Vera Blinn Reber. Tuberculosis in the Americas, 1870-1945: Beneath the Anguish in Philadelphia and Buenos Aires. New York: Routledge, 2018. 348 pp. $149.95 (cloth), ISBN 978-1-138-35950-5.
Reviewed by Carlos Dimas (University of Nevada Las Vegas)
Published on H-LatAm (July, 2020)
Commissioned by Casey M. Lurtz (Johns Hopkins University)
Vera Blinn Reber’s Tuberculosis in the Americas 1870-1945: Beneath the Anguish in Philadelphia and Buenos Aires is a comparative medical study of tuberculosis in Philadelphia and Buenos Aires at the turn of the century. In it, the author examines how patients experienced tuberculosis from a hemispheric perspective, in search of similarities and differences. Trained in the history of the Southern Cone and published extensively on Argentina and Paraguay, Reber expands to the city of Philadelphia as a means of drawing connections between the “microhistorical and the global” (p. 15).
In bringing together these two cities, Reber demonstrates that the ways doctors and patients “constructed” and “framed” tuberculosis were similar, even when respecting the historical contexts of each city. Through a reading of private correspondence between patients and doctors, medical journals, census data, advertisements, and government reports, Beneath the Anguish argues that class, race, and gender formed the experience of tuberculosis in the Americas. Over the course of the era, Reber highlights the tension that arose between medical figures and patients in attempts to arrest the disease’s development. Indeed, she also demonstrates that patients exerted significant agency in the management and treatment of their disease, and did not simply follow medical orders.
From the outset, Reber establishes her basis for comparing Buenos Aires and Philadelphia. Both were international port cities that received an influx of immigrants and internal migrants. The surge in population created the conditions for many of the typical ills of nineteenth- and early twentieth-century cities: cramped housing, trash, and diseases like tuberculosis. One important point that undergirds Beneath the Anguish is that each city contained robust medical communities who formed medical research institutes that advanced tuberculosis-focused public health initiatives as part of the medical state's increased interest in hygiene as a tool for governing.
In the case of Argentina, the use of Buenos Aires as a case study is a natural choice. Beginning in the latter half of the 1800s the city grew in size and population. Simultaneously, the state invested in public health programs and institutions, reform took place in medical education that fostered a closer association between physicians and the state, and the formation of medical associations made Buenos Aires the national center for the medical sciences over smaller medical communities in the provinces, such as Córdoba. This period also witnessed demographic growth. Under positivist ideology of immigration as a means of progress, the state opened its ports to European immigrants in the hope they would populate the sparse interior. Yet many opted to stay in the national capital. Urban spaces did exist in the interior, but they were far behind Buenos Aires and thus constituted “secondary cities.” In the interior, other diseases like malaria and Chagas disease in the northwest were the dominant medical problem, on top of repeated outbreaks of smallpox and cholera. Since I am not a historian of the United States, it is unclear if New York City would have provided a stronger comparison on the correlation of the disease and urbanization, or on the interest amongst doctors. In the end, however, Reber clearly qualifies the choice. Philadelphia housed the oldest tuberculosis research institute in the United States as well as numerous important, internationally renowned medical institutions. For instance, the Cuban epidemiologist Carlos Finlay graduated from Jefferson Medical College in Philadelphia (now known as Thomas Jefferson University). Second, it witnessed significant demographic growth like Buenos Aires.
Beneath the Anguish consists of seven chapters plus an introduction and conclusion. In structure, all chapters follow a similar format. They begin with the chapter’s topic in one city, move to the next, and conclude with an analysis of both together. The first chapter is a synthesis on changing attitudes toward tuberculosis through a reading of medical and nonmedical sources. For instance, before the public associated tuberculosis with the urban poor, it was perceived as the disease of the starving artist. The shift in opinion toward tuberculosis, according to Reber, coincided the globalization of other infectious diseases of the nineteenth century, such as cholera and yellow fever, and the emergence of the hygienist movement. In the positivist language of the era, infectious diseases, like tuberculosis, represented degeneracy and backwardness. However, in line with the developing medical state and the hopes of liberal reformers, tuberculosis also represented an opportunity to foment the formation of what the literature has described as "sanitary citizens" through social interventionist policies. In short, never let a crisis go to waste.
In chapter 2, Reber tracks the increased medical interest in tuberculosis through the formation of private and public associations dedicated to tuberculosis research and the actions of important hygienists in each city For Buenos Aires, Reber centers on the work of the hygienist and statistician Emilio R. Coni and for Philadelphia, Francis Lawrence Flick. For Reber, the main drive of these chapters is to illustrate how doctors developed tuberculosis as a medical and social problem, and to show that in the formulation of this approach medical figures in two distant cities shared more in common than differences. In line with the mentality of the era, the pulmonary affliction was the disease of the poor, the marginalized, and the outsider. It is from here that Reber's work departs from the Argentine medical literature and establishes Beneath the Anguish's contribution to the literature. In the past decades, scholars have developed three methodologies to study Latin America's history. First is the new medical history that highlights Latin American voices in the creation of medical knowledge, as opposed to simply perceiving the region as a consumer of foreign (i.e., European) medical knowledge. The history of public health is the second approach. Here, scholars connect the management of health and the conquest of disease to the formation of the state and questions of power. Last, the sociocultural history of disease employs illness as a lens to assess how societies respond to disease. In most studies all three approaches freely overlap and build upon each other. Reber’s work, on the other hand, seeks to explore in more detail the medical realities of the pulmonary disease, over its social or cultural ramifications and constructs.
In order to uncover the experience of tuberculosis, Reber focuses on the often contested relationship between physician and patient, the demographic impact of the illness, and the moments patients exerted agency in managing their health. Thus the first two chapters serve in demarcating Reber's approach to the study of tuberculosis as a contested space.
In chapter 3, Reber shows that the demographic impact of the disease was prevalent among the most marginalized sectors of society. For instance in Buenos Aires, tuberculosis spread in the city’s growing immigrant neighborhoods. Meanwhile, in Philadelphia it mainly affected the city’s African American community. As a result, this generated certain biases within the medical community against patients, in that tuberculosis became a means to distinguish the other. In both regions, the concentration of disease within marginalized communities exacerbated the standard elite anxieties of the period. From here, the remaining chapters shift their focus from the work of doctors to exploring the doctor-patient relationship, and less on how society and culture at large confronted the disease. In chapters 4 and 5, Reber illustrates how patients exerted agency in how they lived with tuberculosis. More akin to a “medical free market,” tuberculosis patients sought out new forms of treatment and caretakers that met their personal needs, often refusing medication, negotiating for other treatments, or simply following their own course of action. Thus, patients exerted significant agency in their medical lives. In showing as much, Reber calls into question the true extent of power physicians had over their patients.
The final chapter expands to a global approach. Unlike the case with other infectious diseases from the turn of the century, medical science came to a consensus on tuberculosis’s transmission. Based on this, Reber provides a cursory synthesis of approaches to tuberculosis in Great Britain, Germany, France, and Spain to show that various aspects of global narratives on tuberculosis were adopted in Buenos Aires and Philadelphia. All of Asia and Africa are condensed into one short section. Although Reber expands her analysis to a global perspective, this chapter establishes more of a triangular association between Argentina, Philadelphia, and Europe. The Latin American historical literature, including medical studies, has pulled away from centering on northern connections.
By emphasizing the patient experience, Beneath the Anguish allows various detailed microhistories to come to life. These will be of great interest to students and I can foresee how they could be used in the classroom for an assortment of courses and even class assignments. Indeed, one of the book’s strengths is its accessibility to undergraduate and graduate students. In addition, the work contains multiple demographic charts, such as “Pulmonary Tuberculosis Deaths of Minors, Age 0-20 in Buenos Aires, 1900-1911” that can provide a foundation for a potential research paper on the history of childhood, for instance, in combination with numerous other sources that have been digitized, or for a quantitative methodologies graduate seminar. To sum up, Beneath the Anguish provides readers with a starting point to expand their interests on the multilayered medical history of the Americas.
. James Scobie and Samuel L. Baily, Secondary Cities of Argentina: The Social History of Corrientes, Salta, and Mendoza, 1850-1910 (Stanford, CA: Stanford University Press, 1988); James Scobie, Argentina: A City and a Nation (New York: Oxford University Press, 1971).
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Carlos Dimas. Review of Reber, Vera Blinn, Tuberculosis in the Americas, 1870-1945: Beneath the Anguish in Philadelphia and Buenos Aires.
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