{"id":48271,"date":"2012-08-10T17:22:53","date_gmt":"2012-08-10T20:22:53","guid":{"rendered":"http:\/\/revistapesquisa.fapesp.br\/?p=48271"},"modified":"2017-03-03T13:13:19","modified_gmt":"2017-03-03T16:13:19","slug":"a-country-is-made-out-of-people-health-and-illnesses","status":"publish","type":"post","link":"https:\/\/revistapesquisa.fapesp.br\/en\/a-country-is-made-out-of-people-health-and-illnesses\/","title":{"rendered":"A country is made out of people, health and illnesses"},"content":{"rendered":"
\"\"

THE FRED L. SOPER PAPERS<\/span>Member of the eradication group in the Northeast RegionTHE FRED L. SOPER PAPERS<\/span><\/p><\/div>\n

As in all marriages, the joining of Brazil and Brazilians to form a nation took place under the \u201cin sickness\u201d and in health\u201d warning, particularly the former, after physician Miguel Pereira declared back in1916 that the \u201ccountry is a huge hospital,\u201d and national pride turned to undoing the negative image that sullied the \u201ccouple.\u201d The \u201caccidental\u201d 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. <\/em>The \u201cgift\u201d 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 \u201cchief enemy\u201d 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 \u201cYankee imperialism,\u201d this time by means of medicine.<\/p>\n

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<\/em> 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, Get\u00falio Vargas, who wanted a united and healthy nation, even if this was to be achieved forcibly, opened the doors to Soper.<\/p>\n

\u201cThe decision to \u2018eradicate\u2019 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,\u201d states the researcher. \u201cThis 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,\u201d he observes. Even so, the eradication imposed by the United States and implemented by the Rockefeller Foundation helped to \u201ccreate\u201d a country, besides having a major impact on the concept underlying the national healthcare system, responsible, to this day, for achievements and shortcomings.<\/p>\n

\u201cIt 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 \u2018eradication,\u2019 which was then vertical and imposed, disregarding the cultural, hygienic and nutritional practices of Brazil\u2019s rural population, expected to passively receive and \u2018be grateful for\u2019 the benefits provided by the new public medicine,\u201d analyzes Gilberto. \u201cThus, 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, \u2018biomedical citizenship\u2019 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,\u201d he analyzes.<\/p>\n

\"Soper

The Fred L. Soper papers<\/span><\/a> Soper (moustache) and colleagues waiting for a flat tire to be changed (1934)The Fred L. Soper papers<\/span><\/p><\/div>\n

On the side of the Rockefeller Foundation and later of developed countries, Brazil was also fundamental for the defense of the concept of eradication. \u201cSince 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,\u201d 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. \u201cThere 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,\u201d 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 <\/em>Anopheles gambia invasion of Brazil, 1932-1939<\/em> (1994).<\/p>\n

\u201cThese 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,\u201d comments the American. \u201cThe 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 \u201c\u2018etiologic 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,\u201d observes the historian Rodrigo Cesar Magalh\u00e3es, who is working on a project called Development and international health cooperation: the continental campaign to eradicate the <\/em>Aedes aegypti and its impact in Brazil, <\/em>at the University of Maryland, with the support of the Fulbright Foundation. He is researching the Fred L. Soper papers. \u201cEradication, 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,\u201d he tells us.<\/p>\n

\"Soper

The Fred L. Soper papers<\/span><\/a> Soper in1928, when he was already on the staff of the Rockefeller FoundationThe Fred L. Soper papers<\/span><\/p><\/div>\n

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?<\/em>, 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 <\/em>mosquito. The report on this \u201cvictory,\u201d Anopheles gambiae no Brazil \u2013 1930 a 1940<\/em>, from 1943, has just been published by Fiocruz. This is the first faithful version of the study in Portuguese. \u201cThis alleged \u2018success,\u2019 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,\u201d explains Nancy.<\/p>\n

\u201cSoper was an autocratic administrator who wasn\u2019t 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,\u201d the researcher observes. The organizational technology brought a new public health mentality to Brazil, especially as regards its structure. \u201cAs 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,\u201d Gilberto notes.<\/p>\n

Soper was named head of the Rockefeller Foundation in Brazil and SFA coordinator in 1930, the same year as Vargas rose to power. \u201cGetulio 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,\u201d Rodrigo observes. \u201cFrom Soper\u2019s 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,\u201d the French historian Ilana L\u00f6wy 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 <\/em>(1999).<\/p>\n

\"Mosquito

The Fred L. Soper papers<\/span><\/a> Mosquito capturing squadron in the state of Pernambuco (1934)The Fred L. Soper papers<\/span><\/p><\/div>\n

\u201cThe 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,\u201d she analyzes. \u201cThey wanted to \u2018civilize\u2019 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,\u201d Ilana observes. Over the course of time and of failures, the Foundation gradually drew away from Soper\u2019s 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.<\/p>\n

And the political development of the Brazilian State came hand in hand with eradication. \u201cIn 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 \u2018enslave\u2019 individuals,\u201d Gilberto tells us. Once again, health was directly enmeshed with the consolidation of the national State. \u201cThe 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 \u2018almost extinct,\u2019 as the then presidential candidate Juscelino said in 1955, returned to the top of the Brazilian health agenda,\u201d 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.<\/p>\n

However, criticism of this model was increasing and the so-called \u201cdevelopment-oriented health professionals\u201d were advocating horizontal campaigns that would provide basic sanitary infrastructure conditions to fight diseases. Going head-on against \u201cSoperian\u201d eradication, they believed in socioeconomic development as a prerequisite for improving health. The 1964 coup d\u00b4\u00e9tat, however, threw a bucket of cold water upon these alternative visions. The Castello Branco administration (1964-1967) included Brazil in the global \u201ceradication\u201d efforts, now focusing on smallpox rather than malaria, in line with international organizations. \u201cThe 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,\u201d 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.<\/p>\n

\"Soper

The Fred L. Soper papers<\/span><\/a> Soper meeting Vargas in the Northeast in 1940The Fred L. Soper papers<\/span><\/p><\/div>\n

\u201cUnlike the malaria campaign, which didn\u2019t 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\u2019s contact with the health services and the notion that vaccines were a public service to be offered by the State,\u201d 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. \u201cThe 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 \u2018immunological civism,\u201d Gilberto states. Brazil was transitioning from revolting against coercive vaccination to regarding vaccines as an acquired right.<\/p>\n

\u201cIt 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 \u2018remedy\u2019 for this is greater transparency, social control and democracy,\u201d 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 \u201chealth diplomacy\u201d that must eradicate, once and for all, Soper\u2019s old dogmas. \u201cAfter 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.\u201d<\/p>\n

Oddly enough, this combination of health and politics may be proven in the country that brought vertical eradication to the rest of the world. \u201cThere is a theory that I\u2019m examining according to which the return of Aedes aegypti<\/em> 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?\u201d Rodrigo asks himself. \u201cIn 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.\u201d It would be the confirmation that one can help to create a country \u201cin sickness and in health.\u201d The danger, as usual, is \u201cunfaithfulness\u201d or \u201ctill death do us part.\u201d<\/p>\n","protected":false},"excerpt":{"rendered":"Foreign eradication programs influenced Brazil’s construction","protected":false},"author":24,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"footnotes":""},"categories":[165],"tags":[241],"coauthors":[117],"class_list":["post-48271","post","type-post","status-publish","format-standard","hentry","category-humanities","tag-history"],"acf":[],"_links":{"self":[{"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/posts\/48271","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/users\/24"}],"replies":[{"embeddable":true,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/comments?post=48271"}],"version-history":[{"count":0,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/posts\/48271\/revisions"}],"wp:attachment":[{"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/media?parent=48271"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/categories?post=48271"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/tags?post=48271"},{"taxonomy":"author","embeddable":true,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/coauthors?post=48271"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}