Renato da Silva. Carlos Henrique Assunção Paiva. The Juscelino Kubitschek government and the Brazilian Malaria Control and Eradication Working Group - PDF

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The Juscelino Kubitschek government and the Brazilian Malaria Control and Eradication Working Group The Juscelino Kubitschek government and the Brazilian Malaria Control and Eradication Working Group:

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The Juscelino Kubitschek government and the Brazilian Malaria Control and Eradication Working Group The Juscelino Kubitschek government and the Brazilian Malaria Control and Eradication Working Group: collaboration and conflicts in Brazilian and international health agenda, Renato da Silva Professor, Programa de Mestrado de Letras e Ciências Humanas/Unigranrio. Rua Prof. José de Souza Herdy, 1160, Jardim 25 de Agosto Duque de Caxias RJ Brasil Carlos Henrique Assunção Paiva Pesquisador, Casa de Oswaldo' Cruz/Fiocruz; professor, Programa de Mestrado em Saúde Global e Diplomacia em Saúde/Fiocruz e Mestrado em Saúde da Família/Universidade Estácio de Sá. Av. Brasil, 4036, sala 416-A Rio de Janeiro RJ Brasil SILVA, Renato da; PAIVA, Carlos Henrique Assunção. The Juscelino Kubitschek government and the Brazilian Malaria Control and Eradication Working Group: collaboration and conflicts in Brazilian and international health agenda, História, Ciências, Saúde Manguinhos, Rio de Janeiro, v.22, n.1, jan.-mar Available at: scielo.br/hcsm. Abstract Malaria, a disease which was under control in the beginning of Juscelino Kubitschek government, became the most important endemic disease in 1958, when Brazil made a commitment with the World Health Organization to convert its control programs into eradication programs. For this purpose a Malaria Control and Eradication Group was set up under the leadership of the malaria specialist Mário Pinotti. Malaria would become an important bargaining chip in the context of the development policies of Kubitschek. This article focuses on path of the Malaria Control and Eradication Working Group in Brazil, in its varying relationships with the arguments and guidelines established at international level. Keywords: World Health Organization; Juscelino Kubitschek ( ); public health; malaria; Mário Pinotti ( ). Received for publication in July Approved for publication in May Translated by Derrick Guy Phillips. v.20, v.22, n.2, n.1, abr.-jun. jan.-mar. 2013, 2015 p Renato da Silva, Carlos Henrique Assunção Paiva The discovery of the residual properties of dichloro-diphenyl-trichloroethane (DDT) during the Second World War, and its mass use after the end of the conflict, produced a favorable and optimistic environment with regard to the eradication of diseases transmitted by insects, such as malaria. Discussions among the community of malaria specialists occurred more frequently in the 1950s, and were echoed in Pan-American Health Conferences, Regional Meetings of the Malaria Specialists Committee and World Health Meetings. According to J. Jackson (1998, p.193), the need for a malaria eradication program on a global scale was conceived at the meetings of this community. In 1950, at the 13 th Pan-American Conference on Health, the conclusion reached was that Through the adoption of new techniques in the struggle against malaria and the efforts of member-states and territories, the total eradication of malaria can be achieved (Brasil, 1966, p.2). The Pan-American Health Office was a pioneer in the conviction that it was possible to eradicate malaria. It encouraged existing programs, promoted the exchange of ideas, and supplied technical assistance and, in many cases, financial assistance, with the aim of achieving the eradication of malaria throughout the Americas (Brasil, 1967, p.2). A large part of the enthusiasm displayed by the Pan-American Health Office as from 1958, the Pan-American Health Organization (PAHO) came from the fact that its director between 1947 and 1959 was Fred L. Soper, who worked for more than a decade in Brazil and was in charge of the campaign which eradicated Anopheles gambiae in the North-East region of Brazil. Based on this experience, he became one of the authors of the idea of eradication (Cueto, 2004). At the 14 th Pan-American Conference on Health, held in 1954 in Santiago, Chile, it was recommended that countries should convert their control programs into eradication campaigns. In 1955, at the Eighth World Health Meeting, held in Mexico City, a resolution was approved recommending member-states to aim at the eradication of malaria before the carrier species became resistant to insecticides. The World Health Organization (WHO) took the initiative by supplying technical assistance and incentives for national programs (Cueto, 2004, p.3). The 14 th Pan-American Conference on Health (1954) and the 8 th World Health Meeting (1955) added to the debate over the increased resistance to DDT shown by carrier insects when it was used over a long period. The resistance scenario augmented the need for the eradication of malaria (Packard, 1998, p.217). These two international health meetings can be considered as markers in the eradication of malaria at global level. The main proposal which arose from these events was the recommendation that member-states of the WHO should transform their malaria control programs into eradication programs as quickly as possible (Rachou, 1956, p.8-9). The start of the process to convert existing malaria control programs in Brazil into a Malaria Eradication Campaign (MEC) would only occur at the end of the 1950s (Brasil, 1967, p.3). An understanding of the term eradication was essential for the development of programs which aimed to end malaria. According to Rita B. Barata (1998, p.64), the idea was proposed at the Fourth International Congress on Tropical Medicine and Malaria in The concept was the result of experience acquired in control programs in Greece, Venezuela and the USA. An attempt to eradicate Anopheles labranchiae (one of the carriers of malaria) in 2 História, Ciências, Saúde Manguinhos, Rio de Janeiro The Juscelino Kubitschek government and the Brazilian Malaria Control and Eradication Working Group Sardinia was not successful. The program then changed its strategy, no longer focusing on the carrier but on the malaria parasite. The new tactics consisted in an all-out fight against the mosquitoes responsible for infection, through an eradication of the parasites in the insect population (Brown, 1998, p.128). The distinction between control and eradication was finally established by the Malaria Experts Committee of the WHO in According to the Committee, in control programs the objective was to reduce transmission to an acceptable degree, while in eradication programs the aim was to end the disease (Brasil, 1967, p.2). In 1956, the Sixth Report of the WHO Malaria Committee set out the guidelines for transforming control programs into eradication programs (Pampana, 1966, p.303). Campaigns should adhere to the following principles: the total and ongoing elimination of transmission in all areas where it might occur; exclusive operations, the costs of which should be seen as an investment, and not as a permanent item of expenditure; and the diagnosis and classification of all cases, together with periodic epidemiological and administrative evaluations. 1 Using the typical vocabulary of the so-called campaigning health care, which tends to employ military imagery, the Malaria Program, in its attack stage, was to concentrate on two main objectives: attack operations and evaluation operations. The attack operations would strictly speaking be the eradication programs involving the spraying of residual insecticide in every home in a malaria area until transmission was interrupted. The minimum duration of the attack stage was to be three years and might extend to seven years. In some exceptional cases the attack operations could consist in anti-larval measures, with or without the spraying of homes, and the intensive use of prophylactic medicines. Evaluation operations would consist in surveys of malaria infection in positive cases and areas, i.e. research carried out on individuals and areas with malaria. According to Pampana (1966, p.304), these evaluation operations would be the responsibility of the national malaria eradication services of each country. The scheme for malaria eradication planned by the WHO established two criteria, which all countries had to follow, in order to stop DDT spraying operations: firstly, surveillance operations should cover a large and continuous area, and should show a complete interruption of transmission in that area; secondly, there must be no cases of malaria in children. However, there would be a tolerance for recent indigenous cases. In 1964, the Malaria Specialists Committee of the WHO adopted the following criteria: In order to stop the spraying of homes with insecticide, it must be verified that, within a period of 12 months, the number of cases has not exceeded 0.1% among every one thousand inhabitants (Pampana, 1966, p.306). The eradication consolidation stage would begin after there had been total coverage with residual insecticide in the malaria-affected area, bringing an end to the attack stage. According to the Sixth Bulletin of the WHO Malaria Committee (Pampana, 1966, p.307), this stage would come to an end after three years of active surveillance had demonstrated the absence of any new indigenous cases. In such circumstances, eradication of malaria would have been achieved. In 1959, the WHO revised the criteria for the eradication of malaria: (a) the absence of transmission; (b) the end of residual endemic illness; (c) the non-use of measures to control carriers and no routine chemotherapy coverage for three consecutive years (p.307). v.20, v.22, n.2, n.1, abr.-jun. jan.-mar. 2013, 2015 p Renato da Silva, Carlos Henrique Assunção Paiva Although in 1958 the Eighth Report (8 th Report..., set. 1960) produced new criteria to establish the eradication of malaria, the main requirement remained unaltered: the absence of indigenous cases for three years. The maintenance stage began following confirmation of the eradication of malaria. This stage consisted in strict epidemiological surveillance against the reintroduction of the disease. The strategy for the global eradication campaign proposed by the WHO, therefore, involved the standardization of measures adopted in different countries, creating a single model to be followed by all. In this way, the campaign for the eradication of malaria prescribed by the WHO represented a model for public health. This model would be guided by a top-down policy, i.e. programs to eradicate malaria should be the same in any part of the world. As a fundamental part of the campaign, it should be noted that there was a lot of confidence in scientific knowledge and techniques as ways of ensuring a successful outcome of the campaign and of any investment in public health. In the age of development, technically based solutions, which included planning measures of a normative kind, indicated standards of intervention in public life which were understood in terms of inputs and outputs. In other words, given a technical intervention, the expected and planned consequences would result from it (Rivera, Artmann, 2012). Reality, however, showed itself to be much more complicated and challenging. There were concerns with regard to the resistance that carrier mosquitoes attained against the main kind of technical intervention of the period: DDT. These concerns ended by providing the basis for one of the main arguments for a global eradication campaign with the features we have discussed above. In the case of the malaria eradication campaign, DDT was the problem and the solution. It was a problem because it lost its effectiveness, it was the solution because it was the principal instrument for eliminating the disease. The choice of malaria as the most serious illness affecting the world population in the 1950s, however, did not immediately have the same impact in the member-states of the WHO. Brazil was one of the countries in which malaria existed, but it did not seem to be serious any more. At least that was the implication of the public health program put forward by the then presidential candidate, Juscelino Kubitschek (JK). Written by the medical health expert Mário Pinotti, director of the National Malaria Service (SNM), the program made a connection, classic for the time, between health and development. For him and for other health professionals of the contemporary vanguard, disease was partly responsible for poverty and the backwardness of underdeveloped nations. According to JK and Pinotti, the medicine of the 1950s enabled a classification to be made of the principal diseases into three main groups. The first group consisted in the so-called pestilential diseases which, for Juscelino, had already been conquered by the pioneering achievements of Rodrigues Alves and Oswaldo Cruz. The third group of diseases comprised degenerative pathologies such as cancer and cardio-vascular ailments, which were of lesser importance when compared with the diseases of the second group. The latter, in his view, were the diseases which required the attention of the authorities, the mass diseases par excellence: malaria, tuberculosis, leprosy, verminous infestation, yaws, and others, considered responsible for prejudicing the development of countries (Programa..., 1955, p.4). Despite the fact that little or nothing is disclosed in the literature dealing with the JK government, the then candidate Juscelino had an exclusive program of targets for public 4 História, Ciências, Saúde Manguinhos, Rio de Janeiro The Juscelino Kubitschek government and the Brazilian Malaria Control and Eradication Working Group health, in an attempt to resolve the main questions facing public health in Brazil. Without abandoning this debate, the main focus of this article is the course taken by the Malaria Control and Eradication Working Group in Brazil, in its varying relationships with the arguments and guidelines established at international level, particularly in the context of the WHO. It is interesting to analyze the way in which locally defined interests affected the outcome of the directions issuing from Geneva. The conflicts between the most varied interests, from political and institutional concerns, through the specialist communities, down to the public bureaucracies, gave rise to a context which produced important consequences for the reception, in Brazil, of the directions for the eradication of malaria as a global public health problem in the post-war scene. Divided into two parts, the first part of the text discusses the tensions surrounding the debate over the control and/or the eradication of malaria. Far from being a simple dispute over technical terminology, what was at issue in the context of the years was the definition of priorities in the Brazilian public health agenda. In the second part of the text, we discuss the outcome of the fight against malaria at the beginning of the period of military rule, when the National Program for the Eradication of Malaria was set up, in an apparent compliance by the Brazilian government with the ordinances of the WHO. In the last part of the text, we draw up a balance sheet, looking at the part played by various interests in the country and the fading of malaria as a central public health question, both in Brazil and internationally. The Malaria Control and Eradication Working Group There was no immediate adhesion in Brazil to the global plan for the eradication of malaria prepared by the WHO. A historical analysis of the fight against malaria in the country suggests that the building of a certain national tradition in the control of the disease also served to create political and scientific resistance to the plan. Paradoxically, this tradition of malaria control had its roots in the successful instance of the eradication of the carrier Anopheles gambiae. In any event, for the Malaria Experts Committee of the WHO in 1955, the principal objective of the eradication programs was the extinction of the disease, while the control programs which had been tested up till then aimed only at a reduction in transmission. The Brazilian government accepted the eradication plan proposed by the WHO in However, the Malaria Eradication Campaign (MEC) would only be made official ten years later, through specific legislation to this effect. Law 4.709/65 amended law 2.743/56 and created the MEC, repealing decree-laws /58, /58 and /61 (Brasil, 1967, p.4). Legislation before 1965 seems to have served to prepare or convert the existing malaria prevention and control programs to eradication plans, which is slightly curious, because the WHO and the international financing agencies had a clear policy in the matter: funds were only available for eradication programs. In terms of policy statements, Brazil reflected the international pronouncements, but in practice remained faithful to the doctrine of control. At the end of the day, Brazilian experts did not regard the malaria situation with the same degree of gravity as the views espoused by the WHO (7 th Report, 1957, p.7). While the v.20, v.22, n.2, n.1, abr.-jun. jan.-mar. 2013, 2015 p Renato da Silva, Carlos Henrique Assunção Paiva WHO prescribed a preparatory phase of one year for countries to pass specific legislation for the campaign and to put in hand an immediate transformation of their control activities to eradication programs, in Brazil this initial phase lasted for more than three years (Brasil, 1966, p.36). However, as we have already said, the Brazilian government did not blindly follow these recommendations, which in some cases were referred to as demands on the part of the WHO and the US government. How can we explain this ambiguity on the part of Brazil with regard to the recommendations issued by the WHO for the eradication of malaria? We should remember that the second half of the 1950s was an appropriate time for negotiations in the international context. The international context was dominated by the Cold War. Latin America, the countries of which were essentially exporters of agricultural produce and raw materials for the USA and other advanced capitalist countries, suffered from precarious health conditions among its population and from social inequality (Hobsbawm, 1995, p ). The discontent among large social sections of these countries began to concern the US government, which in the post-war environment was engaged in the maintenance and expansion of its influence in the region, principally through the financing of economic and social programs. The period saw an increase in efforts to contain the socialist model propagated by the USSR (Campos, 2006). The government of Juscelino Kubitschek fitted into the same context. JK tried to put into effect the policies which had been defined in his Manifesto, a series of measures which aimed at the industrialization and modernization of the country. By 1958, however, it was already clear that he was encountering difficulties in conducting the government and obtaining the necessary investment which would make his Manifesto a reality. Vizentini (2004, p.89) says that Kubitschek adopted a nationalist position in bargaining with the USA. JK took advantage of the conditions created by the Cold War to negotiate bilateral agreements with the US government. The question of continental security became the occasion for initiating a dialogue with Washington. In 1957, Washington formulated the Eisenhower Doctrine, which was intended to confront nationalism and left wing movements in the Third World. Although this policy had been created because of the outbreak of war in 1956 and the political radicalization of the Middle East, it was of general application, and there was cooperation with the CIA (Vizentini, 2004, p.95-96). According to Vizentini (2004, p.96), the period between the suicide of President Vargas in August 1954 and the launch of Operation Pan-America in 1958 can be characterized as a kind of hiatus between the foreign policies of the populist phase. After 1958, there was a return to a policy which sought to occupy a more independent position in relati
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