Marriage of Convenience: Rockefeller International Health and Revolutionary Mexico (review)

The history of modern philanthropy can be told as a record of altruism or self-promotion. To her credit, Anne-Emanuelle Birn has written an insightful and carefully nuanced account that incorporates elements of both narratives. Her subject is the 30-year-long collaboration between the Rockefeller Foundation’s International Health Division and the political and medical establishment of post-revolutionary Mexico. Even as they worked together to promote public health in Mexico, each of the parties involved pursued their own interests, each influenced the results, and each learned something from their opposite numbers.

Birn notes that Rockefeller Foundation turned to the promotion of public health to restore luster to the tarnished family name by associating it with an undeniably progressive cause. Reflecting modern notions of health as a scientific endeavor, the Foundation chose projects that gave preference “‘to medical and technical measures’ at the expense of socio-economic explanations and solutions” (p. 25). This approach encouraged a degree of arrogance on the part of formally educated North American health promoters in their dealings with impoverished Mexican campesinos and even with their professional collaborators from the Mexican medical community. It also downplayed, conveniently from the point of view of the Foundation’s institutional needs, the role that poverty and political marginalization play in health issues. Nevertheless, writes Birn, because the Rockefeller Foundation was one of the first large scale philanthropies to enter the field of public health, its practices have set a precedent for the work of later health organizations right down to the present.

One of the many strengths of this volume is that it is not just an institutional history, but it also considers the contexts within which the people and organizations involved negotiated the formal and informal terms of their on-going relationship. For example, Birn describes how the eagerness of Mexican political leaders to demonstrate the government’s capacity to bring health services to the public overrode their suspicions of a United States-based organization bearing the name of one of the world’s leading capitalists. In fact, the Obregón administration signed off on a Rockefeller Foundation-designed campaign to eradicate hookworm even though Mexico would pay the lion’s share of the program costs and other medical needs were more pressing. Crucial to their decision was the fact that the highly public campaign was centered in the state of Vera Cruz where Obregón and his allies were struggling to secure the loyalty of the people.

As Birn describes it, the Mexican medical community had a more ambivalent relationship with the Rockefeller Foundation. On the positive side, 68 Mexican physicians, nurses, and health workers received fellowships to study for one or two years in the United States and Canada. Most of them returned as boosters of the Foundation’s approach to health care. On the other hand, some Mexican physicians complained that the North Americans were unwilling to learn from their Mexican colleagues or to address the economic and social factors that were contributing to disease and morbidity. Eventually, the Mexicans’ more localized and holistic approach to public health prevailed in the design and implementation of clinics that emphasized preventive measures and specialized services to women and children.

Birn’s volume is thoroughly researched, making effective use of archival material and personal interviews as well as a wealth of secondary sources. It is elegantly written and its many well-chosen illustrations are linked effectively to the text. If the book has a fault, it is the lack of any discussion of how this partnership influenced the long-term shape and scale of Mexico’s health care system. The current state of health care in Mexico reflects severe social and economic inequalities and a very uneven distribution of medical resources. One cannot help wondering whether this situation represents a betrayal of the revolution’s early promise or a predictable outcome of patterns...