By Kelly Urban

As most history instructors do, when I design my courses, I include weekly primary sources. Research has established the pedagogical benefits of reading and discussing these artifacts: It provides students the opportunity to hone their critical thinking skills, promotes active learning, and “exposes them to the lived experience” of historical actors (Tobbell 2016, p. 127).

At the University of Pittsburgh, I recently designed a new course, “History of Medicine and Health Care: Latin America and the Caribbean.” Students from across disciplines and backgrounds enrolled, but only a handful of them had the ability to read in a language other than English. When designing past courses, such as “Modern Latin America,” I could draw on a host of primary source texts that had already been translated from Spanish, Portuguese, Quechua, or Nahuatl. For the history of medicine in the region, however, primary sources that were already translated and ready for student reading were incredibly difficult to track down.

Several other professors pointed me to the Virtual Archive of the History of Science in Latin America and the Caribbean, a superb collection of predominantly visual sources. For the second class meeting, I assigned selections depicting medical practices in the Florentine Codex, a 16^th century manuscript filled with fascinating illustrations of the lifestyle and history of the peoples of the Aztec/Mexica Empire. While students found the images interesting, discussion of them proved strained and stunted, paling in comparison to what I had seen previous students do with textual sources.

Somewhat discouraged, I shifted to analyzing only secondary sources during the next few units. My students brought original thoughts and careful critique of the articles to these discussions, so I began to wonder if they had simply lacked the scaffolding to make sense of the images from the Florentine Codex. I searched out a pedagogical resource to help them, settling upon Elspeth H. Brown’s “Reading the Visual Record.” She writes in that essay, “While many students have learned strategies for analyzing textual documents, such as identifying the author’s use of metaphor or imagery, few history students have been trained in parallel methodologies for reading visual records” (p. 362).

Armed with the tools she suggested, I planned the following visual analysis exercise during the unit on state-building, citizenship, and health in twentieth-century Latin America.

Lesson Plan

By the end of the lesson, students should be able to:

• Better analyze visual sources, applying their pre-existing knowledge of textual document analysis, while also learning new skills for studying visual documents
• Understand how medical knowledge and the practice of health care shape and are shaped by social relations, political processes, economic structures, and culture (one of the central objectives of the course)
  • Apply this abstract knowledge to a specific historical context, identifying the positive and negative consequences of the anti-tuberculosis campaign in Cuba, and more specifically, its national sanatorium project

To assist their comprehension, before coming to class, students read briefly about the rise of populist movements in mid-twentieth-century Latin America and the resulting expansion of social rights and medical programs (as well as their limits). They also read Elspeth Brown’s article on visual analysis.

Readings:

• Marcos Cueto and Steven Palmer, Medicine and Public Health in Latin America: A History (New York: Cambridge University Press, 2015): 122–25, 135–39, 168–74.
• Elspeth H. Brown, “Appendix A: ‘Reading the Visual Record’,” in Looking for America: The Visual Production of Nation and People, ed. Ardis Cameron (Malden, MA: Blackwell Publishing, 2005): 362–70.

Visual Analysis Activity

As students arrived in class, I projected an image of the front of a postcard on the screen at the front of the room (see Figure 1). The postcard is part of my own collection, so I wrapped it in a protective sleeve and passed it around the class (thus including both visual and kinesthetic learners). While I allowed students to reference the back side of the postcard (see Figure 2) in the final stages of discussion, for the purposes of the image analysis exercise, I directed them to focus solely on the front side.

 

 

I then had students pull out their (hopefully annotated) copies of Brown’s article (the instructional scaffolding for the day) and told them that we were going to go through each of her stages during our time together (Ambrose 2010.)

I. Stage 1 (15 minutes)

Brown’s first stage (and the hardest one for students to complete) is “description.” Here the focus is on only “seeing” the image, without “quickly process[ing] visual information into cultural meanings” (p. 362). I had students describe what they saw, continually urging them to “us[e] only the visual evidence present in the image” (p. 362). By this point, students had asked several times what they were looking at, but I refrained from giving answers, promising them that (most of) their questions would be answered by the end of class.

Brown suggests three steps during stage one: First, describe the physical and material aspects of the image (which is one reason why distributing the postcard is useful, although not necessary); second, discuss the content of the image; and, third, conduct a “formal analysis” of the image (e.g., direction and number of lines, foreground/background).

I had students free write answers on their own for each of these steps and then had several of them briefly (5 minutes) share their descriptions with the entire class. Having them repeat their answers out loud was useful for correcting them when they had made assumptions or jumped to analyzing the meaning of the image.

II. Stage 2 (20 minutes)

The second stage is deduction, in which students “consider the image in relationship to [their] own subjectivity” (p. 365).  The goal is to figure out what meaning(s) the image is trying to convey and how. Students have to perform a balancing act during this stage, considering their own reaction to the image (anchored in their contemporary world), while also keeping in mind the “specific moment in history when the image was in circulation” (p. 367).  I had students take a few minutes to reflect on these questions and then share in pairs.

Then, I asked students to place themselves in the world of the postcard’s image, what Brown describes as “engag[ing] with the image empathetically” (p. 366). My students needed some direction at this point, so you can lead them with more specific questions. Brown asks, for example, “What’s the weather like? Is there a breeze blowing? Would you be warm or cold, comfortable or disoriented if you were inhabiting the pictorial space? Crucially, why?” (p. 366). I then had students share some of their answers with the entire class. (In fact, using the “think/pair/share” strategy is useful at each step of this activity).

I reminded the class that these meanings were just hypotheses at this point, and we would return to accept, modify, or reject them after Stage 3.

III. Stage 3 (10–15 minutes)

We then moved to Brown’s final stage: speculation. At this point, students get to ask questions of the image – and students’ questions poured out at this point, as they had been holding them in from the moment the exercise started. The objective of this stage is to “develop theories and hypotheses about the social and cultural work performed by the image in the historical context of its production and circulation” (p. 367). I had students generate as many questions as they liked in their pair and then each group wrote 2–3 questions on the chalkboard. If they needed help generating ideas at this point, I directed them back to the Brown reading, as she provides a host of questions on pages 367–68.

IV. Contextualizing the Image: Lecture (20 minutes)

Brown’s final step is for students to develop a research agenda based on this exercise and to find primary and secondary sources to answer their research question. As I used this exercise during a time-crunched summer semester, I modified her approach, skipping this step and instead providing students with a lecture that spoke to the wider historical and social milieu of the postcard.

The postcard was distributed in September 1954 (and the photograph was likely taken in 1954 as well), in celebration of the May 1954 inauguration of the Topes de Collantes National Sanatorium, dedicated to the treatment of tuberculosis. The hospital was a prestige project of the central figure of Cuba’s republican period, Fulgencio Batista, who served as a military dictator in the 1930s, president from 1940–44, and then returned as dictator from 1952–58 (see Figure 3).

 

In the first decades of the twentieth century, Cuban public health officials and statesmen were predominantly concerned with yellow fever, a disease that attacked primarily white Spanish immigrants (see Stepan 1978 and Espinosa 2009 to understand the Cuban state’s prioritization of yellow fever). In contrast, tuberculosis killed large numbers of native-born Cubans every year, most of whom were poor and non-white. By the 1920s, amidst the backdrop of popular mobilization and surging nationalism, health activists, physicians, and ordinary citizens began to articulate the right to state health care and the necessity of greater state funding of tuberculosis treatment centers. The visibility and politicization of tuberculosis increased, and in 1936, in order to gain political legitimacy, Batista founded the National Tuberculosis Council (Consejo Nacional de Tuberculosis) to lead a state-directed anti-tuberculosis campaign.

As argued in my forthcoming article in the Bulletin of the History of Medicine, the intersection of disease and politics in Cuba in the mid-1930s pushed Batista to prioritize a disease that was often neglected by other national and colonial governments until the post-war period. Nonetheless, national politics also undermined efforts to control the disease in Cuba. Authoritarianism facilitated Batista’s considerable influence over tuberculosis policy, and he and his advisors pursued political objectives rather than following the technical advice offered by professional groups. As a result, the administration of the campaign was inefficient, nowhere more conspicuous than in the Topes de Collantes Sanatorium project.

The second half of the lecture recounts the saga of the national sanatorium project from 1937 to late 1954 (when the postcard and stamp had been circulating for several months), including how the project advanced and why it often stalled, as well as the benefits of the anti-tuberculosis campaign and its limitations. (I save the final argument of the article – that the criticisms of this disease control campaign and Topes de Collantes Sanatorium had political consequences, informing citizens’ growing dissatisfaction with the Batista regime during a period of political instability in the 1950s – for after the visual analysis exercise is completed, in order to let students draw their own conclusions from the narrative itself.)

V. Final Discussion

 a. Deciding on Meaning(s) (25 minutes)

With this contextual information fresh in their minds, I had them return to the meanings that they previously hypothesized. I asked them to again discuss (in pairs) Brown’s “speculation” questions, such as who the intended audience was and “what sorts of cultural work the image performed and for whom, at a specific historical moment, as well as (perhaps) how these meanings changed over time, and why” (p. 369).

If time permits, it is useful to also discuss the medium of the source (in this case, a postcard). This allows students to draw on questions that they are accustomed to asking of other (textual) primary sources, such as newspaper articles or diary entries. Pertinent questions might include:

• What is the function of a postcard? Why broadcast the image in this medium rather than in some other format (e.g., a national newspaper, a poster, or a book)? Where do the audiences of these different mediums overlap and where do they differ?
• Who is selling this postcard and why?
• Who is buying the postcard? Who can afford it? Why are they buying it? And, if someone has made a choice to purchase and use this postcard, is it still propaganda? (The same questions can also be asked of the stamp.)
• What are the probable contexts of consumption? Where, when, how, why, and who might have seen this image?

Once they were done discussing all of these questions, each pair summed up in one short paragraph (2–3 sentences) what they believed the message of the image to be.

Then, we had another large group discussion, with students sharing their mini-paragraphs and reaching consensus as a group as to the main messages of the image. For this postcard, they decided on three major “meanings”: that the hospital was constructed (in both the material and discursive senses) to communicate Fulgencio Batista’s beneficence; that it served as an exemplar of (medical) modernity on the island; and that it was meant to secure Batista’s political rule.

When students offered possible meanings, I pressed them to provide evidence (from the image, not lecture) to back up their opinion. For example, one student argued that the image primarily conveyed Cuba’s modernity. She pointed to the cutting-edge Art Deco architecture, the size of the hospital, and its juxtaposition with primitive nature. Another student said the image and the hospital itself were used as tools to strengthen Batista’s legitimacy, noting that Batista’s name was in several places on the postcard, including twice on the stamp  (see Figure 4).

 

b. Estimating Reception (10–20 minutes)

Students were then asked: did you find the message(s) of the image convincing? Why/why not? If students tend to be overly critical or overly susceptible to the image, it helps spur discussion to ask what in particular was convincing and what specifically was not convincing. (Many students are skeptical of the message in images, and the former question helps students consider what advances the hospital might represent, especially in comparison to other places in the world, where rural hospitals and TB were not being adequately addressed by the state.)

One interesting question to push students into deeper reflection is to ask them about what Brown calls “blind spots” in the image. For example, what is missing? What did you expect to see but don’t? What does this image not show us? I selected one meaning of the image – the sanatorium as commitment to the health of the Cuban people – and asked what other images could more convincingly prove this message.

One of my students pointed out, for example, that no humans were depicted in this image. The only (implicit) individual is Batista, whose name is on the stamp (and the back of the postcard). I followed up on this astute point by asking which humans might have been included and how that would have changed the message. Another student mentioned the lack of patients, and said he would have been more convinced about the success of the project if he could get a sense of how many people were served by the hospital.

At this point in the exercise, I suggest allowing students to make their own observations and pursue what may seem to be tangents, rather than directing them towards a specific lesson you want to get across. The sophistication and creativity of my students’ answers surprised me, and I was glad to serve as a facilitator of the discussion, rather than the instructor.

Reflections on the Exercise

Even though students resisted the somewhat tedious work of deconstructing the image in Stages 1 and 2, by Stage 3 they were more interested in participating (and had done the hard work of garnering the evidence to create a complex discussion in the final half of class.) Due to the success of the activity, in the future I plan to have students complete this exercise periodically throughout the course, using images from my own research and from the Virtual Archive of the History of Science in Latin America and the Caribbean.

Deconstructing the visual historical medical record using Brown’s stages forces students to deal with the material at hand, but also allows them to make observations and ask questions that are of interest to them. More broadly, using visual sources helps students better understand a culture, place, and time different from their own. This exercise immerses them in that world and peaks their interest in it. Furthermore, much of the learning in this exercise is self-generated, which has been proven to more successfully “effect attitude change,” (Huston 2009, p. 201).

Possible modifications and additions to this exercise:

• We spent approximately an hour and a half on this exercise. I had ample time as I taught it during a three-hour summer semester session and had a group of approximately 15 students. If doing the entire exercise in one class meeting, give one or two 5-minute breaks throughout to ensure students’ attention stays focused.
  • The exercise could be modified for a shorter class meeting, with the lecture given in a previous meeting or context given in readings completed for the day. Alternatively (and preferably), students could also do the first two stages of description and deduction as homework for the meeting, turning in their responses at the beginning of class as proof of preparation and then briefly sharing their findings.
• A possible addendum is to introduce role playing in the final part of the “estimating reception” section. Select 3–4 different subject positions from the historical world of the image and put them on notecards, creating multiples of each subject position so that each student can draw a card. For this exercise, I might select three positions: a Spanish immigrant in Havana, a poor slum dweller in Santiago de Cuba, and a cane cutter in rural Cuba. Students are then asked, would this historical actor find the image’s message convincing? Why/why not?
  • Students can ask you questions about their historical subject (e.g., how far does she live from the sanatorium? Did he support Batista? Does their family have health insurance?) to better understand their character.
  • Students will have just reflected on if they themselves find the image convincing. However, this exercise prompts students to more deeply consider whether this historical actor would find the image convincing, and why or why not.
• Pair the visual exercise with a theoretical framework. In this case, after students have completed the exercise, one could introduce Foucault’s concept of “biopower,” and then ask students how the theory applies to the concrete historical instance that they are now well acquainted with.
• Have students conduct their own research in a visual archive or other database.
  • For example, they could earn extra credit by (1) bringing in another visual example of the intersection of politics and health care, and (2) providing an oral or written analysis of this image.

References

Ambrose, Susan A., et al., How Learning Works: Seven Research-Based Principles for Smart Teaching (San Francisco: Jossey-Bass, 2010), 132–33.

Brown, Elspeth H.,“Appendix A: ‘Reading the Visual Record,’” in Looking for America: The Visual Production of Nation and People, ed. Ardis Cameron (Malden, MA: Blackwell Publishing, 2005).

Espinosa, Mariola, Epidemic Invasions: Yellow Fever and the Limits of Cuban Independence, 1878–1930 (Chicago: The University of Chicago Press, 2009).

Huston, Therese, Teaching What You Don’t Know (Cambridge, MA: Harvard University Press, 2009).

Stefan, Nancy, “The Interplay between Socio-Economic Factors and Medical Science: Yellow Fever Research, Cuba and the United States,” Social Studies of Science 8, no. 4 (Nov. 1978): 397–423.

Tobbell, Dominique A., “Teaching Medical History with Primary Sources: Introduction,” Bulletin of the History of Medicine 90, no. 1 (2016).