Public Health Then and Now
Skirting the Issue:
Women and International Health
in Historical Perspective
Anne-Emanuelle Birn, ScD
The principles set forth at the United
Nations Fourth World Conference on
Women, held in Beijing in 1995, reflect the
continuing struggles for women's health
around the world.' In both industrialized and
underdeveloped countries, women's health
advocates have spent more than 3 decades
condemning doctors' treatment of women2;
challenging the prevailing model of bio-
science3; linking women's health status to
imperialism, development policies, and
social and economic inequity4; critiquing the
medical establishment for excluding women
from research and practice5; and resisting the
excesses of reproductive technology and
population control.6
There have been significant advances in
conceiving broad structural approaches to
gender, health, and well-being that take into
account the economic and social roles and
the public and private human rights of both
women and men.7 However, translation of
these approaches into practice is not yet
apparent, even on the part of governments
and international agencies that have adopted
a "gender and health" discourse over the last
decades.8 The long-standing narrow focus on
the maternal and reproductive aspects of
women's health continues.
Why, when women are central to inter-
national health initiatives, does women's
health continue to be defined in reductionist
reproductive terms? This incongruity may be
traced to early 20th-century intemational
health endeavors. International health agen-
cies have long played an influential role in
defining health paradigms9; this article
explores the origins of the restrictive para-
digm applied to women's health as revealed
in the Rockefeller Foundation's public health
programs in Mexico. As the leading health
foundation through World War II, the Rocke-
feller Foundation played a paramount role in
promoting scientific medicine and public
health at home and abroad; its strategies and
operating principles served as paragons for
public, philanthropic, and supranational
agencies.
A focus on women surfaced in several
Rockefeller Foundation activities in 1920s and
1930s Mexico. These efforts bore a significant
reproductive imprint; women dispensed and
received services oriented to matemal and
childbearing roles. Women's health and social
advocacy movements in Mexico and the
United States partially shaped this interest;
more consequentially, the emphasis on women
in the Rockefeller programs provided an expe-
dient approach to complex ideological and
practical challenges. Women-as health care
providers and patients in a position to channel
public health measures-were used to achieve
the larger objectives of the foundation in Mex-
ico: to convince the Mexican government, the
medical establishment, business interests, and
the general population ofthe value ofthe foun-
dation's public health model; to support the
Mexican government in its state-building
efforts; and to help stabilize Mexico's political
and commercial relations with the United
States.
Gender, Health Statistics, and
Health Education in Mexico
On the eve of Latzaro Cardenas' election
to the Mexican presidency in 1934, he high-
lighted the importance of public health and
other social measures to the nation's progress
and declared, "We must encourage the ambi-
tions of the Mexican woman to help, shoul-
The author is with the Department of Health
Services Management and Policy, Robert J. Milano
Graduate School of Management and Urban Policy,
New School for Social Research, New York, NY.
Requests for reprints should be sent to Anne-
Emanuelle Birn, ScD, Robert J. Milano Graduate
School of Management and Urban Policy, New
School for Social Research, 66 Fifth Ave, New
York, NY 1001 1 (e-mail:aebirn@newschool.edu).
American Journal of Public Health 399
Public Health Then and Now

der to shoulder, with the man in achieving

our aims."'0 At the time of Cardenas' speech,
the Rockefeller Foundation was the most
active purveyor of public health initiatives in
Mexico, but the foundation's International
Health Division (IHD) did not initially con-
sider women as partners in this undertaking,
be it shoulder to shoulder or shoulder to rib.
The IHD's disease campaigns were con-
ceived as largely masculine endeavors,
through which medical graduates would set
up US-style public health programs for peas-
ants. The Rockefeller model of public
health-based on a narrow, biological
approach to health and disease that called for
technical interventions rather than an under-
standing that integrated the social and politi-
cal determinants of disease with their physio-
logical manifestations-was perpetuated by
a select group of medical and engineering
fellows from Mexico who were sent to the
Harvard and Johns Hopkins schools of pub-
lic health and returned to Mexico to shape
and direct public health institutions. "
The Rockefeller Foundation operated
public health programs in Mexico from 1921
to 1951, beginning with yellow fever and
hookworm campaigns and malaria research
and later establishing permanent sanitaiy units,
mostly in rural areas.)2 These efforts had multi-
ple ends, which overlapped with the founda-
tion's concerns at home: eliminating the threat
to commerce posed by infectious disease, dis-
playing US scientific expertise and diplomatic
goodwill, and increasing worker health and
productivity. Beginning as the decade-long
period of the Mexican Revolution was being
replaced, unevenly, by a state-building phase,
Rockefeller programs were well timed to help
the Mexican government begin to satisfy rural Source. Rockefeller Archive Center.
demands for social reform.
The foundation stumbled upon gender A visiting nurse making her afternoon rounds: Veracruz, Mexico, 1929.
differences in health during the hookworm
campaign of the mid-1920s, when brigades
of Rockefeller and Mexican doctors traveled which limited their infection rates, but as lated gendered cliches to encourage young
through villages identifying and treating they grew older and became field laborers, men to seek hookworm treatment. A pam-
cases of hookworm, convincing peasants they tended to concentrate their deposits in phlet titled La Historia de un Nino ("The
that they were anemic and infested with one place. Because they did not customarily Story of a Boy") played on the stereotypes
hookworm, and persuading them to undergo wear shoes, infection rates increased among of Mexican machismo. On the front cover
treatment and build latrines. Almost immedi- older boys and men.'3 of the pamphlet was Toma's Garcia, a
ately, the doctors noted a difference in hook- Scatological channels, then, led to "skinny, swollen, pale, and yellow" boy
worm infection rates by sex and age, reflect- awareness of gendered exposure to disease, with a girlish physique. Tomas "should
ing, it turned out, gendered cultural norms but this awareness did not alter the existing have grown up to be a tall and strong man
surrounding shoe-wearing and defecation. In treatment and latrine construction method but was left weak and small because he had
the town of Alvarado in the state of Vera- advocated by the IHD. Even after the discov- hookworm." The inside of the pamphlet
cruz, for example, girls always defecated in ery of males' occupational exposure to hook- revealed a recovered Tomas, but one who
one location, not far from where household worm, the IHD held that responsibility for had failed to reach his expected manly size
chores were carried out, but they began constructing latrines and buying shoes and strength. His younger sister Elena,
wearing shoes at the age of 10, which remained with households rather than cured of hookworm at an earlier stage, had
reduced their rate of infection. Mexican landowners.'4 Thus, male field laborers grown to be a beautiful and healthy young
health official Dr Bernardo Gastelum remained without shoes or access to latrines. woman, taller and stronger than her older
pointed out that young, adventuresome boys Hookworm health education strate- brother.'5 Here health education was
tended to defecate in a new spot each time, gies, on the other hand, effectively manipu- employed to feminize sickness and to ter-

400 American Journal of Public Health March 1999, Vol. 89, No. 3

Source. Rockefeller Archive Center.
At child hygiene clinics, medical personnel seek to combat infant mortality and mothers are instructed in the feeding and
care of their children: Veracruz, Veracruz Health Unit, 1929.
rorize young men into undergoing hook-
worm diagnosis and medical treatment lest
they lose their masculine appearance.
Elena was used as a foil for Toma's and
other peasant boys rather than as a public
health success story.
The accidental discovery of gender dif-
ferences in hookworm exposure did not lead
to recognition of the disease as an occupa-
tional ailment governed by social circum-
stances and landowner policies. Instead, por-
trayals of the menacing consequences of
untreated hookworm infection for male iden-
tity helped frighten boys and young men into
securing treatment. Mexican notions of
healthy masculinity were infused with Ameri-
can moralism: each peasant's destiny was
determined by his or her own actions. The
IHD detected the centrality of women in a
model of health and disease that made indi-
viduals and households accountable for their
own health. As the IHD extended its programs
in rural Mexico, women became increasingly
influential targets and disseminators of this
public health approach.
March 1999, Vol. 89, No. 3
Nurses and the Making ofPatients
In the late 1920s the hookworm cam-
paign was replaced by an effort to create per-
manent sanitary units, which were estab-
lished cooperatively by the Rockefeller
Foundation, the Mexican Department of
Public Health, and various states and munici-
palities to provide basic health services to
peasants. In an attempt to reach a sizable
population, the units began to target women
directly as patients and as public health
workers, mirroring strategies that were
employed in various regions of the United
States. As patients, women were approached
as mothers and childbearers; their hygiene
practices in the prenatal and child-rearing
phases would determine the health and pro-
ductivity of the next generation of workers.'6
As public health personnel, women served 2
functions. Working-class, and occasionally
middle-class, nurses acted as a bridge
between doctors and peasants, transporting
the Rockefeller ideology of public health-
belief in biological causes of, technical cures
Public Health Then and Now
for, and medical authority over disease. Mid-
wives were co-opted by the health units,
which needed their labor but abhorred much
of their canon. Together, nurses and mid-
wives were used to generate and maintain
the health units' clientele.
Nurses, virtually all of whom were
female, formed a key component of the sani-
tary units' full-time staff. Initially, Rockefeller
Foundation officers believed that it would be
sufficient to train nurses in urban settings, for
their "influence will undoubtedly gradually
radiate from the urban centres as has been the
history of public health nursing development
in the [United] States."'7 Beginning in 1932,
dozens of public health nurses were trained
alongside health officers and sanitary inspec-
tors in 6- or 8-week courses at field training
stations supported by the Foundation. Yet
through the 1930s, Rockefeller representative
Charles Bailey repeatedly complained that
"not one capable nurse is available," even
though "The need for trained nurses is equal
to, if not greater than for health officers." The
fundamental problem, Bailey argued, was that
American Journal of Public Health 401
Public Health Then and Now
Source. Rockefeller Archive Center.
Midwives are instructed in female reproductive anatomy and physiology: Minatitlan, Veracruz Health Unit, 1935.
training in Mexico was "primitive" and nurses
were of "low cultural standing"; before a
nursing school could be created, educational
standards had to be raised to attract "girls of a
higher cultural background." 18
Bailey's concems were corroborated by
the foundation's nursing expert, Mary Ten-
nant, who in 1936 was sent to survey nursing
schools in Mexico and make recommenda-
tions to improve the quality of nursing educa-
tion. She found the level of instruction at the
3 schools in Mexico City to be extremely
limited, with virtually no preclinical training,
few enrollment requirements, and little
awareness of the modem nursing curriculum.
The schools operated on a hospital appren-
ticeship model, overseen by doctors who
were unprepared to teach the principles and
practice of nursing. Tennant found only the
Red Cross Hospital School to be of accept-
able quality, with students who were "young
women of intelligence, refinement, educa-
tion, and [who] have a real interest in learn-
ing."'9 The other schools and public health
nurse training centers were "of inferior qual-
ity. The nurses are not superior, in appear-
ance, in dress, in intelligence, in attitude
toward work or in comprehension of it....
The background of these nurses is so limited
in education and nursing and social stan-
dards"20 that they would require months of
very basic training.
402 American Journal of Public Health
Notwithstanding these laments, reliance
on visiting nurses for community outreach,
which had begun in the foundation's first unit
in coastal Veracruz in 1931, continued unin-
terrupted. Earlier, the unit's 2 nurses occa-
sionally made home visits to administer vac-
cines or to attend persons unwilling to
undergo hookworm treatment, but the new
arrangement specifically addressed matemal
and infant health concems. After having been
trained by the unit's physician and monitored
until they received approval to work indepen-
dently,2' nurses devoted every aftemoon to
home visits to pregnant women and new
mothers, showing them how to care for them-
selves and their children. Tennant observed
home visits and concluded that successful
health education in the home would also
require nurses "from a higher social and eco-
nomic level."22 After Tennant's visit, the
Rockefeller Foundation sent 5 middle-class
nurses to study in the United States, but the
background and training of nurses in Mexico
were slow to change. Regardless of the avail-
ability of appropriately classed and trained
professionals, visiting nurses remained essen-
tial to the foundation's programs.
During each visit, nurses surveyed the
conditions of the home, assessed household
health, and updated vaccinations for family
members. Pregnant women were told to
bathe daily, eat regularly without over-
indulging, defecate daily, and exercise. The
women were advised to purchase baby cribs
instead of sleeping with their newboms, to
stay in bed for 2 weeks after delivering, and
to avoid reading "morbid literature or adven-
ture stories."23 This advice challenged both
the customs and the economic possibilities of
many families, and suspicious mothers some-
times denied entrance to nurses, who "needed
to know how to talk their way in."24
After a pregnant woman was examined,
she was given instructions for a "happy preg-
nancy," which entailed attendance at special
clinics at the sanitary units. There the women
underwent pelvic examinations, urine analy-
sis, blood pressure measurement, treatment
for syphilis, and "the necessary medical
advice to prevent difficulties and disasters."
Thus, the doctors said, the "misfortunes and
tragedies" resulting from poor care could be
avoided. Although infant mortality rates rose
during the 1930s, the Rockefeller Foundation
attributed much of the increase to better data
collection and claimed success in "saving the
lives of countless mothers and babies."25
Once a child was bom, visiting nurses
persuaded the mother to attend the local Com-
mittee for Infant Protection group instruction
in child care. In addition, the unit staff con-
vinced many mothers to enroll in infant clin-
ics so the progress of their children could be
closely monitored. Visiting nurses continued
March 1999, Vol. 89, No. 3

Source. Rockefeller Archive Center.
Members of the Midwife Club, equipped with satchels filled with scissors, soap, silver nitrate ampules, sterile tape, forceps,
and other instruments, pose with the unit director: Cuernavaca, Morelos Health Unit, 1935.
to provide home instruction in bathing, feed-
ing, and care of the baby's health, and they
administered typhoid and smallpox vac-
cines.26 Mothers were also advised to boil
drinking water to "kill all the little animals" so
that their children would not die. As a visiting
nurse recalled, "I told the mother that boiling
water was her own responsibility. I could
come visit her but I did not live in her house.
It was she who had to make sure that she
washed her hands before eating and feeding
the baby and after defecating to make sure her
baby remained healthy."27
Not only did infant and child health
clinics occupy large amounts of the mothers'
time, but women were held personally
accountable for applying the medical knowl-
edge transmitted at these clinics to the care
of their children. Grandmothers, aunts, and
neighbors-a new mother's customary
teachers-were systematically excluded and
criticized by the nurses for their primitive
ways. Only the advice of medical personnel
March 1999, Vol. 89, No. 3
was deemed valid. Even a mother's own
experience was discounted by sanitary unit
doctors, who admonished, "Just because you
have been pregnant before does not make
you an expert."28 Visiting nurses more com-
passionately urged their patients to heed
advice, but the message persisted: Women's
importance derived from motherhood, but
existing practices of motherhood needed to
be medically supervised.
Without explicitly conceptualizing the
visiting nurses' efforts as a women's initia-
tive, the IHD-as did countless health
departments in the United States29-engaged
cross-class and gender-specific strategies,
using working-class (though favoring mid-
dle-class) nurses to bring peasant women
into the medical fold. Nurses employed a
mixture of incentives, coercion, reprimands,
and warnings. The common thread was that
expert knowledge, imparted either in the
health unit or in the home, should replace
customs and superstitions surrounding
Public Health Then and Now
maternal and child health. Trained nurses
represented class and medical authority, and
gender affinity facilitated reception of this
authority. These efforts, while challenging
existing social structures in rural Mexico,
were consonant with many of the goals of
the revolutionary Mexican state, whereby a
growing professional class-including
women nurses-would enable social and
economic modernization across the country.
Midwives, Microbes,
Motherhood, Mortality
Although nurses served as a female-
friendly extension of the health units, rural
communities already enjoyed an existing set
of female healers-midwives. Moreover, the
scope of the Rockefeller Foundation's Mex-
ico program soon exhausted the supply of
elite physicians and trained nurses willing to
work in remote villages. Having promised to
American Journal of Public Health 403
Public Health Then and Now
target infant mortality, the Rockefeller-
sponsored units had no choice but to ask
local midwives to carry out a service the
units could not provide-delivering babies
and regularly caring for new mothers. While
curanderos (traditional healers, often male)
had been swept aside as superstitious war-
locks, midwifery training enabled the incor-
poration of another group of traditional
health practitioners into the sanitary units.
Beginning in the early 1930s, instead of dis-
placing midwives, the units sought to trans-
form scores of them into modem childbirth
attendants by paying them to attend weekly
training sessions. These strategies were simi-
lar to those followed in the southem United
States during the same period, when Black
midwives were first blamed for bad out-
comes and then made subject to state regula-
tions because they served as a "vital link
between poor African Americans and health
departments."30
By addressing pregnancy, child care,
and midwifery, the units were entering terri-
tory that had previously been the domain of
women. The IHD and the local units justified
their encroachment by tying Mexico's high
infant mortality, estimated at more than 200
deaths per 1000 live births, to matemal igno-
rance and the "erroneous practices" of mid-
wives, who attended more than 90% of
births. The 1934 annual report of the Rural
Hygiene Service, which administered the
IHD program for the Mexican Department
of Public Health, complained that "many
women, through ignorance or economy, pre-
fer empirical midwives who charge little,
creating a grave danger for both mothers and
children." Because midwives did not restrict
their activities to delivering babies, they
were also blamed for endangering other
members of the household. Thus it was nec-
essary to identify, monitor, and train mid-
wives in order to "give them a sense of
responsibility and to place limits on their
work so they would not threaten the lives of
mothers or their children."31
At the sanitary unit in Cuemavaca, mid-
wives were pressured to attend classes every
week so that "the Doctor could instruct them
in less dangerous birthing practices." This
training in obstetrics and midwifery, as one
Rockefeller doctor noted, consisted mainly
of instruction in "what they should not do."
It also allowed doctors to monitor midwives
continuously, "because for now it is impossi-
ble to get rid of them and it is worthwhile to
recognize this situation and attempt to edu-
cate them in order to minimize the harm they
cause."32
In rural Mexico, midwives served as the
chief advisors, spiritual guides, and care-
givers to women during pregnancy, child-
404 American Journal of Public Health
birth, and the postpartum period.33 Many
midwives believed they answered a divine
calling, and all underwent apprenticeships to
learn both ritual and clinical practices. Mid-
wives were often respected older women
who provided continuous care through the
phases of birth, thus gaining the confidence
of their patients. Prenatal care involved
observing the color of the nipples, the shape
of the womb, and the position of the fetus
and helping relieve the mother's physical
discomfort with massage and herbal reme-
dies. Delivery usually took place at home in
the presence of the expectant mother's fam-
ily. Traditionally, women gave birth in a
kneeling or squatting position, aided by the
force of gravity. During difficult deliveries,
midwives sometimes employed herbal medi-
cines and massage. The umbilical cord, not
normally cut until the placenta was expelled,
was typically cauterized with a candle flame
or cut with a hot blade. In the weeks follow-
ing the birth, the midwife aided the new
mother with household chores, offering both
emotional and physical support. Within a
few weeks of delivery, the new mother took
one or more steam baths to cleanse herself
physically, ritually, and emotionally. Mid-
wives and their patients believed these baths
increased the flow of milk, prevented illness,
and helped adjust the balance of hot and cold
influences.34
Sanitary unit training sessions, on the
other hand, were designed to limit the mid-
wife's role to a medical one, discarding her
social and ritual functions. Doctors convinced
midwives to use aseptic methods to prevent
microbial infection, to employ and disinfect
instruments such as forceps, and to deliver
women in a supine position.35 They stemly
advised midwives to recognize their limita-
tions and to consult a physician or hospital at
any sign of complication. Many of the mid-
wives arrived at training sessions barefoot
and in ragged clothes, like most of their
patients; at the end of the course, midwives in
starched white uniforms were awarded a bag
of instruments and a Spanish translation of
the Mississippi State Board of Health's mid-
wife manual. Although few were literate,
most midwives learned quickly.36 Yet they
generally finished by losing more than they
had gained, as their status as spiritual guides
diminished and their dependence on outside
knowledge and products rose.
The training programs failed to take
long-held customs into account and
attempted to modify virtually every aspect of
traditional midwifery. Herbal medicine, mas-
sage, umbilical cord cauterization, and other
practices were denounced, even though there
was no evidence they were harmful. In
replacing superstition and empirically based
tradition with science, trainers made some
midwives fear their own practices by wam-
ing, for example, that if the baby hit its head
on the ground during delivery, it was the
fault of the midwife. The Rockefeller Foun-
dation hoped to minimize the importance of
traditional Mexican cultures in the face of
Westem medicine, as well as to increase the
importance of training and licensing mid-
wives in modem obstetrical methods.
The Rockefeller Foundation's message
that empirical midwifery was deadly and
needed to be circumscribed and its drive to
educate nurses as alternatives to midwives
were highly influential in Mexico. In 1937
the governor of Morelos, Jose Refugio Bus-
tamante, inaugurated the state's first school
of nursing and obstetrics with the declaration
that empirical practices carried out by "mid-
wives without the least rudimentary knowl-
edge of scientific medicine" had to be elimi-
nated to "save the nation's defenseless sons
and daughters from grave danger."37 In 1973
a doctor heading the Mexican Secretariat of
Health's midwife training program repeated,
almost verbatim, the Rockefeller Founda-
tion's advice from 40 years before: "Above
all, she should be instructed specifically as to
what not to do."38
By targeting midwifery, the Rockefeller
Foundation narrowed understanding of both
the causes of and the solution to high infant
mortality, at once disregarding its social and
economic determinants and bringing mid-
wives, childbirth, and motherhood itself under
medical control. The foundation reinforced
the ideological dimensions of this reductionist
approach to health by blaming midwives and
their traditional practices for infant and mater-
nal mortality. In addition, by severing the role
of visiting nurse from that of midwife, the
foundation's IHD played class favorites,
expanding the purview of working- and mid-
dle-class public health nurses while shrinking
the role of peasant midwives.
The Skirting of International
Health
Although the IHD did not set out with a
women-and-health agenda, women grew to
play a key role as both translators and targets
of the Rockefeller Foundation's efforts in
Mexico. In part, the IHD's efforts reflected
the attention being paid to maternal and child
health in the United States and Europe,
where such concern coincided with late
19th-century industrialization, immigration,
urbanization, and the building of the welfare
state.39 In the 1850s, infant mortality was
discovered as a problem "in need of amelio-
ration," and reformers attempted to sanitize
March 1999, Vol. 89, No. 3

the urban environment, improve infant feed-
ing practices, and, beginning in the 1880s,
raise the quality of milk supplies. After 1900,
a variety of campaigns focused on mothers'
child-bearing and child-raising abilities.40
Growing medical and social armamentaria
translated into fits and starts of action in
maternal and child health through municipal
efforts led by women, including Josephine
Baker's Bureau of Child Hygiene in New
York (founded in 1908), charity societies and
settlement houses, and federal activities,
namely the US Children's Bureau, founded
in 1912 by Julia Lathrop, and the short-lived
Sheppard-Towner Act (1921-1929).41
In Mexico, a social agenda emerged in
the context of the Mexican Revolution,
spurring regulation of wet-nursing and adop-
tion, assessment of maternal fitness by the
welfare system, and other maternal and child
health reforms.42 Many of these efforts were
consistent with women's search for gender
equity, which, in Mexico and other parts of
Latin America, did not deny femininity and
motherhood but celebrated these roles.
Mother-feminism, based in part on Catholic
spirituality, protested "laws and conditions
which threaten[ed women's] ability" to bear
children and nurture their families, including
war, drugs, prostitution, urban misery, adul-
tery, and exclusion from suff-rage and prop-
erty ownership.43 As in the United States,
these movements were most influential in
urban settings, where middle-class women
made social issues part of public policy and
mobilized to improve and regulate social
conditions for poor women.
The Mexican environment in which the
Rockefeller Foundation operated was more
similar to rural and southern parts of the
United States; here the goal of providing
access to modern health services clashed
with both traditional beliefs and practices
and economic constraints. Using partially
trained nurses and regulated-but still
"empirical"-midwives, and holding moth-
ers responsible for maternal and child health
outcomes, the IHD fashioned a separate, less
formalized package of reforms adapted to
rural, marginalized settings. The added pres-
sure to demonstrate public health success to
help solidify the state made these measures
ever more expedient.
The Rockefeller Foundation's efforts in
Mexico were often coercive, disruptive to
local customs, and slow to show results.
These efforts also led to a paradigm of
women's health based on reproductive and
maternal functions, a paradigm that was sup-
ported by numerous women reformers in the
United States, Europe, and Mexico itself.
However, wider paradigms were also present.
Under the administration of President Liiaro
March 1999 Vol. 89. No. 3
Cardenas, visiting nurses defined their role in
broad social terms to include the improve-
ment of living and working conditions for the
family and the community.44 Likewise, the
convention of local women's organizations
petitioning the presidency (which arose out of
the Mexican Revolution) generated demands
for improved living, working, and health con-
ditions. For example, the Women's Commis-
sion of La Antigua, Veracruz, asked that local
rivers be dredged to eliminate the annual
destruction of crops, homes, and lives caused
by floods and to prevent illness and misery.45
For the women who were the targets of the
Rockefeller Foundation's programs, matemal
and child health was only one of a broad
range ofconcems.
The Rockefeller Foundation's early 20th
century programs in Mexico set the stage for
subsequent tendencies in the field of interna-
tional women's health. Although Mexican
women were not a target population for the
foundation's initial efforts in the 1920s, they
became increasingly central to public health
interventions as childbearers and child rear-
ers. As health care providers, women served
as important vectors for the transmission of
medical ideology. The IHD concentrated
attention on maternal functions and responsi-
bilities: mothers and their midwife collabora-
tors were construed as vessels and conduits
through which disease (and, potentially,
health, if they adhered to IHD precepts) was
transmitted to their offspring.46 Not only were
mothers and midwives blamed for poor
health outcomes, they were made dependent
on medical personnel and stripped of existing
networks providing support in matters of
sickness and child rearing.
The IHD also reinforced class divisions
among women health workers. Uneducated
midwives from the peasant class were to be
trained, but their domain was to be circum-
scribed. Nurses, on the other hand, were to
be recruited from middle-class families and
educated to form a central part of the health
unit team. Empirical nurses and midwives
once hailed from the same communities and
underwent similar and often overlapping
apprenticeships; the IHD tried to crack this
affiliation. The Kellogg Foundation followed
a similar strategy, beginning in the 1940s,
and was more successful.47
The matemal and reproductive focus of
the Rockefeller Foundation's programs was
intensified by population control efforts,
which began in earnest in the 1960s, when
the "population explosion" displaced the
undersupply of healthy laborers as a key per-
ceived problem of underdeveloped countries.
The portrayal of population programs as
women's health initiatives,"8 which has been
heavily promoted by the Rockefeller Founda-
Public Health Then and Now
tion and other large intemational health agen-
cies, has faced tremendous criticism owing to
the many abuses of informed consent in
experiments conducted on women in under-
developed countries and to the reception of
reproductive health programming as a tool of
racism and imperialism rather than as a bona
fide attempt to improve women's health.49
Today virtually all international health
donor agencies explicitly focus on women
and health. Most have incorporated elements
of community participation,50 but few go
beyond maternal and reproductive health,
paying scant attention to sanitation, mental
health, income security, environmental
degradation, illness and chronic pain, hous-
ing, social and economic discrimination, and
other aspects of health and welfare identified
by the Women's Commission of La Antigua
more than 50 years ago. Even attention to
girls' education, it may be argued, has more
to do with curbing fertility than with
women's social and economic well-being.
Analysis of the major activities of the Ford,
Kellogg, and Rockefeller foundations and
leading United Nations agencies over the last
50 years shows that as women and women's
health became a focus of attention in the
1980s, reproductive health issues continued
to command the agenda. The United Nations
Development Program's 1995 Human
Development Report, which highlighted
gender equality and proposed new gender
development and empowerment indices,
measured "women and health security" only
in terms of life expectancy, fertility, maternal
mortality, and contraception usage.51 The
obstacles to translating rhetorical commit-
ments into substantive changes remain large.
In the end, the "skirting" of public health
programs has meant a continued narrow
emphasis on reproductive and maternal
health. Meeting the Beijing objectives for
women's health will require a revolutionary
change in the social fabric, whereby the health
of women and men is advanced as a matter of
social, political, and economic equity. D
Acknowledgments
I am most grateful to Nandini Oomman, Sarah
Zimmerman, Theodore Brown, Patricia Pittman,
Elizabeth Fee, Corinne Whitaker, and the anony-
mous reviewers for their valuable suggestions.
Sarah Zimmerman also provided vital assistance in
the analysis of activities conducted by foundations
and United Nations agencies referred to at the end
of this article.
Endnotes
1. Lesley Doyal, "The Politics of Women's
Health: Setting a Global Agenda," Interna-
tional Journal of Health Services 26 (1996):
American Journal of Public Health 405
Public Health Then and Now
47-65, and What Makes Women Sick: Gender
and the Political Economy of Health (New
Brunswick, NJ: Rutgers University Press,
1995); World Health, Special Issue on Women
and Health (September 1995); Adrienne Ger-
maine and Rachel Kyte, The Cairo Consensus:
The Right Agenda for the Right Time (New
York, NY: International Women's Health
Coalition, 1995); Gita Sen, Adrienne Ger-
maine, and Lincoln Chen, Population Policies
Reconsidered: Health, Empowerment, and
Human Rights (Cambridge, Mass: Harvard
University Press, 1994); Noeleen Heyzer, The
Balancing Act: Population, Development, and
Women in an Era of Globalization, Interna-
tional Lecture Series on Population Issues
(New Delhi, India: The John D. and Catherine
T. MacArthur Foundation, August 29, 1996).
2. Boston Women's Health Book Collective, Our
Bodies, Ourselves: A Book by and for Women,
revised and expanded edition (New York, NY:
Simon & Schuster, 1976, and all subsequent
editions); Evelyn C. White, ed. The Black
Women s Health Book: Speakingfor Ourselves,
new expanded edition (Seattle, Wash: Seal
Press, 1994).
3. Ruth Hubbard, The Politics of Women s Biol-
ogy (New Brunswick, NJ: Rutgers University
Press, 1990); Evelyn Fox Keller, Reflections on
Gender and Science (New Haven, Conn: Yale
University Press, 1985).
4. A powerful critic of the health and economic
effects of patriarchy is Nawal El Saadawi; see The
Nawal El Saadawi Reader (London, England:
Zed Books, 1997). Also see Ester Boserup,
Women s Role in Economic Development (Lon-
don, England: George Allen & Unwin, 1970);
C. H. Browner, "Women, Household and Health
in Latin America," Social Science and Medicine
28 (1989): 461-473; Lenore Manderson, Sick-
ness and the State: Health and Illness in Colo-
nial Malaya, 1870-1940 (Cambridge, England:
Cambridge University Press, 1996); J. Vickers,
Women and the World Economic Crisis (Lon-
don, England: Zed Press, 1991).
5. See Sue V. Rosser, "Androcentric Bias in Clini-
cal Research," in Women 's Health-Missing
Fromi U.S. Medicine (Bloomington: Indiana
University Press, 1994), 3-15, and Tracy John-
son, "Health Research That Excludes Women
Is Bad Science," Chronicle of Higher Educa-
tion (October 14, 1992).
6. Michael 0. West, "Nationalism, Race and Gen-
der: The Politics of Family Planning in Zim-
babwe, 1957-1990," Social History of Medi-
cine 7 (December 1994): 447-471; Rosalind
Pollack Petchesky, "The Body as Property: A
Feminist Re-Vision," in Faye D. Ginsburg and
Rayna Rapp, eds., Conceiving the New World
Order (Berkeley: University of California
Press, 1995), 387-406; Laurie Nsiah-Jefferson
and Elaine J. Hall, "Reproductive Technology:
Perspectives and Implications for Low-Income
Women and Women of Color," in Kathryn
Strother Ratcliff, ed., Healing Technology,
Feminist Perspectives (Ann Arbor: University
of Michigan Press, 1989), 93-17, 1 173-198;
and Mahmood Mamdani, The Myth of Popula-
tion Control: Family, Caste, and Class in an
Indian Village (New York, NY: Monthly
Review Press, 1972).
7. See Beijing Declaration and Platform for
Action, adopted September 15, 1995, by the
406 American Journal of Public Health
Fourth World Conference on Women: Action
for Equality, Development and Peace, in
Women and Human Rights: The Basic Docu-
ments (New York, NY: Center for the Study of
Human Rights, Columbia University, 1996);
Alicia Yamin, "Transformative Combinations;
Women's Health and Human Rights," Journal
of the American Medical Women s Association
52 (1997): 169-173; Nancy Krieger and Eliza-
beth Fee, "Man-Made Medicine and Women's
Health: The Biopolitics of Sex/Gender and
Race/Ethnicity," International Journal of
Health Services 24 (1994): 265-283; Hilary
Standing, "Gender and Equity in Health Sector
Reform Programmes: A Review," Health Pol-
icy and Planning 12 (1997): 1-18; and Nancy
Krieger and Sally Zierler, "Accounting for the
Health of Women," Current Issues in Public
Health 1 (1995): 251-256. Also Rebecca de los
Rios, "Gender, Health, and Development: An
Approach in the Making," in Elsa G6mez
G6mez, ed., Gender, Women and Health in the
Americas (Washington, DC: Pan American
Health Organization, 1993), 3-22.
8. See, for example, United Nations Development
Program, Human Development Report 1995
(New York, NY: Oxford University Press,
1995).
9. See, for example, Marcos Cueto, ed., Mission-
aries of Science: The Rockefeller Foundation
and Latin America (Bloomington: Indiana Uni-
versity Press, 1994); Roy MacLeod and Milton
Lewis, eds., Disease, Medicine, and Empire:
Perspectives on Western Medicine and the
Experience of European Expansion (London,
England: Routledge, 1988); David Arnold, ed.,
Imperial Medicine and Indigenous Societies
(Manchester, England: Manchester University
Press, 1988); Vicente Navarro, ed., Imperial-
ism, Health and Medicine (Farmingdale, NY:
Baywood Publishers, 1981); Soma Hewa,
Colonialism, Tropical Disease and Imiperial
Medicine: Rockefeller Philanthropy in Sri
Lanka (Lanham, Md: University Press of
America, 1995); and Helen Power, "The Cal-
cutta School of Tropical Medicine: Institution-
alizing Medical Research in the Periphery,"
Medical History 40 (1996): 197-214.
10. National Revolutionary Party's Six Year Plan,
1934-1940. Found with notes on Ferrell's trip
to Mexico, February 8-March 1, 1935. RG 2.
Series 300. Box 559. Folder 3790. Rockefeller
Foundation Archives, Tarrytown, NY (hereafter
referred to as RFA).
11. Of 67 IHD fellows over 3 decades, 5 were
women, all nurses. See Anne-Emanuelle Birn,
"Local Health and Foreign Wealth: The Rocke-
feller Foundation's Public Health Programs in
Mexico, 1924-1951" (ScD dissertation, Johns
Hopkins University, 1993).
12. Hookworm was the IHD's usual "entering
wedge" program; its easy diagnosis and treat-
ment effectively convinced governments, busi-
nesses, and the public of the value of public
health services. See John Ettling, The Germ of
Laziness: Rockefeller Philanthropy and Public
Health in the New South (Cambridge, Mass:
Harvard University Press, 1981).
13. Bernardo Gastelum, Report of the Lucha Con-
tra la Uncinariasis, May 1925. RG 5. Series 3.
Box 144. RFA.
14. See Anne-Emanuelle Birn and Armando
Solorzano, "Public Health Policy Paradoxes:
Science and Politics in the Rockefeller Founda-
tion's Hookworm Campaign in Mexico in the
1920s," Social Science and Medicine, in press.
15. La Historia de un Ninio, Departamento de Salu-
bridad Publica, Servicio de Propaganda y Edu-
caci6n Higienica, Lucha Contra la Uncinariasis,
Mexico, 1930. Section 11/021/241. Box 39.
Folder 83. Archivo Hist6rico del Estado de
Morelos. See also Anne-Emanuelle Birn and
Armando Sol6rzano, "The Hook of Hookworm:
Public Health and the Politics of Eradication in
Mexico," in Andrew Cunningham and Bridie
Andrews, eds., Western Medicine as Contested
Knowledge (Manchester, England: University of
Manchester Press, 1997), 147-171.
16. See, for example, Lynne Curry, "Modernizing
the Rural Mother: Gender, Class, and Health
Reform in Illinois, 1910-1930," in Rima D.
Apple and Janet Golden, eds., Mothers and
Motherhood: Readings in American History
(Columbus: Ohio State University Press,
1997), 495-516. For the limits to this approach
for working mothers in Southern mill towns,
see Patricia Everidge Hill, "Invisible Labours:
Mill Work and Motherhood in the American
South," Social History of Medicine 9 (1996):
235-251.
17. Henry P. Carr to John Ferrell, October 14,
1929. RG 1.1. Series 323. Box 19. Folder 156.
RFA.
18. Bailey to Ferrell, April 23, 1935. RG 1.1.
Series 323. Box 19. Folder 160. RFA.
19. Mary Tennant's diary from trip to Mexico, Feb-
ruary 11-March 11, 1936, 43. RG 2. Series
323. Box 135. Folder 1008. RFA.
20. Ibid., 42-43.
21. Report of the Hookworm Campaign, Minati-
tlan-Puerto Mexico Cooperative Sanitary Unit
and the Puerto Mexico Antilarval Service, for
the first quarter, 1931. Communicable Diseases
Section, Departamento de Salud Publica, Mex-
ico, DF. Section 111021/241. Box 39. Folder 83.
Archivo Hist6rico del Estado de Morelos.
22. Mary Tennant's diary from trip to Mexico, Feb-
ruary 11-March 11, 1936, 33. RG 2. Series
323. Box 135. Folder 1008. RFA.
23. Examples of forms giving advice to pregnant
mothers, included with Bailey to DSP chief,
January 23, 1934. RG 1.1. Series 323. Box 19.
Folder 159. RFA.
24. Interview with retired nurse Judith Castor,
April 12, 1991, Cuernavaca, Morelos.
25. Report of the Hookworm Campaign, Minati-
tlan-Puerto Mexico Cooperative Sanitary Unit
and the Puerto Mexico Antilarval Service, for
the second quarter, 1931. Communicable Dis-
eases Section, Departamento de Salud Publica,
Mexico, DF. Section 11/021/242. Box 39.
Folder 84. Archivo Hist6rico del Estado de
Morelos. Also, interview with Judith Castor,
April 12, 1991, Cuernavaca, Morelos.
26. Ibid.
27. Interview with "La Guera" Coronel, April 15,
1991, Cuernavaca, Morelos. She recalled that,
after much convincing, they succeeded in sav-
ing many children's lives.
For a critique of the decontextualized advo-
cacy of oral rehydration therapy, water boiling,
and other technical measures, see David
Werner and David Sanders, Questioning the
Solution: The Politics of Prim1ary Health Care
and Child Survival (Palo Alto, Calif: Health-
Wrights, 1997).
March 1999, Vol. 89, No. 3

28. Examples of forms giving advice to pregnant
mothers, included with Bailey to DSP chief,
January 23, 1934. RG 1.1. Series 323. Box 19.
Folder 159. RFA.
29. For example, see Barbara Melosh, "The Physi-
cian 's Hand": Work Culture and Conflict in
American Nursing (Philadelphia, Pa: Temple
University Press, 1982); Susan Reverby,
Ordered to Care: The Dilenima of American
Nursing, 1850-1945 (Cambridge, England:
Cambridge University Press, 1987); and Karen
Buhler-Wilkerson, "Bringing Care to the Peo-
ple: Lillian Wald's Legacy to Public Health
Nursing," American Journal of Public Health
83 (1993): 1778-1786.
30. Susan L. Smith, Sick and Tired of Being Sick
and Tired: Black Women s Health Activism in
America, 1890-1950 (Philadelphia: University
of Pennsylvania Press, 1995), 119. See also
Margaret Charles Smith and Linda Janet
Holmes, Listen to Me Good: The Life Story of
an Alabama Midwife (Columbus: Ohio State
University Press, 1996).
31. All quotations in this paragraph are from
Annual Report, 1934. Rural Hygiene Service.
DSP. RG 5. Series 3. Box 145. RFA.
In the United States, too, midwives were
blamed for high maternal and infant mortality.
See Frances E. Kobrin, "The American Mid-
wife Controversy: A Crisis of Professionaliza-
tion," in Bulletin of the History of Medicine 40
(1966): 350-363.
32. All quotations in this paragraph are from
Report of the Hookworm Campaign, Minati-
tlan-Puerto Mexico Cooperative Sanitary Unit
and the Puerto Mexico Antilarval Service, for
the second quarter, 1931. Communicable Dis-
eases Section, Departamento de Salud Publica,
Mexico, DF. Section 11/021/242. Box 39.
Folder 84. Archivo Hist6rico del Estado de
Morelos.
33. Although historical evidence relating to mid-
wifery in the 1930s is incomplete, anthropologi-
cal studies conducted from the 1920s through
the 1970s offer a consistent portrayal of the
practice. The first anthropological study of this
kind was Robert Redfield's Tepoztlan-a Mexi-
can Village (Chicago, III: University of Chicago
Press, 1930). Oscar Lewis returned to the same
Morelos village in the mid-1940s. His massive
study, Life in a Mexican Village: Tepoztlan
Restudied (Urbana: University of Illinois Press,
1963), includes a comprehensive chapter on
pregnancy and birth. Ten years later, Isabel
Kelly was commissioned by the World Health
Organization to publish "An Anthropological
Approach to Midwifery Training in Mexico,"
Journal of Tropical Pediatrics 1 (1956):
200-205. Nicolas Le6n's La Obstetricia en
Mexico (Mexico, DF, 1910) also provides a
good introduction to pregnancy and childbirth
practices in early 20th-century Mexico.
34. Sheila Cosminsky, "Midwifery and Medical
Anthropology," in Boris Velimirovic, ed., Mod-
ern Medicine and Medical Anthropology in the
United States-Mexico Border Population
(Washington, DC: Pan American Health Orga-
nization, Scientific Publication No. 359, 1978).
March 1999, Vol. 89, No. 3
35. Interview with Judith Castor, April 12, 1991,
Cuernavaca, Morelos.
36. Interview with "La Guera" Coronel, April 15,
1991, Cuernavaca, Morelos.
37. Jose Refugio Bustamante, Declaration for the
Foundation of the School of Nursing and Obstet-
rics, January 30, 1937. Section 11/021/241. Box
40. Folder 62. Archivo Hist6rico del Estado de
Morelos. According to Governor Bustamante,
this ignorance stemmed from the "economic and
cultural backwardness of the majority of the pop-
ulation, a situation incompatible with the coun-
try's growing economy and its cultural improve-
ment, deriving from the revitalizing action of the
Revolution."
38. J. Arias Huerta, "El papel de la empirica como
promotora de salud matemo-infantil." Paper pre-
sented at the National Conference on Health,
Mexico City, 1973, as quoted in Sheila Cosmin-
sky, "Midwifery and Medical Anthropology."
39. See Deborah Dwork, War Is Good for Babies
and Other Children: A History of the Infant and
Child Welfare Movement in England,
1898-1918 (London, England: Tavistock,
1987); Valerie Fildes, Lara Marks, and Hilary
Marland, eds., Women and Children First:
International Maternal and Infant Welfare,
1870-1945 (London, England: Routledge,
1992); and Seth Koven and Sonya Michel, eds.,
Mothers of a New World: Maternalist Politics
and the Origins of Welfare States (New York,
NY: Routledge, 1993). Here Alisa Klaus argues
that "making maternity compatible with wage
labor was a primary focus of many French
maternal- and infant-health programs" (p 195).
In the French case, protective maternalist legis-
lation stemmed from preoccupation about
babies' dying when mothers gave up breast-
feeding to return to work and from low fertility
resulting from the reluctance of some working-
class women to undergo the physical and finan-
cial suffering of pregnancy and motherhood.
40. Richard A. Meckel, Save the Babies: American
Puiblic Health Reform and the Prevention of
Injant Mortality, 1850-1929 (Baltimore, Md:
Johns Hopkins University Press, 1990), 5-6. See
also Charles R. King, Children s Health in
America: A History (New York, NY: Twayne
Publishers, 1993); Rima D. Apple, Mothers and
Medicine: A Social History of Infant Feeding,
1890-1950 (Madison: University of Wisconsin,
1987); Janet Golden, A Social History of Wet-
Nursing in America: From Breast to Bottle
(Cambridge, England: Cambridge University
Press, 1996); and Samuel H. Preston and
Michael R. Haines, Fatal Years: Child Mortality
in Late Nineteenth-Century America (Princeton,
NJ: Princeton University Press, 1991), 3-48.
41. See especially Molly Ladd-Taylor, ed., Raising
a Baby the Government Way: Mothers Letters
to the Children s Bureau, 1915-1932 (New
Brunswick, NJ: Rutgers University Press, 1986),
and "'Why Does Congress Wish Women and
Children to Die?': The Rise and Fall of Public
Maternal and Infant Health Care in the United
States, 1921-1929," in Fildes et al., eds., Women
and Children First, 121-132, for the fascinating
story of how women's suffrage helped pass the
Public Health Then and Now
Sheppard-Towner Act and physician jealousy
and right-wing hysteria doomed it. See also
Arthur Lesser, "The Origin and Development of
Maternal and Child Health Programs in the
United States," American Journal of Public
Health 75 (1985): 590-598.
42. See Katherine Elaine Bliss, Prostitution, Revolu-
tion and Social Reform in Mexico City,
1918-1940 (PhD dissertation, University of
Chicago, 1996), and Ann S. Blum, Children
Without Parents: Law, Charity, and Social Prac-
tice, Mexico City, 1870-1940 (PhD dissertation,
University of California, Berkeley, 1997).
43. Francesca Miller, Latin American Women and
the Search for Social Justice (Hanover, NH:
University Press of New England, 1991), espe-
cially chapter 4, "Feminism and Social Moth-
erhood, 1890-1938," 68-109. For more on the
development of women's rights in Mexico, see
Anna Macias, Against All Odds: The Feminist
Movement in Mexico to 1940 (Westport, Conn:
Greenwood Press, 1982).
44. Carmen G6mez, "La Enfermera Sanitaria y su
Verdadera Funci6n Social," Revista Sanitaria
Mexicana (February 1939), 44.
45. La Comisi6n Femenil de La Antigua, Veracruz,
to President Avila Camacho, July 31, 1943. RG
Avila Camacho. Folder 151.3/493. Archivo
General de la Naci6n. Mexico City.
46. Paula A. Treichler, "AIDS, Gender, and Bio-
medical Discourse: Current Contests for Mean-
ing," in Elizabeth Fee and Daniel M. Fox, eds.,
AIDS, The Burdens of History (Berkeley: Uni-
versity of California Press, 1988), 190-266.
Treichler discusses the medical and literary con-
vention of viewing the female body, particularly
the vagina, as a carrier and transmitter of dis-
ease. Here it is the female's conscious (but igno-
rant) actions, both inside and outside the body,
that are blamed for maternal and child mortality.
See also Kathryn Carovano, "More Than Moth-
ers and Whores: Redefining AIDS Prevention
Needs of Women," International Journal of
Health Services 21 (1991): 131-142.
47. See annual reports of the Kellogg Foundation,
Battle Creek, Michigan, 1951-1989.
48. For example, Anthony R. Meashem and
Richard A. Heaver, India Famlily Welfare Pro-
gram: Moving to a Reproductive and Child
Health Approach (Washington, DC: The World
Bank, 1996).
49. See especially Bonnie Mass, Population Tar-
get: The Political Economy of Population Con-
trol in Latin America (Toronto, Ontario: Cana-
dian Women's Educational Press, 1976), and
Betsy Hartmann, Reproductive Rights and
Wrongs: The Global Politics of Population
Control and Contraceptive Choice (Boston,
Mass: South End Press, 1995) and her two
related articles in International Journal of
Health Services 27 (1997): 523-557.
50. See Sherry Arnstein, "A Ladder of Community
Participation," American Institute of Planners
Journal (July 1969): 216-224, and Antonio
Ugalde, "Ideological Dimensions of Commu-
nity Participation in Latin American Health
Programs," Social Science and Medicine 21
(1985): 41-53.
51. United Nations Development Program, Human
Development Report 1995.
American Journal of Public Health 407