Nicole Trujillo-Pagán, Modern Colonization by Medical Intervention: U.S. Medicine in Puerto Rico. Leiden: Brill, 2013. ix + 250 pp. (Cloth US$141.00)

In this study Nicole Trujillo-Pagán twines the U.S. intervention in Puerto Rico with the promotion of scientific medicine. She shows how public health was used to conciliate the socioeconomic transformations caused by the new colonizer. The Rockefeller Foundation, the largest public health organization in the world at the end of the nineteenth century, played a major role in this public health offensive. The Foundation had started its activities in public health care in the south of the United States but, encouraged by the results and convinced of the superiority of its methods, decided to promote public sanitation and health care as well as the knowledge of scientific medicine on a global scale. One of its main targets was the control or even elimination of hookworm because it was simple to identify and inexpensive and easy to cure. The role of the Rockefeller Foundation in the Caribbean and Latin America is pretty well documented, but not surprisingly Puerto Rico is a slightly distinctive case.

The focus was on hookworm as a means to reduce mortality: “U.S. colonial administrators used the threatening specter of the death of peons as a metaphor to reject the Spanish colonial legacy and bolster their own authority” (p. 213). Tellingly, in the early stages the campaign was led by two military officers. In some contrast to later campaigns elsewhere, the mission privileged medical treatment over sanitation as one of the early leaders, Bailey K. Ashford, “did not believe sanitation campaigns could eradicate hookworm and he was particularly concerned regulations could compromise the campaign’s ability to cultivate favorable public opinion” (p. 21). Important in the nexus between colonialism and health care was the claim that the cure of anemia (linked to hookworm) justified colonization and the human and economic cost of the Spanish-American War. Ashford identified anemia as the source of the island’s economic problems as it made the workers and peasants weak and lazy. According to Trujillo-Pagán, the “Puerto Rican hookworm campaign became critical to legitimizing U.S. colonial control” (p. 67). She also claims that this campaign was “unique in its emphasis on regenerating Puerto Ricans’ vitality and modernizing public health” (p. 100). Unfortunately, here and elsewhere in this monograph she gives little or no information on campaigns in other parts of the region (or the Philippines for that matter), making it difficult to substantiate this claim or, more generally, to see the Puerto Rican case from a more comparative perspective.

A second, related subject is the position of Puerto Rican physicians. U.S. neo-colonialism created a particular context that informed the nature of the relations between the State and physicians. Many of the island’s physicians, like their counterparts elsewhere in the region, were committed to social reform through improving public health (and thus labor productivity). They saw themselves as part of a European and Latin American professional community; to them, the development of medical science in Puerto Rico was not a justification of the U.S. presence but represented a way to escape the limitations of presumed racial inferiority and participate in the international development of tropical medicine. Yet these criollo doctors were not able to establish themselves as a professional entity distinct from unregulated medical practitioners. Consequently, they were absorbed by the American Medical Association.

Trujillo-Pagán links modernity, the new U.S. presence, and Caribbean nationalism in this stimulating case study of the politics of medical intervention. Her narrative line is sometimes not as succinct and clear as one would wish, which results in many repetitions. That leaves no room for her to discuss the reactions of the jibaros or traditional medical practitioners, except to briefly state that the “many attempts to reform Puerto Rican bodies failed. The reasons for their failure, however, were not ignorance, irrational choices, or a lack of consciousness, but rather, an alternate or competing knowledge” (pp. 220–21). Here I would like to have had more evidence, including her sources, and analysis, for example of the role of religion in this resistance to modern, compulsory medical treatment.

Modern Colonization by Medical Intervention highlights the porous borders between state and private actors in the enterprise of empire branding. The book’s cover, the cartoon “La Fiebre de Ahora” by Mario Brau Zuzuárregui from 1915, clearly ties medical intervention to political intervention. The drawing shows the pioneer Ashford in relation to “enfermedades tropicales” in front of a box labeled “fiebre de independencia.” He holds a worm, indicating that to him the hookworm campaign is associated with the fever of independence. Spot on!