Diseased Relations takes a fresh look at state-building in Latin America, examining the construction of modern Mexico through the lens of public health and disease. In it, Heather McCrea argues that medicine and hygiene constituted ‘a social instrument through which Mexican modernity, nation-building and identity were, in part, forged’ as advances in biological and hygienic sciences interacted with public health agendas, providing ‘policy makers with a powerful tool to penetrate ever more deeply into the private lives of populations’ (p. 4). In Yucatán, public health campaigns took place in the midst of tensions between the centre and periphery, Church and state, and Indians (Mayas) and non-Indians (creoles), which constituted great barriers to successful public health programmes and wider processes of state-building. Nevertheless, key ‘diseased moments’ presented opportunities to develop state-building and modernisation projects, quell rebellion, civilise the population, promote investment and, after 1915, spread revolutionary doctrine.

McCrea shows how Yucatán was an area where ‘the geography of disease was often overlaid by the symbolism of race’ (p. 3). For most of the period, public health issues were articulated within a larger ideology that pitted ‘civilisation’ against ‘barbarism’ in a social context of a small creole elite, a majority rural, indigenous Mayan population and a military situation of ongoing civil war (the Caste War, 1847–1902). The goal to assimilate the Maya thus dovetailed with missions to cleanse, sanitise and regulate daily life. Consequently, writes McCrea, ‘together, the state and the medical community authored the concepts and agenda of a campaign for “civilization” that would give modern medical science the sole authority to define and act on health issues’ (p. 97).

The paradox was that until the very end of the nineteenth century Western medicine was poorly developed, there was wide disagreement over the prevention and cure of disease, and success rates were limited. In this context, as McCrea's work highlights, rather than simply being ‘resistant to modernization’, the Maya selectively incorporated Western cures and practices, yet were reluctant to take up foreign remedies that not only fell outside their epistemological terms of reference but also had little proven efficacy. What perhaps is even more significant is the way in which Mayan cures became incorporated into non-Indian medical practice, particularly in the face of such a devastating disease as cholera, for which Western medicine had little explanation or means of control. The crossover between Mayan and non-Mayan medical understandings and practices that she identifies was lost behind the discourse of civilisation and barbarism and Caste War violence. Thus, as McCrea asserts, the ‘diseased landscape’ discussed in the book ‘provides a series of backdrops for unravelling the history of the Maya and their relationship to the state, the church, landowners, physicians and public health officials’ (p. 6) that goes beyond standard narratives and frames of reference.

One of the highlights of the book is McCrea's analysis of the cholera epidemic of the 1850s, through which she provides insights into the personal and intimate impact of the Mexican Reforma (1856–8), during which time the question of where and how a loved one could be buried emerged as a pivotal issue in the struggle for legitimacy between the Church and the state. At the same time, although the secularising state potentially empowered Mayan religious practices by undermining the monopoly of the Church, its aim to extirpate all traditional and religious epistemologies that were seen as being at odds with ‘modern scientific culture’ meant that Mayan rituals were also targeted. The study of cholera thus provides a novel means with which to understand Church–state conflicts in nineteenth-century Mexico and their relationship to ethnicity and race.

During the modernising ‘order and progress’ of the Porfiriato (1876–1911), the defence of civilisation and modern capitalism morphed together in Caste War campaigns and the expansion of the plantation economy, and were expressed in public health projects that predominantly benefited urban mestizos. The Mayan peasantry, meanwhile, endured rural poverty and perpetual debt servitude on henequen haciendas where disease and epidemics remained rife. The Mexican Revolution also portrayed public health policy as ‘a modernizing force legitimating the state's governance’ (p. 2). However, what differentiated revolutionary governments was their goal of ‘reshap[ing] the landscape of disease prevention in Yucatán by empowering local-level socialist leagues, brigades and residents to take action against disease by targeting insect vectors and disease-causing filth’ (p. 176). Such a grassroots approach found resonance with the Rockefeller Foundation, which helps to explain the success of its disease eradication programme in Yucatán between 1919 and 1924, despite apparent ideological differences with the revolutionary socialism of the regime. Consequently, the book indicates clear differences in public health policy – and therefore state-building – between the Porfiriato and the revolution, and reveals complementarity between the goals of revolutionary governments and ‘agents of US imperialism’ such as the Rockefeller Foundation.

Turning to some of the book's weaknesses, although the author emphasises the importance of elite infighting in compromising the ability of the state to deliver health care in the mid-nineteenth century, the book expresses confusion about the factions involved: in the introduction we are told that liberal centralists from Campeche opposed conservative federalists from Mérida (p. 8); in chapter 1 the campechanos are liberal and federal and Mérida was more centralist (p. 25).

Perhaps more serious is the split between the book's excellent and innovatory research, and an analysis in which ‘the state’ is sometimes conceived of as quasi-totalitarian, ahistorical and dialectically opposed to ‘civil society’. For example, McCrea shows that even during the modernisation of the Porfirian era, the state's reach remained limited – public health campaigns were not permitted within the jurisdiction of private haciendas and had little impact outside predominantly mestizo urban areas, and in the cities the implementation of public health codes was sporadic, confusing, arbitrary and corrupt. Indeed, it was only when the state became more ‘democratic’ during the revolutionary era that public health campaigns – and the state's own reach and legitimacy – really began to extend into the countryside. In a similar vein, burial practices, brothels, taverns, churches and graveyards are all classified as part of a ‘private sphere’ belonging to civil society into which the state seeks to extend its power. Yet these areas were hardly ‘private’: they were governed instead by the rules of the Church, Indian communities and the colonial administration that the liberal state wished to supplant. Related to this overarching division between the state and civil society, the author identifies the emergence of citizens by the 1880s who considered public health to be a right. By favouring henequen elites, we are told, the state generated discontent amongst citizens, fuelling unrest against the regime. However, such ‘citizens’ were a minority of literate urban dwellers that largely identified with the goals of the modernising regime and its discourse of civilisation. They were thus divided in terms of class and culture from the rural Maya majority, whom they probably did not recognise as ‘citizens’ at all. Furthermore, neither literate ‘citizens’ who complained about public health nor the Maya proved to be particularly revolutionary, for when the revolution came, it came ‘from without’ in 1915 in the shape of the Northern Constitutionalist army.