The preceding pages have called the relationship between uncertainty and diagnosis into question. They have also challenged assumptions about the process and practice of diagnosis.
By highlighting the socio-technical assemblages and multiple enactments in medicine this chapter has presented an alternative view of diagnosis which is not neat, straightforward, or linear. However, notions of assemblages and enactments are themselves not entirely satisfactory explanations of diagnosis. Though they emphasise multiplicity they also presume convergence and eventually closure. If you take a broad view of the diagnostic system, and particularly if you look outside of high income settings which are dominated by biomedicine, this becomes less convincing. The notion of a ‘socio-technical system’ has been used to describe a combination of technological and social facets which perform functions in society (Geels, 2004). Here that could be diagnosis; in fact, in scientific and health policy literature
diagnostic and surveillance activity is often described in terms of systems (e.g. Nkengasong, 2009, Olmsted et al., 2010, Saijo et al., 2006, WHO and CDC, 2010). Yet this notion of a system also raises questions about the presumed unity and functioning of the parts within it.
Diagnostic processes span a number of different settings (or ‘production contexts’) as they negotiate various socio-technical assemblages and enactments of disease. How do framings and practices across these settings interact and shape diagnostic pathways in this context?
How will new diagnostics influence these processes? How can the multi-dimensional nature of knowing (and not knowing) be accounted for in the process?
In answer to the above questions I suggest the ‘mangle of practice’ Pickering (1993, 1995).
The mangle of practice was intended as an explanation of scientific practice which was able to do justice to the richness of micro level practices.15 Pickering perceived that the actual performance of science had been overlooked by STS being overly focused on macro level processes such as scientific closure and the social shaping of knowledge thorough interests.
Similarly I have argued that the process and practice of diagnosis have been ignored by the sociology of diagnosis’ focus on themes such as medicalization and labelling. I have also highlighted that understandings of diagnosis must account for the contested nature of viruses which do not follow simple constructivist or realist lines. The mangle offers a way of conceptualising the complexity of therapeutic practice through which a diagnosis emerges across multiple settings.
Pickering tells us that ‘doing’ science involves a complex, reciprocal and inter-dependent pattern of behaviour. Human action, goals and theories are continually reconfigured through interactions with the material world they are attempting to understand or control. In Pickering’s mangle there are human and non-human agencies and these are “mutually and emergently productive of each other” (Pickering, 1995, p567). That is, they interact and respond to each other in a “dance of agency” (Pickering, 1995, p21). Science should be seen as the business of coping with material agency. An important concept in understanding the mangle is the idea of de-centred emergent becoming (Pickering, 2008). This is the idea that
15 Pickering (1995) makes a distinction between practice and practices: practice, in his usage, is the reproduction and extension of scientific culture and knowledge which involves skills and social relations, machines and material culture, and theories and concepts; practices, describes ways of doing things which are usually community or context specific. Practices can be articulated or non-articulated, material or social. Scientific practice can involve many practices. Thus, the practice of diagnosis involves many different practices.
theories, procedures, goals, problems, and functions emerge during the course of practice.
There is no set pathway and the field of agency is diverse. An advantage of the mangle is that it is not hermetically sealed and it offers a theory of diagnosis which is neither socially constructed nor predetermined, in part, because material agency is taken seriously; a person’s diagnosis develops in conjunction with its surroundings and is shaped by many hands (and things) in the process. The field of material agency in this thesis could be the Lassa virus itself.
It is evolutionarily programmed to behave in mysterious ways. Equally it could be seasonal rainfall and muddy roads. They can all be said to exert agency on human practice as they are all involved in a dynamic relationship with patterns of human sickness as well as attempts to identify and deal with them.
Underlying all practice, Pickering tells us, is a pattern of resistance and accommodation between the human and material world. In these struggles, non-human agency is more restricted than human agency which can change its goals. Still, human practice must always contend with the resistance put up by material or non-human agency. Pickering’s summary is useful:
“Scientists are human agents in a field of material agency which they struggle to capture in machines. Further, human and material agency are reciprocally and emergently intertwined in this struggle. Their contours emerge in the temporality of practice and are definitional of an sustain one another. Existing culture constitutes the surface of emergence for the international structure of scientific practice, and as such practice consists in the reciprocal tuning of human and material agency, tuning that can itself reconfigure human intentions. The upshot of this process is, on occasion, the reconfiguration and extension of scientific culture – the construction and interactive stabilization of new machines and the disciplined human performances and relations that accompany them.” (Pickering, 1995, p21)
Pickering elaborates on the processes of resistance and accommodation by introducing the notions of goal orientated practice, modelling, tuning, and stabilisation. Pickering says that practice is goal-orientated, where goals are formulated and revised based on models of the world as that actor knows it. At some point, the interplay between human and material agency may become stabilised, for instance when a machine or an experiment works and can be repeated. This involves ‘disciplined human action’, such as is required when following a protocol (which provides an example of the influence material agency can have on human behaviour). Reaching stabilisation is a ‘tuning’ process whereby human conceptual frameworks can be applied to interpret the reasons for stabilisation (or non-stabilisation).
Politics are evident in people’s practices and relationships with aspects of health, science, medicine and technology (see Ong and Collier, 2005) yet politics do not feature heavily in Pickering’s presentations of the mangle. This is an area where the mangle could be usefully modified. This can be done by a consideration of framings within the mangle. Pickering does use the term ‘framing’ (Pickering, 1995, p83) though in a slightly different sense. For Pickering framing is about how the emergent agency of material objects is interpreted. I use it in a broader sense to acknowledge that the goals, models and practices of different actors in the diagnostic system will be framed differently, as will their interpretations of material agency. This structures what actors in the system intend to do and how they interpret diagnostic signs. In this sense human agency is path-dependent and frame specific. Politics is involved when people’s understandings, knowledge and motivations diverge. Indeed, framings can be seen as a possible source of resistance in the mangle. Partial and subjective views of the world can conflict and may need to be negotiated.
The mangle of practice has been called a theory of everything (Pickering, 2008). So what is to be expected and gained by imagining the practice of diagnosis within Sierra Leone’s Lassa fever diagnostic system to adhere to the principles of the mangle? Quite simply, the mangle tells an open-ended story. Besides an endlessly repeated pattern of resistance and accommodation, it imposes very little on whatever subject matter it is applied to. This is more appropriate for addressing diagnosis in Sierra Leone where it would be premature to impose more prescriptive theories, particularly those developed in higher income settings. Therefore, the mangle provides a way of exploring how technologies are incorporated ‘into the thick’ of existing practice. Importantly it resists the determinism implied in some sociology of diagnosis and technology.
The key aspects of the mangle are: first, the dance of agency; second, a dialectic of resistance and accommodation; third, goal orientated practice involving tuning and stabilisation; and fourth, de-centred emergent becoming. With regards to the first, I provided some examples of non-human agency previously. In the mangle of diagnosis doctors, patients, diagnostics and pathogens will have to negotiate each other’s agencies and resistances. The inclusion of non-human agency seems appropriate in settings where the environment, the virus and the tools used to detect it may not behave as they ‘should’. The mangle suggests that human attempts to define and identify Lassa will face some unruly resistance.
The implication of the second point, the interplay between resistance and accommodation, is fairly self-explanatory. Diagnostic pathways should involve trial and error and the modification of theories to interpret the case at hand. This pattern will occur in all settings. In a broad view of the diagnostic system, it would not be restricted to the application of scientific theories. As chapter five will demonstrate it can also include local classifications of fevers and how they are applied and revised over the disease course. By adding a concern for framing within the mangle a new dynamic between resistance and accommodation is revealed.
Framings may become both a source of resistance and a tool of accommodation. Perceptions about Lassa fever determine how people deal with it, but as we have seen these are partial.
Thus they can obscure significant details. For example throughout the empirical chapters I show how ingrained ideas about Lassa fever’s prevalence in particular regions, or its manifestation in some ‘classic’ symptoms, serve to inhibit the recognition of cases which do not fit those moulds. As such, restrictive and inflexible framings of Lassa fever become a source of resistance within the system.
Concerning the third mangle characteristic, the goals, tuning and stabilisation will be context specific. This relates to the STS ideas explored earlier about the boundedness of ‘machineries of knowing’ and socio-technical regimes. Furthermore, within socio-technical regimes people have various framings which mean they enact disease and diagnosis differently. As later chapter show, in each setting attempts are made to create something stable and understandable. Even within specific sites such efforts come up against contingencies of agency and practice. However, being based on particular framings means that such stabilisations are always partial. A potential issue is that stability can be disrupted when divergent methods of making objects stable compete, both across and within sites. Stability in one setting may not equal stability in another setting. Even if particular technologies claim to be increasingly certain the potential for uncertainty remains across settings.
This brings me to the fourth point about the mangle. This would imply that the process of diagnosis is decentred and heterogeneous. This relates to Mol’s work on difference in medical practice. I favour the mangle’s emphasis on unplanned and unpredictable emergence over Mol’s more problematic suggestion that multiple enactments somehow converge and hang together. However, I will continue to use her language of multiple enactments, assemblages or
amalgams as they convey the diversity of diagnosis clearly. However, returning to the theme of politics within the mangle, it is likely that some conceptualisations of Lassa fever will emerge more forcefully than others depending on differences in the agency, power and interests of those promoting them.