Crafting Immunity

Working Histories of Clinical Immunology

Jennifer Keelan, Kenton Kroker

• Publisher: Routledge
• Year: 2017
• Print ISBN:
  9780754657590
• eBook ISBN:
  9781351947893
• Topic: History
• Subtopic: World History
• Index: History

Immunity is as old as illness itself, yet historians have only just begun to take up the challenge of reconstructing the modern transformation of attempts to protect against disease. Crafting Immunity assembles in one volume the most recent efforts of an international group of scholars to place the diverse practices of immunity in their historical contexts. It is this diversity that provides the book with its greatest source of strength. Collectively, the papers in this volume suggest that it was the craft-like, small-scale, and local conditions of clinical medicine that turned the immunity of individuals and populations into biomedical objects. That is to say, the modern conception of immunity was at least as much the product of the work of healing as it was the systematic result of discoveries about the immune system. Working outside the narrow confines of laboratory histories, Crafting Immunity is the first attempt to set the problems of immunity into a variety of social, technological, institutional and intellectual contexts. It will appeal not only to historians and sociologists of health, but also to social and cultural historians interested in the biomedical creation of modern health regimens.

CHAPTER ONE

Editors’ Introduction

What is Immunity?

This is decidedly not the question we initially posed to our colleagues when we first invited them to participate in a conference to be held at the University of Toronto in June of 2004. We had instead issued a call for papers that sought to understand the diverse ways by which immunological knowledge had been articulated in clinical medicine. At that time, not much more than a decade had passed since scholars in science studies began to issue systematic calls for a general reorientation of their field away from the problem of science as theoretical knowledge and towards issues surrounding scientific practice.¹ Historians of immunology were also starting to mine similar territory, eschewing histories that seemed to follow the ‘invented traditions’ of immunologists themselves and proposing instead that we explore ‘histories of vague and contingent subjects such as immunity, infection, or allergy – topics not often identified as part of the patrimonial legacy of the reinvented tradition’.² Yet there still seemed to be very little in the historical literature that would help us to find out what immunologists actually did, as opposed to what (or how) they thought. And so we decided to try to fill that lacuna by calling a conference on the link between bench and bedside, as Ilana Löwy has so nicely put it.³

The results of our organizational efforts were not quite what we expected. It was not so much the pretences of immunology as a branch of biological knowledge with clinical applications that came under scrutiny as it was the very fact of immunity itself. Throughout the more than two centuries under consideration at the conference, immunity traversed a vast number of domains, from the sweeping claims of public science at the municipal, institutional, national, and even international levels to the micro-practices of histo-pathology, serology, bacteriology, and virology. Immunity served its interlocutors as both idea and experience, as telos and as technique. It could be gendered. It could be standardized. It could even be distributed geographically.

Instead of attempts to historically reconstitute a field of knowledge around practice rather than theory, our conference participants presented us with a series of investigations, each of which showed the way the parameters of immunity had been determined differently in specific contexts. Indeed, in the instances with which our volume begins, it is difficult to identify anything like immunology, properly speaking, even though theories of immunity and their attendant experimental systems did precipitate out of the eighteenth- and nineteenth-century debates over the risks of smallpox vaccination. More recent instantiations of the question of immunity appear no less practical. Identifying and defining AIDS at the National Institutes of Health, for example, seemed to be more a matter of clinical and institutional orientation than theoretical predisposition, while radioimmunoassays appear to have initially emerged and proliferated less for their theoretical value than for the perceived need to find novel and practical applications of radioisotopes.

In short, our authors had captured the diversity of immunity’s history as an investigative object. This volume thus belongs to a larger movement in the sociohistorical study of medicine (and in the study of science more generally) that decentres disciplinary preoccupations in favour of tracing the trajectories of objects, technologies or experimental systems through time.⁴ There are, of course, multiple ways of adopting such an approach. Andrew Pickering’s idea of the ‘mangle of practice’, for example, construes practice as a ‘dialectic of resistance and accommodation’.⁵ He sets off from the catchy slogan of the mangle to present science in terms of scientific realism, as a dialogue between the material world and the actor-network whose negotiations are often invoked by science and technology studies. Each of them, human and nonhuman, is equally important in science. In Crafting Science, Joan Fujimura also recognizes that practice involves contingencies and negotiations surrounding the roadblocks or opportunities for participants on the ‘shop floor’.⁶ Her histories show researchers constructing their problems, defining their area of practice, and negotiating a way forward. Practice here appears as a series of multilateral interactions between actors, events and materials.

Historians of medicine have their own traditions of examining such interactions. Most, if not all, are familiar with the fact that the interaction of clinic and laboratory was the explicit function of the Rockefeller Hospital. Founded in 1910, the Hospital was an objective correlative of the mangle of practice. All who worked there were to be at the same time researcher and clinician. One of those who managed to be both, according to Olga Amsterdamska, was D.D. van Slyke.⁷ Van Slyke’s work on alveolar CO₂, blood pH and clinical diabetes captured both the clinical laboratory and the clinic in practice: his tests were quantitative and they defined new facets of the disease, even as they answered to the needs of the clinic in being quick and simple enough to allow for close monitoring of a patient. Van Slyke’s widely used blood-gas apparatus brought a new instrument to bedside practice. Eighty years on, Alberto Cambrosio, Ronald Guttman and Peter Keating came to a similar conclusion about the use of flow cytometry and its peculiar lymphocyte subsets in the clinic as a means of monitoring graft rejection.⁸ The technique had become ubiquitous by 1994, when they published their study. But did the technology drive the clinic, or did the clinic drive technology? That question, they say, is simple but too crude: the diffusion is better described as a pattern of interaction and feedback between an open-ended set of heterogeneous elements, with ‘the clinic’ and ‘technology’ as networks of people, tools and practices. Elsewhere, they put that as the ‘intersections’ between ‘human actors, the tools, the entities and the bodies that are constitutive of the new medical technologies’.⁹

Some of these accounts of practice come very close to home: Patricia Gossel’s ‘A Need for Standard Methods: The Case of American Bacteriology’, explains how Robert Koch’s tightly controlled and standardized laboratory practices were passed down through his hands-on courses, and could not be mastered by merely reading the literature.¹⁰ In the same collection, Keating, Cambrosio and Michael Mackenzie take on the legendary problem of the definition of avidity and affinity – two words, perhaps with the same meaning, used to express the speed and firmness of antibody binding, which were, and still are, difficult to define in any way other than by practice.¹¹ The use of such terms became a touchstone for practitioners in the discipline of immunology: it is only outsiders that need to try to define them, an example of which they provide by examining the course of a patent dispute. A further paper by this extraordinary team deals not with a new machine, but a new style of practice, the clinical trial, hall-mark of the evidence-based medicine of the present day: like the cell-sorter, the protocol has become ubiquitous, and both drives and is driven by the clinic.¹²

Perhaps the richest accounts of immunological practice, however, are the two fulllength studies produced by Keating and Cambrosio on the one hand, and by Ilana Löwy on the other.¹³ The former’s discussion of ‘biomedical platforms’ frames a compelling argument for the utter transformation of the interplay of the normal and the pathological in a domain that fits rather uncomfortably under the rubric of ‘cancer immunology’. The authors work around this term, as their mission is not to describe a theoretically-coherent sub-discipline or field, but rather to show how investigative practice has, since the 1960s, been re-organized with the introduction of a new ‘platform’ – a term which, like immunity, seems to gain strength from being both ostensible and elusive. One key to this approach is its emphasis on automated systems and their epistemological effects. In comparison to the morphological platform which preceded it (and which is now coextensive with it), flow cytometry acts where humans cannot. Flow cytometry, and biomedical platforms in general, are engineered forms of agency, which redefine and reconstitute surrounding practices, all the way from architectural design to doctor-patient interactions. From the perspective of the platform (on which one is obliged to stand in order to have any perspective at all), the normal and the pathological are no longer separate and distinct spheres of investigation and action. Both are implicated – or rather, built into – the same platform.

Löwy’s Between Bench and Bedside, on the other hand, derives its power from its ability to reconstruct the perspective of the practitioner and patient. Löwy, the professionally experienced native observer, unlike the naïve anthropologist of some science studies literature, is both historian (who knows the back story even better than the tribe themselves) and watcher from the sidelines. She feels there has been an asymmetry between the basic science of immunology and its clinical applications, at least in the field of cancer treatment. There have been several attempts to use an immunological approach in cancer control over the past century, and this reflects not only theory change but different institutional elements, including the postwar appearance of the new specialized bio-science companies and the development of large, multi-centric coordinated clinical trials. As the system has become larger and heavier, its rhetorical power has increased along with its power as an industrial complex. The centrepiece of her analysis is her ‘thick description’ of the experimental testing of IL-2, a lymphokine activating a sub-set of cells that, it was hoped, would attack cancer cells. Her account is personal, yet sociological and scientific, so that, as in reading a good novel, you feel you were there yourself, and know the people she knew. The conflicting dispositions, competing interests, shifting grounds and strategic systems of identity, described by Pierre Bourdieu as integral parts of the ‘craft’ of the scientist, take on flesh and bone in Löwy’s account.¹⁴ The system as she saw it demanded close collaboration between the interests involved: the commercial producers of IL-2, the mouse-centred research immunologists, the hospital technicians and clinical staff, and the patients themselves generated a complex series of interactions taking place in the space between biological knowledge and its clinical application. As she found out, each actor had a personal interest. For some, the results were important as knowledge-gathering, as career-promoting, or as structuring boundaries between immunologists and oncologists. For the patients, the results were not very good: there were some temporary remissions, and some deaths from the effects of treatment, but no true cures. Yet all seem to have shared the doctors’ view, itself based on a general, community understanding of the pathology of cancer, that the acceptance of an end-of-life treatment that gave uncertain results and severe side-effects was ultimately a good decision.

So on the one hand, we have a form of engineered stability that draws upon the abilities of the laboratory-based sciences to be simultaneously ‘self-vindicating’ and innovative.¹⁵ This seemingly paradoxical situation relies heavily on the way that instruments – the focal point of twentieth-century big science – first embody theory, but are then reintegrated into practice only to find novel and unanticipated applications. But on the other hand, we find the dynamics of ‘public science’, self-identity and belief (not just of practitioners but of patients) presented in a fine-grained sociological analysis of systems of practice that seem particularly attuned to the investigation, regulation and exploitation of biomedical risk.¹⁶ The papers in our volume combine aspects of both approaches. When presented with the challenge of how to get at the historical relationship between the immunology of the clinic and that of the laboratory, many of our participants imagined conflict that played itself out at the level of individuals mounting arguments and claims in an agonistic field. Others depicted the stability achieved through instruments, automated platforms and other regulatory devices. But in each case, there is still to be found here a similar interplay of the normal and the pathological, the theoretical and the practical. There are issues of standards and routines, tools and techniques, concepts and strategies, local knowledge and international agreements, public disputes and private reassurances. Although the clinic figures strongly in each chapter, it is not clear that knowledge of the pathological leads the understanding of the normal in any straightforward way, as Georges Canguilhem suggested many decades ago.¹⁷ After all, when you are mounting claims about smallpox vaccination by correlating morbidity rates to the appearance of vaccination scars, it is uncertain what constitutes ‘the normal’ of which you are seeking knowledge. It is rather that you are using claims about immunity to usher into existence the very idea of the normal – by persuasion if possible, by legislative force if necessary. It seems rather that, in each of our cases, the question of ‘what is immunity’? can be traced back to such interactions. Immunity, not immunology, is the object coming into view, and it does so in each case by virtue of an identifiable, if idiosyncratic, set of practices.

We describe such practice as a craft-like process to reinforce precisely this lack of disciplinary coherence to the diverse ways in which immunity has been constituted as a practical and theoretical object of interest. Our vision of craft is not so much an ‘ideal type’ as one that can serve to demarcate an epoch of immunology’s history distinct from the ‘rationalized production’ of late-nineteenth-century bacteriological laboratories and the ‘systematic innovation’ of contemporary immunology.¹⁸ The engineer does not figure strongly in many of our stories. It is rather the case that the investigators under study tend to fashion themselves as engineers of sorts, always attempting to somehow rationalize and thereby disseminate their systems of production, be they of neurotropic viruses or solutions to perennially irritating allergens. Innovation, that much-admired word of university administrators and capital investors, is still on the agenda, though it more frequently appears here on a local scale. Craftwork is innovative at this level precisely because it involves creative use of the tools available, and is accountable only through analysis of its practical results. Sometimes (as it seems in our studies of allergy and epidemic encephalitis) practitioners’ attempt to integrate their results back into immunological theory generate dispute. In other instances, potential instability is silenced by the work of regulatory bodies, be they cyclotrons or international health organizations. Indeed, when taken as a whole, the chapters in this volume present the argument that immunity itself is the product of the craft of negotiating the terrain between the idiosyncratic and individualized ideals of the clinic with the more formalized, regulatory apparatus of the laboratory.

Part I. Reason and Risk

The two chapters in this section describe the invention and rapid adoption of Edward Jenner’s smallpox vaccination at the end of the eighteenth century and the coalescence of political, theoretical and practical problems that tempered late-nineteenth century enthusiasm for the practice. Unlike the treatment given in most vaccination histories, our authors reconstruct the rational contexts of eighteenth- and nineteenth-century vaccination practices as integral parts of the experimental systems used to make artificial immunity a visible and reproducible phenomenon. Andrea Rusnock and Jennifer Keelan both describe how convergences in techniques, theory, and instrumentation underpinned the practices and arguments supporting smallpox vaccination.

Rusnock’s paper adds a unique perspective to the historiography of early vaccination by adding theoretical dimensions to the familiar story of the invention of vaccination. She argues that Jenner’s approach to demonstrating vaccine-...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of Figures
• Notes on Contributors
• Acknowledgements
• 1 Editors’ Introduction
• PART I REASON AND RISK
• PART II THE CONUNDRUM OF ALLERGY
• PART III SOME TOOLS OF THE TRADE
• PART IV INSIDERS, IMMUNITY AND IDENTITY AFTER WORLD WAR II
• Index