Disease in the History of Modern Latin America: From Malaria to AIDS 9780822384342

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disease in the history of modern latin america

Disease in the History of Modern Latin America from malaria to aids Edited by Diego Armus

Duke University Press Durham & London 2003

∫ 2003 Duke University Press All rights reserved Printed in the United States of America on acid-free paper $ Designed by C. H. Westmoreland Typeset in Carter & Cohn Galliard by Keystone Typesetting, Inc. Library of Congress Catalogingin-Publication Data appear on the last printed page of this book.

Contents

Preface vii Disease in the Historiography of Modern Latin America diego armus 1 ‘‘The Only Serious Terror in These Regions’’: Malaria Control in the Brazilian Amazon nancy leys stepan 25 An Imaginary Plague in Turn-of-the-Century Buenos Aires: Hysteria, Discipline, and Languages of the Body gabriela nouzeilles 51 Tropical Medicine in Brazil: The Case of Chagas’ Disease marilia coutinho 76 Tango, Gender, and Tuberculosis in Buenos Aires, 1900–1940 diego armus 101 The State, Physicians, and Leprosy in Modern Colombia diana obregón 130 Revolution, the Scatological Way: The Rockefeller Foundation’s Hookworm Campaign in 1920s Mexico anne-emanuelle birn 158 Between Risk and Confession: State and Popular Perspectives of Syphilis Infection in Revolutionary Mexico katherine elaine bliss 183 Dying of Sadness: Hospitalism and Child Welfare in Mexico City, 1920–1940 ann s. blum 209 Mental Illness and Democracy in Bolivia: The Manicomio Pacheco, 1935–1950 ann zulawski 237

Stigma and Blame during an Epidemic: Cholera in Peru, 1991 marcos cueto 268 Nation, Science, and Sex: AIDS and the New Brazilian Sexuality patrick larvie 290 Contributors 315 Index 317

Preface

Fifteen years ago it would have been unthinkable to even imagine a book on history and disease in modern Latin America. Although the region was vibrant in other historiographies, disease and health were not topics on which scholars working on Latin American issues were focusing their research. There were articles and books on certain issues, of course, but the subfield as such was almost nonexistent. Today the picture is quite di√erent. Innovative studies dealing with diverse agendas and from diverse perspectives on the history of disease in modern Latin America are now available. A number of monographic works are ready for publication, academic journals periodically feature articles on the topic, and, if this could be taken as sign of the dynamic development of the subfield, the 2000 Latin American Studies Conference o√ered sixteen panels dealing with problems of health, disease, and society. It is now possible to gather in one volume a bibliographical essay assessing the state of the subfield and eleven essays on di√erent diseases (malaria, hysteria, Chagas’ disease, tuberculosis, leprosy, hookworm, syphilis, hospitalism, mental illness, cholera, and aids) for six Latin American countries (Mexico, Colombia, Peru, Bolivia, Brazil, and Argentina). Following persuasive examples set decades ago by Michel Foucault’s absorbing interpretations and the more empirically based Anglo-American tradition, Latin American historians, anthropologists, sociologists, and cultural critics have been unveiling a domain in which 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. Today, nobody is surprised when diseases and illnesses are discussed as slippery, ambiguous, complex entities constructed and framed historically taking into consideration the individual and the collective as well as the sociocultural and the biological. From the avatars of biomedical knowledge and therapies in the periphery to the illness narratives o√ered by sick people and health care practitioners,

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from epidemiological trends to metaphors associated with certain diseases, from state health policies to the more or less subtle e√orts to disseminate a presumably proper, civilized, and ordered hygienic code, this scholarly production seeks to expand thematic frontiers as well as to articulate interdisciplinary approaches. Disease in the History of Modern Latin America is part of this intellectual enterprise. It reveals the richness and potential of discussing illnesses from a historical perspective as well as the enormous task that lies ahead. I first began thinking about this book in 1998 while spending a month at the Bellagio Study Center of the Rockefeller Foundation. There, in that more than hospitable setting, I became convinced that the dynamism and strength of the subfield deserved evidence of its findings. What followed is hardly surprising. An informal group of junior and senior scholars from the United States and Latin America committed themselves to what quickly became a collective e√ort. Right from the beginning Valerie Millholland of Duke University Press welcomed and encouraged the project. Anonymous readers provided compelling observations and comments that in some cases were included in the final versions of the articles. Teaching release time from the Provost’s O≈ce of Kean University—my previous institution—and from the Department of History at Swarthmore College—my current one—allowed me to a√ord the demanding task of editing this book. My students Maya Peterson and Katia Bobonis, as well as Terry Brown, gave their generous assistance. And Mindy Conner contributed with her very professional copyediting skills. To all of them, people and institutions, my sincere thanks.

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Disease in the Historiography of Modern Latin America

n the past two decades, disease has become an increasingly prominent theme in Latin American historiography as a result of e√orts to renew the traditional history of medicine, historical studies of the region’s population, and the spread of interpretative approaches borrowed from the humanities and social sciences. What is emerging from this dynamic historiographic pursuit has been called the new history of medicine, the history of public health, or the sociocultural history of disease. All three quests recognize that diseases are complex processes and all of them have somewhat taken into account a very provocative and stimulating reading of that complexity o√ered by one of the most influential scholars in the field: ‘‘Disease is an elusive entity. . . . It is at once a biological event, a generation-specific repertoire of verbal constructs reflecting medicine’s intellectual and institutional history, an occasion of and potential legitimation for public policy, an aspect of social role and individual—intrapsychic—identity, a sanction for cultural values, and a structuring element in doctor and patient interactions. In some ways, disease does not exist until we have agreed that it does, by perceiving, naming, and responding to it.’’∞ This book attempts to give an account of the state of historiography of disease in modern Latin America. On the one hand, the essays included here are meant to be representative of the issues that have driven, and continue to drive, the field’s growth. On the other, and this is worth emphasizing, this selection also indicates problems, themes, and historiographic tendencies that are not exclusively Latin American. This book tries to avoid any temptation to conceive of a history of disease in the region as necessarily focused on tropical diseases and for that reason only marginally concerned with those maladies somehow associated with the processes of urbanization, modernization, and industrialization. Instead, it aims to contribute to a more complex discussion of the widespread modernization that has taken place in the region. In this, the book underlines both the heterogeneity and

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the shared neocolonial condition, with multiple and shifting metropolitan references, that have marked each national history over the past two centuries. This book includes innovative works that underscore the concept that diseases cannot be examined outside their societal frame. Di√erent historical times, social groups, or even individuals produce their own ways of defining the etiology, transmission, appropriate therapy, and meanings for a disease. These definitions reflect not only changing medical technologies and knowledge but also broader influences, including religious beliefs, gender obligations, nationality, ethnicity, class, politics, and state responsibilities. The contributors to this book approach diseases as social constructions, as socially generated ways of grouping biomedical and sociocultural phenomena and endowing them with particular meaning. They represent current and innovative ways of looking at disease from a historical perspective and addressing the powerful interplay among culture, history, medicine, and society. Although all see diseases as settings marked by consensus, tensions, and conflicts, their research agendas are not necessarily similar. In fact, one of the goals of this book is to show the di√erent and in some ways converging historiographical styles developed by senior and junior scholars, Latin Americans and Latin Americanists working in the United States, historians and sociologists of science, medical anthropologists, and social and cultural historians. The authors frame their topics as modern problems spanning a period from the end of the nineteenth century to the end of the twentieth. Their emphases range from the production of scientific knowledge in the periphery (Coutinho on Chagas’ disease in Brazil) to literary metaphors associated with a certain illness (Armus on tuberculosis in Argentina); from social control issues (Bliss on syphilis in Mexico) to medical institutions viewed as a mirror of broader national problems (Zulawski on mental health in Bolivia) and medical representations of imaginary plagues (Nouzeilles on hysteria in Argentina); from public health initiatives generated at the domestic level (Stepan on malaria in the Brazilian Amazon basin) to policies shaped along the lines of agendas of international agencies (Birn on hookworm in Mexico); from the interaction among ideas of sexuality, disease, nation, and modernity (Larvie on aids in Brazil) to the instrumental role of certain illnesses in state-building processes (Obregón on leprosy in Colombia); from state-sponsored welfare e√orts led by the medical profes-

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sions (Blum on hospitalism in Mexico) to individual and state responsibilities with respect to sickness and health (Cueto on cholera in Peru). As with any collection of essays, this book is necessarily limited in scope; some countries, problems, and diseases had to be left out. Despite these unavoidable limitations, this volume features instructive and absorbing cases representing current scholarship bringing new—or renewed—questions to the field. Each chapter forms part of a research agenda that could be read as the product of two paths of inquiry, the first encompassing approaches that started out with the history of medicine and biosciences and ended up weaving rich social, political, and cultural narratives and analyses; the second taking the opposite path. Departing from broader problems initially defined in terms of society, politics, and culture, these studies not only discovered illness as an intriguing and contentious historical issue, but also came to make disease the organizing theme of their historical accounts. This introduction does not attempt to present an exhaustive and detailed account of what has been written, or to suggest a program for what should be done in the future. Its main goal is twofold: first, to frame the essays in this book within the history of medicine, the history of public health, and the sociocultural history of disease; second, to underscore the most imaginative and productive topics in the history of disease in Latin America: the social and political dimensions of epidemics, the development of public health policies vis-à-vis external influences and state-building processes, and the cultural uses of disease.

Writing the History of Disease: The New History of Medicine, History of Public Health, and Sociocultural History of Disease Traditionally, the subject of disease has been a kind of boundary controlled by historians of medicine who wrote histories of changes in treatments and biographies of famous doctors. Beyond their specific contributions, these histories appear to have attempted to reconstruct the ‘‘inevitable progress’’ generated by university-certified medicine, to unify the past of an increasingly specialized profession, and to emphasize a certain ethos and moral philosophy that is presented as distinctive, unaltered, and emblematic of

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medical practice throughout time. The new history of medicine, by contrast, tends to see the development of medicine as a more irregular process. Engaging in dialogue with the history of science, it discusses the social, cultural, and political context in which certain doctors, institutions, and treatments ‘‘triumphed,’’ making a place for themselves in history; and it also examines those that have been forgotten. It strives to understand the tension between the natural history of the disease and some aspects of its social impact.≤ The history of public health, for its part, 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 it focuses 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, historians should research the past in order to reduce the inevitable uncertainties that mark every decision-making process in public health, thereby facilitating in general rather than specific ways interventions in the contemporary scene. This approach continues two overlapping legacies, from late-nineteenth- and early-twentieth-century research and hygiene practices, and from certain national histories of public health written since the 1950s. Both e√orts, which recognized and underlined the social character of disease, are important antecedents when evaluating scholarship on public health issues from a historical perspective. These, then, are the points of departure for studies that in some cases do nothing more than celebrate the first public health physicians and practitioners. Other studies attempt to analyze the issue of health and medicine in structuralist code as epiphenomena of the relations of production.∂ Either way, the emphasis of this history of public health is not so much on the health problems of individuals as on those of social groups, and on the study of political interventions to preserve or restore collective health. This history focuses on moments in which the state—based on considerations that go beyond the strictly medical and are shaped by political, economic, cultural, scientific, and technological factors—has promoted actions intended to combat a particular disease. Public medicine usually appears in a positive and progressive light in such histories, as the fortunate outcome of the association of biomedical sciences with a rational organization of society in which certain professionals—public health doctors above all—o√ered solutions for the diseases

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of the modern world. While this association is seen as potentially beneficial, its concrete achievements are found wanting. This unhappy result is presented as a reflection of the dependent condition of the region, without regard for any temporal or national distinctions. This dependency determined the existence of a ruling elite and a structure of economic power that was unable or unwilling to create and distribute public health resources and services in an equitable and e≈cient manner.∑ Other studies react against the schematic use of the dependency model and summarize the achievements and failures of national or municipal projects aimed at creating or modernizing the basic sanitary infrastructure and reducing mortality. Despite the peripheral condition of Latin America, they claim, in certain countries or cities, at least, the balance was not that negative.∏ The sociocultural history of disease is more recent, the product of studies by historians, sociologists, anthropologists, and cultural critics who have discovered the complexity and possibilities of disease and health, not only as problems in themselves but also as excuses or tools for discussing other topics. This approach barely skims across the history of a given etiology; rarely is there any attempt to set up a dialogue between sociocultural history and the history of biomedical sciences. Instead, it spreads out over topics such as the sociopolitical or sociodemographic dimensions of a particular disease, medical professionalization processes, welfare and social control instruments and institutions, and the state’s role in building health infrastructure.π Some of these histories do not go beyond gathering relevant data and basic information, but others, in their critical analysis of health and disease, argue for a small set of overriding explanatory factors, with uneven success. These studies tend toward top-down and somewhat conspiratorial explanations: the poor have always been wretched because the elites and middle classes lack political will; every public health initiative resulted from an e√ort to increase the productivity or guarantee the reproduction of labor; elites got involved in sanitary reforms for their own security; pioneering initiatives were the product of a new professional state bureaucracy interested in imposing public health measures; or dependent capitalism needed those changes.∫ There have also been Foucauldian interpretations of medicalization—an undoubtedly inspiring line of thinking, especially for certain Latin American intellectuals who found an arsenal of the normalizing resources of modernity in medicine and state public health interventions. This view understands medicine as one of the rationalization enterprises that, having

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developed particular disciplinary languages and practices, aimed to control bodies, individuals, and society.Ω In this context diseases and medical interventions attempting to address them have been seen—often overlooking mediations and particularities—as instruments for regulating society, labeling di√erence, and legitimizing ideological and cultural systems. These three lines of inquiry undoubtedly reflect an e√ort 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 disease—take medicine to be an uncertain and contested terrain where the biomedical is shaped as much by human subjectivity as by objective facts. All three approaches discuss disease and illness as problems that have a biological dimension but are also loaded with social, cultural, political, and economic connotations. This volume o√ers an overview of these historiographical developments. While maintaining their own emphasis and agendas, the contributors to this book try to be attentive to the rich mediations between the state, medical knowledge, public health policies, the requirements of the economic system, perceptions and representations of illnesses, and responses of ordinary people. They also attempt to approach disease in a creative, interpretative way, taking into account both the disciplining and the progressive dimensions of medical initiatives.

Writing on Epidemics as a Historical Problem The most prolific theme in the new history of medicine has been the social and political dimensions of epidemics. This work focuses on contagious diseases such as smallpox, yellow fever, bubonic plague, influenza, and cholera that attacked communities by surprise and with intensity.∞≠ Some of these histories emphasize the social conditions in which the epidemic emerged, the state policies used to combat it, and the reactions of elites and common people. Others include a careful examination of biological and ecological factors, opening a dialogue between social history and the history of the biomedical sciences. Thus, the Latin American cases add to a kind of dramaturgy common to all epidemics, interweaving themes of contagion, fear, stigma, blame, salvation, and individual and social responsibility. But this dramaturgy, it is worth stressing, merely defines the framework for an epidemic event, not its specific cultural, religious, or political features. It also does not speak to the ways societies and certain social groups give meanings

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to the experience of the epidemic, or the availability and use of certain strategies and resources to combat it. Epidemics lay bare the state of collective health and the infrastructure of sanitation and health care. They can facilitate initiatives in public health, and in this way accelerate an expanding state authority, both in social policy and in private life. Nevertheless, society’s familiarity with a certain illness might well lay the ground for ignoring it, either because its persistent presence makes it less extraordinary and surprising or because the political, social, or geographic context does not allow it to become a public, political issue, even though, by definition, it is a collective matter. Before and after the takeo√ of modern bacteriology, epidemics were closely associated with urban life, particularly in great cities. From the end of the nineteenth century until well into the twentieth, this association was also linked to the so-called social question. Thus, with the growing acceptance of monocausal explanations for every illness, references to the larger context were inescapable: the precariousness of garbage disposal, sewer, and drinking water systems; poor housing; biological or racial inheritance; daily habits of hygiene; the work environment; diet and poverty; massive immigration; the ‘‘dangerous’’ teeming multitudes in the cities. At the beginning of the twentieth century, statistics became a staple of social analysis, and in some countries state agencies specifically concerned with questions of public health were created. Hygienists and, later, public health physicians would play a decisive role in modernizing collective urban facilities and the institutional networks of public assistance, reform, and social control, acting almost as a specialized bureaucracy along with other professionals and political, religious, or governmental agents. At times, the struggle against epidemics took on the character of quasimilitary campaigns in rhetoric by defining microorganisms as enemies, and in practice by encouraging intrusive and violent interventions. Perhaps for that reason, these interventions met resistance on certain occasions, even when their methods were not entirely new to the population.∞∞ At other times the larger struggle also included persuasion, aiming to educate the population and disseminate so-called hygienic ways of living. The essay in this volume by Marcos Cueto discusses many of these issues, with a focus on the cholera epidemic that struck Peru in 1991. This case is especially revealing of the recurrence of old urban problems, the worn-out tactic of explaining epidemic crisis by blaming the sick, and the consequences of the current state withdrawal from public health.

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In some contexts, diseases such as syphilis or leprosy were classified as epidemic even though they did not a√ect a large sector of the population. They were turned into national problems for social, cultural, or political reasons and legitimated by medical expertise, attracting public attention and spurring campaigns designed specifically to eradicate them. Diana Obregón’s essay on leprosy in early-twentieth-century Colombia delves into statistical exaggerations of the disease’s impact and the generalized sense of national elites and the medical profession that leprosy was an obstacle to their civilizing and modernizing project. Diseases that did not break out suddenly but were well established in everyday life and sometimes killed and a∆icted more people than epidemic diseases did not always manage to mobilize su≈cient material, professional, or symbolic resources to be perceived as national problems. These might be chronic, such as tuberculosis and gastrointestinal diseases, or endemic, such as malaria, hookworm, and yellow fever. While less spectacular, these diseases had an impact in cities, the countryside, or both. But because they were more widespread, more di≈cult to treat, more closely associated with poverty, more socially or geographically distant from centers of power, and thus more easily overlooked, these diseases could be made visible to public opinion and elite consciousness only with enormous e√ort, and therefore particular policies to combat them were rare or nonexistent. And if in the urban world some of these diseases finally did manage to become public issues—because they came to be seen as part of the social question or to be strongly associated with broader national problems—in the countryside, endemic illnesses were the ones that expanded the area of action of public health interventions.∞≤ The project of sanitizing the countryside or at least combating one of its endemic diseases ignited e√orts to launch social policies and facilitated state expansion, the centralization of power, and nation building.∞≥

Writing the History of Disease vis-à-vis External Influences and State-Building Processes The second theme of this book is the development of public health policies as a result of the interplay between external powers and the national state. Here the dominant approach was a reaction against di√usionist interpretations that assumed a passive reception of knowledge and practices con-

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structed outside the region. Thus, the emphasis was not on importing and transplanting ideas about certain diseases—yellow fever, malaria, hookworm, Chagas’ disease—but on the process of selection and assembly of those ideas and on their creative reelaboration and modification according to specific cultural, political, and institutional contexts. In this interpretive frame, the practices of medical doctors, hygienists, and scientists from peripheral Latin America were sometimes allied with, sometimes competed against, and sometimes challenged practices originating in scientifically and culturally hegemonic Europe or North America. These studies reveal a group of medical professionals actively producing knowledge, debating— before and after the triumph of modern bacteriology—the possible etiologies of certain diseases, creating institutions of scientific excellence, and devoting themselves to more or less original e√orts to make a di√erence in local or regional mortality and morbidity trends.∞∂ Marilia Coutinho’s essay in this book is representative of this approach. Her study of Chagas’ disease in Brazil explores the career of the physician who played a crucial role in developing research and public health policy for this very Latin American disease strongly associated with poverty. Her reconstruction shows another case of scientific discovery in the periphery, in an area—tropical medicine— usually seen as an imperial enterprise. Another issue emerges with certain diseases such as malaria, yellow fever, and hookworm that is closely tied to the politicization of health and the reception and transfer of expertise and practices. At its core is the role played by certain international agencies, in particular the Rockefeller Foundation, whose missions in almost all Latin American countries between the 1910s and the 1930s were visible evidence of the growing influence of the United States in the region. Rockefeller missions were decisive in the organization of single-disease services and the promotion of technical approaches and specific cures to the detriment of more comprehensive, educational, and preventive strategies.∞∑ But in many countries, small and large, health had become a public issue before these missions arrived. During the first two-thirds of the nineteenth century, miasmatic and environmentalist approaches dominated medical perceptions of health and disease without producing major changes in the sanitary infrastructure or overall mortality. Toward the end of the century, modern bacteriology took center stage and profoundly shaped the dynamics of many public health undertakings. It was in this context that some national scientific communities gave greater priority to the study of certain

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tropical diseases. These doctors, many trained in Western Europe, developed novel and specific approaches to research and intervention, sometimes even before their North American peers. Nancy Stepan’s essay on malaria in Amazonia between 1900 and 1920 explores the actions taken by Brazilian public health actors during the rubber industry boom without any connection with international agencies such as the Rockefeller Foundation, which entered the malaria field in Brazil only in the late 1930s. The arrival of the Rockefeller missions in Latin America was a crucial determinant in the orientation of sanitary reforms, particularly those for rural areas and for diseases that could be eradicated at small cost and in a short time. Despite varied and uneven results in di√erent countries and with di√erent diseases, there is no doubt that the Rockefeller Foundation projects mobilized public opinion, especially with regard to the living and health conditions of the rural poor. The projects contributed enormously to centralizing sanitary e√orts vis-à-vis the traditional local and regional ones, and consolidated the position of the United States as the dominant external reference in matters of public health. The missions’ technical-elitist approach had to be adapted to the local population’s idiosyncrasies and perceptions of disease, something the foundation representatives found as di≈cult, and did as badly, as most of the native doctors. The relations between national and foreign medical groups were complex, at times involving subordination, cooptation, alliance, pragmatism, conflict, or mutual adaptation. In both rural and urban areas the mission o≈cers faced the unavoidable problems of when to interfere in people’s everyday routines and customs and when to leave them alone, and when to use persuasion and when to resort to coercion in order to achieve public health goals. In their original design, the missions may have been conceived as purely technical or instrumental endeavors in keeping with a neocolonial philanthropic agenda. But when these interventions materialized, they contributed, intentionally or not, to establishing precedents and laying the institutional foundations for future social and preventive medicine projects that local professional actors would lead.∞∏ Anne-Emanuelle Birn’s essay on the Rockefeller campaign against hookworm in early-twentieth-century Mexico reveals the web of exchanges, tensions, and mutual adaptations that crisscrossed the agenda and actions of the foundation, the everyday life of peasants, and the interests and perceptions of Mexican o≈cials and medical elites.

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Writing the Social and Cultural History of Diseases The third theme of this book is the study of diseases as social and cultural problems in a broad sense. I am referring to historical narratives particularly interested in examining medical discourses, on the one hand, and the metaphorical uses of disease, on the other. The Foucauldian interpretative framework—embraced much earlier and more intensely in Latin America than in the Anglo-American academic world—shaped studies of madness and the specific institutions, theoretical systems, and processes of professionalization associated with the psychiatric order. Thus, madness has been discussed as a subject born in and transformed by a field of intersections that range beyond psychiatry itself and include public hygiene, the spaces of insane asylums, utopian enterprises for collective moral improvement, and the history of nation building and state formation.∞π Gabriela Nouzeilles’s essay traces the major lines of meaning running through the representations of hysteria in turn-of-the-century Buenos Aires. She explores the relationship between doctors and patients, particularly its inherent inequality given the fact that doctors are both narrators and authors of the hysteria cases. That is why anything of the patient’s voice that remains in the medical texts is only a contradictory undercurrent where one can glimpse the rebellious gestures of the hysterical women and their progressive silencing in the course of the cure. Scholars have focused on the emergence of a medical power dedicated to disciplining bodies, normalizing general sanitary status, and shaping the political practices of society on an immanent, rather than exterior, level.∞∫ Some of these pioneering readings have been strongly criticized. The dominant approaches now tend to be more cautious and more anchored in empirical information, emphasizing both the instrumental and controlling aspects of psychiatry and its humanitarian and liberating possibilities with regard to mental health.∞Ω Ann Zulawski’s essay on a Bolivian asylum in the 1940s is an example of this kind of historiographical inquiry. She examines who the mentally ill were, how they were treated, whether the new democratic and populist politics of the period influenced psychiatric practice, and the impact of class and gender on diagnosis and treatment. As for the cultural and metaphorical uses of illnesses, a number of studies have explored the connection between literature and disease. The slippery

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meanings that lie between physical and spiritual disorders and the di√erent discourses that spiral around them are at the very core of these interpretative e√orts, which often are based on a very limited number of texts or sources read with as much imagination as audacity.≤≠ Diego Armus’s essay on tango, gender, and tuberculosis in Buenos Aires discusses metaphors associated with this disease, particularly the guilt and punishment that supposedly marked the lives of young women who dared to leave the domestic world of the neighborhood to try their luck in the city. This melodramatic journey inevitably condemned them to prostitution, poverty, and disease—or so the tangos would have us believe. Written by men, tango lyrics use and abuse tuberculosis as a way of articulating male discomfort and anxiety at a moment when women were occupying a new place in the public sphere. The struggle to eliminate sexually transmitted diseases, particularly syphilis, has been discussed as part of the e√orts to construct a population more susceptible to the interests of a certain biopolitics. Implicitly or explicitly, these campaigns propose to deal with the sex drive by self-control and by the rational and conscious assumption of biological responsibilities. Focused in this way, these histories are framed as chapters in the Western civilizing process which, in the worst cases, end up dissolving or ignoring regional or national specificities. When they do take such factors into account, historical narratives seek to connect the disease to broader issues such as degeneration, race, immigration, and national identity.≤∞ Similarly, other cultural studies have analyzed the emergence of medical models of exclusion based on stereotyping, stigmatizing, and pathologizing behaviors supposedly characteristic of women, homosexuals, or certain immigrant and racial groups.≤≤ Such studies have paid some attention to the complex, porous border between the private and the public in public health issues, an especially important question for aids, but obviously also relevant at other times and with other diseases. This border is at the heart of the historical construction of health rights as individual and social entitlements. Therefore discussions of aids policies have tended to stress the existence of a human rights crisis with a public health dimension, on the one hand, and a public health crisis with important human rights dimensions, on the other. Patrick Larvie’s essay examines the relationships between Brazil’s response to the aids epidemic and ideas about a problematic and unique Brazilian sexual culture. Through an analysis of educational material, o≈cial communications on the fight against aids, and recent work from the medical and social sciences on hiv prevention, Larvie argues that Brazil’s response

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to the epidemic includes e√orts to modernize and develop the nation and its sexuality. The expansion of medical knowledge and practices has also stimulated general histories of medicine or public health. Some studies with both a sound empirical foundation and a Foucauldian frame of analysis have examined the role of medical expertise as co-constructor of a new and modern sensibility. They pay special attention to the consolidation of a medical monopoly of treatment and the concrete sites where that power became hegemonic by being employed on the sick, the poor, women, adolescents, and homosexuals.≤≥ Other studies have sought to put together a history of public health by tracing the genesis, development, limitations, and crises of state welfare policies. These narratives are rather peculiar: while they present state’s institutions and specialists as the primary producers of miseries or splendors in popular health, they do not o√er a detailed reconstruction of the complex process of professionalization and the emergence of state agencies. Focusing on medicine and health in general rather than on a particular disease, these ambitious and sweeping histories are not dominant in the literature.≤∂ For some time now the tone has been set by narrower questions that avoid determinism—Foucauldian, economicistic, or otherwise. One line of inquiry has been Latin American eugenics. Touching on race, science, medicine, nationality, and the future, these studies see eugenics as a neoLamarckian bet on social improvement and selective immigration policies aimed at building healthy ‘‘national races.’’≤∑ The related topics of women and children’s health, state policies, and public welfare have been receiving increasing attention.≤∏ Focusing on Mexico City during and after the revolution, Ann Blum’s essay examines hospitalism syndrome, a developmental condition a∆icting infants in long-term institutional care. Blum explores the idea and impact of revolutionary maternalism: e√orts to reduce the reliance on internment-based care for children’s illnesses by integrating maternal and child public health initiatives with others aimed at relieving orphanage overcrowding. The ideology of hygiene as a means of articulating political concerns in technical terms and the ideology of public health as an instrument in the nation-building process is another theme drawing scholarly attention.≤π Looking at the cultural dimensions of hygiene, some scholars have shown how it achieved great social acceptance as a set of values over the medium and long term. Like education, the hygienic code was incorporated into the

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everyday life of elites and poor alike, regardless of their political or ideological di√erences. Certainly these social groups may not all have had equal access to hygienic practices or have given to hygiene exactly the same meanings. In any case, these studies tend to underline the relevance of individual and collective hygiene as a ‘‘civilizing’’ practice not only encouraged—and at times imposed—from above but also strongly embraced from below.≤∫ There are also post-Foucauldian readings of the concentration of power in doctors resulting from the so-called medicalization of society. Many histories of prostitution, dealing indirectly with venereal disease, have explored the broader issue of state e√orts to regulate or prohibit commercial sex.≤Ω Drawing information instead from popular magazines and newspapers, medical and legal journals, guidebooks to Mexico City, cartoons, ads, and the testimony of the sick, Katherine Bliss’s essay examines how people in revolutionary Mexico made decisions about their risk of contracting syphilis in the context of a popular campaign aimed at preventing the spread of the disease and advancing the medicalization of society. In making sense of this medicalization process, historians have explored people’s response to intrusive and at times compulsory public health e√orts such as vaccination practices. The history of smallpox vaccination unveils a long and ultimately successful process of acceptance marked at certain junctures by individual reactions, collective resistance, and collective demands charged with meanings that went beyond the vaccine itself, revealing the politicization of the public health arena. Some explanations of these revolts look for moral opposition to the government, evidence of elite manipulation of popular discomfort, or examples of popular resistance to urban sanitary and health policies. Other authors have paid particular attention to the behaviors and perceptions of certain racial groups with regard to smallpox control measures.≥≠ Some studies explore the ability of the sick to negotiate or even defy medical power. Whether individually by ignoring a physician’s recommendations, or collectively by organizing strikes, pressuring the political class, and using—and being used—by the mass printed media, tubercular patients asserted their right to try a treatment and a vaccine that were not approved by o≈cial medicine.≥∞ Cancer has also motivated the emergence of a social movement aimed at gaining access to drugs that patients believed to be e√ective in spite of the negative evaluation of the scientific community.≥≤ Malaria, yellow fever, and cholera have ignited resistance as a result of public health measures perceived as ine√ective or contrary to a mix of indig-

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enous and traditional Hippocratic perceptions about these illnesses.≥≥ And inmates of asylums were able to keep some control of their lives even in mental health establishments supposedly designed as ‘‘total institutions.’’≥∂ In the end, these studies on the reactions of the sick to resources aimed at dealing with smallpox, tuberculosis, cancer, malaria, cholera, yellow fever, and mental health seem to point to at least three issues. First, public health interventions and medical practices can be resisted, accepted, or demanded according to local, cultural, social, political, and disease-specific contexts. Second, the impact of such resources needs to be discussed in terms of both the short run and the long run, paying attention not only to particular moments of contention but also to the very successful, and probably therefore less studied, incorporation of these new practices in people’s lives. Finally, these studies reveal the existence of historical agency, indicating that the sick are not merely passive objects of medical practices and knowledges; consequently, their importance in the development of health policies is, and should be, a subject for careful reflection. In fact, health and disease have not been central to the agenda of the labor movement, nor were they central issues for social movements during the first half of the twentieth century. This relationship becomes pertinent only when health and disease are defined in very general terms and combined with other labor problems: the long struggle to shorten the working day, the e√orts aimed at improving the workplace, and the development of mutual-aid societies could be discussed in this way. Occupational health issues were of concern in certain national contexts around the turn of the century, but only in the 1940s did they begin to be part of the social agenda of the state or the labor movement. This same interest in patients’ perspectives has fueled the study of perceptions and explanations of disease, health, the body, and death, especially those that appear as alternatives to o≈cial medicine. Rather than celebrating folk medicine, these studies explore the transactions that take place between hegemonic knowledge and popular knowledge. They emphasize the varied and multifaceted meanings that illness acquires among disparate social, ethnic, or racial groups as well as the importance and complexity of the mutual influences, exchanges, and competition between o≈cially certified and popular medicines. In many cases this pluralistic scenario has been seen as evidence of the broader repertoire of resources available to the sick, who use them to reach goals that go beyond care or assistance.≥∑ Other studies, moving away from this emphasis on medical pluralism, underline the impact of modern work experiences, income, poverty, and

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class on social perceptions of health and illness. The social relevance of modern medical events, these authors argue, can be grasped in a given political and economic context at a specific point in time. Thus, exploring the emergence of a 1970s and 1980s social movement focused on environmental and occupational health, one study concludes that community discussions of health in semirural contexts were framed not in terms of humoral categories, religion, or ‘‘folk’’ healing, but rather on the impact of industrial pollution. Another study with a similar emphasis found a strong correlation between aids and poverty.≥∏ This book o√ers an account of the growth of the new subfield of Latin American historiography: its many directions, its limitations, and its possibilities. Most of the essays employ one or more of the di√erent but sometimes overlapping analytical approaches of the history of medicine, the history of public health, and the sociocultural history of disease, trying to make historical sense of a given disease. This is in itself a risky approach given the fact that human well-being and ill-being cannot be fully captured through the lens of a single disease. As I hope this volume will convincingly show, the symbolic meanings and impact of certain diseases can be understood only when a broad range of factors is taken in consideration. These factors include demographic structures and specific epidemiological histories; levels of urbanization and industrialization; public health and social policies; the priorities of international agencies and professional experts involved in disease control; and the state of scientific, medical, and technological knowledges and practices. They also can include specific social demands; the politics of nationalism and national self-image; the greater or lesser presence of the mass media in people’s lives; broader debates and negotiations between state policies and medical, social, and individual responsibilities; and the political and cultural uses of illnesses. These are some of the most decisive factors explaining how, when, and why diseases are perceived and lived in a particular way. No wonder di√erent diseases have played di√erent roles at the national, regional, and local levels within a given country. No wonder that what became relevant in epidemiological terms in one country had no significance in another. As this book is trying to show, diseases are not only sites where society, culture, medicine, and politics interact in a certain period or time, but also analytical tools to understand the always elusive complexity of the historical experience.

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Notes 1 Charles E. Rosenberg, ‘‘Framing Disease: Illness, Society, and History,’’ in Charles E. Rosenberg and Janet Golden, eds., Framing Disease: Studies in Cultural History (New Brunswick: Rutgers University Press, 1992), xiii. 2 Nancy Stepan, Beginnings of Brazilian Science: Oswaldo Cruz, Medical Research and Policy, 1890–1920 (New York: Science History Publications, 1976); Marcos Cueto, Excelencia Científica en la Periferia: Actividades Científicas e Investigación Biomédica en el Perú, 1890–1950 (Lima: Tarea, 1989); Jaime Benchimol and Luiz Antonio Teixeira, Cobras, Lagartos e Outros Bichos: Uma História Comparada dos Institutos Oswaldo Cruz e Butantan (Rio de Janeiro: Editora ufrj /Casa Oswaldo Cruz, 1993); Diana Obregón, Sociedades Científicas en Colombia: La Invención de una Tradición (Bogotá: Banco de la República, 1992); Marilia Coutinho, ‘‘Ninety Years of Chagas Disease: A Success Story at the Periphery,’’ Social Studies of Science 29.4 (1999): 519–49; Emilio Quevedo Vélez et al., ‘‘Ciencias Médicas, Estado y Salud en Columbia,’’ in Historia Social de la Ciencia en Colombia, vol. 8 (Bogotá: Tercer Mundo, 1993), 161–289. 3 Gilberto Hochman, A Era do Saneamento: As Bases da Política de Saúde Pública no Brasil (São Paulo: Editora hucitec / anpocs, 1998); Susana Belmartino, Carlos Bloch, María Isabel Carnino, and Ana Virginia Persello, Fundamentos Históricos de la Construcción de Relaciones de Poder en el Sector Salud: Argentina, 1940–1960 (Buenos Aires: ops / oms, 1991); Lynn Morgan, Community Participation in Public Health: The Politics of Primary Care in Costa Rica (Cambridge: Cambridge University Press, 1999); Sergio Díaz-Briquets, The Health Revolution in Cuba (Austin: University of Texas Press, 1983); Héctor Hernández Llamas, ed., La Atención Rural Primaria en México, 1930–1980 (Mexico, D. F.: imss, 1984); James J. Horn, ‘‘The Mexican Revolution and Health Care, or the Health of the Mexican Revolution,’’ Latin American Perspectives 10.4 (1983): 24–39. 4 For an example of the celebrant approach, see Jonathan Leonard, ‘‘Carlos Finlay’s Life and Death of Yellow Jack,’’ Bulletin of the Pan American Health Organization 23 (1989): 438–52. For a structuralist interpretation, see Juan César García, ‘‘La Medicina Estatal en América Latina (1880–1930),’’ Revista Latinoamericana de Salud 1 (1981): 70–110; and Pensamiento Social en Salud en América Latina (Mexico D.F.: Interamericana McGraw-Hill/ops, 1994). 5 Vicente Navarro, ‘‘The Underdevelopment of Health or the Health of Underdevelopment: An Analysis of the Distribution of Human Resources in Latin America,’’ International Journal of Health Sciences 4.1 (1974): 5–27. 6 Carlos Escudé, ‘‘Health in Buenos Aires in the Second Half of the Nineteenth

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7

8

9

10

Century,’’ in D. C. Platt, ed., Social Welfare, 1850–1950: Australia, Argentina and Canada Compared (London: Macmillan, 1989), 60–70; Christopher Abel, Health, Hygiene, and Sanitation in Latin America, 1870–1950 (London: Institute of Latin American Studies, University of London, 1996). Diego Armus, ‘‘Enfermedad, Ambiente Urbano e Higiene Social: Rosario entre fines del Siglo XIX y Comienzos del XX,’’ in Diego Armus, ed., Sectores Populares y Vida Urbana (Buenos Aires: clacso, 1984); Jaime Benchimol, Pereira Passos: Um Haussmann Tropical (Rio de Janeiro: Secretaria de Turismo, 1990); Teresa Meade, ‘‘Civilizing’’ Rio: Reform and Resistance in a Brazilian City, 1889–1930 (University Park: Pennsylvania State University Press, 1997); Claudia Agostoni, ‘‘Sanitation and Public Works in Late Nineteenth Century Mexico City,’’ Quipu: Revista Latinoamericana de Historia de las Ciencias y la Tecnología 12.2 (1999): 187–201; Carlos Contrera Cruz, ‘‘Ciudad y Salud en el Porfiriato: La Política Urbana y de Saneamiento de Puebla, 1880–1906,’’ Siglo XIX 1.3 (1992): 55–76; Adriana Alvarez and Daniel Reynoso, Médicos e Instituciones de Salud: Mar del Plata, 1870–1960 (Mar del Plata, Argentina: hisa / Universidad Nacional de Mar del Plata, 1995); Ricardo González Leandri, Curar, Persuadir, Gobernar: La Construcción Histórica de la Profesión Médica en Buenos Aires, 1852–1886 (Madrid: csic, 1999); Adrián Carbonetti, Enfermedad y Sociedad: La Tuberculosis en la Ciudad de Córdoba, 1906–1947 (Córdoba: Emecor, 1998). Ronn Pineo, ‘‘Public Health Care in Valparaiso, Chile,’’ in Ronn Pineo and James A. Baer, eds., Cities of Hope: People, Protests, and Progress in Urbanizing Latin America, 1870–1930 (Boulder: Westview Press, 1998), 178–217; Héctor Recalde, La Salud de los Trabajadores en Buenos Aires (1870–1910) a través de las Fuentes Médicas (Buenos Aires: Grupo Editor Universitario, 1997); Nilson do Rosario Costa, Lutas Urbanas e Controle Sanitário: Origens das Políticas de Saúde no Brasil (Petropolis, Brazil: Vozes, 1985); Carl J. Murdock, ‘‘Physicians, the State and Public Health in Chile, 1881–1891,’’ Journal of Latin American Studies 27 (1995): 551–67. Jurandir Freire Costa, Ordem Médica e Norma Familiar (Rio de Janeiro: Edições Graal, 1979); Oliva López Sánchez, Enfermas, Mentirosas y Temperamentales: La Concepción Médica del Cuerpo Femenino durante la Segunda Mitad del Siglo XIX (Mexico, D.F.: Plaza y Valdés, 1998); Nicolau Sevcenko, A Revolta da Vacina: Mentes Insanas em Corps Rebeldes (São Paulo: Brasiliense, 1984); Hugo Vezzetti, ‘‘El Discurso Psiquiátrico,’’ in Hugo Biagini, ed., El Movimiento Positivista Argentino (Buenos Aires: Editorial de Belgrano, 1985), 362–73; Teresita Martínez-Vergne, Shaping the Discourse on Space: Charity and Its Wards in Nineteenth-Century San Juan, Puerto Rico (Austin: University of Texas Press, 1999). Miguel Angel Scenna, Cuando Murió Buenos Aires (Buenos Aires: La Bas-

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tilla, 1974); Lilia V. Oliver, ‘‘El Cólera y los Barrios de Guadalajara,’’ in Marcos Cueto, ed., Salud, Cultura y Sociedad en América Latina: Nuevas Perspectivas Históricas (Lima: iep / ops, 1996), 87–110; Rodolpho Telarolli Jr., Poder e Saúde: As Epidemias e a Formação dos Serviços de Saúde em São Paulo (São Paulo: unesp, 1996); Beatriz Cano, ‘‘La ‘influenza española’ en Tlaxcala (1918),’’ in Elsa Malvido and María Elena Morales, eds., Historia de la Salud en México (Mexico, D.F.: Instituto Nacional de Antropología e Historia, 1996), 97–114; Agustina Prieto, ‘‘Rosario: Epidemias, Higiene e Higienistas en la Segunda Mitad del Siglo XIX,’’ in Mirta Lobato, ed., Política, Médicos y Enfermedades: Lecturas de Historia de la Salud en la Argentina (Buenos Aires: Biblos/Universidad Nacional de Mar del Plata, 1996), 57– 71; Enrique Florescano and Elsa Malvido, eds., Ensayos sobre la Historia de las Epidemias en México, vol. 2 (Mexico, D.F.: Instituto Mexicano del Seguro Social, 1982); Marcos Cueto, El Regreso de las Epidemias: Salud y Sociedad en el Perú del Siglo XX (Lima: Instituto de Estudios Peruanos, 1997); Diego Armus, ‘‘El Descubrimiento de la Enfermedad como Problema Social,’’ in Mirta Lobato, ed., El Progreso, la Modernización y sus Límites, Nueva Historia Argentina, vol. 5 (Buenos Aires: Sudamericana, 2000), 506–52; Ronn Pineo, ‘‘Misery and Death in the Pearl of the Pacific: Health Care in Guayaquil, Ecuador, 1870–1925,’’ Hispanic American Historical Review 70 (1990): 609–38; Sam Adamo, ‘‘The Sick and the Dead: Epidemic and Contagious Disease in Rio de Janeiro, Brazil,’’ in Ronn Pineo and James A. Baer, eds., Cities of Hope, 218–39; Nara Azevedo de Brito, ‘‘La Dansarina: A Gripe Espanhola e o Cotidiano na Cidade do Rio de Janeiro,’’ História, Ciências, Saúde—Manguinhos 4.1 (1997): 11–30. Luiz Antonio Teixeira, A Rebelião Popular contra a Vacina Obrigatória, Série Estudos em Saúde Coletiva 103 (Rio de Janeiro: ims / uerj, 1994). Diego Armus, ‘‘Consenso, Conflicto y Liderazgo en la Lucha contra la Tuberculosis: Buenos Aires, 1870–1950,’’ in Juan Suriano, ed., La Cuestión Social en la Argentina, 1870–1943 (Buenos Aires: La Colmena, 2000), 191– 216; Luiz Castro Santos, ‘‘Estado e Saúde Pública no Brasil (1889–1930),’’ Dados-Revista de Ciências Sociais 23.2 (1980): 237–50; Diana Obregón, ‘‘De ‘Arbol Maldito’ a ‘Enfermedad Curable’: Los Médicos y la Construcción de la Lepra en Colombia, 1884–1939,’’ in Marcos Cueto, ed., Salud, Cultura y Sociedad, 159–78. Luiz Castro Santos, ‘‘A Reforma Sanitária ‘Pelo Alto’: O Pionerismo Paulista no Início de Século XX,’’ Dados-Revista de Ciências Sociais 36.3 (1993): 361– 92; Saúl Franco Agudelo, El Paludismo en América Latina (Guadalajara: Editorial de la Universidad de Guadalajara, 1990). Jaime Benchimol, Dos Micróbios aos Mosquitos: Febre Amarela e a Revolução Pasteuriana no Brasil (Rio de Janeiro: Editora Fiocruz/Editora ufrj,

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1999); Marcos Cueto, ‘‘Tropical Medicine and Bacteriology in Boston and Peru: Studies of Carrion’s Disease in the Early Twentieth Century,’’ Medical History 40 (1996): 344–64; Simone Petragia Kropf, Nara Azevedo, and Luiz Otávio Ferreira, ‘‘Doença de Chagas: A Construção de um Fato Científico e de um Problema de Saúde Pública no Brasil,’’ Ciência e Saúde Coletiva 5.2 (2000): 347–65; Flavio Coelho Edler, ‘‘O Debate en Torno da Medicina Experimental no Segundo Reinado,’’ Historia, Ciência, Saúde—Manguinhos 3.2 (1996): 284–99; Julyan G. Peard, Race, Place and Medicine: The Idea of the Tropics in Nineteenth-Century Brazilian Medicine (Durham: Duke University Press, 1999). Marcos Cueto, ed., Missionaries of Science: The Rockefeller Foundation in Latin America (Bloomington: Indiana University Press, 1994). Steven Palmer, ‘‘Central American Encounters with Rockefeller Public Health, 1914–1921,’’ in Gilbert Joseph, Catherine Legrand, and Ricardo Salvatore, eds., Close Encounters of Empire: Writing the Cultural History of U.S.–Latin American Relations (Durham: Duke University Press, 1988), 311–32; Anne-Emanuelle Birn and Armando Solórzano, ‘‘The Hook of Hookworm: Public Health and the Politics of Eradication in Mexico,’’ in Andrew Cunningham and Bridie Andrews, eds., Western Medicine as Contested Knowledge (Manchester: Manchester University Press/St. Martin’s Press, 1997), 147–71. Hugo Vezzetti, La Locura en la Argentina (Buenos Aires: Folios, 1983); Rafael García-Huertas, El Delincuente y su Patología: Medicina, Crimen y Sociedad en el Positivismo Argentino (Madrid: Cuadernos Galileo, csic, 1991); Sérgio Carrara, Crime e Loucura: O Aparecimento do Manicômio Judiciário na Passagem do Século (Rio de Janeiro/São Paulo: Eduerj/Edusp, 1998). Roberto Machado, Angela Loureiro, Rogerio Luz, and Katia Muricy, Danação da Norma: Medicina Social e Constituição da Psiquiatria no Brasil (Rio de Janeiro: Graal, 1978). Augusto Ruiz Zevallos, Psiquiatras y Locos: Entre la Modernización contra los Andes y el Nuevo Proyecto de Modernidad (Lima: Instituto Pasado y Presente, 1994); Cristina Rivera-Garza, ‘‘Dangerous Minds: Changing Psychiatric Views of the Mentally Ill in Porfirian Mexico, 1876–1911,’’ Journal of the History of Medicine and Allied Sciences 56.1 (2001): 36–67; Hugo Vezetti, Aventuras de Freud en el País de los Argentinos: De José Ingenieros a Enrique Pichón Rivière (Buenos Aires: Paidós, 1996); Jorge Balán, Cuéntame tu Vida: Una Biografía Colectiva del Psicoanálisis Argentino (Buenos Aires: Planeta, 1991); Mariano Plotkin, ‘‘Tell Me Your Dreams: Psychoanalysis and Popular Culture in Buenos Aires, 1930–1950,’’ The Americas 55.4 (1999): 601–29. Gabriela Nouzeilles, Ficciones Somáticas: Naturalismo, Nacionalismo y Políticas

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del Cuerpo (Argentina, 1880–1910) (Rosario, Argentina: Beatriz Viterbo Editora, 2000); Benigno Trigo, Subjects of Crisis: Race and Gender as Disease in Latin America (Hanover, N.H.: Wesleyan University Press, 2000); Zandra Pedraza Gómez, En Cuerpo y Alma: Visiones del Progreso y de la Felicidad (Bogotá: Universidad de los Andes, 1999); Angela Porto, ‘‘A Vida Inteira Que Podia Ter Sido e Que Não Foi: Trajetória do um Poeta Tísico,’’ História, Ciencias, Saúde—Manguinhos 6 (1999–2000): 523–50; Sylvia Molloy, ‘‘Voice Snatching: De Sobremesa, Hysteria and the Impersonation of Marie Bashkirtse√,’’ Latin American Literary Review 25 (July–December 1997): 11–29. Katherine Bliss, ‘‘The Science of Redemption: Syphilis, Sexual Promiscuity, and Reformism in Revolutionary Mexico City,’’ Hispanic American Historical Review 79.1 (1999): 1–40; Sérgio Carrara, Tributo a Vênus: A Luta Contra a Sífilis no Brasil, da Passagem do Século aos Anos 40 (Rio de Janeiro: Editora Fiocruz, 1996). Patrick Larvie, ‘‘Queerness and the Specter of Brazilian National Ruin,’’ GLQ: A Journal of Lesbian and Gay Studies 5.4 (1999): 527–58; Oliva López Sánchez, Enfermas, Mentirosas y Temperamentales; Marvin Leiner, Sexual Politics in Cuba: Machismo, Homosexuality and AIDS (Boulder: Westview Press, 1993); Jorge Salessi, Médicos, Maleantes y Maricas. Higiene, Criminología y Homosexualidad en la Construcción de la Nación Argentina: Buenos Aires, 1871–1914 (Rosario, Argentina: Beatriz Viterbo Editora, 1995); Lilia Moritz Schwarcz, Espetáculo das Raças: Cientistas, Instituções e Questão Racial no Brasil, 1870–1930 (São Paulo: Companhia das Letras, 1993). José Pedro Barrán, Medicina y Sociedad en el Uruguay del Novecientos, 3 vols. (Montevideo: Ediciones de la Banda Oriental, 1994). María Angélica Illanes, ‘‘En Nombre del Pueblo, del Estado y de la Ciencia . . . ’’: Historia Social de la Salud Pública, Chile 1880–1973 (Santiago de Chile: Colectivo de Atención Primaria, 1993); Héctor Recalde, La Salud de los Trabajadores en Buenos Aires. Nancy Stepan, ‘‘The Hour of Eugenics’’: Race, Gender, and Nation in Latin America (Ithaca: Cornell University Press, 1991); Consuelo Naranjo Osorio and Armando García González, Medicina y Racismo en Cuba: La Ciencia ante la Inmigración Canaria en el Siglo XX (La Laguna, Tenerife: Taller de Historia, 1996); Lilia Moritz Schwarcz, Espetáculo das Raças; Alexandra M. Stern, ‘‘Responsible Mothers and Normal Children: Eugenics and Nationalism in Post-revolutionary Mexico, 1920–1940,’’ Journal of Historical Sociology 12.4 (1999): 369–96; Eduardo Zimmermann, ‘‘Racial Ideas and Social Reform: Argentina 1890–1916,’’ Hispanic American Historical Review 72.1 (1992): 23– 46. Annette B. Ramirez de Arellano and Conrad Seipp, Colonialism, Catholicism,

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and Contraception: A History of Birth Control in Puerto Rico (Chapel Hill: University of North Carolina Press, 1983); Ann Blum, ‘‘Public Welfare and Child Circulation, Mexico City, 1877–1925,’’ Journal of Family History 23.3 (1998): 240–71; Marcela Nari, ‘‘Las Prácticas Anticonceptivas, la Disminución de la Natalidad y el Debate Médico en Argentina, 1890–1940,’’ in Mirta Lobato, ed., Política, Médicos y Enfermedades, 153–92; Donna J. Guy, ‘‘The Pan American Child Congresses, 1916–1942: Pan Americanism, Child Reform, and the Welfare State in Latin America,’’ Journal of Family History 23.3 (1998): 272–91. 27 Sidney Chaloub, Cidade Febril: Cortiços e Epidemias na Corte Imperial (São Paulo: Companhia das Letras, 1996); Luiz Castro Santos, ‘‘O Pensamento Sanitarista na Primeira Republica: Uma Ideologia de Construção da Nacionalidade,’’ Dados—Revista de Ciências Sociais 28.2 (1985): 193–210; Nísia Trindade Lima and Nara Britto, ‘‘Salud y Nación: Propuesta para el Saneamiento Rural. Un Estudio de la Revista Saúde (1918–1919),’’ in Marcos Cueto, ed., Salud, Cultura y Sociedad, 135–58. 28 Diego Armus, ‘‘Salud y Anarquía: La Tuberculosis en el Discurso Libertario Argentino, 1870–1940,’’ in Mirta Lobato, ed., Política, Médicos y Enfermedades, 93–118; Diego Armus, ‘‘O Discurso da Regeneração: Espaço Urbano, Utopías e Tuberculose na Buenos Aires, 1870–1930,’’ Estudos Históricos 16 (1995), 235–50; Diego Armus, ‘‘La Idea del Verde en la Ciudad Moderna: Buenos Aires, 1870–1940,’’ Entrepasados. Revista de Historia 10 (1995): 9– 22; Dora Barancos, La Escena Iluminada: Ciencias para Trabajadores, 1890– 1930 (Buenos Aires: Plus Ultra, 1996), chap. 6; David Parker ‘‘Civilizing the City of Kings: Hygiene and Housing in Lima, Peru,’’ in Ronn Pineo and James Baer, eds., Cities of Hope, 153–77; Zandra Pedraza Gómez, ‘‘La Difusión de una Dietética Moderna en Colombia. La Revista Cromos entre 1940 y 1986,’’ in Diego Armus, ed., Entre Médicos y Curanderos. Cultura, Historia y Enfermedad en América Latina Moderna (Buenos Aires: Norma, 2002), 293– 330. 29 David McCreery, ‘‘ ‘This Life of Misery and Shame’: Female Prostitution in Guatemala City, 1880–1920,’’ Journal of Latin American Studies 18.2 (1986): 333–53; Magali Engel, Meretrizes e Doutores: O Saber Médico e a Prostitução na Cidade do Rio de Janeiro, 1840–1890 (Rio de Janeiro: Brasiliense, 1989); Martha de Abreu Esteves, Meninas Perdidas: Os Populares e o Cotidiano do Amor no Rio de Janeiro da ‘‘Belle Epoque’’ (Rio de Janeiro: Paz e Terra, 1989); Margareth Rago, Os Prazeres da Noite: Prostitução e Codigos da Sexualidade Femenina em São Paulo, 1890–1930 (Rio de Janeiro: Paz e Terra, 1991); Donna Guy, Sex and Danger in Buenos Aires: Prostitution, Family and Nation in Argentina (Lincoln: University of Nebraska Press, 1991); Eileen J. Suárez

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Findlay, Imposing Decency: The Politics of Sexuality in Puerto Rico, 1870–1920 (Durham: Duke University Press, 1999). José Murilo de Carvalho, Os Bestializados: O Rio de Janeiro e a República que não Foi (São Paulo: Companhia das Letras, 1987); Je√rey D. Needell, ‘‘The Revolta contra a Vacina of 1904: The Revolt against ‘Modernization’ in Belle Epoque Rio de Janeiro,’’ Hispanic American Historical Review 67.2 (1987): 233–69; Teresa Meade, ‘‘Civilizing Rio de Janeiro: The Public Health Campaign and the Riot of 1904,’’ Journal of Social History 20.2 (1986): 301–32; José Carlos Sebe Meihy and Cláudio Bertolli Filho, Historia Social da Saúde: Opinião Pública versus Poder. A Campanha da Vacina, 1904, Estudos CEDHAL 5 (1990); Sidney Chalhoub, Cidade Febril: Cortiços e Epidemias na Corte Imperial, chap. 3; María Silvia Di Liscia, ‘‘Viruela, Vacunación e Indígenas en la Pampa Argentina del Siglo XIX,’’ in Diego Armus, ed., Entre Médicos y Curanderos, 27–70. Diego Armus, ‘‘De ‘Médicos Dictadores’ y ‘Pacientes Sometidos’: Los Tuberculosos en Acción. Argentina, 1920–1940,’’ Allpanchis 31.53 (1999): 219–53; Diego Armus, ‘‘Cuando los Enfermos Hacen Huelga: Argentina, 1900–1940,’’ Estudios Sociales. Revista Universitaria Semestral 11.20 (2001): 53–80; Claudio Bertolli Filho, ‘‘Antropologia da Doença e do Doente: Percepções e Estratégias da Vida dos Tuberculosos,’’ História, Ciências, Saúde— Manguinhos 6.3 (1999): 493–522. Emilio de Ipola, ‘‘Estrategias de la Creencia en Situaciones Críticas: El Cáncer y la Crotoxina en Buenos Aires durante la Década del Ochenta,’’ in Diego Armus, ed., Entre Médicos y Curanderos, 371–418. Marcos Cueto, El Regreso de las Epidemias, chaps. 2 and 4. Cristina Rivera-Garza, ‘‘La Vida en Reclusión: Vida Cotidiana y Estado en el Manicomio General La Castañeda, México, 1910–1930,’’ in Diego Armus, ed., Entre Médicos y Curanderos, 179–220. Libbet Crandon-Malamud, From the Fat of Our Souls: Social Change, Political Process, and Medical Pluralism in Bolivia (Berkeley: University of California Press, 1991); Joseph Bastien, Drums and Stethoscope: Integrating Ethnomedicine and Biomedicine in Bolivia (Salt Lake City: University of Utah Press, 1992); Ann Zulawski, ‘‘Hygiene and ‘the Indian Problem’: Ethnicity and Medicine in Bolivia, 1910–1920,’’ Latin American Research Review 35.2 (2000): 107–29; Nancy Scheper-Hughes, Death without Weeping: The Violence of Everyday Life in Brazil (Berkeley: University of California Press, 1992); María Eugenia Módena, Madres, Médicos y Curanderos: Diferencia Cultural e Identidad Ideológica (Mexico City: Ciesas, 1990); Jane Felipe Beltrão, ‘‘A Arte de Curar dos Profissionais de Saúde Popular em Tempo de Cólera: Grão-Pará do Século XIX,’’ História, Ciências, Saúde—Manguinhos 6

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(2000): 833–66; Maria Andréa Loyola, Médicos e Curandeiros: Conflito Social e Saúde (São Paulo: Difel, 1984); Beatriz Texeira Weber, Medicina, Religião, Magia e Positivismo na República Rio-Grandense, 1889–1928 (São Paulo: Edusc, Bauru, 1999); David Sowell, The Tale of Healer Miguel Perdomo Neira: Medicine, Ideologies and Power in the Nineteenth-Century Andes (Wilmington: Scholarly Resources, 2001); Steven Palmer, ‘‘La ‘voluntad radiante’ del Profesor Carbell: Medicina Popular y Populismo Médico en Costa Rica en el Decenio de 1930,’’ in Diego Armus, ed., Entre Médicos y Curanderos, 259–92; Paul Farmer, ‘‘Brujería, Política y Concepciones sobre el Sida en el Haití Rural,’’ in Diego Armus, ed., Entre Médicos y Curanderos, 417–55. 36 Ida Susser, ‘‘Union Carbide and the Community Surrounding It: The Case of Community in Puerto Rico,’’ International Journal of Health Services 15.4 (1985): 561–83; Paul Farmer, AIDS and Accusation: Haiti and the Geography of Blame (Berkeley: University of California Press, 1992).

nancy leys stepan

‘‘The Only Serious Terror in These Regions’’ malaria control in the brazilian amazon

he pitfalls of assessing human health and ill health through the lens of a single disease are many; not the least is the possibility of re-creating in our histories the failed strategy of so many single-disease public health campaigns in the twentieth century. Nonetheless, as I believe many of the essays in this volume attest, we can to some extent transcend this danger by treating a single disease as a concentrated site in which all the possibilities and contradictions in public health and medical politics are sedimented. A broad range of factors—the politics of disease (i.e., which diseases come to the attention of public authorities at particular moments, and why); historical epidemiology; the variety of technologies (social practices) of public health that appear available for use; the role of science and technology in the formation of public health interventions; the influence of international agencies in disease control; the e√ects of nationalism on the definition of the public’s health; and the importance of the larger, symbolic meanings of disease to a nation’s self-image—are in this way brought into view for historical consideration. In this essay I focus on disease in the Brazilian Amazon between 1900 and about 1920 for several reasons: 1. Human imprints: It was the period of the boom and bust of rubber extraction and therefore of major social, economic, and environmental changes, as well as of human migrations. These changes profoundly a√ected the distribution of disease. 2. Disease data: It is a period for which we have some epidemiological data, sketchy data, it is true, but better than nothing. The human costs of rubber extraction gave rise to the first national e√orts to map the region’s diseases and draw up an overall plan of sanitation for the entire Amazon

T

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Valley. The idea was audacious, to say the least; most antimalarial projects at the time occurred in selected urban or delimited spaces, not in vast, rural areas. 3. Brazilian public health: The surveys occurred at a promising moment in Brazilian history, with several successes in public health campaigns already achieved and high expectations of further ones. An additional dimension to the story is that it occurred before the Rockefeller Foundation became involved in disease control in the country. 4. The malaria debates: The realization that malaria was responsible for 80 percent of the morbidity of the Amazon brought Brazilian public health o≈cials into the heart of some of the most interesting debates about disease control going on at the time. The strategies the Brazilians proposed are of interest not so much because of their originality per se, but because they were devised at a time when, as historians are increasingly realizing, despite great advances in the scientific understanding of the character of malaria and its mode of transmission, control strategies were not necessarily obvious or easy, once public health was considered in practice—in relation to specific geographical areas and/or populations—as opposed to in the laboratory or the scientific publication.∞ What techniques were available and considered? What insights and what political, economic, scientific, and symbolic issues framed the Amazonian story? 5. My last reason for selecting malaria in the Amazon relates to the past and present debates on malaria: The first e√orts to deal with disease in the Amazon ended with the collapse of the Brazilian rubber industry in World War I and the corresponding collapse of the political will to deal with malaria. But of course the story of malaria did not end there. In Brazil, two episodes in malaria control in the 1930s and 1940s merit attention: the Rockefeller-led campaign against malaria in the northeast of Brazil in 1938– 39, and Brazilian-U.S. e√orts against diseases in the Amazon in World War II. Both are of historical relevance to the emergence of the eradicationist strategy of the global campaign launched by the World Health Organization after the war. The eventual failure of the who campaign by the late 1960s led to a scaling back of ambitions from complete eradication of malaria to control, with a consequent cutback of funds for malaria work. The significance of this failure, or, more correctly, the failure to grasp the complexities of malaria in relation to human agency as well as biological and environmental variables, is that malaria is, as Cueto has remarked, a ‘‘recurring burden’’ of poor countries.≤

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Today there are two million cases of malaria in Latin America each year, 50 percent of them in present-day Brazilian Amazonia.≥ The recrudescence of malaria and the growing recognition by experts of malaria’s di√erent histories in di√erent parts of the world are leading historians to reassess the past. Latin America is important to this reassessment not only because it has been largely left out of the historical picture (older and newer historical analyses tending to focus on malaria in Europe and Europe’s tropical colonies), but because what happened in the early twentieth century in the Amazon in many ways still defines the essential parameters by which we understand the causes and means of control of malaria today.∂

Malaria Surveys in the Amazon The surveys of malaria carried out in the Amazon before World War I followed in many respects the pattern that was emerging in malaria surveys elsewhere in the world at the time. They were local versions of an international style of investigation involving often short-term reviews of the malaria situation in a specific place or region; field studies of local Anopheles mosquitoes, whose role in transmitting malaria had been established by Ronald Ross, Grassi, and others in 1897–1898; and often programmatic statements about how to achieve control.∑ Brazilian e√orts along these lines were distinguished from those elsewhere in being perhaps even more limited in resources, time, and personnel, and in having greater problems of discontinuity. Malaria stood in the national imagination for rural inertia and backwardness; the surveys were important in reconfiguring inertia as a function of parasitic infection. The federal government’s interest in disease in the Amazon was almost wholly a function of rubber and its decline.∏ Between 1900 and 1910, rubber harvested from the native Hevea brasiliensis plant was the second most important export crop in Brazil (28.2 percent) after co√ee (48.2 percent); even in 1910, when competition from the rubber plantations in the Far East was severe, Brazilian rubber still represented 50 percent of the world’s total production.π Since the late nineteenth century, rubber had brought what the great Brazilian writer Euclides da Cunha called a ‘‘chaotic flood’’ of people into the Amazon.∫ Between 1890 and 1900 an estimated half a million people, many from the northeastern states of the country, were drawn to the region

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to work as rubber tappers.Ω In 1900, some forty thousand people from the state of Ceará alone arrived, driven by the hope of leaving behind a life of misery in their drought-stricken homes. Poor and malnourished, they found in the green forests of the Amazon misery, hard work, and disease, the latter being a major cause of the chronic labor shortage in the region. Disease in turn brought to the region a new generation of sanitation experts, led by Dr. Oswaldo Cruz, director of the Oswaldo Cruz Institute in Rio de Janeiro, a federally funded organization that was arguably the best center of the new microbiological and parasitological medicine in Latin America. Between 1905 and the 1920s, technicians and researchers from the Oswaldo Cruz Institute fanned out over many parts of Brazil—into the semiarid states of the northeast, into the forests of Amazonia, into Mato Grosso, Paraná, Minas Gerais, and São Paulo—to survey the disease conditions of the vast interior of the country and assess the barriers they presented to ‘‘civilization.’’∞≠ Cruz first went to the Amazon in 1905 on a government survey of the sanitary conditions of the main ports of Brazil; on this occasion he visited Belém, Santarém, Óbidos, and Manaus.∞∞ A longer venture into the interior of the Amazon occurred in 1910, when Cruz was asked to assess the medical conditions among the workers of the re-created Madeira-Mamoré project, which was intended to connect Brazil to Bolivia by rail. Basing himself in the hospital at Candelaria, outside Porto Velho on the Madeira River, where the railway company had made its headquarters, Cruz and his assistants spent several weeks examining the conditions along the 113 kilometers of completed railway lines and in the surrounding settlements along the upper Madeira River. The health conditions they found there were appalling, compounded as they were by the periodic influx into old settlements of thousands of newcomers, many of whom had no resistance to malaria from previous infections, and whose immunity to disease was reduced by bad nutrition and high food prices. The absence of any organized medical assistance outside the labor camps, the cost of often adulterated quinine, and the heavy work demanded of the workers further compromised their health. Investigations by the visiting doctors revealed that some 50–75 percent of the often foreign-born workforce was infected with hookworm, which caused anemia and exhaustion; in the case of Brazilian nationals, the figure rose to 90 percent. So terrible were the conditions that the death rate from pneumonia was 50 percent, far higher than elsewhere in Brazil. But above all, Cruz found extraordinary rates of malaria. He calculated

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that malaria infected 90 percent of the workforce of several thousand men. More, 75 percent of those infected had falciparum malaria (then called tropical or malignant tertian malaria), the most lethal form of the disease. ‘‘It is malaria, a preventable disease, that is the only serious terror in these regions,’’ Cruz reported; its control was, he argued, the key to the development of Amazonia.∞≤ In 1912 Cruz was back in the Amazon. Disease control by this time was considered, as Cruz had said it had to be, critical to rubber and labor productivity. Now Cruz was charged by the Committee for the Defense of Rubber, organized by the Ministry of Agriculture, Industry, and Commerce, with the far greater task of assessing the health situation and drawing up a plan for sanitizing the entire Amazon Valley. It was a daunting task given the widespread distribution of people and diseases across the huge terrain and the complete absence of medical and public health facilities except in the larger towns like Manaus. Cruz assembled a small team of medical researchers from the Oswaldo Cruz Institute and sent them westward from Belém and Manaus through most of the main sites of rubber extraction. For five months the doctors traveled up and down the Solimões, Purus, Acre, Yaco, Negro, and Branco Rivers. The medical team was led by Dr. Carlos Chagas, an experienced malariologist who had risen to prominence in Brazil because of his discovery in 1909 of a new human disease, Trypanosomiasis americana (Chagas’ disease).∞≥ Chagas was to write the epidemiological section of Cruz’s report. Lack of knowledge of the cycle of human movements associated with latex rubber collecting and its relation to the cycles of flooding of the Amazon waters meant that the medical team traveled through the Amazon when the rubber trappers were deep in the forests. This limited to some extent the work of the medical survey, because the doctors did not have time to venture much beyond the riverine settlements and track the rubber trappers into the woods in order to examine them for disease. Nonetheless, the researchers carried out extensive examinations of people where they could (hundreds came asking for medical help); investigated their diets, housing, and the prices of food and quinine; and tried to estimate the character, distribution, and mortality rates of the diseases they encountered. Perhaps because they were reluctant to draw any direct connection between disease and the tropical climate; because they believed, like so many Brazilians (and foreign visitors), that the Amazon could one day be made suitable for a huge and healthy agricultural population; and because they

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were strongly committed to the new parasitology, Chagas and his team focused their attention especially on the parameters of disease as defined by the new tropical medicine—on microscopic flagellates and their biological (Anopheles) vectors. They shared the government’s view of the need for economic development in the Amazon and believed that through scientific sanitation, human adaptation to the Amazon environment was possible. But despite their faith in the medical management of the Amazon, they were astonished by what they found. The new territory of Acre they believed deserved its name, the ‘‘champion of death,’’ because of its extraordinarily high rates of disease. ‘‘Never had I encountered such high lethality for an endemic disease and never had I seen more widespread morbidity,’’ wrote Chagas. ‘‘The cases of splenomegaly [spleen enlargement] were considerable . . . and were counted in the hundreds in children and adults.’’∞∂ So great was the death from malaria in infancy in some settlements that the doctors found very few young children. The children who did survive infections in infancy showed the high spleen indexes indicative of histories of repeated infections. In fact, so normal did children consider their condition that when asked if they were ill, they said no, they just had baço (swollen bellies). Similarly, the rubber workers the doctors examined were so used to malaria that only the acute feverish state counted as illness to them; some even refused the pro√ered quinine treatment (which made sense given its high price and erratic quality). Cruz and his team were struck particularly by the intensity of malaria in the Amazon and its variability. Indeed, within the limits of their conceptual framework (which I consider later in the chapter), their observations were often astute. Their work on malaria in the Amazon is interesting because it is left out of histories of malaria (which are still spotty in general for the period between the two world wars) and because, either explicitly or implicitly, it touched on many of the most di≈cult issues surrounding malaria control then and now. It is evident that many of the medical researchers involved in malaria studies at the time appreciated the complexity of the disease, and therefore of its control.∞∑ Through field studies in specific geographical localities, many were developing a multilayered understanding of malaria which, if not fully ecological in our contemporary sense (i.e., not fully integrating all the interactive components of the environment— vectors; pathogens; ecological niches; and the character, condition, and behavior of human populations), we might nevertheless describe as protoecological.∞∏ This knowledge was largely forgotten after World War II,

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when the initial success of ddt and new antimalaria drugs led to a misplaced confidence that malaria control through the systematic eradication of the Anopheles mosquito vectors by the application of long-lasting insecticides to the environment was a fairly straightforward matter.

The Malaria Debates When the Brazilians began their surveys of malaria in the Amazon, debates among malariologists about the disease and how to control it were already intense. One side took its fundamental orientation from the discovery that anopheline species of mosquitoes transmit the malaria plasmodium to man. Control, in this view, focused mainly on the reduction or elimination of the mosquitoes themselves (by insecticides to kill the larvae or adults, or by drainage and oiling of terrain to eliminate aquatic breeding sites). The other ‘‘camp’’ was less impressed with the mosquito vector as such and focused instead on the human host and the need to protect individuals by the use of quinine and other means, as well as by broad social improvements. In very rough terms, Ross and the Americans (e.g., the Rockefeller Foundation, after it entered the international health field in 1913) favored mosquito control while the Europeans (especially the Italians) tended to look to ‘‘quininization’’ of human populations. The U.S. government had already used mosquito vector eradication in Cuba to control yellow fever. Gorgas repeated this success in Panama between 1904 and 1914, eliminating yellow fever and meanwhile also greatly reducing malaria by these means. Ross pointed out in his compendium on antimalaria campaigns, The Prevention of Malaria (1910), that as a result of the mosquito theory of malaria transmission, the traditional strategy of drainage (swampy lands being long associated with the miasma of malarial fevers) could now be targeted more e≈ciently on terrain where specific malaria-transmitting mosquitoes bred. The Italians, on the other hand, were skeptical about a narrow, mosquito-driven method except in exceptional circumstances; they were especially skeptical of its applicability in rural areas (malaria being largely a rural disease). They preferred a broader, more social definition of malaria and advocated improved general sanitation, land drainage and reclamation, improved agriculture, plus the regular use of quinine as a therapeutic and a prophylactic (even though they knew quinine did not kill o√ all plasmodia in the body).∞π There is evidence to

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suggest that the above is a too-polarized picture of the views in the 1920s, and that in fact, the greatest successes in malaria reduction between the two world wars was achieved by an eclectic mix of methods (though perhaps within a generally ‘‘Italian’’ approach concerning general health improvements).∞∫ Nevertheless, disagreements about the best approaches were sometimes intense and there was a tendency to assume that what worked in one place would work everywhere, with the result that e√orts at control failed more often than they succeeded.∞Ω Until the late 1930s, the European position on malaria predominated; it was, for example, the view of the League of Nation’s Malaria Commission that malaria reduction in Europe had generally followed overall improvements in agriculture and nutrition, and that in many places complete mosquito eradication was neither practicable nor cost-e√ective.≤≠ This position began to change in the late 1930s. Brazil played an important demonstration role in this regard when in 1938–39 the Rockefeller Foundation checked a major epidemic of malaria in the northeast of the country by the systematic eradication of the mosquito vector (to which I will return later). The Brazilian campaign was followed by the discovery in World War II of the residual insecticide properties of ddt; its e√ectiveness in controlling malaria led to mosquito eradicationism winning the day. After the war, many areas of the world were in fact cleared of malaria; and in 1955, who announced a campaign to eradicate malaria across the globe based on the mosquito eradicationist strategy.≤∞ But in a cycle of opinion now characteristic of the malaria field, eradicationism ultimately began to lose ground as a public health strategy, as the sheer di≈culty of dealing with malaria by means of a single method became apparent. ddt-resistant anopheline mosquitoes developed following the widespread use of ddt, as did drug-resistant plasmodia strains following the mass use of synthetic antimalarial drugs like chloroquine. Malaria has once again emerged as one of the world’s most serious parasitic illnesses.

Understanding Malaria in the Amazon It is in the light of these debates surrounding malaria that I return to the Brazilian surveys in the Amazon. Malaria was an early research interest of the Oswaldo Cruz Institute; the work involved laboratory investigations into the life cycle of plasmodia as well as field studies to systematize knowl-

Boy with enlarged spleen caused by malaria infection, Boca do Acre, Amazonas, December 1912. Taken during the 1912–13 medical survey of the Amazon conducted by the Oswaldo Cruz Institute. Eduardo Thielen et al., eds., A Ciência a Caminho da Roça: Imagen das Expedições Cientificas do Instituto Oswaldo Cruz ao Interior do Brasil entre 1911 e 1913 (Rio de Janeiro: Casa de Oswaldo Cruz, 1991), p. 136. Courtesy of the Departamento de Arquivo e Documentação da Casa Oswaldo Cruz da Fundação Oswaldo Cruz.

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edge of Brazilian Anopheles mosquitoes.≤≤ At the time, many of the species that acted as the main vectors were not even known (e.g., A. darlingi, the chief transmitter of malaria in much of the Amazon, was not securely identified until 1923). Much, then, remained to be learned about malaria when the Brazilians carried out their surveys. Nevertheless, they brought trained eyes to the project, and their observations are not without historical interest. First, they concluded that malaria in the Amazon was in certain respects novel. Chagas, an experienced clinician as well as a laboratory scientist, was struck by the extreme intensity of the disease in the region. He believed that malaria presented itself in the Amazon in new modalities, a√ecting the plasmodium, the mosquito vectors, and the clinical symptoms. In the town of São Felipe, for example, in the first half of 1911, the year before the doctors arrived, malaria had killed four hundred people out of a total of eight or nine hundred, suggesting a tropical ( falciparum) malaria of exceptional virulence producing paralysis and cerebral comas, which Chagas had not hitherto encountered. Second, however, the Brazilian researcher also discovered extensive malaria in areas without large populations of Anopheles mosquitoes. Chagas knew his Brazilian mosquitoes well, and he was surprised by his inability in certain areas of the Amazon to find large numbers of adult or larval forms of the known Anopheles transmitters of malaria. Without naming it as such, Chagas’s problem of ‘‘malaria without anophelism’’ might be thought of as the other side of ‘‘anophelism (and plasmodia) without malaria,’’ a phenomenon that had been recognized early in malaria work, although it did not become the subject of systematic research until the 1920s and 1930s. Both pointed to the di≈culty of drawing up any simple relation between the presence of Anopheles mosquito vectors and the actual incidence of malaria in human populations (this was one reason why European researchers long doubted that the reduction in Anopheles mosquito populations per se was the route to malaria control).≤≥ With a known mosquito transmitter of a known form of plasmodium, generally speaking, the intensity of infection was believed to relate to the number of mosquitoes in the area or the number of bites a person experienced. What did it mean, then, to find endemic and epidemic malaria without large numbers of anopheline mosquitoes? Chagas speculated that in certain areas of the Amazon, perhaps an unknown plasmodium species or subrace of exceptional virulence, with its own as yet unidentified anopheline vector,

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Inhabitant of the Vista Alegre Plantation, Acre, December 1912. Acre was considered the unhealthiest site visited by the doctors of the Oswaldo Cruz Institute, largely because of the extraordinary incidence and lethality of malaria. Courtesy of the Departamento de Arquivo e Documentação da Casa Oswaldo Cruz da Fundação Oswaldo Cruz, foc (ac-e)6-73.3.

was responsible for the malaria picture he found. This suggestion was supported by clinical observations of the blood of malaria patients, which indicated that the plasmodium did not seem typical in its developmental cycle. He was reaching for the idea that di√erent variants of plasmodia and/or vectors a√ected the manifestations of the disease. A third conclusion connected to the Amazonia surveys of malaria concerned quinine resistance. This phenomenon had first been noticed in Brazil in 1907 by Dr. Artur Neiva, a researcher at the Oswaldo Cruz Institute, when he was in charge of malaria prophylaxis in a workforce of 3,500 men damming the river Xerém in the state of Rio de Janeiro. Neiva’s observations were seconded by Chagas in the Madeira-Mamoré and Acre regions of the Amazon (and at about the same time by Hocht in Hamburg).≤∂ It had important consequences in establishing how quinine might be used e√ectively in malaria prophylaxis. In Xerém, malaria was both endemic (well established in the local population) and liable to be epidemic. Quinine was

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at the time the most important method of individual protection against malaria, yet Neiva discovered that many workers were unresponsive to the very low doses of quinine they were used to taking. And even under a high dosage regime, once they left the malarial region and stopped taking quinine, they suddenly became subject to bouts of malaria fever. Neiva concluded that, in endemic areas, the routine uses of low-level dosages of quinine had over time actually produced permanent races of quinine-resistant plasmodia. The only solution he could think of was to institute a system of very high dosages of quinine and to extend the use of the quinine therapy for much longer than was usual after the infected individual left the endemic malaria zone. The doctors knew that such high daily dosages bordered on the toxic and could have lasting sequelae such as deafness (one reason why patients resisted quinine therapy), but they nonetheless thought that such treatment was better than the disease.≤∑ Finally, Chagas’s observations supported the fourth conclusion the Brazilians drew from their studies of malaria in Amazonia, namely, that malaria had to be thought of in essentially local terms.≤∏ It was highly variable in its vector of transmission and its expression in human populations, an insight the Brazilians shared with other field malariologists working at the same time (this was in contrast to the post–World War II period, when malaria was treated as a single or universal disease open to a universal solution). To deal adequately with malaria therefore required local studies, both clinically, because of variations in its symptoms in di√erent individuals and populations, and in relation to mosquito vectors, which varied in their local habitats and habits. For instance, breeding locations di√ered from species to species and from place to place; some Anopheles species bred in water puddles on the ground, others in water held in epiphytes high up on trees. Feeding habits also varied: some Anopheles fed on humans at dusk or night, while others were day feeders. Some were excellent transmitters of malaria, others more refractory. Many of the observations made by Cruz’s team in Amazonia were valid (though their work was not sustained long enough to achieve the kind of detailed understanding of malaria vectors and their ecology that Swellengrebel, for example, achieved in Indonesia).≤π In the case of quinine resistance, they may even have been original for their day. But Brazilian contributions were not always accessible to European researchers, and some were simply taken to confirm what Europeans had already discovered.≤∫ In the case of quinine-resistant plasmodia, the suggestion of actual (genetic?)

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Inhabitants of Massarabi, Amazonas, February 1913. Photo showing living conditions and ethnic variety of inhabitants of Amazonas taken during the medical survey of the Amazon conducted by the Oswaldo Cruz Institute. Courtesy of the Departamento de Arquivo e Documentação da Casa Oswaldo Cruz da Fundação Oswaldo Cruz, ioc-v-ii-269.

modification or selection of new strains was rejected by the leading British malariologist, Ronald Ross, in favor of the more straightforward notion that quinine delayed the developmental cycle of the plasmodium but did not alter it fundamentally.≤Ω

Controlling Malaria in the Amazon The main recommendations of the Cruz Institute’s researchers for malaria control in the Amazon Valley make interesting reading today. I say reading because nothing was done to implement them at the time. When the rubber boom collapsed, as it had by the outbreak of World War I, government interest in disease in the Amazon did too. Not until World War II, when a new flood of people came to the Amazon as ‘‘soldiers of rubber’’ to collect rubber from wild rubber trees for the war e√ort (Brazil entering the war on

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the side of the Allies), were new attempts made to tackle the disease. Public health then started almost from the same point it had in 1911–13—with medical surveys to establish the basic parameters of malaria epidemiology. In drawing up a plan of action, Cruz grasped that success in malaria depended on the circumstances; di√erent methods were required for different regions (urban versus rural; large versus small) and di√erent human populations (mobile versus stationary). He approached malaria, as I have already noted, as essentially a local disease; programs of malaria prophylaxis therefore had to be developed in situ. Cruz was, of course, familiar with techniques of mosquito eradication, having employed this method successfully against yellow fever in Rio de Janeiro between 1903 and 1907, when he directed the first systematic public health campaigns in the capital. He had fumigated houses, drained water puddles, and introduced larvicidal (mosquito larvae–eating) fish into water storage tanks with the goal of reducing the population of the Aedes aegypti mosquitoes responsible for transmitting the disease.≥≠ An incidental result, he believed, was the simultaneous (though much less dramatic) reduction in Anopheles mosquitoes, and therefore in malaria as well. Cruz’s success led to an invitation from Ross to contribute to Ross’s book, Prevention of Malaria, in 1910 (Cruz was the only Latin American contributor).≥∞ Nonetheless, Cruz was quite aware that malaria had not been the target of that earlier campaign, and that generalizing from yellow fever to malaria was usually a mistake, the vectors being quite di√erent in character and ecology. For construction projects such as railway camps, Cruz relied almost entirely on compulsory quininization as a therapeutic and a prophylactic, and on the strict isolation of the sick (in this regard following the advice of the German bacteriologist Robert Koch). Indeed, for the work camps of the Madeira-Mamoré Railway Company, his plan was draconian—a quasi-military solution to disease control. Considering the mobility of the workforce and the delimited area in which malaria control was to be achieved, all e√orts were to be directed toward protecting the workers through the systematic enforcement of a quinine regime. All power was to be put in the hands of the medical corps employed by the railway company, who were to supervise a rigorous sanitary program of compulsory quininization. Any workers refusing to follow the regime were to be fired; the blood of all new workers coming into the camp was to be tested for parasitic infection before they were hired. Punitive measures were to be used to ensure compliance.

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Such a sanitary regime was not new; it had been tried before in several other work camps in Brazil and says much about labor conditions in Brazil at the time.≥≤ Even so, success proved much more elusive than Cruz expected (a lesson learned eventually by nearly everyone involved in malaria eradication e√orts). Quinine was costly, not always e√ective, hard to standardize, and had unpleasant side e√ects. In 1911, a year after Cruz left behind twenty specific recommendations for the company doctors, whom he praised for their energy and competence, malarial infections of new workers was still reaching 90 percent. Despite this failure, however, the railway line was completed, and the notion of strict medical supervision and quasi-compulsion in matters of sanitation remained a feature of many later public health plans. In drawing up a strategy of control for the entire Amazon Valley, what was required was on a di√erent scale. As I have mentioned, rural malaria, as distinct from malaria in urban areas or in limited work sites, remained largely untouched by antimalaria campaigns until the 1930s. The very notion of proposing to deal with malaria across the vast, forested Brazilian Amazon showed an almost naïve faith in the power of medicine to improve health without touching the structure of the extractive economy. Rubber collecting in the Amazon was based not on plantations confined to specific rural spaces, but on a system of gathering of wild rubber by a huge number of individual rubber tappers who were dispersed throughout a huge region with porous boundaries. Rubber production did not form an enclave economy, and public health could thus not be an enclave system either. By its nature rubber collection involved labor mobility, each tapper being responsible for visiting and revisiting a certain number of rubber trees repeatedly to collect the white latex and bring it back to various collection points. As a system of production it involved many exploitive middlemen, who kept the tappers deep in debt and living precariously from day to day.≤≥ Food was extremely costly and health care almost nonexistent. The whole system of extraction was a recipe for disease production. Certainly, Cruz knew it was unrealistic to try to control malaria by reducing or eliminating larval or adult mosquitoes across the entire Amazon area (Robert Koch said the same thing for tropical rural Africa). The distribution of Anopheles mosquitoes was potentially enormous; moreover, because of seasonal flooding and recession of the rivers, each year huge puddles of water were re-created in the river towns and settlements in which new mosquitoes could breed. Given this situation, it was only in very specific

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places, largely urban and determined largely by geography (i.e., far enough away from flooding), that the drainage of water puddles had any chance of permanently reducing breeding sites of mosquitoes. Even then, antimalarial e√orts failed owing to the chaotic human and material condition of the locations. Testimony on this point comes from the reports of Dr. H. Wolferstan Thomas, a British medical researcher who had been sent to the Amazon on a medical expedition by the Liverpool School of Tropical Medicine early in the twentieth century, mainly to study yellow fever. Reporting on the 1905–9 period, during which urban opulence (even to the extent of an opera house in Manaus, the second largest city on the Amazon) coexisted with the most appalling squalor and poverty, the expenditure of quite considerable sums of money (£9,500 in the case of Belém) to fill in the igarapés (narrow water channels) and puddles to reduce mosquito breeding had not reduced malaria incidence. For every ditch filled in, a new street was constructed that blocked up water and created new puddles. The arrival back in Manaus at the end of the collecting season of tappers infected with malaria and the influx of newcomers without previous immunity to malaria infections made the disease a constant aspect of the town’s epidemiology. Wolferstan Thomas linked malaria, that is, to the intersecting social, economic, and biological environments in which people lived—to exploitation, malnutrition, unfinished streets, and poor sanitation as well as to parasites and biological vectors. Calling it exaggerated, he nevertheless quoted the old saying that ‘‘every kilo of rubber extracted represented one human death,’’ adding, ‘‘All through the Amazon region, where large engineering works have been undertaken, the old familiar story has been repeated.’’≥∂ For the Amazon Valley, then, Cruz recommended a plan of action that concentrated not on mosquito control or eradication, but on the human hosts of malaria. Control was to be achieved by two means: the adequate use of quinine and the routine use of bed nets (screening of houses was impractical because most of the houses lacked firm walls and window frames into which screens could be fitted). At the time of the Amazonian survey, there existed in theory a government project to build several hospitals in the region for the treatment of the sick. Cruz and his team opposed this scheme as unrealistic because most cases of acute malaria infection, requiring immediate attention, occurred in the forest, far from the large riverine settlements where such hospitals were to be situated. He suggested instead the establishment of small, mobile sanitation posts distributed throughout the re-

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gion of rubber collecting, where cheap, standardized doses of quinine would be available (though Cruz did not go as far as the Italians and propose a government monopoly on quinine production and its free distribution) along with cheap mosquito nets. Here lay the germ of the development of rural sanitation posts that would be established in several parts of Brazil in the 1920s.

The Human Factor in Disease What was absent from Cruz’s otherwise quite sensible recommendations was, of course, any adequate recognition of the human factor in disease. This absence operated at two levels: it ignored or downplayed local knowledge, and it ignored the larger role of human actions, in the form of statesponsored ‘‘development’’ projects, in producing disease environments. Cruz and his colleagues used local informants where they could to learn about the diseases common in the Amazon, past epidemics, inadequate diets (related to the high cost of food), and the terrible living conditions. But they were not interested in what local residents had to say about their own ways of managing disease, such as the use of local plant remedies. To the visiting physicians, the local population (usually a mixture of caboclos [people of mixed ethnic origins] and newcomers) represented sick or ignorant people—reservoirs of parasites and bacteria—but not people with any knowledge worth having. The doctors rarely came into contact with tribal Indians, and when they did, they lacked the empathetic eye of a Wallace or a Bates, describing them in the condescending or disparaging terms typical of the times—as impediments to progress, not exemplars of an alternative, and perhaps healthier, way of life. There was no understanding of the complex balance local people might have achieved with their environment, which, outside of contacts with newcomers and rapid environmental changes brought about by development, preserved themselves and their cultures in states of relative healthiness.≥∑ As for the part played by rubber production in generating disease, the Brazilian doctors visiting the Amazon were aware of the immense human costs of the rubber extraction industry, but their indignation at the appalling conditions in which the rubber trappers lived was muted in their reports, as was believed appropriate to a medical survey. Rarely did the published report of 1913 condemn the harsh work regimes imposed by the

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rubber owners (compare this with Roger Casement’s searing indictment of the brutality of rubber production in the Peruvian Amazon in 1912, in a report that outraged British public opinion).≥∏ More, the compulsory quinine model of malaria control carried with it an implicit idea of regulation and enforcement that bypassed individual choice or the active involvement of the local population, instead resting its hope of success in large part on the rubber landowners. In his final recommendations, Cruz suggested that the government convince the rubber owners to impose quinine discipline on their workers, on the principle that the owners had a financial incentive to increase worker productivity by reducing the incidence of malaria. The fact that there was no adequate supply of quinine, that people disliked taking quinine, that quinine was sold for extortionist prices, was adulterated, and had bad side e√ects—all these practical and social aspects of quinine use as the fundamental element in malaria control were put to one side. Though the mobility of the population in the Amazon—the constant arrival of newcomers, many of them desperately poor and therefore at risk from infections, many of them also without acquired immunity to malaria derived from repeated bouts of the disease—was clearly understood as a factor in the spread and distribution of disease, the necessity of rubber development itself was never questioned, and its fundamental role in altering the disease environment was never fully grasped. Indeed, socioeconomic factors (standards of living) in ill health were generally considered to lie outside the purview of parasitology, and therefore outside public health properly speaking. The doctors were as committed to a ‘‘rational’’ process of resource extraction in the Amazon as anyone in the government, and they had high expectations that sanitation itself was the solution to disease. Finally, the lack of appreciation of the human element in disease was connected to what we might call the health of politics (in distinction to the politics of health). By the health of politics I mean the health of political forms of participation in society at large and in programs of disease control. In Brazil, throughout the period when the microbiological, insect-vector approach to disease control was dominant (c. 1900 to the era of the epidemiological transition in Brazil in the 1950s, when workers were finally brought into systems of welfare insurance), rates of political participation were extremely low. The lack of social participation and the very high degree of social inequality in Brazil (features that characterize the country to this day) are significant because historically, public health has been achieved

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at the cost of procedures and social practices that are intrusive or that overturn traditional rights to liberty of action.≥π Success, outside of military or authoritarian rule, therefore depends on the acceptance by a population that the risks and inconveniences of public health measures are outweighed by the advantages they bring. In the Amazon context, this dimension of trust, in a largely illiterate population confronted with a parasitological interpretation of disease causation quite alien to their everyday view, was completely absent.≥∫

Epilogue: Malaria in Brazil in the 1930s and 1940s With the collapse of the Brazilian rubber boom in World War I malaria more or less disappeared from the country’s national consciousness. In the 1930s the Madeira-Mamoré railway line was abandoned once again; the opera house had long since fallen silent; the city of Manaus had fallen into decay. Malaria was once again seen as the almost inevitable aspect of the very environment, social and physical, of rural Amazonia. The main e√ect of the public health surveys in the Amazon was to demarcate the region and its population as epitomizing tropical pathology and backwardness. Not until the 1940s and the Second World War did concern for health in the Amazon revive. By this time the Rockefeller Foundation had entered the field of malaria control in Brazil in decisive fashion and the mosquitoeradicationist strategy was in the ascendance. In 1938–39 a major outbreak of malaria occurred in the northeast of the country. Getúlio Vargas, the authoritarian president and architect of Brazil’s so-called New State (Estado Novo), saw the epidemic as a threat to his project of modernization and industrialization, and to Brazil’s political projection abroad. Vargas invited Fred L. Soper, the regional director of the International Health Board of the Rockefeller Foundation in Rio de Janeiro, to take charge of a newly created antimalaria service and to undertake an intensive campaign to eliminate the imported Anopheles gambiae mosquito, a very e≈cient (anthropophilic) vector of malaria that had arrived in Brazil from Africa in 1930 and was responsible for an epidemic that had infected 185,000 people by the end of 1939 and killed 14,000–20,000. By dint of transferring a very large number of personnel from the Rockefeller Foundation’s anti-yellow fever service to the malaria service; by spending large sums of money on mosquito eradication; by drawing on previous

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entomological studies of the breeding and other habits of the gambiae mosquito (such as its sun-loving characteristics); by rigorous surveillance, patrolling, and inspection of dwellings in a clearly defined and limited area; and above all by systematic insecticide spraying, Soper was able to halt the epidemic in less than two years.≥Ω Though a recent historical review of the evidence suggests that a number of other, contingent factors, in addition to the imported vector, played a role in creating the malaria epidemic (e.g., famine), Soper attributed his success in stopping the epidemic entirely to the systematic and complete elimination of all gambiae mosquitoes.∂≠ The experience of the Brazilian government in malaria control in the Amazon during the Second World War, with U.S. assistance, was, however, very di√erent from Soper’s. In 1942, Vargas created the Special Service of Public Health for the Amazon (Serviço Especial de Saúde Pública [sesp]), organized in cooperation with, and with funds from, the U.S. Institute of Inter-American A√airs (iiaa), in order to boost rubber supplies to the Allies (the plantations in the Far East having been cut o√ by the Japanese) and, as a corollary, to protect rubber workers (and U.S. military personnel) from malaria, the chief disease in the area. Drainage works were carried out in the larger settlements and crude oil and Paris Green were sprayed on stagnant waters to reduce Anopheles mosquito breeding. Health centers were set up throughout the region. But the most significant e√ort concerned the massive distribution of the antimalarial drug Ateprine, which had been developed in the 1930s and was largely tested in the Amazon on Brazilian workers, according to Vieira de Campos, who has given a detailed account of sesp’s history.∂∞ More than 17.7 million tablets of the drug were distributed. The results of this massive e√ort were relatively meager. The targets set for rubber production were not met; the e√ects on malaria incidence were not great. By the end of the war, surveys showed that, in a national population of forty-five million people, there were between two and two and half million cases of malaria a year, half of them in the Amazon. As noted already, the discovery of ddt during the war revived the hope of complete Anopheles mosquito eradication. And in fact its application in Brazil, combined with the introduction of the new synthetic drug chloroquine, reduced malaria by 1970 to 1 percent of what it had been in 1950 (with 70 percent of the cases from the Amazon).∂≤ But then in the 1970s, development in the Amazon started again. The cutting, slashing, building, and damming in the forests altered the land-

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scape and the local ecology of Anopheles mosquitoes while increasing the human populations on which Anopheles could feed. By 1986, with 60 percent of the country’s territory but only 11 percent of its population, the region had 99 percent of the malaria in Brazil. In 1986 there were more than 500,000 cases of malaria.∂≥ Moreover, the incidence of falciparum malaria, the parasite responsible for the most severe form of infection and with the highest risk of death, has grown as a percentage of the total number of malaria cases, in part because the parasite is now resistant to chloroquine, the most important synthetic antimalaria drug available.∂∂ Once again, malaria has become the principal parasitic disease in the region; once again, its control tests our public health models and political will.

Notes 1 On this point, see M. J. Dobson, M. Malowany, and D. H. Stapleton, Editorial in Parassitologia 42.1–2 (2000): 3–7. 2 Marcos Cueto, title to chapter 4 of El Regreso de las Epidemias: Salud y Sociedad en el Peru del Siglo XX (Lima: iep, 1997). 3 Ninety percent of the current 300–500 million cases of malaria a year occur in Africa, which was largely left out of the global campaign against malaria launched between 1955 and 1969 by who. 4 The historical literature on malaria is growing fast. Among older works, see Leonard C. Bruce-Chwatt and Julian de Zulueta, The Rise and Fall of Malaria in Europe: An Historico-Epidemiological Study (London: Oxford University Press, 1980); among newer works, see especially the three excellent issues of the journal Parassitologia (Rome, Istituto de Parassitologia), vol. 36 (1994), vol. 40 (1998), and vol. 42 (2000). Several articles in these latter works are cited at appropriate points in this chapter. For aspects of malaria’s history and control e√orts in Latin America, see Saul Franco Agudelo, El Paludismo en América Latina (Guadalajara: Editorial Universidad de Guadalajara, 1990); Elsy Bonilla, Salud y Desarollo: Aspectos Socioeconómicos de la Malaria en Colombia (Bogotá: Universidad de los Andes, 1991); and Marcos Cueto, ‘‘Identidad Regional y Malaria en el Perú del Siglo XX,’’ in his El Regreso de las Epidemias, 127–72. 5 See W. F. Bynum, ‘‘Malaria in Inter-war British India,’’ Parassitologia 42 (2000): 25–31, especially 26. 6 Malaria, a very old human disease, is probably not indigenous to the New World, but was brought to the continent by the European conquest, fol-

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7

8

9

10

11

lowed by the slave trade. It was established in the Amazon by the midseventeenth century, if not earlier. Eduardo Thielen et al., eds., A Ciência a Caminho da Roça: Imagen das Expedições Científicas do Instituto Oswaldo Cruz ao Interior do Brasil entre 1911 e 1913 (Rio de Janeiro: Casa de Oswaldo Cruz, 1991), 115. Euclides da Cunha’s vivid reports of the quasi-slavery of the rubber tappers are reprinted in Um Paraíso Perdido: Reunião dos Ensaios Amazônicos, ed. Hildon Rocha (Petropolis, Brazil: Editora Vozes, 1976). For excellent analyses of the rubber boom, see Barbara Weinstein, The Amazon Rubber Boom, 1850–1920 (Stanford: Stanford University Press, 1983); and Warren Dean, Brazil and the Struggle for Rubber: A Study in Environmental History (Cambridge: Cambridge University Press, 1987). The human disease consequences of the rubber boom and bust are not mentioned, however. Nancy Stepan, Beginnings of Brazilian Science: Oswaldo Cruz, Medical Research and Policy, 1890–1920 (New York: Science History Publications, 1981), chaps. 4–6. Among the primary sources consulted for this essay are Oswaldo Gonçalvez Cruz, ‘‘Resumo da Memória Apresentado pelo Delegado do Brasil a 3o Convenção Sanitária Internacional Reunido na Cidade de México de 2 à 7 de Dezembro de 1907,’’ republished in Cruz, Opera Omnia (Rio de Janeiro: Impressora Brasileira, 1972), 527–54; Oswaldo Cruz, Madeira-Mamoré Railway Company: Considerações Gerais sobre as Condições Sanitárias do Rio Madeira (Rio de Janeiro, 1910); Cruz, ‘‘The Prophylaxis of Malaria in Central and Southern Brazil,’’ in Ronald Ross, ed., The Prevention of Malaria (London: E. P. Dutton, 1910), 390–98; Ministério da Agricultura, Industria e Commercio, Superintendencia da Defesa da Borracha, Relatório sobre as Condições Medico-Sanitárias do Valle do Amazonas (Rio de Janeiro, 1913); Cruz, ‘‘Algumas Molestias Produzidas por Protozoárias,’’ Brasil-Médico 29.44 (1915): 345–46, and 29.46, 353–56; Belisario Penna and Artur Neiva’s journey is described in ‘‘Viagem Científica Pelo Norte da Bahia, Sudoeste de Pernambuco, Sul de Piauí e de Norte de Goiás,’’ Memorias do Instituto Oswaldo Cruz 8 (1916): 74–224; and Olympio da Fonseca Filho, A Escola de Manguinhos: Contribuição para o Estudo de Desenvolvimento da Medicina Experimental no Brasil (São Paulo: egrt, 1974), 125–47. Useful accounts of the main Instituto Oswaldo Cruz expeditions of 1911–12 preface the publication of the photographs brought back from the interior in Eduardo Thielen et al., Ciença a Caminho da Roça; my analysis of the expeditions and the photographs appeared as ‘‘Portraits of a Possible Nation: Photographing Brazil,’’ Bulletin of the History of Medicine 68.1 (1994): 136– 49. See also Nancy Leys Stepan, ‘‘Tropical Medicine and Public Health in Latin America,’’ Medical History 42 (January 1998): 104–12.

m a l a r i a c o n t r o l i n t h e b ra z i l i a n a m a z o n 47 12 Oswaldo Cruz, Considerações Gerais sobre as Condições Sanitárias do Rio Madeira, reprinted in Opera Omnia, 607. 13 Earlier he had formulated the important principle that malaria is primarily a ‘‘domiciliary disease’’: infection occurs in the home when the mosquitoes that transmit malaria feed on human blood (thus the home is a crucial site for malaria control e√orts; Nancy Stepan, Beginnings of Brazilian Science, 118). On the history of Chagas’ disease, see ‘‘Appearances and Disappearances,’’ in Nancy Stepan, Picturing Tropical Nature (Ithaca: Cornell University Press, 2001), 180–297; and the contribution by Marilia Coutinho in this volume. 14 As quoted in Eduardo Thielen et al., Ciença a Caminho da Roça, 121; my translation. 15 Point made by David J. Bradley in ‘‘Watson, Swellengrebel and Species Sanitation,’’ Parassitologia 36.1–2 (1994): 137–47. 16 Lewis W. Hackett, a Rockefeller Foundation medical scientist who worked in Brazil and later Italy, summarized much of this epidemiological work in his book Malaria in Europe: An Ecological Study (Oxford: Oxford University Press, 1937). Though promoting an ecological view of malaria, Hackett believed malaria control could be achieved independent of overall improvements in standards of living. Most malariologists today would probably disagree. Hackett’s position was thus more ecological (biological) than socioecological. 17 Leonard C. Bruce-Chwatt and Julian de Zulueta, The Rise and Fall of Malaria in Europe; and Hughes Evans, ‘‘European Malaria Policy in the 1920s and 1930s: The Epidemiology of Minutiae,’’ Isis 80 (1989): 40–59. Ross, an often intemperate man, was restrained in his comments on the Italian approach but suggested that the quinine method was adapted to temperate climates and might not work so well in tropical ones; he believed that the most e√ective way to control malaria was to reduce all the vectors in a vicinity. 18 Uriel Kitron, ‘‘Malaria, Agriculture, and Development: Lessons from Past Campaigns,’’ International Journal of Health Services 17.2 (1987): 295–326. 19 We might think of this as an early, tropical version of the later debate about the causes of the mortality revolution in northern European countries in the late nineteenth century, in which McKeown’s ‘‘nihilist’’ thesis that the mortality revolution was caused largely by improvements in nutrition was countered by the thesis of the importance of specific public health interventions. For a review of the current status of this debate, see Simon Szreter, ‘‘The Importance of Social Intervention in Britain’s Mortality Decline c. 1850– 1914: A Reinterpretation of the Role of Public Health,’’ Social History of Medicine 1.1 (1988): 1–38.

48 n a n c y l e y s st e pa n 20 League of Nations Health Organization, Principles and Methods of Antimalarial Measures in Europe. Second General Report of the Malaria Commission (Geneva, 1927), especially 13; and Lewis Hackett, Malaria in Europe, 1–24. 21 J. A. Nájera, ‘‘Malaria and the Work of WHO,’’ Bulletin of the World Health Organization 67.3 (1989): 229–43; and Javed Siddiqi, World Health and World Politics: WHO and the UN System (Columbia: University of South Carolina Press, 1995), 123–92. 22 Olympio Da Fonseca, ‘‘Malária,’’ in A Escola de Manguinhos. 23 B. Fantini, ‘‘Anophelism without Malaria: An Ecological and Epidemiological Puzzle,’’ Parassitologia 36 (1994): 83–106; Lewis Hackett, Malaria in Europe, 47–84. The solution to the European puzzle was the discovery in the 1920s that A. maculipenis, the chief vector of malaria in Europe, was in fact a species complex with several sibling species, only some of which were e≈cient transmitters of malaria. 24 Arthur Neiva, ‘‘Beitrag zur Kenntniss der Dipteren (Contribução para o Estudo dos Dipteros),’’ Memorias do Instituto Oswaldo Cruz 1.1 (1909): 69– 77; and Oswaldo Cruz, ‘‘Algumas Molestias Produzidos por Protozoários.’’ Chagas did not believe he had the means to prove that the intense tropical malaria he encountered in São Felipe was due to a quinine-resistant strain of plasmodium produced by long quinine use because quinine was rarely used in the region. Nonetheless, in general he accepted Neiva’s argument about quinine-resistant strains of plasmodia in certain areas of the Amazon. 25 It is interesting to note that the most important circumstance producing drug resistance in malaria treatment today (e.g., to chloroquine) is the exposure of a whole population of people to inadequate or low drug dosages. 26 The idea of local variations in malaria would later be given clearer exposition, grounded in a wealth of local studies, in a publication of the Malaria Committee of the League of Nations, Report on the Principles and Methods of Anti-malarial Measures in Europe (Geneva, 1932). 27 J. P. Verhave, ‘‘Swellengrebel and Species Sanitation, the Design of an Idea,’’ in Willem Takken et al., eds., Environmental Measures for Malaria Control in Indonesia. An Historical Review of Species Sanitation (Wageningen: Wageningen Agricultural University, 1991), 63–80. 28 A good example was Adopho Lutz’s identification in the first years of the twentieth century of malaria transmitted by a species of Kerteszia mosquito that breeds in water contained in forest bromeliad plants; this work was not recognized until the late 1940s. See Paul Gadelha, ‘‘From ‘Forest Malaria’ to ‘Bromeliad Malaria’: A Case-Study of Scientific Controversy and Malaria Control,’’ Parassitologia 36 (1994): 175–97. 29 Ronald Ross, The Prevention of Malaria, 393. 30 Nancy Stepan, Beginnings of Brazilian Science, 114. Cruz attended the Twelfth

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31 32 33 34

35

36

37

38

International Congress of Hygiene in Berlin in 1907, where the Oswaldo Cruz Institute received a gold medal for its public health work; Cruz may well have heard Ross speak at Berlin in a critical vein about the lack of antimalaria work in tropical countries (meaning tropical colonies of Europe). Oswaldo Cruz, ‘‘Prophylaxis of Malaria in Central and Southern Brazil,’’ in Ross, Prevention of Malaria, 390–98. In 1907, Neiva instituted compulsory quininization of 3,500 workmen damming the Xerém. Barbara Weinstein, The Amazon Rubber Boom, 1850–1920, 15–34. H. Wolferstan Thomas, The Sanitary Conditions and Diseases Prevailing in Manaos, North Brazil, 1905–1909 with a Plan of Manaos and a Chart, Expedition to the Amazon, Liverpool School of Tropical Medicine, typescript, 76 pages, folder 138, box 23, series 2, Record Group 305 Brazil, Rockefeller Foundation Archives, Rockefeller Archive Center, North Tarrytown, New York. This report formed the basis of Thomas’s contribution on the Amazon region in Ross’s Prevention of Malaria (1910), 382–89. On Thomas’s later work in Manaus, see Helen Power, Tropical Medicine in the Twentieth Century: A History of the Liverpool School of Tropical Medicine, 1898–1990 (London: Oxford University Press, 1999), 48–51. Wolferstan Thomas’s reports seem to be connected to his later abandonment of laboratory research (though he continued to be supported by the Liverpool School) for a life as a practicing physician caring for the local Brazilian population. This kind of understanding would not really develop in Brazil until the 1950s, when ethnobotanists and anthropologists began to study how local populations changed and managed their environments, including their disease environments; see Darrell Posey and William Balee, Resource Management in Amazonia: Indigenous and Folk Strategies, Advances in Economic Botany 7 (New York, 1989). The Amazon Journal of Roger Casement, ed. and intro. Angus Mitchell (Dublin: Lilliput Press, 1971), especially 49–52. In 1916, Casement was hanged by the British government for his role in the Easter Rising in Ireland. See Richard G. Wilkinson, Unhealthy Societies: The A∆ictions of Inequality (London: Routledge, 1996), on the relation between social inequalities and inequalities in health; his implications for Brazil—a country with the worst income distribution in Latin America and the greatest social inequalities— are sobering. Kitron’s review of successful malaria campaigns in Palestine/Israel, the southern states of the United States, and Italy between about 1920 and 1950 indicates that community participation and a basic platform of socioeconomic well-being were critical elements. See his ‘‘Malaria, Agriculture and Development.’’

50 n a n c y l e y s st e pa n 39 Fred L. Soper and D. Bruce Wilson, Anopheles gambiae in Brazil, 1930–1940 (New York: Rockefeller Foundation, 1943). A total of $300 million was spent in the campaign, of which the Rockefeller Foundation paid just under 20 percent, and the Brazilian government the rest. 40 R. M. Packard and P. Gadelha, ‘‘A Land Filled with Mosquitoes: Fred L. Soper, the Rockefeller Foundation, and the Anopheles gambiae Invasion of Brazil,’’ Parassitologia 36 (1994): 197–213. The fact that Soper eradicated an imported and thus nonnative species of Anopheles mosquito left many specialists with doubts that his methods could be applied to native species. 41 André Luiz Vieira de Campos, ‘‘International Health Policies in Brazil: The Serviço Especial de Saúde Pública, 1942–1960’’ (Ph.D. diss., University of Texas at Austin, 1997), especially 101–35; and his ‘‘The Institute of InterAmerican A√airs and Its Health Policies in Brazil during World War II,’’ Presidential Studies Quarterly 28.3 (1998): 523–34; ‘‘Combatendo Nazistas e Mosquitos: Norte-Americanos no Noredeste Brasileiro (1941–1945),’’ História, Ciênçias, Saúde: Manguinhos 3 (1998–99): 603–20. 42 Aquiles Scorzelli Junior, ‘‘A Saúde Pública no Amazonas,’’ Archivos de Higiene 10 (June 1940): 97–108; João de Barros Barreto, ‘‘A Saúde Pública no Brasil,’’ Archivos de Higiene 8 (November 1938): 289–304; Leonidas M. Deane, ‘‘Esboço Histórico do Instituto Evandro Chagas,’’ Revista da Faculdade da Fundação SESP (Ministério da Saúde, Rio de Janeiro) 31.2 (1986): 47–55; and his ‘‘Malaria Studies and Control in Brazil,’’ American Journal of Tropical Medicine and Hygiene 38.2 (1988): 223–30; and Rubens da Silveira Britto, ‘‘A Occupação da Amazônia e a Malária,’’ Revista de Fundação SESP, Ministério da Saúde (Rio de Janeiro) 31.2 (1986): 253–57. 43 Donald Sawyer, ‘‘Economic and Social Consequences of Malaria in New Colonization Projects in Brazil,’’ Social Science and Medicine 37.9 (1993): 1131–36. 44 N. J. White, ‘‘Antimalarial Drug Resistance: The Pace Quickens,’’ Journal of Antimicrobial Chemotherapy 30 (1991): 571–85.

gabriela nouzeilles

An Imaginary Plague in Turnof-the-Century Buenos Aires hysteria, discipline, and languages of the body

uring the second half of the nineteenth century, the city of Buenos Aires su√ered the devastating e√ects of various epidemics. These outbreaks—including at least five of cholera, four of measles, four of yellow fever, and three of typhus—eventually forced municipal o≈cials to improve and radically expand the city’s public health system. Invoking the specter of contagion and its terrifying images, doctors and hygienists promoted the adoption of preventive measures and the development of public health programs.∞ Convinced that every sign of pathology could, under certain circumstances, reach epidemic proportions, even doctors in the area of mental health made a sustained e√ort to apply the mechanisms of control and observation recommended by medical experts to prevent and contain the dangers of contagion. Their ideal goal was to create a closed space which, when observed at every point, would aid in detecting and tracking even the most imperceptible movements of citizens. This would facilitate the production of the meticulous reports on the population that swelled the files of scientific and legal knowledge. The social and political outcomes of organized medical intervention—the spectacular growth of the sanitary system and the strengthening of medical authority—seemed to confirm the thesis widely accepted today that the plague as a form of disorder, at once real and imaginary, had as its medical and political correlative discipline. At first, the defensive order put forward by the medical profession limited itself to fighting the exceptional state of plague. But it soon came to function as a condensed model for the modes of operation of modern disciplinary society as the exceptionality of the epidemic became the tacit functioning norm not only for the hospital, asylum, and prison, but also for institutions directly entrusted with the production

D

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of worthy citizens, such as the army and the schools.≤ Since its goal was to distribute bodies according to the distinction between normal and pathological, the operative model of the plague was, among other things, a mechanism for discrimination and exclusion. While in theory its reach included the entire population, in practice certain sectors were more subject than others to the violence of its applications. In several recent studies about the regulating function of medicine in the processes of social modernization that took place in fin-de-siècle Buenos Aires, historians and cultural critics have noted how the specter of the plague was at the root of many sanitary programs whose principal objective was the supervision of such marginal groups as the poor, immigrants, prostitutes, and homosexuals.≥ In each case, what was at stake was the constitution of an ideal national community, imagined as a strong and healthy body whose survival depended on the systematic rejection, or even elimination, of all transgressive di√erences. Because they were connected to excesses of the body and the passions and were suspected of breeding infinite forms of physical and moral corruption, atypical social and sexual behavior were targets of medical policing. Notwithstanding the success and appeal of the disciplinary hypothesis, and without denying its powerful insights, some historians have lately argued that there was more than zealous discrimination in the programs the medical profession helped to deploy. The state sanitary machinery not only had normative and quasi-policing functions; it also fulfilled other roles. These included providing assistance, although insu≈cient and partial, to the most dispossessed group in the city, a function that until then had been in the hands of religious organizations. An important goal of social medicine was to bring the benefits of modernity and hygiene—sewage systems, running water, etc.—to the population at large, in particular to the popular classes, those most a√ected by disease, malnutrition, and poor living conditions.∂ From this other perspective, the plague and the paranoid fears it raised were an opportunity for well-intentioned physicians to call attention to the deficiencies in the city’s sanitary system and advance their reformist ideas. Given the dual nature of the medical agenda, it seems fair to say that the medical managing of the national body was subject to ceaseless negotiations between inclusion and exclusion. The medical response to the plague of hysteria that contemporary sources claimed was virulently attacking a large number of porteña women between roughly 1875 and 1905 both confirms and o√ers a more complex version of the disciplinary hypothesis. On the one hand, the widespread hystericizing

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of women in those years could be a textbook example of the punitive uses of medical diagnosis; notions of pathology were used to label, and even to repress, unacceptable social behavior. On the other hand, if we accept Showalter’s claim that ‘‘hysteria is always dialogical,’’ the result of a perverse collaboration between doctors and patients, these cases of fin-de-siècle hysteria could also be interpreted as women’s contradictory symbolic responses to the disciplinary regime with which modern sexual policies aimed to place limits on female desire.∑ The political meaning of such acts is in no sense transparent. Hysteria could as much embody an act of displaced resistance as manifest an exasperated abjection. By voluntarily or involuntarily imitating signs of physical illness (paralysis, epilepsy, loss of speech, etc.) that society deemed legitimate at the time,∏ some upper- and middle-class women may have assumed a painful pose of sickness in order to avoid the restrictions of the domestic prison they were forced to inhabit. In other cases, perhaps it was a matter of the victim’s impotent squirming or of the literal enactment in one woman’s body of the short-circuit of contradictory images of women then in circulation. But whatever the causality that governed hysteria, as an alternative language it was doubly disruptive. At the same time that it channeled oppositional political attitudes questioning the sexual division of labor, its imprecise identity and the fact that its etiology combined false signs of other illnesses destabilized the relationship between subject and object that was at the core of the disciplinary production of knowledge. By blurring the limits between body and mind, and between object and sign, the hysterical plague produced a hiatus, an epistemological borderland, where the very premises of modern rationality entered into crisis. Despite this, as we shall see, the mimetic disorder intrinsic to hysteria and the accompanying weakening of the split between body and culture was not merely a cause for alarm among Argentine doctors. Some would conclude that the irrationality of hysterical logic could be easily reversed. If the body was not destiny, but instead an e√ect of biocultural articulations, then the objective was not to return to a ‘‘natural’’ normality, but instead to replace the operating pathological fiction with others more productive for the progress and well-being of the nation. From the standpoint of assisting patients, most Argentine medical responses to hysteria are more di≈cult to rationalize. Although the archival sources reveal feelings of concern and a desire to help hysterical patients, the physicians’ notes are frequently filled with unapologetic misogyny as well. Very often, given the disease’s lack of organic causes and its imprecision, the

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hysteric was suspected of being an impostor, a capricious woman distracting the doctor from ‘‘real,’’ more needful patients. At other times, hysteria was seen as the ultimate manifestation of innate female pathologies, which, since they could not be cured, had to be subdued by force. Discipline more than care seems to have been the dominant mode in the treatment of hysterical women in Buenos Aires during the period under study. One of the paradoxical repercussions of the bourgeois fear of the plague is that every epidemic outbreak produces a parallel explosion of stories fixed on it. The contagious multiplication of pathology is thus mirrored by the multiplication of its representations. The somatic imagination is particularly strengthened by untreatable or unreadable diseases, especially once the central premise of modern medicine—that all diseases can be cured sooner or later—has been accepted.π It is these ambiguous diseases, charged with strong cultural resonances, that have historically lent themselves most to narrativization. In fin-de-siècle Buenos Aires, as in other cities undergoing intense modernization, hysteria was the lightning rod for one of these symbolic explosions. Its numerous narrative fictions pointed simultaneously to multiple fields of meaning, all sharing similar ways of thinking the pathological, as well as to a spectacular iconography of the hysterical body. From gynecological exploration and psychiatric study to the pseudopornographic aesthetization and/or contemplation of the attacks that shook the hysterical patients, a variety of discourses and social practices combined to produce hysterical semiosis. Undeniably, hysteria as a sociocultural phenomenon was not the exclusive product of the medical imagination, but was rather the complex result of the intersection of science with other discursive formations such as the legal code, sociology, theater, literature, and photography. To a greater degree than in other famous epidemics, doctors and patients actively participated in the fabrication of hysterical fictions. But this collaboration was far from equal. The production of representations of hysteria was always mediated by a hermeneutic scene in which male medical authority confronted the body of the hysteric with the objective of resolving the mystery it o√ered. Since the hysterical woman was able to represent what she could not verbalize only in an indirect and disordered way, the doctor was unavoidably entrusted with giving her story definitive form. The unequal power relation defining this scene suggests once again that the political e√ectiveness of the hysterical pose was minimal at best. However attractive its oppositional gesturing may be to feminist ideals,∫ hysteria generally expressed a desperate and self-destructive rebellion that left its cultivators in

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a state of extreme psychophysical weakness and, in the final analysis, at the mercy of medical manipulation. In the following pages I trace some of the major lines of meaning running through the representations of the hysterical plague that attacked the women of Buenos Aires as registered in the numerous medical sources of the period. Even though they are important to understanding cultures of hysteria, I will address neither literary fictions nor the aesthetic uses of hysterical symptoms as a strategy for consolidating the public figure of the artist, or as a marker of class for educated men.Ω In this analysis, I have two overall objectives. First, I want to extend the reach of cultural studies of hysteria beyond France, England, and the United States—their exclusive setting until now—to Latin America. In so doing, I wish not only to test the ruling hypothesis of the field of histories of hysteria, but also to underscore the particular nuances that the cultures of hysteria took on in peripheral modernities. Second, since the medical debates about hysteria in Argentina took place in a context of urgency in which female biology posed a threat to the realization of then-popular racialist utopias, I will pay special attention to the inequality that governed the relationship between doctor and patient in consultation and in the treatment of hysteric symptoms. As we shall see, in studying this relationship it is almost impossible to be even-handed in treating the figure of the doctor because he is the narrator and author of the hysteria cases. If anything of the voice and viewpoint of the patients remains in the medical texts, it is only as a contradictory undercurrent in which we can glimpse the blurry outlines of the rebellious gestures of the hysterical women and their progressive silencing over the course of the cure. In no way do I seek to question the contention advanced by some historians that patients are not just passive victims of medical power, and that by demanding, questioning, or resisting medical intervention they also help to shape medical practices.∞≠ What I want to argue instead is that the patient’s room to maneuver is not a given, but rather depends on his or her position within society and the nature of his/her disease. In the late nineteenth century, the Argentine law equated women with children and simpletons whose subordination was justified by their allegedly innate pathological condition. They were second-class citizens who, like their children, required limits and discipline. In addition, unlike the victims of infectious diseases that had an external, identifiable cause, those a√ected by the hysterical plague were to some extent held responsible for their own su√ering. Female hysterical patients were frequently disliked, and their attacks aroused strong feelings of

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disgust. It is my contention that once a woman was identified as a hysteric, her room to maneuver was minimal. She had two options: to keep resisting by changing the syntax of her body language, or to play along and follow the doctor’s directions.

Mutant Women and the Modern Condition Nineteenth-century fictions of hysteria did not break completely with earlier representations. From the ancient Egyptian theory of the wandering womb to Freud’s neurotic conversion, hysterical discourse never ceased to associate the pathological syndrome with female sexuality. If the nineteenth century marked some kind of break, it came above all because of the reach and intensity of the ideological uses of hysteria.∞∞ As in Europe and the United States, in Argentina the figure of the hysterical woman served to conjure and fix the meaning of a series of transformations introduced by modernization. Among them, the redistribution of sexual roles provoked by the progressive entrance of women into the public sphere was, of course, crucial. The formation of women’s associations, the appearance of the first professional women and feminist activists, the revolutionary activism of anarchist and socialist immigrants, and the increased number of prostitutes in the streets were some of the events that marked the changing social placement of women in Argentina, particularly in Buenos Aires. Some of these activities combined with each other. Anarchist women were some of the most active and radical in the struggle for women’s rights in work, family, and religion. And among the first Argentine woman doctors there were several socialists instrumental in organizing the first women’s associations in the country.∞≤ The relative weight and importance of these variables common to the modern history of hysteria everywhere should be measured according to the changes introduced by their insertion into a new geopolitical context. At a moment when Social Darwinism had reified historical events in biological terms, the peripheral character of Argentine modernity and its subordinate and dependent position relative to metropolitan economic and cultural centers meant that local debates on hysteria were situated within a broader debate about what the future of the Argentine race should be and how its fitness in the international struggle for life could be improved. Since the success of every biopolitical program was measured by its capac-

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ity to improve and increase the population, the supervision of women’s bodies was a fundamental part of national programs of public health. After all, doctors claimed, ‘‘the virility of a race, the morality of a State, and the value of its sons’’ depended on them.∞≥ The importance and urgency attributed to the study of female sexuality is evident in the proliferation of medical theses on women’s physiology, pathologies, and health—between 15 and 25 percent of the theses published annually by the Universidad de Buenos Aires between 1875 and 1905—in which the preoccupations of gynecology coexist with those of anthropology. In his 1892 medical thesis, ‘‘La Mujer Argentina,’’ Dr. Arturo Balbastro magnificently summarized the political motives behind such intense scientific interest: ‘‘Science undeniably proves that the degeneration, like the perfecting, of a race always begins with the female sex. Because of her organization, women in all climes and races, because they are more subject to external influences, o√er more plasticity to biological transformations. Therefore, if we want to find the mark of our nationality, if we long to discover its secret, scrutinize its destinies, we must find them in the Argentine woman. ’’∞∂ The importance of women’s biology was greater in Argentina than in other countries, he argued, because it was a nation undergoing a period of rapid transformation as a result of the massive entry of male immigrants from Europe. Since it was imperative to take advantage of this fresh influx of superior racial energies to improve the local population, the woman must replace the gaucho as an object of reflection in debates about the future of the national race: ‘‘In another time, pencils, prose and verse were given over to the genuinely national character—the gaucho. . . . But now, in the face of these spontaneous movements of races and peoples, now . . . the Argentine woman dominates the stage, because she expresses in herself the future of the American races.’’ Yet the very same biological plasticity that, according to Juan Bautista Alberdi in Bases y Puntos de Partida para la Organización Política de la República Argentina (1853), would expedite the assimilation of the flood of immigrants, and thus counteract a colonial history of uninterrupted and undirected racial mixture, could also become the cause of the perdition of the national race. The female body was flexible. But it was also chaotic, unpredictable, and pathological. In the first Argentine thesis on hysteria, ‘‘Etiología y Profilaxia de la Histeria’’ (1883), Julio E. Piñero had already identified female volubility as the primary source of the disease. The woman’s organism was much more perfect than that of the man because it had a ductility that

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contrasted with the fixity and stability of the male organism. Unfortunately, that adaptive superiority was counteracted by a lesser ability to resist and a less stable harmony between the component parts.∞∑ Subject to constant processes of transformation caused by menstrual cycles, pregnancies, births, and menopause, women’s bodies were truly mutant entities whose biological identity was always on the verge of disintegration. Hysteria was nothing more than the maximum expression of women’s natural inclination toward psychophysical instability, which emerged in puberty, the biological threshold leading to the separation of the sexes. In ‘‘Relaciones de la Menstruación con el Sistema Nervioso,’’ Adolfo Martínez described the changes that the female body experiences during this period as a monstrous metamorphosis. At the core of the neutral masculine body that to some degree both sexes had shared during childhood, there began to develop the organs and extremities of a strange being that could bleed without bleeding dry and could be inhabited by another. In this perpetually unstable organism, the appearance of menstruation coincided with the manifestation of several morbid symptoms, nearly all of which referred to the nervous system: ‘‘neuralgias . . . nearly constant hemicranias, epileptiform and hysteriform attacks, raised sensitivities that reached hiperestesis more than a few times, changes in character, exaggerated irritability, endless whims.’’∞∏ The neurotic inclination imprinted on the ‘‘universal’’ nature of women was seen as a defining national trait. Argentine women, and among them those belonging to the urban upper class, were unusually nervous beings, possessed of exaggerated sensitivity and lacking su≈cient reason to govern their own will. Although they were attractive and bright, their overexcited intelligence and the excessive mobility of their character made them obsessive, impressionable, proud, and susceptible to every kind of whim.∞π The already worrisome mental fragility of Argentine women had been further exacerbated by the swift modernization that continued to drastically transform the country’s economic, social, and political foundations, and particularly by the new urban experiences it had introduced. The medical community of Buenos Aires was not long in declaring an epidemic of hysteria in the city. In 1888, Arturo Ferrand claimed with alarm that ‘‘there is hardly any student or doctor who has not witnessed or helped people a√ected by this disease.’’∞∫ Three years later, with similar alarm, Dr. Elvira Rawson de Dellepiane would observe that it was very rare to find a porteña who was not ‘‘hysterical, epileptic, or neuropathic.’’∞Ω The sick women almost always presented an erratic set of symptoms, of variable

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intensity and usually characterized by alternation between the opposing states. In the incomplete list of symptoms that he drew up during his observations at the Hospital San Roque, Arturo Balbastro registered ‘‘palpitations, agitation, menstrual shifts, hypochondria, headaches, meteorism, hallucinations, breathing di≈culty, lack of appetite, heat, cold, spasms, convulsions, sudden changes in character, unprovoked tears and laughter, somnolence, fainting, syncopes,’’ and ‘‘perversions of all senses.’’≤≠ Clearly, the epidemic had been sparked by the drastic changes in customs that characterized urban modernity and the fast pace of everyday life. Doctors attributed the rapid and unprecedented spread of hysteria in all its manifestations to, among other causes, sexual excesses (prematrimonial sexual relations, masturbation), luxury and flirtatiousness in dress, the physical and mental fatigue caused by going to public places (universities, salons, theaters, parks, factories), and intellectual e√orts supposedly incompatible with the innate predisposition to illness of the weaker sex. The theses on hygiene published in those years reveal e√orts to find therapeutic answers to the problem of the nervous Argentine woman. The disciplining of the body through the imposition of a system regulating the body’s rhythm and productivity was o√ered as an indispensable preventive measure to counteract the instability of the feminine condition. In addition to the meticulous washing of their bodies, women could benefit from measured physical exercise (walking, calisthenics) and from eating properly. They could control their feelings by avoiding situations that put them in a state of constant excitement. Despite their ideological di√erences, seemingly opposing political positions accepted hygienic dictates as the ultimate panacea. In Higiene y Educación Física de la Mujer (1898), for instance, the conservative Catholic doctor Justino Ramos Mejía defended the benefits of feminine hygiene for strengthening the national race with nearly the same arguments that feminist Lola Úbeda would use in La Mujer Argentina en la Pubertad in 1902. Although the sources reveal more worry over the fate of bourgeois women, the supposed depositaries of the destiny of the national race, nearly all the cases o√ered as examples are of lower-class women, who formed the majority of patients treated in public hospitals. Doctors argued that in both social groups modern life had made possible, even encouraged, the violation of the sexual laws that confined women to the closed domestic setting, and therefore placed them in situations that threatened their health and that of their families as well. In this sense, the medical debates about hysteria and

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its modern etiology complement the legal debates taking place in those same years about women’s legal status and right to participate more broadly in Argentine public life by means of the vote, higher education, and economic independence.≤∞ On the other hand, the pernicious influence of the city did not a√ect the psychic health of women alone. The syndrome found fertile ground in all the subjects who manifested exaggerated sensibility. It had been proven that there were equally hysterical men, especially those whose moral or physical organism had been modified by reversals of fortune or passionate movements, ‘‘making them of an impressionable character, like the e√eminate.’’≤≤ The symptoms of hysteria implied the bodily inscription of the dark side of progress: the growing acceleration of movement, the exacerbation of desire, and the worship of the artificial and the copy. In this sense, hysterical attacks were both an e√ect of the negative tendencies of modernity and their very incarnation. In its performance, the convulsive syntax that the body of the hysterical woman put in motion questioned the principles of practical reason by confusing or even erasing the founding distinctions between body and mind, sickness and health, truth and fiction. To counter this breakdown of categories, medical diagnosis o√ered a classifying grid aimed at separating that which the hysterical attack mixed together. The task was extremely di≈cult. Time and again, doctors underscored the Protean nature of the illness. As already mentioned, one of its major traits was the ambiguity and imprecision of its symptoms. In response, general studies on hysteria concentrated on determining the permanent traits of the illness and their manifestations. Despite their di√erences, the three interpretive models in use at the time shared a common objective: to immobilize hysteria’s signifying multiplicity. The doctors who adopted gynecological and neurological models tried to localize in the body, in the genital organs, or in the brain the organic lesion that produced the disease. Those who preferred the psychological model that defined hysteria as a disorder of the imagination that altered the capacity to produce correct representations of the real developed methods for identifying and classifying symptoms that allowed hysteria to be distinguished from other nervous disorders.≤≥ The first group produced such works as ‘‘Histeria: Fisiología Patológica y Naturaleza’’ (1884), by Martín Ferreyra; and ‘‘La Histeria en Ginecología’’ (1895), by Cayetano SobreCasas; while ‘‘Síndrome Histérico Simulador del Tabes Dorsalis’’ (1895), by Guillermo Rojo; ‘‘Contribución al Estudio de la Asociación de la His-

h y st e r i a i n t u r n - o f - t h e - c e n t u ry b u e n o s a i r e s 61 Esthesiograms. The distinction between permanent symptoms (or stigmata) and transitory symptoms was one of the main preoccupations among Argentine physicians seeking to establish a distinct symptomatology for the hysterical syndrome. Esthesiograms allowed doctors to map the location and mobility of perversions of skin sensibility on the hysteric’s body. From José Ingenieros, Histeria y Sugestión (Buenos Aires, 1904).

teria con Otras Enfermedades’’ (1897), by Eduardo Rueda; and Histeria y Sugestión (1904), by José Ingenieros are exemplary texts of the second group. Focusing on the opposition between permanent anomalies in sensibility and stigmata, or accidental ones, José Ingenieros made a monumental e√ort to separate hysterical semiosis—what we could call hysteria’s deep grammar—from the manifestations of a variety of diseases ranging from strokes (chapter 3) and rheumatism (chapter 4) to physiological muteness (chapter 7) and nervous disorders with a similar nosology, such as psicastenia and neurasthenia (chapter 9).≤∂ Despite all of these classifying e√orts, the epistemological challenge was never fully resolved. Not only did the disease cover itself with the mask of other diseases, but oftentimes the very hysterical temperament of the patients was manifested in their talent for pretending and exaggerating. ‘‘The

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hysterical woman is nothing but an eccentric woman,’’ Adolfo M. Castro declared firmly in his Ensayo sobre el Histerismo (1886). Almost paraphrasing Castro in his Apuntes sobre las Influencias Morales en el Tratamiento de la Histeria (1888), Salustiano Arévalo insisted that ‘‘we know that these neuropaths have a special character; they want to call attention to themselves at any cost: by flirting, by the discord and spats they search out, by the calumnies they invent, by the works of charity they perform in public, in the most visible places.’’ ≤∑ In Manifestaciones de la Histeria Esencial (1896), Enrique Merlo reiterated that a volatile character and an exquisite impressionability were peculiar to these sick women, in whom the greatest aberrations of whimsy could be observed along with the most astute fictions. Hysterical women were ‘‘irrascible, ill-humored.’’ While sometimes they were disposed toward tolerance, at other times the most minor trifle would occasion sorrows they could not bear alone; they felt the need to ‘‘hatch and scheme intrigues’’ to elevate their importance.≤∏ By means of commentaries like this, which recur in all kinds of medical texts, we can reconstruct the two faces of the porteña hysteric, at once the victim of a possessing illness and a rebellious impostor. As a rebel, her attitude would again split in a contradictory way, since at the very moment she resisted authority, she also aimed to seduce it and make herself ‘‘interesting’’ through the disguise of illness. An artist of disease, her best performance took place when she played her role before the alert gaze of the doctor.

Doctors as Authors La Bolsa de Huesos, a detective story written by Argentine naturalist Eduardo Holmberg in 1893, tells of the investigation by which a detective who is also a doctor and a writer solves a series of crimes. The resolution of the mystery comes with the identification of Clara Lapas, a beautiful and cultured woman who, disguised as a man and appropriating medical knowledge, has first seduced and then murdered several medical students. Holmberg superimposes the classic scene of the final encounter between detective and criminal characteristic of the literary genre on the encounter between doctor and patient from a medical case. The murderer’s capture is also her diagnosis: Clara Lapas is a hysterical woman whose symptoms consist of an extraordinary capacity for disguise and the transgression of the laws of sex. Clara is a social anomaly, a rebellious woman. The fictional doctor-detective disci-

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plines her first by pathologizing her, and later by inducing her to commit suicide by means of suggestion, one of the therapeutic practices then in use. The suicide, which supposedly saves Clara from state prison, represents a radical medical solution in which the madwoman sees her own monstrosity in the mirror of the doctor who diagnoses her, and destroys herself. At the same time, the self-annihilation of Clara places the doctor-detective in an uncomfortable position vis-à-vis the law. Nonetheless, the narrator tells us that the risk has been worth it; even though the state may punish him, the artist-detective has had the privilege of contemplating all alone the spectacular beauty of the crazed murderess before her death.≤π The hysterical woman is a mutant monster who must be annihilated, but she can also be an erotic object to be enjoyed at a certain distance. Holmberg’s story makes obvious the ways in which society at that time made sense of hysteria. It reveals how the two complementary faces of the encounter between the hysteric and the doctor were resistance and disciplining, on one side, and seduction and fascination, on the other. Despite their di√erences, the narrative of power dominating both axes of interrelation places the doctor in a position of authority and control over the hysteric. Although the hysteric gains a certain autonomy through her practice, the functioning of both her resistance and her seduction depends on the formative rules of medical knowledge. We never hear the voice of the crazy woman directly. If present at all, it is mu∆ed. The one who is looking, speaking, and writing is the doctor. The cases or clinical histories that Argentine doctors wrote at century’s end, whether to exemplify their general hypotheses about the illness or, by order of the court to establish the legal responsibility of some patient, are organized according to a similar narrative dynamic. The similarities between a medical case and a detective story partly explain this coincidence. Like a detective story, a medical case is the story of an investigation aimed at resolving the mystery produced by some kind of aberration. To achieve this objective, both the doctor and the detective make use of a technology of representation centered on the interpretation of details and the application of typologies. With this, they carry out the police work of detecting and domesticating all disruptive di√erence from the social order. The suppression of alternative readings of physical or moral deviations forms part of the same hermeneutic system. In the medical histories, we see the traces of a double domestication. On the one hand, they are faithful registers of the techniques of subjection that

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patients were submitted to ‘‘in reality,’’ generally in the form of brutal physical treatments or hypnotic cures. On the other hand, since it was fundamentally a matter of translating the chaotic text of the hysteric body into the transparent language of scientific realism, the cases show how the very technology of medical representation itself exercised a disciplinary function by imposing a unilateral and univocal version of pathological events.≤∫ As in Holmberg’s story, any access to the perspective of the hysterical women is almost completely blocked o√ in the process of medical reinterpretation. The subordination of the patient’s perspective was not exclusive to the treatment of hysteria. Kathryn Montgomery Hunter argues that the internal dynamics of the medical case in general, as a narrative genre, brings with it this displacement. To solve the mystery of pathology, the doctor rewrites the private history of illness that the patient o√ers, and in the process silences it. In an act of professional translation, the doctor transforms the text of su√ering subjectivity and of its bodily symptoms into the supposedly univocal and impartial text of science. At times, the patient resists and questions the reinterpretation of his experiences, but his opinion rarely prevails unless another medical authority comes to validate it. As a result, a silent ‘‘tug-of-war over the possession of the story of illness is frequently at the heart of the tension between doctors and patients, for that tension is in part the struggle over who is to be its author and in what language,’’ says Hunter. Invariably, in the transition from the personal to the professional account, ‘‘the story of the patient’s subjective experience becomes an account of education and control.’’≤Ω In nineteenth-century cases of hysteria, this general trait was further exacerbated by the particular social condition of women and the constitutive ambiguity of the illness. The silencing of the sick woman began even before she met the doctor. In contrast with other sick people who went to the doctor in search of professional counsel after they had already imagined themselves as possible patients,≥≠ hysterical women almost always arrived at the medical o≈ce led by families or spouses who were alarmed by their strange behavior, which ranged from domestic disobedience and amorous indi√erence to invalidity or convulsive attacks. From the beginning, the hysterical woman was rebellious in her sickness, a destroyer of domestic tranquility whose family both worried about and rejected. Whether because she acted out her own silencing or because she refused to communicate, the hysterical woman never had a coherent history of her pathological experiences to tell. From a medical standpoint, her own inca-

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pacity for self-reflective verbalization was compelling proof of her pathological state. The only thing she o√ered to professional deciphering was the crazed semiosis of her own body, partially or completely covered with the signs of nonexistent illnesses. However, at the same time that they made medical work more di≈cult, her silences, contortions, and incoherence also served as invitations to interpretation and telling. Precisely because the hysterical woman could not tell her own story, it was a blank page open to writing that quickly became narrative material for others. But if this was the case, it was also because the hysteric’s story never completely belonged to her.≥∞ By unilaterally possessing the pathological story of the hysteric, the doctor raised himself up as the absolute author of her story, the only one with su≈cient authority and talent to weigh the truth of the representation. After passing successively through the classic narrative sequences of the medical case history—etiology, diagnosis, treatment, and prognosis—the equivocal and bodily language of the hysteric was resolved and subordinated to a fable of control and reeducation. First, etiology explained the hysteric’s symptoms by placing them within a biological or moral narrative causality. From a biological standpoint, hysteria either represented another stage within a hereditary pathological series (an alcoholic father, a neurotic sister) or was the mechanical consequence of female sexual instability (birth, uterine infection, irregular menstruation). Moral explanation did not contradict biological explanation, but rather reinforced it. If the appearance of the symptom was motivated by immoral conduct, its ultimate cause could always be traced back to the predominant animality and excessive sensibility attributed to the ‘‘weaker sex.’’ Once the etiology was established, the diagnosis identified and named the disease, discarding other interpretations as erroneous. A 1903 medical legal report submitted by Drs. Carlos Benítez and Juan Acuña to determine the civil capacity of one Mrs. S. G. de S. at the request of the family of her late husband clearly illustrates how establishing a diagnosis dissolved the ambiguity of hysteric symptoms and their multiple causes, no matter how contradictory the information possessed by the doctors, and confirmed the biased condemnation of the conduct of women under observation. When the course of Mrs. S.’s hysteria is reconstructed, there can be no doubt about the punitive use of medical judgments. The di≈culties had appeared two years after marriage, when the ‘‘extravagances of her character’’ obliged her spouse to place her under a surveillance that

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would later intensify. Her extravagances consisted of neglect of household cleaning, lack of a√ection for her husband and children, and excessive flirtatiousness that degenerated into abandonment of personal hygiene. When she began to drink too much and frequent public bars, her husband locked her up in the house. According to the doctors, these prohibitions were what made ‘‘suddenly burst forth the symptoms that, barely glimpsed up to that point, would later come to mark the insanity’’ a∆icting her. From that point forward, Mrs. S. became supremely irritated by the most minor di≈culty: ‘‘She got angry, su√ered convulsions, screamed, furiously smashed the glass and furniture of the rooms, tore apart her clothes and tried to force the doors and windows to escape and flee. In all these struggles, she was surprised three times at moments when she was trying to commit suicide.’’ In the doctors’ view, patriarchal authority was so unquestionable that not even being locked inside her house with the windows and doors boarded up justified the violence of her attacks. In their professional opinion, nothing in the husband’s actions or motives could explain her behavior. Not even the accusations of abuse and persecution that she made to the family explained them, as they were ‘‘daughters only of the deviations su√ered by the sick brain of his wife in the exaltations of a true state of maniacal agitation.’’≥≤ As it advances, the medical argument takes shape around the conviction that, because she was a woman, the rebellious behavior of Mrs. S. and her breaking of the laws of the home were not only inappropriate and indecent but decidedly pathological. Thus, even though a psychological exam did not reveal any disorder in her mental faculties, her sudden mood changes, exaggerated reactions, eroticism, and, above all, indi√erence and distrust toward her family led the doctors to diagnose a pronounced form of hysteria. They recommended the suspension of her civil rights. With this closing, the narrative logic of the report produced two disciplinary consequences. First, the report identified and, by giving it a medical designation, pathologized her moral deviance, blocking other possible interpretations of her case. Second, the report rea≈rmed patriarchal authority over the rebellious woman by denying her the right to economic independence and custody of her children, which the current Civil Code granted her as a widower, and condemning her to remain under the complete supervision of her husband’s family. If the diagnosis symbolically imposed a punitive sanction, the treatment enabled the application of disciplinary measures to put an end to the hysterical chaos. The objective was to ‘‘reeducate’’ the out-of-control body by

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imposing an order that overcame the mimetic disorder of its false symptoms and contained the passionate outbursts that went along with them. Depending on the guiding epistemological paradigm, doctors made use of three kinds of interventions: internal (surgery and medication), external (isolation, baths, electricity, and exercise) and psychological (hypnosis and suggestion). Since they thought hysteria was a pathology deeply rooted in female sexuality, doctors doubted that any cure could be complete regardless of the therapeutic method chosen. Strictly speaking, hysteria was an untreatable chronic disorder that the biological ups and downs of women could activate at any point. The case of María Mercedes Z., included in the appendix to Juan José Yzaurralde’s thesis, ‘‘Histeria’’ (1889), brings forward the process of domestication implied in treatment and cure in the context of a public hospital. Like Mrs. S., María Mercedes was brought to the doctor by her relatives. They decided to take that drastic step when, after giving birth, the patient began to show symptoms of a ‘‘hysteria without attacks, or nonconvulsive,’’ marked by eccentric and whimsical behavior and a slight, nearly imperceptible, loss of feeling in her larynx. Once more, hysteria and rebellion were part of a progression of symptoms. In constructing a tale of restoration, the doctor-author underscores the transforming e√ect of the recommended treatment, contrasting the stabilizing e√ects of the cure with the description of the patient’s belligerent attitude that opens his account: María Mercedes was not a docile woman. She was tenacious, insu√erable and extremely proud, and when I had to inject her subcutaneously with morphine chlorohydrate, she would be pointing and telling me, ‘‘I want you to do it here.’’ I never agreed to her request and she told me that I didn’t do it because I was whimsical, and refused to go along, since she wanted things her way and I found myself obliged to have her held down by two or three nurses. After that, she o√ered me her arm for the injection and I choose some other region, and thus managed to dominate her haughtiness.≥≥

In this representation of the first meeting between the hysteric and the professional, the patient is a restless being whose pathological symptoms coincide with her resistance to treatment. Given this premise, what the rest of the case does is narrate the evolution of a war of wills in which the doctor made use of all kinds of therapeutic measures to control hysterical outbursts. During eight long months of internment, Mercedes was submitted every day to cold showers and injections of morphine and tonics, in addi-

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European representations of the paradigmatic hysterical attack, such as this narrative sequence of hysterical positions included in Paul Richer’s Études Cliniques sur la Grande Hystérie ou Hystéro-épilepsie (Paris, 1881), were widely available in Buenos Aires professional circles. They o√ered iconographic guidelines to diagnose and classify convulsive episodes, but some Argentine doctors also used them as models to ‘‘produce’’ hysteria in patients’ bodies through suggestion or hypnosis.

tion to three uterine cauterizations per week. By the end of the treatment, when the doctor ruled the sick woman to be satisfactorily reestablished, the disappearance of hysterical symptoms coincided with the disappearance of the rebelliousness of María Mercedes, who ultimately smiled and blushed with shame when reminded of her resistance to treatment. According to the causality imposed by the account of transformation framed by the contrast between the beginning and end of the case, the compliant attitude the patient ended up adopting is the visible and incontrovertible sign of the treatment’s success. But at the same time that María Mercedes’s case demonstrates the extent to which female health was equated with submissiveness, it makes us wonder about the actual catalyst that motivated the changes in her conduct. One might justifiably suspect that after such extreme treatments and such long stays in the hospital, fear was undoubtedly one of the most e√ective and convincing instruments of therapy. Even when patients did not resist medical intervention, the cure always contained an element of breaking the pathological will through the direct

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disciplining of the body. Besides exercise, with which doctors aimed to induce the methodical rhythm of bourgeois routine into the chaotic movements characteristic of certain forms of hysteria, the treatment with the most fascinating implications in this sense was suggestion, either hypnotic or in a wakeful state. This kind of therapy coerced the body solely by manipulating the hysterical imagination. During this process, the interaction between doctor and patient literally functioned as a war between conflicting wills, in which the doctor’s will to power attempted to impose its desire on the will of the patient. The psychological hypothesis behind these procedures was that hysteria was a mimetic disorder that a√ected the capacity for self-representation, and therefore the correlation between mind and body.≥∂ Through suggestion or hypnosis, the doctor systematically replaced the fixed ideas produced by the illness with healthy correct fictions, until the internalization of this replacement by the patient eliminated the need for professional intervention. All the cases of hysteria treated in this way and recorded as successes in ‘‘La Sugestión en Terapeútica’’ (1892), by Gregorio Rebasa, follow this same scheme. Despite the di√erence in focus from other therapeutic methods, once again the rectification of the pathological includes aspects of the moral life of the patients. The case of Petrona A. makes this trait explicit. Petrona was sixteen years old, single, Argentine, and possibly a prostitute. In his detailed account of the succession of attacks and suggestive cures, Rebasa writes: On Monday the eighth, she had an attack that lasted four minutes, as a consequence of having received unpleasant news. . . . I was called right away, I woke her up and she started to cry like a baby. I put her to sleep right away, suggesting to her that she remain asleep for a few minutes, and later she woke happy and content, having obeyed this suggestion. That same day at 5 p.m., I made her sleep and suggested that she have no further attacks. . . . The 11th: The same suggestion, it goes well. I also add that she was now completely healthy and should live a more moral life, since the one she had lived was not good for her. She is released on 11 June 1891. I have since learned that her attacks have not been repeated, and what is most particular about this case is that she left the life she was living, settling herself with living a poorer life, but one more honest and honorable.≥∑

With suggestion, traditional medical treatments entered onto slippery terrain where the professional authority of the doctor was found less in his

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technical capacity to intervene on the body as an organic unity than in his talent to persuade vulnerable patients by the force of his will and the weight of his intellectual and moral authority. In Rebasa’s narration, the mere repetition of a well-formed mandate was enough to rectify hysteric deviations and the symbolic disruptions they caused. As with oratory, the disciplinary e√ectiveness of suggestion rested on the use of words to convince the other to take some action. Once the patient made hers the corrective idea suggested by the doctor and incorporated it, the hysterical illusion disappeared. In this way, the suggestion cure reinscribed hysterical passion in an account whose grammar came from the interiorized voice of the doctor. That voice not only imposed a normal rhythm on the patient’s agitated body, but also imposed a moral code that placed a brake on female sexuality. The process of female reeducation worked like an act of ventriloquism in which the hysterical body ‘‘was spoken’’ by a will that was not its own. Yet unlike that act, here communication actively continued even when the ventriloquist was no longer present. As in the previous two cases, the encounter between doctor and hysteric had the exceptional setting of the hospital as its main stage. Just as the practice of medicine combined elements of discipline and scientific research, so the spatial layout of the hospital was a cross between a prison and a laboratory. Once they entered, hysterics were simultaneously patients to relieve, mysteries to study, and o√enders to contain. In each instance, the hospital provided a visual mechanism for surveillance to satisfy any of these generally overlapping and virtually indistinguishable tasks. At the end of the century, the constantly growing use of hypnotic suggestion to treat hysteria strengthened the connections between the social functions of the hospital and the theater. Gradually, the domestication and ventriloquism of the hysterical body became a favorite number in the pedagogical spectacle in the teaching hospital. Here, as in Charcot’s famous sessions at the Salpêtrière Hospital in Paris, the most respected doctors in the field hypnotized their hysterical patients before a large and static audience of colleagues, students, and curious dignitaries. In Histeria y Sugestión, José Ingenieros included several accounts of public cures in which the demands of pedagogy gave way to the temptations of the voyeur. One of these is especially significant because, in addition to being paradigmatic, it shows that hypnotic suggestion was a method not only for making hysteria disappear, but also for producing it as a virtual phenomenon:

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We presented this interesting patient in one of the ‘‘clinical lessons’’ of the course on Experimental Psychology given at the Faculty of Philosophy and Letters by Professor Horacio G. Piñero. He illustrates his theoretical lessons with experimental work and the presentation of clinical cases. . . . In front of the students of the Psychology course, the sick woman was successively hypnotized by means of the three most common procedures: direct ocular fixation, fascination with a shiny object, and compression of ocular globes. . . . With the patient asleep, simple verbal commands are enough to make her rise and move from one point to another, carrying out the movements ordered by the experimenter. The diathesis of contraction is sharply accented during hypnotic sleep; one need only suddenly extend the arms or lightly rub them to produce an instant contraction, unilateral or double. The member in contraction remains absolutely rigid; three students attempted in vain to violently overcome the suggested contraction, but a mere verbal indication was enough to suppress it. . . . A gradual rub from the neck to the heel can cause a general contraction of the entire body, producing a cataleptic state that allows the patient to lie on top of two seat backs, resting her neck on one and her heels on the other. . . . It was suggested to the patient that the compression of her wrists would cause the end of her attack and this blockage zone was educated repeating the attempt many times during hypnotic sleep. It was su≈cient to tell those close to the patient that when an attack occurred, they should take her by the wrist.≥∏

In this other version of the traditional hermeneutic scene we find both familiar elements and new ones. As in the hypnotic treatments described by Gregorio Rebasa, the silenced body of the crazy woman once again materialized the doctor’s verbal instructions while responding despite itself to the quasi-erotic touch of manual manipulations. But on this occasion, the hypnosis was not limited to reproducing the epileptic symptoms of the original hysterical disorder or to inducing an unconscious block in the patient that would make them disappear when she was taken by the wrist. Strikingly enough, the greater part of the session was dedicated to the artificial creation of the ideal poses that illustrated medical manuals about hysteria. As in a play, Ingenieros was able to produce the ideal iconography of illness, projecting the scientific text onto the hysterical body. From this perspective, one could conjecture that fin-de-siècle hysterics were in part fabrications of the medical profession. This would explain the fact, pointed out by Ingenieros and others, that many of the patients who entered the hospital without classic hysterical symptoms became literal embodiments of the medical manuals during their long internments.≥π The ventriloquism of hysterical choreography represents the perverse but

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complementary flip side of disciplinary ventriloquism. During the explosion of imagination sparked by the hysteria plague that struck Buenos Aires between 1875 and 1905, medical doctors were the authors of contradictory fictions. Despite their di√erences, both kinds of medical fiction were ways of converting the bodily text of the hysterical patients into another text. Policemen of sex, the doctors systematically and meticulously rewrote the symptomatic inscriptions of hysteria as fables of control which, by reintroducing the bourgeois distinction between the normal and the pathological, confirmed and reinforced women’s subjugation to the patriarchal order. Perhaps tempted by the very power they had over the patients they treated, they helped to fix the o≈cial poetics of hysteria as performance. This return to imagination almost never led to any recognition of the act of resistance that was embodied in hysteric contortions.≥∫ If during the attacks hysteria symptoms were embodiments of female frustration and rebellion, during the doctor’s spectacle the unfolding of symptoms was, on the contrary, the result of the manipulation of the hysterical woman before a complicit audience of men. The hysterical woman, a morbid marvel, continued to be the central object of the curiosity and fascination of those present. But just like the ventriloquist’s dummy or the magician’s assistant in the theater or the circus, during the public act of domestication the hysteric’s body functioned primarily as the material means for the doctor to demonstrate both his knowledge and his will to power.

Notes 1 The e√ects of the 1871 yellow fever outbreak, the worst epidemic the city of Buenos Aires had experienced until then, were certainly decisive in this sense. Its reach and destructive power produced immense panic both in the general population and in the porteño elite. The epidemic lasted six months and left fourteen thousand dead. With the express intention of protecting themselves from the contagion, many of the most prominent citizens—including President Domingo F. Sarmiento—abandoned the city. See Carlos Andrés Escudé, ‘‘Health in Buenos Aires in the Second Half of the Nineteenth Century,’’ in D. C. M. Platt, ed., Social Welfare, 1850–1950: Australia, Argentina and Canada Compared (Toronto: Macmillan, 1989), 62–63. 2 Michel Foucault, Discipline and Punish: The Birth of the Prison (New York: Vintage Books, 1979), 198–99. 3 Donna Guy, Sex and Danger in Buenos Aires: Prostitution, Family, and Nation

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4

5 6

7 8

9

10

11 12

in Argentina (Lincoln: University of Nebraska Press, 1991); Héctor Recalde, La Salud de los Trabajadores en Buenos Aires (1870–1910) a través de las Fuentes Médicas (Buenos Aires: Grupo Editor Universitario, 1997); Jorge Salessi, Médicos, Maleantes y Maricas (Rosario, Argentina: Beatriz Viterbo, 1995); Hugo Vezzetti, La Locura en Argentina (Buenos Aires: Paidós, 1985). For instances of this more balanced approach to the political implications of social medicine, see, for example, chapter 6 of Dora Barrancos, La Escena Iluminada: Ciencia para Trabajadores, 1890–1930 (Buenos Aires: Editorial Plus Ultra, 1996); and Diego Armus, ‘‘El Descubrimiento de la Enfermedad como Problema Social,’’ in Mirta Zaida Lobato, ed., El Progreso, la Modernización y sus Límites (1880–1916), Nueva Historia Argentina, vol. 5 (Buenos Aires: Editorial Sudamericana), 509–51. Elaine Showalter, Hystories: Hysterical Epidemics and Modern Media (New York: Columbia University Press, 1997), 11. Edward Shorter calls the set of legitimate symptoms within a given culture the ‘‘symptom pool.’’ By defining certain symptoms as legitimate, a culture limits the number of symptoms the psychosomatic can assume without being accused of not su√ering from ‘‘real’’ diseases. In keeping with this, the unconscious strives to produce only those symptoms acceptable to society. See his From Paralysis to Fatigue: A History of Psychosomatic Illness in the Modern Era (New York: Maxwell Macmillan International, 1993), ix–xi. Susan Sontag, Illness as Metaphor and AIDS and Its Metaphors (New York: Anchor Books, 1989), 5. See, for example, the influential essay by the French feminist Hélène Cixous, ‘‘The Laugh of Medusa,’’ in Elaine Marks and Isaballe de Courtivron, eds., New French Feminisms: An Anthology (New York: Schocken Books, 1981), 245–64. On some of the modes of aesthetic appropriation of neurosis and hysteria, see Gabriela Nouzeilles, ‘‘Narrar el Cuerpo Propio: Retórica Modernista de la Enfermedad,’’ Estudios: Revista de Investigaciones Literarias (Caracas) 9 (1997): 149–76. See, for example, Diego Armus, ‘‘De ‘Médicos Dictadores’ y ‘Pacientes Sometidos’: Los Tuberculosos en Acción. Argentina 1920–1940,’’ in Allpanchis 53 (1999): 219–53. Janet Beizer, Ventriloquized Bodies: Narratives of Hysteria in NineteenthCentury France (Ithaca: Cornell University Press, 1994), 8. Drs. Gabriela Laperrière de Coni and Alicia Moreau de Justo, for example, were among the founders and promoters of two women’s associations, the Women’s Guild Union (1902) and the Feminine Socialist Center (1903). For the history of Argentine feminism and women’s movement, see Marifran Carlson, ¡Feminismo! The Women’s Movement in Argentina from Its Be-

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13 14 15 16 17 18 19 20 21

22 23

24

25

ginnings to Eva Perón (Chicago: Academy, 1988); and Asunción Lavrín, Women, Feminism, and Social Change in Argentina, Chile, and Uruguay, 1890– 1940 (Lincoln: University of Nebraska Press, 1995). Elvira Rawson de Dellepiane, ‘‘Apuntes sobre la Higiene de la Mujer’’ (diss., Universidad de Buenos Aires, 1892), 11. Arturo Balbastro, ‘‘La Mujer Argentina’’ (diss., Universidad de Buenos Aires, 1892), 8; emphasis mine. Julio E. Piñero, ‘‘Etiología y Profilaxia de la Histeria’’ (diss., Universidad de Buenos Aires, 1883), 20–21. Adolfo Martínez, ‘‘Relaciones de la Menstruación con el Sistema Nervioso’’ (diss., Universidad de Buenos Aires, 1881), 20–21. Arturo Balbastro, ‘‘La Mujer Argentina,’’ 66–67. Arturo Ferrand, ‘‘La Histeria’’ (diss., Universidad de Buenos Aires, 1888), 33–34. Elvira Rawson de Dellapiane, ‘‘Apuntes,’’ 40. Arturo Balbastro, ‘‘La Mujer Argentina,’’ 69. The arguments for and against women’s rights always began with an exposition on the biological nature of women and the possible causes of female pathologies. For example, in La Mujer ante la Ley Civil, Política y el Matrimonio (Buenos Aires: Imprenta Coni, 1882), Santiago Guzmán first argued in favor of granting women the same civil rights as men, only to return to the argument about the innate neuropathological condition of women in order to deny them the right to vote and to political representation. Enrique Merlo, ‘‘Manifestaciones de la Histeria Esencial’’ (diss., Universidad de Buenos Aires, 1896), 16. On the dominant paradigms for interpreting hysteria from Egypt and Greece down to nineteenth-century modernity, see Mark S. Micale, Approaching Hysteria: Disease and Its Interpretations (Princeton: Princeton University Press, 1995), 19–29. The preoccupation with distinguishing hysteria from other diseases coexisted with the common practice of associating it with the visible signs of epilepsy or syphilis. On the system of analogies with other illnesses in prevailing descriptions of hysteria, see the stupendous essay by Sander Gilman, ‘‘The Image of the Hysteric,’’ in Sander Gilman et al., Hysteria beyond Freud (Berkeley: University of California Press, 1993), 345–452. Although he rejected the hypothesis of an organic lesion as causing hysteria, Ingenieros continued to identify women and men of ‘‘feminine’’ sensibility with victims prone to the disorder. In this way, the gynecological theory that was rejected at first returned surreptitiously in psychological theory as a founding etiology. Salustiano Arévalo, ‘‘Apuntes sobre las Influencias Morales en el Tratamiento de la Histeria’’ (diss., Universidad de Buenos Aires, 1888), 26.

h y st e r i a i n t u r n - o f - t h e - c e n t u ry b u e n o s a i r e s 75 26 Merlo, ‘‘Manifestaciones,’’ 10–11. 27 Josefina Ludmer places Holmberg’s story within a series of cultural fictions about women who kill that extends across the nineteenth century. See her El Cuerpo del Delito: Un Manual (Buenos Aires: Editorial Perfil, 1999), 353– 400. For a more detailed analysis of ‘‘La Bolsa de Huesos’’ and its connections with the medical imagination, see Gabriela Nouzeilles, ‘‘Políticas Médicas de la Histeria, Mujeres, Salud y Representación en el Buenos Aires del Fin de Siglo,’’ Mora: Revista del Instituto Interdisciplinario de la Mujer (Buenos Aires) 5 (1999): 97–112. 28 On the connections between realism and discipline, see D. A. Miller, The Novel and the Police (Berkeley: University of California Press, 1988), 21. 29 Kathryn Montgomery Hunter, Doctors’ Stories: The Narrative Structure of Medical Knowledge (Princeton: Princeton University Press, 1991), 9. 30 Self-identification as a possible patient was possible only after medicine became the dominant discourse for speaking about the body in the second half of the nineteenth century. From then on, going to see a doctor has always implied having already made a decision, ‘‘perhaps unconsciously, in going to a physician, rather than, say, a priest. There is already a presentation or categorization of oneself as sick, rather than, say, sinful. ’’ Oliver Sacks, ‘‘Clinical Tales,’’ Literature and Medicine 5 (1986): 16. 31 Janet Beizer, Ventriloquized Bodies, 9. 32 Carlos B. Benítez and Juan N. Acuña, ‘‘Locura Histérica e Incapacidad Civil,’’ Archivos de Psiquiatría y Criminologia 2 (1903): 210–11. 33 Juan José Yzaurralde, ‘‘Histeria’’ (diss., Universidad de Buenos Aires, 1889), 141. 34 Francisco P. Meroño, ‘‘Risa Histérica’’ (diss., Universidad de Buenos Aires, 1904), 31. 35 Gregorio Rebasa, ‘‘La Sugestión en Terapeútica’’ (diss., Universidad de Buenos Aires, 1892), 84. 36 José Ingenieros, Histeria y Sugestión (1904; Buenos Aires: Ediciones L. J. Rosso, 1919), 70–72. 37 In his study of the hysterical iconography produced at the Salpêtrière Hospital by Charcot and his collaborators, Didi-Huberman reaches the same conclusion. See Georges Didi-Huberman, Invention de l’Hystérie: Charcot et l’Iconographie Photographique de la Salpêtrière (Paris: Editions Macula, 1982). 38 One remarkable case is that of a young upper-class porteña, a minor, who pretended to be hysterical in order to keep her family from sending her to a convent and thus preventing her from marrying. José Ingenieros alluded to the case in Simulación de la Locura (Buenos Aires: Ediciones L. J. Rosso, 1918), 16–21.

marilia coutinho

Tropical Medicine in Brazil the case of chagas’ disease

or some reason, northerners tend to be more frightened of Chagas’ disease than of other tropical diseases.∞ Perhaps it is because of the disease’s silent onset; it manifests itself long after infection, with irreversible and disabling symptoms. Perhaps it lies in the transmission by a relatively large and clumsy bug instead of an inconspicuous and elegant mosquito. The notion that transmission takes place after the bug defecates in or near the wound, which is preferably located on the victim’s face, magnifies the repulsion. Perhaps the fact that the disease attacks the noble organ—the heart—is the source of the dread. Far scarier than all these, however, are the social determinants of the transmission: Chagas’ disease is a zoonosis whose natural reservoirs are skunks and armadillos. It a√ects humans only when their living conditions become so degraded that they are similar to those of the natural reservoirs. Chagas’ disease is a disease of poverty. It is endemic to Latin America and a√ects the entire continent. An estimated eighteen million people carry the disease. Many years of persistent control measures carried out by local governments and international organizations have succeeded in reducing the transmission in many areas. In spite of that, 25 percent of the Latin American population is still at risk. There is no medical cure for Chagas’ disease.≤ The etiologic agent, a protozoan called Trypanosoma cruzi, is transmitted by insects belonging to the family Reduviidae. The parasite enters the vertebrate host’s bloodstream after the reduviid insect has fed and defecated; infective forms present in the insect’s feces penetrate the wound. Once in the bloodstream, the parasites invade cells, particularly muscle and nerve tissue, where they reproduce by binary division. After a number of divisions, the parasites escape from the infected cells and penetrate other cells. This is the vertebrate cycle. Alternatively, the reduviid insect can suck in the parasite when it feeds and bring the parasite into its own gut. There, the

F

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parasite begins a series of transformations that involve reproduction and ultimately lead to infective forms that are expelled during defecation.≥ Neither parasite nor bug nor disease was known before Carlos Chagas, a young Brazilian physician, exposed them in 1909. The discovery of Chagas’ disease and the research traditions that developed around it are as Latin American as the parasite; however, they are also part of the broader history of tropical medicine. Ecological, scientific, and political factors make the history of Chagas’ disease an interesting case for exploring the interplay between local and international trends in science and public health. This interplay a√ects scientific recognition; the institutionalization of medical research; the acceptability and viability of public health measures; and the construction of political agendas concerning public health, science, technology, and education. These are all matters pertaining to development strategies and social issues that have followed Chagas’ disease from the moment it was discovered to the present day. This chapter summarizes ninety-two years of research and policy measures related to Chagas’ disease, from discovery to disease control in the southern cone of the American continent. These ninety-two years saw di√erent research traditions succeed one another. The e√orts involved di√erent people, di√erent research concerns, and di√erent institutions, but they also preserved common threads: scientific and political agendas that animated di√erent generations of ‘‘chagologists.’’ They concern the pursuit of an indigenous intellectual identity as well as the links that connected Brazilian chagologists to the wider international networks of tropical medicine and defined their place in the world. With this comprehensive treatment of Chagas’ disease research, I hope to contribute to an understanding of the history of tropical medicine that goes beyond its present portrayal as an imperial enterprise.∂

Imperial Tropical Histories of Tropical Medicine Tropical medicine has received much attention from historians in recent years. Whether to celebrate the great deeds of their ancestors or to condemn them as part of colonialist atrocities, tropical medicine is depicted by its commentators as part of an imperialist agenda.∑ Around the turn of the century, these historians say, the time was ripe for the disciplinary demarcation of tropical medicine from the wider biomedical sciences. Tropical med-

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icine institutions were formed and received support from the imperial powers. This moment was preceded by and overlapped with a wave of discoveries of parasites, their transmitting agents (vectors), and transmission mechanisms. These discoveries were accomplished by a new kind of agent, the army physician, and include the discovery of Schistosoma hematobium worms by Theodor Bilharz in 1851 and of its eggs in 1852; the discovery of Filaria sanguinis hominis by T. Lewis in 1872; the elucidation of filariasis transmission by mosquitoes by P. Manson in 1879; the identification of the malaria plasmodium parasites by A. Laveran in 1880; the identification of the malaria insect vector and life cycle by R. Ross and G. B. Grassi in 1897; the discovery of the causative agent of kala azar, Leishmania donovani, by W. B. Leishman and C. Donovan in 1900; the discovery of African trypanosomiasis by Bruce between 1896 and 1902; and the identification of the life cycle of Schistosoma worms by R. Leiper in 1915. Most of the physicians mentioned above were connected to colonial military services.∏ With the accumulated impact of these many discoveries, tropical medicine acquired a space of its own,π both physical and epistemological; the insect vector theory provided a means for separating tropical diseases from the cosmopolitan infectious diseases. Tropical diseases were defined as those transmitted by a vector, an intermediary host for the parasite (preferably an insect), which passed it on to the vertebrate host while feeding on its blood. The dependence on the vector for the completion of the parasite’s life cycle transformations accounted for the ecological (tropical) restriction of this class of disease.∫ The colonial empires expanded in the nineteenth century as the imperialist nations explored new tropical domains, and the colonial powers’ interests converged with those of the physicians and researchers engaged in setting up a disciplinary program for tropical medicine. The colonial powers wanted both to protect the health of soldiers and white settlers, and to keep sanitary control over railroad construction and portage environments for the benefit of their economy. Thus portrayed, tropical medicine is about nineteenth-century European imperialism and military and colonial medicine. Evidence of a di√erent tropical medicine, however, has been emerging and filling in gaps in historical writing. Julyan Peard, for example, has studied the Escola Tropicalista Bahiana, which flourished in Salvador, Brazil, between 1860 and 1890. Its pioneer, Otto Wucherer, identified the embryonic filaria known today as Wucheria bancrofti as early as 1866. The issues with which the Tropicalista

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Photograph of Carlos Chagas, Rocha Lima, and another scientist working in one of the laboratories of the Instituto Oswaldo Cruz (Manguinhos, Rio de Janeiro), circa 1905, sent to Chagas by Oswaldo Cruz as a New Year greeting. Courtesy of Departamento de Arquivo e Documentação da Casa de Oswaldo Cruz da Fundação Oswaldo Cruz.

School dealt were related to development and social justice. Its supporters opposed slavery and openly rejected the tropical degeneration thesis that was popular in Europe in those days.Ω The history of Chagas’ disease belongs to this other, tropical type of tropical medicine. Like his Brazilian predecessors, Chagas was involved with development issues, but he was not a military physician. He was trained in Brazil and worked for the Instituto Soroterápico de Manguinhos, one of a number of institutions created at the turn of the century in Brazil to handle major urban epidemics. These institutes prepared sera and vaccines, designed vaccination campaigns, and launched research initiatives.∞≠ They were created for the practical purpose of controlling infectious diseases, but the pioneers involved in them had a political agenda: they were imbued with the ideals of national development and self-reliance in terms of health care.∞∞ Of all the serum and vaccine institutes created in Brazil at that time, Manguinhos, in Rio de Janeiro, was the only one where experimental research actually flourished early. Oswaldo Cruz, its first director, soon achieved the position of director of the federal public health department. It

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was in this position that Cruz performed the most controversial and successful of his enterprises: he devised and implemented a plan to control yellow fever and other diseases in Rio de Janeiro. The program involved dramatic urban reform and initially met with much resistance, but the success of the control measures soon turned Cruz into a national hero whose every request was granted. He was able to set up a sophisticated research facility in Manguinhos where microbiology research was carried out. Manguinhos was praised in Europe and was recognized as a center for tropical medicine research. Stanislas Von Prowazek, Gustav Giemsa, and Max Hartmann came to Brazil between 1908 and 1909. Prowazek was a professor at the Hamburg Institute of Tropical Medicine (Institut für Schi√s und Tropenkrankheiter), and Hartmann came from the Berlin Institute of Infectious Diseases (Institut für Infektionskrankheiten).∞≤ Although he was only twenty-eight in 1907, Carlos Chagas was not a minor player in this parasite-hunting game. A former student at Manguinhos, Chagas’s first interest was malaria.∞≥ He had already designed and implemented successful malaria control programs as early as 1906. In 1907, he identified new species of mosquitoes, the vectors in malaria transmission. In fact, Chagas had emerged as the highest Brazilian authority on malaria and was a pioneer in research on its control.∞∂

The Discovery of Chagas’ Disease In 1907, a malaria outbreak was arresting the growth of the Central do Brazil Railroad. The work had reached the interior of the state of Minas Gerais; Lassance, a small village, was completely taken by the epidemic. Chagas was put in charge of the control measures. He and Belizario Penna, another physician from Manguinhos, arrived in Lassance in June 1907.∞∑ They were still involved with malaria research when a local engineer named Cantarino Motta brought them some blood-sucking insects that preyed on the local people at night. The bugs lived in the crevices of the wood-and-earth houses built by the local people, who exhibited the symptoms of a strange disease. A blood-sucking insect feeding on sick people was more than enough to arouse the interest of a parasite hunter.∞∏ Chagas dissected the bugs and found protozoa in their digestive tracts. He sent the insects to Manguinhos to be tested in infection experiments with the available laboratory mammals. They proved to be infective and caused serious

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symptoms in some of the animals. Chagas had a vertebrate parasite, its insect vector, and a disease; he finally got parasite blood forms from a feverish child in Lassance, which completed the discovery cycle.∞π In 1909, Chagas published a series of articles describing the etiologic agent, the disease, and the symptoms.∞∫ The identification of the steps from an insect vector, through the parasite, to the symptoms had not been accomplished before in such a short time, and never by a single researcher. Chagas had ‘‘invented’’ American trypanosomiasis.∞Ω Fame quickly followed. In 1910, Chagas was named a full member of the National Academy of Medicine in Brazil. That same year, he was named head of services at Manguinhos. In 1912, Chagas received his highest international scientific honor. Competing with such luminaries as Paul Ehrlich, Pierre-Paul-Emile Roux, Elie Metchniko√, Charles-Luis-Alphonse Laveran, Charles Nicolle, and William B. Leishman, he won an international competition sponsored by the Hamburg Institute for Tropical Diseases. Every four years, the institute granted the Schaudinn Prize (in memory of the pioneer of protozoology) to the researcher who made the most important contribution in protozoology.≤≠ Chagas was also nominated twice for the Nobel Prize, although he never received it. Manoel A. Pirajá da Silva, a Brazilian physician involved with Schistosoma mansoni research, made the first nomination, in 1913. Hilário de Gouvêa, also a Brazilian physician, made the second nomination, in 1921. In 1913, the prize was conferred on Charles R. Richet for his work on anaphylaxis; no one received the prize in 1921.≤∞ In 1917, Chagas became the new Manguinhos director, and in 1920 he was appointed director of the Department of Public Health by a presidential act. In 1921, he received honors at Harvard University, and in 1925, he became a member of the League of Nations Hygiene Committee.≤≤ Chagas’s recognition abroad was mostly related to the protozoological aspect of his discovery, in tune with tropical medicine’s trends. At home, the emphasis was on its public health implications and brought Chagas powerful positions and involvement in policy making. The recognition gave visibility to Chagas’s controversial political positions and institutional style. His patriotic ideals included (1) the eradication of tropical diseases (eradication would be necessary for the improvement of the Brazilian race and for the sanitary ‘‘redemption’’ of the nation; (2) the establishment of an internationally competitive experimental tropical medicine in Brazil; and (3) a centralized national public health system structured on modern scientific

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guidelines of control and prevention. As early as 1911, Chagas had noted that the disease reached into the interior states of Minas Gerais, Mato Grosso, and Goiás. He pointed out that the insect vectors were colonizing increasingly larger areas. Chagas viewed the social structure that kept the rural population in poor living conditions as the cause of the spread of the disease.≤≥ He voiced his opinions about the need for an internationally competitive experimental tropical medicine on several occasions. Most significant, however, were his actions as director of Manguinhos in supporting experimental research. As for the centralized public health system, he would deal with it as director of the Department of Public Health.≤∂

Years of Oblivion The climb up the power and recognition ladder proved to have a bitter price for Chagas. At each step, opposition to his ideas grew stronger. Those discontented with his appointment as head of services silently organized over the years until, in 1916, Chagas was publicly challenged at the PanAmerican Medical Congress in Argentina. His main opponent was Rudolph Kraus, a German microbiologist working at the Bacteriological Institute in Buenos Aires who claimed that there was a discrepancy between the indicators of the disease: on the one hand, the presence of infected triatomines (i.e., bugs of the genus Triatoma), and, on the other, goiter, other accepted clinical indicators, and the presence of blood forms in humans. Kraus had found infected triatomines in Argentina, but he had not detected human cases of infection. Chagas replied that the disease was still not adapted to man in that region, thus the bewildering results. In Kraus’s laboratory, Chagas discovered evidence that his own colleagues in Manguinhos had been feeding evidence to Kraus behind his back.≤∑ To make matters worse, there were serious di≈culties involving the diagnosis of the chronic stage, including the lack of serological techniques (the confirmation of diagnosis still depended on inoculation in laboratory animals) and Chagas’s insistence on goiter, which later proved to be unrelated to Chagas’ disease, as an indicator. The medical community had accepted this, and Miguel Pereira even named the disease ‘‘parasitic thyroiditis.’’≤∏ Aware of the organized opposition and the di≈culties with his clinical research, Chagas returned to Brazil to find Cruz very ill. Cruz died soon after, on February 11, 1917, and Chagas was immediately appointed the

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new director of Manguinhos. Another step, another enemy: Figueiredo de Vasconcellos, who had been the interim director during Cruz’s illness and hoped to retain the position, became Chagas’s enemy for life. In 1920, when Chagas was appointed director of the Department of Public Health, Afrânio Peixoto, a powerful member of the National Academy of Medicine, was upset to have been bypassed for the position.≤π Chagas made other enemies when he instituted modernizing measures in his new public health position. The resentment and anger peaked at a solemn session of the National Academy of Medicine. In November 30, 1922, Afrânio Peixoto spoke to the academy at the ceremony honoring the reception of Figueiredo de Vasconcellos. In an explosive speech, Peixoto charged that Chagas’s American trypanosomiasis was no more than a local curiosity without national epidemiological significance. Moreover, he implied that Chagas had given Brazil a bad reputation by exposing the disease to the rest of the world. Many others joined Peixoto in accusing Chagas of ruining the country’s image and of having appropriated Oswaldo Cruz’s discovery for himself. At Chagas’s request, a commission was formed to discuss and judge the matter. In December 6, 1923, the commission ruled in Chagas’s favor.≤∫ Chagas’s reputation was preserved; the disease, however, was forgotten. For years, no one studied it, no epidemiological surveys were done, and its principles were not taught in medical schools. As a result, physicians were unable to diagnose Chagas’ disease, and thousands of deaths went undiagnosed.≤Ω Only the ‘‘resistance core,’’ a small group of physicians and scientists faithful to Chagas, kept up research on the disease and its parasite and vectors.≥≠ Meanwhile, the disease was relentlessly spreading throughout the continent. When Chagas discovered the disease, the predominant vector was Panstrongylus megistus. In 1950, Triatoma infestans, with larger domiciliary populations, had already reached as far as Minas Gerais and the disease was rapidly spreading northwest.≥∞ Chagas was aware of the epidemiological threat and knew that only improved housing conditions would halt the spread of the disease. He reached out to decision makers and researchers from other countries. In 1918, he stimulated the initiatives that resulted in a congressional decision to regulate rural housing standards—a regulation that was never observed. Chagas’s e√orts were fruitless.≥≤ He died in 1934, not as the national hero and great discoverer that he is

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considered today to be, but as the father of a minor and unimportant tropical curiosity.≥≥

From Bambuí to the World While Chagas’s work was being maligned in Brazil, Argentine physicians had been working on their own. Salvador Mazza assumed the leadership of regional pathology research in the country. In 1926, the Argentine Society for Northern Regional Pathology was formed, the foundation for the future Misión de Estudios de Patología Regional Argentina (mepra, the Argentine Regional Pathology Study Mission). mepra was established in Jujuy in March 1929.≥∂ Mazza published his first works about Chagas’ disease in 1926. He introduced the Guerreiro and Machado diagnostic technique in Argentina and proceeded to record human cases. In order to promote his research, he established a train-laboratory and traveled around the country investigating the disease. By 1935, he had recorded 100 acute cases; by 1946, Mazza had 1,232 cases.≥∑ The decisive finding, however, was Argentine physician Cecílio Romaña’s ‘‘unilateral schizotrypanosic conjunctivitis,’’ an initial symptom of the acute phase consisting of a conspicuous eye infection that became known as the ‘‘Romaña sign.’’≥∏ It was the missing diagnostic marker for the acute phase. The Argentine Society for Tropical Medicine decided to dedicate the 1935 meeting to Chagas’ disease. The mepra study and Romaña’s work were revealed there. The acute cases that had been elusive during Chagas’s life, accounting for much of the epidemiological uncertainty, were now at hand. In the light of this new knowledge, research, control programs, and public health measures were resumed in Brazil. That same year, 1935, the Major Endemic Diseases O≈ce was created and the first epidemiological surveys were done.≥π From a handful of faithful chagologists, the number of researchers rapidly increased.≥∫ In 1939, Amilcar Vianna Martins, a physician from Minas Gerais, discovered a remarkable collection of acute cases in the small village of Bambuí that opened a new era of research in control, clinical approaches, and medical entomology, among other fields. Emmanuel Dias, a young physician trained by Chagas, assumed the leadership of the Centro de Estudos e Profilaxia da Moléstia de Chagas (Center for Studies and Prevention of

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View of the Castello, principal building of the Instituto Oswaldo Cruz in Manguinhos, Rio de Janeiro, 1934, signed by Carlos Chagas. Courtesy of Departamento de Arquivo e Documentação da Casa de Oswaldo Cruz da Fundação Oswaldo Cruz.

Chagas’ Disease) at Bambuí in 1943. Dias found house infestation rates of 70 percent, natural infection of Triatoma cruzi around 30–40 percent, and 45 percent positive serology among rural children under ten years of age. He began to test a variety of methods to control triatomine populations.≥Ω ddt, a potent insecticide, and chloroquine, the first synthetic antimalarial drug, were developed during the Second World War. Tropical medicine was again parasite- and vector-centered, with a chemical twist.∂≠ New compounds were being synthesized, and from 1947 on, Dias’s team screened insecticides.∂∞ Although ddt was not e√ective against the disease, in 1948, the team confirmed the antivectorial activity of some compounds, such as hexachlorohexane (Gamma-bhc). With a control tool in hand, an o≈cial program of Chagas’ disease prevention was created in 1950 in Brazil. National control programs for triatomine elimination were created in Argentina as well.∂≤ Dias also conducted work on what was to become a major trend in Chagas’ disease research: the chronic heart symptoms developed by chagasic

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Emmanuel Dias fumigating a rural house in Bambuí, Minas Gerais, between 1944 and 1945. Courtesy of Departamento de Arquivo e Documentação da Casa de Oswaldo Cruz da Fundação Oswaldo Cruz.

patients.∂≥ In 1956, his group published a paper that influenced the work of many Latin American cardiologists and opened the age of chagasic cardiopathy research.∂∂ Meanwhile, a more hospitable institutional environment for research was developing in Brazil. The University of São Paulo was founded in 1934, and the present funding agencies—cnpq (National Council for Scientific Research) and capes (Coordination for Improvement of Higher-Level Manpower)—appeared in the early 1950s. New universities were being founded in Brazil, some featuring medical schools that became the forefront of Chagas’ disease research.∂∑ Although the e√ort was led by ‘‘resistance core’’ researchers, many of those who restored the interest in Chagas’ disease in Brazil in the 1940s and 1950s were physicians who became involved with research as a consequence of their clinical experience.∂∏ The first wave of new publications of this period is thus clinical, and most of the papers were published in Brazilian medical journals. Likewise, the first wave of doctoral theses about Chagas’

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disease focused chiefly on cardiopathy and on the ‘‘megas’’ issue (the digestive form of the disease revealed in the 1950s).∂π The disease had once again become a priority in the minds and hearts of Brazilian researchers and physicians. The policy leap for transmission control, however, was achieved only later. In 1959, the First International Congress on Chagas’ Disease was held in Rio de Janeiro and some five hundred participants presented papers.∂∫ The following year, the Pan American Health Organization established a working group on Chagas’ disease. Not only was the interest in the biological and medical aspects of the disease growing, but concerns about its social implications were becoming obvious as well; frequently, they went hand in hand. Many parasitologists were politically active and denounced social inequality as determinant in the epidemiology of Chagas’ disease. Parasitology departments were known as ‘‘red departments’’ in some universities, an allusion to the politically critical attitude among faculty members. For this reason, the 1964 military coup d’état and the ‘‘coup within the coup’’ of 1968 (a right-wing toughening) had visible impacts on Brazilian science in general, and on parasitological research in particular. Leaders who had played important roles in stimulating young physicians to pursue research, like Samuel Pessoa at the University of São Paulo and Amilcar Vianna Martins from the Federal University of Minas Gerais, were dismissed.∂Ω Many younger scientists were also fired or left. Although it was a threatening period of political instability, resources for research reached an unprecedented level in the country. The university reform of 1968 reorganized universities and partially adopted the American system of higher education, with positive consequences for university research activity.∑≠ The Brazilian Biochemical Society emerged from immobility in 1971 and decided to meet regularly in the small bathing resort town of Caxambu, Minas Gerais.∑∞ Tropical medicine had undergone a shift at the international level as well. The era of molecular parasitology had begun, and enormous amounts of money were being poured into the malaria vaccine program.∑≤ This is the setting against which a new breed of chagologists made their move. Most were young physicians returning from molecular biology postdoctoral positions in the United States and Europe. Their leaders were a small group of Brazilian researchers with a medical background who were pioneering biochemical investigation on Trypanosoma cruzi. They had more or less indirect links to the former ‘‘resistance core’’ of chagologists.

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Many of them also shared a critical political attitude toward the Brazilian government. They met for the first time in June 1974 in Rio de Janeiro at the Workshop on Trypanosoma cruzi: Nutrition, Growth, and Strain Variation.∑≥ A central issue at the meeting was the normalization of a growth medium preparation for T. cruzi developed by Erney Camargo, the lit medium. With a normalized procedure, researchers would be able to compare results and advance their work. From then on, the group met every year around November, always at Caxambu. The Brazilian molecular parasitology group was born. The group grew in number, vigor, and networking capability: from 24 participants at the first meeting to 1,114 participants at the twentieth meeting in 1993.∑∂ Research teams grew bigger as well. The Caxambu meetings became increasingly international, and the Brazilian molecular parasitology community seeded Chagas’ disease research in North American and European institutions.∑∑ The community’s rapid growth in the initial years had two di√erent sources: students mentored by the early members of the group, who rushed into the newly established Brazilian graduate education system; and the attraction that the molecular parasitology community exerted over other molecular researchers, who traded their ‘‘cosmopolitan’’ (as opposed to regional) organisms (Escherichia coli and Bacillus subtilis, for example) and systems for T. cruzi.∑∏ The success of the molecular parasitology group is related to their ability to attract funding, to their unique organizational characteristics, and to their international connections. Brazilian funding agencies were convinced of their potential and granted them generous support. A special program to provide incentive for research in endemic diseases was established at the cnpq. The pide (Integrated Program for Endemic Diseases) started in 1973. E. Camargo, who analyzed the parallel enrollment of researchers in the program and scientific production in parasitology between 1973 and 1981, observed that the increase in involved researchers corresponded to a rise in publications.∑π The Special Programme for Research and Training in Tropical Diseases, or tdr, established in 1975, was also important in Chagas’ disease research. This program is co-sponsored by the United Nations Development Programme (undp), the World Bank, and the World Health Organization (who) and is supported by voluntary contributions from governments as well as international organizations, foundations, and other nongovernmen-

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tal bodies. The tdr’s Scientific Working Group on Chagas’ Disease began work in 1979. The tdr funded 402 projects in Brazil from 1977 to 1994 with a total of U.S.$20,290,611; 957 publications were the result. tdr funding increased significantly in the late 1980s, reaching more than U.S.$2,000,000 annually around 1990.∑∫ The consolidation of Chagas’ disease research groups in Brazil paralleled the rapid epidemiological control of the disease in Latin America. National serological and entomological surveys have been carried out in Brazil since the 1970s. Chagologists working both inside governmental organs such as sucam (Public Health Programs Agency) and outside succeeded in persuading the military government that Chagas’ disease was a national priority. However, as pointed out by C. Morel, an e√ective control strategy was established only when João C. P. Dias, an active and respected member of the chagologist community, a physician and researcher, became director of the Division of Chagas’ Disease at the Ministry of Health as the military regime ended in 1985.∑Ω Chagologists throughout Latin America had been interacting since the early 1970s. The first visible policy action of this network, the Southern Cone Initiative, a resolution to eradicate Triatoma infestans signed by the ministers of health of Argentina, Bolivia, Brazil, Chile, Paraguay, and Uruguay, was launched in 1991. Peru joined the initiative at the end of 1996. The World Health Organization sponsored the program. The transmission reduction rate in Brazil and Uruguay reached 96 percent in the period from 1985 to 1996 for the pre-fourteen age group. The total reduction rate for the Southern Cone Initiative countries has been 83 percent. In 1997, similar programs were launched in the Andean and Central American countries.∏≠ In Brazil, it is fair to say that chagologists played a leading role in the country’s scientific development and that their actions resulted in the successful control of disease transmission.∏∞

Chagas’ Disease as a Mirror Scientists and physicians who take part in broad research programs or disciplines such as tropical medicine do so under their unique local conditions as well as by observing and contributing to broader intellectual agendas. Parasitologists from Berlin, Hamburg, Paris, Liverpool, and London, with their own petty politics and recognition battles, contribute to tropical medicine

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as well. Tropical medicine looks very di√erent if we include the local outlook of Latin American participants such as Brazil. All of the local contexts highlighted in the conventional portrayal of tropical medicine are imbedded in the imperial enterprise of their respective countries. Including Latin American contexts adds neocolonial, developmentalist, nationalist, and patriotic features to tropical medicine, to say the least. Moreover, it matters a great deal if a disease is endemic to one’s country’s colony or to one’s own country. When it is endemic to the colony, interest drops dramatically with political independence. When the disease is endemic to one’s own country, it is inevitably part of the country’s search for a national identity. Chagas’ disease has always been more than a health threat for Latin Americans, especially Brazilians. It is part of how Brazilians see themselves, how they show themselves to the world, and how the world sees the country. In the heroic years when the disease was discovered and its early concepts were articulated, the disease itself became an argument against the doctrine of tropical degeneration. Carlos Chagas himself said, ‘‘The practical accomplishments of tropical medicine and hygiene have destroyed the old prejudice of climatic fatality.’’∏≤ Chagas failed in most of his e√orts: he failed to consolidate experimental research and secure a space for its pursuit, and he failed to persuade decision makers of the need for epidemiological control. He even failed to convince the medical community that the disease was important. He did, however, set up an agenda in which a critical political perspective, the struggle for a space for scientific research, the defense of the importance of a Brazilian tropical medicine, and the need for health policy reform were deeply intertwined. He demonstrated, even if only briefly, that Brazilians and Braziliantrained scientists were competent to set up a successful experimental medicine institution and to make the remarkable discovery of a new tropical disease. Chagas’s discovery was atypical: a linear sequence from vector to symptom, all in a very short time—any parasite hunter’s dream. Chagas showed that it was both possible and necessary for Brazil and the world to take part in the experimental medicine enterprise in a ‘‘Brazilian’’ way that included taking advantage of the specificity and geographical restriction of tropical diseases. Chagas stressed the indirect transmission mechanism (the insect vector theory) that determined the tropical concentration of such diseases. His research contributed to the articulation of the ‘‘indirect trans-

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mission’’ paradigm. Taking advantage of these ‘‘local research objects’’ was, ironically, to turn misfortune into a blessing.∏≥ To achieve this goal, Chagas advocated scientific and educational modernization. He created the first special hygiene and public health course in Brazil in 1925. In 1926, the first tropical medicine course started at the School of Medicine in Rio de Janeiro. Chagas believed that medical students should be exposed to research early in their academic lives and that the best brains should be directed to it.∏∂ Chagas also recognized that Chagas’ disease was not only tropical, it was poverty related. People were infected by Trypanosoma cruzi not just because they lived in endemic areas, but because they were condemned to poor living conditions. In a previous work I argued that the early research program su√ered from discontinuity. Chagas’s successful career provoked resentment among his countrymen, and his scientific and modernizing patriotism clashed with other nationalist perspectives. Thus, the collapse of the early research program was in large part a result of petty politics and conflicting visions of national development. A wave of experimental di≈culties combined with clinical and epidemiological uncertainty added to the problems. The bonds that connected early practitioners to the international community were severed. Much of this can be attributed to local damage of the institutional setting and a change of emphasis in international tropical medicine research.∏∑ When the interest in the disease was restored in Brazil in the 1940s, the initial problems regarding diagnosis and symptomatic uncertainty were solved. The new chagologists were concerned with the clinical aspects of the disease. They had the tools to investigate them, and their research took a di√erent approach from that of the early parasitological program. The emergence of molecular parasitology also represented a discontinuity in the medical research tradition that had been growing since the 1940s. In fact, during the turbulent ninety-two years that have elapsed since Chagas’s discovery, di√erent research programs in Chagas’ disease have succeeded one another and also coexisted. Nevertheless, the fundamental items of the early chagologist agenda—the specificity of Brazilian public health issues, the scientific road to modernity, and the struggle against inequality— continued to be updated. It could hardly be di√erent: these issues are still part of the search for a national identity. How is Brazil supposed to modernize itself ? What is the state of its people’s health, and how should the

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country deal with problems that are so specific? How is Brazilian society supposed to overcome the social inequality that hinders development? Scientists and physicians were very active in this quest for identity, and Chagas’ disease was a mirror in which a region slowly defined itself. Di√erent types of people looked at themselves in this mirror: political activists, many of whom were medical students, discussed rural reform and revolution with rural workers in endemic areas in the 1960s. Under the military dictatorship established in 1964, these activists combined the need to transform the traditional agrarian structure with the eradication of Chagas’ disease.∏∏ The ‘‘Young Turks’’ of Brazilian biochemistry, returning from their training in the United States and Europe in the early 1970s, traded their fashionable E. coli and B. subtilis research for a more obscure and totally local research object: T. cruzi. They wanted, in the words of Walter Colli, to do ‘‘basic science with an applied critter.’’∏π The history of Chagas’ disease research resembles other histories of scientific and medical endeavors in Latin America. In the late 1920s, for example, the Peruvian physician Carlos Monge Medrano pioneered experimental research on high-altitude physiology. With this research he confronted previous assumptions about the physical inferiority of native populations. Marcos Cueto has demonstrated that scientific and patriotic ideas were intertwined and together animated the new research program. The new Andean biology Monge created thrived, received wide international recognition, and attracted the interest of foreign partners such as the U.S. Air Force and nasa. ∏∫ Monge’s and Chagas’s scientific defense of their people was an integral part of their work. Histories of both Chagas’ disease and Andean biology show sophisticated, internationally ‘‘networkable’’ research deeply rooted in a quest for national identity. Many foreign commentators have depicted successful initiatives in Latin American science, technology, and medicine as imitation or reception of European or North American science, employing some version of the di√usionist model, whose best articulated and most cited work is George Basalla’s ‘‘The Spread of Western Science.’’∏Ω The model claims that ‘‘nonscientific societies’’ are recipients of Western science that gradually grow autonomous through several stages of increasingly creative imitation. Diffusion takes for granted that someone ‘‘central’’ must have passively fertilized the ‘‘nonscientific’’ society’s science. Extended to the individual level,

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the result is ‘‘imitation,’’ ‘‘analogy,’’ and ‘‘reflection’’ of something that has taken place elsewhere. This approach allows no place for a tropical type of tropical medicine. Imperial tropical medicine becomes the only recognized model. In this light, Latin America traditionally appears as a ‘‘deviant’’ case. Our ‘‘mirror stories’’ do not fit well within this framework. But if Chagas’s and Monge’s work was mere ‘‘reception’’ in a chain of di√usion from the center, then what was not? Is the discovery of Chagas’ disease any less original than the discovery of leishmaniasis? Or malaria? If not, should we then classify Laveran’s, Leishman’s, and Donovan’s accomplishments together with Chagas’s and Monge’s as colonial scientific endeavors? The di√usionist model for science is hard to apply. The same goes for conventional interpretations of other aspects of social life. In fact, the Southern Cone Initiative did not imitate or follow from other work. The researchers involved were pioneering an international program according to their own specificities, not deviances. It is time to search for more productive frameworks for the study of science, technology, and medicine in nontraditional contexts. Studies such as Cueto’s and Peard’s, as well as this history of Chagas’ disease, suggest alternatives.π≠ Viewed in a new light, these Latin American mirror stories will find their proper place in history and we will see reflected a more inclusive image of modern societies.

Notes The Program of Small Grants for Research in Social and Economic Aspects of Tropical Diseases of the Laboratorio de Ciencias Sociales—Universidad Central de Venezuela supported this investigation with funds from the Special Program for Research and Training in Tropical Diseases (tdr), undp /World Bank/who. The author is indebted to the careful reading and suggestions provided by Diego Armus and two anonymous referees. 1 Robert S. Desowitz, for example, wrote: ‘‘When the Amerindians reached southern Mexico, they would have met what I consider to be the most terrible disease of the Western Hemisphere.’’ He stressed the resultant sudden death from heart attack, the large number of people exposed and infected with the parasite, and the absence of a chemotherapeutic cure. See Robert Desowitz, Who Gave Pinta to the Santa Maria (San Diego: Harvest Books, 1997), 42.

94 m a r i l i a c o u t i n h o 2 See World Health Organization, Division of Control of Tropical Diseases, ‘‘Chagas Disease Elimination’’ »http://www.who.int/health-topics/chagas .htm…, last accessed February 28, 2001. 3 Ibid. 4 See also Marilia Coutinho, ‘‘Ninety Years of Chagas Disease: A Success Story at the Periphery,’’ Social Studies of Science 29.4 (1999): 519–49. 5 John Farley, Bilharzia: A History of Imperial Tropical Medicine (Cambridge: Cambridge University Press, 1991), 13–156; Roy MacLeod, Introduction to MacLeod and Milton Lewis, Disease, Medicine and Empire (London: Routledge, 1988), 1–18; David Arnold, ‘‘Introduction: Disease, Medicine and Empire,’’ in D. Arnold, Imperial Medicine and Indigenous Societies (Manchester: Manchester University Press, 1988), 1–26; Michael Worboys, ‘‘The Emergence of Tropical Medicine: A Study in the Establishment of a Scientific Specialty,’’ in G. Lemaine et al., Perspectives in the Emergence of Scientific Disciplines (Paris: Mouton, 1976), 73–96; Worboys, ‘‘The Emergence and Early Development of Parasitology,’’ in Kenneth S. Warren and John Z. Bowers, Parasitology: A Global Perspective (New York: Springer-Verlag, 1983), 1–18; Worboys, ‘‘Tropical Diseases,’’ in William F. Bynum and Roy Porter, Companion Encyclopedia of the History of Medicine (New York: Routledge, 1993), 512– 36; Robert Desowitz, The Malaria Capers (New York: W. W. Norton, 1993). 6 Michael Worboys, ‘‘Tropical Diseases,’’ 514; Robert Desowitz, The Malaria Capers, 44. 7 The first institutions were the London and the Liverpool Schools of Tropical Medicine. The separation involved conflicts, as evidenced by the arguments between Manson, with his emerging London School, and the King’s College bacteriologists; see John Farley, Bilharzia, 25–28. 8 Victoria A. Harden, ‘‘Rocky Mountain Spotted Fever Research and the Development of the Insect Vector Theory, 1900–1930,’’ Bulletin of History of Medicine 59 (1985): 449–66, at 450–51; Michael Worboys, ‘‘Tropical Diseases,’’ 514. 9 See Julyan G. Peard, ‘‘Tropical Disorders and the Forging of a Brazilian Medical Identity, 1860–1890,’’ Hispanic American Historical Review 77 (1997): 1– 44; and Peard, ‘‘Tropical Medicine in Nineteenth-Century Brazil: The Case of the ‘Escola Tropicalista Bahiana,’ 1860–1890,’’ in David Arnold, Warm Climates and Western Medicine (Amsterdam: Rodopi, 1996), 108–32. 10 Simon Schwartzman, A Space for Science (University Park: Pennsylvania State University Press, 1991), 83–91. 11 Jaime L. Benchimol and Luis A. Teixeira, Cobras, Lagartos e Outros Bichos: Uma História Comparada dos Institutos Oswaldo Cruz e Butantan (Rio de Janeiro: Editora ufrj, 1993); Simon Schwartzman, A Space for Science, 83– 91.

t r o p i c a l m e d i c i n e i n b ra z i l 95 12 See Jaime Benchimol et al., Manguinhos: Do Sonho à Vida—A Ciência na Belle Époque (Rio de Janeiro: Casa de Oswaldo Cruz, 1990), 45–46; Jaime Benchimol and Luis A. Teixeira, Cobras; Nancy Stepan, Beginnings of Brazilian Science: Oswaldo Cruz, Medical Research and Policy 1890–1920 (New York: Science History Publications, 1976), 118–20. 13 Carlos Chagas, Prophylaxia do Impaludismo (Rio de Janeiro: Instituto de Manguinhos, 1905); Chagas, ‘‘Prophylaxia do Impaludismo,’’ Brasil Médico 20 (1906): 315–17, 337–40, 419–22; 21 (1907): 151–54. 14 Carlos Chagas, Novas Espécies de Culicideos Brazileiros (Rio de Janeiro: Instituto de Manguinhos, 1907); Chagas, ‘‘O Novo Genero Myzorhynchella de Theobald. Duas Novas Anophelinas Brazileiras Pertencentes a este Genero,’’ Brasil Medico 21 (1907): 291–93, 303–5; Chagas, ‘‘Uma Especie do Genero Taeniorhynchus, ’’ Brasil Médico 21 (1907): 313–14; Chagas, ‘‘Beitrag zur Malariaprophylaxis,’’ Zeitschrift für Hygiene und Infektionskrankheiten 60 (1908): 321–34; Olympio da Fonseca Filho, A Escola de Manguinhos: Contribuição para o Estudo do Desenvolvimento da Medicina Experimental no Brasil (São Paulo: egrt, 1974), 19. 15 See Chagas’s first report about Lassance, reproduced as ‘‘Adenda: Lassance, 1907, Carlos Chagas,’’ in Joaquim Romeu Cançado and Moisés Chuster, eds., Cardiopatia Chagásica (Belo Horizonte, Brazil: Fundação Carlos Chagas, 1985), 391–413. 16 Chagas believed in the connection between goiter, endemic in the region, and Chagas’ disease. The nervous form of the disease took a long time to be understood. See, for example, Olympio da Fonseca Filho, A Escola de Manguinhos, 43–66. 17 Descriptions of the discovery have been published since the early days by observers ranging from Chagas himself to his modern heirs. See, for example, Carlos Chagas, ‘‘Descoberta do Trypanosoma cruzi e Verificação da Tripanozomiase Americana: Retrospecto Histórico,’’ Memórias do Instituto Oswaldo Cruz 15 (1922): 67–76; Emanuel Dias, Doença de Chagas: Noções (Rio de Janeiro: Ministério da Educação e Saúde, Serviço Nacional de Educação Sanitária, 1944); Milton Carneiro, História da Doença de Chagas (Curitiba, 1963); Carlos Chagas Filho, ‘‘Histórico sobre a Doença de Chagas,’’ in Cançado, ed., Doença de Chagas (Belo Horizonte, Brazil: Imprensa Oficial, 1974), 5–21; and Chagas Filho, Meu Pai (Rio de Janeiro: Casa de Oswaldo Cruz/fiocruz, 1993); Olympio da Fonseca Filho, A Escola de Manguinhos, 43–66. Other accounts include B. H. Kean, ‘‘Carlos Chagas and Chagas Disease,’’ American Journal of Tropical Medicine and Hygiene 26 (1977): 1084–87; Rachel Lewinsohn, ‘‘Carlos Chagas (1879–1934): The Discovery of Trypanosoma cruzi and of American Trypanosomiasis,’’ Transactions of the Royal Society of Tropical Medicine and Hygiene 74 (1979): 513–23; Rachel

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18

19

20 21

22 23

24

Lewinsohn, ‘‘Carlos Chagas and the Discovery of Chagas’ Disease (American Trypanosomiasis),’’ Journal of the Royal Society of Medicine 74 (1981): 451–55. For historical and sociological analyses of the discovery, see Nancy Stepan, Beginnings of Brazilian Science, 118–20; François Delaporte, ‘‘Chagas, a Lógica e a Descoberta,’’ História, Ciências, Saúde—Manguinhos 1 (1994–95): 39–53; Mathias Perleth, Historical Aspects of American Trypanosomiasis (Chagas Disease) (Frankfurt am Main: Peter Lang, 1997); Marilia Coutinho, ‘‘Ninety Years of Chagas Disease: A Success Story at the Periphery’’; Marilia Coutinho and João C. P. Dias, ‘‘The Rise and Fall of Chagas Disease,’’ Perspectives on Science 7.4 (1999): 447–85. The first article mentioning what became later Trypanosoma cruzi was ‘‘Neue Trypanosomen,’’ in Archiv für Schi√s- und Tropenhygiene 13 (1909): 120; more detailed articles followed. See Carlos Chagas, ‘‘Nova Especie Morbida do Homem, Produzida por um Trypanozoma (Trypanozoma cruzi),’’ Brasil Médico 16 (1909); Chagas, ‘‘Nova Tripanozomiase Humana: Estudos sobre a Morfologia e o Ciclo Evolutivo do Schizotrypanum cruzi, n. gen., n. s. Ajente Etiolojico de Nova Entidade Morbida do Homem,’’ Memórias do Instituto Oswaldo Cruz 1 (1909): 1–62 (published in Portuguese and German); Chagas, ‘‘Nova Entidade Morbida do Homem,’’ Brasil Médico (1910): 43. Chagas created the first concept of the disease; in this sense, he ‘‘invented’’ it. The term invention was also used by Chagas himself to describe his discovery. See Carlos Chagas, ‘‘Lição de Abertura dos Cursos da Faculdade de Medicina do Rio de Janeiro—1928,’’ in A. Prata, ed., Carlos Chagas: Coletânea de Trabalhos Científicos (Brasilia: Editora Universidade de Brasília, 1981), 861–83. See discussion about the atypical nature of Chagas’s discovery in Marilia Coutinho and João C. P. Dias, ‘‘The Rise and Fall.’’ Carlos Chagas Filho, Meu Pai, 90–91; Milton Carneiro, História da Doença de Chagas, 24. See Marilia Coutinho, ‘‘O Nobel Perdido,’’ Folha de São Paulo, caderno 5, February 7, 1999, 11; Marilia Coutinho, Olival Freire Jr., and João C. P. Dias, ‘‘The Nobel Enigma: Carlos Chagas’ Nominations for the Nobel Prize,’’ Memórias do Instituto Oswaldo Cruz 94, suppl. 1 (1999): 123–29. On his travels abroad in the 1920s, see Carlos Chagas Filho, Meu Pai, 122–27. Carlos Chagas, ‘‘Moléstia de Carlos Chagas. Conference delivered in 08-7-11, at the National Academy of Medicine,’’ Brasil Médico 25 (1911): 340–43, 353–55, 316–64, 373–75. On the eradication of tropical diseases, see Carlos Chagas, ‘‘Aula Inaugural da Cadeira de Medicina Tropical, 14 de Setembro de 1926,’’ in Aluizio Prata, ed., Carlos Chagas: Coletânea de Trabalhos Científicos (Brasilia: Editora Universidade de Brasília, 1981), 831–60. About the need for high-quality experimental tropical medicine, see ‘‘Aula,’’ 164; and ‘‘Lição de Abertura.’’

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25 26

27 28

29

30 31

32

33

34

35

About Chagas’s positions in the public health debate of the 1920s, see Carlos Chagas Filho, Meu Pai. Carlos Chagas Filho, Meu Pai, 105. Aluizio Prata, ‘‘Evolution of the Clinical and Epidemiological Knowledge about Chagas Disease 90 Years after Its Discovery,’’ Memórias do Instituto Oswaldo Cruz 94, suppl. 1 (1999): 81–88; Carlos Chagas, ‘‘Moléstia de Carlos Chagas. Conference delivered in 08-7-11, at the National Academy of Medicine.’’ Afrânio Peixoto 1922, in Olympio da Fonseca Filho, A Escola, 65. See also Carlos Chagas Filho, Meu Pai, 225. See the account given by Milton Carneiro in História, 64–75, about the debate he attended as member of the academy and a supporter of Chagas’s opponents. See also Olympio da Fonseca Filho, A Escola, 64–66. Fraga’s letters containing Olympio da Fonseca’s and Magarino Torre’s findings and opinions, read at the academy, are reproduced in Carlos Chagas Filho, Meu Pai, 205–15. See Eurico Villela, ‘‘A Ocurrencia da Molestia de Chagas nos Hospitaes de Bello Horizonte e na População de seus Arredores,’’ Annaes da Faculdade de Medicina da Universidade de Minas Geraes 1 (1930): 1–18. The ‘‘resistance core’’ is an idea developed by Carlos Chagas Filho in ‘‘Histórico sobre a Doença de Chagas.’’ João Carlos Pinto Dias, ‘‘Atualidade de Carlos Chagas: Os 90 Anos do Descobrimento e a Importância Social da Doença de Chagas,’’ Biblioteca Virtual Carlos Chagas »http://www.prossiga.br/chagas… (1998), last accessed February 28, 2001; Christopher J. Schofield, ‘‘The Biosystematics of Triatominae,’’ in M. W. Service, Biosystematics of Haematophagous Insects, Systematics Association special issue, vol. 37 (Oxford: Clarendon Press, 1988), 284–312. H. C. Souza Araujo, ‘‘Doença de Chagas,’’ in H. C. Souza Araujo, A Prophylaxia Rural no Estado do Paraná: Esboço de Geografia Médica (Curitiba, 1919), 305–9. For an analysis of the deconstruction of Chagas’ disease, see Marilia Coutinho, ‘‘Ninety Years’’; and Marilia Coutinho and João C. P. Dias, ‘‘The Rise and Fall.’’ See J. P. Sierra-Iglesias, Salvador Mazza, su Vida y su Obra: Redescubridor de la Enfermedad de Chagas (San Salvador de Jujuy, Argentina: Universidad Nacional de Jujuy, 1990); Andres Ivern, La Vida y obra de Salvador Mazza: Historia de una Epopeya Científica (Rosario, Argentina: Servicio de Publicaciones de la Universidad Nacional de Rosario, 1987). Salvador Mazza, ‘‘La Enfermedad de Chagas en la República Argentina,’’ Memórias do Instituto Oswaldo Cruz 47 (1949): 273–88.

98 m a r i l i a c o u t i n h o 36 Cecilio Romaña, ‘‘Acerca de um Síntoma Inicial de Valor para el Diagnóstico de la Forma Aguda de la Enfermedad de Chagas. La Conjuntivitis Esquizotripanósica Unilateral (Hipótesis sobre Puerta de Entrada Conjuntival de la Enfermedad),’’ MEPRA 22 (1935): 16–28. 37 Carlos Chagas Filho, ‘‘Histórico.’’ 38 For quantitative information on the growth of the chagologist community, new authors of Chagas’ disease publications, and number of publications, see Marilia Coutinho, ‘‘Ninety Years.’’ 39 Emmanuel Dias, Um Ensaio de Profilaxia na Moléstia de Chagas (Rio de Janeiro: Imprensa Oficial, 1944). E. Dias tried everything against the triatomines, from throwing boiling water and using caustic soda to using military flame throwers on infested walls. See João Carlos Pinto Dias and Schofield, ‘‘The Evolution of Chagas Disease (American Trypanosomiasis) Control after 90 Years since Chagas’s Discovery,’’ Memórias do Instituto Oswaldo Cruz 94, suppl. 1 (1999): 103–22. 40 Michael Worboys, ‘‘The Emergence and Early Development’’; Robert Desowitz, The Malaria Capers, 63. 41 Raimundo S. Brito, ‘‘As Realizações do DNERu,’’ in Joaquim R. Cançado, ed., Doença de Chagas (Belo Horizonte, Brazil: Imprensa Oficial, 1968), 560–74. 42 Raimundo S. Brito, ‘‘As Realizações do DNERu,’’ 560–74; who, »http: //www.who.int/health-topics/chagas.htm.… 43 João C. P. Dias, ‘‘Entrevista com João Carlos Pinto Dias,’’ in The Oral History Program of the Núcleo de Pesquisas sobre Ensino Superior, Universidade de São Paulo (Belo Horizonte, M.G., Brazil, April 1995). 44 Francisco S. Laranja, Emmanuel Dias, Genard C. Nóbrega, and Aloisio Miranda, ‘‘Chagas’ Disease: A Clinical, Epidemiologic and Pathologic Study,’’ Circulation 14 (1956): 1035–60. 45 Simon Schwartzman, A Space for Science; Marilia Coutinho, ‘‘Ninety Years.’’ 46 See Jofre Rezende, ‘‘Entrevista com Jofre Rezende,’’ in The Oral History Program of the Núcleo de Pesquisas sobre Ensino Superior, Universidade de São Paulo (Uberaba, M.G., Brazil, October 1994). 47 See Marilia Coutinho, ‘‘Ninety Years.’’ 48 Carlos Chagas Filho, ‘‘Histórico.’’ 49 See Erney P. Camargo, ‘‘Entrevista com Erney P. Camargo,’’ in The Oral History Program of the Núcleo de Pesquisas sobre Ensino Superior, Universidade de São Paulo (São Paulo, S.P., Brazil, March 1995); and J. C. P. Dias, ‘‘Entrevista com João Carlos Pinto Dias.’’ 50 Simon Schwartzman et al., ‘‘Science and Technology in Brazil: A New Policy for a Global World,’’ in Simon Schwartzman et al., Science and Technology in

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51

52 53 54

55 56

57 58

59

60

61 62 63 64 65 66 67

Brazil: A New Policy for a Global World (Rio de Janeiro: Fundação Getúlio Vargas, 1995), 1–56. Walter Colli, ‘‘Entrevista com Walter Colli,’’ in The Oral History Program of the Núcleo de Pesquisas sobre Ensino Superior, Universidade de São Paulo (São Paulo, S.P., Brazil, March 1995). Robert Desowitz, The Malaria Capers. Workshop sobre Trypanosoma cruzi: Nutrição, Crescimento e Variações de Cepas, June 20–21, 1974, Rio de Janeiro, R.J., Brazil. See Marilia Coutinho, ‘‘The Brazilian Molecular Parasitology Experience: A Case Study in the Achievement of Disciplinary Legitimacy,’’ Documentos de Trabalho–NUPES–USP 7 (1996). Erney P. Camargo, ‘‘Parasitologia,’’ in Avaliação & Perspectiva: Ciências Biológicas 1982 (Brasilia: seplan / cnpq, 1983), 315–34. See Erney P. Camargo, ‘‘Entrevista com Sérgio Schenkman,’’ in The Oral History Program of the Núcleo de Pesquisas sobre Ensino Superior, Universidade de São Paulo (São Paulo, S.P., Brazil, March 1995). Erney P. Camargo, ‘‘Parasitologia.’’ Twelfth Programme Report of the UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR) (Geneva: World Health Organization, 1995); undp /World Bank/who, Special Programme for Research and Training in Tropical Diseases (TDR): Country Profile for Brazil (Geneva: World Health Organization, 1995). Carlos M. Morel, ‘‘Chagas Disease, from Discovery to Control—and Beyond: History, Myths and Lessons to Take Home,’’ Memórias do Instituto Oswaldo Cruz 94, supp. 1 (1999): 3–16. João Carlos Pinto Dias is Emmanuel Dias’s son. Christopher J. Schofield and João C. P. Dias, ‘‘The Southern Cone Programme against Chagas Disease,’’ Advances in Parasitology 42 (1999): 1–25; João C. P. Dias and Christopher Schofield, ‘‘The Evolution of Chagas Disease (American Trypanosomiasis) Control after 90 Years since Carlos Chagas’ Discovery’’; who »http://www.who.int/health-topics/chagas.htm…, last accessed February 28, 2001. Marilia Coutinho and João C. P. Dias, ‘‘A Reason to Celebrate: The Saga of Brazilian Chagologists,’’ Ciência e Cultura 51.5/6 (1999): 394–410. Carlos Chagas, ‘‘Aula Inaugural.’’ Ibid.; and Carlos Chagas, ‘‘Lição de Abertura.’’ Carlos Chagas, ‘‘Lição de Abertura.’’ Marilia Coutinho, ‘‘The Rise and Fall.’’ João C. P. Dias, ‘‘Entrevista.’’ Walter Colli, ‘‘Entrevista.’’

100 m a r i l i a c o u t i n h o 68 Marcos Cueto, ‘‘Andean Biology in Peru. Scientific Styles on the Periphery,’’ Isis 80 (1989): 640–58. 69 See, for example, Ilana Lowy, ‘‘Yellow Fever in Rio de Janeiro and the Pasteur Institute Mission (1901–1905): The Transfer of Science to the Periphery,’’ Medical History 34 (1990): 144–63. George Basalla, ‘‘The Spread of Western Science,’’ Science 156 (1967): 611–22. 70 Marcos Cueto, ‘‘Andean Biology,’’ Julyan G. Peard, ‘‘Tropical Disorders and the Forging of a Brazilian Medical Identity.’’

diego armus

Tango, Gender, and Tuberculosis in Buenos Aires, 1900–1940

he history of tuberculosis in Buenos Aires is inseparable from social problems ranging from rapid urban and demographic growth to the gradual broadening of the meaning of social citizenship, from the intrusion of the state in individual lives to the moral development of the masses, from the e√orts to create a ‘‘national race’’ to sexuality and daily habits. The ubiquity of tuberculosis was both an undercurrent in society and impossible to ignore. A kind of subculture emerged in which metaphors and associations related to the disease not only influenced one another but also a√ected the experiences of the sick themselves and those who feared becoming sick. Between 1870 and 1950 tuberculosis was a significant cause of death, a recurrent topic of discussion, and a fact of daily life. Its history, therefore, involves not only the reality of the bacillus but also the discourses and ideas that sought to make sense of the disease. During much of the nineteenth century tuberculosis was shrouded in mystery, and little or nothing was known of its causes and victims. In medical and scientific circles it seemed to be the disease of a thousand causes, all of them floating in a sea of weak medical theories. Beginning in the 1860s with Villemin’s research into the contagiousness of the disease, and especially with the rapid emergence of modern bacteriology and the discovery of the Koch bacillus two decades later, part of that aura of mystery began to dissipate. Nevertheless, the need not merely to explain contagion and susceptibility to contagion, but also to find an e√ective cure greatly spurred e√orts to find explanations for the disease. These ranged from interpretations based on notions of heredity to others stressing its psychosomatic or social dimensions. Thus it should come as no surprise that tuberculosis has also been a breeder of new and old associations and metaphors. Nineteenth-century writers depicted tuberculosis as a romantic disease mainly a√ecting individuals with rarified sensibility, spiritual refinement, or some tragic character

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flaw. With the beginning of the twentieth century, this depiction was joined by others that increasingly emphasized the importance of tuberculosis as a social disease. These changes, reflecting the di√erent ways in which society and culture confronted the ‘‘white plague,’’ seem to have been characteristic of the cycle of tuberculosis in Western modernity.∞ In any case, tuberculosis as metaphor appeared in innumerable guises, some ephemeral and others more enduring, all contributing in various degrees to the ‘‘tuberculosis subculture.’’ But although tuberculosis subcultures emerged in many urbanizing societies, each cultural and social environment produced its own unique type, often saturated with very local and specific perceptions and associations. Such was the case in Buenos Aires between 1870 and 1950. Literary works, mass circulation magazines and newspapers, medical and health publications, tango lyrics, movies, poetry, and sociological essays all referred to tuberculosis, considering it an element of reality as well as using the illness metaphorically or ideologically to speak of other topics and concerns. In the novel Peregrinaciones de una Alma Triste (Pilgrimages of a sad soul), which appeared in 1876, Juana Manuela Gorriti uses the character of Laura, a young tubercular, to challenge the medical lore and patriarchal power that deny her existence as an independent subject.≤ Alexandre Dumas Jr.’s Camille (La Dame aux Camélias) was an essential part of the repertory of European theater companies performing in Buenos Aires during the second half of the nineteenth century, as it would continue to be in Argentine theater troupes such as those of Blanca Podestá, Elsa O’Connor, and Camila Quiroga in the 1920s, 1930s, and 1940s. In 1918 Mundo Argentino, a large-circulation daily, published a short story in which the ‘‘melancholic blessedness’’ of a hospitalized tuberculosis victim emphasized the romantic charge associated with the disease. Only a few months later, the same paper presented its readers with a series of articles that explained tuberculosis as a social sickness.≥ In Horacio Quiroga’s short story ‘‘La Gallina Degollada’’ (The beheaded hen), written in 1925, the disease articulates the phantoms of heredity when a father tries to explain the meningitis and idiocy of his children by reminding his wife that she is tubercular.∂ At the beginning of the twentieth century, the anarchist newspaper L’Avvenire invoked the microbe ‘‘of anarchic tuberculosis,’’ which would end the reign of injustice and open the way for the libertarian dawn.∑ Also in those years, and this time using the disease in an overtly ideological way, the essayist Carlos Octavio

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Bunge applauded the fact (as he saw it) that tuberculosis had decimated Argentina’s indigenous people and population of African descent and thus facilitated social purification and Europeanization.∏ And toward the end of the 1930s, the magazine Viva 100 Años enthusiastically promoted a program of positive health, exercise, fresh air, and optimism, warning those who did not adopt such a lifestyle that they would be future victims of tuberculosis.π This sample from a long list of poems, playwrights, social essays, and journalistic notes illustrates how flexible and serviceable the illness could be. Its continuous and salient presence during much of the nineteenth and twentieth centuries, its weight in the general mortality, the mysteries that surrounded it, and the impotence of medical knowledge against it combined and led to the disease being used in diverse situations both public and private. Tuberculosis as a topic and a metaphor permeated print culture at every level and gave rise to innumerable associations. One of them, particularly prominent in the first decades of the twentieth century, was what was known in popular speech in Buenos Aires as la costurerita que dió aquel mal paso (the little seamstress who stumbled), an expression coined in a poem by Evaristo Carriego around 1910. This evocative figure appeared in tango lyrics and movies, especially in the 1920s and 1930s, and became crystallized in the city’s collective memory.∫ The image refers to the highly melodramatic story of a young working girl who gives up her simple life and work in her home neighborhood to try her luck in the maelstrom of the city center, whose pleasures, temptations, and risks ultimately condemn her to prostitution, poverty, and disease. This melodramatic trajectory is not only a chapter in the history of social mobility and gender relations in modern Buenos Aires, but also a chapter in the history of tuberculosis.

Buenos Aires: Between the Neighborhoods and the Center The population of Buenos Aires grew spectacularly in the early twentieth century: from 649,000 inhabitants in 1895 to 2,254,000 residents in 1930. This demographic growth was caused mainly by immigration from overseas, which changed the social fabric in ways and at a speed never before seen. The immigrants not only increased the numbers of the traditional lower classes but also created the first massive encounter of foreigners with the native born, or criollos. From this new population arose sectors of

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workers who would enliven a very dynamic labor movement led by anarchists, socialists, and anarcho-syndicalists. Nevertheless, and despite the fact that at times they might participate actively or support enthusiastically the collective e√orts promoted by these workers’ organizations, the majority of the laborers were counting on moving up socially through the more individual path of savings and work. It was in this context of change and readjustment that the city’s middle classes emerged, in general by taking advantage of the possibilities of small businesses, posts in the governmental bureaucracy, or the liberal professions. At the same time, the city began to expand into the pampa, as auctioneers sold lots to be purchased in installments, profiting from the desire of many to become homeowners. And so began the family neighborhoods, barrios of honest working people hoping to participate in some fashion in the opportunities o√ered by a relatively open society. Upward social mobility, limited but real, seemed to be available to everyone. Thousands of families perceived it as a journey that, starting out in downtown tenements, or conventillos, would successfully end with a home in a barrio. In a relatively short time, Buenos Aires society became more diverse and complex. Two cultures began to take shape in di√erent parts of the city. In the center reigned the culture of the traditional elites; in the outlying barrios a new culture was in the making, one where immigrants and their children mixed with criollos. Barrio culture developed in the tension between integration and di√erentiation. It challenged the culture of the center but at the same time extended bridges to it. ‘‘A thousand subtle threads’’ connected the two, and by around 1930 these had consolidated into a common and shared fabric.Ω The world of the barrio developed culturally, materially, and socially over time, mingling the new and heterogeneous popular sectors with the emerging middle classes of modern Buenos Aires. Without a doubt it was one of the key public spaces for social integration and Argentinization, two crucial experiences that permitted individuals and families to imagine their future as they were bu√eted by the vicissitudes that accompanied the social climb. Aside from particular traits related to their status as immigrants, criollos, artisans, laborers, small shopkeepers, or government employees, the people of the barrio identified with the values of family, work, savings, hygiene, and education. Formal education o√ered by the public schools was of the greatest importance in this adventure, as was the more informal education o√ered by

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public libraries, lecture series, movies, the new print media—mass circulation dailies, neighborhood papers, weekly magazines—and, a little later, radio. An increasingly sophisticated local public life also played a part, energized by neighborhood associations, political party o≈ces, comités, and barrio clubs. Free-time activities outside the home o√ered new opportunities to get acquainted as well. Some of these, such as soccer and the cafés, were dominated by men; others were more suitable for families, such as the movies, religious life in the parish, or certain dancing parties. It was in this rapidly changing context that the barrio moved toward the city’s center. From the 1920s on, when many barrios had already consolidated and in some respects modernized themselves, tango lyrics, cinema, and literature would reformulate the pioneering and sentimental gaze of Evaristo Carriego and his costurerita, the little seamstress who stumbled. Writers and artists who lived in the barrios would find there the physical, social, and cultural space suitable for developing a rich repertoire of intimate and nostalgic evocations. Those who wrote for the new newspapers such as Crítica or El Mundo would work the theme of the barrio from the center. All contributed to a cultural dynamic of the barrio that included the consuming public—that is, the ordinary people who danced and listened to tangos; read the papers, magazines, and cheap-edition books; went to the movies; and met in the new or renovated spaces for socializing, from the neighborhood club to the local bar.∞≠ Meanwhile, the physical expansion of the transportation network facilitated innumerable encounters and exchanges between the two worlds—the barrios and the center. Buenos Aires not only had grown, but its parts were also better connected. These phenomena of integration generated tension while gaining a noticeable space in the life of the city. Some people from the barrios began to frequent the cafés and cabarets of the center, politicians trolled neighborhoods to build their electoral machines and seek votes, and daily events of the barrios appeared in the newspapers written and produced at the center but read throughout the city. It was in this world of cultural exchanges that the history of the moral and physical decline of the ‘‘little seamstresses’’ from the barrio in the maelstrom of the center took form.∞∞ The costurerita—the character in Carriego’s poems of the first decade of the century—became the milonguita (the cabaret girl) in the tango lyrics, movies, and naturalist and realist literature of the 1920s and 1930s. Both figures illustrate the process of social and territorial integration of the barrio

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and the center. With their travels, real or imaginary, to the center, the costurerita and the milonguita played a part in a chapter of the history of social mobility, gender relations, and tuberculosis in modern Buenos Aires.

Consumptives and Costureritas Evaristo Carriego created the literary barrio; he was, says Jorge Luis Borges, ‘‘the first spectator of the city’s outskirts (the arrabales), their discoverer, their inventor.’’∞≤ In his poems the barrio becomes the emotional geography of the poor. It is also a refuge, a friendly space strongly imbued with the hospitality of home, maternal warmth, a peaceful and safe childhood. In Carriego’s barrios stroll the organ grinder, the tenement child, the godmother, the local lingering in the bar, the drunken husband, the frustrated bride, the blind man, the dying old lady. Among these family and neighborhood types also appear the consumptive and the costurerita, the women Carriego used to develop his story of tuberculosis in the barrio. But the consumptive and the costurerita are not the same. The consumptive lives and dies in the barrio and is a product of a process of deterioration. The costurerita, in contrast, follows the path that goes from the barrio to the center and has a sad end. The figure of the consumptive refers to tuberculosis as a disease of overwork and as a local woe. The costurerita is the protagonist of a journey, an existential adventure that depicts tuberculosis as an illness of worldly passions and degradation, of guilt and moral condemnation. The consumptives of the barrio try to arouse sympathy and ask for compassion. In Carriego’s ‘‘Residuo de Fábrica’’ (Factory leftovers), tuberculosis starts in the workplace routines: The workshop sickened her, and thus, defeated in the flower of youth, perhaps she doesn’t know of a lovely hope that caresses her long su√erings as an incurable.

From the workshop the consumptive moves to her home, where she upsets the family’s daily life and ends up being rejected: She has coughed again. Her little brother who sometimes stays in the room to play, not speaking to her, suddenly

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grows serious as though thinking . . . Then he gets up, and abruptly goes out, murmuring as he leaves, with a little pity and a lot of disgust: —there she goes again, that pig, spitting blood.∞≥

In ‘‘El Alma del Suburbio’’ (Soul of the suburb), Carriego re-creates the traditional romantic cliché of the disease that permeates many nineteenthcentury European novels, with their intense and extremely sensitive women: ‘‘the consumptive across the street’’ mulls over her unrequited love while carrying a ‘‘sweet melancholy of that forgotten but beloved verse, that a gallant troubadour sang to her one day.’’ In ‘‘Las Manos’’ (Hands) the poet speaks of ‘‘the romantic hands of the consumptives who, / in the moribund voice of an arpeggio, like an anxious, agonizing spell, / called on Chopin, dying.’’ The romantic register appears even more clearly in ‘‘La Viejecita’’ (The little old lady), in which Carriego manages to place his tubercular women in the austere and plebeian setting of the city’s barrios: ‘‘such heroines, poor and obscure, in those dramas! / such Ophelias! The barrios have their pure, consumptive Ladies of the Camellias.’’ Consumptives, therefore, are citizens of the world of labor, of sadness and humility, of misadventures always anchored in the world of the barrio. Notably, they have nothing to do with bohemian life. And they are not necessarily or terribly poor; in fact, the hands of one of these consumptives playing Chopin show that at least some of them already possess that icon of middleclass respectability, a piano. Around the figure of the costurerita daily work intersects with the ups and downs of social mobility, the journey to the center and its nightlife. In ‘‘La Costurerita que Dió Aquel Mal Paso’’ (The little seamstress who stumbled) Carriego gives local color to a trajectory that is firmly established in Western literature. It is the story of the journey of a young barrio girl, naïve, of humble but honest origins, who after a brief stay in the world of the night ends up in the bitter territories of prostitution and disease. In this poem the narrator wonders why the downtown lights tempt the ‘‘little red riding hood,’’ when in reality her barrio supposedly o√ers her everything. The journey to the center is, then, a leap into the void, an unnecessary pilgrimage. However, the barrio and the home are loyal and welcome the return of those who abandoned them without cause. The ‘‘stumble’’ is not irreversible. The barrio o√ers the compassion of the good Samaritan, who,

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instead of punishing, gives understanding and succor to those who return from the territories of perdition: Come in without fear, sister we won’t reproach you, the little ones still miss you, and the others will see in you the lost sister who returns; you can stay.

‘‘La Queja’’ (The complaint) also describes this path, focusing on its ending stages. In this poem Carriego refers to a ‘‘mistreated woman, . . . a long-su√ering beast, poor broken down beast,’’ for whom tuberculosis is at the same time impotence and vengeance: impotence when the tubercular prostitute ‘‘screams her useless complaint, . . . inconsolable, . . . illfated, . . . harmless’’; vengeance when with ‘‘her wrath aroused’’ and ‘‘mad with rage, furious, with all her contempt,’’ she spits ‘‘her sick blood’’ at the ‘‘scum’’ who exploits her. Some of the vicissitudes of the ‘‘stumble’’ also appear in Andrés Cepeda’s poetry. Unlike Carriego, Cepeda did not survive the implacable selection process of the history of literature. A poet of the people and the arrabales, Cepeda was arrested several times for robbery and achieved a certain notoriety when some of his verses and songs were put to music and sung by Carlos Gardel.∞∂ He was murdered in 1910. At least two of his poems are forerunners of many of the themes and associations that run through Carriego’s works and the tango lyrics of the 1920s and 1930s. In ‘‘Marta, la Tísica’’ (Marta the consumptive) the narrator meets a woman who left him some time ago for one of his friends, who later abandoned her for ‘‘someone younger.’’ Marta falls ill, begs in the streets, and before dying receives the understanding of the man who at one time loved her ‘‘with all his soul.’’ In this series of abandonments, the man su√ers, but he does not fall ill. The abandoned woman, in contrast, ends up consumptive and dies. In ‘‘La Tísica’’ (The consumptive) the narrator is ‘‘betrayed’’ by a ‘‘false friend’’ and ‘‘the ingrate that he loved as one can only love when one is twenty.’’ In time she ‘‘loses her sight on the precipice’’ and ‘‘sinks into vice.’’ ‘‘Abandoned in the storm,’’ alone, ‘‘she curses her seducer,’’ ‘‘falls prisoner to consumption,’’ and now is ‘‘on her death bed in a hospital.’’ At that point the person she had abandoned reappears as an understanding, caring man capable not only of forgiving and forgetting but also of accompanying ‘‘nobly’’ in death the

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woman who abandoned him earlier.∞∑ In Cepeda’s poetry, tuberculosis is a disease of the passions, with fallen women ending up tubercular and abandoned men capable of forgiving. But where Cepeda’s consumptives are women who travel on the geographical and social borders, Carriego’s are women of the modest homes of the barrio. They are distinguished not by the narrow confines, promiscuity, and overcrowding of the tenements, but rather by their working lives. This association of excessive work and tuberculosis is not original to Carriego. It had been developing since the end of the nineteenth century and continued well into the 1950s. The disease was understood to be the result of unwanted excesses. For this reason, overwork was not comparable to other unrestrained behavior concerning sex, drink, or indulgence, where individual guilt and responsibility could be o√ered as explanations for contagion. On the contrary, Physicians, hygienists, essayists, union leaders, and journalists tended to look at tuberculosis as a disease not of dissipation but of overwork and fatigue; it was viewed as a malady resulting from the working environment, the type of activity advancing what in the future would be labeled occupational disease or capitalist exploitation. Whatever the emphasis, tuberculosis came up again and again, directly or indirectly, whenever there were discussions about improving work conditions: shortening the workday, night work, piecework, home work, fatigue, industrial hygiene, rest, and the pace of production.∞∏ Toward the end of the nineteenth century José Ingenieros made the critique of overwork and fatigue the basis of a regenerating program, of possible improvements that sought to make way for that new ‘‘right of social interests that take priority over individual interests.’’∞π In 1910, in a report commissioned by the national government, Augusto Bunge took up those arguments and referred to ‘‘infections from overburdening’’ resulting from ‘‘the intensity of labor and the overlong work days’’ and ‘‘deprivation of fresh air, overcrowding, dust, lack of ventilation, and light.’’ Besides the physical overburdening he mentioned a ‘‘nervous overburdening,’’ the socalled worker’s neurasthenia resulting from the ‘‘increasing intensity of labor.’’∞∫ In this context fatigue appeared as a ‘‘factor’’ that predisposed one to contract a series of illnesses associated with generalized anemic states whose diagnosis frequently superimposed or mixed neurasthenia with tuberculosis, chlorosis, hysteria, and other diseases. Carriego was part of this climate of ideas, which, in a way, marks the

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presence of tuberculosis among working women. In the 1920s some tangos such as ‘‘Obrerita’’ (Little worker; Eugenio Cárdenas, 1926) and ‘‘Fosforerita’’ (Amaro Giura, 1925) would emphasize the theme. In ‘‘Camino al Taller’’ (On the way to the workshop; Cátulo Castillo, 1925), work and disease announce the inevitable death of the ‘‘poor little seamstress.’’ ‘‘Muñeca de Percal’’ (Doll of percale; Nilo Russo, 1928) o√ers the story of a woman whose dreams are destroyed by the ‘‘infernal noise of the machinery,’’ her health debilitated by a ‘‘noncurable tuberculosis,’’ with the same fatal end.∞Ω Other writers also included working women as characters of their narratives. Josué Quesada and Julio Fingerit wrote short stories about the many ‘‘little seamstresses’’ who surfaced in Buenos Aires in the 1920s, their labor, and their journey to the center. Alfonsina Storni published journalistic pieces in the newspaper La Nación on the home work of the seamstress. And in one of his most successful aquafortes, also published in the daily press, Roberto Arlt explores the routines, fatigue, and need of the female laborer inside and outside the home.≤≠ It is quite clear, then, that by the beginning of the twentieth century women were part of the labor world. In fact, almost three-fourths of the females who worked outside the home worked in domestic service as seamstresses, tailors, pressers, hat makers, or laundrywomen in homes. These were followed, in far smaller numbers and with di√erences according to the trade, by women employed in big manufacturing plants devoted to the textile and clothing industries, foodstu√s, tobacco, and matches. Fewer in number were the schoolteachers, sales clerks, nurses, and those in other service sector occupations. In last place came those employed in the socalled modern jobs such as telephone operators or o≈ce employees.≤∞ According to a 1901 report of the national labor department, women’s domestic work was ‘‘a convenient auxiliary’’ used to augment household budgets based on the ‘‘family man’s income.’’ There were also ‘‘women heads of households,’’ who carried the whole weight of expenses. But the available evidence indicates that women worked in occupations that they could enter or leave easily and that o√ered a flexible work schedule and thus enabled them to accommodate or superimpose these jobs on their household chores. Tuberculosis was no stranger to workers in domestic service— those working on their own or those working for others and without the regulated schedules of a factory. Besides the predisposing factors that were the same for anyone—living conditions, wages, housing—home workers

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also had to deal with the piecework system and sedentarism. Piecework or work on demand was volatile, uncertain, and variable in both income and physical demands, and was particularly intensive when the workers were up against production deadlines. The seamstresses, it was said, demanded too much of their bodies in a monotonous work routine of repetitive motions and a posture that constricted their lungs.≤≤ A 1915 study, however, found that, contrary to what many physicians, hygienists, and journalists repeated almost obsessively—and as many historians would later say in similarly pietistic tones—the predisposing factor for tuberculosis among seamstresses was not the rarefied air of the tenement room (most of them worked in a patio or next to a door or window), but rather the seasonal burdens of the work and the wages, which were frequently reduced by competition with women working in factories and garment workshops controlled by charitable institutions.≤≥ Both factors also a√ected seamstresses employed in the garment workshops of the big stores that generally met the local mass demand for nonluxury goods. In this context the conclusions of a 1912 study mesh quite well with the omnipresence of tuberculosis in the lives of the young barrio working women who populate Carriego’s poems. In fact, 32.7 percent of the mortality of women employed in the garment industry (40.9 percent if we consider cases classified as diseases of the respiratory system) was due to tuberculosis.≤∂ But if Carriego’s consumptives contract tuberculosis because of excess labor and troubles of the soul without abandoning the loving universe of the barrio, the costureritas are protagonists of a journey fed by the desires and dreams of rapid social ascent, which can also end up in tuberculosis. The world of the barrio, innocent or virtuous, is the starting point for this melodramatic trajectory where, as might be expected, the tone is morally polarized, with no in-between situations, and everything is either great joy or great sorrow. The departure from the barrio—whether for deception, ambition, or love—is the moment that interrupts a common life that should go on without great changes or surprises. The departure from the barrio is also the moment of betrayal of one’s origins, one’s home, maternal love. It changes the scenario, and in that change the identity of the costurerita begins to alter now that she is wandering through a world that the narrator usually insists on describing as strange and cruel. Unlike other melodramas, the journey of the costuerita lacks suspense: her descent is predetermined.≤∑

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Milonguitas In the 1920s and 1930s Carriego’s picturesque legacy returned in tango lyrics, film, and literature. Samuel Linnig, José González Castillo, Héctor Pedro Blomberg, Enrique González Tuñón, Celedonio Flores, José A. Ferreyra, and many others labored insistently over the journey of the Estercitas, or ‘‘Little Esthers’’—young girls from the barrio—to the cabarets in the city’s center, where they became milonguitas, cabaret girls, described as ‘‘pebetas que se dieron a la vida,’’ roughly, ‘‘chicks who started walking the streets.’’≤∏ This is the same journey that, ten or fifteen years earlier, Carriego’s costurerita made. What is new are not the stories but their emphasis and setting as well as the authors writing them—journalists, tango lyricists, filmmakers, and fiction writers who saw the milonguita not only as a character needing understanding, but also as someone embodying traces of their own urban experience. The emphasis was on the milonguitas rather than on the Estercitas; that is, on the women in the city center rather than those of the barrio. In the center, the cabaret was the ideal setting for the milonguita. During the 1920s, downtown was already a definitive reference for the leisure time of porteños, as people of Buenos Aires are called. Statistics for 1923 indicate that more than seven million people attended some kind of entertainment that year. On October 9, 1925, the newspapers La Nación and La Razón included more than seventy announcements for movies, vaudeville shows, operettas, zarzuelas, teatro de revistas, chorus performances, music halls, sainetes, and dancing events.≤π Along with these attractions, downtown lights o√ered brothels, dance halls, cafés with female ‘‘servers,’’ and cabarets. A few of the barrios also o√ered such facilities, but their erotic charge was without doubt associated with the life of the center, where there was a greater variety of o√erings for all budgets. In any case, at night men from all walks of life shared the adventure of entertainment by women of humble origin now working as bar girls, cabaret entertainers, or prostitutes. The downtown’s erotic charge grew, and over time it came to be strongly marked by the tango, a hybrid cultural artifact that was born in the city outskirts, picked up choreographic elements from candombe and other dances of Buenos Aires’s blacks, and acknowledged the massive presence of the immigrants. The early years of tango are confused, but no doubt they were found in the arrabales. Around 1870 and 1880, dances were held

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around the soldiers’ barracks with the participation of prostitutes who knew how to dance the complex steps of the milongas, habaneras, and tangos entwined with a casual partner. In the last years of the century the tango reigned not only in the brothels and ‘‘dance houses’’—where it served as simulation and stimulation to entertain the men waiting their turn for commercial sex—but also in the academies of dance instruction, in the vacant lots and barrio streets where dances were organized to the accompaniment of a hurdy-gurdy, and in the cafés frequented by single men. In these original settings the tango’s lyrics were very simple, focusing on the successes and mishaps of the tough guys of the arrabales, where the cult of physical courage and skill with a knife were a part of local politics. The tango’s characters were the tough, the prostitute, the pimp, and the compadrito, a man with pretensions who copied some of the styles of the toughs and pimps but worked for a living. Danced by men accompanied by women from the brothels or by men alone, the tango was above all a dance of the margins. By the beginning of the twentieth century, it had entered the city and began to be accepted in other social circles. Young upper-class men, who from time to time went into the outskirts of the city, carried it first to their more exclusive houses of prostitution and later to their homes. They could see how it was danced in sainetes, listen to it on records, and try to dance it in an open-air dance or during carnival, when everyone felt free to explore a dance that was still associated with prostitution, and therefore generally disapproved. The tango was becoming a respectable cultural form. For one thing, the popular sectors and the emerging middle classes were finding in its lyrics, music, and choreography—stripped of their initial erotic charge—some signs of their urban identity. For another, and largely as a result of the tango’s acceptance and triumph in Europe and the United States, the porteño elite incorporated it enthusiastically into their store of culture because the approval of the rest of the world brushed aside their past censure.≤∫ In only a few years the tango became an essential expression of Buenos Aires. More melodious now, it gained a place in decent salons, well-known confiterías (tearooms), and cafés in the center and in the barrios, and it was heard even in family gatherings on the pianos that began to appear in the modest and middle-class homes. Tango lyrics also infiltrated movies and plays. Often, a tango written to be included in a sainete, if successful, o√ered the story line for another sainete based on the lyrics of that tango. Many movies not only re-created tango stories in images but also took their titles

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from them. With the takeo√ of the record industry, radio, and film; the massive audiences of theater events; the increasing professionalization of musicians and singers; and the appearance of trios, quartets, sextets, and orchestras, tangos tended to o√er fewer opportunities for improvisation. These changes also a√ected the lyrics, which became more important and focused on narrating stories constructed around strong moral dilemmas with which the porteño could easily identify. Thus, the tango became an urban narrative in which the epic of the slum—with its toughs, pimps, prostitutes, and compadritos—began to fade, without altogether disappearing, giving way to new or refreshed topics and characters. Among them was the milonguita, the 1920s and 1930s version of Carriego’s costurerita, a young woman who would reveal something of the anxieties and tensions that came with modern relations between men and women. Tango was the cabaret dance and music par excellence, a place to give free rein to erotic fantasies, and a prelude for paid sex. And for that reason, as also happened elsewhere, it became associated with the entire spectrum of modern threats to the dominant morality, the cult of domestic life, and formal dance.≤Ω By the 1920s cabarets had become well established; there were at least twenty elegant ‘‘social epicenters’’ where the rich spent their time and money far into the night, and those of lesser means, who had to work the following day, enjoyed early evening shows.≥≠ The milonguitas associated cabaret and the city’s center with temptations of luxury, the easy life, rapid social climb, and even an artistic career. For them, the cabaret o√ered three paths to a livelihood: as artistas, or professional singers; as coperas, or bar girls who made conversation and danced with the customers, drank with them, and, after a long and protracted ceremony, sold them love and sex; and as queridas, mistresses of the customers with money.≥∞ Whatever their status, all these women had bet on a life away from the domestic barrio ideal. Their choice for a more autonomous life led many men to see them as a threat to the ruling gender order.≥≤ The journey of the milonguitas became a recurrent topic in film, theater, and tango lyrics. In 1922 José Bustamante made the movie Milonguita. José Agustín Ferreyra, the Carriego of Argentine cinema, treated the journey of the milonguita in El Tango de la Muerte (Death tango; 1917), La Muchacha del Arrabal (The girl from the city outskirts; 1922), Melenita de Oro (Little golden mane; 1923), Corazón de Criolla (Creole heart; 1923), La Maleva (Hell-cat; 1923), El Organito de la Tarde (The hurdy-gurdy of the afternoon; 1925), Mi Ultimo Tango (My last tango; 1925), La Costurerita que

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Dió Aquel Mal Paso (The little seamstress who stumbled; 1926), Muchachita de Chiclana (Girl from Chiclana; 1926), Muñequitas Porteñas (Porteño dolls; 1931), and Calles de Buenos Aires (Streets of Buenos Aires; 1933).≥≥ Delikatessen Haus, a sainete written by Samuel Linnig in 1920, included in one of its acts the tango ‘‘Milonguita.’’ Actually, it was the success of this tango that made the milonguita a recognizable character of porteño cultural life. Two years later, Linnig showed Milonguita, now a sainete that dramatized the story he had advanced earlier in the tango with the same title. This time ‘‘Melenita de Oro,’’ another tango written by Linnig, was part of the piece and also the topic of Ferreyra’s movie of the same title, filmed a year later. Milonguitas appeared time and again in sainetes and music hall shows such as El Rey del Cabaret (The king of the cabaret; by Alberto Weinsbach), where the tango ‘‘Pobre Milonga’’ (Poor milonga) made its debut; and ‘‘Buenos Aires Bajo Cero’’ (Buenos Aires below zero), which included the tango ‘‘No Salgas de Tu Barrio’’ (Don’t leave your neighborhood).≥∂ Tango lyrics were the narratives that best displayed the many meanings of the milonguitas ’ journey downtown. Dozens of tangos, among them ‘‘Flor de Fango’’ (Flower of the mire; Pascual Contursi, 1914), ‘‘Galleguita’’ (Girl from Galicia; Alfredo Navarine, 1924), ‘‘Milonguera’’ (José María Aguilar, 1925), and ‘‘Percal’’ (Percale; Homero Espósito, 1943), portrayed that adventure as an inappropriate e√ort to escape from poverty and also the wrong way to channel personal material ambitions. In ‘‘Margot’’ (Celedonio Flores, 1919) the narrator is blunt: ‘‘Your rambling was your own fault, and you didn’t do it innocently; / obsessed with getting rich / from the day a collar-stud tycoon romanced you.’’ In ‘‘De Tardecita’’ (In the afternoon; Carlos Alvarez Pintos, 1927) the milonguita ’s ambition seems to include an existential dimension: The bright lights of the center made you think that the happiness you wanted was far from your arrabal. Dressing well, living in luxury, was the enchantment of your desire.

The sojourn in the city center, the promised land, sooner or later turns into decadence. In some cases this appears as an inevitable outcome: ‘‘Mano a Mano’’ (Hand to hand; Celedonio Flores, 1923) tells of the ‘‘poor, shortlived triumphs’’ of the milonguita. In ‘‘Pobre Milonga’’ (Poor milonga; Manuel Romero, 1923) night in the center is a punishment from which

Music sheet covers of tangos written mainly during the 1920s in which the topic is the milonguita ’s journey from her barrio to the city center, whose pleasures, temptations, and risks ultimately condemn her, in the view of the male tango writers, to prostitution, poverty, and disease. Courtesy of Biblioteca de la Academia Porteña de Lunfardo, Buenos Aires.

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there is no possible salvation: ‘‘You are going to die always as a Milonga. ’’ And ‘‘No Salgas de Tu Barrio’’ (A. J. Rodriguez Bustamante, 1927), written by a man but voicing the experience of a woman, says: Like you, kid, I too was pretty and I was good; I was humble and I worked, like you, in a workshop. I left the fiancé who loved me . . . for a kid with slicked-back hair who brought me to the cabaret; he taught me all his vices, he trampled on my hopes, he turned me into this garbage, kid, that you see before you.

The cabaret is the decadent setting that appears most often. There, tuberculosis, while exemplifying the dangers of the woman’s fall, also calls out the eroticism and sexual heat, the disillusionment, estrangement, coldness, loyalty, and degradation of her situation. Often it appears as an illness of the soul, of the passions. In one of the short tales that Enrique Gonzalez Tuñón used to construct Tangos, his first book, tuberculosis seduces, arouses desires, and makes people lose their senses. Perhaps it is called tisis, consumption, to underline the romantic connotations of the disease. It is said of two melancholy habitués of the cabaret, a ‘‘yony’’ (an American, or ‘‘Johnnie’’) and a porteño, that a ‘‘lovely consumptive has messed up their attic.’’≥∑ This ‘‘lovely consumptive’’ has very little in common with the ruined girl from the barrio. To the contrary, she is a source of intense, disturbing, almost obsessive passions. In ‘‘Carne de Cabaret’’ (Cabaret fodder; Luis Roldán, 1920), tuberculosis is associated with disappointment and disillusionment and is at the same time a disease of soul and body: Poor doxy . . . sick to her lost little soul who fell into the clutches of a clumsy sugar daddy ..... her illusions died in the cabaret . . . and in her haggard, yellow little face you can see the marks of a faithless love . . . They let her su√er

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and they let her aspirations die. And that was the steep and fatal slope from the cabaret to the hospital.

Juan González Castillo associated tuberculosis with estrangement. In his tango ‘‘Griseta,’’ from 1924, a little French ingenue arrives full of hope in a city that o√ers her only the obscure life of the cabaret. Here is a journey that will also end in the Buenos Aires downtown, but starting from Europe. In the character of Griseta, evoking the consumptives in Giacomo Puccini’s opera La Bohème and those of Alexandre Dumas Jr.’s Camille, tuberculosis is rea≈rmed as a theme of bohemian life, amatory passions, delicate health, and excess: A rare mixture of Musette and Mimí with caresses of Rodolfo and of Schaunard. She was the flower of Paris, brought by a novel-like dream to the arrabal Little Frenchie Who would have said that your poem of Grisette would have only a stanza the silent agony of Marguerite Gauthier . . . With the funereal hum of a bandoneon poor child, she has fallen asleep just like Mimí, just like Manon.

Many young European women like Griseta were tricked into going to the cabaret, carried by their own ambition or by circumstances. In ‘‘Madame Ivonne’’ (Domingo Enrique Cadícamo, 1937), for instance, ‘‘the doll of the Latin Quarter’’ falls in love with an Argentine who, ‘‘between tango and mate ’’ (a traditional Argentine beverage), carries her o√ from Paris. Ten years later she ‘‘no longer is a humble fleur-de-lis,’’ but ‘‘a gray skylark . . . who, sad-eyed, drinks champagne.’’ In ‘‘Galleguita’’ this sadness of the soul has become illness. The narrator commiserates with this young woman who could do nothing with her pristine honesty: And today I see you, Galleguita, sitting sadly and alone . . . and the grief that is killing you is painted clearly

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in your mortal pallor. Yours is an infinite sadness . . . No longer are you the Galleguita who arrived one April afternoon, with no more garments nor treasures than your dark Moorish eyes and your graceful body.

Longing for home, in this case Paris, also permeates the tuberculosis that ends the life of ‘‘La que Murió en París’’ (She who died in Paris; Héctor Pedro Blomberg, 1930): a ‘‘dark-eyed criolla girl’’ leaves her barrio and goes o√ to Paris, the desired and unknown land. A cough that starts ‘‘as soon as she arrives’’ foreshadows a life marked by nostalgia for the world she left behind—‘‘the happy barrio’’—and a death in a foreign land where ‘‘Paris and the snow . . . were killing the flower of the arrabal. ’’ The milonguita ’s journey, whether from a Buenos Aires neighborhood or from Europe, is melodramatic: from barrio to cabaret and from innocence to degradation. The milonguita is beautiful, coquettish, sensual, egoistic, sure of herself, capable of escaping the modest confines of the barrio. What the tangos describe, speaking from the point of view of men, is the risk, even the mistake, of imagining a life outside the barrio, of being carried away by the bright lights of downtown, because su√ering, grief, loneliness, and tuberculosis must follow the inevitable loss of youth. In the end, the rich, unscrupulous men who used her while she was young will abandon the milonguita. But along with the milonguita and the man who takes advantage of her is the narrator, a man who knows the world and the life of the city, a habitué of the café with his gang of friends. Most of the time he is the victim, powerless in the face of the sinister alliance of the pimp’s wealth and the ambition and beauty of the milonguita, an alliance that corrupts the very essence of romantic love. In this context of abandoned men the tango settled into its most familiar strains, those of misogyny resulting from the ever-present threat of the women of the cabaret. There are also other strains, however, revealing the ambivalence and varied types of masculinity of the men who appear in the tangos.≥∏ In a tone not unlike that of Carriego’s ‘‘Costurerita que Dió Aquel Mal Paso,’’ in the tango ‘‘De Tardecita’’ the neighborhood and its people remain loyal to those who have left them: ‘‘And even if you return defeated, / you’ll know that the old gang / has never lost faith in you.’’ In ‘‘Mano a Mano’’ the boyfriend from

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the barrio, himself abandoned, tells the milonguita that when ‘‘you have no more hope in your poor heart, / . . . remember this friend who would risk his skin / to help you however he could whenever you need him.’’ The tone is not merely one of commiseration. This is about a man weathered by life who has no illusions about a romantic love in which friendship, empathy, intimacy, and the pursuit of sexual pleasure are the shared responsibility of the man and woman. He is prepared to take in the milonguita because he has put his faith in another love, maternal love, where he does find a love without limits or conditions, a love not exposed to the temptations of downtown and money. Maternal love is, without a doubt, the opposite of the love and coldness that permeate the milonguita ’s life. This is why, in so many tangos, tuberculosis is pictured as the punishment for the milonguita’s slips, while in the figure of the mother, ever faithful and stripped of eroticism and sexual connotation, disease is absent. In contrast to the milonguita, the mother neither falls into temptation nor o√ers fleeting love a√airs; she maintains the essential strength that saves her from tuberculosis. The men in the tangos do not get tuberculosis either, whether they are abandoned by the milonguitas or ready to welcome them back to the neighborhood, and even though they have lost all faith in romantic love. This sort of moral economy in which the abandoned men do not fall ill but the women who leave the barrio do is absent from the poetry of Nicolás Olivari. In his poems tuberculosis can a√ect men because the disease is part of the life of the urban marginals who have become central figures in literature. Yet even here it is the women who bear the full weight of the disease; tuberculosis is part of their inheritance. In the poems included in La Musa de la Mala Pata (The unlucky muse; 1926), tubercular women circulate through the city and belong to it.≥π It is the city that has made them ‘‘monstrous and sickly,’’ and that condition, definitely marginal, is what seems to make them suitable to share the life of the poet, himself marginal. This is how the poet proposes to his beloved: Let us join our physical wretchedness, my dispirited and sickly manner, your incipient tuberculosis and my metaphysical disquiet.≥∫

But for Olivari’s tubercular women, the disease is not a punishment or a terminal situation. It is, rather, the very representation of urban misfortune. All of these women—working seamstresses who did not stumble, typists,

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prostitutes, lovers, and milonguitas—are women with contorted bodies and ruined souls: a ‘‘sick and so skinny girl,’’ the beloved with ‘‘the flame gone out from her big eyes,’’ a ‘‘muse twisted by poverty and her dead flesh,’’ ‘‘the sick beloved in the city,’’ the ‘‘consumptive and sexless damsel,’’ the ‘‘dreaming lunatic, her plaster face painted by disease.’’≥Ω These women are irredeemably vulgar, of an extreme but ordinary ugliness that can never be elevated to the status of a terrible or fearsome beauty like that of the women who defied the domestic ideal of the barrio. Olivari uses these consumptives as a means to critique the romantic or aestheticist idea of beauty.∂≠ The personal stories of these young women are of no concern to Olivari. There is no barrio or nostalgia for him. There is no melodrama, and as a result there is no idealization of a past when tuberculosis was not yet part of the people’s lives. There is no attempt to arouse the reader’s sympathies or compassion. Olivari’s is a tone that is almost cynical, in which the modern city’s ability to make people sick is a recurrent topic and the victims of tuberculosis are almost always women.

Uneasy Men and Tubercular Women The tuberculosis constructed by certain literature, cinema, and tango lyrics in the first decades of the twentieth century always wore a woman’s face, leaving no place for men as diseased or potential victims. For them, syphilis was the illness on which culture constructed the idea of guilt and articulated broader eugenic and moral concerns. Tuberculosis played that role for women, with their supposedly weaker physical constitution, the overwork that exacerbated their also supposedly natural weakness, and their almost inevitable moral fall. But these tubercular women were not, as in the nineteenth-century European romance, romantically ill women. For Carriego’s costureritas, Olivari’s typists, González Tuñón’s bar girls, the milonguitas of Linnig’s tango and sainete, and the young barrio women in the movies of Ferreyra, tuberculosis could be, depending on the case, a way of talking about compassion, disgust, exploitation, punishment, vengeance, extreme weakness, erotic passions, or death. But it was never a spiritual promotion. Although the image of tuberculosis that emerges from the tangos, cinema, and literature of the early decades of the twentieth century is one of a women’s disease, men feared tuberculosis as well. Between 1880 and 1950, men were dying of tuberculosis in greater proportion than women. After

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the latter part of the 1920s mortality for both sexes tended to decline, most notably among women: in 1928, 72.9 women died of tuberculosis for every 100 men who did, whereas in 1947 the figures were 63.3 women for every 100 men.∂∞ Thus was the demographic impact of the disease in Buenos Aires in the first decades of the twentieth century ignored, and also the histories that might have been written about it. A history of tuberculosis based on those literary narratives, their associations and metaphors, is clearly not the whole story. This conclusion, while hardly original, nevertheless seems relevant in times like the present when the linguistic turn has been imposed on the historical narrative, partly as an aggiornamento of the old history of ideas, partly as a reaction to the until recently arrogant hegemony of the social sciences, and partly as the result of a certain infatuation with the disciplines of language. Regardless of the currently fashionable reign of the history of discourses, however, the plot described by these narratives is a fair reflection of Buenos Aires at the beginning of the century, a society where the di√erences among the social groups below the elite were blurry and, more important, were in no way definitive. The lives of the consumptives of the barrio, the costureritas and the milonguitas, show the possibilities and limitations of a society, of a country, that still invited women to believe that it was also being constructed for them, and would somehow include them. The costureritas ’ and milonguitas ’ journey downtown, whatever its conclusion—which, by the way, was not always tragic—sums up the risks of the very modern adventure of social mobility. The milonguita is convinced that she can conquer the city using talents very di√erent from those of the young women in the barrio, who imagine their future and happiness in the maternal and matrimonial bliss of the hearth. Her gamble, then, put a strain on the certainty that a woman’s place is in the home and the barrio. She was at the opposite pole from the type of woman and of gender relations constructed by primary school texts, sentimental novels, home economics manuals, and women’s sections of newspapers and magazines.∂≤ Nor was she in harmony with the doctoral dissertations, essays, and articles written by physicians—including those by the few women doctors of those years—which, from the late nineteenth century to the early twentieth, discussed women’s health as a subject closely associated with biological productivity, the forging of a national race, and the rea≈rmation of the nuclear family.∂≥ In the face of the flood of changes brought by modernity, medicine was viewed as both a relatively e≈cient means to

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reduce maternal mortality and a discourse aimed at preserving a certain distribution of sexual roles and behaviors. It prescribed that women’s health was possible only within the domestic world. Outside the household, women’s inherent fragility and weakness, the delicate balance of their physiology between puberty and menopause, the nondomestic physical and spiritual demands placed on them, made them an easy target of disease. Many tango lyricists—men—presented the milonguita ’s journey in a tone that aligned them with the doctors and many others concerned—from very di√erent ideological, political, and aesthetic positions—with the moral reform of the masses, and also with the partial reconfiguration of traditional gender relations. It is clear that in the early decades of the twentieth century, women working in factories and workshops, the ladies of the elite active in philanthropy, the employees in the big stores of the center, the women physicians, the typists, the women who rode the tramway, and, certainly, the milonguitas were concrete, not merely rhetorical, evidence of the new place of women in the public sphere.∂∂ These novelties put the tango men in an uneasy situation that fostered their reprobation of the milonguita ’s bid for rapid social mobility. In some cases, certainly very few, men viewed these novelties with a mixture of moral condemnation and the realization of the many trajectories associated with the journey to the center. In ‘‘La Hija del Taller’’ (The daughter’s workshop), for instance, Julio Fingerit introduces the reader to some of them: that of the working woman who can finally run her own workshop; that of her daughter who abandons her mother’s trade, gets married three times, and ends up as a homeowner; that of Juanita, who escapes to the center and after a while gets ‘‘the cruel disease’’; that of Pepa, who runs away with ‘‘the young man of the Ford’’; that of Manuela, who is comfortably living ‘‘with an old chap.’’∂∑ In ‘‘La Costurerita que Dió Aquel Mal Paso’’ Nicolás Olivari suggests that ‘‘things were not that bad’’ for the young women who left the barrio for the city’s nightlife.∂∏ And filmmaker José Agustín Ferreyra shows in his La Chica de la Calle Florida (The girl of Florida Street) the world of a young woman store clerk who has already found through her work and buying patterns a certain independence that the declining patriarchal society was denying her. From the margins of the tango world and the mainstream literature two women articulated a di√erent reading of the milonguita ’s search for upward mobility. In ‘‘Se Va la Vida’’ (Life runs away; María Luisa Carnelli, 1929), one of the few tangos written by a woman (although using the male pseu-

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donym Luis Mario), the narrator invites the young barrio female to take chances if a wealthy man o√ers her a promising life: ‘‘Live your youth!! Do not water the flower of an unhappy dream!! Perhaps the luck will reach you. Do not think on pains or virtuosity!!’’ For her part, Alfonsina Storni, a controversial and subversive voice in Argentine literature of the 1920s, celebrates the public place of the working woman and the irony it involves. On the one hand, she laughs at the male poets who insist on the ‘‘unavoidable stumble’’ of the costurerita willing to leave the neighborhood and the domestic world. On the other, she mocks the young women courageous enough to imagine their lives beyond the marital and maternal horizon of the barrio, but only to dream of ‘‘artificial paradises’’ where they picture themselves as middle- or upper-class women once again confined in the domestic world.∂π But the dominant tone in the tangos, literature, and film is di√erent. In the milonguita ’s fragility, tuberculosis—real or imagined, supposedly feminine—captures something of the discomfort and anxiety of the men of the tango who, while they cannot ignore the growing presence of women outside the home, tell of the young barrio women’s journey to the center as a transgressive adventure, too independent, threatening, and unnecessary. By the 1940s milonguitas began to disappear, among other reasons because tango lyrics tended to emphasize an essential melancholy and because the issue of social mobility during the first Peronist experience, independent of the individual trajectory of Evita, would become more collective and framed within a discourse of enhanced dignity in the home and the workplace. In the 1960s the journey of the milonguita was already part of the cultural history of the city. The tango ‘‘La Ultima Grela’’ (‘‘The last milonguita; Horacio Ferrer, 1967) not only evokes the milonguitas as ‘‘proletarians of love’’ or ‘‘Madame Bovarys from the barrios porteños’’ but also indicates that both the melodramatic trajectory and the character have already become topics of the history of tango, the history of the gender relations in Buenos Aires, and the history of tuberculosis.

Notes 1 Susan Sontag, Illness as Metaphor (New York: Farrar, Straus and Giroux, 1977); Isabelle Grellet and Caroline Kruse, Histoires de la Tuberculose: Les Fièvres del’Ame, 1800–1940 (Paris: Ramsay, 1983); Linda Bryder, Below the

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2

3 4 5 6 7 8 9 10

11 12 13 14 15

Magic Mountain (Oxford: Clarendon Press, 1988); Mark Caldwell, The Last Crusade: The War on Consumption, 1862–1954 (New York: Atheneum, 1988); Sheila Rothman, Living in the Shadow of Death: Tuberculosis and the Social Experience of Illness in American History (New York: Basic Books, 1994). Juana Manuela Gorriti, ‘‘Peregrinaciones de una Alma Triste,’’ in Obras Completas, vol. 1 (1876; Salta: Fundación del Banco del Noroeste, 1992), 75–197. Mundo Argentino, August 21, 1918; March 26, 1919, through November 5, 1919. Horacio Quiroga, Cuentos Completos (Montevideo: Ediciones de la Plata, 1978), 151. L’Avvenire: Periódico Comunista Anárchico, June 30, 2001. Carlos Octavio Bunge, Nuestra América (Buenos Aires: Vaccaro, 1903), 5, 98, 56. Viva 100 Años 4 (1937): 426. Evaristo Carriego, ‘‘La Costurerita que Dió Aquel Mal Paso,’’ in Poesías Completas (Buenos Aires: Eudeba, 1968), 130. José Luis Romero, Buenos Aires: Historia de Cuatro Siglos, vol. 2 (Buenos Aires: Abril, 1983), 17. Diego Armus, ‘‘El Viaje al Centro. Tísicas, Costureritas y Milonguitas en Buenos Aires, 1910–1940,’’ in Diego Armus, ed., Entre Médicos y Curanderos: Cultura, Historia y Enfermedad en América Latina Moderna (Buenos Aires: Norma, 2002), 221–58; Julio Frydenberg, ‘‘Prácticas y Valores en el Proceso de Popularización del Fútbol: Buenos Aires 1900–1910,’’ Entrepasados: Revista de Historia 12 (1997): 7–30; Oscar Troncoso, ‘‘Las Formas del Ocio,’’ in José Luis Romero, ed., Buenos Aires: Historia de Cuatro Siglos, 2:95–102; Beatriz Sarlo, El Imperio de los Sentimientos (Buenos Aires: Catálogos, 1985); Leandro Gutiérrez and Luis Alberto Romero, Sectores Populares. Cultura y Política: Buenos Aires en la Entreguerra (Buenos Aires: Sudamericana, 1995); Aníbal Ford, Jorge B. Rivera, and Eduardo Romano, Medios de Comunicación y Cultura Popular (Buenos Aires: Legasa, 1985); Sergio Pujol, Historia del Baile: De la Milonga a la Disco (Buenos Aires: Emecé, 1999), chap. 4. José Luis Romero, Buenos Aires: Historia de Cuatro Siglos, 2:17. Jorge Luis Borges, ‘‘Evaristo Carriego,’’ in Obras Completas, vol. 1 (Buenos Aires: Emecé, 1974), 119. For Evaristo Carriego’s poems cited in the text I followed versions included in Poesías Completas (Buenos Aires: Eudeba, 1968). Ismael Moya, El Arte de los Payadores (Buenos Aires: Berutti, 1959). Andrés Cepeda, ‘‘Marta, la Tísica,’’ in La Guitarra de los Payadores (Buenos Aires, n.d.); and Cepeda, ‘‘La Tísica,’’ in Víctor Cavallaro Cadeillac, ed.,

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17 18

19

20

21

22

23 24 25

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Glorias del Terruño: Selección Gauchesca Nativista y Lírica de Poesía Popular y Alta Poesía (Montevideo: Cumbre, n.d.). Diego Armus, ‘‘The Years of Tuberculosis. Disease, Culture and Society: Buenos Aires 1870–1950’’ (Ph.D. diss., University of California, Berkeley, 1996), chaps. 4 and 9. José Ingenieros, La Jornada de Trabajo (Buenos Aires, 1899). Augusto Bunge, Las Conquistas de la Higiene Social, Informe Presentado al Excelentísimo Gobierno Nacional, vol. 1 (Buenos Aires: Imprenta Coni, 1910), 12, 79, 188, 133, 190. For tango lyrics cited in the text, see José Gobello, ed., Las Letras de Tango (Selección 1897–1981) (Buenos Aires: Centro Editor, 1995); and Juan Angel Russo, ed., Antología Poética: Letras de Tango (Buenos Aires: Basílico, 1999). Josué Quesada, ‘‘La Costurerita que Dió Aquel Mal Paso . . . ,’’ 65–93, and Julio Fingerit, ‘‘La Hija del Taller,’’ 37–64, both in La Novela Semanal 1917– 1926 (Buenos Aires: Página 12/unq, 1999); Mariela Mendez, Graciela Queirolo, and Alicia Solomone, eds., Nosotras . . . y la Piel: Selección de Ensayos de Alfonsina Storni (Buenos Aires: Alfaguara, 1998); Roberto Arlt, ‘‘La Muchacha del Atado,’’ in Aguafuertes Porteñas (Buenos Aires: Losada, 1998). Zulma Rechini de Lattes and Alfredo Lattes, La Población de Argentina (Buenos Aires: Cicred, 1975), table 6.2; María del Carmen Feijóo, ‘‘Las Mujeres Trabajadoras Porteñas a Comienzos de Siglo,’’ in Diego Armus, ed., Mundo Urbano y Cultura Popular: Estudios de Historia Social Argentina (Buenos Aires: Sudamericana, 1990), 286–300; Fernando Rocchi, ‘‘Concentration of Workers, Concentration of Women: Industrial Growth and Female Labor in Turn-of-the-Century Buenos Aires’’ (mimeo, 1995), 14– 19. Gabriela L. de Coni, Proyecto de Ley de Protección del Trabajo de la Mujer y del Niño en las Fábricas (Buenos Aires: Liga Argentina contra la Tuberculosis, 1902); Eduardo Rojas, ‘‘El Sweating System: Su Importancia en Buenos Aires (diss., Facultad de Ciencias Económicas, Universidad de Buenos Aires, 1913); ‘‘El Trabajo a Domicilio,’’ Boletín del Departamento Nacional del Trabajo 30 (1915): 75–109; Ricardo Etcheberry, ‘‘La Ley Argentina sobre Reglamentación del Trabajo en las Mujeres y Niños’’ (diss., Facultad de Ciencias Económicas, Universidad de Buenos Aires, 1918). ‘‘El Trabajo a Domicilio,’’ 80–82. La Semana Médica, May 16, 1918. Peter Brooks, The Melodramatic Imagination: Balzac, Henry James, Melodrama and the Mode of Excess (New Haven: Yale University Press, 1976), 11– 12.

128 d i e g o a r m u s 26 Enrique Gonzalez Tuñón, Tangos (Buenos Aires, Gleizer, 1926), 125, 8. 27 Beatriz Seibel, Historia del Teatro Argentino: Desde los Rituales hasta 1930 (Buenos Aires: Corregidor, 2002), part 4. 28 Blas Matamoro, La Ciudad del Tango (Buenos Aires: Galerna, 1969), 47–72. 29 Harold Segel, Turn-of-the-Century Cabaret: Paris, Barcelona, Berlin, Munich, Vienna, Cracow, Moscow, St. Petersburg, Zurich (New York: Columbia University Press, 1987), Introduction. 30 Tania, Discepolín y Yo (Buenos Aires: La Bastilla, 1973), 28–29. 31 Ibid., 28–33. 32 Blas Matamoro, La Ciudad del Tango, 121–24; Donna Guy, Sex and Danger in Buenos Aires: Prostitution, Family and Nation in Argentina (Lincoln: University of Nebraska Press, 1990), 144. 33 Jorge Miguel Couselo, El Negro Ferreyra: Un Cine por Instinto (Buenos Aires: Freeland, 1969), 131–45. 34 Beatriz Seibel, Historia del Teatro Argentino, 587. 35 Enrique González Tuñón, Tangos, 17. 36 Eduardo Archetti, ‘‘Masculinity in the Poetics of Argentinian Tango,’’ in Eduardo Archetti, ed., Exploring the Written: Anthropology and the Multiplicity of Writing (Oslo: Scandinavian University Press, 1994), 110. 37 Nicolás Olivari, La Musa de la Mala Pata (1926; Buenos Aires: Deucalión, 1956). 38 Ibid., 50. 39 Ibid., 42, 50, 15, 17, 51, 12, 64. 40 Beatriz Sarlo, Una Modernidad Periférica. Buenos Aires: Buenos Aires 1920 y 1930 (Buenos Aires: Nueva Visión, 1988), 186. 41 Archivos Argentinos de Tisiología 30 (1954): table 8; Diego Armus, ‘‘The Years of Tuberculosis,’’ chap. 9 and Epilogue. 42 Catalina Wainerman and Rebeca Barck de Raijman, Sexismo en los Libros de Lectura de la Escuela Primaria (Buenos Aires: ides, 1987), chap. 2; Beatriz Sarlo, El Imperio, 119; Marcela Nari, ‘‘La Educación de la Mujer (o Acerca da cómo Cocinar y Cambiar a su Bebé de Manera Científica),’’ Mora: Revista del Area Interdisciplinaria de Estudios de la Mujer (Buenos Aires) 1 (1995): 34–39; Delfina Muschietti, ‘‘Mujeres: Feminismo y Literatura,’’ in Graciela Montaldo, ed., Historia Social de la Literatura Argentina: Yrigoyen entre Borges y Arlt, 1916–1930 (Buenos Aires: Contrapunto, 1986), 133–34. 43 Diego Armus, ‘‘The Years of Tuberculosis,’’ chap. 2; Gabriela Nouzeilles, ‘‘Políticas Médicas de la Histeria: Mujeres, Salud y Representación en el Buenos Aires del Fin de Siglo,’’ Mora: Revista del Area Interdisciplinaria de Estudios de la Mujer 5 (1999): 97–110. 44 Catalina Wainerman and Marysa Navarro, El Trabajo de la Mujer en la Argentina: Un Análisis Preliminar de las Ideas Dominantes en las Primeras Décadas

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del Siglo XX (Buenos Aires: ides, 1979), 15–18; Kathleen Newman, ‘‘The Modernization of Femininity: Argentina, 1916–1926,’’ in Women, Culture and Politics in Latin America (Berkeley: University of California Press, 1990), 79. 45 Julio Fingerit, ‘‘La Hija del Taller,’’ in La Novela Semanal 1917–1926 (Buenos Aires: Página 12/unq, 1999), 37–64. 46 Nicolás Olivari, ‘‘La Costurerita que Dió Aquel Mal Paso’’ [1926], in La Musa de la Mala Pata, 45. 47 Alfonsina Storni, ‘‘La Costurerita a Domicilio,’’ 112–16, and ‘‘Las Mujeres que Trabajan,’’ 105–8, in Nosotras y la Piel.

diana obregón

The State, Physicians, and Leprosy in Modern Colombia

n this essay I explore the process of medicalization of leprosy in Colombia in the early twentieth century.∞ The concept of medicalization refers to the process by which an increasing number of aspects of human behavior become assigned to medical control and are redefined as health or illness. Indeed, a new economic and political order in Colombia transformed leprosy from a charitable concern to an obstacle for economic progress and modernization. After the War of the Thousand Days (1899–1902) and the loss of Panama (1903), a new era of peace, political stability, and economic growth started in Colombia. Leprosy became a national embarrassment to this progressive-minded nation. The government and the medical community found the exaggerated late-nineteenth-century data on leprosy a danger for their civilizing project and began to advertise new statistics at international conferences, claiming that the previous figures had been overstated. Based on medical advice, the government put into practice what it had not been able to do in the nineteenth century: it enacted severe laws to enforce the segregation of lepers and to expel their healthy relatives from the lazarettos. Most doctors and the government adopted a racialist approach toward leprosy su√erers, regarding them as racially ‘‘inferior.’’ Patients and residents of leprosaria actively opposed these measures and believed that the situation within the lazarettos worsened after the government took control of them out of the hands of charity boards. Furthermore, the government reinforced the uniqueness of the disease by setting up two public health agencies: one for leprosy and another for the rest of public health a√airs. Leprosy thus remained a disease apart, as it had been since colonial times. One can make a connection between criminological discourses together with penitentiary reform in Latin America and the new policies toward leprosy in Colombia. The carceral reform was based on positivist approaches of criminology and criminal anthropology that promised scientific and e≈-

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cient solutions to the problem of crime; produced anthropometric research within the prison walls; gathered statistics on criminals; and heightened the power of professionals such as physicians, teachers, and criminologists. These experts traveled to Europe and the United States to learn about the latest technologies of punishment. Modern prisons where inmates would become disciplined, obedient workers were seen as a central element of modern republican governments.≤ Colombia’s new policies to control the expansion of leprosy were based on similar new approaches devised by leprologists. They enhanced the authority of experts (physicians and bacteriologists) within the lazarettos and generated research and statistics about the expansion of the disease. Extinguishing leprosy became tantamount to building a new, modern Colombian society, and physicians looked abroad for models to control the spread of the disease.

Leprosy in the Late Nineteenth Century In the middle of the nineteenth century, within the context of the worldwide expansion of colonialism, Europeans and North Americans ‘‘rediscovered’’ leprosy in the colonial world—Hawaii, India, Indonesia, Nigeria, the Philippines, New Caledonia, the West Indies, French Guyana, Martinique, Madagascar, and Senegal, among others.≥ Up until that moment, small endemic foci of leprosy had existed in Norway, Sweden, Iceland, Finland, Russia, Spain, Portugal, France, Italy, Sicily, Crete, and Greece without generating special concern.∂ Although leprosy had long been strongly stigmatized in Western culture, with its medieval image of the leper as a symbol of vice and sin, by the nineteenth century leprosy was generally regarded, together with scabies, tuberculosis, worms, and venereal diseases, as only one of many ailments that a√ected poor European peasants. The stigma revived by the end of the century, however with the colonial rediscovery of a disease that was believed to have expired with the Middle Ages. Old Christian mythologies were reinstated and mixed with racist prejudices.∑ The outbreak of leprosy in the Sandwich Islands (Hawaii) caused especially great alarm at a time when Western powers were competing for political and economic influence on the islands. In 1865 the islands’ board of health opened a leper colony in Molokai to segregate the sick, who were mostly Hawaiians.∏ The infection in the Sandwich Islands, which were previously free from leprosy, was taken as proof that the disease was contagious. In

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1886, Henri Leloir, professor of dermatological and syphilitic diseases at Lille’s Faculty of Medicine, claimed that ‘‘it is mostly because of our colonial possessions that leprosy interests us.’’π Leloir claimed that leprosy disappeared from England, France, Germany, and Holland between the fifteenth and seventeenth centuries thanks to the severe isolation measures of the Middle Ages. At the same time leprosy was receding in parts of the Old World, he contended, the European colonizers carried it with them to the American continent and to other colonies. Leloir not only o√ered an explanation of the epidemiology of leprosy, but also argued for isolation as the main strategy to control its spread.∫ The virtual extinction of leprosy in Norway by the end of the nineteenth century persuaded physicians and governments worldwide that isolation of patients was the only strategy to deal e√ectively with the disease.Ω The First International Leprosy Congress, held in Berlin in 1897, recommended to all nations with local selfgovernment and a su≈cient number of physicians a ‘‘system of obligatory notification, and of observation and isolation, as carried out in Norway.’’∞≠ This was the starting point of the worldwide movement to build leprosaria that soon reached Latin America. During the First Latin American Scientific Conference, which took place in 1898 in Buenos Aires, Baldomero Sommer, a professor of dermatology in Argentina, summarized the conclusions of the Berlin conference on leprosy. This congress gave Latin American doctors the scientific authority they had been seeking since leprosy had become one of their main concerns. Although Latin American physicians accepted the Berlin resolutions, they were keen to argue against Rudolf Virchow, who, unlike Leloir, thought that leprosy existed in America before the European invasion. Indeed, in Berlin Virchow had presented a number of pre-Columbian statues claiming that they showed unequivocal signs of leprosy, such as mutilated noses, lips, and feet.∞∞ Regardless of its origin, the important fact for Latin American doctors was that leprosy was contagious and that it was spreading alarmingly fast in several provinces of Argentina, Uruguay, Colombia, and Brazil.∞≤ In Colombia, where people had lived with leprosy since colonial times, the disease was regarded with horror. Fear of leprosy was attached to the disfiguring e√ects that occurred in some (but not in all) cases, and to the fact that leprosy was regarded as incurable at least until the 1920s. Three lazarettos (Agua de Dios, Contratación, and Caño de Loro) lodged the sick, but these were simply municipalities where leprous and nonleprous people

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mingled together. Around 1890, the doctors, the government, and the Salesian order in charge of the lazarettos created a moral panic about leprosy by claiming that Colombia had more lepers than India. In fact, however, no censuses on leprosy were performed in the country during the nineteenth century. The medical community wanted to medicalize leprosy, which had been in the hands of charity institutions, and the religious missionaries were interested in collecting donations to build lazarettos under their guidance. Indeed, the Salesian priest Evasio Rabagliati traveled throughout the country giving pathetic talks, using hideous metaphors, and seeking donations for the victims of leprosy. The unconfirmed rumor that Colombia had between thirty thousand and fifty thousand lepers was taken by leprosy specialists worldwide as an o≈cial report. The National Academy of Medicine of Colombia came to the conclusion that the only way to halt the spread of the disease and ensure isolation of lepers was to send them to Coiba, a twenty-mile-long island o√ the southwest coast of Panama.∞≥ Similarly, in 1888, the National Department of Hygiene of Argentina had studied the possibility of building a leprosarium in one of the islands of the south, but the proposal was never implemented.∞∂ In Colombia, opposition from the patients and from some doctors, lack of resources, and the War of the Thousand Days prevented the government from organizing an island-lazaretto for Colombian lepers. The o≈cial project then turned into erecting one lazaretto for each of the country’s departments. This plan was hindered by the antagonism of enraged neighbors of possible lazarettos and by some doctors who contended that allowing leprosaria in each department would multiply the foci of contagion.∞∑ These were the debates about leprosy when President Rafael Reyes took the resolution of the leprosy problem into his own hands.

Modernizing the State, Controlling Leprosy A period of political stability and economic growth based on an exportimport economy and on a limited industrialization commenced with the administration of Reyes (1905–9) and continued until the early 1940s. Although during the 1920s and 1930s there was ideological conflict between Liberals and Conservatives, this was essentially di√erent from the political chaos of the previous century. The elites of both parties were committed to the construction of a modern nation and to incorporating Colom-

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bia into ‘‘civilization’’ by establishing permanent economic and cultural links with Europe and the United States. The Reyes government was committed to ‘‘modernizing’’ Colombia, which had been devastated by the War of the Thousand Days and by the loss of Panama in 1903.∞∏ Reyes hoped to place Colombia on the route of progress and civilization through national reconciliation between Liberals and Conservatives, and through economic reconstruction and development. Significant economic and social change occurred in the early twentieth century: Colombia became the second-largest world provider of bulk co√ee and the leading supplier of high-quality mild co√ees. During the Reyes administration co√ee cultivation expanded substantially, and after 1911 the volume of the co√ee trade increased considerably. Co√ee was the only important Colombian export at this time, and the United States was the primary market for the product. The significance of co√ee should be emphasized in light of the successive nineteenth-century failures with quinine, indigo, tobacco, and rubber. Co√ee was the first Colombian product to compete successfully in the international market. Reyes’s economic program aimed to fortify the agricultural export economy by expanding other foreign sales; for example, by promoting the banana industry. In addition, Reyes was convinced that the future of the country depended on foreign investment. Thus, one of his main goals was to normalize relations with the United States, ruined by the conflict over Panama. Reyes’s international economic and political undertakings and achievements were significant. He restored foreign credit for a country whose monetary system had been destroyed by continuous crisis; developed new industries, such as textiles; and increased railroad construction, thus creating a national market. The government also established schools for training army and naval o≈cers; from this point dates the beginning of the professionalization of the Colombian military.∞π Sanitation and public health emerged as important concerns for Reyes. This is not surprising considering his background and interests. He had been an entrepreneur of quinine who in 1873 led an expedition with his three brothers down the Putumayo and Amazon Rivers to Rio de Janeiro. Reyes saw himself as an enlightened pioneer battling to open up the Tropics to civilization.∞∫ At this time, Colombian intellectuals worried that the tropical climate and the Colombian race were not suitable for the development of civilization. Therefore, the government focused on the improvement of the population through education and sanitation.∞Ω The control of

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Women with leprosy and Sisters of Charity at the Agua de Dios hospital. From Juan Bautista Montoya y Flórez, Contribución al Estudio de la Lepra en Colombia (Medellín: Imprenta editorial, 1910).

leprosy became a high priority in Reyes’s administration because leprosy seemed to be an anachronism within the context and image of a modern nation. In his message to Congress in 1904, he demanded not only the reconstruction of the nation and the exploitation of its immense resources, but also the ‘‘extirpation of leprosy, which threatens to destroy all our energies as a healthy and vigorous people.’’≤≠ The elites worried that fear of contamination with leprosy might close the world market to Colombian products. In 1905, a governmental decree created the Oficina Central de Lazaretos to unify the direction of lazarettos, taking them away from local boards of charity. This o≈ce would be in charge of the administration of lazarettos, their income, and organization, while the Junta Central de Higiene would regulate the scientific-medical aspects of leprosy control. In order to prevent private collections of alms for lepers, the government restricted the building, funding, and administration of lazarettos to the state agencies. In the same vein, the revenues of the lazarettos coming from the departments, municipalities, and boards of charity could be administered only by the

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nation. The 1905 decree also ordered compulsory segregation for lepers, specifying home isolation for those with means. Citizens were compelled to notify the authorities of any person a∆icted with leprosy, and physicians were exempted from professional secrecy in the case of leprosy. The Junta and the Oficina ordered other reforms to secure segregation, such as abolishing the status of municipalities previously held by town-lazarettos and barring the movement of healthy people in and out of the lazarettos. It also eliminated the weekly market of Agua de Dios provided by healthy peasants from the surrounding area, ordered that all letters or objects leaving leprosaria be disinfected, and prohibited lepers from taking seats in trains or streetcars. But the governmental measure that most irritated Agua de Dios inhabitants was the establishment of a barbed-wire fence around an area of half a square league (about three square miles) guarded by twentyfive policemen. This was the ‘‘sanitary cordon,’’ and the residents of the lazaretto—even nonleprous people—were constrained to stay within that area.≤∞ Placing experts at the center of his new policy on leprosy, President Reyes appointed Pablo García Medina as consulting physician for the lazarettos in 1905. García Medina, a professor of physiology at the national university, was the most influential person in Colombian public health for almost three decades.≤≤ During his long career as the state’s chief hygienist, García Medina worked hard to ensure that Colombia observed international sanitary agreements. He understood the adverse e√ects of Colombia’s image as a country in which leprosy was uncontrollable. In 1906, the government created a laboratory in Bogotá to verify diagnoses when needed and appointed Juan Bautista Montoya y Flórez, a graduate of the Paris Faculty of Medicine, as chief physician of the lazarettos. A law of 1907 defined leprosy as a ‘‘public calamity’’ and, in an attempt to equalize rich and poor, prohibited home isolation on the grounds that it had been inadequately practiced. In order to prevent contagion, this law forbade the circulation of regular Colombian currency in the lazarettos, replacing it with special money.≤≥ Other reforms e√ected in the lazarettos included building an aqueduct to ensure a regular water supply and erecting nearby houses for resident physicians and pharmacists. After 1908 the government appointed three physicians to work in Agua de Dios and designated nonleprous personnel for the administration of leprosaria, which had previously been in the hands of leprosy patients.≤∂ Other Latin American countries were showing concern about the expansion of leprosy at this time as well. During the first occupation of Cuba by

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Dr. Pablo García Medina, leprosy patients, and physicians in Agua de Dios during one of the latter’s o≈cial visits to the lazaretto in 1906. From Juan Bautista Montoya y Flórez, Contribución al Estudio de la Lepra en Colombia (Medellín: Imprenta editorial, 1910).

the United States in 1899, John Davis, the chief sanitary o≈cer of Havana, ordered the sequestration of all lepers regardless of their social class. In 1902, due to the ‘‘exceptional nature’’ of the disease, Gen. Leonard Wood made Havana’s leper hospital a public institution so that the state would be in charge of the sick.≤∑ In Brazil, leprosy had been one of eight diseases of mandatory declaration since 1902. In 1904, Oswaldo Cruz, the general director of public health in Brazil, acknowledged that the number of lepers was increasing and advised their isolation in a leper colony, preferably on an island. Cruz’s plans had not been fulfilled when he left o≈ce in 1909, but up until 1913 he insisted on the merits of the island called Ilha Grande to isolate leprosy victims.≤∏ In Argentina, Carlos G. Malbrán, director of the National Department of Hygiene, organized a national conference on leprosy in 1906, which concluded that it was necessary to make leprosy a disease of mandatory declaration and that treatment should be compulsory for all persons infected with it. The conference also suggested prohibiting lepers from entering the country, creating a leper colony to treat the sick, and

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gathering statistics on leprosy. None of these recommendations was put into practice until 1926, however, when the first prophylactic law on leprosy was enacted in Argentina.≤π In Colombia, an o≈cial commission appointed by the Academy of Medicine and the government examined Agua de Dios in 1910. The commission, composed of doctors Miguel Canales, Rafael Ucrós, and Jesús Olaya Laverde, presented a detailed account of the lazaretto. Their inspection coincided with a brief stop by the new president of the republic, Carlos E. Restrepo (1910–14). This was the first time a Colombian president had visited a lazaretto, an illustration of the increasing significance the government attached to leprosy. The commission’s account was optimistic, describing the colony as a joyful town with clean, tree-lined streets and an organized administration, in contrast with previous pathetic narratives that had named Agua de Dios ‘‘the land of grief.’’≤∫ Evidently, the commission wanted to emphasize the beneficial aspects of the takeover of the lazarettos by the Colombian government. The medical delegation reported that three powers—ecclesiastical, medical, and administrative—competed for authority in Agua de Dios. Further, they found that e√ective segregation of lepers was di≈cult because sick and healthy inhabitants were accustomed to socialize freely, and they recommended increasing the police force to implement isolation. The committee asserted that the administration of lazarettos involved a variety of situations that were hardly medical, including the collection of the inheritance tax to finance leprosaria and the distribution of rations for leprosy su√erers. Therefore, the establishment of special governmental agencies to deal with leprosy was justified. Leprosy was only partially a medical question; it was also a social problem that needed the Colombian state’s intervention. The government put into practice most of the commission’s recommendations. Strict regulations on isolation implied exclusion of the healthy, not only as a measure to avoid contagion but also as an economic benefit. By 1911, the government had expelled from Agua de Dios more than 250 nonleprous individuals who had been receiving allowances as lepers.≤Ω Some inhabitants of Agua de Dios were so desperate to remain in their homes that they simulated having the disease or tried by all means to get infected with it to avoid being dismissed from the colony. Many had sought refuge there out of economic necessity. Occasionally, physicians reported healthy children of leprous parents as infected with leprosy so that they

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could receive the o≈cial daily ration.≥≠ This fact suggests that lazarettos were in some sense answers to poverty, like hospitals for the mad in eighteenth-century France.≥∞ By 1912, Agua de Dios had three hospitals run by the Sisters of Charity, two asylums for children a∆icted with leprosy, and four physicians appointed by the government. Contratación counted two resident physicians, one hospital for men, a hospital still under construction for women, and two asylums for sick children. In Caño de Loro the government deferred reforms until it could find an appropriate place to relocate the leprosarium.≥≤ The government continued to give leprosy an important place in the national agenda. In 1918, the Colombian parliament enacted a law creating the Dirección General de Lazaretos, which replaced the previous o≈ce, and establishing the Dirección Nacional de Higiene. This law reinforced the disease-apart approach to leprosy by maintaining two separate realms, one for leprosy and one for all other public health concerns. For physicians and for the government, leprosy was unique, and an exceptional strategy was required to deal with it and with its su√erers. The provisions of this law indicate the extraordinary importance that doctors and Colombian authorities conferred on leprosy. Indeed, forty-five (86 percent) of its fifty-two clauses were devoted to leprosy. Only 14 percent of the law’s provisions were dedicated to other public health matters. The law strengthened the principles of compulsory isolation regardless of social or economic status. The Congress granted the new Dirección de Lazaretos ample powers to regulate leprosaria, to isolate the diseased, and to oversee the collection of taxes destined to intensify the struggle against leprosy. The decree also ordered the construction of hospitals within each lazaretto to experiment with special treatments for leprosy and gave the Colombian state the responsibility for caring for children born or living within the leprosaria.≥≥

Opposing Views of Leprosy Control By the early twentieth century, the Colombian medical community had adopted a positivist approach to leprosy; that is, they saw it as a problem they could manage through medical procedures. However, this rational approach did not imply that doctors had abandoned their harsh attitude toward lepers. Leprosy had to be eradicated, and since the mode of

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transmission of Hansen’s bacillus was unknown, most physicians justified nearly any means to control the disease. Juan de Dios Carrasquilla, who opposed the prevailing view, presented a report about the etiology and prophylaxis of leprosy at the Third Latin American Scientific Congress held in Rio de Janeiro in 1905. Against the majority of his Colombian colleagues, Carrasquilla claimed that the spread of leprosy was produced by social circumstances such as poverty. He asserted that the primary result of the Colombian government’s regulations had been persecution of the sick. Carrasquilla conceived of leprosy as a slightly contagious disease whose evolution was slow, and he was one of the first doctors to point out that the number of lepers had been exaggerated and to encourage the authorities to collect statistics in order to determine the real incidence of the disease.≥∂ The role of the bacillus versus the role of other environmental or social conditions was an important issue among doctors. In 1911, the physician Cenón Solano expressed a point of view similar to Carrasquilla’s when he claimed that conclusive, experimental proof of the contagiousness of the disease was lacking, and that direct inoculation from person to person was not yet verified. Leprosy’s contagious character was generally accepted because the leprosy bacillus was consistently present in the diseased, but Solano asserted that knowledge about the bacillus was insu≈cient to make that claim. It was imperative, he said, to introduce methods of observation and experimentation, to conduct bacteriological and micrographic research, and especially to study the specific national pathology of leprosy; he was convinced that the disease presented special characteristics in Colombia. For this physician, even if leprosy proved to be transmissible, it would still be the least contagious of all communicable diseases. Solano maintained as well that Hansen’s bacillus could not be regarded as the unique agent of the spread of leprosy. At least as important, in his view, were oppression, wars, poverty, starvation, lack of public and private hygiene, and alcoholism, along with other social conditions in Colombia. Solano also contradicted the conclusions of the 1910 commission that inspected Agua de Dios, which were the basis of the current policy on leprosy in Colombia.≥∑ Solano’s views on leprosy coincided with theories expressed by H. P. Lie, the general secretary of the leprosy conference of Bergen, which Solano had attended, and the chief medical o≈cer for leprosy in Norway after Hansen died in 1912.≥∏ According to Lie, leprosy was not a very infectious disease, and it could be related primarily to situations of want and

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misery.≥π Montoya and García Medina disapproved of Solano’s interpretation. Leprosy was not a disease of indigence, they insisted, because most of the leprosy patients were peasants whose living conditions were good, and because there were even capitalists among the patients.≥∫ Miguel Canales, who was a member of the delegation that inspected Agua de Dios in 1910, added the argument that pre-Columbian peoples, who were also poor, had never been a∆icted with the disease.≥Ω The role of poverty in the propagation of the disease was critical because it implied di√erent versions of public health policy. The extreme contagionists, like García Medina, Montoya, and Canales, demanded a policy of strict segregation. Carrasquilla and Solano supported a policy of mild isolation and advocated general hygienic measures and social reform. Although Carrasquilla supported measures such as prohibition of immigration of leprosy patients and isolation, he also advocated the creation of hospitals where leprosy would be treated like any other disease: ‘‘Isolation by itself, empiric isolation, has no object other than to get rid of them [leprosy patients] . . . it is inhumane, ine√ective, and must be replaced by rational prophylactic means.’’∂≠ Carrasquilla thought the hospitals should be located in the center of cities and towns where physicians, assistants, and medications were available, instead of segregating lepers in remote colonies. He viewed hospitals for leprosy patients as institutions where doctors could seek a cure through the practice of hygiene, study the disease, and devise scientific treatments, as in the example of Norway.∂∞ Carrasquilla suggested adopting the model of sanatoria whose hygienic and rational treatment for tuberculosis became fashionable in Europe and in the United States in the early twentieth century.∂≤ However, Carrasquilla’s approach remained unpopular. On the contrary, invoking the Second International Conference on Leprosy held in Bergen (Norway) in 1909, Montoya advocated compulsory notification and strict isolation of patients to control the spread of the disease.∂≥ Montoya opposed Carrasquilla’s recommendations, arguing that locating hospitals in cities would be too expensive for the Colombian budget and that the Colombian masses were not ready for a policy of mild segregation as practiced in Norway: It is understandable that in Norway a few white and educated diseased can be watched over by o≈cial doctors, but who watches over an Indian in Fúquene or a Negress in Lloró? . . . [A]nd even assuming that our race were all white,

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there is no need for false hope because even in Bogotá, prominent people who were allowed home isolation, out of negligence and carelessness failed to observe the law and kept on doing their life as usual, infecting the population. This is why . . . the 1907 law revoked the right to personal isolation. . . . To become European, as Argentina is doing, we would need a strong immigration of races from the North to neutralize our inferior ethnic elements and to educate them because, as everybody knows, peoples of color, or mestizos from the white, Indian, and black races predominate here, and these mestizos are precisely the ones who present more cases of elefancia.∂∂

Note that for Montoya, even prominent people equaled the ‘‘inferior races’’ when they became leprous. Montoya promoted an overtly social and political strategy to eradicate leprosy that included considering leprosy a basis for divorce, prohibiting lepers from exercising certain professions, and impeding marriage for leprosy patients, as in 1902 did Carlos J. Finlay, director of the Sanitary Department of Cuba after the first U.S. occupation of the island ceased. Édouard Jeanselme had also recommended similar measures to control leprosy in French Indochina as part of his mission to that colony in 1899–1900.∂∑ Montoya advised forbidding Chinese immigration on the grounds that Chinese coolies had propagated leprosy and other diseases in North America, adding that the Chinese were the most dangerous race because their occuptions often put them in contact with the upper classes.∂∏ Montoya’s belief fitted well with debates on immigration taking place within Colombia at the time. For example, an influential politician, the liberal leader Rafael Uribe Uribe, was opposed to the admission of Chinese coolies to work on co√ee plantations in Colombia.∂π Montoya’s racist position echoed a widespread anti-Chinese sentiment prevalent in the United States, in some European countries, and in Latin American countries such as Brazil, Mexico, and Cuba. This negative image of the Chinese was condensed into the slogan ‘‘yellow peril.’’∂∫ Racism was common among some Colombian physicians at this time. Solano, for example, claimed that ‘‘pure’’ races such as English or Saxon developed mild forms of leprosy that healed easily and quickly, while mixed races such as mestizos, mulattos, or zambos (those born of an Indian and a black) contracted types of leprosy that were more severe and more di≈cult to cure.∂Ω As part of their project of incorporating their country into the civilized world, the Colombian elites encouraged European immigration to ‘‘whiten’’ the Colombian population.∑≠ Colombian physicians such as Luis López de Mesa elaborated racialist doc-

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trines to explain the backwardness of the nation.∑∞ Whereas physicians argued that the ‘‘indolence’’ and ‘‘stupidity’’ of the racially mixed population were responsible for the poverty and inferiority of the country,∑≤ the elites preferred to place the responsibility for the unsatisfactory social and economic situation on inferior outsiders. Carrasquilla’s proposal of building hospitals in cities and towns where leprosy was endemic was discarded; instead, the government chose a mixed system of agricultural colonies, which included hospitals for leprosy patients.∑≥ It is interesting that several Latin American countries, including Chile, Argentina, and Colombia, built agricultural colonies for criminals between the late nineteenth century and the 1930s.∑∂ The Spanish government employed this model for leprosy when in 1907–9 it founded the Fontilles leprosarium in Alicante, a province of Valencia.∑∑ This was also the strategy used by the U.S. occupational government in the Philippines. The latter case is worth discussing here because there are interesting similarities with the Colombian case. When the United States appropriated the Philippine Islands in 1898 as a result of the Spanish-American War, U.S. o≈cers found leprosy among the diseases that ravaged the population. Philippine lepers were sheltered in the Saint Lazarus hospital in Manila, which had been founded in 1784 by the Franciscan order. The U.S. military authorities took over the hospital and started to round up leprosy su√erers. Friars and others estimated the leper population on the islands to be between 10,000 and 30,000; however, statistics collected by U.S. o≈cials soon revealed the exaggeration, instead indicating between 3,500 and 4,000 cases of leprosy, with some 1,200 new cases developing each year.∑∏ Following the model of Molokai in Hawaii, in 1906 the U.S. military authorities built a leper colony on the island of Culion.∑π A law of 1907 gave Director of Health Victor G. Heiser the power to apprehend every person believed to be a leper, and to detain all in whom the bacillus of leprosy could be demonstrated through bacteriological methods.∑∫ As in Colombia, the active campaign to segregate lepers met with resistance from the patients and their families. The measures implemented by the U.S. sanitary authorities in the Culion leper colony are similar in several respects with those e√ected in Colombia. The laws ordering mandatory segregation of lepers between 1905 and 1918, if necessary with the help of the police, and measures such as disinfecting letters and replacing ordinary tender for special coinage were similar in both cases.∑Ω

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The Question of Numbers Nineteenth-century Colombian physicians had a similarly amplified idea of the number of lepers in their country. When Rafael Reyes committed himself to importing the benefits of modernization and economic development, leprosy became a national concern. Colombia’s international position was an integral and prominent part of the government’s strategy. To meet the new national goals set by the bipartisan elite of merchants, agriculturists, and nascent industrialists, the country desperately needed foreign capital.∏≠ According to the elites, the country also required white European immigrants to supply technical knowledge and modern ethical principles. Within this context, Colombia’s reputation as a country plagued by leprosy was simply inadmissible. The elites needed to present an image of Colombia as a healthy country in order to attract foreign investments and personnel. They also needed to overcome concerns of the U.S. government and public about the potential danger of contracting infectious diseases through Latin American commodities.∏∞ The feminist writer Herminia Gómez de Abadía expressed her views on the subject as follows: ‘‘The news of such an alarming situation [the spread of leprosy] reaches the borders of the country and starts panic in European markets relating to our fruits. Everything originating from Colombia is looked at with suspicion because it is thought that in terms of leprosy the country is at the same level of the Mariana or Caroline Islands.’’∏≤ Physicians gained a sudden awareness of the importance of accurate statistics when they realized that the numbers given by their colleagues of the previous era had been widely disseminated. This was certainly the case for Dr. Julio Manrique, who was sent to India by Reyes’s government to learn more about leprolin, a vaccine recently produced by E. R. Rost in that country, that was said to be the latest technology available to treat leprosy.∏≥ When Manrique arrived in London, en route to India, in July 1905, other leprologists had already discredited the use of leprolin, so his trip to India was canceled. Instead, he visited Norwegian leper hospitals, which were the mecca of leprologists given that the health authorities in that country had been quite successful in controlling the expansion of the disease in the nineteenth century. At his return, Manrique submitted a report to the Colombian government, in which he declared: ‘‘The country [Colombia] is enduring genuine and true outrages caused by exaggerated data given by

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the unlearned . . . which are daily published in foreign books and newspapers. . . . In maps depicted in all classical works which indicate the distribution of leprosy in the world our country is stained in red, the color chosen to mark the abundance of the disease. . . . Not even in British India, where the numbers of diseased count in the hundreds of thousands, not even in the Sandwich and Hawaiian Islands, is the stain that stigmatizes as large, nor its color as bright.’’∏∂ Physicians were astonished by the e√ect that the leprosy data publicized by their nineteenth-century colleagues had generated, and they began to look for the reasons for such overstatement. Evaristo García, from the Society of Medicine of Cauca, claimed in 1904 that the desire to collect resources to build lazarettos and the wish of physicians to convince the government of the necessity of hospitalizing lepers were responsible for the exaggeration. Other physicians such as Teodoro Castrillón, who had previously translated and published in Paris an article from the Revista Médica including the exaggerated numbers, and José María Ruiz expressed similar ideas with the intention of denouncing the overstatement of leprosy in Colombia.∏∑ In 1910, Montoya, the first historian of leprosy in Colombia, o√ered a carefully reasoned account of the exaggeration. According to him, nineteenth-century doctors wanted to promote charity by overstating the number of leprosy su√erers. Montoya primarily blamed the Salesian priest Evasio Rabagliati for the exaggeration, ignoring the fact that the latter merely used a strategy that was already being used by physicians.∏∏ Montoya’s account has to be understood within the context of the competition between physicians and religious institutions for the control of leprosy. By incriminating a member of the church, he attempted to exonerate the medical profession of which he was a prominent member. At the same time, Montoya commended the government for having directed in 1905 that all expenses to build or enhance the lazarettos should originate from the public treasury in order to prevent any more grotesque exaggeration. According to Montoya, this overstatement was intended ‘‘to inspire a holy terror, a profitable panic, so that all Colombians would contribute to the great task of isolation, which had, among other inconveniences, the one of isolating us from the other nations, with fantastic figures . . . to the point that the name Colombian was [a] synonym of leper.’’∏π From that moment on, collecting statistical information became a fundamental step in controlling leprosy. In his position as a consulting physician for the lazarettos, García Medina started gathering statistics sent by doctors

146 d i a n a o b r e g ó n Cover of Juan Bautista Montoya y Flórez’s book on leprosy, Contribución al Estudio de la Lepra en Colombia (Medellín: Imprenta editorial, 1910).

from the di√erent Colombian regions. He accomplished this task between 1905 and 1909 and published the results. In 1909 García Medina counted 4,296 lepers in Colombia; 72 percent were isolated in the three lazarettos, contrasting with the 16 percent that had been isolated in 1905.∏∫ Physicians had an additional interest in advertising the new statistics on both national and international levels: as a professional body they wanted to avoid being regarded as incompetent and powerless. Using statistics for rhetorical purposes, doctors emphasized the high proportion of patients who were isolated as an indication of medical e≈ciency. One of the sessions of the Second National Medical Congress, held in Medellín in 1913, was devoted to leprosy. One of the main topics of discussion was the recent statistics of leprosy in Colombia and the urgency of disseminating them abroad to

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eliminate the negative image of the nation and emphasize the e≈ciency of Colombian doctors.∏Ω For at least the first four decades of the twentieth century, Colombian physicians worried about the problem of Colombia’s international reputation as a nation beset with leprosy. Doctors tried to correct this image at international conferences. García Medina, then director of the national Bureau of Hygiene, attended the Sixth Pan American Sanitary Conference, held in Montevideo in 1921. There, he claimed that Colombia’s policy against leprosy since the application of mandatory declaration in 1905 had been highly successful: 80 percent of the Colombian leper population had been isolated and the remaining 20 percent would be segregated within one year. García Medina insisted that the leprosy statistics showed only 6,560 Colombians a∆icted with the disease in the whole country, not 30,000. Exhibiting his political acumen, he declared that the country was able to observe all its current international sanitary obligations.π≠ The First American Conference on Leprosy, held in Brazil in 1922, provided another opportunity for Colombian doctors to advertise what they regarded as an e√ective policy of isolation. Representatives from thirteen American countries gathered to discuss the problem of leprosy. Carlos Chagas, the illustrious Brazilian discoverer of Trypanosomiasis americana, was the president of the conference. José Ignacio Uribe, a professor of dermatology at the national university, was the Colombian delegate, and García Medina presented his study ‘‘Prophylaxis and Treatment of Leprosy in Colombia.’’ Uribe reiterated that only 0.1 percent of Colombia’s population was a∆icted with the disease, as compared with India, which with about 125,000 leprosy su√erers in 1885 was considered worldwide to have the highest rate of infection. The conference’s conclusions encouraged the organization of technical associations to realize scientific research on leprosy and the creation of special leprosy chairs in the medical faculties of the American nations. Neither of these suggestions was put into practice in Colombia for at least a decade.π∞ Despite the lengthy struggle to disseminate their new statistics on leprosy, the conflicting data created deep confusion within the international community of leprosy specialists. In 1925, Leonard Robers and Ernest Muir, recognized authorities on leprosy, declared: ‘‘Very varying statements have been made of the incidence of leprosy in Colombia in recent years, Hicks in 1890 estimating 18,000 or 3 per mille, Hollopeau 30,000, or 7.5 per mille, Sauton 8.2 per mille, while Ruiz in 1908 only knew of 0.85 per mille,

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and Montaya [sic] in 1910 gives nearly 1.0 per mille.’’π≤ Although Colombian physicians made an e√ort to develop a more realistic approach to leprosy, the international image of Colombia as a leprous country remained until at least the 1940s.

Medicalization and Resistance Leprosy patients were not as confident as doctors were about the reorganization of leprosaria. Rather than generating optimism about finding effective treatments, the medicalization of leprosy in the first decades of the twentieth century signified oppression and abuse for leprosy patients. Because the mode of transmission of leprosy was unknown, the medical authorities aimed to take all possible precautions to prevent infection. Patients and residents of the lazarettos actively opposed measures of strict isolation. For example, in mid-1907, residents of the lazaretto destroyed the barbedwire fence surrounding the sanitary cordon. This incident provoked a fierce reaction from the governor of the department of Cundinamarca, who immediately arrived at the lazaretto with a group of soldiers. The transgressors were not found because, as the patient Antonio Gutiérrez recalled in his memoirs, ‘‘it was a common cause among all the diseased.’’π≥ The resistance produced by the reforms increased between 1910 and 1911. Up until this time, leprosy patients had served as medical assistants and pharmacists in the administration of the lazaretto. The new authorities replaced them with employees who were free from the disease in order to enforce isolation. This displacement generated friction and anxiety among the population of Agua de Dios. In May 1911, a group of leprosy su√erers who had escaped from Contratación arrived at Agua de Dios. The minister of government ordered them to return to that lazaretto. At the same time, the authorities of Agua de Dios sent to Contratación a number of their own patients for supposed violation of the lazaretto’s rules, causing consternation among the residents of Agua de Dios. Other dispositions directed to prevent contagion had also generated a climate of fear and apprehension. The lazaretto residents rejected the special currency called coscoja and the requirement of o≈cial permits for sick and healthy inhabitants of Agua de Dios to enter and leave town. On July 9, 1911, the ine≈ciency of the leprosarium’s administration in issuing the mandatory passes prompted a riot among the crowd gathered for the town’s weekly market. Enraged patients,

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some of them with weapons, demanded the immediate distribution of the required certificates. During the tumult, the apothecary’s shop was partially destroyed. The administrator, the physicians, and other employees escaped. The government dispatched additional soldiers to Agua de Dios and nominated a military o≈cer as the new administrator. Subsequently, thirteen lepers were found guilty of the riots and deported to Caño de Loro in the northern part of the country.π∂ After the disturbances, Dr. Miguel Canales, one of the originators of the policy of isolation, came out in favor of increasing the permanent police force within leprosaria.π∑ Writing in the early 1920s, the patient Antonio Gutiérrez compared the last ten-year period of Agua de Dios’s history with the relatively prosperous, flourishing, and almost happy age prior to the government’s reforms: ‘‘The rebuilt barbed-wire fence . . . has since then been protected and reinforced by a . . . Corps of Gendarmerie which with weapons in their arms and fixed bayonet[s] guards permanently the great flock of outcasts which [have been] relegated with their families to their last entrenchments, that is, to their humble dwellings; [they] cannot move except within the narrow perimeter of the triple and intimidating fence, emphatically called sanitary cordon, which surrounds the village.’’π∏ Although lazarettos were always places of confinement, they had also once been sites where lepers were protected from public hostility and prejudice.ππ When the government abolished the weekly market in order to prevent the expansion of leprosy into the areas surrounding Agua de Dios, matters became even worse. The authorities made agreements with a dealer to supply provisions to the lazaretto, but unfortunately, this decision resulted in the organization of a food monopoly that charged exorbitant prices to Agua de Dios residents. Agriculture and craftsmanship had been main sources of livelihood for the lazaretto’s inhabitants. The imposition of the sanitary cordon severely limited these occupations, contributing to starvation and discontent among the residents.π∫ The physicians Julio Manrique and Arturo Arboleda censured this situation when they visited Agua de Dios in 1913.πΩ Not only had the circumstances of patients worsened, they said, but the goal of isolation had not been accomplished. The special currency meant to prevent contagion served instead as a means of corruption and abuse, while regular currency continued to circulate freely. Nonleprous people, usually patients’ relatives, were adversely a√ected because they were subjected to the same requirements for inspections, passes, and disinfecting.∫≠ O≈cial policy required rigorous disinfection for inhabitants who wished

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to leave the lazaretto. Visitors of inhabitants also had to endure the same course of disinfecting; but physicians, apothecaries, civil servants, the Salesian priests, and the Sisters of Charity departed without those procedures, showing that the decontamination was a ritual rather than a real preventive measure. About this León-Gómez wrote with irony: ‘‘Science, Authority, and Religion, preserve [people] from contagion.’’∫∞ Moreover, the patients believed that the anticontagionist policy developed at the lazaretto was ine√ectual; Gutiérrez, for example, claimed, ‘‘The general concept of all the inhabitants of this place of desolation and horror, of tears and bitterness, is that the government and society should not continue supporting any longer such an unnecessary and costly anticontagionist apparatus which, it has been demonstrated, is totally useless and derisory.’’∫≤ Patients insisted that leprosy was not contagious, but they knew that contagionist theories had won the day. Physicians, who were aware of the patients’ beliefs, regarded those opinions as deterrents that needed to be overcome in their crusade against the spread of the disease. The governmental measures caused riots at Agua de Dios until at least 1919. As a result, the o≈cial repression increased, and the lazaretto remained under military rule throughout the period. One government minister referred to Agua de Dios as a ‘‘Bolshevik republic’’ where hate, despair, and envy prevailed.∫≥ These images not only evoked a medieval portrait of the leper as an evil, angry heretic, but also revealed the deeper political anxieties of the upper classes. Since lepers were considered dangerous, they were also objects of political apprehension, as they had been in medieval society.∫∂

Conclusion In the early twentieth century, a new concept of the lazaretto developed along with the new political order in Colombia. As with the penitentiary idea in Latin America, the modern republic demanded institutions to produce the new citizen—an obedient, virtuous, honorable, self-restraining, and diligent individual. Because leprosy was a prominent issue in Colombia, lepers were chosen to become such new model citizens. A modern, democratic regime could not tolerate the paternalistic attitude of previous governments toward leprosy; according to the new law, poor and rich should be treated equally and isolation should be enforced for all. The interested Salesian viewpoint was also to be discarded to reinforce the au-

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thority of the state. Only the state, based on its indisputable jurisdiction to protect society from the dangers of leprosy, was authorized to build and administrate leprosaria and to collect private donations to lepers. However, the practice di√ered from the ideal. Patients actively opposed the isolation measures, and nonleprous residents of the lazarettos never left them despite the e√orts of the government to drive them out. Physicians were certainly empowered, but they were divided in their visions of leprosy control. Most doctors tended to ignore poverty as a major cause of disease, and as a group the medical community remained indi√erent to social reform. Whether or not leprosy was extremely contagious was a matter of contention among physicians, but partisans of extreme segregation imposed their point of view. Other infectious diseases had been arrested by attacking the agents of disease. This model when applied to leprosy degenerated into attacking lepers themselves because they were the only known vectors of infection. The policy to control leprosy produced persecution for patients as lazarettos became prisonlike institutions. Segregation had additional meanings; setting leprosy patients apart was a way for society to preserve itself from the dreaded sight of lepers. Regardless of the o≈cial bombast, the government held a racist attitude toward its own leprosy population and adopted procedures like those devised by the Western nations in their colonial possessions. Colombian su√erers of leprosy experienced the addition of a new, modern stigma: leprosy became a disease originating from ‘‘poor,’’ ‘‘uncivilized’’ countries and ‘‘inferior’’ peoples.

Notes 1 For a more detailed discussion, see Diana Obregón, ‘‘Struggling against Leprosy: Physicians, Medicine, and Society in Colombia, 1880–1940’’ (Ph.D. diss., Virginia Polytechnic Institute and State University, 1997). 2 Ricardo D. Salvatore and Carlos Aguirre, eds., The Birth of the Penitentiary in Latin America: Essays on Criminology, Prison Reform, and Social Control 1830– 1940 (Austin: University of Texas Press, 1996), ix–xxi, 1–43. 3 Zachary Gussow and George S. Tracy, ‘‘Stigma and the Leprosy Phenomenon: The Social History of a Disease in the Nineteenth and Twentieth Centuries,’’ Bulletin of the History of Medicine 44.5 (1970): 425–49, on 440. 4 On the geographical distribution of leprosy in the nineteenth century, see Dom Sauton, La Léprose (Paris: C. Naud, 1901), 43–92. 5 Zachary Gussow, Leprosy, Racism, and Public Health: Social Policy in Chronic

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Disease Control (Boulder: Westview Press, 1989), 201–28. 6 Arthur A. St. M. Mouritz, The Path of the Destroyer: A History of Leprosy in the Hawaiian Islands and Thirty Years Research into the Means by Which It Has Spread (Honolulu: Honolulu Star-Bulletin Press, 1916), 32–34, 63. 7 Henri Leloir, Traité Pratique et Théorique de la Lèpre (Paris: A. Delahaye et Lecrosnier, 1886), 7. 8 Ibid., 265, 306–7. 9 Gussow, Leprosy, Racism, and Public Health, 84. 10 Donald H. Currie, ‘‘Resolutions Adopted by the Berlin Conference of 1897,’’ Public Health Reports 24.38 (1909): 1361. 11 Marcial I. Quiroga, Historia de la Lepra en la Argentina (Buenos Aires: Talleres Gráficos del Ministerio de l’Educación et Justicia, 1964), 64–65. 12 Ibid., 64. On the case of Brazil, see the 1897 report by Dr. Azevedo Lima in H. C. Souza-Araujo, História da Lepra no Brasil, vol. 3: Período Republicano 1890–1952 (Rio de Janeiro: Departamento de Impresa Nacional, 1956), 60– 63. 13 For a detailed analysis of the exaggeration and the proposal to build an island lazaretto, see Diana Obregón, ‘‘Lepra, Exageración y Autoridad Médica,’’ Asclepio L-2 (1998): 131–53; and Obregón, ‘‘Building National Medicine: Leprosy and Power in Colombia,’’ Social History of Medicine 1 (2002): 89–108. 14 Quiroga, Historia de la Lepra en la Argentina, 72. 15 Victor A. Gómez, ‘‘Correspondencia sobre la Lepra,’’ Revista Médica 24.295 (1904): 110–11. 16 With U.S. complicity, Panama declared its independence in 1903. On this issue see David Bushnell, The Making of Modern Colombia: A Nation in Spite of Itself (Berkeley: University of California Press, 1993), 148–54; Steven J. Randall, Colombia and the United States: Hegemony and Interdependence (Athens: University of Georgia Press, 1992), chap. 3. 17 On the government of Rafael Reyes, see Charles W. Bergquist, Co√ee and Conflict in Colombia, 1886–1910 (Durham: Duke University Press, 1978), 225–46; Marco Palacios, Co√ee in Colombia, 1850–1970: An Economic, Social, and Political History (Cambridge: Cambridge University Press, 1980), 141– 47; see also Darío Mesa, ‘‘La Vida Política después de Panamá,’’ in Manual de Historia de Colombia, vol. 3 (Bogotá: Colcultura, 1980), 83–176. 18 Boletín de la Sociedad Geográfica de Colombia, special issue (April 1907): 7– 57. 19 Diana Obregón, Sociedades Científicas en Colombia: La Invención de una Tradición, 1859–1936 (Bogotá: Banco de la República, 1992), 206–10; Javier Sáenz Obregón, Óscar Saldarriaga, and Armando Ospina, Mirar la Infan-

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21

22

23 24 25 26 27 28

29

30 31 32 33

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cia: Pedagogía, Moral y Modernidad en Colombia, 1903–1946, 2 vols. (Medellín: Universidad de Antioquia, 1997), see especially vol. 2. Rafael Reyes, ‘‘Mensaje Presidencial sobre Lazaretos,’’ September 1904, in Baldomero Sanín Cano, Administración Reyes (1904–1909) (Lausanne: Imprenta Jorge Bridel, 1909), 203. Legislative Decree, January 14, 1905, and Resolution 3 from the Oficina Central de Lazaretos, in Juan Bautista Montoya y Flórez, Contribución al Estudio de la Lepra en Colombia (Medellín: Imprenta Editorial, 1910), 165– 76; Resolution 2 from the Junta Central de Higiene, in Revista Médica 25.302 (1905): 332–39. Emilio Quevedo Vélez et al., ‘‘Ciencias Médicas, Estado y Salud en Colombia: 1886–1957,’’ in Historia Social de la Ciencia en Colombia, vol. 8 (Bogotá: Tercer Mundo, 1993), 161–289, on 191. Decree 1,095, September 12, 1906, and law 14 of 1907, in Montoya, Contribución, 178, 183. Pablo García Medina, ‘‘Profilaxia de la Lepra en Colombia,’’ Repertorio de Medicina y Cirugía 1-1.1 (1909): 52–59, on 55–56. Miguel A. González Prendes, Historia de la Lepra en Cuba (Havana: Museo Histórico de las Ciencias Médicas ‘‘Carlos J. Finlay,’’ 1963), 250–57. Souza-Araujo, História da Lepra no Brasil, 115–17. Quiroga, Historia de la Lepra en la Argentina, 73–77. Miguel Canales, R. Ucrós, and J. Olaya Laverde, ‘‘Informe de la Comisión Encargada de Visitar el Lazareto de Agua de Dios,’’ Revista Médica 29.342– 44 (1911): 39–73, on 40. Leprosy su√erers themselves gave various names to Agua de Dios that conveyed the idea of extreme sorrow, pain, and a∆iction. See Antonio Gutiérrez Pérez, Apuntamientos para la Historia de Agua de Dios (Bogotá: Imprenta Nacional, 1925), passim. Decree 903 from 1910, regulating the stay of healthy relatives of patients, in Gutiérrez, Apuntamientos, 378–80; Jorge Roa, ‘‘Notas del Señor Ministro de Gobierno sobre Lazaretos,’’ Revista Médica 29.347–48 (1911): 139–41. Montoya, Contribución, 365. Michel Foucault, Madness and Civilization (New York: Random House, 1961, 1965), 48–49. Pedro M. Carreño, ‘‘Lazaretos,’’ Revista Médica 30.362–64 (1912): 262–76. ‘‘Ley 32 de 1918 (10-29-1918) sobre Organización y Dirección de los Lazaretos de la República y Reorganización de la Dirección Nacional de Higiene,’’ Revista de Higiene 9.3 (1918): 72–78; Enrique Enciso, ‘‘Breve Historia de la Campaña contra la Lepra en Colombia. Nuevo Plan de Lucha contra esta Enfermedad,’’ Revista de Higiene 13.8, 2d época (1932): 257–95, on 265.

154 d i a n a o b r e g ó n 34 ‘‘La Lepra: Etiología, Historia y Profilaxis, por el Dr. Juan de D. Carrasquilla L. Memoria Presentada al Tercer Congreso Científico Latinoamericano que ha de Reunirse en Río Janeiro en Agosto de 1905,’’ Revista Médica 25.301 (1905): 289–302, on 298–300. 35 Cenón Solano, ‘‘Lepra: Herencia y Contagio,’’ Repertorio de Medicina y Cirugía 2–10.22 (1911): 532–60. 36 Cenón Solano, ‘‘La Lèpre dans la Colombie,’’ in Mitteilungen und Verhandlungen II Internationale Wissenschaftliche Lepra-Konferenz Abgehalten vom 16 bis 19 August 1909 in Bergen (Norwegen) (Leipzig: Johann Ambrosius Barth, 1910), 63–73. 37 H. P. Lie, ‘‘Why Is Leprosy Decreasing in Norway?’’ International Journal of Leprosy 1.2 (1933): 205–16. This article is a reprint of a paper read at a dermatological meeting in 1928, but it contained ideas that Lie had been communicating since 1904 in his work on leprosy in Norway. 38 Pablo García Medina, ‘‘Profilaxia de la Lepra en Colombia, Part 2,’’ Repertorio de Medicina y Cirugía 1-2.2 (1909): 112–24, on 121; see the same conclusion in Montoya, Contribución, 229–30. Many historians would contradict the idyllic picture presented by these doctors; for example, Palacios, Co√ee in Colombia. 39 Canales, ‘‘Lepra: Observaciones a una Conferencia del doctor Zenón [sic] Solano,’’ 317–33. 40 ‘‘La Lepra: Etiología, Historia y Profilaxis,’’ 300. 41 Juan de Dios Carrasquilla, ‘‘Los Sanatorios y la Lepra,’’ Revista Médica 26.306 (1905): 65–71. 42 On sanatoria for tuberculosis, see the classical study by René J. Dubos and Jean Dubos, The White Plague: Tuberculosis, Man and Society (Boston: Little, Brown, 1952); see also Lynda Bryder, Below the Magic Mountain: A Social History of Tuberculosis in Twentieth-Century Britain (Oxford: Clarendon Press, 1988); and Sheila M. Rothman, Living in the Shadow of Death: Tuberculosis and the Social Experience of Illness in American History (New York: Basic Books, 1994). On sanatoria for tuberculosis in Latin America, see Diego Armus, ‘‘Cuando los Enfermos Hacen Huelga: Argentina, 1900–1940,’’ Estudios Sociales: Revista Universitaria Semestral (2001): 53–80; and Claudio Bertolli Filho, História Social da Tuberculose e do Tuberculoso: 1900–1950 (Rio de Janeiro: Editora Fiocruz, 2001), chap. 6. 43 Montoya presented his ideas at the Second National Medical Congress held in Medellín in 1913; see Juan Bautista Montoya y Flórez, ‘‘Profilaxis de la Lepra en Colombia (Segundo Congreso Médico Nacional),’’ Revista Médica 31.375 (1913): 321–31, on 327. 44 Montoya, Contribución, 336–37. 45 Édouard Jeanselme, La Lèpre (Paris: G. Doin, 1934), 563–64.

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46 Montoya, ‘‘Profilaxis de la Lepra en Colombia,’’ 322–25; and Montoya, Contribución, 299. 47 Palacios, Co√ee in Colombia, 145. 48 On the case of the United States, see Gussow, Leprosy, Racism, and Public Health, 111–29; on Latin America, see Richard Graham, ed., The Idea of Race in Latin America, 1870–1940 (Austin: University of Texas Press, 1990), 3, 9, 54. 49 Solano, ‘‘Lepra: Herencia y Contagio,’’ 549. 50 Aline Helg, ‘‘Los Intelectuales frente a la Cuestión Racial en el Decenio de 1920,’’ Estudios Sociales 4 (March 1989): 37–52, on 47–48; and Peter Wade, Blackness and Race Mixture: The Dynamics of Racial Identity in Colombia (Baltimore: Johns Hopkins University Press, 1993). 51 Bruce Michael Bagley and Gabriel Silva Luján, ‘‘De cómo se ha Formado la Nación Colombiana: Una Lectura Política,’’ Estudios Sociales 4 (March 1989): 9–36, on 17. 52 On the issue of mestizaje, see Jaime Jaramillo Uribe, Ensayos sobre Historia Social Colombiana (Bogotá: Universidad Nacional de Colombia, 1974). 53 García Medina, ‘‘Profilaxia de la Lepra en Colombia,’’ 55–56. 54 Salvatore and Aguirre, eds., The Birth of the Penitentiary in Latin America, 10–14. 55 Josep Bernabeu Mestre and Teresa Ballester Artigues, ‘‘Lepra y Sociedad en la España de la Primera Mitad del Siglo XX: La Colonia Sanatorio de Fontilles (1908–1932) y su Proceso de Intervención por la Segunda República,’’ Dynamis. Acta Hispanica ad Medicinae Scientiarumque Historiam Illustrandam 11 (1991): 287–344, on 300–303. 56 Ronald Fettes Chapman, Leonard Wood and the Leprosy in the Philippines: The Culion Leper Colony, 1921–1927 (Lanham, Md.: University Press of America, 1982), 1–6. 57 Another Saint Lazarus hospital founded by the Spaniards in Culion in 1784, administered by a Jesuit and nursed by the sisters of Saint Paul de Chartres’s order, probably did not exist in 1906. On the foundation of Saint Lazarus hospitals in the Philippines, see Félix Contreras Dueñas and Ramón Miguel y Suárez Inclán, Historia de la Lepra en España (Madrid: Gráfica Hergon, 1973), 91. 58 Victor G. Heiser, ‘‘Leprosy in the Philippine Islands,’’ Public Health Reports 24.33 (1909): 1155–59, on 1155–56. 59 Chapman, Leonard Wood and the Leprosy in the Philippines, 7–11. 60 Bergquist, Co√ee and Conflict, 225. 61 Abel, Health Care in Colombia, 24–25. 62 Herminia Gómez Jaime de Abadía, Leyendas y Notas Históricas (Bogotá: Imprenta Nacional, 1907), 186.

156 d i a n a o b r e g ó n 63 E. R. Rost, ‘‘The Cultivation of the Bacillus Leprae by E. R. Rost,’’ Indian Medical Gazette 39 (1904): 167–69. 64 Julio Manrique, quoted by Montoya, Contribución, 181–82. 65 Teodoro Castrillón T., Lepra y Leprosos: Conferencia Dictada en los Salones del Centro Artístico (Imprenta Oficial, 1907): Montoya, Contribución, 184–89, 354–55. 66 Montoya, Contribución, 345–47. 67 Ibid., 353. 68 García Medina, ‘‘Profilaxia de la Lepra en Colombia,’’ 120–22. 69 ‘‘Segundo Congreso Médico Nacional,’’ Revista Médica 35.420–21 (1917): 416–21. 70 Pablo García Medina, ‘‘Sexta Conferencia Sanitaria Internacional Panamericana de Montevideo: Informe Presentado por el Delegado de la República de Colombia,’’ Repertorio de Medicina y Cirugía 12-8.140 (1921): 408, 413; see also ‘‘VI Conferencia Sanitaria Internacional de las Repúblicas Americanas,’’ in ibid., 12-6.138 (1921): 288–95. 71 ‘‘La Primera Conferencia Americana de la Lepra,’’ Repertorio de Medicina y Cirugía 14-3.159 (1927): 85–90; and José Ignacio Uribe, ‘‘Sobre Lepra,’’ in ibid., 90–99. 72 Sir Leonard Rogers and Ernest Muir, Leprosy (New York: William Wood, 1925), 44. 73 Gutiérrez, Apuntamientos, 46–48. About patients’ collective mobilizations, see Armus, ‘‘Cuando los Enfermos Hacen Huelga’’ and ‘‘De ‘Médicos Dictadores’ y ‘Pacientes Sometidos’: Los Tuberculosos en Acción, Argentina, 1920–1940,’’ Allpanchis 53 (1999): 219–53; about cancer patients’ struggle for their rights, see Emilio de Ipola, ‘‘Estrategias de la Creencia en Situaciones Críticas: El Cáncer y la Crotoxina en Buenos Aires durante la Década del Ochenta,’’ in Diego Armus, ed., Entre Médicos y Curanderos: Cultura, Historia y Enfermedad en América Latina Moderna (Buenos Aires: Norma, 2002), 371–418. 74 Gutiérrez, Apuntamientos, 57–66. 75 Canales, ‘‘Lepra: Observaciones a una Conferencia del Doctor Zenón [sic] Solano,’’ 333. 76 Gutiérrez, Apuntamientos, 114. 77 This attitude was reflected in earlier accounts of Agua de Dios by leprosy su√erers; see Luis Carlos Pradilla, ‘‘Nuestra Misión y Nuestro Deber,’’ La Voz del Proscrito 1.5 (1880), in Gutiérrez, Apuntamientos, 235–37. 78 Adolfo Léon-Gómez, La Ciudad del Dolor, 3d ed. (Bogotá: Imprenta de Sur América, 1927), 252–54, 278–80. 79 Julio Manrique and Arturo Arboleda, ‘‘Una Visita al Lazaretto de Agua de Dios,’’ Repertorio de Medicina y Cirugía 4-4.40 (1913): 219–20.

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80 León-Gómez, La Ciudad del Dolor, 280–83; and Gutiérrez, Apuntamientos, 90–116. 81 León-Gómez, La Ciudad del Dolor, 288. 82 Gutiérrez, Apuntamientos, 127. 83 León-Gómez, La Ciudad del Dolor, 120; and Gutiérrez, Apuntamientos, 137. 84 For an analysis of the role of persecution of lepers in the period of early state formation in medieval Europe, see R. Moore, The Formation of a Persecuting Society: Power and Deviance in Western Europe, 950–1250 (Oxford: Basil Blackwell, 1987).

anne-emanuelle birn

Revolution, the Scatological Way the rockefeller foundation’s hookworm campaign in 1920s mexico

irca 1890, Parisian statistician-bureaucrat Jacques Bertillon together with several colleagues devised the first scientific classification of diseases for standard use on death certificates. The Bertillon classification was rooted in the physiological topography of the human body, whereby each disease was linked to a particular organ system. Drawing on new developments in medical science, this nosology sought to improve the national collection of vital statistics and enabled, for the first time, international comparisons of disease patterns. Around the same time, international health authorities—including colonial o≈cials, tropical disease specialists, and military medical men—became similarly concerned with classifying disease. These o≈cials employed the Bertillon system but also developed what we might consider a parallel nosology based on the politico-economic topography of disease. In this parallel system, classification derived from each disease’s relationship to the emerging global economic system rather than to its location in particular organs. Cholera, a general disease in the early Bertillon classifications, was for international health authorities a problem of (and reason to suspend) immigration, as migrants were feared fecal transmitters of this menacing disease. Evidence of trachoma, a disease of the nervous system and sensory organs in the Bertillon classification, similarly served as a justification for health authorities, who feared the political and economic consequences of blind newcomers becoming wards of the state, to bar immigrants. Frequently fatal yellow fever was, according to turn-of-the-century international sanitary agreements, a threat to worldwide commerce, for ships could transport the disease-transmitting Aedes aegypti mosquito vector from port to port. The international health nosology was increasingly applied to trop-

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ical diseases within the framework of imperialism, with the political and economic priorities of the colonial powers serving as a classification system.∞ For example, esteemed British malariologists Patrick Manson and Ronald Ross—who in British India uncovered the mosquito as malaria’s agent of transmission—held that disease ‘‘was the main factor holding back development’’ in the tropical world and that science could overcome this problem.≤ In the early-twentieth-century United States, a new player—the Rockefeller Foundation (rf)—added a new disease to this imperialist nosology. Hookworm, the ‘‘germ of laziness,’’ was classified as an impediment to productivity in tropical and semitropical regions; its eradication would pave the way for industrialization.≥ Rarely fatal and largely unrecognized, anemia-inducing hookworm di√ered from other diseases in the imperialist nosology in that its importance was fashioned more from its clear solution than from its appreciation as a pressing economic problem. Easy to diagnose and treat and inexpensive and rapid to combat, hookworm’s control would unleash far more than greater productivity. The rf discovered the potential of controlling hookworm with an inaugural campaign in the U.S. South in 1910–14, and within a decade had expanded its e√orts across three continents. For the rf, hookworm paved the straightest path to public health triumphalism and the concomitant diplomatic, political, social, and economic benefits. The rf’s hookworm campaign in Mexico—launched in 1924—began choppily but eventually managed to o√er something for everyone. Peasants made good on their claims to state services. Doctors began to reap the fruits of rural medicalization. Agricultural barons gained a more productive workforce. Mexican politicians earned popular support. State builders sowed the state. The rf promoted its public health model and dispelled suspicion of the United States. And the United States generally benefited through a much-needed neighborliness that paved the way for more fruitful trade relations. That hookworm was an ailment of secondary importance mattered little; indeed, this made hookworm multiply malleable. With the rf arriving just as the bellicose years of the Mexican Revolution (1910–20) were yielding to concrete demands for broad-based social amelioration, the hookworm campaign was transformed into an expression for revolutionary fervor – not only by a variety of Mexican actors, but by International Health Board o≈cers as well. The imperialist nosology was now redefined ‘‘on the ground’’ in the context of 1920s Mexico: combating hookworm disease became classified not simply as a stimulant to development but rather as part

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of revolutionary social change. This chapter examines the origins of the rf’s hookworm program in Mexico, the ingredients of the campaign, and perspectives of the various constituencies involved, contrasting the campaign’s bumpy beginnings with its subsequent depiction as a revolutionary e√ort.

The Malady Hookworm infection, as understood since the early twentieth century, can produce anemia, stunted growth, fatigue, and swollen bellies—particularly in children. The ailment results from the presence of blood-sucking Necator americanus worms (in North and Central America; Ancylostoma duodenale elsewhere) in the small intestines. The worm larvae enter the human body through tender skin—generally between the toes—and travel to the lungs, where they are coughed out and swallowed into the alimentary tract. There the nourished larvae grow into half-inch-long worms, cling to the intestinal wall, and reproduce, expelling thousands of eggs with the stool. If the conditions are right—warm, moist, shaded soil—the eggs hatch and develop into larvae: transmission often occurs when barefoot persons are exposed to infected feces or swallow contaminated soil. The distribution of hookworm—in tropical and subtropical climates forming a band across the globe, including the southern United States, much of Latin America, northern Africa, southern Europe, and northern Asia—placed hookworm squarely within the geographic purview of the imperialist nosology; the rf was instrumental in making the ailment a political and economic priority.

The RF and the Making of a Hookworm Campaign in Mexico Hookworm’s control di√ered from that of other tropical diseases in its patron. Unlike the sponsors of malaria or yellow fever campaigns in the Panama Canal, for example, the rf represented no direct military or business interest. Rather, it heralded a new era of scientific philanthropy brimming with self-declared humanitarianism whereby charity was replaced with professionally run, systematic e√orts to address societal problems. Oil magnate John D. Rockefeller turned his philanthropic attention from education and research to hookworm in 1909, funding the large-scale Rockefeller Sanitary Commission for the Eradication of Hookworm.∂ Masterminded by Rocke-

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feller’s confidante, Baptist preacher Frederick Gates, together with maverick medical zoologist Charles Wardell Stiles and prominent educator-turnedphilanthropy administrator Wickli√e Rose, the commission sent teams of physicians, sanitary inspectors, and laboratory technicians to countless rural communities in eleven states over a five-year period to prevent and treat hookworm among more than a million poor southerners. Though only moderately successful in disease eradication terms, the Sanitary Commission awakened its funder to a variety of public health and development priorities, including professional training, the organization of permanent health departments, the combating of a certain set of diseases, and popular health education. Such activities became central to the rf, formally incorporated in 1913 with a $50 million endowment (the equivalent of nearly $1 billion today) and an ambitious mission ‘‘to promote the well-being of mankind throughout the world.’’ Public health was particularly suited to the rf’s international agenda of promoting goodwill and improving local technical capacity. Hookworm control served as the hallmark campaign of its new International Health Commission (which became the International Health Board, or ihb, in 1916 and the International Health Division in 1927), beginning with a campaign on the plantations of the British West Indies in 1916.∑ By the early 1920s, rf hookworm campaigns had been carried out in numerous settings in the Americas, the Caribbean, and Asia, eventually reaching fifty-two countries and twenty-nine islands across the hookworm band.∏ Amenable to detection under the microscope, treatment through oral doses of chenopodium and a purgative, and prevention through latrine construction and the promotion of shoe wearing, hookworm—and its elimination—became the very model of the possibilities of modern public health fortified by the triumvirate of specific etiology, the new pharmacology, and Progressive Era notions of prevention. With eradication as the ultimate goal, hookworm activities carried a series of accompanying objectives. The combination of low spending, high visibility, and public drama made hookworm ideally suited to e≈ciently bringing health services to a large rural population; convincing peasants, doctors, o≈cials, and economic elites of the value of modern public health and medicine; helping to stabilize colonies and build emerging states; and improving diplomatic relations with the United States. Mexico’s geopolitical, economic, and social importance to the United States made it an obvious candidate for a hookworm campaign. The rf had

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sought to enter Mexico with a variety of disease-control measures during the Mexican Revolution but was repeatedly rebu√ed. Finally, in 1920, Mexico invited the rf to combat yellow fever, which had reappeared in the country’s major ports and remained an important threat to sea commerce and a continuing challenge for medical science. Over a four-year period the rf led a large-scale assault on yellow fever’s Aedes aegypti mosquito vector, organizing a small army of Mexican and American doctors and local assistants and spending hundreds of thousands of dollars to spray, petrolize, drain, fill, and deposit larvicidal fishes in virtually every home, breeding site, and stagnant water source in the region of Veracruz.π The country’s largest port, Veracruz also harbored insurrectionists who opposed the consolidation of power in Mexico City under newly elected President Alvaro Obregón. Treading carefully, the rf and its yellow fever campaign attracted proObregón military doctors and garnered the good favor of the Veracruz population, largely thanks to the program’s elimination of household bugs. Once yellow fever was eliminated from Veracruz in 1923, the rf proposed a jointly funded (and less expensive) hookworm campaign as a replacement. Pleased with the outcome of the yellow fever campaign, the occasion to distribute plum public health positions, the opportunity to organize state health services, and the prospect of counteracting continuing rural unrest, President Obregón heartily supported the rf’s continued presence in the country, particularly in regions with rebel activity. Thus, the rf and the Mexican Department of Public Health (Departamento de Salubridad Pública, or dsp) enthusiastically approved the campaign in 1923. The five-year budget called for 80 percent financing by the rf in the first year, with increasing Mexican contributions each year until the dsp took over the campaign. Although a dsp o≈cial was given the formal title of campaign director, it was the subdirector—an ihb man—who would remain in charge. From 1924 through 1928, mobile hookworm brigades traveled to scores of villages and towns in the states of Veracruz, Oaxaca, and Chiapas administering more than 300,000 treatments, building more than fifteen thousand latrines, and delivering thousands of talks on the prevention and treatment of the disease. That the ihb had determined hookworm to be of limited epidemiological importance in Mexico was no barrier to the campaign.∫ Unlike in Brazil and some other Latin American countries, where hookworm was a serious problem, the rf’s own 1924 survey had shown that hookworm was a rela-

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tively minor ailment in Mexico.Ω This finding was sidestepped for reasons of convenience. Campaigns against the more pressing problems of malaria, diarrhea, and tuberculosis lacked the simple armamentaria, rapidity, and frugality of the hookworm campaign, making the desired results against those diseases far more challenging to attain. Hookworm needed to become the ‘‘problem’’ because the hookworm campaign provided an unparalleled solution to the issues at stake. The ihb pursued two approaches, one curative, the other preventive. First, each morning the campaign sta√ recruited dozens of people to undergo hookworm treatment. Uniformed ihb o≈cers and Mexican assistants administered an oral dose of chenopodium and a purgative either in a clinic or in the home. Then, small and large group health education strategies were used to explain the disease process and to try to convince rural Mexicans to wear shoes and build and use latrines. Historian John Ettling has noted that before the rf ‘‘could set about the business of destroying’’ hookworm in the southern United States, it had to expend energy and money to ‘‘create the disease in the minds of the people.’’ ∞≠ In Mexico, as in the U.S. South, people with hookworm-induced weakness, fatigue, or distended bellies may have considered these conditions not an illness but rather the unavoidable circumstances of subsistence or plantation farming. Yet ihb o≈cers—perhaps oblivious of both the strangeness of their medical approach and the extremely low levels of schooling and literacy in Mexico in this period— expected their public lectures and illustrated house-to-house seminars on hookworm transmission to replace popular conceptions of sickness and convince the audience to build their own latrines and wear shoes. Possibly the best evidence of the tensions between the medical ideas and practices of the North Americans and those of rural Mexicans comes from a series of photos included with the hookworm campaign reports in the mid-1920s. Although staged by Rockefeller o≈cers themselves to depict the successful outreach e√orts of the Mexican hookworm campaign, the photos belie the distance between the public health o≈cer and the peasants arranged around him. In one instance, a woman and her brood stand outside their straw-roofed hut, squeezed into a semicircle around an rf o≈cer who is using poster illustrations to demonstrate the life cycle of Necator americanus from egg to larva to full-grown worm. The bewildered faces and tense limbs of the Mexican peasants are in sharp contrast to the tall, confident o≈cer, who uses ‘‘simple language’’ to discuss hookworm symptoms,

Rockefeller Foundation health o≈cer and a Mexican colleague question a woman and her family as part of the house-to-house hookworm census. Courtesy of the Rockefeller Archive Center, Sleepy Hollow, New York.

Rockefeller Foundation health o≈cer explaining the life cycle of the hookworm to a rural community. Courtesy of the Rockefeller Archive Center, Sleepy Hollow, New York.

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treatment, and prevention. Another photo depicts a similar scene, this time in the woods behind a group of houses, an area that might otherwise have been used for defecation. Here, a group of adults and bedraggled, barefoot children stare at the camera while the rf o≈cer, his white pants tucked into knee-high boots—displaying perhaps the ultimate protection against lurking hookworms—remains fixed on his hookworm poster and lecture. This problem of ‘‘disease not perceived’’ made the hookworm campaign considerably more challenging than the yellow fever campaign: peasants were asked to accept disease where it did not seem to exist and to submit themselves to unknown treatments and healers in spite of the apparent absence of recognized symptoms. They were appreciative of these unprecedented government activities, but, according to Mexican doctors of the day, few if any became new subscribers to modern medicine. Moreover, the campaign’s aggressive pursuit of patients and autocratic treatment modalities reversed existing norms of healing, in which curanderos and their communities worked together in the healing process and held to a unified concept of spiritual and physical well-being—in a sense, the local nosology.∞∞ But the peasants’ bewilderment was no impediment; instead it made the campaign more assertive.

Latrine-Building and Its Discontents Whether or not peasants came to understand hookworm, the campaign’s initial success required their participation in the program’s two direct thrusts: antihookworm treatment and the use of latrines. For ihb o≈cers, the most challenging part of the campaign was the promotion of latrines. The hookworm campaign’s first ihb representative, Dr. Andrew Warren, a North Carolina native who had helped the rf carry out rural health programs in the United States, found his previous experience of little use. Working in the state of Veracruz, Warren lamented, ‘‘No type [of latrine] suits the needs of the people here. On account of the poverty and the lack of intelligence, the septic tank, the septic privy, the chemical closets, the bucket types, and the concrete dry vault types may be immediately dismissed as being . . . not practical.’’∞≤ Warren was greatly concerned about the low number of latrines constructed, even though his superiors in New York advised him that ‘‘a preliminary period of education’’ was necessary before a large area could be sani-

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tized.∞≥ Warren complained that the need for latrines was absolute—20 percent of houses in most towns had excusados (outhouses), but virtually no dwellings in villages had them. He despaired, however, that for a ‘‘peon’’ to spend a large sum for the ‘‘construction of a place to defecate when he and his ancestors have for hundreds of years used the open spaces without apparent cost, is almost too much for us to expect him to comprehend.’’∞∂ Over the long term, the cost of the excusado would be far smaller than the costs of disease and death, but this was not a ‘‘tangible thing.’’ Warren finally decided on a pit latrine as the ‘‘simplest, the cheapest, the most practical.’’ He designed an inclined platform for squatting rather than sitting because, he noted, even North Carolina farmers ‘‘could not defecate when sitting . . . upon the seat of a water closet.’’ Whether forced to sit on a wooden platform or not, few rural Mexicans used the latrines. Warren explained this refusal by comparing peasants to rabbits, which were not attracted to brightly colored hutches because they were so di√erent from the rabbits’ customary quarters. He believed that Mexican peons—like rabbits—failed to use the sleek new pit latrines because they were ‘‘much better than the houses in which they lived.’’∞∑ Under Warren’s direction, the campaign sta√ downgraded the quality of construction, building rudimentary pit latrines surrounded by wobbly walls in an attempt to increase their acceptability. The actions of Warren and other rf physicians undoubtedly reflected their own social origins and the prejudices of North American culture.∞∏ Most of the o≈cers believed that indigenous populations were morally and scientifically backward, and assumed that notions of sanitation, disease control, and personal cleanliness were unfamiliar. But Warren went considerably further and assigned malevolent motives to Mexican peasants. He argued against o√ering material support to peons in building latrines because ‘‘they are a tricky, trifling lot and they will do nothing they can make some one else do.’’∞π Peons could be instructed, but if supplied with wood, Warren argued, they would sell it rather than build latrines for their families. Because even building the latrines could not guarantee their use, Warren encouraged the Veracruz governor and state health o≈cer to issue a decree mandating the use of latrines. This was a necessary step, Warren argued, because ‘‘the people here are so accustomed to doing things only when they are compelled to.’’ While the decree was readily issued, the Veracruz state health department failed to dispatch personnel to verify compliance. The frustrated Warren was not entirely without support. The ihb direc-

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Student sanitary inspectors constructing a pit latrine, with a Rockefeller Foundation health o≈cer demonstrating the privacy provided by outhouse walls. Courtesy of the Rockefeller Archive Center, Sleepy Hollow, New York.

tor in New York, Dr. Frederick Russell, backed his e√orts, agreeing that convincing peons to use latrines would solve the hookworm problem in Mexico. He suggested a psychological trick the ihb had used in Jamaica, where the government sold wood at cost to the people, thus interrupting resale. Russell also reminded Warren that unless he could get state inspectors to supervise the construction and maintenance of the latrines, the project would fail. But rather than rely on the health department to monitor the latrine e√ort, Russell urged Warren to first thoroughly train the members of his own sta√ to inspect latrines and then transfer them to government service. He pointed out that Warren was probably better at training than was the dsp, and he could ‘‘weed out’’ the incompetent inspectors and ensure compliance.∞∫ The tribulations Warren and his sta√ faced in promoting latrine construction and use suggest that not even coercion could easily change the defecating habits of rural Mexicans. The rf New York o≈ce’s continued support for these e√orts, notwithstanding Warren’s scatological anxieties, suggests that preserving the faith of the ihb’s own sta√ in the hookworm campaign’s methods remained a high priority.

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Treating Peasants? With many peasants ignoring or evading preventive measures, hookworm treatment took on paramount importance. During its fifteen years of experience in hookworm control in Asia, the U.S. South, Latin America, and the Caribbean, the ihb had developed a series of guidelines governing hookworm treatment. In Mexico, however, the hookworm campaign’s scientific underpinnings (including e≈cient spending) became subsumed in its social and political ends. Under Warren’s watch the treatment method that the ihb had refined in a variety of settings became dispensable. Preliminary diagnosis was the first measure to go. Instead, Warren advocated ‘‘mass treatment’’ to reach a larger population and gain results more quickly. Mass treatment called for forgoing initial diagnosis and treating the entire population regardless of the actual fecal presence of hookworms. But the ihb routinely used this approach only in areas of high infection (above 75 percent), where a lower cost per capita could be achieved in this manner. Veracruz—with an estimated 60 percent infection level—was thus not eligible. But under Warren, preliminary fecal examinations were administered only to individuals who refused treatment, becoming a tool of persuasion rather than a scientific measure of the need to treat. He argued that positive results gave ‘‘an added weight to [the inspector’s] already heavy argument, and the individual usually takes the medicine.’’∞Ω By 1925, Warren had also discontinued the use of the dispensary method—which required the population to come to a doctor at the hookworm clinic—because patients could not be supervised during the hours after they swallowed the medicine and because many failed to return to the clinic for subsequent treatments. The intensive method that replaced it required the hookworm brigades to travel from house to house. The antihelminthic, but not the purgative, was administered under the eyes of trained inspectors directly in the homes of those being treated. Assistants returned during the course of the day to monitor their condition. The combined use of mass treatment and the intensive method meant that the hookworm campaign reached virtually the entire population. Even though chenopodium takers were monitored, the zeal behind the mass method meant that the dangers of the treatment multiplied. The rf home o≈ce took a laissez-faire approach to Warren’s shift in treatment methods, apparently giving him considerable leeway in flouting

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ihb guidelines. ihb director Russell praised his man in Mexico for the hurdles he overcame in latrine construction and paid little attention to the not infrequent instances of poisoning by antihelminthics, which had to be reported to the home o≈ce.≤≠ Young children were the most frequent victims of these overdoses, generally dying within hours of chenopodium administration. Although there were a few deaths over the five-year campaign, ihb teams did their best to muzzle publicity, lest the hookworm campaign be jeopardized. Deaths from treatment for hookworm—hardly a major disease of concern in spite of the campaign—resonated far beyond the actual cases because peasants might question whether and why they should undergo treatment. While candid, the death reports o√ered extremely defensive interpretations of events that might put the competence of o≈cers into question. In one case, a nine-year-old girl ‘‘should not have been killed,’’ but she su√ered from malnutrition. Warren denied responsibility for her nutritional state instead of admitting that the hookworm team ought to have recognized her condition and barred treatment.≤∞ In another instance Warren revealed, ‘‘We have had a very unusual experience that involves the question of the advisability of allowing non-technical men of limited secondary education to administer highly toxic drugs.’’≤≤ After receiving chenopodium and carbon tetrachloride, ninety-three people became ill, thirty severely. Warren identified the probable cause not as the antihelminthics but rather as pulque, a homemade alcoholic drink made from fermented maguey cactus and consumed in large quantities, he maintained, by the majority of the population. Warren shifted between blaming his Mexican assistants and Mexican drinking habits for the disaster, but he insisted that the campaign methods themselves were not culpable. The following year, Warren reported that a seven-year-old boy from San Andrés Tuxtla, Veracruz, died from intestinal obstruction, and not from the antihelminthics he had been given. Warren’s argument was that the boy’s entire family was infected with hookworm and the others had survived the treatment. Warren then contradicted himself, accusing the ayudantes (assistants) of improper administration of the antihelminthic drugs. Normally, Warren asserted, the hookworm sta√ was both well paid and well trained, and high-quality men were attracted to the job. The unavoidable hiring of lower-paid ayudantes had led to the deaths of this and other boys. The ayudantes, Warren held, could ‘‘not be trusted. . . . When a $100.00 peso indian tells me he has done something I do not believe him until I have seen the results.’’≤≥ Mexican hookworm campaign director Dr. Juan Solórzano

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Morfín had a di√erent interpretation, complaining that the ‘‘medically ignorant’’ Warren had attempted to increase the number of treatments administered with little oversight. In seeking to expand the work of the hookworm brigades, Warren had approved the rapid hiring of ayudantes who were assigned minimum quotas of weekly treatments.≤∂ Whether it was Warren’s direct fault or not, his cavalier approach met with surprising indi√erence from the ihb’s home o≈ce. That peasants appeared convinced of the importance of undergoing hookworm treatment in spite of treatment mishaps only fueled Warren’s audacity. He boasted, ‘‘The confidence of the people is such that we can kill a member of the family with chenopodium and the other members will demand that they continue to receive their treatment. And to throw this bouquet does not cause me the slightest embarrassment.’’≤∑ If the ihb left Warren to cope with the campaign’s problems in the field, what, then, of Mexican medical authorities?

The Mexican Medical Elite By the late 1920s, the elite academic wing of the Mexican medical profession had established extensive ties with the hookworm campaign. In 1926 the ihb placed Mexican doctors at the head of each of the hookworm brigades, which by then had expanded into the states of Oaxaca and Chiapas. These Mexican physicians, many of whom subsequently held important positions in the dsp, became committed advocates of hookworm eradication. Their involvement led to a significant increase in the number of latrines constructed and treatments administered and to an increase in public confidence in the campaign.≤∏ These men also formed part of the first generation of Mexican doctors to receive rf fellowships to study public health in the United States, and they served as e√ective ambassadors for the rf and its programs in Mexico. At the same time, Mexican doctors inside the campaign sought to distinguish themselves from the ihb with regard to several scientific aspects of the campaign. Certainly the reports produced by Mexican doctors working with the hookworm campaign reflected more appreciation of the cultural norms surrounding healing, shoe wearing, and defecating in Mexico. But it was not simply a question of sensitivity: the Mexicans’ understanding of hookworm’s specific etiology was far more sophisticated than Warren’s. By

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posing the question of who was the expert of the hookworm campaign, Mexican doctors challenged the ihb’s expertise. Soon-to-be minister of health Bernardo Gastélum’s May 1925 report on the hookworm campaign in Alvardo, Veracruz, for example, demystified the age and gender patterns of hookworm exposure. He explained that although girls defecated in only one place, they began wearing shoes at the age of ten, which subsequently reduced their rate of infection. Younger boys always defecated in a new place, but by ten years of age they concentrated their scatological excrement in one place. Because they did not customarily wear shoes, older boys thus had higher infection rates than girls. Young men of the area, most of whom were fishermen, were less exposed to hookworm infection. As they became older and returned to work in their villages as net menders, these men were once again at greater risk of contracting hookworm. Gastélum’s anthropological observations were extremely useful from the standpoint of a public health campaign, for they identified the origins of the hookworm problem and the best points of intervention for the various groups in the community. But he had little chance to pursue this avenue. His report concluded with a gripe not dissimilar to Warren’s: ‘‘Breeding sites would be avoided if each town had 2 public latrines and citizens were obliged to use them instead of defecating on the ground without realizing what they are doing.’’≤π Though the more scientific approach advocated in Mexican hookworm campaign reports contested the ihb’s expertise, there were few possibilities to challenge its administrative control. Some doctors in larger towns saw the ihb campaigns in narrow terms as direct competition for patients. Such competition was deemed unfair given that the ihb was generating demand for modern technology at the same time that it was reducing the burden of disease and therefore reducing demand for medical services.≤∫ Nevertheless, the majority of Mexican doctors welcomed the rf as a booster to medical prestige and a sure route to increasing the state’s recognition of the importance of health services. Only a handful of elite physicians regarded the hookworm campaign as an explicit menace to Mexican medical sovereignty. In a series of seminars held by the Mexican Medical Association and through articles in the Gaceta Médica de México, Dr. Juan Solórzano Morfín, a former local director of the hookworm campaign, made a public presentation on hookworm diagnosis and treatment to the Mexican Academy of Medicine as part of his bid for membership.≤Ω He attributed the awakening interest in the research and control of this ‘‘silent and draining plague on tropical countries’’ to govern-

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ment e√orts, preventive and curative measures put in place by doctors working for mining and agricultural firms, and the collaboration of the ihb.≥≠ Modern medicine, he said, had triumphed in its scientific understanding of the epidemiology, prevention, and treatment of the disease, but the great task of eradication remained. While Solórzano Morfín acknowledged the role of foreign investigators and the rf, he emphasized the large part Mexican doctors had played since the turn of the century.≥∞ In 1902 Dr. Ricardo Manuell, a prominent military physician, had discovered a group of soldiers su√ering from hookworm in the military hospital of Mexico City. Subsequently, hookworm was encountered in a number of coastal and mining states. In 1912, another physician conducted a meticulous survey of the nation’s doctors to determine the extent of hookworm infection among their patients, and over the years, more than a dozen Mexican physicians had published articles about hookworm. Solórzano Morfín ranked a long list of locally developed antihelminthic treatments (all of which were less toxic than chenopodium), including traditional medicinal plants, that had not been tested by the rf.≥≤ He also condemned the pharmaceutical manufacturers for failing to provide medicine to treat adverse reactions to their drugs. This was a case the rf had not made, even though field o≈cers complained that their budgets did not cover therapeutic remedies. While Solórzano Morfín accepted the explanations of the biological cause of hookworm, he was concerned that the rf’s hookworm campaign overlooked the likelihood that hookworm infection would make individuals more susceptible to other parasitic ailments, tuberculosis, or malaria. Solórzano Morfín was also highly critical of the unnecessary deaths caused by hookworm treatment. He blamed these problems on the poor management of the hookworm campaign, which remained entirely in the hands of the rf representatives, even though by this time the dsp furnished the bulk of the budget.≥≥ Solórzano Morfín was awarded a prize for his presentation, but his assessors at the Mexican Academy of Medicine—apparently loath to publicly pass judgment on the rf —did not acknowledge his disputes with the rf, and they criticized his ranking of hookworm treatments.≥∂ In a subsequent article, Solórzano Morfín was far more conciliatory. He optimistically pronounced that the arrival of rf-donated microscopes in the humblest of rural clinics marked the ‘‘splendid future of scientific medicine in Mexico.’’≥∑ This time the article’s evaluator declared that accepting Solórzano Morfín

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‘‘into the bosom of the Mexican Medical Association has been an act of justice, rewarding him who deserves.’’≥∏ In the end, the lure of the ihb was too great. Solórzano Morfín was advocating Mexico’s therapeutic independence to a physician elite willing to sacrifice medical sovereignty in the interest of professional success. Not only did Mexican physicians gain scientific and technical knowledge and armamentaria thanks to its presence, they also benefited from the rf’s promotion of an expanded medical purview, leading both the public and the government to accept a wider societal role for medical practitioners.

The State’s Stake With physician and peasant stakeholders mollified, if not gratified, the remaining partner of import was the Mexican state, here represented by the dsp. The dsp, one of several new national social welfare departments created under the 1917 Constitution, replaced the largely ine√ectual Council of Public Health that had existed from the 1840s through the Porfirian dictatorship. Mexico’s rebuilding in the wake of the revolution was an enormous political, social, financial, and technical undertaking. The appearance of an outside agency—even one from a still menacing North America—to help shoulder this burden at apparently little cost was a boon. The dsp benefited enormously from the rf’s behind-the-scenes approach, which enabled Mexican authorities to take credit for responding to the rural population’s claims on the revolutionary state. High levels of satisfaction in Mexico City meant that the hookworm campaign could be deemed successful on multiple levels. Notwithstanding hookworm’s secondary importance, the Mexican government successfully built its legitimacy by delivering state services to many rural areas for the first time. In 1925, dsp o≈cial Angel de la Garza Brito declared to the ihb, ‘‘Our sanitary work is improving day by day and we hope in two or three years we will have such a fine Health Service as yours. Our motto by now is the words you told us ‘Better health and less politics’ and it runs quite well.’’≥π ihb director Russell optimistically echoed the prospects for social stability and nation building: ‘‘It may be that public health work will help to clarify . . . a new relationship between the peon and the state and federal

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governments, and help the peon to understand and appreciate the duties and responsibilities of government to the people and convince him that the government has a real interest in his welfare, health and happiness.’’≥∫ For many years the dsp agreed that the hookworm work served as the best showcase for governmental public health activities, even after the rf formally ended its participation in the campaign in 1928. Well into the 1930s, the dsp’s new network of cooperative sanitary units—founded to address the leading health problems of rural areas—featured hookworm diagnosis and treatment, the testing of antihelminthic drugs, latrine construction, and popular health education lectures as their principal pursuits. The continued emphasis on hookworm long after the establishment of the sanitary units rested on the need to show concrete achievements. Hookworm’s easy identification and treatment made it far simpler than any other public health endeavor. The draw persisted: at seven each morning, dozens of empty-stomached persons would line up for hookworm treatment, receiving ‘‘the same attention as in the private o≈ce of the best physician,’’ but for free.≥Ω Throughout the 1930s, Mexican reports repeatedly stressed the importance of hookworm in Mexico’s excess morbidity and mortality rates. The first was an exaggeration and the second close to a lie, but years of hookworm propaganda had convinced many Mexican health o≈cials that hookworm eradication was the nation’s most valuable public health crusade. Indeed, no other e√ort was as successful as the hookworm campaign in medicalizing rural Mexico.

The International Health Board Men The ihb’s men ‘‘on the ground’’ served as the fulcrum of its endeavors and the yardstick of its success. Yet in order to act as ambassadors against disease, these men had to be fully convinced of the value of hookworm eradication. In Warren’s case the convincing took place in Mexico before he was sent to the classroom: Warren spent almost three years running the show before beginning his own graduate studies in public health; he was called back to the United States in autumn 1926 so that he could go to the Johns Hopkins School of Hygiene and Public Health. That he was being recalled to become a student did not humble his assessment of his success in the least. Toward the end of his stay, Warren proudly reported that despite the numerous problems it had encountered, the campaign had rapidly become

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more scientific and had achieved ‘‘extraordinary cooperation between State and National health departments.’’∂≠ Warren’s successor, Dr. Henry Carr, having just completed his own graduate public health degree, encountered similar problems, although he expressed them more delicately. Hookworm infection, he held, ‘‘depends upon the unsanitary habits of night soil disposal and these customs are very firmly fixed in the instincts of the people.’’∂∞ He recognized the di≈culty of rapidly changing defecation ‘‘habits’’ and turned to treatment as the ihd’s ‘‘best sort of propaganda for good health.’’ Each cure of hookworm was ‘‘a very obvious and dramatic occurrence’’ that became ‘‘an advertisement for better hygiene.’’ Like Warren, Carr held a revolutionary zeal: by ‘‘curing’’ cases of hookworm, rural inhabitants would be convinced to take the individual measures of paying for and building latrines in order to prevent the disease in the future. The New York o≈ce encouraged these claims for the campaign. Following a site visit to Veracruz in 1925, ihb director Russell contentedly remarked that Mexico had become much more pro–United States since the revolution. ‘‘During the next ten years,’’ he promised, ‘‘we will have an opportunity to do pioneer work, and one can reasonably expect big results in that time.’’∂≤ Both Warren and Carr became convinced of the primacy of hookworm work. Though Warren was aware that hookworm could not compare with more fatal diseases as a public health threat, and though he had been repeatedly solicited for cooperation in tuberculosis control (which the home o≈ce routinely rejected because ‘‘it takes too many years to show results’’), he came to regard hookworm as a root cause of poverty in Mexico.∂≥ Likewise, Carr, who had witnessed the epidemiological insignificance of hookworm firsthand when he was briefly in Mexico to conduct a hookworm survey in the early 1920s, became committed to hookworm eradication after taking over from Warren. Despite ample evidence to the contrary, Carr deemed hookworm ‘‘more important than malaria.’’∂∂ Carr retained his hookworm fervor throughout his career, in 1950 advocating that the rf return to hookworm control, for ‘‘there is just as much hookworm disease in countries where the climate is favorable for it, as there was in 1913 when the Foundation was established. I know because I have seen it all, and there is no public health work that benefits so many people and in such a real and vital way.’’∂∑ The views of Warren and Carr suggest that the rf’s outward commitment

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to disease eradication was most instrumental in influencing its direct representatives in the field. In 1927 Russell took this commitment to a new level, complimenting new campaign director Carr on the ‘‘revolution you have brought about in sanitation’’ and for the ‘‘good cooperation from district peons,’’ which Russell jointly credited to Carr and the dsp.∂∏

You Say You Want a Revolution Within the space of a few years the hookworm campaign moved from a frustrated preventive e√ort and an unscientific (in the rf’s own terms)—if not outright dangerous—treatment endeavor to an accepted, welcomed, and even successful activity. Amid all of his troubles with the campaign, Warren retained a believer’s assurance in the value of hookworm work. In 1925 he predicted a great future for the hookworm-free peasant: ‘‘With an increase in the ability of an individual to produce more, as a result of an improvement in his health or physical condition, there will be a corresponding increase in his earning power. This will result in more money in his pocket with which to buy better food, better clothes, better homes, and better schools. With better schools there will come enlightenment. Intelligence will displace ignorance and with intelligence there will come a true social revolution and a better understanding between all classes of men.’’∂π Warren inverted the meaning of revolution in Mexico: rather than setting the stage for government-led improvements in social conditions, including relief from disease, hookworm eradication would lead to social revolution. Of course, this was a time of social revolution in many countries, from the Russian Revolution to the creation of new welfare states in Europe, the Americas, and elsewhere that emerged before, and particularly during, the Great Depression. Certainly the rf’s position overlapped with the optimistic tenets underlying contemporary movements around the world—that public health e√orts would help improve social conditions. But the narrowly technical disease eradication determinism expressed by Warren was quite distinct from a social medicine approach that called for access to medicine and public health as part of larger societal e√orts to overhaul housing, education, employment, and the human condition generally. How did the rf’s hookworm campaign, with all of its impediments, become interpreted as revolutionary? By attacking an ailment that was rarely fatal and of low epidemiological consequence but resulted in stunted

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growth and weakness, the campaign sought to build a Mexican man with moral, intellectual, and physical strength; the capacity to produce and consume more; and an alternative revolutionary means of improving his lot. The hookworm campaign played a further, underlying role in turning peasants into individual citizens—with both rights and responsibilities—who would make Mexico modern. By calling for family latrines, shoe wearing, and submission to physicians, the hookworm campaign o√ered the benefits of treatment to participants but put responsibility for disease in the custody of households and individuals rather than the larger community. Yet, despite the disdain with which rf o≈cers often regarded Mexican politics, the campaign was—at its broadest level—consistent with Mexican revolutionary goals. Hookworm educational strategies echoed Minister of Education José Vasconcelos’s call for universal schooling, and the organization of rural health services fulfilled expectations for a welfare state laid out in the 1917 Constitution. During the first half of the twentieth century, U.S. philanthropy, most visibly the rf, was unique in promoting international health outside strictly colonial relationships. The rf’s flexibility, independence, and limited accountability enabled much of its work; because of its worldwide scope and in contrast to colonial medical administrations—which were directly bound to military, economic, and political power—the rf was able, and perhaps forced, to continually learn and adapt from its experiences in the field to ensure that it would remain well received. The rf’s tendency to see all of its e√orts as successful is evident in Mexico.∂∫ The campaign sought and seemed to please all constituencies. Mexican peasants began to flock to the mobile hookworm brigades, conscious of new public services if not of hookworm’s etiology. The rf home o≈ce was convinced that state and local authorities need only be exposed to the hookworm campaign in order to ‘‘create . . . a desire for a local health service capable of dealing with the more pressing public health problems.’’∂Ω Mexican o≈cials and medical elites, with their own interests at stake, shared these notions despite predictably persistent problems in creating a federal system of health services. But it was ihb o≈cers who were the long-term hookworm proselytizers: the rf’s fashioning of a scatological revolution took greatest hold in the bowels of its own organization. But, of course, medical revolution also took place on a grander scale. The rf not only furthered the imperialist nosology, it molded its own nosology linked to its particular aims. If hookworm was a gastrointestinal ailment in

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the Bertillon system and a disease responsible for low productivity in the imperialist one, its classification in the rf nosology was tailored even more meticulously. Hookworm worked as a ‘‘preliminary survey’’ of health and disease conditions, an introduction to the role and value of public health, and a demonstration of cure, prevention, and philanthropic goodwill.∑≠ Just as medicine was becoming more scientific, knowledge and control of disease became increasingly subject to classification by state bureaucrats, colonial powers, and philanthropists, who fashioned an understanding of disease suited to their respective agendas.

Notes I wish to thank Diego Armus, Nikolai Krementsov, the anonymous reviewers, and participants in the David Rogers Health Policy Colloquium, Cornell University Medical College, for their helpful suggestions. 1 See, for example, Warwick Anderson, ‘‘Disease, Race and Empire,’’ Bulletin of the History of Medicine 70.1 (1996): 62–67; David Arnold, ed., Warm Climates and Western Medicine: The Emergence of Tropical Medicine, 1500–1900, Clio Medica 35, Wellcome Institute Series in the History of Medicine (Amsterdam: Editions Rodopi, 1996). 2 Michael Worboys, ‘‘The Emergence of Tropical Medicine: A Study in the Establishment of a Scientific Specialty,’’ in Gerard Lemaine, Roy MacLeod, Michael Mulkay, and Peter Weingart, eds., Perspectives on the Emergence of Scientific Disciplines (The Hague: Mouton, 1976), 75–98; Kenneth Warren, ‘‘Tropical Medicine or Tropical Health: The Health Clark Lectures, 1988,’’ Reviews of Infectious Diseases 12 (1990): 142–256. Also see Peter Brown, ‘‘Malaria, Miseria, and Underpopulation in Sardinia: The ‘Malaria Blocks Development’ Cultural Model,’’ Medical Anthropology 17 (1997): 239–54. 3 For a thorough account of the Rockefeller Sanitary Commission for the Eradication of Hookworm, see John Ettling, The Germ of Laziness: Rockefeller Philanthropy and Public Health in the New South (Cambridge: Harvard University Press, 1981). On the Rockefeller Foundation and hookworm internationally, see Soma Hewa, Colonialism, Tropical Disease and Imperial Medicine: Rockefeller Philanthropy in Sri Lanka (Lanham, Md.: University Press of America, 1995). Christian Brannstrom, ‘‘Polluted Soil, Polluted Souls: The Rockefeller Hookworm Eradication Campaign in Sao Paulo, Brazil, 1917–1926,’’ Historical Geography 25 (1997): 24–45; James Gillespie, ‘‘The Rockefeller Foundation, the Hookworm Campaign and a National Health Policy in Australia, 1911–1930,’’ in Roy MacLeod and Donald De-

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4

5

6 7

8

9

noon, eds., Health and Healing in Tropical Australia and Papua New Guinea (Townsville: James Cook University, 1991), 64–87; Christopher Abel, ‘‘External Philanthropy and Domestic Change in Colombian Health Care: The Role of the Rockefeller Foundation, ca. 1920–1950,’’ Hispanic American Historical Review 75.3 (1995): 339–75; Esteban Rodríguez Ocaña, ‘‘Foreign Expertise, Political Pragmatism, and Professional Elite: The Rockefeller Foundation in Spain, 1919–39,’’ Studies in the History and Philosophy of Biology and Biomedical Science 31.3 (2000): 447–61. For the most extensive portrait of the Rockefeller Foundation to date, see Raymond B. Fosdick, The Story of the Rockefeller Foundation, 2d ed. (New Brunswick: Transaction, 1989). By this time Rockefeller already had a decades-long pattern of carefully targeted donations to scientific and educational institutions—the University of Chicago in the 1890s, the Rockefeller Institute for Medical Research (later the Rockefeller University) in New York City starting in 1901, and the General Education Board, established in 1901 to promote public education, initially in the rural South. By 1950 the ihb had organized dozens of hookworm, yellow fever, malaria, and other infectious campaigns in some ninety countries around the world (including almost all of Latin America and the Caribbean); trained thousands of public health administrators and technicians; and sponsored hundreds of fellows to study public health in the United States. See Fosdick, Story of the Rockefeller Foundation; and Robert Shaplen, Toward the WellBeing of Mankind: Fifty Years of the Rockefeller Foundation (New York: Doubleday, 1964). Shaplen, Toward the Well-Being, 30. See Armando Solórzano Ramos, ¿Fiebre Dorada o Fiebre Amarilla? La Fundación Rockefeller en México, 1911–1924 (Guadalajara: Universidad de Guadalajara, 1997). Henry P. Carr to Frederick Russell, September 18, 1924, rg 5, series 1.2, box 193, file 2470, Rockefeller Foundation Archives of the Rockefeller Archive Center [hereinafter rfa]; and Henry P. Carr, ‘‘Observations upon Hookworm Disease in Mexico,’’ American Journal of Hygiene 6, suppl. (July 1926): 42–61. Also see Steven Palmer, ‘‘Central American Encounters with Rockefeller Public Health, 1914–1921,’’ in Gilbert Joseph, Catherine LeGrand, and Ricardo Salvatore, eds., Close Encounters of Empire: Writing the Cultural History of U.S.-Latin American Relations (Durham: Duke University Press, 1998), 311–32. See, for example, Luiz Antonio de Castro-Santos, ‘‘Power, Ideology, and Public Health in Brazil, 1889–1930’’ (Ph.D. diss., Harvard University, 1987); and Paulo Gadelha, ‘‘Conforming Strategies of Public Health Cam-

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10 11

12 13 14 15 16

17 18 19 20 21 22 23 24 25 26

paigns to Disease Specificity and National Contexts: Rockefeller Foundation’s Early Campaigns against Hookworm and Malaria in Brazil,’’ Parassitologia 40 (1998): 159–75. On the rf’s survey, see Anne-Emanuelle Birn and Armando Solórzano, ‘‘Public Health Policy Paradoxes: Science and Politics in the Rockefeller Foundation’s Hookworm Campaign in Mexico in the 1920s,’’ Social Science and Medicine 49 (1999): 1197–1213. Ettling, The Germ of Laziness, 23. Interview with Alberto P. León, former rf fellow, Health Department o≈cial, and current Institute of Health and Tropical Diseases professor, Mexico City, April 10, 1991. See, for example, Elsa Malvido and Maria Elena Morales, eds., Historia de la Salud en México (Mexico, D.F.: Instituto Nacional de Antropología e Historia, 1996); Kaja Finkler, Spiritualist Healers in Mexico: Successes and Failures of Alternative Therapeutics (New York: Praeger, 1985); Xavier Lozoya and Carlos Zolla, eds., La Medicina Invisible: Introducción al Estudio de la Medicina Tradicional de México (Mexico, D.F.: Folios Ediciones, 1983). Warren to Russell, July 7, 1925, rg 5, series 1.2, box 226, folder 2875, rfa. Russell to Warren, July 1, 1925, rg 5, series 1.2, box 226, folder 2875, rfa. All citations in this paragraph are from Warren to Russell, July 29, 1925, rg 5, series 1.2, box 226, folder 2875, rfa. Ibid. On seeing the Aztec calendar, Rockefeller Foundation yellow fever o≈cer M. E. Connor declared, ‘‘At least some of the ancients possessed culture.’’ Connor to Florence Read, March 16, 1924, rg 5, series 1.2, box 192, file 2468, rfa. All citations in this paragraph are from Warren to Russell, July 9, 1925, rg 5, series 1.2, box 226, folder 2875, rfa. Russell to Warren, July 18, 1925, rg 5, series 1.2, box 226, folder 2875, rfa. Warren, Report of the Lucha Contra la Uncinariasis for the Quarter Ending March 31, 1925, rg 5, series 3, box 144, rfa. Russell to Warren, March 19, 1925, rg 5, series 1.2, box 226, folder 2875, rfa. Juan Solórzano Morfín, ‘‘Tratamiento de la Uncinariasis,’’ Gaceta Médica de México 58.6 (1927): 363. Warren to Read, July 26, 1924, rg 1.1, series 323, box 17, file 139, rfa. Andrew Warren, Report of Case of Poisoning by Antihelminthic, March 29, 1926, rg 5, series 2, subseries 323, box 33, file 196, rfa. Juan Solórzano Morfín, ‘‘Tratamiento de la Uncinariasis,’’ 336. Warren to Russell, July 15, 1926, rg 5, series 1.2, box 258, file 3282, rfa. Warren to Russell, May 27, 1926, rg 5, series 1.2, box 258, file 3281, rfa.

t h e h o o k w o r m c a m pa i g n i n 1 9 2 0 s m e x i c o 181 27 Bernardo Gastélum, Report of the Lucha Contra la Uncinariasis, May 1925, rg 5, series 3, box 144, rfa. 28 Anne-Emanuelle Birn and Armando Solórzano, ‘‘The Hook of Hookworm: Public Health and the Politics of Eradication in Mexico,’’ in Andrew Cunningham and Bridie Andrews, eds., Western Medicine as Contested Knowledge (Manchester: Manchester University Press/St. Martin’s Press, 1997), 147– 71. 29 See Juan Solórzano Morfín, ‘‘Tratamiento de la Uncinariasis’’; F. Bulman et. al., ‘‘Dictamen Presentado a la Academia Nacional de Medicina, por la Comisión Encargada de Estudiar el Trabajo de Concurso Titulado. Tratamiento de la Uncinariasis, y Emparado por el Problema: Pro Aris et Focis Certare,’’ Gaceta Médica de México 58.6 (1927): 372–81; Juan Solórzano Morfín, ‘‘Algunos Datos para el Estudio de las Parasitosis Intestinales de México,’’ Gaceta Médica de México 58.12 (1927): 742–59; and E. Cervera, ‘‘Contestación al Trabajo del Nuevo Académico, Dr. Juan Solórzano Morfín,’’ Gaceta Médica de México 58.12 (1927): 760–64. 30 Juan Solórzano Morfín, ‘‘Tratamiento de la Uncinariasis,’’ 329. 31 On the little-known role of nineteenth-century Brazilian physicians in the debate over hookworm’s etiology, see Julyan Peard, Race, Place, and Medicine: The Idea of the Tropics in Nineteenth-Century Brazil (Durham: Duke University Press, 1999). Old-school Rio de Janeiro physician José Martins de Cruz Jobim held that climatic and meteorological conditions combined with bad hygienic habits were the cause (and hookworms the result) of the disease; and upstart Dr. Otto Wucherer, of the Bahian Tropicalista School, averred that hookworm parasites together with secondary factors relating to diet and hygiene caused the ailment. 32 Juan Solórzano Morfín, ‘‘Tratamiento de Uncinariasis,’’ 329–33. 33 Ibid., 329–71. 34 F. Bulman et al., ‘‘Dictamen Presentado a la Academia Nacional de Medicina, por la Comisión Encargada de Estudiar el Trabajo de Concurso Titulado,’’ 372–81. 35 Juan Solórzano Morfín, ‘‘Algunos Datos para el Estudio de las Parasitosis Intestinales de México,’’ 742–59. 36 E. Cervera, ‘‘Contestación al Trabajo del Nuevo Académico, Dr. Juan Solórzano Morfín,’’ 760–64. 37 De la Garza Brito to Russell, November 1, 1925, rg 3, series 1.2, box 226, folder 2872, rfa. 38 Russell to Warren, December 31, 1925, rg 5, series 1.2, box 226, file 2876, rfa. 39 Report of the Hookworm Campaign, the Minatitlán–Puerto México Coop-

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40 41

42 43 44 45 46 47 48

49 50

erative Sanitary Unit, and the Puerto México Antilarval Service for the Second Quarter, 1931, Communicable Diseases Section, Departamento de Salud Pública, Mexico, D.F., Section II/021/242, box 39, folder 84, Archivo Histórico del Estado de Morelos. Warren to Russell, July 15, 1926, rg 5, series 1.2, box 258, file 3282, rfa. All citations in this paragraph are from Carr, Narrative Report of the Lucha Contra la Uncinariasis for the Fourth Quarter of 1926, rg 5, series 3, box 144, rfa. Russell to Florence Read, September 18, 1925, rg 5, series 1.2, box 226, folder 2872, rfa. Russell to Warren, March 26, 1926, rg 5, series 1.2, box 258, file 3281, rfa. Carr to Russell, December 11, 1928, rg 1.1, series 323, box 21, file 169, rfa. Carr to G. K. Strode, June 1, 1950, rg 3.1, series 908, box 14, folder 148, rfa. Russell to Carr, March 24, 1927, rg 5, series 1.2, box 296, file 3753, rfa. Warren, Brief Narrative Report on the Work of the Hookworm Campaign in Mexico for the Second Quarter of 1925, rg 5, series 3, box 144, rfa. John Farley, ‘‘Species Eradication: The Sardinia Anopheles Eradication Project (1945–1950)’’ (paper presented at the Conference on ‘‘Disease and Society in the Developing World: Exploring New Perspectives,’’ Philadelphia, September 1992). Ferrell to Carr, October 8, 1929, rg 1.1, series 323, box 17, file 140, rfa. International Health Board, Summary of Policies in Force, Public Health Work, May 25, 1927, rg 3.1, series 908, box 11, file 123, rfa.

katherine elaine bliss

Between Risk and Confession state and popular perspectives of syphilis infection in revolutionary mexico

n 1909 Dr. Eduardo Lavalle Carvajal published an article in the Gaceta Médica de México describing current venereal disease prevention programs in the nation’s capital. A syphilis specialist and member of Mexico City’s Sanitary Inspection Service, the corps of physicians charged with preventing the spread of disease among the city’s residents, Lavalle Carvajal argued that sexual hygiene in Mexico was in a sorry state. Not only did the incidence of syphilis infection seem to be on the rise, but those people at the greatest risk for contracting and spreading the disease, sexually promiscuous men and women, went to great lengths to avoid medical examinations. The mere mention of the city’s public sifilicomio for women, the Hospital Morelos, he said, filled the capital’s prostitutes with terror. Lavalle Carvajal then went on to describe a recent episode in which one patient he diagnosed with a sexually transmitted infection was so enraged at having to be confined for medical attention that she mailed him threatening letters filled with pubic lice when she left the hospital. Was there not some way, Dr. Lavalle Carvajal wondered, to convince the Mexican population of the benefits of state-supervised disease prevention?∞ Thirty-one years after Dr. Lavalle Carvajal shared his concerns about syphilis prophylaxis with the nation’s medical elite, Roman Barrón sent President Lázaro Cárdenas a letter complaining about what was apparently still the deplorable state of sexual hygiene in Mexico City. In 1940 Barrón, a Mexican citizen who had been living in the United States, wrote Cárdenas that he had recently taken several American friends on a tour of his homeland. While enjoying the pleasures of metropolitan life in the revolutionary nation’s capital, he said, the men had visited several downtown nightspots and had contracted syphilis from the prostitutes they met there. Rather than

I

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chastise his friends for visiting prostitutes or blame the women themselves for the spread of a devastating and potentially life-threatening disease, Barrón wrote to Cárdenas to protest the government’s negligence with respect to venereal disease prophylaxis: ‘‘In the last three years I have visited this city in the company of friends from our neighboring country, who are involved in di√erent activities. And on three occasions all of them have taken away the worst impressions.’’ Barrón insisted that the group was ‘‘deserving of better luck, seeing that my friends in great part are young [and] had the opportunity to see the worst of Mexico, with the shameful consequence that 90% of them came down with a venereal disease.’’ Invoking his nationalist concerns over Mexico’s image, he concluded, ‘‘In the good name of my country and in your good name, I beg you to turn your attention to this matter.’’≤ Barrón’s frank description of his young friends’ activities and physical ailments stands in sharp contrast to the reticence described by Lavalle Carvajal in his dire portrayal of popular reaction three decades earlier. In 1909, men and women ignored infection, according to the syphilis doctor, who reported that people of all ages consistently sought to avoid medical examination, diagnosis, and treatment out of fear of doctors, reluctance to divulge their sexual activities, mistrust of state institutions, or all of the above. But by 1940 Barrón felt comfortable writing to no less an o≈cial figure than the president of Mexico to complain about his friends’ sexually acquired infections. Had something changed to make Mexican citizens see the government as their ally in the struggle to conquer bodily a∆iction? Popular perspectives on privacy, sexual activity, and medical treatment represented the greatest challenge to what one specialist had called the number one health problem confronting Mexico’s revolutionary government: preventing the spread of the often deadly and intractable venereal disease syphilis to Mexico’s future generations. As early as 1926, the chief of Mexico’s Department of Public Health, Dr. Bernardo Gastélum, had told the audience at an international sanitary conference that some 60 percent of the nation’s population su√ered from the complications of Treponema pallidum infection, which included fevers, hair loss, skin lesions, neurological disorders, gastrointestinal problems, and premature death.≥ With at least half of the nation’s syphilitics living in the capital city, Dr. Gastélum emphasized, it was as important to focus on preventing the spread of the disease as it was on promoting a cure. Since the bacterium easily spread through sexual/genital contact and from mother to child at birth, he recommended

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that the government work to protect young women from becoming sexually active before marriage, dissuade men from seeking transitory sexual encounters, and encourage all infected members of the population to seek medical treatment. Even if the weekly injections of neo-salvarsan, the arsenic derivative, which promised the best treatment, did not completely eliminate syphilis from the patient’s body, it seemed to reduce infectiousness and prevented people from developing symptoms of the more advanced stages of the illness. Over the next decade and a half, public health o≈cials endeavored to reduce the impact of ‘‘social disease’’ in Mexico through a series of steps that included establishing public reformatories to dissuade young women from being sexually promiscuous; presenting public lectures on venereal disease transmission and treatment; organizing anonymous, free medical clinics for those who su√ered from a sexually transmitted disease; abolishing stateregulated prostitution; and ultimately criminalizing the spread of sexually contagious maladies, a category that included syphilis and such other infectious agents as chancroid and gonorrhea, by 1939.∂ Dr. Gastélum and his colleagues had tried to eradicate syphilis in the capital city in the years after 1926, but Barrón’s 1940 letter to Cárdenas suggests that public policies had had little success in altering popular attitudes toward transient sexual encounters, poor women’s occupations, men’s leisure pastimes, or the risk of contracting a deadly disease. Despite the development of public institutions to treat their illnesses and to help them find ‘‘honorable’’ work, thousands of young women in the capital still turned to prostitution in the 1930s as a means of earning a living, and many more engaged in premarital or extramarital sexual intercourse. And although they must have been aware of posters in public parks and factory washrooms proclaiming that ‘‘easy women are the easiest way to get syphilis,’’ men of all social classes still viewed a brothel visit as a time to socialize with each other and to engage in nonfamilial leisure pursuits. Moreover, prostitutes and their clients still contracted venereal disease from their interactions. A 1937 survey of medical students—whom one might have supposed to be on the cutting edge of infectious disease information—showed that 97 percent of those a∆icted with a sexually transmitted disease acknowledged contracting it from sexual intercourse with a ‘‘public woman.’’∑ To underscore the issue, the popular press frequently ran stories about the miserable lives prostitutes led and the dangers this ‘‘feminine battalion of death’’ posed to the public’s well-being.∏ Even if they were vistors from a

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foreign country, Barrón and his friends must have been aware that having sexual intercourse with a prostitute posed an inevitable health risk. Nonetheless, they chose to make the rounds of Mexico City’s numerous brothels and cabarets, became infected after having sexual intercourse with prostitutes, and then blamed the government for their problems. Barrón’s letter to Cárdenas raises questions about the potential for public policy to alter popular, private behaviors, on the one hand, and about the assumptions people make about the state’s relationship to their bodies and to social hygiene, on the other. Unlike such other common infections as tuberculosis or influenza, syphilis was often assumed to ‘‘confess’’ the patient’s otherwise private sexual involvement with someone who had had at least one other sexual partner. A print advertisement placed by the Department of Public Health, in fact, urged men and women to seek treatment, stating, ‘‘If you don’t confess it, your children will show it.’’π This ‘‘confession,’’ whether spoken or expressed through telling physical symptoms like chancres, moist sores on the hands and feet, subdermal lumps, or oral lesions, could reveal a daughter’s loss of virginity or a boyfriend’s prior sexual experience; it could also reveal a husband’s infidelity or a woman’s participation in an undesirable trade such as prostitution. All of these were scenarios that made disease victims reluctant to acknowledge their infections. Asymptomatic or convinced that their health problems were not serious, syphilitic men and women infected sexual partners as well as their newborns, who entered the world with medical complications and often led short and painful lives. Health campaigns thus urged Mexicans to shed their notions of privacy, confess their disease status, and seek medical treatment for the benefit of the nation and its future. But to what extent did people actually internalize the new ideas about gender equality, disease prophylaxis, and social reform? Conversely, to what extent did popular ideas about sexuality and syphilis shape or limit the reform agenda that emerged by 1940? This essay examines the historical, social, and popular dimension of attitudes toward syphilis and sexuality in early-twentieth-century Mexico. Building on a growing body of literature regarding prostitution and syphilis in historical perspective, this analysis moves beyond examining o≈cial discourses surrounding women, disease, and deviance to question what prostitutes, patrons, and patients themselves understood about sexuality and infection in a reformist context. To understand why people like Barrón and his friends were still willing to risk disease, and how they came to see the government as their ally when they did,

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it explores the formation of attitudes regarding disease risk, contagion, health, and bodily well-being.∫

Problematic Prophylaxis: The Reglamento para el Ejercicio de la Prostitución, 1867–1926 Since 1867 the key to the Mexican government’s e√ort to fight syphilis had been the Reglamento para el Ejercicio de la Prostitución.Ω Syphilis had long a∆icted members of all social classes in Mexico, but only in the last decades of the nineteenth century did public o≈cials elaborate a plan to halt its spread and treat those considered to be at the greatest risk for infecting the general population: female prostitutes. Under the terms of the Reglamento, young women over the age of eighteen who were no longer virgins and who wished to speculate in sexual commerce were required to register their activities with sanitary authorities, report for weekly physical examinations, and undergo compulsory medical treatment if found to harbor venereal disease.∞≠ The laws were inspired by the sanitary legislation French imperial administrators had imposed to protect European soldiers during the occupation of Mexico between 1863 and 1867, but Liberal o≈cials had adopted the measures in the years of the Restored Republic under the idea that maintaining regular medical surveillance over women who had multiple sex partners might similarly protect the health of sexually promiscuous Mexican men and their families.∞∞ Although most doctors stipulated that abstinence, marriage, and monogamy represented the best means of protecting Mexico from the ravages of a venereal disease epidemic, experts noted that ‘‘male chastity before marriage will always be exceptional among our population.’’∞≤ Some sexuality specialists, in fact, advocated making a select number of prostitutes available to young men under the idea that they might alleviate the temptation to otherwise engage in the ‘‘disgusting and repugnant vice’’ of masturbation, an activity that higienistas, as medical experts in hygiene and sanitary matters were known, acknowledged led to homosexuality, ‘‘dementia, epilepsy, hypochondria, and hysteria,’’ not to mention impotence.∞≥ The Reglamento thus rested on medical and legal assumptions that the normal Mexican male would be sexually adventuresome but that a woman who had more than one sexual partner was morally if not criminally deviant and should therefore be subject to state surveillance. In fact, according to sanitary law, a woman who was merely ‘‘notorious’’ for her activities,

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whether or not she actually collected money for her sexual favors, could be forcibly registered as a practicing prostitute. By 1926, when Dr. Gastélum questioned the e≈cacy of the reigning syphilis prevention regime, the Reglamento’s provisions had changed little since the middle of the 1860s.∞∂ For nearly three quarters of a century sexually promiscuous women served as the nation’s idealized repository of contagious sexually transmitted disease. Over the years that the Reglamento was in e√ect it became clear to medical practitioners that it was of dubious success in curbing the spread of infectious disease through sexual channels. First, the Reglamento’s assumption of heterosexuality meant that sanitary legislation completely overlooked and failed to regulate the apparently large number of male prostitutes willing to exchange sex with other men for money in downtown Mexico City.∞∑ Public o≈cials and self-appointed prostitutólogos, or experts in the study of the social ills associated with sexual commerce, asserted that although the law prohibited the presence of children in brothels, most brothels kept one or two adolescent males to appeal to clients with sexual appetites for boys or young men.∞∏ Physical examination of homosexual men arrested for engaging in ‘‘scandalous behavior’’ in Mexico City’s main plaza, the zócalo, moreover, demonstrated that like mujeres públicas, many were syphilitic, leading some experts to worry that there might be a sizable population of clandestine male prostitutes and their clientele whose activities and diseases were completely outside the scope of the Reglamento’s female-focused surveillance authority.∞π More vexing to health o≈cials, however, was the apparently cavalier attitude of female prostitutes with respect to disease prevention itself. Sanitary law required women who worked in brothels to keep prophylactic chemicals in their bedrooms and to require clients to cleanse their genital areas with a potassium permanganate solution before and after engaging in sexual intercourse.∞∫ As Dr. Lavalle Carvajal wrote in the Gaceta Médica de México in 1909, however, the actual state of hygiene in most of the city’s brothels was deplorable. A recent tour of some of the city’s sexual commerce venues had convinced him that the health department’s sanitary regulations were being routinely disregarded. ‘‘I asked for o≈cial permission to visit brothels of the lowest class, which are of the greatest interest, and while I was waiting for that, ignoring the possibility of threats or a disagreeable encounter with a pimp, made discreet visits, taking a survey of the range of o≈cially established centers of vice’’ in the capital, he reported. On this ‘‘secret’’ trip through the lowest echelons of the metropolitan underworld, Lavalle Car-

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vajal found that the brothels’ public entertainment spaces were disgustingly unclean and the private rooms in which prostitutes met with clientele were little better. ‘‘When I examined pallets and beds, I saw dirt and uncleanliness that startles the senses and hygienic deficiencies covered over with silk and golden fabric. Downstairs [there was] painfully obvious and repugnant filth; upstairs, su≈cient cleanliness, but the objects that should be required for sexual hygiene in those temples of rented love do not even exist.’’ Even the best-appointed bordellos failed to provide clients with the items necessary for a comfortable postcoital genital cleansing. Instead, Lavalle Carvajal said, ‘‘they do not even have a bidet or hygienic fountain to allow one to wash in a comfortable position instead of having to balance ridiculously, squatting over a wash basin or tray of questionable sanitary status.’’ Clients could hardly be expected to take prophylactic measures, the doctor observed, if they were required to perch precariously while naked in front of a strange woman. The hygienist recommended at the very least two liters of water per room per person so that both prostitutes and their clients could cleanse themselves of syphilis-causing bacteria immediately after each act of intercourse.∞Ω Given the number of women who complained about clients who refused to pay and the reports about men who murdered ‘‘public women’’ out of jealousy or anger, however, it seems unlikely that prostitutes had much control over their clientele, much less the power to require them to use a preparation that raised questions about a man’s infection status.≤≠ If clients’ unwillingness to engage in syphilis prophylaxis hampered state surveillance and disease prevention strategies in Porfirian Mexico, prostitutes’ own anxieties over registration and examination similarly limited o≈cial e√orts to check the spread of sexually transmitted infection in early-twentieth-century Mexico City. Most brothel managers, older women known as matronas, tried to avoid excessive police attention by registering their new pupilas, as women who worked in brothels were known; however, women who worked outside the brothel system were not always so eager to register and enter the rigid regime of licensing, fees, weekly inspections, forced hospitalization, and, by many accounts, police harassment and doctors’ abuse.≤∞ Moreover, the fact that sanitary legislation e√ectively acknowledged the sharp di√erences in social class and decorum that characterized prostitutes and their clients worked to undermine the Reglamento as well. According to sanitary practice, inspectors classified women who sought o≈cial registration according to their physical appearance, age, and health status in terms that ranged from the special first-class ‘‘de primera

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preferente ’’ through ínfima, or lowest, class.≤≤ Although studies showed that most prostitutes came from families of modest economic means, those who had the good looks and connections to work in brothels frequented by the city’s wealthiest and most influential men adopted the dress and manners of the capital society’s bourgeois ladies.≤≥ In a 1909 article, one inspector complained that first-class prostitutes’ habit of wearing several layers of underclothes in imitation of Mexico City’s most dignified señoras severely undermined doctors’ ability to inspect them for signs of syphilis or gonorrhea. As he put it in the article, ‘‘Those of the highest class limit themselves to the exposition of the genital organs, the hands (in some cases), and the face. Those of the regular first class and those in the second class show all that plus some of the thigh, because they are not in the custom of wearing underwear. Those of ínfima clase, barefoot, show all of their lower body as well as the majority of the abdominal wall and sides, their arms, neck, part of the breast and back.’’≤∂ More serious problems for inspectors included the fact that some diseased women cosmetically disguised the lesions that characterized venereal disease, tricking clients and doctors alike. Others apparently placed their faith in divine intervention, burning matches arranged in the shape of the cross to ward o√ disease before heading out for their weekly physical exam.≤∑ When miracles or disguise failed, prostitutes apparently preferred to bribe o≈cials rather than risk hospitalization. As a 1907 internal public health department memo noted, Eloisa López and Esperanza Sarazúa had each paid a peso to municipal security agent Juan Viveros in exchange for his falsifying information regarding their health status on their registration cards.≤∏ Prostitutes’ fear of doctors and medical clinics was widespread. Syphilitic women frequently escaped from the Hospital Morelos, for example, after tiring of the interminable rhythms of treatment and confinement. Back on the streets, they convinced male clients that they were disease-free and initiated the cycle of infection all over again.≤π If prostitutes’ ideas about class, work, and the medical establishment limited the Reglamento’s potential to halt the spread of syphilis in the Porfirian era, popular perspectives on sexuality and disease similarly created tension between the state and the sexually promiscuous population. By 1910, in fact, several prominent members of the Mexico City medical establishment had published reports claiming that the general citizenry’s ignorance of disease symptoms, reckless attitude with respect to infection, and fear of medical treatment undermined o≈cial e√orts to stop the spread of infectious sexually transmitted disease. Fathers, brothers, and cousins, for example, took

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their younger male relatives to visit prostitutes as a rite of passage from childhood to adolescence, exposing their younger male relatives to contagion at an early age. One young convict told criminologist Carlos Roumagnac that he had been having regular sexual relations with prostitutes since the age of seven.≤∫ While some doctors blamed early sexual activity on the easy availability of erotic literature and ‘‘lubricious spectacles’’ in the capital, others, such as eminent hygienist Dr. Luis Lara y Pardo, blamed Mexico’s lower-class male culture. In his 1908 study of prostitution in the city, Lara y Pardo advised his readers to ‘‘notice with what great curiosity the young man who has barely escaped from the frontiers of infancy stares at those brothel balconies, where tempting shadows dance on darkened windows and from which whirlwinds of laughs, exclamations, and sensual music escape.’’ The conviction that sleeping with a virgin was a sure way to avoid syphilis infection also led many men into risky sexual liaisons, according to the higienista, who asserted cynically that some men ‘‘pay for virginity as if it were a precious jewel! And how often that virginity is long gone!’’ Dr. Lara y Pardo also reported that no less than a high-ranking bureaucrat had recently been accused of having seduced two young girls, o√ering them candy in exchange for reporting to his secret love nest to engage in weekly sexual orgies ‘‘that rivaled the Romans for their decadence.’’ And men were not the only ones to profit from the supposed virtues of female virginity. In his denouncement of popular sexual practices in Mexico, Lara y Pardo reported another famous case in which a mother ra∆ed o√ her youngest daughter to a crowd of neighborhood men seeking a virgin.≤Ω On the eve of revolution in Mexico, it was clear to public health experts— if not to the population at large—that the age-old e√ort to control the spread of syphilis through the regulation of prostitution was of dubious merit because men and women routinely engaged in extramarital sexual encounters that fell outside the state’s moral and sanitary purview. Was there not, many wondered, a better way to stop the spread of sexually transmitted disease?

Sanitation and Reform: A Revolutionary Approach to Syphilis Eradication, 1926–1937 That the Porfirian syphilis prevention regime was showing signs of strain at the outbreak of armed conflict was clear to Mexican health o≈cials, who had relied on the Reglamento to contain promiscuous sexual activity within

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brothels and the licensed accesorias, or rooms, where independent prostitutes plied their trade. But nearly a decade of fighting, the flow of refugees toward the capital, and the constant passage of armies through Mexico City itself between 1910 and 1917 had both hampered the bureaucracy and transformed the sex trade, still the most obvious source of disease transfer in this period. With thousands of young women visibly practicing unregulated prostitution on the city’s streets, public health o≈cials studied and then formulated a revolutionary plan to stall the spread of syphilis in the nation. Rural warfare destroyed families and threatened villagers’ livelihood across the Mexican republic, but it was especially devastating to young women, who faced rape by invading armies if they remained at home or abandonment and starvation when parents or siblings died in the conflict. Between 1910 and 1917 thousands of young women traveled to the city on their own, with family members, or to join older female relatives who had already established residence in the capital; others who left their villages to join traveling military units as soldaderas—women who provided food and other services for the armies—similarly found themselves alone in the capital after the men with whom they traveled died or left them as they moved on to engage in fighting elsewhere in the republic.≥≠ Social workers’ interviews and documents prepared by doctors make it clear that a startlingly high number of these young women turned to prostitution in the di≈cult economy that characterized Mexico City in the late 1910s and early 1920s. For some, the move toward prostitution may have been a desperate attempt to earn a living in a strange city in which they were without the economic help or moral support of friends and family. For others, the experience of life as a soldier’s woman may have convinced them that tra≈cking in sexual favors might prove a reliable means of earning a living. In the aftermath of the worst of the fighting, young women who could not count on family or friends in the city developed a social life at the capital’s public dances, movie theaters, and cantinas. They met young men there and sometimes spent the night with them at inexpensive downtown hotels—activities which, if not precisely sexual commerce, nevertheless concerned public health o≈cials because they suggested that the city’s jovencitas were ‘‘at risk’’ for falling into ‘‘la vida.’’ Underage prostitutes, moreover, found it di≈cult to find work in the established brothels or licensed accesorias and instead openly solicited customers as clandestinas on city streets. Young, inexperienced, and completely outside the regulation system, these adolescents, doctors feared,

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would be the first to succumb to infection and then would pass the disease to their sexual partners and o√spring.≥∞ In addition to reshaping the demographic dimension of Mexico’s sex trade, the revolution also transformed the spatial organization of metropolitan sexual commerce and further challenged the state’s ability to control the spread of syphilis. The Reglamento had long enshrined the matrona and the brothel as the keys to maintaining control over prostitutes and disease transmission, but between 1915 and 1918 newly established dance halls and cabarets began to compete with long-established bordellos as sites of sexual permissiveness. Over this period, seeking to smooth relations with commanders of the military units that set up camp in the capital, the Mexico City ayuntamiento had granted licenses for dance halls and cabarets to army commanders and other politically connected men whose nightclubs quickly became unsupervised sites in which clandestine sexual commerce flourished beyond the scope of the state’s legal intervention.≥≤ Some cabarets o√ered special rooms for couples who wished to engage in intimate activity on the premises, while others were conveniently located next to hotels that rented rooms at an inexpensive hourly rate. Matronas complained bitterly to city councillors that competition from the new cabarets and young clandestinas severely undermined their own beleaguered businesses, which, they claimed, su√ered doubly in the postrevolutionary era thanks to municipally mandated shorter hours and steeper licensing fees.≥≥ As Salvador Hernández, a lawyer who represented several local matronas, told the city councillors in a protest of the new fee scale, ‘‘We must take into account the current economic situation, a crisis for my clients, in that there is not a su≈cient market for prostitution, as it now exists, to make it even remotely like the business it was in former times.’’≥∂ As matronas shut their brothel doors, increasing numbers of women working outside the confines of the Reglamento’s surveillance scheme thwarted o≈cial oversight of sexual activity and further challenged the antiquated regime of syphilis prevention. As proof that the old plan of sequestration and surveillance was failing miserably, public health o≈cials in the early 1920s pointed to the fact that syphilis among the population was increasing at an alarming rate. In 1925 Dr. Adrian de Garay, director of the city’s anti–venereal disease dispensaries, estimated that the majority of male and female patients examined in the municipal syphilis clinics were in the first and second stages of the disease. Estimated mortality from syphilis had doubled between 1916 and

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1925, and obstetricians at the city’s maternity hospitals concluded that venereal infection was the leading cause of miscarriage. In addition, some 80 percent of the children at a local elementary school had tested positive for the disease.≥∑ Careful study of Mexico City’s postrevolutionary sex trade and the burgeoning syphilis epidemic led public health o≈cials to posit a new approach to disease prevention and eradication. Rather than continue to regulate prostitutes and the sites where sex was sold, why not instead work to transform the popular ideas about women, men, and sexual behavior that seemed to underpin the supply and demand for commercially available sex, on the one hand, and the population’s fears about disease diagnosis and treatment, on the other? Over the period between 1926 and 1937, public o≈cials inspired by faith in the new revolutionary government’s potential to e√ect social change devised educational programs and created new institutions to challenge what Dr. Gastélum described as Mexico’s predatory ‘‘cult of masculinity,’’ working to protect young girls from falling into a life of prostitution and to penetrate the extreme privacy with which the population seemed to regard sexual matters.≥∏ Mexico’s adolescents, considered the population most at risk for developing syphilis and other sexually transmitted infections, were the first targets of the new syphilis eradication campaign. Curing and reforming teenagers who were already infected with venereal disease represented the first line of attack. Health o≈ces infused the old prohibition against registering underage girls as prostitutes with new purpose, sending sanitary police out into the city to arrest underage clandestinas who solicited clients in cabarets and on street corners outside theaters and public dances.≥π Girls whose parents were dead, lived elsewhere, or could not be counted on to protect their daughters from renewed involvement in sexual commerce were sent first to the Hospital Morelos and then to the casa de corrección, a wing of the newly established juvenile court that sought to redeem Mexico’s young delinquents and inspire them with revolutionary ideologies of good health, education, and faith in the new government’s potential to create a better future for the nation.≥∫ Preventing Mexico’s youngest children from engaging in risky behavior represented the campaign’s second front.≥Ω Elementary school teachers not only inspected schoolchildren but also awarded ribbons for cleanliness and anatomical knowledge in what was known as the ‘‘Game of Health.’’∂≠ Girls, moreover, were warned of the perils of premature sexual activity by teachers

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Between September 1927 and May 1928 public o≈cials associated with the Departamento de Salubridad Pública presented nearly fifty talks on personal health and hygiene to cinema audiences. Before the matinee on February 19, 1928, higienistas Dr. Afredo M. Saavedra and Dr. Manuel Martínez Baez warned this laregly male audience at the Cine Imperial about the risks of syphilis infection. From Memoria de los Trabajos Realizados por el Departamento de Salubridad Pública, 1925–1928, vol. 2 (Mexico City: Ediciones del Departamento de Salubridad Pública, 1928), graphic insert, no page number.

and parents alike. As one mother editorialized in the feminist magazine Nosotras, ‘‘When my daughter is an adolescent I will have the strength to take her to a hospital so that she can see the sublime pain that a mother who gives birth su√ers; I will then take her to contemplate women who have been infected with incurable diseases which spread from generation to generation, bestowing, as fruit, deformed children who are blind and feeble. It is absolutely necessary that she understand how transcendental the sexual act is and how much disgrace it can carry.’’∂∞ But while girls learned to be wary of engaging in premarital intercourse, boys received special instruction not on the perils of sex but on how to pick good sex partners. Dr. Juan Soto, an education consultant and a member of the board of directors of the Federal District’s Campaign against Venereal Disease, wrote a manual on

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the matter, advising parents and teachers to tell boys to ‘‘avoid those friendly girls who are the most sought after for their youth and attractiveness, who look so fresh, who use all means to attract men to ‘play love,’ who try to pass as serious, married women and who in reality are nothing more than semiprostitutes, more dangerous because of the extent of their venereal disease infection.’’∂≤ But since adult men and women still made up the majority of new syphilis cases reported each quarter, sexual education for adults complemented the Department of Public Health’s approach to preventing children and adolescents from being exposed to the deadly infections. Public health and education o≈cials used factories, parks, markets, and community centers as venues in which to impress sexually active men and women with information not just about disease prophylaxis but also about sexual health in general. Doctors conducted informal discussions about disease symptoms and prophylaxis, and nurses warned women against precocious sexual activity and emphasized the merits of sobriety, monogamy, and marriage. In conjunction with the Secretariat of Public Education, the public health department published a series of pamphlets for popular distribution as well. In the last quarter of 1927 the department embarked on a massive propaganda campaign, distributing some 630,000 pamphlets on syphilis, 430,000 on gonorrhea, and 251,000 on bodily hygiene. This printed and graphic material was designed, its promoters said, to ‘‘break old, narrow-minded and vicious popular customs and to destroy the prejudices and beliefs that ignorance has engendered among the popular classes.’’∂≥ One set of guidelines, for example, encouraged men to exercise sexual restraint, stating: ‘‘The abuse of sex causes many nervous system disorders and quickly leads to impotence. We understand ‘abuse’ to mean the daily indulgence in sexual activities; some higienistas recommend a young, healthy man make use of a woman only once a week and that as he ages he should diminish his sexual unions, insofar as semen is very rich in necessary nutrients, and if it is used up then there will be a general deterioration of the body with grave consequences.’’∂∂ Public o≈cials also promoted radio dramas and films intended to inspire listeners and viewers with sympathy for characters whose vices had led them to an old age marked by mental degeneration and physical agony.∂∑ Despite their ambition to change adult sexual behavior overnight, health policy-makers acknowledged that the Mexican population’s sexual habits

s y p h i l i s i n r e v o lu t i o n a ry m e x i c o 197 This pamphlet distributed by the Departamento de Salubridad Pública in the 1920s warned readers that newborns could acquire syphilis through the birth process and encouraged all sexually active men and women to seek a medical diagnosis at one of the department’s free venereal disease treatment clinics. From Sífilis (Mexico City: Departamento de Salubridad Pública, 1928).

were well established. They worked to undermine the population’s sexual privacy, noted some twenty years before by Dr. Lavalle Carvajal, by encouraging frank and open discussion of sexuality and sexually transmitted disease among all members of the community. Dr. Gastélum blamed the Mexican popular classes’ ideas about sexual secrecy on the Catholic Church, which many revolutionary reformers believed had kept the population in ignorance and superstition. Others posited that false social hierarchies were to blame for men’s and women’s ‘‘false modesty’’ with respect to physical examination and disease treatment. In order to encourage disease prophylaxis and treatment in this climate of secrecy and privacy, the health department developed a series of free, anonymous venereal disease clinics for men and women. The idea underpinning the clinics was that women might be more likely to seek treatment if they were not worried about being branded as prostitutes and that men would be more likely to seek treatment if they were not worried that their families would find out about their

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a∆ictions.∂∏ The clinics were open late into the evening and were scattered around the city so that men and women of all social backgrounds could access the latest syphilis-combating techniques.∂π Finally, public o≈cials advocated deregulating prostitution altogether. In addition, inspired by the movement to abolish such regulations in North America and Europe, self-styled progressive members of Mexico’s health establishment advocated legal reform by which the act of knowingly passing a disease to another person might be criminalized. Such reformers argued that the regulation system was an antiquated posture that compromised the health of poor, uneducated Mexican women in order to protect Mexican men. Some detractors, such as Dr. Juan Soto, insisted that Mexico was not prepared to take the ‘‘civilized’’ step of deregulating sexual commerce, saying that ‘‘it [abolition] is linked with the acquisition of a high level of cultural attainments which for us are still quite distant.’’ Others attacked Mexico’s ‘‘cult of masculinity’’ as the problem.∂∫ The anonymous author of one article in the Boletín del Departamento de Salubridad Pública pointed out that not only did the Reglamento ‘‘guarantee neither individual nor collective health’’ and ‘‘give the public a false sense of security,’’ it also ‘‘create[d] an antisocial and antirevolutionary social subclass that is incompatible with the ideas put forth by the current revolutionary government.’’∂Ω Dr. Eliseo Ramírez, a public health specialist and prominent member of Mexico’s Eugenics Society, headed the city’s central laboratory and pointed out that the monogamous ideal to which married women were subjected—not to mention the chastity expected of single women—forced men to go to brothels to ‘‘satisfy their sexual appetites.’’∑≠ Higienistas such as Dr. Enrique Villela, head of the federal government’s Campaign against Venereal Disease, similarly lamented the cultural emphasis on male sexual prowess ‘‘in which feminine purity is trampled.’’∑∞ By educating the public, by suppressing laws that endangered women to protect men, and by eliminating brothels and thus making prostitutes more di≈cult to find, experts posited, revolutionary Mexico might ultimately witness new and more equitable relations between classes and between the sexes. By the 1930s, suppressing the Reglamento and implementing a new, gender-blind regime of syphilis prophylaxis struck many reformers and higienistas as the most appropriate means of promoting community health and social equality. As Dr. Villela noted, ‘‘these reforms are based on the application of one of the fundamental principles of public health, which establishes that, on the one hand, no individual has the right to be a threat

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to Society and, on the other, that the state has the right to ensure that he is not.’’∑≤ In 1937, then, the department proposed suppressing syphilis by abolishing the Reglamento, criminalizing disease transmission, and ultimately dismantling the zona de tolerancia.

Embodying Reform: Popular Perspectives on Abolitionism, Health, and the Body Despite the Department of Public Health’s promotion of new antivenereal legislation as representing the ideal fusion of revolutionary ideology and public health practice, deregulating prostitution and criminalizing disease generated considerable controversy among capitalino men and women in the late 1930s and early 1940s. Public health o≈cials posited that abolishing regulations would protect the revolution’s promises to redeem the Mexican people through eliminating ‘‘antisocial subclasses’’ and protecting the right of all citizens to good health. However, the very people supposed to benefit from abolitionism, the prostitutes for whom the Reglamento’s antisyphilis provisions had been most onerous, opposed what they perceived to be an attack on their right to work and a threat to their ability to earn a living for themselves and their children. Clients, likewise, rejected abolitionism as a threat to their own pursuit of good health as defined by engaging in regular sexual activity. The opposition of both prostitutes and their clients to the new health proposals centered on their own ideas of welfare and bodily well-being. Prostitutes actively opposed deregulation for several reasons. In the first place, they seriously questioned the Departmento de Salubridad Pública’s position that the measure would guarantee their rights as Mexican citizens to good health. Medical reformers, for example, had long stated that it was the duty of the revolution to ensure the well-being of each individual Mexican and also to redeem those members of the lower classes who had been downtrodden under previous regimes. As Michoacán physician Dr. Arturo Oviedo Mota wrote Pascual Ortíz Rubio, president of the republic, in 1929, ‘‘The Revolution, in its program to redeem the popular classes, is obligated to combat this ‘necessary evil’ left over from the Dictatorship. For the Porfirians, the popular classes were despised by Society, and it mattered little or not at all that their children, fodder for the cannon or the brothel, suffered.’’∑≥ But at the 1935 meeting to discuss whether or not to suppress the

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Reglamento Dr. José Siurob, a revolutionary general and the new Public Health director, lamented the fact that the city’s prostitutes seemed not to have captured the revolutionary spirit engulfing the rest of the nation. Stating that the government wanted only to help them move away from an undesirable trade, he noted, ‘‘The first lesson we learned from those women was bitter. We were guided by our sense of revolutionary democracy, which tries to abolish these hateful classes in which a poorly organized society is divided, and we arrived, o√ering them our comradely hand but received in response a hostile demonstration of their inferiority complex.’’∑∂ But after considering the department’s proposals, Maria Millán, a veteran prostitute and cabaret dancer, questioned the o≈cials’ concern for poor women’s health. Referring to her body, ravaged by repeated abuse and exposure to disease, Millán stated: ‘‘This life is tragic, the cabaret chews out our guts. And afterward? When we are no longer attractive, it spits us out!’’ She went on to blame the government for the problem. ‘‘What do they know of those of us who work in the cabarets? What do they know if we go without sleeping or eating, if we su√er without food because we are sick?’’∑∑ Prostitutes like Gloria Mendoza Valdéz, who stated that she solicited clients in the capital’s commercial and political districts, voiced similar frustration with the new antisyphilis campaign. In a 1939 letter to President Cárdenas, Mendoza echoed Millán’s concerns about body and health, noting that the abolition of regulated sexual commerce complicated the prostitutes’ already miserable lives by making them vulnerable to greater police corruption, physical abuse, and harassment. Mendoza criticized the department’s equation of good health with being syphilis-free, pointing out that the beatings and mistreatment she and her colleagues regularly su√ered at the hands of disreputable policemen posed a greater threat to them and to their families than the risk of disease. She complained passionately that ‘‘we have become the victims of beatings on the part of the police’’ and that ‘‘they [the police] charge us fines, they don’t give us receipts, and most of the time we cannot pay them anyway.’’∑∏ On the one hand, Mendoza’s and Millán’s statements raise questions about the state’s ability to change popular attitudes; on the other, they shed light on some women’s reactions to the state’s intrusion into their domestic and sexual lives. Were the women’s bodies and their children’s lives less important than the national syphilis threat, the prostitutes wondered? Men who were accustomed to visiting prostitutes in established vice

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centers found fault with the new antisyphilis regime as well. While they did not specifically oppose the government’s e√orts to criminalize disease transmission, their statements reflect capitalino men’s belief, even in the 1930s, that indulging in regular sexual activity was a healthy pursuit that provided physical benefits that o√set any risk of acquiring syphilis. Unmarried men, in particular, believed regular sexual activity was medically necessary and were among the most vocal opponents of the ban on o≈cially regulated prostitution. A group of individuals who identified themselves to Cárdenas as ‘‘various bachelors’’ stated: ‘‘Those of us who don’t have girlfriends, because we have nowhere to take them, must now go visit the prostitutes in their homes.’’∑π Not only did the ‘‘bachelors’’ object to the inconvenience of searching out prostitutes in their homes, they also worried about the impression such visits made on the young children who lived in the city’s least expensive quarters, where many prostitutes now resided. Prostitutes and clients alike engaged in sexual intercourse ‘‘for necessity or for the health of the body,’’ they insisted. ‘‘For those women and the single men, the houses with discreet rooms and the hotels should remain open.’’∑∫ Was it not worse for young children to witness the women’s sexual promiscuity, the ‘‘bachelors’’ worried, than to maintain the system of regulated sex? Men and women elaborated alternative notions of health and well-being, in part thanks to the growing visibility and influence of advertising campaigns regarding bodily care, good health, and beauty care in Mexico over the late 1930s and 1940s. Magazines that targeted male and female readers generated images and information about the benefits of physical exercise, plastic surgery, and disease prophylaxis, suggesting that true happiness—if not national progress—was linked to an image of physical fortitude. Women’s magazines such as Mujer and Nosotras encouraged women to take their health into their own hands and to assume responsibility for the physical well-being of themselves and their children. Mujer, a late-1920s publication that advocated the ‘‘moral and intellectual elevation of the Mexican woman,’’ recommended that teenaged girls practice swimming and attend dances, ‘‘which are necessary for the health of the body as well as the soul.’’∑Ω Advertisements in these magazines, moreover, promised to help women readers resolve the embarrassment associated with gynecological treatment: Dr. Amelia Green announced that she provided ‘‘discreet’’ medical services for ‘‘female problems,’’ and Dr. C. Carrillo y Cárdenas similarly promoted an o≈ce that specialized in ‘‘secret sicknesses of men and women.’’∏≠ Nu-

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merous merchants and international companies sponsored ads that encouraged women to employ the latest cosmetic and technological advances to radiate a personal image of bodily perfection and good health.∏∞ Like women, male readers and consumers learned to assume personal responsibility for their own health and hygiene. In fact, male brothel clients began to demand an assurance of hygienic excellence from bordellos during the 1930s. A 1933 pocket guide to metropolitan nightlife, México de Noche: Guía para el Hombre Que Quiera Divertirse, for example, provided readers with a dazzling choice of cabarets, bordellos, and ‘‘discreet rooms’’ that, the editors boldly asserted, guaranteed not only ‘‘the most attractive and suggestive shows to be found in this great metropolis’’ but also projected ‘‘an absolute principle of moral ethics.’’ Bordello proprietresses promoted their establishments with advertisements that proclaimed their hygienic status. Carmen Uribe, for example, assured potential clients that her bordello on Mérida Street was ‘‘the safest house in the colony,’’ while another spot on Colima Street promoted itself as ‘‘the most discreet and hygienic house in the city.’’∏≤ Magazines that catered to a largely male readership, such as Detectives, a weekly crime circular, regularly titillated readers with stories about drug addiction and prostitution as well as provided information on popular cures for inconvenient genital infections and advice on disease prevention. In addition to making the sensationalist sex guide Ignorancia Total available to its readers at a discount, men’s magazines sold ‘‘Testofort,’’ an aphrodisiac to combat impotence, and ran copy announcing an over-thecounter cure for gonorrhea called ‘‘Bleno-Blenol,’’ which could be ordered directly from the manufacturer.∏≥ When Román Barrón wrote Lázaro Cárdenas to complain about his friends’ venereal disease infection, Mexican men’s and women’s perspectives on syphilis and secrecy and the state’s relationship to the population’s bodies had changed significantly since Dr. Eduardo Lavalle Carvajal had first lamented the capitalino population’s resolute ignorance of disease symptoms, prevention, and treatment. Men and women were more likely to recognize venereal disease symptoms in 1940 than they were in 1909, thanks to health information and education programs. They demanded hygienic work and leisure conditions and could also count on a well-established system of free, anonymous clinics in which they might seek treatment at a low cost to their pocketbooks and their respectability. The history of syphilis prophylaxis popularization in Mexico reflects changes in the ideas of risk and well-being over time. At one level, the idea

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These advertisements touting brothel hygiene appeared in a 1930s guide to nightlife in the capital. In the aftermath of vigorous prophylaxis campaigns brothel clients had learned to appreciate clean brothels and healthy prostitutes, but they were reluctant to accept the revolution’s broader goal of dispensing with sexual commerce altogether. From México de Noche: Guía para el Hombre que Quiera Divertirse (1933), reprinted with permission from the Bancroft Library, University of California, Berkeley.

of risk encompassed an individual’s calculation regarding the likelihood of acquiring syphilis, gonorrhea, or any other venereal disease from a sexual encounter. At another level, popular conceptualizations of risk included the chance that a body would manifest or confess its owner’s involvement in deviant or promiscuous sexual behavior by developing disease symptoms. Over the thirty years that public health o≈cials worked to reconcile revolutionary ideology and public health practice, people’s concerns about acquiring disease remained low while their concerns over having their infection status made public decreased as well, as Millán’s, Mendoza’s, Barrón’s, and the ‘‘bachelors’ ’’ communications with public authorities suggest. By 1940, when disease transmission was criminalized and the last vestiges of the prostitutes’ Reglamento were swept away, men and women were less fearful of ‘‘confessing’’ their infection or involvement in sexual commerce either as practitioners or clients. However, they did resent the government’s

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e√orts to change their sexual behavior or their use of sexual services to earn money for their families. In protesting the Department of Public Health’s new policies, men and women presented their own visions of health and well-being to public o≈cials. For single women, this vision included freedom from physical abuse and harassment. For single men, it included the ability to have sexual intercourse with a variety of women on a regular basis. Both groups coincided in expressing concerns over protecting Mexico’s youngest citizens from exposure to vice and deadly disease. Men and women alike articulated a double-edged understanding of well-being that included both the individual’s freedom to engage in risky sexual behaviors as well as his or her right to expect medical treatment at the community’s expense.

Notes This research on which this essay is based was funded by the Andrew W. Mellon Foundation, the William and Flora Hewlett Foundation, the University of Chicago Department of History, and the Population Research Center at the University of Chicago. I am also grateful to Diego Armus, Ann Blum, and Alexandra Stern for sharing their thoughts and comments on this topic. 1 Dr. Eduardo Lavalle Carvajal, ‘‘Profilaxis Venérea: Medios Prácticos de Fácil Aplicación y de Prontos Resultados,’’ Gaceta Médica de México 5.5 (1909): 308–58. 2 Román Barrón, Indiana Harbor, Indiana, to Lázaro Cárdenas, 1940, Archivo General de la Nación [agn], Administración Pública de la República [apr], Presidentes: Lázaro Cárdenas [lc], file 525.3/1. 3 Bernardo Gastélum, ‘‘La Persecución de la Sífilis desde el Punto de Vista de la Garantía Social,’’ Boletín del Departamento de Salubridad, no. 4 (1926): 8. 4 Carmen Madrigal, Los Menores Delincuentes: Estudio sobre la Situación de los Tribunales para Menores, Doctrina y Realidad (Mexico City: Ediciones Botas, 1938); Archivo Histórico de la Secretaría de Salubridad y Asistencia [ahssa], Salubridad Pública [sp], Inspección Anti-venérea [iav], box 5, file 1; Congreso, Cámara de Diputados, Diario de los Debates de la H. Cámara de Diputados, 37th Legislature, Extraordinary session, vol. 1, no. 27 (April 27, 1938). See also Cámara de Senadores, Leg. 37, vol. 2, no. 32, Ordinary Session (December 29, 1939). 5 ahssa, sp, iav, box 5, file 1, p. 12. 6 Editorial: ‘‘El Batallón Femenino de la Muerte,’’ Detectives 1.30 (April 25, 1932): 2.

s y p h i l i s i n r e v o lu t i o n a ry m e x i c o 205 7 Mujer: Revista para la Elevación Moral e Intelectual de la Mujer Mexicana, March 1, 1927, back cover. 8 There is a well-developed literature on concepts of risk, behavior, and disease in historical and anthropological literature. See, for example, Arien Mack, ed., In Time of Plague: The Historical and Social Consequences of Lethal Epidemic Disease (New York: New York University Press, 1991). On popular conceptualizations of body, disease, and infection, see Emily Martin, Flexible Bodies: The Role of Immunity in American Culture from the Days of Polio to the Age of AIDS (Boston: Beacon Press, 1994). 9 Proyecto de Reglamento de Mujeres Públicas, ‘‘Reglamento para la Prostitución en México,’’ 1867, ahssa, sp, iav, box 1, file 1. See also Ricardo Franco Guzmán, ‘‘El Régimen Jurídico de la Prostitución en México,’’ Revista de la Facultad de Derecho en México 85–86 (1972). 10 ‘‘Reglamento para el Ejercicio de la Prostitución,’’ 1872, ahssa, sp, iav, box 1, file 1. 11 On the Parisian sanitary codes, see Alain Corbin, Women of the Night: Prostitution and Sexuality in France from 1850 (Cambridge: Harvard University Press, 1990). See also ‘‘Reglamento para el Ejercicio de la Prostitución,’’ 1872, ahssa, sp, iav, box 1, file 1. 12 Lavalle Carvajal, ‘‘Profilaxis Venérea,’’ 349. 13 Jose María Reyes, ‘‘Estudio sobre la Prostitución en México,’’ Gaceta Médica de México 9.23 (1874): 147. 14 See, for example, ‘‘Reglamento de Sanidad,’’ 1898, ahssa, sp, Servicio Jurídico [sj], box 12, file 2; Secretaría de Gobernación, Reglamento para el Ejercicio de la Prostitución en el Distrito Federal (Mexico City: Imprenta del Gobierno Federal, 1914); and Reglamento para el Ejercicio de la Prostitución en el Distrito Federal, 1926, ahssa, sp, sj, box 17, file 19, and box 7, file 4. 15 Carlos Roumagnac, Los Criminales en México: Estudio de Psicología Morbosa (Mexico City: Librería de Ch. Bouret, 1906), 151–52. Male prostitution per se was not regulated or prohibited, but the presence of boys in brothels was. See Reglamento para el Ejercicio de la Prostitución, 1872. 16 Luis Lara y Pardo, La Prostitución en México (Mexico City: Librería de Ch. Bouret, 1908), 65, 75. 17 Roumagnac, Los Criminales en México, 151. 18 Reglamento para el Ejercicio de la Prostitución, 1872, ahssa, sp, iav; Lara y Pardo, La Prostitución en México, 64. 19 Lavalle Carvajal, ‘‘Profilaxis Venérea,’’ 335. 20 Carlos Roumagnac, Matadores de Mujeres (Mexico City: Librería de Ch. Bouret, 1910), 25, 26, 27, 29, 30, 35, 123, 135, 155. 21 Federico Gamboa’s famous novel Santa, about a first-class prostitute in

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22

23 24 25 26 27

28 29 30

31 32 33 34 35

Porfirian Mexico City, clearly depicts the process by which matronas registered their new pupilas to comply with the terms of the Reglamento; see Federico Gamboa, Santa (Mexico, D.F.: Ediciones Fontamara, 1993), 13. Reglamento para el Ejercicio de la Prostitución, 1872, ahssa, sp, iav, box 1, file 1; see also José Marroui, ‘‘Memoria de la Prostitución Presentada por el Dr. José Marroui al Presidente del Consejo Superior de Salubridad,’’ 1872, box 1, file 4. Sergio González Rodríguez, ‘‘Cuerpo, Control y Mercancía: Fotografía Prostibularia,’’ Luna Córnea 4 (1994): 73. Lavalle Carvajal, ‘‘Profilaxis Venérea,’’ 344. Lara y Pardo, La Prostitución en México, 73. ‘‘Diversos Oficios de la Inspección de Sanidad, Dando Cuenta de Vigilancia a Casas Sospechosas’’ (1907), ahssa, sp, iav, box 2, file 27. Cristina Rivera-Garza, ‘‘Prostitutes, Sexual Crimes and Society: Mexico, 1867–1930’’ (paper presented at the Conference on the Contested Terrains of Law, Justice and Repression, Yale University, April, 1997). Roumagnac, Los Criminales en México, 90–93, 81. Lara y Pardo, La Prostitución en México, 56, 58, 132, 59. See, for example, Judith Friedlander, ‘‘Doña Zeferinga Barreto: Biographical Sketch of an Indian Woman from the State of Morelos,’’ in Mary Kay Vaughan and Heather Fowler-Salamini, eds., Women of the Mexican Countryside (Tucson: University of Arizona Press, 1994); ‘‘A Mexican Peasant Woman Remembers,’’ in June Hahner, ed., Women in Latin American History, rev. ed. (Los Angeles: University of California at Los Angeles, Latin American Center Publications, 1980), 153–65; and the story of Jesusa Palancares, as told to Elena Poniatowska, Hasta no Verte, Jesús Mío (Mexico, D.F.: Ediciones Era, 1969). Elizabeth Salas o√ers an analysis of the social experience of revolutionary soldaderas in ‘‘The Soldadera in the Mexican Revolution: War and Men’s Illusions,’’ in Heather Fowler-Salamini and Mary Kay Vaughan, eds., Women of the Mexican Countryside, 93–105. Matilde Rodríguez Cabo, ‘‘El Problema Sexual de las Menores Mujeres y su Repercusión en la Delincuencia Juvenil Femenina,’’ Criminalia 6.10 (1940). Boletín Municipal: Organo del Ayuntamiento de la Ciudad de México 1.1 (1915): 20. ahssa, sp, iav, box 3, file 6. Archivo Histórico de la Ciudad de México [ahcm], Sanidad, vol. 1, 3891, file 200. Adrián de Garay, ‘‘Los Dispensarios del Departamento: Los Dispensarios Venéreo-sifilíticos,’’ Boletín del Departamento de Salubridad Pública 4 (1925): 91; ‘‘Causas de Muerte Intrauterina de Enero 1916 a la Fecha,’’ in ibid. 1

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36

37 38

39

40

41 42 43

44

45

46

47

48 49

(1921): 83; ahssa, sp, iav, box 5, file 1, p. 35; Gastélum, ‘‘Persecusión de la Sífilis,’’ p. 6. For a discussion of the Sociedad Mexicana de Eugenesia’s proposed syphilis eradication program, see Alexandra Stern, ‘‘Responsible Mothers and Normal Children: Eugenics, Nationalism and Welfare in Post-revolutionary Mexico, 1920–1940,’’ Journal of Historical Sociology 12.4 (1999): 369–96. agn, Consejo Tutelar para Menores Infractores [ctmi], various files between 1926 and 1940. Katherine Bliss, ‘‘The Science of Redemption: Syphilis, Sexual Promiscuity and Reformism in Revolutionary Mexico City,’’ Hispanic American Historical Review 79.1 (1999): 1–40. Analysis of welfare debates over the state’s duty toward young children can be found in Ann S. Blum, ‘‘Public Welfare and Child Circulation, Mexico City, 1877–1925,’’ Journal of Family History 23.3 (1998): 272–91. Archivo Histórico de la Secretaría de Educación Pública [ahsep], Document Group: Departamento de Psicopedagogía e Higiene, Series: Educación Higiénica de los Niños/Proyectos, file 142.27. Nosotras: Revista de la Mujer que Lucha, June 1934, 7. Juan Soto, La Educación Sexual en la Escuela Mexicana: Libro para los Padres y los Maestros (Mexico City: Ediciones Patria, 1933), 152. Sección de Propaganda y Educación Higiénica, Memoria de los Trabajos Realizados por el Departamento de Salubridad Publica, 1925–1928, 2 vols. (Mexico City: Ediciones del Departamento de Salubridad Pública, 1928), 249–50. ahsep, Document Group: Departamento de Psicopedagogía e Higiene, Cartilla de higiene escrita especialmente para la población del Valle de Oaxaca, 1925, file 135.1. The End of the Road was originally produced in the United States for dissemination among army troops in World War I. See Allan M. Brandt, No Magic Bullet: A Social History of Venereal Disease in the United States since 1880 (New York: Oxford University Press, 1987). Adrián de Garay, ‘‘Los Dispensarios del Departamento: Los Dispensarios Venéreo-sifilíticos,’’ Boletin del Departamento de Salubridad Pública (1925): 91. Samuel Villalobos, ‘‘Tratamiento de las Enfermas Sifilíticas en la Sala Armijo del Hospital Morelos,’’ Boletín del Departamento de Salubridad Pública 2 (1925): 85–87; and agn, Letter from Dr. C. A. Newcomb to Dr. José Siurob, 1937, apr, Presidentes—lc, file 425.1/25. Juan Soto, La Educación Sexual en la Escuela Mexicana, 145. ‘‘La Nueva Legislación Antivenérea,’’ Boletín del Departamento de Salubridad Pública, segundo trimestre, 1938. This article pointed out that at one health

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50 51 52

53 54 55 56 57 58 59 60 61

62

63

clinic, 48 percent of the women diagnosed with infection were registered with the Sanitary Inspection Service, while 52 percent were clandestinas. Eliseo Ramírez, ‘‘Dictamen Acerca de la Reglamentación de la Prostitución,’’ ahssa, sp, sj, unclassified. ahssa, sp, iav, box 5, file 1. Enrique Villela, ‘‘La Prostitución y las Enfermedades Venéreas en México: En pro de la Reforma Abolicionista y de la Nueva Orientación de la Campaña Antivenérea,’’ Departamento de Salubridad Pública, Oficina General de la Campaña contra las Enfermedades Venéreas, ahssa, sp, iav, box 5, files 1, 2. Alberto Oviedo Mota, ‘‘El Problema Social de la Prostitución,’’ letter to President Pascual Ortíz Rubio, 1930, ahssa, sp, sj, box 20, file 10. ‘‘La Campaña de Salubridad en los Cabarets,’’ El Nacional, October 25, 1937, 8. ‘‘La Vida Miserable y Trágica de las Cabareteras Revelada ante Varios Funcionarios Oficiales,’’ El Gráfico, October 19, 1937, 12. agn, apr, lc, file 525.3/001. Letter from ‘‘varios solterones’’ to Cárdenas, 1940, agn, apr, file 523.3/1. Ibid. ‘‘Madres: Vigilar a Vuestras Hijas,’’ Mujer: Para la Elevación Moral e Intelectual de la Mujer Mexicana 1.1 (1926): 3. ‘‘Dra. Amelia Green Cura Todas las Enfermedades de la Mujer,’’ in ibid., 8; ‘‘Dr. C. Carrillo y Cárdenas,’’ Nosotras, July 3, 1934, 17. ‘‘La Cirugía Estética,’’ Nosotras, June 2, 1934, 29; see also advertisement for ‘‘Salón de Belleza Medal,’’ which stipulated that it provided ‘‘hygienic and courteous’’ aesthetic therapies: Nosotras, July 3, 1934, 21. México de Noche: Guía para el Hombre que Quiera Divertirse, 1933, 2, 99, 101. Although there is little publication information about this pamphlet, it may have been published or sponsored by Martell Cognac. Advertisement for Ignorancia Total and ‘‘Bleno-Blenol,’’ in Detectives: El Mejor Semanario de México 1.26 (1932): 4, and 1.13 (1931): 4.

ann s. blum

Dying of Sadness hospitalism and child welfare in mexico city, 1920 – 1940

ospitalism, a debilitating and often fatal developmental syndrome a∆icting infants in long-term institutional care, puzzled doctors treating the inmates of Mexico City’s public foundling home. The most advanced hygienic and medical regimen only made the babies worse, but infants with hospitalism recovered on visits to their impoverished families. Those families, particularly the mothers, numbered among the target clientele of an intensive campaign initiated during the 1920s by the Mexican revolutionary state to reduce the nation’s high rate of infant mortality. To improve infant survival, a network of urban clinics developed pre- and postnatal medical services in the capital’s poorest neighborhood. To combat disease, the clinics instructed mothers in modern hygienic child care techniques. Yet the regimen of scientific infant care promoted so aggressively by public health programs produced contradictory results when fully enforced at the foundling home: there, infants sickened, declined, and died. Since the eighteenth century, foundling home administrators had observed that inmates of their infant wards su√ered from a strange despondency and that many died ‘‘of sadness.’’ Philanthropists attributed foundling death to a flaw or weakness inherited from the babies’ unmarried or poor mothers, whose immorality and incompetence justified their children’s internment and care by pious benefactors. A century later, physicians dressed those rationales in scientific terms to explain their failure to keep foundling hospice populations alive, but the problem remained. After the Mexican Revolution, however, doctors working in public welfare and public health programs confronted the contradictions between a high-priority national campaign to reduce infant mortality and infants dying in state custody. In the 1930s, having recently established the Mexico City foundling home

H

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as one of the nation’s leading centers of clinical pediatrics, sta√ doctors undertook a comprehensive study of hospitalism and ways to alleviate the malady. The resulting reorganization of Mexican child welfare programs incorporated innovations developed internationally and also heightened medical supervision for infant welfare clients. But medical and hygienic care that improved infant survival in the general population had detrimental e√ects when infants lacked the attentions of a primary caregiver. Attempts to reduce hospitalism within federal child welfare programs of the 1930s and 1940s illustrate clearly how far policy-makers could go toward assembling the elements of a solution to the problem, and at the same time demonstrate why concerned physicians and welfare administrators stopped short of identifying and fitting in the final piece to the puzzle. Placing clinical medicine at the center of the constellation of Mexican child welfare programs and identifying mothers as a prime cause of infant mortality, public health programs and social assistance policy continued to favor institutional internment and medical supervision of infancy over programs that supported mothers and children in the home. Hospitalism would persist as long as social assistance separated infants from mothers or failed to provide substitute mothers.

The Puzzle By 1934, Dr. Federico Gómez Santos, director of the Mexico City foundling home and a leader in Mexican pediatric medicine, had accumulated wide experience working in the public health system of the capital. In the vanguard of child health programs initiated by the Mexican revolutionary state, Gómez shared with many of his physician colleagues the conviction that medical science could provide more than far-reaching health benefits to the Mexican people: medicine, they believed, could cure social ills. The state foundling home, the Casa de Cuna, stood at the juncture of the social and medical consequences of poverty. The institution admitted orphaned and abandoned children from birth to age five and children whose families were too poor or disrupted to care for them. Many children admitted for these social reasons also su√ered from malnutrition, undiagnosed or untreated illness, and infections originating in contaminated water or food. At the foundling home, doctors and child specialists recognized an extraordinary opportunity to demonstrate the e≈cacy of medicine in the service of so-

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cial welfare. But since his arrival in 1926 as a sta√ physician at the Cuna, Dr. Gómez had observed that interned babies responded to medical treatment di√erently from their counterparts in the general urban population; indeed, he noted a disturbingly high morbidity and mortality among the infant inmates that resisted all medical solutions. Gómez and the other Cuna physicians could understand why infants brought to the orphanage su√ering from the consequences of their mothers’ or their own undernourishment, in the advanced stages of diseases untreated owing to a family’s poverty, or weakened by a period of abandonment and exposure contributed to the institution’s high mortality statistics. But seemingly healthy babies often sank quickly into an unnatural apathy, sickened, and died of infections detectable only with autopsy, prompting Dr. Gómez to undertake a study of the special problems of institutional infant care. He grounded his own clinical observations of Cuna inmates on a thorough review of the historical documents of the foundling home as well as the recent European medical literature on interned infant populations. After delivering a report on his study at a medical congress in Dallas, Texas, the doctor sent a copy of his paper, ‘‘The Problem of Prolonged Hospitalization in Infancy,’’ to the directorate of Mexican public welfare, the Junta Directiva de la Beneficencia Pública.∞ His report served notice to the government o≈cials that the tiny inmates of the Casa de Cuna presented symptoms confounding modern medicine and thwarting national public health initiatives of the highest priority. Dr. Gómez’s paper examined an old problem from a new perspective. Foundling hospice administrators in Europe and the Americas had long recognized that in addition to the respiratory and intestinal infections and diseases like measles attacking the young inmates, many became sick, Gómez noted ‘‘ ‘from sadness,’ some said, from lack of a√ection and home, said others, from the monotony of the walls and ceilings of the wards.’’ This sickness ‘‘in spirit’’ was a distinctive condition associated specifically with interned infant populations. But in addition, the a∆icted babies developed a range of other symptoms, some only recently connected to the extended institutionalization of very young children. Compounding their indi√erence and apathy, the a√ected babies also failed to develop physically and socially. Dr. Gómez had observed that Cuna infants less than one year old who acquired the syndrome seldom cried, not even to complain or demand attention. At ten or eleven months they could not sit unassisted. At a year they could not pull themselves up and remained

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immobile and expressionless. ‘‘They sit, propped up,’’ he wrote, ‘‘and stay that way for hours on end without protesting of weariness; wet or dry, they never reveal by the least movement or demonstration any discontent; one never sees on their faces happiness or sadness; they give the impression of living sacks that vegetate in an untiring monotony.’’ Still more troubling to Gómez and his colleagues was that despite the most assiduous medical attention, nutritious food, a sanitary environment, and hygienic handling, these babies became increasingly vulnerable to infection, and mortality among the a√ected group was very high. After four or five months, even babies who had entered the Cuna in good health became pale and anemic. Infections that in the general urban population had a highly benign prognosis, wrote Gómez, ‘‘in the wards of the Casa de Cuna kill with an astonishing rapidity.’’ Linked directly to institutionalized babies, the syndrome had come to dominate the meaning of the conditions collectively labeled ‘‘hospitalism,’’ a term that applied generally to physical and emotional deterioration over long periods of hospital confinement.≤ Contrary to their expectations, the physicians at the Mexico City foundling home noticed that when children with this condition were released for family visits they underwent a dramatic change for the better. Even when their relatives ignored the doctors’ instructions on feeding and hygiene, the children returned from their home visits improved—as if, wrote Gómez, they had received ‘‘an injection of life.’’ They regained their color, appetite, activity, and resistance to disease. All other measures to combat hospitalism met with failure. Children raised in institutions from infancy lagged in all their vital functions, while those raised in even the most impoverished homes, marveled Gómez, ‘‘were so di√erent and so normal, even though they do not receive the daily medical attention, nor the careful diet given the inmates.’’ How was it that children who failed to thrive under the doctors’ vigilance recovered in the care of families who ‘‘transgressed rules of hygiene’’ in ways that the Cuna medical sta√ ‘‘would not by any means excuse in the wards’’? In hospitalism Gómez had identified a medical conundrum, and an embarrassing one. Reducing infant mortality—technically, the death of children less than one year of age—ranked as a top priority in Mexican federal public health policy in the decades following the Mexican Revolution. In the immediate aftermath of the revolutionary conflict, o≈cial statistics of infant mortality ran high, even with significant underreporting. In Mexico City during the month of April 1920, for example, deaths of babies up to

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one year old constituted 59 percent of reported deaths of children under the age of ten, and 27 percent of the total reported mortality in the capital. In 1923, 28 percent of the babies born alive in Mexico City died before reaching the age of one, equal to infant mortality for the immediate postwar year of 1917 and similar to figures for the first half of the 1920s. Nationally, infant mortality was almost 22 percent from 1924 to 1926.≥ To arrest this staggering loss of human and national potential, the revolutionary state allocated scarce resources to child health education campaigns and to founding urban clinics, centros de higiene infantil, devoted to improving infant survival. A rapidly expanding public health system enlisted specialists like Dr. Gómez to spearhead the national e√ort in the capital region. Physicians working in the baby clinics in some of the Federal District’s poorest neighborhoods administered vaccines and medicines, and a dedicated corps of visiting nurses instructed mothers in home hygiene and nutrition for infants and young children. Gómez, director of one of the clinics since 1929, had observed firsthand how the lack of basic household resources combined with the absence of even rudimentary sanitary facilities took infant lives. Many of the Casa de Cuna’s inmates came from families living in such conditions. The profound poverty in the urban barrios revealed the unequal distribution of the benefits of modernity like sanitation and was a distressing reminder that the social injustice blamed on the deposed regime of Porfirio Díaz persisted in the heart of the nation’s capital. Similarly, the institution of the foundling home was itself a vestige of an earlier era when a more punitive moral climate pressured unmarried mothers to conceal their shame by anonymously abandoning their newborns. Founded in 1767 by Archbishop Francisco Antonio Lorenzana y Buitrón, the Mexico City foundling home, originally named the Casa de San José y Niños Expósitos, provided baptism for foundlings and shelter, education, adoption, and suitable employment for any who survived early childhood. Despite low annual admissions through most of the nineteenth century, the establishment endured decades of city bankruptcy, political strife, and cycles of legal reorganization of charitable institutions, holding its place in the social life of the capital as abandonments increasingly reflected poverty rather than motives of protecting family honor.∂ Although many of the doctors with experience in the public health administration worked at the Cuna during the 1920s, the institution remained marginal to initial revolutionary child health campaigns. In 1933, however, the Casa de Cuna moved to a new and specially de-

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signed compound on the Avenida Hidalgo in the suburb of Coyoacán, where the up-to-date facilities inspired the sta√ with a fresh sense of mission focused on medicine. Gómez joined a team of young and enthusiastic pediatricians, a specialty building rapidly in Mexican medical schools. On becoming director, he provided the leadership for the foundling home to attain a reputation for innovation in pediatrics, even publishing a medical journal to disseminate to national and international audiences the sta√ ’s studies of their most challenging cases. The orphanage, ‘‘stirred by enthusiasm for the awakening of pediatrics,’’ became a required stop on the itinerary of distinguished visiting specialists from the United States, which was considered by Gómez and his colleagues to be at the forefront of children’s medicine. Having trained in pediatrics in St. Louis, Missouri, Gómez was particularly alert to international trends in children’s medicine. His paper on hospitalism displayed a thorough grounding in the European and American medical literatures and advances in child welfare; his presentation to the Texas conference put the Mexico City foundling home on the map at this intersection of pediatrics and public services.∑ But despite their high-quality resources and exemplary e√orts, the pediatricians at the Casa de Cuna failed to save the inmates who declined and died ‘‘of sadness.’’ In the contexts of federal policy and medical professionalism, the death of infants in state custody constituted a blot on the record of participating physicians and public health o≈cials. It cannot have been comfortable for Dr. Gómez to concede that the only known cure for hospitalism, an often fatal syndrome acquired in a state institution of medicine and social welfare, was to return the a√ected children to the very homes and families whose poverty or disruption had necessitated their institutionalization in the first place. More than a decade after Dr. Gómez conveyed his observations to his supervisors, child psychologist René Spitz would demonstrate conclusively that infants developed hospitalism when deprived of maternal attention during the first year of life. So severe were the e√ects of early deprivation that they could result in irreversible developmental deficits or death. Spitz, an Austrian war emigré to the United States, had belonged to Viennese psychiatry circles that included Anna Freud, also a specialist on children. To Spitz goes the credit for introducing the term hospitalism to the psychiatric literature and for identifying the syndrome’s psychodynamic dimensions. But Spitz acknowledged the long history of awareness of the condition by opening his landmark paper with a quotation from the 1760 diary of a

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Spanish bishop: ‘‘In the Foundling Home the child becomes melancholy and many of them die of sadness.’’∏ Spitz’s finding that the deprivation of maternal attention caused hospitalism challenged centuries of Western social policy rooted in the assumption that unmarried and poor women made bad mothers. Indeed, his study seemed designed specifically to counter such prejudices. Spitz and his associates compared the development of the infant population of a foundling home, where ‘‘a su≈ciently relevant number’’ of inmates were born to ‘‘socially well-adjusted, normal mothers whose only handicap is inability to support themselves and their children,’’ with that of the infants of the inmates of a ‘‘penal institution in which delinquent girls were sequestered,’’ many ‘‘pregnant on admission,’’ some ‘‘psychopathic, or criminal.’’π Surprisingly, the delinquent girls became good mothers; their babies flourished. In contrast, the foundling home infants, under the care of a trained sta√ and constant medical supervision, su√ered from all the symptoms of hospitalism, and the babies who survived their first year showed a marked decline in all developmental indicators. Working without the benefit of Spitz’s insights, Dr. Gómez and his medical and administrative colleagues in the Mexican federal public health and welfare systems traveled an indirect path toward resolving the contradictions that produced hospitalism. For indeed, the cure for hospitalism lay not in medical advances but in fundamental changes in social thinking and public policy on the family, changes that encouraged doctors and bureaucrats to entrust to mothers the critical task of raising the nation’s children, revolutionary Mexico’s future citizens.

The Germ of Death Historically, explanations of hospitalism conflated physical and moral causes. Foundling death was the inevitable outcome of birth outside marriage and parental poverty, and therefore beyond the reach of medicine. As early as the eighteenth century, lay and clerical philanthropists knew that interning large groups of infants in foundling hospices was detrimental to their health. The vast majority of the babies abandoned to foundling homes entered only to die. But fatal melancholy was merely one of many causes of death among foundling hospice inmates. Throughout the eighteenth and nineteenth centuries, when foundling

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homes proliferated throughout Europe and the Americas, infant mortality in the general population and especially among the poor created a context in which foundling deaths represented only an exaggeration of the norm. In 1900, Mexico had a national infant mortality rate of 30–35 percent, within range of secular trends at the Mexico City foundling home.∫ During the Cuna’s early years, for example, the overall rate of mortality within the institution varied considerably, from a high of 80 percent during the first year of operation to a more moderate 56 percent in 1773, but the percentage of inmates who died during the first year of life demonstrated somewhat less fluctuation: from 45 percent in 1767 to a low of 31 percent in 1773. One hundred years later, between 1877 and the end of 1879, 70, or virtually half, of the 141 deaths among the Cuna’s general inmate population were of children less than one year old. But as late as the 1920s and early 1930s, as the Mexican federal government deployed significant resources to lower infant mortality in the capital city, foundling home infant mortality statistics far outstripped figures for the general population: 81.2 percent in 1926, 79.5 percent in 1928, and a lower but still problematic 61.3 percent in 1931.Ω Foundlings were subject both to the childhood diseases and epidemics that circulated in the general population and to the dynamic of infection within the enclosed environment of the asylum. For more than a century, administrators at the Casa de Cuna followed child-rearing conventions and placed incoming infants with wet nurses on the outskirts of Mexico City, where, if the children survived infancy, they stayed until well after weaning. Cuna wards still in the care of their village nurses succumbed year-round to intestinal and respiratory infections and to epidemics such as meningitis. The foundling home’s internal mortality rates reflected the poverty of the inmates’ families of origin; maternal malnutrition and unassisted childbirth increased the babies’ physical vulnerability. But Cuna mortality figures also reflected the institution’s use as a hospital of last resort by the poor, who brought their newborns with severe congenital anomalies, multiple and premature births, and sick or injured babies on the verge of death. Some babies entered the institution already infected with smallpox or tuberculosis, but respiratory and gastrointestinal illness accounted for most deaths, or weakened children su≈ciently that they died of other infections such as measles. The Cuna’s registers record as cause of death a number of symptoms suggestive of hereditary syphilis, although an explicit diagnosis of syphilis was rare until the twentieth century, when doctors charted an increasing incidence.∞≠ In short, the onset of melancholy in interned infants

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may have prefigured their decline and probable death, but it was by no means the sole reason for foundling mortality. Nevertheless, in addition to the diseases for which eighteenth- and nineteenth-century medicine knew neither preventions nor remedies, many observers believed that foundlings had a special penchant for death over and above other infants. Foundlings’ inherent melancholy stemmed, according to received opinion, from their mothers’ sin in conceiving outside marriage. Foundling home administrators attributed the general fatality of infections to the ‘‘defective predisposition’’ of the foundlings’ ‘‘illegitimate origin,’’ or invoked ‘‘fatal seeds,’’ gérmenes mortales that the o√spring of fallen women carried within themselves.∞∞ Condemning the mothers for their moral failure was fully compatible with sympathy for foundlings who died of sadness. The moral imperative to provide charity for the innocent victims of parental vice justified the separation of illegitimate infants from their corrupt mothers and provided the underlying rationale for foundling hospices. Foundling death may have been virtually inevitable, but at least the babies died baptized, and the Casa de Cuna provided for their burial, which was often beyond the means of the destitute parents. As long as morality condemned the mothers and piety motivated charity toward foundlings, philanthropists emphasized the benefits that the foundling home provided. Visitors to the Casa de Cuna commented mainly on the apparent well-being of the inmates. The management of the establishment could not fail, an inspector noted in 1863, to give the visitor pleasure and to inspire a profound compassion for the inmates: ‘‘In the Cuna, all is cleanliness and order.’’∞≤ It was better for the children to be under the care of a good institution than that of unfit mothers. Over time the stigma of giving birth outside marriage lessened and abandonments increasingly reflected economic conditions. The capital city presented mothers without male partners with steep obstacles both to keeping and to supporting their babies. Occupations open to women paid low wages and tended to be seasonal or insecure. Employers preferred to hire women without children. In late-nineteenth-century Mexico, as the economic policies of the Díaz regime displaced rural families, pushed them toward the cities, and undermined their ability to sustain family life, admissions to the Mexico City foundling home mounted toward a historic high. Many mothers declared that poverty, falta de recursos, forced them to place their babies in the orphanage. The accelerating Cuna admissions provoked the philanthropic and administrative classes of the capital to revive and

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rearticulate dormant rationales for foundling mortality, combining moral arguments with explanations borrowed from the new social and biological sciences. The author of an 1881 report on Mexico City welfare institutions, Juan de Dios Peza, considered foundling death inevitable. To make the point that other nations shared the problem, Peza quoted a French authority: ‘‘Those poor creatures, frequently born of a union of vice and poverty, carry at birth the germ of death. Deprived of maternal milk and ministrations, they perish immediately, and neither science nor the dedication of their benefactors can give them the same prospects that other children have.’’ Echoing these themes in his vignettes describing the Mexican capital, Manuel Rivera Cambas attributed the sorry survival rate of Cuna inmates to the poverty and corruption of their mothers: ‘‘A great many of the children arrive at the hostel carrying the germ of death, with a weak or sickly constitution, emaciated, pale and with agitated features, frequently a√ected by the onset of diseases that originate in inebriation and licentiousness.’’ Moreover, warned Rivera Cambas, surviving foundlings became a threat to society.∞≥ Doctors working in the Casa de Cuna resorted to similar explanations but expressed them in scientific terms. Notably, physicians at the foundling home never attributed individual deaths to ‘‘sadness,’’ but always identified biological agents. Even so, records of the causes of inmates’ deaths in the 1880s and 1890s began for the first time to include the biological equivalent of ‘‘fatal predisposition,’’ described as ‘‘weakness’’ and ‘‘congential weakness,’’ debilidad and debilidad congénita. This new recognition of inherited defects reflected the influence on medicine of the model of progressive evolution based on Darwinian natural selection. Herbert Spencer, whose writings attained wide popularity among Mexican intellectuals, recast Darwinian evolution to attribute progress, or lack of it, in human societies to biological causes such as race. Social analysts argued that the marginality of Mexico’s poor, disproportionately of mixed descent, stemmed from their Indian ancestry. After 1898, when wet nursing fell out of favor and the Cuna’s supervising ministry insisted on bottle feeding with the formulas preferred in Europe, foundling home doctors attributed the fatal results to the ‘‘idiosyncracies’’ of the Mexican ‘‘race.’’∞∂ The artifical feeding program greatly expanded medical supervision at the foundling home but also introduced new complications. Among the bottlefed infants, digestive disruptions predominated as the cause of death. It is also likely that the new feeding regime established the conditions for an

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increase in hospitalism, although physicians and administrators recorded no observations on the subject. Removing nursing infants from the homes of the wet nurses and feeding them on a schedule and with a bottle reduced the babies’ physical and social contact with caregivers. The Cuna continued to employ in-house wet nurses for the babies who reacted poorly to formula, but owing to the shortage and constant turnover among those employees, most infants shared a nurse and therefore lacked a consistent primary caregiver. Similarly, the time of weaning had long been known as a hazardous period. Switching to inappropriate or contaminated food might lead to potentially fatal intestinal infections, but breaking emotional ties with the nurse, the primary caregiver, could also be harmful to a toddler’s health. In his 1933 paper on hospitalism, Dr. Gómez cited the Cuna’s 1774 regulations, which noted that when foundlings were weaned, ‘‘their natural sadness becomes more acute and it has been observed that some die without [their caretakers’] being able to discover any other cause than melancholy.’’ Whether from the point of view of morality or medicine, foundling death remained overdetermined. Abandoned infants carried ‘‘the germ of death’’; they sickened and died because of individual inherited weakness or more generalized ‘‘racial’’ peculiarities compounded by natural melancholy. These explanations conflated moral and physical infection and emotional predisposition into a seamless cycle providing the rationales for foundling internment and mortality, and absolving institutional administrators and physicians of direct responsibility. The Mexican Revolution, however, installed a new moral climate in which doctors assumed primary responsibility for saving children’s lives.

Medical Management of Infancy As Mexico emerged from the violence of civil war, reformers embraced the task of rebuilding society. The delegates who produced the Constitution of 1917 infused the document with an optimistic nationalism, incorporated provisions for more equitable access to land and protections for labor, restricted the political and social influence of the Catholic Church, and assigned a leading role for the state in these initiatives. Revolutionary principles in turn shaped public health priorities linked to social reform. A burgeoning social hygiene movement mobilized doctors, educators, law-

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yers, and social workers committed to recasting public policy on issues ranging from sanitation to morality; many of the revolutionary public health initiatives converged on women and families.∞∑ Women held an ambiguous place in the revolutionary program. Women of the popular classes had marched and fought with the armies. Feminists convened at congresses to argue for legal and educational equality. The new constitution, however, denied women the vote. Participants in the more radical feminist organizations advocated a real integration of women’s work and family responsibilities, but these concerns remained marginal to consolidating social and political agendas. One measure of the contradictions of women’s position within revolutionary society was that the new family code granted mothers a stronger legal authority over their children while many zealous reformers blamed Mexican mothers for the nation’s high rate of infant mortality.∞∏ Mexico’s loss of population from war, disease, and emigration focused the attention of reforming higienistas on the value of children, the agents of Mexico’s future and also the most malleable members of society. In particular, the alarming statistics on infant mortality prompted an active program of nationalistic state interventions to improve child health. Alberto Pani, engineer and insider in the triumphant Constitutionalist faction, deplored that in Mexico City ‘‘we have to record the awful fact that eight thousand one hundred children less than five years old die annually.’’ He considered Mexican mothers the chief culprits: ‘‘In this frightful toll of human life, more than forty per cent of the total, we must recognize surely, besides the physical causes of contagion, of defective feeding, and unhealthful habitation, this other vital cause of a moral order: crass ignorance and lack of motherly care.’’∞π Pani’s diagnosis echoed throughout the emerging field of puericulture, the combination of medical, scientific, and educational approaches to improving child health and development. Although they remained essential for reproduction, Mexican mothers put the nation’s future at risk with their antiquated and harmful child-rearing practices. An army of experts stood ready to instruct mothers in modern and hygienic methods. Inspired by revolutionary precepts, Mexico puericulturists drew also on the agendas of the international child protection movement, institutionalized in organizations like the League of Nations and the congresses of the Pan American Children’s Institute.∞∫ There was a significant overlap between puericulturists, many of whom were physicians, and adherents of the Mexican eugenics movement, which promised racial im-

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provement through the application of science and medicine. Mexican puericulture institutionalized quickly. A cadre of child specialists, employed in both federal agencies and private organizations, convened in 1920 at the First Mexican Congress on the Child, sponsored by the Mexico City newspaper El Universal. Participants urged a comprehensive program of medical vigilance and intervention starting before conception; o√ered detailed prescriptions for hygienized pregnancy, childbirth, and infant care; elaborated instructional campaigns to be carried out in schools; and advocated legal reforms to enforce their agenda. The Departamento de Salubridad Pública publicized these measures in a Week of the Child, part of the centennial celebration of Mexican independence in September 1921. And the department carried the campaign forward through the Servicio de Higiene Infantil, directed by Dr. Isidro Espinosa de los Reyes, who was also active in Mexican eugenics organizations.∞Ω The revolutionary state’s program of scientific family interventions polarized the politics of motherhood. The Catholic conservative newspaper Excelsior instigated the first Mother’s Day in 1922 to protest birth control and sex education campaigns in the Yucatán, and continued to promote the annual holiday, tarring motherhood with the brush of reaction. In 1926, church-state conflicts ignited the Cristero Rebellion, an armed uprising of Mexican Catholics against the federal government that was not resolved until 1929. Catholic women’s activism in protesting state enforcement of anticlerical measures, as well as their clandestine support of the Cristero movement, made all women doubly suspect as reactionaries and subversives in the eyes of federal o≈cials. President Plutarco Elías Calles, who dominated Mexican politics in the late 1920s, believed that only women and the lower classes were truly devout Catholics and that both groups clung to religion out of superstition and lack of education.≤≠ This clientele—poor women, among them recent migrants from the states in the grip of the Cristero conflict—became the principal target of medical social reform in Mexico City. By the end of the 1920s the Servicio de Higiene Infantil operated seven centers devoted to pre- and postnatal health in working-class neighborhoods of the capital. Intended as well-baby clinics for vaccinating children, charting their weight, and instructing mothers in approved child care methods, the clinics quickly joined the frontlines in the campaign against syphilis, a leading cause of miscarriage and infant mortality. Although syphilis appeared to be the long-suspected biological link between poverty and

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immorality, the clinic physicians actively pursued a healing rather than punitive policy. Much of their practice was devoted to administering medications, attempting to bring the pregnancies of syphilis-infected mothers to successful term, and then treating the infants.≤∞ The clinics of the Servicio de Higiene Infantil provided unquestionable medical benefits for mothers and children in the capital region and testified to the government’s commitment to improving the health of the working classes. Attendance statistics demonstrated that thousands of women eagerly took advantage not only of the clinics’ medical services but also of the hygiene and child care classes held in the centers. To carry the infant health campaign beyond the clinics and into the home, the agency generated an advice literature on scientific infant care. Pamphlets produced by the agency asserted that patriotic Mexicans owed the fatherland children healthy in body and mind. The literature covered topics from house cleaning and protection from fly-borne disease to detailed instructions for measuring baby food to the gram or cubic centimeter. Child care brochures also pitched their message to draw mothers back to the clinics with warnings against following the advice of their friends and neighbors; all questions should be referred to a physician.≤≤ Leaflets prepared in 1934 for distribution through the clinics urged not only the strictest hygiene but also a highly regimented routine for infant care. Composed as a series of letters to a mother during her baby’s first year, the leaflets instructed: ‘‘habituate [your little one, el pequeñito] to a schedule.’’ ‘‘Never give him the breast between the regular hours of feeding.’’ In addition to o√ering advice on scheduled feedings, naps, baths, and daily fresh air, the pamphlets urged mother to minimize touching and social interaction in the interests of keeping the baby infection-free: ‘‘Your child is growing quickly . . . already he smiles, gurgles and wants to grasp when you touch his little hands. It must make you want to pick him up in your arms and kiss him; but do not do it, nor let others do it. Kissing him may lead to catarrh or other illnesses.’’ ‘‘Do not take him in your arms to put him to sleep, nor permit your friends or family to do so, or let them sing to him to soothe him; noises upset babies and make them nervous.’’ ‘‘Accustom him to have fixed hours for play’’ (the letters suggested one hour in the late afternoon). If the baby survived the perilous first year, the letters admonished, it was because the mother had ‘‘faithfully followed the advice of your doctor, our visiting nurse,’’ and the clinic physicians.≤≥ It is unlikely that many of the mothers who frequented the clinics or

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attended the child care classes implemented such recommendations to the letter. The advice literature presumed a middle-class home and a mother without other obligations and set a standard unattainable on marginal incomes in dwellings without running water. The demands of other children and work often prevented adherence to the full routine, especially the recommended social isolation of mother and child. Women employed outside the home or bringing piecework into the home often left infants in the care of neighbors or older siblings. Or, slung across their mothers’ backs in knotted rebozos, babies and toddlers napped, snacked, played, and flirted with passersby as the women made their daily rounds. More than negating the social environment of their intended audience, the infant care leaflets’ strictures against kissing, touching, and soothing condemned spontaneous expressions of maternal a√ection. An overly demonstrative mother might infect her baby with a disease. As early as 1909, Mexican eugenicists had promoted the English ‘‘Kiss Me Not’’ campaign. Signs pinned to children’s clothes warded o√ kisses, considered the means of transmitting diseases from syphilis to tuberculosis. One author believed that a grandmother’s frequent kisses had planted lupus on the cheek of a three-year-old girl. He urged doctors to ‘‘declare war against the casual kiss.’’≤∂ The advice literature from the Servicio de Higiene Infantil struck a less strident note but nevertheless depicted such a sanitized mother-infant relationship that mothering hardly required mothers. It could be carried out as well or better under the direction of medical professionals. The infant care regimen promoted by the public health campaign measured the gulf of class and worldview that separated the sta√ physicians and administrators from their clients. The clinics’ medical sta√s believed that they were using the weapons of modern science to fight for the lives of the nation’s children against the harmful e√ects of maternal superstition and ignorance. Some of the women chafed at the paternalism and condescension and complained to the press that the doctors would examine only the bathed and well dressed. For their part, the clinic doctors categorized the mothers as ‘‘obedient’’ or ‘‘disobedient’’ in their monthly tabular reports, implying that when their infant patients died, it was the mothers’ fault.≤∑

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Hospitalism as a Medical Achievement Throughout the 1920s, the Casa de Cuna seemed pointedly left out of the high-profile child health campaigns despite considerable overlap in medical personnel with the Servicio de Higiene Infantil. Housed in the suburb of Tacuba from 1918 to 1932, the Cuna sank to a nadir of corruption and disease. O≈cials investigated allegations of mistreatment of the children. Overcrowding required two or three children to share a bed. In 1931, admissions were suspended because of epidemics of measles, rubella, diphtheria, and whooping cough among the inmates. Only a few months later, with Mexico feeling the impact of the worldwide economic depression, a health inspector reported an inflated inmate population of 440, hygiene deficient in all respects, and described the nonmedical sta√ as untrained and undisciplined. The 1933 move to the new facilities in Coyoacán permitted a break with the past. Although some disciplinary problems persisted among the lower-level sta√, inspectors found the technical and medical services in good order, placing the foundling home at a key juncture of public health and public welfare initiatives.≤∏ The Casa de Cuna’s new compound in Coyoacán was designed according to medical criteria. Looking back, one of Dr. Gómez’s colleagues wrote that the new facilities transformed the institution ‘‘from an asylum for abandoned children . . . into an establishment where children were studied meticulously from the point of view of integrated pediatrics.’’ The new plant boasted X-ray equipment, diagnostic laboratories, facilities to analyze the nutritional components and metabolic reactions of di√erent diets, and a freezer bank for human milk. There were ample bathing facilities to maintain the requisite standard of hygiene. Each ward had observation posts for the supervising nurses. The new regulations mandated that sta√ physicians record and sign diagnoses and indicated therapies. In the interests of preventing epidemics within the Cuna, new admissions spent ten days in quarantine, in ‘‘enclosed cells.’’ Even when integrated into the general wards, each nursing baby occupied an individual cubicle.≤π In short, the new facilities transformed the foundling home into a children’s hospital. In this environment sta√ doctors could enforce the ideal infant care regimen promoted by the Servicio de Higiene Infantil. The prescriptions, however, produced unanticipated and counterintuitive results. The emphasis on medicine and hygiene in the foundling home reinforced the isolation of the

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Niñeras in training with their infant charges, 1937–39. Courtesy of México, Archivo General de la Nación, Archivo Fotográfico Enrique Díaz, Sección Cronológica, 61/10.

infants. The more clinical the orphanage routine became, the more the younger inmates, especially those not yet walking, were confined to their cribs. Not only feedings but also attention and handling were likely to be strictly scheduled. Confinement and feeding by the clock restricted the babies’ social and physicial contact with other children and with caregivers. Describing morbidity in the babies with hospitalism in his 1945 paper, René Spitz enumerated symptoms that matched exactly those Gómez had observed and documented in Mexico City’s Casa de Cuna more than ten years earlier. Despite ‘‘impeccable’’ hygiene and the isolation of children with contagious diseases from uninfected inmates, wrote Spitz, ‘‘the children showed, from the third month on, extreme susceptibility to infection and illness of any kind. There was hardly a child in whose case history we did not find reference to otitis media, or morbilli, or varicella, or eczema, or intestinal disease of one kind or another. No figures could be elicited on general mortality; but during my stay an epidemic of measles swept the institution, with staggeringly high mortality figures, notwithstanding liberal administration of convalescent serum and globulins.’’ Indeed, Spitz

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noted that ‘‘the worst o√enders,’’ the institutions where hospitalism was most prevelant, ‘‘were the best equipped and most hygienic.’’≤∫ Hospitalism represented an ironic medical achievement, the fruits of scientific infant care and the triumph of clinical pediatrics. Although hospitalism had a history at least as long as that of foundling homes, only when doctors could identify individual infectious agents and by the process of elimination clear the field of causation could they grasp the peculiar etiology of the syndrome: melancholy, developmental deficits, heightened susceptibility to infection, death. Indeed, only when medical science could keep a greater number of interned babies alive could physicians observe the longterm trajectory of the syndrome and its permanent e√ects. The prevalence of hospitalism among the Cuna’s inmates, Gómez’s astute observations of the syndrome, and his familiarity with the international literature on the subject marked the successful establishment of clinical pediatrics within the state structure and the overall progress of Mexican medicine, the nation’s most developed field of science and a centerpiece of the revolutionary social program. To combat hospitalism, Gómez urged the directorate by Beneficencia Pública to implement European innovations in child welfare establishments. He noted that the latest foreign medical journals suggested that orphanages create a homelike environment and place more children in foster care. Gómez advocated a program of ‘‘intense propaganda through the home-visit social workers to seek adoptions for orphans, even promising free medical care.’’ Parents who interned their children in the Cuna, moreover, should be required to take them out periodically. If the family was very poor, the Cuna should send food supplements for the period of the visit. If possible, foundling homes should also be relocated to the country, where children could play outside, receive personal attention, and mix with children of other ages. Gómez perceived that infant health required social stimulation as well as medical treatment. Despite the acuity of his empirical observations and his best intentions, however, as a physician he viewed hospitalism from a clinical perspective, defined the syndrome as a medical problem, and urged the new measures in the interests of preventing or alleviating a disease. Although Gómez admitted that medicine alone could not cure hospitalism, he stopped short of recognizing that the foundling home’s attainment of ‘‘integrated pediatrics’’ on a clinical model may have perpetuated a flawed model of child welfare services. His proposals for reducing hospitalism included

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institutional adjustments, adoption or fostering of Cuna inmates, and more visits from available family. But if an institution of public welfare could provide medicine to adoptive families and food for the duration of family visits, why not take the next step and advocate comprehensive social assistance to support and preserve families in their homes?

State-Led Maternalism Dr. Gómez made his recommendations for institutional reform to alleviate hospitalism at a fortuitous moment. A positive model of nationalistic motherhood came to fruition during the presidency of Lázaro Cárdenas (1934– 40). The president’s openness to feminists’ demands for expanded political, economic, and social rights for women did not result in female su√rage, but it did influence federal social programs. The state’s new formulation of motherhood linked pronatalism and social policy bearing on the family to Cardenista prolabor politics and state-led industrialization. To reclaim maternity from conservative Catholics, federal agencies developed a secular version of motherhood by staging events such as the 1936 Homage to the Proletarian Mother, organized by the federal Department of Labor. Public Mother’s Day ceremonies, coordinated by rural and industrial departments within the Secretaría de Educación Pública, celebrated working-class and agrarian mothers and promoted the works of Mexican authors, President Cárdenas’ nationalization of the oil industry, and, of course, medicine and hygiene.≤Ω Mexican welfare o≈cials, an increasing number of them women, were also influenced by developments in the international arena, where child advocates promoted assistance aimed at keeping children in the home. The integration of Mexican family and child welfare with broad national social, economic, and political goals and with international models received a further boost in 1935, when the Seventh Pan American Congress on the Child met in Mexico City. In the aftermath of the meetings, Mexican public welfare expanded and multiplied existing extramural programs such as kindergartens and soup kitchens, opened mothers’ centers in working-class neighborhoods, and introduced a limited program of family pensions. Not all initiatives for policy shifts came from above. The basic needs of the clients of the urban child health clinics gradually augmented the service to encompass community assistance. Through the visiting nurses, families pressed for the

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removal of garbage dumps and for clean drinking water.≥≠ Together these measures provided social services that helped sustain families through economic crises and improved urban sanitation essential for child survival. All programs that strengthened family coherence reduced pressure on poor mothers to intern their infants in the foundling home and acted as indirect but important preventive measures against hospitalism. Further steps toward a solution to the problem of hospitalism in the foundling home emerged from the convergence of the state’s revalidation of motherhood and the influence of psychology on child welfare policy. Throughout the 1920s the Casa del Niño, the orphanage for older children, had, like the Cuna, remained largely outside the reformist policy mainstream. But under Cárdenas the principles of rehabilitation and reintegration that informed programs for juvenile delinquents filtered into the administration of the public orphanage system. For the first time, welfare o≈cials recognized the negative e√ects on children’s emotional development of large-scale, long-term internment. Psychological testing revealed that orphanage inmates su√ered from ‘‘inferiority complexes.’’ An institutional ambience thwarted the development of the ‘‘self-esteem’’ needed to form a confident citizenry able to build a modern, competitive Mexico. Children su√ering from developmental deficits and behavioral and emotional problems, moreover, were more di≈cult to reintegrate socially, either through adoption or through placement in employment.≥∞ In 1939, Silvestre Guerrero, secretary of the reorganized public welfare agency, Asistencia Pública, announced an initiative to reduce children’s internment in large asylums by establishing a number of smaller facilities, especially for very young children. Guerrero noted that children past the age of weaning were prone to emotional problems of separation and neglect: ‘‘Almost always they become sick—some cases are fatal.’’ In the foster homes, originally intended for a maximum of five children, ‘‘substitute mothers’’ would nurture them in a ‘‘cozier and more human’’ environment than the Casa del Niño, notorious for its overcrowding and lack of discipline. The state would pay a pension for each child and cover medical and maintenance costs. Women—married, single or widowed—who applied for the positions would undergo rigorous inspections of their health, conduct, cultural potential, and habits. State-supported motherhood required conformity to state-approved criteria.≥≤ Gómez’s report on hospitalism had clearly influenced the new policy. Guerrero asserted that the innovation was based on the acknowledgment

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that ‘‘the asylum, in Mexico as in other countries, in reality does not permit the child, despite hygienic care . . . a complete and easy development in the physical, the intellectual or in the moral sense.’’ Invoking but not naming hospitalism, Guerrero noted that ‘‘frequently the little ones sadden and become sick without anyone having been able to discover the way to combat successfully this strange malady.’’ In contrast, children flourished when placed in smaller settings, ‘‘where they encounter the warmth of the family’’ and ‘‘establish cordial and a√ectionate relations’’ with other children and caregivers.≥≥ Within days of first publicizing the program, Guerrero announced that Asistencia Pública had opened twenty foster homes to ‘‘reduce to a minimum the collective internment of tiny tots [ pequeñuelos]’’ and ‘‘settle them in the heart of honorable families.’’ Most of the 160 children selected for transfer to the smaller environments were inmates of the Casa de Cuna; all were ‘‘healthy and normal.’’ Internment, however, was still preferred for children su√ering from ‘‘some abnormality which requires medical attention.’’≥∂ Indeed, the establishment of the group homes on a family model may have encouraged specialization among public welfare institutions, promoting warmth and a√ection in small settings and emphasizing medical attention and a clinical ambience at the foundling home. A 1940 report criticizing the foundling home for its strict institutional regimen indicated, on the one hand, that the Cuna had not achieved a homelike atmosphere, and, on the other hand, that the benefits of a more a√ective environment had won considerable public acceptance. Angel Paz, writing for the Mexico City newspaper El Nacional, deplored the unbending managerial style and strict scheduling at the Casa de Cuna. Paz bypassed wards of the infants and babies not yet walking and thus did not observe the infant care regimen. Focusing on the toddlers, the reporter noted that the happy, healthyseeming children assembled at their refectory tables presented a cheerful and innocent image similar to the happiest homes. But, warned Paz, ‘‘that atmosphere is deceptive. . . . There exists no independence . . . life is severely regimented. A rigid automatism sets the hour of eating, of rising, of play.’’ Such a routine meant that by the age of six children ‘‘already carried inside them the seeds of psychiatric illnesses,’’ and if they remained under institutional care, those germs of psychosis would develop fully.≥∑ Notably, Paz attributed the origins of illness neither to the children nor to their parents, but to the misguided policy of a state institution.

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Doctor and nurses attending older babies in the recently opened Casa de Cuna, Coyoacán, 1933–34. Courtesy of México, Archivo General de la Nación, Archivo Fotográfico Enrique Díaz, Sección Cronológica, 40/22.

Bolstered from the outside by the consolidation of an international consensus on the benefits of home care, and nationally by presidential support of policies that preserved ‘‘family integrity,’’ the group home program continued to hold its place in federal child welfare policy through the administration of Manuel Ávila Camacho, who succeeded Cárdenas. In 1941, Dr. Gustavo Baz, the secretary of Asistencia Pública, reinforced the rationales in a radio address: ‘‘Throughout the world the practice of keeping children in large concentrations has been abolished . . . for nullifying their personality. Everywhere children are placed in small groups in homes, returning to them the a√ect they have lost.’’≥∏ Despite such strong evidence and the growing weight of international opinion, infancy remained the physician’s domain in Mexican public welfare. In 1943, at the First National Congress on Social Assistance, Dr. Luis Berlanga Berumen summarized the principles sustaining the policy of infant internment on a clinical model: ‘‘Owing to the lack of understanding of puericulture among the general population . . . the biological care that the nursing baby requires for the first year and a half of life is better achieved and

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at lower cost in technically constructed and well organized foundling homes than in substitute or foster homes.’’ Only when children had reached the age of eighteen months would they be transferred to the smaller group homes, for after that age it was believed that internment in large asylums was ‘‘highly prejudicial’’ to the child—the longer the internment, the worse the damage.≥π Berlanga’s statement reflects the influence of Dr. Gómez on both counts: the recognition of the importance of homelike environments and the insistence on institutionalized scientific oversight of children in their first year of life. Gómez’s paper on hospitalism had initiated real innovation in Mexican child welfare policy and contributed to the establishment of the small group homes. He had also made infancy his pediatric specialty and had dedicated his career to consolidating clinical pediatric medicine within the state structure. With the Casa de Cuna as a springboard, Gómez worked tirelessly to realize his ambition of establishing a federal children’s hospital in the capital. His crowning achievement, the Hospital Infantil de México, opened in 1943. In addition to supervising the services for premature and nursing infants, Gómez directed the institution for many years.≥∫

Conclusion From 1934, when Dr. Gómez applied the latest international medical research on hospitalism to the Mexican state foundling home, to 1945, when René Spitz published his definitive study establishing the cause of the syndrome, physicians and o≈cials in the Mexican public health and welfare administrations followed the logic of the politically driven evolution of national policy, on the one hand, and international welfare trends, on the other, to arrive at a nearly complete solution to the problem of hospitalism. The missing piece to the puzzle—keeping infants with their mothers or placing them immediately with substitute mothers—highlighted not only the importance of Spitz’s insights to understanding infant development but also the problematic status of motherhood in Mexico’s revolutionary social program. The presence of hospitalism at the Mexico City foundling home and the initiation of reforms to alleviate the syndrome illuminated both the strengths and weaknesses in the state’s public health and welfare policy. The diagnosis of hospitalism at the Cuna represented a benchmark of progress

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in Mexican medical professionalism, proving that the state foundling home could attain a previously elusive level of hygienic management. Similarly, Dr. Gómez’s paper on hospitalism indicated that Mexican medical practitioners were fully abreast of and integrated with international trends in the developing specialty of pediatrics. The reforms that Gómez advocated to prevent hospitalism incorporated the latest policies advocated by PanAmerican and European puericulturists. The subsequent promotion of small group homes also reflected international trends that moved children’s social services away from large-scale internment toward home-based care. In applying and adapting research and innovations pioneered elsewhere in the world, Mexican physicians and welfare o≈cials introduced important improvements in federal social services for local infants and their families. The last obstacles to eradicating the conditions that produced hospitalism were by no means unique to Mexico but were nevertheless deeply embedded in Mexican public health and welfare policy. The centrality of medicine in eugenics and puericulture and their rapid institutionalization in revolutionary social programs privileged medicine in welfare policy concerning very young children. Mexican pediatricians, building their field within the state bureaucracy, made a significant investment in their role as medical managers of infancy, both within public institutions and through public outreach programs. Scientific, ‘‘biological’’ infant care underwrote the revolutionary campaign to improve child survival and contributed to the achievement of dramatic benefits: Mexican infant mortality declined steadily, from 13 percent in 1934 to 9.6 percent in 1950.≥Ω At the same time, medical management on a clinical model made infancy the physician’s domain, raised the qualifications for motherhood su≈ciently high to justify replacing mothers with doctors, and at the foundling home perpetuated a model of social services predicated on the separation of mothers and infants.

Notes I owe special thanks to Dr. Cheryl Springer for her insights into the psychiatric literature on hospitalism, and to Diego Armus and Katherine Bliss for their helpful discussions and comments. Thanks also to Alexandra Stern and Alison Alonso, who provided sources that contributed to this study, and to the press’s outside reader for suggestions for improving this essay. 1 Federico Gómez, ‘‘El Problema de la Hospitalización Prolongada en la In-

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3

4

5

6 7 8

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fancia,’’ March 9, 1933, forwarded to the President of the Junta Directiva de la Beneficencia Pública, May 7, 1934, Archivo Histórico de la Secretaría de Salud [ahss], Beneficencia Pública [bp], Establecimientos Asistenciales [ea], Casa de Niños Expósitos [cne], file 20, folder 5. All subsequent discussion and quotations of Gómez on hospitalism come from this source. René A. Spitz, ‘‘Hospitalism: An Inquiry into the Genesis of Psychiatric Conditions in Early Childhood,’’ in The Psychoanalytic Study of the Child (New York: International Universities Press, 1945), 53–74, reprinted in Robert N. Emde, René A. Spitz: Dialogues from Infancy (New York: International Universities Press, 1983), 5–22, at 5. ahss, Salubridad Pública [sp], Estadística, box 11, folder 1; Isidro Espinosa de los Reyes, La Mortalidad en la Primera Infancia en México: Sus Causas y Remedios (Mexico City: Imprenta Manuel León Sánchez, 1925), 8– 10; Eduardo Cordero, ‘‘La Subestimación de la Mortalidad Infantil en México,’’ in Ignacio Almada Bay, comp., La Mortalidad en México, 1922–1975 (Mexico City: Instituto Mexicano de Seguro Social, 1982), 205–27; and Alfonso Reyes, ‘‘La Mortalidad,’’ in ibid., table 5, p. 22. Pilar Gonzalbo Aizpuru, ‘‘La Casa de Niños Expósitos de la Ciudad de México: Una Fundación del Siglo XVIII,’’ Historia Mexicana 31.3 [123] (1982): 409–20; Ann Shelby Blum, ‘‘Children without Parents: Law, Charity, and Social Practice, Mexico City, 1867–1940’’ (Ph.D. diss., University of California, Berkeley, 1998); and Blum, ‘‘Public Welfare and Child Circulation, Mexico City, 1877–1925,’’ Journal of Family History 23.3 (1998): 240–71. Alberto Del Castillo Troncoso, ‘‘La Visión Médica del Porfiriato en Torno de la Infancia’’ (paper presented at the Twenty-second International Congress of the Latin American Studies Association, Miami, Fla., March 2000); Eugenio Toussaint Aragón, Hospital Infantil de México, Dr. Federico Gómez, 1943–1983 (Mexico City: Hospital Infantil, 1983), 19–21. Spitz, ‘‘Hospitalism,’’ 11. Ibid., 11–12. Robert McCaa, ‘‘The Peopling of Nineteenth-Century Mexico: Critical Scrutiny of a Censured Century,’’ in James Wilkie, Carlos Alberto Contreras, and Cristof Anders Weber, eds., Statistical Abstract of Latin America 30.1 (Los Angeles: ucla, Latin American Center, 1993): 602–33, 617. Felipe Avila Espinosa, ‘‘Los Niños Abandonados de la Casa de Niños Expósitos de la Ciudad de México, 1767–1821,’’ in Pilar Gonzalbo Aizpuru and Cecilia Rabell, eds., La Familia en el Mundo Iberoamericano (Mexico City: Instituto de Investigaciones Sociales, unam, 1994), 265–310, table 6, p. 302; ahss, Casa de Niños Expósitos [cne], register 16 [1877–80]; Federico Gómez, ‘‘El Problema de la Hospitalización.’’

234 a n n s . b lu m 10 Edward Henoch, Lectures on Diseases of Children: A Handbook for Physicians and Students (New York: William Wood, 1882), 40–51. 11 See, for example, Archivo Diputación Almería (Spain), Actas de la Junta de Caridad, book 1385, October 9, 1825, cited in Trino Gómez Ruíz, El Hospital Real de Santa María Magdalena y la Casa de Expósitos de Almería (Almería, Spain: Instituto de Estudios Almerienses, 1997), 203. 12 Joaquín García Icazbalceta, Informe sobre los Establecimientos de Beneficencia y Corrección de esta Capital, ed. José María Andrade (1863; Mexico City: Moderna Librería Religiosa, 1907), 33–39. 13 Juan de Dios Peza, La Beneficencia en México (Mexico City: Imprenta de Francisco Díaz de León, 1881), 110; Manuel Rivera Cambas, México Pintoresco, Artístico y Monumental, reprint ed., 3 vols. (1880; Mexico City: Editora Nacional, 1957), 2:173–74. 14 ahss, cne, registers 19 [1884–95] and 27 [1899–1901]; Charles A. Hale, The Transformation of Liberalism in Late Nineteenth-Century Mexico (Princeton: Princeton University Press, 1989), 206, 211–12; [Manuel Domínguez, Director, Casa de Niños Expósitos, to Dirección General de la Beneficencia Pública], June 19, 1905, ahss, cne, Administración, 86: 471–73. See also Robert M. Bu≈ngton, Criminal and Citizen in Modern Mexico (Lincoln: University of Nebraska Press, 2000), 61–63. 15 Katherine Elaine Bliss, ‘‘The Science of Redemption: Syphilis, Sexual Promiscuity, and Reformism in Revolutionary Mexico City,’’ Hispanic American Historical Review 79.1 (1999): 1–40, at 3–5. 16 Anna Macías, Against All Odds: The Feminist Movement in Mexico to 1940 (Westport, Conn.: Greenwood Press, 1982); Ley sobre Relaciones Familiares, Expedida por el C. Venustiano Carranza, Primer Jefe del Ejército Constitucionalista, Encargado del Poder Ejecutivo de la Nación (Mexico City: Edición Económica, 1917). 17 Alberto J. Pani, Hygiene in Mexico: A Study of Sanitary and Educational Problems (New York: G. P. Putnam’s Sons, 1917), 33. 18 Donna J. Guy, ‘‘The Pan American Child Congresses, 1916–1942: Pan Americanism, Child Reform, and the Welfare State in Latin America,’’ Journal of Family History 23.3 (1998): 272–91. 19 Memoria del Primer Congreso Mexicano del Niño (Mexico City: El Universal, 1921); Servicio de Propaganda y Educación Higiénica, Memoria de la Semana del Niño (Mexico City: Departamento de Salubridad Pública, 1921). 20 Marta Acevedo, El 10 de Mayo (Mexico City: Secretaría de Educación Pública, 1982); Jean A. Meyer, The Cristero Rebellion: The Mexican People between Church and State, 1926–1929, trans. Richard Southern (New York: Cambridge University Press, 1976), 59; Robert E. Quirk, The Mexican Revo-

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22

23 24 25

26 27 28 29

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lution and the Catholic Church, 1910–1929 (Bloomington: Indiana University Press, 1973), 127. ‘‘Rapport Présenté au Comité de la Protection de l’Enfance, Réuni à Genève, sur les Travaux Réalisés par le Département d’Hygiène de la République Mexicaine en Faveur de l’Enfance,’’ 1923, ahss, sp, Congresos y Convenciones, box 11, folder 19; [Statistical Report, 1925–29], ahss, sp, Higiene Infantil [hi], box 4, folder 21. See also Alexandra M. Stern, ‘‘Responsible Mothers and Normal Children: Eugenics and Nationalism in Post-revolutionary Mexico, 1920–1940,’’ Journal of Historical Sociology 12.4 (1999): 369–96. Alfonso R. Ochoa, El Niño (Mexico City: Departamento de Salubridad, 1921); Servicio de Propaganda y Educación Higiénicas, A los Padres de Familia, 2d ed. (Mexico City: Departamento de Salubridad Pública, 1923). Cartas [nos. 1–12], [1934], Servicio de Higiene Infantil Post-natal, Departamento de Salubridad, Mexico, D.F., ahss, sp, hi, box 10, folder 14. Dr. Martínez, ‘‘Higiene: El Beso en los Niños,’’ La Cruz Blanca: Periódico de Propaganda Sanitaria y Moral 1.1 (1909): 4. ‘‘Irregularidades en Delegaciones y Centros de Higiene,’’ La Prensa [April 1931?], ahss, sp, hi, box 9, folder 16; [Mortalidad Infantil, October 1930], ahss, sp, hi, box 7, folder 14. ahss, bp, ea, cne (1928–29), box 17, folders 3, 6, 11, 19; (1931–33), box 19, folders 4, 6, 17, 19. Toussaint Aragón, Hospital Infantil de México, 8, 19–20. Spitz, ‘‘Hospitalism,’’ 6, 10. Esperanza Tuñon Pablos, Mujeres que se Organizan: El Frente Unico Pro Derechos de la Mujer, 1935–1938 (Mexico City: unam, 1992); Secretaría de la Asistencia Pública, La Asistencia Social en México: Sexenio 1934–1940 (Mexico City: Secretaría de la Asistencia Pública, 1940), 51; ‘‘Nueva Forma el 10 de Mayo,’’ El Nacional, May 9, 1938, 8. League of Nations, The Placing of Children in Families, 2 vols. (Geneva: League of Nations, 1938); Congreso Panamericano del Niño, Memoria del VII Congreso Panamericano del Niño, 2 vols. (Mexico City: Talleres Gráficos de la Nación, 1937); El Nacional, October 22, 1938, and February 20, 1939, 8; [1929–30], ahss, sp, hi, box 6, folder 11, box 7, folder 5; ‘‘Los Centros de Higiene Infantil,’’ El Nacional, February 20, 1940, 8. Fernando Ortega, ‘‘Estado Actual de la Legislación sobre Tribunal para Niños en México,’’ Memoria del VII Congreso Panamericano del Niño, 2:162– 69; see also Katherine Bliss, ‘‘The Science of Redemption,’’ 16–25; ‘‘Función Social de los Hogares,’’ El Nacional, May 11, 1939, 8;[1940], ahss, bp, ea, Hospicio de Pobres, vol. 54, folder 4. ‘‘En Favor de los Expósitos,’’ El Universal, April 17, 1934, 9.

236 a n n s . b lu m 33 ‘‘Constitución de 20 Hogares Substitutos,’’ El Universal, April 21, 1939, 9. 34 Ibid. 35 [August 15, 1935], ahss, bp, ea, cne, box 20, folder 14; Angel Paz, ‘‘Temas Nacionales,’’ El Nacional, May 15, 1940, 8. 36 ‘‘El Presidente Recomienda Medidas para Proteger la Integridad da la Familia,’’ La Prensa, November 10, 1941, 10. 37 Secretaría de Salubridad y Asistencia, Memoria del Primer Congreso Nacional de Asistencia (Mexico City: Secretaría de la Asistencia Pública, 1946), 276. 38 Toussaint Aragón, Hospital Infantil de México, 29–37. 39 Dirección General de Higiene y Asistencia Materno-Infantil, Higiene Materno-Infantil: Programas, Normas, Instructivos (Mexico City: Secretaría de Salubridad y Asistencia, 1958), table 7, p. 322.

ann zulawski

Mental Illness and Democracy in Bolivia the manicomio pacheco, 1935 – 1950

n 1947 an advertisement for the Manicomio Nacional Pacheco, Bolivia’s only true mental hospital, appeared on the last page of the published proceedings of a major national medical conference that had been held that year.∞ The ad said that the Manicomio, located in Sucre, o√ered the latest in treatment for psychiatric disorders: Cardiazol, electroconvulsive therapy, even psychoanalysis, and proclaimed: ‘‘Mental diseases are curable. As perfectly curable as any other illness that is opportunely treated.’’ It went on to stress that all mental or nervous conditions should be treated by specialists and urged readers to eschew charlatans, whether they were Bolivians or foreigners. It also announced that the Manicomio Pacheco had special accommodations for male and female patients who could a√ord to pay for treatment. Five years earlier, Dr. Miguel Levy, the chief health o≈cer for the department of Chuquisaca, in which the city of Sucre is located, published an article entitled ‘‘La Declinación Mental de Indio’’ in a respected national medical journal.≤ In it Levy combined Social Darwinist conceptions about the survival of the fittest and Lamarckian ideas on the inheritance of acquired characteristics with Freudian notions of emotional development to prove that Bolivia’s Indian population was mentally deficient. It was ‘‘a utopia,’’ Levy said, to think that ‘‘the present Indian or his next descendent [could be] a citizen in the strict sense of the word.’’≥ According to the article, both intellectual inactivity and the small brain size of Bolivian Indians contributed to their primarily vegetative existence. A stunted emotional development resulted in a simplification of all psychic functions: the Indian maintained a childish egotism throughout life and was incapable of real love or complex emotions. An absence of imagination and intellectual

I

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curiosity, minimal memory, a short attention span, and the paucity of the Aymara, Quechua, and Guaraní languages made the native Bolivian in general unsuited for education. When an Indian did achieve some minimal schooling, Levy continued, he became a tyrant, abusing and victimizing other illiterate Indians.∂ Several important things about the advertisement and Miguel Levy’s treatise make them representative of views in 1940s Bolivia. The fact that the ad was placed in a medical publication that would primarily be read by doctors is significant. Clearly it was a statement by psychiatrists and the authorities at the Manicomio Pacheco of their professional expertise and a call for their colleagues in other specialties to defer to them in matters of mental health. In fact, it was in the 1940s that doctors who attended the mentally ill in Bolivia began to feel that rather than simply confining patients they could e√ect considerable improvement in the conditions of some by using new types of treatment. More patients were admitted to the hospital during the 1940s than in any other decade between 1884, when the hospital was founded, and 1960. Perhaps this was because of greater consciousness of mental illness on the part of doctors and other health o≈cials and increased hopes for recovery. The advertisement was also a defense of the facilities of the state-run hospital at a time when the first private sanatoriums in Bolivia were beginning to treat people with mental disorders. The fact that the Manicomio now had special pavilions for those who could a√ord to pay was intended to attract wealthier families who might have had qualms about sending their relatives to an institution that was in a chronic state of indigence. In fact, reports by hospital directors before the 1940s (when special quarters for pensionados were introduced) consistently detailed horrendous conditions in the Manicomio due to lack of funds.∑ The hospital’s administration may have hoped to use pensionados’ fees to subsidize improvements in the Manicomio, improvements that would eventually enhance the prestige of mental health professionals and psychiatry in general. Miguel Levy’s treatise, on the other hand, is representative of the era because it was an extreme, but not atypical, reaction against a new democratic political discourse that was developing in Bolivia in the 1940s that rejected discrimination and inequality. Particularly concerned to refute those who favored education as a right for all Bolivians, Levy specifically took exception to the writings of sociologist José Antonio Arze, who proposed the recuperation of stolen lands, the end of forced labor, and

m e n t a l i l l n e s s i n b o l i v i a 239 An advertisement for the Manicomio Pacheco that appeared on the back page of the proceedings of a medical conference held in 1947. From Actas de las Segundas Jornadas Médico-quirúricas Nacionales (Sucre: Universidad Mayor Real y Pontificia de San Francisco Xavier de Chuquisaca, 1948), 410.

educational opportunities as the best ways of helping Indians to realize their potential.∏ Further, Levy’s assessment of native Bolivians as psychologically di√erent and inferior to non-Indians raises questions about the criteria physicians used to recognize and treat mental illness in patients of di√erent ethnicities. This essay examines who was mentally ill in Bolivia in the 1940s and how they were treated by studying the records of the Manicomio Pacheco and the writings of physicians who worked with mental patients. It asks whether the new democratic and populist politics of the period influenced psychiatric practice and what impact class and gender had on diagnosis and treatment. And it examines how doctors understood the intellectual ability and emotional stability of Indians and women, two groups within Bolivian society that were not accorded full rights of citizenship.

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The Period The 1930s and 1940s were years of social and political upheaval in Bolivia exacerbated by the Chaco War with Paraguay (1932–35). The war, which Bolivia was militarily unprepared to win, brought into sharp relief all the ethnic and class contradictions inherent in the nation and ultimately caused the downfall of the political oligarchy of landowning and mining interests that had controlled the country since independence. During the war the vast majority of conscripts were Aymara- and Quechua-speaking peasants who were either sent to the frontlines or forced to do back-breaking work opening roads into the area of the conflict.π In either case, they often had almost nothing to eat or drink, and more of them succumbed to disease than died of wounds.∫ As the military incompetence of those in command and a starving, untrained army contributed to defeat after defeat for the Bolivians, many civilians began to perceive an inherent injustice in the fact that those at the front were experiencing extreme hardships while the more privileged white and mestizo o≈cers generally remained in relative comfort and security behind the lines. In the end, Bolivia was forced to admit defeat and sign a peace treaty in June 1935. The end of the war meant more than the loss of territory to Paraguay; in the aftermath of the debacle there was an upsurge of popular organizing, the creation of new left and populist political parties, and questions of agrarian reform and the nationalization of the mines were placed on the country’s agenda. In the late 1930s the country experimented with a reformist ‘‘military socialism’’ with the presidencies of Col. David Toro and Col. Germán Busch (1936–39). During this period the holdings of Standard Oil of Bolivia were nationalized, a new constitution was drafted that emphasized the nation’s responsibility for the well-being of its citizens, and a labor ministry was formed for the first time. An Indian movement demanding land and education that had emerged in the 1920s and 1930s was revitalized and in the post-Chaco period became associated with a growing militant labor movement.Ω Women workers were active in this union activity, organizing anarchist-oriented unions of cooks, flower dealers, and women who sold in public markets. These organizations also raised gender-based demands for government-funded child care centers and equal rights for single mothers.∞≠ While the governments of military socialism were primarily reformist-

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populist in nature, there was a clear influence, especially during the presidency of David Toro, of corporatist and even fascist ideas. Some supporters of national socialism even went so far as to support the anti-Semitic policies of Nazi Germany.∞∞ The changing political climate also brought new initiatives in public health. In 1936 the Ministerio del Trabajo, Prevision Social y Salubridad was founded, and in 1938 a separate Ministerio de Higiene y Salubridad was created. New attitudes were evident in the radicalized writings of medical professionals of the period. At the First National Medical Congress, held in 1939, Dr. José Antezana Estrada presented a project for a new sanitary code in which he characterized Bolivia as a ‘‘semicolonial’’ country with the lowest economic level in the world.∞≤ A summary from a congress of mining doctors held in the same year reported that two political tendencies emerged at the meeting: one that ‘‘defended established interests’’ and another that ‘‘supported the rights of the proletarian classes.’’∞≥ But alongside these Marxist-inspired analyses were others that suggested alternatives to socialized medicine based on private initiative or favored various eugenicist solutions, including sterilization of criminals and the demented.∞∂ In addition to Miguel Levy, several doctors associated with the Manicomio and a few other physicians concerned with mental health published articles in the late 1930s and 1940s about psychiatry and social issues. In general, however, there was far less emphasis on mental illness as a problem that should be addressed by a new democratic state than there was on other types of disease. This may be in part because psychiatry everywhere in the world lacked the prestige of other medical specialties, since, despite much experimentation, doctors were not particularly e√ective in curing those with serious mental illness. Also, mental illness may have seemed of secondary importance to doctors and social reformers interested in promoting economic justice, because it apparently a√ected far fewer people than typhoid, tuberculosis, or malaria. In Bolivia, furthermore, treatment for mental illness prior to the late 1930s and 1940s had been particularly rudimentary, limited by the shortage of both funds and trained physicians.

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The Manicomio Pacheco and Its Patients Bolivia’s first and only mental asylum was founded in 1884 on the initiative of Gregorio Pacheco, a leading silver industrialist who was president of Bolivia from 1884 to 1888. Although a professorship in psychiatry was established at the university in Sucre in 1890, through the first half of the twentieth century there were very few trained psychiatrists to sta√ the hospital.∞∑ Nicolás Ortiz, the director of the hospital from 1884 to 1923, was a gynecologist who may have accepted the position because he was the sonin-law of Gregorio Pacheco. Jaime Mendoza, the director from 1923 to 1926, was actually a general practitioner who had specialized in obstetrics and been a professor of pathology and pediatrics before coming to the Manicomio. In fact, it was not until the 1940s that Bolivia had several doctors who had actually specialized in psychiatry. One was Alberto Martínez, the director of the hospital from 1944 to 1970. Although the hospital’s statistics are not entirely reliable, it is clear that there were never enormous numbers of patients in the Manicomio. Alfredo Caballero, who has studied the institution, estimates that perhaps twenty thousand people passed through its doors between 1884 and 1984, but this figure seems low, since there were as many as two hundred patients in both the men’s and women’s sections in some years.∞∏ In the first years of the institution, the vast majority of patients were simply diagnosed as ‘‘incurable’’ and their only treatment was ‘‘indefinite confinement.’’∞π By the 1940s, however, the records of the Manicomio Pacheco featured virtually the same diagnostic terms as appeared in statistics on psychiatric patients in the United States and in Western European countries. Nevertheless, an examination of the most commonly diagnosed conditions in Bolivia demonstrates some key di√erences. For instance, while the most common reason for admission to mental hospitals in both the United States and Bolivia was schizophrenia, the second most frequent cause for admission in Bolivia was epilepsy.∞∫ Yet, by the 1930s epilepsy was no longer considered a mental disease in either country, a fact that hospital director Julio C. Fortún mentioned in 1930 when he wrote to the president of the Municipal Council of the City of Sucre requesting that the city not send epileptics who did not have symptoms of mental illness to the hospital because they could be more appropriately treated elsewhere.∞Ω On the other hand, manic depression, the second most common reason for admissions to mental hospitals in the

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United States, was quite rare in the statistics of the Manicomio Pacheco.≤≠ And a small but significant number of patients were hospitalized in Bolivia because of psychosis related to untreated malaria.≤∞ In other words, a large number of people were in the Manicomio for conditions essentially related to poverty: lack of other treatment facilities for those with seizure disorders and inadequate public health measures against malaria. The patient population of both the men’s and women’s sections of the hospital was quite young. The largest group of the men in the Manicomio in 1937 and 1941 was between the ages of twenty-one and thirty, and twothirds were forty or younger. Among 454 women admitted in the 1940s for whom ages are available, the largest ten-year cohort was between twentyone and thirty years old (105), and almost three-quarters were forty or younger. Most men in the hospital in 1941 and 1937 were listed as being single. In 1941, only 12 percent were married; in 1937, 17 percent were. Among the women admitted in the 1940s, 33 percent were married. Since many couples in Bolivia at this time were not legally married, however, it is not certain that the people listed as single were not, in fact, in common-law relationships. The Manicomio Pacheco was the only hospital in Bolivia that dealt exclusively with mental illness, so in terms of social class and race the population of the hospital was diverse. However, race was inconsistently entered in intake records and clinical histories, so it is not possible to establish even approximate percentages of how personnel categorized patients ethnically. According to the 1941 records, of the 177 male patients in the hospital in that year, 67 were white, 76 were mestizo, and 34 were Indian. This is a relatively small number of Indians compared with this group’s probable representation in the population at large, which was recorded as 63 percent in the 1950 census without taking into account a number of small lowland ethnic groups.≤≤ In any event, as will be evident later, the category of race could change in the hospital records, reflecting a fluidity typical of the society at large. In terms of occupation, the largest number of men were peasants or farm laborers (60), but there were also 22 students, 13 merchants, several craftsmen, several white-collar workers, 1 doctor, and 1 accountant. The occupations of the male patients seem to be consistent with general demographic trends since Bolivia was an overwhelmingly agrarian country at the time. Among the women admitted to the hospital during the 1940s, the vast majority (206) were listed as working in their homes (labores de casa), a

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description that included women of greatly varied economic circumstances. Of the women who gave other professions there were 29 servants, 28 seamstresses, 24 women involved in commercial activities, 14 students, 13 teachers, and 12 palliris (women who worked in mining areas sorting ore according to quality). Cardiazol and insulin were often used to treat schizophrenia and manic depression. Insulin, which was first used in treating schizophrenics in Austria in the 1930s, produced hypoglycemic comas in patients that seemed to alleviate their symptoms, at least in the short run.≤≥ It was also extremely dangerous, causing death in almost one out of one hundred patients in U.S. hospitals where it was extensively used.≤∂ Cardiazol, a drug similar to camphor, induced convulsions without coma. Although it was said to produce remarkable improvement in some patients, it had unpleasant side e√ects including anxiety, nausea and vomiting, and severe muscle pain in the area of the injection.≤∑ In 1944 director Alberto Martínez for the first time treated patients with electroconvulsive therapy (ect) in the Manicomio Pacheco. Of ten female patients in the experiment (nine schizophrenics and one manic-depressive), four experienced complete remission; four others (including the manic-depressive) were significantly improved, and two did not respond favorably to the treatment.≤∏ In addition to insulin, Cardiazol, and ect, patients were dosed with a variety of other medicines, including bismuth and mercury for syphilis. It is interesting that the Manicomio continued to rely on these two drugs long after the arsenic-based compound Salvarsan became the treatment of choice for the disease, and even in the late 1940s hospital physicians did not administer penicillin to its patients with syphilis. Patients in the Manicomio also sometimes received phenobarbital for seizures, quinine for malaria, and various vitamins and ‘‘tonics’’ for general revitalization. There are rare references in hospital records to psychoanalysis and psychotherapy, sometimes in conjunction with ect, but there are no indications of which doctors practiced these therapies or notes indicating the patients’ progress. Entries in records indicate that some patients received ‘‘praxitherapy,’’ which usually meant helping out with the work of maintaining the hospital: cleaning, cooking, and perhaps gardening. Despite greater possibilities for prescribing medication or therapy for mental patients than had existed in earlier decades, those who received treatment in the 1940s were still in the minority. Monthly summaries for the male patients for 1947 and 1948 indicate that on average 35 percent

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received some form of treatment (including vitamins), 59 percent were in ‘‘simple confinement,’’ 3 percent were under observation, and 3 percent were discharged.≤π While medication o√ered some the hope for improvement, the prognosis for many patients was not particularly good. Of the 288 women admitted to the hospital in the 1940s for whom the exit condition was recorded, 44 percent (128) died and 54 percent were discharged and said to be cured or improved. Of those who were discharged in a positive condition, the largest percentages were among those diagnosed with schizophrenia (67 percent) and psychosis (64 percent); 62 percent of those listed as su√ering from epilepsy died in the hospital. Of those women who were recorded as leaving the hospital well or alleviated, most had been in the Manicomio one year or less (79 percent); the longer a patient was in the hospital, the more likely she was to leave in a co≈n. But a considerable number of those who died (44 percent) had been in the hospital a year or less. The cause of death for those who had been in the hospital for a short time was usually a serious complicating medical problem such as malnutrition, malaria, typhoid, or enteritis. Although the statistics for men are not precisely comparable (since they are for all the men present in the hospital in two years), they indicate the same trends. Of the 50 men who left the hospital in 1937, 2 were ‘‘cured’’ and 10 ‘‘improved,’’ while 31 died and 7 had escaped. Of the 51 men who left in 1941, 15 were listed as ‘‘cured or improved,’’ 29 had died (57 percent), and 7 had escaped.

The Doctors in Their Writings The most prolific of the Bolivian doctors who wrote on psychiatric subjects, Jaime Mendoza, was a firm believer in the physiological basis of psychiatric disease. In an article on schizophrenia published in 1938 Mendoza characterized the illness as a progressive, destructive brain disease that began with lesions in the thalamus and then gradually spread to other areas. He held out little hope for a cure but maintained that certain treatments, such as insulin shock, seemed to be e√ective when used in the early stages of the disease.≤∫ Mendoza also was the only Bolivian physician to attempt to make a theoretical contribution to the understanding of the human psyche. In 1937 he published ‘‘El Trípode Psíquico’’ (The psychic tripod) in the Revista del Instituto Médico Sucre, in which he combined his belief in the physi-

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cal (rather than emotional) causes of mental illness with categories similar to Freud’s id, ego, and superego (although he did not acknowledge the similarity). Mendoza pointed out that by looking at the inside of a skull one could see that the human brain was divided into three sections: the occipital lobe, the temporal lobe, and the frontal lobe. He then hypothesized that di√erent aspects of human consciousness were associated with these different areas of the brain. According to Mendoza, instinct was controlled by the occipital area, a√ect was located in the temporal region, and intellect was associated with the frontal lobe.≤Ω Although he was a physician, Jaime Mendoza is actually better remembered today as a novelist and essayist. Much of his early work that does not specifically deal with medicine is marked by an apparently contradictory combination of social criticism and voluntarism. On the one hand, he pointed to exploitative working conditions and lack of government regulation as the causes of the horrible living conditions of working-class families; on the other, he often blamed the poor, especially Indian women, for infant mortality and poor health.≥≠ Even in a late article on infant mortality (1937) written after the Chaco War, Mendoza still discussed Bolivian society in racist terms: ‘‘The cholo, originally the o√spring of the Indian and the Spaniard, lost much of the organic resistance of the Indian to destructive agents. . . . Then there is the moral or educational factor. The fact that the cholo finds himself in direct contact with his social superiors has caused him to more easily assimilate than the Indian the defects and the vices [of the upper classes] instead of their good qualities.’’≥∞ Yet Mendoza was also aware that the dire economic conditions and hardships of the postwar period had negatively a√ected infant and child health. He called on individual philanthropists to take actions to protect women and children and stressed the need for the government to support these private initiatives.≥≤ ‘‘And now that socialism is being promoted so much,’’ he concluded, ‘‘the necessity [to protect the nation’s children] is even greater. The future of the nation is with the children. To abandon them is an antisocial act, or if you will, an antisocialist act.’’≥≥ More than ten years later another former director of the Manicomio, Emilio Fernández, also wrote an article in the Revista del Instituto Médico Sucre about the welfare of children and their mothers. Unlike Mendoza, Fernández put the responsibility for the welfare of children squarely on the state and proposed laws designed to protect women workers and their children: paid maternity leave, child care centers sta√ed by well-educated

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care providers, economic assistance to single mothers, a minimum wage for families. He stressed that private aid and charity had become secondary in the twentieth century and that medical attention and protection against work accidents were seen as rights. He acknowledged changes in attitudes toward women, who were no longer viewed as ‘‘instruments of pleasure’’ but rather as workers in their homes and in commerce and industry. He stressed the patriotic function women fulfilled in raising children and providing them with good homes. Finally, Fernández insisted that any new laws that protected women should be extended to peasant women, who were ‘‘our sisters in Christ and nationality.’’≥∂ Fernández also saw his proposed laws as having eugenic functions: ‘‘The fundamental principle of the law consists in the defense of human capital, attempting to improve the physical, moral, and intellectual qualities of individuals—that is, the race—without resorting to euthanasia or the strict selection of progenitors.’’≥∑ He went on to propose public health campaigns against syphilis, tuberculosis, and parental alcoholism. He also stressed the importance of preventing consanguineous marriages and procreation by people who were either too young or too old, which could result in o√spring with mental defects. War, poverty, and malnutrition could also have deleterious e√ects on pregnant women that could lead to unhealthy o√spring. In general, Fernández proposed the kind of ‘‘social,’’ or ‘‘preventive,’’ eugenics that Nancy Stepan has shown was widely accepted in Latin America, especially in the 1920s. This approach drew on Lamarckian ideas about the possibilities of environmental change causing genetic alteration and considered movements for sanitation and hygiene to be eugenic—that is, leading to improvement of the race. Contrary to those who took a ‘‘hard’’ eugenicist position and argued that the ‘‘unfit’’ (which could include Indians or people of mixed race) should not be allowed to reproduce, or should even be allowed to die out through neglect, an environmental eugenicist approach in Bolivia held out the hope of creating a healthy nation through social policy and public health measures. Although by 1949, when Fernández wrote the article, eugenics had been discredited for many because of its associations with Nazi Germany, in Bolivia a ‘‘soft’’ eugenics primarily focused on social legislation for women and children seemed to blend well with populist calls for democracy and social justice.≥∏ Not all those who wrote on the issue of mental health subscribed to a ‘‘soft’’ eugenics approach, however. In 1941, Dr. Cesar Adriazola, a pro-

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fessor of psychiatry at the medical school in the city of Cochabamba and Bolivia’s former general director of health, wrote an article proposing selective sterilization.≥π Maintaining that the majority of social conflicts were caused by mentally disturbed perpetrators, and that most mental disorders were inherited, Adriazola drafted a law for ‘‘social’’ sterilization. This was necessary in Bolivia, he said, precisely because reform measures of the type supported by Fernández could never be successful. The ‘‘inferior cultural level of the masses and the enormous propagation among them of alcoholism and criminality’’ would prevent it.≥∫ Thus he proposed sterilization for four groups: (1) habitual or congenital criminals, degenerate criminals, and those su√ering from moral insanity; (2) delinquent psychopaths, including those su√ering from epilepsy, schizophrenia, dementia praecox, paranoia, or retardation; (3) delinquent alcoholics (without exception); and (4) the mentally ill, who, although they were not delinquent, had been institutionalized for violent or aggressive actions.≥Ω Weighing in for even more extreme measures was Miguel Levy, the departmental director of health who had written the article on the mental decline of the Indian in 1942. In 1944, in what must have been a slap in the face to director Emilio Fernández and the entire sta√ of the hospital, Levy proclaimed that conditions in the Manicomio were so bad that it would be preferable to ameliorate the situation with ‘‘selective euthanasia as was done in the most civilized European countries.’’∂≠ In the light of Levy’s opinions on Indian degeneracy, one cannot but wonder which mental patients he might have selected for elimination. Most psychiatrists and doctors concerned with psychiatry (other than Jaime Mendoza) tended to write on subjects of a social or political nature that were related to mental illness or emotional development but were not specifically medical or technical. Although the doctors had some knowledge of Freudian psychology, as is obvious in the Manicomio’s records, almost nothing was written about psychoanalytic theory or psychotherapy in Bolivia. This was in contrast to neighboring Peru, where in the first decades of the century, young left-wing intellectuals like José Carlos Mariategui had embraced psychoanalysis as a liberating tool for understanding human motivations and desires.∂∞ One of the few writings that introduced psychoanalysis to a medical audience was a two-part article published in 1926 by Dr. Gregorio Mendizábal in which he outlined some of the principles of Freudian psychology, including the use of psychoanalysis for the treatment of neurosis.∂≤ In 1940,

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in a general article on normal mental and physical functions, Dr. Otto Kleinberger, a physician at the Manicomio Pacheco, used the categories ‘‘unconscious’’ and ‘‘subconscious’’ to describe di√erent aspects of human development.∂≥ Neither of these articles refers to the actual therapeutic practice of psychoanalysis in Bolivia. Almost all of the writings by doctors associated with mental health issues in Bolivia touch in one way or another on gender. Jaime Mendoza and Emilio Fernández clearly linked gender with ethnicity. In several early works Mendoza attributed high infant mortality in the mining areas of Bolivia and among Indians to mothers’ drunkenness. He said Indian women fed their children inappropriately, did not get medical help when it was necessary, and carried their babies on their backs during their revels and then fell down in drunken stupors and su√ocated them.∂∂ Although Fernández rhetorically reached out to peasant women, he still seemed to believe that Indian mothers’ ignorance was responsible for poor maternal and infant health. At the end of his article in the Revista del Instituto Médico Sucre he gave his opinions of rural birth and child-rearing practices: indigenous midwives were dirty old hags, carriers of puerperal infections who made women give birth in the ‘‘praying position,’’ which caused hemorrhages and uterine inversions. Indian babies were wrapped in rags and confined in girdles that converted them into ‘‘types of cigars.’’ Indigenous children were destined to lives of oppression and su√ering because of their mothers’ negligence.∂∑ Several authors devoted considerable attention to hormonal changes and sexual impulses as causing disturbances in women. Although some emotional changes were noted in boys during puberty, they were not seen as being the specific causes of mental illness. Otto Kleinberger saw menstruation as a particularly threatening time for women and capable of causing mental disturbances, and viewed menopause as a potential relief; after it, women ‘‘returned to a physical and psychic equilibrium that until then had been disturbed by menstruation.’’∂∏ In an article on education during puberty Miguel Levy expressed various seemingly contradictory views of women.∂π He said that ‘‘nature in its wisdom has made woman a weak but active being, with a delicate but fertile organism.’’∂∫ Later in the same article, however, he referred approvingly to the ideas of contemporary feminists and said, ‘‘Today’s woman has a lively intelligence, she is precocious and vivacious not timid or submissive . . . she is capable of heavy work, only her sex di√erentiates her from the man.’’∂Ω But

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later still he referred to the physiological changes girls experience at puberty, especially menstruation, as often being the cause of hysteria in women, especially those whose mothers had not adequately prepared them with ‘‘delicate and moral’’ sex education.∑≠ And when discussing the objectives of education for adolescents, he said that the goal for a boy was to develop into ‘‘a truly moral man, healthy in body and spirit,’’ while the girl was to become ‘‘an a√ectionate and respected mother.’’∑∞ Certainly Levy’s opinions were not unique for the period (or even for more recent times), but they and the ideas about women held by other members of the profession were important, as we shall see below, in influencing how mental disorders were understood in female patients. Some doctors went even further in their analysis of what constituted mental illness in women. For instance, in his discussion of mental deviants Gregorio Mendizábal classified ‘‘the prostitute’’ as a psychopathic personality and believed that most women dedicated themselves to the profession because they enjoyed frivolous diversions such as going to cabarets and wanted to adorn themselves and avoid work.∑≤

Society, Inside and Out In March 1928, Lucia Guevara, the mother of a patient, wrote to the Manicomio’s director asking how much she should send for her son’s care. She explained that she was disposed to pay whatever was required so that he would be treated better. In July she wrote again, saying, ‘‘I beg you to give him all the injections necessary to cure him. I will pay all the costs of the treatment.’’ She apparently felt that o√ering to pay for treatment was not enough to guarantee the best care for her son, for at the end of the letter she pathetically added that she was sending three boxes of candy to the hospital, one for the director of the men’s section of the hospital, one for the doctor, and one for her son.∑≥ While there had always been relatives like Mrs. Guevara who sent money to hospital administrators to ensure that patients received better treatment, in the 1940s two classes of patients were o≈cially recognized: pensionados and gratuitos. On the one hand, this regularized a situation that was ripe for abuse, and it must have been reassuring for relatives to know that they could pay the established fees and not have to curry favor with the hospital sta√ in order for their relatives to receive good care. On the other hand, it was

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somewhat ironic that at a time when there was an outcry against privilege in Bolivian society and health care was beginning to be viewed as a right, separate and unequal facilities were institutionalized for the mentally ill. Pensionados had their own sections and better and more plentiful food. There is also evidence that they frequently received treatment while gratuitos with the same diagnoses did not. For instance, in August 1943 two patients diagnosed as schizophrenic were admitted to the hospital. Genaro Serrano, twenty-two, a chofer, was admitted on the first of the month as a pensionado. He was treated with insulin therapy and was said to improve enormously; he was released on November 17, 1943.∑∂ On August 12, Santiago Rivera, a malnourished agricultural worker, arrived at the hospital as a gratuito. He was given no treatment ‘‘because of lack of drugs.’’ There is no record of the outcome of his case.∑∑ There is also some evidence that measures were not even taken to save patients’ lives if they could not pay for them. On April 8, 1943, Toribio Márquez, a thirty-year-old miner, was admitted and diagnosed as having ‘‘tubercular psychosis.’’ He was said to be extremely malnourished and less than a month later died of ‘‘tubercular wasting.’’ The clinical history indicates that he had begun to work in the mines at an early age, ‘‘always with inadequate nutrition.’’ The intern who wrote up the history noted that he ‘‘eats very little.’’ There is no indication that he was given any intravenous feeding or that any actions were taken to improve his emaciated state.∑∏ On the other hand, Alfredo Rivas Mayorga, a white o≈ce employee su√ering from alcoholic psychosis, arrived in June 1942 as a pensionado and was given all kinds of intravenous serums to build him up, including an ‘‘invigorating sugar serum’’ and ‘‘hepatic stimulants.’’∑π Even pensionados who were clearly moribund received far more attention than nonpaying patients in similar conditions. Maximiliano Méndez, a sixty-two-year-old white merchant from La Paz who entered the hospital in May 1938, was diagnosed with neurosyphilis, an advanced form of the disease in which spirochetes invade the lining of the brain or the spinal column. He eventually died of heart failure in November 1943, but before that the hospital doctors continued to try various treatments although his condition was understood to be chronic. He was given mercury and bismuth for his syphilis and a malaria therapy.∑∫ On the other hand, Manuel Camargo, a forty-year-old miner from Corocoro with only one month’s schooling, entered the hospital su√ering from malnutrition on October 22, 1942, diagnosed, like Méndez, as having progressive syphilitic paralysis. His

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case was considered hopeless, and he died on December 9 from intestinal tuberculosis without ever receving any treatment.∑Ω Class considerations were important even in determining how patients arrived at the Manicomio and the reception they received. On September 26, 1932, the president of the Municipal Council of Cochabamba wrote to the director of the hospital explaining that the next day Mr. Selem Abad, a businessman of Syrio-Palestinian nationality, was going to arrive ‘‘on one of the planes of Lloyd Aéreo Boliviano.’’ Mr. Abad had had the ‘‘misfortune of losing his reason,’’ and the council president asked the director to show him all possible consideration because Mr. Abad was ‘‘a foreigner with a deep love of Bolivia.’’∏≠ The president of the Municipal Council of La Paz had likewise written the director about Hector Valcárcel Moscoso, who was coming to the hospital because of ‘‘mental attacks due to epilepsy.’’ The president asked that the hospital sta√ ‘‘show deference’’ to Mr. Valcárcel because he was ‘‘una persona decente ’’ of La Paz.∏∞ Much more common were the mental patients who were brought to the hospital by police agents and who frequently were not even accompanied by relatives because family members could not a√ord to make the trip. A letter from the head of the Hospital Viedma in the city of Cochabamba in December 1928 explained that ‘‘every one of the ‘alienados ’ that I am dispatching was sent to me by the police who rounded them up in the countryside.’’∏≤ Sometimes the records of newly admitted patients included letters from local authorities or notarized documents from relatives or employers explaining that the patients were violent and dangerous and could not remain in their homes. A particularly sad one was from Rafaela Ramírez of Sucre, who requested the confinement of her Indian servant, Alejandro N., a minor and an orphan who su√ered from ‘‘mental alienation’’ and ‘‘couldn’t remain in the street,’’ suggesting that she had thrown him out of the house because of his aberrant behavior.∏≥ Frequently there would also be a letter from a local doctor explaining that he had treated the ill person but that the gravity of the condition required internment in the Manicomio. For the poor, being in the hospital even as a gratuito could be expensive because the loss of the income of an adult member of a family could be a significant hardship. Such was the case for Jorge Plaza Ponce, who on August 9, 1943, wrote to Miguel Levy in his capacity as chief health o≈cer of the department of Chuquisaca asking to be discharged from the Manicomio. He said he had been in the hospital for two months and that thanks to the attentions of the director and doctor he was now in perfect health. He

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went on to explain that his wife had come to Sucre to take care of him, leaving behind their young children in his home in Vilacaya, and his small harvest was going to be ruined as a result of his absence. He begged the authorities to let him go home. The fact that Plaza’s wife was in Sucre with him indicates that patients who could not a√ord to pay for better care may have been attended by a family member who presumably brought food and clean clothing to the hospital. Clearly, his wife’s absence from home was another financial burden for the family to bear.∏∂ Yet, once a patient was released from the hospital, getting home could also be a considerable expense. In January 1933 an intern wrote to Mrs. Tomasa C. Viuda de Chamorro in the city of Tarija saying that the medical director of the Manicomio had found her son to be sane and that he had not shown any mental disturbance during his stay in the hospital. He then went on to explain that for her son to be released she would have to send money to pay for his trip home and for someone to accompany him.∏∑ Class di√erences are evident in the hospital records not only in the treatment of patients but also in what they say about the few professional employees of the Manicomio versus the more numerous attendants or servants who were in contact with the patients on a regular basis. Generally the professional sta√ included the director, one or two doctors, and one or two interns. In 1937 there were twenty-six nonprofessional employees in the men’s section of the hospital and nineteen in the women’s section.∏∏ Directors habitually complained about the attendants and servants and accused them of abusing the patients, but apparently without much success in changing the situation. During his tenure (1923–26) Jaime Mendoza complained of the various means of control or punishment of the patients that were ‘‘to the liking of the servants,’’ such as straitjackets, confinement cells, and cold baths at six in the morning.∏π In 1937 Director Emilio Fernández asked: What could one do with subalterns who didn’t do their jobs and committed abuses that showed an absolute lack of dignity and respect for the institution, such as the servant who satisfies his perverse sexual instincts with the patients, or another who mistreats them, showing up for work drunk and then rents out the patients for construction work in the neighborhood, or another who at night steals food from the hospital pantry or sells the patients’ bread for his own profit, or one who on the pretext of searching patients for sharp objects robs them of the little money their relatives have sent, or finally the employee who takes the clothing that patients receive in the mail.∏∫

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Hospital employees were paid far less than doctors, and frequently did not even receive what was owed to them because the federal government failed to regularly send funds to the Manicomio’s administration. In 1940 the director’s salary was 1,100 pesos a year. Each of the medical interns received 800, while the male aids who worked with the patients on a daily basis received 160 pesos annually.∏Ω The aides were given no training in how to deal with the mentally ill, and, in fact, some of the employees were patients who were put in what was referred to as praxitherapy. So, untrained workers, some of whom had mental problems themselves, were on the frontlines in the madhouse. The possibilities for loss of control and violence are obvious. Ignorance and lack of respect and appreciation for their e√orts could lead employees to callousness and brutality. As Fernández commented, ‘‘It seems that with time and constant contact with human pain, sensibilities became anesthetized and the servants adjusted to the pain of their fellow beings until they became indi√erent.’’π≠ Yet, one wonders if there was not a tendency for the upper-class professionals to blame their subordinates for problems in the institution that were in fact structural and ultimately were more the responsibility of the administration and the doctors than the workers. Class and race were closely related in the hospital records, and, as in Bolivian society at large, racial categories could be flexible. Not all intake forms recorded race; on those that did there was sometimes, in addition to a place to indicate race, also a space for ‘‘color.’’ Thus, a person could be of the white ‘‘race’’ but have his or her color listed as blanco (white) or trigueño (olive skinned), or even on occasion moreno (dark). Mestizos could likewise be moreno or trigueño, but Indians seemed always to be listed as moreno. The Bolivian writer Alcides Arguedas, in an attempt to explain the di≈culty of distinguishing whites from mestizos in Bolivia, wrote in Pueblo Enfermo that ‘‘the ethnic quality of an individual is the result of his social position,’’π∞ and ethnic labeling by the sta√ of the Manicomio seemed to operate on this principle. Not only were race and color somewhat independent variables in the hospital records, but sometimes a patient’s race could change, apparently because of social or economic considerations. For instance, on her intake form Nelly Liscano Barrancos, a twenty-two-year-old student from Cochabamba, was first listed as mestiza, but this word was erased and replaced by blanca (mestiza is still clearly evident on the form although erased).π≤ Further down, the form indicated that her uncle lived in Sucre and was a judge

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of the Supreme Court. One can imagine that when the person recording the information found out about the uncle he or she went back to the beginning of the form and changed the racial category. Another patient, Santiago Almafuerte, also seemed to change racial category according to the information hospital sta√ had about his education and occupation. The earliest information on Almafuerte said he was a mine worker from Oruro and listed him as mestizo. Later records indicated that he was a twenty-two-yearold university student who worked part time for a mining company and labeled him as white.π≥ Although patients were frequently listed as Indian or indígena, the clinical histories give few indications that doctors made meaningful use of cultural factors in their diagnoses. Evaristo Balmaceda, who entered the hospital on August 1, 1942, is a case in point.π∂ Balmaceda’s intake form said he was a married, thirty-five-year-old Indian peasant, and the intern who interviewed him described him as wearing ‘‘unusual clothing.’’ In fact, Balmaceda wore three berets and a large hat over them adorned with flowers, two jackets, and a necktie. He carried a bag with various items the intern thought were useless: wire, an ox tail that he said was the cause of his illness, and cutting tools. On his left foot he wore several stockings and a rubber gaiter. On his shoes he had various nails and horseshoes. Rubber bands wrapped his wrists like bracelets. Balmaceda spoke incoherently, with great animation and many hand gestures. He smoked cigarettes and chewed coca constantly. Claiming to be completely sane, he said he had been brought to the Manicomio because of people’s false accusations. He said he had seen and continued to see angels and devils and that they were under his power. The wind was his compadre, and if he wanted to he could tell the wind to turn the world upside down. He claimed to know everything that happened in the world either due to internal or external forces. The sun was his god, his doctor, and his master; the moon was his Virgin Mary. Balmaceda was diagnosed as su√ering from schizophrenia, and the recommended treatment was Cardiazol shock. Although there are no records of any such treatment, he was discharged on April 5, 1943, said to be cured. There is no indication in Balmaceda’s clinical history that the hospital professionals understood that some of his statements reflected Andean religious beliefs. For instance, in Andean cosmology the sun is indeed a god and the creator of life and the moon is considered the sun’s queen, a female leader-deity frequently identified with the Virgin Mary in Christianity. Yet,

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Balmaceda’s references to these spiritual concepts were simply treated in the clinical history as evidence of his delusions. One also wonders if delusions of grandeur and excessive loquaciousness might have been seen as particularly aberrant in Indians, who were believed by many to be stolid and unimaginative by nature.π∑ Evaristo Balmaceda may have disconcerted doctors with his delusions that turned the world upside down, making an Indian peasant the master of the universe. Even Balmaceda’s eccentric clothes were not those normally associated with native Bolivian dress; instead they seemed almost a caricature of a European gentleman’s outfit. The doctors were also puzzled by thirty-year-old Carmelo Balsa, an Indian peasant from Muyupampa who was admitted in 1943. Diagnosed as schizophrenic, Balsa claimed to be able to speak English, French, German, Greek, and Turkish and said he was a ‘‘Hitlerista ’’ from the party of Germán Busch. The doctor doing the interview was apparently surprised at Balsa’s sophistication because he asked him how he knew about Hitler. Balsa replied that the wind and the sun had told him.π∏ Even if doctors had been inclined to take cultural di√erence into account, the forms used for the clinical histories discouraged them from doing so. By the 1940s the Manicomio Pacheco had adopted questionnaires modeled on those used in similar institutions in the United States and Europe. The change was made in an e√ort to standardize information and professionalize psychiatric practice, and it was an important step toward treating all patients equally. Each patient (or a relative if the patient was unable to speak) was asked the same questions, which apparently did not make clinical assumptions based on social position or ethnicity. Unlike psychiatric interviews today, however, in which the physician generally begins by asking the patient’s assessment of the situation,ππ the Manicomio’s forms, with their questions about the patient’s age at dentition or length of menstrual periods, tended to force everyone into the same mold and left little or no room for the patient’s or relative’s thoughts on the illness. Nor was there space (except in the margins) for information about a person’s life, such as the fact that Hipólito Caldas, a peasant from Valle Grande in Santa Cruz, had been working from dawn to dark every day in the fields since he was eight or nine years old (a detail the doctor doing the interview squeezed in, apparently thinking it might be relevant).π∫ In fact, when doctors did not use forms but simply conducted the interview and wrote up the results, there tended to be much more anecdotal information about the person and

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his/her problems and more attention to the patient’s social and personal situation. Sometimes this additional information is as revealing of the doctor’s attitudes as it is about the patient’s condition, as in a case from 1939, when a doctor (not identified) wrote of twenty-six-year-old Emma Almagro of La Paz: ‘‘She uses expressions and styles very superior to her station and education.’’πΩ In the hospital records, race and class are never independent of assumptions about gender. The gendering of the information began with the entry questionnaires, which di√ered in some important ways for men and women. While both asked similar questions about family history of illness, alcohol use, family temperament, the patient’s childhood diseases, etc., in the section on sexual history there were significant di√erences in the information elicited. Most of the questions for women concerned menstruation: age at onset, length of menstrual period, and discomfort during period. These questions were in keeping with several doctors’ writings that stressed the psychic dangers linked to menstruation. Another question asked: ‘‘Have your sexual relations been normal or abnormal?’’ (The answer was uniformly ‘‘Normal.’’) Yet another one inquired: ‘‘Before or after your first period have you had any little vice? Masturbation, lesbianism, etc.?’’ (No one admitted to any.) The men’s section on sexual history began by asking if the patient was ‘‘a womanizer, an onanist or a pederast.’’ On the forms this was either left blank or the patient said he was a womanizer. The section went on to ask about sexually transmitted diseases, whether the patient enjoyed sexual contact and under what circumstances, and whether he had ever been impotent. Given the wording of the questions on sex, it is not surprising that they elicited virtually no information. Everyone said their sexual relations were normal; most men said they had never had a sexually transmitted disease even when their blood tests showed otherwise; none admitted that they had ever been impotent. Yet the questions themselves reveal important assumptions about the di√erences between men and women and the causes of their mental problems that are evident in other sections of the clinical histories. Many of the men did in fact su√er from venereal diseases, and a good number were in the hospital because of the paralysis and dementia of neurosyphilis. The records also put considerable emphasis on alcoholism as a precipitating factor in the men’s illnesses. Patients diagnosed as schizophrenic, manic, demented, or psychotic were often said to have at least aggravated their conditions by drinking. For instance, in 1942 Manuel J.

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Barreta Cáceres, a forty-two-year-old merchant, was diagnosed as schizophrenic. He reported that he heard voices that told him to pray because he was a sinner, he had seen fires that did not exist, and he claimed to have married only a few weeks before although he had actually been married for many years. Dr. Otto Kleinberger, who examined him, attributed the illness to excessive abuse of alcoholic beverages.∫≠ Bolivia was not alone in having numerous patients whose mental disorders were caused by alcoholism or syphilis. Since the late nineteenth century Western European countries and the United States had seen increases in the number of people (overwhelmingly men) who were admitted to asylums for insanity related to these conditions.∫∞ While the records sometimes attributed the mental symptoms of women to alcohol abuse, it was far rarer than in male patients. Although some also had venereal diseases, I did not encounter a single example of neurosyphilis among women patients in the Manicomio. Sex had a di√erent significance in mental illness for women: illicit sexual relations, jealousy, prostitution, and inappropriate gender roles were all thought to be important in causing mental derangement. In other words, the doctors seemed to take a rather crude psychoanalytic approach to women that they never used with men, even when there was no clear physiological cause for the man’s presenting problem. Hospital sta√ seemed considerably less constrained by the questions on the clinical history forms for women and more likely to fill several extra pages discussing sexual experiences and even amorous adventures. The examples abound. Emma Almagro’s schizophrenia seemed to have resulted from her complicated personal life, about which she was said to feel a great deal of guilt. Admitted to the hospital in 1939 when she was twentysix years old, she had been cohabiting for five years with an army o≈cer. Although her mother approved of the relationship, Emma herself had serious misgivings about it because she was deeply religious. Nonetheless, while she was living with the o≈cer she began to have sexual relations with a young acquaintance of his. She was terrified of being caught by her companion, and this caused her considerable distress, which increased when she became pregnant and had an abortion. It was after this that she began to exhibit symptoms of paranoia, accusing her family of talking about her behind her back and turning her lover against her.∫≤ Raquel Banzer Santander was twenty-three years old when she was admitted to the hospital in 1940 su√ering from epilepsy. She was illiterate, single, and worked as a laundress. She had been abandoned by her family at

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an early age and ‘‘since then had lived a miserable life both materially and morally.’’ As a result of her situation she began to practice prostitution, and this was believed to have contributed to her breakdown.∫≥ However, the doctors also treated her for syphilis and found that the medication cleared up the symptoms of the disease, which she had recently contracted, and also alleviated her seizures. The doctor examining Bertha Juárez believed that guilt for past transgressions was an important factor in her illness. The thirty-six-year-old housewife from Oruro entered the Manicomio in July 1940 su√ering from visual and auditory hallucinations. The doctor noted in the medical history: ‘‘She is an illegitimate child; before marrying she reportedly led a dissipated life, beginning sexual relations very early, at approximately ten years of age. Possibly the worry she has had about this life has a role in her mental disturbance.’’∫∂ The fact of having deviated from acceptable social roles was also considered a contributing factor in women’s mental breakdowns. Hilda Guerra was a dental student from 1947 to 1951, when she was told to stop studying by her physician, who thought it was contributing to her nervous condition. According to her mother, she was one of the best students in her class before becoming ill.∫∑ Even more deviant was Constantina Bejar Meriles, whose age was not recorded. She was an excellent student and athlete, participating in cycling and equitation. She was said to be of an a√able and generous disposition and had written a textbook for primary school students. The problem with Constantina that led her parents to take her to the hospital was that she liked to wear masculine clothes and rejected men’s amorous advances.∫∏ ‘‘A woman with considerable experience of the world’’ was the description given for Clorinda Gutiérrez, a sixty-year-old from Oruro who ran a bar that was patronized by soldiers; she herself drank a good deal. In June 1933, while she was intoxicated, she apparently insulted the local prefect, who had her seized by the police, taken to the local hospital, and eventually sent to the Manicomio in Sucre. To their credit the doctors there did not consider her mentally ill. She was treated for alcoholism and released.∫π Jealousy caused by their husband’s real or imagined infidelities was said to be one of the first signs or symptoms of many women’s disease. Estefanía Calderón Herrera, a weaver who entered the hospital in June 1941, was said to be extremely jealous of her husband, even imagining that he had sex with animals.∫∫ Likewise, for Lily Restrepo de Justiniano, the first indication of insanity was her jealousy of her husband.∫Ω But if some were jealous, a larger

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number were abused by their husbands. Many women dated their first episodes of illness to blows received from their husbands. This was the case with Isabel Almazán, a forty-three-year-old widow from Cochabamba.Ω≠ Another patient, Celia Almeida de Alcazar, was reported to be ‘‘too resigned’’ because she had put up with the hostility and aggression of her mother-in-law and sister-in-law and accepted the blame for her mistreatment by her husband.Ω∞ The roots of other women’s disorders were traced to the loss of a lover. For example, Benedicta Alvarado, a single laundress, had had only one lover, and he had married another woman. Benedicta, now forty and in menopause, was said to be distraught because of her failure to have a family.Ω≤ Finally, there was considerable emphasis in the women’s records on ‘‘female problems,’’ specifically emotional distress related to menstruation. For instance, Ofelia Gondra Siles, a nineteen-year-old student in a convent, was believed by the nuns to have become ill because she bathed during her period.Ω≥ Another patient, Pura Correa de Kagel, went mad after a series of robberies occurred near her home in the countryside. At one point she lay on the bed clutching her husband’s revolver and waiting for intruders. Her husband said that she emitted a strong smell when she did this and that he saw a stream of blood running between her legs.Ω∂

Insanity and Di√erence By the 1940s, although most people still would not have been pleased to be admitted, the Manicomio Pacheco was no longer a dungeon where patients ate cats and there were only thirty spoons for sixty patients in the men’s section, as had been the case in 1918.Ω∑ The hospital had attempted to augment its meager resources by charging patients who could a√ord to pay. Doctors had experimented with new forms of treatment, most notably electroshock therapy, and many, like Alberto Martínez, probably felt gratified to be able to say that more of their patients had now returned to their homes and were ‘‘socially rehabilitated.’’Ω∏ There is evidence in the clinical histories that the professional sta√ was at least attempting (often in a rather crude manner) to take emotional factors into account when analyzing patients’ problems. By using the same intake forms for everyone, physicians were making an e√ort to professionalize practice and to treat everyone the same, not jumping to conclusions based on class position or ethnicity.

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On the whole, the Manicomio Pacheco and the doctors who wrote about mental health seem to have been fairly representative of the situation in Bolivia, reflecting the social conflicts and contradictory ideas of the period. Miguel Levy still openly maintained that Indians were not ready for full citizenship, a position that was beginning to be embarrassingly anachronistic in the radical 1940s. Yet other, more progressive doctors, such as Emilio Fernández, who favored many social programs to ameliorate the situation of the working class, also saw the backwardness of the Indian population as preventing their complete social integration. Although, ironically, Levy could wax eloquent on modern women’s equality with men, none of the doctors in their writing about human development or the welfare of women and children went so far as to suggest full citizenship for women. Because of the social diversity of the patients in the hospital, the same types of hierarchies existed inside the Manicomio as were found in the country at large. Those with money received better treatment, food, and lodging, and local o≈cials intervened for them with the hospital administration. Poor people, who constituted the majority, received little or no treatment; if they were lucky, their relatives brought them food and clothing. It was also the poor who ended up working in the hospital in various menial capacities. Although few doctors would have agreed with Miguel Levy’s proposal of selective euthanasia for mental patients, in a way that is just what was taking place. Because of lack of care, many patients, particularly the poor ones, were dying from malnutrition, seizures, malaria, enteritis, etc. Despite the uniformity of the questionnaires used for intake interviews, the Manicomio’s physicians still clearly had di≈culty treating indigenous patients the same as non-Indians admitted to the hospital. Preconceptions were hard to get rid of, and the idea that a person could be di√erent but not inferior was not widely held. The clinical histories contain indications that certain kinds of behaviors did not fit with the physicians’ understandings of Indian nature: delusions of grandeur, wearing clothing that was not considered ‘‘Indian,’’ too much knowledge of current events. Assumptions about women seem to have been just as deeply ingrained as those about Indians. Women were praised as mothers of the nation yet seen as the bearers of backward Indian practices, and with few exceptions their psychiatric ailments were attributed in various ways to sex. This appears to be related to the influence of a superficial Freudian psychology that nicely validated beliefs about women’s biological destiny. Tellingly, despite doctors’ apparent familiarity with some psychoanalytic interpretation, male patients in the

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Manicomio were never said to have sexual conflicts that contributed to their illnesses. During this period in Bolivia, under increasing pressure from the people, su√rage laws were liberalized somewhat: men had only to prove literacy to vote (property requirements were eliminated), and in 1945 literate women were given the right to vote in municipal elections. Also in 1945, informal consensual unions were given the legal status of marriage. So at a time when women and lower-class men (some of whom were Indians) were beginning to acquire political equality, doctors at the Manicomio were still insisting on their ‘‘di√erence.’’ Women, Indians, and workers (clearly not exclusive categories) were often viewed as insubordinate ‘‘others’’ when they demanded citizenship rights. The insane were commonly also viewed as people outside the bounds of the human community; those who had ‘‘lost their minds’’ were considered profoundly, frighteningly ‘‘other.’’ Yet ironically, a symptom of insanity in an Indian might be not acting ‘‘Indian’’ enough; some of the women in the mental hospital were also seen as insu≈ciently feminine. These patients in a sense became ‘‘others’’ when their behavior failed to conform to what was expected of them. For women, going crazy was also commonly associated with their very female being: reproduction and sexuality; and Indians were still considered congenitally emotionally immature and intellectually inferior. Turning finally to the doctors’ mental processes: their writings and attitudes toward patients show just how complicated changes in consciousness are. Many doctors were swept up in the movement for democracy that developed in the post–Chaco War period, but as members of a privileged, educated elite they clearly had some di≈culty recognizing or accepting its implications for their professional lives.

Notes 1 Actas de las Segundas Jornadas Médico-quirúricas Nacionales (Sucre: Universidad Mayor Real y Pontificia de San Francisco Xavier de Chuquisaca, 1948), 410. 2 Miguel Levy, ‘‘La Declinación Mental del Indio: Sus Procesos Mentales,’’ Revista del Instituto Médico Sucre [hereinafter RIMS] 74 (January–March 1942): 15–33.

m e n t a l i l l n e s s i n b o l i v i a 263 3 Ibid., 16–17. 4 Miguel Levy, ‘‘La Declinación,’’ 19–22, 25–31. Many of these points had been made by Bolivian intellectuals earlier in the century. See Alcides Arguedas, Pueblo Enfermo (Barcelona: Casa Editorial de vda. de Luis Taaso, 1910), especially chap. 11; Marie Danielle Demelas, ‘‘Darwinismo a la Criolla: El Darwinismo Social en Bolivia, 1880–1910,’’ Historia Boliviana 1.2 (1981): 55–82; Brooke Larson, ‘‘Race, Democracy, and the Politics of Indian Education in Bolivia: Crafting Neocolonial Modernity, 1900–1920’’ (paper presented at the Latin American Studies Association meeting, Chicago, 1998). 5 Juan Manuel Balcazar, Historia de la Medicina en Bolivia (La Paz: Ediciones Juventud, 1956), 521. 6 Herbert S. Klein, Bolivia: The Evolution of a Multi-ethnic Society, 2d ed. (New York: Oxford University Press, 1992), 211–13. 7 René Danilo Arze Aguirre, Guerra y Conflictos Sociales: El Caso Rural Boliviano durante la Campaña del Chaco (La Paz: ceres, 1987), especially 39– 82; Herbert Klein, Bolivia, 181–94. 8 Aurelio Melean, La Sanidad Boliviana en la Campaña del Chaco (Cochabamba, 1938), 125–55. 9 Herbert Klein, Bolivia, 201–7; Silvia Rivera Cusicanqui, Oprimidos pero no Vencidos: Luchas del Campesinado Aymara y Quechua, 1900–1980 (La Paz: hisbol-csutcb, 1984), 57–62. 10 Ana Cecilia Wadsworth and Ineke Dibbits, Agitadores de Buen Gusto: Historia del Sidicato de Culinarias (1935–1958) (La Paz: tahimapu / hisbol, 1989); Zulema Lehm A. and Silvia Rivera C., Los Artesanos Libertarios y la Etica del Trabajo (La Paz: Taller de Historia Oral Andina, 1988); Ineke Dibbits, Elizabeth Peredo, Ruth Volgger, and Ana Cecilia Wadsworth, Polleras Libertarias: Federación Obrera Femenina, 1927–1965 (La Paz: tahimapu / hisbol, 1989). 11 James Dunkerley, Rebellion in the Veins: Political Struggle in Bolivia, 1952–1982 (London: Verso, 1984), chap. 1. 12 José Antezan Estrada, ‘‘Proyecto de Código Sanitario de Bolivia,’’ in Primer Congreso Médico Nacional ( Trabajos Presentados) (La Paz, 1939), 2. 13 Boletín del Ministerio de Higiene y Salubridad 2.2 (1939): 142. 14 E. L. Osorio, ‘‘El Ejercicio de la Medicina ante los Actuales Problemas de Reforma del Orden Social,’’ RIMS 81 (1946): 3–11; Cesar Adriazola, ‘‘Ley de Esterilización Social,’’ RIMS 73 (1941): 48–50. On eugenics in Latin America, see Nancy Leys Stepan, The Hour of Eugenics: Race, Gender and Nation in Latin America (Ithaca: Cornell University Press, 1991). 15 According to Alfredo Caballero Zamora, in 1988 there were only twenty-six psychiatrists in Bolivia; see his La Institucionalización de la Locura en Bolivia (Quito: Consejo Latinoamericano de Ciencias Sociales, 1989), 200.

264 a n n z u l a w s k i 16 Ibid., 146; Archivo Nacional de Bolivia [anb], Instituto Psiquiátrico Nacional de Mujeres [ipm] 41, Estadísticas; Instituto Psiquiátrico Nacional de Varones [ipv] 75, Estadísticas. 17 Alfredo Caballero Zamora, La Institucionalización, 149. 18 All statistics on men discussed below come from anb, ipv 75, Estadísticas. All statistics on women discussed below come from anb, ipm 41, Estadísticas. Bureau of the Census, Patients in Hospitals for Mental Disease, 1934 (Washington, D.C.: U.S. Government Printing O≈ce, 1936); Bureau of the Census, Patients in Hospitals for Mental Disease, 1935 (Washington, D.C.: U.S. Government Printing O≈ce, 1937); Bureau of the Census, Patients in Hospitals for Mental Disease, 1936 (Washington, D.C.: U.S. Government Printing O≈ce, 1938); National Institute of Mental Health, Patients in Mental Institutions, 1927 (Washington, D.C.: U.S. Government Printing Office, n.d.); National Institute of Mental Health, Patients in Mental Institutions, 1948 (Washington, D.C.: U.S. Government Printing O≈ce, n.d.); National Institute of Mental Health, Patients in Mental Institutions, 1949 (Washington, D.C.: U.S. Government Printing O≈ce, n.d.). 19 Julio C. Fortún al Presidente de Honorable Consejo Municipal de Sucre, November 14, 1930, anb, ipv 11, Correspondencia; Jerrold E. Levy, ‘‘Epilepsy,’’ in W. F. Bynum and Roy Porter, eds., Companion Encyclopedia of the History of Medicine (London: Routledge, 1993), 713–18. 20 Out of 464 women admitted to the hospital in the 1940s for whom a diagnosis was recorded, only 4 were said to su√er from manic depression. Three of 127 men in 1937 and 4 of 177 in 1941 were so diagnosed. 21 Of the women in the hospital, 4 percent were diagnosed as having malarial psychosis. 22 Silvia Rivera Cusicanqui, Oprimidos pero no Vencidos, 15. 23 Edward Shorter, A History of Psychiatry: From the Era of the Asylum to the Age of Prozac (New York: John Wiley and Sons, 1997), 210–14. 24 Ibid., 212. 25 Ibid., 214–16. 26 J. Alberto Martínez Z., ‘‘ ‘El Electro-shock’ (Electro-plexia): Su Aplicación en el Manicomio Nacional ‘Pacheco,’ ’’ in Primeras Jornadas Médicoquirúrgicas Nacionales (La Paz: Ateneo de Medicina de La Paz, 1946), 298– 303; Alfredo Caballero Zamora, La institucionalización, 183–84. 27 anb, ipv 73, Resúmenes, 1947, 1948. 28 Jaime Mendoza, ‘‘La Esquizofrenia,’’ RIMS 68 (1938): 1–8. 29 Jaime Mendoza, ‘‘El Trípode Psíquico,’’ RIMS 65 (1937): 65–80. 30 For example, Jaime Mendoza, En las Tierras del Potosí (1911; Cochabamba, Bolivia: Los Tiempos–Los Amigos del Libro, 1988); Mendoza, ‘‘Una In-

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31 32 33 34 35 36

37 38 39 40 41

42 43

44

45 46 47 48 49 50 51 52 53

dicación (en Favor de los Niños de las Clases Obreras),’’ RIMS 38 (1920): 455–72. Jaime Mendoza, ‘‘La Defensa de los Niños,’’ RIMS 65 (1937): 11. Ibid., 4–5, 12–13. Ibid., 14. Emilio Fernández, ‘‘Protección a la Madre y al Hijo,’’ RIMS 85 (1949): 56–57. Ibid., 57. On the Lamarckian influence in Latin American eugenics and its importance in racially mixed countries of Latin America, see Nancy Stepan, The Hour of Eugenics, chap. 3, especially 84–95. César Adriazola, ‘‘Ley de Esterilización Social,’’ RIMS (1941): 48–50. Ibid., 49. Ibid., 50. Alfredo Caballero Zamora, La Institucionalización, 180. Augusto Ruiz Zevallos, Psiquiatras y Locos: Entre la Modernización contra los Andes y el Nuevo Proyecto de Modernidad. Perú, 1850–1930 (Lima: Instituto Pasado y Presente, 1994), 121–37 and passim. Gregorio Mendizábal, ‘‘Higiene y Profilaxis Mental,’’ RIMS 44 (1926): 39– 51, and 45 (1926): 19–53. Otto Kleinberger, ‘‘El Principio y Desarrollo de las Facultades y Actividades Mentales y Corporales, y Consideraciones de la In y Subconsciencia,’’ RIMS 72 (1940): 13–22. Jaime Mendoza, El las Tierras del Potosí, 61; and Mendoza, ‘‘Una Indicación.’’ On the perception of women as being more ‘‘Indian’’ and maintaining Indian cultural traditions, see Marisol de la Cadena, ‘‘La Mujeres Son Más Indias: Etnicidad y Género en una Comunidad del Cuzco,’’ Revista Andina 9.1 (1991): 7–26; Marcia Stephenson, Gender and Modernity in Andean Bolivia (Austin: University of Texas Press, 1999). Emilio Fernández, ‘‘Protección a la Madre,’’ 63–64. Otto Kleinberger, ‘‘El Principio y Desarrollo,’’ 22. Miguel Levy, ‘‘Educación en el Período de la Pubertad,’’ RIMS 51 (1929): 55–70. Ibid., 56. Ibid., 61. Ibid., 62–63. Ibid., 58. Gregorio Mendizábal, ‘‘Higiene y Profilaxis Mental, Part 2,’’ 30–31. Casta L. viuda de Guevara a Antenor de la Vía García, Cochabamba, March 29, 1928, and July 19, 1928, anb, ipv 9, Correspondencia. Patients’ surnames have been altered to protect their identity.

266 a n n z u l a w s k i 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75

76 77

anb, ipv 63, Historias Clínicas. anb, ipv 60, Historias Clínicas. anb, ipv 59, Historias Clínicas. anb, ipv 63, Historias Clínicas. anb, ipv 59, Historias Clínicas. Ibid. Guillermo Prudencio al Sr. Presidente de la Sociedad Administradora de Manicomios, Cochabamba, September 26, 1932, anb, ipv 13, Correspondencia. Oficial Major del H. Consejo Municipal de La Paz al Señor Director del Manicomio Pacheco, La Paz, July 3, 1931, anb, ipv 12, Correspondencia. Ysrael Segarra al Director del Manicomio Pacheco, Cochabamba, December 7, 1928, anb, ipv 9, Correspondencia. Rafaela Ramírez al Sr. Director del Manicomio Pacheco, Sucre, October 31, 1928, anb, ipb 9, Correspondencia. Jorge Pérez Ponce al Jefe de Sanidad Departamental, Sucre, August 9, 1943, anb, ipv 60, Historias Clinícas. Practicante interno a Sra. Tomasa C. viuda de Chamorro, Sucre, January 19, 1933, anb, ipv 14, Correspondencia. Alfredo Caballero Zamora, La Institucionalización, 234. Juan Manuel Balcazar, Historia de la Medicina, 521. Ibid., 521–22. anb, ipv 75, Estadísticas. Juan Manuel Balcazar, Historia de la Medicina, 522–23. Alcides Arguedas, Pueblo Enfermo, 3d ed. (1936; La Paz: Libreria Editorial Juventud, 1991), 36. anb, ipm 2, Papeletas de Ingreso. anb, ipv 59, Historias Clínicas. anb, ipv 59, Historias Clínicas. Megan Vaughan has pointed out that in Nyasaland in the 1930s, English psychiatrists considered that African patients were su√ering from ‘‘European type’’ delusions if they expressed power and strength (‘‘I am God,’’ ‘‘I am wealthy’’), as opposed to ‘‘African type’’ delusions that the Europeans thought were in keeping with their culture (‘‘My wife is committing adultery,’’ ‘‘I want to eat people’’). She argues that part of what made Africans ‘‘crazy’’ by European standards was that they were insu≈ciently ‘‘other,’’ that is, they exhibited symptoms thought not to be characteristic of their emotional development. See Vaughan, Curing Their Ills: Colonial Power and African Illness (Stanford: Stanford University Press, 1991), 100–128. anb, ipv 63, Historias Clínicas. ‘‘The Psychiatric Interview,’’ in Merck Manual, 15th ed. (Rahway, N.J.: Merck, Sharp and Dohme Research Laboratories, 1987), 1458–62.

m e n t a l i l l n e s s i n b o l i v i a 267 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96

anb, ipv 59, Historias Clínicas. anb, ipm 1, Filiaciones. anb, ipv 59, Historias Clínicas. Edward Shorter, A History of Psychiatry, 53–60. anb, ipm 11, Historias Clínicas. Ibid. Ibid. Ibid. Ibid. Ibid. Ibid. anb, ipm 12, Historias Clínicas. anb, ipm 11, Historias Clínicas. Ibid. anb, ipm 1, Filiaciones. Ibid. Ibid. Alfredo Caballero Zamora, La Institucionalización, 169. Alberto Martínez Z., ‘‘El Electro-shock,’’ 301.

marcos cueto

Stigma and Blame during an Epidemic cholera in peru, 1991

pidemics can contribute to the exposure of the needs of the poor and the limitations of health services, blame the sick as the cause of infection, and reinforce authoritarian political decisions.∞ This was the case with the epidemic of cholera in Peru in 1991, the first major outbreak of the disease in the Western Hemisphere during the twentieth century. Cholera, a disease that can be fatal if untreated, occurred in a country marked by its social extremes, a nation devastated by a severe economic crisis, political violence, and instability; public services had virtually collapsed, and Peru was moving to a radical scheme of reduced social intervention implied in the government’s neoliberal policies. This essay examines the dramatic conditions of the water and sewage systems that created the basis for cholera, the heroic work of the health personnel who fought the disease, the popular and o≈cial perceptions that emerged during the epidemic, and the legacy of the epidemic for Peruvian public health. Among the results of the epidemic were the stigmatization of the urban poor for their ‘‘unhealthy’’ lifestyles and the reinforcement of a trend of restricting the health services provided by the state.

E

The Ecology of the Disease In late January 1991, epidemic cholera produced by Vibrio cholerae (serovariant 01, biotype El Tor, serotype Inaba) appeared almost simultaneously in three coastal areas of Peru: the town of Chancay, the port city of Chimbote, and Lima. One hundred and forty-nine cases were registered in the week of 20–26 January. The figure jumped to 16,335 during the week of 10– 16 February.≤ During the rest of that month an average of 1,200 cases were reported weekly. Approximately sixteen days after the start of the epidemic,

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cholera crossed the Andes to attack cities in the highlands, and thirteen days after that, cities in the Amazon such as Iquitos were a√ected. By the fifth week of the epidemic, cases had been reported from twenty-four of the country’s twenty-nine departments.≥ The sudden appearance of the disease after an absence of more than one hundred years and its acute symptoms—acute dehydration, vomiting, and watery diarrhea—produced panic, pain, and death.∂ Within a few months the cholera had spread to other South and Central American countries, spreading panic across the continent.∑ The epidemic in Latin America was part of the seventh pandemic wave of cholera that began in 1961 in Southeast Asia, on the East Indonesian Island of Celebes, and reached Africa in the 1970s. It is not clear why twenty years elapsed before the cholera spread to Latin America. Radical and sometimes irrational measures appeared along with the disease. Many foreign governments banned food imports from Peru, even frozen or canned foods; airplane passengers arriving from Peru were meticulously checked in several airports of the world; Bolivian navy boats patrolled Lake Titicaca with orders to seize and destroy food shipped across the lake from Peru; and tourists all over the world changed their plans to visit Machu Picchu and other Inca monuments in the summer of 1991. In a meeting of the Subcommittee on Western Hemisphere A√airs of the U.S. House of Representatives that took place in May 1991, a speaker predicted ‘‘as high as 6 million [cholera] cases and possibly 40,000 deaths in Peru.’’∏ Although the epidemic did not match those catastrophic projections, 322,562 Peruvians experienced cholera in 1991, and 2,909 died of the disease.π For a population of 20 million inhabitants this meant that a little more than 1 percent had the disease. The epidemic also showed regional and social di√erences in each of the three natural regions of the country: coast, highlands, and jungle or Amazon. Although the highlands had the smallest number of cases of the three regions, the rate of mortality from the disease was higher there than in the coast. The ratio of deaths to hospitalized cases reached 1.2 percent in the coast, and 8 percent in the highlands and the jungle,∫ mainly because the majority of the population of the highlands and the jungle did not have ready access to health services. In spite of the extent of the epidemic, the national case-fatality rate was low, less than 1 percent, although in rural areas it climbed to 10 percent, and in the Amazon region to 6 percent.Ω These figures contrast with the forecast case-fatality rate of 10–30 percent based on the experiences of other parts of the world.∞≠

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The origin of the disease was originally attributed to an Asian ship that released its contaminated bilge water into the harbors of several Peruvian ports, including Chimbote, just before the epidemic began. However, serologic examinations undertaken when the ship reached Europe found no recent Vibrio cholera 01 infections in the crew. The original source of the cholera that broke out in Peru remains unknown, but there is still a suspicion that ballast water discharged by this or other vessels in the harbors was the source. In any case, experts recognized a major di√erence from the African epidemic: in Peru, contaminated water and not food became the main means for the transmission of cholera. The rapid di√usion of cholera in Peru can be traced to poor municipal water systems with little chlorination and intermittent flow, and, worse, to sewage disposal systems that contaminated rivers and harbors used as fishing areas. In 1991 only 55 percent of the population of the country had access to safe drinking water (22 percent in rural areas and 67 percent in urban areas).∞∞ Water distribution networks were in poor condition and poorly supervised. For decades, water supply programs had focused on building (suited for political ceremonies) or expanding services and paid little attention to the quality of the water distributed. In shantytowns, the crowded periurban slum communities that multiplied in the 1980s in Lima and the other major cities of the country, the situation was more critical. Only 24 percent of the inhabitants of these urban areas had access to safe water, and water was more expensive there than in middle-class neighborhoods.∞≤ In addition, people in shantytowns lacked water pipes in their homes and had to purchase water from private street vendors who brought it in tanker trucks. The early 1990s saw in Peru and in many other Latin American countries the failure of the ‘‘Drinking Water and Sanitation Decade’’ promises made in 1980 by several national and international health agencies. Diarrheal diseases like gastroenteritis, dysentery, and typhoid fever, which have environmental means of transmission similar to that of cholera, were major causes of retarded growth, malnutrition, and death in children less than one year old. Between 1965 and 1990 Peru had a high rate of infant mortality associated with diarrheal diseases.∞≥ In 1991, infant mortality in Peru was seventy-eight per one thousand, the third highest in Latin America and the Caribbean after Haiti and Bolivia.∞∂ Treatment of solid wastes, food inspection, and control of insects were all seriously deficient. Most coastal cities had sewers for sewage collection, but very few of them had sewage treatment facilities. Untreated wastewater was

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Cartoon from the magazine Oiga, February 18, 1991.

frequently discharged into rivers, lakes, or the Pacific Ocean. Sewage was also used to irrigate fruits and vegetables that were cultivated near the cities and eaten without cooking. Fish and shellfish marinated in lemon juice and onions were consumed nearly raw in a popular dish called ceviche.∞∑ In addition, street vendors sold contaminated foods and beverages. Many urban workers obtained their lunch from these vendors because it was cheap, rapid, and could be consumed immediately. Other sources of contaminated water were low-pressure delivery systems; insu≈cient or no chlorination; frequent breakdowns in the service; and water storage in cylinders, buckets, tins, pots, and other containers with wide openings that let people put their hands in. The epidemic broke out in a country marked by economic hyperinflation, terrorism, and political instability. In 1990 the hyperinflation rate was estimated at 7,650 percent per year. Many state services had virtually collapsed, and the few governmental resources remaining were devoted to the fight against the Shining Path, a radical Maoist terrorist group created in 1980 by a university professor of philosophy named Abimael Guzman whose practices resemble those of the Cambodian Khmer Rouge. The Peruvian military and the Shining Path waged a brutal war that frequently had as innocent

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victims peasants and urban shantytown dwellers. Thousands disappeared, and human rights violations were numerous.∞∏ By 1992 an estimated twentyfour thousand people had died in the battle between the Shining Path and the Peruvian military. In 1991 eighty-seven national provinces were o≈cially under a state of emergency, and the Shining Path leaders declared that they had achieved ‘‘strategic parity’’ with the government and were preparing their final assault. A magazine cartoon published at the time compares Guzman and Vibrio cholerae, suggesting the fears, threats, vulnerability, and desperation experienced by the Peruvian population. What role did the state and the health community play during the epidemic in a country that was in the middle of a profound economic and political crisis?

The O≈cial Response On February 8, the Peruvian government declared a state of emergency in all cities of the coast attacked by cholera and devoted four million dollars to fight the epidemic. Initially, the leader of the government’s response was the minister of health, medical doctor Carlos Vidal, who had been for years a distinguished o≈cer of the Pan American Health Organization (paho), a regional o≈ce of the World Health Organization based in Washington, D.C. Vidal had spent most of his career in Buenos Aires and Washington, D.C., before returning to Peru to become minister of health. An advocate of primary health care, Vidal tried to establish new priorities and reform the chaotic and disorganized public health service. The system was in economic crisis, lacked an adequate infrastructure, was fragmented (several sectors provided health services with little coordination) and of limited e√ectiveness, and su√ered from a maldistribution of physicians and medical personnel, who were chronically underpaid. Vidal followed the advice of international agencies such as the Centers for Disease Control in Atlanta and paho in organizing the response to cholera. These organizations believed that seafood and shellfish were the reservoir and that transmission occurred through contaminated food and water, and stressed that cholera could be prevented and treated and that no vaccines should be used. The vaccine was not su≈ciently e√ective; the immunity that it conferred lasted only three to six months; and it did not reduce the rate of asymptomatic infection. Moreover, it was believed that vaccination would

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produce a false sense of security for health authorities and for the population, and that preventive measures would not be applied as a result. The o≈cial recommendations of the Peruvian Ministry of Health included drinking only water that had been boiled, eating only food that had been thoroughly cooked, avoiding raw seafood, avoiding food and drink sold by street vendors, and washing the hands frequently, especially before and after using the bathroom.∞π The ministry also suggested using chlorine tablets to purify water stored in domestic containers. Vidal and the international health agencies were also convinced of the importance of providing clear information of the epidemic situation at all times and of enrolling the active participation of the central government and the president in the fight against cholera. Vidal used the media to explain the usefulness of epidemic control measures such as quarantine, import restrictions, police control of restaurants, surveillance, and education. His main strategy was to avoid high mortality by improving hygiene and by emphasizing the rapid treatment of cases. Since it was impossible to perform bacteriological tests on all patients, the ministry established that any reported case of acute diarrhea (in Spanish, enfermedad diarreica aguda, or eda) should be considered as potentially cholera. Partly because Vidal followed international recommendations, he was able to obtain several million U.S. dollars from paho, unicef, usaid, caritas, the Italian Cooperation Agency, and from other European countries during the year of the epidemic.∞∫ Treatment consisted of adequate fluid replacement through oral rehydration therapy (ort), which was strongly recommended by the World Health Organization. Normally these ort packets, which were mixed with water, were used by pediatricians in Peruvian hospitals and in primary care units to treat the typical summer diarrhea of children. In addition, antibiotics such as tetracycline were administered. Hospital services created cholera treatment units for rapid diagnosis and treatment of patients requiring hospitalization. In several urban centers the entire hospital functioned as a cholera treatment unit and relatives of cholera patients and administrative personnel were recruited to help treat the sick. The epidemic placed an enormous burden on the material and human resources of the hospitals. The overcrowded public hospitals of Peru frequently lacked essential prerequisites for the practice of medicine. For example, the hospital La Caleta of Chimbote was jammed with three times more people than there were beds in the hospital. In the same hospital there

274 m a r c o s c u e t o ‘‘At the Hospital La Caleta, in Chimbote, the sta√ cannot attend to hundreds of infections.’’ From Caretas, no. 1146, February 11, 1991, p. 57.

was water for only two hours a day, blankets and hospital gowns were scarce, extra beds for cholera patients were placed in alleys and waiting rooms, relatives and administrative personnel assisted doctors, and basins were improvised from plastic bottles.∞Ω The conditions for the control of the epidemic were also worsened by the fact that during the epidemic a number of health workers at public hospitals began a strike demanding better salaries.≤≠ The proportion of patients su√ering from eda is an indicator of the number of cholera cases treated in a hospital. During the whole year of 1991 in Cayetano Heredia, an important hospital in Lima, 89 percent of the patients received in the emergency room were eda cases. In contrast, in 1988 only 32 percent of the emergency room patients presented acute diarrheal disease.≤∞ Local production of ort packages and e√orts to educate both the population and the medical community have been developed in di√erent parts of

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the world since the 1960s.≤≤ In the mid-1980s units of oral rehydration (uros) were produced in several Peruvian communities and shantytowns under the supervision of the ministry and with the support of unicef and other international agencies. The uros were a valuable lifesaving device for mild and moderate cholera cases, but they could not eliminate a disease caused by water polluted with sewage and contaminated food. In addition, in 1991, before the onset of the epidemic, Peru began to produce locally oral rehydration salts that were used during the cholera epidemic. Less common in Peru was the use of intravenous fluid infusion for treating severe cases of cholera who could not drink the ort because they were comatose or vomiting. According to a Peruvian physician, some doctors were afraid to use this method because they fear provoking lung edema and death.≤≥ Many patients died in the emergency wards because of dehydration. The best answers to the dehydration problem were the polyelectrolytic solutions containing bicarbonate or lactate, such as Ringer’s Lactate, recommended by the World Health Organization. The ministry followed the standard international recommendation for the early treatment of cases of shock and provided details on how to use these solutions,≤∂ but they were expensive and scarce in the pharmacies and hospitals of the country. The ministry even issued some directions on how to make polyelectrolytes, something that was never really done because it was complicated and still expensive, and it used precious time during the treatment of a patient in the emergency wards. Many Peruvian physicians and nurses creatively replaced the polyelectrolytic solutions with simple saline or sodium chloride solutions that were vigorously administered. With the use of these cheap, accessible, innovative, and e√ective solutions, the signs of shock subsided and many lives were saved.≤∑ As a matter of fact, one of the Peruvian achievements during the epidemic was the discovery that the international literature regarding the treatment of severe cases of cholera was wrong. The Peruvians found that when traditional industrial solutions were in short supply, the low-cost, easy-toprepare saline solutions were su≈cient to control cholera in severe cases. Sometimes fluid replacement was done in both arms and legs. Since distinguishing mild from severe cases was di≈cult, a combination of oral and intravenous methods was also used to save lives. These methods plus the heroic e√orts of overworked hospital personnel to stretch scarce resources to serve a large number of people under adverse conditions helped to reduce the mortality of cholera and reevaluate the role played by the hospitals. The

276 m a r c o s c u e t o ‘‘Totally dehydrated and in a state of shock, a fisherman from Chimbote tries to resist death. His look, however, appears to accept the triumph of the cholera.’’ From Caretas, no. 1146, February 11, 1991, p. 52.

Ministry of Health and the main medical establishments that provided cholera treatment free of charge also provided a solid foundation of support. During the 1980s, partly due to the primary health care movement, public hospitals in Peru had been considered elite, stagnant, and clumsy institutions with little to contribute to community health, the promotion of healthy habits, and prevention of disease. Following a world trend, the organization of basic health centers was encouraged, and people went there for treatment. In contrast, during the cholera epidemic people sought hospitals for medical attention, information on how to prevent and control the disease, and access to ort packages. This might be explained by the fact that during an epidemic, hospitals have a greater concentration of medical personnel and patients, treatments become uniform, and limited resources are more economical and e√ective. Initially, there was an exaggerated compliance of the population, municipal authorities, and the government with the sanitary recommendations.

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People improved their personal hygiene and stopped eating raw and cooked fish and vegetables. The police created roadblocks and restricted access to beaches during the hot summer.≤∏ Provincial authorities prohibited the consumption of ceviche, burned cargoes of fish coming from Chimbote, accused the agriculturists who used sewage of poisoning the people, and improved garbage collection and inspection of domestic water containers. Police stopped fishermen from setting out nets in a campaign to stop the sale of seafood.≤π After a few weeks, however, the attitude of local authorities and of the central government changed. Criticism emerged against the sanitary campaign developed by the Ministry of Health because it was considered an additional source of social upheaval in the country. Little could be done by a National Cholera Commission that tried to organize the Ministry of Health in Lima and in some provinces to encourage intersectorial interventions. The Ministry of Health lacked su≈cient legitimacy to mobilize the population or align the bureaucracy of other ministries under the goals of the cholera campaign. Furthermore, at no point in the epidemic was the active collaboration of the central government obtained. President Alberto Fujimori did not lead a coherent policy of seeking international resources to improve Peru’s sanitation infrastructure or use the media to call for national support, even though Vidal asked him to appear on tv. The government left the Ministry of Health alone to carry the major responsibility for the campaign. This attitude was partly related to the governing style of the inexperienced president, Alberto Fujimori, who played the ministers of his cabinet against each other, feared that the sanitary campaign was too expensive, and from the very beginning feared that the epidemic would damage his popularity. Moreover, Fujimori was at the time abandoning the populist discourse that had helped him to obtain valuable support from the political parties of the center and the left and win the elections of June of 1990 against the conservative candidate, the writer Mario Vargas Llosa.≤∫ Ironically, after becoming president, and mainly because of strong international pressure from the World Bank, Japan, and the United Nations, Fujimori moved progressively toward the neoliberal politics that Vargas Llosa had advocated during the presidential campaign. Moreover, his orthodox plan of economic austerity has been considered even more extreme than that proposed by Vargas Llosa.≤Ω Fujimori’s first cabinet included ministers, such as Vidal, who did not agree with neoliberalism. Some of the

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goals of Fujimori’s new structural adjustment policies were to reduce the size of the state in order to solve the fiscal crisis and repay the foreign debt. This meant that the budgets of social programs in Peru such as public health had to be cut and reorganized. The new political orientation was strongly supported by the appointment of a new minister of economics, Carlos Boloña, in the middle of the epidemic. Boloña replaced the first minister of economics, Juan Carlos Hurtado, who had worked actively with Vidal during the first weeks of the sanitary campaign. Hurtado knew and respected Vidal partially because he was himself the son of Dr. Alberto Hurtado, the founder of the Universidad Cayetano Heredia, a medical school where Vidal was a professor.≥≠ Boloña, in contrast, defended an orthodox and rigid program of adjustment and was strongly supported by the International Monetary Fund. In addition to the fight against inflation, Fujimori and Boloña planned to defeat the Shining Path, attract foreign investment, and privatize state-owned companies.≥∞ According to Carol Graham, one of the main failures of the government’s program of economic stabilization was its inability to implement a safety net.≥≤ This feature appeared clearly during the epidemic. Despite this situation, Graham underlined the ability of the urban poor in Peru to create ngos and informal systems to obtain food, shelter, and health. Fujimori was also sensitive to the pressure of di√erent economic groups that were against Vidal and his sanitary campaign. Among them were physicians and health o≈cers who felt displaced by a new minister who had spent most of his career abroad and tried to change too much relying on young and new personnel. Stronger opposition came from some businesses engaged in exports and tourism, fishermen, small restaurant owners, agriculturists, and even pharmaceutical companies that opposed the reform policies of Vidal. According to Vidal’s critics, the Ministry of Health transformed the epidemic into a scandal, terrorized people, and scared away foreign investors and commerce.≥≥ For them, the information provided by the ministry augmented the international perception of chaos in Peru. These critics preferred the strategies used by other Latin American governments of denial, containment, and underreporting.≥∂ In addition, Vidal was blamed for the decision of many countries to halt fish, fruit, and vegetable imports from Peru and even in some cases to quarantine passengers arriving from Peru. The fear of infection had irrationally extended to frozen and canned products coming from Peru. In

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addition, many South American countries made the political decision to keep down their cholera figures by registering only cases confirmed by laboratory exams. In contrast, Peru continued for the rest of 1991 to use a definition that considered any case of acute diarrhea as cholera. Criticism against the ministry’s campaign also came from the provinces, which received little support from the central authorities in Lima. Provincial fishermen accused the ministry of causing unemployment, insisted that they consumed raw fish and never got sick, and organized rallies under the motto ‘‘Fish yes, chicken no!’’ (poultry was temporarily used to replace seafood in ceviche).≥∑ Fujimori and some of his ministers irresponsibly denied the risk of consuming raw fish by eating ceviche in front of tv cameras.≥∏ Trying to modify public perceptions, the president invited a selected group of journalists to a luxurious restaurant in Lima where he explained that Peruvian fish was not seriously contaminated and that lack of individual hygiene and the critical poverty inherited from former governments were responsible for the epidemic. Fujimori frequently blamed preceding regimes and political parties for the severe social and economic problems of the country; it was part of his political discourse.≥π As a result, the president appeared as the defender of the diverse groups interested in bringing the health campaign to a halt. Vidal was isolated with a policy that was recognized only by health personnel and international health organizations. Partly for this reason (he was also against the neoliberal economic policies implemented by Fujimori) Vidal left the government before the epidemic ended. With the departure of Vidal, the campaign lost visibility and coordination. In this climate of political uncertainty, the popular and somewhat disorganized perceptions of the disease multiplied.≥∫

Perceptions Cholera revealed and produced a series of fears, associations, and stigmas that transcended the biological reality of the disease. The classical themes of the origin of epidemics—such as religious punishment, disease as a token of reproach and social inferiority as well as a metaphor for the social and epidemiological realities—appeared very frequently, as did resignation to inescapable fate, heroic behavior, and human solidarity. Common to popu-

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lar perceptions was the idea, reinforced by the government, that there was an individual responsibility for acquiring the disease. The idea of individual responsibility carried a strong stigma. Popular and o≈cial perceptions usually revolved around three issues: the origin of the disease, the causes of individual contagion, and the measures that should be taken. The most widespread popular belief was that the epidemic was God’s will to punish the sinful Peruvians. The Fujimori administration used this belief as a way of blaming the ‘‘irresponsible’’ and ‘‘corrupt’’ governments that had ruled Peru since the return to democracy in 1980 and the inability of political parties to solve the problems of political violence and economic crisis. Other popular and o≈cial external explanations of the origin of the disease focused on the small Asian cargo ship mentioned above. Another popular explanation blamed uncontrollable international factors such as the Gulf War that ‘‘polluted’’ the rest of the world.≥Ω Many people considered the disease something external to the nuclear family: cholera was acquired in the street, not at home. Garbage, dogs, beaches, flies, ice cream, drinks, and fruit encountered outside the home were blamed. Some shantytown dwellers believed that the illness was caused by a combination of heat and dirt, an indication that old Hippocratic and miasmatic ideas still exist among the people.∂≠ The testimony of one victim illustrates the popular perception that the disease was external to the home: ‘‘After going to the beach I and other members of the family ate watermelon and chicha morada [a local drink] after a while I began to vomit.’’∂∞ The attribution of the disease to an external agent alleviated the stigma of cholera, especially at a time when the government was insisting that there was a close relationship between lack of individual hygiene and contagion. The explanation even reached the pages of the New York Times. An article sent from Lima explained that a cholera patient ‘‘attributes her sickness to a bowl of soup she bought in the streets of Lima.’’∂≤ Fujimori, the newspapers, o≈cers from some ministries, and even a few members of the Ministry of Health insisted throughout the epidemic that the main cause of cholera was poor individual hygiene. This explanation underlined the traditional association between this disease and poverty not to stress the lack of social services infrastructure, but to point to the unhealthy habits of the poor and their inability to get ahead in life. Little was said about their unequal access to water or health services, and even less on the relationship between the vulnerability of the poor to cholera and mal-

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Posters collected by author at Hospital La Caleta, Chimbote.

nutrition, polluted environments, scarce economic resources, and di≈cult access to education. Contagion was usually presented as a result of negligence, ignorance, laziness, poverty, and a particular lifestyle. O≈cial propaganda frequently called the sick ‘‘pigs’’ (cochinos) or ‘‘filthy’’ (los sucios).∂≥ The negative association between filthiness and cholera was more intense in the slum areas of the cities, where a survey indicated that many people denied having cholera because they were ashamed.∂∂ The association between filthiness and disease made the sick socially undesirable. Even more, it promoted the perverse notion that cholera persisted because there were some people, namely los sucios, who enjoyed filthiness. The government used individual filthiness to explain the epidemic as a means to overlook the urgencies associated with a drinking water system in crisis, to avoid a position of leadership in the fight against the epidemic, and to stigmatize the sick individuals. For many politicians and even for some health o≈cers, stressing personal hygiene, health education, and early use of ort packages seemed the practical route to combat the epidemic because there was little political possibility of beginning a national crusade to improve the water and sewage systems. As a result, the association between filthiness and the disease was used to

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support a campaign that cost little, avoided dealing with the real problems that generated the epidemic, and reinforced the neoliberal trend taken by the Fujimori government. This hygienic vision of cholera extended among some physicians, nurses, and patients as well. Some medical doctors appeared on tv and in newspapers proclaiming the miraculous power of water and soap. The hygienic discourse blamed the failure to boil drinking water; the food habits of the population; and popular practices of the urban poor such as storing water in open-mouthed vessels, giving boiled water only to children, rarely using soap, and washing the hands in drinking water. Several testimonies of cholera patients include accounts of medical doctors interrogating their patients in the emergency wards. Two crucial questions frequently asked were what they ate and where they had been in the last twenty-four hours. It is interesting to note that after a short denial, many patients confessed that they secretly ate fruit or drank a beverage outside their home. In this way the narration of contagion became a confirmation of the medical and political assumptions of the campaign and a way of coping with the illness. It also showed other people how to behave in order to avoid the disease.∂∑ Some journalists usually critical of the government accepted poverty as the main cause of the disease, and in some newspapers it was said to be more important than the Vibrio. This obviously implied some criticism of the social order because it was immediately noticed that most of the people who died of cholera came from the slums and the poorest urban sections. For many, cholera confirmed that the people living in the cities of Peru received very di√erent kinds of public services in terms of access to water, sewage disposal, and garbage collection. Some of the journalists realized that it was almost impossible for people living in poverty to maintain hygienic habits. Cholera was not an equalopportunity disease. Although they knew that personal hygiene was crucial and desirable, the poor were frequently unable to buy soap, eat lunch at home, or obtain the means to boil water, and therefore were more vulnerable to the disease. This was partly confirmed in a study made in shantytown areas that found that although people recognized the importance of washing their hands after going to the bathroom, 80 percent of the water used for this purpose was contaminated.∂∏ With regard to treatment there was some tension due to a conflict be-

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tween modern and traditional medical practices. For example, in the communities of the Andean highlands of Cajamarca, boiling water was incompatible with ancient concepts of nature. These people and many others believed that orts and boiled water were dangerously artificial and had a strange flavor.∂π Many of those living in rural locations attacked by cholera were against the decision of sanitary authorities to restrict prolonged funeral rites to reduce contact between relatives. Some resorted to medicinal herbs generally used for diarrheal diseases, sometimes taken with alcohol and lemon, ‘‘to kill microbes.’’∂∫ The strong association between filth and disease was part of a more complex relationship of the state with public health services. Since the midtwentieth century, populist regimes and politicians had promised to provide free access to health care and to expand the public health system to all citizens in order to support social improvement and equal opportunity. Although the promise was never kept, until the 1980s the o√er of universal public health helped to legitimate the state in urban areas. However, the Peruvian state and its social policies had been in a situation of collapse since the mid-1980s. The political solution sought by Fujimori was a drastic reduction of the state’s role in social policy. The stigma and blame created against the victims of the epidemic by the government and the undermining of Vidal’s sanitary campaign were instrumental in breaking forever the association between the Peruvian state and free public health services for the population. The epidemic reinforced the popular belief that the work of the state in public health would at best be benevolent but insu≈cient, intermittent, and frequently irrelevant to the general welfare of the family. As Charles Briggs has argued, cholera stigmatization in Latin America was instrumental in further marginalizing the poorest inhabitants of the cities.∂Ω

Conclusion The sanitary campaign against the cholera epidemic in Peru was unable to transcend the technical sphere. After some debate, the o≈cial discourse advanced by the government stressing individual hygiene became hegemonic. President Fujimori saw epidemic disease as a technical problem within the minister of health’s scope rather than a responsibility of the cen-

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tral government. Because Fujimori was winning the war against inflation and the Shining Path, many of his supporters paid little attention when cholera became an endemic disease in a country that had not known it in the past. Despite the fact that personal hygiene and health education improved after 1991 and water treatment plants increased the chlorination of drinking water, 284,090 cases of cholera were registered in Peru between 1992 and 1993.∑≠ Despite chlorination of the main urban water supply systems, the quality of the water was still not good enough, and it was necessary for all residents to treat drinking water at their homes. In addition, Peruvians now accepted as a fact of life a disease that until 1991 did not even exist in the country. The 1997–98 summer season produced 34,000 cholera cases and 265 deaths in Peru.∑∞ All the Latin American countries a√ected in 1991 continued to report cases in 1992 and 1993.∑≤ Although Peruvian physicians have been able to control outbreaks and avoid a new epidemic, the cholera experience foreshadows other health threats. In 1994, for example, the situation with regard to diarrheal diseases was again critical. There were 629,639 cases of eda, 51 percent in children under the age of five; a high percentage was caused by enterotoxigenic Escherichia coli.∑≥ In 1998 the eda figure had fallen only slightly to 600,515 cases.∑∂ The campaign against cholera was considered a success by the government, by some international organizations, and even by some Peruvian physicians. The low fatality rate was regarded as a remarkable medical achievement.∑∑ Undoubtedly, ingenious and rapid treatment resulted in the very low death rate, the early recovery of thousands of patients, and improved personal hygiene. Sanitary authorities informed the entire population about the epidemic quickly, and their active promotion of personal hygiene, early treatment, and rehydration techniques did much to lower the death rate, as did the hard work and solidarity of physicians, nurses, hospital personnel, the church, nongovernmental organizations, and other grassroots institutions. However, it is di≈cult to consider the campaign a success story because it did not solve the acute problems of water and sewage systems in Peru. The campaign failed to generate a sustained coalition of public and private sectors working on health improvement. Sanitation lagged behind the extensive use and distribution of orts. The campaign also reinforced previous traditions that emphasized the use of limited resources not on infrastruc-

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ture, sanitation, and prevention, but on treatment of the sick. In addition, after the epidemic the government returned to and even reinforced billing practices for people using public hospitals. Because of these reasons, the health expectations of the population changed after the cholera epidemic. Many Peruvians realized that taking care of the sick was an individual and family responsibility and expected less from the state.∑∏

Notes 1 The interaction between medicine and politics in cholera epidemics is analyzed in a number of remarkable historical works; see Charles E. Rosenberg, The Cholera Years: The United States in 1832, 1849, and 1866 (Chicago: University of Chicago Press, 1962); Margaret Pelling, Cholera, Fever and English Medicine (Oxford: Oxford University Press, 1978); François Delaporte, Disease and Civilization: The Cholera in Paris, 1832 (Cambridge: MIT Press, 1986); Richard Evans, Hamburg: Death, Society and Politics in the Cholera Years, 1810–1910 (Oxford: Oxford University Press, 1987); Esteban Rodríguez Ocaña, El Cólera de 1834 en Granada: Enfermedad Catastrófica y Crisis Social (Granada: Universidad de Granada, 1983); David Arnold, Colonizing the Body: State Medicine and Epidemic Disease in Nineteenth-Century India (Berkeley: University of California Press, 1993). 2 The Pan American Health Organization reported 366,017 cases of cholera in 1991. Of these, 88 percent were from Peru; ‘‘Cholera Situation in the Americas,’’ Epidemiological Bulletin of the Pan American Health Organization 12.1 (1991): 1–7. 3 Robert Tauxe, Luis Seminario, Roberto Tapia, and Mario Libel, ‘‘The Latin American Epidemics,’’ in I. Kaye Wachsmuth, Paul A. Blake, and Orjan Olsvik, eds., Vibrio cholerae and Cholera: Molecular to Global Perspectives (Washington, D.C.: American Society of Microbiology, 1994), 321–44, on 324. 4 Robert V. Tauxe and Paul A. Blake, ‘‘Letter from Peru, Epidemic Cholera in Latin America,’’ Journal of the American Medical Association 267.10 (1992): 1388–90. 5 Rubén Suárez and Bonnie Bradford, The Economic Impact of the Cholera Epidemic in Peru (Washington, D.C.: Environmental Health Project, 1993); Margarita Petrera and Maibi Montoya, ‘‘Impacto Económico del Cólera, Perú, 1991,’’ Boletín Epidemiológico: Organización Panamericana de la Salud 13.2 (1992): 9–11. 6 House Subcommittee on Western Hemisphere A√airs of the Committee on

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7

8 9

10 11

12

13

14

15

16 17

Foreign A√airs, Hearing on the Cholera Epidemic in Latin America, Wednesday, May 1, 1991 (Washington, D.C., 1991), 1. ‘‘Cholera in the Americas,’’ Weekly Epidemiological Record, World Health Organization 67 (1992): 33; O. Mujica, R. Quick, A. Palacios, et al., ‘‘Cólera en la Selva Peruana: Factores de Riesgo y Protección,’’ Revista Peruana de Epidemiología 4.2 (1991): 62–69; Allen A. Ries, Duc J. Vugia, Luis Beingolea, et al., ‘‘Cholera in Piura, Perú: A Modern Urban Epidemic,’’ Journal of Infectious Diseases 166.6 (1992): 1429–33. ‘‘Cholera Situation in the Americas,’’ Epidemiological Bulletin of the Pan American Health Organization 12.1 (1991): 1–7. Some cases of cholera were identified in Peru in 1984 and 1988 but did not receive much attention. B. A. Kay and R. B. Sack, ‘‘Vibrio cholera Non-01 Isolated from Five People with Diarrhea in Lima,’’ Lancet 28.1 (1984): 218; R. A. Batchelor and S. F. Wignall, ‘‘Nontogenic 01 Vibrio cholerae in Peru: A Report of Two Cases Associated with Diarrhea,’’ Diagnostic Microbiological Infectious Diseases 10 (1988): 135. ‘‘La Situación del Cólera en las Americas,’’ Boletín Epidemiológico, Organización Panamericana de la Salud 15.1 (1994): 16. Luis Antonio Loyola, La Epidemia de Cólera en el Perú y Relación con los Problemas de Salud Ambiental (Lima: Organización Panamericana de la Salud, 1991), 19. R. I. Glass, M. Liberl, and A. D. Brandling-Bennet, ‘‘Epidemic Cholera in the Americas,’’ Science 256 (1992): 1524–25; Luis Seminario, Augusto Lopez, Esther Vásquez, and Marcela Rodríguez, ‘‘Epidemia del Cólera en el Perú, Vigilancia Epidemiológica,’’ Revista Peruana de Epidemiología 4.2 (1991): 8–10. Organización Panamericana de la Salud, Las Condiciones de Salud en las Américas, 1994 (Washington, D.C.: Organización Panamericana de la Salud, 1994). Programa de las Naciones Unidas para el Desarrollo, Informe Annual de la Cooperación para el Desarrollo, Perú, 1991 (Lima: pnud, 1992); Dieter K. Zschock, Health Care in Peru: Resources and Policy (Boulder: Westview Press, 1988). Scott McLellan, ‘‘La Muerte como Modo del Vida: El Cólera Mata pero la Epidemia en el Perú También Ha Salvado Vidas,’’ CERES, Revista de la FAO 24.137 (1992): 39–43. See Steve J. Stern, ed., Shining and Other Paths: War and Society in Peru, 1980–1995 (Durham: Duke University Press, 1998). L. Puglielli, C. Cattrini, J. Resa, et al., ‘‘Symptomless Carriage of Vibrio cholera in Peru,’’ Lancet 339 (April 1992): 1056–57; Organización Panamericana de la Salud, ‘‘Epidemia del Cólera en el Perú, Pautas para su

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18

19 20

21 22

23 24

25

26

27 28 29 30

31

Control,’’ Boletín de la Oficina Sanitaria Panamericana 110.4 (1991): 277– 97; Eduardo Gotuzzo, ‘‘El Cólera en el Perú,’’ Revista Médica Herediana 2.3 (1991): 105–7. Ulysses B. Panisset, International Health Statecraft, Foreign and Public Health in Peru’s Cholera Epidemic (Lanham, Md.: University Press of America, 2000), 168. Diego Gonzalez, ‘‘El Hospital bajo la Furia del Cólera,’’ Revista Médica Herediana 2 (1992): 54–56. Javier Rios Dávila, ‘‘Impacto de la Epidemia del Cólera y la Huelga de Salud en el Servicio de Emergencia, 1991’’ (diss., Universidad Peruano Cayetano Heredia, Lima, 1993). Ibid., 14. Joshua N. Ruxin, ‘‘Magic Bullet: The History of Oral Rehydration Therapy,’’ Medical History 38 (1991): 363–97; David L. Swerdlow, M. D. Allen, and A. Ries, ‘‘Cholera in the Americas, Guidelines for the Clinician,’’ Journal of the American Medical Association 267.11 (1992): 1495–99. Interview with Juan Rosado, doctor at the Hospital La Caleta, Chimbote, March 15, 1996. Ministerio de Salud, ‘‘Protocolo de Manejo Médico de los Casos de Cólera en Establecimientos Hospitalarios, Febrero 8, 1991,’’ document provided by Dr. Eduardo Monge from Hospital Daniel A. Carrión, Callao. M. Vargas, L. Huicho, V. Salcedo, and E. Monge, ‘‘Use of Isotonic Sodium Chloride in the Early Treatment of Cholera Diarrhea: The Peruvian Experience,’’ Journal of Wilderness Medicine 4 (1993): 62–67; Javier Cieza, ‘‘Esquema para el Manejo de Pacientes Desidratados por Cólera,’’ Revista Médica Herediana 2 (1991): 68–69. ‘‘La Guerra del Ceviche Ha Terminado,’’ Resumen Semanal, Desco 14.611 (1991); Bruno Benavides, ‘‘Consumo de Alimentos en Comedores Populares de Lima durante la Epidemia de Cólera,’’ Revista Peruana de Epidemiología 4.2 (1991): 102–8. James Brooke, ‘‘Peru’s Neighbors Halt Food Imports,’’ New York Times, February 15, 1991. Cynthia McClintock, ‘‘Peru’s Fujimori: A Caudillo Derails Democracy,’’ Current History 92.572 (1993): 112–19. Carol Graham, ‘‘Economic Austerity and the Peruvian Crisis: The Social Costs of Autocracy,’’ SAIS Review 13.1 (1993): 49. A renewable financial fund existed throughout the campaign thanks to the amiable relation between Vidal and Hurtado. See ‘‘Cólera: Estado de Emergencia,’’ Resúmen Semanal, Desco 14.607 (1991): 1. Joseph Tulchin and Gary Baland, eds., Peru in Crisis: Dictatorship or Democracy (Washington, D.C.: Woodrow Wilson Center, 1994).

288 m a r c o s c u e t o 32 Carol Graham, ‘‘Economic Austerity and the Peruvian Crisis,’’ 45. 33 ‘‘Cólera Afecta al Sector Exportador,’’ Resumen Semanal, Desco 14.608 (1991): 5; ‘‘Entrevista a Carlos Vidal, Ex–Ministro de Salud,’’ Medicamentos y Salud Popular 5.6 (1991): 6. 34 On the di√erent systems of registering cases of cholera, see Denise Koo, Hector Traverso, Mario Libel, Christopher Drasbeck, Robert Tauxe, and David Branding-Bennet, ‘‘El Cólera Epidémico en América Latina de 1991 a 1993: Implicaciones de las Definiciones de Casos Usadas en la Vigilancia Sanitaria,’’ Revista Panamericana de Salud Pública 1 (1997): 85–91. 35 ‘‘Miles de Pescadores sin Trabajo en Marcha Comen Pescados Crudos para Probar que no les Pasa Nada,’’ Satélite (Trujillo), February 15, 1991, 1; ‘‘Marcharon Protestando Pescadores Artesanales y Vendedores de Pescado,’’ Diario de Chimbote, February 16, 1991, 1. 36 Carlos Reyna and Antonio Zapata, Crónica sobre el Cólera en el Perú (Lima: Desco, 1991). 37 ‘‘Fujimori Insiste,’’ Resumen Semanal, Desco 14.609–10 (1991): 3. 38 Mary Fukumoto and Beth Yeager, Percepciones de la Población Respecto del Cólera, Informe Final (Lima: Instituto de Investigación Nutricional, 1993). 39 Ibid., 15. 40 ‘‘También Tenemos Derecho,’’ in Jenny Menacho Menacho, ed., Cólera: La Versión de los Afectados (Chosica, Peru: predes, 1991). 41 Bruno Benavides, Roberto del Aguila, Enrique Jacoby, and Joaquin Novara, ‘‘Conocimientos Preventivos y de Manejo de Casos de Cólera en Poblaciones de Lima y Piura Luego de la Epidemia,’’ Revista Peruana de Epidemiología 5.1 (1992): 10–15. 42 Nathaniel C. Nash, ‘‘Spread of Cholera Brings Frenzy and Improvisation to Model Lima Hospital,’’ New York Times, February 17, 1991. 43 ‘‘Hospital Regional,’’ Diario de Chimbote, February 6, 1991, 4. 44 José Antonio Iturri, ‘‘A Epidemia de Cólera no Perú como um Evento Social: As Representações das Lideranças Comunitárias de Villa El Salvador, Lima, 1991’’ (diss., School of Public Health, Fundación Oswaldo Cruz, Rio de Janeiro, Brazil, 1994), 135. 45 Roberto del Aguila, Bruno Benavides, Enrique Jacoby, and Joaquin Novara, ‘‘Reconocimiento del Cólera por Personas Sintomáticas después del Brote Epidémico en las UDES Sur y la Sub-región Luciano Castillo-Región Grau,’’ Revista Peruana de Epidemiología 5.1 (1992): 5–9. 46 ‘‘También Tenemos Derecho,’’ 54. 47 R. Gilman, G. S. Marquis, G. Ventura, M. Campos, W. Spira, and F. Diaz, ‘‘Water Cost and Availability: Key Determinants of Family Hygiene in a Peruvian Shantytown,’’ American Journal of Public Health 83.11 (1993): 1554–58.

c h o l e ra i n p e ru 289 48 Interview with Alfredo Myres, Cajamarca, January 16, 1996. 49 Charles L. Briggs, ‘‘Lessons in the Time of Cholera,’’ in Infectious Diseases and Social Inequality in Latin America: From Hemispheric Insecurity to Global Cooperation (Washington, D.C.: Woodrow Wilson International Center for Scholars, 1999), 1–30. 50 ‘‘La Situación del Cólera en las Américas,’’ 13–16. 51 Wendy Marston, ‘‘In Peru’s Shantytowns, Cholera Comes by the Bucket,’’ New York Times, December 8, 1998. 52 Robert Tauxe, Luis Seminario, Roberto Tapia, and Mario Libel, ‘‘The Latin American Epidemics,’’ 321. 53 Ministerio de Salud, Situación Actual de Control de las Enfermedades Diarreicas Incluyendo el Cólera en el Perú (Lima: minsa, 1996); R. E. Begue, G. Castellares, K. E. Hayashi, et al., ‘‘Diarrheal Disease in Peru after the Introduction of Cholera,’’ American Journal of Tropical Medicine and Hygiene 51.5 (1994): 585–89. 54 ‘‘Indicadores de la Situación de Salud: Morbilidad,’’ in Ministerio de Salud, Bases para el Análisis de la Situación de Salud Perú, 1999 (Lima: Oficina General de Epidemiología, 1999). 55 This interpretation is brilliantly presented in an article written by medical doctors and scientists of the Hospital Cayetano Heredia (Lima); see Eduardo Gotuzzo, Javier Cieza, Luis Estremadoyro, and Carlos Seas, ‘‘Cholera, Lessons from the Epidemic in Peru,’’ Infectious Disease Clinics of North America 8.1 (1994): 183–205. 56 Carmen Tocón and Antonio Acosta, Con la Vida a Cuestas. Mujer, Empleo y Condiciones de Vida (Chimbote, Peru: Casa de la Mujer, 1994).

patrick larvie

Nation, Science, and Sex aids and the new brazilian sexuality

or many U.S. media consumers, Brazil recurs as a fantasyland of minimalist beach attire and carnival, o√ering forbidden pleasures and untold dangers to privileged white visitors. Such representations are not new and historically have not been limited to U.S. media products. Colonial-era representations of Brazil reflected Europeans’ fascination with ‘‘savage’’ customs, especially those related to sex. Jesuit depictions of Brazilian colonial society blamed degenerate Portuguese colonists for sowing the seeds of sexual and physical debauchery, seen as especially destructive among a population morally and physically ‘‘weakened’’ by miscegenation.∞ Throughout its history, the territory now known as Brazil has been described as having a persistent and troubled relationship to sex. Brazilians’ allegedly peculiar sexual customs have been attributed to tropical climate, lush vegetation, miscegenation, slavery, and insu≈ciently vigorous state intervention into the private sphere. These representations share a concern not only with Brazilians’ bodies and bodily practices—real or imagined—but also with their significance within systems of social reproduction and governance. In the postcolonial era, representations of a unique and problematic sexual culture have been central to designs for the construction of a modern and distinctly Brazilian civilization in the Tropics. Twentieth-century scientific and political elites channeled concerns about national sexual customs through programs for improving public health and reducing crime; the proposed interventions included elaborate schemes for a eugenic reengineering of the national population, the importation and control of female prostitutes, wide-scale provision of ‘‘family planning’’ services, and, most recently, a response to the aids epidemic that rearticulates relationships between sexuality, disease, and nationality.≤ The measures instituted to combat aids reflect the persistent centrality of sex and disease as sites for modernizing and developing the Brazilian state and nation.

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This essay examines the interaction between two ideological constructs that have been key in twentieth-century Brazil, namely, the concept of Brazilian sexual uniqueness and the imperative for developing a nation-state within a framework of political and scientific modernity. By addressing the links between these two constructs, I wish to draw attention to the importance of sexuality and disease as a symbolic nexus within and against which ideals of nationality are elaborated and revised. The relationships between sexuality and nation building have only recently drawn the attention of U.S. scholars of Latin America and, more specifically, Brazil. Some have focused on the role of women in the formation of key state institutions and ideologies in Latin America.≥ Drawing on the analytic frameworks of lesbian and gay studies, other English-language scholars have begun to examine the status of sexual minorities within Latin American societies, particularly from the perspectives of social history and anthropology.∂ I wish to both draw on and extend these analyses in my examination of aids in Brazil to elucidate the ways that ideas of sexuality, disease, and nation interact with complex hierarchies of development, race, geography, and social class. I will argue that Brazilian e√orts to control the aids epidemic refer both to a historically specific set of representations about disease and sexual customs in Brazil, and to a larger set of presumptions about the status of a ‘‘developing’’ nation with a racially mixed population. I will use Brazil’s response to aids as a lens through which to examine a contemporary political context in which nations, bodies, and sexualities are evaluated against imperatives of political and scientific modernity.

Brazilian Sexual Uniqueness Representations of Brazil as a peculiarly and problematically sexualized place date back to the sixteenth century, to the age of the Portuguese ‘‘discoveries’’ and a European worldview that divided the globe into regions of higher and lower forms of humanity. When Pedro Alvares Cabral first arrived in the early sixteenth century, the colony was christened ‘‘the Land of the Holy Cross.’’ Some years later, the territory was renamed Brazil in reference to a burning ember, or brasa, suggesting an important symbolic shift in the Portuguese worldview toward representations of an inferno or purgatory rather than a terrestrial paradise.∑ Later representations of the Brazilian colony would be marked by a persistent duality contrasting the

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lush vegetation and tropical climate against the alleged barbarity of its inhabitants. For Portuguese colonists, Brazil’s luxuriant landscape and abundant natural resources were suggestive of a biblical paradise, but the presence of ‘‘savages’’ with ‘‘immoral’’ sexual customs were taken as reminders that the territory was indelibly marred by human weakness. The ambiguous moral nature of the Brazilian colony prefigured later scientific constructions of the Brazilian ‘‘race.’’ On the one hand, Brazil and Brazilians had the advantages of a verdant landscape and seemingly limitless natural resources; on the other, the ‘‘savage’’ customs of indigenous peoples were seen as evidence of the imperative of the colonial enterprise. In the nineteenth century, previous constructions of the moral inferiority of non-Europeans were revised through the lens of the natural sciences, and especially the medical sciences. Late-nineteenth-century European scientists suggested climate and race as key factors for explaining the political, economic, and cultural hierarchies that organized the relationships between imperial powers and their colonies. The heat of the Tropics, especially, was theorized as an important factor in producing Brazilians’ supposedly lax morality. The high temperatures were linked to a precocious onset of reproductive maturity and the allegedly exaggerated sexual activity of Brazilians.∏ Through the language of geography and biology, Brazil’s former status as a morally degraded outpost of the Portuguese empire was transformed into a scientific fact about the nature not just of tropical climates, but also of those who lived under those climatic conditions. That is, inferiority was a product not just of inheritance, but also of place. Perhaps the most important scientific ideas about the inferiority of Brazil and Brazilians were those that linked the biological concept of race to the analysis of the political, economic, and cultural status of nations. The science of eugenics, pioneered by Sir Francis Galton in the nineteenth century, mapped political hierarchies of nations onto genetics and early scientific concepts of race. According to many European and Latin American scientists in the late nineteenth and early twentieth centuries, the economic, political, and moral ‘‘inferiority’’ of nonwhites was a by-product of genetics. In this view, nations whose populations included large numbers of nonwhites were relegated to positions of economic and cultural inferiority. Just as important for Brazil, miscegenation was often cited as one of the causes of racial ‘‘degeneration’’; it produced hybrids who did not fully retain the positive qualities of the original racial types and catalyzed their often latent

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negative traits. According to eugenic theories, nations with miscegenated populations would languish at the fringes of world civilization until their governments were willing or able to intervene into the sexual and reproductive habits of their nonwhite subjects. Ideas about the negative e√ects of miscegenation were particularly important for Brazil, which at the end of the nineteenth century had a large population of former slaves, many of whom had become integrated into urban lower and working classes. Until the abolition of slavery in 1888, much of the Brazilian economy was based on slave labor, placing the descendants of European settlers in close contact with a large population of African descent as well as with indigenous populations. The slave-based economy was often cited as a factor in the creation of a social system said to foster the moral and sexual laxity that abolitionists attributed to the Brazilian landowning class. That social system was said to have catalyzed rather than inhibited miscegenation by providing a sexual outlet for white landowners who, according to abolitionists, had lost their ability to control their lust.π An amalgamation of genetics, geography, and tales of moral decline, theories of Brazilian inferiority in the late nineteenth century focused closely on the sexual habits of the nation’s inhabitants and particularly on the potential for exchange between Europeans and nonwhites. Although the science of eugenics was complex and o√ered a relative diversity of positions about the inherent qualities of distinct races and racial hybrids, most nineteenth-century scientists agreed that white Europeans were superior to other racial types, and that the miscegenation that had occurred in much of Latin America posed significant problems to the development of postcolonial nations.∫ Drawing on theories of genetics and demography, these scientific ideas recast political, social, and economic hierarchies as the ‘‘natural’’ products of biological processes. While Brazil shared many features of its racial, social, and economic organization with other postcolonial societies in the Americas, the nation’s problematic relationship to sex was in part attributed to aspects of political and economic life that were specific to the Brazilian context during this period. These factors included the persistence of slave-based agriculture and the emergence of an intellectualized governing elite when the Brazilian monarchy was replaced by a republican regime in 1889. This elite, drawn largely from the urban bourgeoisie, looked to Europe and the United States for the scientific theories on which to found their ‘‘modern’’ approaches to public

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administration. In other words, theories of Brazilian inferiority, including sexual inferiority, were part of a larger context in which new economic and political powers began to emerge in Europe and North America. In the first decades of the twentieth century, political and intellectual elites in Brazil’s republican government elaborated policies intended to alter the nation’s racial composition. Known as a policy of ‘‘whitening,’’ this intervention, based loosely on principles of genetics, imagined that by increasing the number of whites and encouraging interracial marriage, the ‘‘dominant’’ traits of Europeans would eventually eliminate the ‘‘recessive’’ traits of the nation’s nonwhites.Ω This measure embraced miscegenation and, by extension, heterosexual reproduction as the engines of national development, reflecting an important shift in Brazilian intellectual and scientific thought. While accepting the basic premises of European cultural and racial superiority, Brazilian intellectual and political elites were increasingly willing to contest at least some of the conceptual foundations of racist science. In e√ect, this policy suggested that miscegenation might well function as a catalyst for, rather than an impediment to, national development. The influence of biological and medical sciences in the formulation of Brazilian theories and policies related to race and sex deserves particular attention. The work of early-twentieth-century Brazilian physicians specializing in syphilis is especially illustrative of the willingness of local intellectuals to reformulate the racist science prevalent during this period. In the late nineteenth and early twentieth centuries, most European and Brazilian syphilographers—as such specialists were known—believed that syphilis was exceptionally widespread in Brazil, an idea largely supported through claims of a peculiarly Brazilian sexual excess.∞≠ Some syphilographers claimed that as many as half the children born in Rio de Janeiro showed signs of the disease. Others suggested that statistics were unnecessary; anyone who had spent a significant amount of time in Brazil could be considered syphilitic.∞∞ Such formulations, which circulated as scientific assertions in specialized circles, rested on representations of Brazil and Brazilians as both sexually overactive and diseased, ideas taken as unproblematic assumptions in the work of many European and even Brazilian medical scientists. As Brazilian syphilographers gained prestige in international circles, however, their ideas about the relationships between Brazil, sex, and disease changed. While accepting the idea that syphilis was of American origin, some Brazilian syphilographers suggested that it came from the Caribbean and was brought to Brazil by Portuguese colonists.∞≤ Further,

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some Brazilian syphilographers also reformulated ideas about the alleged sexual excesses of the population, identifying the Portuguese as the particularly lustful propagators not just of syphilis, but also of ‘‘perverse’’ sexual practices such as sodomy.∞≥ The theories of Brazilian syphilographers were instrumental in shaping the work of one of the country’s most important twentieth-century social theorists, Gilberto Freyre. Based principally on a historical and cultural analysis of northeastern plantation economies, Freyre’s research on Brazilian society stressed miscegenation as the key to establishing a new civilization in the Tropics. In his view, the bodies of white Europeans were ill adapted to the tropical climate, making miscegenation a necessary step in national development by permitting the transfer of European civilization to a new physical and national body. From this perspective, the hypersexuality of Brazilians, which he attributed to early Portuguese colonists, was an adaptive characteristic rather than a mechanism of ‘‘degeneration.’’∞∂ Moreover, Freyre suggested that the signs that had long been interpreted as evidence of the dysgenic e√ects of miscegenation were in fact the consequences of syphilis, a disease whose spread he linked to the expansion of the Portuguese colony.∞∑ Freyre’s work rejected much of the racist science of his day, whose theories would have relegated Brazil and Brazilians to the margins of world civilization. His anthropological account of the development of Brazilian society also placed a positive value on the sexual ‘‘excess’’ and racial mixture once held to be responsible for the ill health of Brazilians and for the subordinate position of their nation. In so doing, Freyre’s work provided scientific evidence for what would become Brazil’s myth of ‘‘racial democracy,’’ a nationalist ideology meant to transform miscegenation from an explanation of national failure into a symbol of Brazilian pride. While the diversity of medical and anthropological theories developed in Brazil during the first three decades of this century goes beyond the scope of this essay, understanding the positions of Freyre and some of Brazil’s syphilographers is important to understanding the ideologies that link Brazilian sexual uniqueness to ideas of disease and national development. First, these theories reformulated ideas about national singularity while retaining the racial and sexual markings attributed to Brazil since the colonial period. In this respect, these scientific theories innovated rather than revolutionized notions of national identity, altering the values associated with ideas of Brazilian sexual excess and racial mixture. Second, by positing that the e√ects of diseases such as syphilis had been mistaken for the supposedly

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dysgenic e√ects of miscegenation, these theories o√ered the possibility of a technocratic and scientific solution to the problems of national development. Through the police, judicial, and especially the public health institutions that were being consolidated during the early decades of the twentieth century, the medical and anthropological sciences played a critical role in national development, contributing to the discourse and policies of modernization. Physicians and anthropologists repeatedly focused on the nation’s sexual habits and customs as appropriate sites for modernizing interventions, and saw institutions of public health and policing as appropriate positions from which to propose policies. Debates on the ‘‘problems’’ of prostitution and homosexuality, for example, illustrate the importance of sexual politics to both emerging state agencies and evolving nationalist ideologies.∞∏ If Brazilian sexual culture were to be of value in a broader political and social project of modernization, then the public and private spheres would require close attention from scientist-managers. Their function would be to assure that the ‘‘adaptive’’ qualities of Brazilian sexual culture would not be threatened by disease and perversion, believed to be potential by-products of a sexual culture marked by excess and race mixing. The policing of sexual customs primarily targeted the lower and working classes of the country’s urban areas, where commercial sex and subcultures of homosexuality first became visible to health and police authorities. While rejecting the racist ideologies that ‘‘explained’’ the political and economic position of Brazil relative to other countries as a function of genetics, modernist sexual science rea≈rmed the importance of domestic hierarchies based on social class and race. These often subtle shifts in Brazilian scientific thought during the early twentieth century a√ected contemporary constructions of sexuality, disease, and nationality. Early public health interventions to mold Brazilian sexual uniqueness dislocated the problems of miscegenation and Brazilian sexual excess from the racist field of eugenics into the arena of nationalist state formation. Rather than ‘‘explaining’’ why Brazil had ‘‘failed’’ to become a new United States, these ideas informed the policies of state institutions meant to improve public health and police the public sphere. Finally, these interventions occurred during a period that was critical for the development of nationalist discourse, state institutions, and cultural symbols that would unify a national population largely divided by race, social class, and geography. In reconfiguring discourses that were once mobilized as explanations for and evidence of Brazil’s subordination within hierarchies of nations and

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bodies, scientists and government o≈cials also attempted to unify a national body widely imagined to be at risk of fragmentation from those internal di√erences. That these symbolic shifts occurred during a critical period of state formation attests to the power of scientific and especially medical discourses of sexuality and race in the formulation of Brazilian nationality. These representations would be revived and mobilized in a very di√erent context during the period of state reformation that followed the dissolution of Brazil’s military dictatorship (1964–85) and coincided with the appearance of aids as a threat to national health.

Early O≈cial Responses to AIDS When the first confirmed cases of aids were reported in Brazil in the early 1980s, national health authorities refused to acknowledge that the country might be facing a serious threat to public health. In fact, Brazilian public health o≈cials, along with many of the nation’s leading media outlets, seemed to take a perverse delight in the idea that the country was experiencing a health problem identified with wealthy American homosexuals, a sharp contrast to the malaria, yellow fever, and cholera epidemics more typically associated with Third World nations.∞π Early o≈cial responses to aids suggested that it was a problem of jet-setting Brazilian homosexuals, and thus was unworthy of the attention of public health institutions concerned with the control of more ‘‘traditional’’ epidemics prevalent among poorer populations. This notion was confirmed by early Brazilian media accounts of the epidemic, which implied that information on the new syndrome was relevant to the public more for the scandalous ‘‘confessions’’ it exacted from celebrities so diagnosed than because hiv presented a real threat to ‘‘average’’ Brazilians. Media attention to the deaths of Markito, a prominent Brazilian fashion designer, and U.S. celebrities such as Rock Hudson helped to create a public image that located the problem of aids in a distant world of entertainment, sexual perversion, and scandal far from the day-to-day realities of life for most Brazilians. Although the Brazilian Ministry of Health o≈cially created the National Program on aids in May 1985, e√orts at prevention and treatment were largely thwarted by the inconsistent and scant allocation of resources, ineffective management, and a general refusal to work with community-based organizations.∞∫ In the 1985 decree that created the program, the Ministry

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of Health named only two ‘‘risk groups’’ as needing prevention services at all: homosexual and bisexual males. They were to be instructed by health care providers as to the risks of ‘‘promiscuity’’ and encouraged to avoid sex with ‘‘multiple partners’’ or with ‘‘partners not known to them.’’∞Ω The early history of the National Program on aids is one of denial of the real dimensions of the epidemic, which was imagined to be a relatively minor matter whose impact would be limited to the clinical setting. In other words, this early definition of aids as a problem of highly stigmatized sexual minorities also redefined the term public health to exclude homosexuals and bisexuals. Although the Ministry of Health focused its e√orts on teaching clinical care workers how to diagnose aids and handle hiv-infected tissue, the early o≈cial prevention campaigns were su≈cient to create a deep-seated and enduring animosity between government o≈cials and community-based organizations. Television spots encouraging Brazilians to ‘‘avoid promiscuous sex’’ pointed to prostitutes and homosexuals as vectors of transmission while failing to provide useful information about how to avoid infection. Meanwhile, the number of confirmed cases of aids and hiv infection continued to increase at an alarming rate, with the number of cases attributed to contaminated blood products pointing to an epidemiological pattern that was inconsistent with the ministry’s prevention focus on discouraging transgressive sex. The mid-1980s was a moment of severe economic crisis and profound political change in Brazil, both of which seriously a√ected the provision of public health services. The country was su√ering through one of the most di≈cult economic crises of the century, with a recession that resulted in a declining economic output and a resultant loss in tax revenue. Faced with a huge foreign debt accumulated under the military regime, the Brazilian state was unable to maintain previous levels of spending for social programs, including health care, much less increase outlays for problems such as aids. The Brazilian Constitution of 1988 made health care a right for all citizens for the first time in national history. This had important consequences for responses to aids in Brazil. For example, the existing public health infrastructure would be severely tested, required to serve a population far greater than that for which it had been designed. Although the reformulation of the Brazilian health care system was complex, it was generally organized around a version of a single-payer health system known as sus (Sistema Único de Saúde), into which municipal, state, and fed-

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eral funds were channeled. As part of the e√ort toward decentralization, municipal-level councils were to be established to monitor the expenditures and performance of local health care services. Although the intent of this massive reorganization was to put the control of health care services in the hands of local citizens, the system’s design opened the possibility for vast inequalities based on the economic status of local communities and the priority given to specific illnesses. Coupled with the crisis in the availability of funds to cover social programs, the universalization and decentralization of the health care system posed one of the greatest challenges to public health that contemporary Brazil has had to face.

AIDS and the Brazilian Social Body: Civil Society Responds The economic and legal changes to the Brazilian health care system a√ected social and political mobilization around health services generally, and aids specifically. Civil organizations—ranging from neighborhood associations to nongovernmental agencies operating on a national scale—had increased in number, visibility, and political e≈cacy during the final decade of the Brazilian military regime.≤≠ In the period of transition between military and democratic rule (roughly 1985–90), civil organizations played a decisive role in advocating a broad definition of the rights of citizenship, especially as they concerned the health care system. For example, Herbert de Souza from the Rio de Janeiro–based Brazilian Institute for Social and Economic Analysis (ibase) led a nationwide campaign to ban the commercialization of blood products. Explicitly related to the aids epidemic, this successful initiative prefigured later mobilizations around hiv and aids. Community advocates for aids prevention and treatment adopted similar strategies in their campaigns, and de Souza went on to found one of the most important aids organizations in Brazil during the late 1980s and early 1990s, the Riobased Brazilian Interdisciplinary aids Association (abia). In the political context of postdictatorship Brazil, an adequate strategy for preventing hiv infection and treating those with aids came to be seen as a test of citizenship. Since many of the oversight agencies and community councils were not operational at the end of the 1980s, the Constitution functioned largely as a set of intentions rather than as a legal mechanism to guarantee rights. However, the redefinition of citizens’ rights to include access to health care,

300 pa t r i c k l a r v i e ‘‘Men sex men.’’ From a pamphlet produced by the abia and Grupo Pela vida (São Paulo). The Brazilian Ministry of Health’s National Program on aids and stds provided the funds for this printing in February 1995 as part of their support for an initiative that targeted men who did not identify themselves as gay or bisexual, yet sought sexual contact with other men. In a radical departure from previous campaigns, the pamphlet encourages and even celebrates homoerotic culture.

together with the largely homophobic reaction of Brazilian public health authorities during the early years of the epidemic, configured aids as not just a matter of citizenship, but a matter of sexual citizenship. Up until the late 1980s, Brazilian public health o≈cials did not directly engage previous representations of a unique national sexual culture in aids policies. To the contrary, health authorities insisted that the aids epidemic in Brazil would mirror that of First World countries such as the United States. This was an attempt to minimize the importance of aids to the Brazilian population, a homophobic dislocation of duty and blame from public o≈cials to members of already stigmatized groups who were labeled as victims of their own transgressive sex acts. According to o≈cial discourse in the first five years of the epidemic, there was nothing uniquely Brazilian about the epidemic or the principal routes of transmission. Even the En-

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glish term aids (rather than the Portuguese acronym, sida ) was adopted in Brazil, attesting to both private and public insistence that the problem was alien to the country. One of the principal discursive and political strategies of Brazilian aids organizations, which had grown in number from one in 1984 to more than fifty by 1990, was to show that certain features of the epidemic were unique to the country and to its sexual culture. For aids activists, to demonstrate that the epidemic was a Brazilian problem requiring Brazilian solutions was to demand that public o≈cials revise their policies and allocate considerably greater resources to understanding the most appropriate means of preventing and treating aids at the national level. Perhaps most important, aids advocates demanded that they be included in all phases of the elaboration and execution of prevention and treatment policies, both to ameliorate public o≈cials’ lack of expertise and to comply with the Constitution of 1988. Among the first arguments leveled by critics focused on the epidemiological analysis put forth by public health o≈cials, who had contended that as in the United States, hiv transmission in Brazil would be concentrated among homosexual and bisexual males. According to the critical analyses of organizations like abia in Rio de Janeiro, o≈cial reports of the epidemic were unreliable for many reasons, including a faulty epidemiological surveillance system and, especially, the use of transmission models inappropriate for Brazilian sexual culture.≤∞ The division of sexual actors and acts into a trichotomy defined by the ‘‘modern’’ and ‘‘medical’’ terms homosexual, bisexual, and heterosexual was not appropriate for Brazilians, critics argued, because such sexual identities were uncommon among the local population. Critics viewed this classification system as a research flaw that ignored the large number of Brazilian men who were married to women but who nonetheless maintained sexual relations with other men. Such persons were likely to see themselves simply as ‘‘men,’’ not as bisexual, homosexual, or even heterosexual. Critics argued that Brazilians tended to describe their sexual lives in terms of broad social identities such as ‘‘man,’’ ‘‘woman,’’ or even ‘‘normal’’ rather than in terms that linked social identities to specific forms of sexual desire. Further, the number of cases of aids ascribed to blood transfusions pointed to another dynamic in the epidemic that would distinguish Brazil from First World countries, one that drew a relatively direct connection between the precarious health care system and the rate of new infections. Following this rationale, Brazilian aids activists in the late 1980s suggested that the imposition of an epidemiological model

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based on sexual categories developed in the First World illustrated not only the inappropriate response of the nation’s health authorities to the epidemic, but also a misunderstanding of the importance that specificities of Brazil’s sexual culture might have for the management of the epidemic.

AIDS-era Representations of Brazilian Sexual Culture The early arguments from community-based critics were supported by a growing literature on Brazilian sexual culture, much of it written in the light of the aids epidemic. Drawing on analyses from earlier anthropological work on sexuality in Afro-Brazilian religions, a new literature on Brazilian sexuality argued that local sexual cultures presented significant di√erences when compared with those of the United States and Europe, with vast implications for managing the aids epidemic.≤≤ Richard Parker’s theory for a ‘‘Brazilian sexual grammar’’ was perhaps the most influential in terms of its impact on representations of the Brazilian aids epidemic. In broad terms, his work suggests a dual model for understanding sexuality in Brazil, the first associated with Western, First World modernity, the other with ‘‘folk models’’ said to be prevalent among rural and especially lower-class Brazilians.≤≥ Significantly, the divergence between the two models is most apparent in their representations of and the meanings ascribed to sexual acts between persons of the same biological sex, a fact which attests to the centrality of male homosexuality within representations of the Brazilian aids epidemic. The first of these models is organized around concepts of homosexuality, heterosexuality, and bisexuality, terms linked to Western science and modernity that are said to be present in Brazil but limited to an educated urban elite.≤∂ This model follows a literature on sexuality that has pointed to the importance of medical institutions and discourse in the elaboration of social identities for nonheterosexuals in the West since the nineteenth century. As employed in this model, homosexuality provides a basis for understanding sexual acts and desires between persons of the same biological sex and is associated with the homosexual communities of the United States and Western Europe. However, this model is said to be relatively uncommon in Brazil, where such discourse is theorized as having arrived later. The second model, described as a ‘‘folk system,’’ is organized around the gender binary

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masculine/feminine and the sexual binary active/passive. In this model, sexual actors and acts are either masculine or feminine, identities whose origin is in sex acts but which extend to the social sphere. Here, male is ‘‘active,’’ linked to the penetrative role in male-female sex and to the assumption of the social role ‘‘man’’ as defined hierarchically in relation to ‘‘woman.’’ As a corollary, female is ‘‘passive,’’ linked to sexual penetration by a man, which then corresponds to a social role hierarchically inferior to that of men. In this system, men who have sex with each other are not necessarily homosexual. Only the ‘‘passive’’ partner is labeled as gender-deviant, an identity that does not necessarily or perfectly correspond to that referenced by the modern concept of homosexual. In the first model, homosexual men have sex with each other, both the product of and a condition for the formation of communities. In the second, homosexual men have sex not with each other, but with males whose gender identity is unmarked, a fact that precludes the formation of U.S.-style homosexual communities. Like the early criticism of epidemiological models used to describe patterns of hiv transmission, much of the evidence for the predominance of the second model over the first is based on the relative absence of an organized homosexual community in Brazil. Such arguments found resonance among some Brazilian intellectuals, since most aspects of this description of competing models of homosexuality were also present in debates within the Brazilian gay movement, many of which were reproduced in popular and social science media during the early 1980s.≤∑ Although these models are more complex than can be described here, they suggest two points relevant to an analysis of representations of Brazilian sexual culture as seen through the lens of aids. First, Brazilian sexual culture is described as unique in terms of the distance—cultural, economic, and spatial—between Brazil and Western First World nations. The relative absence of scientific discourse on sex is attributed primarily to the country’s economic underdevelopment. However, the prevalence attributed to preexisting folk models is also described as a product of Brazil’s social history, including the ideologies of national sexual di√erence that emerged in the early twentieth century. Second, measured principally in terms of the presence or absence of homosexual identities and communities, this concept of cultural distance rhetorically allies the notion of ‘‘modern’’ with the First World and the West, while Brazil is coupled with premodern ‘‘folk models’’ developed prior to or in the absence of scientific discourse on sexuality. In

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essence, Brazilian sexual culture is represented as di√erent from that of other nations principally because of its alleged distance from Western culture and modern science, in which the homosexual figures as a key sign.≤∏ These anthropological constructions of a unique Brazilian sexual culture were part of a boom of writing and research on sexuality in Brazil during the 1990s. Books and scientific papers were published on Brazilian sexuality in numbers never before seen, focusing chiefly on populations seen as being ‘‘at risk’’ for hiv and aids, such as homosexual and bisexual males, women, ‘‘street children,’’ sex workers, intravenous drug users, and school-aged adolescents.≤π Although there is considerable variation within this literature on the specifics of Brazilian sexual culture, the authors generally shared the belief that scientific descriptions of such di√erence must inform local responses to the epidemic. Moreover, this scientific work is frequently linked to social mobilizations around hiv and aids, causes with which many authors identified as activists, project administrators, or, less frequently, community representatives. This literature linked a national sexual culture to an activist project for public health, one that would provide leverage for the inclusion of community-based organizations in the formulation of aids policy.

AIDS and the New Brazilian Sexuality These specialized scientific representations provided a rallying point for social and political mobilization around aids in Brazil precisely because the production of specialized knowledge about the epidemic in Brazil was so closely linked, both socially and theoretically, to activism. At times, the lines between activism and science were blurred, with authors taking on dual roles as producers of scientific knowledge and as actors within a contested field of policy making and resource allocation. For example, in a 1994 seminar on the links between homosexuality and aids held at a university in Rio de Janeiro, the president of an organization of mostly gay men from the state of Amazonas in northern Brazil wrote not just of national but also of regional di√erences in sexual culture: Some Amazonian characteristics tend to influence sexual behavior and the precocious sexual initiation of the state’s population. The majority of the population is [composed of] descendants from Indians and mestizos. By

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tradition, they use little clothing, whether by custom or because of the high local temperatures, [making] people sexier and more inclined to sexual practices. . . . With respect to [homosexual men], one of their principal characteristics, which di√erentiates them from [those in the rest of the country], is that they tend to be passive in sexual relationships, diminishing the number of relations within this group and increasing the search for partners in other groups, principally among heterosexuals. . . . Given these characteristics, sexual practices are normal from a very early age, and given that the majority of the population is ignorant of [safe sex], hiv is easily disseminated within the population.≤∫

While the author of this text presented his ideas as a representative of a gay organization and not as a social scientist, his mastery of certain elements of early- and late-twentieth-century constructions of Brazilian sexual culture is revealing. As in previous representations of Brazilian sexual uniqueness, race, climate, and geography are mobilized as factors said to influence the early onset of sexual activity, an inclination to unusually frequent sexual activity and a threat to public health. More recent representations of a Brazilian sexual culture in which homosexual men have sex only with heterosexual men are applied to a state in the Amazon region in a rhetorical move similar to that which defines Brazil’s sexual di√erence in terms of isolation from Western modernity. This description is of a unique and problematic sexual culture that requires specialized social science knowledge and activist intervention to adequately confront a public health problem. As with other aids-era representations of Brazilian sexual uniqueness, exotification based on race, climate, and geography functions as a device to leverage access to processes of political power brokerage. It is interesting that the figure of the homosexual, as configured in aidsera representations of Brazilian sexual culture, is rhetorically aligned with Western modernity and economic development. As in the depiction of homosexuality in the Amazon, same-sex relations occurring outside the frame of modern homosexuality were often linked not just with ‘‘folk models’’ of sexuality, but also with isolation, ignorance, prejudice, and an exacerbation of the problems related to aids prevention in Brazil. In other words, the specifics of Brazil’s sexual culture were often linked to disease. This discursive strategy was available for a di√erent kind of interpretation of Brazilian sexual uniqueness, one that configured certain specificities of local sexual culture—such as the absence of communities defined by modern concepts of sexuality—as problems in and of themselves.≤Ω The links be-

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tween Brazilian sexual culture and underdevelopment allowed representations of local sexual customs to function in a slightly ironic fashion. While specialized knowledge of national sexual di√erence helped community organizations gain access to spheres of political decision making and resource allocation, an interpretive frame that linked modernity to progress might just as easily identify the specificities of Brazilian sexual culture as impediments to national development. Following this rationale, one possible solution to the di≈culties of preventing aids among, say, homosexuals in the Amazon might be the creation of modern sexual identities and communities to replace the existing sexual culture, which is closely associated with ignorance and disease. In this sense, the same community leaders or social scientists who claimed to have expertise on a local sexual culture in which ‘‘modern’’ sexual identities were said to be absent might be included in the process of policy formation on the condition that they participate in a larger project to ‘‘modernize’’ a national sexual culture linked to disease.

Managing Sexual Cultures: Brazil’s National Program on AIDS In 1994, the National Program on aids was reorganized under the terms of a World Bank financing agreement that was in part leveraged by pressure from local aids activist groups. This massive restructuring of the National Program on Sexually Transmissible Diseases and aids increased the financial and technical resources available for prevention and treatment. It is important that the loan agreement was also conditioned on the inclusion of community-based organizations in the formulation and execution of aids prevention and treatment policy.≥≠ In part, this was because the bank obliged Brazil to adopt World Health Organization standards for the development of its national program, which required the involvement of community-based organizations for reasons of e≈cacy as well as administrative e≈ciency. But this link was also related to the bank’s assessment of the nature of risk for hiv and sexually transmissible diseases (stds) in Brazil, which was predicated at least in part on notions of a unique national sexual culture: ‘‘Every major behavioral risk factor for aids transmission exists in Brazil. Recent work indicates that sexual practices in Brazil are characterized by infrequent use of condoms and high incidence of stds. Among homosexual and bisexual men, a large number of partners and frequent sexual activity further exacerbate risks. . . . High frequency of bisexuality and

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‘‘Do this one now.’’ Circulated in magazines appealing to middleclass readers, this aids awareness ad highlights its appeal to two of the audiences deemed most at risk by Brazilian health authorities: men who have sex with men, and women of reproductive age. Rather than encouraging heightened self-control and abstinence as a means of promoting health, this campaign encouraged viewers to learn more about safe sex and get an anonymous test for hiv.

frequent contact with commercial sex workers, both male and female, combine to place a large proportion of the Brazilian population at risk.’’≥∞ Here, risk in Brazil is presented as exacerbated not only by the frequency of contact with sex workers, low rates of condom usage, and high background rates of stds, but also by an allegedly high prevalence of homosexuality, bisexuality, and commercial sex. Although the bank’s report focuses little attention on the nation’s sexual culture, the construction of risk that informs the largely economic analysis of the proposed loan agreement hinges on the idea, cited here, that a large number of Brazilians are at risk for hiv infection. This concept of national risk is attributed to a new configuration of Brazilian sexual ‘‘excess,’’ one that is defined through aids-era notions of ‘‘risk groups’’ such as homosexuals, bisexuals, and sex workers.

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Further, the risk is compounded by what the report qualifies as a relatively undeveloped community infrastructure for high-risk groups as homosexuals. Citing the homosexual community of San Francisco, the report argues that interventions meant to contain hiv can be e√ective as long as local communities have good infrastructure and access to information. As this is not the case among homosexuals or many other of the ‘‘at-risk groups’’ in Brazil, the bank report suggests investment in community-based interventions as a means to improve the program’s e≈cacy.≥≤ In essence, the report expands on one of the possible interpretations of the aids-era literature on Brazilian sexual uniqueness to suggest that building communities among populations at risk for hiv infection might be one way to prevent the continued expansion of the epidemic. Here, the absence of ‘‘communities,’’ including homosexual communities, is seen as not just a particularity of local social organization, but as a problem of public health. Of the many changes to aids policies in Brazil over the years following the World Bank agreement, perhaps one of the most significant is the extent to which community organizations became involved in carrying out prevention initiatives. Organizations of homosexuals, sex workers, and transvestites, and other community-based agencies were represented on national, state, and local aids councils. Nongovernmental organizations working with aids increased in number from just one in 1984 to more than five hundred in 1994, but they also increased in the specificity of the communities they served and represented. More specifically, the changes in national aids policy were paralleled by an increase in the number of organizations specifically representing homosexuals and transvestites, which numbered fewer than ten in 1988 and more than sixty by 1994.≥≥ Intervention initiatives that encouraged the development of community, self-esteem, and culturally specific forms of aids prevention were developed and implemented by nongovernmental organizations for women, lesbians, truck drivers, adolescents, transvestites, sex workers, and indigenous populations.≥∂ Although these interventions varied widely in terms of technique, they shared a common emphasis on the modern idea of sexuality as key to the success of prevention initiatives. Through a dual focus on the centrality of community in the formulation and delivery of services and on sexuality as a key concept to reducing risk for sexually transmissible infections, these interventions can be seen as comprising a development initiative whose significance goes beyond the aids epidemic. O≈cial communications from the National Program on aids confirmed

a i d s a n d t h e n e w b ra z i l i a n s e x u a l i t y 309 ‘‘The std and aids Comic Book,’’ a booklet meant to appeal to working-class women, featured stories involving questions about fidelity, sexual and reproductive health, and the e√ects of gossip. Although morally questionable in its implicit support for nonmarital sex, the condom, as seen on the cover, is ultimately represented as the defender of female and family health.

the relatively broader aims of aids policies, which were linked to struggles for modernity in terms of civil rights, public attitudes, and the reform of public administration. The director of the program in 1994, Lair Guerra de Macedo Rodrigues, addressed the opening of the Fourth National Congress of Transvestites and Liberated Persons (astral) by saying: ‘‘Our society is one that can no longer live with the fears and taboos which certainly only serve to impede our objectives, which are life, the attainment of better days, and the dignity of being able to work knowing that our obligations are fulfilled and our rights guaranteed.’’≥∑ She went on to commend the organization of transvestites for their prevention work, which she cited an example of civic virtue for all Brazilians to follow. Although Rodrigues did not say so in her speech, the work of groups like astral figures as evidence that the kind of development imagined in the

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1993 World Bank technical report is not only possible but highly desirable for groups, including homosexuals and transvestites, lacking access to political processes related to the development of public health policies and the allocation of resources. Her words located the objectives of the national program and astral —one of the nongovernmental organizations that received funds from the program to carry out prevention initiatives— squarely within a broad program of national development. Stressing the elimination of taboos and the attainment of the rights of citizenship as its goals, the national program should be understood not just as a public health initiative, but as part of a history of social and political mobilization around the idea of Brazilian sexual uniqueness. Taken as a whole, the program’s policies and programs focus not just on containing the spread of hiv, but are also meant to modernize those aspects of Brazilian sexual culture that were once represented as linked to ignorance, economic underdevelopment, and the absence of modernity. While the social history of aids in Brazil is of a complexity that goes beyond the scope of this essay, the aspects of the epidemic that I have highlighted here illustrate the power of representations of a national sexual uniqueness to mobilize society and change state policies. Images of Brazil as economically underdeveloped resonated with aids-era constructions of Brazilian sexual culture to formulate a national program, financed through a multilateral development agency, whose explicit objective was to reduce the impact of a serious national health crisis, but whose implicit intent was also to alter local sexual habits and the forms of social organization with which they were associated. As in the early twentieth century, aids-era representations of sexuality in Brazil relied on implicit or explicit hierarchies of nations, bodies, and even diseases based on geography, race, and economic development. The role of these representations in the mobilization of civil society organizations, government agencies, and, to a lesser extent, international development agencies attests to the importance of sexuality as a symbolic nexus through which ideas of Brazilian nationality continue to be constructed.

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Notes 1 Paulo Prado, Retrato do Brasil (Rio de Janeiro: F. Briguiet, 1931); João Silvério Trevisan, Perverts in Paradise (London: gmp, 1986), chap. 1; Laura de Mello e Souza, O Diablo e a Terra de Santa Cruz (São Paulo: Companhia das Letras, 1984 [1986]), chap. 1. 2 Sérgio Carrara, ‘‘The Symbolic Geopolitics of Syphilis,’’ Curare, Special Issue on the Medical Anthropologies of Brazil (1997); and Patrick Larvie, ‘‘Queerness and the Specter of Brazilian National Ruin,’’ GLQ: A Journal of Lesbian and Gay Studies 5.4 (1999): 3. 3 For example, see Donna Guy, Sex and Danger in Buenos Aires: Prostitution, Family, and Nation in Argentina (Lincoln: University of Nebraska Press, 1999); and Sueann Caulfield, ‘‘The Birth of Mangue: Race, Nation and the Politics of Prostitution in Rio de Janeiro 1850–1942,’’ in Daniel Balderston and Donna Guy, eds., Sex and Sexuality in Latin America (New York: New York University Press, 1997), 86–100. 4 James Green, ‘‘The Emergence of the Brazilian Gay Liberation Movement: 1977–1981,’’ Latin American Perspectives 21.1 (1994): 38–55; Jared Braiterman, ‘‘Sexual Science: Whose Cultural Di√erence?’’ Sexualities 1.3 (1998): 313–25; and Peter Beattie, ‘‘Conflicting Penile Codes: Modern Masculinity and the Brazilian Military 1860–1916,’’ in Daniel Balderston and Donna Guy, eds., Sex and Sexuality in Latin America, 65–85. 5 Laura de Mello e Souza, O Diablo e a Terra, chap. 1. 6 Sérgio Carrara, ‘‘The Symbolic Geopolitics,’’ 90. 7 See Gilberto Freyre, The Masters and the Slaves: A Study in the Development of Brazilian Civilization (Berkeley: University of California Press, 1986), chaps. 4 and 5. 8 For an analysis of eugenics in Latin America, see Nancy L. Stepan, The Hour of Eugenics: Race, Gender and Nation in Latin America (Ithaca: Cornell University Press, 1991). 9 Thomas E. Skidmore, Black into White: Race and Nationality in Brazilian Thought (New York: Oxford University Press, 1974); and Nancy Stepan, The Hour of Eugenics. 10 See Sérgio Carrara, Tributo a Vênus: A Luta Contra a Sífilis no Brasil. Da Passegem do Século aos Anos 40 (Rio de Janeiro: Editora Fiocruz, 1996), chaps. 2 and 3. 11 Ibid., 111–27. 12 Sérgio Carrara, ‘‘The Symbolic Geopolitics.’’ 13 Sérgio Carrara, Tributo a Vênus, 101–7.

312 pa t r i c k l a r v i e 14 Gilberto Freyre, The Masters and the Slaves, chaps. 4 and 5. 15 See Sérgio Carrara, ‘‘The Symbolic Geopolitics,’’ for an analysis of the links between Brazilian syphilography and the work of Gilberto Freyre. 16 For an analysis of early-twentieth-century debates on prostitution, see Lena Menezes de Medeiros, Estrangeiros e o Comércio do Prazer nas Ruas do Rio de Janeiro (1890–1930) (Rio de Janeiro: Arquivo Nacional–Ministério da Justiça, 1992). For an analysis of debates and policies related to homosexuality, see Jared Braiterman, ‘‘Sexual Science’’; Peter Beattie, ‘‘Conflicting Penile Codes’’; James Green, ‘‘The Emergence of the Brazilian Gay’’; and Peter Fry, ‘‘Febrônio Índio do Brasil: Onde Cruzam a Psiquiatria, a Profecia, a Homosexualidade e a Lei,’’ in Eulálio Alexandre, ed., Caminhos Cruzados: Linguagem, Antropologia e Ciências Naturais (São Paulo: Editora Brasiliense, 1982), 65–80. 17 See Claudia Moraes and Sérgio Carrara, ‘‘AIDS: Um Vírus Só Não Faz Uma Epidemia,’’ Comunicações do ISER 17 (1985): 5–19; Claudia Moraes and Sérgio Carrara, ‘‘Um Mal de Folhetim,’’ Comunicações do ISER 17 (1985): 20–31; and Paula Treichler, ‘‘AIDS and HIV Infection in the Third World: A First World Chronicle,’’ in Barbara Kruger and Phil Mariani, eds., Remaking History (Seattle: Bay Press, 1989), 31–86. 18 I refer here to the Ministry of Health’s Portaria 236 (May 2, 1985). The national program was reorganized several times between 1985 and 1993. The details of this history can be found in Miriam Ventura da Silva, ed., Legislação sobre DST & AIDS no Brasil (Brasilia: Ministério da Saúde, sascg / pn-dst / aids, 1995). 19 Brazilian Ministry of Health, Portaria 236 (May 6, 1985), section 2, paragraphs 1.4, 3, and 3.1 20 For an account of the role of nongovernmental organizations in the process of democratization in Brazil, see Rubem Fernandes and Leandro Carneiro, ‘‘Brazilian NGOs in the 1990s: A Survey,’’ in Rubem Fernandes and Leandro Carneiro, eds., New Paths to Democratic Development in Latin America: The Rise of NGO-Municipal Collaboration (Boulder: Lynne Rienner, 1995), 71– 84; and Leilah Landim, ‘‘A Serviço da Comunidade,’’ Cadernos do ISER 20 (1988). 21 See Herbert Daniel, ‘‘We Are All People Living with AIDS: Myths and Realities of AIDS in Brazil,’’ International Journal of Health Services 22 (1991): 531–51. 22 Peter Fry, ‘‘Male Homosexuality and Spirit Possession in Brazil,’’ Journal of Homosexuality 11 (1985): 137–53. 23 Richard Parker, Bodies Pleasures and Passions (Boston: Beacon Press, 1991), chaps. 2 and 3. 24 See Richard Parker, ‘‘Sexual Diversity, Cultural Analysis, and AIDS Educa-

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25 26 27

28

29 30

31 32 33 34 35

tion in Brazil,’’ in Gilbert Herd and Shirley Lindenbaum, eds., The Time of AIDS: Social Analysis, Theory and Method (Newbury Park: Sage Press, 1992), 225–42. Patrick Larvie, ‘‘Queerness and the Specter’’; see also Edward MacRae, A Construção da Igualdade (Campinas, Brazil: Editora da Unicamp, 1990). For an analysis of recent work on Brazilian and Latin American sexual ‘‘difference,’’ see Jared Braiterman, ‘‘Sexual Science.’’ For example, see Vera Paiva, Em Tempos de AIDS (São Paulo: Simmus, 1992); Richard Parker, Cristiana Bastos, Jane Galvão, and José S. Pedrosa, eds., A AIDS no Brasil (Rio de Janeiro: Associação Brasileira Interdisciplinar de AIDS, Instituto de Medicina Social da Universidade do Estado do Rio de Janeiro e Editora Relume Dumará, 1994); and Maria A. Loyola, AIDS e Sexualidade: O Ponto de Vista das Ciências Humanas (Rio de Janeiro: Relume Dumará, 1994). Adamor Gudes, ‘‘Políticas de Prevenção à AIDS: A Realidade na Amazonia’’ (presentation given at the Instituto de Medicina Social, Universidade do Rio de Janeiro, December 1994), 6; translation is mine. See Patrick Larvie, ‘‘Queerness and the Specter.’’ The International Bank for Reconstruction and Development/The World Bank and the Government of the Federative Republic of Brazil, Acordo de Empréstimo (Projeto de Controle de AIDS e das DST), March 16, 1995, loan number 3659 BR. The World Bank, Sta√ Appraisal Report: Brazil, AIDS & STD Control Project, October 8, 1993, report no. 1734-br, p. 3. Ibid., annex D: 69. Patrick Larvie, ‘‘Queerness and the Specter.’’ Brazilian Ministry of Health, National Program on STDs and AIDS, Catálogo e Organizações Não-governamentais (Brasilia: np-dst / aids, 1995). Speech given by Lair Guerra de Macedo Rodrigues, director of the National Program on STDs and AIDS, at the opening ceremony of the Fourth Annual Congress of the Associação de Travestis e Liberados, June 26, 1996, Rio de Janeiro; translation is mine.

Contributors

diego armus teaches Latin America history at Swarthmore College. Among his publications are Mundo Urbano y Cultura Popular: Estudios de Historia Social Argentina and Entre el Curandero y el Médico: Cultura, Historia y Enfermedad en América Latina. He is currently working on a book entitled The Years of Tuberculosis: Disease, Culture, and Society in Buenos Aires, 1870–1950. anne-emanuelle birn teaches history of public health and health policy in Latin America at the New School University. Her research has appeared in Social Science and Medicine, the American Journal of Public Health, the International Journal of Health Services, the Journal of the History of Medicine and Allied Sciences, and the Journal of Public Health Policy. katherine elaine bliss teaches Latin American history at the University of Massachusetts, Amherst. She is the author of Compromised Positions: Prostitution, Public Health and Gender Politics in Revolutionary Mexico City and articles published in the Hispanic American Historical Review, the Journal of Family History, and the Latin American Research Review. ann s. blum teaches Latin American studies at the University of Massachusetts, Boston. Her research, published in The Americas and the Journal of Family History, focuses on intersections of family and state formations in modern Mexico through institutional regulation of child welfare, child labor, and maternal-child health. marilia coutinho is Coordinator of Science and Technology Policy at the Center for Higher Education Research at the University of São Paulo (Brazil). Her work is on public policy, concentrating on science and technology and on ecology and tropical medicine. On the topic of Chagas’ disease she has published in Perspectives on Science and Social Studies of Science. marcos cueto teaches history of public health at the Universidad Peruana Cayetano Heredia in Lima. Among his publications are Missionaries of Science: The Rockefeller Foundation and Latin America; Salud, Sociedad y Cultura en América Latina: Nuevas Perspectivas Históricas; Return of Epidemics: Health and Society in Peru during the Twentieth Century.

316 c o n t r i b u t o r s patrick larvie is the former director of the Institute for the Study of Religion in Rio de Janeiro. He studies Brazilian aids prevention policies, new ideals of sexual citizenship in Brazil, and political mobilization among Brazilian sexual minorities. His work has appeared in Curare and GLQ: A Journal of Lesbian and Gay Studies. gabriela nouzeilles teaches in the Department of Romance Studies at Duke University. She is the author of Ficciones Somáticas: Naturalismo, Nacionalismo y Políticas del Cuerpo, and the coeditor of The Argentine Reader: History, Culture and Politics and Culturas de la Naturaleza: Cuerpo, Paisaje y Sexualidad. diana obregón teaches at the Universidad Nacional de Colombia. She is the author of Sociedades Científicas en Colombia: La Invención de una Tradición 1859–1936; and Batallas contra la Lepra: Estado, Medicina y Ciencia en Colombia. Her work on the history of medicine and health in Latin America has appeared in Social History of Medicine, Asclepio, and Science, Technology and Society. nancy leys stepan teaches Latin American history and the history of science at Columbia University. Her publications include Beginnings of Brazilian Science: Oswaldo Cruz, Medical Research and Policy, 1890–1920; The Hour of Eugenics: Race, Gender and Nation in Latin America; and Picturing Tropical Nature. ann zulawski teaches history and Latin American studies at Smith College. She is the author of ‘‘They Eat from Their Labor’’: Work and Social Change in Colonial Bolivia, and her work on the social history of medicine in Bolivia between 1900 and 1950 has appeared in Latin American Research Review.

Index

Acquired Immune Deficiency Syndrome. See aids Agua de Dios, 136, 138, 140, 148–50 aids, 12, 290–310; and civil organizations, 299–301, 308–10; epidemic (Brazil), 290–310; government responses to, 297–99, 306– 10; and homophobia, 297–98, 300; and homosexuality, 297–98, 300– 310; and media, 297; National Program on aids, (Brazil), 298, 306, 308; and politics, 298–99; and poverty, 16; prevention of, 305–9; public education about, 300, 307, 309; and ‘‘risk groups,’’ 297–98, 304, 307– 8; and sexuality, 290–91, 297–98, 300–310; and stigmas, 300–301. See also Brazil; Sexual hygiene; Sexually transmitted diseases Alcoholism: and mental illness, 251, 257–59 Amazon, 24–50, 27 American trypanosomiasis, 81, 83 Andean biology, 92 Anopheles, 27, 31, 34, 36, 38, 39, 44–45; Anopheles gambiae, 43 Anti-Chinese sentiment, 142–43 Argentina, 137; and leprosy, 137–38, 143; physicians, 84. See also Buenos Aires Argentinization, 104 Argentine Society for Northern Regional Pathology, 84

Bacillus, 101 Bacteriology, 101 Balbastro, Dr. Arturo, 57 Bambuí, 84 Barrio, 103–6, 108–9, 111, 114, 120– 23, 125 Barrón, Roman, 183–84, 185, 186, 202 Bertillion classification system, 158, 178 Bismuth: treatment of syphilis with, 244, 251 Blood-sucking insect, 76; Reduviid insect, 76; Chagas’s interest in, 80; Panstrongylus megistus, 83; Triatomas infestans, 83. See also Trypanosoma cruzi Bolivia: and mental health, 237–67; and citizenship, 262 Brazil, 12–13, 25–45, 76–100, 137, 142, 290–310; and aids, 291, 297– 313; aids organizations within, 299–301, 308–10; and Caxambu meetings, 88; and Carlos Chagas, 79–80; and Chagas’ disease, 76–93; and eugenics, 290–96; and hygiene, 81–82, 90–91, 139; and leprosy, 137, 142; and malaria, 25–45; and military regime, 298–99; and Ministry of Health, 297–98; and modernity, 90–92; and nation-building, 295– 97, 310; and public health, 26, 90– 91; politics of, 42–43, 90–91, 297; and racial mixing, 291–97; and rubber industry, 25–27, 29–30, 37, 39–

318 i n d e x Brazil (cont.) 41, 43–44; and sexual uniqueness, 291–96, 300–306, 310; and slavery, 293; and tropical disease, 76–100; and University of São Paulo, 86–87; and World Bank, 306, 308, 309. See also aids; Chagas’ disease; Malaria; Rubber Brazilian Biochemical Society, 87 Buenos Aires, 12, 51–70, 101–25, 132; culture of, 102–10; demographics, 104; history of, 103–6, 112, 123, 125; and hysteria, 51–70; leisure time, 112; and modernization, 56, 59; and nationalism, 57, 58; population of, 103; and politics, 60; public health in, 51, 52; social divisions of, 104, 123; social mobility in, 105–6, 123–25; and tango, 112–25; and tuberculosis, 101–25; women of, 52– 70, 123–25. See also Hysteria; Tango Bunge, Carlos Octavio, 102–3 Cabaret, 105, 112, 114, 115, 118–19 Camille, 102, 119 Cancer, 14 Caño de Loro, 132, 139. See also Lazarettos Cárdenas, Lázaro, 183, 186, 200, 202, 227–28, 230 Cardiazol, 237, 244 Cardiology, 86 Carrasquilla, Juan de Dios, 140, 141, 143 Carriego, Evaristo, 103, 105–9, 111, 122 Carvajal, Lavalle, 183, 188–89, 197, 202 Castillo, Juan Gonzalez, 119 Castrillón, Teodoro, 145 Catholic Church: political influence of, 219; and sexuality, 197

Catholicism, 221 Chaco War, 240 Chagas, Carlos, 29–30, 34–36, 77, 79– 81, 90, 147; agenda of, 90; death of, 83; and malaria research, 80; opposition to, 82–83; recognition of, 81 Chagas’ disease, 29, 76–93; and Brazil, 76–93; discovery of, 80–83; e√ect on policy, 77; fear of, 76; history of, 92; and politics, 87; and poverty, 76, 87; research on, 87–88; social determinants of, 76; Southern Cone Initiative, 89; spread of, 83; symptoms of, 76, 81, 84, 85; transmission of, 76 Chagasic cardiopathy research, 86 Chagologists, 77, 86, 89; and politics, 87 Child welfare programs: in Bolivia, 246–47, 261; and clinics, 209, 213, 221–22; foster homes and adoption, 226, 228–33; foundling homes, 210– 32; in Mexico, 209, 213, 221–24, 226, 228–33, 210–32; and nationalism, 227; reform of, 228–29; Servicio de higiene infantil (Mexico), 221–23, 224 Chloroquine, 45 Chlorosis, 109 Cholera: causes of, 268, 270–72, 279; and economy, 278; epidemic (Peru), 268–89; and fear, 278–79; and hospitals, 273–74; and Ministry of Health (Peru), 273, 276, 277, 280–81; and mortality, 269, 284; number of cases, 268–69; nonscientific explanations for, 279–80; and political climate, 271–72, 283–84; and poverty, 280–81; and preventative measures, 269, 272, 276–77; and stigma, 279–80, 283; treatment of, 272–76, 282–83, 284 Climate: and race, 292; and sexuality,

index 290, 292, 295, 304–5. See also Tropical disease Colombia: economics of, 133–34; and leprosy, 130–51; and loss of Panama, 130, 134, 140; modernization of, 133; national image, 130, 142–43, 144, 147; politics of, 133–39, 142; and public health, 130, 133–39; and racism, 130, 142–43 Colonialism, 292 Committee for the Defense of Rubber (Brazil), 29 Consumptive, 106–7, 108, 111, 118, 124 Contratación, 132, 139, 148. See also Lazarettos Costurerita, 103, 105–7, 111, 112, 125 Coventillos, 104 Crime: in Colombia, 130, 131, 143; and leprosy, 130–31, 143; research on, 130–31; and technologies of punishment, 131 Cruz, Oswaldo, 28–30, 36, 38, 40, 79– 80, 82–83, 137 Cuba, 31, 137, 142; and leprosy, 137, 142; sanitary department of, 142 Culion leper colony, 143 Da Cunha, Euclides, 27 Darwinian evolution, 218 ddt, 85 Departamento de Salubridad Pública (dsp). See Mexican Department of Public Health Dias, Emmanuel, 84–85 Dirección General de Lazaretos, 139. See also Lazarettos Disciplinary ventriloquism, 72 Dumas, Alexandre, 102, 119 Electroconvulsive therapy (ect), 237, 244, 260

319

Epidemics, 6–7; cholera (Peru), 268– 89; aids (Brazil), 290–313 Epilepsy, 242, 245, 248, 252, 258–59 Epistemology, 61, 78 Esthesiograms, 61 Etiology, 65 Eugenics: in Bolivia, 241, 247–48, 261; in Brazil, 291–97; and Lamarckian heredity, 237, 247–48; and nationalism, 296–97; and miscegenation, 291–96 Europe, 27, 31–32, 36 Europeanization, 142, 144 Falciparum malaria, 45 Fernández, Emilio, 246–49, 253, 254, 261 Ferreyra, José Agustín, 114–15, 122, 124 Fingerit, Julio, 110, 124, 125 Fontilles leprosarium, 143 Foucauldian interpretation, 5, 11, 13–14 Foundling homes (Mexico): Casa de Cuna, 210–32; facilities of, 224–26, 209–32; infant mortality in, 215–18; overcrowding in, 224; and poverty, 210–11, 215–17; public criticism of, 229 Franciscans, 143 French Indochina, 142 Freudian thought, 237, 246, 248, 261. See also Psychoanalysis Freyre, Gilberto, 295 Gaceta Médica de México, 183, 188 Gamma-bhc, 85 Garcia, Evaristo, 145 Gastélum, Bernardo, 184–85, 188, 194, 197 Gender: and mental health care, 239, 249–50, 257; and tango, 120–23. See also Men; Sexuality; Women

320 i n d e x Gómez Santos, Federico, 210–15, 219, 225–28, 231–32 Gonzalez, Enrique, 118, 122 Guerreiro and Machado diagnostic technique, 84 Gutiérrez, Antonio, 148, 150 Hansen’s bacillus, 140 Hawaii, 143, 145 History of medicine, 3–4; sociocultural, 5; Foucauldian interpretation of, 5, 11, 13, 14 Holmberg, Eduardo, 62, 63 Hookworm, 159–82; and age, 171; campaigns against, 158–78; causes of, 160, 171, 175; and development, 159, 161; and gender, 171; and imperialism, 159–61, 171–73, 177–78; and International Health Board, 159, 161–63, 165–75, 177; and Mexican Revolution, 159–60, 173, 176– 78; and Mexico, 158–78; and poverty, 175, 176; prevention of, 161, 165–68; and public health publicity, 163–65; and Rockefeller Foundation, 159–78; symptoms of, 160, 163; treatment of, 161, 163, 165, 168–70, 172, 175; and Warren, Andrew, 165–70, 174–76 Hospitalism: and foundling homes, 209–32; and infant mortality, 212, 215–16; moral causes of, 215–18; physical causes of, 214–15, 218–19, 225; and poverty, 209, 210, 213–18; and psychology, 214–15, 225, 228; symptoms of, 211–12, 226; treatment of, 212, 214–15, 226–27 Hospitals: mental health, 237–62; in Peru, 273–74, 175–76. See also Hospitalism; Foundling homes (Mexico); Manicomio Nacional Pacheco (Bolivia)

Hygiene, 133, 135, 141; in Brazil, 81– 82, 90–91, 139; Dirección Nacional de Higiene (Brazil), 139; and hysteria, 52, 59, 66, 109; ideology of, 13; Junta Central de Higiene (Brazil), 135, 136. See also Sanitation; Sexual hygiene Hypnosis, 69, 70, 71 Hysteria, 52–70, 109; in Buenos Aires, 51–70; case studies, 63, 66–69; descriptions of, 62, 65–66, 67; and modernity, 51, 52, 56, 59; and politics, 60; role of physicians in, 53, 68, 69– 70, 71; symptoms of, 52, 60, 62, 69; treatment of, 60, 64, 67–68, 69–70, 71; and women, 52–70 Hysterical semiosis. See Hysteria Imperialism, 77, 158–60; and nosology, 159, 177–78; and Rockefeller Foundation, 159–78. See also Mexico Indians: and mental illness, 237–39, 243, 254, 255–57, 261–62; social movements of, 240 Indonesia, 36 Infant mortality: attempts to reduce, 212–13, 216; and foundling homes, 215–18; and hospitalism, 209, 211– 12, 215, 216; in Mexico City, 212– 13, 216; and mothers, 210, 217, 220, 223, 232 Ingenieros, José, 61, 70, 71, 109 Insect vector theory, 78 Instituto Oswaldo Cruz. See Oswaldo Cruz Institute Instituto Soroterápico de Manguinhos: See Manguinhos Integrated Program for Endemic Diseases (pide), 88 International Congress on Chagas’ Disease, 87 International Health Board (ihb):

index and hookworm 161, 162–63, 167, 168–75, 177; and Mexico, 161, 162– 63, 167, 168–75, 177; and sovereignty, 171–73 International Health Commission. See International Health Board International Health Division. See International Health Board International Leprosy Congress, 132, 141 Italy, 31, 32 Koch bacillus, 101 Kraus, Rudolph, 82 La costurerita que dió aquel mal paso, 103, 107 Lamarckian inheritance theory. See Eugenics Lara y Pardo, Luis, 191 Latin American Scientific Conference, 132 Latin American Scientific Congress, 140 Lazarettos, 130, 132–33, 136, 139, 145, 148–51; conditions of, 149–50; currency of, 148; Dirección General de Lazaretos, 139; e√ectiveness of, 150; and poverty, 139; riots in, 148–49. See also Agua de Dios; Ceño de Loro; Colombia; Lepers; Leprosarium; Leprosy League of Nation’s Malaria Commission, 32 Lepers, 130, 148–51; isolation of, 130, 133, 136, 137, 139–41, 142–43, 148; prejudice toward, 130, 132–33, 139– 41, 150; relatives of, 130, 149; resistance of, 148–49; as symbol, 131 Leprolin, 144 Leprosarium, 139, 143. See also Lazarettos

321

Leprosy: cause of, 141; in Colombia, 130–57; compared to crime, 130– 31, 143; control of, 131, 134–37, 139–41; contagiousness, 131–32, 136, 140; and economic progress, 130, 134, 144; fear of, 132–33, 145; history of, 131, 133–35, 139; medicalization of, 130, 133, 139–40, 148– 50; and modernization, 130, 133– 34, 144; and national identity, 130, 142–43, 144; and politics, 130–31, 133–39, 142, 144; and public policy, 131, 134–43; research on, 140–41, 144–45, 147; and society, 131, 139, 141; spread of, 131–33, 136–37; statistics, 144–45; treatment of, 133, 141 Levy, Miguel, 237–38, 241, 248–50, 252, 261 Liverpool School of Tropical Medicine, 40 Madeira River, 28 Major Endemic Disease O≈ce (Brazil), 84 Malaria, 14, 80; and Anopheles mosquitoes (see Anopheles); and Brazilian Amazon, 25–45; and Chagas, 80; control of, 25, 31, 37–41; and ddt, 31, 32, 44; debates concerning, 31; as endemic 34, 35; human cost of, 40; localism of, 36, 38; ‘‘malaria without anophelism,’’ 34; and mental illness, 243, 244, 264; and mobility, 42; outbreak of, 80; and politics, 42–43; and poverty, 40, 42, 82; research on, 29; and rubber industry, 25–27, 29–30, 37, 39–41, 43, 44; treatment of, 38–41 Manguinhos, 79, 80 Manic depression, 242–44, 257, 264

322 i n d e x Manicomio Nacional Pacheco (Bolivia): admission to, 252–57; class and race in, 243–44, 250–57, 261– 62; discharge from, 252–57; improvements in, 260; in comparison to U.S. hospitals, 242; mortality in, 245; patient population of, 243–44; sta√ of, 253–54 Manrique, Julio, 144, 149 Martínez, Alberto, 242, 244, 260 Medicalization, 5, 130 Medina, Pablo García, 136, 141, 145– 47 Men: and aids, 301–4; and Brazilian sexuality, 301–4; in tango, 120, 124; and tuberculosis, 121 Mendoza, Jaime, 242, 245–46, 248, 249, 253 Mental illness: and alcoholism, 257– 58; diagnosis of, 255–57, 242; and gender, 249–50, 257, 261–62; and hysteria, 52–70; and psychoanalysis, 248–49; and sex, 257–60, 261–62; and social class, 242–44, 250–52; and social factors, 261–62; treatment of, 238, 244–45, 248, 250–52, 261. See also Hysteria Mercury: treatment of syphilis with, 244, 251 Mexican Department of Public Health, 162, 167, 170, 173–74, 176; and child welfare, 221–23, 224; and hookworm, 162, 167, 170, 173–74, 176; and International Health Board, 162, 173, 176; and Rockefeller Foundation, 162, 167, 170, 172, 173–74; and syphilis, 184, 196–99, 204 Mexican Medical Association, 171 Mexican Revolution, 159–60, 173, 176–78; and child welfare, 210, 212, 219, 232; e√ects on women, 191–92; and hookworm, 159–60, 173, 176–

78; and prostitution, 192–93, 298– 301; and public health, 192–97, 202–4; and syphilis prevention, 192–97; and women, 220, 231 Mexico, 13, 14, 142, 159–78; and hookworm, 159–78; and hospitalism, 209–36; and medical sovereignty, 171–73; and nationbuilding, 173–74; and Rockefeller Foundation, 159–78; and syphilis, 183–208 Mexico City, 183–208; and prostitution, 185–94, 198–204; and public health campaigns, 183–208; and syphilis, 183–208 Military socialism (Bolivia), 240 Milonguita, 105, 112, 114–22, 123, 124; description of, 120, 123; and men surrounding, 120; and tuberculosis, 105, 118–20. See also Tango Ministry of Agriculture, Industry, and Commerce (Brazil), 29 Misión de Estudios de Patología Regional Argentina (mepra), 84 Missionaries, 133, 143, 145, 150 Modernity, 29–30, 39–41, 51–52, 56, 90–92, 119, 122, 125, 130, 133–34, 144; in Argentina, 120–22, 125; in Brazil, 90–92; and Colombia, 134, 144; and hysteria, 56, 59, 60; and sexuality, 302–4, 308, 310; and women, 56, 59 Modernization, 91–93; of Colombia, 134, 144. See also Modernity Monge Medrano, Carlos, 92–93 Montoya, Juan Bautista, 136, 141–42, 145, 146 Morfín, Solórzano, 169–70, 171–72 Mosquito eradication, 31, 32, 38–40, 43, 44; techniques of, 38. See also Malaria Muir, Ernst, 147

index National Academy of Medicine of Colombia, 133 National Department of Hygiene of Argentina, 133 Nationalism: in Argentina, 57, 58; in Mexico, 200, 221, 227–28 National Medical Congress (Colombia), 146 Norway, 140, 141, 144 Nosology, 158–60, 177–78; and imperialism, 158–60, 177–78 Oficina Central de Lazaretos, 135, 136 Olivari, Nicolás, 121, 124 Oral rehydration therapy. See Cholera: treatment of Oswaldo Cruz Institute, 28, 32, 33, 35, 37 Panama, 28, 130, 133, 134, 140 Pan American Health Organization, 87, 272–73 Parasites, 76, 78, 80, 89, 91–92 Parasitic thyroiditis, 82 Patient perspectives, 15, 63–64 Peru: cholera epidemic in, 268–89; and health services, 269, 272–76, 283, 284–85; Ministry of Health in, 273, 277–78, 280; and neoliberalism, 277–78; political and economic instability in, 271; water and sewage systems in, 268, 270–71, 273, 277, 280–82, 284 Philanthropy, 159–62, 177–78; and Rockefeller Foundation, 9–10, 26, 31–32, 43, 160–62, 177–78; scientific, 160–62, 177–78; and social change, 159–60 Plasmodia, 31–37 Prostitution, 183, 185; and brothels, 188–90, 193, 202; and Buenos Aires, 112; deregulation of, 198–201; male,

323

188; and medical exams, 184, 187, 190; and mental health, 250, 259; and Mexican Revolution, 191–93, 198– 201; as part of class culture, 191; Reglamento para el Ejercicio de la Prostitución (Mexico), 187–93; and sanitary regulations, 187–89; and sexually transmitted diseases, 183–94, 198–205, 296, 298, 308; and tango, 113–25; and young women, 192, 194 Psychoanalysis, 237–44, 248–49, 258, 261 Psychology: and hospitalism, 214–15, 225, 228. See also Mental illness Public education: about aids, 300, 307, 309; and child welfare, 221–23; and cholera, 273, 280–82; and parenting, 209, 213, 222–23; and sex, 194–97, 201; and sexually transmitted diseases (stds), 185, 186, 194– 97, 201–2 Public health policy, 8; in Brazil, 26, 90–91; in Buenos Aires, 51; in Colombia, 134–35, 136, 140–41; development of, 8; in Mexico, 73–74, 165–70, 178, 184–204; in Peru, role of science in formation of, 25; and Rockefeller missions, 9; and use of technology, 25; and vaccinations, 14; and welfare, 13 Quinine, 35, 36, 40–42, 134; resistance to, 35–36 Rabagliati, Evasio, 133, 145 Rebasa, Gregorio, 69, 71 Racism, 130, 142–43, 144, 151; in Colombia, 130, 142–43; and mental illness, 243, 249, 255–57; and miscegenation, 291–96; and science, 292– 96; and sexuality, 293, 294, 305; and slavery, 293

324 i n d e x Reduviidae (insect family), 76 Reglamento para el Ejercicio de la Prostitución (Mexico), 187–93 Reyes, Rafael, 133, 144; and control of leprosy, 134–36; and economics, 144; and international identity, 144; and modernization of Colombia, 134, 144; and public health, 134–36 Rio de Janeiro, 140 Robers, Leonard, 147 Rockefeller, John D., 160 Rockefeller Foundation, 9–10, 26, 31, 32, 43, 159–78; and hookworm, 159–78; and Mexican Revolution, 159, 162, 173, 176–77; and Mexico, 159–78; and philanthropy, 160, 177–78 Rockefeller Sanitary Commission for the Eradication of Hookworm, 159– 78; and malpractice, 168–70; and Mexican sovereignty, 171–73; and treatment of hookworm, 161, 163, 165, 168–70, 172, 175 Romaña, Cecílio, 84 ‘‘Romaña sign’’ for Chagas’ disease, 84 Ross, Ronald, 26, 31, 37, 38, 78 Rubber, 25, 26, 27, 29, 30, 37, 39–40, 41, 43, 44; committee for the defense of, 29. See also Brazil Russell, Frederick, 167, 169, 173 Salesian order, 133, 145, 150; in Brazil, 26, 29, 31, 39–42 Sanitary programs: in Argentina, 51, 52. See also Hygiene; Reglamento para el Ejercicio de la Prostitución Sanitation, 26, 29–42, 51–52, 134–35, 140–41, 268, 270–71, 277, 280–82, 284; in Argentina, 51, 52; in Brazil, 26, 29, 31, 39–42; in Colombia, 134–35, 140–41; in Mexico, 165–68, 174, 187–93; in Peru, 276–77, 282,

284–85. See also Hygiene; Sexual hygiene Scabies, 131 Schizophrenia, 242, 244, 248, 251, 254, 257–58 Sedentarism, 111 Sexual hygiene, 183–203; changing role of the state in, 184, 186–87, 202–3; and clinics, 183, 185, 190, 194, 197–98; education about, 185– 86, 194–97, 201–3; and privacy, 186, 197; and prostitution, 183–94, 198– 204 Sexuality: and climate, 290, 292, 295, 304–5; and mental illness, 257–60, 261–62; and modernity, 302–4, 308, 310; and police, 296; and privacy, 186, 197; and sexual customs in Brazil, 290–98, 306, 310; and the state, 187, 194, 196, 202 Sexually transmitted diseases (stds), 12, 122, 131, 183–208, 223, 290– 313; aids, 290–313; criminalization of, 198–99, 203; syphilis, 183– 208, 294–95. See also aids; Sexual hygiene; Syphilis Scientific philanthropy. See Philanthropy Shining Path: and cholera epidemic, 271–72, 278 Sisters of Charity, 139, 150 Smallpox, 14 Social Darwinism, 56, 237 Social integration, 104, 105 Social mobility, 123, 125 Solano, Cenón, 140, 141 Sommer, Baldomero, 132 Soper, Fred L., 43, 44 Soto, Juan, 195, 198 Southern Cone Initiative, 89, 93 Spanish American War, 143 Special Programme for Research and

index Training in Tropical Diseases (tdr), 88, 89 Special Service of Public Health for the Amazon, 43 Spitz, René, 214–15, 225–26, 231 stds. See Sexually transmitted diseases Syphilis, 12, 122, 183–208, 223; in Brazil, 294–95; e√ects on reproduction, 194; and infant mortality, 221; and medical exams, 184, 187, 190; and mental health, 244, 251, 257, 258, 259; mortality from, 193; and poverty, 221; prevention of, 183, 187– 89, 193–99; public education about, 194–97; symptoms of, 184, 186, 196–97; transmission of, 183–85, 187, 190, 198; treatment of, 185, 201 Tango, 11, 110–13, 120–25; characters of, 113; history of, 112–13, 125; and love, 121; and media, 113–14; and men, 120–21, 122–23; and prostitution, 113–25. See also Milonguita T. cruzi. See Trypanosoma cruzi Technology, 25 Thomas, Dr. H. Wolferstan, 40 Triatoma, 89 Tropical disease: in Brazil, 77–93; control of, 81, 84–5; history of, 77–78; and hookworm, 159–60, 175; and imperialist agenda, 77, 78; and local outlook, 90; and military, 78 Tropicalista School, 78 Trypanosoma cruzi, 76, 87, 88, 91, 92 Tuberculosis, 101–25, 131; and art, 102–3, 106–11; causes of, 101, 109, 111; contagiousness of, 101, 109; and culture, 102–10; cures for, 101; decline of, 123; and demographics, 101, 103–4; depictions of, 101–2; and drama, 103, 109–11; and Europeanization, 103; and gender

325

Tuberculosis (cont.) roles, 121, 122–25; history of, 101– 25; and literature, 102–3, 106–9; and men, 121–25; as metaphor, 102; and nationality, 101, 104; and passion, 119, 121, 125; and public policy, 109; research on, 101, 110, 111; and sexuality, 101, 109; subculture, 102–3; and tango, 110–25; and urban society, 101, 103, 111, 121; and women, 106–25 ‘‘Unilateral schizotrypanosic conjunctivitis,’’ 84 United Nations Development Programme (undp), 88 United States, 26, 31, 41, 43, 92, 143 U.S. Institute of Inter American Affairs, 43 Valencia, 143 Vargas, Getúlio, 43 Vasconcellos, Figueiredo de, 83 Venereal disease. See Sexually transmitted diseases Ventriloquism, 72 Vidal, Carlos, 272–73, 277–79 Villemin, 101 Virchow, Rudolf, 132 War of a Thousand Days, 130, 133, 134 Warren, Andrew, 165–70, 174–76 White plague, 102 Worms, 131 Women: and ambition, 119, 123–25; in art, 106–9, 112–25; as a labor force, 110; and mental illness, 239, 249–50, 257, 262; and Mexican Revolution, 220, 231; and modernity, 119, 122, 125; and motherhood, 214–17, 220–23, 227–28, 231–32, 249; and prostitution, 249; and role

326 i n d e x in society, 123–25; and tuberculosis, 109–25; and workplace and urbanization, 110, 120–25. See also Costurerita; Milonguita Women’s health, 56–59, 60, 64, 68, 124, 125; and Argentinian nationalism, 57, 58; and the body, 56, 57– 58; and mental illness, 239, 249–50, 257, 262; and modernization, 56, 59; and politics, 60; social conditions of, 64; and submissiveness, 68

World Bank, 88 World Health Organization, 26, 32, 88–89, 272 World War I, 26, 37 World War II, 26, 32, 37, 43, 44 Yellow fever, 14, 31, 38, 40, 43, 80, 158, 160, 162; and the Rockefeller Foundation, 162 Yellow peril, 142

Library of Congress Cataloging-in-Publication Data Disease in the history of modern Latin America : from malaria to AIDS / edited by Diego Armus. p. cm. Includes index. isbn 0-8223-3057-1 (cloth : alk. paper) — isbn 0-8223-3069-5 (pbk. : alk. paper) 1. Social medicine—Latin America. 2. Diseases—Latin America—History. I. Armus, Diego. ra418.3.l29 d575 2003 614.4%28—dc21 2002151597