A Spanish edition of this masterly and thought-provoking book was deservedly awarded the Premio Iberoamericano by the Latin American Studies Association in 1998. The publisher is to be congratulated for making this excellent translation available to the English-speaking world. Although ostensibly about epidemics, it has much to say about the development of public healthcare systems in developing nations in general and the way in which they are moulded by economic, political, and ideological forces. The book comprises five main chapters, each of which focuses on an epidemic. The five epidemics considered are: the outbreak of bubonic plague in 1903; the yellow fever epidemic in 1919-22; typhus and smallpox outbreaks in the Andes in the 1930s; malaria epidemics and eradication in the 1930s and 1940s; and the cholera epidemic in 1991. For each of the epidemics, the author looks briefly at its biological and ecological causes, but the greater part of the analysis examines its impact and the health measures taken to control it, whether by the state, individual practitioners, or the popular sectors, who were often the worst affected. The analysis is based on extensive use of Peruvian national and local archives, the Rockefeller Foundation Archives in New York, and also inter-views. Although each epidemic is discussed in a separate chapter, since they are arranged chronologically, a clear picture emerges both of the evolution of public health care in the twentieth century and of the broad changes occurring in the Peruvian economy and society. Hence it reveals the significance of the role of indigenismo, a regional and ethnic movement in the 1930s, in promoting community health care, and of modernization in fostering technocratic solutions to health problems. However, in drawing out broad themes, Cueto does not overlook the role of individuals. In particular, he examines the roles of Manuel Nimez Butron in organizing sanitary brigades, known as rijcharys, which aimed to stimulate local communities to look after their own health, incorporating rather than rejecting traditional healers; and of the govemment-hired North American, Dr Henry Hanson, whose technical solution for the control of yellow fever and plague resulted in the demolition of a significant part of the town of Paita. Responses to these epidemic episodes varied. In common with historic epidemics Cueto stresses how there was still a propensity to blame the victim. Very often the victims were the poor who lived in overcrowded and unsanitary conditions that favoured the spread of disease. The poor often belonged to a distinct ethnic group. Hence the Chinese were blamed for the spread of bubonic plague in 1903, a prejudice that resurfaced with the cholera epidemic of 1991 when a Chinese freighter that discharged effluent off the coast was held responsible. In the early twentieth century, epidemics often heightened ethnic differences between the coast, highlands, and forested lowlands, since they were often confined to specific geographical regions. The study also shows how responses to outbreaks frequently exacerbated conditions for the poor, who were often the victims of technical solutions or increased social control, or, as in the case of the cholera outbreak of 1991, were neglected by the state on the grounds that the solution lay in changes to personal hygiene. Overall, specific responses at different times are shown to reflect economic and political priorities, not only in Peru but also in the USA. Although responses to epidemic crises might vary, the study shows how, during the twentieth century, public health in Peru came to depend less on charitable institutions and came increasingly to be recognized as a function of the state. Although advances in health care were made during this period, it reveals the continuing strong relationship between poverty and disease and argues that further advances will only be made through attention to preventive and essential primary health care, based on a productive dialogue between modem and traditional medicine. It is one more reminder that epidemics are not yet a thing of the past. It is impossible in this review to summarize all the themes running through this book, despite its short length. It is exceptionally rich in detail and wide-ranging in its analysis and conclusions. It not only makes a significant contribution to our knowledge of epidemics and public health, but also encapsulates the history of Peru in the twentieth century, revealing the economic, political, and ethnic cleavages that have such fundamental implications for the health of ordinary people. By demonstrating that the history of medicine can only be understood in its social context, it is a most worthy and valuable addition to the series.
