The Return of the Epidemics: Health and Society in Peru during the Twentieth Century (review)

Marcos Cueto begins his excellent book on epidemic disease in twentieth-century Peru by examining the outbreak of bubonic plague that occurred in the early 1900s and ends it with an analysis of the cholera epidemic of 1991. These two essays clearly demonstrate both the connections between poverty and disease and the inadequacies of the Peruvian public health system. Bubonic plague, which was first diagnosed in coastal Peru in 1903, was a disease of the poor, who lived in flimsy houses easily invaded by rats. Cholera, which spread all over Latin America in the 1990s, likewise primarily affected the poor, who lived in areas without safe drinking water or proper sewage systems. In both cases, official discourse and popular belief saw the epidemic not as the fault of the state, which failed to provide minimal, healthful living conditions for its citizens, but as the fault of the afflicted. Contracting plague or cholera was associated with being lower class, dirty, ignorant, and lazy. This led people to hide the sick and delay treatment out of shame. The thing that makes Cueto's comparison of these two epidemics even sadder is that in the early twentieth century, despite the tendency to blame the poor for the disease, plague at least became the impetus for the state's reluctant acceptance of responsibility for public health. In the 1990s, on the other hand, while heroic efforts on the part of medical professionals managed to keep the mortality rate for cholera low, Peru's public health system was grossly underfunded, and a neoliberal government promoted the idea that medical care was an individual responsibility.

Other essays in the book reveal different responses to epidemics in Peru: the autocratic nature of the campaign against yellow fever led in the 1920s by Henry Hanson and the Rockefeller Foundation and supported by the modernizing Leguía regime; the government's belated response to malaria in the south in the 1930s followed by massive, but ultimately unsuccessful, efforts to eliminate it completely between the 1940s and the 1970s; and the fascinating story of Dr. Manuel Núñez Butrón, who created sanitary brigades to fight smallpox and typhus in the southern Andean department of Puno. By linking public health to respect for native culture and the struggle of Andean communities to retain their lands, Indian sanitary workers were able to educate many rural people about typhus and encourage them to voluntarily accept vaccination against smallpox. The embrace of indigenismo by local intellectuals, the presence of Indian members of the Seventh Day Adventist Church who were interested in health and education, and Núñez Butrón's ability to work with local healers combined to make the 1930s campaign in Puno successful, albeit short lived. Núñez Butrón's effort to introduce Western medicine in the interest of defending the Indian stands out as a positive alternative to the coercive approaches generally used.

The Spanish version of The Return of the Epidemics received the Latin American Studies Association's "Premio Iberoamericano" in 1998, and its translation is a welcome addition to the English-language literature on public health and the history of medicine. It is also an important book for anyone who wants to understand the reality of modern Peru, because once again Cueto shows that the history of medicine provides new vantage points for understanding political and social change. Cueto ends the book with a call for governments to assume responsibility for public health "because it gives citizens a feeling of security, hope, order, and equal opportunities" (p. 141). He also calls for an engaged approach to the history of medicine that considers the beliefs and opinions of ordinary people as well as doctors, which can "help strengthen the elements of solidarity...