Uruguay's Dead Children Being Put in Ground Beef
Am J Public Wellness. 2005 September; 95(9): 1506–1517.
Uruguay on the World Stage
How Child Health Became an International Priority
Accepted September 11, 2004.
Abstract
The development of international health has typically been assessed from the standpoint of central institutions (international health organizations, foundations, and development agencies) or of ane-style diffusion and influence from developed to developing countries.
To deepen understanding of how the international health calendar is shaped, I examined the little-known case of Uruguay and its pioneering function in advancing and institutionalizing child health every bit an international priority betwixt 1890 and 1950.
The emergence of Uruguay every bit a node of international health may be explained through the country's early gauging of its public health progress, its borrowing and accommodation of methods developed overseas, and its dissemination of its own innovations and shortcomings.
THE HISTORY OF INTERNATIONAL wellness has typically been examined from the perspective of metropolitan institutions such as the World Health Organization, the International Red Cantankerous, and the Rockefeller Foundation.1–5 While some works trace the interactions of these agencies with far-flung actors, the motives, ideas, and operations of international wellness are invariably portrayed as centrally determined, and so diffused effectually the world. To augment this account of the evolution of the international health calendar, I examine the little-known example of Uruguay and its pioneering role in advancing kid health every bit an international priority betwixt 1890 and 1940.
Uruguay became involved in international wellness at least in function to search for solutions to its intractable babe mortality problem, and it ended up offer local approaches—including a children'southward code of rights—that had global appeal. As the home of the International American Institute for the Protection of Childhood (Instituto Internacional Americano de Protección a la Infancia, or IIPI), the starting time permanent arrangement of its kind, founded in 1927, Montevideo became a node of international health which—though defective the political cachet of Washington, DC, or Geneva, Switzerland—helped shape a worldwide children'south health agenda.
The transformation of Uruguay's domestic debates into an influential plant can be observed through the international networks of Uruguayan doctors and child wellness advocates, the opportunities and interests that gave ascension to the IIPI, and its repercussions, including Uruguay's Children'due south Lawmaking. My analysis, unlike a conventional history, highlights the emergence of a significant initiative from a peripheral location through the interplay of local political and social conditions with widely shared health priorities.
THE URUGUAYAN WAY
Despite its pocket-size size and its distance from the centers of power, Uruguay became engaged with international health developments first in the late 19th century. Founded in 1830 following a longstanding conflict between Kingdom of spain/Argentina and Portugal/Brazil over possession of its territory, Uruguay enjoyed relative stability and a cattle-based economy later on its civil wars subsided in 1851. Its loftier levels of urbanization and school attendance, tiny ethnic population, secular authorities, uniform and attainable geography, and mild, Mediterranean-similar climate differentiated Uruguay from most of its neighbors. The country was peopled largely by Castilian and Italian immigrants, with a pocket-sized elite of French ancestry and a few descendants of African slaves. Uruguay's approximately 1 1000000 residents (ane 3rd of whom lived in the capital, according to the1908 census)vi shared a cocky-effacing longing for Europe while developing their ain make of state protectionism.
Uruguay differed from near Latin American countries in that the Catholic Church and the landed elites were relatively weak forces as the modern state began to take shape in the tardily 19th century. Moreover, the country's sparse institutional infrastructure in the social loonshit left room for state growth.7,8 The rapid expansion of public didactics for both sexes that started in the 1870s—making Uruguay the region's leader in literacy, with 54% literacy in 19009—presaged the welfare state, which emerged in full force nether the reformist Colorado Party administrations of President José Batlle y Ordóñez (1903–1907 and 1911–1915). Enabled by relative prosperity and the sidelining of the opposition Blanco Party, Batlle's first administration opened a wide-ranging dialogue on issues such equally universal suffrage, maternal benefits, and working conditions. Concretely, it established retirement and other benefits for the ceremonious service.ten
A astringent economic crisis in 1913 accelerated the implementation of various Batllista policies—including an 8-hour workday and exemption from taxes on essential appurtenances—that seemed to prefigure Keynesian approaches to mitigating the social and economical inequalities provoked by capitalism. Indeed, Batlle conceived of a protective state that offered compensation for injustices suffered by various segments of the population. His ambitious agenda of centralization and redistribution included erstwhile-age pensions, worker protections, land monopoly of finance and other sectors, and public assist for women, children, and the poor.11,12 That progress in enacting reforms was slow—in role because the reforms yielded contradictory results, such as lower wages13–fifteen—did not crusade the country to be viewed equally a failed experiment. Instead this stepwise approach elicited attention: a variety of voices engaged in decades of lively debate, domestically and internationally, over the effectiveness of the Batllista country and of its particular features, such as those improving child health and welfare.
Uruguay's place in the globalizing wellness system was at once peculiar and typical. Like Central and Eastern European countries at the time, Uruguay shared many of the modern land-building and cultural values of Western Europe but had a withal largely rural economy. Similar other Latin American countries, Uruguay was non tied to a single international mandate, instead interacting with a changing panorama of public health examples.
Mid–19th-century European concerns with preventing the spread of epidemic diseases—and the economic consequences of the resulting trade interruptions—were echoed in a series of meetings held in Montevideo and Rio de Janeiro starting in 1873 aimed at standardizing quarantine measures and maritime sanitation. The meat- and hide-exporting economies of Argentine republic and Uruguay were particularly intent on guarding confronting yellow fever from Brazil, since nearly ships inbound the Río de la Plata afterwards leaving Brazil stopped in both Buenos Aires and Montevideo. The 1887 sanitary convention signed by Brazil, Argentine republic, and Uruguay—the first of its kind to be ratified in the Americas—detailed quarantine periods for ships bearing cholera, yellow fever, and plague and was in effect for 5 years earlier it broke autonomously. A 1904 successor convention included reciprocal notification. These treaties presaged pan-American efforts to prevent infectious outbreaks originating from immigrant and commercial vessels.16
GAUGING INFANT Bloodshed
In the tardily 19th century, Uruguay began to consider social policy an important underpinning of public health. Initially it was French legislation—maternity leave, welfare provisions, mandatory breastfeeding for abandoned infants, milk hygiene, and other puericultural (from Adolphe Pinard's notion of the scientific cultivaiton of childhood and the improvement of child health and welfare through better conditions of childrearing) measures—that was most influential. In the 1930s many Uruguayan social policy-makers and doctors admired the Soviet health system. By the 1950s, Uruguayan public wellness was increasingly influenced by the technical and biomedical approach of the United States. Uruguay was never "passively derivative"17 of these models, instead selecting features from abroad and melding them with the ideas, reality, and politics at home.
A particular mark of Uruguay'due south early participation in international wellness discussions was the founding of the Civil Registry in 1879, mandating the regular collection of birth and death records. Virtually of the nations that developed comprehensive vital statistics systems before 1900 were major powers concerned with population wellness as a sign of economic vitality. Rapidly industrializing England, French republic, and Frg, for example, monitored the survival of children equally an indicator of workforce and military readiness and imperial strength.18,19 Though information technology had piffling industry and no pretense to empire-building, Uruguay had plenty of livestock to count: its first statistical annual, published for the 1873 World Exhibition in Vienna, was sponsored by the Uruguayan Agricultural Clan.20
The European connections of the Uruguayan elites too propelled data collection. The state's statistical annuals were self-consciously modeled after Parisian volumes,21 2nd half of the 19th century: more xl medical periodicals were founded, numerous hospitals and clinics were organized, and the country's first friendly society (providing mutual help for unemployment and medical care) was established in 1854. The University of the Republic's Faculty of Medicine was founded in 1875, and by the time its country-of-the-art inquiry facility was built in 1911, there were several dozen graduates per year.22,23
Statistical annuals compiling cause-specific mortality data were beginning published in 1885,24 with baby deaths added in 1893. This allowed health experts to follow the country's uneven only sure decline in infant bloodshed from 104 deaths per yard live births in 1893 to 72 per thousand in 1905. Over the next 35 years infant mortality stagnated, fluctuating between 85 and 113 deaths and averaging 95 deaths per 1000 live births. Only afterward 1940 did infant mortality resume its decline. Although other countries reported higher levels of baby mortality than Uruguay at item points in time, virtually every other setting experienced continuous—if sometimes bumpy—declines25–27 (Figure i ▶).
International comparisons of babe mortality rate,1893–1953.
Uruguay was thus unusual on several counts: in establishing a performance civil registry early, in achieving lower infant mortality rates than several European countries, and in experiencing a prolonged stagnation in infant bloodshed rates. The land's early on successes and its subsequent setbacks with infant mortality impelled health experts to identify the underpinnings of local circumstances and to search for international approaches that might prove helpful.
URUGUAYAN PUBLIC HEALTH Abroad AND AT HOME
In 1895, approximately a decade after Uruguay'due south civil registry achieved regular coverage, public health powers were consolidated under the National Council of Hygiene. Uruguay now had data, centralized potency, and a core of medical and public health experts keen to participate in international health developments. This group of experts documented Uruguayan health and mortality domestically and comparatively; advised policymakers; ran health and welfare institutions; saw patients in clinical settings; and participated in international congresses, publications, and other scientific activities.28,29
An early on member of this group was Joaquin de Salterain (1856–1926), whose career illustrates the back-and-forth betwixt international and Uruguayan developments in wellness. Of French and Castilian parentage, de Salterain was among the first graduates of Uruguay's Kinesthesia of Medicine in 1884 and won a regime scholarship to get to Paris for specialized grooming in ophthalmology. Rather than narrowing his focus, his fellowship widened it, and on his return to Uruguay he became involved in a range of health activities. De Salterain was a constituting member of the National Council of Hygiene, and in the mid-1890s he began to publish detailed analyses of Montevideo's bloodshed statistics.thirty,31 De Salterain headed Montevideo's Section of Public Health and was a program manager in the Pereira Rossell Children's Hospital (founded in 1905) and the Dámaso Larrañaga children's asylum (established in 1818). His work helped set the stage for Uruguay'due south role abroad, simply he was maybe most effective at using his international interchanges to leverage increased attending and resources at home.
From the 1890s on, Uruguayans participated in virtually every international congress related to public health and social welfare. They published their ain presentations in either Uruguayan or international journals and typically issued analytic summaries of the briefing discussions in Uruguay's Boletín del Consejo Nacional de Higiene (Bulletin of the National Quango of Hygiene). Medical elites from throughout the Americas received advanced training in Europe during this catamenia, making contacts, attending congresses, joining scientific networks, and pressing their own governments to expand activities. But few countries, specially small countries, accomplished every bit consistent an international presence as did Uruguay. Nearly countries sent 1 representative to the 1900 Paris briefing at which the International Classification of Diseases was first revised; Uruguay sent 2.32 Similarly, the 7-person delegation Uruguay sent to Washington, DC, for the 15th International Congress on Hygiene and Demography in 1912 was larger than that of all simply a scattering of countries.33 That this attendance was at state expense—at a fourth dimension when the National Council of Hygiene relied on a largely volunteer labor forcefulness—implies that politicians and bureaucrats believed Uruguay's health learning would take identify internationally.
Uruguay's reorganization and expansion of social welfare fit with this notion of selectively adapting strange developments. In 1907 Uruguay was amidst the showtime countries outside Europe and its colonies to found a milk station (gota de leche) based on the French model (goutte de lait) to distribute pasteurized milk and provide medical attention to needy mothers and their infants.34 By 1927, 33 milk stations had been established throughout the country, arguably covering the largest proportion of mothers and infants in the world. This number was exceeded merely in France.
The 1910 nationalization of Uruguay'south charity institutions into the Asistencia Pública Nacional was likewise self-consciously patterned on France's Assistance Publique, so expanded into 1 of the most far-reaching social aid programs in the world.35 Uruguay also maintained Anglo-America–mode individual aid agencies (typically run by women), some of which received authorities grants to deliver services.36–38 The total legalization of divorce (including divorce unilaterally initiated by women) in 191339—giving the country 1 of the world's most liberal divorce laws—was farther evidence of Uruguay'southward "borrow and alter" social policy approach.
THINKING Insufficiently, CONTRIBUTING INTERNATIONALLY
Uruguayans were conspicuously adept at participating in international health networks and adapting foreign innovations to serve local needs. Equally striking is how Uruguay's self-publicized bug catapulted the country to regional and international attention.
In the tardily 19th century European countries began to conduct mortality comparisons, a practice Uruguay fully adopted. De Salterain observed in 1896 that Uruguay'due south mortality charge per unit was dropping steadily and that Montevideo's rate was lower than those of Paris, London, St Petersburg, and Buenos Aires. De Salterain boasted, "What other explanation could there be for such pleasing results than the progress of our public welfare institutions, health assistants, and hygiene education?"40
Other colleagues followed suit, specially afterwards the infant mortality rate emerged equally an international indicator around 1900.41 In 1913, Julio Bauzá, the doctor heading Montevideo's milk stations, went and so far equally to contend that little attention needed to be paid to infant bloodshed considering Uruguay'due south rates were so much lower than those of Chile, France, Russia, and Germany. He affirmed, "The truth is we are in an enviable position for a myriad of European and American countries."42
These early comparative analyses were aimed more often than not at domestic audiences, but local experts before long recognized that Uruguay'due south well-documented mortality patterns had relevance far across the country'due south borders. Luis Morquio (1867–1935), the founding begetter of Uruguayan pediatrics and a leading authority on both medical and social aspects of child health, was the nearly prominent translator of the local experience to the international scene. In 1895, upon returning to Montevideo from grooming in Paris, he became medical director of the external services of the Orphanage and Foundling Home. There he oversaw an extraordinarily low—for the fourth dimension—mortality rate of 7% of children, which he attributed to careful attention to babe feeding, including weekly visits to his clinic by wet-nurses and their charges.43,44
Morquio was presenting his analyses of Uruguay's experience to Latin American medical congresses past 1904 and to European audiences soon afterwards. If Morquio agreed that Uruguay's babe mortality rates—rates favored, he believed, past ecology cleanliness, low population density, and loftier levels of breastfeeding45—deserved some international appreciation, he did non dwell on success, arguing that half of the infant deaths were avoidable46 (Figure 2 ▶).
Postage stamp commemorating the 100 years since Dr. Luis Morquio became the Chair of Pediatrics at the Kinesthesia of Medicine at Uruguay's University of the Republic. Bottom right corner includes the statue of Morquio with a child that stands along one of Montevideo's chief boulevards. The postage stamp was designed by Daniel Pereyra. (Courtesy Administración Nacional de Correos, Uruguay.)
Morquio's moderation proved perceptive. Equally of 1915 Uruguay's infant bloodshed record, although however improve than virtually European levels, was stationary, if not worsening. This was particularly troubling given that the national nativity rate was steadily declining.47 Morquio—who by this time had served as the medical manager of the largest children'southward asylum, chief of the pediatric dispensary in the primary public hospital, and a professor of clinical pediatrics—believed that some of the international measures adopted by Uruguayan health authorities had unintended consequences. He worried that milk stations discouraged breast-feeding past offering free or subsidized milk, and that this milk was ofttimes contaminated.48
Thereafter, numerous doctors chimed in on sometimes acerbic debates over the function of public health institutions, social and economic atmospheric condition, illegitimacy, abandonment, sanitation, climate, and cultural factors in Uruguay's stagnating infant mortality.49 Such discussions were non unique to Uruguay, but they were unusual in the international attention they generated. Uruguayan authors were extremely prolific on this question, publishing more than 1000 journal articles related to child and infant health between 1900 and 1940 (estimate based on a bibliographic database compiled by A.-E.B.).
Morquio himself was a major contributor to Uruguay'south international renown, writing an boilerplate of 9 articles per yr betwixt 1900 and 1935. Almost one-half of his output appeared in foreign publications, including Archives de Médecine des Enfants (France), La Nipiología (Italy), Journal of Nervous and Mental Diseases (United States), and the Archivos Latino Americanos de Pediatría, which he cofounded.50 Most of his articles focused on specific childhood medical problems, giving him credibility in the worlds of medicine and research as well as public health. Morquio became widely known for his 1917 book on gastrointestinal problems of infants, which was published in several languages and bridged his diverse interests. Numerous pieces he published in Uruguay were reissued by international journals. In 1928, for example, a talk he gave in Montevideo on infant mortality was reprinted in the Boletín de la Oficina Sanitaria Panamericana,51 which introduced it past emphasizing its "universal relevance."
Almost as soon as they began to be compiled, Uruguay'due south infant mortality statistics were viewed simultaneously in national and international terms. Scrutinized through comparative lenses, Uruguay initially accounted itself a success story. Conversely, as the problem of infant mortality stagnation unfolded domestically, the repercussions went far across the national realm.
URUGUAY'S HEALTH INTERNATIONALISM
Past the 1920s the international health landscape consisted of a handful of permanent agencies, based principally in Europe and North America, with limited but growing prestige. In Dec 1902 the Wedlock of the American Republics (precursor to the Organization of American States) sponsored the International Sanitary Convention in Washington, DC, at which the International Sanitary Bureau was founded. The International Sanitary Bureau, renamed the Pan American Germ-free Bureau (PASB) in 1923, was the world's first international health agency.52
Operating out of the US Public Health Service under the directorship of the U.s.a. surgeon general until the mid-1940s, the PASB worked on treaties and commercial concerns related to epidemic diseases, with quadrennial congresses creating an important venue for public wellness exchange among the region's professionals. In 1907 the PASB established an International Germ-free Office in Montevideo for the collection of health statistics from South American countries, but the precariously funded office disappeared within a decade. The PASB's sixth conference in Montevideo in 1920, at which U.s.a. Surgeon Full general Hugh Cumming became director, marked a renewal of activity. The PASB'due south widely distributed Boletín de la Oficina Sanitaria Panamericana was founded in 1922, the Pan American Sanitary Code was passed in 1924, and cooperative activities with fellow member countries were also initiated in the 1920s.53,54
Some other key agency involved in international health was the New York–based Rockefeller Foundation, founded in 1913. The foundation'due south International Wellness Board launched a series of campaigns confronting hookworm, xanthous fever, and malaria in Latin America and throughout the world, equally well as establishing schools of public wellness in Europe, the Americas, and beyond.55,56 Interestingly, Uruguay was virtually the simply state in the region untouched by the Rockefeller Foundation (perhaps because it no longer experienced whatever of the foundation's showcase diseases), leaving the country all the more inclined to pursue public health approaches broadly.
In Europe it took more than than half a century to transcend imperialist jealousies in order to establish a uniform organisation of illness notification and maritime sanitation. The culmination of 11 international germ-free conferences held since 1851, the Function International d'Hygiène Publique was founded in Paris in 1907 to hold periodic conferences, regulate quarantine agreements, and conduct studies on epidemic diseases. It too served every bit the international repository for wellness statistics before this responsibleness was causeless past the Globe Health Organisation in 1948.
The devastation of World War I lent new urgency to international wellness organizations. In 1921 the Geneva-based League of Nations founded an epidemic committee to command outbreaks of typhus, cholera, smallpox, and other diseases in Eastern and Southern Europe. The head of the epidemic committee, the Polish hygienist Ludwik Rajchman, ably transformed it into the League of Nations Health System (LNHO) in 1923. The LNHO helped war-torn nations reorganize their health bureaucracies and pursued an aggressive programme of surveillance, research, standardization, professionalization, and technical assist. Under Rajchman (who subsequently helped establish UNICEF), the LNHO expressed a special concern for the health and welfare of children, working closely with the war relief agency Salvage the Children (founded in Britain in 1919, with an international counterpart established in Geneva in 1920).1,57
Uruguay became involved with the LNHO in the early 1920s, most notably through Paulina Luisi, the country's offset woman doctor and its leading liberal feminist.58–60 Active in regional feminist, scientific, and child welfare circles, Luisi presently leapt to prominence on the international scene. She was the just Latin American woman delegate to the start League of Nations Associates, participating in various treaty, disarmament, and labor conferences. In 1924 she became an skillful delegate on the League of Nations advisory commission on white slavery, and for 10 years she was 1 of merely 2 Latin American delegates on the Committee for the Protection of Childhood (the other being an IIPI representative). Luisi forcefully advocated increased Latin American perspectives in the League of Nations' work for children, including surveys of needs and policies as well as greater representation in governing bodies61–64 (Effigy 3 ▶).
Paulina Luisi, Uruguay'due south first female person doctor, with her Faculty of Medicine classmates in September 1901. (Photo courtesy of the Section of History of Medicine, Faculty of Medicine, Academy of the Republic, Montevideo, Uruguay.)
THE BIRTH OF THE IIPI
Another key dimension of international organizing in this period consisted of periodic congresses, mostly held in Europe, devoted to questions of hygiene, demography, statistics, and child welfare.41 Two international associations for childhood protection were conceived in Brussels in 1907 and 1913, only their institutionalization was aborted and their activities were absorbed by League of Nations committees in the 1920s.
In the Americas, meanwhile, Pan American Child Congresses were launched in Buenos Aires in 1916, serving every bit a vibrant forum for Latin American reformers, feminists, physicians, lawyers, and social workers devoted to improving the health and welfare of poor and working-grade women and children. The 8 hemispheric meetings held before World State of war II influenced the passage of dozens of laws delineating rights in such areas every bit adoption, infant health, state assist, and child labor.65 Although the start Pan American Child Congress was organized by "maternalist feminists" who viewed the lot of children equally inextricably linked to the rights of women equally mothers,60,66 control over the Latin American child welfare movement was before long seized by male professionals, as evidenced by the preponderance of male person presenters at the successful 2nd congress, held in Montevideo in 1919. Even presider Paulina Luisi was upstaged by Luis Morquio'southward high profile.67
It was at this congress that Morquio chosen for an international institute for childhood protection to be based in Montevideo, a proposal enthusiastically sanctioned by the Uruguayan government through a 1924 decree and canonical by the fourth Pan American Child Congress, held in Santiago subsequently that year.68 But the founding of the IIPI awaited an exterior impetus, which—plain cheers to Luisi—came in the guise of LNHO sponsorship of a conference held in June 1927 in Montevideo.
This briefing, the Due south American Conference on Infant Mortality, was the start League of Nations briefing of any kind to be held in Latin America. Attended by both Rajchman and the LNHO'south president, Danish bacteriologist Thorvald Madsen, the conference was a prestigious forum for Morquio and other experts in infant wellness and welfare.69 Through the IIPI, the LNHO backed a set of infant mortality surveys in Argentina, Brazil, Chile, and Uruguay similar to surveys information technology had sponsored in Europe.lxx,71 The results, presented at the Sixth Pan American Kid Congress in Lima in 1930, demonstrated the demand for improvements in vital statistics, centralization of services, and a range of public health, social assist, economic, and educational measures to reduce infant mortality.72–74
The IIPI itself was launched past ten participating countries (Argentine republic, Republic of bolivia, Brazil, Chile, Cuba, Ecuador, Peru, the Usa, Uruguay, and Venezuela; by 1949 the founders were joined past all other countries in the region), each with 1 official delegate. After 1936 the IIPI requested 2 representatives from each country—one technical and based in the abode country, the other resident in Montevideo (a diplomat, for instance). In the early years, most IIPI operating funds were provided by the Uruguayan authorities, with intermittent support from other fellow member countries.
The IIPI's charge was to collect and disseminate research, policy, and practical data pertaining to the intendance and protection of infants, children, and mothers. It sought to "[Latin] Americanize" the study of childhood and then that the region was understood as singled-out from and not only derivative or cogitating of Europe.75 At the same time, the IIPI ensured that the region'due south bug, research, and policies entered into international discussions. The IIPI's widely circulated Boletín del Instituto Internacional Americano de Protección a la Infancia, its library, its health education materials, and the child congresses information technology sponsored apace established its strong reputation and generated a large network of collaborators throughout Latin America and the world.76
In its first decade, the IIPI was governed past a group of distinguished physicians. Gregorio Aráoz Alfaro of Argentine republic served as president for the first 25 years of IIPI's existence, with Uruguayan Víctor Escardó y Anaya as secretary. Morquio was the IIPI's first director; after his death in 1935 his compatriot Roberto Berro held the position until 1956. In improver to editing the Boletín and working with the international advisory board, the managing director oversaw a modest permanent staff who ran the Institute's library and archive; collected laws, statistics, and reports on child protection from member countries and beyond; and sent information to correspondents around the globe.76,77
The IIPI navigated complicated waters between independence and patronage. It was a consulting bureau to both the League of Nations and the Panamerican Union until World War II, and in 1949 it was integrated into the Arrangement of American States. (The IIPI is now known equally the Instituto Internacional del Niño, or International Institute of the Kid.) The LNHO had hoped that its function in the IIPI would give information technology a foothold in various S American inquiry and educational instititions,69 only tight resources in Geneva meant that the LNHO could do trivial more than than encourage activities at the IIPI. (A lingering question is why the LNHO rather than the PASB provided the organizing spark for the IIPI, and whether the PASB's territoriality—based equally it was in US isolationist politics and a Monroe Doctrinism applied to wellness—helped derail the LNHO's ambitious plans in Latin America.)
The IIPI propelled Uruguay to international attention. In 1930 Morquio was named to the presidency of Save the Children in Geneva, providing a worldwide platform for the policies and practices he and other Uruguayans had developed. The Pan American Child Congresses continued to meet until 1942, offering a key venue for exchange of ideas and learning during a period of fertile social policy activity throughout the region.65
Perhaps nearly visibly, the IIPI'southward Boletín, founded shortly later on the 1927 briefing, brought considerable acclaim to Uruguay. Unique in its scope, the IIPI's Boletín—published quarterly in English, French, and Spanish—covered topics ranging from the organization of children'southward social services to summertime camps, school wellness, sports, education, wellness campaigns, marginalized children, and the causes of baby or child mortality. It was one of the near international journals of its mean solar day: of the 1000 authors published in the journal'southward get-go 2 decades, approximately one fifth were from Europe and Northward America and four fifths from throughout Latin America. Slightly more than one third of the authors were Uruguayan. A pocket-sized number of Uruguayan pieces profiled kid welfare systems in other countries, simply for the nigh part Uruguayans used the IIPI's Boletín to highlight domestic problems and achievements in infant, kid, and maternal welfare.
URUGUAY'S CHILDREN'S Lawmaking
As the Uruguayan public health community grappled with the continued stagnation of its infant mortality rates, it became clear that increasingly specialized medical approaches were insufficiently integrated with social provisions for child health. This realization offered a chance for IIPI influences to be expressed through local developments, but in 1933 Uruguay'due south liberal era came to a sudden finish with the dictatorship–cum–bourgeois-populist regime of Gabriel Terra. Rather than impede integrated child welfare policy, nonetheless, Terra's efforts to rationalize and centralize power reinforced the country's widely supported protectionism78,79: the IIPI served as a social policy umbrella under which new initiatives were researched and debated.
In 1933 Morquio, Bauzá and other colleagues were invited past the merely-founded Ministry of Child Protection—the first of its kind in the earth—to form a legislative advisory commission to organize the various programs and agencies involved in infant and kid welfare in Uruguay. Nether the leadership of Roberto Berro, a disciple of de Salterain and Morquio and an advocate of "childhood social medicine,"80 the commission did not limit itself to the administrative procedure of merging overlapping agencies. Instead, it called on the country to adopt a children'southward code spelling out children's rights to health, welfare, didactics, legal protections, and decent living conditions and creating specific institutions to run and oversee kid and maternal help programs.
Following a lively debate in Uruguay's national Assembly, the unanimous recognition past foreign delegates to the Seventh Pan American Conference in 1933 that such a lawmaking would put Uruguay "in the vanguard," and expressions of broad professional person and pop support, the Uruguayan parliament approved the Children's Code in 1934. With passage of the code, the Uruguayan government explicitly recognized the importance of integrating medical approaches to the improvement of child health with social approaches, including better housing, sanitation, road-paving, schools, and family allowances81 (Figure iv ▶).
Annotated version of Uruguay's Children's Code.
To enable its interdisciplinary work and avoid turf battles with other ministries, the Ministry of Kid Protection was refashioned into the Consejo del Niño (Children's Council) under the Ministry building of Public Education. Although the Consejo was headed by a series of doctors, it was purposely separated from the new Ministry of Public Wellness (established in 1934) to emphasize its social, rather than medical, approach to child well-being. The Consejo organized its services by age group (prenatal, infant, child, and adolescent divisions) and jurisdiction (didactics, law, social services, and school health divisions), establishing offices throughout the country and absorbing a series of kindergartens, orphanages, asylums, homes, camps, and reform institutions. With this purview, the Consejo reached virtually every Uruguayan child, at minimum through school wellness exams and, for poor and working-form children, through all-encompassing coordinated services.82,83
The relationship between the IIPI and the Consejo was very shut, with ongoing exchange of staff and ideas. Berro, for instance, directed the Consejo before condign head of the IIPI; Bauzá was an IIPI representative before condign a division head and and so director of the Consejo. Descriptions and assessments of Consejo projects were frequently published in the IIPI'southward Boletín, probably bringing Consejo activities to greater international attending than the children's services of any other land.84,85
Although several other countries had previously enacted children's codes—and Save the Children founder Eglantyne Jebb'south Declaration of the Rights of the Child had been adopted by the League of Nations in 1924—these efforts were more symbolic than substantive. It was Uruguay—with its well-developed welfare state, close links to the IIPI, anxiety about babe mortality, and international profile—that offered an implementable model of children's rights in a particular national setting. Through the IIPI, the PASB, the LNHO, and other networks, Uruguay'southward experience became widely known and discussed, particularly as its infant mortality rates finally began to improve in the belatedly 1930s. Countries with active social medicine movements, such every bit tardily-1930s Republic of chile under the leadership of Minister of Health Salvador Allende,86 built upon and strengthened Uruguay's efforts. The IIPI and PASB jointly issued the Pan American Children'south Lawmaking in 1948, and in 1989 the Un Full general Associates adopted the Convention on the Rights of the Kid, both of which drew extensively on the Uruguayan code.
Uruguay'southward Children'southward Code was the effort of decades of activism on the role of several generations of Uruguayan public health and social welfare advocates whose domestic work enjoyed international recognition. It was the interaction between Uruguay'due south international leadership and the protectionist Batllista state that, despite its flaws and boring pace, provided a laboratory of legislation and practice in the area of children'south well-being.
CONCLUSIONS
Equally this exam of the founding and activities of the IIPI demonstrates, the institutional panorama of international health included more the "usual suspects" among metropolitan organizations. With existing agencies in identify in the United States and Europe, Uruguay did not seem a propitious locale for a new international health part. But the country used its strengths—a stable welfare state, well-placed professionals, leadership in child wellness—and its weaknesses—small-scale size, remoteness, persistent baby mortality problems—to secure a place on the globe stage. A key additional ingredient for establishing the IIPI in Uruguay was the legitimacy provided by the land'southward ties to another international agency—the League of Nations. In obtaining the League'due south support, the cosmopolitan physicians who anchored Uruguay's international engagement in public health benefited from the essential legwork of the "maternalist feminists" who had launched the Pan American Child Congresses.
It might exist suggested that Uruguay was able to carve out a niche in international health that was of little moment to the larger customs. Merely given the LNHO's early interest in the IIPI, the all-encompassing worldwide concern with maternal and child wellness that was manifested during this menstruation,19 and the international attention that was later paid to children'southward health through such organizations equally UNICEF,87 this thesis holds lilliputian water. Still, in 1927 children did not top the list of concerns of the PASB, which would have been the IIPI'south logical patron. With several PASB conferences in the 1920s (including the 1920 Montevideo meeting), in that location was aplenty opportunity for sponsorship. Merely the PASB spent its first decades focused on the interruption of commerce caused by epidemic diseases, even equally the delegates to its conferences requested attention to other wellness priorities.88 Making faraway Montevideo into "the Geneva of S America" does not seem to accept irked PASB Director Cumming: the PASB was officially supportive of the IIPI,89 though Cumming failed to mention the IIPI in several fundamental overviews of health cooperation that he published.90
Once the IIPI was established, maternal and kid wellness took on a higher contour at the PASB, particularly in its Boletín de la Oficina Sanitaria Panamericana. Child well-being finally reached the PASB's calendar at its ninth conference, held in Buenos Aires (together with the Latin American Eugenics and Homiculture Congress) ("Homiculture" is a Cuban-coined term expanding Pinard'south concept of puericulture to include cultivation of the child from prebirth to adulthood.) in 1934, shortly after the passage of Uruguay'southward Children'southward Code. The PASB supported the position articulated past the IIPI's Berro, which fostered "positive" eugenics as embracing a "broad, non-coercive public wellness and social welfare approach directed toward the child" in contrast to the United States'southward focus on heredity and sterilization.91 Given the IIPI's activities and its very being—bolstered past the advancement of several member countries—the PASB could no longer overlook maternal and child wellness.
The IIPI's modus operandi differed significantly from that of other international health agencies. Rather than evolving into a regional outpost of the LNHO or the PASB, it maintained cordial relations gratuitous of "parental" constraints. Attributable to the combination of fortunate timing, Uruguayan authorities back up, and the regional backing of kid health Pan-Americanists, the IIPI remained unencumbered past imperial or industrial interests. It drew its agenda from the concerns of health experts, feminists, and child advocates grounded in local bug in settings where child health policies were intertwined with burgeoning protectionism. The "Uruguay circular" of international health suggests that the field is shaped by more than center–periphery logic.
Acknowledgments
Partial funding for the writing of this newspaper was provided past the Global Health Trust'due south Articulation Learning Initiative on Human Resource for Wellness and Development and the Canada Research Chairs program. The initial inquiry was funded past the National Institute on Aging (grant 16813-01) and the National Institutes of Health, National Institute on Child Wellness and Human Development (grant 37962-02).
I am grateful to Gregory Kim for carrying out the analysis of the Boletín of the IIPI. My thanks to Sandra Burgues, Fernando Mañé Garzón, Raquel Pollero, Wanda Cabella, and Nikolai Krementsov for their helpful comments and suggestions, likewise as to the "Public Health And then and At present" editors and the anonymous reviewers.
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