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Oswald0 Cruz and the Flowering of Public Health in Brazil1

umanity’s penchant for neglecting from further harm; but all vulnerable adult H the unpleasant has helped us to for- visitors, immigrants, and nonimmune get that as recently as 1900 the city of Rio residents afoot in Rio during yellow fever de Janeiro was a running sore. Sanitation season ran a high risk of quick and horrid was poor, medical knowledge limited, death. public health weak.3 There, as elsewhere While it may seem surprising that this in Brazil, the ordinary run of diseases like health picture has been forgotten, the tuberculosis, diarrhea, and measles took really surprising thing is how it changed. their toll, while certain more dramatic Beginning in 1903, a broad public health killers like smallpox and bubonic plague campaign began. Some measures, like were rife. widening of narrow streets and im- But the great terror of Rio in those days, proved sanitation, were fairly general. the ill that slew waves of immigrants and Others, like destruction of plague-bear- really gave the city its bad name, was ing rats and yellow fever mosquitoes, were yellow fever. Also known as the “black more specific. Al1 in all, the results were vomit,” yellow fever reached Rio in 1849, startling. As if some enchanter had waved erupted into a fearsome epidemic that a magic wand, plague retreated, yellow killed some 4 000 residents, and for the fever vanished, the death rate fell, and next half-century lingered as a shadowy Rio’s health, happiness, international assassin claiming hundreds or thousands prestige, and self-esteem began to rise. of lives a year. In time it became well The person who spearheaded this known that all who survived a yellow transformation was a quiet, strong-willed fever attack (including a mild or unno- young man named Oswald0 Cruz. When ticeabIe childhood attack) were immune he became director of Brazil’s diminutive public health department in 1903, Cruz took the bull by the horns. In three years ‘This is the sixth in a series of profiles on individ- he vastIy expanded the department, uals who have made outstanding contributions to planned and managed large national public health in the Americas. gonathan Leonard is a freelance medical writer and campaigns against various problems in- editor of the Bulletin of PAHO. cluding plague and yellow fever, and es- 3Bacellar RC, p 237. tablished a permanent beachhead for

Bullefin of PAHO 27(l), 1993 65 Pictures taken of Oswald0 Cruz in 1903 (right) and in 1911 (below, left). The 1908 cartoon at lower right appeared over the caption “This is the way the country receives its sons that honor and love the nation; it crowns and blesses them.” (Drawing by Klixto, Fan-Fen magazine, Rio de Janeiro, January 1908; photos courtesy Casa de Oswald0 Cruz Archive.)

66 Bulletin of PAHO 27(l), 1993 medical research in Brazil. In the process Higiene PtibZica); by 1890 he was assistant he roused fiery political controversy, to Brazil’s top public health officer, the achieved spectacular success, and be- Inspector General of Health; and in 1892, came his country’s first and greatest pub- a few months before his death at the age lic health hero. of 47, he himself became Inspector Gen- It is true that Cruz, trained in micro- eral of Health. biology and aware of key public health In those days, of course, the scope of discoveries abroad, was a man in the right Brazilian medical science and public health place at the right time. But he also started was limited. Medical laboratories and basic in 1903 as a virtual unknown with limited tools like microscopes were rare. Medical experience in medicine, laboratory sci- schools existed in Bahia and Rio, but these ence, public health administration, and had serious shortcomings. As Nancy politics. He worked so fast that his feats Stepan reports in her excellent book The seemed the stuff of legend-like medical Beginnings of Brazilian Science, there was sleight of hand. And no other Latin no chair in microbiology anywhere until American country ever experienced such 1901, and as late as 1904 the lone pro- a swift, self-generated public health rev- fessor of microbiology at the Rio de Ja- olution, though at least one other, Ar- neiro School of Medicine “was attempt- gentina, was medically more advanced. ing to instruct one hundred and fifty So it is worth looking closely at who students with a single microscope. The Oswald0 Cruz was and what he did. situation in histology and pathology was much the same.“4 EARLY YEARS Public health laws existed in these years, but ignorance of disease origins, effective Oswald0 Gongalves Cruz was born in quarantine rules, and appropriate sani- the small Brazilian town of SZio Luis de tary measures prevented such laws from Paraitinga on 5 August 1872. Perhaps being effective. The resources at the com- partly because he was an only son (he mand of public health authorities were had six sisters but no brothers), from early few. And despite the explosive growth childhood he tried hard to follow in his in medical knowledge then under way father’s footsteps. That took him inter- outside Brazil, principally in Europe, the esting places-because his father, Bento circle of Brazilians directly involved with Goncalves Cruz, was a private physician public health was very small. with uncommon dedication to learning, Oswald0 Cruz, who grew up within medical science, and public health. that circle, was quiet, studious, and pre- In 1877, when Oswald0 was five, Bento cocious. His mother taught him to read and his wife Amalia moved their family at age 5. He then proceeded to finish from Sao Luis to Rio de Janeiro so the school in 9 years. After that, at age 14,5 children could get a regular education. he began university studies equivalent to There they lived in Jardim Botanico, then college plus medical school at the Na- a poor neighborhood, where Bento got a tional School of Medicine in Rio, the same morning job as physician at a textile fac- institution his father had attended. tory, the Fdbrica de Tecidos Corcovado, and At the university, Cruz came in close ran a private practice in the afternoon. contact with several well-known clini- As time passed his reputation grew. Nine years later, in 1886, Emperor Dom Pedro II made him a member of the country’s *Stepan N, Beginnings of Brazilian science, p 55. public health board (the @zfu Central de 5Moreira M, pp 29-30.

Feature 67 cians. One of these, Professor Rocha Faria, ian’s second language. Moreover, the supervised the medical school’s first mi- Emperor Dom Pedro II had invited Louis crobiology laboratory. Cruz, who worked Pasteur to visit Brazil in 1883; and though for some time as an assistant there, found the invitation was declined on account of himself increasingly drawn to microbi- Pasteur’s ill health and age, Dom Pedro ology and wound up doing his medical remained unabashedly impressed by thesis under Rocha Faria on transmission Pasteur’s work against rabies and con- of microbes by water. tributed generously when the Pasteur In- That could have been the end of his stitute was founded in 1885. involvement with research. By 1892, when When Cruz applied-around the time Cruz received his medical degree, he had Louis Pasteur died in X395-the Pasteur exhausted the training available in Brazil. Institute was impressive. Organized to His father’s death the same year left him combine basic research, applied research, with scant resources. And his marriage and student training, it consisted of five in 1893 to a girl named Emflia Fonseca, departments-one dealing with rabies, with whom he ultimately had six chil- one with microbe morphology, and three dren, obliged him to settle down. So he with microbiology. Its department heads, took his father’s old job at the Fdbrica de charged with pursuing research in their Tecidos Corcovado and for some years pur- own areas while working as fully as pos- sued a career in clinical medicine. sible with others, included some of the Fortunately, Oswaldo’s interest in mi- most original scientific minds in Europe. crobiology got strong backing from his And its approach to advanced medical re- father-in-law, whose wedding present was search, combined as it was with student the cash Oswald0 needed to build a small training, tended to forge close associations home medical laboratory. Dr. E. Sales between researchers and students. Guerra, a prominent physician and head When Cruz began his Paris studies in of the Internal Disease Service of the 1896, excitement about serum therapy was General Polyclinic of Rio, was impressed high, and the institute’s work was strongly by the laboratory and asked Oswald0 to focused on developing immune sera and set up and run a diagnostic laboratory for vaccines. So Cruz received extensive the polyclinic. Another leading clinician, training in the most advanced techniques Dr. Francisco de Castro, was also im- emerging within this branch of medicine. pressed and aroused Cruz’s interest in But he also planned to return to Brazil; continuing his scientific training at the he knew his country’s research under- Pasteur Institute in Paris. pinnings to be weak, and so he studied Cruz followed up on both suggestions. many other things. He put on a work- He set up the diagnostic laboratory at the man’s blue shirt and learned glass-blowing polyclinic, where he and Sales Guerra be- techniques used to make scientific glass- came close friends; and in due course he ware at a local factory; he kept up with applied to the Pasteur Institute, was ac- published research on various ills, most cepted, and with his father-in-law’s fi- notably yellow fever, which he likened nancial support took his family to Paris in his letters home to “an invisible stain and began two-and-a-half years of study. that disgraces and humiliates US”;~ he at- Cruz did not choose France and the Pasteur Institute by chance. From the early 19th century onward France and Brazil “Brazil, Congress0 National, Annaes da Cdmara dos Deputados, 1903, vol 6, Sessbes de 1 B 31 de outu- had enjoyed close cultural ties, to a point bro, p 168, as quoted in Stepan N, Beginnings of where French was the educated Brazil- Brazilian science, pp 72-73.

68 Bulletin of PAHO 27(l), 1993 tended courses at both the Pasteur Insti- surgeon famed for his promotion of vac- tute and the Paris Municipal Laboratory; cination against smallpox and diphtheria, and he wrote Salas Guerra that besides who in 1900 was chief of the federal gov- microbiology he was studying histology, ernment’s vaccination institute. It soon pathology, hygiene, and chemistry with turned out that municipal funds for the the aim of establishing a laboratory for antiplague laboratory were lacking, so the the diagnosis of morbid diseases on his federal authorities took over the project return to Rio.7 in May 1900 and put Baron Afonso in The end result was that when Cruz charge. The Baron looked around for arrived home in 1899 he came as a fully technical personnel to help him, and trained bacteriologist highly attuned to among others asked Oswald0 Cruz to join modern medical discoveries. However, his team. his immediate situation was not drasti- The choice was logical. The Baron may cally changed. Brazil was essentially the not have known that Cruz’s training at same. Medical research was limited, ad- the Pasteur Institute had taught him about vanced research in microbiology un- plague and had steeped him in the world’s known. So at first there seemed no op- latest knowledge of immune sera and tion but to pick up his work more or less vaccines. But he knew Cruz had helped where he left off at the factory and poly- the government to confirm the first sus- clinic and to reopen his private clinical pected plague cases in Brazil, and he knew practice, which is what he did. him to be one of the few available experts in this field. THE SEROTHERAPY INSTITUTE Cruz, who saw the offer as a chance AT MANGUINHOS to use his training, decided to accept, and soon the project started. A city-owned What interrupted this routine was the farm named Manguinhos, some miles bubonic plague. An ancient scourge har- outside of Rio, was chosen as the labo- bored by rats, transmitted by fleas, and ratory’s site; conversion of Manguinhos’ encouraged by poor sanitation, plague had ramshackle physical plant got under way; been a classic disease of Europe and Asia and on 25 May 1900 the facility was in- that was utterly unknown in the New augurated as the Federal Institute of Ser- World. But a plague pandemic that began otherapy. Soon after that the Baron set in the Far East in 1894 found its way to off for France to recruit a technical direc- Brazil in 1899 and struck Rio in 1900. That tor with the high skill needed to direct year it killed at least 295 people in the safe production of sera and vaccines from capital, and city authorities asked the Yersinia pestis, the deadly plague bacillus. federal government to help build a lab- The Baron found no French bacteriol- oratory that could blunt the crisis by pro- ogist of repute willing to take the job. ducing antiplague immune sera and That was not surprising-because, aside vaccines. from the dangers posed by Yersinia pestis, The original suggestion to build this Brazil was a distant backwater, the gov- laboratory had come from Baron Pedro ernment was only offering a 6-month Afonso de Carvalho France, a talented contract, and yellow fever had everybody scared. But Afonso, who had already re- cruited two bacteriologists in Brazil (Cruz Titepan N, Beginnings ofBrazilian science, p 72, based and Col. Ismael da Rocha, an army doc- on Brazil, Congresso National, Annaes da Chara dos Deputudos, 1903, vol 6, Sessdes de 1 B 31 de tor), did recruit a veterinarian named Car& outubro, p 166. in Paris. And he heard about Cruz’s abil-

Feature 69 ities from Professor Emile Roux, a dis- funds ran short. So, seeing the work well tinguished pupil of Louis Pasteur and managed, having had some clashes of tem- Vice-Director of the Pasteur Institute, who perament and will with his technical chief, remembered Cruz and praised him highly. and wishing to travel to Europe, the Baron Thus reinforced, the Baron returned to resigned in December 1902. Early the next Manguinhos determined to proceed with year Cruz was named director. his mostly local staff. That proved only the beginning of Os- That staff soon shrank. Col. da Rocha Waldo Cruz’s meteoric rise. On 15 No- was called away to deal with a plague vember 1902 Francisco Rodrigues Alves outbreak in the army; and the veterinar- became President of Brazil. Previously, ian Car&, citing health reasons, cut his as Governor of %o Paulo State, Alves contract short and returned to France. had been intimately involved with com- However, by then the Baron was suffi- bating yellow fever, so he knew about ciently impressed with Cruz to leave him the yellow fever work of the Reed Com- in charge of all technical operations; and mission in Havana confirming that the so, with the assistance of a technician mosquito Aedes aegypfi transmitted the from the Vaccination Institute, two med- disease. What’s more, he had founded ical students, and a number of service his campaign for the presidency on a personnel, the work progressed. “renovation” platform that stressed the Fortunately, besides knowing what he need to sanitize Rio de Janeiro and its was about, the quietly assertive Cruz port of Guanabara. turned out to be a gifted manager and In early 1903 Alves was still looking for teacher. So the work proceeded quickly someone to direct the federal department despite inexperience, scarce funds, poor of public health, which in those days was equipment, and a rudimentary physical under the Ministry of Justice and Inte- plant. By October, less than 6 months rior. The new Minister of Justice and In- after the project started, the first boxes terior, J.J. Seabra, knew Dr. Sales Guerra, of plague vaccine were ready. In nine had been one of Salas Guerra’s patients, months, by February 1901, antiplague and was generally impressed by the em- immune sera were also ready. And by inent clinician. So one day, soon after the end of 1903 the institute had supplied taking office, he asked Salas Guerra to the government with immunizing prod- be the new public health director. ucts worth an estimated 324 000 milreis Salas Guerra declined. As he ex- (equivalent to about LJS$ 80 000 then, or plained, he was mainly a clinician and roughly US$ 800 000 now). was not especially well versed in public By then the Baron had departed. His health. But he knew from personal ex- relations with Cruz had proved uneasy, perience that Oswald0 Cruz was an able partly because he could be an irascible manager in close touch with the fast- administrator, partly because he knew moving health science frontier and ded- little of advanced vaccine and serother- icated to improving public health in Brazil. apy techniques, and partly because Cruz Among other things, Cruz had recently wanted to make Manguinhos a beach- brought Salas Guerra an article describ- head for medical research in Brazil-a ing measures taken to rid Havana of yel- role far beyond anything the Baron had low fever and had argued forcefully for in mind. Then too, the Baron had done applying the same measures in Brazil. So his work gratis for nearly 3 years, and in- Salas Guerra recommended him.8 deed had sometimes provided the project with money from his own pocket when 8Moreira M, pp 45-47.

70 Bulletin of PAHO 270, 1993 Above: The Federal Institute of Serotherapy (laboratory in center and stables at right) in 1903. Below: Cages for small animals used in the institute’s research, constructed in 1904. (Courtesy Casa de Oswald0 Cruz Archive.)

Feature 71 That came as a surprise. The minister, itary code for the whole country that among and later the president, had to ask “Who other things made vaccination against is Oswald0 G-LIZ?” But when inter- smallpox compulsory. viewed, Cmz impressed them both as an Cruz was very firm about the prospects able man of science deeply committed to for knocking out yellow fever. “The ex- the cause of public health. Cruz also out- tinction of yellow fever is a problem which lined ambitious plans for controlling has already found a practical solution,” smallpox, plague, and yellow fever, plans he told Minister Seabra. “We can . . . con- that must have fit well with what the sider the question solved.. . . Yellow fever president already knew of yellow fever. will end in Rio de Janeiro when Congress So despite his youth, at the age of 30 gives us the means.“9 Oswald0 Cruz became Director of the Despite this prognosis, however, the Federal Department of Public Health. proposed law caused an uproar. It was expensive. It emerged from the office of THE PUBLIC HEALTH a medical unknown. It appeared to pro- CAMPAIGNS OF 1903-1907 pose unproven measures against yellow fever (even in Reed’s own United States As we have seen, in those days public of America the Reed Commission rec- health was small potatoes. Before Alves, ommendations were controversial). And the whole federal department had con- it cut deeply into what many congress- sisted of the director, five aides, one san- men regarded as the cherished right of itary inspector, five servants, and a each state to set its own health policy. coachman. Reasons were not hard to find. For these reasons, the ensuing debate was First, past public health measures had long and bitter. generally failed, so enthusiasm for big But Cruz didn’t wait for the debate. programs was lacking. Beyond that, each Well before the bill was even proposed, Brazilian state bore responsibility for his campaign against yellow fever in Rio health within its borders, while the mu- had begun. He sent an observer to Ha- nicipality of Rio de Janeiro was respon- vana to view the work of the American sible for health in all parts of the city authorities; he issued new yellow fever outside the Federal District. Therefore, regulations; and he used funds already the jurisdiction of the federal department authorized to create a Yellow Fever Pro- extended only to the Federal District phylaxis Service. By mid-April 1903 the within Rio and to certain activities di- prophylaxis service had set to work sec- rected against foreign diseases-mainly toring Rio de Janeiro into health districts, imposition of quarantines at major ports. policing suspected zones of infection, de- With Alves’ support, Cruz set out to stroying mosquito foci, and identifying, change all that. On 15 May 1903, less isolating, and registering yellow fever than two months after his appointment, patients. the government presented the legislature The intensity of all this provoked with a comprehensive health reform bill. resistance. People barred their doors to This called for (1) expansion and reorgan- sanitary inspectors. Special tribunals had ization of Manguinhos; (2) unification of to be established to force compliance with the federal and municipal health services the rules. Announcements from Cruz’s of Rio de Janeiro; (3) a large and costly office explaining the need for strong campaign against yellow fever in Rio based on recommendations of the Reed Com- mission in Havana; and (4) a rmiform san- 9Bacellar RC, p 247.

72 Bulletin of PAHO 27(l), 1993 measures were commonly ignored. And Cruz and Alves continued to press the Cruz himself became the butt of news- issue. Then a smaIlpox epidemic struck, paper jokes and cartoons showing him causing some 130 deaths a week in July as a “monster ruthlessly imposing the 1904, and a bill requiring compulsory cruel techniques of science upon a cow- smallpox vaccination became law that ering population.” In a way CIUZ could October. This law evoked a thunderous not have wanted, “his name became a response from the positivists and other household word.“lO opposition elements, one that soon flared This hostility had several causes be- into a military revolt against the govern- yond the yellow fever measures and the ment. The uprising, which took several challenge to states’ rights. Among them: lives and posed a serious threat, was put The Alves Government, determined to down quickly. However, it showed once clean up Rio’s open sewers and narrow and for all how strongly people felt about unpaved streets, had embarked on a ma- compulsory vaccination. So the govern- jor street widening and improvement ment backed off; the new law was not program that disrupted business, irked enforced. Smallpox vaccination remained commercial interests, and upset those who a matter of individual choice, and the owned and occupied the buildings being disease continued to assail Brazil for nearly torn down. The Positivist Church in Rio, seven decades before being finally erad- a powerful religious body, threw its weight icated in 1973 following mass vaccination against compulsory smalIpox vaccination campaigns. on grounds that it limited free choice. On other fronts, however, the public And a hodgepodge of many different health campaign did very well. The gi- groups opposing Alves saw the public gantic work of cleaning and remodeling health campaign as an opportunity to Rio made marked inroads against the un- discredit the government. sanitary conditions and rat reservoirs that As the tide of dissension rose, legis- harbored plague. To strengthen the work lators called Cruz an idiot and worse. His against plague, Cruz did several things. plans for the Manguinhos Institute were He made doctors report plague cases. He termed self-serving. The former federal set out to inform the public about the director of public health, Dr. Nuno de problem, so that afflicted people would Andrade, openly questioned the mos- not hide the disease and would seek quito theory of yellow fever transmis- treatment. He carried out appropriate sion-a theory Nuno de Andrade had serotherapy and vaccination. And he be- espoused the year before. And a cloud gan a large program in plague-ridden of opposition to compulsory vaccination neighborhoods to trap and destroy rats. grew threateningly dark. Seeing this, a Cruz was under no delusions that any decision was made to jettison the com- of these measures offered perfect an- pulsory vaccination proposal; Congress swers, or that he could eradicate the rats. dumped most of the proposed changes But he persisted, and he got results. In for Manguinhos; and in this reduced form 1903 there were 360 reported plague the bill was passed in December 1903. deaths in Rio; in 1908 there were 54; and Perhaps regrettably, the struggle for in 1912, three years after Cruz stepped compulsory smallpox vaccination did not down, there were none. end there. Convinced they were correct, A bigger and more challenging target was yellow fever. Besides unifying the health services of Rio, the new public “‘Stepan N, Beginnings of Brazilian science, p 90. health law formally released funds to pay

Feature 73 yellow fever workers. By then the Yellow ceives its sons that honor and love the Fever Prophylaxis Service already had a nation; it crowns and blesses them.“” technical director, medical inspectors, carpenters to build patient isolation MEDICAL RESEARCH, 1903-1917 rooms, and squads of workers to kill mosquitoes. But now the pace quick- While all this was going on, Mangui- ened. A laboratory was set up to diag- nhos was not forgotten. Ever since his nose suspected cases; isolation wards were years in Paris, Cruz had dreamed of cre- installed in hospitals; cases were rigor- ating an institute in Brazil that would ously reported and isolated; and provide a strong base for health research, throughout the city mosquito-killing bri- and Manguinhos gave him an opportu- gades staffed by up to 2 500 men, roughly nity to do it. So all during his years with 1% of the city’s work force, became a the public health department he re- common sight. mained director of the Serotherapy In- Under terms of the new law, Cruz had stitute, and even during the intense 3 years, until President Alves’ term ex- congressional battles he typically worked pired, to control the yellow fever epi- there three mornings a week. demic or face revocation of the law. Hap- His 1903 proposal to revamp Mangui- pily, that never became an issue because nhos showed what he wanted. That pro- the campaign worked. Despite a resur- posal called for expanding the Sero- gence in 1905, yellow fever deaths de- therapy Institute, then technically attached clined precipitously-from 548 in 1903 to to the federal public health department, 42 in 1906. That year Cruz reported to into a place “for the study of infectious incoming President Afonso Pena that and tropical diseases along the lines of “yellow fever no longer exists in epi- the Pasteur Institute of Paris.“l* Under demic form in Rio.” this plan the revamped institute would But the campaign did not end there. teach and conduct original research in Cruz kept his post, kept the work going, bacteriology and serum and vaccine pro- and kept gaining. In 1907 there were 39 duction. It would be separated from the yellow fever deaths; in 1908 there were public health department and put di- 4; and in 1909, the year Cruz stepped rectly under the Justice and Interior Min- down as public health director, there ister. It would also be accorded status were none. equal to that of the medical schools of Of course, this feat did not eradicate Rio and Bahia, and would be supported yellow fever elsewhere in Brazil, or even by a special research endowment fund ensure its permanent banishment from that would free it from the vagaries of Rio. Nor did it eclipse work spearheaded federal budgets. by Cruz on many other fronts. But it de- When Congress rejected most of these feated Rio de Janeiro’s greatest terror, proposals, Cruz went ahead anyway. The fundamentally altered Brazil’s self- public health department began sending confidence and international image, and a growing stream of microscopes, glass- transformed Cruz in the public mind from something of a scientific tyrant into a public hero. In this vein, one of many “Stepan N, Beginnings of Brazilian science, p 91. For other laudatory political cartoons of this nature, 1908 political cartoons reversing his “mad see Oliveira V, Osvaldo Cruz, pp 72 and 74. scientist” image showed Cruz with a ‘*Brazil, Congresso National, Annaes da Cdmara dos hero’s garland above an adoring caption Dipufados, 1903;5:586, as quoted in Stepan N, reading “This is the way the country re- Beginnings of Brazilian science, p 93.

74 Bulletin of PAHO 27(I), 1993 ware, and experimental animals to Man- While all this was important, the key guinhos. Books and journals were pur- to Manguinhos’ success was Cruz’s per- chased for a new library coIlection. sonal attention. “As Director of the In- Technicians hired for the public health stitute, he followed all the research al- campaign went to Manguinhos for train- most step by step, always stimulating ing and to help prepare sera and vac- personal initiative, noting every diffi- cines. Students from the Rio Medical culty. When a student was confronted by School were sent there to prepare their a real problem, he would appear, chari- medical theses. table and serene, pointing out the road. Altogether, this influx of talented peo- When he himself could not make a de- ple and supplies was such that by 1905 cision, he indicated the books, some- Manguinhos was bursting at the seams. times the chapter, or personally wouId As Cruz pointed out in a report to the look for a way to help a student.. . .“I4 Interior Minister that year, By the end of 1906, with the yellow fever campaign a recognized success and It is unbelievable that, in this small house his political prestige at its peak, Cruz sent (sic), which is no doubt unmatched in its a bill to Congress similar to his 1903 pro- poverty even by the most useless of pro- posal. At this point Congress found him vincial laboratories, we are trying to do the hard to refuse. So, following debate, steps same work as that being carried out in the were taken changing the institute’s name large and comfortable European or Ameri- to the Institute of Experimental Pathol- can institutions. The real wastage and sac- ogy of Manguinhos, tripling its budget, rifice this effort entails, and the danger, can only be appreciated by those who know and covering the cost of completing the how an institute such as ours works.13 new construction. Other measures taken in 1907 gave the To remedy that situation before Presi- institute the autonomy and authority of dent Alves’ term expired, C~LLZhad a Por- a major research center. As Cruz had tuguese architect draw up plans and in wished, it was detached from the pubIic 1906 proceeded to construct new buildings health department and made an inde- at Manguinhos. The key addition was a pendent science institute under the Min- new main building, probably modeled istry of Justice and Interior. Its director after the Montsouris Meteorologic Ob- came to be elected by a special technical servatory in Paris, that was tall and or- commission and appointed by decree. Its nate with patterned tiles and Moorish cu- fiscal autonomy was ensured by a per- polas. Overlooking Guanabara Bay from manent fund of government bonds. And the Manguinhos site, this bizarre but it was authorized not only to prepare vac- striking structure made an impressive cines and sera, but to study infectious statement, came to serve as the institute’s and parasitic diseases, create a schooI of hallmark (it still appears on its station- veterinary medicine, and organize sci- ery), and dwarfed every other building entific commissions of inquiry. on the site. By then the high-quality research that these official measures sought to pro- mote was already under way. The staff- including such rising names as Henrique ‘%tepan N, Beginnings of Brazilian science, p 96, from Araggo, Antanio Cardoso Fontes, Carlos Brazil, Directoria Geral de Sadde Ptiblica, Xelafdrz’o apresentado ao Emo. Sr. Dr. J. J. Seabra, Ministro da Justica e Negocios Inferiores, pelo Dr. Oswald0 Gon- Ealves Cruz. 1905, p 9. 14Bacellar RC, p 151.

Feature 75 Staff members of the Oswaido Cruz Institute and visiting scientists (above) photographed in front of the institute’s dining hall in 1908. Seated, from left to right: Carlos Chagas, Jose Gomes de Faria, Antonio Cardoso Fontes, Gustav Giemsa, Oswald0 Cruz, Stanislaus von Prowazek, and Adolf0 Lutz. Standing, from left to right: Arthur Neiva, Henrique da Rocha Lima, Henrique Figueiredo de Vasconcellos, Henrique de Beaurepaire Aragao, and Alcides Godoy. Below: Oswald0 Cruz looking into a microscope at one of the institute’s laboratories. (Courtesy Casa de

76 Bulletin of PAHO 27(l), 2993 Chagas, Alcides Godoy, Artur Neiva, and mobbed” when he came home from Eu- Henrique da Rocha Lima-was proceed- rope. The next spring, in March 1908, ing to develop various vaccines and sera, President Afonso Pena issued an execu- study diverse bacteria and protozoa, de- tive order renaming the Institute of Ex- velop malaria prevention methods, and perimental Pathology the Oswald0 Cruz describe new mosquito species. In 1906 Institute in honor of Cruz’s service to Alcides Godoy announced discovery of a Brazil. vaccine against maquiera plague, a key By then Cruz was getting ready to step disease of Latin American livestock; and down as public health director. Why he in 1907 Henrique Aragao unraveled the did so is not entirely clear. He may have life-cycle of a plasmodium parasitic in pi- felt that his work at the department was geons, leading the way to understanding complete. He may have seen that the in- the life-cycle of the malaria parasite in stitute was coming of age and wanted to man. give it more attention. Or he may have This work depended on a successful felt physically spent and unable to man- system of recruitment linked to training, age the department and the institute to- and of training linked to employment and gether. In any case, for whatever rea- research. It worked like this: As already sons, in 1909 he left the public health noted, promising Brazilian medical stu- department and gave all his remaining dents and health workers were encour- energies to the singular research center aged to do work at Manguinhos. There, that bore his name. under Cruz’s supervision, they were At the institute, this was an exciting trained in glassware making, sterile tech- time. Two noted European scientists, nique, serum and vaccine production, and Gustav Giemsa (inventor of the Giemsa microbiology. In this way knowledge was stain) and StanisIaus Von Prowazek (a passed from Cruz to the students, and top student of famed German bacteriol- from one student to another, as part of ogist Fritz Schaudinn), came to work there an informal cooperative venture. Even- under contract. The first numbers of the tually, the more routine tasks of serum institute’s journal, Memo&s do Ivlstituto and vaccine production were assigned to Oswaldo Cruz, were published. And on lower-level technicians, freeing the stu- 14 April 1909 staff member Carlos Chagas dents and doctors for research. discovered American trypanosomiasis, a International recognition came quickly. revelation that sparked great medical in- In 1907 Brazil became the only Latin terest and in 1912 won Chagas the Schau- American country invited to participate dinn Prize, an international award given in the XII International Conference of once every 4 years for the best work in Hygiene in Berlin. Cruz set his staff to parasitology and tropical medicine in the work preparing exhibits for the confer- world. I5 ence that described the Institute of Ex- But fate can be fickle. None of these perimental Pathology at Manguinhos and things ensured permanence. Cruz had set its roIe in research and public health- out to build an experimental research in- most notably its work against yellow fe- stitute-preferably one that would en- ver and malaria. Highly impressed, the dure. Yet human history is littered with conference judges awarded their highest the bones of novel institutions that died prize, a gold medal, to the institute for when their powerful leaders perished- its role in advancing the health sciences. News of this unprecedented award ex- cited Rio, and Cruz was “practically Leonard J, pp 233-34.

Feature 77 partly because nobody could fill the lead- One member of the group was Miguel er’s shoes, partly because the leader’s fol- Cuoto, commonly regarded as the father lowers turned elsewhere. Here Cruz’s own of modern clinical medicine in Brazil. prominence worked against him. And so, Thanks to the careful preparations of Cruz despite his success in building the insti- and Chagas, Cuoto had no doubt about tute and staffing it with locally trained who deserved credit. As he explained people, he had no assurance it would afterward, long survive his death. This was no hypothetical matter, be- “On that day it was up to me to give a cause Cruz’s health was poor. As early name to those traditional diseases of the as 1908 he began to suffer from debili- Minas [Gerais] backlands, which were now tating kidney disease. This may have been unified as one disease with cause and de- brought on or aggravated by the stress velopment clearly established. To name it of his two man-killing jobs, and it prob- after only one of its symptoms would be to limit its description, and to name it for all ably had something to do with his deci- its symptoms would be impossible.... And sion to leave the government. In any case, so, at dinner, while toasting Carlos Chagas, it sharpened awareness of the institute I . . . chosen because of my age, standing staff members and of Cruz himself that with Oswald0 Cruz on my right and sur- his time could well be short, underlining rounded by the men most representative of the need to plan for his death or early Brazilian medicine of that era, with a grav- retirement in advance. ity equal to a liturgical act in our religion, Those plans took several forms. Dur- such as a baptism, gave the name of Cha- ing the years Cruz was with the health gas’ Disease to that illness . . . in the name department, he had been forced to dele- of the entire delegation.“16 gate many of the institute director’s tasks to others. After the institute was reor- As part of this general strategy, Cruz ganized in 1908, this arrangement con- departed from the accepted Latin Amer- tinued, with the job of standing in for ican practice of attaching his own name the director when he was absent being to his subordinates’ published works. He rotated monthly among the eight de- could justifiably have claimed much credit; partment heads. In this way experience for although he did no research himself in dealing with the institute’s adminis- after 1902, he kept up with research trends trative problems was spread around. and did a first-rate job of guiding work Beyond that, Cruz made sure that his and suggesting research topics to stu- researchers got full credit for their work, dents and staff members. But he was in- while he himself adopted a self-effacing tent on directing attention to his people. stance. For example, consider what Cruz So instead of crediting himself, he did did when Carlos Chagas discovered the opposite; and from 1909 onward, while American trypanosomiasis. He first took the Memo’rias do Institute Oswald0 Cruz was the normal step of immediately announc- gaining international prestige, none of the ing the discovery to Brazil’s National bylines on its myriad articles ever in- Academy of Medicine. But he then took cluded the name “Oswald0 Cruz.” the unusual step of assembling a singular As the years passed, the institute con- group, including some of the nation’s most tinued to expand. It began teaching a for- distinguished physicians, to make a pil- mal course in microbiology based on a grimage. This group visited Chagas at the rural site where the discovery was made and personally reviewed his work. 16Remarks by M. Cuoto quoted in Kean BH.

78 Bulletin of PAHO 27(l), 1993 Left: The main building of the Oswald0 Cruz Institute (front view). Below: The nearly completed main building in 1908 (rear view), showing Guanabara Bay in the distance and the remains of the original laboratory at Manguinhos on the right. (Courtesy Casa de Oswald0 Cruz Archive.)

Feature 79 similar course taught at the Pasteur In- the Memo’rias do Insfituto Oswaldo Cruz that stitute, for which students received credit aptly described what Cruz had done. But from the Rio Medical School. By 1911 its in 1917 it was the journal’s policy to de- library housed over 10,000 books and pe- scribe only scientific work, so not a word riodicals, the largest collection of spe- appeared to mark its founder’s passing. cialized scientific works in South Amer- That silence, reflecting the policy of self- ica.17 Its scientific interests continued to effacement, is what Cruz would have broaden, eventually coming to include a wanted. Better than any printed state- diverse array of disease agents and re- ment, it stands as mute testimony to the lated microorganisms. And it continued staff’s respect for him, to his own selfless to pursue a series of large health projects dedication to science, and to the iron will under contract-such as a campaign of a quiet but precocious youth who against yellow fever in Belem that began sought to follow in his father’s footsteps in 1910 and two major surveys of health and who, in a brief span of years, suc- conditions in the Amazon in 1910 and ceeded in advancing Brazilian medical re- 1913. search and public health beyond his or By then Cruz was declining fast. Pic- anyone else’s wildest dreams. tures taken of him in 1903, when he be- came public health director, show a dash- BIBLIOGRAPHY ing youth. But his appearance in 1911, a couple of years after his kidney problem Ara@o H. Carlos Chagas, diretor de Man- surfaced, bears no trace of either dash or guinhos. Mem Inst Oswaldo Cruz. 1953;51: youth. And pictures taken in 1916 show l-10. a frail, white-haired, and prematurely aged AragCo H de B. Noticia hist6rico shbre a fun- da@o do Institute Oswald0 Cruz (Instiixto man. In 1916 Cruz began having frequent de Manguinhos). Mem Inst Oswaldo CYUZ. kidney crises. In August 1916 he had a 1950;48:1. bout from which he never really re- Bacellar RC. Brazil’s contribution to tropical mecl- covered. A few months later he resigned icine and malaria: personalities and institurions. as institute director, and on 11 February Rio de Janeiro: Grhfica Olimpica Editora; 1917 he died at the age of 44. 1963. As he had intended, the Oswald0 Cruz Cooper DB. Oswald0 Cruz and the impact of yellow fever on Brazilian history. Bull Institute survived. Under Carlos Chagas, Tulane Med Fat. 1967;26:49-52. who became the new director and later Fraiha H. Oswaldo Cruz e a febre amarela no Park head of Brazil’s public health service, it Belbm: Grafisa; 1972. continued to grow and to serve as a cat- Freitas CA. Atualidades: & mem6ria de Os- alyst for health research in Brazil and other Waldo Cruz. Rev Bras Malariol Doengas Trap. parts of the Americas. Indeed, largely be- 1978;30:129-133. cause it was built so well, it has remained Kean BH. Carlos Chagas and Chagas’ disease. an active force in this field ever since. Am J Trop Med Hyg. 1977;26(5):1084-1087. Decades after Cruz died, in 1950, an Leonard JA. Carlo< Chagas, health pioneer of the Brazilian backlands. Bull Pan Am Health elderly Henrique Araggo published an Organ. 1990;24(2):226-239. account of the institute’s early years in Moreira M. Oswaldo Cruz. SBo Paulo: Editora T&s; 1974. Neghme A. Homenaje a Oswald0 Cruz en “Institute Oswald0 Cruz, museum document, Bi- ocasi6n de1 centenario de su nacimiento, bliofeca do Institute Oswald0 Cruz: balance dado en 1872-1972. Bol Of Sanit Panam. 1973;74: janeiro de 2911, cited in Stepan N, Beginnings of 65-66. Brazilian science, p 112. Oliveira V. Osvaldo CYUZ: pa&o, gl6ria e morte.

80 Bulletin of PAHO 27(l), 1993 Recife: Companhia Editora de Pernambuco; Waldo Cruz, medical research and policy, 1890- 1974. 2920. New York: Science History Publica- Penna B. Oswaldo Crux impressoes de un disci- tions; 1976. pulo. Rio de Janeiro: Revista dos Tribunaes; Stepan N. Initiation and survival of biomed- 1922. ical research in a developing country: the Serpa P. Aspectos da vida de Oswald0 Cruz. Oswald0 Cruz Institute of Brazil, 1900-20. Gaz Clin, Pub Med Paulista (Slio Paula). 1936; 1 Hist Med. 1975;30(4):302-325. 34:4&-53. Wells WC. Oswald0 Cruz, 1872-1917. US Nav Stepan N. Beginnings of Brazilian science: Os- Med Bull. 1917;11:521-525.

Center for Information on Health Promotion

PAHO’s Division of Health Promotion and Protection (HPP) has set up a Center for Information on Health Promotion (HPIKIPS), located at PAHO Headquarters in Washington, D.C. The Center selects, col- lects, and distributes printed information and audiovisual materials on such topics as disease prevention, control of noncommunicable chronic illnesses, health problems of the elderly, tobacco use, accidents, nutri- tion, mental disorders, akoholism, and drug dependency. The Center acts as a reference service to facilitate exchange of informational prod- ucts (including documents, microfiches, transparencies, posters, calen- dars, videotapes, films, flip charts, audio tapes, and others) between centers in the Americas specializing in social communication about health. It also prepares sample collections of audiovisual materials and provides guidance on the preparation of similar products for use in educational activities and technica meetings. Professional and technica personnel in the health and social sci- ences are invited to send the Center samples of any relevant materials produced in their countries. Additional information on the Center can be obtained by contact- ing the Pan American Health Organization, HPPKIPS, 525 Twenty- third Street, N.W. (Room 729), Washington, D.C. 20037, USA; telepone (202) 861-3333; fax (202) 861-8466; EMAIWBITNET: HOFFENBL@PAHOHQ.

Feature 81