1 Introduction

The introduction of discrete public health policies was accomplished in Latin America by a range of different actors who gained importance in the late nineteenth and early twentieth centuries. Amongst them were workers’ unions, the women’s movement, and medical professionals, in particular. This case study on Chile and Uruguay puts the latter at the centre of attention. It analyses how medical professionals from two countries that were pioneers in public health used transnational venues to exchange concepts and ideas on public health policies and sought to strengthen their domestic political position. The Latin American Medical Congresses are highly important as venues which enabled doctors to address, among others, questions of power and resources while they also highlighted their monopoly on questions of health and disease prevention. Furthermore, the Latin American Medical Congresses also served to legitimise a new and highly ambitious epistemic community which sought to validate its activities. At the same time, these congresses offered the various national communities of doctors the opportunity to show their skills and the superiority of their training. This chapter therefore focusses on four Latin American Medical Congresses that took place between 1901 and 1909. These were important forums for the exchange of medical knowledge and ideas during the early twentieth century that have largely been ignored by historical research (de Almeida 2006) and political science. The congresses show how two mechanisms—legitimisation and competitive cooperation—were at play in a process that positioned the medical profession at the centre of state policies in health and served to cement its leadership in a new field of state action.

The analysis of the two mechanisms, their interplay and dynamics also draws attention to the timing of the congresses. These took place at a very remarkable time in Latin American history because back then, none of the countries had yet established any social security system. The medical profession was still young, and at an early stage of professionalisation, and it was breaking ground in a new field which was still in the making: public health. Thus, this period offered these historical actors a unique window of opportunity for the transnational debate on health and social policy introduction. The fact that the Latin American nations had begun to consolidate since the second half of the nineteenth century only adds importance to the congresses. The new republics had just left behind violent conflicts over independence and were undergoing an unprecedented transformation whose results were difficult to predict (Sábato 2018); yet, by the last quarter of the nineteenth century, it was clear that the independent Latin American nations were ready to embark on a new phase of their existence that would redefine their relationship with each other. The congresses were only one manifestation of this change.

The timing of the congresses is also relevant in a further respect. During the first decades of the twentieth century, nation states in the Americas increasingly perceived the health of their citizens to be endangered by endemic and epidemic diseases. This, in turn, increased the attention they paid to hygiene and disease prevention. Particularly the latter demanded more cooperation among Latin American countries as epidemics did not stop at national borders at a time when trade and migration were increasing. Historians of public health in Latin America have furthermore highlighted that this was when “cooperation, including in the sanitary realm, became a genuine possibility” (Birn et al. 2017, 20). Thus, the congresses highlight the existence of an “inter-state collaboration in South America” which resonates with current Latin American debates on how to control the COVID-19 pandemic and how to act together (Birn 2020, 357).

The willingness to cooperate and discuss the future of public health and the medical profession had certainly made the Latin American Medical Congresses possible in the first place, but this cooperation also went hand in hand with competition. And this competition was twofold: it referred to the Latin American countries that sent delegations as well as to Europe, the example medical doctors sought first to emulate and then to surpass. European doctors and Latin American doctors who had been trained overseas were excluded from the congresses; nevertheless, Europe was ever present at these events: it provided the medical profession in the Americas with a model, it provided a road-map to professionalisation and set the standards for public health development as well as for social security systems. While the latter were not debated at the Latin American Medical Congresses, the state of European medical science and public health inevitably were. In sum, the Latin American Medical Congresses provided an ideal space for competitive cooperation and for legitimisation. To analyse it, this chapter focuses on two countries that were not only Latin American pioneers in the field of public health, but also pace setters at these congresses: Chile and Uruguay.

In both countries, the early professionalisation of medical doctors had contributed to the formation of an important epistemic community whose relevance to the development of public health is part of the history of the medical congresses studied here. The congresses also fostered the careers of individual doctors who presented important papers at these events and commended themselves to their respective national states as advisors and partners in public health development. While the medical profession was an important driving force behind national public health policies, it also was an interested party in the process of policy development. In this way, the path towards public health legislation evidences “the close alliance of medical and state interests” that historian Julia Rodríguez has observed for Argentina (Rodríguez 2006, 40).

This alliance is particularly valid for the cases of Chile and Uruguay, which also confirm that while in Latin America medicine and public health were “(…) acutely political, (…) even their most nationalist expressions were internationalist and cosmopolitan in origin, orientation, and networks” (Cueto and Palmer 2015, 59). The Latin American Medical Congresses thus call attention to the transnational dimension of national health policies and underscore the interlinkage between “nationalism and internationalism” of health that political scientist Evelyn Huber identified (Huber 2006, 458).

Chilean and Uruguayan doctors were very aware of this interlinkage. They shared an interest in changing national public health policies and at the same time pushed for public health agendas for all of Latin America. Overall, both nations performed well at the Latin American Medical Congresses; however, the dynamics and rhythm of public health policy implementation varied significantly in the two countries. Even more, although Chile and Uruguay regularly sent large delegations to the Latin American Medical Congresses and, in turn, hosted one of the events, these events meant different things for the respective epistemic community. While Chilean doctors were intent on fostering cooperation within the Southern Cone and competing with respect to medical progress in the region, Uruguayans took special pride in challenging Europe’s leading role, claiming to be on a par or even outrivalling it. Thus, the congresses were about bringing the leading Latin American physicians together, while they also were about putting Europe and its achievements into perspective.

This chapter will trace the mechanism of competitive cooperation and the mechanism of legitimisation that can explain the activities of physicians who successfully lobbied for increased state involvement in public health. Taken together, both complex causal mechanisms explain the dynamics and the impact of the events on public health ideas. Particularly, the competitive cooperation mechanism highlights the importance of transnational factors for understanding national social policy developments that are increasingly gaining importance among social policy researchers (Leisering 2019).

By drawing attention to both complex causal mechanisms, this analysis furthermore hopes to understand the limitations of the community’s “authoritative claim”, analysing both the potential and the limitations of epistemic communities at the time. In this way, this chapter accounts for the success as well as for the failure of one specific epistemic community to promote and impose discrete policy measures within the national context.

The empirical research is based on the close reading and analysis of proceedings of the first four Latin American Medical Congresses which took place between 1901 and 1909. Their proceedings fill various volumes, and this material is complemented with other contemporary publications in the field such as books on public health and its implications for state action, personal memoirs, and medical journals.

This chapter starts with a recapitulation of the concept of an epistemic community, a first examination of the two complex causal mechanisms, and an overview of the congresses which then will be followed by two case studies, starting with Chile which initiated and hosted the first congress in 1901. The importance of this congress lies not only in the topics it covered but also in that it became the model for all future congresses. While it was deemed a huge triumph, which added to national prestige, unlike other members of the epistemic community, Chilean doctors frequently failed at imposing their policy preferences. Chilean physicians had succeeded in legitimising themselves through transnational events, but at the beginning of the twentieth century they still did not wield enough power to change national social policies or establish a ministry of health. This is the more revealing as this level of institutionalisation was then one of the main goals of the profession in Chile. When the Ministerio de Higiene, Asistencia y Previsión Social was eventually founded in 1924, its first minister was one of the doctors who had been involved with the Latin American Medical Congresses, as we shall see. Nevertheless, the Chilean experience differed significantly from the Uruguayan.

The second case study analyses Uruguay at the first four congresses through a specific group of medical doctors, focusing in particular on public health expert and renown medical doctor José Scosería. This case study also assesses interlinkages between these international events and national public health debates about the foundation of a new central institution, the Asistencia Pública Nacional (1910). In 1932, that is 11 years after the last congress had taken place, it finally merged into the Uruguayan Ministry of Health. A conclusion sums up the findings with regard to the two complex causal mechanisms and assesses the differences between the two cases with regard to the political use they could make of these events.

2 The Epistemic Community of Medical Doctors and the Mechanisms of Competitive Cooperation and Legitimisation at the Latin American Medical Congresses, 1901–1909

We conceptualise the role of the medical profession in Chile and Uruguay at the time of the medical congresses as a well-established epistemic community. The mechanisms of competitive cooperation and legitimisation can explain how they carved out a position for themselves within the newly established field of public health. With respect to the concept of epistemic community, we follow the definition proposed by political scientist Peter Haas who defined an epistemic community as a “network of professionals with recognized expertise and competence in a particular domain and an authoritative claim to policy-relevant knowledge within that domain” (Haas 1992, 3).

The Latin American Medical Congresses served to expand and strengthen the connections within this network. We argue that crucial aspects of this development can be understood by using a mechanism-based approach to identify specific sequences within these interconnected processes and to explore the potential of comparative analysis (Kuhlmann and Nullmeier 2021). While historical studies have studied the establishment and development of expert networks and their influence on decision- and policymakers in countries such as China (Greenhalgh 2008, 195), recent research in political science has begun to focus on epistemic communities in connection with complex causal mechanisms to understand their influence on decision-makers and the role of policy entrepreneurs (Löblová 2018; Safuta 2021). In this way, it is possible to elucidate the question why some epistemic communities have been more successful than others in bringing about policy change in domestic contexts. Ultimately, by studying smaller sequences, larger processes of influencing policy decisions can be disaggregated to really explain how “knowledge and evidence make its way into policy” (Löblová 2018, 161).

The legitimisation mechanism helps us to understand how the epistemic community of Latin American doctors sought to claim its role and position that in the future would enable it to influence decisions. The competitive cooperation mechanism, on the other hand, asserted their position within transnational and international contexts.

The actors involved were medical doctors who had been trained at one of the new national schools of medicine, and they epitomised the epistemic community which soon enough would encompass nurses and other providers of healthcare. At the time of the Latin American Medical Congresses, these groups were not yet included and thus not invited to the congresses.

The Latin American Medical Congresses were events which brought the epistemic community together, and as they are important for this chapter, some preliminary understanding of the congresses is required. While they were prestigious and important at their time, they have overall met with little scholarly attention. Brazilian historian of science Marta de Almeida is a notable exception, and she has identified and analysed the congresses as important venues for the exchange of knowledge and ideas. The congresses also fostered the professionalisation of medicine and the legitimisation of physicians as political actors (de Almeida 2004, 2006). Others have only been interested in the congresses to trace the rise of competing epidemiological theories (Caponi 2002), to indicate the growing rapprochement between Latin American academic medical communities (González Leandri 2013), and to illustrate how public health development in one country, in this case Argentina, was showcased (Veronelli and Veronelli Correch 2004).

In order to situate the congresses in time and space, it is important to note that during the time of the Latin American Medical Congresses under study here, medical congresses had become more numerous and more important and awareness of the spread of diseases had grown, in particular in Europe (Zylberman 2006). Also, within the contemporary landscape of sanitary and medical congresses, the Latin American Medical Congresses managed to fill a gap. Until then, Latin American physicians and hygienists had mainly met at three different types of venues: international sanitary conferences in South America (1873, 1878, 1888, see Chaves 2013), the Pan-American Medical Congresses that had been inaugurated in the United States in 1893, and the Latin American Scientific Congresses (Bastias Saavedra and Plaza Armijo 2016). The latter had been taking place since 1898 and counted with large medical sections.

The Latin American Medical Congresses, on the other hand, focused exclusively on medicine and health, including sanitary questions related to epidemics, and were meant to be free of influence from the United States. The latter had begun to claim a leading role in matters as diverse as scientific development, medical progress, and public health (García 1981). Envisioned and organised by Chilean doctors, the first Latin American Medical Congress was an important innovation that can also be viewed as a continuation of the international medical congresses that had been taking place in European cities since 1870 with mainly European participants. Following the example of European medical doctors, the Latin American organisers of their continental medical congress aspired not only to showcase the medical state of the art, but also to make themselves heard in matters of public health and hygiene.

The first four Latin American Medical Congresses were hosted exclusively by countries of the Southern Cone: the initial congress took place in Santiago de Chile in 1901, and the following congresses were held in Buenos Aires, Argentina, in 1904, in Montevideo, Uruguay, in 1907, and in Rio de Janeiro, Brazil, in 1909. These events emphasise the pioneering role of these four countries of the Southern Cone which, in many ways, were closely connected to each other and functioned as a “corridor of ideas” (Biagini 2000; Kuhlmann et al. 2020). When the congress reassembled for the fifth time in Lima, Peru, in 1913, this marked an important shift of focus: on the occasion of this event, the Latin American Medical Congress merged with the Pan-American Medical Congress (de Almeida 2006, 741). Finally, the sixth and last Latin American Medical Congress took place in Havana, Cuba, in 1922.

Overall, the Latin American Medical Congresses started off as and can be characterised as events of the Southern Cone: in particular, the first four congresses were dominated by physicians from the region whose large delegations were tirelessly delivering the largest number of papers. As a direct outcome and a mirror of medical professional consolidation, these congresses offered the epistemic community an occasion to celebrate itself. On the occasion of the congresses, the epistemic community of Latin American medical doctors for the first time defined itself by its sites of training and thus legitimised its aspiration to debate and decide public health matters. Chilean medical doctors already had excluded medical doctors who had been trained outside of Latin America in the context of their first national congress in 1889 (see Sect. 3 of this chapter). Also, it is noteworthy that all these congresses were cost intensive and needed the backing of the national governments. The role of the host required a budget for the opening and closing ceremonies, the publication of the conference proceedings and other related costs, which were considerable. The conference proceedings show that these congresses clearly put financial strains on national governments; also, it was expensive to send delegations to the congresses, which is why the conference calls usually asked Latin American governments to help the epistemic community with travel expenses (“Circular enviada” 1902). The fact that these calls were answered, at least in the cases studied here, reinforces the argument of the great importance these events had. It also points to a successful rise of medicine as a profession which could claim public funding for its events.

3 Calling for Cooperation While Excelling in Competition: The Chilean Epistemic Community at the Medical Congress of 1901

3.1 The Historical National Background

At the beginning of the twentieth century, the Republic of Chile was in the midst of preparations for the celebrations on the occasion of its first 100 years of independence from Spain. This was an opportunity to assess national development, and Chilean medical doctors in particular found much to criticise: unlike its hemispheric neighbour Uruguay, Chile was not undertaking broad public health reforms. After independence, the state had mainly invested in education (Mac-Clure 2012). It had been reluctant to intervene in health, yet public health was much debated in the last third of the nineteenth century. Real progress was only made from 1918 onwards and in particular during the 1920s under presidents Alessandri and Ibañez del Campo. Also, the new constitution of 1925 was another important milestone (Rengifo 2017). Welcomed with high hopes for a better future, this normative text for the first time in Chilean history explicitly included health as a field of state intervention which Ibañez del Campo would later define as “not only the absence of illness but (…) the plentifulness of life” (Góngora 1981, 85).Footnote 1 Both politicians left an important mark on the structure of the Chilean national state, as Góngora has rightly pointed out, because they coincided in stressing that it was the state’s responsibility to take care of all the different groups and classes of society, including their health (Góngora 1981, 88). The new and all-encompassing concept of health which, among others, concerned living conditions and the workplace was further expanded until the military coup in 1973 and system change set a new agenda (Cruz-Coke Madrid 1988).

In 1900, however, the Chilean state was still in its formational phase. It had not fully assumed its interventionist, albeit paternalistic role, and social unrest was revealing the contradictions and limitations of modernisation (Rinke 2002), while the “social question” remained unresolved as labour unions and protests were calling into question Chile’s path for economic and social development of Chile. Economic growth served only a few because, in spite of its wealth, Chile had failed to address widespread poverty and social inequality which also impacted public health. In comparison to Uruguay, the Chilean state was lagging behind: while it did institutionalise health and established a ministry of health in 1924, it only implemented the Servicio Nacional de Salud Pública in 1931, long after the Uruguayan Asistencia Pública had been established.

The epistemic community of Chilean medical doctors, however, had come a long way comparatively fast: within three decades, it had shed the image of a dirty and unprofessional field that members of the elite would shy away from (Cruz-Coke Madrid 1995). At the end of the nineteenth and early twentieth centuries, it showed all the “ideal observable manifestations” Olga Löblova calls indispensable (Löblová 2018, 165) to speak of an epistemic community. Chilean physicians counted with a medical society, a scientific journal, and members who were well known within the community and beyond. It also had successfully sought the support of other important groups such as the armed forces; it had promoted discrete policies such as physical education at schools and advocated for vaccination against smallpox which eventually would be implemented by law (González de Reufels 2020). Finally, a new medical school and an innovative national conference whose proceedings were published five years after the event had taken place attested to its success, while it clearly ranked among the leading Latin American nations in medicine and was proud of it (Maira 1893).

Nevertheless, the epistemic community was still in need of legitimisation to be able to consolidate its bureaucratic power. So far, it had aimed at political accommodation of its interests by styling itself as a resource of the state, rendering relevant services as articles in the journal Revista Médica de Chile show. The journal explicitly promoted public health and emphasised that it was meant to be a publication that offered policy-relevant knowledge and data (Schneider 1872). Nevertheless, the political reach of Chilean medical doctors remained limited, which is remarkable at a point in history defined by economic expansion and increased exchanges of people, goods, and disease (Harrison 2012). The epistemic community was not yet able to push through all its propositions for public health, and it had not reached the level of institutionalisation it wanted: a ministry of health was still necessary to turn doctors into members of national government and increase their resources, guaranteeing access to the inner circle of national politics. Chilean doctors felt that they had come far, but not far enough.

When it came to representing the nation at European events, Chilean decision-makers relied on the epistemic community. For example, the government sent off doctors to the Paris exposition of 1889 which certainly was not only a “market of wares of nineteenth-century industrial capitalism” (Rodgers 1998, 8), but also a venue to discuss hygiene and social assistance with European peers and to compete with them. Thus, renown Chilean medical doctors were called upon to impress the Europeans with their achievements and report on the progress of the country to, as one physician wrote, make “us [i.e. Chile] known abroad” (Murillo 1889, VII). Thus, the ability to excel in competition with European experts emphasised the importance of the community that was meant to put Chile on the world map with respect to medical progress, even though at home the epistemic community continued to struggle for legitimisation and access to political power. Like their US counterparts, Chilean physicians had upheld their authority to “define and interpret the standards and the understandings that govern medical work” (Starr 1982, 421), but their calls for new legislation such as a national sanitary code and new agencies would not be heard until 1918 and 1925, respectively (Cruz-Coke Madrid 1995, 412). Also, it took a military coup and a short-term regime change to create the national ministry concerned with hygiene, public assistance, and social provision. It was led by Alejandro del Río Soto-Aguilar, who had been trained as a doctor in Chile, then received a fellowship to spend three years in Europe and returned to Chile to become involved in the medical journal and one of the most influential medical doctors in the country (Cruz-Coke Madrid 1995, 479). He had also been a regular participant at the Latin American Medical Congresses, which emphasises the nexus between the congresses and nascent national health institutions in Chile. The connections between medical doctors and national politics were manifold because as early as the nineteenth century, medical doctors had joined the Chilean National Congress to increase funds and the political influence of the epistemic community (Cruz-Coke Madrid 1988), but health reforms were stalling at the turn of the century because the community’s reach remained limited.

When Chilean doctors began to organise the transnational event in 1900, it was based on the concept of their first national medical congress and drew on this experience. The Latin American event featured opportunities for cooperation within the hemispheric region and promised to compete with leading European venues while also showing off the reach of the epistemic community in Chile itself, which can be explained by the mechanism of competitive cooperation. The mechanism of legitimisation can be identified in the attempts to increase the epistemic community’s leverage on national Chilean politics and to promote public health as the basis of a future healthcare system. Also, by 1900 high infant mortality rates such as Chile’s were considered alarming as they had become synonymous with a lack in modernity and progress in public welfare and hygiene (Chávez Zúñiga 2019). To succeed in public health became even more pressing as population growth was stalling, and cases of highly infectious diseases such as syphilis and tuberculosis soared. They were considered especially dangerous as there was not yet any reliable cure for them, and they damaged the health of future generations.

3.2 Chile at the First Medical Congress in 1901

The first Latin American Medical Congress was held in Santiago de Chile in 1901 to underscore the leading role Chilean medical doctors claimed amongst their hemispheric and European peers. This event did not include any female doctors although in 1886 Eloisa Díaz, the first Chilean female physician, had graduated from the national medical school. Her graduation was especially applauded by the epistemic community and in retrospect highlights its ability to change over time to include new historic actors (Maira 1893). It is important to note that the congress of 1901 set the example of all congresses until 1922, and in this way, the Chilean epistemic community left its mark on a transnational event. This was particularly the case because the event furthermore built directly on the first Chilean medical congress of 1889 that was characterised by contemporaries as the “seed” of the Latin American congress (Pérez Canto 1910). Just like this national congress, the first Latin American Medical Congress excluded medical doctors who had been trained in Europe and only admitted younger and nationally trained medical doctors (Primer Congreso 1901). They represented the future of the epistemic community that could now compete with European peers. Still, the congress followed the blueprint of European medical congresses and copied their organisation, sections, and publications. In spite of this act of copying European events, the mechanism of competitive cooperation explains why the congress expressly excluded “Europeans” (“Bases del congreso” 1901, xiii), as did all the following congresses. This also shows how the mechanism of competitive cooperation is connected to the legitimation mechanism, because the new “national quality” legitimised the claims of the Chilean epistemic community and drew attention to the equally “national quality” of the public health challenges it was addressing.

Also, the Congress of 1901 put the epistemic community and its achievements in medical science and public hygiene on display. Again, this feature of the congress brought Latin American doctors together to learn from each other, as the calls to solidarity and cooperation emphasised which reminds us that cooperation was in fact crucial. The advances in medical science and the enormity of the task that all republics had to take on in public health were at the centre of the first congress of 1901. Also, hygiene loomed large at a special exhibit which was huge and had been organised since 1900 and for which manufacturers and experts had been approached in time (“Crónica” 1900, 439). It was to inform the general public and medical doctors about the state of the art in sanitation and healthcare, thus the Exposición de Higiene and the congress of 1901 functioned as interconnected spaces of policy debate and policy presentation. Furthermore, this was a marketplace for medical equipment, while it also was a forum to display different national social policy measures. Hemispheric neighbour Argentina, for example, asserted its superiority and competitiveness as well as its willingness to cooperate in public health by providing material which, as one visitor would later on write, “illustrated very much the discussion of the problems of health and hygiene which are impressively current amongst us” (“Revista de la exposición de hygiene” 1901, 58), that is the region as a whole. This was a moment to study, copy, or reinvent the measures other nations had implemented which also explains why the Chilean Instituto de Higiene, founded in 1892 (Cruz-Coke Madrid 1995, 414), was part of the Exposición de Higiene. It used this exhibit to display its services and efforts to improve the sanitary conditions of Santiago while skilfully drawing attention to the shortcomings of national hygienic infrastructure: drawings of the sewage systems of the German city of Berlin reminded visitors of the lack of water management in the capital and elsewhere in the country. In this way, the institute’s exhibit also gave ample proof of how important its work was at a time when Santiago obviously was losing the competition with Europe.

But, as stated before, this congress was also about cooperation: the congress of 1901 invited medical doctors to work together on solutions for recurrent health problems in the hemisphere and argued for the establishment of networks of colleagues: acclaimed as an event whose most valuable result was that it had “created enthusiasm for scientific collaboration” (“Crónica” 1901, 128), this event called for “fraternity and union under the banner of science” (“Nuestras felicitaciones” 1901, 7). Both, fraternity and union, would serve to legitimise the epistemic community in its national context, while this also asserted a new identity as a pioneer in the Southern Cone. In spite of this, the papers presented at the congress in 1901 also sought to assess Chile’s progress in comparison to Europe where dentistry, for example, had become a field in its own right and vaccination campaigns were held widely.

In the same vein as this congress, all other Latin American Medical Congresses that were to follow rendered cooperation with the neighbouring republics and competition amongst Latin American nations and with Europe recurrent themes. Still, the congress of 1901 was special in that the largest group present was made up of Chileans who used this event to show off their capacity in front of the Chilean government. Although this was considered an international event that counted with acclaimed Latin American physicians, such as the Argentinian doctor Emilio Coni, the congress largely functioned as a national event that was held for a national audience and served to legitimise the epistemic community. Also, some of the foreign attendants were not medical doctors but diplomats and representatives of the Latin American republics who resided in Santiago and could hardly interfere with the agenda the Chilean epistemic community had set for the congress. Therefore, it is not surprising that the event picked up on national Chilean debates on, for example, alcoholism, tuberculosis, or venereal diseases such as syphilis which had long been identified as endemic and a burden to Chile (Murillo 1869). While these diseases were also discussed in the neighbouring countries, they were considered to be particularly rampant in Chile and especially detrimental to demographic growth (Chávez Zúñiga 2019). Given the absence of so many of their Latin American peers, the Chilean doctors in the end debated many issues largely amongst themselves. Current worries were voiced, for example, about the spread of leprosy, which was debated at a session during the first day of the congress, and there were calls to create common standards in the medical disciplines across all of Latin America (“Congreso Médico Latino-Americano” 1901, 18–19). Infectious diseases claimed special attention as did epidemics whose prevention required cooperation between the states as smallpox and bubonic plague had only recently returned to Argentina (“La peste bubónica” 1900). Now, this was an opportunity to show that Chileans were competent in fighting such an outbreak. After all, the epistemic community was aware that, as the medical journal put it, epidemics did not stop at national borders and measures had to be taken to stop the advent of the plague (“La peste bubónica” 1900). Competitive cooperation among Latin American doctors amplified the efforts and reach of Chilean doctors who hoped to achieve national reform, for example, in the field of child health and wished to see progress in related fields much faster.

Last but not least, the congress of 1901 was a social event which added lustre to the epistemic community and thus legitimised its current position and its claims for increased influence in the near future. Its opening took place at the theatre in Santiago where plays and concerts would usually take place. As the authors of the conference proceedings have pointed out, the event counted with the massive presence of the Chilean government, turning this congress into a political event which enabled physicians to openly ask for political support and funds (“Sesión de apertura” 1901). Furthermore, the debates at this congress included, amongst others, housing problems and the risks of unhealthy living conditions, which were especially evident in Santiago and other large Chilean cities. These debates echoed national debates which Chilean medical doctors had unsuccessfully pushed for some time, such as sanitary and decent housing for the masses. Although it is difficult to pinpoint the development of Chilean legislation to the first Latin American Medical Congress, the Ley de Habitaciones Populares finally was passed in 1906. Equally important was the question of how to advance the treatment of syphilis and tuberculosis, and because the Chilean doctors had lamented the policymakers’ inertia, the resolution of the Latin American Medical Congress on the formation of a Commission on Tuberculosis was very much applauded.

The newly won awareness of the need to take action in the field of health served the interests of the epistemic community. It chose to cooperate within the hemisphere to be up to the competition with Europe and to thus advance its standing. Nevertheless, Chilean doctors only succeeded much later at implementing policy measures debated at the Latin American Medical Congress at the national level because their propositions met with resistance on all levels of the Chilean state. Political actors in the Chilean national congress and the Chilean senate, on the municipal level and within state administrations, were not convinced of innovation in the field of public health (Cruz-Coke Madrid 1995; Laborde Duronea 2002, 40) and thus did not support policy changes. The medical congresses of 1904, 1907, and 1909, in turn, raised important issues such as the establishment of systematic vaccination schemes and specialised hospitals for children that required active political support the Chilean doctors could not yet count on: compulsory smallpox vaccination and vaccination schemes in general would only be achieved in 1918 when the Código Sanitario and the law 3385 were approved. Still, hospitals for children only came into existence in the 1920s. Therefore, when Chile celebrated its first 100 years of nationhood in 1910, Dr. Pérez Canto vented his anger and wrote that all progress made in matters relating to health was due to the initiatives of the professional society and not to the government (Pérez Canto 1910). Although it had successfully performed at the first Latin American Medical Congress and would continue to do so over the next years, the epistemic community of medical doctors in Chile was left to its own devices when it attended the medical congresses studied here.

4 Envisioning Cooperation While Winning the Competition: Uruguayan Policy Entrepreneurs at the Latin American Medical Congresses

4.1 The Historical Background in Uruguay

The Latin American Medical Congresses coincided with a major restructuring and expansion of the public provision of health, sanitation, and hygienic infrastructure in Uruguay. Changes in the public health system were closely related to a broader transformation of the Uruguayan state that was stimulated by the batllistas, a fraction of the liberal Colorado Party that owes its name to two-time president José Batlle y Ordoñez (1903–1907, 1911–1915). A first modernising reform era in the 1880s had seen the establishment of a comprehensive public education system (Hentschke 2016). After decades of civil war, the batllistas sought to radically break with the past to construct a new country from scratch (Caetano 2000, 16). This was enabled by the expansion of state institutions, the creation of state enterprises, and the co-optation of organised workers through labour and social reforms. Here, the key to the expansion of the state was the reconstruction and foundation of public institutions.

In the field of public health, the creation of the umbrella institution Asistencia Pública Nacional in 1910 was the most important and visible embodiment of the “model country” Batlle y Ordoñez aimed to create. The history of this institution was closely linked to the career of physician Dr. José Scosería. Born in 1861, Scosería belonged to an influential generation of Uruguayan medical pioneers and higienistas who had started their careers when “everything was still to be done” (Soiza Larrosa 2010), both within the academic and the political sphere. In many ways, these men were pioneers and convinced of the public relevance of their medical knowledge and succeeded in forming an influential epistemic community. Many physicians within this community gained individual fame both within and outside of Uruguay for their medical expertise, but especially for their role in creating and shaping Uruguay’s public health institution. Among the most prominent figures are Luis Morquio, who conducted research on child mortality and directed infant welfare services, Rafael Schiaffino, who specialised on school hygiene, and Augusto Turenne, an obstetrician who would lead the field of maternal health. José Scosería, on the other hand, did not primarily gain fame for a specific field of medicine or public health, but quickly climbed up from one directing position to the next. As most of his peers, he had studied medicine at the Faculty of Medicine of Uruguay’s public university in Montevideo. Scosería enrolled in 1880, only four years after the faculty’s foundation. From 1898 to 1904 he served as the faculty’s dean, while his public health career started in the Comisión Nacional de Caridad y Beneficiencia in 1903, of which he became the director in 1905. From within this institution, he worked to reform and transform it into the Asistencia Pública Nacional, becoming its first director in 1910. The Asistencia strengthened and centralised state control over public hospitals, orphanages, asylums, and so on and, most importantly, followed through with the secularisation of these institutions. The religious congregations that had been taking care of the sick and dependent since the institutions’ founding in the mid-nineteenth century were expulsed as part of a power struggle between different generations and groups of actors. Here, the secular and liberal batllista physicians that Scosería belonged to, and the more conservative and Catholic practitioners that had dominated the Comisión de Caridad until Scosería became its director in 1905, had been at odds. Although Scosería succeeded in implementing reforms from 1905 onwards, his actions were far from uncontested: heatedly debated in congress and the national public, the congress finally adopted the Ley de Asistencia Pública Nacional on November 7, 1910.

With this background and time frame in mind, this case study argues that the Latin American Medical Congresses from 1901 or rather 1904 to 1909 served as an important forum for exchange and cooperation for the Uruguayan policy entrepreneurs, while they were also a venue to promote, gain support, and legitimise this national reform process. This case study thus traces the mechanisms of competitive cooperation and legitimisation that were driving forces of Uruguayan reform ideas at the congresses. The congresses further point to how the mechanism of legitimisation worked for José Scosería and the medical doctors around him to favourably influence public opinion and politicians in Uruguay. The Uruguayan case furthermore complements the analysis of the two complex causal mechanisms with classical studies on the role of policy entrepreneurs as social policymakers (Heclo 1974). Just like their British and Swedish counterparts, Uruguayan reformers were trained as physicians, but when it came to the field of public health they merely were “talented amateurs” (Heclo 1974, 309).

4.2 Uruguay at the Latin American Medical Congresses, 1901–1909

The first Latin American Medical Congress in 1901 counted with very little Uruguayan presence.Footnote 2 One possible explanation is that Uruguay was to host the Second Latin American Scientific Congress in Montevideo two months later, and its organising committee was mainly made up of physicians with a focus on public health (Segunda Reunión del Congreso Científico Latino-Americano 1901, III).

But from 1904 onwards, the who is who of Uruguayan public health attended the Latin American Medical Congresses, starting with over 100 individual and a dozen institutional participants from Uruguay at the congress in Buenos Aires. A similar number arrived from Brazil and even more from Chile (“Nómina de Miembros Adherentes” 1904, 133–146). By 1904, José Batlle y Ordoñez had just come into office for the first time, and José Scosería had begun to work for the Comisión Nacional de Caridad y Beneficiencia, a position from where he could promote his idea to replace charity with social rights. Thanks to this position, Uruguay’s participation at the Second Medical Congress was already in his hands: he presided over the Uruguayan delegation and was elected as honorary president of the congress and as head of the commission to organise the next congress that was to take place in Montevideo in 1907. The existence of national delegations and preparatory committees within all participating countries underlines the strong role of the nation state in this endeavour to stimulate international and transnational cooperation in the region. In the Uruguayan case, the national committees were instituted and financed by the government. These committees were dominated by public health professionals who elaborated strategies on how to best present national progress that was always framed in a competitive manner. Furthermore, a letter from Scosería, written as president of the preparatory committee to the Uruguayan Minister of the Interior in the context of the congress in Rio in 1909, illustrates his desire to subordinate all the national participants and exhibitors to the committee’s master plan (Scosería and Etchepare 1909). He was thus a policy entrepreneur who not only interacted with all parties involved in the financing and preparation of the congress, but who could also use his official position to exert influence on all Uruguayan participation at the exchange venue according to his own ideas.

The third Latin American Medical Congress in Montevideo in 1907 came at the perfect time for the Uruguayan policy entrepreneurs: as hosts of the congress, they could showcase before an international audience the progress of Uruguay’s public health institutions in general as well as of the commission that Scosería had directed since 1905 in particular. And they intended to channel international praise for that progress to strengthen their position in the national debates about the restructuring of the Comisión de Caridad to the Asistencia Pública Nacional. As at the other congresses, Uruguayans gave several presentations that reflected the joint interests of the transnational epistemic community. Luis Morquio stood out among the Uruguayan speakers with two lengthy presentations on school hygiene and infant mortality. As hosts, the Uruguayan delegation further had the largest number of exhibitors and offered visits to many public health institutions in the capital and its surroundings. The conference proceedings, as always written and edited by the hosts, listed all these excursions, the applause Uruguay had received from its distinguished foreign visitors and some of the speeches delivered (Pou Orfila 1908, 73–87). This is how we know, for example, that the Director of Public Health of the city of Montevideo meant to “show our true aim for progress” when he mentioned that Uruguayan public institutions had started to serve pasteurised milk exclusively from cows that had previously received a vaccination against tuberculosis. According to him, this measure had preceded the recommendations of the International Congress on Tuberculosis in 1905 by nine years (“Discurso del Dr. Enrique Figari, Director de Salubridad” 1908, 80). Obviously, public health achievements could best be emphasised by pointing to a successful competition with Europe, and to enact a measure much earlier than any European counterpart was what could be termed the highest “currency” of progress.

Publications which had been specifically prepared for distribution among the participants also served to showcase the country’s progress. The high-end publication with over 500 pages of text, photographs, and figures about the accomplishments of the Comisión Nacional de Caridad y Beneficiencia Pública up to 1905 (Comisión Nacional de Caridad y Beneficiencia Pública 1907) pursued an additional and more specific goal: although the book had been compiled by the commission’s former president, his successor in office, José Scosería, seized the opportunity to add a preface. In it, he thanked his predecessor for the work and progress of all the institutions under the commission’s umbrella but emphasised that important changes had started under his, Scosería’s, directorship. These changes reflected the “new orientation of the philosophic ideas of the majority of the commission”, and more specifically, the abolition of all religious symbols in the health and charity institutions, and the employment of secular teachers in all institutions for the protection of children (Comisión Nacional de Caridad y Beneficiencia Pública 1907, ix–x). By the time the fourth congress took place in 1909 in Rio de Janeiro, the project to secularise public health in Uruguay had taken further important steps.

In 1908, a commission that drafted the law for the new Asistencia Pública Nacional had started its work under Scosería’s direction, and parliamentary discussion of this proposal was about to begin. According to the report that Scosería together with five other official delegates to the congress in Rio sent to the Interior Minister of Uruguay, their colleagues from the neighbouring countries had praised this legislative project in the making. They reported that Scosería had presented a paper on “The Intervention of the State on Matters of Public Assistance” and that whenever matters of public health and assistance were discussed, the congress attendants had spoken very highly of Uruguay, acknowledging that it was becoming “maybe the first among the American countries” to “incorporate the recognition of the right to assistance to its positive legislation” (Scosería et al. 1909, 456). Here the mechanism of competitive cooperation becomes very visible as the epistemic community referred to an alleged advantage over the neighbouring countries with whom it nevertheless was cooperating to influence policy reforms. In fact, the whole report recollected the praise Uruguay had received on the occasion, summing up its high rank in comparison with other countries: apparently, this was the best approach to present the success of the delegation and their national institutions to the minister. The report also includes explicit references to the national discussions of the drafted law which underscores the importance of the competitive cooperation mechanism: transnational success was cited to favourably influence political and public opinion within Uruguay (Scosería et al. 1909). Similar to these findings, Anne-Emanuelle Birn has argued in her research on Uruguayan child health policies that the “international interchanges” of Uruguayan physician Joaquín de Salterain were “most effective (…) to leverage increased attention and resources at home” (Birn 2006, 41).

In the years to come, Scosería continued to participate in the Latin American Medical Congresses and used his presentations, for instance, to document his country’s progress in the prevention of tuberculosis among children, illustrating the institution’s success with photographs that formed part of the hygiene exhibit in Rio. Furthermore, he pointed out that this was one of only three existing programmes in Latin America, and at the end, the self-praise tied in with a resolution calling all Leagues against Tuberculosis in Latin America to initiate preventive programmes for children focused on “living in fresh air” and the hope that these private leagues would encourage state institutions to follow (Scosería 1909). The resolution was one of many passed at the congress, and it points to how an approach focused on cooperation, in this case the preventive measures against tuberculosis, fostered national policies and was intertwined with the competitive character of the congresses.

When the Latin American Medical Congress met for the fifth time in 1913, the Uruguayan Asistencia Pública Nacional had been founded, and President Batlle y Ordoñez was in the middle of his second term. Thus, the congress in Lima presented the unique opportunity to showcase the success of this new public health institution, which led to the publication of yet another comprehensive book (República Oriental del Uruguay 1913). It is noteworthy that although Uruguayan public health experts participated in international congresses all over the world during the 1910s and 1920s, the two major publications on Uruguayan public health were produced for Latin American Medical Congresses. This points to their particularly high status as venues for exchange, cooperation, and competition both with Europe and within the continent.

5 Conclusion

In the time frame under study here, the new nation states welcomed scientific cooperation and intensified processes of exchange and support within Latin America. Here, public health claimed special interest. While Europe remained the point of reference and centre of medical modernity, it clearly now served as a model to be surpassed. The transnational events of the Latin American Medical Congresses offered ample opportunity for cooperative competition and legitimisation of the epistemic community and their national reform agendas.

The Chilean case underscores that while doctors could claim that medicine was indispensable for societal progress and build impressive careers on this assertion, this claim did not suffice to promote the epistemic community’s preferred public health policies when their introduction to national policy was discussed. Even though Chilean doctors mustered the support of their hemispheric peers at the periodically reoccurring event, the national context and discussions usually neutralised the transnational impulses in the field of public health, which in most of the cases would have an impact only much later. Our analysis of Chilean discussions at the first Latin American Medical Congress in 1901 also points to the Chilean state’s reluctance to intervene in the field of public health and assume full responsibility for the well-being of the citizens on the one hand. On the other hand, this also points to the still limited power on the side of the doctors; the congresses which followed until 1909 reinforce this result as the Chilean governments continued to be sceptical of the doctor’s proposals for public health reform. The Chilean case thus shows that the mechanisms of competitive cooperation and legitimisation certainly worked within the framework of the congresses but were of limited reach. Although transnational venues certainly were important to shape and exchange concepts and ideas, it was the national framework which decided on the translation of these impulses into public health policies. None of the mechanisms studied here ultimately fostered the transmission of these ideas into the realm of social policy decision-making. This would also explain why the corresponding national agencies were not established although the epistemic community demanded them. But, when the Chilean political framework changed, the transnational impulses and the legitimacy gained by the Chilean medical community through transnational competitive cooperation eventually led to policy implementation. Thus, for instance, the Chilean sanitary code of 1918 preceded the Pan-American Sanitary Code of 1924 (Cueto 2007, 63–68). By 1924, that is, two years after the last Latin American Medical Congress, Chile counted with a Ministry of Hygiene and Social Welfare and a Mandatory Workers Insurance Fund which enabled the state to cover illness, disability, old age, and death (Rengifo 2017).

However, the importance of the national framework for the success of an epistemic community and the value of the competitive cooperation mechanism is reinforced by the Uruguayan case study. Here, the receptive national framework served to amplify the efforts of the community to learn and to cooperate, and to compete with cutting-edge policies at transnational venues. National public health policies reflected transnational impulses, while they also served to improve the nation’s international standing and increase its visibility as a leader in public health and in social policy development.

The analysis of the Uruguayan case study further points out that cooperation and competition at transnational events served to strengthen the participants’ position and added to their national standing. The restructuring of the major Uruguayan public health institution was led by the batllista physician José Scosería from 1903 to 1910, the years when he and his colleagues used the Latin American Medical Congress to gain international support for the national reform process. This again stresses the importance of dynamics that lie beyond the nation for national developments, which is why batllista physicians were able to use the support of the epistemic community to strengthen their position in national debates. Also, these physicians did not miss the chance to report the favourable reception of Uruguay’s progress. Here, the competitive cooperation and legitimisation mechanisms worked for the epistemic community and those medical doctors who drove national reforms. They successfully linked the medical congresses to national public health debates.

Still, contrary to Chilean developments, Uruguay would not see the creation of its Ministry of Health until 1933 and of statutory health insurance until four decades later. Interestingly, it was José Scosería of all people who lamented this fact in the 1920s. His career within Uruguay’s public health bureaucracy had continued after his directorship of the Asistencia Pública Nacional, a task he assumed from 1910 to 1917. More than ten years later, he went on to direct the Consejo Nacional de Higiene, a post he held from 1928 to 1931. This state institution was responsible for developing, implementing, and monitoring sanitary and public health jurisdiction in Uruguay and would be merged with the Asistencia Pública Nacional into the Ministry of Health in 1933, a process that Scosería claimed to have initiated (“Discurso del Doctor José Scosería” 1936, 49). In his position as director of the Consejo Nacional de Higiene, he also entered an important international realm of exchange: in 1928, he took on the task to study Uruguay’s social security landscape in order to collaborate with a joint commission on health insurance and public health by the League of Nations’ Health Organization (LNHO) and the International Labour Organization (ILO) (Borowy 2009, 222, 371). We can assume that the mechanism of competitive cooperation was equally important in this context. Scosería prepared a lengthy report on social security in Uruguay, taking a critical stance on the low coverage, fragmented character, and dispersed institutionalisation of social security systems in his home country. He especially lamented the absence of health insurance and tried to push for its introduction. His ideas were well received in Geneva, but this time this reaction did little to promote his agenda at home: public health insurance would only be introduced in Uruguay in 1975 (Soiza Larrosa 2010).