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« Yellow Fever's Evolution in the Western Hemisphere | Main | Epidemics and Economic Performance »
Friday
Mar202009

The History of Brazilian Health and Disease in Textbooks

Today I intend to look how the “era of epidemics” is represented by popular textbooks on Brazilian history that are available in the U.S. I find that what one might call the “popular authoritative history of Brazil” says far too little about health and commits factual errors. My purpose is not to criticize these books, but to show that there is still so much to be learned about a series of epidemics that killed hundreds of thousands and destabilized the country for decades and the efforts to fight them.

Just to be clear, what I am calling a "textbook" is a narrative that organizes a broad sweep of history into a thread devoted to the development of Brazil as a nation.  These books help guide classes from logical beginnings to the Brazilian nation as it "is" today.  There are a handful of textbooks in English available for a survey of modern Brazilian history, but only four are commonly used. Here is a list with today’s Amazon.com sales rank:

There are a series of related events that I think should be included in any textbook on Brazil because they exerted a lasting consequence on the development of Brazil as a nation and Brazilians within a defined sociocultural area.  Before 1849 Brazil was widely believed by foreigners and nationals to be healthy place, healthier in fact than North America or Europe.  This ended in 1849 when yellow fever took on a terrifying form as an urban epidemic. It reappeared many times after this, increasing in virulence and unexpectedly spreading into the interior by the 1870s. The cholera epidemic of 1855-56 was the most destructive epidemic Brazil had experienced up to that point (excluding, perhaps, the smallpox epidemics that decimated indigenous groups in the sixteenth and seventeenth centuries). Finally, smallpox caused more deaths during the second half of the nineteenth century because more people crowded together in urban areas. Despite the attention of these epidemics, tuberculosis and neonatal tetanus killed far more Brazilians.  All of these deadly diseases became far less of threats by the 20th century.  In the early 1900s, mosquito campaigns eradicated yellow fever from most urban areas, vaccination campaigns immunized Brazilians against smallpox, and chlorinization and other sanitary measures greatly reduced cholera and gastrointestinal diseases from water and foods.  As a result, mortality levels dropped and the overall public health improved in the early 1900s, thus ending this unusual six-decade epidemiological period.  Although most historians credit Brazil's exponential growth between 1890 and 1920 to European immigration, a far more important driver of this growth was natural increases caused by better public health.

This is my broad narrative, backed up by evidence that I have listed in this journal and in the source gallery. Do the textbooks on Brazilian history paint a similar picture?

One author attributes epidemics as one of the causes for “the shift of support away from the Monarchy” and lists “smallpox, cholera, yellow fever, plague” as the main infectious diseases. He does not give any more details about these scourges. While I believe that disease did weaken the monarchy (but this remains to be proven), plague occurred for the first time in Santos in 1899, a decade after the monarchy was toppled.

Later in this same textbook, the author spends a good deal of time on the urban revolts in Rio de Janeiro in 1904 that were prompted, but only in part, by a compulsory vaccination program. Several other authors also write much more about this fairly minor urban revolt than enormous amount of hardship and grief that these diseases caused or the remarkable successes that public health officials had in the early twentieth-century.

One textbook sets the stage for the anti-vaccine revolt with several mistakes that should have been caught by the author or the reviewers.  He writes the Republican government “decreed that all residents must be vaccinated against yellow fever, under a program administered by Oswaldo Cruz of the Pasteur Institute.” First, the vaccination campaign of 1904 in Rio de Janeiro was for smallpox, not yellow fever. This is not a minor detail, since it is widely documented that the Brazilian government had supported and promoted a nation-wide variola (smallpox) vaccination program for more than a 100 years, often against a great deal of popular resistance. Furthermore, popular mistrust was justified: officials reported in the provincial reports that the smallpox vaccine sometimes killed recently immunized, while others who had been supposedly “immunized” were later killed by disease. Smallpox vaccination still presents a small risk today, and people had good reasons to be afraid of it in 1904.  The second, more trivial error is that while Oswaldo Cruz studied briefly under Pasteur, he never officially represented the Pasteur Institute.  The Instituto Pasteur was founded in São Paulo in 1903 to research rabies, but was not involved with the Sanitary Campaign in Rio.

Another commonly assigned textbook runs into mistakes. This author claims that the “Brazilian authorities were alarmed by the outbreaks of yellow fever and cholera in the 1840s. Medical researchers traced the source of these epidemic diseases to recently arrived African slaves, providing another powerful piece of self-interest for ending the trade.” Unfortunately, this author seems to have gotten his dates wrong, with some consequences for his claim. Yellow fever struck in the final months of 1849 and cholera in mid-1855. Yellow fever may have been a “piece of self-interest” for some opposed to the slave trade, but it was commonly believed that Africans, and thus imported slaves, had innate resistance to the fever (epidemiologists today believe that African born people have greater innate resistance to yellow fever relative to other groups). Did this author confuse yellow fever and smallpox?   In one little known but important study, Dauril Alden and Joseph C. Miller demonstrated that smallpox epidemics in Africa and Brazil coincided.  Either way, cholera was certainly not yet on the minds of officials who passed the decree ending the international slave trade to Brazil in 1850.

Other textbooks are more accurate, although none spend sufficient time on the diseases and their impact. Only one textbook avoids the temptation to overemphasize the vaccine revolts, choosing instead to give some evidence for the benefits of the sanitation campaign. He writes: “Oswaldo Cruz’s energetic and effective campaign made the capital [Rio de Janeiro] as healthy as any contemporary European city.” He then backs up this statement with figures showing that yellow fever disappeared in Rio de Janeiro between 1903 and 1906. According to government reports, mortality levels in Rio de Janeiro were indeed similar to European cities by 1906, but this may have excluded large parts of city, unrecognized by the government, where mostly poor people lived miserably, many who were former slaves or children of slaves.

Perhaps the best textbook in terms of history of disease and public health in Brazil is James Hufferd’s little known and self-published Cruzeiro do Sul. He gets dates and disease propensity right when talking about Bahia: “the year 1860 itself was a year of seca [drought]—what turned out to be the first of three severe ones in succession—and yellow fever, almost endemic since 1849, continued devastating the white, or almost-white, part of the population” (Vol. II, pg. 163). And this is the best textbook in describing the sanitary campaign in Rio: “The already eminent Dr. Osvaldo Cruz was appointed to head up the effort against this recurrent [smallpox] plague, which killed 584 city residents in 1903, the year the campaign began, and some 4000 during the concurrent years-long epidemic. Cruz adopted techniques employed by North American health officials in eradicating yellow fever first in Cuba, then in the canal area of Panama” (pg. 263). 

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