GER week 5+6

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Sorting Things Out. Geoffrey C. Bowker and Susan Leigh Star. © 1999 The MIT Press.

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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 allow- ing the 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

�

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 undel ~stand 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 psy- chic, 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 '\'\'ith 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 ?

2 I ntrod uction

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 appli - cations, 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 chil -

dren occupy a higher shelf than safer ones; books for reference are shelved close to whe11e 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 , em -

ployee). ""Then 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 cate- gories represented in the various folders of email and papers : " fun ,"

" take back to office ," " remember to look up ," " misc . ," " misc . corre -

spondence," " 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 stan- dardized 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 sometimes -

visible 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 marT change them ? When and why do they become visible? Ho "\l\f' 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 , elabo- rate, 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 ignor - ing your gender classification and use instead whichever toilets are the nearest; try to locate a library book shelved under the wrong Librar )T 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 stan- dards. 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 l-esidential 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 intermit - tently 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 ordel-. Anthropologists have studied classification as a device for understanding the cultures of others- categories such as the raw and the cooked have been clues to the core organizing principles for colonial Western understandings of " primi - tive " 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 entr )T 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 "\I\f'ith social movements, such as the

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 Man- ual 3 (the DSM, a handbook of psychiatric classification) followed direct and vigorous lobbying of the ..L~PA by gay and lesbian advocates (Kirk and Kutchins 1992). 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 catego- ries. As Ann Figert (1996) relates, they even felt their own identities and professional judgments to be on the line . Allan Young (1995) 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 mul -

tiple racial categories was introduced as part of the u .s. government 's routine data-collection mission, following Statistical DirectivTe 15 in October 1997. The Office of Management and Budget (OMB ) issued the directive ; conservatively, its implementation will cost several mil - lion 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 op- posed 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 1998 ) .

4 Introduction

Despite the contentiousness of some categories, however, none of the above-named disciplines or social movements has systematicall)' addressed the pragmatics of the invisible forces of categories and standards in the model~n built world , especially the modern informa - tion technology world . Foucault's ( 1970., 1982) work comes the closest to a thoroughgoing examination in his arguments that an al~chaeologi- cal 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 de- scribed 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. Noone , including Foucault, has systematically tackled the question of how these properties inform social and moral order via the new technological and electronic infra - structures . Few have looked at the creation and maintenance of com -

plex 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 examin - ing several cases of classification, some of which have become formal or standardized , and some of which have not . We have several con -

cerns 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 100 years ago (Durkheim 1982 ) .

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

To Classify Is Human 5

6 I ntrod uction

bad , but dangerous . For example , the decision of the U . S . Immigration

and Naturalization Service to classify some races and classes as desir -,I

able for U . S . residents , and others as not , resulted in a quota system

that valued affluent 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 stan -

dardization in the United States on \ THS , rideotapes over Betamax , for

instance , may seem ethically neutral . The classification and stan -

dardization of types of seed for farming is not obviously fraught with

moral weight . But as Busch ( 1995 ) and Addelson ( 1994 ) 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 knowl -

edge 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 1988 , 1991 ; Beghtol 1995 ; Star 1998 ) . But

everyone uses and creates them in some form , and they are ( increas -

ingly ) 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 catego -

ries , 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 formallv 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 overwhelm -

ing , 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 proble -

matics 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 quer )Ting 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 pre - viously disparate families of technology - for instance , using one 's tele -

vision to retrieve email and browse the Web , using one 's Inter - net 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 uni \rersity 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 applica- tions 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 Usenet posts- category boundaries surely never meant to be crossed by a job search committee . Fortunately for us as committee members , we inter - preted 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 1965). 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 clas- sification 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 moralit } T 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 ?

To Classify Is Human 9

Investigating Infrastructure

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 un -

folding 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 1999 ) . 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 stan- dards and classifications: the left handers in the world of right -handed magic, chronic disease sufferers in the acute world of allopathic medi- cine , the vegetarian in MacDonald 's (Star 1991b ), 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

Classification

Introduction10

nature . At the same time , he pays no attention to the work of con- structing the simulations , or the infrastructural considerations that undel ~write 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 l~eal 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 repre - sentation. Their pyrotechnics may hold our fascinated gaze, but they cannot provide any path to answering our moral questions.

Two Definitions ." 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 .l4 classification is a spatial, temporal, or spatio-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 - bureau - cratic or knowledge production . In an abstract, ideal sense, a classifica- tion 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 ol~igin and descent (Tort 1989). A genealogical map of a family 's histol~y 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

To Classify Is Human 11

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 s~ystem 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 discovTery, 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 , fOl~ example ,

may have a consistent Library of Congress system in place , but sup - plement 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 expen - sive 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 ph )Tsical placement .

What Are You ?

I grew up in Rhode Island , a New England state large I)' 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 )TOU 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 clas- sification , and especially with the problem of l~esidual categories, or, the " other , " or not elsewhere classified .

- Leigh Star

12 I ntrod uc lion

For the second point , mutual exclusivity may be impossible in prac- tice, as when there is disagreement or ambivalence about the member- ship of an object in a category. Medicine is replete with such examples, especially when the disease entity is controversial or socially stigma- tized. On the third point , completeness, there may be good reasons to ignore data that would make a system more comprehensive. The dis- covery 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 demon- strate ways of reading classification systems so as to be simultaneously sensitive to these conceptual, organizational , and political dimensions.

Consider the International Classification of Diseases (ICD ), which is used as a major example throughout this book . The full title of the current (tenth ) edition of the lCD , is: " ICD - IO- International Statis- tical 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 ICD 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 nomencla- ture on a single, stable system of classification principles , as for exam- ple with botany (Bowker, in press) or anatomy. In the case of the lCD , diagnostic nomenclature and the terms in the ICD 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 rep - resents 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 : 215 ) .

The lCD , however , presents itself clearly as a classification scheme

and not a nomenclature . Since 1970 , there has been an effort under -

way 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 entit ) " , ( ICD - 10 , 1 : 25 ) .

For the purposes of this book , \ \ Joe 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 turn -

things perceived as real are real in their consequences ( Thomas and

Thomas 1917 ) . If we took a purist or formalist view , the ICD , , ' ould

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 sociol -

ogy 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 1996 , 54 - 55 )

The work of making , maintaining , and analyzing classification systems

is richly textured . It is one of the central kinds of work of model ' nity ,

including science and medicine . It is , " "' e argue , central to social life .

Standards

Classifications and standards are closely related , but not identical .

While this book focuses on classification , standards are crucial compo -

nents 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 . \ t \ That 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 .

Introduction14

3 . Standards are deployed in making things work together over dis -

tance and heterogeneous metrics . For example , computer protocols for Internet communication involve a cascade of standards (Abbate

and Kahin 1995 ) that need to work together well for the average user

to gain seamless access to the ""Teb 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 mes- sages from one network to another , for attaching documents to mes- sages, and so forth .

4 . Legal bodies often enforce standards , be these mandated by pro -

fessional organizations , manufacturers ' organizations , or the state . We

might say tomorroV 't'y 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

diplomac }T. Without a mechanism of enforcement , howe ,rer, Ol~ a grass- roots movement , we shall fail .

5. There is no natural law that the best standard shall win - QWERTY ,

Lotus 123 , DOS , and VHS are often cited as examples in this context . The standards that do win may do so for a ,rariety 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 ( 1985 ).

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 1993 ). 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 mastel ~ 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 , Turn -

bull notes , many cathedrals did fall down !) It is no longer possible to build a complex collective project without

standardized measurements . Consider a modern housing develop - ment where so much needs to come together from distant and proxi -

mate sources - electricity , gas, sewer, timber sizes, screws, nails and so

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 1994- for a rich treatment ). It is key to knowledge produc - tion as well . Latour (1987) 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" embod- ies 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 mayor 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 , evel~y 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 1995). Throughout this book, we speak of classifications as objects for cooperation across social worlds , or as boundary objects (Sta11 and Griesemer 1989). Drawing from earlier studies of

To Classify Is Human 15

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 anyone 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 struc- tured in common use, imposing stronger structures in the individual - site 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.

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

I ntrod uc lion16

The Structure of This Book

To explore these questions , we have written a first chapter detailing some key themes of the work to fo 110 \\IT. 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 I ), classification and

biography (part II ) , and classification and work practice (part III ).

Weaving these three themes together , \\ITe can explore the texture of

the space within which infrastructures work and classification systems

from different worlds meet , adjust , fracture , or merge . In two conclud -

ing chapters , we elaborate some theoretical conclusions from these studies .

wash their hands of germs before eating, and later, to appl )T antiseptic salve to a cat scratch or an inflamed fingernail . Company washrooms sprouted signs admonishing employees to wash hands before return - ing to "\I\ITork, 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, meas- ured , and standardized just about everything - animals, human races, books, pharmaceutical products , taxes, jobs , and diseases. The catego- ries so produced lived in industry , medicine , science, education , and govTernment. 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 consor -

tia , and scientific committees created the standards and category sys - tems . So did mail - order firms , machine - tool manufacturers , animal

breeders , and thousands of other actors . Most of these activities be -

came 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 consid- ered by most to be boring , trivial , and unworthy of investigation .

There are some striking similarities to our own late twentieth - century histol~ical 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 epi- demics and markets ) would not be confined to one country . In the

nineteenth centurYT, 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. Espe- cially 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

To Classi[ 'V Is Human 17

18 Introduction

R U � S S A� E

Figure 1.1 Map indicating the geographical distribution of the sources of cholera and �the progress of cholera epidemics� by land and sea routes. The progression by land is shown by the line with small vertical marks (1 823�i 847), by sea in 1865 via ship, and new progressions overland from 1892. Note the sea routes marked between Mecca and Marseilles.

Source: A. Proust 1892.

called at ports on the way back from Mecca had to fbllow a period of quarantine during which anyone infected would becoirie sympto- matic�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 freedom of transport. This was a costly delay fbr 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 fbr reporting were in place.

To Classify Is Human 19

For over 100 years, however, 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 for 1)0th treatment and classification differ. Trying to encode both causes results in serious information retrieval problems.

In addition, classifications shift historically. In Britain in 1650 we find that 696 people died of being �aged�; 31 succumbed to wolves, 9 to grief, and 19 to �King�s Evil.� �Mother� claimed 2 in 1647 but none

in 1650, but in that year 2 were �smothered and stifled� (see figure 1.3). Seven starved in 1650 (Graunt 1662), but by 1930 the WHO would make a distinction: if an adult starved to death it was a misfor- tune; if a child starved, it was homicide. Death by wolf alone becomes impossible by 1948, where death from animals is divided between

venomous and nonvenomous, and only dogs and rats are singled out for categories of their own (lCD-S 1948, 267).

�- ---- lii N° REPUBLIQUE FRAN AISE PORT 0

p TENTE DE SANTE ADMINISTRATION SANITAIRE z

4 PATENTE DE SANT1

Neal dec bâtiment... cc Nature dii bàtiment.. Nous, de Ia sante a

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Canons L i i Nature du bâtiment... Malades a bord Pavilion

Appartonant an port d 0 Tonneaux Etat hygidnique du na- Destination Canons vire .

Appartenant au port d Etat hygidnique de 1 - Nero du capitaino.. Destination quipage (couchage, Nom du mddecin w Nom du capitaine vŒtements, etc.)

Nom du mdclecin. Etat hygiØnique des Equipage (tout corn-cc Equipage (tout compris) passagers pris).... Vivres et approvision-Passagers nements divers Passagers Cargaison Eau

4 Cargaison . Conformdment aux articles 30, 31, 32 et 33 dii regle-

�Dent, I�dtat sanitaire du navire a dtØ vdrifld, la visite Etat hygiØnique du na-I- mddicale a etc passde au moment do l�embarquement

vire des passagers et ii a etC constatd quit n�existait bord, ate moment du depart, aucun malade atteint d�affection

Etat hygidnique do 16- pestilentielle (cholera, fidvre jaune, peste), ni lingo sale, quipage (couchago, z ni substance susceptible de nuire a la sante du bord. vDtements, etc.)....

Nous certifions, en outre, dii port est Etat hygidnique des que l�dtat sanitaire des environs est passagers U)

et qu�il a CtC constatC dans le ( cas de choidra Vivres et approvision- port(ou ses environs) pendant cas de fiŁvre jaune

cements divers la derniŁre semaine CcoulCe cas de peste Eau z En foi de quoi, nous avons ddlivrd ia prŒsente pa-

tente, a , le du mois d

0 189 , a beure dii LExpØditionnaire Sceau de l�Administration,

Ialades äbord I- de ix Patente, 4 Lx ox LA SANT

cc Etat du port

sanitaire des environs I- 11 a dtd constatddans

I c port ou ses environs U) pendant la dernidre PRESCRIPTIONS EXTRAITES DU REGLEMENT GEN RAL sernaine dcoulde:

z DE POLICE SANITAIRE MARITIME cas de cholera.

cas de fiŁvre

jaune.

cas de peste. 0

D l jvrŒe le du mois

d 189 4 VOIR AU VERSO. I c heure du

Figure 1.2 French bill of health. An original �clean bill of health.� Source: A. Proust 1892.

To Classify Is Hu,man 21

The first part of this book is dedicated to understandig the construc - tion of the International Classification of Diseases (ICD ) : a classifica -

tion 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 at- tempt 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 yea11s since the 1890s , 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 .

\\ That 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 pub - lic health bureauc11acy. 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 \"\I~ith the state and its occupational health concerns , the classification of work -related dis -

eases (including industrial accidents ) became very important . Life ex -

pectancy 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 al -

ways line up : companies might have been reluctant to take responsi - bility 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 .

Contemporar )T abortion wars in the United States and western Eu11ope attest to the enduring and irreconcilable ontologies inv'olved in these codifications .

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For a bureaucracy to establish a smooth data collection effort , a means must be found to detour around such higher order issues. 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 in - volved , although they may obscure them . For decades, priests, femi - nists, and medical ethicists on both sides have debated the question of w hen a human life begins. The moral questions involved in encoding such information - and the politics of certainty and of voice involved - are much more obscure.

Forms like the death certificate , when aggregated, form a case of what Kirk and Kutchins (1992) call "the substitution of precision for validity " (see also Star 1989b). That is, when a seemingly neutral data collection mechanism is substituted for ethical conflict about the con-

tents of the forms , the moral debate is partially e11ased. One may get ever more precise knowledge, without having resolved deeper ques- tions, 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 1927, 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 1,000 pages each. This is clearly not a pragmatic choice for conduct - ing a task that most physicians also find boring , low-status, and clini - cally 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 1958). As an indicator of this, studies of the validity of codes on death certificates repeatedly show that doctors have favorite categories; these are region -

24 Introduction

To Classify Is Human 25

~ Tith 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 OUl~ own lives. When we use email filters , fOl~ example, we risk losing the information that does not fit the sender's category': junk email is very hal~d 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 tra - ditional bibliographic categories across media, versions, genres, and author . The freedom entailed is that we can customize OUl~ own library spaces; but as Jo Freeman (1972) pointed out in her classic article , " The Tyrann )T 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 inter \Tiewed in

ally biased; and autopsies (which are 1-arely done) have a low rate of agreement with the code on the form (Fagot-Largeault 1989).

Even when there is relatively simple consensus about the cause of death, the act of assigning a classification can be socially 01- 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 discreetl)7, and a statistical cause filed anony- mously 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.

Ove1- 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 uncer - tainty is to distribute the residual categories. " Not elsewhere classified" appears throughout the entire lCD , but nowhere as a top -level cate- gory. So since uncertainty is inevitable , and its scope and scale essen- tially unknowable , at least its impact ","'ill not hit a single disease or location disproportionately . Its effects ","'ill remain as local as possible; the quest for certainty is not lost, but postponed , diluted , and abridged .

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 refer -

ences had better be ones that are listed electronically and available

without walking across campus .

The ICD classification is in many ways an ideal mirror of how people

designing global information schemes struggle with uncertainty , am -

biguity , standardization , and the practicalities of data quality . Digging

into the archives , and reading the ICD 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 work -

ers 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 man } ' with chronic illness , live under a

confusing regime of categories and metrics ( see also Ziporyn 1992 ) .

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 measure -

ments : 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 -

dom from the sanatorium regime as well as, ultimately , the date of release.

Of no surprise to medical sociologists, the interpretation and nego- tiations 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 A1agic 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. Biog- raphy , 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 interac - tional 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 inter - pretation 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 1950 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 groups- white/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 move- ment . This system became the target of worldwide protest and even- tually came to a formal end . These facts are common knowledge . What

To Classify Is Human 27

28 I nlrod uc lion

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 mix -

ture of brute power , confused eugenics , and appropriations of

anthropological theories of race . The scientific reason given for apart -

heid by the white supremacist Nationalist party was " separate devel -

opment " - the idea that to develop naturally , the races must develop

separatel ) " .

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 win -

now 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 100 , 000

people made formal appeals concel ~ ning 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 tra -

jectories . 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 III .. Classification and Work Practice

In part III , chapters 7 and 8 , look at how classification systems organ -

ize 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 inter -

ventions 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 :

" 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 theil ~ system of nursing inter - ventions inductively . They created a preliminary list that distinguished between nursing interv'entions and activities, then nurtured a large grass roots 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 rev'iewed for clinical relevance, and a coding scheme was developed. The classification s)Tstem grew through a co- operative process, with nUl1ses in field sites trying out categories, and suggesting new ones in a series of regional and specialist meetings. Since 1992 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 vTisible 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, caregiv- ing , and helpful - but not a part of the formal patient -doctor informa - tion 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 occu- pation meet the medical bureaucracy, which would account for every pill and every moment of health care workers ' time , contradictions

To Classify Is Human 29

I ntrod uction30

ensue. This is especially true in the " softer" areas of care. Social- psychological care giving is one of the areas where this dilemma is prominent . For example, NlC lists as nursing interventions " anticipa - tory 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' " rork 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 treat- ments are usually bundled in with the room price . NIC is used in the development of nursing health care systems and may provide a plan - ning vehicle for previously untracked costs. As we shall see, NIC can also be problematic for nurses. Like any other classification scheme that renders " Tork 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 NlC 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 Classi/)1 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. Ulti - mately, 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 tradi - tional 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 u p- 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 back- wards 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 librar )' 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 V\JTho 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 infra - structures .

Your job is to describe this forest. You may write a basic manual of forestry, Ol~ paint a landscape, compose an opera, or improve the maps used throughout . What \\rill 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 re- main ). We will show that abstract schema that do not take use into account- say, maps that leave out landmarks or altitude or how read- ers 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.

32 I ntrod uction,

This excerpt from

Sorting Things Out. Geoffrey C. Bowker and Susan Leigh Star. © 1999 The MIT Press.

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