Sorting Things Out: Classification and Its Consequences

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In a sense, the International Classification of Diseases is the backbone of a sophisticated, very large computer-supported cooperative work (CSCW) system as well as a form of large-scale organizational memory. It is also a decision-making tool for all sorts of policymakers. On the basis of data collected using the ICD system, decisions are made about allocation of resources, whether and how to control epidemics or endemic illnesses, and whether there are shifts in population based on infant mortality rates, and so forth. This chapter considers the nature and design of the ICD seen as a kind of super-CSCW or coordinating and decision-support tool.

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The story of information infrastructures is not, in this sense, the history of great people. Much of the work has been done offstage by communities of hackers, technicians, and engineers, and in maintenance, upgrades, and integration. Creating an infrastructure is as much social, political, and economic work as it is theoretical. Although in some sense knowledge is its raison d’être, it bursts the bounds of traditional history of ideas.

==== Sorting Things Out p. 121 ====

This latter is footnoted: “Except accidents from transport, accidents in mines and quarries, agricultural and forestry accidents, or accidents due to machinery, classed under nos. 169–176, and deaths from operations of war, classed under nos. 196 and 197” (ICD-5, 976). The pattern is clear. The railway authorities needed to keep track of the number of bodies of suicides they had to recover and manage. The London underground introduced “suicide pits” between the rails (still in use today).

The historical problem is particularly complex since there has been a secular change in the form that death takes. People no longer die the way that they used to at the turn of the century, as noted above. In 1900, the overriding causes of death were the single great epidemic diseases: tuberculosis, pneumonia, smallpox, and influenza. These tended to attack people indiscriminately, from their prime to old age. Nowadays, with antibiotics and other medicines, people tend to live longer and to break down more slowly. As noted in chapter 2, they tend to be carried off not by a single disease but by a complex of diseases (Israel et al. 1986, 161). Matching this trend, the emphasis in applications of the ICD has changed. It has gone from recording a single underlying cause of death to looking for a complex of causes.
Designed and standardized in the 1930s, the death certificate echoed the positivist analytic philosophy of the time. Now the trend is toward fractured, postmodern, multiple causation. (Nordenfelt 1983 has an excellent discussion of this philosophical history.) The history of philosophy, the history of ways of dying, and the history of death classification—are these three histories or one? This question makes no sense unless we look at the ways the ICD as an information infrastructure knits together temporal, philosophical and scientific concerns. Earlier in this century, historians in general effected closure on the past by bringing what we now see as problematic single historical actors (“great men”) before the tribunal of history. Similarly, the original ICD also tried to effect closure: to provide a single, centralized record of the great epidemic diseases. Modern historians constantly point to the openness of the past.

The most famous resultant record system, still operating today, is COSTAR: the Computer-Stored Ambulatory Record. This was developed at the Massachusetts General Hospital, starting in 1969, where it was first applied to a population of some 37,000 Harvard Health Care Plan patients. The record was designed to be used by researchers, doctors, and government agencies. Its programming was written in a special interactive programming language called MUMPS (the Massachusetts General Hospital Utility Multi-Programming System) (Barnett 1975, 4).

“We are often reminded that medical knowledge has grown to the point where we require the assistance of computers to manage it. One response has been the construction of controlled vocabularies to facilitate this process. We are now at the point where the vocabularies themselves have reached unmanageable proportions and must again call on computers for help” (Cimono et al. 1989, 517). The call now is for a unified medical language system (UMLS) that will provide for automatic, flexible communication among all authorized controlled medical vocabularies.

Given Star and Ruhleder’s (1996) definition of infrastructures as being hybrid creations of work practice and information medium, such figure-ground switches are helpful historically. Working infrastructures like classification systems are deeply embedded both in practice and in technology. Their history cannot be told independently of the work practices that they constitute or the media in which they are inscribed. The work practices associated with the ICD link its history with of a set of classificatory practices defining the modern state and later the modern corporation. The media associated with the ICD link its history with a set of classificatory principles associated with a particular technological base developed for the management of distributed information. The analysis of information infrastructures forces


How can one know who is dying of what or where? And yet from the point of view of very large organizations, information, and diversity, this would be to abandon as well a great deal of rich information. This information includes not only content, but also methodological information about the ways in which software and its attendant categories become “frozen policy.” The question is extremely complex.


There is a double complexity to this cycle. The first is the fact that the first author, Toni Tripp-Reimer, is a cultural anthropologist turned nursing informatician well versed in Kuhn, Lakoff, and other philosophers of science and language. The organization that produces NIC has to be broadly enough construed, on occasion, to include the community of sociologists of science and linguists, even though this inclusion may never be represented overtly in the records of the classification scheme. In passing, these alliances can form a kind of organizational memory that becomes instead forgetting. It means storing information in locations once within the network of an organization but now outside of it; a variety of outsourcing gone sour. The alliances may be fragile, or historical circumstances may change. Thus, for example, the problem of using a centralized external memory source like the library at Alexandria. . . .


Instead, the system must be rebuilt on a design different from that of most approaches used today: it must be a data-driven rather than a process-driven system. A dominant feature of the new system is its focus on the acquisition, management, processing, and presentation of “atomic-level” data that can be used across multiple settings for multiple purposes. The paradigm shift to a data-driven system represents a new generation of information technology; it provides strategic resources for clinical nursing practice rather than just support for various nursing tasks. (Zielstorff et al. 1993, 1).


Three social institutions, more than any others, claim perfect memory: the institutions of science, the law, and religion. The legal and clerical professions claim perfect memory through an intricate set of reference works that can be consulted for precedence on any current case. The applicability of past to present is a matter of constant concern often argued in the law courts or in theological disputes. Scientific professionals, though, have often claimed that by its very nature science displays perfect memory. Furthermore they structure their recall primarily through a myriad of classification systems that give them a vast reserve of potential memory. Scientific articles are in principle—though never in practice—encoded in such a way that, hopefully, an experiment performed one day in Pesotum, Illinois, can be entirely replicated 100 years later in Saffron Walden, England.


Cole notes, “An artifact is an aspect of the material world that has been modified over the history of its incorporation into goal-directed human action. By virtue of the changes wrought in the process of their creation and use, artifacts are simultaneously ideal (conceptual) and material. They are ideal in that their material form has been shaped by their participation in the interactions of which they were previously a part and which they mediate in the present” (Cole 1996, 117). The materiality of categories, like that of other things associated with the purely cognitive, has been difficult to analyze.


Both Engeström and Strauss go to great lengths to demonstrate that an idea, or something that has been learned, can also be considered as having material-objective force in its consequences and mediations. “Object” includes all of this—stuff and things, tools, artifacts and techniques, and ideas, stories, and memories—objects that are treated as consequential by community members

307 Boundary objects

Boundary objects are the canonical forms of all objects in our built and natural environments. Forgetting this, as people routinely do, means empowering the self-proclaimed objective voice of purity that creates the suffering of monsters in borderlands. Due attention to boundary objects entails embracing the gentle and generous vision of mestiza consciousness offered by Anzaldúa. Casual versus Committed Membership Another


In the past 100 years, people in all lines of work have jointly constructed an incredible, interlocking set of categories, standards, and means for interoperating infrastructural technologies. We hardly know what we have built. No one is in control of infrastructure; no one has the power centrally to change it. To the extent that we live in, on, and around this new infrastructure, it helps form the shape of our moral, scientific, and esthetic choices. Infrastructure is now the great inner space.


The importance lies in a fundamental rethinking of the nature of information systems. We need to recognize that all information systems are necessarily suffused with ethical and political values, modulated by local administrative procedures. These systems are active creators of categories in the world as well as simulators of existing categories. Remembering this, we keep open and can explore spaces for change and flexibility that are otherwise lost forever. Such politics are common to most systems employing formal representations. Rogers Hall, in his studies of algebra problem solving by both children and professional math teachers, talks about the shame that children feel about their unorthodox methods for arriving at solutions (1990). Often using innovative techniques such as imaginary devices, but not traditional formulaic means, they achieved the right answer the wrong way. One


Working infrastructures contain multiple classification systems that are both invisible, in the senses above, and ubiquitous. The invisibility of infrastructure makes visualization or description difficult. The metaphors we reach for to describe infrastructure are ironic and somehow childish. We speak of “way down in the underwear,” “underneath the system,” or use up-down metaphors such as “runs under,” or “runs on top of.” Lakoff and Johnson (1980) write of metaphors we live by. Our infrastructural metaphors show how baffled we often are by these systems.

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