Medical Statistics and Public Health Legislation

As in neighboring countries that were navigating state-building amid civil conflict and economic vicissitudes, Uruguayan authorities were intent on developing modern legal-administrative frameworks even as instability hindered full implementation. In the realm of medical statistics, parishes initially continued to compile registries of baptisms, marriages, and deaths, relaying the information to the statistical agency of the country’s new Ministry of Governance. In 1837, with the Public Hygiene Board now involved, physicians were required to submit a daily table to the board documenting the age, sex, and diseases of patients they saw as well as a death tally. The board, in turn, produced three sets of statistical tables (initially quarterly, later annually) listing, respectively, births and marriages, deaths by sex and age, and deaths by causes.

This policy put public health authorities in charge of vital statistics, transforming collection of medical statistics into an important function of public administration. While parish-based registries were not eliminated, the epidemiological information gleaned from cause-of-death data gave state medical authorities a formidable tool that transcended the role of parishes. This transition was less tortuous in Uruguay than in countries where the Catholic Church retained a larger governance role. In 1858 cemeteries began to be secularized, moving under the purview of municipal authorities and death registrars, a process that unfolded gradually until the Civil Registry’s founding in 1879. Even so, problems of incomplete and irregularly submitted information persisted until the late 1800s. Still Uruguay’s administrative framework, together with such factors as its small size, accessible geography, and “lay” state, would eventually make it a Latin American frontrunner in collecting demographic and epidemiological information.

Meanwhile, legislation was afoot. In 1838 new sanitary police regulations spawned yet another Public Hygiene Board, comprising four physicians abetted by four permanent commissions. Beyond medical statistics, the Board’s reinforced roles and powers included: (a) advising the government on public health measures necessary to safeguard pure air and prevent the spread of epidemic disease; (b) recommending measures to maintain the cleanliness and ventilation of hospitals, barracks, and prisons; (c) ensuring the national supply and administration of (smallpox) vaccine; (d) preventing abuses related to medical and pharmaceutical practice; (e) conducting annual inspections of pharmacies; and (f) providing forensic and legal medicine advice.⁷ The new regulations further specified the composition and role of sanitary boards at the nation’s ports: inspection, quarantine, and issuance of bills of health for ships arriving from countries with plague, yellow fever, cholera, or typhus.⁸

Yet given underfunded mandates, unpaid services of board members, and concentration of authorities in Montevideo (resulting in relative neglect outside the capital), public health’s reach remained limited. It differed little from other governance areas in this regard, except that recurring epidemic diseases pressured the government to act, especially after the Guerra Grande subsided.

Epidemic Crises and Regional Agreements

Uruguay, as elsewhere, experienced repeated disease outbreaks throughout the 19th century, including smallpox, scarlet fever, yellow fever, and cholera. Epidemic eruptions of infectious/contagious diseases were generally time-delimited and resurged only sporadically. But as the population and international interchange grew, these diseases became endemic or appeared more often, albeit with different levels of intensity and impact.⁹

Smallpox was a major problem. Considered epidemic during the 18th century, by the 1840s it became endemic, with frequent outbreaks. In 1829 a vaccine preservation commission was established to prevent outbreaks but was understaffed (with just one vaccinator), lacked adequate regulations, and experienced problems with the serum itself. Ten years later, a new Central Vaccine Administration—run by local sanitary authorities country-wide—amplified the reach of smallpox vaccination.

Although public schools instituted a vaccine mandate in 1829, expanded vaccine efforts generated resistance, especially in rural areas. For instance, in the early 1840s the Public Hygiene Board president blamed both unvaccinated European immigrants and rural populations for the long duration of a smallpox epidemic in Montevideo.¹⁰ Rural–urban differences in vaccination rates persisted throughout the 19th century.

Particularly terrifying were a string of yellow fever epidemics, which hit Montevideo especially hard in 1857, when perhaps one-third of the population was infected, killing one-third of those—estimated at 60 percent of all deaths that year.¹¹ Yet the Public Hygiene Board did not recognize the outbreak as yellow fever, instead attributing it to severe gastrointestinal fever arising from environmental factors, and advising “atmospheric” measures consistent with miasmatic theories.¹² In the early 1870s, yellow fever struck both banks of the Río de la Plata. The infamous 1871 Buenos Aires epidemic decimated immigrant-dense areas and provoked panic, prejudice, and chaos (a subsequent Montevideo outbreak caused over three-hundred deaths).

The epidemic also prompted Argentinean officials to propose a sanitary convention with Uruguay as a bulwark against yellow fever from Brazil. This posed a dilemma: Uruguay’s sizeable trade in dried beef to feed Brazil’s enslaved and other immiserated populations centered on the yellow fever-endemic region of Bahia. Still, since most ships arriving to the Río de la Plata docked first in Montevideo (closer to the Atlantic), and abundant traffic crisscrossed the waterway, a harmonized bilateral response with a system of shared isolation hospitals was deemed highly useful.

In 1873, Brazilian authorities—concerned at the prospect of lengthy quarantine measures against its vessels—quickly jostled their way into an initial conference in Montevideo, over the objections of Argentinean diplomats. After several months of etiological and political tussles, especially vis-à-vis the familiar theme of quarantine length (Brazil forcing a three-day reduction during winter months), medical and diplomatic delegates managed to hammer out an accord. However, larger Argentine–Brazilian hostilities (regarding Brazil’s occupation of Paraguay following the War of the Triple Alliance) impeded its ratification.¹³

Cholera, too, remained a periodic menace, with a brutal 1868 epidemic linked to over one-third of Montevideo’s deaths that year.¹⁴ This time, Uruguayan officials were compelled to act. Sanitary authorities attributed the disease to vessels arriving from Brazil, Argentina, and Europe and accelerated opening of a lazaretto to isolate sick ship passengers.

In the mid-1880s, with tensions tempered, sanitary coordination was once again attempted. Now Brazil blamed cholera on its southern neighbors. In late 1886 Brazil closed its ports (except for one quarantine station) to all vessels from Argentina and from all other cholera-infected ports. Uruguayan officials, alarmed at the interruption of beef exports, dispatched a diplomat–physician–pharmacist trio (the last delegate charged with scientifically demonstrating that beef could not transmit cholera) to Rio. Argentineans soon joined the deliberations.

By then, medical specialists, their authority rising, met separately from—and informed the decisions of—the diplomats. Pursuing the region’s own priorities around trade and immigration, the three countries (under imperial Brazil’s dominant hand) came to agreement, years before hyper-competitive European powers were able to cooperate in this manner. With unanimity regarding the transmission of cholera (but not yellow fever), the ratified 1887 convention and accompanying health regulations stipulated preventive sanitary control measures in ports and on shipboard, and the use of lazarettos with quarantine lengths staged differentially for cholera (the shortest), yellow fever, and plague (the longest).¹⁵ Although the accord ended after four years (a 1904 replacement included reciprocal notification), it resonated across the continent and beyond: in quick succession, Andean countries signed the 1888 Lima Convention.¹⁶ South America’s developments foreshadowed the international (mostly European) sanitary conferences that began in 1851 but only resulted in conventions (initially for cholera) in the 1890s.

In sum, if Uruguay’s post-independence efforts at public health state-building yielded inadequate results amid civil conflict, budget shortfalls, and administrative vagaries, by the later 19th century the legislative and policy scaffolding that had been created, bolstered by regional agreements, put Uruguay at the cusp of sanitary progress.

Uruguay’s Modernizing Push

Uruguay gradually increased its participation in international markets, supplying food and primary materials. The backbone of the economy was export-oriented livestock agriculture, principally hides, wool, and meat, with Europe, the United States, Argentina, and Brazil as leading trading partners. Technological developments (including wire enclosures of private farmlands, animal breeding, and incipient mechanization) resulted in high rural unemployment, stimulating urban migration. This, combined with waves of immigration, spurred the growth of both Montevideo (which comprised 30 percent of the country’s total population by 1908) and regional capitals and larger towns. Early urbanization was accompanied by “modern” reproductive practices, reflecting the values of societal elites favoring lower fertility, in turn shaped by European ideologies and practices. Such values then diffused (initially) in urban settings.¹⁷

Alongside these economic and population trends, the main political forces, influenced by liberal and positivist ideas, were solidifying. Political elites implemented important policies that contributed to the country’s stability, peace, productivity, and progress, such as free, lay, and compulsory education for 6–14 year-olds (both boys and girls) and the secularization of schools, health facilities, and other institutions.¹⁸

Policies geared to public health and urban order meanwhile helped drive down mortality, especially among infants and children.¹⁹ In the 1880s Montevideo became the first Latin American city to install clean water, drainage, and sanitation systems, as well as street paving, electric street lighting, and routine garbage collection. The situation was so propitious that from 1890 to the early 1910s leading hygienists bragged about low infant and overall mortality was compared to most places that were then clocking such data in Europe and the Americas.²⁰

As one author put it optimistically, Uruguay merited the label “Promised Land.”²¹ Into this self-confident scenario, the 1908 Census, up to then the most comprehensive in the country’s history, was conceived as a tool to scientifically gauge progress, calculate the country’s population and economic growth, and plan for the future. It was also a wakeup call.

Conducted in the aftermath of Uruguay’s last two post-independence civil wars (1897 and 1904), the census showcased the country’s consolidation as a modern, democratic, legitimate state. However, the population was smaller than expected (contemporaries hoped it would greatly exceed one million inhabitants, but just one million were counted).²² Making matters worse, after Montevideo’s initial urban-planning successes, it was not adequately prepared for subsequent population growth: it experienced an “urban penalty,” that is, a relative excess of mortality due to poor living conditions.²³ The 1908 Census found that more than 10 percent of Montevideo’s population lived in tenements in the city center or in suburban shacks built from tin and wood. Because of greater crowding and deteriorated sanitary and living conditions, Uruguay’s health situation, as gauged by infant mortality, was worse in the city than the countryside.²⁴

Health, Well-Being, and an Incipient Social Welfare State: Institutional Developments

Uruguay’s pioneering social welfare reforms—associated with overall improvements in social conditions—are generally dated to José Batlle y Ordoñez’s early 20th-century administrations, but crucial developments presaged this period.²⁵ The government statistics office was strengthened in 1874 under director Adolphe Vaillant, who modeled Uruguay’s annual volumes on exemplars from his native France. The Civil Registry was instituted in 1879, assuming responsibility at a national level for registering births and marriages (from parishes), and deaths (from municipalities). This milestone in reliable, secular vital statistics collection enabled, starting in 1885, the publication of cause-specific mortality data based on a local 1874 adaptation of the nomenclature used in Paris’s Bulletin de Statistique Municipale.²⁶ In 1895 Uruguayan authorities adopted the classification developed by Jacques Bertillon and became active in periodic discussions around its revision.²⁷

In the meantime, confusing and overlapping responsibility for public health prompted various efforts at rationalizing and centering power in the hands of the Public Hygiene Board (Junta de Higiene Pública). As Vaillant argued, “public hygiene could and should form the basis of a bona fide national Ministry as is the case in several European countries.”²⁸ By 1895, pressure from the press and parliamentarians to emulate Europe and Argentina finally led to the creation of the National Public Health Council (Consejo Nacional de Higiene [CNH]) as a centralized sanitary authority with power to dictate and enforce domestic and maritime health policies. It still reported to the Ministry of Governance, and its members were contractual physicians.

The CNH set norms and regulations regarding epidemic disease, vaccination, prophylactic measures for prostitutes, environmental hygiene, and animal health, in addition to recording health statistics. It was also charged with coordinating efforts to prevent infectious diseases. As such, quarantine and isolation facilities and their equipment were all under the CNH’s aegis. To ensure the nationwide reach of CNH policies, provincial-level councils were created across the country, later replaced by roving health inspectors. In sum, the CNH had a broader purview than its predecessor, though its direct provision of care only spanned border inspections and quarantine administration.²⁹

The formation of the CNH reflected a larger medicalization tendency, which began in Europe in conjunction with medical and biological advances, the professionalization of physicians and scientists, and industrial needs. Uruguay’s medical elites trained in European hubs, such as Paris, Montpellier, Vienna, Berlin, and Edinburgh, bringing their learning to the University of the Republic’s Faculty of Medicine, organized in 1875.³⁰ In 1895, also heeding European influences, the new Institute of Experimental Hygiene was founded, with a star Institut Pasteur graduate, Italian Giuseppe Sanarelli, at the helm, briefly placing Montevideo at the cutting edge of bacteriology and parasitology research to combat prevalent infectious threats. The institute was involved in serum preparation (against diphtheria, typhus, etc.), public health and microbiology training, and clinical research.³¹ The belated launch of Uruguay’s medical faculty (compared to other Latin American countries) meant that medical hierarchies were less entrenched and more receptive to the latest scientific developments.

To note, at this time the state lacked a defined healthcare delivery role. Under colonialism, imperial authorities had focused on the health of soldiers, constructing three hospitals in the stronghold of Montevideo. After independence and until the early 20th century, healthcare services for the impoverished and newcomers were run by civil society actors. The well-off received care at home.

Montevideo’s charity hospital, founded in 1788, continued to serve poor and unhoused populations, with care provided by nuns. Starting in 1878 the medical faculty operated specialized clinics, mainly for instructional purposes, but also proffering care.³² There were also two asylums (for orphans and the destitute) and a mental hospital. Not all institutions were located in the capital: for example, the Paysandú Hospital, some 250 miles north, was inaugurated in 1862. In the late 1870s, three maternal asylums were established, inspired by European institutions. They functioned only during daytime hours, as a daycare-like arrangement for small children whose parents worked outside the home.³³

Meanwhile, mutual aid societies proliferated wherever immigrants conglomerated. Atop providing assistance for the unemployed and for burial costs, they purveyed medical care. The first such collective solidarity society, the Asociación Española de Socorros Mutuos, was set up in 1853, followed by French (1854), Italian (1862), and Neapolitan (1880) variants, among others. Initially, they covered principally laborers and owners of small businesses, serving as the origin of the early 20^th-century healthcare delivery infrastructure.³⁴ The first immigrant hospital, the British Hospital, was founded in 1857, with ensuing Italian and Spanish counterparts decades later.

It was only in the context of a series of social reforms, under Batlle’s first presidency (1903–1907) and his successor Claudio Williman, that state responsibility for healthcare was decreed.³⁵ An early measure targeting the most vulnerable populations was the 1908 creation of the first gotas de leche (child health clinics), modeled on French clinics. In 1910, the national charity commission was replaced by a modern National Public Assistance agency (Asistencia Pública Nacional [APN]). The APN was fashioned after—but even more expansive and centralized than—France’s Assistance Publique, with indigent persons granted the “right to free services provided by the State.”³⁶ Care for the chronically ill, the aged, abandoned children, and poor pregnant women and new mothers was organized via a coordinated system of orphanages and foundling homes, maternal asylums, charity hospitals, and other establishments (see figure 1).³⁷ In essence, these reforms refashioned traditional understandings of motherhood and placed maternal and child protection policies at the service of reproducing the Batllista state through fit and healthy future citizens.³⁸ The new law’s conceptual shift was crucial: health was now both an individual right and a state responsibility that guaranteed free care to needy populations in public, secular institutions, even as private (charity and mutual aid) and municipal services for the sick and the indigent continued to operate.³⁹

Open in new tab

Figure 1. APN First Aid Kiosk on Playa Ramírez in Montevideo.

Source: Colección Ministerio de Salud Pública y Asistencia Pública, Archivo Nacional de la Imagen y la Palabra (SODRE), Montevideo, Uruguay

A flurry of other laws followed, rounding out the state provision of social welfare: workers’ compensation, an eight-hour workday, a mandatory rest day, paid pregnancy leave, and tax-free essential goods. Batlle’s ambitious agenda unleashed decades-long redistribution and protectionist policies: old-age pensions, occupational safety, unemployment insurance, publicly funded higher education, and so on.⁴⁰ Together, these measures made Uruguay an early social welfare leader in the Americas and beyond.

Health and Mortality Dynamics

As these societal transformations were unfolding, Uruguay’s demographic profile shifted from high birth and death rates to lower ones. The principal motor of this transition was a decline in mortality, which began as early as the 1880s, succeeded by a drop in the birth rate, especially in Montevideo. In 1900 Uruguay was among the world’s healthiest countries, illustrated by its life expectancy at birth of forty-eight years, longer than most European and all Latin American countries.⁴¹ Infant mortality was less than a hundred deaths in a thousand births—besting every country then recording vital statistics except Norway and Sweden—almost a third lower than France’s rate.⁴²

In 1896 Montevideo’s public health officer, Dr. Joaquín de Salterain, touted his country’s plunging mortality, noting that Montevideo’s death rate was lower than those of Paris, London, and Buenos Aires. According to Salterain, social conditions, public health institutions, and hygiene education, as well as the mild climate, were crucial elements of these “pleasing results.”⁴³

An important aspect of the mortality decline was infectious and epidemic disease control. By 1900, a medico-political consensus on how to combat epidemics was emerging, with miasmatic notions displaced by bacteriological theory. Prior attention to purifying air in urban disease foci was replaced with identifying the source of epidemic outbreaks, such as contaminated water receptacles, and preventing the transmission of airborne diseases.

Interventions specified in CNH regulations included surveillance, quarantine, disinfection, border inspections of goods and travelers, systematic isolation in the lazaretto, obligatory physician reporting of certain infectious diseases, and, eventually, vaccination. Politicians supported these measures, recognizing that epidemics also engendered economic problems.

The aforementioned international sanitary conventions were aimed at preventing “exotic” diseases (yellow fever, cholera, plague), but the main epidemic diseases of the era were smallpox, diphtheria, scarlet fever, and typhoid, among others, which contributed far more to mortality than the frightening exotic diseases.

During the 1880s children faced repeated diphtheria outbreaks. Amid an 1887 episode, health authorities counseled, “Because croup and diphtheria are highly contagious and have no known medication, healthy children should avoid all contact with those infected.”⁴⁴ Of course, isolation was impossible in low-income households. Pastorian Émile Roux’s diphtheria anti-toxin, announced in 1894, held great promise for treating sick children of all social classes. Within just a few months of its establishment, Montevideo’s Institute of Experimental Hygiene began producing the serum, quickly becoming self-sufficient and fully covering all social assistance needs. In 1930, a statue was dedicated to Roux in Montevideo’s central Parque Rodó “from thankful Uruguayan mothers.”

On other fronts, as late as 1904 and 1909 severe scarlet fever outbreaks motivated temporary school closures, and in 1907 Uruguay reported on the problem of school transmission of measles and whooping cough to what would become the Pan American Sanitary Bureau (PASB).⁴⁵

Montevideo’s Municipal Vaccine Conservatory, founded in 1889, was Latin America’s first such institute. It both produced and supplied vaccines for the entire country.⁴⁶ Thereafter, smallpox vaccination coverage escalated, but distribution remained unequal into the 20th century. In 1901 CNH member Joaquín Canabal warned that organization of the vaccine service outside of Montevideo lacked resources. Other than two national vaccinators who worked for the CNH, the various authorities responsible for vaccination (municipal vaccinators, municipal physicians, health inspectors) responded to outbreaks but only secondarily administered preventive doses during lulls between epidemics.⁴⁷ The 1908 Census reported that 61 percent of Uruguay’s population was vaccinated, with rates varying from 87 percent in Montevideo to 55 percent in the countryside, and lowest of all in the most rural areas with poor literacy rates.⁴⁸ Border regions with Brazil, where smallpox was endemic and vaccination rates low, experienced especially frequent outbreaks. Yet vaccine mandates were slower to come to Uruguay than many places due to two influential anti-vaccination movements: one focused on individual liberties, the other claiming that reducing the prevalence of smallpox would lead to spikes in other diseases.⁴⁹ It was not until 1911 that vaccination and revaccination became obligatory at a national level, after a successful lobbying effort by a chorus of physicians led by the CNH. Sadly, this was too late to save public health officer Gabriel Honoré, who died while attending to a 1910 smallpox outbreak.

Throughout this time, tuberculosis (TB) was a major problem—as the endemic contagious disease associated with the greatest number of deaths. With its moral and disciplining dimensions directed to the working and popular classes, TB control was emblematic of the hygiene movement.⁵⁰ Preventive measures were deemed essential to both recovery and minimizing contagion to others. Among these were required reporting of TB cases (1896), periodic disinfection of the clothing and dwellings of indigent people with TB (1903), inspection and hygienic renovation of tenements, and veterinary inspection of stables and dairy farms to address bovine TB.⁵¹ In 1902 Salterain, then director of the Municipal Census and Statistics Office, founded the non-governmental Uruguayan League against TB, which purveyed prophylactic advice to the sick, along with medical attention, medicines, clothing, bathhouse access, and nourishment.

Other diseases tied to poor social conditions included typhoid fever, stemming from deficiencies in clean water and sanitation. In 1908, other than in Montevideo’s oldest and wealthiest neighborhood, running water only reached between 1 percent and 14 percent of dwellings in most areas. Oftentimes, even if infrastructure was in place, the high cost of services precluded popular classes.⁵² In more remote regions and minor cities, cisterns and septic tanks were common.⁵³ Only in the late 1910s did the typhoid vaccine begin to be distributed.

In sum, the optimism of the “Promised Land” concealed another reality. Despite institutional and modernizing advances, ever-aspirational plans, and the hubris expressed by health professionals, the country was continually struggling between success and failure. Rapid urban growth meant that Montevideo’s infrastructure could not keep up with population needs. A prime illustration of the gap between intentions and realization is the case of infant mortality.

Uruguay’s Growing Public Health Infrastructure and International Engagement

As elsewhere, Uruguay’s early 20th century was marked by growing health infrastructure, personnel, and institutions. Between 1910 and 1930, ten new medical facilities were created in Montevideo, with another twenty-eight in the main towns and cities of the country’s other eighteen departments (provinces). New bacteriological and chemical laboratories were established, and specialized centers, such as nutrition and preventive medicine clinics, also proliferated. Permanent provincial-level public health offices gradually replaced traveling health inspectors. In-country training of doctors accelerated, with physician per capita ratios doubling between 1910 and 1934.⁵⁴ In the 1920s, health authorities prioritized training of visiting nurses and social workers. This period also saw increased public health personnel and purview over sanitation, housing, food and water inspection—including in prisons and school refectories—and milk hygiene (involving the regulation and monitoring of pasteurization, storage, and transport).⁵⁵ Preoccupation with port and maritime outbreaks and the health of immigrants was ongoing, as were perennial concerns regarding sex workers and venereal diseases.⁵⁶

Uruguay also became a player in the emergent landscape of international health. The PASB, initially International Sanitary Bureau, —founded in Washington, DC in 1902 as the world’s first international health organization and for several decades operating under the aegis of the US Public Health Service—set up a regional base in Montevideo in 1907 for the collection of South American health statistics.⁵⁷ Although short-lived, the office’s location and Uruguayan management served as recognition of Uruguay’s public health capacity, as well as the Batlle era’s clear political alignment with the United States.⁵⁸ In 1920 Montevideo hosted the PASB’s 6th Sanitary Conference, well before Rio de Janeiro or Buenos Aires did so.⁵⁹ Uruguay was also a member of the Paris-based Office International d’Hygiène Publique, launched in 1909, which oversaw sanitary treaties and shared disease statistics among member countries. Additionally, in the 1920s, Uruguayans became active at the League of Nations and its Health Organisation (LNHO).

Back home, public health authorities continued their long-standing efforts to control infectious/contagious diseases. Diphtheria remained a significant problem: in the mid-1920s, treatment with anti-serum was coupled with preventive vaccination (produced at the Institute of Hygiene) and then neutralizing antitoxin.⁶⁰ Anti-diphtheria educational campaigns and house-to-house administration stepped up in the 1930s, later followed by mandatory vaccination for schoolchildren.⁶¹

Warm weather epidemics were also concerning. Atop existing sanitation and clean water measures, preventive vaccination against typhoid fever, also prepared in Montevideo laboratories, began in the 1920s, initially focusing on the military and certain hotspots outside the capital. The vaccine was soon administered free of charge in Montevideo, but typhoid abounded in suburban areas where housing was cheaper but sanitary conditions worse.⁶²

Trachoma, a highly contagious eye disease leading to blindness, was also prevalent among poor populations living in crowded, unhygienic conditions. Often associated with immigrants, trachoma concerns rose after 1900 as eye clinics mushroomed across Montevideo. Because late-stage trachoma lacked effective therapeutics, prophylaxis was emphasized via screening, health education, obligatory reporting, isolation, tenement inspections, and reductions in the cost of household water access.⁶³ Most contentious was a 1915 decree blocking the entry of people with trachoma by maritime sanitary authorities. This practice became embroiled in controversy, with the APN director seeking to attenuate overly harsh rejections of family members or doubtful cases; others calling for tighter trachoma restrictions at land borders; and ophthalmologists advocating for their own professional purview of trachoma inspection and control at the border and within the country alike.⁶⁴ Whether trachoma among immigrants exacerbated public dependency seems questionable. Unlike other disabilities, trachoma could be readily diagnosed by specialists. Moreover, for authorities, trachomatous immigrants (who constituted up to half of medical rejections at early 20th-century Argentinean borders, for example) were an easy target, unlike the cost and effort of improving living conditions in urban shantytowns.⁶⁵

Meanwhile, TB remained a highly feared disease. Building on prior efforts, in 1927 a new Children’s TB dispensary produced, distributed, and administered Bacille Calmette-Guérin (BCG) vaccine to prevent infection in newborns of tuberculous mothers. Named in honor of BCG co-discoverer Albert Calmette, it was the first such dispensary outside France. Two years later, the APN launched a dedicated anti-TB service, coordinating ambulatory treatment centers in Montevideo and at regional hospitals staffed by pulmonologists, radiologists, laboratory technicians, and professional nurses, and operating a TB sanatorium.⁶⁶

Uruguay did not escape the 1918–1920 influenza pandemic (at least the second and third waves), bearing both similarities to European and North American trends (the poor were hit in the earlier wave, the well-off subsequently) and significant differences: immigrants, more than troops, were seen as the primary conduits.⁶⁷ Despite the apprehension surrounding influenza (and its high morbidity), endemic diseases persisted as Uruguay’s prime mortality drivers in this period.⁶⁸

The burgeoning of institutions, personnel, and health measures culminated in the 1934 creation of the Ministry of Public Health, which unified the functions of the APN and CNH, streamlining regulations and centralizing governance in a single institution.

While promising, these developments masked an undercurrent of health problems that remained inadequately addressed.

The Paradox of Infant Mortality

No domain better illustrates these tensions than infant/child health. As discussed, c. 1900 Uruguay’s precocious (for Latin America) and extensive Civil Registry coverage showed encouragingly low infant mortality rates, including compared to European frontrunners. Moreover, the country’s early investment in gotas de leche seemingly ensured continuation of this excellent record.

But just as Uruguay’s social welfare laws were flourishing, its infant mortality advantage began to unravel. Rather than declining, as in virtually every other setting then compiling and monitoring these data, Uruguay’s infant mortality rate stayed stuck around the same level (roughly 10 percent of births) as before 1910 and stagnated for over three decades. With both pediatric experts and government officials bewildered, health authorities tried almost every known measure to improve infant health.

A prime contributor was diarrheal infant mortality, perpetually alarming in summer months, and spurring successive targeted campaigns.⁶⁹ Certainly, as contemporaries observed, milk quality deteriorated when the weather was hot. Health experts highlighted another factor, namely omnipresent flies—even worse in summertime amid poor sanitary conditions and due to the city’s sizeable (working) horse population and many stables—believing that flies were important vectors in the spread of disease.⁷⁰ Addressing this, in 1919 health officials formed a special anti-fly commission, promoting a large-scale educational effort. The campaign lasted several years, yielding few tangible results.

In addition to the ever-increasing reach of the gotas and the APN, health leaders heeded a panoply of French child health approaches, founding a children’s hospital (1908), and introducing a maternal refuge and paid pregnancy leave (1915). Services were consolidated in an Infant Protection Office (1919) that regulated wet nurses, provided maternity subsidies, distributed breast-milk, and created a centralized Children’s Home to organize all of these services under a single roof (1925). Still, charity activities, usually operated by women elites—Catholic damas, liberal feminists, and, mostly, conservative “maternalists” (some married to the very men administering state maternal and child health and welfare services!)—did not disappear. Instead they accompanied social welfare measures, providing complementary material assistance, food, and shelter to poor women and their children.⁷¹

That infant mortality levels stayed essentially unmoved through all of these efforts sheds light on the limits and unspoken priorities of the Batllista state. It was, at least initially, conceived to protect workers and vulnerable populations. A specific focus on child health only emerged after the infant mortality paradox was detected and decried.⁷²

Uruguay’s Rising International Role and the International American Child Protection Institute

Notwithstanding domestic disillusionment, Uruguayans sustained their international involvement, spanning both political and health realms. Batlle had famously journeyed to Europe after his first presidential term, studying the crafting and implementation of social and economic policies and adapting his learning during his second term. Although not directly party to WWI, Uruguay benefited from increased meat exports and saw many of its nationals join French forces, including a team of doctors under surgeon Eduardo Blanco Acevedo (later Uruguay’s first health minister), who spent five years at the helm of foreign medical-military support.

In parallel, Uruguayan child health and social welfare specialists consistently pursued relationships with French, other European, and Latin American colleagues—via conferences, visits back and forth, and publications—gradually becoming exporters of ideas and practices as much as importers. The APN’s founding director José Scoseria, for one, was much sought after as a speaker and delegate at international agencies and social welfare congresses.⁷³

French physicians recognized Uruguayan savants, sponsoring a Franco–Uruguayan medical fraternity in Paris.⁷⁴ By the 1920s internationally famed pediatrician Luis Morquio and his colleagues frequently published in European medical and child health journals.⁷⁵ Morquio was named officer of the Légion d’Honneur, member of the Académie Nationale de Médecine, and was a regular invited lecturer to Italy’s nipiologia meetings and across Europe. The 25th anniversary of his pediatrics chair was applauded in Europe and throughout Latin America.⁷⁶ Additionally, Uruguay was often the sole country outside North America, Europe, and Japan whose good-quality data warranted inclusion in comparative assessments of health statistics.

At the LNHO—formally established in Geneva in 1923 in the wake of a post-WWI epidemic control commission focused on helping war-torn nations—Uruguayan experts, among other Latin Americans, were convened to participate in an ambitious program of surveillance, research, standardization, professionalization, and technical aid.⁷⁷ APN director Scoseria served on LNHO’s governing board, and in 1925 the LNHO vice president, Dr. Léon Bernard of the University of Paris, visited Uruguay to study the country’s public health organization and hygiene teaching.⁷⁸ That year Uruguayan school health expert Rafael Schiaffino participated in a prestigious six-month North American and European tour consisting of nine Latin American doctors.⁷⁹

Another high-profile League of Nations (LN) participant was Dr. Paulina Luisi, the first woman graduate of Uruguay’s medical faculty, the country’s leading liberal feminist, and a regionally and internationally renowned champion of women’s rights and children’s well-being.⁸⁰ She was the only Latin American woman delegate to the first LN Assembly and participated in various treaty, disarmament, and labor conferences. Luisi also served as an expert delegate on the LN’s advisory commission on human trafficking and for ten years was one of only two Latin Americans on the Child Welfare Committee.⁸¹ She forcefully advocated for increased Latin American perspectives in the LN’s work for children, included in surveys of social conditions and policies, and for greater representation in governing bodies.⁸²

Luisi paid special attention to the LNHO’s sponsorship in 1926 of an infant mortality survey of urban and rural districts in seven European countries.⁸³ Using her savoir faire and perch at the LN to become a transnational interlocutor with South American child protection experts, she helped shepherd the realization of a Montevideo-based child protection institute. Originally the brainchild of the women-launched Pan American Child Congresses (first held in Buenos Aires in 1916) that convened reformers, nurses, policymakers, sociologists, physicians, lawyers, and social workers from across the Americas, Luisi and other feminist leaders were soon upstaged by Morquio and other male physicians. Even so, Luisi’s LNHO channels proved invaluable. Extending the LNHO’s infant mortality surveys to South America, with Morquio arranging for an LNHO conference in Montevideo to initiate this project, served as the ideal vehicle to inaugurate the International American Institute for Child Protection (IAICP).⁸⁴

The momentous June 1927 “South American Conference on Infant Mortality” was the first LN conference of any kind held in Latin America, particularly notable given US antagonism to LN activities in the region. Attended by both its talented director Ludwik Rajchman, plus the LNHO’s president, the conference brought a prestigious world stage not only to the IAICP but to Uruguay and its child health experts.⁸⁵

From the outset, the IAICP, co-founded by ten countries and encompassing the entire region by 1949, delineated a pathbreaking child rights approach to health and well-being. Foreshadowing Uruguay’s protagonism in this area, Minister of Education Enrique Rodríguez Fabregat called for full social rights to housing, parental recognition, education, nutrition, economic assistance, land, legal standing, happiness, and integrated well-being.⁸⁶

The IAICP’s first major activity was overseeing LNHO-sponsored infant mortality surveys in Argentina, Brazil, Chile, and Uruguay. The results, presented at the 6th Pan American Child Congress in Lima (1930), called for enhancements in vital statistics coverage, centralization of services, and a range of public health, social assistance, economic, and educational measures, all well established in Uruguay itself.⁸⁷

Uruguay initially underwrote the IAICP’s budget, enabling it to fulfill the scope of its activities: collecting and distributing research, laws, statistics, and practical information from around the world pertaining to the protection of infants, children, and mothers; publishing a widely circulated, multilingual journal; organizing periodic child congresses; and parlaying the region’s problems and policies into international debates.⁸⁸ Uruguay retained a strong imprint on the IAICP. Morquio was the inaugural director, succeeded after his death in 1935 by his disciple, Roberto Berro, for over two decades.

Repression and Child Rights: Uruguay’s Children’s Code and Its International Reverberations

Until the 1930s, Uruguayan authorities had pursued an adopt–adapt–share approach to child health and welfare policymaking and institution-building, with the IAICP providing ever-greater access to overseas experiences and policies. But increasingly specialized medical approaches to child health remained inadequately integrated with social measures and, critically, failed to address stagnating infant mortality.⁸⁹ The situation demanded a sweeping approach: when Uruguay’s liberal era abruptly ended with President Gabriel Terra’s March 1933 internal coup d’état, an opportunity materialized. Within Terra’s junta was Berro, who immediately maneuvered to create a pioneering Ministry of Child Protection and a commission to review child welfare legislation.

If the regime’s overall intent was to move the country from a cosmopolitan to a nationalist outlook, the child health arena deviated from the script. That Terra arose from Uruguay’s traditional pro-welfare state party—a Batllista, if one for “times of crisis”—helps explain his forwarding of social policies from previous decades, albeit under decidedly distinct political conditions (see figure 2).

Open in new tab

Figure 2. Public health poster included in the “Cultural Crusade,” a 1934 nationwide traveling train exhibit during Gabriel Terra’s regime.

Source: Archivo Nacional de la Imagen y la Palabra (SODRE), Montevideo, Uruguay

Berro convoked Morquio, Bauzá, and others in the tiny but vibrant child health community to reorganize the country’s proliferating infant and child welfare measures and agencies, consistent with Terra’s penchant to rationalize and centralize power. Under Berro’s leadership, the commission did not simply merge overlapping efforts: it called for a Código del Niño (Children’s Code [CC]) to “defend all of the rights of the child,” based on the broad principles pronounced at the IAICP’s inauguration.⁹⁰

The CC amalgamated Uruguay’s existing policies and institutions, covering child health, education, legal tutelage (of “delinquents” and abandoned children), nutrition, housing, social services, and other aspects of well-being. Also guaranteeing paid maternity leave and maternal care, it stipulated eugenic measures, such as prenuptial exams, similar to the “preventive eugenics” approaches of other Latin countries.⁹¹

Passed in April 1934, the CC maintained appeal for Batllista, union, and even some left-wing constituencies, demonstrating that despite political rupture, repression, the depression, and pro-business policies, Uruguay’s protectionist state would continue.⁹² Pro-government newspaper El Debate commended Berro and heralded the CC as “a magisterial consolidation” of children’s rights and a hallmark of “social prophylaxis carried out by a revolutionary government,” surpassed only by Mussolini’s national maternal and child health “masterpiece” and Britain’s 1933 Children and Young Persons Act.⁹³

Uruguay’s CC quickly reaped international acclaim. Praise poured in from across Latin America, the United States, Belgium, Italy, Spain, and beyond.⁹⁴ Nowhere were the accolades higher than in and from France, the very country that most shaped Uruguay’s child health approach. In 1934 prominent Assistance Publique physician Julien Huber wrote admiringly of Uruguay’s new CC in France’s Revue Médico-Sociale de l’Enfance, apologizing for the lengthy article, justified by Uruguay’s “unique” achievements.⁹⁵ Paris’s La Presse Médicale and other periodicals followed suit, one asking, “Might it be possible for us [France] to obtain similar results with analogous methods? Assuredly no.”⁹⁶ The assiduous “student” appeared to be outstripping its French “teacher.”

Undoubtedly Uruguay’s CC revealed a profound state patriarchalism. That this policy passed under an authoritarian regime, but was nonetheless couched in a language of child rights, underscores welfare reformers’ political opportunism and the paradoxes of early 20th-century child health and protectionism.

Indeed, the CC and its implementation arm, the Children’s Council (Consejo del Niño), established by the 1934 Constitution, seems mired in contradictions.⁹⁷ A panoply of services was provided free of charge despite constrained state revenues. Castigating fathers, it protected mothers and children, helping secure state legitimacy through increasing social and economic rights under a repressive milieu, akin to a “sanitary dictatorship.”⁹⁸

All the while, the Children’s Council’s expansive and expanding services (including via mobile units) offered an unprecedented level of protection, making Uruguay a world leader in assuring that children’s rights were not only rhetorically invoked but realized through public policies.⁹⁹ Delivering free services by age group (prenatal, infant, childhood, and adolescent divisions) and jurisdiction (education, law, social services, and school health divisions), the Council was headquartered in Montevideo, eventually establishing offices throughout the country.¹⁰⁰ Though headed by a series of doctors, the Council’s intentional separation from the new health ministry unambiguously confirmed the need to decenter medicine’s mounting armamentarium by foregrounding social approaches alongside medical ones.

Within five years the Children’s Council’s budget reached almost 2 percent of total government spending. Given its wide mandate, the Council interacted with virtually every Uruguayan child, at minimum through school health checkups and, for poor and working-class children, via extensive coordinated services.¹⁰¹ In just a decade, children’s well-being improved markedly. For example, foster children numbers plummeted by 85 percent, and infant mortality resumed its decline.¹⁰²

A Public Health Transition, 1930s–1940s

Various other public health improvements unfolded in the 1930s. The issue of milk hygiene had sparked an acerbic decades-old dispute between Morquio and fellow pediatrician Julio Bauzá regarding whether the gotas (under Bauzá’s watch) were distributing contaminated milk and discouraging breastfeeding, thereby jeopardizing infant health.¹⁰³ Addressing this concern, several milk-processing plants, heeding hygienic pasteurization and storage practices, were established in Montevideo during the 1920s. However, only in January 1934 was pasteurization mandated by a Montevideo ordinance.¹⁰⁴ The 1935 founding of the National Cooperative of Milk Producers (CONAPROLE) proved instrumental. With centralized milk hygiene standards and inspection, plus production controls, the cooperative gradually displaced independent dairy farms and raw-milk sellers, by 1944 supplying 84 percent of the capital’s milk consumption.¹⁰⁵ Outside Montevideo, poor milk hygiene and inadequate bottle cleaning prevailed until the late 1940s.

Meantime, medical and social policy had synergistic effects. In the 1930s, use of sulfonamides—moderately effective anti-bacterial agents—became widespread, followed in the 1940s by intravenous therapy (to counter dehydration), and penicillin after WWII. These were amplified by resurrected anti-diarrheal public health campaigns, now more medicalized and more successful in the city than the countryside.¹⁰⁶ Likely most impactful was a 1943 socioeconomic measure: family wage legislation.¹⁰⁷ A small surge in birth registration (incentivized by subsidies for each registered child) made infant mortality rates appear to drop, given the larger denominator of births. The decline endured, indicating the policy’s long-term impact on poverty and inequality. By this time, both Terra’s dictatorship and the depression had passed. Abundant state coffers and a return to social welfare democracy ushered in a new wave of redistributive social policies, including minimum wages and housing and water improvements.