1 Introduction

This chapter examines the strategic coalition between the military and the medical profession and how it impacted social policy development in the field of public health in Chile. Both, the military and medical doctors, advocated for policies that were driven by the aspirations of modern medicine on the one hand and the necessities of modern warfare on the other. When this coalition unfolded, Latin American nation states were experiencing a decisive phase of state formation and modernisation that provides the backdrop to the events traced in the following. The interdependency reviewed here is military rivalries and the exchange of concepts and ideas across national borders, while the complex causal mechanism at play relates to the demand for able men and public health concerns (Obinger et al. 2018, 11). Here, social policymakers and leaders of the military become aware that poor health of soldiers jeopardises military success and weakens national defence as well as national productivity. This insight, however, was the result of the rise of medicine as a discipline that led to a re-interpretation of health as a resource of the state and established state responsibility for the health of national citizens.

Recent historical studies (Agostoni 2016; Hochman 2011) argue that Latin American public health was established by doctors and politicians, and evolved around the fight against endemic diseases, vaccination campaigns and the introduction of concepts of hygiene. They highlight the political dimensions of public health and point out that “political doctors” in particular (Cueto and Palmer 2015, 65) demanded state intervention in health matters. While this is certainly true, the military also was an important actor that is conspicuously absent from the narratives established by historians.

This coincides with welfare history research in general in which the military is not considered (Obinger et al. 2020, 8), yet this absence also reflects the assumption that the Latin American state in itself owes little or nothing to war (Centeno 2002). In this view, neither the expansion of the state nor social spending was driven by military conflict, or military rivalries. Because Latin America experienced few interstate wars (Scheina 2003; Centeno 2007), military conflict, military interest, and military rivalries have met with little scholarly attention. Nevertheless, the observation of other Armed Forces and the preparation for wars—even if these never materialised—were an important factor in the development of the Latin American state and its policies.

This chapter first traces the origins of the understanding between the military and the medical profession that lay in their professionalisation, then focuses on the discovery of health as a social problem by physicians and the military, before the case study of Chile is briefly examined.

2 The Rise of the Military and the Medical Profession, and Their Relationship with the Latin American State

The causal chain analysed here hinges on modernisation and professionalisation—that is, education, career paths and specialisation—of medical doctors and military officers during the second half of the nineteenth and early twentieth century. The connection of both professions expands a well-studied causal chain of how professionalisation of certain groups can foster social policy at a specific point in history.

By the time the health of men, women and children claimed political attention and health was conceptualised as a social problem (González Leandri 2013, 24), doctors and military officers had professionalised. They had employed strikingly similar strategies to consolidate as professions: medical doctors and military officers had modelled their profession on European examples by analysing and importing European approaches and ideas, and both professions had founded specialised schools and translated European textbooks. In general, medical schools preceded the military academies: Argentina, for example, opened its first school of medicine in 1852, and a military school in 1900 (Nunn 1983, 47).

All over Latin America, the two professions would recreate European training settings, hire European instructors and invest in specialised libraries, although in some countries this would begin later than in the Southern Cone. But everywhere military professionalisation focused on the officers and worked from top to bottom (Nunn 1983). Furthermore, professional journals were founded to communicate, exchange and diffuse ideas and opinions within the respective countries and abroad. In this way, the journals also served to amplify the voices of the professions at a national and international scale; they also served to promote the profession’s interests. All of these similarities facilitated a meeting of minds that would lead to the coalition examined here.

When doctors “fought to establish lasting alliances with state power” (Cueto and Palmer 2015, 65), they stressed the uniqueness of their knowledge, demanded the monopoly on all matters of health, and sought the protection of their career paths and economic gains. In this they would be supported in Chile by the military, as the case study will show. By the last third of the nineteenth century, medicine already was a new “super science” capable of taking care of individuals and of societies as a whole, while military leaders likewise envisioned a universal role for the Armed Forces in republican society. In fact, military officers strove for expertise, modernity and closeness to the seat of power just as the medical doctors did. As an institution stemming from the wars of independence and closely connected to the colonial past, the military sought to readjust its position in the nation and its relationship with the state (McCann 2004).

Also, officers had first-hand evidence of European modernity: those who were sent to France and Imperial Germany to study modern warfare and to learn more about European armies encountered modernity within and beyond the barracks. This made them look for ways to reform not only the military but also the society back home. Here, different countries took different approaches: In Bolivia, for example, the military would take on different non-military tasks to claim a new relationship with society (Shesko 2011) while in Argentina the Armed Forces claimed to contribute to the education of the male population (Ablard 2017). This “teaching function” of the Brazilian army during the nineteenth century was as or even more important than defence (McCann 2004).

Nevertheless, the ultimate mission of the military was to win wars, which first and foremost required healthy soldiers. Thus, the interests of Latin American doctors and the military converged when poor health became an obstacle to modernisation and imperilled progress, depriving states of able male bodies for labour and combat, and of healthy female bodies for reproduction.

3 The “Discovery” of Health as a Social Problem

The insight that health has a medical and scientific as well as a social dimension, fundamentally changed the role of medicine in Latin American societies. Health became a complex field of state intervention that was also understood to entail questions of social order and economic progress (Armus 2000). Therefore, Latin American countries engaged in “the transformation of health into a public good, and the establishment of broad collective arrangements to produce this good” (Hochman 2011, 4). Public health was deemed necessary to preserve order, to secure progress and the future of the nation (Armus 2000); however, the social dimension of health had to be assessed before public health measures could be designed. This proved difficult for the Latin American nation states because they lacked specialised agencies that systematically collected policy-relevant information.

Although networks of individuals, new institutions and public agencies emerged, their reach and thus the information they could provide was limited: in the early stages, public health development was focused on urban centres (Cueto and Palmer 2015). Public health was advanced by urban physicians and policymakers who knew little about the national population in general. They knew nothing about remote areas of their countries when the majority of the Latin American population still was living in the countryside. Here, the state was furthermore often present only in abstraction. This was particularly the case because the national territory and the ethnically diverse populations had not yet been fully integrated into the Latin American republics.

It is remarkable that in the 1880s and 1890s the Latin American military, however, was present in out-of-the-way areas, building barracks, roads and hospitals that catered to the troops as well as the local population. Also, the military knew much about the poor male population that made up the troops and was familiar with the health conditions not just of the troops, but of the locals in general. While physicians assessed the problems of health in the urban centres, the military was able to discern health as a social problem in the poor neighbourhoods of the cities, and in the countryside. When both professions combined their first-hand knowledge, they were able to draw a more complete picture of the situation of the national population. Thus, doctors and military officers collected complementary policy-relevant information that was used to advocate for state intervention in public health.

4 A Case Study: The Coalition Between Doctors and the Military in Chile

Chile is a pioneer of social policy in Latin America; it is also an early example for the shared interests of military officers and medical doctors in the field of health. Chile may be a special case because it was centralised by the 1830s (Centeno 2002) and politically stable at a very early stage of nationhood. Chile won all its wars (Centeno 2002; Nunn 1983) and implemented general conscription in 1900 before other Latin American nations did. Also, Chile was famously preparing for a war with Argentina for most of the nineteenth and part of the twentieth century that never happened. While all of this may put Chile in an exceptional position, the country nevertheless provides a telling example of how the coalition between both professions was established and impacted social policy. It also raises questions that can be considered for other countries.

By Latin American standards, Chilean medical professionalisation started early: the centralised republic established the national university and national faculty of medicine in 1842. French, Italian and German professors of medicine were hired, and they trained a foundational generation of doctors, some of whom founded in 1872 the influential journal Revista Médica de Chile (Cruz-Cooke Madrid 1995). The number of physicians in Santiago increased, and because other professional options were scarce, first positions tended to be in military hospitals and the barracks (González de Reufels 2020). These doctors understood the organisation of the Armed Forces and its priorities; they also witnessed the military reforms during the last third of the nineteenth century that followed the War of the Pacific (1879–1883). During this crisis the military recruited physicians in large numbers who were also called to start a commission to train doctors for future wars (Cruz-Cooke Madrid 1995).

At the end of the nineteenth century new agencies such as the National Institute of Health (1892) were established with the cooperation of the military. These provided doctors with new opportunities for employment, yet the military remained an important option for employment. Fields such as military hygiene required close collaboration between leading circles of the military and medical doctors to, among other projects, revamp barracks and establish new routines for physical training. The biography of the first director of the National Institute of Hygiene furthermore epitomises the coalition analysed here. Federico Puga Borne (1856–1935) was an important physician who, like many others, had served during the War of the Pacific as medical doctor, and was the director of the sanitary service of the army (Cruz-Cooke Madrid 1995). While he never formally became a member of the Armed Forces, his remarkable career in medicine and in politics was marked by his closeness to the Chilean military.

It is important to note that this experience of working for the military had a lasting impact on medical doctors. It provided them with a future reference on the national poor based on the encounters with the troops. While their tasks gave the doctors access mainly to men, this nevertheless allowed them to draw conclusions for the health of women and children (González de Reufels 2020) and what to them were alarming morals and “bad habits” that undermined the health of the masses. High rates of sexually transmitted diseases in soldiers such as syphilis meant that women suffered from the disease as well. This required the control of prostitution, characterised in 1869 by a military doctor as the “shadow of the military” (González de Reufels 2020, 122), so doctors began to pressure the Chilean state to take measures. Tuberculosis and related diseases were as rampant as alcoholism that wrecked families, caused poverty and produced sick and weak national citizens (González de Reufels 2020). This also led to high infant mortality (Chávez Zúñiga 2019) that highlighted the shortcomings of welfare and medical progress. It furthermore endangered Chilean demography that also mattered to the military.

The military and medical doctors advocated for vaccination against smallpox, although liberal Chilean governments were reluctant to implement vaccination laws and the differences between the measures that were debated and the measures that were implemented became very clear (González de Reufels 2020). Here, both groups sought to protect the health of the general population and the troops of the present. When they argued for the fight on syphilis and on tuberculosis, they also hoped to secure the health of future generations, taking an active interest in the health of new-borns, young children and the training of mothers. This became a priority of the Chilean government in the early twentieth century, and an “Institute for Small Infant Care” was founded in 1906. This field of public health also was of concern to the military: in 1920 the military journal El Memorial del Ejército demanded in a long article that Chilean government should implement, among others, “ample laws to protect childhood as part of a solid social constitution” (Maldonado 1920, 194). There the military also advocated for restrictions on child labour, which were considered detrimental to the health of the young.

The coalition between the two groups reached into national politics in the early twentieth century (Cruz-Cooke Madrid 1995). As part of the national government, the coalition effectually implemented institutional changes, laying the foundations for further welfare development. When a military junta assumed power in 1924, medical doctors seized the opportunity to establish a ministry of health they had demanded for many years (Bennett Argandoña 1926, 243). This Ministerio de Higiene, Asistencia y Previsión Social was headed by Alejandro del Río Soto-Aguilar, who was a leading figure in medicine and involved in the creation of the National Institute of Hygiene (Cruz-Cooke Madrid 1995). Clearly, the coalition of medical doctors and the military also impacted institutional and bureaucratic development.

Finally, during the first Popular Front coalition, the two professions were willing to “defend the race”, as contemporaries put it. This became a topic in the early twentieth century, and it was argued for by medical doctors and the military alike. This is furthermore exemplified by former military doctor Carlos Ramírez Bravo who in 1938 referred to his experiences in the military (Ramírez Bravo 1938, 627) to demand active intervention by the national government because the mothers of the urban poor were allegedly slowly eroding the health of the Chilean masses (Ramírez Bravo 1938, 629) and degenerating the race. This, Ramírez Bravo wrote, forced physicians to take measures as the defence and the productivity of the fatherland depended on the health of its population.

In Chile, eugenic sterilisation was openly discussed during the final years of the 1930s. While this reminds us that at this time a growing number of Latin American doctors were advocating eugenics whose ethics they did not question, this calls to mind that the military was also in favour of it. But the reach of the coalition between the two groups had its limits, and these limits were set by other actors such as the Catholic Church. Thus, Chile debated but never implemented eugenic legislation.

5 Conclusion

Social policy development in the field of public health was in large measure driven by medical interests and specific military concerns. When the medical and the military professions rose and professionalised in the nineteenth century, they sought to establish alliances with the state and to impose their own views on which course public health was to take. The brief case study points out how a strategic coalition between the two groups had lasting and far-reaching implications for the policy field examined here; the coalition also affected their own progress as professionals.

This coalition was made possible by professionalisation, which started the complex causal mechanism examined here. It was also made possible by the opportunities the Armed Forces offered to doctors and was then advanced by shared experiences with the poor male population, the shared experience of war and, most importantly, by converging interests. These lay in the eradication of endemic diseases, the prevention of disease and the development of measures that would improve the health of civilians and the troops. At the same time, doctors and the military sought to make Chile a modern country inhabited by healthy people on whom the nation could rely in peace and war.

The dynamics of the coalition depended on past strategies of professionalisation and their lasting influence on, among others, the self-conception of the professions, shared attitudes and expectations. Here, the interdependency of the transfer of ideas and its impact is very clear. Because other Latin American countries also imported European models to professionalise both, medicine and the military, and sought to prevent deadly diseases and to improve the health of the population in general, it is fair to assume that the coalition observed in Chile occurred elsewhere as well. It is therefore necessary to study the points in history when these groups professionalised, examine the social policy measures they were particularly interested in and look for connections between physicians and military officers in different countries and different aspects of public health over time.

The convergence of interest between both professional groups and its impact on social policy become particularly clear with the concern for the health of Chilean children. Then both, medical doctors and the military, warned against the dangers posed to the country by sick future generations. Here the coalition between the two groups addressed the present and unfolded their vision for the future by demanding public health measures focused exclusively on children. Their nutrition, living conditions and physical training became a priority of the Chilean state whose public health development was particularly calibrated by two professional groups that joined forces.