dealing with a four-dimensional archaeology. The systems move in space, time, and process. Some of the archaeological structures we uncover are stable, some in motion, some evolving, some decaying. They are not consistent. An institutional memory about an epidemic, for example, can be held simultaneously and with internal contradictions (sometimes piecemeal or distributed and sometimes with entirely different stories at different locations) across a given institutional space. In the case of AIDS, classifications have shifted significantly over the last twenty years, including the invention of the category in the 1 980s-from gay-related immune disorder (GRID) through a chain of other monikers to the now accepted acquired immune deficiency syndrome (AIDS). It is now to some extent possible to look back at cases that might previously have been AIDS (Grmek 1 990) before we had Some Tricks of the Trade in Analyzing Classification 43 When Is It a Harley? One of the ways the past becomes indeterminate is through gradual shifts in what it means to "really be" something-the essence of it. Sitting in a tattoo parlor, surrounded by people I do not usually hang out with. Young men in black leather vests and sun-bleached hair. I turn to the waiting room reading material, which in this case is the monthly Thunder Press, a newsletter for motorbike aficionados. The lead article asks the question: " Is It Still a Harley" if you have customized your bike yourself? The Oregon Department of Motor Vehicles makes the definitive call: "Anything that is not totally factory built will make it a reconstructed motorcycle, and it will be called 'assembled' on the title" (69). A major activity in the Harley social world is customizing features of one's motorcycle, and there are important symbolic and affiliative signs attached to the customizing process. Deleting the name Harley from the registration form is perceived as an insult to the owner, and this insult is stitched together in the article with others that come from the government toward bikers (restricting meeting places, insisting on helmetwearing, being overly enthusiastic in enforcing traffic violations by bikers). This is a pure example of the politics of essence, of identity politics. It is echoed in many areas of life, for example, in James Davis' (1991) classic study Who Is Black ? where the question of the one-drop rule in the United States, and the rejection of mixed-race people as a legitimate category is an old and a cruel story. The central process here is the distillation of the sine qua non out from the messy and crenellated surrounds-the rejection of marginality in favor of purity. When this occurs, the suffering of the marginal becomes privatized and distributed, creating the conditions for pluralistic ignorance ("I'm the only one"). Meeting the purity criteria of the essentialized category also becomes bureaucratized and again the onus is shifted to the individual alone. Only when the category is joined with a social movement can the black box of essence be reopened, as for example with the recent uprisings and demonstrations of mixed race Hispanic people toward the U.S. census and its rigid categories. The problem becomes clear if one is both black and Hispanic, a common combination in the Caribbean. Through which master trait will the government perceive you? -Leigh Star Source: Anonymous, "Is It Still a Harley," Thunder Press 5:4 (July 1 996, 1 and 69). 44 Chapter 1 the category (a problematic gaze to be sure, as Bruno Latour (forthcoming) has written about tuberculosis). There are epidemiological stories about trying to collect information about a shameful disease; there is a wealth of personal and public narratives about living with it. There is a public health story and a virology story, which use different category systems. There are the standardized forms of insurance companies and the categories and standards of the Census Bureau. When an attempt was made to combine these data in the 1 980s to disenfranchise young men living in San Francisco, from health insurance, the resultant political challenge stopped the combination of these data from being so used. At the same time, the San Francisco blood banks refused for years to employ HIV screening, thus denying the admission of another category to their blood labeling, as Shilts (1 987) tells us, with many casualties as a result. Whose story has categorical ascendancy here? That question is forever morally moot-all of the stories are important and all of the categories tell a different one. Practical Politics The fourth major theme is uncovering the practical politics of classifying and standardizing. This is the design end of the spectrum of investigating categories and standards as technologies. There are two processes associated with these politics: arriving at categories and standards, and, along the way, deciding what will be visible or invisible within the system. It follows from the indeterminacy discussed above that the spread or enforcement of categories and standards involves negotiation or force. Whatever appears as universal or indeed standard, is the result of negotiations, organizational processes, and conflict. How do these negotiations take place? Who determines the final outcome in preparing a formal classification? Visibility issues arise as one decides where to make cuts in the system, for example, down to what level of detail one specifies a description of work, of an illness, of a setting. Because there are always advantages and disadvantages to being visible, this becomes crucial in the workability of the schema. As well, ordinary biases of what should be visible, or legitimated, within a particular scheme are always in action. The trade-offs involved in this sort of politics are discussed in chapters 5 on tuberculosis and 7 on nursing work. Someone, somewhere, must decide and argue over the minutiae of classifying and standardizing. The negotiations themselves form the Some Tricks of the Trade in Analyzing Classification 4 5 There's No Such Thing as a Rodent An article in the San Jose Mercury News by Rick Weiss declares: "Researchers say there's no such thing as a rodent." He quotes an article from Nature, which argues that the 2 ,000 species of animals ordinarily considered rodents-including rats, mice, and guinea pigs-did not evolve from a common ancestor. The finding is deeply controversial. Weiss says, "On one side are researchers who have spent their careers hunched over fossils or skeletal remains to determine which animals evolved from which." On the other, the article continues, are those who would use DNA analysis to make the determination. The fossil studiers say that DNA is not yet accurate enough. The classification of species has always been deeply controversial. Biologists speak of a rough cut among their ranks: Jumpers (those who see fewer categories and more commonalties) versus splitters (those who would name a new species with fewer kinds of difference cited). There are always practical consequences for these names. Splitters, for example, often included people who wanted a new species named after them, and the more species there are, the more likely is an eponymous label. The deliberately provocative headline of this article demands a response : "well, don't tell that to my cat." We often refer implicitly in this fashion to the power of namingblurring the name of the category with its members. (San jose Mercwy News, June 13, 1 996: 5A by Rick Weiss) basis for a fascinating practical ontology-our favorite example is when is someone really alive? Is it breathing, attempts at breathing, or movement? And how long must each of those last? Whose voice will determine the outcome is sometimes an exercise of pure power: We, the holders of western medicine and scions of colonial regimes, will decide what a disease is and simply obviate systems such as acupuncture or Aryuvedic medicine. Sometimes the negotiations are more subtle, involving questions such as the disparate viewpoints of an immunologist and a surgeon, or a public health official (interested in even one case of the plague) and a statistician (for whom one case is not relevant). Once a system is in place, the practical politics of these decisions are often forgotten, literally buried in archives (when records are kept at all) or built into software or the sizes and compositions of things. In addition to our archaeological expeditions into the records of such negotiations, this book provides some observations of the negotiations in action. 46 Chapter 1 Finally, even where everyone agrees on how classifications or standards should be established, there are often practical difficulties about how to craft them. For example, a classification system with 20,000 bins on every form is practically unusable for data-entry purposes. The constraints of technological record keeping come into play at every turn. For example, the original ICD had some 200 diseases not because of the nature of the human body and its problems but because this was the maximum number that would fit the large census sheets then m use. Sometimes the decision simply about how fine-grained to make the system has political consequences as well. For instance, describing and recording someone's tasks, as in the case of nursing work, may mean controlling or surveilling their work as well, and may imply an attempt to take away discretion. Mter all, the loosest classification of work is accorded to those with the most power and discretion who are able to set their own terms. There are financial stakes as well. In a study of a health insurance company's system of classifying for doctor and patient reimbursement, Gerson and Star ( 1 986) found that doctors wanted the most fine-grained of category systems, so that each procedure could be reimbursed separately and thus most profitably. Data-entry personnel and hospital administrators, among others, wanted broader, simpler, and coarser-grained categories for reasons of efficiency. These conflicts were, however, invisible to the outside world, which received only the forms for reimbursement purposes and a copy of the codebook for reference. Both the content of the categories and the structure of the overall scheme are concerns for due process within organizations-whose voice will be heard and when will enough data, of the right granularity, have been collected? Infrastructure and Method: Convergence These ubiquitous, textured classifications and standards help frame our representation of the past and the sequencing of events in the present. They can best be understood as doing the ever local, ever partial work of making it appear that science describes nature (and nature alone) and that politics is about social power (and social power alone). Consider the case of psychoanalysts discussed at length in Young (1995), Kirk and Kutchins (1992), and Kutchins and Kirk ( 1 997). To receive reimbursement for their procedures, psychoanalysts now need to couch them in a biomedical language (using the DSM). Some Tricks of the Trade in Analyzing Classification 47 Fitting Categories to Circumstances An academic friend on the East Coast tells an anecdote of negotiation with her long-term psychoanalyst about how to fill out her insurance forms. She was able to receive several free sessions of therapy a year under her health insurance plan. Each year, she and her therapist would discuss how best to categorize her. It was important to represent the illness as serious and long-term. At the same time, they were worried that the information about the diagnosis might not always remain confidential. What could they label her that would be both serious and nonstigmatizing? Finally, they settled on the diagnosis of obsessivecompulsive. No academic would ever be penalized for being obsessivecompulsive, our friend concluded with a wry laugh! (Kirk and Kutchins (1992) document similar negotiations between psychiatrists and patients.) Theoretically, this rubric is anathema to them, systematically replacing the categories of psychoanalysis with the language of the pharmacopoeia and of the biochemistry of the brain. The DSM, however, is the lingua franca of the medical insurance companies. Thus, psychoanalysts use the categories not only to obtain reimbursement but as a shorthand to communicate with each other. There are local translation mechanisms that allow the DSM to continue to operate in this fashion and, at the same time, to become the sole legal, recognized representation of mental disorder. A "reverse engineering" of the DSM or the lCD reveals the multitude of local political and social struggles and compromises that go into the constitution of a "universal" classification. Standards, categories, technologies, and phenomenology are increasingly converging in large-scale information infrastructure. As we have indicated in this chapter, this convergence poses both political and ethical questions. These questions are by no means obvious in ordinary moral discourse. For all the reasons given above, large-scale classification systems are often invisible, erased by their naturalization into the routines of life. Conflict and multiplicity are often buried beneath layers of obscure representation. Methodologically, we do not stand outside these systems, nor pronounce on their mapping to some otherworldly "real" or "constructed" nature. Rather, we are concerned with what they do, pragmatically speaking, as scaffolding in the conduct of modern life. Part of that 48 Chapter 1 analysis means understanding the coconstruction of classification systems with the means for data collection and validation. To clarify our position here, let us take an analogy. In the early nineteenth century in England there were a huge number of capital crimes, starting from stealing a loaf of bread and going on up. Precisely because the penalties were so draconian, however, few juries would ever impose the maximum sentence; and indeed there was a drastic reduction in the number of executions even as the penal code was progressively strengthened. There are two ways of writing this history: one can either concentrate on the creation of the law; or one can concentrate on the way things worked out in practice. This is very similar to the position taken in Latour's We Have Never Been Modern (1993). He argues that we can either look at what scientists say they are doing (working within a purified realm of knowledge) or at what they actually are doing (manufacturing hybrids of nature-culture). We think both are important. We advocate here a pragmatic methodological development-pay more attention to the classification and standardization work that allows for hybrids to be manufactured and so more deeply explore the terrain of the politics of science in action. The point is that both words and deeds are valid kinds of account. Early sociology of science in the actor-network tradition concentrated on the ways in which it comes to appear that science gives an objective account of natural order: trials of strength, enrolling of allies, cascades of inscriptions, and the operation of immutable mobiles (Latour 1 987, 1 988). Actor network theory drew attention to the importance of the development of standards (though not to the linked development of classification systems), but did not look at these in detail. Sociologists of science invited us to look at the process of producing something that looked like what the positivists alleged science to be. We got to see the Janus face of science as both constructed and realist. In so doing we followed the actors, often ethnographically. We shared their insights. Allies must be enrolled, translation mechanisms must be set in train so that, in the canonical case, Pasteur's laboratory work can be seen as a direct translation of the quest for French honor after defeat in the battlefield (Latour 1 988). By the very nature of the method, However, we also shared the actors' blindness. The actors being followed did not themselves see what was excluded: they constructed a world in which that exclusion could occur. Thus if we just follow the doctors who create the ICD at the WHO in Geneva, we will not see the variety of representation Some Tricks of the Trade in Analyzing Classification 49 systems that other cultures have for classifying diseases of the body and spirit; and we will not see the fragile networks these classification systems subtend. Rather, we will see only those who are strong enough and shaped in such a fashion as to impact allopathic medicine. We will see the blind leading the blind. This blindness occurs by changing the world such that the system's description of reality becomes true. Thus, for example, consider the case where all diseases are classified purely physiologically. Systems of medical observation and treatment are set up such that physical manifestations are the only manifestations recorded. Physical treatments are the only treatments available. Under these conditions, then, logically schizophrenia may only result purely and simply from a chemical imbalance in the brain. It will be impossible to think or act otherwise. We have called this the principle of convergence (Star, Bowker and Neumann in press) . Resistance Reality is 'that which resists,' according to Latour's ( 1 987) Pragmatistinspired definition. The resistances that designers and users encounter will change the ubiquitous networks of classifications and standards. Although convergence may appear at times to create an inescapable cycle of feedback and verification, the very multiplicity of people, things and processes involved mean that they are never locked in for all time. The methods in this chapter offer an approach to resistance as a reading of where and how political work is done in the world of classifications and standards, and how such artifacts can be problematized and challenged. Donald MacKenzie's (1990) wonderful study of "missile accuracy" furnishes the best example of this approach. In a concluding chapter to his book, he discusses the possibility of "uninventing the bomb,'' by which he means changing society and technology in such a way that the atomic bomb becomes an impossibility. Such change, he suggests, can be carried out in part at the overt level of political organizations. Crucially for our purposes, however, he also sensitizes the reader to the site of the development and maintenance of technical standards as a site of political decisions and struggle. Standards and classifications, however dry and formal on the surfaces, are suffused with traces of political and social work. Whether we wish to uninvent any particular aspect of complex information infra- 50 Chapter 1 structure is properly a political and a public issue. Because it has rarely been cast in that light, tyrannies of various sorts flourish. Some are the tyrannies of inertia-red tape-rather than explicit public policies. Others are the quiet victories of infrastructure builders inscribing their politics into the systems. Still other are almost accidental-systems that become so complex that no one person and no organization can predict or administer good policy. The magic of modern technoscience is a lot of hard work involving smoke-filled rooms, and boring lists of numbers and settings. Tyranny or democracy, its import on our lives cannot be denied. This chapter has offered a number of points of departure for evaluation, resistance, and better analysis of one of its least understood aspects. I Classification and Large-Scale Infrastructures In the f<>llowing three chapters, which analyze the international classification of diseases (lCD) we look at the operation of classification systems in supporting large-scale infrastructural arrangements. Chapter 2 concentrates on the text of the lCD itself� producing a reading of this classification which has over the past century ingrained itself in a multiplicity of forms, work arrangements, and laws worldwide. We examine how i ts internal structure affords the prosecution of m ultiple agendas. Chapter ;3 discusses the history of the lCD, showing how it has changed over time in step with changing inf()rmation technology and changing organizational needs. Chapter 4 draws general design implications from the study of this highly effective, long-term, and wide-scale classification scheme. 2 The Kindness of Strangers: Kinds and Politics in Classification Systems Most Enlightenment naturalists joined the chorus of praise for system in the abstract; but their responses to particular systems were apt to be less cohesive. The very icons of classification-the tables and diagrams prefixed and appended to works of Enlightenment zoology to distinguish them from the unstructured productions of previous ages-could simultaneously evidence this lack of unity. (Ritvo 1 997, 21) Introduction: Formal and Informal Aspects of Classification How people classify things, and what relationship those categories have with social organization, has long been a central topic within anthropology, especially cognitive anthropology and cognitive science. In this chapter, we touch on some of the issues raised in those disciplines, such as the relationship between what is singled out as different and what is considered normal. Our primary project is a pragmatic one, not a logical or cognitive one. We want to know empirically how people have designed and used classification systems. We want to understand how political and semantic conflicts are managed over long periods of time and at large levels of scale. Equally, as good pragmatists, we know that things perceived as real are real in their consequences (Thomas and Thomas 1 970 [ 1917]). So even when people take classifications to be purely mental, or purely formal, they also mold their behavior to fit those conceptions. When formal characteristics are built into wide-scale bureaucracies such as the WHO, or inscribed in hospital software standards, then the compelling power of those beliefs is strengthened considerably. They often come to be considered as natural, and no one is able completely to disregard or escape them. People constantly fiddle with them, however, and work around the formal restrictions (Hunn 1 982). When we 54 Chapter 2 look over a long enough period of time, the formal and the informal are completely mingled in infrastructure. There has been a recent trend in social informatics and science studies to move away from dichotomizing the formal and the informal. 11 In the early 1 980s, the original eclat of discovering the failures of formalisms led to a kind of enthusiastic debunking. People do not really follow formal rules; they make up their own. They tailor rigid computer systems to their everyday working needs. Expert systems do not formally model people's thoughts as they fail to capture tacit knowledge. People do not devise formal, abstract plans and goals and then execute them, as the old cognitive model of Miller, Galanter, and Pribram ( 1 960) would have it. Rather, they use a dynamic and situated improvisation (Suchman 1 987) where plans are resources and are renegotiated as circumstances warrant. Suchman's situated action perspective constituted a powerful critique of artificial intelligence's claim that the mind could be formally specified. Building on this initial set of findings and especially Suchman's notion that plans are also material resources for action-whether or not people follow them exactly-a more sophisticated model has emerged in recent years. Although it is true that maps do not fully capture terrains, they are powerful technologies (Becker 1 986). They help to find one's way, as originally formally intended. And they serve as resources to structure all sorts of collective action-dreams of vacations, crossword puzzle solutions, explanations of social distance (Schmidt 1 997, Zorbaugh 1 929). Marc Berg analyzes the formalisms of medical decision making in use as powerful both formally and as spurs to informal action (1997b 1 998). Just because people do not do exactly what they say will, does not mean they are doing nothing. Nor does it mean that they do not believe in the stated formal purpose and tailor their behavior to it. Obvious as this point may appear from a common sense perspective, it has not been obvious in scientific writing about cognition and classification. In this book we offer a balanced reconsideration of classifications as formal and informal resources, often annealed together. People juggle vernacular (or folk) classifications together with the most formal category schemes (as detailed in Atran 1 990). They subvert the formal schemes with informal work-arounds. Indeed, the various approaches are often so seamlessly pasted together they become impossible to distinguish in the historical record. For instance, a physician decides to diagnose a patient using the categories that the insurance company The Kindness of Strangers 55 will accept. The patient then self-describes, using that label to get consistent help from the next practitioner seen. The next practitioner accepts this as part of the patient's history of illness. As many of the examples in this book will show, this convergence may then be converted into data and at the aggregate level, seemingly disappear to leave the record as a collection of natural facts (Star, Bowker, and Neumann, in press) . Any classification system embodies a dynamic compromise. Harriet Ritvo writes of zoological classification in the nineteenth century: But if the experts resisted granting recognition to competing claimants of the zoological territory they had staked out, they tacitly acknowledged the objections of various laymen in many ways. They even quietly incorporated vernacular categories into their classificatory schemes, especially with regard to mammals, the creatures most important to people and most like them. This consistently inconsistent practice illuminates both the nature of scientific enterprise during the period and the relation of science to the larger culture. (1997, xii) As Ritvo shows us, these tracks do not disappear completely. Traces of bureaucratic struggles, differences in world-view, and systematic erasures do remain in the written classification system, however indirectly. The trick is to read the classification itself, restoring the narratives of conflict and compromise as we do so. This reading requires that we juggle the formal and ilnformal aspects of classification while reading. Our reading teases out the cognitive, bureaucratic, and formal aspects of the work of designing and using classification systems. We are not here treating the generation or the detailed implementation of these categories-both topics well worthy of attention. (Young's (1995) description of posttraumatic stress disorder is a model here). For the purposes of this chapter, our emphasis is on reading the system, our argument being that one can read a surprising amount of social, political, and philosophical context from a set of categories-and that in many cases the classification system in practice is all that we have to go on. Sitting down and reading a document like the lCD is a curiously perverse activity. The three volumes of iCD-10, more than 2,000 pages long, have very little in the way of overt narrative. There is a short history of the enterprise of producing international classifications of disease at the beginning of volume two, which contains explanatory or prescriptive notes. It provides most notably a set of rules for using the classifications of the lCD with directions on what to do in ambiguous 56 Chapter 2 1�1•1 Heart failure Excludes: complicating: 150.0 150. 1 150.9 Figure 2.1 • abortion or ectopic or molar pregnancy (000-007, 008.8) • obstetric surgery and procedures (075 .4) due to hypertension (111.0) • with renal disease (113.-) following cardiac surgery or due to presence of cardiac prosthesis (197 .1) neonatal cardiac failure (P29. 0) Congestive heart failure Congestive heart disease Right ventricular failure (secondary to left heart failure) Left ventricular failure Acute oedema of lung Acute pulmonary oedema Cardiac asthma Left heart failure Heart failure, unspecified Biventricular failure } with mention of heart disease NOS or heart failure Cardiac, heart or myocardial failure NOS Heart failure as specified in the ICD-10. Source : lCD 1 0, 1: 494. situations. Volume three is an index, a vital tool since diseases have multiple designators and so many paths into the classification system must be provided. The first volume is the largest. It is primarily a long list of numbers with names of diseases or modifying conditions. (An example is given in figure 2.1) Reading the lCD is a lot like reading the telephone book. In fact, it is worse. The telephone book, especially the yellow pages, contains a more obvious degree of narrative structure. It tells how local businesses see themselves, how many restaurants of a given ethnicity there are in the locale, whether or not hot tubs or plastic surgeons are to be found there. (Yet most people don't curl up with a good telephone book of a Saturday night.) Aside from this direct information to be retrieved, an indirect reading can be instructive. A slim volume indicates a rural area. Those with only husband's names listed for married couples indicate a sexist society. The names of services may change The Kindness of Strange1�5 57 over time, indicating changed community values. In the Santa Cruz, California, phone book, for example, Alcoholics Anonymous and Narcotics Anonymous are listed in emergency services; years ago they would have been listed under "rehabilitation," if at all. The changed status reflects the widespread recognition of the organizations' reliability in crisis situations, as well as acceptance of their theory of addiction as a medical condition. Under the community events section in the beginning, next to the Garlic Festival and the celebration of the anniversary of the city's founding, the Gay and Lesbian Pride Parade is listed as an annual event. Behind this simple telephone book listing lie decades of activism and conflict-for gays and lesbians, becoming part of the civic infrastructure in this way betokens a kind of public acceptance almost unthinkable thiry years ago. ICD-10 is an equally rich text. In the example of common "heart failure," given above, several primary divisions of heart failure are spelled out: congestive, left ventricular, and so forth. Yet those failures caused by mechanical failure of a prosthesis-pacemaker breakdownare explicitly excluded at this point. We read this and wonder: if the breakdown is due to a manufacturing defect, would that constitute criminal negligence, and so is this the reason the category is kept separate? If the person passed through an area posted as proscribed to pacemakers, could it be suicide as well as heart failure? Or an accident? Or if it were due to a contributing cause like illiteracy, and if so, is there room in the ICD to make this kind of connection? The narrative questions begin to appear. When we look in the crossreferenced section under pacemaker (cardiac prosthesis), there are two factors influencing the category of heart failure-presence of a pacemaker (Z95 .0) and the activity of its maintenance and management (Z45 .0). A failed pacemaker as proximal cause of death must be pieced together as a narrative by the physician, but then reencoded and reembedded in the statistical list. In final form the death certificate would read as sudden death, with pacemaker in place. We did sit down and read the lCD, and another detailed classification system, the International Classification and Nomenclature of Viruses (INV). This chapter analyses their embedded narrative structures, formal and informal, and the narrative structures in which they are embedded. Our work here is an exercise both in restoring the stories of practical classifying, conflict, and consensus therein and in understanding the design of the list itself. 58 Chapter 2 The Classification of Acupuncture In 1991 the World Health Organization came out with a "proposed standard international acupuncture nomenclature" (WHO 1 991). The initiative began in 1 960. The report notes that the whole system of acupuncture of 36 1 points was complete in about A.D. 300 but the past 20 years had seen an explosion, with 48 extra points being added (WHO 1 991, 1-2). The WHO report gives a typical sequence of reasons for developing an international classification: " Even when the practice of acupuncture was largely restricted to China, Japan, and neighboring Asian countries, the lack of a uniform nomenclature caused serious difficulties in teaching, research, and clinical practice" (WHO 1 991, 1 ). The bottom line was scientific development: " Putting acupuncture on a firm scientific basis requires rigorous investigation of the claims made for its efficacy. Many institutions and modern medical colleges are carrying out useful investigations to this end. Some are looking into the physiology and mode of action of acupuncture treatment, others are studying its efficacy in certain pathological conditions. These workers need to exchange information with one another regularly so as to facilitate their clinical and basic research. Such international communication is possible only if a common language is used by all concerned" (WHO 1 991, 5). So now the "triple energizer meridian," the "conception vessel" and the "governor vessel" are internationally known and accepted terms. Ironically, the classification system retains an interesting (literal!) indexicality: the 48 points were only recognized if they were at least 0.5 cun from a classic acupuncture point, where a cun is: "the distance between the interphalangeal creases of the patient's middle finger" (WHO 1 991, 14) . Formal Classification The structural aspects of classification are themselves a technical specialty in information science, biology, and statistics, among other places. Information scientists design thesauri for information retrieval, valuing parsimony and accuracy of terms, and the overall stability of the system over long periods of time. For biologists the choice of structure reflects how one sees species and the evolutionary process. For transformed cladists and numerical taxonomists, no useful statement about the past can be read out of their classifications; for evolutionary taxonomists that is the very basis of their system. These beliefs are reflected in radically different classification styles and practices, for The Kindness of Strangers 59 example, whether or not to include the fossil record in the classification system; fossils being a problem since they perpetually threaten to create another level of taxa, and so cause an expensive and painstaking reordering of the whole system (Scott-Ram 1 990). There is even a metadiscipline of classifying that examines the architectonic features of classification systems in general. Using a variety of statistical techniques, these specialists analyze data structures, overall shape and structure of taxonomies and categories, and assess the elegance and durability of a classification system much in the way an architect would assess the structural and aesthetic features of a building. The International Classification Society regularly meets to discuss these issues, as does the Special Interest Group in Classification Research of the American Society for Information Science (SIG-CR of ASIS). The kinds of readings and assessments brought to bear by these specialists has not traditionally dealt explicitly with political or cultural issues at the metalevel (although those debates are the stuff of classification design and revision for any applied group, such as the WHO). Practical Classifying, Folk, Vernacular, and Ethno-classifications Practical classifying is the stuff of cultural anthropology-how people classify their everyday worlds, including everything from color to kinship. Traditionally much ethno- or folk-classification research has examined tribal categories in nonindustrial societies. How people in industrial societies categorize on an everyday basis is less well known, especially in natural workaday settings. Most of the extant research, in linguistics or cognitive psychology, has been in experimental settings highly constrained in focus. Here, we use the term practical classifying to mean how people categorize the objects they encounter in everyday situations, including formal classification schemes. Part of reading classifications is understanding the nature of these encounters, and the interplay between vernacular and formal systems. The kind of reading we do here emphasizes the range of ways classification systems may be fuzzy or logical, reflective at once of bureaucratic concerns, scientific grounds, formal considerations, and cognitive theories. Our reading will not resolve the divergent perspectives created by these different needs, but will hopefully restore some of the stories to the dry lists that shape so much of our lives. In the 60 Chapter 2 section below, we frame our reading by briefly describing some of the theories about classification that have informed cognitive and social science discussions of classification. Kinds of Classification in Theories about Classification Within the field of the sociology of science, the Edinburgh School has developed a rich analysis of scientific classification. In many ways its analysis of classification goes back to Durkheim and Mauss's classic "De quelques formes primitives de classification: contribution a I' etude des representations collectives." Durkheim and Mauss had made the strong claim that classifications of the natural world in "primitive" societies directly reflected kinship structure in the sense that they projected the microcosm of social organization onto the macrocosm of the world-social tools were used for describing the natural world. They concluded that "the history of scientific classification is one by which the element of social affect has become progressively weaker, leaving more place for the reflective thought of individuals" (Durkheim and Mauss 1 969, 88). David Bloor ( 1 982) produced a rereading of Durkheim and Mauss that both defended them against the attacks on the validity of their analysis and extended their work to scientific classifications in seventeenth-century physics. He claimed that Boyle and Newton were producing classifications of entities in the world that reproduced their theological and political beliefs; in his words, both sides in the debate "were arranging the fundamental laws and classifications of their natural knowledge in a way that artfully aligned them with their social goals" (Bloor 1 982, 290). This position prefigures the mechanism Latour ( 1 993) gives for the projection of social categories out into nature and then their reimportation in the process of political debates ("if they are out there in the world then they must be real and so we must model our society accordingly"). Bloor used firstly Hesse's network model of classifications and more recently (Barnes, Bloor, and Henry 1 996) he and colleagues have offered a finitist model. Common to both' philosophical descriptions is the position that no category stands alone-when a new member is added to a class, this has ramifications for the class and the system of which it is part. Just as Lakatos ( 1 976) argued about mathematical objects, the new exemplar can change the whole nature of the system. Specific classification choices are "underdetermined and indeterminate. It will emerge as we decide how to develop the analogy between the finite The Kindness of Strangers 61 number of our exiting examples of things and the indefinite number of things we shall encounter in the future" (Barnes, Bloor, and Henry 1 996, 55). While this is a useful general model, it does not have the power to trace exactly how changes are made, this has been the great breakthrough of Rosch's prototype theory discussed below. Starting as well from a reading of Durkheim and Mauss, Mary Douglas observed a similar kind of mechanism for the reification of social categories: "How a system of knowledge gets off the ground is the same as the problem of how any collective good is created . . .. Communities do not grow up into little institutions and these do not grow into big ones by any continuous process. For a convention to turn into a legitimate social institution it needs a parallel cognitive convention to sustain it" (Douglas 1 986, 46). For her, classification systems of all types are at base social institutions that reflect and describe the way things are in the social world. Again prefiguring Latour, she argues: Before it can perform its entropy-reducing work, the incipient institution needs some stabilizing principle to stop its premature demise. That stabilizing principle is the naturalization of social classifications. There needs to be an analogy by which the formal structure of a crucial set of social relations is found in the physical world, or in the supernatural world, or in eternity, anywhere, so long as it is not seen as a socially contrived arrangement. When the analogy is applied back and forth from one set of social relations to another, and from these back to nature, its recurring formal structure becomes easily recognized and endowed with self-validating truth. (Douglas 1 986, 48) Douglas and Bloor here draw attention to a key feature of classification systems, that they grow out of and are maintained by social institutions. Building on this broad generalization, our approach in this book is to offer fine-grained analyses of the nature of information infrastructures such as classification systems and thus to demonstrate how they simultaneously represent the world "out there," the organizational context of their application (an issue discussed in Dean 1 979) and the political and social roots of that context. We suggest that at this finer grain we detect rather a coconstruction of nature and society than a projection of the social onto the natural. A classic divide among kinds of classification systems-and one that can lead us to this kind of coconstruction-is that drawn by Taylor, who distinguishes between Aristotelian classification and prototype classifications. Experimental psychologist Eleanor Rosch (1978) 62 Chapter 2 defined the prototype classification. This distinction is going to be an important one through this chapter, so let us explore it in some detail. An Aristotelian classification works according to a set of binary characteristics that the object being classified either presents or does not present. At each level of classification, enough binary features are adduced to place any member of a given population into one and only one class. So we might say that a pen is an object for writing within a population consisting of pens, balls, and bottles (Taylor l 995). We would have to add in one more feature to distinguish it adequately, for example, from pens, pencils, balls, or bottles. A technical classification system operating by binary characteristics is called monothetic if a single set of necessary and sufficient conditions is adduced ("in the universe of polygons, the class of triangles consists of figures that have three sides"); polythetic if a number of shared characteristics are used. In our example, we might say a pen is thin, cylindrical, used for writing, has a ball point, and so forth (Blois 1 984). Desrosieres (1993) points to a typical breakdown between monothetic and polythetic classifications in the work of statisticians. He associates the former with Linnaeus and the latter with Buffon (who engaged in local classification practices, just using the set of traits needed to make a determination in a specific instance); and writes, " These local practices are often carried out by those working in statistical centers, according to a division of labor whereby the chiefs are inspired by Linnaean precepts but the working statisticians apply, without realizing it, Buffon's method" (Desrosieres 1 993, 296, authors' translation). Aristotelian models-monothetic or polythetic-have traditionally informed formal classification theory in a broad range of sciences, including biological systematics, geology, and physics. According to Rosch's prototype theory, our classifications tend to be much fuzzier than we might at first think. We do not deal with a set of binary characteristics when we decide that this thing we are sitting on is a chair. Indeed it is possible to name a population of objects that people would in general agree to call chairs which have no two binary features in common. Prototype theory proposes that we have a broad picture in our minds of what a chair is; and we extend this picture by metaphor and analogy when trying to decide if any given thing that we are sitting on counts. We call up a best example, and then see if there is a reasonable direct or metaphorical thread that takes us from the example to the object under consideration. George Lakoff ( 1 987) and John Taylor The Kindness of Strangers 63 ( 1 995) have powerfully developed prototype theory within the field of sociolinguistics. One finding of the theory is that different social groups tend to have quite different prototypes in mind when classifying something as, say, a piece of furniture. Thus when surveyed, a group of Germans came up consistently with a different set of best examples than did a group of Americans (Taylor 1 995, 44-57). For the Americans, chair and sofa are best fits for furniture, for the Germans, asked about mabel, it was bed and table. An important implication of the theory is that there are levels at which we most easily and naturally distinguish between objects in the world, and that supervenient or subvenient levels tend to be more technically defined. Looking at a picture of a Maine coon cat, a nonexpert will say that this is a picture of a cat, while an expert might call it either a Maine coon cat or a vertebrate. This distinction between two main types of classification is a very useful one. There are a number of reasons, however, for saying that it is not an absolute distinction. Indeed, one could say that we all probably have our own prototype of the ideal Aristotelian classification system, but that no one system in practice fully meets a single set of Aristotelian requirements (Sweetser 1 987). As Coleman and Kay note, while blackboxing the notion of " knowledge of the occasions": It seems that the use of some words, like lie, may depend on two sorts of considerations. One is the traditional question of what count as criteria for classifying a real-world thing in the category: perhaps we would like to reserve the term semantic prototype for this constellation of things. But a second consideration is knowledge of the occasions, reasons, etc., for deciding whether or not to classify something in a particular way. A frequent reason for reporting something as a lie is that we want to blame or criticize the person who said it. (1981, 37) Our analysis here stresses precisely this latter criterion of"in practice." Turning to an example from the workplace, it is possible to begin to see how practice and location mediate such divisions. In the medical arena, the criterion emerged from a survey of physicians in 1 979 in the United Kingdom that general practitioners, "had a constant tendency to regard a wider range of phenomena as disease" than the hospital physicians, who in turn were more inclusive than the lay public. The perceived need for medical intervention was the determining axis (Prins 1 981, 1 76; Campbell, Scadding, and Roberts 1 979). An influential factor, Prins notes, appears to have been whether or not medical intervention was required-for the lay public measles and 64 Chapter 2 mumps might be prototypical diseases; but arthritis, a card-carrying ICD- 10 disease, might be seen rather as a condition. So why do we sometimes appear in practice prototypical in our classifications, even if in principal we are Aristotelian? For two main reasons: because each classification system is tied to a particular set of coding practices; and because classification systems in general (we are not making this as an ex cathedra pronouncement) reflect the conflicting, contradictory motives of the sociotechnical situations that gave rise to them. Ritvo notes a similar phenomenon in eighteenth-century zoological classification, and for the same reasons; she states that: Eighteenth-century systems reflected competing, if unacknowledged, principles of organization that undermined both their schematic novelty and their claim to be based on objective analysis of the natural world. These competing principles usually divided animals into groups based not on their physical characteristics but on subjective perceptions of them .... Rather than analyzing nature exclusively on its own terms-the claim embodied in their formal systems-naturalists often implicitly presented it in terms of its relationship to people, even constructing formal categories that echoed the anthropocentric and sentimental projection characteristic of both the bestiary tradition they had so emphatically discarded and (then as now) of much vernacular discourse about animals. ( 1 997, 38-39) Goldstein (1987, 379) also notes that prototypical categories are themselves manufactured, accented, and dramaturgically presented. In her discussion of the development of neurological categorization in the nineteenth century, she notes the, ... theatricality of Charcot's Friday lessons, where patients in nervous crisis and hypnotic trance were exhibited before an avid audience, including artists and litterateurs as well as physicians. When Charcot lectured on tremors, for example, the affiicted patients appeared wearing headdresses decorated with long plumes, whose distinctive, feathery vibrations illustrated the different varieties of the pathology. (Goldstein 1 987, 1 69-171) At any given moment, she points out, a particular category may become famous or politicized, or seize the popular imagination. This is of course the case throughout the worlds of classification. Practices Consider the lCD. When originally drawn up, it had a maximum of 200 categories. As we note above, this was not the number of diseases The Kindness of Strangers 65 in the world, but the number of lines on Austrian census forms. If too many diseases got identified then there would be no way of maintaining and analyzing registers of causes of death, as the technology would not hold more information. In addition to this inheritance, there is a practical Occam's razor. When doctors come to code causes of death they are frequently faced with a set of difficult judgments (which may require an autopsy and further diagnostic work). They can simply go for the easiest way, by using a generalized 'other' category. They can then get back to dealing with their live patients (Fagot-Largeault 1 989, chapter 3 ). So the classical beauty of the Aristotelian classification gives way to a fuzzier classification system that shares in practice key features with common sense prototype classifications-heterogeneous objects linked by metaphor or analogy. The powerful habits of practice with respect to the humble tasks of filling out forms are often neglected in studies of classifying. Goodwin (1996) provides an elegant description of working student archaeologists matching patches of earth against a standard set of color patches in the Munsell color charts. He argues that earlier cognitive anthropological work on color assumed a universal genetic origin for color recognition, but failed to examine the kinds of practices that informed the ways in which color tests were designed and carried out in the course of this research. He notes: Rather than standing alone as self-explicating textual objects, forms are embedded within webs of socially organized, situated practices. In order to make an entry in the slot provided for color an archaeologist must make use of another tool, the set of standard color samples provided by a Munsell chart. This chart incorporates into a portable physical object the results of a long history of scientific investigation of the properties of color. The version of this chart that archaeologists bring into the field has been tailored to the distinctive requirements of their work situation. ( 1 996, 66) The archaeologists constantly compare the pieces of earth against the chart, negotiate with each other, and transform their everyday terms for the earth into the formal numbered categories on the chart. The uncertainties they face along the way are removed once the numbers are selected and reported: " The definitiveness provided by a coding scheme typically erases from subsequent documentation the cognitive and perceptual uncertainties that these students are grappling with, as well as the work practices within which they are embedded" 66 Chapter 2 (Goodwin 1 996, 78; see also Star 1 983). In general, classificatory work practices involve politics, kinds of both prototypical and Aristotelian classifications, and deletion of the practices in the production of the final formal record. Contradictory Requirements of Classification Systems in General Classification systems in general inherit contradictory motives in the circumstances of their creation. This is very clearly illustrated by items in the ICD covering such charged ethical or religious issues as abortion or stillbirth. Over the years, as we will discuss in the next chapter, defining the moment of birth differed radically from Protestant to Catholic countries and with technological changes. The final definitions given in the lCD directly reflect the charged political and ethical atmosphere of the subject, distinguishing, for. example, legal and illegal abortion as separate categories. In this sense, the lCD can also be read as a kind of treaty, a bloodless set of numbers obscuring the behind-the-scenes battles informing its creation. This dryness itself contains an implicit authority, appearing to rise above uncertainty, power struggles, and the impermanence of the compromises. Indeed, one might observe that technical classification schemes are constructed in such a way as to fit our common-sense prototypical picture of what a technical classification is. Thus when the International Committee for the Nomenclature of Viruses, to which we shall return, floated the idea of using "siglas"-a series of code letters attached to the virus name to indicate its characteristics-Matthews describes the response: "Leading virology journals were only lukewarm to try out cryptogram ideas. Among comments from this period: 'Why should they be given funny names? Are we not exposing ourselves to the laughter of the general public? Do we want to join the ranks of old-fashioned botanists and zoologists so soon?'" (Matthews 1 983, 1 3- 1 4). A good technical classification should not only be correct in Aristotelian terms, it should, in good prototypical fashion, look and feel scientific. This is not an isolated case-the developers of the Nursing Interventions Classification (NIC) have made similar observations for example (as we shall see in chapter 7, they initially did not classify "leech therapy" not because it was not a scientific intervention but because it did not look and feel like one). With respect to the lCD, there has been a long debate within its patient community about naming chronic fatigue syndrome (CFS) for example (as there was for The Kindness of Strangers 67 AIDS). Consider this discussion among patients suffering from chronic fatigue syndrome. "Many patients feel that one of the greatest burdens of having chronic fatigue syndrome is the name of the illness. The word fatigue (which many patients refer to as the 'F' word) indicates everyday tiredness. It reinforces negative perceptions that remain with the public and most medical doctors, despite a decade of steady, gradual research advances" (Chronic Fatigue Syndrome Electronic Newsletter, 20 February 1 997). One option was to name it after Darwin, but it was felt that although he had the scientific cachet, he didn't necessarily have the disease. Inversely, Florence Nightingale's diagnosis is somewhat more certain but less prestigious: Nightingale's. (A general note: no historical figure has been definitively diagnosed with CFS/M.E. Purists may object to choosing any person in history, who may not have actually had the disease, as the basis for an eponym.) Florence Nightingale is a widely respected and world-renowned figure who founded the International Red Cross and the first formal school for nursing. For decades she had an undiagnosed, severely debilitating illness, whose symptoms were similar to CFS. Despite Nightingale's considerable talents and her personal character, many doubted that she had a physical illness. Her illness was quite controversial. A 1 996 paper by D.A.B. Young which appeared in the British Medical Journal indicates that Nightingale's illness was likely to have been chronic brucellosis (a disease with symptoms similar but not identical to CFS). Patient groups have promoted Nightingale's birthday, May 1 2, as International CFIDS/M.E. Awareness Day, and Nightingale is a familiar symbol to those who know this disease. However, some argue that women's diseases often have difficulty in getting recognized and accepted. Choosing Nightingale's name as an eponym might add to, rather than offer relief from, current name-associated problems. (Chronic Fatigue Syndrome Electronic Newsletter, 20 February 1 997) More generally, Taylor from a linguistic perspective and Durkheim and Mauss-for whom primitive, social classifications, "seem to link, without any discontinuity, with the first scientific classifications" (Durkheim and Mauss 1 969, 82)-from an anthropological one have observed that technical classifications grow out of and have to answer to our common sense, socially comfortable classifications. It just would not be socially feasible to call a donkey a fish, no matter how good your scientific grounds. There is no great divide between folk and scientific classifications. Below, we discuss one particular fault line between the two: a fracture that is constantly being redefined and changing its nature as the plate of lived experience is subducted under the crust of scientific 68 Chapter 2 knowledge. This fault line is the ways in which temporal experienceshistory, events, development, memory, evolution-are registered in and expressed by two formal classification systems, the lCD and the INV. The crack comes when the messy flow of bodily and natural experience must be ordered against a formal, neat set of categories. We will trace this particular fault line across the two classification schemes. It is the case that all complex classification schemes have multiple sets of faults and fractures arising from similar tensions. Chapter 5 sets forth a model of the fault process as it occurs for clinical and bodily trajectories in tuberculosis. On a meta level, the system of faults and tensions forms a kind of texture of any given organizational terrain; mapping this texture is a major research challenge for the field of social informatics. The International Classification of Diseases Is a Pragmatic Classification To communicate information in the aggregate, we must first classify. At any time over the past 1 00 years one can find complaints about the Tower of Babel that affiicts the storage and communication of medical knowledge.12 David Rothwell notes that " More than two hundred statistical systems are being used by the United States government to monitor health, occupational and environmental conditions through the country. Despite the incredible amount of information accumulated, there is no method of coordinating these data into a single coherent database, a national health information system" (1985, 1 69). Mark Musen complains: The medical-informatics community suffers from a failure to communicate. The terms that WMR uses to describe patient findings generally are not recognized by Medline. The manner in which Iliad stores descriptions of diseases is different from that of Dxplain. Therapy plans generated by ONCOCIN are meaningless to the HELP system .... Each time another developer describes yet another formalism for encoding medical knowledge, the number of incompatibilities among these different systems increases exponentially. (Museu 1 992, 435) He points out that there is no clear relationship between "the Unified Medical Language System [UMLS] advanced by the National Library of Medicine and the Arden syntax proposed by the American Society for Testing and Materials as a standard for representing medical knowledge" (Musen 1 992, 436). The lCD, he points out, originated as The Kindness of Strangers 69 a means for describing causes of death; a trace of its heritage is its continued difficulty with describing chronic as opposed to acute forms of disease. This is one basis for the temporal fault lines that emerge in its usage. The UMLS originated as a means of information retrieval (the MeSH scheme) and is not as sensitive to clinical conditions as it might be (Musen 1 992, 440). The two basic problems for any overarching classification scheme in a rapidly changing and complex field can be described as follows. First, any classificatory decision made now might by its nature block off valuable future developments. If we decide that all instances of sudden infant death syndrome (SIDS) are to be placed into a single box (R95 in ICD-10), then we are not recording information that might be used by future researchers to distinguish possible multiple social or environmental causes of SIDS. We are not making it impossible to carry out such studies; but we are making it difficult to retrieve information. Inversely, if every possibly relevant piece of information were stored in the scheme, it would be entirely unwieldy. For these reasons, the decision not to collect is the most difficult to take for people maintaining any sort of collection based on a classification system, whether it be the acquisition department of a library, the curator of an art museum, or the collector of information for vital statistics. There are always practical budget and storage issues. These are balanced against two other factors, the need for a well-ordered and in some sense parsimonious repository that can be used, and the side bets that are made about what material will be useful in the future. This latter is particularly difficult. Collectors and curators of all sorts must become future forecasters and decide the boundaries of what will be useful for the future. There is no perfect answer, only a set of practical tradeoffs. This is a problem that has plagued museums of natural history. Fossils found in the nineteenth century might come along with general information about the depth at which they were discovered and the surrounding geological features (though they often did not). Even if this information was included, it was never as precisely noted as would be useful for geologists and paleontologists today: since there was no conception at that stage of the kinds of dating techniques that are used nowadays. The museum is then faced with the choice between recording as much as possible now (which is very expensive and possibly not useful anyway) and having the collection perhaps last longer into the future, or recording a judicious amount now (which will keep the administrative costs down) and having the 70 Chapter 2 collection possibly be not so useful in the future. The latter has generally been the de facto choice and is generally a reasonable one to have made since new criteria of relevance cannot be predicted. Second, different designers of the classification system have different needs, and the shifting ecology of relationships among the disciplines using the classification will necessarily be reflected in the scheme itself. As with the insurance company example above, these relationships must be resolved to make a usable form, often obscuring power relationships in the process. As Goodwin notes, "A quite different kind of multivocality, one organized by the craft requirements of a work task rather than the genres of the literary academy, can be found in mundane, bureaucratic forms" (1996, 66). But one must dig to find the voices. The process of filling out the forms may further obscure them. For example, the designers of the ICD recommend that its classification scheme be interpreted economically: The condition to be used for single-condition morbidity analysis is the main condition treated or investigated during the relevant episode of health care. The main condition is defined as the condition, diagnosed at the end of the episode of health care, primarily responsible for the patient's need for treatment or investigation. If there is more than one such condition, the one held most responsible for the greatest use of resources should be selected. (ICD-10, 2: 96) This reflects a constant condition of the use of the ICD: it has been recommended throughout its history that priority should be given to coding diseases that represent a threat to public health. This goal is clearly a good one; equally clearly it can discriminate selectively against the reporting of rare noncontagious conditions. In chapter 4 we discuss an ongoing battle between statisticians (who are not generally interested in the very rare occurrences of disease) and public health officials (who want to know about even one case of bubonic plague or Ebola!). Faced with these problems, the WHO has been consistently pragmatic in its aims and clear in its explanations of the ICD. From the time of the ninth revision on, it has been recognized explicitly that "the ICD alone could not cover all the information required and that only a 'family' of disease and health related classifications would meet the different requirements in public health" (IDC- 1 0, 2: 20). This "family" is pictured in ICD- 10 as shown in figure 2.2. The family itself is a diverse one: there are various standard modifications of the I CD. The most significant in the United States is the ICD-9-CM, where CM stands for "clinical modification." This INFORMATION SUPPORT TO PRIMARY HEALTH CARE INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS lCD 3-Character core Classification • Diagnoses • Lay reporting • Other community-based information schemes in f----------j, • Symptoms Abnormal laboratory findings heal th OTHER HEALTH RELATED CLASSIFICATIONS • Impairment. Disabilities and handicaps • Procedures • Reasons for encounter (complaints) Figure 2.2 • Injuries and poisonings • External causes of morbidity and mortal ity • Factors in!fuending health status Short !CD � tabu!- character ation classiticl ists ation - The Kindness of Strangers 71 SPECIALITY-BASED ADAPTIONS . Oncology . Dentistry and stomatology . Dennatology . Pychiatry . Neurology . Obstetrics and gynaecology . Rheumatology and orthopaedics . P aediatrics, etc . • General medical practice !INTERNA TIONAL I NOMENCLATURE OF DISEASES (IN D) Pigeonholing the classification-the lCD family. Source: Adapted from ICD-10, 1. document has a complex history, tracing back to the development of modifications of the ICD for use in hospital information systems. It is now the classification of record in a wide variety of medical settings, and it is used for billing, insurance, and administration as well as in patient medical records. This institutional entrenchment of ICD-9-CM has made it very difficult for I CD -10 to be fully adopted in the United States: the clinical modification necessarily lags behind the production of the classification itself. When we come to look at the ways in which culture and practice interweave in the text of the ICD, we are not unmasking a false pretender to the crown of science; we are drawing attention to an explicit, positive and practical feature of ICD design: " The ICD has developed as a practical, rather than a purely theoretical classification. 72 Chapter 2 . There have ... been adjustments to meet the variety of statistical applications for which the ICD is designed, such as mortality, morbidity, social security and other types of health statistics and surveys" (ICD- 1 0, 2: 1 2). The preamble to the classification defines a classification of diseases as: 'a system of categories to which morbid entities are assigned according to established criteria' (ICD- 1 0, 2, vol. 1). A statistical classification, such as the ICD "must encompass the entire range of morbid conditions within a manageable number of categories" (ICD-10, 2: 1). It is not meant to be a net to capture all knowledge, but rather a workable epidemiological tool. This practical goal does not make it less scientific. All classification systems are developed within a context of organizational practice. The goal of the ICD's designers is to create what Latour (1988) has called immutable mobiles, inscriptions that may travel unchanged and be combinable and comparable. Indeed the term immutable mobile might almost have been in the designers' minds when they wrote, " The purpose of the lCD is to permit the systematic recording, analysis, interpretation, and comparison of mortality and morbidity data collected in different countries or areas and at different times. The ICD is used to translate diagnoses of diseases and other health problems from words into an alphanumeric code, which permits easy storage, retrieval and analysis of the data" (ICD-10, 2: 2). The ICD has become the international tool for "standard diagnostic classification for all general epidemiological and many health management purposes" (ICD-10, 2: 2). The world has changed since the ICD was first introduced, and the classification scheme has evolved to try to encompass these changes. The ICD is thus both highly responsive and tightly constrained. A large-scale change in the way that people die (Israel et al. 1 986, 161) has led to the addition of one line in the internationally recommended death certificate (see figure 2.3). One of the main bureaucratic uses of the ICD is the recording and compiling of causes of death from bureaus of vital statistics via coroners, hospitals, doctors, or priests: In considering the international form of medical certificate of cause of death, the Expert Committee had recognized that the situation of an aging population with a greater proportion of deaths involving multiple disease processes, and the effects of associated therapeutic interventions, tended to increase the number of possible statements between the underlying cause and the direct cause of death: this meant that an increasing number of conditions were being entered on death certificates in many countries. This led the committee to recommend the inclusion of an additional line (d) in Part 1 of the certificate. (ICD-10, 1: 1 8) Cause of Death Disease or condition directly leading to death* (a) ..................... ......... . The Kindness of Strangers 7 3 Approximate interval between onset and death due to (or as a consequence of) Antecedent causes (b) ···· ··························· Morbid conditions, if any, giving rise to the above cause, stating the underlying condition last due to (or as a consequence of) (c) ................... ........... . (d) .......... ............ ........ . II Other significant conditions contributing to the death, but not related to the disease or condition caus ing it This does not mean the mode of dying, e.g. heart failure, respiratory failure. It means the d isease. inj ury, or comp l ication that caused death. Source : Adapted from Fagot-Largeault, 1 986. Figure 2.3 A standard international death certificate. Source: Adapted from Fagot-Largeault 1 986. Thus there is now one more blank line on the form to indicate multiple causation. A major change incorporated in the classification scheme in the last two revisions has been the so-called "dagger and asterisk" system, this is a means of cross-referencing manifestations and underlying causes for a particular disease. The ICD and its instruments have thus, through a pair of small-scale formal changes (a line here and an asterisk there), loosened up their implicit causality and thus their picture of the past. Histories now can be more fluid than they once could. More complex narratives are possible. 74 Chapter 2 The classification scheme is responsive to changes in medicine and medical technology in many ways; there are constant changes in the allopathic understanding and description of diseases reflected in the classification scheme itself. The development of new diagnostic technology in the 1 940s, for example, led to the reclassification of tuberculosis (otherwise there would have been too many cases). The 1 955 edition of Diagnostic Standards and Classification of Tuberculosis notes that new laboratory tests had made it more difficult to decide whether a particular case of tuberculosis was active or inactive, since activity could now be seen at sites previously considered inactive. At the same time, one would not necessarily want to call the "new" active sites cases of tuberculosis, since they very well may not progress to the point of needing treatment. The committee cites the 1 955 version of the book. " The Committee, however, recognizes the fact that all classifications are ephemeral. They are useful only as long as they serve their purpose. The purpose of a clinical classification of tuberculosis is, however, a most important one. On it depend such matters as legal requirements for isolation, medico-legal considerations with respect to compensation for disability, standards for the return of patients to work, and similar matters" (Diagnostic Standards and Classification of Tuberculosis, 1 955: 6). We will discuss the classification of tuberculosis in more detail in chapter 5. For another similar example, the discovery of the lentiviruses led to the description of a new set of disease entities: slow-acting viruses from which one could suffer asymptotically for extended periods. In the interests of creating a working infrastructure, Aristotelian principles are here deliberately violated: C15 Malignant neoplasms of oesophagus Note: Two alternative subclassifications are given: .0-. 2 by anatomical description .3-. 5 by thirds This departure from the principle that categories should be mutually exclusive is deliberate, since both forms of terminology are in use but the resulting anatomical divisions are not analogous. (ICD-1 0, 1: 1 90) Where the state of the art is unclear, so is the scheme itself, Note: The terms used in categories C82-C85 for non-Hodgkin's lymphomas are those of the Working Formulation, which attempt to find common ground among several major classification schemes. The terms used in these schemes are not given in the Tabular List but appear in the Alphabetical Index; exact equivalence with the terms appearing in the Tabular List is not always possible. Includes: morphology codes M959-M994 with behaviour code /3. The Kindness of Strm1gers 75 Excludes: secondary and unspecified neoplasm of lymph nodes (C77.-). (ICD-10, 1: 215) There are several specialty-based adaptations of the lCD originating in different national or international bodies (dermatology, stemming from the British Association of Dermatologists; and, under development, rheumatology and orthopaedics from the International League against Rheumatism). (!CD 10, 2, vol. 5-6). The lCD is also directly responsive to other types of changes in the world. Diseases themselves die (smallpox), are superseded (GayRelated Immune Disorder (GRID) becomes AIDS), are newly born (radiation sickness with the discovery of radium), or fall into disrepute (hysteria or neurasthenia). Since the lCD is a statistical classification, a disease with no incidence is of no interest. Thus smallpox was still well defined within ICD-9, 050 Smallpox Excludes: arthropod-borne viral diseases (060.0-066.9) Boston exanthem (048) 50.1 Variola major hemorrhagic (pustular) smallpox Malignant smallpox Purpura variolosa 50.1 Alastrim Variola minor 50.2 Modified smallpox Varioloid 050.9 Smallpox, unspecified (ICD 9CM: 11) By ICD-10 this had collapsed into: "B03 Smallpox," with a footnote: "In 1980 the thirty-third World Health Assembly declared that smallpox had been eradicated. The classification is maintained for surveillance purposes" (lCD-I 0, l, 150). Or again, malnutrition is defined in relativistic fashion-as the population changes so does the definition: The degree of malnutrition is usually measured in terms of weight, expressed in standard deviations from the mean of the relevant reference population. When one or more previous measurements are available, lack of weight gain in children, or evidence of weight loss in children or adults, is usually indicative of malnutrition. When only one measurement is available, the diagnosis is based on probabilities and is not definitive without other clinical or laboratory tests. In the exceptional circumstances that no measurernenL of weight is available, reliance should be placed on clinical evidence. (lCD-I 0, I: 290) In these cases, then, the fact that the world is changing is reflected direct.ly in the classification scheme. Another source for this recogni- 76 Chapter 2 tion is the development of accident categories, which also in their explanations display a historical cultural specificity. For example, this set of accident categories describes a series of tumbles more common in the industrial world than for a nomadic tribe: E884 E884.0 Other fall from one level to another Fall from playground equipment E884. 1 Excludes: recreational machinery (E9 1 9.8) Fall from cliff E884.2 Fall from chair E884.3 Fall from wheelchair E884.4 Fall from bed E884.5 Fall from other furniture E884.6 Fall from commode Toilet E884.9 Other fall from one level to another (ICD-9-CM, 289) Fall from: Fall from: embankment haystack stationary vehicle tree There is a relatively impoverished vocabulary for talking about natural accidents. The lCD is richest in its description of ways of dying in developed countries at this moment in history; it is not that other accidents and diseases cannot be described, but they cannot be described in as much detail. Differentiating insect bites and snake bites, for example, is very important for those living in the rural tropics. While arthropods, centipedes, and chiggers are singled out under "bites" in the lCD index, however, snakes are only divided into venomous and nonvenomous, as are spiders.13 Clearly this makes sense to some extent, given that this is a pragmatic classification. There is only a point in making fine distinctions between types of accident if those distinctions might make a difference in practice to some agencymedical or other. At the same time, those agencies have traditionally been more accountable to Western allopathic medicine and to the industrial world than to traditional indigenous or alternative systems. So the lCD bears traces of its historical situation as a tool used by public health officials in developed countries. It also reflects changes in the world at large, either the eradication of diseases or culturally charged changing understandings of certain conditions. Further, it is very much an entrenched scheme. There is a natural reluctance to operate changes, since each change renders a previous set of statistics incomparable and thence less useful. The Kindness of Strangers 77 The first and last entries in the lCD describe a sociotechnical trajectory. The first disease in the lCD over the years has been cholera; unsurprising, since cholera was the issue that in the 1 850s brought participants to the table in an attempt to deal with it as an international threat. As we noted in the introduction, this threat was exacerbated by the development of steamship technology, which allowed cholera sufferers to carry the disease back to Europe before dying. The last condition given in the book takes us to the other end of the sociotechnical arc-the creation of cyborgs. The last condition listed in the lCD is: zgg "Dependence on enabling machines and devices, not elsewhere classified"; with the very last entry, Z99.9, being "Dependence on unspecified enabling machine and device." By some standards we all now qualify for the Z99.9 condition. The original sequence produced by William Farr (1885, 232) is reproduced in the latest lCD: The ICD is a variable-axis classification. The structure has developed out of that proposed by William Farr in the early days of international discussions on classification structures. His scheme was that, for practical, epidemiological purposes, statistical data on diseases should be grouped in the following way: • epidemic diseases • constitutional or general diseases • local diseases arranged by site • developmental diseases • lllJUfleS This pattern can be identified in the chapters of ICD- 10. It has stood the test of time and, though in some ways arbitrary, is still regarded as a more useful structure for general epidemiological purposes than any of the alternatives tested. (ICD- 1 0, 1: 1 3) This classification scheme, then, makes no exaggerated claims to timeless truth. To the contrary. Its designers have attempted to paint a fluid picture of the world of disease-one that is sensitive to changes in the world, to sociotechnical conditions, and to the work practices of statisticians and record keepers. There Are Many Aids to Storytelling in the lCD The classification system that is the lCD does more than provide a series of boxes into which diseases can be put; it also encapsulates a 78 Chapter 2 series of stories that are the preferred narratives of the ICD's designers. Certain attributions of intentionality are easy to make; others are rather difficult. Some ways of life are clearly considered to be well led, others are called into question. Sometimes context is important; sometimes it can be ignored. Stories also come and go, narratives fade in importance (the example of AIDS moving, in medical terms, from a specifically gay-linked disease to a more general one). If one should have doubts about how to encode a given story, one can turn to volume 2 of the classification, which gives an extensive set of rules for the interpretation of causes of death. In this section, we will look at the various aids to storytelling to be found within the lCD. The Setting Frequently, when diseases have first been named, they have taken on the name of their first scientific describer, of a famous victim, or of the place where they occur. Each of these kinds of naming strategy tells a simple story to accompany the classification. Throughout the history of classification systems over the past 200 years such specifications have progressively been winnowed away to make way for new kinds of context and new kinds of description now considered more interesting and relevant. What many sufferers of amyotrophic lateral sclerosis know as Lou Gehrig's disease is coded by the ICD-10 as G12.2: motor neuron disease. (With the famous physicist Stephen Hawking now suffering from the disease, it may in future be more well known to the lay public as Hawking's disease, though baseball player Lou Gehrig first brought it to public awareness.) In the index to the lCD, the Parisian neurologist Charcot can lay claim to an arthropathy (tabetic), a cirrhosis, and a syndrome. In the body of the text, the great doctor tends to slip away; Charcot's syndrome becomes 173.9 peripheral vascular disease, unspecified, and there is no mention of Charcot. The I73s (other peripheral vascular diseases) are an interesting category. They show the various forms of modality: 173.0 is still proudly Raynaud's syndrome, 173. 1 is thromboangiitis obliterans [Buerger], 173.8 is other specified peripheral vascular diseases, and includes acroparaesthesia-simple [Schultze's type] or vasomotor [Nothnagel's type]. In general, as the modalities get deleted the name of the person goes from being the name of the disease to a bracket after the name to an entry in the index, until finally it slides gracefully out of the index onto the scrap heap of history. A similar The Kindness of Strangers 79 process occurs with deletion of detail and the uncertainties of discovery in any scientific publication, as Latour and Woolgar noted in their classic Laboratorj' Life ( 1979; see also Star 1983). Places follow a similar path to abstraction and formal representation. The ideal ICD disease is not tied to a particular spot, it is rather identified with a particular causal agent. Up to and including ICD-9, howeve1; leishmaniasis was a classification that told a travelers' tale; not only do we know what you got sick of but where you got sick: 085 Leishmaniasis 085.0 Visceral [kalaazar] Dumdum fever Leishmaniasis: Infection by Leishmania: dermal, post-kala-azar donovani Mediterranean infantum visceral (Indian) 085.1 Cutaneous, urban Aleppo boil Leishmaniasis, Baghdad boil cutaneous: Delhi boil dry form Infection by Leishmania late tropica (minor) recurrent Ulcerating Oriental sore 085.2 Cutaneous, Asian desert Infection by Leishmania tropica major Leishmaniasis, cutaneous: Acute necrotizing Rural Wet form Zoonotic form 085.3 Cutaneous, Ethiopian Infection by Leishmania ethiopica Leishmaniasis, cutaneous: Diffuse Lepromatous 085.4 Cutaneous, American Chiclero ulcer Infection by Leishmania mexicana Leishmaniasis tegumentaria diffusa 085.5 Mucocutaneous (American) Espundia Infection by Leishmania braziliensis Uta 085.9 Leishmaniasis, unspecified (IC0-9-CM, 16) 80 Chapter 2 Similarly, for ICD-10, we can still find "Delhi boil" in the index, but the main entry itself is a svelte : B55 B55.0 B55. l Leishmaniasis Visceral leishmaniasis Kala-azar Post kala-azar dermal leishmaniasis Cutaneous leishmaniasis B55.2 Mucocutaneous leishmaniasis B55.9 Leishmaniasis, unspecified (ICD-10, 1: 1 66) So we go from primacy being given to a place (Baghdad boil) to primacy being given to a kind of place (urban cutaneous) to primacy given to a universal agent. Gradually the narrative of travel inscribed in the disease code and thus on the patient's form, present earlier, is deleted. The loss of eponymy and place markers can of course be read as a story of the advance of science: the replacement of the local and specific with the general; the thing with the kind; the mutable immobile with the immutable mobile, and the concrete instance with the formal abstraction. Another line of argument, however, also deserves attention. As we have already seen, the lCD reflects historical states of the world, and the world has changed. With the huge increase in international travel over the past century and a half, it is more rare for a disease to be tied to any one particular location; rather diseases themselves tend to spread to kinds of location. The malaria map of the world hanging on the wall at the WHO headquarters in Geneva shows the expected tropical venues, and it also shows small red circles around major airports as mosquitoes are transported from the tropics. We are as a world becoming more abstract in this way. Similarly, research now is not attributed to single great figures who can claim sole responsibility for a discovery. Medical work was always done in teams, but they have become larger, involving complex social and institutional relationships of attribution as Gallo and Montaignier would be the first to remind us (Grmek 1 990). A typical scientific article has so many authors that the death of the individual scientific author appears certain. In general, the lCD has gone from being the holder of a set of stories about places visited, heroic sufferers, and great doctors to holding another set of stories. The Kindness of Strangers 81 The Context of Disease As people and places have moved out of eponymous and loconymous classification, these specific categories are replaced by a general set, what we call the kindness of strangers. By this we mean that the classification system operates a shift away from our being individuals experiencing the world to our being kinds of people experiencing kinds of places. The constructions of social and natural science and of the legal world have moved in. Broken legs and ski resort locations coevolve, as do cancer rates and toxic waste dumps. The classification system, as we shall see in this section, has become a site that holds these constructions together and, through excluding other kinds of story, makes them more real. With the lCD providing the main legitimate means for describing illness, the social, economic, and political stories woven into its fabric become by extension the main legitimate narrative threads for the science of medicine. Although particular places have moved out, two places have come to play a more significant role in the classification system, the laboratory and the "sociological home." This latter appears in the extra categories developed for ICD-9 as supplemental codes, which in lCDI 0 have become fully integrated, what we might call the context codes. Thus housing is one of the conditions that can be broken down and described as part of the classification. In ICD-9 it is described as follows: V60 V60.0 V60. 1 V60.2 V60.3 V60.6 Housing, household and economic circumstances Lack of housing Hobos Social migrants Tramps Inadequate housing Lack of heating Restriction of space Transients Vagabonds Technical defects in home preventing adequate care Inadequate material resources Economic problem Poverty NOS Person living alone Person living in residential institution Boarding school resident V60.8 Other specified housing or economic circumstances V60.9 Unspecified housing or economic circumstances. (ICD-9, 1: 267) 82 Chapter 2 The related code m ICD-10 is expanded to include discord with neighbors and lack of adequate food (ICD-1 0, 1: 1, 1 52). In both, the name of the city gives way to the name of the social category and social condition. These context codes define what is considered to be medically relevant in one's material surroundings. They make it easy to structure studies in these terms (for example, what effect does poor housing have on the incidence of tuberculosis?). At the same time, these codes do make it much more difficult to deal with unrecognized contexts (what effect does conspicuous consumption have on cholesterol levels?). It is not impossible to do these latter studies, but the information is not at hand in the way that it is for medically sanctioned contexts. The reason we stress this point is that it can be taken as a sign of the correctness of allopathic medicine: it has isolated the basic variables that need to be taken into account in the development of public health policy or medical science. Although the lCD is a powerful tool in this sense it also, as infrastructure, enforces a certain understanding of context, place, and time. It makes a certain set of discoveries, which validate its own framework, much more likely than an alternative set outside of the framework, since the economic cost of producing a study outside of the framework of normal data collection is necessarily much higher. This sort of convergence is an important feature of large-scale networked information systems. Convergence, again, is the double process by which information artifacts and social worlds are fitted to each other and come together (Star, Bowker, and Neumann, in press). On the one hand, a given information artifact (a classification system, a database, an interface, and so forth) is partially constitutive of some social world. The sharing of information resources and tools is a dimension of any coherent community, be it the world of homeless people in Los Angeles sharing survival knowledge via street gossip, or the world of high-energy physicists sharing electronic preprints via the Los Alamos archive. On the other hand, any given social world itself generates many interlinked information artifacts. The social world creates through bricolage, a (loosely coupled but relatively coherent) set of information resources and tools. Thus people without houses also log onto the Internet, and physicists indulge in street gossip at conferences as well as engage in a whole set of other information practices. Put briefly, information artifacts undergird social worlds, and social worlds undergird these same information resources. We will use the concept of convergence to describe this process of mutual constitution. The Kindness of Strangers 83 With these processes of convergence, the site of the medical work itself has gained in importance. The classification of tuberculosis, canonically difficult to diagnose accurately (see chapter 5; and compare Latom� forthcoming) retains the story of what has been done in the laboratory as well as what has occurred in the body. (In chapter 4 we discuss the intersection of these different forms of time.) Al5 Al5.0 Respiratory tuberculosis, bacteriologically and histologically confirmed Tuberculosis of lung, confirmed by sputum microscopy with or without culture Tuberculous, • bronchiectasis } • fibrosis of lung • pneumonia • pneumothorax } confirmed by sputum microscopy with or } without culture A 15.1 Tuberculosis of lung, confirmed by culture only Conditions listed in Al5.0, confirmed by culture only Al5.2 Tuberculosis of lung, confirmed histologically Conditions listed in Al5.0, confirmed histologically Al5.3 Tuberculosis of lung, confirmed by unspecified means Conditions listed in A15.0, confirmed but unspecified whether bacteriologically or histologically (lCD-10, 1: 1 13) In this case, the disease itself is always classified in terms of the work that has been done in the medical laboratory. Again, as new technologies are invented, historical shifts occur, as seen with the relationship between epilepsy and the EEG machine as diagnostic many decades ago. The doctors themselves enter the story at the moment of classification, while the patient rarely does. This comes out clearly if we compare migraine and epilepsy in ICD-9. Epilepsy is a condition that is defined by the doctor in the context of laboratory and so is a real condition: 345 Epilepsy The following fifth-digit subclassification is for use with categories 345.0, .1, .4-.9: 0 without mention of intractable epilepsy I with intractable epilepsy (ICD-9CM, 80) 84 Chapter 2 So here the question 1s whether or not the patient objectively has intractable epilepsy in the opinion of the doctor. The determination of intractable migraine, however, relies on the voice of the patient and so is marked as a suspicious designation: 346 Migraine The following fifth-digit subclassification is for use with category 346: 0 without mention of intractable migraine 1 with intractable migraine, so stated (ICD-9CM, 80) The laboratory context then is the 'real' context of the disease; the classification serves to reinforce the separation of the patient from ownership of their condition. We should note at this point that we are not arguing that this makes the ICD a tool for evil and oppression. On the contrary. What we are trying to do is work out what kind of a tool it is, what work it does, and whose voice appears in its unfolding narrative. The legal context is often enfolded into the classification system. Thus the classification of blindness takes account of the American system of medical benefits: 369 Blindness and low vision Note: visual impairment refers to a functional limitation of the eye (e.g. , limited visual acuity or visual field). It should be distinguished from visual disability, indicating a limitation of the abilities of the individual (e.g. , limited reading skills, vocational skills), and from visual handicap, indicating a limitation of personal and socioeconomic independence (e.g. , limited ability, limited employment.) The levels of impairment defined in the table on page 92 are based on the recommendations of the WHO Study Group on Prevention of Blindness (Geneva, November 6-10 1 972, WHO Technical Report Series 518), and of the International Council of Ophthalmology (1976). Note that definitions of blindness vary in different settings. For international reporting WHO defines blindness as profound impairment. This definition can be applied to blindness of one eye (369. 1, 369.6) and to blindness of the individual (369.0). For determination of benefits in the United States, the definition of legal blindness as severe impairment is often used. This definition applies to blindness of the individual only. 369.0 Profound impairment, both eyes 369.00 Impairment level not further specified Blindness: NOS according to WHO definition both eyes 369. 3 Unqualified visual loss, both eyes Excludes: blindness NOS: The Kindness of Strangers 85 legal [U.S. definition] (369.4) WHO definition (369.00) 369.4 Legal blindness, as defined in United States Blindness NOS according to U.S. definition Excludes legal blindness with specification of impairment level 9369.0 1- 369.08, 369. 1 1-369. 1 4, 369.2 1-369.22) (ICD-9CM, 91) Note in the above example that "blindness of the individual" might be psychogenic, due to brain damage, or other organic cause outside the eye itself. The problem of localized versus whole organism conditions creates serious coding challenges. For example, depending on one's theory of cancer, it would be an immune disorder affecting the whole person, or a localized phenomenon to be surgically removed, and with many gray areas in between for the different types of cancer. In the example above, the legal definition can take precedence over the cultural and social. Thus cannabis dependence has its own category, while the culturally profoundly different absinthe and glue addictions are lumped together: 304.3 Cannabis dependence Hashish Marihuana Hemp 304.6 Other specified drug dependence Absinthe addiction Glue sniffing Excludes: tobacco dependence (305. 1) (ICD-9CM, 69-70) Few would argue that glue sniffing and absinthe addiction are similar phenomena. The former leads to more serious physical conditions than 'cannabis dependence' (a category many would challenge), and yet it does not rate its own category. Absinthe addiction is, one suspects, a hangover from earlier days. Because the origins of the ICD were French, and absinthe abuse an important problem in Paris in the nineteenth century, it persists. These accidents of history, practice and crime contain many clues to re-narrativizing the ICD. E970 to E979 in ICD-9 is an interesting set that covers injuries caused by legal interventions: Legal intervention Includes: injuries inflicted by the police or other law-enforcing agents, including military on duty, in the course of arresting or 86 Chapter 2 attempting to arrest lawbreakers, suppressing disturbance, maintain order and other legal action legal execution Excludes: injuries caused by civil insurrections (E990.0-E999) (ICD-9CM, 304) This set includes state executions. Note that civil insurrections, where the definition of legal intervention is on the table, are classified together with war. The definition of legal, of course, may be subject to its own retrospective reconstruction, as in the case of the Rodney King trial, l4 Types of abortions, which may be to all intents and purposes medically equuivalent, are marked differently in the lCD according to their legality: 635 Legally induced abortion Includes: abortion of termination of pregnancy: elective legal therapeutic Excludes: menstrual extraction or regulation (V25.3) 636 Illegally induced abortion (ICD-9CM, 1 54) Includes: abortion: criminal illegal self-induced Each type of abortion (spontaneous or 634, legally induced, illegally induced, unspecified, failed attempted, or 638) has the same set of complications attached-nine difficulties, each accorded a digit (making it one of the most closely coded category sets in the lCD). When the issue arises, then, the lCD privileges the voice of the doctor and the laboratory over the voice of the patient; and legal discourse over cultural and social discourse. There are no mentions of what Adele Clarke calls "subtle forms of sterilization abuse" (1 983) or of the abortions that never made it into any formal record that Leslie Reagan describes in her book When Abortion Was A Crime (1 997). The controversial "abortion drug" RU486 is not mentioned in the ICD-10. One can read another order of social history from the nature of the silences in the story. In general, the lCD carries with it its own context. This is a common feature of classification systems. One way of reading them is that they provide a stabilizing force between the natural and the social worlds. They hold in place sets of arrangements that allow us to read the The Kindness of Strangers 87 natural as stable and objective and the social as tightly linked to it. For the ICD this means describing disease in a way that folds the socially and legally contingent into the classification system itself, and so naturalizes it. Inversely, the disease entity out there in the world is brought into the laboratory where the social and organizational work of its stabilization can best be guaranteed. Cutting Up the World To tell stories of the sort we are most familiar with, one needs objects in the world that can be cut up spatially (Berg and Bowker 1 997) and temporally into recognizable units. Narrative structures are typically formed with a moving time line, protagonists, and a dramatic structure unfolding over time. The ICD does in fact operate this kind of dissection, which we will discuss below. In the last section we saw the constitution of a context within the ICD, in this section we will see the constitution of actants to populate that context and those stories. Time Story One: The Life Cycle Temporally, the classification system provides a picture of acute (temporally bounded) episodes within an otherwise well-ordered life. It is notoriously bad for describing chronic diseases: the interest is in the episode of treatment (Musen 1 992). Let us go through some temporal units presented by the ICD. Birth is extremely important and is very closely defined: Live birth is the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of the pregnancy, which, after such separation, breathes or shows any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached; each product of such a birth is considered live born. (ICD-10, 2: 1 29) We will discuss in chapter 4 the political and religious dimensions of this definition, which have been very closely attended to throughout the period of the ICD's development. For our present purposes, it is sufficient to note that time flows very quickly for the newborn, and so temporal units vary accordingly: The neonatal period commences at birth and ends 28 completed days after birth. Neonatal deaths (deaths among live births during the first 28 completed days of life) may be subdivided into early neonatal deaths, occurring during the first 7 days of life, and late neonatal deaths, occurring after the seventh day but before 28 completed days of life. 88 Chapter 2 The age at death during the first day of life (day zero) should be recorded in units of completed minutes or hours of life. For the second (day 1 ), third (day 2), and through 27 completed days of life, age at death should be recorded in days. (ICD-10, 2: 131) Given the bump in mortality that occurs around birth, this is not surprising. When we get into adult life, things start to slow down. Adults are defined in ICD9-CM (xiii) as people between 15 and 1 24 years old. If you make it to 1 25, you are "hors de categorie!" In this middle period, there are some indications of what constitutes a good life. It should be well ordered and rhythmic. Things should happen at the right time. Thus sexual development has its own timing: 259 Other endocrine disorders 259.0 Delay in sexual development and puberty, not elsewhere classified Delayed puberty 259. 1 Precocious sexual development and puberty, not elsewhere classified PED Sexual precocity: (ICD-9CM, 51) NOS constitutional cryptogenic idiopathic Similarly, problems with temporal regulation of menstruation are well defined-too early, too late, too frequent, not frequent enough-natural rhythms should not be upset. A relatively recent temporal problem in addition is jet lag: 307 .45Phase-shift disruption of 24-hour sleep-wake cycle Irregular sleep-wake rhythm, nonorganic origin Jet-lag syndrome (ICD-9CM, 71) Rapid time-zone change Shifting sleep-work schedule The reference to the "nonorganic origin" highlights that this is a situation-bound condition: the context (jet travel or night-shift work) is directly folded into the disease. To an outside observer, there is remarkably little reference to the process of aging. An adult is a timeless being who should be healthy: The Kindness of Strangers 89 disease is not in general indexed by age. Further, the body is not present as something that gets used up and worn out: such stories have to be superadded. (Indeed, the category of being "worn out" was in earlier additions of the lCD but has since been removed). If you rent a house, your agreement with the landlord includes a " fair use" or "normal wear and tear" category: it is expected that houses depreciate over time and this is written into the legal and tax codes. There are only two references to normal wear and tear in the whole lCD. First, one can as an adult step out of the well-ordered life and suffer from premature or delayed senility, puberty, birth, and aging. Among the conditions under "delay" are delayed birth, development (including intellectual, learning, reading, sexual, speech, and spelling), menstruation, and puberty. In this case the cycle structure is the same, but the patient is taking the steps too early or too late. Second-and there is only one example of this-you could use your body badly. The only specific instance of this, however, is that you can grind or otherwise mismanage your teeth: 52 1 Diseases of hard tissues of teeth 52 1.1 Excessive attrition Approximal wear. Occlusal wear (ICD-10, 1: 1 25) In ICD-1 0, abrasion of teeth carries with it an illuminating set of contexts: dentifrice, habitual, occupational, ritual, and traditional. Occupational abrasion in earlier times included the hazard "tailor's tooth," for example, where the teeth were abraded due to biting off the thread in hand sewing. In principle, the timeless adult could do many things excessively-there are categories for excessive thirst, secretion, salivation, sex drive, and sweating and binocular convergence among others. Such superfluity, however, is indexed only in this one case against an aging body. Note that there are of course diseases associated more broadly (and often implicitly) with excessive wear and tear, for example, cirrhosis of the liver associated with alcoholic excess. But here we are concerned directly with representation in the classification system. This curious invisibility of aging as wear and tear is one way in which the ICD stabilizes context and disease entity, the human body as the substrate of both is outside the flow of time. The human adult body becomes the unmarked category, the cipher against which laboratory, social, and natural time must be coordinated. Indeed one could go a 90 Chapter 2 step further and see the adult male body as the unmarked category, since there are many more diseases restricted to women than restricted to men; there are sixteen categories or clusters of categories that apply only to males and forty-two that apply only to females. (ICD- 1 0, 2: 26). Feminist critics of medicine have long remarked on the relative pathologizing of the female body (for example, Ehrenreich and English 1 973). Nobody Dies of Old Age To finish with the life cycle before moving on to other temporal features, we should note that death itself is remarkably poorly defined by comparison with life. One can scarcely die of old age (FagotLargeault 1 989).15 Unlike in the earlier editions of the lCD (see figures 2.4a and 2.4b), the closest that one may get comes under a banner disclaimer: Ill-defined and unknown cause of morbidity and mortality (797-799) 797 Senility without mention of psychosis Old age Senile: Senescence debility Senile asthenia exhaustion Excludes: senile psychoses (290.0-290.9) (ICD - 1 0 , I: 215) The ICD's life cycle for humans is as follows: a spurt of intense activity at birth; timeless adulthood, when one is afflicted with a range of woes that carry their own temporalities; and an inglorious, ill-defined end. The effect of this is, paradoxically, to make the individual an undefined, tabula rasa onto which various diseases are inscribed. From this blank sheet one can read various stories (with the aid of the lCD), restoring first context and then interpretation (which we shall deal with in the next section). Time Story Two: The Virus Diseases themselves change over time. HIV, for example, mutates rapidly in the individual sufferer, so that no two people suffer from the same disease, nor may the disease be identical with itself over time even within a person. This extreme variability of the object world is a problem for any classification system. The case of virus classification illuminates many features of categorizing difficulties and the strategies used to control them. We look here at some of the work of the The Ki1ulness of Strangers 91 TABULAR LIST 164. Senility. This title includes: Age (70y+) Asthenia (70y+) Atony (70y+) Atrophy (70y+) of old age Cachexia (70y+) of old age Debility ( 70y+) of old age Decline (70y+) Degeneration (70y+) Dementia of old age Euthanasia (70y+) Exhaustion (70y+) of old age General atrophy (70y+) breaking down ( 70y+) debi�ity (70y+) dechne (70y+) marasmus (70y+) senile failure weakness (70y+) Gradual decline (70y+) Imbecility of old age Inanition (from disease, 70y+) Infirmity (70y+) Malassimilation 70 +) ;\