Eric D. Carter
Introduction
In recent years there has been rising interest in the history of social medicine in Latin America (Birn & Nervi, 2015; Galeano, Trotta, & Spinelli, 2011; Krieger, 2003; Porter, 2006; Waitzkin, 2011). Meanwhile, there have been calls in the history of public health in Latin America to go beyond national case studies (and even comparative studies) to more fully understand the dynamics of international and/or transnational institutions and networks (Birn, 2006; Birn & Necochea LĂłpez, 2011; Borowy, 2009). This paper examines the international networks that influenced ideas and policy in social medicine in the 1930s and 1940s in Latin America. While the character, functions, and influence of international networks in Latin American social medicine since the 1970s are relatively well understood, as a result of living participants, better documentation, and the existence of key coordinating institutions, such as ALAMES (Galeano et al., 2011), for the âfirst waveâ of Latin American social medicine, rising in the interwar period and continuing into the 1940s, the contours of such international networks are less well understood.
Nevertheless, there are many assumptions about how ideas travelled internationally in social medicine. One commonplace notion is that the idea of social medicine migrated to Latin America from Europe, passed down from pioneers like Rudolph Virchow, in the mid-1800s, via his intellectual progeny, through academic networks, into Latin American countries, starting with âearly adoptersâ like Uruguay, Argentina, and Chile (Cueto & Palmer, 2015; Waitzkin, 2011). Another school of thought points to the efforts of progressive international institutions, such as the League of Nations (LN) and the International Labour Organization (ILO), which helped foster more integrative analyses of population health problems in line with social medicine (Dubin, 1995; Weindling, 1995, 2006).
Such narratives demand further scrutiny. One problem is that the influence of international networks is often inferred from the mere existence of associations or relationships (such as membership in organisations or attendance at conferences). Relatedly, ideas are often seen to flow, in a top-down or centreâperiphery pattern, without due consideration of the give-and-take between Latin Americans and their counterparts abroad. We actually know little about how ideas in international health and social policy were received by the Latin American social medicine milieu.
This paper focuses primarily on the role of Latin American scientists and experts in formal institutional networks organised by the LN and the International Labour Organization during the 1930s, in two major policy domains, social security and nutrition. I argue that international networks were not just âconveyor beltsâ (Plata-Stenger, 2015, p. 108) for policy ideas in these domains from the industrialised countries of the US and Europe into Latin America. Rather, international meetings were sites of contestation over the causes of health inequalities, the universality of liberal welfare-state policy models, and the role of science in policy. Latin Americansâ participation in these networks tended to reinforce perceptions of difference between Latin America and the global geopolitical core regions; prompted the search for ânational solutions to national problemsâ in some Latin American countries; and fostered stronger intra-regional ties among progressive doctors, scientists, and other intellectuals interested in social medicine.
Thus, this paper embraces the newer historiographic tendency to âfully reconsider so-called centreâperiphery and imperial-colonial relations, emphasising how each party shapes and is shaped by others through multidirectional influencesâ (Birn & Necochea LĂłpez, 2011, p. 519). To understand these relations, I build upon the work of historians who have pored over the Geneva archives for evidence of Latin American participation in the international health and welfare organisations of the interwar period. I extend this important research by emphasising the local reception of proposals from the international health and social policy episteme in two Latin American countries, Chile and Argentina, as conveyed in published and unpublished local materials, such as medical journals and conference proceedings.
Analysis of formally structured networks around social medicine is complicated by the fact that there were no prominent international organisations for the promotion and advancement of social medicine per se, despite the fact that the interwar period is understood as a period of florescence for social medicine. Generally rising usage of the term in noun (medicina social) or compound adjective (mĂ©dico-social) forms during the 1930s â in journal, book, and article titles; academic departments; conferences and conference sections; and government programmes in Latin American countries â is a cue that the concept was gaining relevance. While no international meetings on social medicine, as such, were organised in the region during this time, it was a cross-cutting approach employed to analyze an array of health and social problems.
Although defining the field of social medicine is a challenge, two features made social medicine distinctive for its proponents and recognisable as an approach in health science and policy in the interwar period. First and foremost, social medicine advocated for an integrative causal framework that stressed the social, economic, and political causes of health problems, in tension with reductionist and increasingly prominent âbiomedicalâ frameworks (Löwy, 2011; Packard, 2016). Second, social medicine questioned the model of liberal medicine and called for the state to take a strong role in developing and regulating health systems to serve the collective needs of national populations. With faith in classically liberal, free-market principles at perhaps a low ebb during the economic crisis of the 1930s, such proposals were aligned with the ideological tendencies of the era.
In this paper, after examining the architecture of formal international networks I trace their influence on social and health policy in two areas: social security and nutrition. These were key issue domains that were both shaped by international networks and testing grounds for the relevance of social medicine ideas.
Institutional panorama
Major Geneva institutions of the interwar period, the LN and the ILO, were idealistic experiments to sustain an international liberal political order. Due mainly to its failure to prevent the catastrophe of World War II, the LN particularly has long been dismissed as a failure in international governance, but a revisionist history emphasises the Geneva institutionsâ roles as pioneer in humanitarian internationalism and as a laboratory for social policy (Borowy, 2009; Kott & Droux, 2013; McPherson & Wehrli, 2015). The Geneva institutions developed a technocratic approach to governance, an ostensibly non-ideological style of policy innovation and transfer, which made them a forerunner to post-war international institutions such as the World Health Organization (WHO), United Nations, and the World Bank (Guthrie, 2013).
The League of Nations Health Organization (LNHO) played a key role in international health governance during the interwar period. The economic dislocations of the Great Depression moved the LNHO towards a âsocial medicineâ orientation in the research it sponsored and policies it supported (Packard, 2016). Ludwik W. Rajchman, a Polish bacteriologist who served in the key role of medical director of the LNHO from 1921 to 1939, was known for promoting a âconception of a social medicine serving humanityâ and the LNHO paid âgrowing attention to social medicine in the 1930s, when [member] governments turned toward social welfare policiesâ (Dubin, 1995, pp. 59â63). The LNHOâs activities shifted, from a focus on technical assistance in programmes to combat specific diseases and epidemiological surveillance, to a âbroader inquiry into disease etiology that encompassed the roles of nutrition, housing, working conditions, agricultural production, and the economyâ (Packard, 2016, p. 57). In Europe, this new orientation was especially evident in rural hygiene and malaria policies (Packard, 2007, 2016; Weindling, 1995). But institutional weaknesses and concerns over political neutrality tempered the LNHOâs leftward tilt (Dubin, 1995).
Similar to the LN, the ILO â generally known in Latin America as the OIT, OrganizaciĂłn Internacional del Trabajo â had a high-minded purpose: that âlasting peace can be established only if it is based on social justice,â and social justice â often used interchangeably with the concept of âsocial peaceâ â could be achieved only through agreements between labour, capital, and the state, meeting together on equal footing (Guthrie, 2013; International Labour Office, 1944, p. 16). Intrinsic to the ILOâs governance practices was the âtripartiteâ format, whereby representatives of three parties (labour, employers, and the state) were supposed to negotiate and hammer out resolutions, which initially dealt with regulating industrial working conditions, at regular meetings in Geneva. Though the ILO was not conceived as a public health organisation, its policy models integrated labour and health issues in a variety of ways, first by seeking to address workplace safety, such as a ban on the manufacture of âwhite leadâ (basic lead carbonate), one of the first examples of international regulation of a chemical occupational hazard. In the 1930s, the ILO increasingly looked beyond questions of occupational safety, workplace conditions, and fair labour contracts towards broader questions of worker health and security.
The Geneva institutions, especially the LNHO, were notoriously âEurocentric,â and relations with Latin America were sporadic and slow to develop. Partly due to the costly and time-consuming travel to Geneva, Latin American presence in the LNHO was weak, although notables such as Carlos Chagas of Brazil and Gregorio ArĂĄoz Alfaro of Argentina represented their countries at the LNHO (Dubin, 1995; Weindling, 2006). In dialogue with a French school of âpuericulture,â this Latin American contingent pushed for LN involvement in child and maternal health issues. The LN sponsored a conference on this topic in Montevideo in 1927, leading to the creation of the Instituto Internacional Americano de ProtecciĂłn de la Infancia (IIPI), also based in Uruguay. The IIPI served as a âbridgeâ between the LN and American states, including the US though mainly Latin American countries, but at the same time it had considerable autonomy, both in financial terms and in setting an agenda on child health (Birn, 2006; Scarzanella, 2003). Meanwhile, ILO involvement in Latin America began in 1925 when Albert Thomas, the organisationâs director, visited Chile to recognise the progressive labour and social laws its government had enacted in 1924. These included the creation of the Caja del Seguro Obrero (CSO), a large social insurance fund that offered medical services, and Chileâs prompt ratification of several ILO declarations (Wehrli, 2012).
During the tumultuous 1930s, in a push for legitimacy and to ensure their survival, the Geneva institutions increased their activities outside of Europe (Packard, 2016). The ILO intensified its engagements with the region in the 1930s, not least because the ILO leadership âwas aware that the organisation was in dire need of Latin American support if it wanted to survive the looming European crisisâ (Plata-Stenger, 2015, p. 97). The ILO also recognised that, in comparison to Europe, Latin American countries were relatively peaceful and politically stable, and already showing demonstrable advances in welfare state policies (Herrera GonzĂĄlez, 2012). With much of the worldâs territory still colonised by European powers, Geneva found it hard to ignore Latin Americaâs independent states, who were already involved with closely allied US-led health institutions, the Pan-American Sanitary Bureau (PASB) and the International Health Division (IHD) of the Rockefeller Foundation (RF). Such engagements, argue Cueto and Palmer (2015, p. 106), âwould provide the principal blueprint for the fully âinternationalâ health apparatus that emerged in the post-World War II era, when the nation-state became the global norm.â
Relations between the US- and Geneva-based institutions were complicated and inconsistent. While the US remained outside of the LN system, some Americans were well-placed within the LNHOâs advisory body, and the RF enjoyed a âsymbiotic relationshipâ with the LNHO, supplying about 30 percent of its budget (Dubin, 1995). And while the ILOâs relocation to Montreal, Canada during the war facilitated its work in the Americas, its leadership had to be mindful of Washingtonâs desires and âthe competitive force of Pan-Americanismâ (Singleton, 2012, p. 241). Meanwhile the United States reasserted its hemispheric hegemony with the soft diplomacy of initiatives like the Good Neighbor Policy of 1933 and an attempt to create a Pan-American Labor Organization to supplant the ILO in the Americas. As a result, the planning of meetings to discuss seemingly innocuous and technical policy matters often entailed fraught diplomatic negotiations behind the scenes (Herrera GonzĂĄlez, 2012; Singleton, 2012).
Ultimately, friction with the US kept Genevaâs health institutions from developing strong and sustainable ties with Latin America. For example, the PASB was initially indifferent to child health initiatives, so it did not block the LNâs sponsorship of the IIPI. However, just a few years later, PASB director Hugh Cumming (of the US) influenced the composition of the expert team conducting the LNHO-sponsored nutritional survey of Chile in 1935 and intervened to block LNHO sponsorship of a rural hygiene conference in Mexico the same year (Birn, 2006). The IHDâs heavy involvement in the control of infectious and vector-borne diseases in Latin America deterred all LNHO efforts in this domain, except for a leprosy research centre in Rio de Janeiro (Birn, 2006).
Thus, during this period Latin American social policy experts, bureaucrats, and sympathetic politicians were often required to gauge and triangulate their interests against those of Europe and the United States. However, the root of these tensions did not necessarily lie in philosophical differences about health and social policy. Packard (2016), among others, has suggested that the Geneva institutions championed social medicineâs programme of broader, systemic so...
