Conjuring the State: Public Health Encounters in Highland Ecuador, 1908–1945 by A. Kim Clark (review)

Reviewed by: Conjuring the State: Public Health Encounters in Highland Ecuador, 1908–1945 by A. Kim Clark Jasmine Gideon (bio) Conjuring the State: Public Health Encounters in Highland Ecuador, 1908–1945 By A. Kim Clark. Pittsburgh: University of Pittsburgh Press, 2023. Pp. xiii + 208. In this highly engaging book, Clark explores the creation of a public health service in Ecuador in the early twentieth century. In essence, the book is a historical analysis of the interconnections between several different technologies, most notably the development and spread of medical knowledge as evidenced through the growing control over the spread of infectious disease, alongside the development of the railway, which facilitated the spread of bubonic plague across Ecuador. Clark employs historical and political anthropological approaches in her work and bases her analysis on a rich source of uncatalogued archives of letters and documents from a variety of stakeholders. This allows her to produce a fascinating institutional ethnography of the establishment of the Servicio de Sanidad. Clark is not the first scholar to consider the complex process of state formation, including in a Latin American context. Among several influences, she highlights political geographer Joe Painter's assertion that the "everyday or prosaic practices can help our understanding of state formation" (p. 10). Moreover, Clark underlines the gendered and racialized nature of these everyday practices, which she previously examined in her book Gender, State, and Medicine in Highland Ecuador (2012). As Clark notes, few studies have analyzed the question of state formation through a focus on public health, and here she acknowledges Paul Farmer's analysis of Ebola in West Africa in Fevers, Feuds, and Diamonds (2020), one of the first books to differentiate between "containment" and "care" in disease eradication. Clark's analysis starts in 1908, when although the laboratory identification of the bubonic plague pathogen had already occurred, many questions around its transmission remained. Unfortunately, as Clark contends, the arrival of plague in the port city of Guayaquil, Ecuador, also coincided with the near completion of the new railway line linking the city with the capital city, Quito, and providing connections between Ecuador's five largest cities. Given the lack of treatment options for plague at the time, containment of the disease was vital, and this became the focus of local health board initiatives in Guayaquil. In effect, the city provided a testing ground for subsequent interventions. Yet, although this was important work potentially bringing health benefits to the population as a whole, there were clearly some very problematic and frequently racialized impacts of these developments. Officials relied on forced labor, often Indigenous peasants, to conduct the "dirty" End Page 681 frontline work of the anti-plague campaign, resulting in significant deaths among Indigenous communities. The book traces how, as scientific knowledge around plague transmission grew, this underpinned the nationwide expansion of the public health service. Clark highlights the exchange of letters between early public health officials and notes how many of these relationships were also very personal—exchanging family news—as well as professional. Inevitably, the problem of plague moved along the new routes opened up by the railways, and the need to control the spread of plague became ever more urgent. Clark reveals the challenges encountered by those doctors who used their scientific knowledge to push forward the construction of the Servicio de Salud. Moreover, the evolution of the Servicio also represented a radical transformation of understandings of "health." Previously, doctors were focused on individual encounters with patients and concerned only with addressing their particular symptoms. In contrast, the notion of "public health" forced not only doctors but the state as a whole to consider health as a vital matter of public concern. Public health officials came to understand the importance of recordkeeping—carefully documenting issues of concern such as every new case of plague—and how this data could help inform their understanding of the nature of the disease. Subsequent chapters examine the challenges faced by public health officials as they advocated for greater authority in order to effectively implement necessary legislation to protect the health of the population. For example, officials were given powers to conduct domestic inspections to ensure toilets were installed to comply with new sanitation...