Historiographical reflections on health and medicine in Latin America: a conversation with Diego Armus.

Palmer, Steven

During a pause in the 2008 colloquium at the Universidad Nacional Autonoma de Mexico where the contributions to this special issue of CJLACS were first presented, Diego Armus agreed to submit to a "historiographical interview," a relaxed discussion of the tendencies that he sees at work in the field, the reasons for his own trajectory into thinking about the history of disease and public health, and his thoughts on the paths historians of Latin American medicine are likely to pursue in the coming years. Armus is la persona indicada for such an interview: in the past seven years, he has edited or co-edited four important collections that have been instrumental in constituting the field. Both Entre medicos y curanderos: Cultura, historia, y enfermedad en la America Latina moderna (2002) and Avatares de la medicalizacion en America latina, 1870-1970 (2005) were issued by important Argentine publishing houses; Disease in the History of Modern Latin America: From Malaria to AIDS (paperback 2003; e-book 2007) artfully and ecumenically presented these themes and some of their leading authors to an English-speaking audience; and in 2004 he co-edited, with Gilberto Hochman, a Portuguese-language collection, Cuidar, controlar, curar: Ensaios historicos sobre saude e doenca na America Latina e Caribe, which was released by Brazil's leading publisher in the area of health and medicine. The breadth of these works is revealed by the fact that they all involve authors from across the major "regions" of scholarship in the Americas and with few exceptions the contributions are not repeated across collections. His innovative work, La ciudad impura: Salud, tuberculosis y cultura en Buenos Aires, 1870-1950, appeared in Argentina in 2007, and a North American version of the book will shortly be published in the US. Armus, who lives in New York City, is a professor of Latin American history at Swarthmore College and teaches regularly at several Latin American universities.

As we convened in Mexico City, a government jet carrying the minister of the interior crashed into the heart of rush hour, and ubiquitous mute television screens cut between the fiery scene on the Paseo de la Reforma and Barack Obama's increasingly apparent election victory, the latter event eliciting celebratory honking from motorists inching along the boulevard outside. To this rather apocalyptic backdrop, Armus sat down in a hotel room on a southern stretch of Avenida de los Insurgentes to talk about the state of historical research and writing on medicine, disease, and public health in Latin America.

Steven Palmer [Palmer]: Four edited volumes in seven years! What was the motivation?

Diego Armus [Armus]: I arrived in the United States in the late 1980s; I began to think about the so-called need for a collection in the late 1990s. In those 10 years what I perceived was that this subfield was emerging, both in Anglo-American academia and also in some areas in Latin America, and I noticed that I was part of it. This is one element. The other element is that, since my life has one leg in the United States and the other leg in Buenos Aires, I want to play a role of sort of bridging these two worlds. That's why the emphasis on trying to put together the production of Latin Americanists living in Latin America and Latin Americanists living in the North. Also, in the last decade or so, as a result of the Internet and other very complex processes related to a much faster circulation and sharing of ideas and research agendas, the work coming from north and south of the Rio Grande has been finding common ground. In that context, and as always happens with new topics or subfields, it seemed appropriate to think in terms of a collection able to show where we were, and what questions and historiographical styles were marking this emerging subfield. I wanted to be as inclusive as possible--in fact, I confess that for me it was a sort of exercise in academic pluralism to include works I did not like at all, but that were somewhat representative of current trends.

Palmer: How did you get involved in studying this topic to begin with?

Armus: Well, in Buenos Aires, my first job as a professional historian was in a centre for urban research, and there I started working on issues of immigration and housing. And labour history. British historians E.P. Thompson and Eric Hobsbawm and the Argentine Jose Luis Romero were my references. And from housing, at some point I discovered that I wanted to do something a little bit different in which the cultural dimension might also play a role. In this process of trying to enhance my agenda, I bumped just by chance into the book by Susan Sontag, Illness as Metaphor (1978), and I was totally fascinated by it (I say "by chance" because in the late 1980s US historians and intellectuals were by and large absent in Argentine academia). And I said, well, maybe I can spend a couple of years on the social and cultural history of urban diseases.

I began to work on a very broad topic--health conditions of urban popular sectors in the Southern Cone of Latin America--with other young researchers from Uruguay and Chile and with a more mature and always enthusiastic urban historian, the late Jorge Enrique Hardoy. Soon the possibility to do my Ph.D. at Berkeley under the direction of Tulio Halperin Donghi became real. It was at Berkeley that I understood the significance of my encounter with Sontag's book. It was a sort of first chapter in my discovery of the vibrant and fast-growing British, French, and US historiographies that were already celebrating Illness as Metaphor, but also bringing in nuances and even expressing some reservations. By then I was beginning to draft my dissertation project: a "total history" of tuberculosis [TB] in modern Buenos Aires. Certainly it was a very ambitious start, one that I now judge both necessary but also a little bit naive. I had no idea about the availability of primary sources for such a topic and for that approach. In any case, and perhaps revealing how difficult it was to gather those sources, the edited collections came out before my "total history" of

TB in Buenos Aires--one that, in fact, tried to be "total" but now I know it isn't.

Palmer: Having been so engaged in editing these collections, in gathering this work together, evaluating and re-presenting it, what trends do you see as characteristic of the field now?

Armus: I see three major "ways of writing": biomedical history or new history of medicine, history of public health, and sociocultural history of diseases. Of course, there is plenty of overlap among them and it is unnecessary to underline that, in general, these three ways of writing are present in modern historiographies for other areas of the world. I know that some people are not totally comfortable with this manner of breaking down the field but, as in any historiographical discussion, you need to classify ways of writing, and of course there are plenty of arbitrary decisions. In fact, most of the time, especially in those works that are most convincing, historians try to deal with all three of these dimensions--what happened with biomedical knowledge and technology; what happened with the state, public health, and health in general; and what happened with culture and actors in the process of health and disease. I would say that this is probably the most challenging task--trying to combine these three dimensions.

Palmer: All right, but can you explain what distinguishes them from one another?

Armus: Biomedical history tries to renovate the major questions that the traditional history of medicine used to have, emphasizing contextualization of medical technology, underlining victories but also failures, highlighting the key role of some individual scientists or public health physicians as well as the decisive role played by national and international networks that facilitated the circulation and adjustment of biomedical knowledge in the world periphery. This last issue is particularly relevant. In fact, in the Latin American peripheries in the post-bacteriological era one can find examples of original biomedical research. That was and continues to be a line of research that, in the end, aims to disprove the generalized conviction that basic science is only produced in the centre. I am not referring to "natives" or even hybrid medical traditions, but what we call Western biomedicine. My impression is that this is a promising approach but one that has to be done carefully. In other words, "looking desperately" for a few Latin American examples of innovative biomedical research could misplace what is probably the dominant and most significant feature of this process, that is, the complex adjustment of science produced in the centre to the local/national conditions of the Latin American peripheries.

Palmer: The history of public health?

Armus: It is a history that mainly looks at power, the state, the medical profession, the politics of health, and the impact of public health interventions on mortality and morbidity trends. In general, and to a large extent, this is a history focused on the relations between health institutions and economic, social, and political structures. For some of its practitioners the goal is to better know certain healthrelated problems in the past and perhaps inform somewhat the understanding of public health issues of the present. For others, practicing history of public health is also practicing history "in" public health in the sense that they search the past in order to find certain evidence that, they think, can legitimate public health actions and interventions that should shape the immediate and future public health agendas. It is, no doubt, a history that regards itself as useful and instrumental, seeking in the past lessons for the present and future. This approach continues and updates two overlapping legacies, from late 19th and early 20th century hygiene practice and research on the one hand, and from national histories--mostly self-congratulatory--of public health written since the 1950s on the other.

Both efforts, which recognized and underlined the social dimensions of disease, are important antecedents when evaluating the current scholarship on public health issues from a historical perspective. But the current scholarship on public health history is more diverse and in many cases more sophisticated. Some studies emphasize key public health figures and try to contextualize them. Others attempt to analyze the issue of health and medicine in structuralist code as epiphenomena of the relations of production. Others use tools and categories that originated in so-called institutional history, producing, as can be expected, a narrative strongly shaped by political actors and institutions. Either way, the emphasis of these accounts is on the study of state interventions--or lack of them--to encourage preventive policies and preserve and/or restore collective health. It focuses on the moments in which the state--based on considerations that go beyond the strictly medical and are shaped by political, economic, cultural, scientific, and technological factors--has promoted health-specific actions. Lately, this approach seems to be changing somehow, at least for some of its practitioners. If it started as a history of public health, now it's becoming what I would label "history of health," in the sense that there is recognition that the public health agenda--with its institutions and actors--was not inclusive enough of all the ways people tried to take care of their health or dealt with diseases.

Palmer: And the third--the socio-cultural history of diseases?

Armus: Here the emphasis is more on diseases than on public health or just health. And diseases are discussed as problems in and of themselves or as excuses for discussing other, broader historical issues. In the first case, these histories seem to assume--somewhat in line with that very useful entry to the problem articulated by Charles Rosenberg in his early 1990s essay "Framing Disease: Illness, Society and History"--that diseases do not exist until we have agreed that they do, by perceiving, naming, and responding to them. In the second, diseases serve broader agendas to understand social and cultural dimensions of the past, such as processes of professionalization and medicalization, welfare and social control instruments and institutions, the state role in building health infrastructure, people's perceptions of and experiences with certain diseases, metaphors and representations associated with specific illnesses. Some of these histories do not go beyond gathering relevant data and basic information. Others argue for a small set of overriding explanatory factors in a deliberate attempt to discuss health and disease problems from a critical perspective. At times, though not always, these studies tend toward top-down and somewhat conspiratorial explanations: the poor have always been wretched because of a lack of political will on the part of elites and the middle class; every public health initiative resulted from an effort to increase productivity or guarantee the reproduction of labor; elites got involved in sanitary reforms for their own security; pioneering initiatives were the product of the workings of a new professional state bureaucracy interested in imposing public health measures; or dependent capitalism needed those changes.

There have also been Foucauldian interpretations of medicalization, an undoubtedly inspiring line of thinking that consistently found, in medicine and state public health interventions, an arsenal of normalizing resources aimed at the consolidation of a modernity, though most of the time these works are vaguely defined and lack substantial specific historical references to the place under study. In this context diseases and medical actions attempting to address them have been seen--quite often overlooking mediations and particularities--as instruments for regulating society, labelling difference, and legitimizing ideological and cultural systems.

Finally, there are ambitious studies in which a certain disease is used as an excuse to discuss broader problems, from metaphors of nation building to illness literary narratives, to the formulation of public health policies and its consequences, to people's experiences with a certain pathology, mainly those of the sick--who are not always patients--and also those who try to provide some kind of care.

Palmer: You were saying earlier that you found in putting together the collections that there is a common agenda regardless of where the historians are working; that the new Latin American history of medicine, disease, and health is actually being done in very similar ways, North and South.

Armus: Yes, I have no doubt about that. I do find that the approaches of those working in Latin America are of quite a similar range to those working in North America and Europe. There is a convergence, especially in the studies on the post-bacteriological period starting in the 1870s. More than that, my impression is that they are particularly well integrated into worldwide historiographical developments, but these features do not translate themselves into globalized or comparative narratives of the history of a certain disease or a certain biomedical process. Instead the emphasis has been on the local/regional/national dimensions. And only on a few occasions does Latin America emerge as a category of analysis. In any case, and independently of their geographical scope and if the scholarly work comes from the North or the South, this historiography results from a research agenda that could be read as the product of two paths of inquiry. The first encompasses approaches that started out with the history of medicine and bio-sciences and ended up weaving rich social, political, and cultural narratives and analyses. The second took the opposite path. Departing from broader problems initially defined in terms of society, politics, and culture, these studies not only discovered illness as an intriguing and contentious historical issue, but also came to make disease the organizing theme of their historical accounts.

Palmer: What about directions? Where is this field going to, and do you feel it's coalescing into some defined project, or is it about to disperse in many different directions?

Armus: The first thing I would say is that there is no such thing as a coalescing project. And there is certainly plenty of dispersion. But this dispersion is not something unique to this subfield. In the last two or three decades of Western historiography what dominates is a very fragmented object of study. And the subfield of history of disease, biomedicine, and health is part of that fragmentation. From my perspective there is no reason to imagine that we are going to be different than this general historiographical trend. At least for the immediate future.

Palmer: Let me mention two possible cohering energies. One is the strange beast that is area studies. Now that you've edited four collections on health, disease, and medicine in Latin America, does it make sense to study this subfield, this series of topics, at the level of Latin America, and if so, will that be one cohering structure that will keep the field focused in some way? And the other question I have is about institutions, but maybe you can answer the "area studies" question first.

Armus: It is not an easy question. I would say that probably for a while we will continue to grow and to gain in sophistication as part of the Latin American historiography, for at least two reasons. On the one hand is the way in which academia is structured in the North. In Canada, the US, and Europe, scholars are Latin Americanists first--they are hired as such, they teach Latin America--along with that initial identity they need to define a sort of national specialization. Out of this peculiar context, most of the work done by Latin Americanists of the North is country-specific but with a sort of more or less apparent tension that tends to somewhat deal with the region at large. And I am not talking, necessarily, about comparative histories. On the other hand is the way Latin American scholars based in Latin American countries are working. In their cases, professional identities have been historically associated with national histories. Lately, however, one can see an emerging concern, timid but consistent, to insert national cases within the Latin American region. The existence of quite active Latin America-based networks, such as Red HISPALC, (1) is clear evidence of what I am saying.

Let me bring a very personal anecdote that, I think, is not exceptional at all and I hope illustrates well what I am saying: to put it bluntly, I discovered Latin American history at Berkeley. In other words, it was in the US where I became a Latin Americanist. By and large, in the '70s, '80s, and even the '90s, Latin Americans were discussing Latin American history as part of discussions shaped by the political urgencies of the present, discussions that most times were firmly anchored in long-term national narratives that used the region only as a sort of default background. In the last decade or decade and a half, things have been changing somewhat. In some Latin American universities the problem of unity and diversity of Latin America as a subject matter has gained, correctly from my perspective, a visible presence in almost any subfield of the current Latin American historiography. So, and as I told you when you asked me about why I invested myself in four edited volumes aimed at showing the state of the art on the history of disease, health, and biomedicine, I currently do see not only a consistent North/South convergence in terms of agenda and styles of writing, but also the need and convenience of working with the region as such, recognizing both similarities and differences among and within Latin American nations.

But connected to this problem there is another one--very specific to our subfield and not necessarily present in others--that, I believe, is behind your question (correct me if I am wrong). Diseases, biomedicine, and certain public health issues might be easily discussed in global terms. No doubt, the local dimension is crucial in the way these processes took place; some kinds of medical and health practices and ideas do indeed remain rooted in particular languages, cultures, and sociopolitical systems. But it is equally doubtless that many aspects of medicine travel widely, that medical commodities may be shipped from place to place while various kinds of practices and concepts also move about.

It is in this context and with these concerns it seems almost inevitable to display a concerted effort to be informed by, and to begin a fluid dialogue with, what other historiographies are doing about these problems or diseases away from the Latin American region. And not only a dialogue. One can wonder if, with this multi-sited approach, a regional/Latin American focused discussion of hookworm, yellow fever, or malaria--or for that matter another region of the world--is the most appropriate way to go. In other words, to what extent does Latin America as a supposedly well-defined and quite homogeneous historical entity offer anything particularly peculiar in the histories of those diseases? I am thinking in terms of a collective and very ambitious agenda. Of course you have to start somewhere, with a city, a province, a country, even a region. What I am trying to indicate is that we might have to think in terms of a global history of malaria, one anchored not only on, let's say, London-based colonial and tropical medicine, but also on the very diverse ways malaria affected specific places. Or a global history of tuberculosis that, along with the usual French, British, and US cases, will include peripheral areas of the world where processes of urbanization and industrialization reveal plenty of both similarities and differences from those that took place in the metropolitan centres. Or--using an example you know better than I do--a history of Rockefeller Foundation interventions equally attentive to the foundation's agenda as well as the adjustments this agenda ended up having in the many world peripheries.

In this effort to creatively weave the local with the global, my impression is that we are particularly well equipped, even better equipped than historians working on the centre of capitalism. After all, Latin Americanists--not North Americanists or Europeanists--were trained with the "obligation" of knowing the available literature on a certain topic, no matter how far away from the Latin American experiences those places might have been. A byproduct of that "obligation" generated among Latin Americanists the custom of adding footnotes in books and articles dealing with Latin American cases that mentioned studies located outside the region. I am referring to that unfortunately very common "for this issue in France or in England please see such and such authors." Sometimes, especially in studies written in Latin America, the same pretentious style works, but referring to Latin American examples. Of course, there are cases in which these references are necessary. What I really dislike is what I consider an unnecessary way of legitimization and false erudition that has nothing to do with global or regional approaches.

We all know that nowadays it is even trendy to deal with certain issues using the "global" label. However, advancing real global historical interpretations is more than a label. Let me illustrate with an example of what I am trying to suggest: I still remember a meeting in England, a couple of years ago, focused on the global history of TB in which the "global" resulted in 28 papers on Western Europe and only 2 on other areas of the world, one on Latin America and the other on colonial India. An easy justification of this geographical bias could be to say that, after all, this is a reflection of what we know about this disease. But this explanation is not any longer valid and acceptable given the fact that in the last two decades national or city histories of TB have been in steady growth on every continent. Interestingly enough, at the meeting there were discussions about the need to going beyond these more traditional TB histories written 40 or 50 years ago as natural global histories, in which what had happened in England or France was assumed as a global process, diluting or, worse, not even mentioning other European national cases or far-away places of the world periphery. Real global histories of a certain disease should offer, I think, a quite different narrative, one that balances the local, the regional, the national, and the international, that deals with similarities but also differences, taking into account as many areas of the world as possible.

In any case, and returning to your question, it seems that for certain diseases this trend is not at all an agenda for the future. We do have global histories of malaria that really aspire to be global, even if at times they are mainly or only based on English written secondary literature (a limitation that authors of those histories could somewhat begin to overcome without much effort, at least with studies written in Spanish and Portuguese). I would say that probably in the field of international health this is a process that is already well on its way, not only by the very nature of the field but also because in the last years it became a very hot topic of research for which there are plenty of resources.

Palmer: So you think the Gates Foundation will include history in its Grand Challenges? [Laughs.]

Armus: If not, yeah, someone is supposed to tell them that they should! Seriously, it seems that in the current wave of increasing and extremely fast internationalization of health problems, old and new epidemics, and massive circulation of people, there are plenty of reasons to try to understand better and more what happened in the past.

But again--and let me stress that this is my take on this issue since I am totally conscious that many of my colleagues in this subfield think otherwise--practicing history of disease, health, and medicine does not necessarily mean finding lessons from the past in order to define the right actions and policies in the present. What the history of international health can offer, I think, is some sense of complexity at the moment of dealing with current international health problems, some knowledge of the past that could be instrumental at the moment of reducing the inevitable uncertainties that mark every decision-making process in international health in the present. In so doing, the history of international health facilitates in general rather than specific ways the making and justification of certain interventions in the contemporary scene.

Palmer: Returning to the other question relating to possible forces of cohesion, which has to do with institutions. To my way of seeing things, there is an "elephant in the room" phenomenon in the field of history of medicine, health, and disease in Latin America, and that is the Casa Oswaldo Cruz, and Fiocruz [see "Introduction"]. For once, the institutional behemoth, the institutional giant is not in the United States, it's in Brazil. And this group of social scientists, in which historians play a predominant role, is quite large--the size of a history department in a fairly big US university, with a big graduate program, all working in this subfield. What are your thoughts on that?

Armus: My first comment is I'm totally envious. I mean, if there is one place that I really enjoy, it's when I go to Rio de Janeiro and I can hang out with all these people who are talking more or less the same language. Frankly, this is something I can't experience in the United States. Perhaps the Wellcome Institute in the UK could offer something similar, but I'm not that familiar with it. No doubt--this is an amazing institutional development where basic science, humanities, and social sciences coexist in a very creative way.

Palmer: What's your measure of the role that Fiocruz plays?

Armus: I think that they are playing a very, very important role not only for the rest of Latin America but also for North American Latin Americanists. I believe that it's only recently that our Casa Oswaldo Cruz friends are really beginning to realize their relevance. For reasons that would take us hours to discuss, my impression is that Brazilian scholars tend to be very endogenous, in some cases even provincial, perhaps in a similar vein as when one talks about the inability of British, French, or US scholars to think beyond their borders. As I said, it is only lately that they are beginning to realize that they can play a different role, a much more internationalized role--taking the lead, defining, facilitating ... basically facilitating the circulation of ideas. Manguinhos [the journal of history of science, medicine, and health published by the Casa Oswaldo Cruz] is a very clear example of what I'm saying. I have no doubts that if Manguinhos were produced in the United States, Manguinhos would be in almost every university library. I sincerely hope that Brazilians--and particularly the Casa Oswaldo Cruz--will continue to play that leading role with even more imagination and conviction. To be clear: we're not talking about soccer, an area in which I am not that ready to recognize their leadership..

Palmer: Do you think the institutional energy of Fiocruz will work against the kind of atomization of study you were discussing?

Armus: My feeling is that within the Casa Oswaldo Cruz you see exactly the same tendencies as in the rest of the historiography: some people are doing history of public health, others are doing history of biomedicine and science, still others are doing sociocultural history of diseases. The good thing about Fiocruz is that they are all under the same umbrella.

It seems to me that you are a little bit concerned about the future, in terms of atomization of our field, no?

Palmer: Not necessarily. One thing I am wondering, though, is do you see a kind of "major statement" coming out of this subfield? In other words, is it going to generate some kind of classic text, do you think? Other than your own work, of course!

Armus: Mine is already a classic text! [Laughs.] Well, I don't know; probably not for the moment. But do you think that other subfields are producing these sorts of classics?

Palmer: Well, in some sense, yes, and they certainly would claim, especially in the United States, through the way they market certain texts, that ... you know, if you were to ask people in Latin American studies, they would probably pick out two or three books that, over the past 10 years, have kind of brought together all of the trends in a research agenda, that have become reference points and touchstones for the next stage of the research journey.

Armus: If you don't mind, give me an example.

Palmer: Well, you know, James Scott, Weapons of the Weak, or something like that.

Armus: But that was not very Latin American.

Palmer: I should have done my interview prep better--had my team of researchers pick out some texts! OK, how about Womack's Zapata, you know, which somehow became a reference point for the ability of Latin American historians to step out of that developmentalist, "child of the 1950s--social science" mode, move into the new social history, and start talking about the issue of revolution from a very different perspective--the fibre of everyday life, the nature of peasant existence, incipient searches for the way ethnicity factored into rural radicalism--that's one you can probably agree with, right?

Armus: Yes, to a certain extent. But the Mexican Revolution is one of the most--if not the most--debated topics in modern Latin American history, and after 30 years or so of historiography since Womack's book you have so many new things that I don't know to what extent this book is still a defining piece. But you asked me about my picks ... I would mention the work of Jose Luis Romero, especially his Latinoamerica: Las ciudades y las ideas, a book that does not circulate as much as it should in the US. I can't comment about its influence in Latin American historiography at large, but in my personal case, it was decisive. I discovered cultural history firmly rooted in society through Romero, before cultural history became more mainstream.

Palmer: That's a good example ... I wasn't saying that it would forever remain the touchstone, only I was wondering if you could see a kind of coalescence of energies in the field or subfield of health and medicine in Latin America that might produce a book of that impact. One that would have an impact, not just among those who work in this subfield, but would have an impact in the larger historiography of Latin America or indeed beyond.

Armus: For me key books are those that somehow have an aspiration of totality. I still remember, when I was a student in Buenos Aires and had to read the French historian, Pierre Vilar, the moment in which I began to appreciate his invitation to aim for total history. He was very clear on presenting that aspiration of totality as an agenda, as a sort of lighthouse (in fact, many of Vilar's actual works are not really examples of total history). In any case, these books that I think you are looking for are those that somehow try to reconstruct the past taking into account as many dimensions of life as possible, to reconstruct a climate in a certain time and space. And context, plenty of context. This is something we can practice even when our focus is not an amazingly broad topic--like that of Latin American urban societies in Romero's book--but a more specific one like certain diseases or health issues. The problem is that not everybody is Jose Luis Romero--certainly I am not.

But I do think the aspiration for total history in our subfield is pertinent and, from my perspective, necessary. Allow me a sort of personal anecdote. When I discovered Sontag's Disease as Metaphor I was totally fascinated with the idea of centring my work on representations. The beauty of this book, along with the linguistic turn in historical narrative that was dominating the field, marked me as another young historian ready to contribute to the expanding territory of history of discourses about diseases as history of diseases. But soon, after a number of years of working on the subfield and with TB--and certainly now--I am convinced that metaphors and discourses--literary, political, legal, and so on--are only one dimension at the moment of dealing with the aspiration of writing a total history of a certain disease. Along with metaphors and associations, one has to delve not only into politics, policies--those that were discussed, those that were effectively implemented, those that made an impact, if any, in real life--but also into the state, civil society, and also into people's experiences: the sufferers and with them all the other protagonists associated with health care practices. I am totally conscious that this is very difficult to do. And if for whatever reason one decides to focus the attention on discourses--which is totally legitimate--or on policies, it is a good idea to know the scope of one's work.

On the other hand, I think that we are at a stage in this subfield where we need to keep on accumulating basic research, works that probably will be far from good examples of total history but anyway good foundations that will provide starting points for further, more ambitious, and contextualized interpretations. I am a strong believer in the convenience and need of accumulating studies with a very strong empirical base. More than that, I am totally convinced that good historical narratives, those that cultivate an aspiration of total ity, cannot be written without those well-grounded studies of--in our subfield--health institutions, caregivers, the sick and patients, state policies, external influences, and so forth. It is from this sound empirical base that we'll be able not only to begin weaving connections between disease or health and other broader problems, but also to attempt a dialogue with other disciplines. For instance, issues of state formation--a key topic among political scientists and sociologists--cannot be discussed ignoring public health problems, and the other way around. Something that, in the history of public health so far, I think that we don't have. Those people who are cultivating public health probably are not very into the idea that what we are discussing in the end is state formation. Or for instance, this dialogue with more anthropological studies and the whole world of the healers, which is an area that we know almost nothing about.

Palmer: And about which anthropologists know almost nothing historical.

Armus: Of course. But the dialogue is possible . in fact necessary. I think the field is becoming extremely multidisciplinary ... My main concern is what is coming out of cultural studies, honestly. Not those doing cultural history of disease--those coming from the cultural studies group.

Palmer: Why? What is the concern?

Armus: Because most of their contributions have a very, very weak empirical base. For some reason, these works tend to be very appealing, if not to the general audience, to the more restricted university and academic world. Broad generalizations, quite often presented almost as trans-historical processes and without mediations between the diverse worlds of Latin America and, let's say, what Michel Foucault, Norbert Elias, Mary Douglas, or Susan Sontag have said for other contexts, are not from my perspective a good recipe to write history. And let me stress that I am mentioning four authors that I always have on my desk. I'm not saying that everything coming from cultural studies is empirically inconsistent, but it concerns me when you see many of these works based just on a couple of sources. You do not have to spend years working with primary sources in order to write a good piece of history, but with only a bunch of texts it's not enough, I would say. I remember a conversation with a good friend, a very imaginative practitioner of cultural studies. He labelled us, historians, as the empiricists of the late 20th and early 21st centuries. And I responded, to his surprise, that I was taking his comment as a sort of a compliment. But I am not sure if he got what I was trying to mean, probably not .

Palmer: The other issue that interests me and that you have a very privileged perspective on is the issue of audience--how this historiography is being consumed by different publics. Do you want to talk a little bit about the experience you've had with that in Argentina and the US especially? Because I find it interesting that you felt that the agenda of the researchers working in North America, Brazil, Spanish America, turned out to be very complementary if not co-terminous, coincidental. But I wonder if the same could be said about the publics who are showing an interest in this historiography?

Armus: Here we have basically two problems. One is with the general public. And my impression is that here we have the same problems scholarly historiography in general has. I am saying nothing new stating that the history produced by academia is not easy to read by the lay public and that history books have to assume the difficult but not impossible task of reaching a broader audience without sacrificing complexity. And I think that topics like diseases in history could or should facilitate, to a certain extent, this effort of reaching out to a non-academic but intellectually curious audience. The other problem--and this is very specific to our subfield--is how we can reach out to the potential readership of physicians and health professionals. This is something I've been experiencing in Argentina with my last book on TB. And I have to say that contrary to many stereotypes--oftentimes held by supposedly very seasoned editors in commercial presses--physicians read, and read a lot. And they have networks in which professional information, including an amateur interest in history of medicine, health, and disease, can circulate at an incredibly fast pace and with great intensity. In other words, and this is particularly telling in my personal case since I consider myself more a social and cultural historian of diseases than a historian of medicine or public health, there are plenty of physicians who are particularly open to read more contextualized narratives, even those that somehow tend to underline that they have to put aside the traditional assumption that health and disease is a territory where they are not the only players.

Palmer: We talked a little bit about the idea that global history of disease might become one place in which the accumulated capital of the past 20 years of historiography in Latin America can play an important role. What other outlets, what other new possibilities do you see emerging in this field? What were the chapters in the collections you put together that you wish you could have had but nobody was writing?

Armus: To tell you the truth, I didn't have a clear agenda. What I wanted to do with those books was to somehow present the state of the field. And in fact, in two of these books I decided to include articles that I don't like at all. But it seemed to me that these are styles of writing about disease and health that in fact have a place, a presence. In a way, and preparing those books, I was very pragmatic. I was trying to show what the field was able to produce, not to tell where we are supposed to go. As for the other part of your question, and in terms of new trends or emphasis I see in the making, the most apparent one is a strong and to a certain extent new focus on the second half of the 20th century with "old" and "new" topics: international health in the context of the Cold War; diseases discussed in ways in which the global dimension occupies a more prevalent place, but without sacrificing the local; a more nuanced presentation of the making of public health systems where medical pluralism is not a marginal topic; and the perspective of the sick.

Palmer: Moving away from the late 19th and early 20th centuries, and into the early part of our parents' lifetimes.

Armus: Exactly. And our times.

Palmer: Unfortunately, yeah.

Armus: And this is the other thing, I guess we have to take into account: the issue of how we are going to incorporate oral history in our field, as we move on in the 20th century. This is one of my concerns, because if we want to grasp the experience of the sick, we cannot ignore this resource. In all of my current projects, more situated throughout the 20th century than previous ones, I am trying to work with the perspective of the sufferer. And oral history is both particularly useful and problematic in this endeavour. Useful for the obvious reasons that individual voices make easier to a certain extent the work of the historian interested in incorporating the sick in the historical narrative. Problematic because with this research approach we have to deal with the tricky issue of memory and history. And quite often the personal experience of a disease is not necessarily enough material when the goal, the aspiration, the aim, is to write a total history of the disease. The challenge is to integrate both, bottom-up as well as top-down approaches.

In one of my current projects, focused on the history of smoking in Buenos Aires, I am doing my best in order to work with both. I am not intending to do a history of, let's say, pulmonary cancer. I am intending to do, instead, a history of a habit. In a way, what I'm trying to do is comprehend the transformation of a well-accepted habit in cultural terms for most of the 20th century into something that will end up totally medicalized. I would say that is more the history of a habit than the history of a disease. But again, returning to a topic we already discussed, as soon as you contextualize issues of health and disease you end up discussing so many other things.

Works Cited

Armus, Diego, ed. 2002. Entre medicos y curanderos: Cultura, historia, y enfermedad en la America Latina moderna. Buenos Aires: Grupo Editorial Norma.

--, ed. 2003. Disease in the history of modern Latin America: From malaria to AIDS. Durham, NC: Duke University Press.

--, ed. 2005. Avatares de la medicalizacion en America Latina, 1870-1970. Buenos Aires: Lugar Editorial.

--. 2007. La ciudad impura: Salud, tuberculosis y cultura en Buenos Aires, 1870-1950. Buenos Aires: Edhasa.

Hochman, Gilberto, and Diego Armus, eds. 2004. Cuidar, controlar, curar: Ensaios historicos sobre saude e doenca na America Latina e Caribe. Rio de Janeiro: Editora Fiocruz.

Romero, Jose Luis. 1976. Latinoamerica: Las ciudades y las ideas. Buenos Aires: Siglo XXI. [Available in English as Latin America: Its cities and ideas. 1999. Washington, DC: Organization of American States.]

Rosenberg, Charles. 1992. Framing disease: Illness, society and history. In Framing disease: Studies in cultural history, edited by Charles E. Rosenberg and Janet Golden, xiii-xxvi. New Brunswick, NJ: Rutgers University Press.

Scott, James C. 1985. Weapons of the weak: Everyday forms ofpeasant resistance. New Haven, CT: Yale University Press. Sontag, Susan. 1978. Illness as metaphor. New York: Farrar, Straus & Giroux. Womack, John. 1969. Zapata and the Mexican revolution. New York: Vintage.

Select Bibliography of Historiographical Reviews of Latin American Health and Medicine

Armus, Diego. 2003. Disease in the historiography of Modern Latin America. In Disease in the history of modern Latin America: From malaria to AIDS, edited by Diego Armus, 1-23. Durham, NC: Duke University Press.

--, and Adrian Lopez Denis. In press. Disease, medicine, and health, 15001950. In The Oxford handbook of Latin American history, edited by Jose C. Moya. New York: Oxford University Press.

Carbonetti, Adrian, and Ricardo Gonzalez Leandri. 2009. La historia de la salud y la enfermedad en Brasil y Argentina. Estudio de caso y nuevas perspectivas. In Historias de salud y enfermedad en America Latina, siglos XIX y XX, edited by A. Carbonetti and R. Gonzalez Leandri, 299-325. Cordoba: Universidad Nacional de Cordoba.

Cassia Marques, Rita de, Dilene Raimundo do Nascimento, and Diana Maul de Carvalho, eds. 2004. Introduction. Uma historia Brasileira das doencas. Brasilia: Editora Paralela.

Cueto, Marcos. 2005. Health institutions and power in Latin America. Dynamis 25: 47-57.

De Barros, Juanita, Steven Palmer, and David Wright. 2009. Introduction. In Health and medicine in the circum-Caribbean, 1800-1968, edited by J. De Barros, S. Palmer, and D. Wright, 1-18. New York: Routledge.

Note

(1) Red HISPALC is an acronym for the Historia da Saude Publica na America Latina e Caribe Network, created in 2001 as a web-based tool for disseminating news concerning publications and events of interest to researchers in the area, and since 2004 operated by Brazil's leading history of medicine, health, science, and technology research centre, the Casa de Oswaldo Cruz.

STEVEN PALMER (interviewer)

University of Windsor