Unequal Cures: Public Health and Political Change in Bolivia, 1900-1950

by Ann Zulawski

Overview

Unequal Cures illuminates the connections between public health and political change in Bolivia from the beginning of the twentieth century, when the country was a political oligarchy, until the eve of the 1952 national revolution that ushered in universal suffrage, agrarian reform, and the nationalization of Bolivia’s tin mines. Ann Zulawski examines both how the period’s major ideological and social transformations changed medical thinking and how ideas of public health figured in debates about what kind of country Bolivia should become. Zulawski argues that the emerging populist politics of the 1930s and 1940s helped consolidate Bolivia’s medical profession and that improved public health was essential to the creation of a modern state. Yet she finds that at mid-century, women, indigenous Bolivians, and the poor were still considered inferior and consequently received often inadequate medical treatment and lower levels of medical care.

Drawing on hospital and cemetery records, censuses, diagnoses, newspaper accounts, and interviews, Zulawski describes the major medical problems that Bolivia faced during the first half of the twentieth century, their social and economic causes, and efforts at their amelioration. Her analysis encompasses the Rockefeller Foundation’s campaign against yellow fever, the almost total collapse of Bolivia’s health care system during the disastrous Chaco War with Paraguay (1932–35), an assessment of women’s health in light of their socioeconomic realities, and a look at Manicomio Pacheco, the national mental hospital.

Product Details

ISBN-13:	9780822339168
Publisher:	Duke University Press Books
Publication date:	01/17/2007
Edition description:	New Edition
Pages:	264
Product dimensions:	6.00(w) x 9.25(h) x (d)

About the Author

Ann Zulawski is Professor of 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.

Read an Excerpt

Unequal Cures

Public Health and Political Change in Bolivia, 1900-1950

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By ANN ZULAWSKI

Duke University Press

Copyright © 2007 Duke University Press
All right reserved.
ISBN: 978-0-8223-3916-8

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Chapter One

HYGIENE AND THE "INDIAN PROBLEM"

Ethnicity and Medicine in the Early Twentieth Century

This chapter examines the proposals of two Bolivian doctors, Jaime Mendoza and Néstor Morales, for improving the health of the native population. These proposals are looked at in the context of a larger debate about ethnicity and citizenship in the first decades of the twentieth century. Intellectuals struggled with what they referred to as the "Indian problem," because the situation of Bolivia's native population was at the core of the elite's contradictory social and economic situation and raised central questions about national identity. On the one hand, the exploitation of Indians as hacienda colonos (peons) and workers made possible Bolivia's role in the world market as an exporter of raw materials and financed the lifestyle of the elite. On the other hand, Indians and their culture were considered the main obstacles to Bolivia's entering the world community as a civilized and progressive country. The question of the Indian's role in the nation became a more pressing problem in the early twentieth century, as a growing economyrequired more labor and as improved communications brought Indians and non-Indians into closer contact. Elite intellectuals began to consider whether Indians might somehow be "improved" enough to be part of a modernizing nation. As pedagogues and politicians proposed and debated means of integrating native Andeans into national life while still limiting their educational, professional, and political roles, indigenous people were taking matters into their own hands. They were seeking better employment opportunities in the cities, demanding education as an important prerequisite for citizenship, and using their political and literacy skills to fight to reclaim lands titled to them that had been illegally seized by hacendados.

The entry of native people into the broader political and social life of the nation, despite efforts to minimize it, became a topic of discussion for doctors and politicians concerned with public health. Elite fears of contagion were awakened by the likelihood that they would have more contact with Indians as the economy expanded and "new elements" entered urban areas. Furthermore, there was recognition that if Indians were to supply the labor power for mining and increased agricultural production, they had to have at least a minimal standard of well-being. Here doctors entered the fray with their own particular professional, humanitarian, and corporate agendas. A central goal for university-trained doctors in the first decades of the twentieth century was proving the efficacy of biomedicine and discrediting other practitioners, particularly Andean herbalists, who were patronized by most people in the country and who arguably had a success rate at least as great as theirs.

The doctors studied in this chapter, Jaime Mendoza and Néstor Morales Villazón, set out to do just that. Of the same generation (Mendoza was born in 1874, Morales in 1878), they both were from families of the provincial elite; they each studied medicine in Bolivia and then pursued advanced training in Europe. Both were influenced by the bacteriological discoveries of the late nineteenth century and early twentieth, and both held important posts in the country's major medical institutions. However, there the similarities between the two men ended. Although Morales was originally trained as a pediatrician, his main professional focus was bacteriology, and he hoped to make his mark by being the first Bolivian doctor with a major scientific breakthrough in the field that would also have a significant impact on the nation's health. Mendoza, in contrast, practiced and wrote in many medical fields, from psychiatry to pediatrics to infectious diseases. He also was a novelist, an essayist, and a political activist with a deep nationalist commitment. His approach to elevating the prestige of the medical profession was through the active promotion of public health policies that would improve the lives of the poorest Bolivians. Some of Mendoza's writings on medicine are discussed in other chapters of this book. What is striking about a comparison of Morales and Mendoza is that although their political inclinations and medical interests varied widely, in many ways they coincided in their ideas about the country's Andean majority. They both brought to the discussion of public health an ambivalence about ethnicity that was typical of most members of the Bolivian elite.

The Context

In the first two decades of the twentieth century Bolivia enjoyed something of an economic boom based on exporting tin, which had replaced silver as the country's most important export around the turn of the century. Related to the economic ascendancy of the tin producers was the rise to power of the Liberal Party, which had seized control of the country from the Conservatives in a military revolt in 1899, which became a civil war. The nation's most important tin-mining centers were located closer to the city of La Paz than to the capital in Sucre, the center of silver-mining interests and of the Conservative Party. Thus 1900 marked a shift in the economic center of gravity to La Paz that was reflected in the Liberals' decision to move almost all important government offices and functions to that city.

As mentioned in the introduction, in 1900 Bolivia had a population of 1,633,610 people. About 51 percent of them were Indian, according to that year's census. About 73 percent of the population lived in the countryside, and only 16 percent of those over seven years old had received any schooling. Since literacy was technically a qualification for voting and there were financial requirements for holding office, political participation was theoretically limited to a small, urban group of educated men. Yet, in fact, suffrage was not as limited as it sounds, because in the first decades of the century mestizos and recent cholo arrivals to cities and towns did participate in elections, often as clients of Liberal or Conservative politicians.

During the two presidencies of Liberal Ismael Montes (1904-9, 1913-17), the government embarked on ambitious programs for improving Bolivia's infrastructure, particularly constructing railroads that would facilitate transporting tin, thus furthering the Liberals' export-oriented plan for development. Encouraging scientific progress and improving public hygiene were also part of the Liberal agenda, and after 1900 a number of initiatives were undertaken: urban electrification projects were begun, smallpox vaccinations were made mandatory in 1902, piped drinking water became available for part of the city of La Paz in 1903, and a modern general hospital was completed in the city in 1920.

The Liberals had come to power by mobilizing Indian communities of the high plateau (altiplano) near La Paz to fight for them against the Conservatives, but, when it became clear that if necessary the peasant communities would press their demands for land and self-government against the Liberals as well, the Liberals turned on their native allies, killing the more militant leaders. Andean communities had hoped that in return for their support the Liberals would back them in their efforts to hold on to lands that had been under attack since at least the 1860s, when a series of laws outlawed native communities and proposed various means of privatizing Indian lands. In fact, they were hoping for help that directly conflicted with many Liberals' class interests, especially those in the La Paz area, where creole landowners favored the incorporation of Indians into the haciendas as colonos instead of the theoretical liberal project of small-scale landownership. Despite the serious blow, indigenous communities eventually responded to Liberal betrayal after the civil war by organizing to reclaim usurped lands and to demand the rights (political representation, education, access to markets for their produce) that liberalism theoretically promised all Bolivians.

It was in this atmosphere of struggle that elite intellectuals were revising their assumptions about the roles native Andeans could play in the new liberal nation. Social Darwinism had been the dominant philosophical approach to understanding the "Indian problem" in the last decades of the nineteenth century, with some writers going so far as to hope that in the struggle for survival the Indian would be defeated or even eliminated by the whites. After the turn of the century, and particularly after about 1910, new theoretical constructs were developed that combined biological explanations with environmental ones. Particularly Lamarckian understandings of genetics that emphasized the possibility of inheritance of acquired characteristics now blended with a new ethnographic approach to culture to produce new racial ideologies. These ideologies both explained how the Indian population had become congenitally degenerate as a result of colonial exploitation and also offered some small hope that under very favorable circumstances, Indians might be changed enough to take on a (debated) role in a modern nation. Among those who accepted this more environmental approach were a number of the doctors who wrote on national health problems in the early twentieth century.

Doctors and the Nation's Health

Bolivian physicians were painfully aware of their country's health problems, and medical journals poured out statistics confirming the country's hygienic deficiency. Although they did not use the term, many of the health hazards they pointed to would today be considered the results of underdevelopment. What the doctors themselves said was that the existence of these problems placed Bolivia far behind European, and even some other Latin American, countries on the road to modernity and civilization. For instance, in 1902 Revista Médica stated that out of 3,337 babies born in the city of La Paz in 1900, 1,298 (39 percent) died before reaching their third birthdays, and 19 percent died in the first year of life. Most of these deaths were traced by the author of the article to intestinal infections, which in turn were said to be primarily the result of impure food and water. The poor quality and lack of filtration of the city's drinking water were also said to be the causes of at least a quarter of the identifiable deaths in the city in 1911, and a doctor writing in another medical journal estimated that probably an equal number of undiagnosed deaths were from gastrointestinal illness as well. The same author, on the basis of chemical and bacteriological tests conducted on La Paz's drinking water, classified it as worse than that of any other city for which statistics were available and comparable to water that was commonly used only for industrial purposes.

Epidemic diseases were major killers both in urban and rural areas. A vaccine for smallpox was developed in 1796 in Europe, and Bolivia had first attempted to make the vaccine available after independence in 1826. In 1902 a new law was enacted making vaccination mandatory, but in 1909 it had to be repromulgated in the face of serious epidemics. Even then vaccination was not widespread, and most people remained vulnerable to the disease. Typhoid was always endemic in the country; throughout the first years of the century, there were waves of serious typhoid epidemics that caused high mortality.

Medical institutions-such as laboratories, hospitals, and medical schools-were considered by those who worked in them to be at the best underfunded but diligently run and at the worst to be national disgraces. The library of the medical school in La Paz had only 758 volumes in 1914, and the head of the school indicated that 49 of these had been acquired during his tenure in 1912-1913. He also pointed with pride to the fact that the school would soon have a pathology laboratory for the first time. A report on medical education in Bolivia prepared by a representative of the Rockefeller Foundation twelve years later gives a more somber assessment: "Teaching laboratories, strictly speaking, cannot be said to exist. In a rented building I saw a room 12 ft. square with one ordinary table, a small cabinet, and scattered about on each some miscellaneous pieces of dust-covered glassware. This was called the chemical laboratory. In another, somewhat larger room, containing low public school desks [there] were a few anatomical models. These were referred to in the regimento interno as the anatomical museum."

In 1918, before the new Hospital General was completed, a doctor described the city's two main hospitals as the reasons that people preferred to die at home. He also pointed out that the infectious disease sections of the men's hospital were so unhygienic, and the wards so crowded, that a patient could easily come in with one illness and die of another contracted in the hospital. And, as grim as these assessments of the situation in La Paz are, it is important to keep in mind that Western health facilities of any type were entirely lacking in rural areas.

There was considerable variation in how doctors understood these problems, believed they should be ameliorated, and connected them to ethnicity and social issues. However, there were a few key realities that affected public health and the physicians' professional situation. First of all, in the early twentieth century medical science in Bolivia not only lagged behind that in European countries and the United States, but also was backward when compared to other Latin American countries. In the late nineteenth century and early twentieth, European discoveries in bacteriology were very influential; Latin American scientists were inspired to apply this new knowledge to health problems in the region. Carlos Finlay conducted pioneering (although not properly appreciated) research on yellow fever in Cuba; Oswaldo Cruz, Carlos Chagas, and others in Brazil did research on various vector-born diseases, which lead to the discovery of American sleeping sickness, or Chagas disease. Research institutes in some Latin American cities, such as Cruz's Manguinhos Institute, combined bacteriological research with the production of vaccines to fight epidemic diseases, and for many other countries this became a model to emulate. Even Peru, which did not have the resources of Argentina or Brazil, surpassed Bolivia in university research in bacteriology and the development of its public health system in the first years of the twentieth century.

Because of the limited reach of Western medicine in Bolivia (there were only 142 graduated doctors in the country's major cities in 1900), and the lack of medical research institutions, university-trained doctors were generally not accorded the same respect as members of other liberal professions. Indeed, they were not completely differentiated from other medical practitioners in the Western tradition, whom the doctors themselves sometimes referred to as empiricists and often simply as charlatans. Furthermore, despite the advances in bacteriology and other fields of medical science, in all countries in the early twentieth century there were still major gaps in biomedical knowledge: in many instances in Bolivia, herbalists known as Kallawaya or other Andean curers were more effective than academically trained physicians. Consequently, there was a special urgency to Bolivian doctors' writings about social problems and the importance of hygiene, because improving the country's abysmal public health situation was ultimately linked to the physicians' professional status and credibility. To that end, a good number of doctors began to enter politics at the local and national level and often used these positions to publicly express their views on medicine and the public good.

(Continues...)

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Table of Contents

Illustrations viii

Acknowledgments ix

Introduction 1

1 Hygiene and the “Indian Problem”: Ethnicity and Medicine in the Early Twentieth Century 21

2 The Medical Crisis of the Chaco War 52

3 The Rockefeller Foundation in Bolivia, 1932-1952 86

4 Women and Public Health, 1920s-1940s 118

5 Mental Illness and Democracy: The Manicomio Pacheco 157

Conclusion 190

Notes 197

Bibliography 225

Index 243

Editorial Reviews

This is a significant contribution to the field of Andean historiography, as well as to broader studies of gender, ethnicity, health and politics. . . . [T]he book’s originality rests in the way it links conflicts and policies pertaining to the establishment of a public health program in a small, poor country during the first half of the twentieth century to the larger context of gender, ethnic, and political history.

American Historical Review - Teresa Meade

Zulawski has written one of the most comprehensive histories of public health on a country often deemed, even by foreigners, of little importance to the region. Her book will help to transform this misperception. [E]ssential reading for anyone interested in the history of medicine or public health in the developing world and specifically in Latin America.

Bulletin of the Pacific Circle - Gabriela Soto Lavega

Ann Zulawski’s study of health and the distribution of medical care in Bolivia in the first half of the twentieth century provides an insightful and subtly drawn account. It is a welcome addition to, and one of the finer examples of, a growing literature on health and medicine in Latin American history.

The Americas - Julia Rodriguez

Unequal Cures is a well-written and thoroughly researched historical analysis of health care that neatly weaves together issues of gender, ethnicity, international health care, and medical access in Bolivia from 1900 to 1950. There is very little historical research on medicine or public health in Bolivia, and therefore Zulawski’s book is a welcome addition to the literature.

Journal of World History - Susan Tanner

Unequal Cures is an original and well-crafted historical study that opens fresh new perspectives on old issues, namely the formation of racial, class, gender, and national identities in a modernizing multiethnic nation—in this case, Bolivia. This fascinating and sweeping history of nation-making told through the rare lens of public health discourses and policies is a first-rate contribution to the fields of Andean studies and the social history of medicine in Latin America.”—Brooke Larson, author of Trials Nation Making: Liberalism, Race, and Ethnicity in the Andes, 1810–1910

“This meticulous study of Bolivia, one of the poorest countries in Latin America, shows why doctors and public health officials were unequal to the task of improving the health of the majority of its citizens in the first half of the twentieth century. Using the tools of social and medical history to great effect, Ann Zulawski demonstrates that the divisions of ethnicity separating the small white elite from the mass of the Indian population meant that the gap between the rhetoric of biomedical improvement and the reality of Indian ill health remained huge, even in the more progressive 1940s and 1950s. A sad and important contribution to the field.”—Nancy Leys Stepan, Professor of History, Columbia University

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