La ciudad impura, a volume that originated in a revised version of the author's doctoral dissertation, is a fine example of the renewal that studies on health, diseases and medicine have undergone in Latin America in recent years. Using the history of tuberculosis as a master narrative, the volume introduces the reader into different dimensions of the cultural, social and political history of the city of Buenos Aires during a period of 80 years. Within this period, according to Armus, tuberculosis became a metaphor for doctors, urban planners and politicians to talk about many other things, such as the place of immigrants in society, morality, the discipline of bodies, childhood, womanhood, utopian urban models, and the role of doctors. Thus, each chapter is organised like a mosaic discussing these specific topics. The diversity of the subjects discussed shows the author's impressive familiarity with a wide variety of sources including literature, tango, popular and medical publications, interviews with former patients (not with doctors, however), and works on urban planning, that he aptly turns into historical evidence. The volume stands therefore – and this is one of its most important merits – at the crossroads of intellectual, social, political and professional history.
The mosaic-type structure of the book has important strengths but also some weaknesses. On the one hand, it allows for the introduction of different viewpoints to the problem. Like the society he describes, Armus also uses tuberculosis to talk about different things. On the other hand, this fragmentation generates some tensions that are not resolved within the text and that are associated with the specific approaches used in the different chapters. In some parts of the book, for instance, the author highlights the dimension of social control implied in some of the policies and treatment against tuberculosis. Thus, we read: ‘En las instituciones manejadas por la medicina diplomada, el tuberculoso devenía en paciente y, como tal, comenzaba a circular en una zona donde el médico pretendía controlarlo todo. Se iba prefigurando así una relación desigual donde el lugar subordinado del tuberculoso era indudable’ (p. 363). However, in several other parts of the book Armus shows that the control that doctors supposedly exercised over patients was more wishful thinking than reality, since doctors had, in fact, little more than hope to offer to patients until the diffusion of antibiotics in the 1950s. Doctors had to compete for the loyalty and obedience of patients, sometimes at a disadvantage with quacks, healers, and heterodox medicine.
Although Armus is well aware of the differences between discourse and actual action, there is sometimes an overemphasis on the former, which is probably due to the limitations of the sources available. However, and precisely because they shift the focus from discourse to facts, I found the last two chapters particularly successful and original. Chapter Eight shows the limits to the process of professionalisation of medicine during the era covered by the volume, when there were few changes in the therapies available which themselves had very little to offer. Although other authors have tackled this topic, Armus' discussion, full of examples and new evidence, is particularly enlightening. Chapter Nine, on the other hand, focuses on the tensions between adaptation and resistance in the behaviour of patients with tuberculosis being treated in hospitals and sanatoriums. Resistance was associated with issues such as food, discipline or the provision of certain medications. Armus ably shows in this and in the previous chapter, however, that in many cases what patients did was not to resist, but simply not to play by the rules of the medicalised society, using other (and sometimes more efficient) ways of treatment such as self-medication, or consultation with healers of different kinds.
The scope of the book is massive and it is perhaps unfair to ask the author to cover even more topics than he already did. However, the readers would have certainly benefited from a deeper insight into issues such as the actual organisation of hospitals, what other actors such as the Catholic Church had to say (if anything) about tuberculosis, the impact of antibiotics on the perception of the disease, and a discussion of the changes introduced by Perón and his active Secretary and later Minister of Public Health Ramón Carrillo in the treatment and public perception of tuberculosis until 1950. Moreover, Armus' insistence on the continuities throughout this long period (in my opinion, one of his most important hypotheses) sometimes overlooks important changes that took place on specific but important issues, particularly in relation to the role of the state in the regulation of medicine and disease, considering the fundamental changes that the state underwent between 1870 and 1950.
As Armus makes clear in the introduction, he eschews a comparative perspective. The discussion is centred on, and limited to, Buenos Aires. Although no reader has the right to take to task an author for not doing what s/he says s/he has no intention of doing, this lack of comparative perspective becomes a limitation. Some kind of discussion about how tuberculosis was dealt with in other Latin American cities would have considerably enriched the volume, showing what was specifically porteño about the policies and discourses about tuberculosis analysed in the book. Similarly, a more thorough discussion of the channels through which these ideas were received and circulated would have also provided a better insight into the mechanisms by which discourses and policies were produced. Finally, the profusion of examples gives some chapters in particular and the book in general a tone that is more descriptive than analytical. This latter dimension of the volume also suffers from the lack of a general concluding chapter.
Overall, La ciudad impura is a very good piece of scholarship that will surely appeal to a broad public. It is to be hoped that an English translation will be available soon.
