Published in 1998, then again in 2006, and once more in 2012, this amply cited and well-read book appears in English at last, making a clear case for the relationship between elite interests and the expansion of the state's health policing role in early twentieth-century Brazil. The affirmation of public health as a governmental responsibility, and the gradual development of health agencies with coercive prerogatives, were the two main legacies of this process. Both of these are still current, given the establishment of the Sistema Único de Saúde in the late 1980s, and the contemporary effects of phenomena such as privatisation on the SUS's reach.
Brazilian policymakers confronted the tensions of governmental power distribution early in the First Republic (1889–1930). The 1891 constitution delineated the state and federal jurisdictions formally, with the federal government put in charge of Federal District health policies, port sanitation, and aiding states during health emergencies, and state authorities made responsible for all other health issues in their territories. The pragmatic federal recognition of the power of state bosses gave way to increasing federal firmness beginning in 1902. Yellow fever, plague and smallpox epidemics encouraged greater assertiveness on the part of Francisco de Paula Rodrigues Alves's administration, which pulled municipal doctors, urban cleaning workers and infectious disease prevention tasks under federal purview.
In the early 1900s, leading Brazilian health experts, witnessing the spread of cholera in Europe and the United States, extolled the notion of social interdependence and came to value permanent, compulsory and broad-ranging government actions to prevent mass infection. However, the nationwide spread of this sanitary vision hinged not on its logical soundness, but on elites’ appreciating the net benefits they would accrue by making health into a governmental duty. As Gilberto Hochman explains, the decision depended on ‘calculations and bargaining involving the costs and benefits of tasking the state with health vis-à-vis the costs imposed by disease’ (p. x).
It is somewhat challenging to grasp the significance of these elite calculations because readers don't learn precisely who are the calculators, especially at the state levels. On the other hand, Hochman addresses the theme of interdependence deftly and in detail, especially once the rural sanitation campaign gets under way in 1910. This public health movement aimed to transform the self-portrayal of Brazil, from a paradise of disease communicability into a community that endeavoured to secure health for its people. Led by intellectuals such as Dr Belisario Penna, the rural sanitation campaign paid attention to new illnesses (such as hookworm, malaria and Chagas disease), new regions (the sizeable northeastern backlands, the sertões), new populations (the sickly inhabitants of rural areas, long ignored by the state, and understandably mistrustful of it), and new health partners (most importantly, the International Health Board of the Rockefeller Foundation).
After 1910, these sanitary reform advocates’ ambitions grew to encompass nation-building as a goal, bucking the trend that viewed Brazil's chances of economic modernisation as slim. To nationalist reformers after World War 1, better health could become a lever of racial improvement and even material prosperity. Between 1916 and 1920, organisations such as the Pro-Sanitation League of Brazil encouraged top-down governmental reforms, while criticising the federal neglect of vast swaths of Brazil's population, whose incorporation into the nation as a healthy and productive citizenry could but contribute to the nation's wealth. There was no simple path laid out to bring these ideas to fruition. Bolstering the federal government in health matters would require, for starters, revising the state/federal power balance established in 1891. It would also demand treating individual health as a kind of public good, which the government must protect even if, on occasion, this meant impinging on the liberty and property of individuals and states.
Congress took up this heady debate in 1918. A number of states, including Minas Gerais, Pernambuco, Bahia, Rio de Janeiro, Paraná and São Paulo had already enacted sanitary codes and rural sanitation policies, on their own or in collaboration with the Rockefeller Foundation. These initiatives had made elites increasingly aware of how the communicability of diseases made all in Brazil interdependent, which played in favour of granting new powers to national agencies. However, this prospect also stoked fears of local autonomy loss, and of the unwitting creation of a big and ineffective federal bureaucracy. Once again, calculating (and still elusive) elites decided that strengthening the federal hand was worth the risks. A broad consensus resulted in the creation of the National Department of Public Health, within the Ministry of Justice, in 1919. The bargain stipulated that states could enter into agreements with the federal government to share the costs of new health campaigns, and also that states could opt out of such agreements if they deemed it in their best interest to do so. In practice, this possibility was real only for the state of São Paulo, but the opt-out clause was crucial in preserving the principle of state autonomy within Brazil's political structure. Entrusted with new powers and resources, Brazilian public health authorities presided over a growing infrastructure through the 1930s. This growth, in turn, legitimised the aims of the rural sanitation movement.
Readers will not find an analysis of how lay people may have felt about the build-up of the Brazilian public health apparatus, or of how race and class prejudices shaped and shape access to the state's health resources. Rather than evincing an aversion to social historical granularity, this underlines Hochman's formidable lesson in realpolitik: in the absence of popular challenges, it was calculating elites alone, with their strong mutual ties and overlapping interests, who bargained among themselves to drive health policymaking during Brazil's First Republic.
