A debate over the link between Salvador Allende, Max Westenhöfer, and Rudolf Virchow: contributions to the history of social medicine in Chile and internationally^*

Abstract

In the history of Latin American social medicine, numerous works have presented a harmonious link between Rudolf Virchow, Max Westenhöfer, and Salvador Allende, which establishes the origin of ideas of Latin American social medicine in a prestigious European source, represented by Virchow. A key to that story is that Allende was a student of Westenhöfer, a disciple of Virchow who lived in Chile three times (1908-1911, 1929-1932, and 1948-1957). Based on primary sources and contextual data, this article problematizes the relationship between Allende and Westenhöfer, and questions the influence of Virchow in Chilean social medicine.

Salvador Allende (1908-1973; Max Westenhöfer (1871-1957; Rudolf Virchow (1821-1902; social medicine; Chile

Resumen

En el marco de la historia de la medicina social latinoamericana, numerosos trabajos historiográficos han presentado un vínculo armónico entre Rudolf Virchow, Max Westenhöfer y Salvador Allende, afirmando una procedencia virtuosa de las ideas de la medicina social latinoamericana en una prestigiosa fuente europea, como es la que representa Virchow. Un dato crucial en ese relato es que Allende habría sido estudiante de Westenhöfer; un discípulo de Virchow que vivió en Chile en tres ocasiones (1908-1911, 1929-1932 y 1948-1957). Este trabajo problematiza, usando fuentes primarias y datos de contexto, la relación entre Allende y Westenhöfer, y cuestiona la influencia de Virchow sobre el pensamiento médico-social en Chile.

Salvador Allende (1908-1973; Max Westenhöfer (1871-1957; Rudolf Virchow (1821-1902; medicina social; Chile

The importance of Salvador Allende as a leading figure in Chilean social medicine is indisputable, for a variety of justifiable reasons: his participation in the well-known group of leftwing doctors who called themselves the Vanguardia Médica during the 1930s; the incisive analysis of his book La realidad médico-social chilena – a text published in 1939 during his term as minister of Health during the Popular Front government of 1939-1942 –; his persistent legislative activity to build a national health care system; and the progressive health policy he promoted during his term as president, representing the Popular Unity coalition between 1970 and 1973 (Illanes, 2010; Labra, 2004; Molina Bustos, 2010). However, when Allende is portrayed as one of the protagonists of social medicine at an international level, it is often claimed that he was a student, and even a disciple, of Max Westenhöfer, a German scientist and professor at the Medical School of the University of Chile, who in turn was a student of Rudolf Virchow back in Germany. Virchow is often recognized in the history of Western medicine as the founder of social medicine, which gives the scholarly connections between Virchow and Westenhöfer, and later between Westenhöfer and Allende, the special meaning of a continuous intellectual genealogy that suggests the evolution of a coherent project of social medicine at a transnational scale and over the course of many decades.

The description of this link (Virchow-Westenhöfer-Allende) is found in many works, although it is more common in the English-language literature in history of medicine, public health, and the human right to health in Latin America (Paluzzi, 2004, p.764; Porter, 2006, p.1668; Brown, Birn, 2013, p.19; Apráez Ippolito, 2010, p.4; Hartmann, 2016, p.2145; Gaffney, 2018, p.67). In a book on the concept of the human right to health, Adam Gaffney, a writer from the United States, offers a typical example of claims about this connection:

Virchow’s influence also had an international reach. His ideas were influential on Latin American social medicine, which was in part the result of the emigration of some of his pupils to Latin America in the late nineteenth century. One such individual, Max Westenhöfer, became the director of the department of pathology at the University of Chile, where he influenced the future President of Chile, Salvador Allende, who in turn wrote both an influential social medicine text and introduced legislation that led to Chile’s National Health Service (Gaffney, 2018, p.67).

Even though this way of telling the history of Latin American social medicine is widespread, and sounds plausible enough, until now no one has stopped to ask these important questions: is it true? Is there evidence to support such claims?

The goal of this article is an effort to correct, on the basis of direct and contextual documentary evidence, this piece of received wisdom in the history of Latin American and Chilean social medicine. Specifically, in this article we express our reasonable doubt about the existence of any direct and substantial link between Westenhöfer and Allende. This might be viewed as a small error, understandable for writers who do not have firm grounding in the history of Chile in the first decades of the twentieth century, but the reiteration of this claim is part of a larger tale; thus, this small correction has much larger consequences, as we hope to show here.

First, the very idea that Allende was a student of Westenhöfer in the Medical School of the University of Chile in the early 1930s does not have solid foundations in the available sources. And, beyond the absence of this particular connection, it is unreasonable to argue that Westenhöfer’s political or philosophical ideas had any influence on the social medicine ideology of Salvador Allende. Moreover, it does not appear that Allende, or his circle of leftist doctors in the Vanguardia Médica, recognized Virchow as an icon or predecessor. The recognition of Virchow as a precursor in Latin American social medicine is a historiographical innovation of the last four decades, and this is not a genealogy that many in the field of social medicine in the region would have acknowledged in the first half of the twentieth century.

Thus, this article seeks to make a contribution towards a new way of looking at the history of social medicine and collective health in Latin America. Starting in the 1970s, approximately, there has been a resurgence of social medicine in Latin America, with recent historical studies addressing biographical trajectories and international networks in the field (Galeano, Trotta, Spinelli, 2011; Birn, Brown, 2013), analysis of the scientific production in journals that specialize in social medicine (Spinelli, Librandi, Zabala, 2017), and histories of institutions such as the Latin American Association of Social Medicine (Asociación Latinoamericana de Medicina Social – Alames) (Rojas Ochoa, Márquez, 2009) and Brazilian Association of Collective Health (Associação Brasileira de Saúde Coletiva – Abrasco) in Brazil (Lima, Santana, Paiva, 2015). Nevertheless, it is not easy to connect contemporary social medicine with the social medicine of the past; not only was there a long period where the project of social medicine seemed to wane in importance in the middle of the twentieth century, but also there are distinctive epistemological and ideological differences between the two major “waves” of social medicine. Among other things, the “new” social medicine is distinguished by a strong contribution from Marxist (and post-structuralist) theories to problematize the dominant positivist and functionalist tendencies in the discourse of international public health (López Arellano, Peña Saint Martin, 2006).

In spite of these and other important differences, the allusions to historical continuity in the ideology of social medicine since (at least) 1848 are commonplace (Krieger, 2003), and the supposed link between Virchow and Allende, via Westenhöfer, serves this historiographic agenda. Referring to the European context, Dorothy Porter and Roy Porter (1988, p.93) pointed out that “the history of ideas about social medicine brings to light many competing – often contradictory – systems of belief;” thus, we argue that the narrative we are questioning may distort or overshadow certain important components of the history of social medicine by reducing it purely to a project of the political left, when in reality it was a relatively open field – in the sense of ideological pluralism – and from today’s perspective full of nuance and lacking in philosophical coherence.

A history of social medicine in Latin America should also be situated in the context of the health sciences as they developed in the first half of the twentieth century. We suggest that many of the protagonists of social medicine had complex professional and intellectual identities that led them to link with different national and international scientific networks. Specifically, we propose that Westenhöfer brought Virchow’s knowledge in the field of pathological anatomy to Chile, without necessarily being committed to sharing and disseminating the political thinking of his teacher. In more general terms, it is necessary to carefully examine the relationships between different scientific fields and analyze their contributions to social medicine in detail, in the Latin American case.

On the other hand, we recognize that it is almost impossible to prove a negative; that is, to verify that Allende was not influenced by the socio-medical thought of Virchow and his disciple Westenhöfer. Nevertheless, we argue that there is no direct evidence of such a sequential and consistent link between the three doctors and that there is also circumstantial evidence, in both primary and secondary sources, to support our contentions.

Because of his political, social, cultural, and humanistic influence, the figure of Doctor Salvador Allende Gossens – democratically elected president of Chile, overthrown by a military coup in 1973 – will likely always be situated in a disputed historiographical space. Not only are there serious historiographical disputes about Allende as a doctor and minister of Public Health of the Popular Front government of Pedro Aguirre Cerda (Sánchez Delgado, sep. 2017), but also Allende has been the object of defamatory treatment by conservative writers. In this context, we highlight the controversy generated by a series of works by Chilean philosopher and historian Víctor Farías (2005), in which he tried to associate Allende with racist and fascist currents in his approach to crime and eugenics. Our article does not aspire to offer a balanced or final judgment on Salvador Allende in social medicine, a field in which, for the reasons already mentioned, his value and contribution are undeniable. But we maintain that a history of Chilean social medicine centered almost exclusively on the heroic figure of Allende, as a direct descendant of Virchow, is quite problematic.

In the following section, we explain the origins of the story that we challenge as incorrect or dubious, then we give our reasons for disputing the Virchow-Westenhöfer-Allende connection. Next, we explain the consequences for the historical interpretation of Chilean social medicine, and for the broader historiographic practice of either questioning or continuing to maintain the importance of this connection. To finish, we propose an alternative narrative, in which the correction of a small body of facts has enormous consequences.

The birth of a tale

As mentioned in the introduction, the link between Virchow, Westenhöfer, and Allende has already become a kind of conventional wisdom in the historiography of Latin American social medicine. This story seems to originate in the work of Howard Waitzkin, an expert in, and passionate advocate of, Latin American social medicine. Waitzkin has mentioned the existence and importance of the link between Westenhöfer and Allende in several works (Waitzkin et al., 2001b, p.1592; Waitzkin, 2005, p.739; 2006, p.8; 2011, p.159). Waitkzin (2006, p.8) writes: “Max Westenhöfer, a leading German pathologist influenced by Virchow, led the department of pathology at the Medical School of the University of Chile for many years and influenced generations of students, including Salvador Allende, medical student and activist and future president of Chile.” A master-disciple type of relationship is logically implicit in this statement, while in works that cite Waitzkin it becomes a concrete teacher-student relationship (e.g., Porter, 2006, p.1668; Apráez Ippolito, 2010, p.4).

In this context, Waitzkin’s biography and intellectual trajectory are of interest. After the 1973 coup in Chile, he became a defender of the overthrown regime and its health policy. Early on, he explained the nefarious geopolitical maneuvers behind the military coup in Chile to an audience of medical professionals in the United States, in the pages of the New England Journal of Medicine, one of the most important medical journals in the country (Waitzkin, Modell, 1974). Hilary Modell, Waitzkin’s collaborator in that article, lived in Chile during the months of political upheaval that resulted in the 1973 coup and played an active role in a health promotion program of the Popular Unity government. At the same time, it would not be an exaggeration to say that the overthrow of Allende produced a very active response among progressive doctors and the political left at the international level; these actors made efforts to support the Chilean doctors in exile after the coup, and this activity was an important factor in the revival of social medicine (in Brazil, saúde coletiva, or collective health) during the 1970s (Apha…, 1977, p.71-73; Waitzkin et al., 2001a, p.315-323; Birn, Brown, 2013, p.151-152). Early on, Waitzkin joined Alames, helped build an online bibliographic database on social medicine in Latin America, and, in the early 2000s, began to publish a series of important and valuable research articles on the history of social medicine internationally, in English and Spanish.

It is not our intention to question the great value of Waitzkin’s intellectual and political work in the field of social medicine. In addition, the story we criticize already seems to have taken on a life of its own, gradually changing with its reiteration in academic writing and taking on meanings, connections, and uses that cannot be attributed to Waitzkin alone.

Max Westenhöfer, between Germany and Chile

The trajectory of Westenhöfer (the spelling of the surname varies in the sources) is not as well known as those of Virchow or Allende. Born in Bavaria in 1871, he excelled as a doctor in the German army, and with the support of his mentor, Rudolf Virchow, he became head of autopsies at La Charité Hospital in Berlin. Westenhöfer was in Chile four times: three times in long residencies and once on a somewhat shorter visit, in 1938. He was professor of pathological anatomy at the University of Chile between 1908 and 1911 (Sánchez Delgado, 2018a). It should be noted that, from his arrival in Chile, Westenhöfer was a great defender and disseminator of the work of his teacher Rudolf Virchow in the field of pathological anatomy, as is clear from the inaugural lecture he read there in 1908, in which he presented Virchow as a genius who followed the paths “of morphology; that is, Pathological Anatomy; that of pathological physiology, that is, the observation of the patient; and lastly, one that summarizes and completes the two previous ones: pathological experimentation” (Westenhoeffer, 1908, p.880). Westenhöfer’s devotion to Virchow would always be related to pathological anatomy, while it is less evident that he ever defended Virchow’s political or socio-medical ideas in the Chilean context. In an article published in Germany in 1911, Westenhöfer analyzed the causes of morbidity in Chile and denounced the terrible state of health among the poor, which he blamed directly on governing elites and the local Catholic church. But this study was unique in Westenhöfer’s body of work in Chile, and moreover it was only translated to Spanish at the end of the 1950s, after his death (Sievers Wicke, 1958, p.88-126).

Westenhöfer then lived in Chile between 1929 and 1932, when he was hired by the Junta Central de Beneficencia to train doctors in pathological anatomy at Hospital El Salvador in Santiago. In the library of the hospital’s Institute for Pathological Anatomy – which was specially built for Westenhöfer’s task – he placed a bust of Rudolf Virchow (Westenhoefer, 1931), which, in an archival photograph, seems to keep vigil over the intellectual activity of Chilean anatomical pathologists from the heights of the reading room. Thus, Westenhöfer’s actions in Chile reveal clearly that he was an admirer and follower of Virchow’s clinical ideas and practices, but they say very little about his defense of Virchow’s political ideas, or a body of concepts clearly recognizable as “social medicine.” Westenhöfer later visited the country in 1938 as cultural ambassador of the Third Reich and finally departed from a defeated Germany in 1948, living in Chile from that date until his death in 1957 (Sievers Wicke, 1958, p.15-18).

Westenhöfer and Allende

So, then, what personal or professional links were there between Salvador Allende and Westenhöfer? When Westenhöfer was a professor of pathological anatomy at the Medical School of the University of Chile between 1908 and 1911, Allende was of preschool age (he was born in 1908), so we must seek out the possible link in the second period; that is, from 1929 to 1932, when Allende was a student at the School of Medicine. But during that period, Westenhöfer was in Chile under contract with the Junta Central de Beneficencia, with the task of training a select group of doctors to assume the services of pathological anatomy in the hospitals that belonged to that institution, in Santiago’s Hospital El Salvador. Allende was not part of that group and had not even finished his medical studies at that time; he completed medical school with the acceptance of his thesis on “Mental hygiene and delinquency” in 1933 (Sánchez Delgado, sep. 2017, p.22-23). Westenhöfer’s position in Chile from 1929 to 1932 was set up by his closest disciples, those trained during his first stay in the country, between 1908 and 1911. By the end of the 1920s they had positions of power in the Junta Central de Beneficencia and they brought Westenhöfer to Chile to train the doctors who would be the future chiefs of the departments of pathological anatomy in the most important hospitals in the country.

The task entrusted to Westenhöfer, to train the anatomical pathologists of the Junta Central de Beneficencia, was made possible by the political context of the presidency of Carlos Ibáñez del Campo, who assumed power in 1927 and who, during this presidential term, implemented policies that reflected his increasingly nationalist and authoritarian corporatist tendencies. When the Ibáñez government went into crisis, it became clear to everyone involved in the direction of the Junta Central de Beneficencia that there was no longer political support for Westenhöfer’s stay in Chile, and he returned to Germany in 1932, just at the moment when his work as a master teacher in pathological anatomy was starting to bear fruit. At the same time, it should be noted that Salvador Allende joined the leftist group Avance, which was opposed to Ibáñez, and that all his biographers report that Allende was a student activist vehemently opposed to the Ibáñez regime (Figueroa Clark, 2013, p.22-23). So it is not surprising that, at a farewell banquet organized for Westenhöfer by the pathologists he trained between 1929 and 1932, the name of Salvador Allende is not among the detailed list of attendees, which included more than 100 doctors and medical students (Los medicos…, 5 oct. 1932).

In addition, it is essential to clarify that between 1929 and 1932 Doctor Max Westenhöfer had no systematic or formal academic activity at the University of Chile. His employer was the Junta Central de Beneficencia and he devoted all his energy to creating the Institute of Pathological Anatomy of Hospital El Salvador, in the capital, and training the anatomical pathologists who would direct similar services in other hospitals administered by the board. There is plenty of evidence to support our claim. For example, when the political landscape became adverse for Westenhöfer in 1932, some initiated a campaign to keep him in the country, and in that context El Mercurio newspaper in Santiago wrote: “As is known, he was hired by the government of Chile to direct the services of Pathological Anatomy of the Junta Central de Beneficencia” (La prolongación…, 28 jul. 1932, p.9). Further proof comes from drafts and final copies of the agreement forming the Institute of Pathological Anatomy, directed by Westenhöfer between 1929 and 1932; this document is found in his archive at the Ibero-American Institute of Berlin, with the title “Bases y condiciones fijadas por la Junta Central de Beneficencia, por acuerdo N° 29 del 13 de Julio de 1930, para el funcionamiento de su Instituto de Anatomía Patológica y para la matrícula de los alumnos” (Westenhoefer, 1931, p.4-5). This contract was approved, stating that Max Westenhöfer was “Director of the course” and Doctor Ismael Mena the prosector (p.4-5). From the same documents and in others it is possible to see exactly those enrolled on Westenhöfer’s course; Salvador Allende is not on the list and is never mentioned among the pathologists in training. The course of the Institute of Pathological Anatomy of El Salvador Hospital was comprised of Doctors Juvenal Barrientos, Hardy Bremmer, Ismael Mena, Eduardo Calderón, Hernán Apablaza, Alberto Guzmán, Héctor Rodríguez, Ernesto Herzog, and Ernestina Peña. Some members of this course and other Chilean students of Westenhöfer’s formed a tight circle around the German teacher and shared cultural and political affinities; that is, a nucleus of disciples formed around Westenhöfer, within which there was a smaller group that admired Nazism and welcomed the extermination of the Jews (Sánchez Delgado, 2018a).

The work of Westenhöfer as an instructor in pathological anatomy in Chile does coincide with the beginnings of Salvador Allende’s career. In 1932, mainly for economic reasons, Allende worked as an assistant in pathological anatomy at Hospital Van Buren in Valparaíso. Undoubtedly, this position was important in his scientific and political education. As he expressed in his well-known 1939 book, his previous experience as a pathologist inspired him to conduct “a succinct and objective examination of our socio-medical reality,” and many years later, Allende would testify before a session of the national Senate: “These hands ... they have conducted 1,500 autopsies, I earned my daily bread by putting them in pus, cancer and death, but I earned it honestly” (Allende, 1999, p.8; Diario…, 12 mar. 1968, p.2629; Figueroa Clark, 2013, p.30). We could speculate that the future Chilean president was linked to the pathological anatomy training that Westenhöfer conducted in the country between 1929 and 1932, since this scientific field in Chile at that time would have encompassed a very small circle of people. But Allende’s practice of pathological anatomy in Hospital Van Buren does not demonstrate that he was a student of Westenhöfer; rather, Allende assumed this role while the head of that department, Doctor Hernán Apablaza, trained in Santiago with the German professor. After a couple of years of work as a pathologist, Allende embraced politics and Apablaza continued as director of the Institute of Pathological Anatomy of the same hospital (Caorsi, 2017; Reunión Anual…, 1935, p.567).

In addition, in no work written by Allende, nor in any interview with him, nor in any news report about Allende, is Westenhöfer (or, indeed, Virchow) ever mentioned, with one exception. The only documented personal encounter between Allende and Westenhöfer was at a testimonial dinner that the most dedicated group of Chilean disciples held for Max Westenhöfer at the University of Chile in 1951, which Allende attended in his capacity as president of the Colegio Médico de Chile at that time; that is to say, an encounter of an institutional character, when Westenhöfer no longer exerted any formative role and Allende was already an experienced politician. On March 30, 1951, the newspaper El Mercurio of Santiago noted that “the medical corps of Santiago will pay tribute today to Dr. Max Westenhoeffer, in recognition of the work he has done for many years in the teaching of medicine and in the organization of hospital services” (Hoy cuerpo…, 30 mar. 1951, p.29). If in principle the homage to Westenhöfer was presented as part of a recognition by the entire national medical corps, this event was actually organized by the Normal and Pathological Society of Chile (Sociedad de Anatomía Normal y Patológica de Chile); that is, mainly by the students of the German doctor trained between 1929 and 1932. According to the reports of this celebration, Westenhöfer’s impact in Chile was perceived clearly – as is still the case today – in the field of pathological anatomy. In the aforementioned homage, Doctor Ismael Mena highlighted him “as the founder of pathological anatomy in Chile” (Prof. Max…, 31 mar. 1951, p.27), without any allusions to an influence of Westenhöfer in relation to social medicine or to the diffusion of the ideas of his teacher Rudolf Virchow in that field. The speech by Salvador Allende, who, again, attended the tribute as part of his position as president of the Board of the Medical College of Chile (Colegio Médico de Chile), did not focus on social medicine or even on Westenhöfer himself, but dealt with “the evolution of medicine so far in this century and how the Chilean doctors have placed themselves today at the forefront of progress” (Prof. Max…, 31 mar. 1951, p.27). In this tribute of March 30, 1951, the minister of Health, Doctor Jorge Mardones, also participated, by giving Westenhöfer a medal, and the general director of Health, Doctor Nacianceno Romero, gave him a diploma that recognized him as an honorary member of the Chilean League against Cancer. Consistent with all the above, Westenhöfer’s thank-you speech did not touch on social medicine or Virchow at all, but rather dealt directly with “the progress of studies of pathology in Chile” (Prof. Max…, 31 mar. 1951, p.27).

Although he was a pupil of Virchow, Westenhöfer seems to have followed his line of research in pathological anatomy, and was not interested in the socio-medical or political thinking of his teacher. In his positions as professor of pathological anatomy at the University of Chile and director of the Institute of Pathological Anatomy of the Junta de Beneficencia (1908-1911, 1930-1932), he remained firmly linked to this discipline. Hugo Sievers Wicke (1958, p.12), one of Westenhöfer’s students and his biographer, reported that all those who collaborated in paying for the burial of the German professor, who died in Santiago in 1957, were anatomical pathologists. No published work by Westenhöfer of a socio-medical nature is mentioned in this biographical report, although his “Report on the activity of the Institute of Pathological Anatomy of the University of Chile, 1908-1909” (Westenhöfer, 1959) is included, and translated for the first time into Spanish (Sievers Wicke, 1958, p.88-126). This report served as a portrait, through autopsies and analyses of the causes of death, of the miserable health conditions of Chile at that time. But this article was published in Germany in 1911, and it was translated into Spanish only in 1958 by Sievers Wicke, so it was evidently not well known in Chile until that date. It was also during his first stay in Chile (1908-1911) that Westenhöfer collected autopsy data from corpses of different ethnicities, including indigenous men and women, during expeditions to the Araucanía, to support the evolutionary theories that gave him some world fame after he exhibited them at the International Congress of Anthropology in Salzburg in 1926 (Sánchez Delgado, 2015, 2018a).

Ultimately, we can conclude that from the 1920s until 1950, there is not a single allusion by Allende to the German academics Virchow and Westenhöfer.

For his part, to support the connection between Virchow, Westenhöfer, and Allende, Waitzkin cites, in different works, Allende himself (La realidad médico-social chilena) and the historian María Angélica Illanes (“En el nombre del pueblo, del estado y de la ciencia”). Allende, in his well-known 1939 book, actually alludes to neither Westenhöfer nor Virchow, despite exhibiting knowledge of the work of other German scientists, for example, as related to the social causes of tuberculosis (Allende, 1999). In the aforementioned book, Illanes (2010, p.239) refers to Westenhöfer only once and Virchow’s name appears only in the context of an allusion to him made by Doctor Hernán Romero in 1968 (p.455). Within her book, both the original edition of 1993 and the second edition of 2010, Illanes does not assert any link between Westenhöfer and Allende.

The absence of Virchow and Westenhöfer is also noteworthy in secondary sources that offer accounts of speeches, written works, and memories of Allende. For example, the American historian Peter Winn interviewed Allende, then the president of Chile, in 1972, a meeting that he summarized years later in the journal Socialism and Democracy (Winn, 2005). Winn writes that “as a medical student, Allende stressed to me that he became particularly aware of the problems of the poor of Chile – and of the problem of widespread poverty in Chile” (p.132-133). But, according to the same interview, it was the medical “students” who most influenced him in his political activity, in addition to his contact with the less privileged sectors in the neighborhood around the Medical School of the University of Chile. Allende mentions other people who influenced him, such as an anarchist shoemaker from Valparaíso, Juan Demarchi, who became his “political godfather” (Winn, 2005, p.132). In 1974, similar details of Allende’s student career were reported by Modell and Waitzkin (1974-1975, p.3), with no mention of Westenhöfer. On another occasion, Allende alluded to his relationship with the anarchist Doctor Juan Gandulfo, as a model of the activist in the field of university politics and social medicine (Craib, 2016, p.169; Pavez, 2009). In other biographies of Allende, as far as we know, there is no mention of a link between him and Westenhöfer (Martínez, 2009).

When we take into account the political conditions that prevailed in Chile and internationally in the 1930s and 1940s, it is not surprising that Allende would have kept his distance from Westenhöfer. As leader of the Federation of Students of Chile, the young Allende, in one of his first political activities, took an active role in the struggle against the government of Ibáñez, whose downfall led Westenhöfer to leave the country in 1932. Of course, political alliances in Chile in the 1930s were complicated and unstable; however, it is unlikely that Allende and Westenhöfer shared the same ideological basis in social medicine, since the German expert showed himself to be an adherent of the political right wing, served faithfully as a Nazi diplomat through the Ibero-American Institute of Berlin, and advocated an evolutionary model that diverged from Anglo-Saxon Darwinism with strong racist notes (Sánchez Delgado, 2018a). Meanwhile, Allende and the Socialist Party were part of Chile’s Popular Front of 1939, which, despite participating in various compromise agreements with the Chilean right at the time to maintain the political balance in the center, maintained a leftist political imaginary and an anti-fascist stance.

Virchow and his influence on Latin American social medicine

Of course, Rudolf Virchow could have influenced Allende’s ideology without Westenhöfer’s involvement, for example, through the international lettered culture in scientific and political thought. But, perhaps surprisingly, in the world of social medicine that Allende knew during the 1930s, evocations of Virchow were a rarity. In our review of several years of the Boletín Médico de Chile (BMC) – a Valparaíso journal that served for many years as the voice of the Vanguardia Médica and as a forum for political and philosophical debates in social medicine – we found only one mention of Virchow, in an article that does not even seem to have been written by a Chilean, but rather a translation of a report in French from the Secretariat of the League of Red Cross Societies in Paris (Rodolfo…, 29 feb. 1936, p.4). It is worth mentioning that Allende served as a member of the editorial board of this journal (Modell, Waitzkin, 1974-1975). During a typhus epidemic in Chile, which was a major topic in the BMC between 1933 and 1935, there is no mention of Virchow in this context, either. This is striking, because of the often-cited association between Virchow and typhus: in the revolutionary year of 1848, he conducted an analysis of the social causes of an epidemic of this same disease in the Upper Silesia region (then part of Prussia, later Germany, now Poland), a famous episode in the annals of social medicine (Gaffney, 2018, p.63-66). If the doctors of the Vanguardia Médica had been familiar with Virchow’s biography and work, surely they would have taken advantage of this historical parallel to support their own socio-medical analysis of the local epidemic. It is worth mentioning that Westenhöfer, while a military doctor in Germany, also played a prominent role during another typhus epidemic in 1898 (Gaffney, 2018, p.16), but there is no allusion to this activity in the Chilean social medicine episteme during the 1930s.

Additionally, essays on the history of social medicine written in Chile and other Latin American countries before the 1950s rarely allude to Virchow. For example, in an article in the Boletín Médico-Social (Santiago, Chile) in 1938, Manuel de Viado (1938) offered a detailed history of European social medicine (more than 60 pages), in which he named René Sand and Max von Petenkofer, among others, but with no mention of Virchow. However, it is possible that this omission was done on purpose, since it was an official journal – a publication of the Caja del Seguro Obrero – and Viado was an official in the ministry of Health under Eduardo Cruz-Coke, who had various disagreements with Allende and the Vanguardia Médica (Del Campo, 2008; Molina Bustos, 2010; Zárate Campos, 2012). However, we can safely assert that across the political spectrum, from a liberal like Cruz-Coke to the socialist Allende, Virchow was not perceived as an indispensable figure in a history of social medicine. Apparently, Virchow’s works had not been translated into Spanish during this time, another fact that would explain the lack of attribution of decisive influence in this field to this German scholar.

If today a history of social medicine would be inconceivable without mention of Virchow, this was not always the case. For example, René Sand, from Belgium, did allude to Virchow in his book Social medicine and national progress, a compilation of a series of lectures he gave in Santiago in 1924. But he placed Virchow in a broad group of precursors of social medicine, with the same level of importance as Frederick W. Taylor, the expert in industrial organization, or Adam Smith, the English political economist (Sand, 1925, p.13). The Argentinean Germinal Rodríguez (1933), in a 1933 article, traced the history of social medicine, mentioning several “German authors” and the events of 1848 in Europe, but made no reference to Virchow (and we note that Rodriguez, besides being a doctor, was a politician in the Independent Socialist Party of Argentina). In his 1936 book Chile en la Vanguardia, which extolled the Vanguardia Médica of Chile, the Argentinean Juan Lazarte (1936, p.49) emphasized “the perspective of Medicine as a Great Social Science,” without acknowledging the similarities of this notion to an axiom of Virchow: “Medicine is social science, and politics is nothing but medicine on a large scale.” In 1941, the Argentinean Juan Ramón Beltrán (1941) did not say anything about Virchow in an article entitled “History of social medicine,” although he did mention other Germans (such as Max von Petenkofer) and the health reforms that took place in Germany because of the revolutionary actions of 1848. However, Hynek Pelc (1939), from Czechoslovakia, in a speech delivered in Prague and translated into Spanish for the Anales de la Asociación Argentina de Biotipología, Eugenesia y Medicina Social in 1939, did allude to Virchow as a key figure in European social medicine (a professor of social hygiene in his country, Pelc was executed by the Nazis in 1942). In the syllabus of a social medicine course at the University of Costa Rica, published in 1956, there is only one reference to Virchow, with his name misspelled (“Wirchow”), and he is presented in a section on the bacteriological revolution, without discussion of his political program (Jimenez, 1956).

Thus, the notion of Virchow as a hero of social medicine was not widespread in Chile or elsewhere in Latin America until many years after his death. Of course he was not an unknown character; Virchow was an important figure in the clinical aspects of pathological anatomy thanks to his celebrated cellular theory. For example, in the card catalog of the Enrique Laval Museum of the History of Medicine, which catalogs the contents of the old library of the School of Medicine of the University of Chile, there are four records in which Virchow appears as author, and all of these works are about pathology and autopsies, but nothing about social medicine. However, we should recognize that Virchow had a subtle influence on Latin American social medicine at that time; for example, the hygienist Carlos Enrique Paz Soldán, from Peru, gave the name La Reforma Médica to his own journal (widely diffused throughout the continent) in homage to the journal of the same title (in German) that Virchow published in the nineteenth century (Birn, Brown, 2013, p.17; Cueto Palmer, 2015, p.169).

Historiographical consequences

Now, for the sake of argument, let us accept that there is no clear link between Allende, Westenhöfer, and Virchow. Beyond rectifying a historical fact, what does it mean to dismantle this story? Here we offer some reflections on the importance of this small work of revisionism, in both a historical and a historiographical sense.

The assertion of the Virchow-Westenhöfer-Allende connection is based on a very well-established concept in Western culture: that ideas are transmitted, like family relics, from one generation to another, through the relationship between teacher and student. Perhaps the most famous of this kind of relationship would be that of Socrates, Plato, and Aristotle in ancient Greek culture. It is possible that, since we are academics (and at the same time, products of a formal educational system), there is a bias that leads us to place too much importance on the relationship between teacher and student, sometimes more than what is justified by the sources at hand. We should be cautious, though, because newer methodologies for historical research of social networks, while expanding the number and density of connections that a historian can understand, sometimes lead to the same analytical fallacy, that ideas are transmitted from one person to another by contact, either by teacher-student relationships, as participants in the same scientific conferences, or as colleagues in the same academic institution or government agency. Well-constructed analyses of historical scientific expert networks – for example, an exhaustive study of networks in eugenics between Argentina and the rest of the world (Miranda, Vallejo, 2012) – balance a clear tracing of professional connections with a deep examination of positions, discourses, and political-intellectual debates among the individuals that comprise the network.

The supposed connection that we have interrogated also reflects certain Europeanizing tendencies of the history of ideas in general, and specifically in the field of social medicine. Allende’s socio-medical ideas seem to acquire greater importance because of their presumed link with Europe and its culture. By downplaying this link, a different picture emerges, in which Salvador Allende can be understood as subject to a broad range of ideological influences, in which Westenhöfer and Virchow were relatively insignificant. Allende’s concepts in social medicine seemed to come mainly from discussions and debates in the local cultural milieu, which was not always dependent on (and was often opposed to) European trends (Carter, 2019). Without denying the influence of European actors in Western scientific and political culture, it can be argued that a discursive field of Latin American social medicine developed with considerable autonomy from European events and from a recognition of the particular geopolitical and economic circumstances of the region (López Arellano, Peña Saint Martin, 2006).

Once we abandon the idea of a sequential and consistent lineage between Virchow, Westenhöfer, and Allende, we might also discount the importance of Allende himself in a history of social medicine viewed from the hegemonic Western perspective (mainly from the vantage point of Europe and the United States). Here we concur with Birn and Necochea López (2011), that sometimes there is a gap between the historical research on social medicine (and public health) written in Latin America and the uses of this history in the English-speaking world. For the adherents of social medicine in this second group, Chilean social medicine often revolves around Salvador Allende; he is the protagonist (and often the only person named) in this story. Of course, the real story is more complicated: there were important figures in the social medicine movement that preceded Allende, such as the aforementioned anarchist Doctor Juan Gandulfo (Pavez, 2009); important groups promoting social medicine in which Allende never participated, such as the Sindicato de Médicos de Chile, formed in 1924 (Molina Bustos, 2010); other important figures from the Vanguardia Médica and the Amech, such as Ángel and Jaime Vidal Oltra, Juan Marín, Gustavo Molina and Juan Garafulic (Del Campo, 2008); and many non-socialist proposals in the social medicine episteme, such as those proposed by doctors like Eduardo Cruz-Coke or Jorge Mardones Restat (Zárate Campos, 2012). In addition, there were state institutions such as the Social Hygiene Division of the General Directorate of Health, which was active from 1925 to the 1940s, whose director between 1927 and 1939 was Waldemar Coutts (who was Allende’s teacher, but a member of the extreme right, politically) (Sánchez Delgado, 2018b), and the Caja del Seguro Obrero Obligatorio, whose founder, Doctor Exequiel González Cortés, was inspired by similar institutions in Germany. Nor can it be taken for granted that the authorship of La realidad médico-social chilena corresponds to Allende alone, since it offered a program of the Popular Front government. The socio-medical policies of Chile were influenced by international institutions, which were of a progressive or reformist, but not necessarily a socialist, character, such as the League of Nations and the International Labor Organization (Carter, 2019). Allende arguably introduced a novel analytical framework to Chilean social medicine, based on “historical materialism” (Labra, 2004, p.213), inherent in the socialist line of social medicine. And it is true that the figure of Salvador Allende, due to his international reputation, serves as a “hook” to communicate the relevance of social medicine in Chile to various publics. However, any history so focused on a single personality may be inadequate.

An alternative history

We propose a different narrative. During the heyday of Chilean social medicine (between 1920 and 1940), Rudolf Virchow’s medico-social thinking was almost unknown, and he was treated instead as an expert in cellular pathology and pathological anatomy. Max Westenhöfer conveyed Virchow’s expertise in these branches of medical science, but he did not carry Virchow’s concept of social medicine to Chile. Allende, like the other figures of the Vanguardia Médica (and important predecessors, such as Gandulfo), generated their social medicine programs within a fruitful, diverse, and complex political-intellectual environment, all of which makes it impossible to draw a direct line between Virchow and Allende, via Westenhöfer.

Meanwhile, in the course of the twentieth century and in other latitudes, a historical revival of Rudolf Virchow was carried out. He was resurrected as a hero of social medicine by the work of historians of leftist orientation, such as Henry Sigerist and his students George Rosen and Edwin Ackerknecht, who published in English and German (some had important links with Switzerland and Germany and were opponents of the Nazi regime) (Porter, Porter, 1988; Rosenberg, 2007). In The great doctors – originally published in German in 1932, then in English in 1933 –, Sigerist (1949) devotes a chapter to Virchow, although a Spanish translation of this work was not published until 1949. Ackerknecht, from his PhD thesis of 1932 (under Sigerist’s supervision) to a much-cited biography of Virchow he published years later (Ackerknecht, 1953), was the source of what Rosenberg (2007, p.531) describes as the “the Ur-narrative” of social medicine originating with Virchow’s actions in Upper Silesia in 1848.

Later, the story of Virchow was disseminated in small circles of Latin American social medicine, which experienced a rebirth in the 1970s and 1980s. This group sought not only to understand the historical background of its field of study (and action in social and health policy), but also to solidify the links between social medicine and an international socialist movement. They ended up situating Virchow – with good reason, it should be said – in the revolutionary fraternity of 1848, which of course includes Marx and Engels. In this historical revival, works by Juan César García and Gustavo Molina were crucial (and later, the aforementioned Howard Waitzkin). García said specifically, at a conference in Rio de Janeiro in 1974: “In 1848 the concept of social medicine is born; it is also the year of the great revolutionary movements in Europe. As with the revolutions, the concept of social medicine emerges almost simultaneously in several European countries” (García, 1994, p.144). Another interesting fact is that Michel Foucault (1977) also gave a lecture on “The birth of social medicine” in Rio de Janeiro that same year, which included the history of the nineteenth-century revolutionary upheavals that gave rise to German state medicine, but with no mention of Virchow.

Gustavo Molina Guzmán was Allende’s comrade and an important leader in health policy in Chile, from the time of the Vanguardia Médica to the Popular Unity government. He attended a weekly Sigerist seminar at Johns Hopkins University in 1941 together with a large group of Chileans, among them some founding faculty of the School of Public Health at the University of Chile (Terris, 1975). Years later, during his detention by the military government after the 1973 coup d’état, and then during his exile in Colombia, Molina translated a collection of Sigerist essays into Spanish (Sigerist, 1974; see also Terris, 1975). Molina’s translation originates from a compilation edited by Milton Roemer (1960), an expert in health systems, who had also been a student of Sigerist at Johns Hopkins. These works probably helped to amplify Virchow’s historical significance. Since then, Latin American social medicine has been explicitly located within a broader political-intellectual history, with an international scope and with solidly leftist European ideological roots.

This alternative history explains the origins of Virchow’s coronation as the father of social medicine and how this narrative was disseminated in the realm of Latin American social medicine. But the same chronology of historiographic production suggests that left-leaning Chilean physicians in the period from 1930 to 1950, Allende among them, would have been unaware of Virchow’s ideological and political legacy, and they would not have recognized their own position on a trajectory of the development of a field of social medicine originating with this German scientist.

Final considerations

Until now, within the historiography of Latin American social medicine – especially the one developed in the Northern Hemisphere – Salvador Allende and his social medicine milieu in Chile in the 1930s have been situated in a narrative of coherent intellectual discipleship with deep and secure roots in European intellectual history; that is, with Virchow. Max Westenhöfer, a direct disciple of the father of cellular theory, who developed a relationship with Chile that led him to treat this country as his “second homeland” (Westenhöfer, 1951, p.III), would seem the ideal figure for transmitting Virchow’s social medicine ideas to Allende.

However, the link between Virchow and Allende, via Westenhöfer, should be classified as a convenient but ultimately untrue story that deserves to be discarded, thereby paving the way for research based on a greater wealth of historical evidence, which may offer, we believe, a less harmonious and more complicated story; Chilean social medicine ends up being a field less dependent on the figure of Salvador Allende, whose international renown has other bases and other causes.

In the spirit of historiographical renovation that we have initiated here, Chilean social medicine may come to present a panorama in which local creativity, together with the transnational flow of ideas in politics, medicine, and public health, casts doubt on the genealogies that we take for granted and which reproduce Eurocentric tendencies. When Allende entered public life, the tradition of socio-medical diagnosis in Chile already had a long history, from The social question of Augusto Orrego Luco in 1884. And such critical studies of national problems drove the development of a legal and political infrastructure for public health, social insurance, and other health and social protections in Chile. Although often deficient, these health and social policies were developed without the need for major contributions or pressures from abroad. The different ideological positions within the field of social medicine were calibrated to the conditions presented by existing health institutions.

This local creativity had several roots, but during the period we have examined here (from 1930 to 1950, approximately) it can be explained in large part by the lack of ideological hegemony in international public health policy. Although there were international organizations involved in health (among them, the League of Nations, the International Labor Organization and the Pan American Sanitary Bureau), they lacked the institutional weight and financial resources to impose certain norms on the organization of public health and national health systems. That is why social medicine, both in Chile and in other countries where this idea gained strength, was a relatively open field and not prone to reject policy ideas for ideological reasons.

Thus, in metaphorical terms, social medicine in Latin America does not so much resemble a branch of the family tree of European Marxism, but rather resembles a kaleidoscope: supposedly incompatible or conflicting ideological elements (of positivism, socialism, anarchism, liberalism) that may have been borrowed from another place, be it Europe or the United States, which were then placed in unimagined ways in new assemblages in Latin America (Sánchez Delgado, 2016).

That is why we propose a line of historical research that is capable of examining in depth the relationship between political ideology and the sciences in the field of social medicine. In the contemporary context of the new history of medicine and public health, political ideas seem to be placed above (or prior to) facts, networks, and characters in the scientific-academic field, as the engines of historical change. We propose that more attention be paid to the development of scientific thought through networks of professionals whose political orientations do not sufficiently explain their actions in the development of a social medicine program. Moreover, as per Acha and D’Antonio (2010, p.243), with regard to Latin American Marxism, “it is not possible to conceive of it as sustained in theoretical coherence, but rather it seems advisable to trace its transformations in the face of reciprocally transformative dialogues.” This position would not deny the influence of ideologies of the left in social medicine, but it would call us to resist an assumption of ideological continuity and coherence; that, as in all historiographical practice, we must demonstrate it rather than assuming it, and avoid applying our appraisals and perceptions of the present day retrospectively to ideological formations of the past. The same commitment to a dialectical analytical method, an elemental characteristic of Marxism, perhaps forces us to question not only the durability of ideologies, but also the stability of the parameters of ideological conflicts over time; thus, the key framings of the social problems of 1848 are not the same as those of 1939, 1973, or the present. We do not propose a history without politics, but rather a history even more committed to the truth and with the possibility of thinking about history on firm foundations, and thus to re-imagine, ponder, and construct a Latin American social medicine.

As we know, history is always open to new and better interpretations and we do not intend to close the discussion, but rather to enrich it by incorporating reliable sources and contributing, to the best of our abilities, to refuting a story that is convenient, but unnecessary and incorrect. By dissolving the supposed connection between Max Westenhöfer and Salvador Allende, new possibilities open up for the history of Latin American social medicine, with greater complexity in the North-South dialogue and with foundations somewhat more in line with the historical evidence.

ACKNOWLEDGMENTS

The authors declare no conflict of interest. For Carter, this article is part of a research project on the history of Latin American social medicine funded by the US Fulbright Scholars program and an American Council of Learned Societies fellowship. For Sánchez this article is part of a research project Conicyt Fondecyt Iniciación n.11170565 “La profesionalización de la anatomía patológica en Chile desde fines del siglo XIX hasta 1950. Redes y actores para un cuerpo moderno.”

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• *
  [Editor’s note] On this subject, Howard Waitzkin responded on a letter (http://dx.doi.org/10.1590/S0104-59702020000400019), to which the authors replied on another letter (http://dx.doi.org/10.1590/S0104-59702020000400020).

Publication Dates

• Publication in this collection
  23 Oct 2020
• Date of issue
  Jul-Sep 2020

History

• Received
  23 Aug 2018
• Accepted
  13 Mar 2019