Hanni Jalil-Paier¹ and Guillermo Donado²

¹ University of California, San Diego, CA, USA and Universidad ICESI, Cali, Colombia. hanni_jalil@yahoo.com
² Universidad Externado de Colombia. Bogotá, Colombia. guijodon@hotmail.com

Received 18th November 2009 /Sent for Modification 20th June 2010/Accepted 1 July 2010

ABSTRACT

Key Words: Social medicine, public health, alcoholism, tuberculosis (source: MeSH, NLM).

RESUMEN

En Colombia, el surgimiento de un Estado moderno y la centralización del poder político y administrativo en Bogotá comenzaron durante las últimas décadas del Siglo XIX. Dentro de un discurso de modernidad que buscó la consolidación de una identidad nacional, el Estado jugó un importante papel. Dentro de las tareas asignadas al Estado moderno se encontraban políticas de salud pública y control social. Estas políticas deben ser analizadas como parte de una ola centralizadora y la necesidad de forjar ciudadanos sanos. Las campañas de salubridad buscaban erradicar el vicio, la inmoralidad, la enfermedad y la ignorancia bajo el manto de reformas sociales. De 1910 a 1925, médicos, higienistas y políticos se enfocaron en la erradicación del alcoholismo y la tuberculosis, con la intención de evitar una crisis nacional. Este trabajo explora como el alcoholismo y la tuberculosis se convirtieron en temas recurrentes en el discurso medico de principios de siglo, el cual enmarcaba a estas dos enfermedades como símbolos de la decadencia social y moral del pueblo colombiano.

Palabras Clave: Medicina social, salud pública, alcoholismo, tuberculosis (fuente: DeCS, BIREME).

Setting the stage: public health, sanitation and disease in Colombia

Dr. Pablo G. Medina, director of the National Hygiene Board, lamented the government's hesitancy to regulate the sale and consumption of alcohol in an official report delivered to the national legislature on July 15th 1922. According to Medina, the lack of adequate government support on the legislative front hindered the campaign's success, in spite of the efforts put forth by the National Academy of Medicine, National Medical Congresses and the National Hygiene Board to counteract alcohol addiction in Colombia. Medina and other members of the medical establishment regarded the fight against alcoholism as being part of a wider modernization project that tied individuals' health, well-being and productivity to the Colombian nation's future. High rates of alcohol consumption combined with the spread of infectious diseases such as tuberculosis and venereal disease to produce a nation of, "mentally ill citizens, epileptics and criminals." Such "social diseases" were also responsible for high mortality rates, particularly amongst children, thereby directly affecting "tomorrow's citizens," thus threatening the nation's future (1).

The term "civilization" acquired a new scientific meaning for Latin-America's medical doctors, hygienists and public officials between 1880 and 1930. This new scientific language, imbued with the discourses of social Darwinism, positivism and degeneration theory, helped doctors and public officials view the state and its population as being a biological organism susceptible to contagion and disease (2). Colombian government officials used dichotomies juxtaposing "civilization/barbarism," "respectable people/mob," "educated/ignorant" to justify popular groups' political exclusion, legitimizing periods of both conservative and liberal rule. In many instances members of the country's medical establishment identified with, and formed part of, the ruling national and regional elites, sharing common perceptions of Colombia as a country being in need of strong modernization and civilizing projects. Such larger impetus aimed at modernizing their nation prompted public officials and doctors to debate potential strategies and tactics to create "ideal citizens" and try to make sense of their country's unique position as being a predominantly mixed race, Catholic, rural nation (3).

Fiscal realities: coffee markets and cyclical legislative enthusiasm regarding public health expenditure

Understanding the urgency expressed by Colombia's leaders for safeguarding its citizens' health means acknowledging the factors that helped to create what officials often expressed as the imperative need to stop the spread of disease and counteract the degeneration of their nation's racial stock. In an era when the experience or news of an epidemic seemed part of a recent past and an uncertain future, elite fears over the real threat of contagion by disease were not only understandable, given their nation's social realities, but these fears also expressed both personal and class-based anxiety. Death and disease threatened entire societies during an epidemic so that even as government campaigns rhetorically linked disease to the nation's underprivileged classes, or singled out their social environments as being the type of surroundings most susceptible to disease, they also acknowledged the fact that their entire society would suffer the consequences of poor sanitation and inadequate public health initiatives. Preventing the social and biological repercussions inherent in the rapid and uncontained spread of disease made sense, as even elites were at risk.

Successful public health initiative implementation required several factors to become orchestrated. Colombia's government needed to create and fortify an adequate infrastructure which would extend the reach of central administrative agencies from Bogotá to the rest of a regionally-fragmented country. Creating such infrastructure was, of course, an ongoing process, one that paralleled a larger political centralization process which started in the 1880s during Rafael Nunez's term in office. The success of government efforts in creating such infrastructure was, in turn, tied to other variables such as reliance on a bureaucratic cooperation. The administrative apparatus created to oversee public health and sanitation relied on a network of agencies. This network (headed by the National Department of Hygiene) depended on periodic reports filed by departmental hygiene board directors, in turn, relying on municipal leaders to compile an overall picture of their department's sanitation needs and public health concerns. This administrative network's general efficiency turned bureaucratic cooperation into a requirement for successfully implementing public health initiatives. Moreover, finding adequate financial resources to fund these campaigns became a point of contention between local public officials and the national agencies overseeing departmental hygiene boards. The national legislature's need to locate financial resources for carrying out extensive sanitation measures and promoting public health programmes partly explains why legislative concern with public health went through periods of cyclical enthusiasm. Enthusiasm ran high during years of economic upturn whilst approval of any programme requiring extensive national funding was less likely to be approved during years of economic hardship.

Official reports filed by departmental board directors during times of economic recession are filled with complaints noting the limited success of programmes legislated and mandated by national decrees, but funded solely by local resources. The frustration voiced by these local bureaucrats offers an example of natural tension between local demands for government support and the nation's inability to meet all of its prescribed financial responsibilities. Even during times of economic prosperity, governments must decide where their fiscal priorities lie and invest accordingly. Economic downturn intensified such ongoing bargaining process as the state began to cut costs, downsizing national funding efforts and relying instead on regional governments, international aid organizations or the private sector to offset the effects of financial hardship.

During a particularly difficult fiscal year, as coffee prices plummeted in the midst of world recession, Pablo G. Medina (director of the Central Hygiene Committee-JCH) filed a lengthy report on July 15th 1918 addressed to the home secretary in whom he offered a detailed summary of current sanitation efforts and public health campaigns in Colombia. Despite his emphasis on the overall improvement of Colombia's public health establishment, Medina's report is filled with passages expressing his disappointment and frustration. Medina laments the still deplorable condition of housing for the cities' urban poor in his report on typhoid fever in Bogotá and Medellin (4).

Medina's message seems quite clear, efforts to eradicate disease and improve the nation's health even during a year of fiscal misfortune were relatively successful compared to previous years, but there was still a lot of work to do, work which would require a good measure of bureaucratic cooperation and compliance on the part of stubborn departmental board directors. According to Medina, some departmental board directors refused to cooperate with the JCH and instead filled the pages of their reports with excuses concerned with how inadequate government funding prevented their organizations from carrying out national programmes. In Medina's view, unfavorable reports filed by regional directors were simply unjustified, especially given the efficiency and the initiative demonstrated by directors from the Antioquia, Cauca, Caldas and Atlántico departments. According to Medina, other departmental directors should have followed their example instead of citing inadequate funding as an excuse for their own shortcomings and inefficiency. Of course, Medina's explanations for what motivated these "inefficient and stubborn directors" can in turn be interpreted as an attempt on his part to excuse the JCH and the national government's inability to carry out their mission and meet the needs of its constituents.

Moreover, his reference to the four departments mentioned above (Antioquia and Caldas, part of Colombia's coffee-belt, and Atlántico, the gateway to the Caribbean coast and location for United Fruit Company expansion) provides evidence of another aspect of Colombia's social reality during the period being studied and in many ways its reality to this day - that of strong regional differentiation which has a tendency to follow prosperous economic niches. The discrepancy in available fiscal resources amongst departments evident in Medina's report was in turn tied to their economic importance in fiscal geography related to an expanding export economy. Even during a year of noted economic downturn, revenue from departments such as Antioquia, Caldas and Atlántico surpassed revenue from other departments marginalized from or only tangentially connected to an expanding or shrinking economy.

The very nature of Colombia's public health establishment called for the JCH's reliance on its departmental counterparts, even during periods of economic prosperity, the central government's responsibilities vis-à-vis sanitation efforts were never entirely a national enterprise. Programmes entirely funded by the national treasury to promote sanitary measures pertained only to port sanitation and campaigns being mounted against epidemics. Thus, during years of economic hardship, Medina's request for departmental hygiene boards to meet the costs of basic hygiene programmes falling outside the national treasury's pressing need to invest its resources elsewhere was not particularly atypical.

Legislating morality, eradicating vice: anti-alcoholic leagues and the fight against consumption

The Colombian government published an instructional pamphlet in 1905 in an attempt to educate the country's youth and warn them against the evils of falling prey to alcoholism. The pamphlet entitled, Enseñanza del antialcoholismo, was distributed amongst the nation's schools and it marked the beginning of the government's "official" efforts to eradicate alcoholism. The Ministry of Public Instruction asked Catholic teacher Martin Restrepo Mejia to write another instructional pamphlet in 1913 chronicling the story of two brothers (drunken Thomas and wise Luis). The pamphlet's message was clear; while Luis' story provided a solid example of a moral and virtuous life, his brother Tomas embodied the image of vice, filth and decadence (5).

A group of renowned medical doctors and hygienists met earlier that year (1913) in Medellin during the Second National Medical congress where alcoholism and tuberculosis figured prominently among the topics being discussed. Doctor Jose de la Roche from Antioquia tied tuberculosis to widespread problems such as alcoholism and syphilis, warning against this disease's detrimental effects on Colombia's working class. According to la Roche, "We can discern important causes amongst which we can cite alcoholism, syphilis and noxious living quarters for [tuberculosis] a formidable enemy annually destroying a tenth of humanity, choosing for its pernicious labour that most productive period in a man's life, a time when he is the most useful to his society, when his physical and mental vigour are in full development (i.e. between the age of eighteen and forty)."(6) Tuberculosis and alcoholism thus became conditions having biological and social dimensions for Colombia's doctors, public health officials and its ruling class.

However, official concerns about the rate of alcoholism in the nation had reached a national high by the time the third National Congress of Medicine met in 1918. The country's medical community answered accordingly. Future doctors wrote medical theses on the subject seeking to explain the causes of this disease and provide possible solutions that could help eradicate this "social disease." Julio G. Valdivieso's undergraduate medical treatise and classic study, Alcoholismo en Colombia, documented the detrimental effects of alcoholism amongst Bogota's working class and urban poor. Valdivieso found that nine out of the twenty prisoners in el Panóptico de Bogotá (a prison) reported a background of parental alcoholism; seven of these nine men were, "clearly impulsive drunkards. Some had experienced seizures as children; all their siblings were drunkards, cretins, insane, epileptics or prostitutes. All of these examples were of the highest degree of nervous and hereditary degeneration." (8)

Dr. Pablo García Medina started an official report addressed to Cundinamarca's governor by expressing concern over the current state of affairs in a country where, "the increasing abuse of alcoholic beverages among us brings as its consequence the immediate increase of criminality, the destruction of public and private property and the subsequent ruin of the individual, his family and society as a whole." There was a clear connection between alcohol and crime for Medina: the higher the rates of alcohol consumption, the higher the crime rate. The country's future depended upon the successful eradication of this terrible social ill. Local cantinas and places selling alcoholic drinks made from corn and, "places of perversion, waiting rooms for jails, prisons, hospitals and asylums," took Colombian men from their homes, "sowing disgrace in the bosom of their families." Colombian society needed solid moral education to counteract the ruinous effects of this disease and to safeguard the future of the nation (9).

The family, as a site of moral and physical regeneration and the fundamental unit of social organization, became a potential laboratory to which doctors and hygienists could turn their attention and from which the incipient prohibition leagues could launch a successful attack against alcoholism. This campaign's goal was simple; the fight against alcoholism would only succeed through a concerted effort to educate Colombia's working class and its urban poor. Educating the masses was only possible through a joint effort with doctors, hygienists and women where they help inculcate basic principles of sobriety, thrift, modesty and morality upon their male counterparts, through their role as mothers, wives and daughters. They needed to become, "soldiers and allies in the struggle against vice, alcohol, filth and disease…moralizing agents in our society." In their efforts, "women helped individuals leaning towards antisocial acts as they had become overtaken by their alcoholic stupor and lacked the inhibition to regulate their passion." (9).

Several of Colombia's leading intellectuals and medical practitioners ardently petitioned for the adoption of more pro-active measures in their fight against this disease. They appealed to the government, advocating the sale and consumption of alcoholic beverages to become regulated. Such open petitions reiterated the urgency of purging the nation of vice, immorality and alcoholism. Pablo G. Medina (one of this campaign's most ardent patrons) commented on other national campaigns' success against alcohol consumption. He highlighted the success and the edifying benefits of such regulatory measures in other nations. Mounting educational campaigns was not enough to procure eradication, only, "outright repression through law and regulation, as deployed by the nations listed is truly effective." Ratifying such regulatory measures was necessary, "to avoid the ruin and desolation of countless Colombian homes." Medina petitioned for, "the assemblies and the governments of all the departments within Colombia to pass ordinances to apply the measures regarding the repression and regulation of alcoholism suggested by national medical congresses," as acting director of the National Hygiene Board. He enlisted departmental hygiene directors to enact legislative measures and create grassroot organisations which could, "gather the resources and start this most important campaign against such a terrible social disease." (9)

Later that year, the National Department of Hygiene, "in full use of its legal attributes, and considering that alcoholism is one of the agents promoting the spread of tuberculosis, that it aggravates infectious diseases and that it is a leading characteristic among the insane, epileptics, and criminals as well as contributing towards an increase in mortality rates," promulgated resolution 146, Article 1, in which it created an administrative board to be in charge of organising the National Alcohol Prohibition League. The league's goals were clear. Their campaign would rely on three key strategies: institutional support, research and awareness. In order for the league to succeed it would need to set-up strong infrastructural support by creating abstinence and temperance societies. It would need to conduct research and help create a portrait of the country's population most affected by this social disease (i.e. Colombia's working class and urban poor). The league would seek to raise awareness by deploying educational campaigns, at the very least preventing this condition from spreading and hopefully decreasing the numbers of inhabitants affected by it.

Like the fight to eradicate alcoholism, early campaigns against tuberculosis had relied on publicity and tactics to raise awareness in promoting government efforts to inculcate hygiene among the nation's popular classes and arrest the spread of this formidable enemy. Tuberculosis and alcoholism had emerged as two of the most prominent themes discussed during the second National Congress of Medicine in 1913. Both these conditions prompted distinguished members of Colombia's medical establishment to present separate reports on how to fight against these "insidious threats" to their nation's prosperity (5).

Tuberculosis preyed on the nation's popular classes. According to the report, extreme poverty and deprivation, inadequate nutrition, poor ventilation and hygiene (exacerbated by residential crowding) combined with physical and moral decadence to turn Colombia's poor into vulnerable targets for the disease. Once de la Roche had recognised the country's popular classes as being the social group most susceptible to this disease, he moved beyond this, placing responsibility for prophylaxis on both the state and members of the nation's privileged classes. He urged Colombian elites to help fund publicity efforts and set up specialised wards in local hospitals to treat destitute patients affected by tuberculosis. He hoped elites would take note of the importance of this mission, motivated if not by humanitarian and patriotic concerns then by fear of contagion. According to de la Roche, "the rich should generously open their coffers, keeping in mind that if they do not do so, sooner or later members of their families or they themselves will fall victims to this malady because the poor, afflicted by tuberculosis, wandering and without recourse, unintentionally take vengeance upon those, who in spite of their status and fortune, ignore their fellow men." (6)

Three years went by after Dr. de la Roche had delivered his report and before the Colombian legislature passed a law which would formally organise anti-tuberculosis campaigns. Law 66/1916 ordered the creation of a National Anti-tuberculosis Board to oversee and carry out publicity campaigns to raise awareness, establish local free treatment facilities (dispensaries) and subsidise departmental boards' regional campaigns. Organising a national board to oversee official efforts to eradicate tuberculosis, supported by Law 66 and decree 33 (approved by the JCH) relied on a network of pre-established links between the JCH and its departmental counterparts. Official protocol required departmental directors to file regular detailed reports with the JCH; now, regional directors would file special reports with the Anti-Tuberculosis Board in an effort to target this particular disease. Moreover, boards were required to oversee the creation of grass-roots leagues funded by municipal councils in departments having high rates of infection to provide further infrastructural support and supplement their efforts (10).

JCH director Pablo Medina complained about the indifference expressed by some regional directors towards the National Anti-tuberculosis Board's mission in a 1918 government report. Their apathy or inefficiency did little to promote the campaigns mandated by Law 66/1916 and thus failed to endorse the state's mission to create healthy and productive citizens who would lead the nation. Little had changed by 1921. Medina's frustrations once again took centre stage in the April issue of La Revista de Higiene: Organo de la Direccion Nacional de Higiene, in an update where he despaired about the future of a nation where tuberculosis and infectious diseases ran rampant. By then, and after several years serving Colombia's medical establishment, Medina emphasized the need to establish local dispensaries funded through private philanthropy. According to Medina, these dispensaries would fill the gaps left by a lack of resources and insufficient funding for government-sponsored clinics (10).

Analyzing sanitary campaigns, social reform programmes and public health legislation between 1910 and 1925 uncovered two distinct currents within Colombia's national discourse; there was a political and social dimension (exemplified by political treatises and debates, legislation and policy) and a narrower, more specific medical construction regarding tuberculosis and alcoholism as being biological and social diseases. Class and gender became essential components underlying such "civilizing" mission in both instances. The way in which public officials and doctors recreated hierarchies of class and gender helped to reinforce the creation of a national other, embodied by the alcoholic, sexually promiscuous, irresponsible, ignorant and unclean worker and his social milieu. During this time government preoccupation with counteracting the spread of tuberculosis and eradicating alcoholism expressed concrete fear and pressing concerns regarding the nation's future. Sanitation and health campaigns took on social and political dimensions. Government-sponsored publications, manuals and pamphlets promoting public health burst into Colombia's public sphere. For the nation's elite, contemporary ideology viewing society as a live organism exposed to illness and vice brought workers and their productive capacity under closer scrutiny, in essence turning their bodies into objects of scientific study and tying their physical and moral health to the nation's progress. Such process brought together the production of medical knowledge, the implementation of public health legislation and the establishment of confinement and assistance institutions in Colombia.

1. Medina PG. Resolución Número 146, Sobre la Campaña contra el alcoholismo. Revista de Higiene (órgano de la Dirección Nacional de Higiene de Colombia) 1922; 12 (141): 37- 47.        [ Links ]

2. Foucault M. The History of Sexuality. Vol. I. New York; 1978.        [ Links ]

3. Palacios M. Between Legitimacy and Violence: A History of Colombia, 1875-2002, Durham and London: Duke University Press; 2006.        [ Links ]

4. Medina PG. Informe de la Junta Central de Higiene al Ministro de Gobierno; 1918. p. 10.        [ Links ]

5. Noguera CE. La Lucha Antialcohólica en Bogota: de la Chicha a la Cerveza. In: Márquez J, Casas A, Estrada V (eds). Higienizar, Medicar, Gobernar: Historia Medicina y Sociedad en Colombia. Medellín: Universidad Nacional; 2004.        [ Links ]

6. De la Roche J. Profilaxis de la Tuberculosis. En: Memoria del Segundo Congreso Medico de Colombia. Medellín; Enero de 1913. p. 314.        [ Links ]

7. Márquez LC. Consumo de las Bebidas Alcoholicas en Colombia. En: Memoria del Segundo Congreso Medico de Colombia. Medellín; Enero de 1913. pp. 291-308.        [ Links ]

8. Valdivieso JG. Alcoholismo en Colombia. Bogotá: Tipografía Minerva; 1918. pp. 23-24.        [ Links ]

9. Medina PG. Sobre la Campaña Antialcohólica. Revista de Higiene (órgano de la Dirección Nacional de Higiene de Colombia). 1921; 11 (140): 223-225.        [ Links ]

10. Informe de la Junta Central de Higiene; 1918. p. 35.        [ Links ] ]]> 1 1922 12141 37- 47 2 1978 I 3 2006 4 1918 10 5 2004 6 Ener o de 314 7 Ener o de 291-308 8 1918 23-24 9 1921 11 140 140 223-225 10 1918 35