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

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. Zulawski sets out to examine the interconnected dynamic between medical concepts and practices and the larger social and political changes of the era, especially in terms of the impact of medicine and public health on national debates about modernization and the incorporation of popular groups.

Combining the methods of intellectual history, the history of medicine, and social history (along with a judicious selection of statistics), Unequal Cures documents in detail the pervasive inequality of Bolivian health care, reflective as it was of larger social hierarchies. She finds that at the root of health care distribution in this period were deeply entrenched ideas about racial difference that had a great impact on the majority-indigenous and impoverished population. Such ideas were shaped by ideas about class and gender as well. While Zulawski demonstrates change over time, in particular the tendency for the state to take on increasing social responsibility for public health as a greater good, at the end of the day, it is the destructive racism of early twentieth-century Bolivian physicians and officials that comes through most clearly.

After an exceptionally clear Introduction that puts the main themes of the book in the larger Latin American historiographical context, Zulawski delves into elite ideas about the health of the large indigenous population. Health, she notes in Chapter 1, was recognized as central to the "Indian problem," although physicians could disagree about the best methods to address their ills. Chapter 2 looks at the Chaco War of the 1930s, both in terms of disease on the front and in the larger wartime society. An untended outcome of the war was an increased government focus on its citizens' health. Chapter 3 tells the story of the Rockefeller Foundation in Bolivia. Zulawski both adds to and expands upon the literature on public health philanthropy in Latin America, viewing local factors as crucially influential in the outcome of the international public health campaign; in Bolvia's case, the filtering of racist ideas from local elites to the international health officials was of particular significance.

Next, Zulawski examines medical views towards women, finding that from the 1920s physicians and government officials head an increasing interest in controlling women's reproductive health for the greater good of the nation. This provocative chapter packs in a great deal of material: reviews of programs to address infant mortality, abortion, and venereal disease, although it less successfully links these subjects to larger themes such as citizenship and nationalist discourse. The next and final chapter is a riveting account of the treatment of mental illness in Bolivia. Centrally focused on the nation's only mental institution, the manicomio Pacheco in Sucre, the chapter goes well beyond the walls of the asylum. Shocking facts about mental health treatment in Bolivia, for instance that most patients in this period were admitted with epilepsy and untreated malaria, reveal the poverty of healthcare and basic well-being in the country at large. Poor conditions, such as an astoundingly high death rate in the asylum, and impoverished conditions (for instance, the existence of 30 spoons available for 60 patients in 1918) were ameliorated over time, but underlying social inequalities shaped by race, class, and gender remained largely unresolved. Bolivia was and is one of the poorest and unequal nations in Latin America. As Zulawski demonstrates, health and disease are a major part of that story, but are also inevitably central to any solutions that may exist.

This thought-provoking and finely tuned study should be of great interest in a range of specialized courses in Bolivian, Andean, and...