Pathways to Credibility

If raw evidence alone does not resolve scientific controversies, and if the credibility of claims-makers must be invoked to give claims their force, what sorts of credibility are most potent? Certainly nothing in this study casts doubt on the supposition that the presentation of suitable and traditional credentials is the simplest and easiest route to establishing and maintaining credibility in biomedicine. Indeed, this is true not only in the construction of orthodox science but in the promotion of "heresy" as well. Even Sonnabend, a doctor with a history of scientific research, had no luck, after 1984, in gaining scientific support—or substantial extrascientific support—for his views. It took Duesberg's weightier status as a renowned molecular biologist and virologist to bring the causation controversy to general attention. (Hence, even those lay supporters of Duesberg who prided themselves on their iconoclasm typically pointed to Duesberg's impeccable credentials as an indicator of the legitimacy of dissent.)

Anyone doubting the power inherent in traditional markers of scientific accomplishment need only look to the example of Luc Montagnier, who (despite being rejected by both Duesberg and Gallo) was so frequently invoked as an ally for this or that side in debates about causation. Was Montagnier a dissident at heart? Had he undergone a conversion experience over time? Or was he just a mainstream researcher within a research community that was actually far more open to a range of views than the dissenters cared to admit? The multiple Montagniers who have been presented in the causation controversy

are testament to the widespread recognition that Montagnier's support (or his perceived support) was a coin well worth possessing.

In a politicized and public controversy, however, credentials are a less sturdy indicator of credibility than they may first appear. One reason the media play such a crucial role in these stories is precisely because they transmit and construct meanings about what sort of expertise a credential entitles one to claim: "Media are likely to place greater emphasis on such credentials as awards (especially the Nobel Prize) and institutional affiliation and less emphasis on the scientist's disciplinary area of expertise," notes Rae Goodell.^[5] Furthermore, the "anointing" of spokespersons by the media affects perceptions of credibility by constructing a parallel system of informal credentials. Media visibility, for example, has helped to cement the status of treatment activist leaders such as Mark Harrington and Martin Delaney, who are quoted routinely and regularly in publications such as the New York Times and not infrequently in the scientific press. Media designations of who counts as a spokesperson do not simply mirror the internal stratification of a social movement or a scientific community, but can even construct such hierarchies.^[6]

Of course, Harrington would not have been quoted in Science or the New York Times in the first place had not ACT UP already succeeded in establishing itself as a credible player. These are perhaps the most interesting questions about credibility in the case of AIDS: What tactics do social movements pursue in order to marshal credibility in scientific controversies? How do movements that seek not to reject science but to transform it develop their capacity to make an impact "on the inside"? The case of AIDS treatment activism is instructive: it suggests that certain kinds of social movements, when pursuing distinctive strategies, can acquire credibility within specific domains of scientific practice. It matters that biomedicine is relatively more open to outside scrutiny than are other arenas of science and technology. But it also matters that activists have played their cards well.

First, activists imbibed and appropriated the languages and cultures of the biomedical sciences. By teaching themselves the vocabularies and conceptual schemes of virology, immunology, and biostatistics, activists have succeeded in forcing credentialed experts to deal with their arguments. Experts who maintained even nominal adherence to the notion that scientific arguments should be evaluated "without regard to person" have often found it difficult to dismiss such arguments simply on the basis of their "questionable" origin.^[7] Second, activists

have successfully established themselves as the voice of the clinical investigators' potential population of research subjects. Activists have thereby located themselves as an "obligatory passage point," and researchers and NIAID officials have had little choice but to engage them in discussion about trial protocols.^[8] But activists also came forward as the bearers of privileged knowledge of patients' desires that would benefit researchers seeking to accrue subjects for their trials. Some researchers therefore came to welcome, or at least acknowledge benefits of, activist participation in the design of clinical trials.

Third, activists have gained credibility by yoking together moral (or political) arguments and methodological (or epistemological) arguments. For example, activists have contended that the inclusion of women and members of racial minority groups in clinical trials is both more ethical, insofar as it provides widespread access to experimental medications, and scientifically preferable by virtue of the fact that it produces more generalizable findings. Though activists' credibility in some arenas (such as the media) typically reflects their capacity to monopolize the moral high ground, their influence on scientific procedures owes more to their knack of translation between political and technical languages. Finally, activists have seized upon preexisting lines of cleavage within the biomedical establishment. In debates between biostatisticians and researchers, and between researchers and practicing physicians, activists have thrown their weight on one side or the other—sometimes tipping the balance.^[9] In effect, activists have been able to "enroll allies" with the same result as that described by Bruno Latour in his analyses of scientists: they have strengthened their scientific claims against assault by bringing supporters on board.^[10]

Once activists succeeded in establishing their credibility, they were able to gain representation on NIH and FDA advisory committees, institutional review boards at local hospitals and research centers, community advisory boards established by pharmaceutical companies, and—most recently—President Clinton's National Task Force on AIDS Drug Development. These strategic positions, in turn, have provided activists with an enhanced capacity to advance their arguments and augment their credibility. By introducing new "currencies" of credibility into circulation, and by successfully establishing a value for these currencies within the scientific field, activists have, in effect, transformed the field's mechanisms of operation—that is, they have transformed how biomedical knowledge gets made.^[11]

The much greater leverage exerted by laypeople in AIDS treatment

controversies than in the causation controversies reinforces the point that such successes are highly dependent on context. Although laypeople have played a crucial role in stoking the fires of the causation controversies, ultimately, lay actors have been far less capable of influencing debates about causation (a more insulated preserve of biomedicine) than those concerned with treatment (a more public and "applied" domain). Indeed, in the causation controversies, the rhetoric of "democracy" has been limited mostly to questions of academic freedom and the right of dissenting scientists to speak their piece. And even within the domain of treatment research, activists have been most successful when focused on clinical research as opposed to basic research, despite interesting recent moves by activists in the latter direction. The conduct and interpretation of clinical trials is the area where AIDS activists have made the most impact—where their tactics for obtaining credibility have proven most efficacious and where such credibility has proven most consequential in shifting the social construction of certainty.

This contribution to knowledge-making is, in the most direct sense, enabled by the activists' own vantage point: they (or the research subjects they represent) are implicated within the experimental apparatus—they are part of the experiment—and thus they have insights into how such experiments might be better conducted. To use Donna Haraway's term, activists can generate "situated knowledges": "partial, locatable, critical knowledges" produced by social actors on the basis of their position or location in society.^[12] Like the environmental justice activists described by Giovanna Di Chiro, whose expertise is rooted in their very "living" and "breathing" at the epicenter of a toxic environment, AIDS activists have something to say simply because of where they stand.^[13] This more immediate role of patients in clinical research, combined with the relatively greater accessibility of research methods to lay comprehension, explains the enhanced capacity of laypeople to intervene in debates about trial design and interpretation.