This essay reviews the following works:
Medicine and Nation Building in the Americas, 1890–1940. By José Amador. Nashville: Vanderbilt University Press, 2015. Pp. ix + 219. $39.95 paperback. ISBN: 9780826520210.
Medicine and Public Health in Latin America: A History. By Marcos Cueto and Steven Palmer. New York: Cambridge University Press, 2015. Pp. ix + 306. $32.99 paperback. ISBN: 9781107633018.
A History of Family Planning in Twentieth-Century Peru. By Raúl Necochea López. Chapel Hill: University of North Carolina Press, 2014. Pp. xii + 234. $37.50 paperback. ISBN: 9781469618081.
Progressive Mothers, Better Babies: Race, Public Health, and the State in Brazil, 1850–1945. By Okezi T. Otovo. Austin: University of Texas Press, 2016. Pp. x + 273. $29.95 paperback. ISBN: 9781477309056.
In 1999 this journal published a book review article suggesting that Latin American scholarship on science and medicine appeared ready to “take off.”1 The prediction was just partially right. Although social studies on science in general have been growing in relevance, almost two decades later they are still in a sort of preliminary stage. However, with studies focused on health, disease, and medicine issues, the balance is significantly different, and there is no doubt about the consolidation of a vibrant subfield of historical inquiry.
Only four years after the publication of the LARR article, the first collection of essays in English focused on the history of diseases in modern Latin America was published, anticipating a trend that over time would both gain strength and enhance its agenda.2 Today monographic works, articles, bibliographies, state-of-the-art reviews, and edited volumes as well as panels, conferences, and workshops on issues of health and disease in Latin America are recurrent features across the Anglo-American, European, and Latin American academic worlds, frequently in conversation.3
Recreating, revising, or adjusting questions and problems also discussed in other academic milieus, Latin Americanists from many disciplinary backgrounds—historians, medical anthropologists, public health scholars, sociologists, and cultural critics—have unveiled a domain where health, medicine, healing practices, and disease meanings are contestable, debatable, and subject to controversy. They have increasingly been occupying a terrain previously monopolized by traditional historians of medicine, physicians, and antiquarians. Now, diseases and health issues are time and again discussed as slippery, ambiguous, and complex entities constructed and framed historically, taking into consideration the individual and the collective as well as the sociocultural and the biological.
Among their most relevant topics are the production of biomedical knowledge and therapies in the many Latin American peripheries, the illness perceptions offered by sick people and health care practitioners, epidemiological trends, and the metaphors associated with specific diseases. Also, state health policies and the influences of foreign players—from subtle efforts to institute a presumably proper, civilized, and ordered hygienic code to attempts to discipline or assist the population. Three ways of writing that have plenty of overlaps have been trying to make sense and interpret these topics: the new history of medicine, the history of public health, and the sociocultural history of disease.
Traditionally, scholarship on disease, health, and medicine has been controlled by historians of medicine, who wrote histories of changes in treatments and also biographies of famous doctors. Beyond their specific contributions, these histories appear to have been aimed at reconstructing the “inevitable progress” generated by university-certified medicine, to unify the past of the increasingly specialized medical profession, and to emphasize a certain ethos and moral philosophy presented as distinctive, unaltered, and typical of medical practice throughout time. The new history of medicine, by contrast, tends to see the development of medicine as a more uncertain and faltering process. Engaging in dialogue with the history of science, it discusses the social, cultural, and political contexts in which certain doctors, institutions, and treatments “triumphed,” making a place for themselves in history. It strives to understand the tension between the natural history of a disease and some aspects of its social impact.
The history of public health—the second subgenre—emphasizes political dimensions, looking at power, the state, the medical profession, the politics of health, and the impact of public health interventions on mortality and morbidity trends. To a large extent, this is a history focused on the relations between health institutions and economic, social, and political structures. It is also a history that regards itself as useful and instrumental, seeking in the past lessons for the present and future because it assumes that health is an open-ended process. Thus, practitioners of the history of public health research the past to reduce the inevitable uncertainties that mark every decision-making process, thereby facilitating (in general rather than specific ways) potential interventions in contemporary public health practice. The history of public health tends to focus on the moments in which the state—whose considerations go beyond the strictly medical and are shaped by political, economic, cultural, and technological factors—has promoted actions intended to combat a particular disease or public health problem.
The sociocultural history of disease emphasizes the complexity of both disease and health as problems in themselves but also as tools for discussing other topics. This writing focus has addressed a wide spread of subject matter: among them, the sociopolitical dimensions of particular diseases; the increasing medicalization of modern societies; the cultural uses and representations of illnesses in the many modernities present in the Latin American experience; and the responses of ordinary people vis-à-vis taking care of their health. Also, the ways different historical times, social groups, or even individuals have defined for themselves the etiology, transmission, appropriate therapy, and meaning of a given disease, definitions that reflect not only changing medical technologies and knowledge but also broader influences, including religious beliefs, gender obligations, class, age, nationality, ethnicity, class, politics, and state responsibilities.
These three lines of inquiry undoubtedly reflect an effort to escape the limitations of the traditional history of medicine. All of them—the new history of medicine, the history of public health, and the sociocultural history of diseases—take medicine to be a contested terrain where the biomedical is shaped as much by human subjectivity as by objective facts. All of them also discuss disease and illness as problems that have a biological dimension but are also loaded with social, cultural, political, and economic connotations. The four books under review constitute a good sample of recent historiographical trends and collectively demonstrate how these three ways of writing continue to shape scholars’ perspectives when discussing issues of medicine, health, and disease.
Medicine and Public Health in Latin America: A History is an ambitious overview spanning more than five centuries, from pre-Columbian times to the present day. Marcos Cueto and Steven Palmer provide a comprehensive account of the region’s medical and public health history and articulate a number of provocative propositions for interpretative frameworks. In this long-term approach, the period 1860 to 1950 receives a more intense and subtle discussion, an emphasis that reflects the abundant and well-localized historiography for those decades in comparison with the relatively more modest scholarship available for pre-Columbian and colonial times as well as for the early nineteenth century and the decades following the 1950s.
Some concepts and topics garnered intense and quite careful attention in Cueto and Palmer’s narrative. Medical pluralism is one of them. Given the diverse healing practices incubated during Latin American colonial times, a resilient medical mestizaje resulted from the changing and flexible frontiers that connected European, African, and indigenous medicines. For quite some time people have resorted to these hybrid and mixed practices. Interestingly enough, the process of medicalization that began to take shape with the arrival of the bacteriological era and the growth of public health under the auspices of modern nation-states did not lead to the erasure of this mix of healing practices. What’s more, some of these practices survived and even gained presence during times of urban expansion, sanitarianism, and biomedical hegemony. In other words, Cueto and Palmer say, the medical mestizaje incarnated in a broad range of healers and priests coexisted—and in many cases dialogued—with university-based medicine and doctors.
Cueto and Palmer introduce two other concepts—“culture of survival” and “health in adversity”—that organize their discussions of the distinct exchanges, negotiations, and conflicts around health and disease throughout Latin American history. With the term “culture of survival,” the authors underline the resilient fact that Latin American public health policies have been marked by intense, sporadic, emergency-oriented, and unsustainable efforts, rather than long-term, integrated approaches aimed at controlling and eradicating disease and health inequities. The most frequently occurring examples of this approach were the many top-down programs aimed at the eradication of infectious diseases. In other words, public health policies have historically focused on short-term fixes. “Health in adversity” is something like the counterpart to the “culture of survival”: the capacity of Latin American public health professionals and institutions to respond and react in spite of shortfalls in funding, lack of trained personnel, and shifting policy priorities. The term refers to efforts seeking to mobilize health initiatives as mechanisms of social integration that could reduce inequality. Although both concepts are well applied and very productive in the Latin American scenario, they are not in any way peculiar to Latin America. Underlining this would not have diminished their relevance.
Another topic discussed with attention is the central role of physicians as educators, politicians, researchers, sanitarians, and public health practitioners in late nineteenth- and early twentieth-century national state-building endeavors. Through this participation, physicians gained an increasingly influential presence in local and national politics. Two issues closely connected to this role deserve commentary.
The first is an unveiling of the work of Latin American health officials—and also some researchers—to actively challenge miasmatic theories of disease from the standpoint of contagionism and germ theory. Cueto and Palmer emphasize local health officials’ capacity and agency to adapt and adjust. They underline that since the beginning of the twentieth century up to the present, and often despite asymmetries of power, Latin American health officials have been able to negotiate with foreign actors. Building on well-researched case studies, the authors offer a convincing discussion on the workings of the Rockefeller Foundation, which at times imposed its agenda, at times learned to negotiate with the perceptions and initiatives articulated by local, regional, or national public health actors.
The second issue related to the role of local physicians and health officials refers to the fact that during the twentieth century, the region became a site for international health interventions under United States hegemony. As a result, Latin America became an arena for health innovation, contributing decisively to the subsequent design of the post-WWII international health system wherein Latin Americans became vital protagonists in the making and consolidation of international health agencies. On this matter Medicine and Public Health in Latin America adds on to an emerging literature that decenters accounts of global health, emphasizing that Latin America was far from a passive recipient of international health efforts—from the early days of the Rockefeller Foundation’s philanthropic hookworm campaigns to the disease eradication efforts of the Cold War times.
Cueto and Palmer also eschew simplistic and dubious center-periphery or dependency models, wherein Latin American scientists and health bureaucrats appear as merely following and accepting innovations from the medical science metropoles in the United States and Europe. Instead, they show repeated processes of negotiation between different policy approaches and types of social authority, and adaptation to changing geopolitical priorities and associated funding streams. Within this authoritative and convincing reading of very localized processes of negotiation, one issue deserves perhaps a more critical discussion: the problem of medical and scientific excellence, highlighted in the book and pivoting on the work of some very distinguished figures who made relevant contributions to modern biomedicine. However, it is fair to wonder to what extent these were no more than exceptional cases. In other words, the intense celebration of such medical and scientific excellence should not overshadow the central issue of the peripheral condition of the region in the production of science. Again, the pursuit, study, and recognition of Latin American scientific achievements should not obscure the even more central problem of the active negotiation local actors have displayed with initiatives and influences coming from abroad (an issue, as it was said, the book deals with compellingly).
The peripheral condition of Latin America invites us to think critically about several issues that seem particularly challenging to some of the overarching discussions presented in this book. One such problem is the very complicated matter of the unity and diversity of the region. Perhaps a narrative more engaged with the idea of many Latin American peripheries—as well as modernities—could have avoided the blurring effect of looking for sweeping regional similarities. This reservation—that is, the problem of the scale of analysis—is also pertinent to the use of the concepts of a “culture of survival” and of “health in adversity” mentioned above. These concepts, when applied too broadly, could cloud important features of specific national public health histories. After all, and as Cueto and Palmer themselves recognize in many sections of the book, policy decisions at particular historical junctures have produced successful public health outcomes in some countries but not in others.
Another problematic concept is the position of the West, or in particular of Western biomedical knowledge, in a region with a long and intense history since its incorporation into the Atlantic world. Is Latin America a unique dynamic border between Western and non-Western medicine, as the authors indicate? Or is it one of the many dynamic borders present in other areas of the world? If the resilience of medical pluralism invites such an assertion, perhaps it is then worth asking if, as was suggested above in these notes, the strength of this feature has been a peculiarity of the whole region with similar intensity and has been equally present throughout colonial and modern times. Its relevance, however, is beyond doubt, and the book is convincing on this matter. What perhaps needs even stronger underlining is the very fact that the medicalization of modern societies has been a historical process. In this process, primarily when it was in its initial steps or when it was not very socially inclusive, medical uncertainties vis-à-vis certain diseases or health issues have offered plenty of room for health care alternatives with origins outside or on the fringes of university-legitimized biomedicine. And needless to say, this has been a process present in many regions of the world, not only Latin America.
Between the local, the national, the regional, and the global, this book offers a well-informed, comprehensive, and inevitably incomplete narrative that navigates through the problems and interpretations articulated around the three ways of writing mentioned above—the history of public health, the sociocultural history of diseases, and the new history of medicine. It is an impressive result that expresses twenty years of dynamic and imaginative collective scholarship as well as the subtle skills of two of the most active contributors in the consolidation of this subfield of Latin American historiography.
Medicine and Nation Building in the Americas, 1890–1940 is a good example of those approaches emphasizing the cultural dimensions of health. José Amador aims to link early twentieth-century public health initiatives to changing intellectual understandings of race and national identity in Cuba, Puerto Rico, and Brazil. He focuses on the discourses articulated by policy-makers, cultural institutions, scientists, and intellectuals.
Two central issues organize this book: first, narrative representations of public health dangers, namely yellow fever in Cuba, hookworm in Puerto Rico, diseases and Rockefeller-funded health initiatives in rural Brazil; and second, discussion and commentary—most of the time articulating a pessimistic outlook—on how health, race, civilization, and nation wove complicated webs of meaning in the late nineteenth and early twentieth centuries. The book presents a gallery of voices from scholars, experts, writers, and officials who racialized sectors of their societies as particularly likely to be afflicted due to their supposed susceptibility to certain maladies.
Amador is emphatic in indicating that the backdrop of these processes is a transnational space characterized by the emerging and hegemonic presence of the United States in the countries under examination during the first half of the twentieth century, most notably through the Rockefeller Foundation’s International Health Commission. His remarks are in line with the historiography on this topic, which in the last decade or so has continued to add more and more sophisticated readings and national case studies. What this book brings as a relative novelty is an attempt to deal with these cases in a more transnational fashion and with an emphasis on cultural and policy issues.
Medicine and Nation Building looks for entanglements among Brazilian, Puerto Rican, and Cuban histories at the level of ideas, experts, policies, external influences, and exchanges with the explicit purpose of enhancing a scholarship that has tended to focus on public health and medicine anchored in nation-states’ experiences. It is more successful when discussing those entanglements as problems located in the realm of intellectual history, and less so when locating them in the realm of public health policies, programs, and initiatives. Reflecting this focus, Amador delves into how intellectuals in these societies, whose commonalities include both recent histories of slavery abolition and the persistent presence of plantation agricultural systems as the dominant source of wealth, articulated and elaborated nationalized discussions about race as a cultural artifact, not just as a biological reality. The book convincingly explores elite anxiety over how health affected race relations, and how racial statements, knowledge, and prejudices took shape according to national specificities. The international entanglements of those discourses are also discussed, at times with imagination and success, at times simply suggesting exchanges in a way that invites the reader to articulate further questions about their intensity and relevance that perhaps future research will be able to explore. This book is another fine example of a history that rests mostly in the discursive realm, that is, as mainly a history of discourses. The cultural history that Amador emphasizes does not spend much time discussing people’s physical experiences with diseases or changing environmental dimensions whose timings were not necessarily defined by those discourses.
In Progressive Mothers, Better Babies: Race, Public Health, and the State in Brazil, 1850–1945, Okezi T. Otovo studies the gendered and racialized history of maternal-infant health, exploring the interplay between medical ideas, discourses, and practice, as well as patient experiences in the construction of maternalism in the northeastern state of Bahia. The period the book covers spans from the gradual abolition of slavery during the First Republic (1889–1930) to Getúlio Vargas’s corporatist welfare state (1930–1945). Although its title is somewhat misleading in its geographical scope—a recurrent problem in the historiography of many subfields, including that focused on issues of disease, health, and medicine—this is a scholarship that intentionally reveals the relevance of localized studies, this time focusing on a region rather than on a nation or group of countries. Otovo uses several symbolic and highly gendered archetypes—the mulata velha, the mãe preta, the mãe desnaturada, the curiosa, and the pai dos pobres—to analyze the constraints caused by gender, race, and class hierarchies on the experiences and practices of maternity for black mothers.
Otovo contends that Bahia maternalism did not start with women of the elite and later reach the poor; instead, she highlights the decisive role of the poor women and women of color who participated in the process of the construction of certain maternity and social assistance. In so doing, the author identified more continuities and adjustments than radical changes. Over time, she stresses, maternalism provided expanded services and improved the health of numerous Bahian women and children. The narrative deals comfortably with ambiguity, avoiding the precise cuts that most of the time might exist in theoretical frameworks of analysis, but are scarce in real social and individual life. I see in Otovo’s book another significant achievement: Progressive Mothers, Better Babies is not merely a history of discourses about maternalism but a history that delves into the tensions between medical discourses, clinical practices, and women’s experiences.
The discussion of the tensions between biomedical practices and discourses on childbirth, on the one hand, and the role of folk midwives, on the other, eloquently illustrates Otovo’s effort to move away from the temptation of thinking or suggesting that a history of discourses is the whole history. She demonstrates that in the 1930s and 1940s, male physicians attempted to displace women experts while promoting a scientific approach to mothering, reformulating childbirth as an issue under male supervision as a way to expand the process of medicalization. In this effort, doctors blamed midwives for the dangers of childbirth, labeling them with the usual arguments of being dishonest, backward, incompetent, and life-threatening. Doctors also facilitated the founding of the only institutional birthing clinic in the state; but despite this symbolic success, clinic attendance remained rare during the first half of the century, and the scarcity of state resources impeded the establishment of in-home birthing with visiting nurses. In other words, Otovo does not confuse the rhetoric of a successful medicalization with actuality; instead, she acknowledges its limitations in real life. And so did the male medical doctors who ended up directing their efforts to reconcile obstetrical theories with the widely accepted esteem and prestige of midwives. In another example of this kind of subtle reading of medicalization, Otovo discusses the way puericulture education entered in the households of middle- and upper-class women, who would use this modern knowledge to supervise their domestic servants better as well as to perform specific childcare duties themselves. And even while Vargas’s Estado Novo “assistentialist” initiatives targeted working men as a matter of national policy, local Bahia policies were primarily aimed at women, tacitly recognizing that plenty of women were crucial household breadwinners, that male industrial labor was tiny, and that fathers were often absent or quite irrelevant to family life. In the end, the Estado Novo’s paternalism—its self-construction as the pai dos pobres—ended up including features of Bahian maternalism, a nuance Otovo underlines to make relevant the scale of her analysis, that is, the adjustment of national policies at the regional level.
In A History of Family Planning in Twentieth-Century Peru, Raúl Necochea López delves into issues of medicalization and access to health care, women’s reproduction and fertility, gender relations, the state, society, and governance in Peru. The book explores the shifting constellation of actors and organizations that promoted, suppressed, and interacted with family planning during a twentieth century marked by urbanization, civil war, political upheaval, and advances in reproductive medicine and technologies. It is a book that offers a clear example of a scholarship that contextualizes public health issues, connecting them to other social, political, cultural, and economic processes.
Necochea López challenges one of the assumptions comfortably seated in demographic transition and modernization theories, namely that of the decisive foreign influence in the process of launching family-planning initiatives, as well as the desired transformation of so-called traditional societies with large families into modern ones where family size would be considerably smaller. He also includes many of the actors who throughout the century underlined that reproductive issues were not individual matters but ones with clear implications in the realms of the family, community, and nation. A History of Family Planning follows the discourse and action of doctors, eugenicists, feminists, individual women and men, proponents of contraceptive initiatives, local and international government agents, and the Catholic Church. Along with these traditional subjects, the book also includes women who regularly relied on indigenous plants and remedies to both control and enhance their fertility.
Avoiding generalizations and historicizing family planning by dealing with specific contexts and conjunctures (with less attention to space, no doubt a thorny issue in the vast and very diverse Peruvian geography) Necochea López navigates plenty of grey areas and ambiguities. On some topics worth mentioning, he offers a historical narrative based on discourses; with others, he deals more with the tensions between discourses and effectively applied policies, as well as with the tensions between these discourses and the lived experiences they described and contributed to produce.
When dealing with the contours of Peruvian eugenics in the first half of the 1900s, this book discusses puericulture, racial degeneration, tuberculosis, syphilis, and sexual morality in the broader context of the politics of nation building and urban population growth. However, early efforts to encourage European immigration to strengthen what the elites perceived as positive “racial qualities,” as well as the medical advocacy of eugenic birth control programs that targeted migrants from the Sierra settling in coastal cities (mainly Lima), were by and large just discourses. Eugenics is an issue that perhaps needs an even deeper discussion given the recurrent way in which plenty of historical studies of this topic in Latin America tend to deal with discourses while ignoring or neglecting whether these discourses became practices. A similar tension emerges when Necochea López highlights the limitations of investment in family-planning projects and the failure to deliver better indicators of maternal and child health.
Discussing the Peruvian Catholic church, A History of Family Planning is rich on nuances and subtleties. Particularly after WWII, this institution embraced birth control—alongside health exams, sexual education, and parenting classes—as an issue connected to a long tradition of tackling questions of socioeconomic inequalities, as well as a way of strengthening Catholic families and Catholic forms of parenting (as opposed to individual women’s prerogatives). How much of these initiatives were materialized and incorporated into the daily life of ordinary Peruvians is an interesting question for which there are as of yet no convincing answers.
The tension between discourses and experiences also surfaces in Necochea López’s discussion of abortion, a practice that, while illegal, was initially not heavily criminalized. For more than half a century of high rates of maternal and infant mortality, other forms of pregnancy loss were more common than abortion. At the same time, there were plenty of medical doctors who understood and sympathized with the socioeconomic reasons that prompted women to seek therapeutic abortions. In fact, and by examining Lima’s criminal cases involving abortion or suspicious miscarriages between the early 1960s and late 1970s, Necochea López reveals that only around 1973 did a significant rise of police investigations of such cases take place. Unfortunately, this striking and in-depth finding does not have an equivalent in the discussion of the extensive sterilization campaign carried out in the 1990s, which involved tens of thousands of tubal ligations performed on Indigenous women without their consent.
A History of Family Planning also unveils the challenges related to the scale—local, national, or international—of historical analysis. In the 1960s, a confluence of factors, including urbanization (mainly concentrated in Lima), a demographic explosion, and transnational collaborations on health care and population control, brought family-planning clinics to Peru. These commonly provided counseling, dispensed contraception, and even, on occasions, assisted women in search of abortions. But the nationalist politics of the military regime in those years further intensified anti-imperialist reactions to family planning initiatives supported by US organizations, effectively leading to the separation of reproductive issues and fertility control from maternal/child health care programs. In so doing, public financial resources were diverted to the latter areas and away from family-planning services, with uneven success.
These four books faithfully represent several current ways of looking at the history of health, medicine, and disease, addressing with different emphases and agendas the powerful interplay between culture, the economy, science, the environment, politics, and society. They make apparent that over twenty years or so, this subfield of study has been able to achieve sophistication, self-reflection, and a presence in the academic world that not long ago was the territory of medical doctors with interest in past medical achievements and the history of their profession. Now, those engaged in this subfield of study come from many other disciplines, mainly—but not only—history. Now, too, in exploring new themes or revising old ones already discussed with renovated imagination and questions, most studies in this subfield problematize and contextualize their subjects. And their subjects keep on expanding, be they a virus, a hospital, a medical journal, a pill ad, a doctor, a healer, the sick, or a health insurance plan, as well as patient’s individual and collective memories, medicalization of habits, changing meaning of disability, political economy of health, paramedical professions and healers. This purposeful expansion, no doubt, will contribute even more to the vitality of this subfield of study.
3For a quite updated but not complete picture of the subfield, including works in English, Spanish, and Portuguese, see Diego Armus, “History of Health and Disease in Modern Latin America,” Oxford Bibliography Online – Latin America, 2013.
Diego Armus teaches Latin American history at Swarthmore College. He is editor or author of half a dozen books in English, Spanish, and Portuguese on topics related to the history of disease and health, among them The Ailing City. Health, Tuberculosis, and Culture in Buenos Aires, 1870–1950 (Duke University Press, 2011). He is currently working on the history of cigarette smoking in modern Buenos Aires.