Colonial Roots of Global Health

Lessons learned for modern humanitarian health

Paul Farmer, Peter Drobac, and Zoe Agoos

A piece in the Washington Post last September observed that “For a Global Generation, Public Health Is a Hot Field.”[i] The generation in question was, of course, that of the primary readership of this journal. In the words of one American pollster, yours is the generation appositely termed the “First Global.” But even if this trend is new—and it seems to us that its scope is unprecedented—the collection of problems classed under the rubric of global health is not new, although there are many new twists (such as acquired resistance to antimicrobials, which could not have occurred prior to their invention and widespread use). The basic lineaments of the debates are not new, either, nor are efforts to affect the health of populations far from home. The issues facing those interested in global health are old ones; many of the institutions confronting these challenges are mature bureaucracies. Even the identification of ranking challenges—what historians of science have called “problem choice”—is constrained by social forces with roots in the 19^th century and before.

Although we are not historians, we have been trained to recognize the importance of history in any serious exploration of contemporary health problems. To understand the trajectories of the intended and unintended consequences sparked by global health interventions, we have three goals in this essay: to trace, in however cursory a manner, the historical roots of global health; to reveal key continuities and also ruptures with the past; and to interrogate some of the work we do, by drawing on history and social theory to explore the limitations of humanitarian models of global health.

1. Vignettes from the Nineteenth Century

It’s hard to know when to start the clock ticking on modern public health, because every innovation—from quarantine to modern sewers to the stains that helped make modern microbiology possible—can be said to stem from previous ones. Instead, let us engage in a different and less obvious exercise: linking together an exploration of the roots of international health with one that looks at the way in which subjects (under others’ authority without autonomy), if they are lucky enough, become citizens (with rights and responsibilities to the state). When Foucault writes of “biopower,”[ii] he illuminates our understanding of modern obsessions with the body as subject and citizen, showing us how knowledge-power (of medicine and of public health) transforms human life through mechanisms of control at the level of both the individual and population. Paul Rabinow’s term “biosociality”[iii] casts light on the links between biology and identity—for example, the redefinitions of self and social identity spurred by new genetic testing capabilities (hence his book French DNA[iv]). Adriana Petryna uses the term “biocitizenship”[v] to look at ways in which access to medical care and other limited social goods mediates the relationship of citizens to the state.[vi] It is this notion of biocitizenship that we wish to interrogate in the context of global health, colonial medicine, and history.

Whether we look in the past or the present, we’ll see continuities. Thus is today’s “global health” the vigorous child of international health, which was itself begat by colonial enterprises large and small. Although historians of public health will reach back to maritime trade and efforts, usually fruitless, to contain plagues,[vii] colonial aspirations were often the crucible of transregional efforts to improve health in order to reach other, usually extractive, goals. For some, the global era was unleashed not in the 20^th century but rather at the close of the 15^th: how else to understand efforts to protect property, including human property, in Europe’s first New World colonies?

Slaves, citizens, and notions of rights

We will speak of the French colony of Saint-Domingue, with which we have some familiarity and what would prove to be the most productive slave colony in the world. Haiti, as it’s now called, is a very important example of how subjects—not yet citizens—came to be regarded as investments. That is the key to international health in this era: understanding that international and public health were being advanced through, and because of, commercial interests.

So let us return to Haiti, and to slaves. Haiti became the leading port of call for slavers in the 19^th century, with up to 29,000 slaves brought in each year shortly before the French Revolution in 1789. And as we all know, slaves were considered even less than subjects: they were property, investments. By 1788, when the burgeoning French Revolution led to the writing of France’s Declaration of the Rights of Man and the Citizen, the notion of rights was of widespread currency. But were these rights natural and universal? Or did they have to be conferred? The original Declaration, which underlined popular sovereignty as opposed to the divine right of kings, asserted that: “Men are born and remain free and equal in rights. Social distinctions may be founded only upon the general good.”[viii] This was of course a swipe at the special rights of the nobility and clergy, but no mention was made of women or of slaves, and it was of course slavery that interested the grand majority of the Haiti’s inhabitants.

The short version: when in the late 19^th century the mulatto freedmen Jean-Baptiste Chavannes and Vincente Ogé traveled from Haiti to France to press for rights in Haiti, they went to press for the rights of mulattos to own slaves. Thus the distinction between human (or natural) rights—those rights inalienably endowed by being human (who is human?)—and citizens’ rights—those rights acquired through citizenship and sovereignty (who are citizens?)—took on a special meaning in Haiti and in the slave-owning swathes of the United States and parts of Latin America.[ix]

Looking back, we could describe these hypocrisies—the French promoting human rights, but not so stridently that their own colonial subjects might be freed to enjoy such rights—as a tension between policy and practice. So it is with many policies, from slavery to Jim Crow to apartheid to Darfur: we tend to look back wondering, How could we have ever cautioned that?

We are not surprised, in retrospect, that the Haitians rejected Napoleon’s subsequent blandishments: it’s clear enough to us (given our access to available documents) that Napoleon planned to re-establish slavery in French holdings in the New World.[x] And so a full decade of revolt and war led to the establishment, in November of 1803, of Latin America’s first republic. But if slaves became citizens first in Haiti, and later in other settings, it did not mean that being nominally a citizen meant that one would enjoy the rights of the citizen as laid out in various declarations by that name.

Germs, poverty, and the birth of public health

But what of plague and other pandemics? Europe had been home not only to regular outbreaks of cholera, but also of smallpox and plague. In some ways, the latter half of the 19^th century was the heyday of public health. Recall the example of John Snow and the Broad Street pump.

By mid-century, there was still no agreement regarding discrepant claims of causality of epidemic disease. Were these caused by miasmas, bad air, or by invisible microbes? In 1854, after investigating a London outbreak of cholera, Snow sought a meeting with the local health authority called, aptly enough, the Board of Governors and Directors of the Poor. The Board’s records show that “Dr. John Snow has respectfully requested an interview with them. He was admitted and presented an account of his investigation so far. As a result the committee issued an order that the handle be removed from the Broad Street pump.”[xi] The pump handle was removed the next day, and the cholera epidemic subsided.

There’s a lot more to this famous story. As a pioneering anesthesiologist and activist, John Snow fought suffering on several levels. On March 5, 1855, for example, Snow walked to a poor neighborhood to administer chloroform so a young man with a “weak constitution” could have teeth extracted. Then on to the Mayfair district, where he chloroformed an old man having dead bone debrided from his leg (imagine having that done without any anesthesia, as had been standard practice). Then Snow crossed the River Thames to help remove a kidney stone.[xii]

That was just in the morning. Later that day, Snow testified before the Houses of Parliament. The English were leaders in the process of gentrification and the city’s grandees were trying to get rid of what they called “the offensive trades.” They weren’t talking about the precursors of Lehman Brothers or AIG, but rather “trades that released foul-smelling, noxious fumes,”[xiii] like bone boilers and tallow melters. In Snow’s biography, we read that the “sanitary reform movement was driven by the medical opinion that poisonous vapors, whether miasmas rising from marshes or from decomposing organic matter near human dwellings, were the main cause of disease, including epidemic cholera, which had killed tens of thousands of people in England since 1831.”[xiv]

Snow regarded the miasma theory as rubbish, and said as much to the select committee seeking to remove the offensive trades. In a famous book, he presented the two studies on cholera that would make him famous to future epidemiologists. One traced the aforementioned link between a virulent Golden Square cholera outbreak and the contaminated water pump at Broad Street; the other analyzed differential mortality rates in London subdistricts against their water sources.[xv]

The select committee was not very friendly to Dr. Snow. He noted, “I have paid a great deal of attention to epidemic diseases, more particularly to cholera, and in fact to the public health in general; and I have arrived at the conclusion with regard to what are called offensive trades, that many of them do not assist in the propagation of epidemic diseases, and that in fact they are not injurious to the public health.”[xvi]

Snow was then questioned by one Sir Benjamin Hall. “Are the Committee to understand,” Hall inquired incredulously, “taking the case of bone-boilers, that no matter how offensive to the sense of smell the effluvia that comes from the bone-boiling establishments may be, yet you consider that it is not prejudicial in any way to the health of the inhabitants of the district?”

“That is my opinion,” Snow replied. The problem, he showed, lay elsewhere.[xvii]

Before the advent of germ theory, when epidemic disease began to be understood to be the result of microbes rather than of “miasmas” or the wrath of a divine being, the chief social responses to such epidemics often included accusations that one or another human group was responsible for propagating the affliction in question.[xviii] Similarly inaccurate and ineffective beliefs abounded when the arrival of European colonists led to catastrophic outbreaks of communicable diseases among indigenous populations in the Americas, and these viewpoints continued to hold sway during subsequent pandemics of cholera. But by the late 19^th century, as public health historian Marcos Cueto observes, many influential public figures were convinced. He notes that, in 1903, “The Paris Conference brought together 21 countries, including the until-then reluctant Great Britain, which held that quarantines generally worked against trade…The Paris Sanitary Conference recommended implementation of John Snow’s discovery about cholera.”[xix]

So how was this reflected in colonial medicine? By the time colonial medicine and public health became important forces in Latin America, Africa, and other locales, the notion of sanitation dominated. But claims of causality of disease in public health were also divided into broad categories of social causation and microbial causation at the start of the 20^th century. The idea that social conditions (including fouled water) generated ill health versus the claims that organisms caused ill health became a central tension in public health during this time.

But it is impossible to move into the 20^th century without mentioning the devastating impact of the Columbian Exchange. To return to Haiti as an example, it is estimated that there were up to 8 million indigenous people living on the island of Hispaniola before the Spanish arrived in 1492. By the 17^th century, not a single one had survived. They died from mistreatment at the hands of Europeans, but also in droves from measles, smallpox, and tuberculosis—a pattern that emerged all over the New World in the following centuries.

This widespread appearance of epidemic disease was the backdrop of 19^th century endeavors, and fear of epidemic disease was inextricably tied to commerce (recall our earlier mention that the interests of trade and profit have long served to direct public health efforts). The notion of quarantine has its origins in the 18^th century and earlier around shipping regulations and mitigating the spread of plagues; the United States’ acquisition of Cuba, Puerto Rico, Guam, and the Philippines through the Treaty of Paris at the end of the Spanish-American War of 1898 and subsequent terror of tropical disease for the troops permanently stationed in the Caribbean was another link between commercial interests and public health concerns.

2. The Panama Canal and the Roots of PAHO

Perhaps the best example of this symbiosis is that of the construction of the Panama Canal and the birth of the Pan American Health Organization (PAHO). Marcos Cueto writes that the “Organization’s creation was the product of the expansion of international commerce, medical advances, and a new political and diplomatic relationship among the countries of the Americas. From this confluence, a new concept of health, not just as an individual aspiration, but also as a right and a duty—a right of the people and a duty and responsibility of the State—was forged.”[xx]

We will return, in closing, to the notion of health as “a right and a duty,” but here it is important to underline, as Cueto does, the role of international commerce as midwife to what would prove the first real international health organization. Linking the Atlantic and Pacific was a 16^th century dream, one that was stalled until the completion of the Panama Railway in 1855. But a railroad was a modest endeavor compared to the one that would allow ships to cross the narrow isthmus separating the seas, as the Suez Canal did when completed in 1869.

But between 1881 and 1889, the period of active French construction of the Panama Canal, more than 21,000 employees died—many of them from yellow fever or malaria.[xxi] The project floundered; epidemic disease had thus far defeated the dream.

One of the chief French players began pressing the United States government to bring the canal to life, hiring a well-known American lawyer, William Nelson Cromwell, as a lobbyist. The United States was considering constructing a canal across Nicaragua, and Cromwell’s job was to convince members of Congress that Nicaragua would be a dangerous place to build such a canal. In one slick play, he had a stamp issued with an image of a long-dormant volcano coming to life and later used it to mail letters to every member of the Senate.[xxii]

In 1902, three days after senators received the stamps,[xxiii] the United States announced its plans to complete the canal in Panama.[xxiv] To be successful, and to complete the project designed to grease the wheels of international commerce, they would have to do what the French had been unable to: find a way to keep their workforce healthy.[xxv]

But epidemic disease is never eradicated by fiat. Something was killing thousands of laborers dispatched to build the canal, and many of their titular bosses, including engineers, were also dying. As noted, there were those who favored miasmas as explanation. But the notion of pathogen and vector was gaining ground. By the end of the 19^th century, as the canal lay stalled, there were advances in medical knowledge. Some, primary among them Dr. Carlos Finlay, began to argue that mosquitoes were the vector for two diseases: malaria and yellow fever.[xxvi] By 1898, Finlay’s colleague, Dr. Walter Reed, working in Cuba during the Spanish-American war, had come to agree. Both doctors, along with many others, turned their attentions to eradicating the mosquito vector and to making the construction area safe for workers.

Shortly after announcing the U.S. initiative to complete the Panama Canal (which they eventually did in 1914), President Theodore Roosevelt convened the First International Sanitary Convention of the American Republics in Washington D.C. in 1902. Perhaps a signal of the rising currency of mosquito vector control, Dr. Finlay was one of four individuals appointed to the convention’s organizing committee. The First Convention focused on diseases’ impact on international trade generally, and discussed quarantine, prevention, and shipping regulations. [xxvii] During the Second International Sanitary Convention in 1905, an American committee member, Dr. H.L.E. Johnson, explicitly acknowledged that U.S. strategic and commercial interests in the Panama Canal project were a driving force behind the new pan-American effort:

I feel sure that as a few months or years pass by the diseases which have stood in the way of the completion of the Panama Canal, which we might term the ideal of the President of the United States to accomplish, will be removed and that the great good to this country which is expected in health, wealth, and prosperity will flow from it…[xxviii]

President Roosevelt himself expressed “the greatest interest and confidence in the work of the sanitarians in the Isthmian Canal Zone.”[xxix] The subsequent International Sanitary Bureau, led by U.S. Surgeon General Walter Wyman, spearheaded the eradication of yellow fever in Panama by 1905. The bureau was later renamed the Pan American Health Organization (PAHO), now the world’s oldest international public health agency.

3. The Legacy of Colonialism

While roughly two-thirds of Latin America had achieved independence by 1900, there was only a single free state in Africa at the turn of the century. Thus the legacy of colonialism, particularly in regards to health and rights, lies especially heavy on that continent. Megan Vaughn’s Curing their Ills explores “colonial power and African illness” in certain parts of Africa, largely British colonies, between the 1890s and 1950 or so. She has “argued that the history of ‘bio-power’ in colonial Africa was rather different from that described by Foucault for Europe. The fundamental difference was that Africans were always conceived of as members of a collectivity as colonial people, and beyond that as members of collectivities in the forms of ‘tribes’ or cultural groups.”[xxx]

Rwanda offers a chilling example of the consequences of this overstate and largely externally-imposed social grouping. The history of the 1994 genocide in Rwanda will be contested terrain for generations, but some conclusions are inescapable: that European notions of race and ethnicity, including those inspired by colonial-era eugenics, helped to harden the pre-colonial social categories of Hutu and Tutsi; that the biased bestowal of colonial-era privileges in a social field of scarcity laid the framework for inter-group violence that began in 1959, at the close of the colonial era; and that control over the state apparatus, and the economic and social privileges associated with proximity to political power, was the chief goal of the government leaders who were the architects of the Rwandan genocide.[xxxi]

Vaughn raises the “question of how far colonial power operated through the production of subjectivities at all, and how far it relied upon the kind of ‘repressive’ power which Foucault sees as characterizing pre-modern regimes.”[xxxii] In other words, Vaughn asks: how does power, and the lack thereof, get into the body and cause disease? In Rwanda, the internalization of disparity and inequity—Foucault’s “subjectivities”—was fostered by the objectification of ethnic division, initially through the faux science of eugenics and later for the political convenience (for the colonizers) of indirect rule by a privileged minority.

Lacking valuable natural resources or strategic position, there was little to extract from Rwanda-Urundi, as the colony was known. The colonial power, Belgium, therefore had no incentive to invest in public health or educational infrastructure. As such, the “fruits” of development were enjoyed by a precious few in Rwanda, mostly belonging to that privileged minority. By independence in 1959, more than three decades after the introduction of ethnic identity cards, inequality among Rwandans was staggering. In the decades to follow, ethnic conflict proved a ready outlet for tensions over persistent social scarcity, such as land pressure, hunger, and poor health.

4. The Modern Era?

Even in the early heyday of vaccine development, no global institutions tackled the health problems of the world’s poor. Colonial powers did address (with varying degrees of effectiveness and sources of motivation) the ranking infectious killers in regions now known as the developing world, but universal standards or even aspirations for international public health and medicine were still far in the future. Although the League of Nations concerned itself with health issues like malaria in the early 20^th century, and although various organs of the nascent United Nations—including the United Nations Development Program (UNDP) and the United Nations Children’s Fund (UNICEF)—also addressed health issues, the World Health Organization (WHO) was the first truly global health institution. Since its founding in 1948, the WHO has witnessed dramatic shifts in population health and in its own stature as the premier global health institution. In line with a long-standing focus on communicable diseases that readily cross administrative and political borders, leaders in global health, under the aegis of the WHO, initiated the effort that led to what some see as the greatest success in international health: the eradication of smallpox.

Historians of the smallpox campaign note the preconditions that made eradication possible: international consensus regarding the potential for success, an effective vaccine, and the apparent lack of a nonhuman reservoir for the often-lethal and highly infectious etiologic agent. The primary obstacle was the lack of effective delivery mechanisms for the vaccine in settings of poverty, where health personnel were scarce and health systems weak. Close collaborations across administrative and political borders were clearly necessary. Naysayers were surprised when the smallpox eradication campaign, which engaged public health officials throughout the world, proved successful at the height of the Cold War.[xxxiii]

The optimism born of the world’s first successful disease-eradication campaign invigorated the international health community, if only briefly. Global consensus regarding the right to primary health care for all was reached at the International Conference on Primary Health Care in Alma-Ata (in what is now Kazakhstan) in 1978. However, the declaration of this collective vision was not followed by substantial funding, nor did the apparent consensus reflect universal commitment to the right to health care. Moreover, as is too often the case, success paradoxically weakened commitment. Basic-science research that might lead to effective vaccines and therapies for tuberculosis and malaria faltered in the latter decades of the 20^th century after these diseases were brought under control in the affluent countries where most such research is conducted. U.S. Surgeon General William H. Stewart supposedly declared in the late 1960s that it was time to “close the book on infectious diseases,”[xxxiv] and attention was turned to the main health problems of countries that had already undergone an “epidemiological transition”[xxxv]; that is, the focus shifted from premature deaths due to infectious diseases toward deaths from complications of chronic non-communicable diseases, including malignancies and complications of heart disease.

5. Citizen and Subject in Global Health

The rich and complex set of problems that all agree constitute today’s global health are linked to equally complex but more hidden concepts of power and control, and the question of who holds that power. How can any intervention, either simple or complex, be expanded—scaled-up—outside of the public sector? How can any entity other than the state confer rights to citizens? The concepts with which we began this essay, social theory from Foucault and others, lead us to again consider who is a citizen and subject.

Returning to the example of Rwanda, the refugee crisis that developed in the wake of the 1994 genocide illustrates with terrible clarity the consequences of treating aid “recipients” as humanitarian subjects, rather than rights-bearing citizens. In July 1994 nearly two million mostly Hutu refugees, both innocent civilians and genocidaires, fled Rwanda into neighboring countries, predominantly what was then Zaire. After reacting with quiet consternation but little action during the 100-day massacre, the international community flooded the burgeoning Zairean camps. Struggling to maintain order and contain outbreaks of epidemic disease, aid workers were largely oblivious when the former Rwandan (genocidaire) government reconstituted itself in the camps, which they used as civic and military bases of operation.[xxxvi] Fiona Terry of Médecins Sans Frontières, which was working in the Goma camps, made no bones about it: the genocidaires, not the humanitarians, ran the camps. Aid organizations could not keep up with the need for sanitation facilities and subsequent epidemics of cholera and dysentery, which killed over 50,000 refugees in the month after their arrival.[xxxvii] Continued militarization of the camps, under the watch of the humanitarian community, sparked a regional conflict that has since claimed approximately 3 million lives, the majority from starvation and disease.[xxxviii]

Moreover, the presence and actions of humanitarian groups presented their own complications. By default, the intervention of these groups implies a perceived political or ethical failure of the host country, and is thus inevitably a politicized act.[xxxix] Extending this concept forward, Mahmood Mamdani, a government and anthropology professor at Columbia, makes a rather chilling argument that what he calls the “new humanitarian order” will ultimately undermine rights and sovereignty in Africa. Using the example of Darfur, Mamdani outlines the politicization of international aid and humanitarian efforts through the degradation of the concept of citizenship. He writes:

That responsibility is said to belong to the ‘international community,’ to be exercised in practice by the UN, and in particular by the Security Council, whose permanent members are the great powers. This new order is sanctioned in a language that departs markedly from the older language of law and citizenship. It describes as ‘human’ the populations to be protected and as ‘humanitarian’ the crises these suffer from, the intervention that promises to rescue them and the agencies that seek to carry out intervention. Whereas the language of sovereignty is profoundly political, that of humanitarian intervention is profoundly apolitical, and sometimes even antipolitical.

The international humanitarian order, in contrast, does not acknowledge citizenship. Instead, it turns citizens into wards. The language of humanitarian intervention has cut its ties with the language of citizen rights. To the extent the global humanitarian order claims to stand for these rights, these are residual rights of the human and not the full range of rights of the citizen. If the rights of the citizen are pointedly political, the rights of the human pertain to sheer survival; these are summed up in one word: protection.[xl]

Rudolph Virchow, a contemporary of John Snow, once argued that “Medicine, as a social science, as the science of human beings, has the obligation to raise…problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution.”[xli] But this is never easy in the doing; the devil is often in the details, as anyone working to redress poverty and inequality will know. Just as daunting are the larger problems, which are almost philosophical in scope. For all of us who work in global health, it behooves us to think about these difficult questions of citizenship, power, and rights, and to remember the checkered history of this endeavor—from the eugenics that helped to spawn a genocide to the successful global cooperation that eliminated a deadly disease—as we develop the solutions for very practical problems.

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[i] Brown, David. “For a Global Generation, Public Health is a Hot Field,” The Washington Post, September 19, 2008.

[ii] Foucault, Michel. The History of Sexuality: An Introduction. London: Penguin, 1990.

[iii] Rabinow, Paul. “Artificiality and Enlightenment: From Sociobiology to Biosociality.” In The Science Studies Reader, ed. M. Biagioli, 407- 416. New York and London: Routledge, 1999.

[iv] Rabinow, Paul. French DNA: Trouble in Purgatory. Chicago: University of Chicago Press, 2002.

[v] Petryna, Adriana. Life Exposed: Biological Citizens after Chernobyl. Princeton: Princeton University Press, 2002.

[vi] An illustration of this concept is the diagnosis of Posttraumatic Stress Disorder and its relation to entitlements. See: Young, Allan. The Harmony of Illusions: Inventing Posttraumatic Stress Disorder. Princeton: Princeton University Press, 1995.

[vii] Turshen, Meredith. The Politics of Public Health. New Brunswick: Rutgers University Press, 1989.

[viii] Declaration of the Rights of Man and of the Citizen. Article 1. Approved by the National Assembly of France, August 26, 1789. Available at: http://www.hrcr.org/docs/frenchdec.html.

[ix] See: Farmer, Paul. The Uses of Haiti. Monroe, ME: Common Courage Press, 1994.

[x] Auguste, C. and M. Auguste. L’Expedition Leclerc, 1801-1803. Port-au-Prince: Imprimerie Henri Deschamps, 1985.

[xi] Vinten-Johansen, Peter et. al., Cholera, Chloroform and the Science of Medicine: A Life of John Snow.    Oxford: Oxford University Press, 2003, p. 294.

[xii] Vinten-Johansen, 2003, pp. 6-7.

[xiii] Vinten-Johansen, 2003, p. 7.

[xiv] Vinten-Johansen, 2003, p. 7.

[xv] Vinten-Johansen, 2003, p. 7.

[xvi] Vinten-Johansen, 2003, p. 8.

[xvii] Vinten-Johansen, 2003, p. 9.

[xviii] McNeill, William H. Plagues and Peoples. New York: Bantam, Doubleday, Dell Group, 1976.

[xix] Cueto, Marcos. Missionaries of Science: the Rockefeller Foundation and Latin America. Bloomington, Indiana University Press, 1994, p. 12.

[xx] Cueto, 1994, p. 3.

[xxi] Cueto, 1994.

[xxii] Cueto, 1994.

[xxiii] Kinzer, Stephen. Overthrow: America’s Century of Regime Change from Hawaii to Iraq. New York: Henry Holt and Company, 2006, pp. 58–59.

[xxiv] Packard, Randall. The Making of a Tropical Disease: A Short History of Malaria. Baltimore: Johns Hopkins University Press, 2007.

[xxv] Cueto, 1994, p. 20.

[xxvi] Packard, 2007.

[xxvii] Transactions of the First General International Sanitary Convention of the American Republics, Held in Washington, D.C., December 2, 3, and 4, 1902, Under the Auspices of the Governing Board of the International Union of the American Republics. Washington D.C.: Government Printing Office, 1903.

[xxviii] Transactions of the Second General International Sanitary Convention of the American Republics, Held in Washington, D.C., October 9, 10, 12, 13, and 14, 1905, Under the Auspices of the Governing Board of the International Union of the American Republics. Washington D.C.: Government Printing Office, 1906, p. 94.

[xxix] Transactions of the Second General International Sanitary Convention of the American Republics, p. 30.

[xxx] Vaughn, Megan. Curing Their Ills: Colonial Power and African Illness. Stanford: Stanford University press, 1991. p. 202.

[xxxi] See: African Rights. Rwanda: Death, Despair and Defiance. London: African Rights, 1995 (1994); Gourevitch, Philip. We Wish to Inform You that Tomorrow We Will Be Killed with Our Families. New York: Picador, 1999.

[xxxii] Vaughn, 1991, p. 203.

[xxxiii] Koplow, David A. Smallpox: the Fight to Eradicate a Global Scourge. Berkeley: University of California Press, 2003.

[xxxiv] Martin, Douglas. “William H. Stewart Is Dead at 86; Put First Warnings on Cigarette Packs [obituary].” The New York Times. April 29, 2008.

[xxxv] Omran, A.R. “The Epidemiological Transition: A Theory of the Effects of Population Change.” Milbank Memorial Fund Quarterly, 1971. 49(4): 509-538.

[xxxvi] Terry, Fiona. Condemned to Repeat? The Paradox of Humanitarian Action. Ithaca, NY: Cornell University Press, 2002.

[xxxvii] Goma Epidemiological Group. “Public Health Impact of Rwandan Refugee Crisis: What Happened in Goma, Zaire, in July, 1994?” Lancet, 1995. 345(8946): 339-344, p. 342.

[xxxviii] Prunier, Gérard. Africa’s World War: Congo, the Rwandan Genocide, and the Making of a Continental Catastrophe. Oxford, UK: Oxford University Press, 2008.

[xxxix] Redfield, Peter. “Doctors, Borders, and Life in Crisis.” Cultural Anthropology 2005. 30(3): 328-361.

[xl] Mamdani, Mahmood. “The New Humanitarian Order.” The Nation, September 9, 2008, p.18.

[xli] Ackerknecht, Erwin. Rudolph Virchow: Doctor, Statesman, Anthropologist. Madison: the University of Wisconsin Press, 1953.