Even a cursory survey of current geographic scholarship would evidence that research on human disease and health has expanded in recent years. Judging from the recently published special issue of the Annals of the Association of American Geographers, the state of geographical research on health is quite broad and draws from contributions across multiple subfields. Yet given the discipline's traditional strengths in examining the construction of place identities, critical development studies, and nature–society interactions, the implications for studies on human disease remain underemphasized. Key geographic subfields, including development geography and political ecology, have broadened their traditional areas of emphasis toward human disease by providing greater attention to environmental history, competing health imaginaries, and disease discourses. Outside of geography, the fields of public health and environmental history have broken new ground in showing how infectious disease is produced by human activities while efforts at control can be power-laden and contested. Simply put, the sociopolitical dimensions of infectious disease are receiving expanded attention from across the social sciences, and geography is well positioned to contribute.
Eric D. Carter's book Enemy in the Blood: Malaria, Environment, and Development in Argentina arrives at a particularly opportune moment to engage with these emerging currents. Enemy in the Blood is a historical examination of malaria eradication campaigns in Argentina with a particular focus on how these initiatives have been intermingled with geographical imaginaries of certain regions and sometimes aggressive landscape transformation. Weaving together detailed archival analysis with interviews and oral histories of public health officials, the book demonstrates the coproduction of place and disease, arguing that a geographical imaginary of northwest Argentina as a malarial zone was produced by certain social actors from the time of malaria's discovery in 1890 until its eradication in 1950. Central to Carter's analysis is the contention that malaria control needs to be seen as a political issue that was entangled with competing techno-scientific understandings of the disease and development agendas on the ground. Carter evidences the value of intensive historical analysis of disease–environment interactions and their value for a number of geographic fields, including political ecology, development studies, and historical geography.
Carter explains that the geographical imaginary of malaria was facilitated by its general isolation in the northwest, which then enabled elites to justify particular development interventions that advantaged urban planners and centralized agriculture. What is particularly notable about Carter's analysis is his demonstration of how public health campaigns, in this case malaria eradication, were about much more than the disease. Rather, these campaigns were waged on a wider canvas that unveiled deeper concerns about the body politic and nation. Malaria eradication was seen as necessary to the life and vitality of the Argentinian state, in essence becoming a marker of national progress. This enabled a host of elites to take advantage of the disease to advocate for development interventions ranging from agricultural intensification to urban sanitation. Carter documents a key shift in early thinking about malaria in Argentina, specifically the decline of miasmatic theory in explaining malaria etiology. Miasmatic theory emphasized that malaria was a disease of the environment that was produced by corrupted landscapes such as marshes and swamps. Carter explains that a hybrid miasmatic-microbiological framework resulted in malaria control being coupled with other sanitation efforts, including those for potable water and sewage systems. In essence the specter of malaria was mapped onto northwest Argentina with blame assigned to particular landscapes that required sanitation. Leading figures in the malaria eradication movement, particularly Dr. Eliseo Cantón, advocated a rationalized approach that included sanitizing landscapes through drainage, cultivation, tree plantations, and other land uses. Carter argues that miasmatic theory facilitated the transformation or outright removal of particular human settlements including sewers, cemeteries, and prisons. This form of environmental sanitation, or saneamiento, was the dominant approach to malaria control for decades.
As richly detailed in one of my favorite chapters of the book, it would not be until the 1930s when Cantón's saneamiento model would be replaced by a new approach to malaria control, one more firmly grounded in the etiology of malaria and mosquito ecology. Central to this shift was Dr. Carlos Alberto Alvarado, who in leading the Malaria Service challenged previous assumptions with documented scientific studies. Arguing the importance of thinking like a mosquito, Alvarado championed a narrower view that drew on and expanded knowledge of the anopheles mosquito with effective results. Carter points out that Alvarado emphasized rigorous experimentation and an empirical methodology that was previously absent from public health campaigns. Taken together with an ecological framework that emphasized species sanitation, a new approach was advanced that by the 1950s would prove effective in eradicating malaria. The widespread use of DDT was the final, and perhaps decisive, factor in ending the public health campaign. Although Carter notes that DDT is widely credited with the demise of malaria in northwest Argentina, his analysis asserts that its effectiveness was enhanced by its positioning within the Alvarado model of malaria control.
One question that lingered in the reading of this impressive book was the coupling of economic development with infectious disease. Carter seems to insist that the presence of malaria in northwest Argentina facilitated particular economic development interventions to transform the landscape to improve human health. Yet in interpreting the occasionally contradictory approaches pursued by local governmental officials and landowners, it is unclear how coherent these approaches actually were over time and space. Additionally, although Carter asserts at key points that malaria “controlled the prospects of the region,” the rates of prevalence and generally low incidents of mortality suggest that this was largely a narrative to justify particular development interventions. As such, one wonders how central malaria actually was to the geographical imaginaries of northern Argentina. In other words, was malaria the trigger for economic development as presented in this book, or was economic development simply justified as needed to manage infectious diseases, including malaria, within the perceived disease region in the north?
A final point is the recognized challenge of constructing a complete historical account of an infectious disease such as malaria. Carter asserts that the Northwest's malaria problem was an object of interest to a broad constellation of social actors, including conservative aristocrats, state public health agents, entomologists, epidemiologists, engineers, physicians, and labor rights activists, but the book does not give these groups equal weight. Rather, the perspectives of a small number of governmental officials are given the most credit for producing the dominant malaria orthodoxies within Argentina. This is a credible analysis but an unfortunately incomplete one. Largely silent are the populations that lived and died from malaria, which would have helped contextualize the experiences of the region while also documenting an important point made in the volume; namely, that although malaria was widely prevalent in the region it was not a major cause of mortality. Silent also are the other infectious diseases that populated the region at this time such as tuberculosis, or Chagas disease, which so preoccupied one of the leading malaria figures, Salvador Mazza, that a feud with Carlos Alvarado resulted in his isolation from the malaria campaign. As such, it is unclear exactly how central malaria was in the presentation of the unhealthy north compared to other health challenges. Much as the discussion of malaria overwhelms the broader development approaches in the region, it also negates the potential role of other infectious diseases that might have informed state perspectives and responses.
These minor points aside, this is a much needed volume that attends to the sociopolitical dimensions of infectious disease. Carter brings together historical documents with a place-based analysis to inform the production of malaria eradication campaigns in Argentina in a way that offers much to the social sciences. Enemy in the Blood serves as a model for the benefits of geographic frameworks for studies on human disease and should inform future research not only within geography but also in related disciplines.