Feature 444 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.