A country is made out of people, health and illnesses : Revista Pesquisa Fapesp

THE FRED L. SOPER PAPERSMember of the eradication group in the Northeast RegionTHE FRED L. SOPER PAPERS

As in all marriages, the joining of Brazil and Brazilians to form a nation took place under the “in sickness” and in health” warning, particularly the former, after physician Miguel Pereira declared back in1916 that the “country is a huge hospital,” and national pride turned to undoing the negative image that sullied the “couple.” The “accidental” best man in this marriage was a foreigner, the International Division of the Rockefeller Foundation, active amongst us since the 1910s, partnering with the Brazilian government in the fight against ancylostomiasis and yellow fever and in the training of health professionals. The thesis of health as the driver of the nation is put forth by historian Gilberto Hochman, a researcher at Casa de Oswaldo Cruz of the Oswaldo Cruz Foundation and coordinator of the project Public health and the construction of the State: national policies, international organizations and programs to control and eradicate diseases in Brazil. The “gift” presented to the newlyweds was the belief in a program recently adopted by the foundation, the eradication of illnesses and their vectors, as opposed to the mere control of disease. The latter view was the one espoused by Brazilian physicians, who preferred to face diseases such as malaria, at that time the “chief enemy” of progress, by improving the life of the poor and by prescribing quinine. Hochman provides an alternative view of what was then regarded as merely another form of “Yankee imperialism,” this time by means of medicine.

The Rockefeller Foundation, in the context of the unrestrained enthusiasm for science at the time, rejected palliatives and promised to uproot such evil and eradicate illnesses once and for all with the technological apparatus then available and an almost military combat organization, headed up by physician Fred Soper (1893-1977), whose experience with tropical diseases was limited to a three-week intensive course. According to him, if the Anopheles gambiae mosquito found in the 1930s in the Northeast of Brazil were not eradicated, control of the epidemic would be lost and, even worse, the epidemic would reach the United States. According to the researcher, the new head of the Brazilian State, Getúlio Vargas, who wanted a united and healthy nation, even if this was to be achieved forcibly, opened the doors to Soper.

“The decision to ‘eradicate’ diseases must be seen from historical, ideological and political viewpoints. In Brazil, it was embraced thanks to external pressures that, given the type of political forces then in power, were accepted with caution or alignment with this concept. Public health was crucial to the process of constructing the national State. Territories and populations were incorporated into Brazil by means of needles and syringes. In this process, one of the fundamental elements was the interaction between international and national health organisms. This was conducted, at first, to fight malaria, from 1939 to 1969,” states the researcher. “This did not occur without dialogue, tension and conflict between these two parties, having involved networks of political and economic interests as well as the diversity of and asymmetry between the countries, players and institutions,” he observes. Even so, the eradication imposed by the United States and implemented by the Rockefeller Foundation helped to “create” a country, besides having a major impact on the concept underlying the national healthcare system, responsible, to this day, for achievements and shortcomings.

“It was also important for an entire generation of young physicians and epidemiologists that took part in the campaigns and who subsequently helped to review the concept of ‘eradication,’ which was then vertical and imposed, disregarding the cultural, hygienic and nutritional practices of Brazil’s rural population, expected to passively receive and ‘be grateful for’ the benefits provided by the new public medicine,” analyzes Gilberto. “Thus, after a long historical pathway of healthcare policies tied to the process of building a national State, of development linked to power, inequality, inclusion, control, and civil rights, ‘biomedical citizenship’ was achieved little by little, an outcome that the population could not have foreseen. This was consolidated in the 1988 Constitution, which converted immunization from coercion into a right,” he analyzes.

The Fred L. Soper papers Soper (moustache) and colleagues waiting for a flat tire to be changed (1934)The Fred L. Soper papers

On the side of the Rockefeller Foundation and later of developed countries, Brazil was also fundamental for the defense of the concept of eradication. “Since the nineteenth century, the country had maintained a strong relation with international healthcare issues and bodies, connected with epidemics of cholera, smallpox, yellow fever and malaria. It was here that the trials of how to conduct a health campaign were carried out. These formed the basis for broader and more global undertakings,” Gilberto assessed. From these experiments arose the idea that it was urgent to eradicate diseases on a global scale, a notion that was at the top of the agenda of international organizations in the post-WWII period. Science and medicine were then regarded as a fundamental means of raising poor countries to the pantheon of the First World, thus avoiding the growth of populism and socialism in these regions. “There was a belief, still espoused by many technicians and organizations, that it was disease that stood in the way of the socioeconomic development of poor countries, rather than the other way around, meaning that poverty is what generated diseases,” observes the medical historian Randall Packard, from Johns Hopkins University, and the author, along with the Brazilian researcher Paulo Gadelha, of the study A land filled with mosquitoes: Frederick Soper, the Rockefeller Foundation and the Anopheles gambia invasion of Brazil, 1932-1939 (1994).

“These were times of great enthusiasm for the capacity of science to change things. But this expertise was a privilege for those in only some parts of the world and needed to be transferred to those not receiving it. According to this view, most of the world lacked certain solutions that came from abroad, even if this meant a total lack of knowledge of what was really happening in the countries where the intervention was being carried out,” comments the American. “The eradication was designed to consist of technical interventions, conducted by experts that aimed to completely eliminate diseases, one by one, without any type of involvement with the social and economic determinants of the health-illness relation. This was “‘etiologic universalism, meaning that wherever the disease was to be found, it was assumed that it had the same cause and that it could be eliminated using the same methods, regardless of the differences in the economic, geographic, and class circumstances of the populations; none of this was taken into account,” observes the historian Rodrigo Cesar Magalhães, who is working on a project called Development and international health cooperation: the continental campaign to eradicate the Aedes aegypti and its impact in Brazil, at the University of Maryland, with the support of the Fulbright Foundation. He is researching the Fred L. Soper papers. “Eradication, of which Soper was the strongest advocate, had a universally-oriented nature. For him, there was no need for deep social reforms to reduce the incidence of diseases such as malaria and yellow fever,” he tells us.

The Fred L. Soper papers Soper in1928, when he was already on the staff of the Rockefeller FoundationThe Fred L. Soper papers

Soper, who came to Brazil between 1920 and 1942, is the central character in the most recent book, Eradication: ridding the world of diseases forever?, written by Nancy Stepan, an American historian, Brazilianist and professor emerita at Columbia University. The American physician led a health campaign in the Brazilian Northeast that culminated in the eradication, in record time (only 35 months) of the most efficient carrier of malaria, the Anopheles gambiae mosquito. The report on this “victory,” Anopheles gambiae no Brazil – 1930 a 1940, from 1943, has just been published by Fiocruz. This is the first faithful version of the study in Portuguese. “This alleged ‘success,’ which proved to be passing and misleading, shows how international eradication campaigns are an obstacle to the development of basic health systems, as they drive governments to invest in expensive activities that are not always based on the needs of the given country and that jeopardize the existing local programs. Diseases are often chosen to be the target of international campaigns based on political, economic and symbolic criteria; in other words, for reasons other than the devastation that they cause relative to the other illnesses and problems of a country,” explains Nancy.

“Soper was an autocratic administrator who wasn’t very interested in research and was suspicious of the efficacy of vaccines, preferring to eradicate disease vectors. He felt that each national program ought to be an independent entity with its own staff and a coordinator reporting directly to the head of State. In the Brazilian case, his partnership with the authoritarian Vargas regime was perfect,” the researcher observes. The organizational technology brought a new public health mentality to Brazil, especially as regards its structure. “As early as the 1920s, one can already see how eradication along the lines of the Rockefeller Foundation and Soper reorganized the country. In the midst of the Old Republic, with its exacerbated federalism, the Americans timidly developed a vertical campaign with total precision whereby one supervisor timed with a chronometer the time it took an agent of the Yellow Fever Service (SFA) to cover one block. It was astonishing,” Gilberto notes.

Soper was named head of the Rockefeller Foundation in Brazil and SFA coordinator in 1930, the same year as Vargas rose to power. “Getulio wanted to modernize and to unify the country, to create a nation, and he gladly accepted the collaboration of the Americans. The fight against disease consolidated state authority in several regions and was ideal for his project of a cohesive and strong national State,” Rodrigo observes. “From Soper’s point of view, the lack of democracy made his health work easier. You could arrest anyone that refused to collaborate with the technicians and there are even cases of shots being exchanged between recalcitrant inhabitants and SFA agents,” the French historian Ilana Löwy tells us. She is the research director of Inserm (the National French Institute of Health and Medical Research) and the author of the study Representation and intervention in public health: viruses, mosquitoes and specialists from the Rockefeller Foundation in Brazil (1999).

The Fred L. Soper papers Mosquito capturing squadron in the state of Pernambuco (1934)The Fred L. Soper papers

“The Rockefeller people were aware that diseases such as tuberculosis, typhoid fever or gastroenteritis caused a larger number of victims than yellow fever or malaria, but as the former were considered to be diseases tied to standards of living, they were seen as inappropriate for eradication activities with exemplary purposes,” she analyzes. “They wanted to ‘civilize’ Brazilians, but this was not a mere expression of racism or imperialism. The Rockefeller Foundation employees promoted the interests of American construction companies, guaranteeing contracts in urban sanitation projects for them. At the same time, they were also convinced that Brazil would benefit from their activities,” Ilana observes. Over the course of time and of failures, the Foundation gradually drew away from Soper’s ideas, but unexpected setbacks, such as the outbreak of yellow fever in Rio de Janeiro in 1928 and malaria in 1938, invariably put eradication back in the limelight.

And the political development of the Brazilian State came hand in hand with eradication. “In the 1950s, optimism about health and the Cold War crossed. This led to malaria being elected as the target of international attention and of the US foreign policy of the Eisenhower administration. Eradication acquired a new momentum, seen as the preliminary condition for releasing populations for economic activities, thus avoiding social movements. An association was even devised between malaria and communism, both being able to ‘enslave’ individuals,” Gilberto tells us. Once again, health was directly enmeshed with the consolidation of the national State. “The Juscelino Kubitschek administration was facing a serious economic crisis and external finance problems for its development projects and the construction of Brasilia. The American policy of health-oriented cooperation, a key element of the Cold War, provided financial aid to fight malaria only to those countries that converted their control programs into eradication programs. As a result, in 1958, malaria, which was ‘almost extinct,’ as the then presidential candidate Juscelino said in 1955, returned to the top of the Brazilian health agenda,” the researcher states. Thus, malaria found itself at the intersection between local health policies, the international agenda, development projects, and American interests. Yet again, eradication brought together Brazilians and foreigners and influenced the model of the national State and the healthcare system.

However, criticism of this model was increasing and the so-called “development-oriented health professionals” were advocating horizontal campaigns that would provide basic sanitary infrastructure conditions to fight diseases. Going head-on against “Soperian” eradication, they believed in socioeconomic development as a prerequisite for improving health. The 1964 coup d´état, however, threw a bucket of cold water upon these alternative visions. The Castello Branco administration (1964-1967) included Brazil in the global “eradication” efforts, now focusing on smallpox rather than malaria, in line with international organizations. “The eradication of smallpox may have been a political response of the military to the international community, lending legitimacy to the government at a time when censorship and internal repression were on the rise. At the same time, it was an opportunity for health professionals to acquire qualifications,” Gilberto comments. The campaign was expanding the healthcare agenda beyond the eradication of just one disease, creating an opportunity to increase the production of vaccines.

The Fred L. Soper papers Soper meeting Vargas in the Northeast in 1940The Fred L. Soper papers

“Unlike the malaria campaign, which didn’t require the participation of the public, the smallpox campaign required mobilizing multitudes of people for the vaccination effort. Although this had not been part of the plan of the military, this movement increased the population’s contact with the health services and the notion that vaccines were a public service to be offered by the State,” the researcher observes. The dozens of millions of doses applied over five years, with apparently residual use of coercive means, modified the pathway of immunization in Brazil. “The eradication of polio and the target of eradicating other immuno-preventable diseases are the direct consequence of the smallpox campaign, that influenced the increasing supply of vaccines for a population that increasingly demands immunization, in a sort of ‘immunological civism,” Gilberto states. Brazil was transitioning from revolting against coercive vaccination to regarding vaccines as an acquired right.

“It is a victory of citizenship, although not only positive, because the choices of society often ignore the fact that the money spent on a given campaign could be used to improve basic health conditions, which are just as important as vaccinations or eradications. The ‘remedy’ for this is greater transparency, social control and democracy,” the historian assesses. For Gilberto, today, the issue is understanding the possibilities of autonomous domestic health policies in a world that is increasingly interdependent. This requires “health diplomacy” that must eradicate, once and for all, Soper’s old dogmas. “After all, we have seen that state health policies in post-WWII Brazil had their own internal dynamics, but they resulted from and were conditioned by interaction from international pressures. The nationalization of health has been conducted during the course of the twentieth century as part of the formation of the Brazilian State, often using external elements in its very construction.”

Oddly enough, this combination of health and politics may be proven in the country that brought vertical eradication to the rest of the world. “There is a theory that I’m examining according to which the return of Aedes aegypti to Brazil, in the 1950s, after it had been eradicated, may have resulted from poorly conducted eradication in the southern United States. There are several previously unpublished letters from Soper accusing the US government, because the health authorities had not done the work that was being conducted in the rest of the continent. But how might such a model of campaign be implanted in a democratic context such as that of the United States, with its consolidated culture of liberty and privacy?” Rodrigo asks himself. “In the conflict between eradicating the mosquito and individual liberty, the latter would have prevailed, thereby adversely affecting an entire continent. Should this theory prove to be correct, it would be ironical if the issue of eradication and democracy were confirmed, giving rise to a broad discussion about alleged American imperialism in the Americas in the health field.” It would be the confirmation that one can help to create a country “in sickness and in health.” The danger, as usual, is “unfaithfulness” or “till death do us part.”

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