The Transnational Formation of a Healthy Nation: Uruguayan Travelling Reformers in the Early 20th Century (1905–1931)
La formación transnacional de una nación sana: reformistas uruguayos en movimiento a comienzos del siglo XX (1905-1931)
A formação transnacional de uma nação saudável: reformadores uruguaios em movimento no início do século XX (1905-1931)
The Transnational Formation of a Healthy Nation: Uruguayan Travelling Reformers in the Early 20th Century (1905–1931)
Revista Ciencias de la Salud, vol. 19, no. 3, 2021
Universidad del Rosario
Received: 22 january 2021
Accepted: 17 may 2021
To cite this article: Huhle T. The Transnational Formation of a Healthy Nation: Uruguayan Travelling Reformers in the Early 20th Century (1905–1931). Rev Cienc Salud. 2021;19(3):1–22. https://doi.org/10.12804/revistas.urosario.edu.co/revsalud/a.10153
Abstract: Introduction: This study traces the different forms of trans- and international interactions of the Uruguayan public health reformers in the first three decades of the 20th century (1905–1931) and proposes to analyze these interactions regarding the factors that facilitated them, the purposes they followed, and the meanings which the reformers attributed to their travels and missions. Development: The analysis of this study is divided into five sections. The first section provides a thorough literature review of the transnational perspectives on health, welfare, and labor policies in early twentieth century Uruguay, followed by a second section that introduces this study’s main group of actors—Uruguayan health reformers attached to key state institutions—and identifies the different forms of their transnational interaction. Three analytical sections follow, which take a closer look in turn at the reformers’ participation in international conferences, their individual study tours to specific institutions in Europe and the Americas, and individual participation in a collective study tour organized by the League of Nations Health Organization (lnho). Conclusion: This study ends with a summary of the findings, examines their relation to the existing literature, and provides an outlook toward further questions to explore.
Keywords: Uruguay, public health, history, 20th century, physicians.
Resumen: Introducción: este artículo traza las distintas actividades de reformistas uruguayos de sanidad pública en los ámbitos trans e internacionales en las primeras tres décadas del siglo xx (1905-1931). Se analizan las confluencias y factores que las facilitaron, tal como las intenciones y significaciones que los reformistas mismos asignaban a sus viajes. Desarrollo: el artículo expone su argumento a lo largo de cinco secciones. La primera repasa los estudios efectuados desde una perspectiva transnacional, sobre sanidad, estado social y políticas laborales en Uruguay a principios del siglo xx. La segunda sección introduce a los actores principales de la investigación, esto es, los reformistas de sanidad uruguayos vinculados a las instituciones estatales claves, e identifica varios modos de interacciones transnacionales. A continuación, se analizan tres de estos modos de interacciones: la asistencia de reformistas uruguayos a conferencias internacionales, varios viajes individuales de investigación a instituciones en Europa y las Américas y la participación en un viaje de estudios en grupo organizado por la Organización de Higiene de la Sociedad de las Naciones. Conclusión: el artículo finaliza con un resumen de los resultados de la investigación, haciendo referencia a la historiografía presentada en la parte introductoria y al desarrollo, a la vez que propone algunas tareas de investigación pendientes.
Palabras clave: Uruguay, salud pública, historia del siglo XX, médicos.
Resumo: Introdução: este artigo traça as diferentes atividades dos reformistas da saúde pública uruguaios em nível trans e internacional nas três primeiras décadas do século xx (1905-1931). São analisadas as confluências e os fatores que as facilitaram, bem como as intenções e os significados que os próprios reformistas atribuíram às suas viagens. Desenvolvimento: o artigo apresenta seu argumento em cinco seções. A primeira apresenta uma revisão sinótica de estudos, realizados desde uma perspectiva transnacional, sobre saúde, situação social e políticas de trabalho no Uruguai no início do século xx. A segunda seção apresenta os principais atores da pesquisa, ou seja, os reformistas da saúde uruguaios ligados às principais instituições do Estado e identifica vários modos de interações transnacionais. Três desses modos de interação são analisados a seguir: a presença de reformadores uruguaios em conferências internacionais, várias viagens individuais de pesquisa à instituições na Europa e nas Américas e a participação em uma viagem de estudo em grupo organizada pela Organização de Higiene da Liga das Nações. Conclusão: o artigo termina com uma síntese dos resultados da pesquisa, fazendo referência à historiografia apresentada na parte introdutória e no desenvolvimento, propondo algumas tarefas de pesquisa pendentes.
Palavras-chave: Uruguai, saúde pública, história do século XX, médicos.
Uruguay is regularly praised as the first democratic welfare state in Latin America and a forerunner in social legislation even on a global scale. This praise forms part of an exceptionalist narrative around the formation of the Uruguayan nation-state during the first three decades of the twentieth century by the batllistas, a faction of the liberal Colorado Party that owes its name to two-time president José Batlle y Ordoñez (1903–1907, 1911–1915). However, these decades also coincide with a golden age of transnational cooperation and internationalism, in which Uruguayan reformers participated fully.
Historical research on transnationalism has emphasized the paradox of an era in which transnational networks thrived, while “national borders and national forms of social legislation” gained importance simultaneously (1: p. 61). Similarly, the accounts of the history of public health in Latin America have stressed that “reforms… in public health were central to state-and nation-building in the region” (2: p. 58)—since health infrastructure allowed the state to engage with its citizens and vice versa—while “even their most nationalist expressions were internationalist and cosmopolitan in origin, orientation, and networks” (2: p. 59).
This study places the Uruguayan public health policies in the first three decades of the twentieth century at the center of this tension between nation-state building and transnational and international cooperation. It uses historical institutional journals to trace different forms of trans- and international interactions of the constantly travelling Uruguayan health reformers who worked for the growing and consolidating Uruguayan state. The analysis of these interactions is guided by three questions: Which factors facilitated the exchanges? Which purposes did they follow? And which meanings did the reformers, but also the broader public, attribute to their travels and missions? Thus, this study aims to add an analytical answer to the question of how exactly the transnational processes in the development of public health policies in early twentieth century Uruguay unfolded. Consequently, it contributes both to the history of the Uruguayan welfare state and to the transnationalization of the history of social policies.
Transnational and global history approaches are on the rise in the historiography on social policies and the welfare state in the Americas and Europe since the 1990s. The first systematic summaries of these approaches have been proposed by Christoph Conrad (3) and Daniel Rodgers (4). Despite an unfortunate bias towards research on Europe and North America as well as on transatlantic connections that neglect “South Atlantic Crossings” (5), both authors offer valuable generalizations on transnationality in social policy research.
Christoph Conrad’s synthesis led him to a nine-fold typology of “forces and practices” that he also calls “vectors of transnationality” (3: p. 223). These vectors are as follows:
1. The circulation of models, that is, processes of observation, appropriation, and refusal of foreign social policy models in specific national contexts.
2. The “transnationalizing” role of international institutions and organizations.
3. Individual expert actors, their communities, and networks.
4. The languages of cross-border communication, such as statistics and law.
5. Mobile actors, most prominently migrants, on the demanding, receiving, and providing side of social policies.
6. Travelling problems, such as health risks.
7. International and transnational law.
9.Global social policy. (3: p. 223–233)
Daniel Rodgers instead engages more critically with the transnational turn in the history of social policies, claiming that transnationally informed research on social policies has been able to trace all kinds of transnational movements, transplantations, appropriations, and exchanges but that it lacks methods to identify patterns within these movements. His methodological proposal is to look less at the transfer of individual policies and instead more at policy clusters and the narratives that provide them with prestige and power (4).
Despite their differences, these summaries show that the discussion has reached the point wherein the existence and relevance of transnational exchange, cooperation, and competition in the genesis and transformation of national social policies no longer needs to be proven. Similarly, within the larger field of global history, some authors even consider the analysis of entanglements exhausted (6), whereas others have shown that key methodological approaches, e.g., circulation, still lack clarity (7). By analyzing the facilitating factors, purposes, and attributed meanings in the trans- and international interactions of Uruguayan health reformers, this study aims to contribute further analytical explanation of the transnational dimension of social policies in the beginning of the twentieth century.
The analysis of this study is divided into five sections. The first section provides a thorough literature review of transnational perspectives on health, welfare, and labor policies in early twentieth century Uruguay, followed by a second section that introduces this study’s main group of actors—Uruguayan health reformers attached to key state institutions—and identifies the different forms of their trans- and international interactions. Three analytical sections follow, which take a closer look in turn at the reformers’ participation in international conferences, their individual study tours to specific institutions in Europe and the Americas, and individual participation in a collective study tour organized by the League of Nations Health Organization (lnho). This study ends with a conclusion that summarizes the findings; examines their relation to the existing literature, such as Conrad’s typology; and provides an outlook toward further questions to explore.
The empirical basis for this study are journals, magazines, newspapers, brochures, monographs, and grey literature from and about the reformers and the institutions they worked for. The revision of these sources takes into account that these sources are biased insofar as it is somewhat self-evident that the reformers framed their own actions as important and influential. However, since this study does not aim to assess the relative importance of their actions, but rather the official purposes and the meanings which the reformers attributed to the trans- and international elements, they constitute valuable sources.
Concretely, this study is primarily based on the complete assessment of the journal of the Consejo Nacional de Higiene, which is the main organ for accounts of conferences and research trips. Although this state institution was founded in as early as 1895, the journal only started to be printed in 1905. It existed until 1931, when the Consejo Nacional de Higiene was dissolved in order to soon merge into the Ministry of Health. The years of publication of this central source thus mark this study’s beginning and end point. Further sources include the selected issues of the journal of the Asistencia Pública Nacional—a second key state institution—and the abovementioned types of historical literature. Exchanges with the lnho are furthermore well documented in the United Nations archive in Geneva.
Transnational perspectives on public health and social policies in early twentieth century Uruguay
When José Batlle y Ordoñez came to power in 1903, he and his fellow batllista reformers aimed for a radical break with the past. They saw themselves as the creators of a new country invented from scratch that allowed for experimental reformism in a laboratory-style setting (8: p. 74). José Batlle y Ordoñez framed the project as the construction of a “país modelo” in a letter to his friend Domingo Arena in 1988 (8: p. 16).
Early on, this model country gained both international notoriety—as being “autocratic” or “socialistic” according to certain British observers (9: p. 27)—and fame, as the us economist Simon G. Hanson wrote in 1938. “With José Batlle y Ordoñez furnishing the directive impulse, the nation embarked on a programme of state socialism and advanced social legislation that made it the chief laboratory for social experimentation in the Americas and a focal point of world interest” (10: p. 5). By the time Hanson formulated his praise, Gabriel Terra had staged a coup d’état (1933) and put an end to the three decades of democratic reformism. Even though the years between Batlle y Ordoñez’ first election (1903) and the Terra dictatorship were far from uniform with regard to legislative majorities and executive programs, several historians frame the whole period as “República Batllista” (11), “Uruguay batllista” (12), or “batllista state” (13).
Historians have also long participated in the batllista mythmaking (9: pp. 27–30). They continue to acknowledge the peculiarities of a reformism that included women’s right to divorce on their sole demand in 1913, the eight-hour work day in 1916, and the establishment of state enterprises, to name only a few of the most cited examples. But at the same time, recent historiography is de-constructing that myth, and batllista exceptionalism has been questioned in several regards.
First and foremost, scholars have shown that the batllista state did not constitute the sharp break with the past as its contemporaries had framed it. In a recent handbook on Uruguayan history, historian Gerardo Caetano underlines how a key feature of batllismo—the interventionist, entrepreneurial state—had already been established in the last decades of the nineteenth century (8: pp. 51–52). This search for nineteenth-century precedents to batllista reformism also guides Jens Hentschke’s monograph on education reforms (9). Another line of myth-breaking can be found in the discussion on whether or not the batllista system deserves to be called a welfare state (12: pp. 36–37).
With regard to the early labor legislation and the discussions preceding it, Lars Peterson has emphasized the role of organized labor and questioned the image of Batlle y Ordoñez as the workers’ ally. He further reveals how the legislative debates on labor laws were fueled by a discourse on progress and the idea to make Uruguay a “first” among its sure-to-be envious neighbors (14). Furthermore, Christina Ehrick’s work deconstructs the idea of the state within the welfare state, by showing how the new welfare institutions of the batllista state cooperated with and depended on the very philanthropic institutions, both secular and Catholic, that they meant to replace from the 1910s to the 1930s (13).
Finally, whereas Peterson and Ehrick’s works are limited to the national setting,2 nation-centered batllista historiography has also been challenged by a number of scholars who have started to analyze the history of public health and social policies in Uruguay from a transnational or global history perspective. Among others, these works provide hints regarding the forms of interactions under study here.3
This is mostly the case with Anne-Emanuelle Birn’s research on Uruguayan child health and welfare policies from the 1890s to the 1940s and their repercussions in international organizations (19,20). She has analyzed the processes that led to the foundation of the Montevideo-based Instituto Internacional Americano de Protección a la Infancia in 1927 and focused on how Uruguay had “international bearing and influence” (19: p. 55) in child health and welfare policies. While the Uruguayan reformers’ ways of international interaction are not her primary interest, she still looks at a range of “tools and media of the day” (19: p. 57), e.g., study times and advanced training in Europe, research abroad, and participation in congresses and exhibitions. Moreover, she has analyzed Uruguayans’ publications in international journals and their role within the lnho. Furthermore, she has underlined how the comparison of, for example, infant mortality rates was the dominant practice of relating Uruguay to the world and measuring its relative progress.
Focusing on the public education ideas and reforms in Uruguay from 1868 to 1915, Jens Hentschke also uses a transnational approach. He argues that “in no other policy field were transnational interactions more apparent” and asks how “ideas travel[led]” (9: p. 50) between Uruguay, the usa, and Europe but especially within the region, that is, between Uruguay and neighboring countries, such as Argentina, Chile, and Brazil. He traces these interactions and travelling of ideas by looking at study trips, exile, communication, libraries, bibliographies, congresses and exhibitions, etc.
For the history of physical education in Uruguay, Paola Dogliotti Moro has uncovered the significant role of a us Young Men’s Christian Association (ymca) professional, who was stationed in Montevideo, in institutionalizing the field. He arrived in Montevideo in 1911 and for two decades served as the director of the recently founded Comisión Nacional de Educación Física. He served later as its honorary advisor (21).
Transnational contacts to us reformers also figure prominently in Sönke Bauck’s recent study on anti-alcohol activism in Uruguay and Argentina. He analyzes this activism as both part of a transatlantic reform world and a key element of nation-building in the region. Regarding the transnational interactions between the South American reformers and their us and European counterparts, Bauck highlights a discursive tension between appropriation and demarcation, while also analyzing the concrete transatlantic cooperation, especially among female activists (22).
Finally, a further contribution to the transnational history of batllista reforms takes place within diplomatic history. James Charles Knarr, who has analyzed the relations between batllista Uruguay and the United States, argues that many historians overlook the importance of the us model for batllista state builders. Knarr claims that “Batlle borrowed selectively” from the Progressive Era reforms on “education, populating the interior and public works” (23: p. 9). This approach is problematic for its focus on the person of Batlle y Ordoñez and the underlying assumption of unidirectional learning, but Knarr’s study offers interesting methodological suggestions regarding the ways of adaption. He distinguishes between three strategies employed by Uruguayan reformers: rhetorical reference to us events in order to argue for reform proposals, the role of diplomats in forwarding Progressive Era literature, and the invitation of us experts by the Uruguayan state (23: p. 104). However, unlike the other authors and this study, he did not include travelling in his assessment.
Overall, the works of Birn, Hentschke, Dogliotti Moro, Bauck, and Knarr have underlined that the history of public health and social policies in batllistaUruguay is analyzed most fruitfully, when the trans- and international interactions of the actors and institutions involved are taken into account.
Public health institutions and reformers in early twentieth century Uruguay
Mapping the institutions and reform areas that tackled public health and hygiene in early twentieth-century Uruguay leads to a complex and diverse picture. As in the rest of Latin America (2: pp. 58–105), fostering the health of the nation came in many facets. It included not only the inspections and quarantines in the times of epidemics and the sanitation of Montevideo’s port and streets but also the creation and takeover of hospitals, asylums, nurseries, and orphanages granted that “every individual lacking of resources” had the right to receive free assistance from 1910 onward (24: p. 7). It further meant the foundation of institutions that reflected a special concern for children’s health, among them the Gota de Leche (1907) and Cuerpo Médico Escolar (1908). This second body is but one of several examples on how health and education policies overlapped, and the expansion of physical education is another. Labor legislations like the eight-hour day (1916) or those on the prevention of work accidents (1914) also had an important health dimension.
Preventive public health measures came both in coercive forms, most notably regarding prostitution and the prevention of venereal diseases, and as campaigns that called for the voluntary change of unhealthy behaviors, such as the consumption of alcohol. This still incomplete overview likewise includes the formation of state-funded public health personnel, such as nurses, sanitary engineers, social workers, and visitadoras escolares, and the regulation of wet nurses and midwifes.4
Contemporary international observers—among them public health experts, physicians, journalists, and diplomats—were especially impressed with the Uruguayan child health and welfare efforts. Uruguayan pediatrician Luis Morquio gained international fame, and the clinic he directed attracted students from all over Latin America (25: pp. 16–17). Activities in the reform field of physical training also received international appraisal, for example, from the United States’ embassy and the Argentinean press (26,27: pp. 121–122). In a ranking of Latin American public health accomplishments, renowned Argentinean hygienist Emilio Coni stated in 1920 that Uruguay was first with regard to medical efforts against tuberculosis, alcoholism, and syphilis (28: pp. 473–476).
The two most important state institutions for matters of public health and hygiene were the Asistencia Pública Nacional (founded in 1910), which was responsible for the administration of public hospitals and other welfare institutions, and the Consejo Nacional de Higiene (founded in 1895), which was responsible for developing and monitoring hygiene, health, and sanitary policies, among others. In 1933, they merged into the Ministry of Health. On the directory level, these institutions had almost exclusively men on staff, most of them liberal physicians close to the Colorado Party. Many of them had further direct links to politics, serving as parliamentarians or diplomats at some point in their careers.
These reformers were in the center of the massive gain of prestige and political influence by physicians, medical knowledge, and the Medical Faculty on Uruguayan politics starting in the late nineteenth century. In a Foucauldian tradition, historian José Pedro Barrán has described this ascent of power as both a symptom and motor of the medicalization of Uruguayan society in the first three decades of the twentieth century (29). An important common trait in the biographies of this generation of Uruguayan “political doctors” and “higieniestas” (3: pp. 65–73) from the late nineteenth and early twentieth centuries was that nearly all of them spent some time studying abroad. Paris—the “capital of Latin America” (30)—was their most important destination: some studied there, repeated their studies, presented their doctoral thesis, or were interns in French hospitals or conducted studies of specialization (15: p. 23).5
Batllista Uruguay also saw the first generation of female physicians graduating in Uruguay, and they were just as active in matters of public health as their male colleagues. For certain reform areas, it can be argued, as in Argentina, that “women build the welfare state” (31). Paulina Luisi is the most famous Uruguayan female health reformer, and she played an important international role as both a feminist and a physician (32,33). She represented Uruguay at various international organizations and congresses, for example, at the Fourth ilo conference in Geneva 1922 (34: p. 27). But neither she nor any other woman made it into the governing bodies of the Asistencia Pública Nacional or the Consejo Nacional de Higiene.6
The professional life of the largely male reformers who composed these institutions was also characterized by frequent, sometimes constant, travelling and a dense trans- and international network. A thorough analysis of the sources that were outlined in the introduction show that their trans- and international interactions mainly encompassed study and specialization times abroad, exchange and cooperation at congresses, and study tours on specific topics. With regard to these tours and the congresses, international organizations, such as the League of Nations and the Pan-American Sanitary Bureau, played a special role, especially from the 1920s onwards. Diplomacy is also identifiable as a channel for cooperation and knowledge transfer in its own right. Within these identified forms of interaction, the participation in international congresses and in study tours, both organized independently and through international organizations, are richest when it comes to the analysis of how the actors attributed meaning to them. Thus, they will be the three forms examined in depth in the following sections.
International congresses as transnational exchange fórums
The participation in international congresses was a recurrent motif in travels abroad for the Uruguayan reformers within the growing public health institutions. The Uruguayan state provided the finances so that they could participate at “virtually every international congress related to public health and social welfare” (19: p. 42). Tellingly, two members of the Consejo Nacional de Higiene substantiated their proposal to follow the Argentinean invitation to an international congress of medicine and hygiene held in Buenos Aires in 1910, with a reference to the “established practice” of participating in that kind of congress in the Americas and Europe (35: p. 217).7
The congresses took place on different regional scales: international, Pan-American, and Latin American. Conferences announced as international most often took place in Europe and ranged from the encompassing conferences on hygiene and demography (starting in 1877) to the more specialized ones. Uruguayan delegates participated in international discussions on professional diseases (Brussels 1910)8 and tuberculosis (e.g., San Sebastián 1912), among others. On the Pan-American level, the well-known International Sanitary Conventions started in 1902, with Uruguay participating from the beginning, but just as in the international framing, Uruguayan reformers also travelled to specialized Pan-American congresses, such as those on venereal diseases (Washington D.C. 1920) or tuberculosis (Córdoba 1927). On the Latin American level, both the scientific and the medical congresses were important exchange forums for Uruguayan public health reformers.
The example of Uruguay’s participation in the Fourteenth International Congress on Hygiene and Demography that took place in September 1907 in Berlin serves to illustrate the selection of delegates. In a letter dated February 13, two members of the Consejo de Higiene addressed the “señor Presidente” José Batlle y Ordoñez with their proposal for the suitable candidate among “one of the Uruguayan physicians residing in Europe.” Concretely, they proposed Oriol Solé y Rodríguez, a physician who was serving as Uruguay’s consul in Hamburg at the time. Notably, the letter also included a list of panels that the Consejo de Higiene regarded of special interest and wanted the delegate to attend and report on (38).
This points first to a centralized selection of delegates who did not participate in their private function as physicians, but as national representatives, and to strategic information and model seeking within the council’s directive. Second, when it came to international congresses, this is only one among several examples wherein ambassadors or consuls served as Uruguay’s delegate in their countries of residence or those nearby. As this might look like the least expensive solution, Solé y Rodríguez was not the only diplomat who attended such congresses on public health from a very informed position. A noticeable number of Uruguayan diplomats were physicians by training, including Rafael Fosalba, the Uruguayan minister to Cuba since 1910. As Birn has pointed out, Fosalba carried out widely published works on infant mortality rates in Cuba while stationed there (19: pp. 41–42).
Interest in Uruguayan participation in public health-related international congresses was not limited to expert audiences, as a preliminary analysis of Uruguayan newspapers shows. The readers of Batlle y Ordoñez’s newspaper El Día were informed in several studies in 1912 that the Second International Congress on Tuberculosis in San Sebastián had been a “triumph” for Uruguay. They learned that the Spanish press was full of praise for the Uruguayan progress in combatting the deadly disease; that the Uruguayan delegate Constancio Castells presented several studies that received much enthusiasm; and that one of them even received a prize. As a result, El Día reported that Spanish public health officials thought of introducing fundraising events against tuberculosis in analogy to similar initiatives of the Liga Uruguaya contra la Tuberculosis.9 These studies emphasized on Uruguay’s international success in terms of proving its progressiveness, rather than on the contents discussed in the conference. The present study illustrates that just like world fairs (41: p. 5), these congresses not only served transnational cooperation and exchange but were also venues of competition at which national reformers tried to prove their country’s high stage of civilization.
When examining the Asistencia Pública Nacional, it is interesting that major publications about this institution were prepared and printed on the occasion of the international congresses. Thus, they were prepared for an international audience that should learn of Uruguay’s progress in the care of its citizens in need.10
Importantly, Uruguayan reformers not only participated in numerous international public health conferences, but Uruguay also hosted several itself, among them the third Latin American Medical Congress in 1907, the second American Children’s Congress in 1919, and the Sixth Pan-American Sanitary Conference in 1920. Hosting such conferences gave large numbers of Uruguayan reformers the possibility to participate and was an opportunity for the Uruguayan state to showcase domestic progress. Of special importance was the first conference of the lnho that took place in the Americas, the South American Conference on Infant Mortality, that brought “a prestigious world stage to Montevideo” in 1927 (19: p. 50) and was hosted by renowned Uruguayan physician Luis Morquio. According to Birn, this was possible due to the contacts Paulina Luisi had already established with a variety of League of Nations bodies. She had been the Uruguayan delegate to the League’s first general assembly in 1922 and became an expert delegate on the so-called white slavery two years later (19: p. 48).
Individual study tours
Congresses were not the only state-funded travels that Uruguayan reformers embarked upon. Both the Asistencia Pública Nacional and the Consejo Nacional de Higiene commissioned a large number of study tours to different public health institutions in the Americas and Europe. Reports of these trips were printed in the journals of both institutions. These reports include the information of the places and institutions visited, but not about the length of the trips. Still, from the description of the tours, it is possible to calculate that they could last up to several months. When it comes to the purposes of these study tours and to how the travelling reformers made sense of their endeavors, a closer look at their reports reveals that they referred to their trips as occasions for learning but also as opportunities to make Uruguayan reformism known abroad.
This second aspect dominated in the case of the Inspector de Farmacias del Uruguay, Ernesto Paccard, who was sent to Paris to study the French legislation on pharmaceutics in 1909. Thanks to a translation printed in the Boletín del Consejo Nacional de Higiene, we know that a French colleague, “doctor Thévenard,” in the journal La Pharmacie Francaise, covered his visit. The study also contained a summary of the Uruguayan legislation on the matter, introduced by Thévenard as a text that disproved the assumption that “Europe was the only part of the world that could consider itself civilized.” Thévenard also explained that he knew Paccard because of his own interest in yerba mate and told his readers that Paccard and his “markedly” French name were already well known to them (“us”) for his publications in French journals (43). As we can assume that almost all Uruguayan state officials and especially physicians spoke French, the study in the Boletín del Consejo Nacional de Higiene shows that in Uruguay’s migrant society, personal backgrounds played a role in facilitating transnational cooperation and exchange.
Within the health and assistance institutions organized under the umbrella of the Asistencia Pública Nacional, the professionalization of “mental hygiene,” most notably within the psychiatric hospital, Hospital Vilardebó, stands out as a field in which its principal reformers travelled frequently and for long periods of time. This may reflect the importance attributed by the Uruguayan statesmen to eradicate certain “elements” from their “imagined model country,” as historian Nicolás Duffau has argued (16: p. 9). When the physician Bernardo Etchepare came back from a lengthy trip to Europe in 1912, the Asistencia Pública Nacional devoted a whole journal issue to his two-hundred-page-long report on how England, Germany, Austria-Hungary, Denmark, and France treated “débiles mentales.” He explicitly discussed which of these approaches could serve as a model for Uruguay (44: pp. 706–707).
The Consejo Nacional de Higiene also commissioned a large number of study trips, as shown in the following examples. In 1912, Julio Etchepare, in his function as Montevideo’s Inspector de Sanidad Terrestre, reported to the council on his commissioned trip to Buenos Aires. He had crossed the River Plate in order to study the city’s system for garbage disposal and expressed the hope that his mission’s findings would help resolve this problem of urban hygiene in Montevideo (45). On a very different topic, but with parallel learning purposes, in 1920, the Consejo Nacional de Higiene sent physician Abel I. Zamora to study prophylactic measures against syphilis in Paris. His lengthy report concluded with the remark that he believed to have fulfilled his mission. He thought that the report would serve to improve Uruguayan laboratories scientifically and would satisfy his own desire to improve national science (46: p. 881). He thus framed transnational learning as a patriotic achievement.
In 1927, the council sent Montevideo’s inspector for maritime sanitation, Alberto Eirale, to various European and Latin American countries in order to study the sanitary organization of their ports. His reports show that the council had equipped him with a lengthy and detailed list of points to investigate, among them the treatment of contagious passengers, veterinary inspections on the ships, and visiting hours of the sanitary authorities (47). Thus, just like international congresses, these study trips were vigorously tailored to specific questions on which the council wanted input.
In exceptional cases, the answers to these questions can be directly traced to reform proposals within Uruguay. That was the case with a study trip to Vienna on social housing by council member Mario Ponce de Leon in 1930. According to his report, the trip had been commissioned by the council but proposed by a politician on the highest executive level who immediately after Ponce de Leon’s return incorporated his newly acquired knowledge into a legislative project on housing standards in Uruguay (48). A few months later, Ponce de Leon drafted a law of his own, this time specifically on the construction of hygienic housing for workers, including a paragraph that called for the construction along the Viennese model as described in his report (49).
The League of Nation’s first exchange of Latin American health officials
As these study tours were individual endeavors, the founding of the lnho in 1923 opened the doors for travelling in larger groups. According to Iris Borowy, for its founding director Ludwik Rajchman and “the Health Section under his leadership connecting people was a health issue as much as a political ambition. (…) For some years, interchanges were the dominant form of lnho-organized transnational cooperation” (50: p. 191). Largely financed by the Rockefeller Foundation, national governments usually paid only about a third of the travel expenses (50: pp. 193–194 and 199). The first Uruguayan to benefit from this approach was physician Rafael Schiaffino. He was one of ten men to have participated in 1925 in the “first exchange of Latin American health officials,” which was according to Paul Weindling a “high-status exercise” and “mark of honor” for the countries selected (51: p. 7). The lnho praised the exchange for uniting all “races” in a common struggle for public health and as a necessary global response to the global spread of contagious diseases. However, the topics of the exchange included much more than prevention from infection (52).
Schiaffino, born in 1881, had started practicing medicine in first aid during the last battles of the Uruguayan Civil War that ended in 1904. He started his career as a public health expert when he became a member of the Cuerpo Médico Escolar in 1911, an institution that he started to direct in 1918 (53: pp. 3–4). The field of school hygiene was first established in close cooperation with Argentine hygienists and institutions, as illustrated by recurring references to an “Argentine model” (54: pp. 4–5)11 and by Schiaffino’s membership on the board of directors of the Boletín de Higiene Escolar, printed in Buenos Aires. Until he participated in the lnho exchange in 1925, his international experience had been mostly within the Cono Sur, having attended several international congresses in the region, most notably the Pan- American Congresos del Niño in Montevideo, Buenos Aires, Santiago de Chile, and Rio de Janeiro (53: p. 5).
The lnho exchange of 1925 brought Schiaffino to Cuba, the United States, Canada, England, Holland, Belgium, Switzerland, France, and Italy. Additionally, he went on an individual tour through Germany and served as both a Uruguayan delegate and technical adviser on hygiene at the League of Nations Assembly in 1925 (53: pp. 5–6). Detailed reports of these travels were published in three issues of the Boletín del Consejo Nacional de Higiene in 1926. He described his observations from Germany, Canada, and Italy therein. The topics covered ranged from school hygiene in Berlin, the Canadian public health administration in various provinces, and anti-malaria campaigns in Italy to industrial hygiene and social housing of German companies Bayer and Thyssen Krupp (55-57). The sources include no explanation for the selection of these three countries.
While in Geneva, the delegates met with lnho officials and also with delegates who had just been on a similar exchange trip to Yugoslavia. The meetings included presentations on the “sanitary conditions in their respective countries” and on the “immediate results of their studies during the recent trip” (52: p. 3). A stenography from Schiaffino’s speech shows us how he framed Uruguay’s situation and his lessons learned. His general introduction to his home country stressed that it was inhabited by people from the “European race,” whereas the “problem of negroes and Indians” did not exist in Uruguay, since these people had allegedly disappeared more than a century ago (58).
This false and racist claim had been a standardized consensus among the Uruguayan elite since independence and a core element of nation-building in Uruguay (59: pp. 2–3,60). The motif of Uruguay’s “whiteness” as a marker of its high degree of civilization was cemented in the first decades of the twentieth century in a large number of nationalistic publications that have been characterized as “laic catechisms” (61: pp. 17–19,62: pp. 213–214). It included the auto-perception of living on an “European island” that had little in common with its neighboring countries (8: p. 16).
The second aspect Schiaffino stressed in the brief presentation in Geneva on his home country was the favorable living conditions of the Uruguayan working class. Schiaffino ascribed them to his country’s labor and social legislation, listing the eight-hour workday, protection for women and children, and public assistance for the disabled regardless of their religion, among others. Schiaffino’s praise sounded just like the official propaganda of the Oficina de Exposiciones, a state agency created in 1910 to present Uruguay at world fairs and other international forums. The office summarized the country’s progresses in a bilingual brochure in 1915 as follows: “The political organization is in harmony with the most advanced democratic principles and day by day it is being rounded out by new social laws which are making of Uruguay the most favorably situated country among the nations of the world” (63: p. 22). Despite him being an opponent of Batlle within the liberal Colorado Party, Schiaffino’s speech thus reiterated with a second key trope of batllista elites, for whom reforms were everything (8: pp. 20–21).
Regarding health and hygiene, Schiaffino underlined the otherness of the Uruguayan countryside and its so-called simple inhabitants, whom he accused of culturally based unhealthy living conditions and nutrition habits. For example, he held the sharing of drinking straws when consuming yerba mate responsible for the transmission of infectious diseases, such as syphilis and tuberculosis. Overall, he attributed Uruguay favorable hygienic conditions, but identified child mortality rates and tuberculosis as its most pressing public health issues. The existing Gota de Leche program was, according to his judgement, not enough and had to expand with the integration of experienced nurses. He also believed it necessary to further ameliorate the alimentation of children but dismissed the advice the delegation had received from the Netherlands—to instruct mothers how to prepare milk instead of giving out prepared milk—as coming from an “advanced country” and therefore not applicable everywhere. With regard to tuberculosis, he again stressed the necessity to train more nurses, in this case, with the task to teach preventive measures (58).
In a second speech that survived in the League of Nation’s archive and that he most likely also held while in Geneva, he added persistence in the “anti-venereal fight” and housing conditions to the most pressing health issues in Uruguay and stressed again on the formation of auxiliary nurses as the most important lesson learned during the trip. If applied, they could transform Uruguay with its already “not bad” hygienic conditions into one of the healthiest nations of the world (64). Interestingly, this “lessons learned” narrative does not form part of the aforementioned studies that Schiaffino published about the trip in the Boletín del Consejo Nacional de Higiene. Nevertheless, it was indicated that within the Cuerpo Médico Escolar, he successfully incorporated more auxiliary female staff. Thus, 3 years after the study tour, he pushed for the expansion of the Cuerpo Médico Escolar through the formation of visitadoras escolares. He based his idea on learning about the importance of good training of the technical personnel in all hygienic institutions during the lnho-sponsored trip to North America and Europe (65,54: pp. 6–7).
The Uruguayan public health reformers in the first three decades of the twentieth century formed part of the transnational, regional, and international reform communities. Their formation abroad, their participation in international conferences and in exploratory study tours, their involvement with international organizations, and their diplomacy were the main forms of their trans- and international interactions. These correspond with three of the “vectors” of transnationality in social policies that Christoph Conrad identified: processes of observation, appropriation, and refusal of foreign social policy models in specific national contexts; the “transnationalizing” role of international institutions and organizations; and—to a lesser degree—the role of individual expert actors, their communities, and networks.
Even though earlier research on public health and social policies has not put these forms in the center of analysis, this study’s findings further correspond with the forms that Birn (19,20) and partly Hentschke (9) and Bauck (22) have discussed in their studies. However, contrary to Dogliotti Moro (21) and Knarr (23), the invitation of foreign experts could not be traced in this study’s sources as a decisive form of transnational interaction at play in the formation of public health policies in early twentieth century Uruguay.
The analysis of three of these forms—international conferences, individual study tours, and one of the several collective study tours organized by the lnho—centered on the factors that facilitated these interactions, the official purposes behind them, and especially the meanings which the reformers attributed to their travels. The analysis was based on a number of sources, most importantly the journals of the main public health institutions within the Uruguayan state.
With regard to the facilitating factors for the success of the trans- and international interactions, the role of physicians in diplomatic positions, and migratory ties could be identified. The purposes of the reformers’ conference participation and study tours more often than not turned out to be thoroughly tailored to the interests of the state institutions that commissioned the reformers, that is, the Consejo Nacional de Higiene and the Asistencia Pública Nacional. They sent the conference participants to specific conference panels and equipped individually travelling reformers with detailed questionnaires. These processes are identifiable as strategic information-and model-seeking.
Consequently, when reporting on their exchanges abroad, far from only summarizing the results, the reformers thoroughly discussed what they considered best models and lessons learned for Uruguay but also what advice was to be dismissed. In some cases, they also attributed the insights from their travels as being directly responsible for reform proposals in their home country, and they were often in the position to stimulate these reforms themselves.
However, this analysis of the attributed meanings revealed that the reformers also used their encounters to showcase Uruguayan successes in the realm of public health in particular and in becoming a model country of reformism in general. This look at successes also guided newspaper reports on their travels. The reformers further framed both their investigation in other national contexts and their presentation of Uruguayan efforts to colleagues worldwide in nationalistic terms. This finding directly corresponds with the initially referred to simultaneity of nation-state building in the high times of transnational cooperation. Moreover, it relates to Daniel Rodgers’ argument that social policy ideas travelled in clusters and narratives. This is best illustrated with the example of Rafael Schiaffino’s speeches in Geneva. It could be shown that his re-presentation of Uruguay followed the established contemporary narrative of highlighting Uruguay’s high state of civilization and progressiveness.
With regard to further studies, it is necessary to distinguish carefully between using a reference to European and other examples as a mere rhetoric and the actual processes of learning and adaptation whenever the findings were used to substantiate the proposal of certain reforms within Uruguay. Thus, when reformers argued for the necessity of certain public health reforms within the Boletín del Consejo de Higiene Pública, they referred to European models in an almost standardized fashion (e.g., 66,67).
Another interesting point to investigate would be the discursive line among Uruguayan reformers in the early twentieth century that sought to evaluate local Latin Americanknowledge on public health as well as the extent to which outsider knowledge could be transferred. Similar debates have already fruitfully been analyzed in the discussions on social medicine in international networks of the 1930s (68). Finally, while this study focused on the transnational connections of male reformers, it is important to stress that they were not the only participants in the formation of public health in Uruguay embedded in trans-and international networks. This is just as true for the female philanthropists, those of the middle-class welfare personnel, and those engaged in the worker’s movement. Furthermore, future research could thus provide a more comprehensive look at the actors whose travels shaped the Uruguayan public health policies in the early twentieth century.
Conflict of interests
The research for this study was funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation)–Projektnummer 374666841–SFB 1342.
The author would like to thank Delia González de Reufels, the participants of the symposium on “New Histories of Public Health and Social Policy in Latin America” at LASA 2019, all colleagues from the Transnational and Area Studies Colloquium at the University of Bremen, and the two anonymous reviewers for their valuable input on the earlier versions of this study.
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2 A primarily national framework further characterizes a range of traditional Uruguayan history of medicine publications (e.g., 15) but has recently also been applied in studies on Uruguayan psychiatry (16) and the country’s first hospital for children and women (12).
4 There is no encompassing account on the history of public health in Uruguay. For the period under study here, the most important references are 20, 12, and 16. These works analyze specific institutions or reform fields and also touch upon the larger history of public health institutions and nation state building in Uruguay.
5 According to Cueto and Palmer, “everywhere in Latin America the prestige of a Paris training was unequaled” (2: p. 62).
6 However, women directed the public health institutions that formed part of these umbrella organizations, especially those linked to child care, women’s health, and education. They also heavily engaged in so-called philanthropic work, with activities ranging from fundraising to hosting conferences and lectures with an influential lobbying and agenda-setting function.
7 All English translations are provided by the author.
8 The Consejo Nacional de Higiene proudly introduced its delegates’ report on the congress with the information that Uruguay had been the only Latin American country to attend (36). This assertion can be found in other conferences as well, indicating that being the only Latin American country present could be used to mark Uruguay’s progress vis-à-vis its neighboring countries (see 37).
9 The summary is based on the following two studies, with the second one being a reprint of a text written by a Spanish public health official on Castells’ lecture about the events against tuberculosis (39,40).
10 In the case of the Asistencia Pública Nacional and its predecessor, the Comisión Nacional de Caridad y Beneficiencia, this is true for two voluminous and expensively produced memorias. The first one was published in 1905 for the exhibition that accompanied the Second Latin American Medical Congress in Montevideo in 1907. Moreover, the second one was produced in 1913 for the Fourth Latin American Medical Congress that took place in Lima in the same year (42,24).
11 However, the point in this specific reference was not to follow the Argentinean but the us model instead.
* Correspondence: firstname.lastname@example.org