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EDITORIAL |
Anne-Emanuelle Birn is with the Department of Public Health Sciences, University of Toronto, Toronto, Ontario. Natalia Molina is with the Department of Ethnic Studies, University of California, San Diego.
Correspondence: Requests for reprints should be sent to Anne-Emanuelle Birn, ScD, MA, Department of Public Health Sciences, University of Toronto, 1st Floor, McMurrich Bldg, 12 Queen’s Park Crescent W, Toronto, ON M5S 1A8, Canada (e-mail: ae.birn{at}utoronto.ca).
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INTRODUCTION |
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History, despite its wrenching pain, Cannot be unlived, but if faced With courage, need not be lived again.Maya Angelou
"On the Pulse of Morning"
In the late 19th century, eugenics—a set of ideas about the biological betterment of human stock—emerged in Britain and was soon incorporated into social and public health policy in numerous settings. By the 1910s, advocates of positive eugenics in Catholic Europe and Latin America combined with pediatric and other health reformers to back family wages, universal preschools, foster care, housing codes, and school health exams, all with the goal of improving the conditions of childhood and of the human stock more generally.1,2 During the 1920s in the Soviet Union, eugenics was construed as a form of social medicine and supported by the official public health agency. Scientists appealed to eugenics as a demonstration of the utility of genetics to public health, while the policy implications of a Bolshevik-style positive eugenics for a time coexisted with "environmentalist" social hygiene approaches.3
In the better-known applications of negative eugenic thinking in Protestant settings—in Scandinavia,4,5 Great Britain,6–8 the United States,6,9 and, most infamously, Nazi Germany10,11—various interventions including sterilization were employed to "breed out" certain "defective" human characteristics, initially a variety of mental conditions and behaviors defined as criminal or immoral. Although by 1920 the Hardy–Weinberg principle12 had shown the futility of such attempts to alter the gene pool, eugenics continued to be invoked to justify the use of sterilization practices on a widening pool of so-called undesirables, increasingly defined as immigrants, the poor, and racial/ethnic minorities.
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EUGENICS, CALIFORNIA STYLE |
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In correcting the perception that American eugenic sterilization was advanced by a narrow set of actors in an era long gone, Stern raises a set of disconcerting issues for public health practitioners and advocates today. The most obvious of these, and the most troubling for its contemporary resonance, is the social prejudice that marked activities pursued in the name of public health. The extent to which health and medical policies absorb and reflect the dominant class and racial logic of the time has been well documented.
As Vanessa Gamble has argued, the US Public Health Service’s 40-year study of untreated syphilis in 400 Black men in Tuskegee, Alabama, represents only 1 episode in a sea of institutionalized practices and daily interactions that has produced a legacy of overtreatment, undertreatment, and mistreatment of African Americans.16 Nayan Shah has likewise documented the portability of the health department’s and the public’s scapegoating of the Chinese community in San Francisco, California, from epidemic to epidemic across 2 centuries17 (3 if we include the severe acute respiratory syndrome [SARS] epidemic of 2003). The classism of health and medical institutions—in the US context, often intertwined with racial and ethnic discrimination—reveals similarly pernicious patterns of prejudice.18–21
Stern investigates how public health institutions evolved into a key site of racialization from the late 19th into the 20th century.13 Public health not only reproduced larger societal tenets but also exerted influence well beyond the profession and practice of public health. While sterilization laws may not have mentioned race and class explicitly, they were racialized and class-oriented in enforcement. Immigrants, particularly those of color, were not only sterilized in disproportionate numbers but also were marked as inferior by the practice.
California’s sterilization law was justified as a preventive measure that was at the same time cost saving, desirable for the patient and her family, and good for the public. Yet, remarkably, California state legislators acknowledged that implementation of the law might result in legitimate legal claims, and in 1917 they modified the law to protect doctors who carried out state-sanctioned sterilizations from legal retaliation.13
This explicit recognition of the potential for violation of patients’ rights was perversely echoed in the ruling in Madrigal v Quilligan (No. 75 Civ 2057 [CD Cal June 30, 1978], aff’d, 639 F2d 789 ([9th Cir 1981]) some 60 years later. Despite the existence of informed consent practices by the early 1970s—developed in part because of the involuntary sterilizations of the previous half century—the judge in this case interpreted the sterilization of the Mexican American plaintiffs to be the result of cultural misunderstanding rather than the product of powerful incentive systems for doctors to perform these procedures or of provider manipulation or of willful ignorance of patient preferences. In an inversion of their intended use, informed consent policies protected not patients but doctors, who were believed to be obtaining patients’ consent properly whether or not this was actually the case.
Moreover, the racial logic that girded the sterilization projects of the 1920s was transformed and presented as a defense strategy in Madrigal v Quilligan. The judge did not rule against the defendants on the basis of half century–old racial logic, but he summoned a "clash of cultures" argument that nonetheless rested on a belief in racial hierarchy.
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THE PAST AND THE PRESENT |
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TOPINTRODUCTIONEUGENICS, CALIFORNIA STYLETHE PAST AND THE...References |
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At another level, this process of reevaluation and refinement of policies may lead to frustration; if institutionally based ethical measures are not linked to larger movements for social rights, we may find ourselves developing ever more detailed ethical codes while endlessly battling class and racial prejudice.
A further jarring issue highlighted by Stern has to do with how seemingly well-understood public health activities are reshaped in various political contexts. Although many accounts portray eugenics as a unitary movement informed by conservative ideas and supported by political counterparts, it was above all a technocratic development that could be and was appropriated and refashioned by utopians, social progressives, nativists, and Nazis. The evolution of eugenic policies in Protestant countries—where sterilization was almost universally adopted as the preferred means of achieving eugenic goals—is in distinct contrast to the situation in many Catholic settings, where a positive eugenics of enhancing prenatal and childraising circumstances substituted for sterilization.
In linking eugenics to right-wing political agendas, some scholars have inaccurately pointed to the end of World War II and the discrediting of "Nazi science" at the Nuremberg trials as the demise of eugenics.25 Yet, as Stern shows for California, eugenics did not disappear then; support for eugenic sterilization merged with growing concerns about overpopulation and family planning. Birth control, at bottom a technocratic measure, was also appropriated differentially by various actors. Seized upon as a means of freedom for elite and middle-class women, birth control has had more conflicted meanings and consequences for poor and working-class women around the world.26–28
In the end, we must examine the ideological footprint left by proponents of eugenics through their writings, the policies they developed, and the professionals they trained. Early eugenicists generated influential policies that helped embed racial and classist reasoning into public institutions. Stern13 lays the theoretical groundwork for us to see how a belief in a racial and social hierarchy was at the core of sterilization projects in the 1920s and the 1970s and the passage of Proposition 187 in the 1990s. (Proposition 187 was approved via referendum by California voters in 1994 to prevent undocumented immigrants from receiving public benefits or services, including health care and education; it was never implemented because of legal challenges.) If we see these projects as historically linked, we cannot relegate such dangerous approaches to an unprogressive past.
The past is infinitely complex, but surely not impenetrable. Public health history teaches us that scientific and technical developments interact continuously with the political and social context and that health policies and their implementation both reflect and shape the political context and social hierarchy within particular societies. Facing history with courage compels us to raise questions of the past based on the pain of the present and to raise questions of the present based on the pain of the past.
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Acknowledgments |
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This editorial was based on a presentation given at the session "Immigrant California: Inequality and Public Health in Historical Perspective" organized by the Spirit of 1848 Caucus History Committee, 131st Annual Meeting of the American Public Health Association, San Francisco, Calif, November 17, 2003.
Accepted for publication December 2, 2004.
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References |
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2. Adams MB, ed. The Wellborn Science: Eugenics in Germany, France, Brazil, and Russia. New York, NY: Oxford University Press; 1990.
3. Adams M. Eugenics as social medicine in revolutionary Russia: prophets, patrons, and the dialectics of discipline-building. In: Solomon S, Hutchinson JF, eds. Health and Society in Revolutionary Russia. Bloomington: Indiana University Press; 1990:200–223.
4. Broberg G, Roll-Hansen N, eds. Eugenics and the Welfare State: Sterilization Policy in Norway, Sweden, Denmark, and Finland. Lansing: Michigan State University Press; 1997.
5. Weindling P. International eugenics: Swedish sterilisation in context. Scand J Hist. 1999;24:179–197.
6. Barkan E. The Retreat of Scientific Racism: Changing Concepts of Race in Britain and the United States Between the World Wars. New York, NY: Cambridge University Press; 1992.
7. Mazumdar PMH. Eugenics, Human Genetics and Human Failings: the Eugenics Society, Its Source and Its Critics in Britain. London, United Kingdom: Routledge; 1992.
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12. Sturtevant A. A History of Genetics. New York, NY: Harper & Row; 1965. Available at: http://www.esp.org/books/sturt/history (PDF file). Accessed May 1, 2005.
13. Stern AM. Sterilized in the name of public health: race, immigration, and reproductive control in modern California. Am J Public Health. 2005; 95:1128–1138.
14. Pernick MS. Taking better baby contests seriously. Am J Public Health. 2002;92:707–708.
15. Pernick MS. Eugenics and public health in American history. Am J Public Health. 1997;87:1767–1772.
16. Gamble VN. Under the shadow of Tuskegee: African Americans and health care. Am J Public Health. 1997; 87:1773–1778.
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18. Rosenberg CE. Social class and medical care in nineteenth-century America: the rise and fall of the dispensary. J Hist Med Allied Sci. 1974;29:32–54.
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20. Markel H. "Knocking out the cholera":, class, and quarantine in New York City, 1892. Bull Hist Med. 1995;69:420–457.[Medline]
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22. National Center for Cultural Competence. Available at: http://gucchd.georgetown.edu/nccc/products.html. Accessed October 25, 2004.
23. Cross TL, Bazron BJ, Dennis KW, Isaacs MR. Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed. Washington, DC: Georgetown University Center for Child Health and Mental Health Policy, CASSP Technical Assistance Center; 1989.
24. Fadiman A. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. New York, NY: Farrar, Straus, & Giroux; 1997.
25. Paul DB. Controlling Human Heredity: 1865 to the Present. Atlantic Highlands, NJ: Humanities Press; 1995.
26. Nelson J. Women of Color and the Reproductive Rights Movement. New York, NY: New York University Press; 2003.
27. Hartmann B. Reproductive Rights and Wrongs: The Global Politics of Population Control and Contraceptive Choice. Boston, Mass: South End Press; 1995.
28. Briggs L. Reproducing Empire: Race, Sex, Science, and U.S. Imperialism in Puerto Rico. Berkeley: University of California Press; 2002.
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