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date: 23 April 2019

History of Public Health in Latin America

Summary and Keywords

From the late 19th to the late 20th century, Latin America was a developing region of the world in which public and private health discourses, practices, and a network of agencies were consolidated. Many organizations appeared as a response to pandemics, such as yellow fever, that attacked the main ports and cities, and they interacted with global agencies such as the Rockefeller Foundation. Frequently, single-disease-focused and technocratic approaches were promoted in a pattern that can be defined as the “culture of survival.” However, some practitioners believed in public health programs as a tool to improve the living conditions of the poor, the most important being comprehensive primary health care, which emerged in the late 1970s. Toward the end of the Cold War (ca. 1980s), neo-liberal reformers supported a restrictive idea of primary care health that overemphasized cost-effectiveness and efficiency.

Keywords: history, Latin America, public health, culture of survival, Rockefeller Foundation, 20th century, Brazil

Ideas and practices of prevention existed in pre-Columbian and colonial Latin America and during the early era of independent republics in the first half of the 19th century. (Cueto & Palmer, 2015). However, only from the mid-19th century did a network of institutions, journals, scholars, and university chairs linked to public health become stable and prominent. This article summarizes the more recent history up to the late 20th century and emphasizes a pattern in the official public health of Latin America captured in the notion of a “culture of survival.” This term means that most official health interventions have not sought to solve fundamental problems that, in the final analysis, have to do with living conditions. The authorities have generally promoted a short-term, palliative, and temporary form of public health looking for rapid technological solutions to disease problems.

First Institutions

Since the mid-19th century, Latin American medical leaders, usually known as higienistas (supporters of hygiene), sought strong representation of physicians in municipal, state, and national governments to address sanitary emergencies and support urban reforms. The term “hygiene” essentially referred to practices of urban cleanliness that helped to protect economic and social development. Higienistas made progress implementing the public health reforms envisioned in the late colonial period (the late 18th century for most countries) such as permanent systems for the cleaning of streets and garbage collection, smallpox vaccination, quality control of food sold in markets, modern sanitation in ports and maritime commerce, and hygiene education in schools. These reforms followed the mercantilist argument that to strengthen the state it was crucial to increase the nation’s population and to protect and increase its exportation of primary products. Argentina’s health pioneer, Guillermo Rawson (1821–1890), an advocate of European immigration, was an example of a “political doctor” who became a member of parliament and Minister of the Interior under Bartolomé Mitre, a president who gave priority to regular accounting of population growth for medical, economic, and political purposes. Notably, when Rawson retired from politics for good, he returned to university teaching and became the first holder of a chair in public hygiene in Argentina.

These institutions and individuals were tested by the great pandemics of the 19th century: cholera, yellow fever, and bubonic plague. Major outbreaks of cholera in the main Latin American cities occurred in 1848–1850, 1854–1857, 1865–1867, and 1873–1874. Almost everywhere, the first response was flight from the infected locations, religious processions, prayers, and miraculous cures. On top of the suffering caused by cholera came yellow fever, a disease considered until the middle of the 19th century restricted to the Caribbean basin. In Argentina, at a time when the mode of contagion was still unknown, yellow fever attacked the city of Buenos Aires in 1852, 1858, 1870, and 1871. The latter epidemic was tragic, producing panic and massive mortality among the poor. Both diseases became political priorities because they were new to many places, attacked ports and cities above all, and paralyzed trade. The arrival of bubonic plague in the ports and cities as part of a pandemic that began in Hong Kong in 1894 shaped the public health networks of Latin America. The disease arrived with infected rats that hid in the merchandise of commercial ships. Plague was feared because it was a new disease to the Americas and already stigmatized by virtue of being “Asian.” Plague attacked Asunción (Paraguay), Rosario (Argentina), and Santos (Brazil) in 1899; Montevideo in 1901; Iquique (Chile) in 1903; and Lima in 1904. With the exception of Ecuador and Peru, it did not have a significant impact on mortality in Latin American countries, but it was still feared for its potential danger, and it catalyzed the efforts of higienistas to promote sanitation in the cities. Latin America’s bubonic plague years made the sanitary deficiencies of its cities more visible. Rodents could procreate easily in urban areas due to the overcrowding, garbage accumulation, precarious slums, and inadequate sewerage. Mayors, prefects, and planners found resources to imitate what had been done in European cities in terms of sanitation, policing, and urban reforms.

Epidemics also generated moralizing archetypes of a healthy body and ideal lifestyles and stereotypes of gender, patriotism, and citizenship. Some considered poverty the social cause of disease, even going as far as to blame lazy individuals. That is, the diseases of the working classes were explained in terms of their perverse anti-hygienic habits, little regard for moral values and the waywardness of their private and family lives, visible not only in the filth around them but in alcoholism, “venereal” diseases, and even mental illness. These explanations were functional during a period of urban growth and changes in social hierarchies. Extreme overcrowding in housing and unhealthy working conditions came with incipient industrialization.

An important result of these epidemics was that the first stable sanitary services and expert personnel emerged, initially in municipalities and later under the jurisdiction of national ministries of education, justice, or the interior. Bacteriological institutes also appeared, following scientific developments in Europe, under the assumption that they would produce the sera and vaccines to control infectious diseases like plague and smallpox. All of these emerged at the turn of the 20th century replacing miasmatic medical ideas that blamed rotten matter, swamps, and garbage as the cause of infectious diseases and replacing ephemeral institutions or boards that functioned only during epidemics or that had a limited mandate to protect a specific city. They were a key element in the formation of public health elites who wanted to bring government sanitary authority to the entire territory that was formally—but not effectively—under state jurisdiction. An old desire dating back to the colonial period seemed to be coming to life: coercive state intervention in the everyday life of families, careful medical supervision of economic activities linked to the export economies, and the right of public authority to protect the healthy by segregating the sick. The increasing power of official public health led to more supervision of popular health practices, discrimination against indigenous and Afro-American healers, and greater medicalization of everyday life.

A major scientific achievement would consolidate the political power that public health networks were achieving during the turn of the 20th century. The control of yellow fever in Havana—concentrating on Aedes aegypti mosquito control—in the wake of the American Spanish War in Cuba (1898) was one of the most important episodes in the modern history of medicine in Latin America. It produced a marriage between science and hygiene, ridding a major city of a deadly disease that had been endemic there for over a century (Espinosa, 2009). In doing this, it confirmed the promise of the control of disease-carrying insects. The Havana yellow fever triumph also occurred in the wake of its independence from Spain thanks to the support of the US military and US military physicians (who worked with Cuban physicians who had been studying the disease such as Carlos Finlay). It marked the beginning of greater US influence in Latin American medicine and public health and promoted technological health programs. Shortly thereafter, Cuban-style programs of mosquito control against yellow-fever transmission were carried out in Mexico, Panama, Rio de Janeiro, São Paulo, and New Orleans, among other cities. The first methods to combat mosquitos included fumigation, the covering of water containers with metal screens, the creation of quarantines, and, sometimes, the destruction of places. Some of these methods were complex, expensive and uncertain (fumigation, for example, consisted of the incineration of sulphur in a box that was placed for hours in a building sealed with cloths). That is, only the most powerful nations could apply the methods. By 1910, campaigns concentrated on the destruction of larva in domestic water containers had become the method of choice in most places. However, the system did little to change the tradition to store water in precarious containers and to modernize unsafe water and sewage systems (that helped the proliferation of the Aedes mosquitoes).

Converging developments in medical science and public health helped to further institutionalize public health in Latin America at the beginning of the 20th century. New and stronger sanitary programs, frequently associated with specific campaigns against a disease, were created. Thus, sanitary health systems took the form of a collection of vertical disease-control services. These campaigns legitimized the political support and economic investment in new organizations formed for basic and applied research among political elites for whom science was only justifiable on utilitarian grounds. One of the most important campaigns and services inspired by what had taken place in Cuba was launched by Oswaldo Cruz (1872–1917) in Rio de Janeiro (Benchimol, 2001). A few years after he returned to Brazil after his postgraduate studies in the Pasteur Institute of Paris, he convinced the government of the urgency to create a research institute for production of plague serum and other biological products for medicine. The government agreed and Cruz became director of the new institution (Oswaldo Cruz Foundation, or today, Fiocruz, the main biomedical institute of the country). The institution was inaugurated in 1900 in Rio de Janeiro with the mandates to conduct original investigations, train researchers and to design effective public health policies. Later, Cruz was named Director General of Public Health. As in the case of Cruz, starting in the 1910s, Latin America’s central governments, in the process of expanding their authority, began to form cabinet-level secretariats of health, to create agencies to administer social security plans and consolidate the links between European medical science, teaching, and research in medical schools and public health programs.

The Rockefeller Foundation

Hygiene and the “Americanization” of medicine in the region received a boost from a private philanthropic organization that believed it had a mission to spread Western medicine throughout the world: the Rockefeller Foundation (RF). The objectives of the RF resonated with a confidence in the civilizing powers of western medicine. The organization’s main presupposition over the first half of the 20th century was that backwardness was mainly due to infectious disease that not only caused death but undermined productivity and life expectancy. The missionary motivation was clearer in some RF field officers who generally did not hesitate to work side by side with local doctors, and who believed they were creating incentives for the making of modern, national medical systems.

The International Health Board (later Division, IHD) of the RF began work in Central America and the Caribbean in early 1914, forging its characteristic method that subsequently would have influence in the rest of the world. The RF usually began its work by establishing a hookworm treatment program because it was considered the best way to establish contacts and credibility with local political and medical elites, as well as with vanguard public health actors, and to demonstrate the virtues of its approach to the widest possible audience (Palmer, 2010). The Rockefeller hookworm treatment programs were frequently reshaped into public health ventures that incorporated local participation and priorities, and bore little resemblance to the objectives articulated in the New York office. The same cannot be said for all RF missions, however. With other diseases and in other countries, officers of the RF could be rigid and authoritarian in its methods and some officers were less willing to interact with local actors. The case of yellow fever, for example, reveals a distinct RF methodology. After 1916, a key objective of the RF was the eradication of yellow fever in endemic cities of the Americas. This decision was due to three factors: (1) a fear that the ports of South America would reinfect the southern United States; (2) the danger that the inauguration of the Panama Canal in 1914 would allow for the spread of yellow fever from the Caribbean to tropical Asia (until then free of the disease); and (3) the search for a US scientific triumph in identifying the etiological cause of the disease. In 1918, the RF undertook its first campaign against yellow fever in Guayaquil, a port considered the source of infection in the Pacific region of South America. Subsequently, the Japanese-American bacteriologist Hideyo Noguchi announced that he had isolated the microorganism that produced the fever: Leptospira icteroides. Upon his return to America, Noguchi produced a serum and a vaccine, and although these were never the primary means of prevention and cure, both were used on thousands of people in Latin America.

During the 1920s, the RF was convinced that it was possible to achieve the eradication of yellow fever and that all that was needed was to apply modern techniques against the Aedes a. However, starting in the late 1920s, fever outbreaks in the interior of Brazil, Colombia, and Venezuela indicated that these hopes and Noguchi’s discoveries were wrong. It was realized that yellow fever was transmitted by several species of mosquito and that there was a virus reservoir in infected monkeys living in the jungle. These findings were parallel to scientific studies. In 1927, an RF laboratory in Africa found that the fever was caused not by Leptospira i. but by a virus, and it was only in 1937 that an effective vaccine appeared. At the same time, it was realized that massive vaccination was impossible.

In Brazil, the RF notably supported the main medical and public health faculties and operated the Brazilian Yellow Fever Service where Fred Soper of the USA and a number of Brazilians—usually trained in US universities like Johns Hopkins—distinguished themselves. The fight against the disease was carried out through rural posts, in areas where the disease was widespread. On top of this, in 1938 Soper carried out a successful military-style campaign that allowed for the elimination of the malaria-transmitting African mosquito, Anopheles gambiae, which had invaded the Brazilian state of Ceará (Packard & Gadelha, 1994). The success inspired other such efforts in Latin America and the rest of the world during the 1940s and 1950s. Using strict military discipline, Soper successfully controlled the epidemic and effectively destroyed this species of mosquito, though he did not make malaria disappear from Brazil.

Scholarships and donations from the RF began to promote a US model in public health and medical education. This model emphasized the training of a professional elite experienced in laboratory methods that would direct the changes in medicine and health and promote the need for adequate pay for full-time positions at Universities. The RF offered fellowships and grants to Latin Americans to study in or visit the USA, as well as promoting the visit of US medical scientists and health leaders to Latin America. One assumption that came with the awards was that the fellows, once back home, would reproduce the US model of medical education, public health, and scientific research (often taking as the prototype Johns Hopkins University as a model). One result of these scholarships was that US influence increased, surpassing those who still considered France or Germany the model of medical education and research. In the RF’s educational work with local public health institutions, the North Americans took advantage of prior experiences like the hygiene courses that had been taught since the 19th century to professionalize public health.

An example of the former was the chair, and later a department in hygiene, established in the University of São Paulo’s Faculty of Medicine (located in the richest state of Brazil). The first professor of the chair was Samuel Taylor Darling, sent by the RF in the early 20th century. One important Brazilian professor who emerged in the 1920s in this institute was Geraldo Horácio de Paula Souza, a graduate from the Johns Hopkins School of Public Health who would go on to play an important role in the creation of the World Health Organization. By 1929, medical doctors could get a diploma in public health by doing a specialized course and in 1931 the institute was transformed into a school for hygiene and public health that was different from the medical school of the University of São Paulo. In Mexico, also with RF support, a school of public health separate from the faculty of medicine was created in 1922, offering a diploma in public health medicine.

For Latin America, the years between the two world wars was a period of economic and political difficulties, but also one of institutionalized social policy demands that led to the consolidation of specialized health agencies with direct representation in cabinet-level ministries. Starting in the 1930s, processes of institutionalization in the area of health were intertwined with the emergence of social and political movements. Following the depression of 1929, populist movements, generally led by charismatic leaders, brought an end to oligarchic regimes with limited citizenship that had characterized most countries since the late 19th century. The institutionalization of health in Brazil advanced in the 1930s under the leadership of lawyer Gustavo Capanema, the Minister of Education and Health at the helm of a ministry created in 1930 by the populist government of Getulio Vargas. Significantly, Capanema remained in his cabinet post for a long time, something uncommon in Latin America. In 1937, he reorganized jurisdictions in Brazil and mandated in each a federal health delegation as a link between the central government and local authorities. Capanema expanded the sanitary interventions against endemic rural diseases begun in the early 20th century. Under his direction, and partially funded by the RF, a series of national services were organized in a way that verticalized the fight against specific diseases like yellow fever, leprosy, and malaria.

Similar developments occurred during and after World War II. Mexico’s official health policies were reinforced with the 1943 creation of the Ministry of Health and Welfare to regulate all federal matters related to health care and hospitals. The new ministerial entity merged the Department of Health, founded in 1917, with a Secretariat of Welfare that dated from 1938. The ministry sought to control epidemic outbreaks, organize immunization campaigns, provide maternal and child health, and help the construction of safe water systems in urban areas. In Argentina, the populist government of Juan Domingo Perón created a Ministry of Health in 1949 that until 1954 was led by Ramón Carrillo (1906–1956) who was able to centralize state power in the area of health. He also promoted an epidemiological reporting system and obligatory notification of infectious diseases, constructed new hospitals and health centers and tried to establish meritocratic criteria in health bureaucracy. According to Carrillo, health facilities should not only provide medical care but also educate people about nutrition, hygiene, and medicine through free brochures, films, and radio advertisements. However, the health ministries operated in a fragmented system of social policies. Ministries of labor, armed forces, and private medical hospitals, and even a philanthropy of the wife of Perón, also dealt with individual and collective treatments and sanitary conditions. Thus, the attempts to implement articulated universal health policies was never a full reality.

The international work of Latin American public health during the interwar period included one of the first multilateral agencies: the Pan American Health Organization, created in 1902 as the International Sanitary Bureau (and named until 1959 the Pan American Sanitary Bureau). In 1920, the Sixth Conference of the Sanitary Bureau held in Montevideo brought a renewed impetus to Pan-American sanitarianism and to the influence of the USA. Its new director was Hugh S. Cumming (1869–1948), also Surgeon General of the United States and its budget was mainly funded by the US government. Cumming would be director of the agency for the next 27 years, from 1920 until 1947, reelected at each of the subsequent sanitary conferences. Soon after the Montevideo meeting, from 1923 onward, the bureau began the regular publication of an influential bulletin. The agency was essentially made up of a group of functionaries who worked in Washington, DC. They ran a few field operations, especially with regard to plague control and smallpox vaccinations, and maintained contact with the health authorities of each nation (with the important exceptions of Canada and the European colonial possessions in the Caribbean). All this was done with a budget more limited than the one used by the RF. The Sanitary Bureau made one remarkable contribution: recognizing health as a legal right of countries and people in the American Sanitary Code adopted at the Seventh Conference held in Havana in 1924.

US influence in the public health systems of the region was reinforced during World War II with the intervention of a US federal agency: the Office of the Coordinator of Inter-American Affairs. It was created in 1941 as an arm of the State Department and directed by Nelson A. Rockefeller, grandson of the oil magnate who had established the RF, to counter Nazi influence in the region and strengthen trade, medical and cultural ties between the USA and Latin America (Campos, 2006). This office conducted educational and public health programs that included building hospitals and water and sewage systems and providing scholarships for medical students. There was also an interest in keeping close supervision of primary products vital to the war effort, including quinine that existed in the Andes and rubber in the Amazon (and for which a number of medical expeditions were organized). These activities were developed in each country by organisms called “cooperative public health services” that were formally under the supervision of the ministries of health, but enjoyed de facto autonomy.

During the formative period of the World Health Organization (WHO), from 1945 to 1948, the new United Nations agency absorbed almost all previous international health agencies. It did not, however, absorb the Pan-American Health Organization, to the chagrin of some European and Asian health experts who argued that WHO should be really unique. Meanwhile, Latin Americans discussed their position on the WHO and felt that the Europeans did not respect Pan-American traditions enough. The issue was settled in January 1947 at the XII Pan American Sanitary Conference held in Caracas where delegates assured people that it was possible for the countries of the Americas to maintain membership in two bodies—the WHO and the Pan-American Sanitary Bureau—because the creation of other regional offices in the former was expected. As a result, a resolution stated that the bureau would work as the regional arm of WHO for the Americas.

The main public health campaign in Latin America of the post-World War II period was part of an international effort. In 1955, the WHO Eighth World Health Assembly, held in Mexico City, approved a global malaria eradication campaign—an effort to eliminate a disease that plagued rural areas and was transmitted by the Anopheles mosquitoes (it is important to note that the WHO was then directed by a Brazilian, Marcolino Candau, who was a former Rockefeller officer). Great hopes existed around the insecticide DDT to kill mosquitoes during and after World War II. Latin American governments, USAID (United States Agency for International Development), UNICEF (United Nations International Children’s Emergency Fund), and the Rockefeller Foundation agreed to finance the campaign for five to eight years, the amount of time WHO had deemed sufficient for eradication by mainly using DDT against the Anopheles. US support of eradication was part of a Cold War policy that aimed at winning the political will for capitalism in countries searching for development in a bipolar world where the Soviet Union was an important reference. Eradication was launched when authoritarian pro-business regimes were interested in capital-intensive agriculture and in the full assimilation of rural dwellers into ideal models of citizenship. In the following years, Mexico became a model of malaria eradication for the rest of the region and vertical campaigns were tried in other health programs like family planning to control the growth of the so-called overpopulation of the region. The eradication program succeeded in driving malaria out of periurban areas of the Americas, but in its overall goal it failed and the disease returned dramatically in the late 1960s. By the end of that decade and into the 1970s, Latin America, suffered again from endemic malaria in several rural areas (Cueto, 2007).

During the early 1970s, a political context favored the emergence of a concept alternative to the vertical approach enshrined in malaria eradication: primary health care. New holistic proposals for health and development appeared that emphasized the work of medical auxiliaries, promoted the reorganization of health services and criticized the assumption that an extension of traditional medical services would per se improve the health of the population. Primary health care was also favored in the region by the spread of anti-imperialist and leftist movements in Latin American countries. These changes led to new proposals on development and modernization was no longer seen as the replication of the model of development followed by the United States. The landmark event for primary health care was the International Conference on Primary Health Care that took place at Alma Ata September 6–12, 1978. Alma Ata was the capital of the Soviet Republic of Kazakhstan, located in the Asiatic region of the Soviet Union. Most Latin American countries sent representatives from their ministries of health and in some cases—like Costa Rica, a country that had a remarkable health system—politicians.

While PHC did not emerge from Latin America, and many experts consider that it has yet to be fully implemented, many partial and national programs in the region anticipated the global consensus reached at Alma Ata. The continent’s most ambitious primary health care-based systems, in particular that of Cuba, offer the promise of health services to all members of society and the integration of popular medicine, biomedicine, rehabilitation programs, and preventive medicine into a dynamic health system. Starting in the early 1960s Cuba had followed many of the socialist countries in the Soviet sphere in reforming its health system. One important difference was that these changes had to take place in a country that was basically rural and had a high degree of illiteracy. That is, the objectives of literacy, industrialization, and improvements in the quality of life accompanied the efforts made in the health realm. A new ministry of public health was formed, there was a dramatic expansion in the coverage of vaccines, and the pharmaceutical industry was nationalized after it opposed the lowering of the price of medicines. At the same time, there was a remarkable building of hospitals and dispensaries in the countryside where the majority of the population lived. Medical and public health education in a much-expanded university system was radically reformed and made free. All these reforms laid the basis for a single, free, and universally accessible health system which was rare in Latin America (Feinsilver, 1993).

Changes in Cuba through the 1960s and 1970s coincided with criticism, of both a radical and a moderate kind, by some Latin American doctors, politicians, and intellectuals of the traditional modernization programs that replicated approaches put in place in industrialized countries. A leader of this criticism was the Brazilian physician and communist militant Antonio S. Arouca (1941–2003), who had a background in preventive medicine and sociology. He helped to coin the term “collective health,” or saúde coletiva, which became widespread in Brazil in the 1980s as part of struggle against the military dictatorship of the day. The term advocated a widening of citizenship to include social rights like health, major improvements in living conditions and to the full exercise of democracy. In March 1986, Arouca presided over the Eighth National Conference on Health that led to the creation of a social movement and a unified Brazilian single health system (SUS). The event was inaugurated by President José Sarney (who came to power after decades of military dictatorship in a transition period towards a democratic regime). The movement was able to bring together private, state, and religious organizations, as well as health research institutes to back the guarantee of access to services by the entire population. In addition, by the 1970s a trend that came from the previous decade consolidated public health systems: the link between development and public health programs. The success achieved in the worldwide elimination of smallpox in 1980 (Latin America as the first developing region in the world to achieve this goal a few years before) was instrumental to reinforce this link (Hochman, 2009).

Health After the Cold War

The emergence of new diseases and new public health challenges to the region in the 1980s changed the shape and format of public health (Smallman, 2007). The first Latin American responses to AIDS (acquired immune deficiency syndrome) in the early 1980s were marked by irrational fear and counterproductive segregation as well as the demand for blood tests prior to civil marriage. An inhumane regime appeared in Cuba, where patients were isolated initially in sanatoria, though this system was terminated relatively quickly. Nevertheless, the death of Latin American actors and artists—more than that of poor and unknown migrants returning from New York or San Francisco to die in their homeland close to family—obliged governments to intervene. Physicians, patients, and activists bravely confronted the predominant neo-liberal political current to make AIDS a priority public health issue. Toward the middle of the 1980s, it was accepted that the disease existed in the region. The first to accept this publicly were the governments of some cities and states, after its existence was absurdly denied by some politicians and national health authorities (an argument that in some countries consisted of the claim that there were not many homosexuals in Latin America). It is worth noting that the resulting, more proactive governmental action was a product of two factors above all. First was the pressure exerted by non-profit NGOs (nongovernmental organizations). Second was the acceptance by the medical community at about the same time that new diagnostic tests, known as ELISA, constituted a technology capable of demonstrating empirically the existence of the disease and a means for recording it.

By 1985, at least ten Brazilian municipalities and states, beginning with the city of São Paulo, had created anti-Aids programs that delivered advice, promoted sex education, and fought homophobia. This was how local state HIV-AIDS programs preceded the federal program that appeared only in 1986. The National Program for Sexually Transmissible Diseases and AIDS followed the directives of WHO’s Global Program on AIDS, at the time directed by Jonathan Mann, who became a champion in linking human rights and public health. By 1995, more structured anti-AIDS national programs had emerged, ones that took some of the previous ideas and that were decidedly supported by a new multilateral entity that did not depend on WHO: UNAIDS (United Nations Programme on HIV/AIDS). This new organism played an important leadership role and led to the creation of more complex and bold national programs that were capable of carrying out more pointed and effective campaigns to promote condom use. UNAIDS often promoted the recruitment or cooptation of NGO leaders in the new national programs that were better financed by a series of agencies, among the most prominent being USAID and the European Union.

Since the mid-1990s, AIDS responses were marked by the use of expensive antiretroviral medicines and the example of Brazil. In a neo-liberal context the Brazilian program challenged the giant pharmaceutical companies by developing and distributing generics (drugs identical to the brand-name ones) on the basis of their being a humanitarian good. In late 1996, the Brazilian government authorized the free access of anti-AIDS through the public health system and later promoted the production of generics as medicines against AIDS. In the late 1990s, a renewed program against AIDS, sustained by a coalition with health activists and educators, distributed generic antiretrovirals to AIDS patients, challenging the established rights that allowed powerful transnational pharmaceutical companies to patent their drugs. It is important to note that the dialogue between the Brazilian state and the companies in question was never completely severed and a skillful Brazilian Minister of Health got them to reduce the selling price of their medicines. By June 1998, some 58,000 Brazilians living with AIDS were being treated with therapies that only a little earlier had been virtually inaccessible. As a result there was a drop in the number of deaths, a reduction in hospitalizations, and, in turn, significant savings in the health budget. Most important, the quality of life of people living with AIDS improved (Nunn, 2009).

The Brazilian example was taken up by WHO, which at the beginning of the 21st century launched an ambitious program to treat three million people with antiretrovirals by 2005 (a program known as “3 x 5”), and they received the backing of the World Bank, UNAIDS, the Global Fund for AIDS, TB and Malaria (created in 2001), and other agencies. In this sense universal access to antiretroviral treatment became a battle cry of patients, including in Brazil where states that do not provide them were taken to court in a process that is giving new meaning to the constitutional right to have free access to medicines.

AIDS revealed that Latin America was part of a globalized world. As well as AIDS, cholera, multiple drug-resistant tuberculosis (TB-MDR), and dengue emerged in South America (the latter coming from the Caribbean). In February 1991 cholera, broke out simultaneously in Peruvian cities but spread to virtually every city of Latin America within a short period of time. Despite the extension of the epidemic, cholera took a surprisingly light lethal toll: the death rate was less than 1 percent of cases. Nevertheless, in rural areas the rate reached 10% mortality and in the Amazon region about 6%. These statistics contrast with those from other parts of the world like Africa where at the beginning of the epidemic a lethality of 30–50% was registered. These outcomes were thanks to the dedicated work of health personnel who discovered during the emergency phase the power of oral rehydration packets. They sometimes rehydrated patients via both arms and legs, and sometimes intravenously and orally; these were all heterodox methods not considered in medical manuals but that proved very effective. One result of this epidemic in Peru and in other countries like Venezuela was the blaming of the principal victims. “The dirty folk”—los sucios—and the indigenous people were presented by governments as those who chose a lifestyle that created the conditions of the epidemic (Briggs & Mantini-Briggs, 2003). Cholera was used as a means of underlining who were considered “sanitary citizens”—that is, individuals who by initiative and education exercise hygienic practices and rely on regular medicine and so deserve more care and attention from governments. Stigma was functional given the little effort to solve the social determinants of disease (unsafe water systems) and the disease became endemic in some countries.

The fight for holistic primary care programs was challenged by neo-liberal health policies during the late 1980s and 1990s. Toward the end of the Cold War (ca.1989) neo-liberal proposals began to define a technocratic idea known as selective primary health care (SPHC). They conceived of health interventions principally in terms of cost-effectiveness and limited treatment interventions to control diarrheas in shantytowns, and promote better nutrition and immunization programs. Neo-liberal reforms also implied the introduction of a managerial regime in social as well as health policies, with the assumption that the private sector was more efficient and less corrupt than the public sector. They meant a return to the pattern of understanding health as a mending patch, namely, as part of a culture of survival. Attempts were made to reduce the role of the state—with more intensity in Colombia and Mexico—to regulating (rather than providing) services, with the idea that a free market would promote competence, generate competition in social security, and so offer treatments of better quality. As a result, new actors and institutions appeared in the region, like prepaid medical companies linked to international finance. Many health systems, seeing the way their budgets and personnel were being reduced, tried to improve health monitoring and change their language to use the new key words like efficiency, efficacy, productivity, and clients (patients who had to be “satisfied”). The new medical-administrative vocabulary announced the return of the culture of survival. Many medical doctors working in Latin American ministries of health had greater difficulty in coordinating their activities with other public and private sectors especially with non-professional health workers. For supporters of neo-liberal reforms the ideal was a mixed public-private system. Public health had to deliver a package of limited intervention treatments.

For some, neo-liberal health reforms were little more than a re-elaboration of imperialism seeking greater opportunities for finance capital in health and social security markets (Hernández, 2004). Researchers and organizations defend the idea that health should not be reduced to improving productivity or maintaining national security but rather is a fundamental right of people and of countries and a means to promote solidarity. These include the Latin American Association for Social Medicine (Asociación Latinoamericana de Medicina Social, ALAMES) and the Brazilian Association for Collective Health (Associação Brasileira de Saúde Coletiva, ABRASCO). They accused neo-liberal health reforms of overemphasizing efficiency and cost-effectiveness over equity and paying little attention to prevention and community participation.

Conclusion

The case of malaria eradication in the 1950s is an example of public health understood as a culture of survival. The first characteristic of this model was the glorification of technology. The technologistic imprint granted no great importance to the construction of integral health systems or to community participation in the design of the health programs’ needs. At the same time, the triumphalist trumpets sounding for new technologies—DDT in the case of malaria, or more recently the concentration on distribution of antiretrovirals for AIDS—have taken for granted that the objective of the campaigns could be achieved without the improvement in living conditions of the poorest and marginalized people. The latter was a process perceived as more difficult. The “culture of survival” assumed, moreover, that all the necessary technology was available, and had been validated in international academic journals and approved by bilateral and multilateral agencies.

A second characteristic of the “culture of survival” was a discontinuity in efforts and institutional fragmentation. In such cases campaigns generally ended up diluted when they failed to achieve their objectives in the terms initially proposed, or if the programs languished. This ended up creating confusion and a disorganized recoiling from what might have been a laudable motivation to put an end to important human problems. Insufficient attention was paid to the need to analyze the difficulties encountered or the gains made in order to spotlight the challenges that public health had to confront. When things went badly there was a recurring attitude of forgetting the initial objectives proposed, celebrating the small gains made, and reorienting involvement toward something different. From the failure to eradicate malaria, there was a shift with very little discussion to new objectives and new deadlines, like the one expressed in the motto “Health for all by the year 2000” launched at WHO’s Alma Ata conference in 1978. Such discontinuity became a characteristic of health work. Many Latin American health systems—such as the ones that existed after the decline of malaria eradication—were marked by such fragmentation; they had, for example, weak vertical programs similar to the eradication campaign and some more holistic alternatives embedded in a general culture that was disintegrating. The main problem with this tension was that it created rivalries and overlaps. Thus, the second characteristic of the “culture of survival”—discontinuity and fragmentation—weakened the construction of unified and flexible sanitary systems.

Finally, the third characteristic of this “culture of survival” was the promotion of a limited version of the nature of public health, understood as a patch for emergencies, with occasional and cost-effective interventions. The end result was that whether to promote the control of diseases or to engage in health promotion was presented as a kind of dilemma—a false one, evidently. The first seemed a priority while the second received less attention. Large segments of the poor in Latin American countries sincerely believed that official public health was a temporary response to emergencies, directed against epidemic outbreaks considered “intolerable” by politicians and the media. Sometimes health interventions were symbolic rituals, complemented by governmental indolence in the face of the deterioration of living and environmental conditions. Health work was popularly perceived as a short-term activity with little visibility and limited value in terms of lasting changes to society. In these conditions stigma and discrimination associated with disease was easier. In countries with various emergencies competing for the attention of the press, public health problems were frequently only dealt with when they became a scandal. As a result, the principal characteristic of public health—prevention—was weakened. Even worse, there developed an attitude toward morbidity of preventable endemic diseases as something “banal.” The “culture of survival” meant that often the poor got used to tolerating the deterioration in their living conditions and in taking on the care of their life and health, struggling for access to official or private social services to reduce pain, protect their loved ones, and postpone death. In other words, hegemonic public health renounced its nature as an activity that would guarantee equality of opportunities in life and the exercise of citizenship, independently of the circumstances of birth like social class, gender, or ethnicity.

Some health workers resisted the “culture of survival,” often by adapting official programs to local conditions. The dilemma that health workers have had to confront in sanitary emergencies throughout the 20th century is whether to save lives or to promote campaigns for prevention and the modification of the social conditions behind the disease in a way that becomes political. Generally, they have opted for the former, and they surely did what was expected of a doctor or health professional in saving those in danger, curing their loved ones, consoling those who are suffering, or protecting them from disaster. Latin American public health has been trapped by the culture of survival. Overcoming this restraint will require the transformation of a history and a sanitary culture that aspires only to survive, not to perdure or to see long-term, and fundamental changes in the living conditions of the majority of the people.

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