Who Breathes in the Andes?

This essay on the history of climatotherapy and biomedicine in Peru is the third piece in the “Commons for Whom?” series, which investigates the role of identity, ethnicity, accessibility, and coloniality in the politics of the commons. Inspired by the ASLE + AESS 2023 conference theme “Reclaiming the Commons,” our series “Commons for Whom?” especially engages the implicit “we” in calls to reclaim common, public, and outdoor spaces. “Commons for Whom?” is a collaborative, cross-platform series, published across Edge Effects, NiCHE, and Correspondences. Series editors: Addie Hopes (NiCHE), Ben Iuliano (Edge Effects), Rebecca Laurent (Edge Effects), Weishun Lu (Edge Effects), Kelly McKisson (Correspondences), and Richelle Wilson (Edge Effects).

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When the COVID-19 pandemic struck Peru, the country’s readiness to recover from a short-term health crisis became a pressing concern. Like many other countries, Peru experienced widespread panic-buying and harrowing scenes of mass burials in the media. While aggregate data shows that Peru experienced the highest death rate in the world, the pandemic had differential impacts across the country. Coastal and Amazonian cities, with predominantly mestizo populations, suffered immensely due to large amounts of informal labor and a lack of compliance with quarantine measures. Lima, despite having the most hospitals and healthcare facilities nationwide, was hit the hardest and became a symbol of the government’s failure.

In contrast, cities and towns in the highlands were relatively spared. As in other mountainous places around the globe, the Andean population’s acclimatized bodies initially resisted the virus’s respiratory damage during the first half of 2020. However, preexisting unequal healthcare and vaccination regimes for poor departments in the Andes and the Amazon neglected non-COVID and chronic diseases, reinforcing regional health inequalities. Given the systematic, bureaucratic dysfunction that plagued the national health infrastructure, the acute shortage of oxygen supply severely impacted the ability to provide respiratory support to patients in overcrowded and under-resourced hospitals.

Structural inequalities in access to medical care have a long history in Peru. As Christina Ewig has argued, the country’s public health system developed along racial, class, and gender divisions, but these have not been static. The Andean environment—long seen by Peruvian intellectuals as a place of state neglect because of the supposed lack of modernity among its “native population”—went from a backward niche to a necessary zone of capitalist penetration and institutional development.

While the pastoral livelihoods of the Andean peasants became increasingly subject to mining investment and property expansion by the landlord class, Lima-based physicians sought to increase the public health apparatus for two reasons: to “civilize” the Indigenous population through modern medicine, and to seize the healing properties of the Andean air to cure the pulmonary ailments of mainly coastal-mestizo populations.

Contemporary instances of high dependence on biomedical tools to treat COVID-afflicted lungs coupled with uneven access to common resources recall the history of climatotherapy (prescribed relocation to a more favorable climate for recovery from an ailment) in the Andean mountains for the treatment of tuberculosis during the twentieth century. In both cases the issue of mobility is at stake, both for people and biomedical material. Climate provided a justification to Western elites for the scientific appropriation of the Sierra by conditioning the relationship between nature and humans under a racialized vision of the environment. As a result, the perceived “Indigenous” Andes were to be put at the service of the medical community to cure the nation’s pathologies. 

Once climatotherapy waned, most of the cutting-edge biomedical advances for tuberculosis treatment were centralized in Lima, further diminishing any incentives for the Ministry of Health to rectify the unequal modernization of the country’s health infrastructure. Medical regimes of care and action regarding the travel experience towards Jauja—where the most famous sanatorium was located—deepened the social meaning of where it was possible to take a breath to enjoy the virtues of a dry and mild climate, and most importantly, who would be able to do it. By restricting the commons under the guise of public health, elites in effect turned the Andean air into medical good to benefit the urban-mestizo population. Local ecology fulfilled its purpose until scientific advancements rendered it useless, and structural inequalities remained unchanged.

Lima’s Apothecary

Since Peru became an independent country in 1821, the local scientific community has had conflicting views about the healthfulness of its climate. During the 1820s and 1830s, some enlightened physicians who had witnessed the demise of Spanish rule believed that the Andes mountains made the nation’s climes unique in the world. This singularity was based on the ideas of the Creole physician Hipólito Unanue, who saw a historical continuity from the environment that had enabled the expansion of the Inca Empire to contemporary opportunity for the Creole ruling class to guide the local people’s future.

Unanue’s ideas helped institutionalize scientific nationalism as a dominant discourse among unionized medical practitioners in the Republic. However, rapid urban growth fueled by guano revenues challenged the long-held belief that Lima, the country’s capital, had a relatively disease-free atmosphere. In reality, limeños lived in a city with garbage and waste piled up on the streets, and respiratory problems became the leading public health issue.

During the second half of the nineteenth century, politicians and members of the medical elite attributed the rampant spread of tuberculosis to the social maladies caused by city life. With the sudden opening of Peru to foreign markets after decades of protectionism, there was a cycle of economic development unevenly shared between the capital and the rest of the territory. 

The economic disparity between the coast and the Andean region provided a common ground for the respiratory anxieties of the limeños and the capitalist ambitions of the political class, who were eager to connect international markets from the coast to the perceived underdeveloped and racialized Andean environs. Peruvian elites saw railways as a tool for progress to modernize the Indigenous populations. 

Jauja, a small city in the Sierra located a few miles south of the most critical mining center at the time and the first Spanish capital of Peru, was envisioned as the ideal destination to heal the lungs of the ruling class and expand modernity. Not only would limeños benefit from the region’s clean air and fertile soils, but developing logistical infrastructure to connect Lima with the Central Highland would also make it more accessible to inject foreign and domestic capital into the Andean domestic markets.

As historian Mark Carey has explained, discussions about building a sanatorium in Tamboraque, located in the highlands of the Lima department, gained some support due to the site’s proximity to the city. However, limeño physicians ultimately picked Jauja because building a centralized public health center for the treatment of tuberculosis also provided a tangible medium to “civilize” the Indigenous populations by integrating their labor force and natural resources with the modernizing aims of the Creole elite.

In 1922, the Lima Welfare Society received a vital sum from philanthropist, rancher, and businessman Domingo Olavegoya. The funds enabled them to expand the infrastructure of the existing Our Lady of Lourdes Hospital to establish the sanatorium in the southeastern part of the town. It was an ideal location, away from the urban area, to circumscribe upper and lower-class patients under disciplinary therapy regimes.

The Andean Sanatorium City  

For Peruvian society in the 1930s, Jauja’s rapid development became closely linked with the growing reputation of the Olavegoya sanatorium. Atypical for a rural Andean town, Jauja boasted one of the country’s premier radiology labs and a modern sewage system, which was vital for the hygienic treatment of tuberculosis patients. 

According to historian Florencia Mallon, several factors contributed to the region’s development during the early twentieth century, such as the infusion of foreign capital into mining enterprises, the modernization of agricultural production, and the formation of cattle-ranchers associations. The progressive capitalization of productive sectors led to the seasonal migration of peasants to the main productive centers inside and outside the central highlands. While this influx of peasant-turned-white-collar workers greatly benefited the elite of Jauja, workers in the mines and haciendas did not see improvements in their living conditions.

The injection of capital associated with tuberculosis treatment became an important source of revenue, as the sanatorium’s facilities had a hierarchical organization that depended on admission fees. Patients were interned for at least half a year and had their vital signs constantly monitored. Their therapeutic process included analyzing their blood, monitoring pollutants in their lungs, and receiving daily doses of yakotonin (a Japanese calcium phosphate and fructose drug that effectively treated pulmonary illnesses).¹

The Olavegoya sanatorium was at the top of the scale of Peru’s biomedical solutions to treat tuberculosis. And traveling to the Sierra to recover your lungs was prescribed only after undergoing base-level therapeutic measures, which included seeking treatment in a local dispensary, where patients with mild cases of tuberculosis received an initial diagnosis, while also serving as a platform for sanitary campaigns. These were highly concentrated in urban-coastal cities, while rural towns usually had ill-equipped facilities and few physicians.

While the popularity of climatotherapy for respiratory ailments declined in the Global North in the 1930s, Peruvian physicians still prescribed “changing climate to the Sierra” as part of their therapy regimen when patients’ conditions worsened after receiving supplements and analgesics.² Due to the limited access to the Bacillus Calmette–Guérin (BCG) vaccine produced by the Pasteur Institute, some patients had to rely solely on treatments from the pre-bacteriological era. The lack of accessibility to cutting-edge biomedical solutions highlighted the glaring disparities in health infrastructure between regions, particularly concerning the “vulnerable” Indigenous populations.

During the 1940s, Peru’s public health system underwent a significant expansion, adopting a more diversified and centralized approach to fighting tuberculosis. This coincided with global campaigns promoting the widespread use of BCG vaccines as a “magic bullet” against the disease in the postwar era. In 1949, Swedish physician Curt Gyllensward visited Peru and highlighted the country’s growing concern for tuberculosis. The Ministry of Health introduced mandatory vaccination for newborns in hospitals in Lima and Callao in 1948, but less than five percent of all births occurred in healthcare institutions. Because Peru needed to invest more in infrastructure to store BCG fluid properly, Gyllensward recommended the WHO’s Tuberculosis Research Center in Copenhagen to assess the situation. ³)

However, at a time when biomedical solutions were in vogue, it took more work to both improve the existing health infrastructure across the country and allocate resources to create new facilities. Nonetheless, in 1952 the future WHO General Director and Brazilian physician Marcelino Candau agreed to give a fully equipped bacteriological laboratory to Lima’s leading tuberculosis treatment center, Bravo Chico’s Hospital-Sanatorium, providing additional technological tools to properly diagnose and monitor patients’ clinical progress. 

With these advances, the local preference for climatotherapy finally began to wane. In the era of biomedical solutions as the essential tool of public health policies, the possibility of reducing regional structural inequalities in healthcare access became a false promise of modernization, as it was possible to improve the country’s population health without necessarily incorporating other cultural perceptions about the experience of illness and healing.⁴

Lingering Maladies After the Antibiotics Era

During the initial stages of the Cold War, the unwavering confidence in eliminating diseases led to the widespread adoption of eradication campaigns as the cornerstone of international health policies in Latin America. As historian of science Marcos Cueto has explained, the focus on authoritarian measures aimed at disease control, without improving local sanitary infrastructure, became the norm in the region’s poorer areas.

Under the technical advice and guidance of the Pan-American Health Organization, western medical institutions overlooked different socio-cultural beliefs and practices related to diseases, disregarding any social or ecological context as irrelevant to a technoscientific approach. Eventually, multilateral and bilateral agencies ceased to give major economic and material resources to the Latin American countries because of the low success rate of the campaigns in the long run. As new health challenges emerged, local governments needed further motivation to continue a domestic version of the previously attempted sanitary programs.

In 1968, the first national seminar on tuberculosis was held in Huaraz, shedding light on the harsh realities of the disease’s impact across the country. Peruvian physician Luis Cano recognized the urgent need to vaccinate Andean and Amazonian people, replicating the common perception of them as vulnerable groups due to lack of hospital access and economic underdevelopment. Meanwhile, Dr. Halfdan Mahler, then the WHO’s Chief of the Tuberculosis Unit, emphasized the importance of ambulatory services over recurrent hospitalizations to treat tuberculosis. By generating a global consensus about a disease for which environmental treatments had long been abandoned in most developed countries, the new medical agenda for the Global South effectively ended the lasting but outdated healing legacy of climatotherapy.⁵ With these insights, Peruvian physicians better understood how to improve the country’s health services, but as the current situation demonstrates, local sanitary authorities still operate on a precarious and poorly organized public-health system.

As one walks through the old pavilions of the Olavegoya Hospital, it is clear that the once-great institution has fallen on hard times. Bureaucratic negligence and lack of academic interest have reduced its historical significance to cracked plaques, dusty clinical files in storage, and stories told by long-time employees. Despite its decline, the hospital remains a vital healthcare center for the Junín region. However, the scars left by the COVID-19 pandemic are still visible, with used oxygen cylinders scattered throughout a recreation area that was once a restricted resource for well-to-do patients who were given preferred access to the commons of “healing Andean air.” The lasting effects of the prevalence of a reduced group of technocrats who decided over Andean commoners about the best use of their local environment still linger. This history of exploitation and negligence hang over any attempt to break the cycles of social and political inequality in present-day Peru.

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Featured image: Laguna de Paca, located four kilometers north of Jauja, Peru. Image courtesy Martintoy.

José Ignacio Mogrovejo holds a B.A. in History from the Pontificia Universidad Católica del Perú. His undergraduate thesis examined the role of medical geography in structuring racial inequalities in Modern Peru during the second half of the nineteenth century. Contact.

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1. Register 2727, Index N11, 1938-1939, Olavegoya Sanatorium Archive (hereafter OS Archive). ↩

2. Register 5832, Index S125, 1946-1948, OS Archive. ↩

3. “Preliminary report by Prof. C. Gyllensward on a visit to Peru regarding BCG work,” 30 April 1949, Tuberculosis Survey and Vaccination Demonstration, folder 45, series Regional Office for the Americas-Peru, Microform, World Health Organization Archives (hereafter WHO Archives. ↩

4. “Letter from the Pan American Health Organization Acting-Director Dr. Marcolino Candau to Peru’s Minister of Public Health Dr. Edgardo Rebagliati,” 17 June 1952, Tuberculosis Survey and Vaccination Demonstration, folder 45, series Regional Office for the Americas-Peru, Microform, WHO Archives. “Informe final presentado por el consultor Dr. Andres Arena, referente al proyecto de instalación y organización de un laboratorio central de diagnóstico bacteriológico de tuberculosis en Lima, Perú,” 8 October 1953, Tuberculosis Survey and Vaccination Demonstration, folder 45, series Regional Office for the Americas-Peru, Microform, WHO Archives. ↩

5. “Seminario Nacional de Tuberculosis, julio 26 al 30 de 1966, Huaraz-Peru,” 1966, T9/86/19, WHO Archives. ↩