Gender, State, and Medicine in Highland Ecuador: Modernizing Women, Modernizing the State, 1895-1950 by A. Kim Clark (review)

Kim Clark's excellent study explores some of those questions about the politics of health and rights that we should ask about any history of nation-building in the Americas: When did the responsibilities for citizens' health shift from its roots in notions of charity to a sense of citizens' entitlement to state services? When, and under what circumstances, can people put pressure on their political leaders and make states accept the responsibility for citizens' health? And how can we best understand the roles women played in the negotiations over gendered responsibilities and rights in modernizing nations?

To address these questions, Clark effectively links the history of Ecuadorian state formation to women's experiences and agency. She examines four key areas in which state officials identified women's behaviors that allegedly needed special attention and required state intervention. The first two areas, child welfare and prostitution, show how state officials sought to modernize the nation by addressing problems of infant mortality and venereal disease. The third and fourth areas, women's professional training and employment in two professional areas, midwifery and nursing, offer truly revealing insights into the process of negotiation between women citizens and the state. The state gave preferred employment opportunities to single, widowed, or divorced women—to protect and control those female citizens who could become a moral or economic burden to society and would thereby threaten the modernization of the nation. But this book is about state formation and women's agency, and shows that those women who became targets of state services because their behaviors were considered in need of modernization also contributed to the modernization of the state itself.

This pattern is brought to life through individual women's histories that introduce some of Ecuador's unique patterns of nation-building. The life of Matilde Hidalgo, for example, the first woman who earned the degree of medical doctor in Quito in 1921, is a remarkable tale of one person's dedication to the cause of higher education, as much as it is a journey through the institutional and moral boundaries that limited women's professional choices. When Hidalgo sought to pursue her education, shortly before the turn of the nineteenth century, her hometown of Loja did not have a secondary school for girls. Her fight to get permission to enroll at an alternative school created a brief public scandal. Yet, Hidalgo moved on, and her subsequent professional successes are all the more remarkable given the gendered expectations and moral concerns that so dramatically limited women's choices. She met the admission standards to the medical program in Quito's Universidad Central, but was rejected simply because women were expected to enroll in what were considered proper fields for women, that is, midwifery or pharmacy. Even after Hidalgo became a successful medical student elsewhere, her entry into the male professional world was slow. Moral expectations, for example, automatically assigned her to an internship at the maternity ward where she would treat only female patients.

Hidalgo's story is exemplary of the conundrum many women faced: they pursued the new professional opportunities that gradually opened up in Ecuadorian society, and simultaneously negotiated gendered behavioral codes. In the 1920s, the state began to employ women in greater numbers in medical professions. Access to stable employment was liberating for many women who became midwives, but the intensified monitoring of their work and behavior was also constraining. And the preference of nurses to midwives in some professional settings pitted one group of female professionals against another. But in the process, women used state services not only to pursue their own goals, but also to promote new models of female professionalism.

Although professional women who worked for the government were carefully monitored and had to comply with moral expectations, some restrictions to women's citizenship rights were lifted in...