Ann Zulawski, Unequal cures: public health and political change in Bolivia, 1900–1950, Durham, NC, and London, Duke University Press, 2007, pp. x, 253, £53.00, $78.95 (hardback 978-0-8223-3900-7), £13.99, $21.95 (paperback 978-0-8223-3916-8).

Abstract

This new monograph on the history of medicine and health care in Latin America is a welcome addition to a rapidly evolving historiography. Where most of the literature on the subject addresses the major and intermediate countries of the continent, this examines a minor republic that was the poorest in South America in the period covered. Building on the ground-breaking work of Nancy Leys Stepan, the author broaches both issues that have been tackled by scholars in other contexts, like the role of the Rockefeller Foundation and the relationship of women and the public health apparatus, and themes barely touched on elsewhere, especially the medical crisis caused by the one major international war in the continent in the first half of the twentieth century—the Chaco War between Bolivia and Paraguay—and the history of mental illness, especially at the Manicomio Pacheco, located in the city of Sucre. Ann Zulawski gives a largely convincing account of the ideological and social changes that altered medical thinking between the turn of the nineteenth and twentieth centuries and the Revolution of 1952, which presaged the beginnings of universal suffrage, together with the nationalization of the tin mines—the main source of export revenues—and the onset of an agrarian reform designed to benefit the indigenous and mixed-race rural poor. Bolivian medical elites and their allies were influenced by conflicting international trends ranging from socialism and reformist liberalism to various kinds of thinking rooted in eugenics. By the late 1930s and 1940s an expansion of provision of public health care that was fostered by a modernized and enlarged profession of medical doctors became essential to the consolidation of a state that was still fragmented, weak and insecure, even by the standards of most of Bolivia’s neighbours. Entrenched racial and gender prejudices, however, made for and exacerbated inequalities in health care, with women and the indigenous poor often being the victims of low-quality care and concentration of access in the major urban centres. The book makes a useful contribution on diverse issues. One example is the ways in which Bolivian physicians saw contracts from the Rockefeller Foundation as means of avoiding political interference and overcoming political rivalries between national and departmental officials. When the Foundation left the country in 1952 it was the object of criticism from outside that it had failed to act comprehensively on its assumption that health care was a right for all Bolivians, and from within that its resources were spread too thinly over too many health issues to be effective. Another example is the analysis of the role of midwives and of the attempts of professional physicians to limit their professional independence. Pragmatic recognition that in some rural provinces a shortage of physicians meant that doctors aiming to proscribe prescription of medication by midwives had to accommodate local realities that graduate physicians were unable to supply all the obstetrical services needed. Zulawski’s discussion of mental health contains the tantalizing paradox that in the 1930s the most frequent cause of admission to the mental hospital at Sucre was epilepsy, even though it was no longer considered a mental illness. Fierce debate about psychoanalysis and its uses in the 1940s had only a slender impact because policy innovation was inhibited by the extreme poverty of Bolivia and by competing pressures on budgets, especially in the aftermath of the Chaco War. The significance of questions of race and ethnicity in health uses gives rise to a similarly rewarding discussion. Bolivian intellectuals argued strongly that the behaviour of Amerindians made them both susceptible to disease and resistant to conventionally prescribed treatments, and went on to acknowledge the structural causes of ill health—poverty and inequality—while never fully relinquishing racial explanations of the diseases suffered by specific indigenous groups. The book makes a valuable contribution to the subject, but is published prematurely. It is marred by some looseness of expression: for example (p. 76): “If people in Bolivia were eager to disassociate themselves from the Indians, from the poor …”, were the Indians and the poor not people? More significantly, it is regrettable that the author follows the social history conventions of the 1980s in dismissing “the older institutional history” (p. 14) so lightly and so casually. Had she shown more alertness to it, she would have used such terms as “democracy”, “oligarchy”, “authoritarianism” and especially “populism” with more care and rigour, and to sharper effect. She would also display a more nuanced grasp of complex relationships between branches of government, especially at national, provincial and local levels. A greater alertness to recent literature on social policy would also have helped considerably.