Rural Endemic Diseases, Civilization, and Nation-State Building

Yellow fever and cholera epidemics frequently occurred in the Brazilian capital, Rio de Janeiro, and the principal port cities from 1849 onward. Later, bubonic plague and smallpox outbreaks also occurred. These diseases arose in a context of rising urbanization and modernization initiatives following the arrival of the Portuguese Court in 1808, which intensified after the independence in 1822 and the establishment of the Segundo Reinado in 1840. Yellow fever, in particular, followed the railroads and advanced inland through coffee-producing areas at the end of the 19th century. These epidemics caused serious problems for an essentially agricultural country that was an importer of immigrant labor, something that had been encouraged as a result of the emancipatory laws and the end of slavery in 1888. Furthermore, these diseases paralyzed the capital and the country’s ports, preventing the circulation of goods and people, thereby generating a negative international image of the country and its capital as a “dirty port.”

Yellow fever, smallpox, and the plague were selected as the priorities of national public health services and brought under control in the first decade of the 20th century. Control that was the result of intense public health campaigns led by Oswaldo Cruz and Emilio Ribas, among other preeminent doctors, under the republican regime created in 1889. The fields of experimental and tropical medicine were established in new research institutes in Rio de Janeiro and in São Paulo, such as Instituto Soroterápico Federal created in 1900 (renamed Instituto Oswaldo Cruz in 1909), and served as a base for public health services, in particular actions against the yellow fever mosquito, inspired by the work of the Reed Commission in Cuba (1900–1901). Under the direction of Oswaldo Cruz in public health (1903–1909) these campaigns gained salience and a special meaning in the federal capital, the center of which was profoundly transformed with the intention of making it the window of a civilized and modern Brazil, a belle epoque city in the tropics. This process did not occur without the resistance of those forcibly removed from central areas of the city and those who were subjected to autocratic public health intervention. The best-known episode in this resistance was the revolt against the obligatory smallpox vaccination that shook the federal capital in November 1904.

In the 1910s the attention of Brazilian public health turned to rural endemic diseases, a new category proposed by Carlos Chagas following his 1909 discovery of a new tropical disease in the country’s hinterland, American trypanosomiasis—or Chagas disease. These endemic illnesses would come to be seen as the “diseases of Brazil.”³ The dissemination of the idea that the great national problem was the rural endemic diseases, which in a general sense “degenerated” rural populations, informed both the medical-scientific debate and health policy over the following six decades. As a result, despite the advances and conquests of medicine and public health in the first decade of the 20th century, Brazil was still for many “a vast hospital,” as Miguel Pereira, president of the National Academy of Medicine and professor of the medical school of Rio de Janeiro, dramatically stated in October 1916. These phrases, appearing in newspaper headlines, had a great impact at a time marked by nationalism and World War I.⁴ The image of Brazil as a hospital haunted generations of Brazilian doctors, intellectuals, and politicians who sought to deny it, reaffirm it, or transform it.

This discovery of a “sick Brazil” inhabited by an abandoned and illiterate population, infested and famished, was a diagnosis based on numerous scientific expeditions into the country’s inland regions and the Amazon, in which prominent doctors and scientists participated, such as Oswaldo Cruz, Arthur Neiva, Belisário Penna, Adolpho Lutz, and Carlos Chagas. Several of these expeditions were made to assess health conditions in infrastructure works and to implement the prophylaxis of malaria. These expeditions and Chagas’s discovery of the disease that bears his name led to an uncomfortable meeting between these doctors, members of the coastal elite, and men and women from the sertões (backlands, hinterland) of Brazil.⁵ According to the doctors, they were sick because they had been abandoned by the government and were beyond the reach of public health. This discomfort led to a strong intellectual and political movement for rural sanitation and also to the reform of the public health system from 1916 onward. Surprisingly, until the mid-20th century there were no reliable national records of morbidity and mortality caused by malaria or other endemics. In general, spectacular numbers were based on the extrapolation of local inquiries and the observations of fieldwork and expeditions by scientists and doctors such as, for example, the “great hospital” or “ten million suffering from impaludism (sick from malaria)” announced by the writer Monteiro Lobato in 1918 and repeated by many.⁶ According to this estimate one third of the Brazilian population, almost thirty million people, were suffering from malaria. Nevertheless, these alarming numbers were less a certified truth and more a successful rhetorical resource used by rural public health advocates based on an imprecise epidemiological picture.

In the dramatic image painted by Belisário Penna, a doctor, hygiene propagandist, and leader of the Liga Pró-Saneamento do Brasil (Pro-Sanitation League of Brasil), founded in February 1918, the disease malaria, Chagas disease, and hookworm formed a type of “Unholy Trinity.”⁷ Politician and historian José Maria Bello ironically proposed a new territorial division of Brazil defined by the endemic presence of these three diseases: hookworm on the periphery of the capital and the large cities; malaria along the coast, rivers, and lakes, and in the sertões, and American trypanosomiasis.⁸ The bodies of Brazilians were seen by these doctors as divided into different parts, each defined by microscopic and pathogenic fauna. It was as if the very body of the nation was infected with parasites. Diseases such as malaria were not necessarily death sentences but physically and mentally degraded those living in the interior, incapacitating them and rendering them unable to obtain an income. In its nationalist fervor, the public health movement denounced the fact that the populations of endemic regions did not even identify as Brazilian due to the absence of government action there.

The rural health movement presented the disease as an explanation for the national ills and thereby intended to absolve the country from being condemned to backwardness due to miscegenation and the tropical climate, as many had been claiming since the 19th century. Public medicine needed to revitalize rural populations, freeing them from endemic diseases and incorporating them into an imagined national community that was productive, lettered, and healthy. A hierarchical incorporation proposal did not recognize the rights of the populations who were subjected to this intervention, according to the liberal-oligarchical republican model then in force. Indeed, Brazil was incapable of recognizing the relations between rural endemics and working/living conditions and land concentration in rural areas characterized by latifúndios. However, there were proposals in the opposite direction of hardline eugenic ones that emerged in the same period.⁹ This new medical science was presented as modern and forged “in the tropics” and shared the knowledge and techniques of metropolitan tropical medicine but not all its colonial commitments. To the contrary, it sought its social and political legitimacy by being a modern and cosmopolitan science applied to national health problems.

The fight against malaria encountered political obstacles. The federalist system enshrined in the 1891 Constitution prevented the provision of an extensive range of public health services outside the federal capital and the country’s ports, except for emergency situations provoked by epidemics. Furthermore, the technical and financial incapacity of the majority of states to implement rural public health services worsened the picture and imposed costs on the federal capital and the most dynamic economy of the federation, that of the state of São Paulo. The Liga Pró-Saneamento demanded rural sanitation policies under the direction of the central government, a proposal that received much support and considerable attention in the press and medical journals. It was intensely debated in the National Congress, albeit not without fierce resistance. It was necessary to convince the political elites of the need for positive action by the government beyond the coast and in the interior of Brazil without directly contesting the constitutional autonomy of the individual states. The solution encountered was encouraging the voluntary adhesion of states to a rural public health policy under the auspices of the central government. The International Health Division (IHD) of the Rockefeller Foundation, present in Brazil since 1917 campaigning against hookworm, was pressured by the federal and state governments to add malaria (and later other diseases) to its list of concerns and activities in Brazil.

In a few years all state governments, except for São Paulo, made rural public health agreements with the central government and IHD. This political process, which involved much negotiation with state elites, resulted in the creation in 1918 of the Serviço Oficial de Quinina (Official Quinine Service) to freely produce and distribute the anti-malarial drug and in 1919 the Serviço de Profilaxia Rural (Rural Prophylaxis Service), part of the National Public Health Department and a body with amplified attributes, scope, and a multifaceted and detailed public health code in 1920, expanded in 1923. Under bilateral rural sanitation agreements between states and the federal government in 1922 there were more than eighty rural prophylaxis posts in the states and Federal Capital and another fifty-eight posts for prevention and treatment of worm infestations in cooperation with the Rockefeller Foundation. This public health reform inaugurated more national, systematic, and organized rural health actions, in particular against malaria, through the draining of swamps, rivers, and lacks, combating mosquito larvae with larvicide oils (especially Paris Green), and the burning of sulfur and pyrethrum in habitations, as well as the prophylactic and therapeutic use of quinine and hygiene education campaigns.

At the beginning of the 1930s, Carlos Chagas, director of the Oswaldo Cruz Institute (1917–1934), produced an overview of the “problem of malaria” in Brazil. He called attention to the main areas where malaria remained endemic: the Amazon, the São Francisco River Valley, which ran through areas in the southeast and northeast, and Baixada Fluminense, a region located on the outskirts of the capital of the republic (and thus close to the country’s elites). His report also indicated the need for anti-malaria campaigns to concentrate on the mosquitoes that transmitted it and on houses in endemic areas.¹⁰ This argument had been outlined in 1906, when the domiciliary nature of the mosquito vector was highlighted, something that would only be recognized years later. By emphasizing the fight against the Aedes aegypti mosquito and its larvae, the Yellow Fever Service, created in 1923 and coordinated by the Rockefeller Foundation until the end of the 1930s (and initially operating in the northeast of Brazil), provided administrative, technical, and scientific arguments for the fight against malaria in later decades. Arguments that were not consensual, since they were opposed by European malariologists and resisted by the Malaria Commission of the League of Nations, which defended an improvement in the social conditions of populations in endemic areas as integral part of the anti-malarial arsenal.

Chagas believed the approach of Brazilian public health services to malaria needed to be reviewed. This was defined—including under his direction between 1919–1926—by a combination of engineering works, the use of larvicides, education, and medication. Instead, public health actions needed to focus on the vector and its larvae. Once again, this change in strategy maintained the principal antinomies inspired by malaria and established in previous decades by Chagas’s own generation of doctors and scientists: between disease and civilization, between the coast and inland regions, between a rich country and a sick population, and between a generous nature and the impossibility of using it. Malaria continued to be considered as one of the principal obstacles to reaching a more advanced stage of civilization, but little was done in comparison with the efforts, for example, involved in the eradication of yellow fever, a global priority of the Rockefeller International Health Division in the 1920s and 1930s.

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Figure 1. Sanitary engineering works against malaria at Ribeirão Cachoeira, Mesquita Region, State of Rio de Janeiro, November 11, 1922. Reference code BR RJCOC BP-06-TP-04-v.12-016, Casa de Oswaldo Cruz Archives, Fundação Oswaldo Cruz, Fiocruz.

These issues were raised at a moment of dramatic transition in the history of Brazil: the economic and political impacts of the 1929 crisis and the rupture in 1930 with the oligarchic republic along with the establishment of a new regime with a modernizing, centralizing, and (after 1937) dictatorial nature (the Estado Novo, or New State), which would last until 1945. The outbreak of World War II and the direct involvement of Brazil in the Allied war effort changed the dynamic of Brazilian politics and health policies, in particular the control of malaria. In the field of public health, the Ministry of Education and Health was created in 1930. This ministry was the result of a long-standing demand of reformist doctors, with the aim of increasing the organizational and technical capacity to act throughout Brazil, which accelerated an ongoing process of expanding public health and rural prophylaxis services. Public health services were therefore successively reformed under the auspices of the new ministry until the creation in 1941 of the National Malaria Service (NMS), together with other national services organized “by disease” (leprosy, plague, tuberculosis, cancer, mental health). Led by Getúlio Vargas, the new statist, corporatist, and nationalist government had the aim of constructing a “Brazilian worker” and “social peace” through labor legislation and social insurance and social assistance systems. However, these were directed at urban workers belonging to professional categories recognized by the state and organized under its guardianship, such as those who covered by the public protection provided by a social security system and labor legislation. Although it was reformist, industrializing, and modernizing, the Vargas administration did not challenge the Brazilian agrarian structure since labor legislation, and social security did not protect peasants and rural workers. Public health services thus became responsible for providing care to the various non-organized groups not covered by this social policy and who continued to lack social rights, in particular the rural population.

Malaria, War, and Optimism

Malaria returned in dramatic fashion to the Brazilian public health agenda by different internal and external paths, which intersected in a more definitive manner at the end of the 1930s. In March 1930, Raymond C. Shannon, entomologist of the Cooperative Yellow Fever Service (CYFS), linked to IHD, identified the larva of the Anopheles gambiae mosquito in the city of Natal, capital of the Northeast state of Rio Grande do Norte. It was the first time that this vector of malaria originating in tropical Africa had been found in the western hemisphere. Shortly afterward the first outbreaks of malaria occurred in Natal, which were controlled through the use of traditional methods of combating mosquito breeding sites: drainage, landfills, and the use of kerosene in pools of water. Efforts to fight the transmitting mosquito were initially organized by the Yellow Fever Service, afterward being transferred to state services. In the following years the mosquito spread rapidly northward, following the coast, though without provoking any outbreaks of epidemics, until in the Jaguaribe River Valley in State of Ceará it caused “perhaps the greatest epidemic of malaria that ever occurred on our continent,” according to a participant in the fight against A. gambiae, resulting in almost sixty-three thousand victims and eight thousand dead.¹¹ Traditional emergency responses were no longer sufficient. In 1938 the Serviço de Obras contra a Malária (Public Works Service Against Malaria) was created, but it was unsuccessful in containing the mosquito. It was feared that in addition to causing human tragedies in Brazil, the invading mosquito would spread to other areas of the Americas, including the United States. An agreement between the Vargas administration and the Rockefeller Foundation’s IHD created an autonomous agency, the Serviço de Malária do Nordeste (Northeast Malaria Service, or NEMS) in January 1939 under the coordination and the leadership of Fred L. Soper, Rockefeller’s top-ranking official in Brazil, who had until then been directing CYFS. The administrative structure of NEMS, which was based in Fortaleza, capital of Ceará, was established in a similar manner to the yellow fever service. Personnel were requisitioned for it, and soon staff members numbered four thousand.

The strategy adopted for the mosquito eradication campaign was based on the detailed, organized, and intensive combat of the larval and winged phases in infested territory and adjacent areas, the fumigation of vehicles leaving infested areas to prevent the spread of the mosquito, and systematic research aimed at determining the presence of the vector in new areas or its decline as a result of the activities of NEMS. Based on spatial delimitation and the mapping of regions, the campaign organized the “territory of the disease” and guided their actions to prevent expansion to other areas. Little attention was paid to either those who were ill or indeed the population of the region in general. It was believed that they were the responsibility of regular health services and not a campaign to eliminate a vector, especially in a region marked by periods of drought and by poverty that generated other social and public health problems. The campaign against gambiae carried out by NEMS produced rapid results: in a two-year period the mosquito was eliminated, which drastically reduced the incidence of death and disease in the region. Starting in 1939 in the states of Ceará and Rio Grande do Norte, it obtained success in extensive areas that were considered “clean” in 1940. In the memoirs of some participants and in the writings of analysts of this campaign the iron discipline imposed by Soper in the anti-larval and anti-mosquito service was seen as the key to its success. In November 1940 field research found what was said to have been the last mosquito in a previously infested territory, indicating the successful elimination of the autochthonous A. gambiae in Brazil. As a result, the services were gradually deactivated and ended in 1942. The experience of the eradication of this vector marked the history of malaria by introducing into the international public health agenda the debate about the real possibilities of the global eradication of malaria solely based on combating the mosquito.

While the campaign against malaria progressed in the northeast, the Getúlio Vargas administration made efforts to ensure a greater integration of central Brazil and the Amazon region based on the demands of local politicians and intellectuals as part of a broader “March to the West” agenda, increasing the presence of the national state in areas of the country considered by many as “empty” and “abandoned.” In a new context, the government renewed the idea that malaria and other endemic diseases would reduce the possibilities of human occupation and productive activities in the Amazon River Basin, a region in crisis since the decline of the rubber economy in the 1910s. In 1940 the minister of education and health commissioned a public health plan for the region from a committee of specialists. This took place at a moment when new national services were being organized and preparations were being made for the first visit by a president of Brazil to the city of Manaus, capital of Amazonas state, which occurred in October 1940. In December 1941 the “Amazonian Public Health Plan” was published. Malaria was chosen as the principal enemy of the region’s development and integration. Furthermore, the plan proposed broader public health actions in health service organizations; the training of specialized staff, nutrition, and social and medical assistance; and the provision of water, sewage, and garbage service. All this took place because public health was seen as “the set of activities aimed at improving the health and living conditions of the inhabitants of the Amazon.”¹² The commission clearly recognized that the model used in the campaign against malaria in the northeast, under the auspices of the Rockefeller Foundation, was inadequate for the Amazon region.

The plan was dropped by the federal government, since it implied changing the more restricted conception of public health policies then in force and principally because the meaning of malaria in the Amazon was transformed when the United States entered the war in December 1941. Japanese control of Asian rubber-producing areas made the Amazon a strategic region for the war effort, and the fight against malaria became a way to also facilitate the production of latex. The economic difficulties caused by the war and irresistible US pressure prevented a national public health plan for the Amazon being carried out, although not without the criticisms of its formulators. The same occurred with Fred Soper’s proposal to transfer the structure of the campaign against the A. gambiae mosquito (organization, vehicles, staff, equipment) to the fight against malaria in the Amazon. In 1942, malaria in the Amazon became a military question of continental and strategic security for the United States.

In July 1942 the Serviço Especial de Saúde Pública (Special Public Health Service, SESP) was created in an agreement between the Ministry of Education and Health and the Office of Inter-American Affairs, directed by Nelson Rockefeller and linked to the State Department. SESP was a direct result of Brazil’s involvement in World War II after the severing of diplomatic relations with the Axis on January 28, 1942, and the declaration of war on August 31, 1942, following the successive torpedoing of ships off the Brazilian coast. SESP’s principal role was the fight against malaria and other transmissible diseases in areas where strategic resources were extracted for the war effort, such as Amazonian rubber and minerals from Minas Gerais, areas in which the recently created National Malaria Service did not operate in.

Between 1943 and 1945 a complex organizational network was established to bring thousands of men from the northeast—“the rubber soldiers”—to work with the extraction of latex in various rubber plantations in the Amazon, funded by the United States. SESP was responsible for guaranteeing the health of these workers in the dramatic process of recruitment, during the long and dangerous journey by truck and boat, and in production areas—in particular the goal of prevention and treatment of malaria. Despite being subordinated to the war effort, the Vargas administration saw this process as an opportunity to settle the Amazon through internal migration and the establishment of health services. Malaria was also the principal fear of the main US military bases in Belém (in the state of Pará), where the disease was endemic in suburban areas, Natal, and Recife (in the state of Pernambuco) where the main military airport was located with flights to Africa, Europe, and Asia. Rigid regimens were implemented for vehicles, aircraft, soldiers, and support personnel on bases and neighboring areas. The end of the war in 1945 meant the end of interest in Brazilian rubber, considered economically viable only in wartime. “The Battle for Rubber,” as this dramatic episode became known, left a legacy of separated families, workers abandoned in extraction areas, poverty, and disease. Malaria in the Amazon thus once again returned to being an exclusively Brazilian problem.

A new arsenal of anti-malarial technologies emerged in the 1930s and especially after the war: larvicides, pesticides, medicines, models of organizing campaigns and administrating services, and new knowledge about the epidemiology of malaria, mosquitoes and their ecology, parasite biology, and industrial chemistry. The conflict also spiked the demand for pesticides and insecticides for the war in the Pacific and for synthetic substitute for quinine—whose supply was strongly affected by the conflict. In the Brazilian case, the need to control malaria during the war signified advances in medical, biological, and epidemiological knowledge about the disease in studies of anopheline mosquitoes of the Amazon region and the Northeast by both SESP and MNS. Tests for drugs, insecticides, and techniques for fighting the disease and its vectors were also carried out. In Laurie Garret’s words, “health optimism” took shape in the postwar period: in other words the certainty that the new techniques then available—insecticides, antibiotics, and vaccines—would allow the elimination of the principal transmissible diseases through government and international cooperation actions.¹³ Anti-malarial medication such as Atabrine and Chloroquine and insecticides such as diclorodifeniltricloroethane (known as DDT) were some of the artifacts directly linked to the fight against malaria used in World War II and rapidly incorporated by public health services of several countries The new insecticides also created a new market for domestic use.

From 1941 to 1956, the National Malaria Service established itself as the main Brazilian public health organization. Initially, NMS maintained the traditional strategy of fighting the aquatic phases of the transmitting mosquitoes. Notable among these measures were drainage, landfills, and the use of larvicide substances, such as Paris Green and petroleum, as well as epidemiological and entomological investigations. In the south of Brazil, the destruction of bromeliads, water storing plants in which anophelines reproduced, through manual removal and deforestation, was the form MNS used to control malaria in the south region but at the expense of immense environmental devastation. Under the influence of wartime innovations, NMS came to privilege the use of DDT, combined with the distribution of anti-malarial medicine, chloroquine. In 1947, DDT was used in a campaign in the São Francisco River region, which covered endemic areas in Northeastern states (Bahia, Alagoas, and Sergipe) and Minas Gerais; these were regions with a dispersed, extremely poor, and predominantly rural population. In December of the same year, NMS started a broad campaign to control malaria in the state of Rio de Janeiro—in the so-called Baixada Fluminense—which would last two months in hundreds of locations from the north to the south of the state, including all the territories neighboring the then federal capital. This campaign is considered the first in Latin America to have had the principal strategy of using DDT on a massive scale in urban and peri-urban domiciles in endemic areas. NMS also provided medical care to the sick, based on the free administration of chloroquine. For this reason, a large network was organized for the distribution of this anti-malarial, which in addition to the previously existing health centers, also included public and private schools, philanthropic and charity institutions, the main buildings of agricultural plantations, municipal government buildings, post offices, and churches. By the end of the 1940s, the federal government had succeeded in controlling malaria along the coastline of the country and in the urban and peri-urban area of the southeast and south. Successful in this venture, Mário Pinotti, director of NMS since 1942, and Brazilian malariologists believed that malaria would be controlled in Brazil in the short term. Their great challenges still being the endemic regions of the Northeast and the Amazon.

Brazilian Challenges in the Era of Eradication and Development

In 1952 new research, laboratory experiments, and fieldwork were undertaken with the aim of developing a contextual anti-malarial strategy that would resolve the endemic problem in the Amazon: out of this emerged a table salt and chloroquine mixture eventually known as the Método Pinotti, as it had been conceived by the director of NMS. Inspired by the iodization of salt to prevent endemic goiter, malariologists believed that the free distribution of the chloquinated salt by the government could interrupt the transmission of malaria in the Amazon. An “autochthonous solution” that would replace insecticides whose ineffectiveness was due to the social and geographical conditions of the region. It was characterized, outside of urban areas, by activities such as hunting, fishing, garimpo mining, and the extraction of rubber, with a dispersed population living in precarious residencies that in addition to the wild habits of the principal transmitting mosquito also hindered the use of DDT in houses and shelters.

In the mid-1950s the prospects of health programs aimed to control endemic diseases were promising, especially due to the creation of the Ministry of Health in 1953 and the establishment of the National Department of Rural Endemic Diseases (DNERu) in March 1956. This new agency absorbed the structures and attributions of national services created in 1941 and assumed the responsibility of organizing and implementing the fight against the principal endemic diseases in the country, among them malaria, leishmaniasis, Chagas disease, plague, brucellosis, yellow fever, schistosomiasis, hookworm, filariasis, hydatidosis, endemic goiter, yaws, and trachoma. Having gained immense prestige due to his chloroquinated salt and the reduction of endemic areas of malaria, Mário Pinotti was appointed as the first director of DNERu (1956–1958) and, afterward, Minister of Health (1958–1960), both positions in the administration of Juscelino Kubitschek (1956–1961).

The democratic experience of 1945–1964, the Cold War, and the increasing activism of international organizations and bilateral cooperation agencies in the area of health and development made the challenges of Brazilian public health more complex in the postwar period. Political and economic choices were underpinned by the objective to be part of the “First World.” Tensions were established that divided Brazilian society and intellectuals in times of democracy and development, as expressed by the doctor from Pernambuco, Josué de Castro, in placing the Brazilian dilemma as a choice between “bread or steel.” The new public health organizations maintained the policy, corroborated by international health organizations, such as the World Health Organization (WHO), of prioritizing centralized and vertical health interventions, technologically oriented to the resolution of specific public health problems and not committed to needed structural changes mandated by other public policies. Economic development was not a prerequisite for the “conquest of tropical diseases.” The pace of development was slower than that of public health, now capable of resolving its serious health problems with its “magic bullets”: antibiotics, DDT, and anti-malaria drugs. The end of malaria would thus allow populations and territories to be incorporated into economic production cycles.

On assuming the Presidency of the Republic on January 31, 1956, Juscelino Kubitschek (popularly known as JK) considered malaria a problem on its way to being resolved. The priorities were to be the other rural endemics—leprosy and tuberculosis, for example—and diseases of the developed world such as cancer that began to afflict a nation in which the urbanization and industrialization process was accelerating. During the 1955 electoral campaign Kubitschek commented on the advances of health due to the defeat of “pestilential diseases” such as yellow fever and the plague. Reframing Miguel Pereira’s 1916 phrase, stated that Brazil could no longer be characterized as simply a hospital and Brazilians as sick.¹⁴ The country had to move in the direction of development, and the image of a “vast hospital” had to be revised. Following the creation of DNERu, the government launched a series of campaigns against rural endemic diseases with the aim of improving the health of rural populations and to enable projects to modernize the hinterland and agricultural production. The recovery of the interior of the country—“Central Brazil” and the Amazon—and integrating its populations in development inspired the creation and actions of DNERu. This was also in line with many of JK’s projects, especially the challenge of constructing in his presidential term a new capital in the “heart of Brazil”: the city of Brasília, which would be inaugurated on April 21, 1960. Rural health was completely subordinated to the development projects of the 1950s, in particular, in the case of Kubitschek, of achieving “50 years in five.” In the context of the Cold War, public health and social assistance in rural areas were also seen as preventive actions against the emergence of peasant and rural workers organizations in the Brazilian Northeast. Poverty, disease, and Communism were seen as a dangerous combination.

Over time the Kubitschek administration adopted different positions in relation to the 1955 WHO decision to establish a Malaria Eradication Program (MEP). The Brazilian government initially did not accept the WHO recommendation to convert its control program into one of eradication into a new an autonomous federal agency. Brazilian malariologists, under the leadership of Pinotti, rejected a radical modification of a strategy they considered to have been successful in controlling malaria and that they believed would result in the elimination of malaria within a few years. Nor did the Brazilian government still consider malaria to be a priority. They also believed that malaria in the Brazilian Amazon could not be eradicated through the intensive use of DDT. Instead, the “Pinotti method” was proposed as a Brazilian alternative.

Once again internal and external factors modified the directions of campaigns against malaria in Brazil. With the declaration of the “war on malaria” by Dwight D. Eisenhower at the beginning of his second term, the United States became the primary funder of the WHO eradication program, making the adoption of eradication programs obligatory for countries that wanted funds from the International Cooperation Agency (ICA) to combat malaria. The eradication of malaria was understood as a precondition for development and an instrument for the consolidation of American security in the international arena. The intention was to raise the standard of living of rural populations in underdeveloped countries, creating workers and consumers, and reinforcing the idea of economic progress in a context marked by a Cold War discourse that associated Communism and malaria as conditions that “enslaved” individuals and societies and kept them “backward.”

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Figure 2. DDT house spraying in interior of State of Bahia, c. 1966, Malaria Eradication in Brazil, Brazil—0200 project, Salvador, June 1966. WHO Historical Archives, Geneva, Switzerland.

Photographs by José Moquilaza, Sanitarian.

In the Brazilian case, this international scenario combined with an economic crisis made the government more willing to change its malaria program in exchange for funding and loans. Starting in 1958 the Kubitschek administration began to convert its control program into one of eradication, privileging the Northeast region. On the other hand, the Brazilian program of distributing the chloroquinated salt in the Amazon was recognized by international organizations as part of the 1959–1961 phase of the eradication campaign, with resources and personnel mobilized to make this feasible. It was also recommended for regions with similar characteristics in Africa and Asia. The country would only carry out an effective Malaria Eradication Campaign in 1965, under the military regime that was aligned with US policy, just five years before WHO declared that the aim of eradication was not feasible in the short term and discontinued MEP. In 1970 the number of cases of malaria registered in Brazil was reduced to seventy thousand, concentrated in the Amazon region. The failure of eradication efforts and a certain invisibility of the disease provoked an abandonment of more systemic anti-malaria actions. In the 1970s a new cycle of large infrastructure and colonization projects in the region sponsored by the military government led to an exponential growth in the number of cases of malaria, only reversed in a new international and national context at the end of the 20th century.

Discussion of the Literature

The failure of the WHO eradication program and the criticisms of the vertical and technological model has made malaria eradication a neglected theme among public health professionals, scientists, and historians. The cloroquinated salt was considered a failed policy, and some even saw it as responsible for the resistance of the plasmodium to chloroquine. The bibliography on malaria in Brazil in the field of history expressed in articles, books, and book chapters is thus quite a recent development and still not comprehensive enough. Until the 1990s, a considerable portion of the narratives about the anti-malarial campaigns was published by scientists, doctors, and malariologists who had participated in research and anti-malarial campaigns in previous decades. Articles such as those of Tauil and colleagues and Loiola and colleagues present a series of analyses and relevant information.¹⁵ Epidemiological studies of malaria from a historical perspective, with an emphasis on the experience of state of São Paulo, appear in books by Barradas Malária e seu Controle (1998) and Matos, Malária em São Paulo. Epidemiologia e História (2000).¹⁶ Some personal and institutional memories, albeit not very critical ones, are relevant for the comprehension of this long history of the control of malaria in Brazil as of Moraes´s book Sucam: Sua Origem, Sua História.¹⁷

The argument about the importance of the disease and of health in the intellectual and material construction of the nation-state is the theme most examined by Brazilian literature in the field of history of health and medicine, in particular in relation to the first republican period (1889–1930) and the first Vargas administration (1930–1945). Books by Hochman, A Era do Saneamento—as Bases da Política de Saúde Pública no Brasil (1998), by Lima, Um Sertão Chamado Brasil—Intelectuais e Interpretações Geográficas da Identidade Nacional (2013), by Fonseca Saúde no Governo Vargas (1930-1945): Dualidade Institucional de um Bem Público (2007), and Kropf Doença de Chagas, Doença do Brasil: Ciência, Saúde e Nação (2009) and articles by Castro-Santos, Lima and Hochman, and Lima develop this argument for the first half of the 20th century, using different approaches and objects.¹⁸ This type of approach criticizes the Foucauldian and Marxist perspectives of public health in Brazil in favor in the 1970s and 1980s, such as the books of Machado and colleagues Danação da Norma—A Medicina Social e Constituição da Psiquiatria no Brasil (1978), by Costa Lutas Urbanas e Controle Sanitário: Origens das Políticas de Saúde no Brasil (1985), and by Merhy O Capitalismo e a Saúde Pública: A Emergência das Práticas Sanitárias no Estado de São Paulo (1985) and A Saúde Pública como Política—Um Estudo de Formuladores de Políticas (1992).¹⁹ Medical and scientific expeditions into the Brazilian hinterland as a factor in the understanding and publicizing of public health problems (particularly malaria) in the early years of the republic are analyzed in works such as those of Thielen and colleagues A Ciência Vai À Roça—Imagens das Expedições do Instituto Oswaldo Cruz (1911-1913) (1991), and the articles of Schweickardt and Lima, Sá, Vital and Hochman, Lima and Botelho, and Vital.²⁰ The importance of malaria to the feasibility of infrastructure works in the infrastructure of Brazil (telegraphic services, railways, works against drought) is a recurrent theme in the bibliography, with the most relevant articles being those of Benchimol and Silva, Caser and Sá, and the Hardman´s book Trem Fantasma: A Ferrovia Madeira-Mamoré e a Modernidade na Selva (1988).²¹

The more regional aspects of the history of campaigns against malaria have been only cursorily examined, especially in relation to the Amazonian region. Nevertheless, some works have focused on malaria as the principal obstacle to human occupation and the development of the region. The expeditions of doctors and scientists discussed in so many works were principally to the Amazonian region. In relation to the centrality of malaria in this region during the First Republic Nancy Stepan’s book chapter “The Only Serious Terror in These Regions” (2003) is relevant.²² Urban and public health reforms in the city of Manaus, capital of the state of Amazonas and the economic center of the rubber economy until the mid-1910s, and threatened cyclically by outbreaks of malaria and yellow fever, have been analyzed in detail in a book by Júlio C. Schweickardt’s 2011 book Nação e Região: As Doenças Tropicais e o Saneamento no Estado do Amazonas, 1890–1930.²³ Malaria is also one of the protagonists of Seth Garfield’s In Search of the Amazon (2013) about the Amazon as a symbolic and material border between Brazil and the United States and its multiple agendas, interests, and projects.²⁴ The attempts of the Vargas administration to launch a public health plan in the Amazon on the eve of the entrance of the United States into World War II are discussed in Andrade and Hochman’s 2007 article “O Plano de Saneamento da Amazônia (1940–1942).”²⁵

Most recently the period of World War II and later decades has been privileged in academic work. André Luiz Vieira Campos’s Políticas Internacionais de Saúde na Era Vargas: O Serviço Especial de Saúde Pública, 1942–1960 (2006) analyzes the Special Public Health Service (SESP) created in 1942 and addresses US–Brazilian cooperation in public health during the war.²⁶ In particular, actions related to the control of malaria and the protection of workers’ health in mineral (Minas Gerais) and rubber (Amazon) producing areas, fundamental for the war effort, is another theme appearing in the Garfield book. Campos also highlights the efforts to keep US military bases in the Brazilian northeast “clean” of malaria. His book is part of a historiographic tendency to understand the relations between the “international,” the “imperial,” and the “national” or “local” in a more negotiated manner and not strictly imposed and vertical as defended by a literature with a Marxist or structuralist bias. In this case, the control of malaria is seen as situated in the intersection between national policies and international agendas, with the weight of the interests involved varying according to the context and also depending on the form in which public health was structured at the national and subnational levels. Submission, resistance, autonomy, and adaptation were thus part of a repertoire of actions and policies that varied according to context and conjuncture.

From this perspective, a set of articles looks at the Brazilian experience of the distribution of the chloroquinated salt in the Amazon, the control program of the National Malaria Service (NMS), and the Malaria Eradication Campaign (MEC) from 1958 onward.²⁷ These articles focus on the relations between Brazil, US cooperation agencies (ICA), and international health organizations such as WHO, United Nations Children’s Fund (UNICEF), and Food and Agriculture Organization (FAO).²⁸ These papers are offshoots of the recent expansion of the history of international organizations, in particular the history of global health. The central point of them is to show, through internal and external dynamics, how and why the Brazilian government in 1955 rejected, and afterward progressively adopted, the recommendations of WHO’s Malaria Eradication Program between 1958 and its end in 1970. The relationship between the Brazilian Malaria Eradication Campaign and eradication of other diseases such as smallpox and yaws has been examined by only a handful of authors.²⁹ In the Brazilian history of health field there thus prevails an emphasis on national dynamics, focusing on their interfaces with international health and international relations, in particular within the Cold War context. This perspective is also adopted by important books about the eradication of malaria in other Latin American countries, such as those of Marcos Cueto on Mexico and Adriana Alvarez and Eric Carter on Argentina.³⁰ The international and intellectual history of development has been influenced by Gunnar Myrdal and Charles Winslow’s articles published in 1951–1952 by WHO on the relationship between health, diseases, poverty, and development.³¹

A large proportion of the non-Brazilian literature that deals in some form with the anti-malaria campaigns in Brazil focuses on a singular event (i.e., the most prominent and scrutinized one), namely the campaign against Anopheles gambiae in the Brazilian northeast between 1939 and 1942. The main challenge of this literature is to create a critical dialogue with the powerful and heroic narratives of the protagonist of this campaign, Fred L. Soper, who published with Bruce Wilson the book Anopheles Gambiae in Brazil, 1930 to 1940 almost immediately after the end of the campaign (in English in 1943 and in Portuguese in 1945).³² His memoir Ventures in World Health: The Memoirs of Fred Lowe Soper was published in 1977 and also consolidated these narratives.³³ A chapter of Gordon Harrison’s now-classic 1978 work looks at the eradication of the mosquito in the Brazilian northeast, while John Farley’s 2004 book about the history of IHD dedicates a chapter to A.gambiae.³⁴ This episode is seen as an important episode in a global history of malaria, as it resulted in the elimination of a malaria transmitting species of mosquito, thereby validating the eradication vision that would prevail in the following decade. The pioneer article of Packard and Gadelha “A Land Filled with Mosquitos: Fred L. Soper, the Rockefeller Foundation and the Anopheles Gambiae Invasion of Brazil” (1997) and the book by Packard The Making of a Tropical Disease: A Short History of Malaria (2007) are certainly the principal references for this theme.³⁵ Gadelha and Packard established an important criticism of the monocausal perspective (i.e., mosquito as a single cause) calling attention to nutrition and living and working conditions as explanatory elements for the severe malaria epidemics in 1938–1939. The responses and perceptions of the population of the Rio Jaguaribe Valley to the 1938 epidemic are addressed by Silva’s 2006 chapter.³⁶ The analysis of the campaigns against yellow fever and malaria in Brazil in the 20th century are central in Nancy Stepan’s 2011 book about the idea and practices of eradication of diseases, issues also covered in the books by Benchimol Febre Amarela: A Doença e a Vacina, Uma História Inacabada (2002), by Lowy Vírus, Mosquitos e Modernidade—A Febre Amarela no Brasil entre Ciência e Política (2006), and by Magalhães A Erradicação do Aedes aegypti:, Febre amarela, Fred Soper e saúde pública nas Américas (1918–1968) (2016).³⁷ However, Stepan puts more emphasis on the unsuccessful experience of Soper and Rockefeller with yellow fever in Brazil in the 1920s and 1930s in the construction of their eradicationist perspective rather than their success in the elimination of A. gambiae.

Health and development in Brazil has not been a common theme in the Brazilian literature, even though all the works that analyze anti-malaria campaigns after 1945 examine this relationship. The recognition that health has rarely been present on the Brazilian agenda, evidenced by its almost complete absence in national development plans since the 1940s, was dealt with in Pena’s 1977 article “Saúde nos Planos Governamentais.”³⁸ This has discouraged historians and social scientists from considering the relevance of health to understanding the ideas the alternatives proposed for Brazilian development. Works written by economists, such as Braga and Paula’s book Saúde e Previdência: Estudos de Política Social (1981), have discussed these relations as part of the dynamics of Brazilian capitalism.³⁹ In the field of intellectual history Hochman and Lima’s Médicos Intérpretes do Brasil (2015) presents contributions on how doctors have reflected on the relationships between endemic diseases and Brazilian society and politics.⁴⁰ Here mention should be made the works of Paiva (2006), Escorel (2015), and Hochman (2015) about so-called developmentalist public health, which was critical of vertical models such as the eradication campaigns.⁴¹ Recent books and articles have sought to reassess and understand the place of malaria and rural endemic diseases in developmentalist discourse and projects, in particular in the Juscelino Kubitschek administration (1956–1961), such as the articles by Hochman (2015) and Muniz (2013) and the book by Simone Kropf (2009).⁴²