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be modified. This gives the WHO a degree of control at the second level that it has lost at the primary one. The advantage of this secondary control is that it gives an algorithm for working back from the modified list to the ICD itself. Recoverability, while expensive, is theoretically possible and the open history is maintained in part. |
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Full Complementary Localization |
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In some instances, it has been suggested that the list itself be ignored and detailed local studies be carried out instead. Thus the Registrar General of England and Wales, responding to the call for an International List of Causes of Morbidity to complement the ICD, recommended "large sample investigations into particular groups of morbid conditions . . . instead of international classification, which would impose an order which masked the inherent vagueness of diagnosis" (CH/experts stat/87). Even for notifiable infectious diseases, he noted, intranational (let alone international) comparison is difficult. Furthermore, doctors were too diverse a group to unite internationally around a given list. "Dr. Roesle is tacitly assuming that the flagrant noncomparability of existing morbidity statistics is chiefly due to diversity of classification. The cause of the divergence may lie deeper and may reflect important differences in the points of view of the practitioners themselves" (CH/experts stat/87). The registrar's conclusion was that time spent on classification was wasted. For example, he wrote of breast cancer: "The fact that this disease does not greatly contribute to the statistical incidence of morbidity, is an evil not capable of remedy by any international rules of classificationit can only be cured by raising the standard of hygienic education; that of the public at least as much as that of the medical profession" (CH/experts stat/87). |
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This solution is a further step from the ambiguity discussed above or of the necessary diversity of these lists. It suggests that no list at all is valuablelocal practices should be the focal point. From the point of view of the ICD, however, opening up this denegation in fact served to strengthen the ICD as a boundary object. Through open recognition of the tension between the local and the international-universal, the ICD has been continually tested and its limits set. Boundary objects do not claim to represent universal, transcendent truth; they are pragmatic constructions that do the job required (Star 1989a). |
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Not all the work that has made the ICD more applicable has been done internally through modifications to the list. Indeed, one back- |
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