Historians often struggle to convey the immediate relevance of their profession to the broader public, especially in the future-oriented culture of Henry Ford’s United States. History deals with the past—which is, by definition, no longer present—and can thus seem a luxury of mere refinement rather than a fundamental necessity. There are, however, moments when the relevance of historians becomes broadly obvious and they eagerly sally forth from their cloisters to contribute their expertise to the discourse. Perhaps nothing more clearly demands a historian’s input as much as topicality: when the pressing affairs of the moment so resemble and recall past events that even the philistines must recognize its utility. Our ongoing struggles with the SARS-CoV-2 virus and the associated global pandemic is one such moment.
The books examined here, most of which appeared prior to the COVID-19 outbreak of 2020, collectively address disease and the diverse medical cultures of Mexico, Central America, and the Caribbean since the seventeenth century. Amid widespread perceptions of the “extraordinary” circumstances of the current pandemic, the books discussed in this essay collectively reveal a more banal, if discomfiting truth: we are not living in extraordinary times. New diseases appear regularly. They cause death and suffering. They also spark cultural, political, economic, and ideological upheavals. Epidemics lay bare and exacerbate preexisting social divisions; they undermine the credibility of flustered and impotent authorities; and they inflame conflicts as people contend with alarming new infringements on their mortality and quality of life. Epidemics can even shift the geopolitical landscape itself.
That diseases drive changes both within and between societies is not a new insight. “When there is a general change of conditions,” wrote Ibn-Khaldūn in the aftermath of the bubonic plague, “it is as if the entire creation had changed and the whole world been altered … a world brought into existence anew.”Footnote 1 Nor is this a counterintuitive or esoteric revelation. According to one New York Times reporter, the coronavirus pandemic “increasingly looks like one of the defining events of our time,” likely to reshape politics, the economy, and culture for the foreseeable future.Footnote 2 Yet, while it might be easy to blame these upheavals on the pathogens themselves, the books reviewed here demonstrate that they are also contingent on a host of human factors. These include the existence of different and conflicting medical paradigms within a particular society; how these perceive the nature and causes of illness; the capacity for one medical regime to assert supremacy, impose itself on the population, and discredit rivals; the degree to which the population cooperates with such a regime over or alongside alternatives; and even the charisma and success of individual health practitioners within formal or informal marketplaces. In other words, these books reveal illness, disease, and health care to be social, cultural, and political experiences as well as scientific and medical ones. Diego Armus and Pablo F. Gómez term this broader approach to medical history “the sociocultural history of disease and healing,” as it peers beyond medical treatises and specific treatments to explicitly target the human-pathogen interface where and among whom it occurs (5).
Accordingly, most of the works reviewed here redirect the history of medicine away from abstract stories of scientific progress and toward more mundane matters. By rooting health care and its application within specific political, social, and cultural circumstances, they reveal the practical limits of medical science itself. According to Armus and Gómez, medicine is not a perfect science with clear and universally recognized parameters and procedures, but “an uncertain and contested terrain, where the biomedical is shaped as much by human subjectivity as by objective facts” and where disease and sickness have “not only a biological dimension but also social, cultural, political, and economic connotations” (6). Thus, while their conclusions and emphases range widely, most of these authors eschew heroic and teleological accounts of the rise of modern biomedicine. Some do trace the activities and writings of trained professionals and authorized practitioners but regard them as fallible, often confused, and self-interested humans engaged in trial and error. Far from being a fixed and eternal science, their medical paradigm was adaptable, open to foreign ideas, and sensitive to politics, ideology, and other markedly unscientific concerns.
Proceeding from this skepticism, a strong subset of these works also explicitly and intentionally addresses the decolonizing and revisionist concerns of today’s scholarship and expands the history of medicine to encompass a broader range of people, especially women and those of non-European background. We must recognize this as a substantial shift in emphasis in the field of medical history, one that may offer clues to understanding today’s pandemic. These works look beyond what Armus and Gómez term “biomedically defined effectiveness” to comment on power relationships. Indeed, several explicitly proceed from Michel Foucault’s critique of “biopolitics” and how modern medicine empowers authorities by monopolizing the naming and definition of illnesses.Footnote 3 They emphasize how public health measures justified and facilitated the growth of state power and regard resistance to such efforts as reclamations of autonomy. Others consider Western biomedicine as merely one of many legitimate ways of knowing. This approach reconsiders the health practices of nonelite and marginalized people, as well as their influence over the real-life unfolding of epidemiological events. It also reassesses the remedies of culturally rooted health practitioners, revealing benefits that were simply illegible or irrelevant to the universal prescriptions of hegemonic medicine.
Together, these books suggest that the historically fragmented and unequal nature of Latin American societies produced a diversity of partially conflicting medical regimes—a cacophony reflected in the wide array of words used to signify different kinds of practitioners, each with their own connotations, from “physician” to “healer” and from “sorcerer” (brujo) to “snakeman” (culebrero). Formally educated doctors, heirs to the deep history of Greco-Roman, Arabic, and European medical knowledge, wielded the political, economic, and discursive power to define their practices as universally correct and rational—even as they were heterogeneous and continuously evolving—while defending their privileged place with education, licensing requirements, guilds, and punishment. “Popular” or alternative health care deliverers, meanwhile—often of Indigenous, African, or mixed ancestry and including many women—fought illness in other ways, equally heterogeneous, results oriented, and adaptable.
Not surprisingly, different medical knowledge regimes came into frequent and sometimes violent conflict, especially during outbreaks. Yet the new research reveals that the relationship was not always, not inevitably, or not entirely adversarial. In fact, many practitioners—elite, middling, and nonelite alike—pragmatically drew from multiple therapeutic traditions as they responded not only to epidemiological realities but also to market demands, certainly fickle and vulnerable to snake oil, but nonetheless attuned to local priorities and everywhere bounded by the simple empirical need to demonstrate efficacy. Crucially, this pragmatism characterized not only urban apothecaries and a colorful and eclectic cast of rural healers but also the leaders of public health campaigns, the more savvy of whom understood that their success depended on cooperation and organization at every level of society. In short, seeing health care in Latin America as defined by an unbridgeable gulf between medical science and folk healing can obscure a far more complicated and interesting reality in which cross-fertilization was common, popular health practitioners were knowledgeable and effective in their own ways, and medical practices overall were always evolving to incorporate new information, techniques, and materials.
Kyle Harper’s Plagues upon the Earth is a grand and sweeping update on William McNeill’s classic Plagues and Peoples.Footnote 4 Across thousands of years and every continent, Harper pursues the story of the tragic and eternal struggle between humanity and its five major sources of ailments: viruses, bacteria, fungi, protozoa, and helminths (worms)—all of which are persistent, adaptable, and serenely unconcerned with our welfare, our civilizational progress, or any human flights of fancy such as justice or fairness. Like McNeill, Harper reveals that pathogens have massively shaped the trajectory of human history. However, Harper benefits from new technologies, such as gene sequencing, to produce a history of the pathogens themselves. This allows him to pinpoint with some precision when the great maladies of humankind emerged and therefore to link them to contemporaneous developments in human culture and society. This analysis suggests that diseases respond to us as much as we respond to them. It seems that all human efforts to escape our tiny predators—no matter how ingenious, no matter how scientific—ultimately drive evolutionary adaptations among them. The result is a perpetual cycle in which pathogens force changes among human societies, either by culling populations or by requiring us to deploy the gifts of Prometheus to find relief. These actions, however, prompt evolutionary responses in which new pathogens emerge (or old ones adapt) to exploit new vulnerabilities. If Hegel had been an epidemiologist rather than a philosopher, his dialectical theory of history might have looked something like this.
Plagues upon the Earth is global in scope, as it is a history of pathogens as much as humanity, and pathogens do not recognize cultural, political, or temporal boundaries. Harper identifies four critical moments in this history, major shifts in social organization and behavior and the subsequent maladies they facilitated. The first was the mastery of fire, which enabled Homo sapiens to migrate beyond their evolutionary homelands, spreading old diseases across the globe while also encouraging others to evolve. The second was the rise of agriculture, which brought people together in large settlements and spurred the development of crowd diseases and infections. Next was the Columbian exchange, which transplanted African and Eurasian pathogens into the Americas while supercharging them by the conditions of early modern urbanization and globalization. Finally, the industrial revolution enabled transportation at speeds that rendered distance epidemiologically meaningless, leading to the first truly global pandemics.
Human ingenuity fought back all the while, restraining pathogens at the margins with preventative behaviors such as quarantines, inoculations, and the regulation of known hazards. Humanity only made substantial progress, however, in the nineteenth century, with advanced public health measures such as sanitation infrastructure, biomedical interventions such as vaccines, and new understandings of disease derived from the discovery and isolation of microbes. Harper regards the resulting unprecedented boom in the human population—our liberation from the morbid prophecies of Thomas Malthus—as “the Great Escape,” a (hopefully) lasting respite from the universal likelihood of an early death that had been our inheritance since the beginning of the species. Harper concludes by detailing current threats to this tenuous state of victory, including COVID-19, thus moderating his triumphant tale with a sober reminder of our ongoing vulnerability. As he explains, the very Darwinian success of humanity since the Great Escape all but ensures the development of new pathogens evolutionarily honed precisely to exploit our massive, interconnected numbers and evade the health measures that have been so transformative over the past two centuries (503–509).
Harper’s massive tome exemplifies the conventional history of medicine more than any of the other works examined here and can serve as a useful counterpoint to their emphasis on power relationships and the sociocultural. The quantitative and empirical focus on diseases, their biological evolution, and their physiological effects on humans—as measured in terms of death rates and life expectancies—revolves entirely around the question of “biomedically defined effectiveness.” Harper neither questions the universal applicability and efficacy of biomedicine nor critiques it as a tool for hegemonic control; in fact, he rejects voguish portrayals of the great health and longevity of hunter-gatherers as overly romantic and explicitly attributes recent improvements in general health outcomes to progress in our biomedical understanding of disease. “It is the advance of scientific knowledge, actualized by public policy and private behavior,” he writes, “that has given humans the advantage over microbial threats” (374).
Sound science and policy can only do so much, however, as their implementation requires compromises with the messy realities of human societies. Just as there are no frictionless surfaces in applied physics, there are no purely rational, knowledgeable, or malleable people. This is one of the lessons of Enlightened Immunity, by Paul Ramírez, a sophisticated look at public health efforts in late colonial Mexico. If Harper provides an elegant overview of the eternal war between humans and pathogens, Ramírez points out the fog and confusion of specific battles. At the ground level, broad conceptualizations like Harper’s break down. Authorities may not have the power or understanding to act effectively; illness can take on political or ideological valences that compromise trust between health officials and communities; and leaders do not set aside immediate goals and rivalries in devising their responses. Enlightened Immunity reveals the inadequacy of medical histories that focus only on the perceptions and intentions of scientific and political authorities, and overlook how preventative treatments and cures are applied (or misapplied, or not applied) among flesh-and-blood communities.
Enlightened Immunity traces the eighteenth-century transition, in the Mexican context, from the old medical regime of humors and miasmas to the biomedical regime of viruses and immune responses. It also reveals the importance of the cultural and political media within which this transition occurred, and therefore its complexity and incompleteness. According to Ramírez, while Enlightenment-era medical campaigns were conceived and planned by Spanish and creole men, their success depended on the cooperation and participation of a much broader swathe of Mexican society, from local priests to Indigenous women. Avoiding triumphalism, he addresses public health failures as well as successes, recognizing that these were just as influential in shaping outcomes. Ramírez organizes his research thematically and chronologically, starting with the devastating matlazahuatl epidemic of 1736–1737, probably typhus, which, according to contemporary accounts, killed perhaps 40 percent of the communities it affected (29). This allows him to demonstrate that the transition from baroque to enlightened medicine was neither neat nor immediate; instead, new concepts and techniques appeared to complement rather than replace older conceptualizations of disease and health. Ramírez then explores creole medical journals in the late eighteenth century, which spread the new science of medicine to the educated Mexican readership, and examines how these played a role in the earliest organized smallpox inoculation campaigns in the 1790s. The book’s climax is an account of the Royal Philanthropic Vaccination Mission of 1804–1805, in which the crown sought to induce smallpox immunity in its massive empire, as well as the often hostile response that public health officials encountered in the provinces due to mistrust, miscommunication, and misinformation spread through rumors.
These experiences revealed to the Spanish and creole leadership that no success on this front was possible without investment and participation from trusted locals, including priests, town leaders, and families. All this meant compromise and negotiation between the enlightened agenda of the state and complex realities on the ground—a dynamic that, for example, forced Enlightenment medicine to market itself via appeals to the saints, and colonial doctors to accommodate some of the concerns of resistant parents. Elite demands were not the final word, as “commentary from diverse and disjointed publics was admitted by default and necessity.” The result,” writes Ramírez, “was a policy pastiche, at once technologically forward-looking and nostalgic for the caste categories, charitable impulses, and devotional practices that contributed to resolving crises in the past” (131).
Ramírez’s account complicates the heroic narrative (partially embraced by Harper) that hails the triumph of biomedicine in the nineteenth century by emphasizing the true complexity of the process by which it emerged as well as the gritty compromises necessary for its application in any real-world context. But Ramírez also gently challenges the Foucauldian narrative that would see any and all public health campaigns as de facto coercion and control. Viceregal authorities may have greatly desired the power to impose their preferred solutions on the population without compromises, but they had no such ability; the lower classes, moreover, may have often been skeptical of the unfamiliar medical solutions being introduced, but they were also active participants in the quest for improved health outcomes (15). “The nature of colonial power,” writes Ramírez, “comes to look more diffuse, the meanings of public health campaigns and medical technologies less fixed, once we consider the variety of people enrolled to transport, inject, elaborate, and judge” (212).
Paula S. De Vos’s Compound Remedies also reveals the inadequacy of conceptualizing medical traditions as static, monolithic, and coherent paradigms. Yet De Vos focuses specifically on the materials that health practitioners used in their therapies. Compound Remedies traces the cross-cultural, transnational, multicontinental development of pharmaceutical regimes within the ancient Galenic paradigm, which saw illness as the result of imbalances between the four “humors”—blood, phlegm, black bile, and yellow bile—that constituted the chemical makeup of the human body. Galenic pharmacy aimed to moderate and balance the humors with organic and synthetic materia medica, the potency of which needed to be enhanced and controlled by skilled apothecaries in tinctures, powders, pastilles, and other consumables. De Vos’s achievement is considerable. To reveal the truly ancient and heterogeneous series of ideas and practices of Galenic pharmacy, her story begins in Roman antiquity, where Galen of Pergamon (129–216 CE) recorded his treatment regimes. De Vos then examines some of the fundamental premises and principles underlying the tradition and traces its evolution through the medical treatises of post-classical Arab and Carolingian writers, to the late medieval theorists and practitioners of Iberia, to the multicultural milieu of viceregal New Spain and, finally, to the corner apothecaries of eighteenth-century Mexico City.
Compound Remedies is, therefore, both a conventional history of medicine as well as a challenge to some of its conventions. While tracing the long history of Galenism by way of its healing substances, it also reveals that the regime was anything but simple. Instead, Galenism was as diverse and heterogeneous as were its many practitioners across three continents and two millennia. Each apothecary operating within the paradigm, consciously or not, also partly authored an ever-expanding knowledge tradition, contributing materials and ideas derived from local conditions that created branches and refinements to a global range of practices stretching from Damascus to Mexico, and from Rome to today’s internet purveyors of homeopathic remedies. De Vos is also careful to account for how Galenic practitioners adopted materia medica from the Americas after 1492. One of the major lessons of Compound Remedies is that one of the roots of what is commonly referred to as “Western medicine”—often as a foil or straw man to be theatrically defeated—was never a single, monolithic body of ideas and practices, nor was it impenetrable and unchanging. It was an always evolving set of practices with multiple origins, a deeply empirical element molded by constant trial and error, and a wide capacity for adapting to new circumstances and incorporating new ideas.
Martha Few’s For All of Humanity even more explicitly and intentionally expands the history of medicine to include people and practices that had been previously excluded or ignored. Few highlights Guatemala’s active participation in the development of new medical practices during the transatlantic Enlightenment. This is a difficult task, because “Guatemala” as a coherent sociocultural entity was highly fragmented and notional, with the rural and Maya majority culturally remote from the creole and peninsular urbanites. Nonetheless, like Ramírez and De Vos, Few rejects “oversimplified dichotomies of Western medicine and Mesoamerican medicine” and the corresponding fallacy that Native peoples were always or only resistant to or collaborators with colonial rule (21). Instead, she draws on her deep expertise in Mesoamerican knowledge and healing practices to reveal the existence of a complex “guatemalteco” medical culture—sometimes revealingly referred to in compound terms as “Mesoamerican and colonial medicine”—with multiple overlapping influences. These ranged from erudite transatlantic networks to local clergy and tradespeople and to the disparate healers who applied therapies reflecting Maya medical knowledge. The book makes two interrelated claims: first, that colonial leaders adopted and participated in Enlightenment-era developments in medical science and public health, and second, that their efforts were heavily informed and structured by Mesoamerican therapies and understandings of disease and the body.
For All of Humanity centers on several medical issues that rose to prominence in eighteenth-century Guatemala, including the battle against typhus, the early inoculation efforts against smallpox, and the arcane, yet highly revealing practice of postmortem cesarean operations, mandated by the ruling tribunal in 1785 specifically to showcase Guatemala’s membership in the circle of advanced and humane nations (98). Few examines the scientific, political, and religious dimensions of these efforts—as well as their racial and gendered connotations—and notes how their success depended on accommodating the wide-ranging concerns of many different communities and interests (61). This could mean simply enlisting local barbers and priests as bloodletters. It could also mean rapprochement with Mesoamerican practices, such as allowing Maya practitioners to determine how and where particular health practices would take place—for example, the lancing of smallpox pustules for inoculation by women with obsidian blades to accommodate their conceptions of the symbolic meaning of blood (146–148).
On one level, Few’s research aligns closely with Ramírez’s. Its overall story reveals that Native peoples and the rural poor forced Guatemala’s creole leaders to accommodate their diverse health preferences through overt and passive resistance. The latter, meanwhile, understood the necessity of accommodating such preferences at the margins in order to realize their humanitarian goals and participate in the spirit of the Atlantic Enlightenment. The result was “a medical landscape that continued to be shaped by multiple medical cultures” from the provinces to the urban centers, an ideologically and scientifically complex mélange that nonetheless influenced the development of Central American medicine before and after independence (196). But far from telling a triumphant tale of medical mestizaje, Few explicitly invokes Foucault in the conclusion, emphasizing that what began as a patriotic and humanitarian emphasis on improving peoples’ lives evolved through its own logic into new forms of state control. As the medical elites encountered resistance and indifference to their plans to alleviate suffering, they increasingly resorted to coercion and violence. Any victories for public health, then, could be seen as tragic or Pyrrhic in certain ways; “antiepidemic successes,” Few writes, “can also be viewed as an extension of state encroachments on the bodies (in both health and sickness) of colonized populations” (200).
Death Is All Around Us, by Jonathan M. Weber, targets a more specific moment in the history of medicine but similarly frames its findings in Foucauldian terms, detailing improvements in public health that expanded state power at the expense of poor and working-class people. Weber’s research examines the efforts by officials within the regime of Porfirio Díaz (1876–1911) to intervene in what they viewed as an unhygienic and dangerous set of Mexican behaviors surrounding death. The problem was an unsightly growing pain in a rapidly burgeoning metropolis—namely, an unmanageable excess of unclaimed corpses in public spaces that required safe methods of transportation and disposal. Rotting bodies were a major eyesore, a public health hazard, a gruesome food source for feral dogs, and an embarrassment to the image-conscious Porfirian modernizers who wished to brand Mexico City as an American Paris (208). “While the capital could boast of electric lights, wide boulevards, electric trams, and open green spaces for walking,” notes Weber, visitors frequently noted “numerous decomposing corpses found outside corpse deposits, inside and outside of cemetery walls, [and] onboard electric trams” (220). Weber chronicles how the Díaz regime, following in the footsteps of the colonial-era reformers addressed by Ramírez and Few, sought to rationalize and medicalize how Mexican citizens went about death and to change it from a church- and family-mediated to a state-mediated process.
Weber’s book highlights the Porfirian officials most involved in regulating the process of death with new policies, technologies, and techniques in funerary and mortuary science. The scientists and planners discussed were indeed “men of science” inasmuch as they earnestly and sincerely pursued effective solutions to a pressing problem. However, like Few, Weber also stresses the role of state impositions in facilitating these developments. Beyond their sterile autopsy rooms and crematoriums, what could have been a strictly health-related issue quickly accumulated ideological and political baggage as “Porfirian officials created a discourse that linked death, public health, medical science, and technology into a cohesive narrative that promoted Mexico City as a model of modernity for the rest of the country” (13). Far from merely expressing scientific and humanitarian concern for common welfare, the corpse-handling reforms justified and obligated increased control over the urban underclass. Weber notes that the campaign to rid Mexico City of its rotting corpses was popular among the middle and upper classes, but its burdens fell especially among the poor. It was they who would have to change their behaviors and shoulder the costs of the political goals of the reformers, for example, by foregoing customary in-home celebrations of deceased relatives, replacing traditional shrouds with expensive coffins, and paying exorbitant fees to bury and register corpses in authorized cemeteries (186–192). Facing such impositions, many people simply ignored the new regulations. Like Ramírez, Weber chronicles a case where the distance between the scientific ideal and its implementation was vast, and a poorly implemented public health campaign had unintended consequences that compromised its gains while exacerbating social rifts.
A second group of books targets the social dimensions of humanity’s struggle against sickness and death in nineteenth-century Mexico. Rather than critiquing biomedicine or attempting to decolonize medical history, these works focus on the activities and experiences of those who contended with illness either as sufferers or as doctors. Donald Fithian Stevens’s Mexico in the Time of Cholera is, as its title’s allusion indicates, ultimately not about cholera but about life, love, and courtship in a society where sudden disease and death lurked menacingly in the background at every stage in life. Revolving loosely around the horrific Mexico City cholera epidemic of 1833, the book offers snapshots of lives drawn from memoirs, newspapers, correspondence, and poetry to detail the practices and institutions that shaped the expression and realization of love and desire from birth to marriage to death.
Underlying Stevens’s interpretation of Mexican culture is the changing role of the Church and Catholicism in general. Specifically, the book traces the role of Catholic beliefs and institutions in mediating not only the love lives of Mexican citizens but also how Mexican society responded to pressures such as the cholera epidemic. For example, Stevens shows how archbishops were active in late colonial anti-smallpox measures such as the creation of extramural cemeteries, and how regular people responded to the cholera outbreak by delaying marriage and childbirth, and perhaps by becoming more accepting of widows and nonvirgin women in general. If cholera was a catalyst for cultural changes in the early nineteenth century, the contrasting emphases of Catholicism and liberal individualism constituted the broader solution in which the reaction occurred.
Luz María Hernández Sáenz’s Carving a Niche is perhaps the only work reviewed here entirely concerned with professional medical doctors, conventionally understood. It serves as a counterpoint to Mexico in the Time of Cholera, as it also focuses on a group of people rather than on disease or health practices per se. Carving a Niche examines the political, legal, and intellectual efforts by Mexico’s exclusive cohort of formally educated physicians and surgeons—what Hernández calls the “medical elite”—to establish and guard their profession, its reputation, and its integrity during the nineteenth century (15). Hernández consciously situates the history of Mexico’s medical elite within the contemporaneous development of the Mexican nation more generally. Their place and role evolved considerably during this period, tracking broader political and social changes as the country moved from colonial rule to an uncertain liberalism and to the consolidation of state positivism, elitism, and Francophilia during the Porfiriato.
But despite its more conventional object of inquiry, Carving a Niche likewise challenges heroic histories of medicine because it treats doctors not as the purely unselfish relators of scientific truth caricatured and criticized by Foucault but as a politically and intellectually active guild. Mexico’s doctors during the nineteenth century believed in the possibilities inherent in biomedicine, but their livelihood required active negotiations with worldly entities—a process that inevitably affected how they conceptualized the science itself. As revealed in Hernández’s research, their task, from era to era, was to navigate the changing ideological and political climate to preserve themselves and their particular medical paradigm as the sole arbiters of official medicine. They did this through monopoly and gatekeeping, such as establishing the Academy of Medicine and educational and licensing requirements, and by differentiating themselves from unapproved and “popular” health practitioners, whom they viewed as competitors and charlatans. By revealing and tracing the political and social (rather than scientific) establishment of elite medicine in Mexico, Hernández explicitly rejects “the view of a linear advance to modernity” (30).
A third group of books more intentionally and explicitly seek to fairly represent otherwise neglected, misunderstood, or misrepresented health care practitioners in Latin American history. These set out to complicate not only conventional historiography but also our understanding of medicine and health themselves. This priority is most apparent in how they expose the ideologically laden language with which we typically refer to those who provide health services, terms that often connote quackery as well as a skepticism shaped by racial and gendered expectations. “Doctors” versus “healers,” or “surgeons” versus “sorcerers” are examples. These works make a concerted effort to replace such labels with a more precise and objective terminology. Ultimately, they force us to contend with philosophical questions about what, exactly, “medicine” is, and to recognize that the definitions of both “health” and “illness” can be arbitrary, culturally determined, incomplete, and highly protean.
To comprehensively and fairly address the complex totality of medical paradigms and health as actually practiced in Latin America is the goal of The Gray Zones of Medicine, edited by Diego Armus and Pablo F. Gómez. The book exemplifies the new historiography of medicine as it explicitly seeks to recognize the true diversity of medical regimes operating across Latin America’s diverse communities, their uneasy, but not strictly adversarial relationship to Western biomedicine, and the ways that religious, cultural, and political priorities shaped how practitioners and patients alike delivered and received health care. Armus and Gómez deconstruct the prejudices that, they argue, have heretofore prevented us from understanding this complexity. Like Few, they deny that Latin American health practices can be understood by positing a stable dichotomy between “Western” and “alternative” paradigms. Instead, they point out that many individual practitioners thought nothing of “code switching”—that is, they freely drew from multiple medical traditions to fashion their therapies. Going further, they also echo De Vos by rejecting the presumption that any single medical tradition, “Western” or not, was ever static, coherent, and entirely discrete in the first place (7–8).
Armus and Gómez begin by arguing that sickness and health, far from being purely scientific or physiological conditions, bear on the “fundamental issues of human existence and the imagination of lifeworlds” (8). The result is an illuminating series of professional biographies of health practitioners that illustrate the political, cultural, ideological, and social dimensions of medicine as applied in Latin America from the sixteenth century to today. The volume’s contributors each examine a specific practitioner who operated within the titular “gray zones”—that is, the beliefs and therapies that exemplified the complex and dynamic interplay of ideas and practices that characterized the Latin American medical scene. These were not necessarily “marginal” practitioners—although some certainly were—but rather those who applied idiosyncratic therapies in an ambiguous or contentious relationship to officially approved medicine. They drew from multiple sources of knowledge and marketed their services with some combination of charisma, an acute awareness of the (perhaps nonmedical) desires and needs of their patients, and a compelling claim to effectiveness.
Because this is a history of the sociocultural rather than the biological, the contexts themselves are highly important. The volume is quite comprehensive in this regard, with examples as wide ranging as the Afro-Caribbean, multiple Indigenous populations throughout time, the Brazilian interior, the sugar plantation, Chinese Peru, and urban Buenos Aires. The gray zone practitioners were not all or necessarily people of low caste or class; some (like Mexican president Francisco Madero) were quite elite and educated indeed. One of the volume’s conclusions is that contact with multiple medical traditions—more likely among those who were widely read and well-traveled—was a factor in incentivizing and facilitating the kind of health care entrepreneurialism that the volume describes.
The Gray Zones of Medicine reflects a historiographical perspective that the coeditor Pablo Gómez applied in his earlier monograph, The Experiential Caribbean. In this work, Gómez foregrounds health practitioners from the Afro-Caribbean in the seventeenth century to demonstrate that the epistemological and methodological principles of rationality and empiricism were by no means limited to the emerging “scientific” paradigms associated with Western modernity. They operated throughout the Black Caribbean as well, reflecting the unique cosmopolitanism that arose in that theater at the time, in which diverse people from various African, Indigenous, and creole traditions encountered and interacted with one another in a fluid and mutually unfamiliar environment marked by constant migration, political upheaval, and frequent epidemics. But Gómez does not contend that Afro-Caribbean practitioners contributed to the rise of Western modernity or biomedicine; in this he differs from Few’s conclusions in For All of Humanity. Rather, he traces the development of an entirely different—and largely incommensurate—strain of empirically rooted medicine, one that developed despite the opprobrium of colonial authorities.
To capture and represent the epistemological-medical paradigms wrought by Afro-Caribbean practitioners, Gómez sets aside questions about the “true nature” of the illness they faced—for example, by eschewing today’s epidemiological classifications (such as “yellow fever”) in favor of colonial-era descriptions (“black vomit”). Gómez also focuses on where matters of health and illness intersected with evolving Caribbean perceptions of reality. According to the author, the success of any practitioners depended on their ability to demonstrate power over the natural and supernatural worlds. As what constituted “disease” varied according to local conditions and multiple cultural traditions, health care delivery became a prime opportunity for entrepreneurs to “display … powerful narratives about the nature of the world” (69). Gómez writes, for example, that European ways of knowing were only one dimension of how Caribbean peoples perceived reality; “for black Caribbean ritual practitioners, they were the ones who defined how the world worked and created the dominant model according to which the world could be sensed” (117). By seriously inquiring into the reasons for the evident success of such practitioners, Gómez identifies a sort of alternate scientific revolution taking place in the early modern Afro-Caribbean, an “epistemological revolution in which the experiential replaced first principles as the basis for Caribbean ways of knowing truths about the natural world” (167).
James Waldram’s An Imperative to Cure is not a history of medicine but an anthropology of contemporary medical practitioners, or iloneleb’, among the Q’eqchi’ Maya of Belize. But its spirit and philosophical intent align closely with The Gray Zones of Medicine and The Experimental Caribbean, as it also proceeds from the premise that Western biomedicine hardly has a monopoly on an empirical trial-and-error approach to promoting health. But whereas Armus and Gómez are somewhat more concerned with deconstructing the scorn and fear with which state-aligned medicine regarded those who operated outside its licenses, parameters, and definitions, Waldram is critical of those who romanticize and perhaps belittle Indigenous therapeutic systems by asserting that their main concerns are to heal the soul or correct spiritual imbalances. According to Waldram, medical anthropology erected a false dichotomy between a sterile “Western biomedicine” and “ethnomedicine,” in which the former is scientific, open to progress, and geared toward pathogens while the latter is static, culture bound, and more relevant to supernatural or psychological maladies. Although this scholarship was overtly couched as a critique of the narrow and purely physiological focus of Western doctors, Waldram finds this approach infantilizing as well as blind to the true scope of iloneleb’ knowledge and therapies. According to Waldram, “the goal of Q’eqchi’ medical practitioners is to alleviate sickness and make their patients better, and they are open to new information, new technology, and new techniques that may assist them” (17). “The idea that within ethnomedical systems some problems are actually medicalized,” he writes, “or that within biomedicine ‘cultural sensitivity’ and open communication are indeed possible, simply is not entertained in much of the research” (9). Indeed, the Maya practices, while deeply attuned to and reflective of local spiritual and cultural concerns, aim to “cure” disease rather than “heal,” they incorporate tools and technologies (such as pharmacologically active drugs) that attack disease at the biological level, and they are thoroughly empirical and experimental. Proceeding from this premise, Waldram intentionally organizes his book like a conventional medical textbook, with an account of his subjects’ understandings of illness vectors, nosology, general principles, and diagnoses.
Together, the books examined in this essay reveal that the history of medicine and disease cannot be extracted from the history of society, culture, and politics—not only because illnesses and treatments take place among specific peoples, but also because how we define “medicine” and “disease” themselves are ideologically and culturally emergent. Most of these works either expand on conventional definitions of “doctor” to include a broader range of people or emphasize the mutable, heterogeneous, and incomplete nature of medical science itself. In other words, the practical technologies of experimentation and empiricism were not limited to learned white European men, and medical treatments are never applied in a vacuum, but among flesh-and-blood people in particular communities governed by specific political and cultural imperatives. Public health efforts may derive from “pure science” and begin as pristine plans in the minds of the powerful, but their execution is inevitably far more complicated, as it necessarily involves a much broader cast of characters, each with their own agendas and concerns.
But let us return to the issue of topicality. Topicality admits the danger of inapt analogies, but if historians are to rebut suspicions of irrelevance and vanity, we must nonetheless attempt to make sense of our present by reference to the past. Absent a conspiracy between writer and reader to ignore the obvious, to address this scholarship at this moment in time inevitably bears on our present circumstances.
Our ongoing experience with the COVID-19 virus, along with the long view of the history of health offered by Kyle Harper’s work, may indicate balance and open-mindedness in how we wield the Foucauldian critique of modern public health. As many of these authors demonstrate, it is a powerful tool for revealing how health measures enable and justify control over human lives and bodies. This approach naturally lends itself to sympathy for the dissenters. Paul Ramírez, for example, acknowledges the ways modern medicine alleviated historical suffering, but is also fair-minded enough to sympathize with those who resisted it, portraying them as social antibodies to ill-conceived or ill-administered health campaigns that violated trust. “Malcontents” who rejected public health efforts based on rumors, he writes, were not irrational, despite how they were portrayed by exasperated elites; they were “theorists and producers of knowledge … alongside doctors, scientists, and historians. Their skepticism—as well as hope, anxiety, and faith—was no less part of the world of the literate, and they should be integral to the stories we tell about the dilemmas of public health and technological change” (238). The examples that Ramírez and the other authors offer in this regard are powerful and convincing. But today’s pandemic, and Harper’s research, cannot but retrain our attention back on the “dilemmas of public health.” Not all public health interventions were purely humanitarian, well designed, and fairly implemented, but some were better than others. And in the necessarily utilitarian calculus of anti-epidemic efforts, reticence can have adverse consequences for everyone.
Going further, not all forms of dissent are honest. The above works confirm that there are and have been many legitimate alternatives to biomedicine and sincere objections to poorly implemented public policy. But quackery exists. As we unpack how that label has been abused we must not overlook the reality that there has always been a market for sham science and dubious cures, and supply meets demand. Today’s internet bears not a small resemblance to the colonial rumor mills that encouraged some to reject the smallpox vaccine two centuries ago. If “health” is indeed subjective and medical science often is incomplete and wielded for unscientific purposes, true quackery may be less about specific beliefs and practices than intentions and harmful outcomes. The YouTube entrepreneurs and Facebook influencers who downplay contagious threats and inflame primeval fears about bodily integrity may indeed be “theorists and producers of knowledge” of a sort, little Foucauldians resisting the hegemonic impositions of a medicalizing (deep) state. But they are hardly healers operating in good faith within coherent medical paradigms reflecting subaltern community interests; they are profiteers capitalizing on a distinct market opportunity: spreading fear and confusion to then exploit for monetizable clicks. A fair and careful history of medicine that acknowledges quackery and its harms need not reinforce the logic of biopolitics; rather, it can—following Armus, Gómez, and several others addressed here—reveal much about how, when, and why their messages proved attractive, and about the spiritual or psychological benefits they offered that went unrecognized and unmet by medical authorities.
Thankfully, the current pandemic merely hints at the true harshness of the biological old regime endured by our ancestors, a world of ubiquitous, endemic, and largely untreatable suffering from smallpox, typhus, tuberculosis, malaria, plague, cholera, and many other diseases. But it nonetheless suggests that our ability to set aside entirely the question of “biomedically defined effectiveness” may be an academic luxury in the age of the Great Escape. The books examined here argue convincingly that medical history must acknowledge power differentials and maintain skepticism about the pretensions of science and top-down efforts to regulate health, illness, and death. But Harper’s history reminds us that, whether or not we pay attention to them, the pathogens also have a say. “Health” and “sickness” may be subjective experiences, but viruses, unfortunately, are impervious to poststructuralist criticism.
Overall, these new works remind us that our contemporary struggle unites us and does not set us apart from our ancestors, whose lives were shaped enormously by similar experiences. They also remind us that they, like us, brought all the ignorance and selfishness of human nature to the fight: our cultural rifts, our class divisions and ideological disagreements, our jealousies, and our hatreds. Yet we also bring creativity and ingenuity to the battle. As the above books demonstrate, these are the exclusive domain of no single culture or people.
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