History of hospital care in São Paulo: State grants to the misericórdia charitable associations

This article investigates how the santas casas de misericórdia charitable associations in the state of São Paulo were subsidized by the municipal, provincial, and state governments at the turn of the twentieth century. Budget appropriations from 1838 to 1915 were examined to evaluate these charitable grants as well as the growth in funding during this period. While a care network created with strong state backing, it was put into action by philanthropic assistance. This network of hospital care retained the same format until at least the first third of the twentieth century, and included misericórdia establishments created within the interior of the state of São Paulo.

T he understanding of charity within São Paulo began to change in the 1850s. In contrast with early readings on Brazilian generosity during the early days of colonization, there was a growing perception of health problems affecting the capital and other cities in this state. This transformation underscores other alterations which in turn call attention to alterations in measures adopted to address topics of health and sanitarianism between the Imperial and Republic periods (Santos, 1985;Hochman, 1998;Benchimol, 1999;Cukierman, 2007;Silva, 2014).
We will discuss health assistance in this article against the backdrop of new understandings about government activities related to health problems and which actions were expected for individual health care.
As presented elsewhere, parliamentary debates in the administrative seats of the province of São Paulo for quite some time demonstrated the belief which was widely held until the mid-eighteenth century that "the city remained healthy despite isolated problems" (Silva, 2011, p.66-67). 1 My proposal here is to indicate that this understanding extended to health assistance.
I perceived that both situations (sanitarianism and assistance care) carried with them the expectation of assistance in cases of exception and rupture, when something pushed the physical environment to the breaking point, or when the affected individuals themselves were the exception: the poor, invalids, or abandoned people, widows and orphans. In all these cases, illness (an ambiguous and exceptional occurrence, but also one that can be expected during the course of a lifetime) made individuals who required care beyond financial support from their families into social pariahs.
Yellow fever epidemics began to appear in the second half of the nineteenth century, most notably after 1853, at a time when public health emerged as a major concern alongside the debate on expanding problems related to attention to the urban space (Machado, 1978).
In terms of assistance, attention turned to expanding the santas casas de misericórdia, which began to have a greater presence in the state of São Paulo from the end of the nineteenth century. The profound lack of studies on this subject in Brazil is well known, although studies on philanthropic and charity assistance are gaining ground. However, there are still few studies on the growth of the santas casas in the state of São Paulo.
How did the overall process of supporting philanthropic health institutions using specifically directed resources from public authorities come about? We shall see two different snapshots of state healthcare through the official aid budgeted by the São Paulo government, during the 1838-1899 period and again from 1891 to 1915. Individual healthcare and assistance to the poor were not the subject of legal concern in São Paulo prior to the mid-twentieth century, unlike public health, which became a formal obligation of the municipalities, even when they still depended almost exclusively on resources from the provincial government (during the Imperial period).
In terms of assistance, state support expanded for those santas casas which already existed, as well as those created during these two periods. The same was true for other charity hospitals (both new and pre-existing). In this way, assistance continued to be managed through philanthropy (both religious and secular), even into the twentieth century, in consensual proximity with the provincial governments and later, the state administrations.
Part of the international bibliography on the Anglo-Saxon countries and France has expanded the debate around established notions on the history of charity. Initially, the time periods in this bibliography are broad; the 1850s is suggested as a limit because of questions related to the production of medical knowledge and organization of the profession, as well as broader social issues (Jones, 1993(Jones, , 1989Bynum, 1993).
Before 1850, Christian charity (with its socio-political and religious objectives) kept hospitals closely related to the control and domination of the poor and invalids, although not even during this period was philanthropy exclusive to Christian piety, much less any potential "charity imperative." On this topic, Colin Jones (1993Jones ( , p.1470 questioned the categoric division between religious and secular powers in his bibliography on charitable activity: The supposed dichotomy in relation to charitable motives, ranging from Christian volunteerism in the field of health care and the element of obligation and requirement inherent to modern state welfare systems also proved unfounded in many recent studies. Other references mention Islamic institutions that were important at the time, even if they did not strongly impact the Portuguese world. Various discussions have also emerged about this period with respect to how social welfare was transferred from charity to the state, which takes on nuances indicating that Christian charity still drove industrial society even after the 1850s. As stated by Jonathan Barry and Colin Jones (1991, p.2): The ideals and practices of charity have shaped much of modern medicine and without doubt played as important a role as medicine in the twentieth century. But the connection between charity and medicine has as problematic as it is significant, characterized by failures in both vision and practice and by power struggles between groups of patrons, donors and recipients, lay and medical interests.
After 1850, São Paulo's government and population saw epidemic diseases drawing near, making health a definitively public matter. This perception was associated with the period in which coffee became the main economic activity in the Rio-São Paulo region, extending throughout the Paraíba Valley and the central region of the state; at this time, poverty spread after the end of slavery, while the population expanded as a result of European workers immigrating to work in agriculture.
The end point of this analysis is the year 1915, at a time when health policy in the state began to turn toward sanitarianism in the rural areas of the country, more clearly defining a framework for state-supported assistance (albeit still in the hands of philanthropic and charity organizations). This framework only changed effectively in the 1940s, when demand for hospital care increased and forced the state to respond.
This article compared budgets and reports to demonstrate that resources directed toward different allocations indicated a concern with health assistance. These allocations appear under various headings, with some differences already described in the literature such as "shelter, maternal support, nursing home, medical-surgical assistance, maternity ward, maternity clinic, health ward, clinic, dispensary, nursing ward, hospital, institute, maternity hospital, polyclinic, emergency room, picking up the insane, sanatorium, and hotel-sanatorium" (Mott, Sanglard, 2011, p.XXI). This diversity can be seen in the different types of institutions which were deemed worthy to receive state resources, such as the santas casas in the state.
The start of the relationship between the santas casas and public authorities during the Imperial period The Santa Casa de Misericórdia in the capital of São Paulo was first mentioned (as indicated by Laima Mesgravis, 1976, p.38) in documentation from 1608, recorded in the Minutes of the Chamber of the Village of São Paulo. But documentation produced by the Statistics and Archive Department of the State of São Paulo in 1909 refers to the origin of the Santa Casa in the capital in a different year: "Founded on September 26, 1680, has been effectively functioning since April 24, 1715 in its own building" (São Paulo, 1910, p.280).
Other documents indicate an earlier origin, around 1560, for this association in São Paulo "known as the Confraria da Misericórdia de São Paulo dos Campos de Piratininga" (Khoury, 2004, p.671). However, the dates indicated for the beginning of hospital care converge at 1714-1715.
The Brazilian misericórdia organizations of this period, like their Portuguese counterparts, were based on the Christian ethic of hospitality, and their most noble goal was caring for prisoners, outcasts, and the destitute (Franco, 2014;Sá, Lopes, 2008). Care for poor invalids brought illness into this list of concerns; people with leprosy and mental illness were a significant component of those served by this type of institution, along with other assistance activities such as burials, education, and aid to orphans. The existence of the santas casas in Brazil since the beginning of colonization, and the creation of similar institutions during subsequent periods, demonstrates a long-lasting arc of care for the destitute in different regions, which requires attention to the topic of poverty and the "social issue" (Sanglard, Lopes, 2018).
But these institutions also served as a distinct space for charitable administrations and brothers. Acting as a "pillar" of stability for the Portuguese Empire as it made its colonial incursions around the world, they later professionalized their administrators and healers. Within this scenario, care for the poor brought new socioeconomic considerations and medical concerns to the concept of medical care. This consequently indicates that what we can understand to be different types of assistance existed, and that these were modified over time. From the few people who received attention in the early days of charitable care, there reached a time when the demand for assistance (both social and hospital) began to reflect the increased demands associated with the enormous growth of modern cities, which was particularly acute in São Paulo but also occurred in other place in Brazil (Barreto, 2011;Abreu, 2001).
This aspect, with regard to the demand and relevance of the medical care provided by the santas casas in Brazil, is quite visible in these institutions, particularly in São Paulo. At the Irmandade da Santa Casa in the capital, announcements of some type of hospital care dated back to 1715, when (as mentioned earlier) a precarious and "primitive" hospital began to be mentioned; it appears to have existed on the Rua da Glória in the Centro district of the city. Several attempts were subsequently made at expansion, seeking funds and a specific physical space for health care. At the beginning of the nineteenth century, the Irmandade acquired four small houses (also in Centro), which were expanded in 1836. In 1884 the great Hospital Central, which was built specifically for medical care, opened in the Santa Cecilia district. It expanded several times since then, and still exists today (Mesgravis, 1976).
Life in the city and the state has always been reflected in the activities of the institution. Laima Mesgravis, author of the first detailed work on the Santa Casa in São Paulo, noted the importance of privileges granted to its administrators, as did various chroniclers such as Alfredo Ellis Jr., Ernesto de Souza Campos, and Raul Votta (Silva, 2010;Carneiro, 1986). This connection was later confirmed by other authors (Fonseca, 2012;Ibañez, Duarte, Dias, 2011;Fernandes, 2009;Jorge, 2006;Kuhlmann Jr., Rocha, 2006;Rocha, 2005).
These privileges, together with the administration of assistance itself, went far beyond supporting the charity; it also provided a way for the elites to address the city management, as pointed out by Mesgravis (1976, p.35) in her description of the study by the Portuguese historian D.R. Boxer, who in Mesgravis' words indicated that the santas casas "were directed by the same oligarchic groups that ruled the city council." Mesgravis refers to this situation in summarizing the role of the charity in São Paulo in its early days: "The Misericórdia, during the first century of its existence, was led by the local 'elite,' composed of settlers, bandeirantes, clergy, and some traders interlinked by ties of kinship" (p.59).
Throughout the eighteenth century, responsibility for the health of the population had fallen to the doctors who had begun to practice there, and the state took responsibility for legislating the practice of this profession. This was what occurred under the Regimento da Fisicatura, which was installed in Brazil by royal decree and ultimately subject to the Portuguese administration; a similar situation was soon seen in Europe: The revolutionary decade caused immense damage to the creation of charitable institutions not only in France, but in neighboring regions that France occupied militarily during those years (Netherlands, West Germany, northwest Italy). As a result, greater state intervention seemed essential. But it would be wrong to imagine that this necessarily meant a reduction in the role of volunteer and voluntaristic efforts. The states tended to extend their commitments to well-being through legislation, welfare requirements (which were often left to private organizations), and support, instead of replicating existing charity institutions (Jones, 1993(Jones, , p.1477). William F. Bynum (1993, p.1485 refers to a similar process in Great Britain and the United States; in his opinion, "the voluntarist tradition also helped catalyze more formal state involvement of the state in assistance activities, in part by increasing public awareness of the enormity of social deprivation and need." In Brazil, municipal councils were the front for action on issues related to cleanliness in the cities. Health responsibility was only specifically transferred from the central administration to the municipalities with the Constitution of 1824, ratified by Dom Pedro I, which charged municipal councils with health-related functions, identified as "Policy Postures." These postures involved overseeing various hygiene activities in the cities and health-related concerns in each municipality. The literature indicates the importance of the city council's activities: "Despite their subordinate role, the municipal councils constituted the policy scenario par excellence by historically carrying out key negotiations and definitions in relation to the urban order" (Rolnick, 1997, p.18).
Of the 73 articles of the law of October 1, which reshaped the municipal councils and regulated the Imperial Constitution of 1824, three referred specifically to health and to inspections to be carried out by the municipalities: Article 69 -They shall care for the establishment and maintenance of charity houses, to care for those children at risk, cure the needy sick, and vaccinate all the children in the district and adults who have not yet [been vaccinated], with a doctor or surgeon.
Article 70 -In the elementary schools, the education and future of poor orphans and children at risk shall be inspected; and when these establishments and the charity institutions addressed in art. 69, wheresoever located by law, or in fact made responsible in some city, or to other individual or collective authorities, the Councils shall always assist for the prosperity and expansion of such establishments.
Article 71 -The Councils shall deliberation [sic] in general on the means of promoting and maintaining the tranquility, safety [sic] health, and comfort of inhabitants; cleanliness, safety, elegance, and external regularity of buildings and streets in the villages, and shall form their postures on these subjects which shall be published in public notices before and after confirmation (Lei…, 1 out. 1828).
After the rules for the municipal councils were instituted by the 1824 Constitution, these councils became the starting point for municipalities to independently define their respective postures. Even so, the first Code of Postures for São Paulo was only created in 1875 (São Paulo, 31 maio 1875). The General Council of the Province of São Paulo was installed in 1828 and functioned until 1834, when the Additional Act ratified by the Emperor created the provincial assemblies, which were the seed for current legislative powers and began to legislate on health organization in the capital city and municipalities. 2 The General Council was one component responsible for "creating the independent Brazilian state" (Leme, 2008, p.198); its activities included managing taxes and providing a space for bills to be proposed and later taken up by the central government. It was also intended to "encourage agriculture, commercial, industrial, educational, and health-related development, establish new Chambers and create roads, proselytize Indians and facilitate the gradual emancipation of slaves (Article 24, Carta de lei, 20 out. 1823)" (cited in Leme, 2008, p.199).
As for the Council's financial planning, which is our topic of interest, Mariza Leme (2008, p.212) indicates its importance to planning in São Paulo: As can be seen in the attitudes that prevailed in the General Council of the Province on the eve of Abdication, notwithstanding the centrifugal force of economic demands in relation to the central government, what was most important to São Paulo was national financial order, not disorder, as the best element for the province's very existence.
At they faced political and administrative restructuring, as well as their own functions, the santas casas began to seek approval for their commitments from the General Council of the province of São Paulo. 3 The first to send a request was the Santa Casa in Santos, recognized by law n.43 of 21 March 1836 (São Paulo, 21 mar. 1836). In the same year, the Santa Casa in Paranaguá sent its documentation, recognized by law n.29 of 7 March 1836 (São Paulo, 7 mar. 1836a), as well as the Santa Casa of São Paulo, recognized by law n.2 of 9 February 1836 (São Paulo, 9 fev. 1836). In the latter case, it should be noted that this was the year in which the Santa Casa began providing hospital care in its own buildings, demonstrating the official (if precarious) nature of hospital assistance provided at that institution.
In that same year, law n.27 of 7 March 1836 granted the Santa Casa of Paranaguá the ability to acquire "all titles recognized by law and own up to the amount of 40:000$000 in property to sustain the pious purposes of its institute: waived any provision to the contrary" (São Paulo, 7 mar. 1836b, p.67). These were the steps toward rapprochement with the government of the province, which would impact and regulate the activities of private charity institutions.
The Santa Casa in Santos was the first to formally appear as a beneficiary in financial arrangements in the deliberations of the General Council in a law from 1836. Law n.18 of 27 February 1836 granted the irmandade in Santos the right to a charitable lottery for five years (São Paulo, 19 fev. 1836, p.63); and law n.7 of 19 February 1836 entitled this group to "purchase all titles recognized by law, and own up to the amount of 200:000$000rs. in property" (São Paulo, 19 fev. 1836, p.58). The Santa Casa in Santos had previously received a recommendation from the General Council in 1835 that the same prerogatives granted to the santa casa in the capital be extended "in all their fullness, in favor of the misericórdia hospital in the village of Santos, the contribution of the navy, established in the court of Rio de Janeiro by the provisions of the operating license" (São Paulo, 19 fev. 1836); indicating in Article 2 that "The provisions of the preceding article shall also extend to any other misericórdia hospital that may be established in any other port of the province, as said establishment and its statutes are approved by the legislature of the province" (São Paulo, 23 mar. 1835).
The Santa Casa in São Paulo, in turn, had already appeared as a recipient of some types of official aid at other times, as stated in the Primeiro relatório da Misericórdia [First Misericórdia report] written by Francisco Martins de Almeida, which reported a city council resolution from 7 August 1832 which granted permission to double the value of the assets acquired by that misericórdia (Santa Casa…, 1909).
The relationship between the state and charity was highlighted briefly by Mesgravis, indicating the intermittent nature of official aid, transformations in fundraising methods, and the new sources of funding the santa casa in São Paulo began to use during the Empire, a shift which can also be seen in other Brazilian misericórdias; these changes included interest-bearing loans, acquisition of shares in railroad companies, public bonds, and other financial transactions.
The Legislative Assembly, which replaced the General Council in 1834, expressed its opinion in debates on granting lotteries or minor modifications to its commitments to the santas casas: law n.27 of 12 March 1846, which granted "the Irmandade da Santa Casa de Misericórdia in the village of Paranaguá two lotteries, of 60 contos de réis each" (São Paulo, 12 mar. 1846, p.667); law n.27 of 16 March 1847, granting "four lotteries to the Santa Casa de Misericórdia Hospital in the city of Santos and two to the mother church in Bragança" (São Paulo, 16 mar. 1847, p.751); law n.23 of 16 March 1837, in order to "recommend the deceased brothers of Santa Casa" (São Paulo, 16 mar. 1837, p.160).
New laws were only seen again after 1879, and continued to feature new lottery concessions (São Paulo, 27 mar. 1880, p.21), extended grants (São Paulo, 14 abr. 1880, p.35) of 4:000$000 to the santas casas de misericórdia in Sorocaba, Mogi Mirim (São Paulo, 30 jun. 1881a, p.81), and Jacareí (São Paulo, 30 jun. 1881b, p.81). It is important to confirm that the Irmandades were being cited in the requests to provincial bodies according to the petitions they themselves sent, from their directors' offices, since as private institutions (albeit praiseworthy and philanthropic organizations) they still had formal administrative independence.
Transport for burials in the Consolação cemetery was another topic of discussion. This was first entrusted to Joaquim Marcelino da Silva, for a period of 15 years through Provincial law n.28 of 28 April 1856 (São Paulo, 28 abr. 1856); transport was transformed into a privilege for another 15 years by law n.101 of 30 April 1870 (São Paulo, 30 abr. 1870), but on 2 April 1876 this service was transferred to the Santa Casa of São Paulo, more broadly and including other responsibilities: Art. 1 -The Government is authorized to grant the Santa Casa de Misericórdia of this Capital, or to whomever offers better conditions, the privilege of establishing burial services for 20 years, including vehicles to transport cadavers, caskets, frames, and other mortuary objects (São Paulo, 2 abr. 1876, p.71).

Budgets for health activities
The question of health, which intensified in the early twentieth century, was also present in the provincial budgets during the Empire, but was in line with the expectations outlined previously in response to the exceptional corruption of the environment. From a medical perspective, considering European contact with the New World, understanding of the relationship between the environment and disease arises as a significant factor for understanding the correlation between diseases and nature. The concepts of medical meteorology, topography, and geography which started to appear in the medical repertoire in the seventeenth century further showed the need to seek self-preservation and avoid disease rather than prevention (as this type of precaution is currently understood).
Construction of homes and buildings thus was approached in terms of avoiding disease, ideally with as much ventilation as possible and a safe distance from places considered deleterious (Rolnick, 1997). In addition to housing, care with the body, nutrition, and clothing were also ways of avoiding illness. Although transmission itself was not widely discussed, the concept of miasma continued to be an explanation for corrupted air, which could signal the arrival or presence of disease with bad smells. One example of concern with miasmic corruption of the air and the environment can be seen in the popular petition presented to the Legislative Assembly of São Paulo in the latter part of the nineteenth century. In 1869, the title already provides an idea of the issues involved in the general understanding of the potential for disease: Melhoria da saúde pública: mudanças do matadouro e tapamento das bocas de lobo [Public health improvements: changes in the slaughterhouses and covering storm drains].
As a matter of broader concern, the smallpox vaccine also started to appear in official funding for the province in 1835. Although it was sporadic, the line item "vaccine" received allocations of 1,000$000 (São Paulo, 11 abr. 1835, p.15), much less than values for spending on roadways, which included those destined for Santos (36,000$000), Rio de Janeiro (12,000$000), and Curitiba/Morretes (4,000$000). But the recommendations for vaccination slowly began to expand in 1838, for the capital as well as the districts of Atibaia, São Roque, São Vicente, Capivari, Guaratuba, and Areias (Silva, 2011, p.82-86).
We therefore see that health activities in the Empire, although restricted, corresponded to the prevailing knowledge related to miasmas and the perception of contagion in certain specific diseases, namely leprosy (which was addressed by confining the sick in institutions) and smallpox (with vaccinations and revaccinations based on Jenner's work). In 1852, the same values denoted for "vaccine" continued to appear, alongside amounts for "aid to the Misericórdia Hospital in Sorocaba," 400$000 and additional lotteries for the Santa Casa in São Paulo "via the plan granted in the Court" (São Paulo, 19 jul. 1852, p.56).
The specific health institutions created during the Imperial period in São Paulo had been present in the budgets since their creation: the Hospital de Lázaros [for leprosy patients],  (1880), and the Repartição de Higiene (founded in 1884). Spending on the Hospital dos Alienados was described as follows: § 17 -For the insane hospital 3,140$000. The government is authorized to modify the wages of employees as it sees fit, and even eliminate some, as well as the hospital itself, as soon as the Pedro II hospice has attained an accord for funding for the poor insane of this province for this hospital, with authorization to spend the quantity of 600$ réis (São Paulo, 2 maio 1853, p.66).
After 1861, some santas casas began to appear periodically in "Miscellaneous expenses," under the heading of "Aid to Charity Institutions" and with the addition of Jacareí, Ubatuba, Santos, and Sorocaba (São Paulo, 3 ago. 1861).
In 1888, under provincial president Francisco de Paula Rodrigues Alves, a new law (São Paulo, 17 mar. 1888) indicated various actions in favor of more care institutions including churches, schools, and various misericórdias. This law established new lotteries for the Santa Casa in the capital to complete its new hospital; the same was done for the charity in the cities of Faxina, Pindamonhangaba, Lorena, and Bananal, as well as the mother churches in Pindamonhangaba, Lorena, Vila da Bocaina, the parishes of Sapé and Queluz, and a lottery for the Santa Casa in Casa Branca: Art. 1 -The government authorizes one or more lotteries, with a total benefit of 1,000 contos de réis, in favor of the Santa Casa de Misericórdia in the capital.
Single § -Half of this amount will be applied to work necessary to complete the respective building, and the other half will be collected as a loan to the provincial treasury with an annual interest rate of five percent, to form a heritage for the aforementioned institution.
And to construct a Misericórdia in the city of Faxina. ...
As mentioned in another article, "disease was always cited as an exceptional case" (Silva, 2011, p.67), since there was a general understanding that São Paulo was generally healthy, at least until the cycle of epidemics which began in the 1850s. Nothing in this understanding disagrees with comments in the classic literature related to the early roots of public health as opposed to individual health, which especially began to appear as a topic in the 1870s until at least the first third of the twentieth century, both in general and in the specific bibliography (Nunes, 2000;Rosen, 1979Rosen, , 1994. Only in 1884, with the creation of the ephemeral Hygiene Inspectorship of the Province of São Paulo, did the state attempt to broaden its attention to public health issues, such as "demographic and health statistics (principally in the capital), supervision of the medical and pharmaceutical professions, health surveillance, combating epidemics, especially smallpox" (Mascarenhas, 1973, p.435), although even according to Mascarenhas himself these activities were limited.
After the Proclamation of the Republic, health entered the state budget as a condition for the new system of government, under new item lines instead of potential spending. As stated in the classic text by John Blount (1972, p.41): The Brazilian Constitution, promulgated in 1891, created a Federal Republic which left administrative responsibility in most areas (including public health) to the state authorities. In area of hygiene, the national government only controlled the ports. Under the new constitution, the Republican regime in São Paulo acted quickly to formulate the state`s health policy. State Law n.12 of 1891, established the São Paulo Health Service.
The Republic's first legislation on the topic of public health in São Paulo, law 12 of 28 October 1891, created the Health Inspectorship (São Paulo, 28 out. 1891). This body was subordinate to the Secretary of the Interior, together with the Health Council, the Hospício dos Alienados, and the Board of Health. This Board was comprised of a health engineer and the Vaccine Institute, Bacteriological Laboratory, Pharmaceutical Laboratory, and Chemical Analysis Laboratory (Silva, 2014;Almeida, 2003;Ribeiro, 1993Ribeiro, , 2004Santos, 1985;Mascarenhas, 1949).
But also in 1891, the Inspectorship was replaced by the São Paulo State Health Service, at the same time that the Health Council was eliminated and replaced by the General Disinfection Service and the Demographic and Health Statistics Division. Prior to 1893, different laws had been established to consolidate the organization of the Health Service, 4 and the Service appeared in the annual budget from 1892.
The first state Health Code under the Republican regime was ratified by Decree 233 of 2 March 1894 (São Paulo, 8 mar. 1894); it contained 520 extensive articles establishing rules for urban intervention, hygiene, and public health. In the words of Maria Alice R. Ribeiro (1993, p.28), the new Code "extended health standards to other spheres of city inhabitants' lives in a more rigorous way than the Municipal Postures" from 1875.
After this Code was ratified in 1896 (São Paulo, 3 ago. 1896), 5 the Health Service was restructured, with the Health Board renamed the Sanitary Service Board. Initially, resources were sent as priorities to sanitation work in the capital and in Santos, with smaller amounts also going to Campinas.
According to Rodolpho Telarolli Jr. (1996, p.207), the first decade of the Republic saw successive reforms around the organizational model that would guide "the legal framework of the model for organizing health practices in São Paulo which had been shaped in the previous years, and which favored increasing state intervention in health processes in the municipalities." This same author states that 1911 signaled the end of a period in which municipal autonomy reflected changes in health organization and power relationships between the municipalities and the state, ending the previous campaign-policy model that came alongside the consolidation of the previous health model. As for budgets, Telarolli Jr. (1996, p.234) adds: "The municipalities continued to have a wide range of assignments, which were impossible to carry out with their own budgets, [and] continued to be at the mercy of negotiations with the state government, dependent on its cooperation." Considering the difficulties related to resources and the struggle between powers, the move to sanitarianism did not include earmarked resources for assistance. As for childrelated assistance, Fonseca and Narita (2017, p.320) state that one of the characteristics of establishing care institutions such as homes, schools, and orphanages was the "prevalence of private organizations and establishments" in the city, which also spread into the interior of the state with the same spirit: The directors of funding associations, philanthropic leaders and directors of establishments talked with the Provincial Legislative Assembly, calling for financial grants, tax exemptions, and land donation. … On the part of philanthropy, the legislature was petitioned to obtain benefits which, if they did not sustain all of the work funded by the funding associations, at least envisioned major concessions such as land grants, complementation of resources to construct buildings, lotteries, and exemption from real estate transaction fees, which despite not composing the entire budget permitted headquarters to be built or maintained with an eye to long-term existence (Fonseca, Narita, 2017, p.321). We see that even though they were not managed by the state, the subsidized establishments needed to be inspected by the Health Service after the Republic was established. This led to a scenario in which philanthropic attention to care was situated within the legal framework of the state, since these establishments constantly received all types of subsidies and support and were correspondingly subject to formal supervision. The inspection reports were sent to both the health authorities and the Secretary of the Treasury. Image 1 shows a report on the Santa Casa in the city of Faxina, but all the santas casas which appear in the subsidies have similar documentation. The aid headings differed in the budgets under the Republic. The heading "Hospital Assistance maintained by the State," in other words, institutions created by public authorities, only covered support for the smallpox hospital (which was transformed in 1894 into a quarantine hospital and had been featured in budgets since the Empire) and the Vaccinogenic Institute, which since its creation had also appeared in the province and state budgets. The other care establishments listed in the budgets were all maintained privately, through philanthropy or charity assistance of various kinds.
Briefly, the types of subsidized institutions can be grouped into four large groups: the first consists of homes, shelters, and hostels for the indigent, poor, aged, and infirm, as well as homes for children and orphanages; the second is comprised of hospitals for the insane, charity hospitals, the santas casas de misericórdia, as well as polyclinics, maternity hospitals, children's milk distribution centers, protection associations, sanatoriums, and dispensaries for tuberculosis and leprosy patients; the third group combines educational institutions such as academies, universities, colleges, schools, boarding schools, kindergartens, and schools of arts and trades; the fourth comprises cultural institutions such as women's and artistic associations, reading groups, student unions, recreational clubs, literary and charity clubs, as well as science centers and workers' groups. In 1910 these amounted to a total of 126 institutions in 77 municipalities, 12 in the capital (São Paulo, 1911).
This was a large and ever-growing network of institutions carrying out public duties and benefiting from public resources. Hospital care was thus incorporated into the state structure, as the reports have just shown, but through the administrative conduct of local elites, whether these were in the capital or the interior region; this can be seen in the composition of the medical boards, administrations, and corps. We can consequently see that the state was formally responsible for monitoring, even without exercising this power, and supported this with this local agreements stable enough to ensure care in these institutions and maintain an annual flow of resources.
In the case of the Santa Casa in São Paulo, this concomitance can be seen (among other examples) in aid from the Silva Prado family, which were simultaneously donors and part of the Santa Casa administration on various occasions, served terms as representatives in the Provincial Assembly, and were also among the families which founded the Society to Promote Immigration in São Paulo (Silva, 2010).
Accommodations between the public and private sectors were part of the management of urban space which was transferred from the state to individuals and from individuals to the state, as assistance specialized and changed in terms of spatialization. This management occurred when the various types of aid allowed unassisted undesirables to be taken off the streets through medical care provided to all types of poor and destitute people, and also gathered children into orphanages, seminaries, schools and trade schools, pregnant women into maternity wards, and beggars into shelters, houses of charity, conferences and dispensaries.
Since the beginning of urbanization in São Paulo, the question of the dispossessed has been addressed in various ways in the literature (Dias, 1995(Dias, , 2005. The example of institutionalizing the asylum space to treat mental illnesses, as in the Juquery Hospice founded in 1895 (Cunha, 1988), confirms that to the elites, population growth in the major cities of São Paulo appeared to be a problem related to discipline and adaptation to new ways of life (Foucault, 2007). In the legislation of the period, references to hospital institutions are notable because of the conditions of their operation, requirements for inspection, compliance with hygiene and construction standards, and as a place of isolation in the case of epidemic diseases.
To strengthen this relationship, it should be remembered that the demographic explosion during the period indicates a new level of concern with the urban space. This is one of the aspects which has been addressed for some time in the historiography, starting as Brazil positioned itself among the promises of modernization (Love, 1982). As the new post-abolition society took shape, amid immigration policy to replace slave labor and social management of the "dangerous classes," urban expansion during the early twentieth century can be seen as another topic which impacted hospital care, as depicted in Table 1.

Health in the budgets
Examination of the resources allocated to health services in the state of São Paulo shows that the same institutions remained in these budgets over time, affirming the notion that a network of different types of assistance was formed. As we will see in the following tables, the budget for the province and later the state of São Paulo can be viewed in two dimensions: as appropriations for government agencies, and grants to private establishments linked to philanthropy, charitable organizations, and care. Health funding was divided into categories of "Public aid," relating to hygiene and services to preserve public health, and "Assistance and subsidies." The first category involved resources to "improve the health status" of the capital, stating that spending was "For payment of respective staff," "Food, clothing, wages to laborers and other expenses," and for "Purchase of drugs, utensils, and other expenses." The second category contained the santas casas which received assistance throughout the state. The difference can be seen in the amount of resources allocated to the Santas Casas in the interior and those in São Paulo, Santos, and Campinas, generally which generally received more.
In the same category of "Assistance and subsidies" were resources passed on to the municipalities for them to organize sanitarian and health care locally. Within the resources of the municipalities, part of the money was also allocated for health care services. This form of allocation was constant in reports from different municipalities, and it can be assumed that this was an accepted form of passing on funding to cities in the interior of the state.
Another item in the budgets was for "Attachments," which provided definitions in their general provisions of services that could receive additional credits. These were normally distributed for road construction, emergency work, and assistance institutions, which generally included assistance establishments and "Public aid," as seen in the state budget for the 1892 fiscal year: Budget funding, for which supplemental credit can be created. Insane hospital: for what is lacking to pay for food, clothing, wages to laborers, founding three agricultural homes for the insane, one in Guaratinguetá, one in Sorocaba, and one in Itapetininga.
... Hygiene distribution. For the costs of reorganizing the respective service. … public aid and improvement of health status; for what is lacking for payment under this heading (São Paulo, 18 jun. 1892). Tables 2 and 3 show the amount of resources spent in the first three years that the São Paulo Sanitary Service was implemented, from 1891 to 1893, and in 1915 at a time of transition in management of the Republican State, the end of the period under study. Comparatively, grants for hospital care provided by the santas casas de misericórdia in the state were also seen to grow in relation to their own budget line.  There was also a group of new hospitals that began to appear in the budgets at that time. The Samaritano Hospital was emphasized, and later received grant funding from 1892, and other charity hospitals belonging to different associations aside from the irmandades de misericórdia, such as Proteção à Infância and Amas de Leite. Different administrative bodies which addressed health concerns also began to receive grants that year, such as the Sanitary Engineering Division and Health Commissions of Santos, Campinas, and Ribeirão Preto, the Health Inspectorships of Taubaté and Guaratinguetá, the Anti-Trachoma Commission, and the Sanitation Division in Santos (São Paulo, 27 dez. 1915). Growing grant funding was also identified for other services pertaining to the Santa Casa de Misericórdia in São Paulo, such as the Maternity of São Paulo and the Asilo de Mendicidade, for the misericórdia hospitals in Campinas and Santos, and those created in the interior of the state. Table 4 compares the number of santas casas which received grant funding in the annual budgets and those consolidated in the statistics published in 1909 and 1910 under the title "Statistics for institutions receiving funding from the state of São Paulo." These two editions contain the complete lists of asylums, charity homes, high schools, dispensaries, milk distribution centers, hospitals, and charitable societies throughout the state which received financial resources. They show that in 1895 there was a total of 17 santa casa establishments, and in 1915 a total of approximately 63 misericórdia institutions received funding, when the situation became much more complex.  * The foundation dates refers to the irmandades de misericórdia, not the establishment of their hospitals. Given the differences in the documentation consulted for this article, the oldest date was utilized. The irmandades that did not submit a report at that time were listed as not informed (n/i).
Through the Secretary of the Interior, the state government of São Paulo requested periodic reports from the institutions which received funding, as mentioned earlier.
The stated objective was to evaluate the care of the indigent in order to verify whether these establishments deserved the budgeted resources. The reports to the Secretary of the Interior, which was responsible for financial management of the state, were reproductions of the original reports sent to the General Board of Health Service of São Paulo, which was responsible for assessing and preserving public and individual health, with state policy and structure functions.
All these reports were produced by health inspectors in the region where the Santa Casa was located; when these were not present, the reports were drafted by physicians indicated specifically for this function by the municipal government. The mayors were generally responsible for forwarding these reports. All the reports consulted presented the same data distribution, with few exceptions. Basically, they indicated financial data, number of care visits, and description of revenue and property belonging to the different subsidized institutions. The revenue from these institutions came from various sources; in addition to grants, they included fees collected from members, rental income from homes, donations, resources from financial investments, interest and dividends received, as well as smaller values related to the paying public and fees collected. The values for real estate and expenses are most notable, followed by the quantity of care provided, with a description of the entry, stay, and exit of patients, subdivided into numbers for those which were cured, not cured, and deceased.
Even considering the various types of income mentioned above, the values granted by the state (and occasionally, municipalities) generally exceeded all other resources combined. This can be seen in the report for the Santa Casa in Capivari for 1909. Revenues were distributed as follows: monthly membership fees, 897$000; deposits and diplomas, 50$000; state grant, 5,000$000; municipal grant, 2:000$000; interest, 990$000; building rentals, 900$000; and other sources 433$680 (São Paulo, 1910, p.8). In this example, state and municipal grants combined to comprise 68.15% of resources, versus 31.85% from other sources.
In addition to the balance sheet, the flow of patients in the nursing wards is also described in these reports. This item shows the number of hospitalized patients remaining carried over from the prior year to the year of the report in question, the number that entered during the reporting year, and the total number of patients treated. Discharged patients were distinguished from those who had died during the year in question, broken down by gender and nationality. This item also contained information about the responsible physicians, founding date, and the beginning of hospital activity. The inspector's report invariably indicated that the institution deserved the subsidy provided for in the state budget.
Two examples of these reports can be seen in Images 2 and 3. In general, succinct tables containing patient admissions and discharges at the Santa Casa de Misericórdia in São Paulo were published in the medical journals that circulated at that time. They showed the numbers of patients admitted, of sick healed, and of patients who were not healed and died; the tables illustrate the desire to publicize these activities in the face of the increasing amounts of care provided. The Revista Médica de São Paulo from July 1, 1889, during the first year under a Republican government, also contains the numbers of "external" visits, in other words care provided to patients who were not admitted to the Santa Casa of São Paulo, with a total of 352 consultations and 356 prescriptions for medication from the pharmacy of that hospital (Movimento…, 1 jul. 1889).
A similar table, published in a Santa Casa report (Image 4), allows comparison of patient volumes between 1900 and 1908. It is important to remember that the total quantity of patients for the Santa Casa in São Paulo in this report is many times higher than the average number of visits at other Santas Casas in the state, as indicated in reports submitted to the General Board of Health Services which have been cited here; the Santa Casa in the capital also served patients from different cities in the interior of the state.  Casa de Misericórdia Hospital in São Paulo, 1903-1908(Santa Casa..., 1932 For comparison purposes, the following report shows the patient flow published in the first Misericórdia Report for São Paulo in 1875, referring to the previous five years (Table 5). Table 6 presents a summary of the sparse data on the different santas casas in the interior of the state, in order to show changes in the number of patients served during the period of interest.

Final considerations
As we have seen, the financial organization for the Santas Casas across the state of São Paulo changed between the Empire and the Republic, in relation to the composition of financial assets pertaining to the Santas Casas (initially comprised of donations including alms and donations such as sacks of coffee, animals, and privately held property) as well as the number of patients and the expanded complexity of care.
In addition to the annual fees charged to the brethren in their respective organizations, revenues increasingly came to rely on interest and dividends from the financial system. As indicated by Ibañez, Duarte, and Dias (2011, p.175) when they describe the "modernized administration" of the Santas Casas, we can see that the "ways of employing resources" were being replaced by others from financial applications such as "interest-bearing loans" and "financial investments in real estate and public bonds," including dividends from railroad stock, in addition to the traditional goods received in wills and inheritances and revenues from private services and pensioners.
In 1874, it was clear that access to the financial system was a matter of gratification and had practical results in expanding the institutions' assets, as indicated in the report for the Santa Casa in São Paulo: The Board is elated to announce that income has increased considerably, even though significant donations to the brotherhood did not appear as they have previously. … the current administration was able to increase the number of public bonds to 85, built one home, completely rebuilt three and the Hospital, and bought another on the Rua da Consolação (Irmandade..., 1874, p.7).
At least four types of resources can consequently be observed: the financial system, philanthropy, income from services, and public grants. Examination of the first existing budget for São Paulo, from the province's General Council in 1828, shows that health as a whole was not highlighted, for various reasons. First, the province's resources went towards organizing roadway and administrative infrastructure, and second, health was generally considered charity work. Little by little, health services began to emerge as epidemic diseases appeared. Care institutions began to receive funding, but these were initially related to those establishments which isolated those affected by mental illness, smallpox, tuberculosis, and leprosy; the exception was resources for smallpox vaccination.
We have seen that the state's resources were used to create a privately administered assistance network in conjunction with philanthropic institutions, using public resources. Even after health and sanitation institutions grew more complex, the hospital network was supported by charity hospitals and their enormous assistance network. noTes 1 In this and other quotes from texts published in other languages, a free translation is provided.
2 There is disagreement as to the date the Council was created. Some authors indicate 1828, while the Legislative Assembly of São Paulo itself states 1826 (before regulamentation, and closer to the date of the Constitution of 1824).