Hochman, Gilberto. 2016. The Sanitation of Brazil: Nation, State, and Public Health, 1889-1930. Translated by Diane Grosklaus Whitty. Urbana, Chicago and Springfield: University of Illinois Press.

In his book, The Sanitation of Brazil, Gilberto Hochman seeks to answer the question, “when does health become public?” More importantly, under what circumstances do individuals in a position to do so decide that only the state can fulfill the responsibility of protecting the people’s health? What is the process by which the state assumes this responsibility and, specifically, how does change come about through the efforts of individuals pushing the bureaucracies they administer and control? Finally, and this is the most valuable insight of the book, what is the relationship of implementing and altering national health policy to the formation of the state? Does state-building play a role in expanding public health? Since the issue of public versus private regarding the servicing of healthcare has been politically fraught in many societies, especially the United States, Hochman’s study provides valuable insights that extend beyond Brazil.

Hochman displays a solid understanding of not only the politics surrounding health policy in Brazil, but also brings in helpful comparisons with the United States, and to a lesser extent other countries. The involvement of the Rockefeller Foundation is particularly relevant to understanding outside expertise in advancing public health in Brazil. Originally published in Portuguese in 1998, the book appeared in English translation in 2016. It is to the credit of the University of Illinois Press that a valuable contribution to the study of public health is now available to an international audience researching and writing about the history of science. Because of the near decade-long delay in publishing the book in English, Hochman and his excellent translator, Diane Grosklaus Whitty, worked together to provide an updated and lucid book.

The heart of Hochman’s study is a detailed analysis and timeline of the controversies and power struggles involved in the development of a national healthcare system during the First Republic (1889–1930). As his purpose is to demonstrate the close ties between public health and state-building, Hochman moves beyond studies of sanitation campaigns in the Federal District of Rio de Janeiro during the same period and the early, successful sanitation of São Paulo. The real test of nationhood and healthcare rested in the rural areas. The book argues that the rural health campaign had two outcomes. On the one hand it spotlighted the people’s interdependence in the face of combatting communicable diseases, while on the other it championed the idea that the prevention of contagion is a national, not regional, project. Hochman asserts that the health and sanitation campaign in the country at large “provided the means by which the 1891 constitution could be extended to draw together the entire nation.” In the final notes to the book, he expresses his admiration for the policymakers in the First Republic who pushed for a national health policy. As we have unfortunately seen in the past years of managing the Covid-19 pandemic, making a policy endure is the current challenge. Even a solid public health system can be severely damaged under incompetent leadership, opportunist undermining of scientific practice, and private entrepreneurs willing to sacrifice the greater good health of a population on the altar of quick profits.

In his final chapters Hochman points to the advances in São Paulo’s sanitation campaign, which matched the “advanced nations” in Europe and North America. North America, or the United States at least, in the early 20th century had a federated, racist system. The poor states in the US South, where the population is highly African descendant, were excluded for much of the century from enjoying the benefits of a national health plan, and still lag far behind. Yet today it is ideology rather than science that prevents conservative white leaders from providing health care to the poor, which in the US occurs under Medicaid extensions. In this light, the comparison with São Paulo’s successful sanitation drive on a regional level is instructive. The regional contradictions that interfered with the provision of healthcare in the poor, large African-descendant Northeast resulted from racism. The success in São Paulo occurred because of the immigrant dynamic in a whitened developing economic powerhouse that proved to be a model for the nationwide program.

This book was written before some important studies of race and regional identity, most notably Barbara Weinstein’s The Color of Modernity. Weinstein shows that São Paulo’s economic development has been interpreted in juxtaposition to the “backwardness” of the Northeast. To a great extent avoiding the starkly racial terms that infuse the discourse of north versus south in the United States, Brazil’s regional story rests on unspoken racial innuendo. I could not help but think of Weinstein’s book as I read Hochman, wondering why he had not included at least some reference to Brazil’s history of racial and class prejudices. He generalizes about “elites” without probing the class and racial/ethnic interests the elite represented. Hochman discusses eugenics with little mention of the racial and class stereotyping upon which eugenics is founded.

This well-organized and readable book provides a trove of information on the development of Brazil’s public health agencies, the political forces that promoted the health and sanitation drives, and the force individuals exerted in moving bureaucracies to implement national health policies.