martes, enero 20, 2009

Armus (2003)

Diego Armus (2003). Disease in the Historiography of Modern Latin America.
In this introduction to the book, Diego Armus maps three (some times overlapping) currents in the historical analysis of diseases in modern Latin America: a new history of medicine, the history of public health, and the sociocultural history of disease. He highlights, and I agree with him, that these attempts to try to make historical sense of any given disease are a risky approach: “given the fact that human well-being and ill-being cannot be fully captured through the lens of a single disease” (16). But given that disease is an “elusive entity” that at the same time is biological, meaning-seeking, has a medical intellectual and institutional history, it’s a site for public policy, a feature of social role and individual identity, has cultural values, and a central component of doctor-patient relationship, given that disease is all this, there is also the recognition that “disease dos not exist until we have agreed that it does, by perceiving, naming, and responding to it” (1). Still one important point made by Armus is that diseases cannot be investigated outside their societal context. Armus wants to frame the articles of this book within three approaches (new history of medicine, the history of public health, and the sociocultural history of disease) having in mind the socio-political features of epidemics, the expansion of public health policies in relation with outer influential powers and state-formation processes, and finally, the cultural use of disease.
(I) In terms of the new history of medicine, Armus considers that now historians are less inclined to look at the biographies of the “big men” in the history of medicine, the “pioneers”, and instead they analyze how medicine work as an irregular process in tension with socio-cultural and political contexts in which doctors are immersed, and where certain doctors, institutions and treatments made their way to be more visible and successful while others. And this process of visibility/invisibility success/failure within medicine has to be analyzed in all its complexity to grasp the social and political dimensions of epidemics. Before the modern bacteriology the blame of epidemics was put on urban conditions that allowed the enemy (microorganisms) to grow and which forced intrusive and violent interventions. But according to Armus there is distinction between, on the one hand, more or less visible diseases and, on the other hand, countryside or urban settings, and these tensions influence the way public opinion and elites consciousness would consider specific diseases as epidemic or not (independently of the large or small impact on the population, for instance syphilis or leprosy were seen as epidemics whereas TB or malaria not having the latter more impact than the former). Armus reminds us that “the project of sanitizing the countryside or at least combating one of its endemic diseases ignited efforts to launch social policies and facilitated state expansion, the centralization of power, and nation building” (8).
(II) The history of public health has, however, another approach: it focuses on the political, economic and social dimensions of health institutions. Health problems faced by individuals and social groups and the political interventions to maintain or reinstate collective health are considered in this approach. A key factor here is the differential availability of public health resources at regional levels within Latin America and how different national projects have dissimilar impacts according to different regions. Another important issue is the interrelationship between external influential powers and nation-building processes. Although medical professionals were aware of what was going on in Europe and North America, they were in need to find specific solutions for specific problems often very different than of Europe or North America. Certain diseases such as Chagas were particular of Latin America but other such as malaria or yellow fever were politically constructed through an inter-national site of production/reception/transfer of expertise and practices in which international agencies such as Rockefeller Foundation played a big role in the region. These tensions between national and international medical groups were “complex, at times involving subordination, cooptation, alliance, pragmatism, conflict, or mutual adaptation” (10).
(III) The third approach, the sociocultural historical dimension of disease, considers the “socio-political or socio-demographic dimensions of a particular disease, medical professionalization processes, welfare and social control instruments and institutions, and the state’s role in building health infrastructure” (5). This considers the medical discourse of illness and the metaphorical use of disease. In terms of psychiatric medical power these studies focus on empirical information that highlights both the “instrumental and controlling aspects” of psychiatry and the “humanitarian and liberating” options in relation to mental health. Thus mental health is a space that goes beyond psychiatric power and incorporates public hygiene, mental institutions, utopian seek for collective moral development, and the history of nation-formation and state-formation.
The three approaches regard medicine as an “uncertain and contested terrain where the biomedical is shaped as much by human subjectivity as by objective facts” (6). And in doing so, they emphasize the importance of individual and collective “hygiene” as a “civilizing” project promoted (and often imposed) not only from above but also strongly supported from below. There is a tension in here between the medical enterprise and the ability and capacities of the sick to negotiate and even challenge the medical power. Therefore, three issues are important to highlight: 1) “public health interventions and medical practices can be resisted, accepted, or demanded according to local, cultural, social, political, and disease-specific contexts”; 2) these tensions should be considered in a short and long run to look at how medical practices are incorporated in specific instances but in the long process within people’s everyday life; and 3) focusing on the historical agency of the sick, not considering as a merely passive objects of medical practices and knowledge but as highly implicated in the processes in which they are the object of intervention.
I think that considering this article as an introduction of a book on the historiagraphy of epidemics in Latin America Armus makes a good work trying to synthesize the different approaches historians have developed when dealing with issues of illness and health but sometimes there is too much overlapping in the distinctions he is trying to make. If he is trying to make the point that diseases cannot be studied outside their specific societal context, and this context is surely contested and resisted at the same time maybe there is no other option than to have an overlapped analysis, but perhaps it would have been more useful to consider the specific role of say the nation-state or the medical professionalization in a more analytical way in order to shed more clear light to these issues.

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