Via Grosklaus Whitty's English translation of his important 1998 study of the development of public health in Brazil during the First Republic, Gilberto Hochman meticulously describes for English-speaking readers how the country created a centralized health system even though Brazil had a federalist charter and local elites jealously guarded their political power. He also illustrates how public health initiatives forced the revisiting of the federalist framework of the constitution of 1891 and was ultimately important to state formation in the country. This work is an overdue and essential contribution to the literature in English on the history of health, state formation, and Brazilian political and social history.
Hochman uses the work of sociologists Abram De Swaan and Norbert Elias among others to create a theoretical framework for understanding the interdependence among regions that ultimately made a national health program both attractive and necessary to Brazil's ruling class. Essentially, because contagious diseases could not be contained within territorial boundaries, states and cities required various types of collaboration in health matters. Urbanization, labor migration, immigration, early industrialization, and Brazil's increasing importance internationally all brought people into closer contact and contributed to changing attitudes toward national hygiene. Individual solutions, such as the efforts of the rich to guarantee the quality of their own food supply, or to flee illness, or to leave medical issues to charity and voluntarism, gradually came to be seen as inadequate to deal with the enormity of disease in Brazil under these new conditions.
Hochman sees the push for “sanitizing” Brazil as primarily coming from the economic and social elite, although he does mention that “public opinion” at points was “increasingly troubled by health matters.” Much of the momentum for nationalizing public health in Brazil came from doctors working in public health who focused on the abysmal health conditions in the country, especially in rural areas. A 1912 report by Arthur Neiva and Belisario Penna of a health and scientific expedition into the Sertão described the illness and neglect of the rural population. In 1916, Miguel Pereira gave a powerful speech at the National Academy of Medicine in which he compared Brazil to a vast hospital. Although some believed these assessments of the country's hygienic situation were exaggerated, the appeals found a receptive audience in the federal legislature, where 15 percent of the deputies were medical doctors in 1918–1920.
Much of the book focuses on the incremental means by which public health became “collectivized,” or national, despite the federalism of the country's constitution. This achievement essentially involved compromise among political actors who recognized the dire health situation but held different attitudes toward federal intervention. As Hochman explains, in the end it became a question of weighing costs against benefits. Was the loss of some local autonomy a small price to pay for national help with epidemic disease? Was the expense to the federal government affordable if it meant being protected from diseases that could spread to the Federal District and other cities from impoverished rural areas?
The gradual movement toward cooperation was encouraged by outbreaks of epidemic disease, especially yellow fever, but also the Spanish flu, which affected people of all classes, and which most states could not handle alone. Particularly impoverished states were among the first to be attracted to forming voluntary bilateral agreements with the newly formed National Department of Public Health. As Hochman describes it, “a national public health infrastructure was gradually creeping in through doors pushed open by rural sanitary agreements.” This infrastructure eventually included infant and child care as well as measures to police food safety.
The one state that consistently did not participate in the process of centralization was São Paulo, which had for long boasted of its own advanced public health system. In some ways, São Paulo seemed to be a microcosm of Brazil, in that it early recognized that public health could not be responsibility of the individual municipalities but had to be organized on the state level. Despite the state's extreme federalism, São Paulo politicians the state would have to cooperate with nationwide efforts if it was to reduce the negative effects of disease from other states. This was especially in important for combating rural endemic and epidemic disease. But, as Hochman shows, a condition of São Paulo's participation was that it was not mandatory.
Hochman concludes his book with some sobering comments on the current move toward privatization of health care in Brazil and elsewhere. This reversal of the hard-won achievement of national responsibility for health may in part be the result of the actual success of campaigns against epidemic disease. Are the elite more likely to return to individual solutions if the major health problems are no longer contagious and do not threaten them in the same way as yellow fever or bubonic plague did? However, as evidenced in Brazil and elsewhere, health care as a right has become a key demand of popular groups and this may ultimately prevent a return to market-driven alternatives.
