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História, Ciências, Saúde-Manguinhos

Print version ISSN 0104-5970On-line version ISSN 1678-4758

Hist. cienc. saude-Manguinhos vol.12 no.1 Rio de Janeiro Jan./Apr. 2005

http://dx.doi.org/10.1590/S0104-59702005000100006 

Revisiting the Spanish flu: the 1918 influenza pandemic in Rio de Janeiro1

 

 

Adriana da Costa Goulart

Master's in Social History from Universidade Federal Fluminense (UFF); Rua Mariz e Barros, 98/401; 24220-121 Niterói – RJ Brazil; adrianacgoulart@yahoo.com.br

 

 


ABSTRACT

The article analyzes the political and social impacts of the 1918 Spanish flu epidemic in the city of Rio de Janeiro, then Brazil's federal capital. Through an analysis of press reports from Rio de Janeiro and of other documentation, I explore how the epidemic served as a tool for political engineering. Data sources include annals, reports, and bulletins from a federal ministry, the Mayor's Office, and the Chamber of Deputies, along with studies from the Brazilian Academy of Medicine and dissertations from Rio de Janeiro's Faculdade de Medicina. My concern is how the epidemic impacted the representation of certain political and social actors and how it reaffirmed a group of sanitarians as an intelligentsia with a vocation for political leadership–a group that came to play a key role in the process of modernizing Brazilian society.

Keywords: Spanish flu; epidemic; public health; political and social history; governability; political and social representation; Rio de Janeiro, Brazil.


 

 

Introduction

During World War 1, in mid August and early September of 1918, a few brief items on a peculiar disease began circulating in the newspapers of Brazil's federal capital; however, neither government authorities nor the public at large paid much attention. Starting that past May, Europe and Africa had been swept by an epidemic illness of uncertain diagnosis. It was at first confused with a number of other diseases, like cholera, dengue, and typhus. Only in June did news come from London suggesting that it was a type of grippe or influenza, which had already spread to different corners of Europe. It was to circle the globe in eight months, killing from 50 to 100 million people and earning fame as the greatest enigma in medicine.2

The coinage "Spanish flu" can be traced to the fact that in Spain no bones were made about the damage caused by the epidemic, whereas in many other countries, there were efforts to soften the blow of this evil assailing their societies (Kolata, 2002; D'Avila, 1993). The label "Spanish flu" actually has political roots. Spain was neutral during World War I, and a faction inside the Spanish government was even sympathetic to the Germans, lending a broader political connotation to the name assigned the sickness, chiefly at England's initiative (D'Avila, 1993). The idea of 'hiding' the disease was at first backed by prestigious institutions like London's Royal Academy of Medicine. But by mid September 1918, few still believed in its alleged Spanish origins.

Military-imposed censorship was common back then. Many countries chose to censor news on the epidemic; after all, the flu struck such a blow to the military capabilities of armies that it was first known as "trench fever." One fine example of this is how the reigning disease frustrated the German army's battle plans, condemning the July 1918 offensive to failure. While the plan came close to winning the war for Germany, the defeat compelled its leader, General Erich von Ludendorf, to resign from the German army two months later in response to criticisms over the loss (D'Avila, 1993; Kolata, 2002).3

While the Spanish flu spread across Europe, news about the reigning disease was ignored and treated with disdain, jests, and even a pseudo-scientific tone in Rio de Janeiro, capital of the Republic, where there was a strange feeling of immunity to the disease. Treating the issue in anecdotal form, an article published in A Careta (no. 537) shows how badly people were informed about the problem threatening them:

Spanish influenza and the dangers of contagion – This sickness was created by the Germans, who spread it around the world using their submarines. […] The officers, sailors, and doctors of our fleet, which left one month ago, make their way through hospitals on the front, catching it along the way and falling victim to the Germans' treacherous bacteriological creation, because in our opinion this mysterious sickness was manufactured in Germany, imbued with virulence by the Teutonic know-it-alls, bottled and then distributed by submarines, assigned to spread bottles off the coasts of the allies, so that these bottles are carried to the beaches by waves and picked up by innocent people, spreading this horrible morbus throughout the universe, thereby forcing those who are neutral to remain neutral.4

Together with the cartoon shown below, this excerpt has profound political meaning and demonstrates how the public was critical of the Brazilian government's tardiness in taking a stance in the amphitheater of war. Initiated only after German ships had torpedoed Brazilian ships in 1917 (just as would happen again in 1941), Brazil's eventual entrance into World War I was deemed inevitable if the Brazilian government was to safeguard the sovereignty, autonomy, and grandeur of the nation. This made it imperative for Brazil to enter the fray with a large enough military contingent to defend itself from its enemies.

On the one hand, this kind of sentiment revealed Brazilian society's absolute lack of information or knowledge about the problem threatening it; on the other, it camouflaged the fears of the population, who saw sanitary initiatives as a pretext for reviving earlier measures construed as coercive. Such measures had earned sanitarian Oswaldo Cruz heated criticism while head of the Diretoria Geral de Saúde Pública (General Board of Public Health) during the Rodrigues Alves administration (1902-06); the ensuing regime of tyrannical sanitation policies fueled great social tension, eventually igniting the so-called Vaccine Revolt (Sevcenko, 1984; Benchimol, 1992).

 

 

Another article in A Careta made this position quite clear when it stated that the threat of Spanish flu nurtured a much bigger danger: "the threat of official medicine, of scientific dictatorship," since the Diretoria Geral de Saúde Pública, "enforcing dictatorial measures, threatened to violate the rights of citizens with a series of coercive measures, […] readying all the weapons of scientific tyranny against the liberties of civil peoples" (A Careta, no. 538, Oct. 12, 1918, p. 28).

Epidemics have quite often provoked social and political disruption; the population reacts to government-enacted controls and regulations, and when the government responds to this reaction, it does so in a biased fashion (Evans, 1992). According to an article in Revista da Semana (26 Oct. 1918, p. 16), this is what had to be done:

The evil should not, therefore, be handled with the indifferent disdain of innocence; all care should be taken in providing aid and assistance for victims of the epidemics. […]

Neither sequestering the ill nor cloistering the healthy are trustworthy measures. For the many ill who have been locked away in hospitals, there are many more who would stay freely in their homes and even go about the streets; not to mention those who are healthy but who carry violent germs to the healthy ones who would like to be cloistered.

To protect themselves from the epidemic environment, it would be most difficult for them to avail themselves of an ivory tower that would save them from the dangerous approach of other men.

For many journalists, as well as for large numbers of the population and of political groups opposed to the Wenceslau Braz administration, efforts to fight the sickness were initially viewed as a pretext for interfering in people's lives. Down through history, epidemic diseases have been influenced by political and social factors, as they have impacted different groups of people and incited a gamut of responses.

Historically, epidemics and ideologies have spread in the same way, fostering social conflict and resistance to interventionism and attempts to 'medicalize' society. Classifying a given condition as a disease is not a socially neutral process, and in health-care administration there is a fine line between legitimacy and stigma. Concomitantly, an epidemic disease's impact on society may be a factor in legitimizing government intervention, through legislation that establishes a form of social control and reshapes relations between individuals and between individuals and institutions (Augé and Herzlich, 1995).

The population of Rio de Janeiro was frightened and worried about the measures that might be taken by those in charge of public health. The prevailing opinion was that this was a case of much ado about a commonplace disease–a mere "limpa-velhos" [killer of old people].5 A disease about which so little was known had by 1918 become an enormous challenge that Rio de Janeiro society would have to conquer.

The 1918 flu's high mortality and morbidity rates, its short incubation period, and the extremely high number of deaths it caused were some of the factors that made the Spanish flu a unique event in all senses.

 

The killer flu and daily life under epidemic conditions in Rio de Janeiro

The city of Rio de Janeiro had a population of 910,710 in September 1918, with 697,543 residing in the urban area and 213,167 in the suburbs and rural area. Only 48 died of the flu during this period. In the course of the epidemic, the figure reached unprecedented heights: on October 22, 1918 alone, 930 of a total of 1,073 deaths were attributed to the malady (Fontenelle, 1919). In other words, the mortality rate skyrocketed almost 2,000% during the course of the event.6 In Rio de Janeiro, the Spanish flu killed some 15,000 people and sent another 600,000 to bed–that is, about 66% of the city's population (Boletim, 1918).

The press only started paying greater attention to the reigning disease when members of the Brazilian Medical Mission began succumbing to this mysterious ill while sailing to Dakar on the ship La Plata. A total of 156 died, while the 80 doctors onboard could do nothing for the officers or soldiers who fell to the unknown enemy one by one. The first news of deaths among members of the Medical Mission arrived via cablegram, sent by mission head Nabuco Gouvêa on September 22. Even so, this failed to awaken the city's authorities to the urgent need to devise strategies for fighting the menacing disease.

According to the Diretoria Geral de Saúde Pública's sanitary inspector, José Paranhos (Fontenelle, 1919), the military-imposed censorship hampered efforts to battle the disease and left the population in the dark about events. Such censorship made it hard to monitor the epidemic's progress. A further complication was the total lack of infrastructural preparedness on the part of federal public health institutions, which stirred major tensions and criticisms.

Within the Diretoria de Saúde Pública, the first government agency to come under fire from public opinion was the Serviço de Profilaxia do Porto, responsible for controlling public health at ports. The Service was unable to disinfect every ship that docked at the federal capital. Quarantining vessels was considered 'unnatural' and redounded in political, economic, and social headaches.7 In the heat of the moment, the sanitary inspector for the port of Rio de Janeiro, Jayme Silvado, was accused of abetting the entrance of the epidemic because he agreed to let the Demerara8 dock–being a "positivist, he did not believe in microbes."9

No advance strategy for fighting the sickness was devised to come to the population's rescue. It became apparent during the pandemic that Brazil's sanitary and public health structures suffered many inadequacies, starting with the sanitary administration itself; it has often been said that the epidemic in fact evinced its bankruptcy (Brito, 1991). But the public had already been aware of this situation for some time. The fact that health-care institutions were not equipped to assist the population was the first of many problems revealed during the epidemic. Mr. Nelson Antonio Freire, contemporaneous observer of the facts, left the following valuable contribution to a better understanding of the city's hospital structure:

It was lamentable what shape Rio de Janeiro's hospitals and health facilities had been in for quite some time. Many hospitals operated under more than precarious conditions, as was the case at São Francisco Xavier for a long time. When the hospitals were actually running, they lacked trained people and material to work with.

Public assistance services were worthless; they were merely figurative. If someone got sick in a public place, either he had to depend on the help of passers-by, or he suffered the embarrassment of being rescued either by a police wagon or by some funeral hearse.

The epidemic merely ignited bottled-up anger against health institutions and against the government's negligent attitudes towards health in general. The arrival of the Spanish flu certainly made it imperative to improve the city's health structure. […] There was much disorder in the streets, for we all wanted an explanation for the inertia of health [agencies] and of the government (Nelson Antonio Freire, interview to the author, September 11, 1990).

Corroborating the viewpoint and sentiment expressed in this testimony, in the Boletim da Prefeitura do Distrito Federal we read what the director of Hygiene and Public Assistance had to say about the harsh press campaign, which publicized the agency's limitations and thus created an "embarrassing situation" that hampered the exercise of its duties. Paulino Werneck also gives us a notion of the material and technical precariousness of the agency he managed, when he talks about the "sad state of the ambulances and of clinical equipment in general" (Assembléia Legislativa do Estado do Rio de Janeiro, 1918, p. 185). He also mentions the absence of any regulations grounding his agency's activities and the lack of technical training on the part of nurses, "which leaves much to be desired, […] since they obtain access to their positions following an apprenticeship as cleaning staff and chauffeur's aids" (Assembléia Legislativa do Estado do Rio de Janeiro, 1918, p. 194).

During the flu epidemic, this prior knowledge reinforced the population's idea that political and sanitary officials were neglecting public health and, therefore, the people themselves. The Spanish flu unveiled the stumbling blocks erected by the legislative branch and the administrative structure, which were responsible for the operational areas of public health and hygiene assistance and for developing public health policies and for overseeing sanitary institutions. During a session of the National Academy of Medicine, Dr. José Mendonça compared the federal capital's hospitals, inadequate in number, to a "stray cat" to which no one paid any heed. They were nothing more than government agencies where, owing to "poor finances and political meddling and bureaucracy, a scientific attitude was impossible" (Anais da Academia Nacional de Medicina, 1918, pp. 629-31). While clearly on the wane, the persistence of a clinical tradition within Brazilian medicine also thwarted the flourishing of a scientific attitude at health institutions. Stressing how hard it was to enforce this kind of attitude at Rio de Janeiro's institutions, Dr. Dias Barros stated that:

Pure science […], instituted in laboratories, has not yet left there to have, if you will, a fermenting affect on society; it has not yet moved the masses by applying material found in study and research […] to the normal, ordinary practice of medicine (Dias Barros, 1913, p. 153).

An analysis of documentation on the Spanish flu epidemic also evinces the lack of autonomy enjoyed by the head of the Diretoria Geral de Saúde Pública and the problems he encountered in carrying out his job. The very structure of the Ministry of Justice and Internal Affairs created obstacles for the public health agency. As a department of judicial scope, the Ministry paid less attention to matters of public health than was needed. The minister always had the last word when it came to initiatives taken by the person in charge of public health. The institution's then director, Carlos Seidl, reveals the constraints on his autonomy:

Before September 26, the minister of the Interior himself, from whom I insistently requested information, was unable to tell me what the nature of the epidemic was–he spoke to me of cholera and the bubonic plague. […] Lacking any documentation, I have decided to recommend preventive measures be taken here and at the ports, which I have designated 'indeterminate', that is, aimed at everything that could be the cause of morbid transmission (Seidl, 1919, pp. 15-16).

Contagion occurred very quickly, the incubation period was short, and a large number of people were struck by this extremely deadly sickness.10 The symptoms varied. From ringing in the ears, deafness, headaches, and simple hyperthermia, the disease would progress, presenting symptoms like chills, hemorrhaging, and bloody urine and vomit, accompanied by:

[…] disturbances of the cardiac nerves [and] infections of the intestines, lungs, and meninges, in a few short hours leading the victims to suffocation, diarrhea, stabbing pains, lethargy, coma, uremia, syncope, and, finally, within a few hours or some days, to death (Mota Rezende, 1919, pp. 305-8).

Because of the disease's broad range of symptoms, medical opinions on form of treatment were divided, and so the medical community adopted a variety of discourses (Moncorvo Filho, 1924; Moreira, 1919; Bastos, 1919; Pinto, 1919; Meyer and Teixeira, 1920).

The city soon saw itself poised on the verge of collapse. There was not enough food, not enough medicine, not enough doctors, and not enough hospitals to take in the sickest. Medicine and food were sold at highly inflated prices. Because these goods were both scarce and expensive, the demands of the disease could not be met. Sampaio Vianna, director of the Diretoria Geral de Saúde Pública's division of demographic and sanitary statistics, made it clear how hard it was to provide the whole population with assistance, since most services were only available in urban centers while places lying outside the urban perimeter suffered major shortages and neglect (Sampaio Vianna, 1919).

The city streets gradually were transformed into a sea of unburied bodies, as there were not enough gravediggers to inter the bodies or caskets in which to place them. The sickness displayed an unprecedented violence. One eye-witness to the event shares his memories with us here, leaving us with a clearer idea of the epidemic's psychological impact:

[It] was a terrifying thing! Never in all my life had I seen anything even close to that hellish Sassanid.

There was not a single street in the city where an entire family had not passed away in at least one house. In many homes, everyone in the family had taken to bed, and it was up to whoever went down that street to feed them and give them medicine. It was usually the gravediggers, garbage men, and policemen who helped, handing out medicine and feeding people, sometimes an entire family who had fallen ill. People draped black pieces of fabric in the windows and doors of their houses, so they would know sick people were there and would come to help.

The worst of it all was that people were dying left and right, and the government said in public and in the papers that the flu was benign. One day the papers reported more than 500 deaths, and even so the flu was benign, benign, benign. […] There were so many dead that they couldn't keep up with burying the bodies.

On my street, you could see an ocean of corpses from the window. People would prop the feet of the dead up on the window ledges so that public assistance agencies would come take them away. But the service was slow, and there came a time when the air grew filthy; the bodies began to swell and rot. Many began throwing corpses out on the streets. When the public agencies came to pick up the corpses, the rotted ones would be traded for fresher ones; it was a mephistophelian scene (Nelson Antonio Freire, Sep. 11, 1990).

It was necessary to devise a framework for the disease in order to make it comprehensible and more bearable emotionally. But neither the population nor the sanitary services were able to deal with the violence of the Spanish flu, which eventually incited public disorder. This was because no one had a good response to the new plague assailing the city, which allowed social tensions to erupt and gave birth to an atmosphere of fear, incomprehension, and social collapse in the federal capital.

This social chaos was broadly exploited, not only by the newspapers but also by political groups that opposed the Wenceslau Braz administration. The level of dissatisfaction was aggravated by the slow response in enacting prophylactic measures and by the structural limitations of sanitary institutions, which were wholly unprepared and unequipped to fight the disease. With a paucity of funds11 allocated to public health, it was difficult to implement, equip, and maintain public health institutions and projects, thereby limiting the help available during the epidemic. By and large, the population ended up turning to private bodies for assistance: churches, schools, clubs, and the Brazilian Red Cross.

It was only on September 30 that the government began introducing home assistance and public emergency rescue services. These measures represented official recognition that the federal capital was under siege by an epidemic. But the demands of the epidemic were far from being met. On October 3, Carlos Seidl, director of Public Health, ordered "indeterminate prophylactic measures" to be adopted at the ports, given the unknown nature of the sickness. It had been impossible to come up with any explanation or kindle any positive expectations, the government had been slow to recognize the epidemic, and there were contradictions regarding both diagnosis and treatment of this violent malady–ultimately sparking a political problem that had to be resolved.

It is invariably true that official recognition of an epidemic only comes after a large number of people have fallen ill and died; the situation eventually demands a responsive structure and impels a collective reaction (Rosemberg, 1992; Evans, 1992). An infectious disease is a social event, and in the case of the Spanish flu, it mobilized the population–and not only in Brazil, as each society struggled to find its own answer. In an effort to save itself from this menacing sickness, the public began calling for the revival of such measures as quarantines12 and isolation. Not knowing what strategy to adopt in the fight against the reigning sickness, some physicians defended isolation of the ill as "the first hygiene measure" (Azevedo, 1919, p. 15).

The problem was not only knowing what to do with the 'healthy' carrier–that is, the individual who harbored the micro-organism, or virus, without developing the symptoms but who nevertheless represented a threat to others. There was also the problem of dealing with a broad gamut of social, political, and economic issues that translated into calls for quarantines and isolation–strategies that clashed with the notion of a modern, urbanized, and industrialized society which should view such approaches as 'unnatural'. The challenges also entailed the realm of civil liberties, given the authoritarian nature of these measures. They interfered with the circulation of labor power and of merchandise, both within Brazil and internationally, quite often redounding in diplomatic setbacks.13 According to government stances, these acts were "neither possible, nor legal, nor scientific" (Seidl, 1919, p. 5).

At the October 10, 1918, session of the National Academy of Medicine, Seidl presented a list of nine conclusions about the disease then sweeping the capital; he stated that "in its capricious, wandering march, the influenza […] scorns all regulations, all measures, and all quarantines, isolation being impracticable during an epidemic flu, unless all social relationships and all contacts derived therefrom are interrupted" (Seidl, 1918, p. 591). Seidl's contradictory positions reflected the fact that the Diretoria Geral de Saúde Pública was not equipped to battle the reigning sickness.

 

Medicine in search of new answers

Furthermore, imprecise, often contradictory discourses described the sickness at times as the plain old common cold and at times as a completely new pathological entity, or one confused with other diseases, mainly typhus, cholera, and malaria. With the medical community thus divided, diagnoses varied widely and in some cases the 'Spanish flu' was defined as a new disease, since so little was known about its physiopathology.

Until then, the flu had been considered a common, ordinary disease, especially prone to attacking the elderly (earning it the popular name limpa-velhos in Brazil, that is, killer of old people). But the Spanish flu surprised medical circles by striking principally those between the ages of 20 and 40. Moreover, since unlike other sicknesses often found in Brazil, it did not affect just one specific social group but struck members of all groups, people nourished a "democratic illusion" about the disease (Bertolli Filho, 1986, p. 93). Still, as Bertolli Filho points out, the flu's mortality pattern displayed differences within each social group. It was particularly brutal in areas where sanitary infrastructure was inadequate, like the suburbs and tenements found throughout the city, and it also was especially hard on individuals with nutritional deficiencies or poor health.

Very little was actually known about influenza. Almost nothing was known about its specificities, and among pathogenic diseases of an epidemic nature, flu was in fact the least studied by medical science during the first decades of the twentieth century, in both Brazil and Europe. Information on its infectious agent, form of transmission, and indicated treatment was scant. Because the medical and scientific fields were as yet unprepared to identify the specific disease agent, what resulted were myriad interpretations.

The etiology of influenza was still unknown but the 1889-90 epidemic had brought progress in its study. Following this epidemic, a group of renowned scientists–including Pasteur and Koch–turned their attention to uncovering the etiological agent of the flu. In 1891, Friedrich Johann Pfeiffer, head of the Research Department at Berlin's Institute of Infectious Diseases, isolated a bacterium that was found in victims' lungs: the gram-negative bacillus. What the German scientist had actually isolated was a secondary micro-organism of the infectious process, called Haemophilus influenzae, which became known worldwide as Pfeiffer's bacillus. The 1918 epidemic shook belief in this agent.14

The very process of framing the disease has an explanatory component, as societies attempt to draw connections between the biological order and the social order, interpreting the disease in terms of a social and cultural nature (Augé and Herzlich, 1995; Sontag, 2002; Rosemberg, 1992). As a social event, disease engenders a specific repertoire of discourses that revitalize social values, allowing not just the medical class but the popular classes as well to appropriate intellectual history and medical knowledge in order to lend legitimacy and strength to public policy demands. Our interpretation of a disease, or how we deal with it, relates to how it was seen in the past and how this allowed political, moral, social, and medical assumptions to be proven or reshaped (Ranger and Slack, 1992). This was not possible in the case of the Spanish flu.

A disease's specificity is one aspect of its moral legitimacy. Once the specific entity of the disease is crystal clear, it plays a role in structuring social situations. A disease only comes into existence once we agree that it exists–based on our perception, classification, and responses to it–and once its diagnosis and treatment have been determined, legitimizing public health policies (Rosemberg, 1992). Diagnosis is the key to our experience of the disease, imbuing it with social meaning and triggering a need for specific answers; this in turn makes the disease part of a complex network of social negotiations, often adversarial in nature.

Searching for an answer, the population undertook its own interpretation of medical knowledge. Accordingly, and given the inefficacy of medically prescribed drugs, the household medical practices that the population had always relied on heavily became even more important during the epidemic. Seen as an alternative in the face of this incomprehensible evil, popular medicine, with its various household remedies, teas, poultices, and potions, drew the interest of commercial speculation. The proliferation of miraculous remedies reflected people's dissatisfaction with a number of deficiencies: the absence of medical care, the lack of any precise diagnosis, and the absence of strategies by the government and sanitary agencies. Above all, however, reliance on popular remedies reflected discontent with the limited ability of the country's sanitary institutions to save people from the killer flu. This inability to respond to people's needs and expectations in face of the epidemic meant that various segments of the medical class suffered major losses in political capital and social prestige, contributing to the creation of the treatment merry-go-round (Bertucci, 2002).

Since they had no way of arriving at a precise diagnosis, the medical community concentrated on defining the disease's symptoms; its symptomology would determine what substances would be used to fight it. With both form of contagion and causal agent unknown, the solution was to use individual, symptomatic prophylaxis, opening the door to a broad range of treatments and interpretations about the causes of the disease. This spurred the appearance of a series of medicines never seen before, as well as the exceptional use of known medicines employed as curatives in the case of this influenza. Given official medicine's limited ability to respond to the disease, this all meant the population relied more and more heavily an anything and everything it learned of.

In this process of interpreting the sickness, we can detect a return to herbal traditions and miasmic theories, among others, by then seen as outdated by newer medical knowledge. A number of academic papers attempted to construct an explanation for the Spanish flu. In 1919, a medical student by the name of Altino de Azevedo argued that among the various factors accounting for the Spanish flu were certain emanations from the ground and air, "invaded by smells from the filth that released gases, making the corpuscles of water vapor that hung suspended in the air richer in matter that nourishes certain microbes that can live there and develop more easily and plentifully" (Azevedo, 1919, p. 21).

Dr. Acácio Pires argued that physicians could not ignore "the curative action of nature, nor dispute the spontaneous curing of diseases." Infections, fever, malfunctioning body organs, and circulatory changes altered the body humors believed to be responsible for fighting the disease, making them poisonous to the enemies. So a cure could happen spontaneously, without the need for outside intervention (Pires, 1919).

The revival of these causal theories and of older ways of fighting disease showed how medical knowledge is cumulative in nature and how times of crisis can prompt old theories to be re-contemplated in the search for an answer (Tesh, 1982; Benchimol, 1999). Whoever discovered the causal agent or means of combating the disease would enjoy great prestige, and in the disputes ignited by the competition to accomplish this feat, these theories served as a source of erudition and rhetoric (Benchimol, 1999). The disputes pushed scientists to use knowledge sometimes derived from theories already labeled as outdated, but which once again were taken up as possible truths.

The cartoons that follow illustrate how harshly Rio de Janeiro's newspapers were criticizing medicine–especially official medicine–which presented conflicting diagnoses and explanations, most often incompatible with the reality of a society teetering on the edge of collapse.

Defeated on their own terrain, most doctors repeated the discourse of the disease's inevitability, but they had in fact come up against something far beyond their scope of knowledge and beyond the capacity of the day's science and medicine. Medical discourse was confusing during the epidemic, an expression of medicine's limited notions about influenza infection back then.

The ironic tone of criticisms not just by the press but also by political sectors reflected the fact that the government's top echelons and the well-to-do could not accept that they were being attacked by an unknown disease, and this triggered much tension between society and governmental and sanitary officials. The population grew suspicious of official medicine's discourse, since it failed to explain what was happening. Such criticisms should also be seen as fruit of people's insecurity as they watched their daily lives fall apart (Delumeau, 1993).

 

 

 

 

 

 

 

 

Historically, one of a doctor's social roles is to come up with responses to the diseases that afflict society. The medical explanation of a disease carries much social and emotional weight, as it allows the patient to understand his misfortune. An essential aspect of a doctor's role and social power is his ability to put a name on the patient's suffering (Rosemberg, 1992). With this in mind, we can understand the import of the diagnosis and prognosis of a disease. Even when dealing with a dangerous disease, these mechanisms help render it more comprehensible and emotionally more acceptable than an incomprehensible disease.

According to Richard Evans (1992), such social tensions tend to occur at a moment of political, social, or economic crisis, when government structures may be reshaped in an attempt to control the disease and ensuing discontent. This turmoil is also fruit of an epidemic's impact, which finds no place within the society's emotional structures (Evans, 1992). A disease has to be framed so it can be comprehensible and more bearable emotionally, thereby vanquishing people's tensions (Rosemberg, 1992). Mr. Nelson Antonio Freire helps us better understand the issue:

Close your eyes for a moment, and try to imagine going into a room where, in a bed, there lies a body with a bluish, cyanotic face, a person dying of asphyxia, with blackened feet–the sign that the time had come. Now imagine that this person is your brother, father, mother, or any other dear one. If this were to happen to you and your family, it's logical that you would want to understand what had happened.

Every doctor made an 'attempt' at a different explanation; we didn't know what or who to believe. We waited for an explanation that no one had to give, just as today we are still waiting to know what that hellish Sassanid was all about. It was so intense that the newspapers and part of the population began calling for the revival of quarantines and isolation (Nelson Antonio Freire, interview to the author, Sep. 11, 1990).

One of the objectives of the offered explanations was to reverse the huge political losses suffered by the medical class during this event. The demoralization of these actors cannot be understood separate from the limitations of that era's medicine and science. The Spanish flu mocked the bacteriological discourse that was supposed to prevail, since this discourse posited that infectious diseases could be ended by identifying the pathogens causing them. At a time when:

[…] the miracles of medicine were viewed almost as a religion, thanks to the progress of the germ theory of disease, which in the fifty years preceding the 1918 flu had made it possible to identify a variety of pathogens at almost regular intervals and had nearly stripped death of its significance, the Spanish flu came to make a mockery of the newfound optimism (Kolata, 2002, p. 71).

An epidemic is also an intellectual construct, which takes on its own history and life. Our perception of the disease is shaped by analogies, in which the interaction of ideas is not a one-way street, whether they involve biological changes, or intellectual or political responses. Negotiations over the definition of and responses to the disease are always complex, depending at one and the same time on cognitive and disciplinary elements, on institutional and political mechanisms, and on people's adjustment, or lack thereof, to established models (Ranger and Slack, 1992).

An infectious disease, or an epidemic, really has no meaning in and of itself; it is merely a micro-organism whose significance comes from how it interferes with people's lives, the reactions it causes, and its cultural expression (Sontag, 2002), and also from the political import it acquires (Ranger and Slack, 1992). It is constructed through intellectual factors, professional attitudes, and public policies, as well as through popular knowledge, all of which entails complex negotiations through which society agrees, or not, to accept its legitimacy as a certain malady (Rosemberg, 1992). In other words, a disease only achieves existence as a social phenomenon when there is agreement concerning its perception, classification, and responses to it. As such, a disease is an allusive entity, not just a physiological condition. The representation assigned a disease is fruit of intense, complex social negotiations, rarely free of a certain degree of cultural coercion, which embodies and reflects values and status relationships.

 

Carlos Seidl, scapegoat

The situation created by the Spanish flu epidemic was viewed as a product of the government's negligence, neglect, and administrative incompetence, since it had no strategy for addressing the dangers before the nation–all of which was widely exploited by the press. Popular reaction and tension signaled the government's failure to persuade people that its actions were rational (Ranger and Slack, 1992). The fact that the flu's specific identity was unknown became a political and social problem. The government's insistence that the disease was benign and that the epidemic was receding, in the face of the chaos witnessed on the streets of the federal capital, was seen as an expression of passivity, and it earned the government fierce criticisms.

Likewise, the government's lethargy in enacting prophylactic measures and the structural limitations constraining health care agencies and facilities in their battle against the flu epidemic turned the people's wrath towards a number of government figures, with the main targets being President Wenceslau Braz and Carlos Seidl, then director of Public Health. President Braz was accused of administrative incompetence and of failure to devise strategies for defending the population against the menacing malady. In the newspaper Correio da Manhã, skepticism concerning the official discourse grew more and more blatant:

The epidemic is waning. This is what those interested in lies have to say. […]

This agency, whose name is an appalling irony–Public Health–had the duty if not to wholly avert the outbreak of a malign epidemic, then to lessen its consequences, to use all means to prevent this incredible spreading, while there were enough healthy people to do the job.

Instead, it stands by […] with its arms crossed, declares itself unable to take any measure, and abominably confesses to the complete bankruptcy of its hygiene measures–instead of the steps that should have been put in practice immediately, while there was still time to restrict the consequences that would cause the epidemic to spread, at least as a form of consolation offered by fools joking about with death, in their admitted ignorance of the affliction that was about to begin.

Lo the tremendous carnage, the responsibility for which lies solely with the government, in light of its assertive lies about [the disease's] benign nature, in light of the total, absolute, and admitted bankruptcy of its public health administration, created for a mission that it in no way fulfilled […] (Correio da Manhã, Oct. 24, 1918, p. 1).

According to many newspapers back then, the government's greatest show of incompetence was entrusting the leadership of Public Health to an "imbecilic, irresponsible, and seditious" employee who was only counting the days until his retirement and whose "inveterate inertia and old-time bureaucratic dogmatism" allowed the epidemic to be received "merrily by Public Health" in the federal capital, leaving the population to its own lot.15

One didn't even need to be a prophet. It sufficed to have a bit of good sense and to have followed Mr. Carlos Seidl's administration of the Diretoria Geral de Saúde Pública, to conclude from the start that, beyond the afflictions from which we already suffered, another lay awaiting us: the Spanish flu epidemic.

The first thing that took us by surprise was our public health agency's unbelievable ignorance regarding this sickness, which was sweeping Europe in patently epidemic fashion. Mr. Carlos Seidl knew nothing about it! Every day the newspapers were filled with telegraphic information on the evolution of the illness, on its spread through the Old World, but our public health agency remained unaware of it all and let ships that had departed from questionable ports arrive in Brazil without any sanitary prevention measures. The cases of the naval squadron and the medical mission eventually were reported and only then did the torpor of the Public Health bureaucracy come to an end! Only then did Mr. Carlos Seidl awaken from his lethargic sleep to write his circular letters.

For quite some time we have been analyzing the collapse of the Diretoria Geral de Saúde Pública, ever since–in an unforgivable mistake–the government handed it over to a clinician without a clinic, a worthless big shot who is counting the days to his retirement […]. An agency of this caliber must be led by a man of indisputable knowledge, a worthy scientist.

The honorable director has to be kidding. […] He will remain vigilant! But what good is his vigilance if it was unable to keep the sickness from striking us? […] And Mr. Seidl still comes to an agreement with the Minister of the Interior about not taking exceptional measures "since it is a benign form" (A Gazeta de Notícias, Oct. 9, 1918).

Seidl16 was a recognized member of the medical elite in the federal capital, which dominated the era's chief medical institutions, like the National Academy of Medicine and the Faculdade de Medicina do Rio de Janeiro (Rio de Janeiro Medical School). From its beginning, he had been involved in the political and scientific movement created by the Liga Pró-Saneamento do Brasil, or Pro-Sanitation League of Brazil. But he left the event with his social and political prestige badly marred. Then director-general of Public Health, he was accused of "criminal neglect and abusing the people's patience" (Rio Jornal, Nov. 11, 1918) for failing to take forceful measures: isolating the ill and cleansing the ships that docked at the capital.

On October 16, 1918, the director of Public Health called in vain for the censorship17 of the newspapers that were inciting panic in Rio de Janeiro and threatening the public order. The press took advantage of the degree of disorganization crippling the city and keeping it from leading a normal life, and this cost both Carlos Seidl and Wenceslau Braz tremendous losses in social and political power (Bourdieu, 2000).

As illustrated in the accompanying cartoon, these criticisms of Seidl reflected the fear of death and abandonment occasioned by the limited availability of health-care services and the de-structuring of daily life in the city of Rio de Janeiro. Frightened by the illness's 'democratic face' and upset about the subversion of the social hierarchy–e.g., unconceivable measures like burying victims in a common grave–members of Rio de Janeiro's elite were in good part responsible for this barrage of criticisms. The Spanish flu became known in the federal capital as "Seidel's evil" because, in the public's opinion, the director of Public Health had deemed it unnecessary to take any preventive steps against this affliction, thanks to "his notoriously vast incapacity" (A Gazeta de Notícias, Oct. 15, 1918, p. 1).

It is inarguable that in the eyes of the world, the Spanish flu became the greatest example–even a pedagogical one–of how we are a living part of biological relations that cannot always be controlled and of just how negative the impact of social interdependence can be (Elias, 1993, 1994; Hochman, 1998). When the microbe revealed how it leveled the social playing field (being the third person in every relation), it engendered a kind of equality that was viewed as negative, one that had to be defeated and thus called for efficacious regulation.

The way the events of the epidemic unfolded, the director eventually became a kind of scapegoat, victim of a major defamation campaign and butt of jokes in the papers and among the public. To better grasp this process, we should remember that the late 1910s and early 1920s was a period of profound crises but likewise of profound transformation, a time that would bring revision of political beliefs and projects and that made way for new modernization projects, as society sought explanations for its backwardness (Gomes, 1998; Hobsbawn, 1991). A number of nationalist movements emerged back then, focused on re-examining the topic of nationalism and the bases underpinning the State structure. The experience of the epidemic afforded an important opportunity for re-assessing the republican institutional model itself.

 

 

So it was that the epidemic generated a social crisis and a series of protests against the political activities of the elites; this in turn pushed to center stage the debate on the republican model and how it hampered complete governability of the state, growth of its institutions, and, consequently, adoption of large-scale sanitary measures. One broadly debated issue was how the Executive branch held sway over the Legislative branch, pushing institutional activities off course and, above all, shifting the order of the day within ministries, no longer occupied by "counselors to the president" but merely by those in whom "the president placed his trust" (Lessa,1990).

The newspapers gave the impression that Seidl wanted to destroy Oswaldo Cruz's work. The epidemic exposed the "ignominies and mistakes of hygiene," poorly organized for some years, while the administrative incompetence of government officials led to an overall organizational collapse–"the most frightful non-productivity" (Carvalho, 1918, p. 730). Public health was seen as a victim of political maneuvering by "hypocritical governments" that defended the revocation of sanitary laws and thus completely de-structured the work of Oswaldo Cruz, helping transform it into a "bureaucratic, illusory" organization (Anais da Câmara dos Deputados, Oct. 28, 1918, pp. 721-4).

The cartoon not only critiques Carlos Seidl but also makes a case for creating an autonomous technical, scientific institution devoted solely to public health issues. This argument gained life in early 1918, founding date of the Liga Pró-Saneamento do Brasil. As the epidemic grew, so did this idea. The epidemic in fact revived a series of discussions: public health institutions and policies, reformulation of the Diretoria Geral de Saúde Pública, relations between medicine and society, and the political and sanitary agenda–above all that of the federal capital's.

The fact that nearly nothing was known about the disease, combined with the roadblocks erected by the Legislative branch, ground to a halt ministerial operations, thereby hindering aid to flu victims and giving birth to a "court of public execration" (Correio da Manhã, Oct. 24, 1918, p. 1) where some of the country's top political and sanitary officials were accused of administrative incompetence. In a speech, Deputy Nicanor Nascimento flung criticisms against Wenceslau Braz, who at a critical moment in the history of the federal capital was funneling money that could be used to fight the sickness into works like the Itajubá road. Censuring this posture, the deputy said:

[I have] the impression the government is suffering from acephalia. Death continues its harvest, and there is no sign of the measures that the government should take at this agonizing moment. Hunger, at the height of the crisis, is found throughout the city, and we see how wretchedly the powers-that-be stand there with their arms crossed. Their arms crossed–that describes it well!

When the press complains about our administrative anarchy, the ineptitude of our leaders, the worthlessness of this Congress and the Executive, the politicians shrug their shoulders in indignation, as if we were committing a veritable sacrilege against untouchable vestals.

[…] This government, which would like to be crowned with laurel and roses, felt the epidemic deserved greater attention than the passive, long-suffering people to whom it offers this picture of despair. Mr. Carlos Seidl is allowed to resign when he should be discharged for the well-being of the public; they give in to his interests, serving strange and deplorable injunctions that have turned this country into a rotten burg, injunctions through which we are rendered null and void, as are our essential sources of national dignity.

[…] One could find no more significant symptom of the federal government's collapse. We are left to the mercy of an uncertain fate. No control, no efficient energy defends us; there have been–or there are–no men who could advance proposals of defense worthy of the metropolis of the Republic" (Correio da Manhã, Oct. 19, 1918, p. 1).

 

 

On October 17, Elmano Cardim, secretary to the Office of the President of the Republic, delivered to Carlos Chagas an invitation to head the agency that would fight the epidemic. In a masterful show of political skill, declaring himself first and foremost a man of science, Chagas turned the invitation down. He offered by way of explanation his ties of friendship with Seidl and his belief that the latter had been unjustifiably disgraced, since there was nothing he could have done to prevent the invasion of the flu.

On October 18, Brazil learned that Seidl had resigned and had been replaced by Theophilo Torres. The ex-director's resignation actually came under strong pressure from the Presidency of the Republic, who had sent Elmano Cardim to request an accounting of initiatives to fight the epidemic. Wenceslau Braz blamed the government's slow response on the organization of public assistance services, thereby saddling Seidl with responsibility for the spread of the epidemic. His dismissal was an attempt to respond publicly to criticisms about the failure to stop the spread of the sickness and come to the population's aid. This was how the political elites–and more specifically, Wenceslau Braz–tried to cut their political losses in the face of the social crisis.

Seidl's successor, Theophilo Torres, set about creating temporary hospitals, following earlier orientations that would be expanded after Carlos Chagas' appointment. But Torres was seen as "a bureaucrat of the Carlos Seidl school," and the public health administration needed a name that would "demand respect in light of his moral and intellectual capacity" (Nascimento, 1918, p. 720). The following excerpt from a news item gives us a good idea of how Seidl's performance and his public figure were then being judged:

Carlos Seidl–may the devil look after him–[…] was dealing with a simple head cold, a nasty bug, that was so benign and prosaic that it did not merit the attention of his transcendent sciences.

And the government, despite all complaints, all protests, and all cries for help that arose in unison, disregarded it all, trusting solely in the word of its aide, until the latter, his conscience perhaps set upon by remorse, treated himself to handing in his resignation" (Correio da Manhã, Oct. 20, 1918, p. 1).

Carlos Seidl tried to defend himself from these accusations of incompetence and lack of technical preparation, arguing that "the essential prerequisites" for holding the post of Public Health director had never included "profound knowledge of bacteriology, nor the living laurels of investigator or discoverer, and much less the aura of sage"; the only thing indispensable to holding this job was administrative skill and being "knowledgeable in issues of public hygiene" (Seidl, 1919, pp. 78-80).

His competence was widely discussed in the lower house; many deputies thought it unacceptable that the director of Public Health, along with the president of the republic, could suggest that the microbe that caused the flu "travel[ed] through the air without any organic vector," believing that the "dust from Dakar could come this far" (Anais da Câmara dos Deputados, Oct. 17, 1918, pp. 613-23). Carlos Seidl's position became untenable given the massive attacks by the press and numerous political representatives from the federal capital.

 

Carlos Chagas: hero of the Spanish flu

The selection of Theophilo Torres as Seidl's replacement only made things worse. In light of criticisms of the ex-director of Public Health and of Wenceslau Braz, the press began calling for a new model of government bureaucrat,18 with the support of the population and of political groups who were interested in seeing public health become part of the country's political agenda and, through it, establishing new ways of wielding and normatizing power. According to Federal District Deputy Nicanor Nascimento:

The public health authorities had never had their consciousness awoken to the need to verify the emerging morbus, had never aimed a sharp, keen eye towards recognizing that the work of Oswaldo Cruz had faded away, owing to the unconscionable inertia of the incapacity of the activities of the administration of Mr. Wenceslau Braz. It was this man, Mr. Theophilo Torres, that he found for the job.

[…] Is there anyone in this country who knows that this name is on equal footing with that of Arthur Neiva or Carlos Chagas? It was this man, and he himself has declared that he has no scientific responsibility in this case" (Nascimento, 1918, pp. 714-9).

Nicanor Nascimento's discourse19 gives us a clear idea of how the pandemic event contributed to Oswaldo Cruz's enthronement as a myth-like figure (Brito, 1995) and Carlos Chagas' recognition as his scientific heir. The residents of the federal capital insisted that Chagas head the service agency that would fight the Spanish flu; encouraged by the press, which had successfully roused the people, this demand was also embraced by the government as a way of averting bigger political losses.

It cannot be denied that the absence of any analogy that might make it easier for people to accept the Spanish flu helped strengthen both the figure of Chagas and of the Instituto Oswaldo Cruz as early-twentieth-century references–a status achieved thanks to their intensive disease-control campaigns and research on common, everyday illnesses in Brazil. Yet before the outbreak of the epidemic, Chagas had grappled with problems as head of Manguinhos. Following Oswaldo Cruz's death in 1917, some members of the Institute did not agree with Chagas' appointment to replace him. When he took charge of government response to the epidemic, the flu was already ebbing. It was in this context that Carlos Chagas began to be seen as a genius: the only man capable of saving the country from this carnage.

Chagas earned great renown as a scientist thanks to his discovery of Tripanossoma cruzy (the pathogen that causes Chagas' disease), his services to the Wenceslau Braz administration, and the many titles and awards he received from Brazilian and foreign institutions–for instance, the Schaudinn Award of 1912. The political capital that he had acquired even before the influenza epidemic gave him enough public prestige that he was seen as the only person capable of turning the situation around. The following statement by Mr. Nelson Antonio Freire portrays this in the eyes of those who were the targets of the disease:

The general feeling in the city, wherever it was, was that all would perish sooner or later, that the capital would become a ghost town. It was hoped someone could do something, but at the same time, we knew this hope might be in vain.

The summoning of Dr. Carlos Chagas brought great relief. As if he were the only one who could control this carnage. Since he had been the right arm of Dr. Oswaldo Cruz, who fought yellow fever, nothing could be more appropriate than his leading the fight against this calamity. He was a scientist, he had discovered the microbe of Chagas' disease; it was believed he could find the explanation and the cure, for he had enough credentials to give him legitimacy. We could not believe that the public health authorities were unaware of the problems that restricted his initiatives or of the deficiencies of these actions […] as far as public health and our capacity for internal and external sanitary defense. It was hard to understand, especially after all the arguments presented by Dr. Penna,20 who a few years earlier had published a series of articles in newspapers and given countless lectures all over, that the public health authorities simply would simply say: 'We don't know what it is, how to cure it, it's benign, don't be afraid'. The newspapers and the streets showed that the number of deaths was stupendous (Nelson Antonio Freire, interview to the author, Sep. 11, 1990).

According to Norbert Elias, a 'genius' is a product of a social construct, fruit of social pressures and of interdependence with other social actors of his time. This kind of actor often finds himself drawn into an unplanned social process, and is very often chosen to meet a social demand (Elias, 1994b). Carlos Chagas ended up meeting a subjective demand that was politically necessary from the population's point of view. The demand secured credibility thanks to the sanitarian's posture and to his transformation into the genius who saved the country and the people during the epidemic.

Thanks to the Spanish flu, Chagas, along with other hygienists in his group, reached positions of political power and attained medical knowledge of the event. This is not to say the event made control of medical knowledge possible, but it did foster greater social and political control, embodied in the figure of Chagas and in his connection to Oswaldo Cruz. This strengthened the position of a group involved in nationalist movements–as was the case of the Liga Pró-Saneamento do Brasil, which had been organizing and growing throughout the Old Republic. The Spanish flu thus permitted the reaffirmation of the prestige and power of a professional group with a vocation for political leadership in the intended project to modernize society.21

What was being constructed simultaneously was the notion of a leader who could overcome obstacles to efficacious anti-flu initiatives, a leader who reflected the image of Oswaldo Cruz and left people with "the certainty that they were being protected" (Chagas Filho, 1993, p. 157). Of course, Oswaldo Cruz's supporters and those advocating the expansion and reformulation of sanitary policies and institutions saw this moment as a tremendous opportunity to augment their symbolic and political capital. Hygienists saw it as a chance to reinforce not only their professional and social prestige, their habitus, but also their place in the field as vital players in the modernization of Brazilian society.

Oswaldo Cruz's promotion to the post of 'hero of the nation' following his death was furthered both by workers at the Manguinhos institute and by members of the Liga Pró-Saneamento do Brasil. Cruz served to legitimize the movement's ideas and activities. This image of Cruz and the fact that Carlos Chagas was seen as his intellectual heir in 1918 lent substantial political and social capital to Chagas and to the rural public health movement. Accordingly, Chagas was viewed as the only scientist capable of solving the problems caused by the killer Spanish flu.

Still, Oswaldo Cruz had always had his detractors. Animosities were bred when he was head of Public Health because he was constantly challenging the elites, as well as a number of other economic, political, and social groups. These animosities were also shared by the public at large, who felt threatened by the aggressive, authoritarian measures enforced in the fight against diseases (especially yellow fever), measures that clashed with civil liberties and the economic interests of the day.

The hygienist had constantly been forced to negotiate reforms with various social and political sectors. In 1918, thanks to the hard work of the Pró-Saneamento do Brasil movement and the outbreak of the Spanish flu epidemic, the figure of Oswaldo Cruz came to represent the prestige and social value of the physician. His scientific legitimacy meant that ties of identity and political interest were woven around his figure. But "death silenced all ill-wills" (Brito op. cit. p. 40); in other words, the criticisms of Oswaldo Cruz were gradually 'forgotten' not only after his physical disappearance but also as the epidemic spread throughout all Brazil.

Along with the figure of the sanitarian Oswaldo Cruz, Counselor Rodrigues Alves gained great prestige among residents of the capital ('counselor' being an honorary title granted during the time of the Empire). His rehabilitation came about during the same time he ran for and was re-elected to a new term as president, shortly before the epidemic. According to an article in O Paiz (Oct. 2, 1918, p. 4):

At a time when foreign dangers and domestic concerns were causing Brazilians apprehension about the future of our nationality, it would seem that we should have been spared the anxiety-provoking angst caused by epidemic scourges. But we are not even free from this kind of threat, and now we must add to the many problems we face that of sanitary defense, […] where the sanitary status is far from satisfactory.

With yellow fever eradicated in Rio de Janeiro, thanks to Oswaldo Cruz's tenacity, […] public opinion had tacitly accepted as an axiomatic truth the idea that the sanitary problem in Brazil had been resolved once and for all. […] The powers-that-be lost interest in sanitary matters. Funding diminished year by year.

Unfortunately, the confidence in which our public had swaddled itself–certain that the work of Oswaldo Cruz had accomplished the mission of public hygiene in Brazil–occasioned the backsliding of our sanitary organization. […] The decreased efficiency of the sanitary department is not the result of negligence, or of the incompetence of some staff member or another; it is the inevitable consequence of the neglect of one branch of the administration, whose indispensable role had been forgotten by public opinion.

We are convinced that the sanitary problem will be one of the first matters to which the eminent Mr. Rodrigues Alves will have to pay careful heed. […] And surely the President of the Republic and the Minister of the Interior do not wish to leave a legacy, as an inheritance of their administration, of epidemic scourges that would do nothing to encourage feelings of nostalgia for the four-year term about to expire.

The federal capital was the prime locus of political representation, of construction of a national identity and sovereignty, and of the political interests that represented the entire country (Argan, 1992), and so its state of disorder was a source of shame. This was especially true since the question of a nation's capacity for self-determination was on the order of the day, in preparation for the Paris Peace Conference. The level of disorganization into which the city of Rio de Janeiro sank was seen as consequence of Wenceslau Braz's incompetence and lack of strategies for reining in the political, economic, and social chaos engendered by the Spanish flu, or his inability to deal with any other unusual event.

Rodrigues Alves' supporters had exploited the outbreak of the epidemic for political purposes (Santos, 1993); the Counselor was depicted as a herald of hope, a politician committed to the public good and, above all, to the management of sanitary and public health issues. Rodrigues Alves' candidacy had been heavily criticized by the press, especially the paper O Imparcial. Labeled a "cambalacho palaciano" (palatial bamboozler), he was accused of trying to protect the policies of governing officials by imposing the candidacy of an old man "whose dangerously precarious health" would force the country to "bear the inestimable evils of the period of acephalia, owing to the incursions of the cabal upon the inauguration of a government of invalids" (O Imparcial, Sep. 29, 1918, p. 4). The same paper went on to say that there was no way Rodrigues Alves could live up to the responsibilities of his office and would become a dupe in the hands of this cabal.

 

 

 

 

These cartoons are a critique not only of the federal administration's incompetence–that is, its lack of strategies for saving the population–but mainly of the foes of the first Rodrigues Alves administration, during which he tried to clean up the federal capital and wipe out diseases like yellow fever. At the same time, they show how the Spanish flu served as a valuable tool for political maneuvering; it was used to establish a political image of Rodrigues Alves as a go-getting politician worried about people's health and capable of taming the political forces and stumbling blocks inherent to the republican institutional system itself. The references to Counselor Rodrigues Alves reminded everyone that:

Counselor Rodrigues Alves, who made the sanitation of Rio de Janeiro one of the key issues–if not the key issue–of his first administration, cannot be indifferently observing the carnage that this mysterious plague is wreaking in Brazil, broadly sowing grief and misery. The measures that should now be taken to defend the population of Rio and of Brazil must of course have occurred to his spirit, and especially the names from among which to choose those whose shoulders will bear the tremendous responsibility of defending the Public Health.

You all will have noticed that now just as much importance is attached to choosing the future head of Public Health as to choosing new ministers. The population is anxious to learn the name of the chosen person, discuss the merits of those who are indicated, and ask that the future president make a felicitous appointment. […] It would be best if he were a wise man, and it is essential that he be an energetic administrator. But first and foremost, it must be someone who displays great personal prestige and who knows how to stand up to the government itself (A Noite, Oct. 5, 1918, p. 2).

The epidemic provided members of both the medical and political fields with a whole symbolic framework applicable in constructing a discourse that made the disease a strategic item on the public policy agenda (Bourdieu, 2000). It likewise reinforced the figure of the hygienist as an actor capable of bringing these undesirable relations under control. The dramatic nature of the event made people aware of their social interdependence and, consequently, of the unfeasibility of isolated public health initiatives (Hochman, op. cit.). Within this context, the demands of the Liga Pró-Saneamento do Brasil gained legitimacy; counting Chagas as one of its supporters, the organization was the main expression of a movement advocating sanitation in rural Brazil and calling for public health services to be expanded at the national level and for their administration to be centralized in the hands of the federal government.22

Another factor benefited Chagas' image during the epidemic: Aristides Marques da Cunha, Octavio de Magalhães, and Olympio da Fonseca, all members of the Instituto Oswaldo Cruz, raised the hypothesis that the flu was caused by a filterable microbe and not, as believed, by Pfeiffer's bacillus.23 This fueled a belief that Carlos Chagas had discovered the key to the enigma–'the influenza microbe'–and that an allegedly miraculous vaccine would be developed. Based on researchers' findings, blood extracted from flu victims and vaccines made from filterable mucus were also considered options by those seeking a cure to the Spanish flu. But in November, as the epidemic lost some of its force, there was not enough material for further studies, and research had to be postponed. The medical community adopted a cautious, reserved stance, and one of great curiosity as well.

The epidemic handed these men the opportunity to re-assert themselves as an intelligentsia indispensable to the smooth workings of society and to the development and expansion of health policies and institutions that could defend the population from new sanitary disasters. These professionals were viewed as the only ones who could respond to the negative effects of social interdependence that had sprung from this collective disease. This meant it would be necessary to find the cause of all these troubles in order to get society back on track. In a report to the Ministry of Agriculture, Industry, and Commerce, Dr. Bulhões de Carvalho argued that it was "up to hygienists and bacteriologists to find answers about the true cause of the pandemic, a most difficult task," but he did not believe the morbid entity would be proven through bacteriological exams (Bulhões de Carvalho, Jul. 28, 1919, pp. 202-6).

Yet despite all this, according to Henrique de Beaurepaire de Aragão, the Spanish flu epidemic "afforded the medical clinician and bacteriologist a splendid opportunity to study a fascinating morbid entity" (Aragão, 1918, p. 355). The discovery of the sickness's causal agent gave Chagas a chance to accumulate symbolic capital and, consequently, reinforce his position in the field (professional or political), strengthening his scientific authority and his role as a social reformer.

A new perception of the environment, of public health services, and of anti-epidemic policies is achieved through hygiene and public health initiatives and the knowledge acquired through these. Consequently, many physicians came to see the public health field (not only during the epidemic in question) as a source of new knowledge on diseases, research, and observations and also as a bridge to professional, social, and political recognition and capital. Despite the differences between their areas of knowledge and practice, they had always been interdependent. Based on the art of the laboratory, public health dictated the parameters to be followed in medical practice (Brandt and Gardner, 2000).

Although bacteriology saw its discourse questioned during the epidemic, it lent public health ideological and political legitimacy and was fundamental to the re-assertion of the scientific authority of hygienists and laboratory scientists (Pelling, 1993). As the third party in every social relation, the microbe demands the presence of a fourth party: "the discoverer of microbes" (Latour, 1986, pp. 348-9), the scientist, the lab man. These social actors–the microbe discoverers–became essential since their science, or their art, enabled them to redefine social relations, of which these tiny beings were always a part. As a consequence, they ended up playing an important role by interrupting or redefining these relations.

Through these biological relations with the microbe, even the simplest social relations, as well as relations with the environment, were reshaped. We see this notion expressed in the pamphlet Previna-se contra a gripe (Protect yourself from the flu):

A spray of spit – with danger fraught!

Perdigotos – Que perigo!

My friend, if it's a cold you've caught

Se estás resfriado amigo,

Don't you get near me, please.

Não chegues perto de mim.

I'm weak; I always speak my thoughts:

Sou franco, digo o que penso.

So use a hankie when you cough.

Quando tossir use o lenço

And also when you sneeze.

E, também se der atchim.

Those handrails, money, and doorknobs

Corrimãos, trincos, dinheiro

Are breeding grounds for germs in mobs:

São de germes um viveiro

Of which flu is the prime.

E o da gripe mais freqüente.

Avoiding it cannot be done,

Não pegá-los, impossível.

But here's the trick that's number one:

Mas há remédio infalível,

Wash those hands à your hands.

Lave as mãos constantemente.

If you don't want to catch the flu,

Se da gripe quer livrar-se

Just find a way to play it cool:

Arranje um jeito e disfarce,

Don't shake hands with another.

Evite o aperto de mão.

But if you can't avoid a man,

Mas se vexado consente,

Wash your hands whenever you can

Lave as mãos freqüentemente.

With lots of soap and water.

Com bastante água e sabão.

You're already over the flu?

Da gripe já está curado?

Don't let anyone hurry you

Bem, mas não queira, apressado,

Back to your old fun.

Voltar à vida normal.

Make sure you're truly all restored

Consolide bem a cura,

Or else, my friend, you may once more

Senão você, criatura,

Fall ill and spread the bug. 24

Recai e propaga o mal.

 

Conclusion

During the course of the epidemic, newspapers and some members of the lower house contributed to enhancing the esteem of hygienists and laboratory men, who were depicted as possessing an expert knowledge needed to save society and administrate the country's sanitary problems. Against the backdrop of the influenza, these men and their art became the ideal model of public health administrators.

These skillful laboratory men became the spokespeople of these small beings. Their art claimed the enemy could be found and thus defeated. So discovering the authors of these morbid processions meant a belief was instilled, because identifying the microbe, bacterium, or causal agent would bring order to the realm of epidemiological problems and would also solve the problems of a public nature brought on by the collective disease. Knowledge gathered in the laboratory led to new guidelines for social relations.

The laboratory is the place where scientists try to translate phenomena that arise from the often times undesirable and uncontrollable social relations established between the ill and microbes. With laboratory findings in hand, hygienists can transform these discoveries into precepts of hygiene. Once this scientific knowledge has been applied, medicine can set out medical procedures and government powers can make laws. So in redefining the social composition and social relations, the discoverer of microbes contributes to a power shift, subverting the role of such actors as doctors, sanitarians, and health administrators (Latour, op. cit.).

Discovery of the causal agent of a disease redefines individual freedom, "nullifying the right to contaminate others," even if this entails a bit of "legal coercion […] to protect the greatest number, a position that is not only legitimate but the obligation of societies as one of their essential duties" (Seidl, 1913, p. 188). Seidl's 1913 speech before a conference at Brazil's Biblioteca Nacional demonstrates how disease, as a social phenomenon, affords an opportunity for medicine to legitimize its intellectual and institutional power (as a social system as well) and also for public policies to gain legitimacy.

Disease reveals itself as a tool for social control, making it politically possible to legitimize relationships of status between individuals and between an individual and institutions; as such, disease becomes a central factor within a structured network of social interactions. But the limits within which these roles can be played is often modeled by a disease's biological identity. A medical diagnosis changes the gamut of options available to an individual for modeling his or her own behavior, nature, and meaning as a member of society.

Since a microbe can be characterized as a social leveler (the third person in any relationship), the equality that it produces is always seen as negative, meaning that the ensuing perverse effects must be dealt with. Since an epidemic can be characterized as a paradigm of interdependence, it is imperative that mechanisms be created at least to administer its impacts.

Two features became evident through the pandemic of 1918: disease is a public evil that afflicts everyone indiscriminately, and health is a public good whose protective measures cannot exclude anyone, so long as the individual adapts to the proposed model.

The symbolic framework constructed out of this dramatic event–the Spanish flu–allowed another process to develop, by which other forms of power won legitimacy and played their most important role in sanitary administration, even if only temporarily. The discourse elaborated during the epidemic fulfilled the political role of legitimizing demands for new decisions regarding the reformulation of public health institutions and policies.

Disorder can breed creativity, in that it lays bare latent problems, tensions, and dissatisfactions within the social world; it can likewise prompt the elites to make changes in their decisions and can encourage the emergence of new political as well as social behavior. Laboratory men were believed to be capable of initiating the inevitably complex negotiations surrounding the definition of the disease. The production of solutions was arbitrary yet socially viable, and often temporary–agreement on a definition of a disease could lay the ground for commitments or norms governing administrative actions.

In 1919, new outbreaks of the flu threatened to bring back a killer plague that had been of unusual proportions, one people wanted to lock away in the furthest corners of their memories. Since science had failed to discover the flu's causal agent, Chagas resorted once again to the regimen of quarantines and isolation for ships, as well as mandatory reporting of any case of the disease. But this measure would earn the hygienist many criticisms from medical circles themselves. Since the cause of the sickness was unknown, this seemed to be the only way to avoid contagion and protect the country's sanitary organization. All these measures, especially mandatory reporting, were meant to convince public opinion and above all sectors of the government apparatus how important it was to have such legal rulings in place (Pereira Neto, 2001). Government intervention was seen as a way of managing and providing health services and policies.

But the questions of mandatory reporting, quarantine, and isolation beg the question of how authority, responsibility, and power are divided between medicine and public health; this has always been a terrain of constant conflicts where professional ethos has at times interfered with greater collaboration, although the two sectors have historically been dependent and interactive (Brandt and Gardner, 2000). Public health has often been seen as a field with intimate ties to politics, and thus corrupted by it. On the one hand, enforcing this type of measure affected the doctor-patient relationship, characterized by professional confidentiality; on the other, these measures meant economic losses, since preventive actions might lessen the demand for curative medical services.

For physicians, joining the ranks of government was part of a strategy for maintaining power and status and for creating their own space within the nation's public organization, through the power of medicine. Along with its other roles, medicine thus enjoyed the authority to establish norms governing people's habits, customs, and behavior when up against disease, in hopes of decreasing its incidence and the negative consequences of interdependence, which is part of the biological relations established as a result of the disease. By means of health policies, the government was better able to intervene throughout the national territory; it saw both urban and rural initiatives as ways of advancing the governability of Brazilian society.

The sanitation movement was witnessing the process of professionalization of public health in Brazil, which would reach its apex with the 1925 teaching reform and creation of the first courses for training public health professionals here. This movement hoped to carve out more space where it could act inside the government's apparatus.

The Spanish flu also offered a chance to think about the contradictions of the republican institutional system itself and about the policymaking conflicts between powers that hampered establishment of a political repertoire capable of solving national or even local problems, like the fight against the Spanish flu.

If, on the one hand, the epidemic provoked much dissatisfaction with the governing elites' political activities and their social policies, on the other, it allowed for increased control over official medicine, eventually transforming this group of hygienists into the only actors capable of finding a solution to the crisis. As a result, sanitary knowledge won new merit. Once again, the ruling elites thus called upon these men of science to collaborate with their political and administrative projects, since the latter had the political and social capital needed to address the generated problems.

 

NOTES

1 This article is based on my master's thesis, defended at the Universidade Federal Fluminense in 2003 and entitled Um cenário mefistofélico: a gripe espanhola no Rio de Janeiro (Mephistophelian scenario: the Spanish flu in Rio de Janeiro).

2 Sources have not arrived at a consensus regarding the total number of deaths caused by the Spanish flu epidemic.

3 In Spain, some municipalities proposed that military recruitment be temporarily halted so the flu wouldn't spread. See newspapers from that time (Sep. 23-29).

4 'La carète économique', O Careta, Oct. 5, 1918, p. 31. The cited article is written in a hybrid language–that is, a Portuguesized French–making it even funnier.

5 The disease earned this nickname because the elderly were more vulnerable to it.

6 According to official sources, in the month of October, flu accounted for 76.90% of all deaths while the November figure was 57.01%.

7 For a more thoroughgoing exploration of the topic, see Hannaway, 1993, pp. 292-307; Pelling, 1993, pp. 309-34; Tesh, 1982, pp. 321-42.

8 Sources say that the epidemic made dock with the arrival of the English steamer Demerara in September. The vessel reached the federal capital in early October (Liverpool/Portugal/Recife/Salvador/Rio de Janeiro). But since many other, earlier ships had brought with them passengers suffering from the benign form of the flu, we must take into careful account how the arrival and departure of ships was documented at Brazilian ports. At the Arquivo Nacional, the only logs I found recorded information on the ports of Rio de Janeiro and Santos, which do not add much information.

9 A Noite, Oct. 21, 1918, p. 2. Even Dr. Silvado's underlings were against his continuing to head up prevention services at the port. See A Noite, Nov. 16, 1918, p. 3.

10 The influenza had a number of clinical physiognomies; it was classified as pneumonic, bronchopneumonic, gastrointestinal, choleriform, neurological, intestinal, polyneuritic, meningitic, meningeal-encephalic, renal, asthenic, syncopal, and fulminating influenza. According to Miguel Couto, the designation "intestinal" was coined in Brazil to refer to a variety of flu that seriously affected the intestines (see Anais da Academia Nacional de Medicina, 1924, May 22 session, p. 119). The deadliest form was described as "mixed" (that is, meningeal-encephalic, bronchopneumonic, and gastrointestinal) and was called morbus extremis.

11 Public health funding fell every year. In 1914, budgetary allocations totaled 200:000$000, with an additional 1,100:000$000 spent; in 1915, credits dropped to 50:000$000 and in 1916, to 25:000$000, the same amount being allocated in 1917. The 1918 budget called for 50:000$000, but actual outlays on public rescue efforts during the first half of the year alone came to 66:418$974. See Fundação Biblioteca Nacional, Coleção Relatórios dos Presidentes de Estado, 1918, attachment "Despesas do Ministério," p. 25. See also the reports on the administrations of the presidents of the State of Rio de Janeiro.

12 The most important agreements to suspend the use of quarantines and isolation were the Paris Convention (signed on Dec. 3, 1903, and ratified in 1907) and the Montevideo Convention (signed on Apr. 21, 1914).

13 For a more thoroughgoing look at this question, see Hannaway, 1993, pp. 292-307; Pelling, 1993, pp. 309-34; Tesh, 1982, pp. 321-42.

14 During the Spanish flu epidemic, it was questioned whether Pfeiffer's bacillus was the causal agent of the influenza; so too was the bacterial origin of the sickness. Studies conducted in a number of countries around the world, including Brazil, pointed to a filterable virus as the specific agent of the disease. But the era's laboratory technology was not up to the job of a precise diagnosis. The causal agent of the influenza was only to be pinpointed in 1933, when science was finally able to identify such structures as DNA and RNA, and to see microscopic beings like the retrovirus. See Tognotti, 2003, pp. 97-110.

15 The newspapers back then had unleashed a campaign to denigrate the public and political image of Carlos Seidl. Among newspapers in Rio de Janeiro, we make special mention of A Noite and A Gazeta de Notícias, because both presented more serious discussions. See the months of October and November 1918.

16 It must be mentioned that Carlos Seidl had converted to experimental medicine from the first days of Manguinhos; furthermore, he had been one of the major proponents of the public health reform which was to be implemented following World War I. Theophilo Torres himself, who would replace Seidl as director-general of Public Health, was also a member of this medical elite in the federal capital.

17 Censorship became a viable measure under the state of siege declared by the federal government in November 1917, when Brazil and Germany declared war. However, the Minister of Justice and Internal Affairs, Carlos Maximiliano, warned that leaders must exercise prudence when introducing censorship: "the use of discretionary powers corrupts the most levelheaded; governing without accountability pleases even the strongest" ("Documentos Parlamentares, Estado de sítio: o Brasil em estado de guerra com a Alemanha [1917-1918]," Jornal do Commércio, Rio de Janeiro, v. 8, p. 238. Cited in Abrão, 1985, p. 120.

18 One of the meanings of the term "government bureaucrat" is a rationally trained, specialized expert, whose rationality (in this case, scientific) and specialized knowledge allow him to create an organization grounded in the dictates of science and in new ways of wielding power. The role of government bureaucrat does not stand in opposition to the position of intelligentsia with a vocation for political leadership. In Brazil, we cannot speak of a "pure bureaucracy" but of a bureaucracy intertwined with a multitude of factors, like social, charismatic, and economic power. See Weber, 1982, pp. 229-82; or Freund, 1987, pp. 170-7.

19 Nicanor Nascimento's initiatives in the lower house were centered on defending the creation of labor laws that would better provide a more suitable urban and industrial labor force and improve the working and living conditions of these social actors. The miserable health conditions at workplaces and residences compounded the negative effects of social interdependence.

20 The interviewee is referring to Dr. Belisário Penna.

21 During the 1910s, Instituto Oswaldo Cruz staff traveled around the interior of Brazil in order to map out the disease across the nation's territory; this work was fundamental in shaping a certain view of this group. The creation of the Liga Pró-Saneamento do Brasil, led by the noteworthy figure of Belisário Penna, would serve as an efficient propaganda tool in disseminating the ideas of this medical elite and would bolster its political pretensions. In comparing Brazil to a 'huge hospital'–subsequently transformed by the Spanish flu into a huge cemetery–the group created new ways of legitimizing its prestige and scientific and political power, along with the reforms it espoused.

22 Working within the constraints of the era's medical and scientific knowledge, not only in Brazil, many physicians tried to convey the image that the Spanish flu was only lethal for organisms that had been weakened by other afflictions; this was how they accounted for its deadliness. At a meeting of the Academia Nacional de Medicina, Dr. Emílio Gomes announced that tests on the feces of flu victims indicated that 80% were carriers of ancylostomiasis, an endemic disease quite common throughout the sertão (see Anais da Academia Nacional de Medicina, Oct. 10, 1918 session, pp. 590-2). Many physicians attributed rural endemic diseases to a predisposition of the organisms that would make Spanish flu more deadly than it really was; they were lending support to the ideas and ideals espoused by the sertão pro-sanitation movement, that is, the expansion of political and sanitary institutions and their scope of action.

23 The 'filterable microbe' was so called because it was thought it could pass through pores and membranes. Suggested by Novelle and Lebailly, this characteristic was one of the prime research interests in the many studies conducted during the Spanish flu epidemic. Other investigations, such as those undertaken by Dr. Selter in Germany and by Dr. Yamonuchi in Japan, were manifestations of the worldwide movement to hunt down the specific disease agent (Beget, et al., 1918).

24 Previna-se contra a gripe (n.d.), pamphlet distributed during campaigns conducted by the Serviço Nacional de Educação Sanitária (National Sanitary Education Service). See Fundação Biblioteca Nacional, Sessão de Obras Gerais.

 

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Fontes

Academia Nacional de Medicina.

Anais da Câmara dos Deputados. 1918-1919        [ Links ]

Anais da Academia Nacional de Medicina. 1918-1920        [ Links ]

Arquivos Brasileiros de Medicina. 1918-1919        [ Links ]

Biblioteca da Assembléia Legislativa do Rio de Janeiro

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Boletim da Prefeitura do Rio de Janeiro, vol. 56. 1918        [ Links ]

Brasil Médico. 1918-1923        [ Links ]

Fundação Biblioteca Nacional        [ Links ]

Relatórios do Ministério da Justiça e Negócios Interiores. 1918-1919        [ Links ]

Periódicos (set.-dez. 1918)        [ Links ]

A Gazeta de Notícias        [ Links ]

A Noite        [ Links ]

Correio da Manhã        [ Links ]

O Imparcial        [ Links ]

O Paiz        [ Links ]

Revista Fon-Fon        [ Links ]

Revista A Careta        [ Links ]

Revista da Semana        [ Links ]

Fundação Oswaldo Cruz        [ Links ]

Arquivo Carlos Chagas, Casa de Oswaldo Cruz\Fundação Oswaldo Cruz        [ Links ]

Memórias do Instituto Oswaldo Cruz, 1918-1919.        [ Links ]

 

 

Received for publication in January 2004.
Approved for publication in July 2004.

 

 

English Translation: Diane Grosklaus

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