Physicians, travels, and scientific exchange during the institutionalization of the fight against cancer in Brazil (1941-1945)

Abstracts

Analisa ações de médicos ligados às iniciativas pública e privada e que colaboraram para a incorporação do combate ao câncer, na agenda das políticas públicas de saúde do governo federal, cristalizadas na criação do Serviço Nacional de Câncer em 1941. Objetiva também demonstrar que esse processo histórico se relaciona diretamente ao contexto internacional de intercâmbio científico entre o Brasil e os Estados Unidos, incentivado pela 'política da boa vizinhança', nos anos 1940. Aponta disputas políticas pela primazia da coordenação de ações de combate à enfermidade, no âmbito do poder central.

intercâmbio científico; história das doenças; história do câncer; Brasil

ANALYSIS

Physicians, travels, and scientific exchange during the institutionalization of the fight against cancer in Brazil (1941-1945)

Rômulo de Paula Andrade^I; Vanessa Lana^II

^IDoctoral candidate in the History of the Sciences and Health/ Casa de Oswaldo Cruz/Fundação Oswaldo Cruz (COC/Fiocruz). Av. Gomes Freire, 474/31. 20231-015 - Rio de Janeiro - RJ - Brazil. [e-mail]

^IIDoctoral candidate in the History of the Sciences and Health/COC/Fiocruz. Rua Santa Rita, 267/304. 36010-070 - Juiz de Fora - MG - Brazil. [e-mail]

ABSTRACT

The article analyzes initiatives taken by physicians from both the private and public sectors who contributed to placing the fight against cancer on the federal government's agenda of public health policies, which became embodied in the 1941 creation of Brazil's National Cancer Service. The text also aims to show that this historical process was directly related to the international context of scientific exchange between Brazil and the United States that was encouraged under the Good Neighbor Policy of the 1940s. It calls attention to political disputes over the coordination of efforts to fight the disease at the federal level.

Keywords: scientific exchange; history of disease; history of cancer; Brazil.

The article analyzes government and private enterprise initiatives that contributed in complementary fashion to placing the fight against cancer on the government agenda in the 1940s. Our goal is to show that specificities notwithstanding, the historical process that led to creation of Brazil's National Cancer Service (Serviço Nacional de Câncer, or SNC) was directly tied to two factors: the national context in which the Vargas administration was shaping government public health policy and an international scenario of scientific exchange between Brazil and the United States, promoted by the Good Neighbor Policy during World War II period. Historiographic studies focused on the period have discussed the cultural exchange encouraged by this 'Americanization' of Brazilian society (Moura, 1980; Tota, 2000). Recent research suggests that these contacts had a decisive influence not just by broadening cultural norms but also by impacting the historical path taken by local health policies; they intensified an exchange process begun in the earliest decades of the twentieth century through the creation of bilateral agencies and scholarships (Campos, 2001; Campos, 2006). While the main target of the agency founded by Nelson Aldrich Rockefeller may have been culture, health care was certainly not ignored.¹

The article also highlights the work of two healthcare professionals who, together with surgeon Mário Kroeff, exercised relevant roles in the history of the fight against cancer in Brazil: Antônio Saint Pastous de Freitas, a physician from the state of Rio Grande do Sul, and Antônio Prudente Meireles de Morais, a surgeon from the city of São Paulo. The medical literature cites Kroeff as a central figure in creation of the SNC and as the key protagonist of this historical process. The surgeon did indeed play a vital part in the history narrated here, but our research has identified other people and contexts that likewise figured in the intricate process of institutionalizing services to fight this disease in Brazil.

We begin by focusing on the historical phase when the Brazilian federal government gradually began turning its attention to cancer, as it set about structuring the nation's public health policy in the early decades of the twentieth century. We next explore the intense scientific exchange that took place under the Vargas administration, with a special emphasis on the actors and institutions involved, such as Rio Grande do Sul's Antônio Saint Pastous de Freitas, sent to the United States in 1941 by Oswaldo Aranha, then Minister of Foreign Affairs under Vargas. The purpose of Saint Pastous' visit was to study how the United States organized its cancer institutions, so that proposals could be presented on the shaping of cancer policies in Brazil.

During the second part of our article, we examine the first years of the SNC (1941-1945) and the various government projects for taking action against the disease. Lastly, we analyze the activities of Antônio Prudente Meireles de Morais, director of the São Paulo Association to Fight Cancer (Associação Paulista de Combate ao Câncer, or APCC), who in 1943 presented the federal government with a project entitled the National Network Against Cancer (Rede Nacional Contra o Câncer), with the aim of organizing efforts to fight cancer around Brazil. This initiative sparked tension among government agencies because a National Campaign Against Cancer (Campanha Nacional Contra o Câncer) with similar goals had been created a short time earlier under the umbrella of the SNC.

The first chapters of cancer control in Brazil

Cancer gradually became the focus of attention by various medical groups around the country in the first decades of the twentieth century. In large part, these professionals had gained interest in the issue of cancer because of their contact with the international literature on the topic and chiefly as a consequence of their participation at international medical conferences. We see the first attempts in Brazil to systematize the question of cancer in articles appearing in specialized publications, like one written by Azevedo Sodré in 1904 and one by Olímpio Portugal in 1910; though their interpretations differed, they both wanted to raise Brazilian physicians' awareness about the dangers of the disease (Sodré, 1904; Portugal, 1910).

The first step towards placing cancer as a public health problem on the national policy agenda came under the 1920 sanitary reform, which led to establishment of the National Department of Public Health (Departamento Nacional de Saúde Pública, or DNSP). Within the new Department, the disease was assigned to the Inspectorship for the Prevention of Leprosy and Venereal Diseases (Inspetoria de Profilaxia da Lepra e das Doenças Venéreas). Yet efforts to make this illness part of public health initiatives did not bring immediate results, as the Inspectorship had a limited role in fighting the disease (Sanglard, 2008; Teixeira, 2009). Back then, medical knowledge perceived cancer and leprosy as similar in terms of contagion, with most doctors believing the two illnesses were transmitted in similar fashion; this meant more attention should be paid to their rates of incidence and to finding ways to avoid their spread (Teixeira, 2009). Techniques were developed during this same period that enhanced medicine's power to intervene in the fight against cancer, including greater reliance on and a better understanding of radiology and electrosurgery, the latter introduced to Brazil by Mário Kroeff.² In a context of growing concern over the disease, these innovations prompted the medical community to become more involved with the illness, fueled discussions about controlling cancer's advance, and brought more well-defined proposals to this end (Teixeira, Fonseca, 2007).

One important sign of the medical community's heightened attention to the disease was the 1935 organization of the First Brazilian Cancer Congress (Primeiro Congresso Brasileiro de Câncer). Held at the Rio de Janeiro Society of Medicine and Surgery (Sociedade de Medicina e Cirurgia do Rio de Janeiro, or SMCRJ), the event was attended by political figures within the first Vargas administration, like Education and Health Minister Gustavo Capanema and the director of the National Department of Health (Departamento Nacional de Saúde, or DNS), João de Barros Barreto. Speaking before the congress, Barreto stated that a cancerology center should be established in what was then the Federal District (Barreto, 1936). What is meaningful here is that the federal public health agency, through its spokesperson, took the occasion of the congress to announce a project aimed at prevention and diagnosis of the disease, as well as the establishment of a treatment institute in the Federal District; this was in contrast with the previous Inspectorship, which had confined its actions more to education and to monitoring illness rates (Teixeira, 2009).

In 1941, the government pushed ahead with a program to expand its control of public health initiatives by enacting a large-scale reform, led by Minister Gustavo Capanema. The National Health Department was reorganized, national services were created to fight specific diseases, federal government initiatives were given a vertical structure, and healthcare services were broadened throughout the country. Three months after the law established these national services, and still in 1941, the SNC was created under Decree-Law No.3.643, definitively incorporating cancer into Brazilian public health actions. Establishment of this federal agency signaled the advent of a policy of nationwide scope aimed at extending cancer control initiatives beyond the federal capital through administrative centralization and regulation, as proposed and enforced by SNC director Mário Kroeff. Furthermore, setting up a central agency devoted to cancer treatment and discussions earned the disease a place on the federal government's list of public health priorities.

One of the SNC's assignments was to promote an ongoing fight against cancer, later entitled the National Campaign Against Cancer. It was centered on education about early diagnosis and on federal government assistance for regional initiatives to create treatment facilities for the ill. Although the decree establishing the Service provided for federal coordination of campaign actions, the scope of the agency's activities was quite limited, especially early on. So it was impossible to do without the help of private, state, and local organizations, which had to be incorporated into the campaign. The decree made this clear in its third article, which states that the SNC would be responsible for "guiding and coordinating the action of state and municipal agencies that fight cancer as well as of private institutions that conduct any activities related to this problem." By the time the Vargas government ended in 1945, four private institutions had become part of the National Campaign Against Cancer.³

As argued earlier, the creation of the SNC was directly related to the history of how public health was shaped in Brazil, but local history alone does not explain how cancer care actually came to fall within the government sphere. This structural fact also has to do with the international conjuncture of the 1940s, when Brazil stepped up its cultural and scientific exchange with the United States, sending physicians to that country to learn about anti-cancer actions and also about how its hospitals were organized. The individuals selected to go on these trips had good relations with people close to the Vargas government and played major roles in Brazilian cancerology as leaders of both private and public institutions. One example is the director of the SNC himself, Mário Kroeff, who went to the United States in 1942. The prestige accorded these individuals by the federal government is apparent in the fact that the first two institutions brought into the National Campaign Against Cancer were the Rio Grande do Sul Medical Association to Fight Cancer (Associação Médica de Combate ao Câncer do Rio Grande do Sul, or AMCCRS), headed by Antônio Saint Pastous de Freitas, a physician from that state who also traveled to the United States in 1941, and the APCC, organized by Antônio Prudente Meireles de Morais, a surgeon from the city of São Paulo who had gone to the United States in 1945.

As part of this history, private initiatives from other regions of Brazil had an active role in the process of defining a national cancer policy, as regards both scientific exchange with the United States and the drafting of national cancer projects. We thus argue that the way in which the Brazilian government structured the fight against cancer in the 1940s was directly related to the national and international scenarios of the day, characterized by growing American influence in Brazil, combined with individual and collective initiatives in cancer care. Before addressing the travels of these three specific physicians, we will take a brief look at the foreign conjuncture in question.

Contexts in movement: international relations and scientific exchange in the 1940s

International relations in the early 1940s were marked by the tensions of World War II and ensuing diplomatic redefinitions. Disputing hegemony, blocks of nations devised strategies for gaining allies and strengthening the political and ideological orientations at battle. Brazil tried to stay somewhat neutral and avoided taking a specific stance in hopes of bolstering its bargaining position with both sides and thus benefitting in terms of foreign trade (Moura, 1980). Brazil therefore maintained relations with Nazi Germany, negotiating investments in strategic sectors of the Brazilian economy, in keeping with the interests of the Vargas State and the proposal to strengthen State power and national identity (Campos, 2006). Concomitantly, nations were working to put together a group of allies in Europe that could strengthen the continent's position both in the developing conflict and in how the conflict would reshape world power (Tota, 2000). In 1942, however, the notion of neutrality lost many of its supporters. The shift was the product of foreign factors, like the December 1941 bombing of the U.S. air base at Pearl Harbor, along with internal pressures triggered by other major events, like the bombing of Brazilian ships in the Northeast (Moura, 1995). A decisive moment in the redirectioning of Brazil's decision-making process in foreign relations was the January 1942 Conference of Rio de Janeiro (Conferência do Rio de Janeiro), in which the country broke off relations with Germany, Italy, and Japan. It was during this period that Brazil and the United States signed the economic and military agreements known as the Washington Accords.

These events had an impact not only on the Vargas administration's policies and military plans at a moment when the nation-state was being (re)constructed; they likewise influenced the molding of a national public health policy that had a role in the 1930s and 1940s as both catalyst and framer in the construction and shaping of the nation-state, through government action to regulate, centralize, and provide professional training and specialization in the healthcare sector. These latter aspects were the frequent topic of international discussions, taking into account health indicators reflective of the international conjuncture and questions concerning the interdependence of diseases, health, and economic development (Fonseca, 2007).

Gustavo Capanema's mandate as minister of Education and Health (1934-1945) was a time of intense exchange between health leaders in Brazil and abroad. The country's public health sector was structured in accord with two movements: nationally, it developed in tune with the political context and ideological project of the Vargas administration; in international terms, it was in many ways coherent with the specialized debates occurring in international forums. The international conferences of the 1930s provided direction for public health guidelines for Latin American nations and the result, especially in Brazil, was a convergence of international forum recommendations with the political priorities defined for agencies within the Ministry of Education and Health (Fonseca, 2007).

In these agreements about collaborative efforts to fight disease and in the creation of Brazilian health institutes, the debates kept in step with issues within the international conjuncture. It is well known that a major interest of the day was training public health professionals, mainly through exchange programs, which was an agile way of obtaining specialized training while simultaneously tightening diplomatic ties between nations. These exchanges gathered momentum in the context of the war, between 1939 and 1945, particularly after the 1940 establishment of the Office of Inter-American Affairs (OIAA).⁴ Created by Nelson Aldrich Rockefeller, the Office was supposed to foster commercial and cultural relations between American states, thereby encouraging solidarity and deepening the spirit of cooperation within the Americas in the interest of hemispheric defense (Tota, 2000; Campos, 2006).

This period of travel was also a landmark in Brazilian cancer initiatives, through investment in research and treatment facilities and through the creation of cancer institutions, all as part of the government's public health proposal. It was a time when the disease made the list of government priorities. Discussion forums were better articulated and a corps of professionals gained form. While these professionals may not have been homogeneous in their actions and proposals, they networked on the issue of the disease and brought it to the attention of society and governmental authorities.

It was within this context that Brazilian physicians went to the United States for specialized training in cancer treatment and to learn how cancer services there were organized. Building on our initial argument, it is our contention that this exchange did not merely spread U.S. precepts in cancer care; these travels also dovetailed with initiatives in Brazil, like the creation of cancer institutions and articulated actions involving both the private and public sectors.

Saint Pastous' trip to the United States

Antônio Saint Pastous de Freitas was born on February 11, 1892, in the city of Alegrete, state of Rio Grande do Sul. He earned his medical degree from the Porto Alegre Faculty of Medicine (Faculdade de Medicina de Porto Alegre) in 1915. He took specialization courses in Europe in 1921 and 1922. In late 1922, he created the Institute of Radiology and Medical Electricity (Instituto de Radiologia e Eletricidade Médica) in his home town and as a specialist in clinical medicine did research into cancerology and radiology. In 1935, he became chair of Clinical Medicine at his alma mater (Anais, 1943, p.155).

In August 1941, Saint Pastous inaugurated the Radium, Roentgen, and Contact Therapy Service (Serviço de Radium, Roentgen e Contatoterapia) at Porto Alegre's São Francisco Hospital, which offered treatment of cancer and tumors in general. According to the doctor, the benefits of this treatment center would extend to indigents at Porto Alegre's Mercy Hospital (Santa Casa de Misericórdia) (Anais, 1943, p.155). That same month, in conjunction with other doctors from the state who had collaborated in creating the hospital's cancer treatment wing, he helped found the Rio Grande do Sul Medical Association to Fight Cancer, a private organization whose mission was to systematize and coordinate cancer care in the region, centered on three basic features: diagnosis, treatment, and educational campaigns (p.13). The Association's statutes also called for a broad medical and social program through the Central Cancerology Institute (Instituto Central de Cancerologia), to be created in Porto Alegre; the program would subsequently be expanded to nearby cities, with the opening of regional health posts. The newspaper Correio do Povo lauded the establishment of the organization:

Porto Alegre, which, as we have said, already possesses the largest, best-equipped cancerology service in Brazil, will now become the radiating hub of a broad movement that will reach to all municipalities in the state of Rio Grande do Sul and make its impact felt in other areas of the country, serving as the inspiration for a national campaign of war on cancer, which places such a heavy burden on Brazilian families each year (Correio do Povo, Aug. 19, 1941).⁵

Oswaldo Aranha, former Ambassador of Brazil to the United States, was likewise from Alegrete, where he had been mayor from 1925 to 1927. Now as Minister of Foreign Relations, he appointed Saint Pastous to travel to the United States to gather data and material on the medical and social problems presented by cancer and to learn about hospital organization there (Freitas, n.d., p.5). Before Saint Pastous left, the minister sent correspondence to the authorities who would receive him, including Hugh Cummings, director of the Pan American Sanitary Bureau; Warfield T. Longscope, director of the Johns Hopkins Medical School; and OIAA director Nelson Aldrich Rockefeller, to whom he wrote:

It is with great pleasure and complete confidence in your ability to help my very dear friend Dr. Antonio de Saint Pastous that I call on you to see that his mission in the United States is successfully fulfilled. ... Dr. Saint Pastous is one of the outstanding scientists of Brazil and I don't know of any better way to foster the good relations between our countries than the [exchange] of men of thought and action, as you will find to be the case of Professor Saint Pastous.

Once diplomatic preparations had been finalized, the federal government released special funds for Saint Pastous' trip, pursuant to Decree-Law No. 3.803, dated November 6, 1941. From August 20 to November 9, 1941, the Brazilian physician visited cancer services like the National Cancer Institute in Bethesda, Maryland; the Rockefeller Institute and the American Society for the Control of Cancer in New York; and the Chicago Tumor Institute and the Radium and Radiotherapy departments of the Michael Reese Hospital in Chicago. He also went to other medical institutions and associations, like the Pan American Sanitary Bureau in Washington, the U.S. Public Health Institute in Bethesda, the OIAA - where he met with Nelson Rockefeller - and Johns Hopkins University in New York. He took the opportunity to attend two congresses as well: the 43^rd annual convention of the American Hospital Association and the 42^nd Congress of Radiology, held in Cincinnati (Freitas, n.d., p.7). While abroad, Saint Pastous exchanged letters with Oswaldo Aranha and Gustavo Capanema, which tells us how much interest there was in his trip. Writing to the former, he expressed his thanks for the opportunity.

I am nearing the end of my trip, for whose inspiration I am in your debt. I carry with me a valuable wealth of material and knowledge. ... I am amazed with the new possibilities: the field of knowledge is prodigious, and the benevolence of the people, captivating. ... To their incomparable material wealth, Americans add the charm of their welcoming simplicity. ... I am bringing complete material in popular education from the American Society for the Control of Cancer, of which I was named a member. I have also been included in the Pan-American League Against Cancer, whose board of directors, headed by the esteemed Carther Wood, held a lunch for me yesterday. While in Chicago I received a telegram from Nelson Rockefeller, inviting me to meet with him in Washington (Freitas, Aug. 27, 1941, p.7).

In this same missive, Saint Pastous expressed concern about the prestige of Brazilian cancerologists and their associations among international cancer organizations. With the idea of lending continuity to Brazilian collaboration with foreign physicians, he asked Oswaldo Aranha to speed up the visa process for L.W. Tomarkin, secretary-general of the Pan-American League Against Cancer, who would be leaving the following month on a visit to Latin American nations, where he would conduct preparatory work for the Pan-American League Against Cancer:

I can assure you that [if the visa is not granted], our country will find itself in a peculiar position of inferiority and will miss out on an interesting opportunity (as it already missed the opportunity to centralize supplying of Radium in Canada and to host the Pan American Cancer Congress in 1942, both transferred to Argentina). I would therefore request that, for the sake of the good name of Brazil, you would authorize the Consulate in New York, via telegram, to issue the visa. ... With this trip to the United States, you have given me the best I ever could have hoped for in my medical life. I hope it will prove useful in our medical realm; for me, this will serve as a reward (Freitas, Aug. 27, 1941, p.7).

In his report to Capanema, Saint Pastous made suggestions about the organization of cancer services in Brazil: a cancer research institute should be created; two U.S. cancer specialists should be hired (a researcher and a pathologist); the government should provide grants to a group of physicians specializing in cancerology so they could do internships in the United States; and, in organizing Brazil's social campaign against cancer, the country should take advantage of the cooperation of Tomarkin, given his post with the Pan-American League Against Cancer (Freitas, n.d., p.19).

After returning from the United States, Saint Pastous implemented organizational reforms at cancer treatment services in Rio Grande do Sul. On June 18, 1942, together with the group of doctors who helped found the AMCCRS, he transformed this organization into the Medical Society to Fight Cancer in Rio Grande do Sul (Sociedade Médica de Combate ao Câncer no Rio Grande do Sul, or SMCCRS). The statutes of the new Society, different from the earlier association's by-laws, pinpointed experimental research as one of its chief concerns, alongside treatment, diagnosis, and educational campaigns. Inspired by his visit to the American College of Surgeons, Saint Pastous now championed the concept of integrated cancer clinics as part of general hospitals, in his opinion thus enabling early cancer diagnosis. The prerequisite to an integrated cancer clinic would be a fully-equipped medical facility, with surgery, laboratory, and radiology all under one roof. Saint Pastous' idea was to set up such clinics at general public hospitals, giving the indigent access to this care (Anais, 1943, p.97).

The organization of the SMCCRS was underpinned by the 1942 creation of the Porto Alegre Institute of Cancerology and by the expansion of regional health posts into rural Rio Grande do Sul, in the cities of Pelotas, Bagé, and Santa Maria, all based on the notion of an integrated clinic.

On November 19 that same year under Decree-Law No. 4.975, the SMCCRS joined the National Campaign Against Cancer, coordinated by the newly created National Cancer Service. This meant the Society would receive an annual subsidy from the Brazilian federal government. When Gustavo Capanema sent Getulio Vargas the draft decree-law that incorporated the SMCCRS into the National Campaign, he justified the move in these terms:

The recently founded Medical Society to Fight Cancer in Rio Grande do Sul deserves our consideration and support. It is a private institution organized to take the cancer campaign to the whole of the state. The important work already accomplished by this institution clearly illustrates the firm confidence of the organization and the fine guidance of its work. ... The close cooperation between private initiative and government for the purpose of social assistance has brought excellent results and is indeed the local modality of organization in the national campaign against cancer (cited in Anais, 1943, p.154).

On June 24, 1943, Decree-Law No. 5.617 authorized the SMCCRS's first subsidy, in the amount of Cr$75,000.00. On August 19 of the same year, the Brazilian Cancerology Society (Sociedade Brasileira de Cancerologia) was founded to serve as the SMCCRS's center for scientific studies and exchange. Its statutes provided for creation of a journal called the Anais da Sociedade de Cancerologia. Lastly, that same year João de Barros Barreto, director of the DNS - then the main enforcer of Brazilian public health policy -sung the praises of the SMCCRS in his evaluation of the status of anti-cancer initiatives in Brazil:

In Porto Alegre, the situation is much better. Professor Saint Pastous, through his Association to Fight Cancer, with its radiotherapists, an anatomical pathologist, a dermatologist, a laboratory technician, a surgeon, and clinicians, has facilities for surgical treatment, radium treatment, and deep roentgen therapy at Moinhos de Vento Hospital, with similar facilities at São Francisco Hospital, including a laboratory, ambulatory clinic, infirmaries, and private rooms: in roughly four years, 1,009 patients have been treated, 648 of which were contributors. As to cancer associations, there were only two, one in Salvador, not very active, and the other, Porto Alegre's, whose radius of activities is now extending to Pelotas, Bagé, and Santa Maria (Anais, 1943, p.102).

An analysis of Antônio Saint Pastous' career contributes to our understanding of how private initiative and personal relations were vital elements in the institutionalization of cancer policies under the first Vargas government. However, the main force behind the shaping of cancer initiatives in the 1940s was the National Cancer Service, whose director, medical surgeon Mário Kroeff, traveled to the United States in 1942.

"Freedom from cancer": Mário Kroeff in the land of Uncle Sam

At the request of Gustavo Capanema, Mário Kroeff received government authorization and funding to go to the United States for six months (pursuant to Decree-Law No. 4.734, dated June 15, 1942). During his absence, the SNC was headed by sanitary physician Sérgio Lima Barros de Azevedo. The SNC director left on July 8, intending to purchase radium, which would be used to start up radiology activities at the SNC, and to study how the fight against cancer was being organized in the United States. According to Kroeff, his visits to U.S. laboratories and institutions would guide his plans to create and implement a central cancer institute in Brazil (Brasil, 2007).

During his stay, Kroeff visited a number of institutes in New York - the Rockefeller Institute, Medical Center, Bellevue Hospital, and the American Society for the Control of Cancer - Boston, Philadelphia, Chicago, Rochester, and Washington, where he stopped at the National Cancer Institute. He also observed the services offered at New York's Memorial Hospital with a view to adopting U.S. diagnostic and radiotherapy techniques at the SNC; while there, he showed an SNC movie on 'the fight against cancer.' In a speech before the Tudor City Unit of American Women's Voluntary Services, Kroeff highlighted the work of Vargas's wife, Alzira, in order to show the similarities between volunteer organizations in the United States and Brazil. He also praised organization of the fight against cancer in his host country: "Is it, therefore, any wonder that all mankind looks hopefully to the United States for the radical solution of this problem?" (Brasil, 2007, p.304).

On behalf of Minister Gustavo Capanema, Kroeff received the Walter Reed medal from the American Society of Tropical Medicine, in recognition of Brazil's fight against yellow fever and malaria. Speaking on a program of the radio division of the Office of the Coordinator of Inter-American Affairs in June 1943, Kroeff called attention to cooperation between the two countries:

Although I do not speak Spanish well, I could not refuse the invitation to pronounce a few words into the microphone at the Radio Division of the Coordinator of Inter-American Affairs. ... These are the emotions of yet another resident of this hemisphere, reverberating in the edifying harmony of sentiments emerging today in the Americas. ... These are yet more thoughts entering the stream of messages that flow from the Americas to the Americas, in a mutual understanding of ideas and purposes (Brasil, 2007, p.358).

Upon Kroeff's return in August 1943, a banquet was given in his honor at Rio de Janeiro's Automóvel Clube. In times of world war, the speech praised Kroeff's 'mission' abroad and his drive to fight cancer in Brazil. Speaking about his trip and his personal impressions, Kroeff mentioned his institutional contacts and visits to various health-related organizations in the United States, like Harvard University, the American College of Surgeons, and the New York Academy of Medicine. He underscored the friendly relations between the two countries, observing that dinners, meetings, congresses, visits, and medical seminars bespoke "faithful scientific exchange," which strengthened the principles of continental cordiality that were part of the Good Neighbor Policy (Brasil, 2007).

In an article published in the newspaper Correio da Manhã, Kroeff stated that "the eyes of mankind are on the laboratories of the United States" (Brasil, 2007, p.327) because of the tremendous anti-cancer work that would soon be "yet another freedom won by the current generation: freedom from cancer" - in a reference to Franklin Roosevelt's Four Freedoms address of 1941.⁶ He said he had been impressed by the rapid rise in life expectancy achieved by the United States, and if the measures taken there were also taken in Brazil, the country would have a chance at improving its sanitary situation.

When the government decided to send Brazilian physicians to do research and learn about cancer treatment in the United States, it was grounding itself on a discourse of enhancing national work through exchange experiences involving U.S. initiatives. In addition to these scientific considerations, the act of purchasing radium in the United States, which was the country then wielding the greatest political and economic might, meant progress was being made in cancer treatment with reliance on a curative material that was considered to have great potential at that time. In the words of Gustavo Capanema, the aim was to gather as much data, studies, and information as possible from U.S. scientific sources so that Brazil could use new prophylactic techniques to help cancer patients, based on ever safer, more efficacious methods (Capanema, July 4, 1942).

Yet for Mário Kroeff, his period of scientific exchange did not go as smoothly as he might have imagined. Among other upsets at the time, the SNC facilities had to be temporarily transferred because the Estácio de Sá Hospital where it had been operating was ceded to the Military Police for the purposes of its own hospital. The matter was only settled when the Ministry of Education and Health leased a private building on Conde dos Lages Street in downtown Rio de Janeiro. The situation remained like this until after the Vargas administration, when the SNC headquarters was transferred to Gafrée e Guinle Hospital, in the Rio de Janeiro neighborhood of Tijuca (Teixeira, Fonseca, 2007).

Another disruption was the project to fight cancer at a nationwide level that was submitted to the federal government by Antônio Prudente Meireles de Morais, a native of the city of São Paulo and an activist in Brazil's fight against cancer.

The Prudente Plan and disputes over ascendancy in the fight against cancer

Antônio Prudente de Meireles de Morais was born in the city of São Paulo on July 8, 1906. He was from a traditional São Paulo family and the grandson of Prudente de Morais, Brazil's first civilian president. In 1928 he graduated from the São Paulo Faculty of Medicine (Faculdade de Medicina de São Paulo). He specialized in electrosurgery in Europe, studying under Dr. Franz Keysser, and in reconstitutions to correct problems stemming from tumors. During his medical career in São Paulo, he was appointed assistant professor of the chair of Surgical Technique at the Universidade de São Paulo's Faculty of Medicine in 1931 and was given the chair of Reparative and Plastic Surgery at the São Paulo School of Medicine (Escola Paulista de Medicina) in 1935.

Antônio Prudente's work focused primarily on discussions about cancer and how to control it, and he published a number of articles on the topic. Starting in 1934, he assumed leadership of the initiative to create a league against the disease, which, in his opinion, would be the best way of fomenting cancer initiatives in the state of São Paulo. He proposed that "anti-cancer health posts" be set up in the capital and throughout the state, solely for diagnostic purposes. Like the Saint Pastous plan, the Prudente Plan sought to expand cancer fighting services into rural areas (Prudente, 1935).

The São Paulo Association to Fight Cancer was founded in 1935 with the goals of: raising funds to build a Cancer Institute in São Paulo offering diagnosis and treatment services, educating the public through explanatory and informative campaigns about the disease, and promoting medical specialization in cancer control and treatment (Prudente, 1935). Prudente already held major posts in international associations: he was vice president of the Pan-American League Against Cancer and a member of its board.

The national cancer project presented by Antônio Prudente called for the creation of an organization in Brazil to be named the National Network Against Cancer. The proposal created tension within the SNC and prompted acting director Sérgio Barros de Azevedo to write government authorities and argue that many of the points in Prudente's project coincided with the program already put in place by the Service (Azevedo, Mar. 3, 1943). Azevedo pointed out that the SNC's program had already been submitted to the government and was a firm part of the National Plan to Fight Cancer (Plano Nacional de Combate ao Câncer), which had much in common with the São Paulo proposal.

In his correspondence with DNS director João de Barros Barreto, Sérgio Azevedo's argument is clear: the São Paulo network was unaware of the initiatives underway at the National Cancer Service, which acted in consonance with the Ministry, and therefore had proposed measures that were already on the table. Azevedo stressed that the SNC project had been grounded on painstaking studies conducted in all states and territories of the nation. In addition to encompassing important features of the Brazilian reality pertinent to the initiatives already underway, the SNC project contained detailed information on potential funding sources. Table 1 shows the similarities between the proposals contained in Antônio Prudente's plan and the SNC project.

The organizational similarities between the two plans reveal how Antônio Prudente, Sérgio Azevedo, and Mário Kroeff approached cancer initiatives from the same perspective when it came to structuring public health policies. Far from representing a conceptual dispute over cancerology and how to structure actions, the quarrel between the São Paulo Association and the SNC was a political dispute over managerial leadership of the government cancerology structure being established during this period.

Defending his argument and making an allusion to the unrestricted government support of initiatives implemented through the SNC, Sérgio Azevedo closes his correspondence with these words: "Mr. Director [João de Barros Barreto], these are the considerations that I believe must be taken into account as regards the project of Prof. Antonio Prudente, who of course is not fully aware of our program and activities, which proceed apace and at great sacrifice, despite all the hardships of which you are acutely aware" (Azevedo, Mar. 3, 1943). In this desire to override a private cancer initiative that would not necessarily come under the Service's auspices, it is clear that the SNC is engaged in a territorial dispute.

When Kroeff learned of Antônio Prudente's project while still in the United States, he wrote Capanema and stressed how deeply disappointed he was with the federal government's attitude and with his colleagues in São Paulo (Kroeff, n.d., phot.849-850). Kroeff highlighted the SNC's main activities and its social responses to the problem of cancer, in terms both of public policy and of helping terminal patients. He said that proposing a campaign didn't really amount to much; the true challenge was to suitably coordinate and implement the plan for the general good. Sharpening his argument, he stated: "planning a campaign on paper is meaningless" (Kroeff, Mar. 9, 1943). He pointed out that in its actions, the SNC had been guided by a sense of responsibility that befit the topic, by prior planning, and by consciousness-raising about the difficult work to be undertaken. He openly criticized his São Paulo colleagues for their sudden presentation of these ideas, which were in conflict with the interests of the SNC and its work and had been drawn up and submitted while he was out of the country.

Capanema received Mário Kroeff's letter via Luiz Simões Lopes, who left him a note with the letter attached. For Lopes, Kroeff had not received the correct information, which would account for the bitter tone of his letter (Kroeff, Mar. 9, 1943). João de Barros Barreto, director-general of the DNS, also commented on what he called the Prudente Plan:

Leaving aside any evaluation of the bio-statistical data upon which this physician has based himself, I must stress that ever since its creation, the SNC has made haste to conduct a precise survey in the state capitals of Brazil. As indicated in the 1941 report, ... a national action plan was drafted, which I only did not forward you in deference to the Director of the Service, Dr. Mário Kroeff, who is not in Brazil. ... The SNC also took into account the question of funding, in a more practical form than that suggested by Dr. Antônio Prudente ... . In summary, Honorable Minister, the Prudente Plan constitutes a contribution to the solution of the problem, to which the SNC has not failed to direct its efforts, despite the tremendous hardships with which it has struggled and is endeavoring to overcome (Barreto, Mar. 4, 1943).

From this discussion we perceive that the project by São Paulo's Antônio Prudente created an impasse between the heads of the SNC and the Ministry of Education and Health. As mentioned earlier, what was at play was ascendancy and leadership in proposing articulated nationwide actions to fight cancer in Brazil. The SNC claimed this role for itself, based on a discourse of officialdom: the Service had been created and was embedded in the Vargas ministry - which in no way negated the fragile nature of the agency, which was still taking but timid action against the disease and still shaping its institutional parameters.

On October 19, 1943, the São Paulo Association to Fight Cancer was incorporated into the National Campaign Against Cancer and thus subordinated to the SNC (Decree-Law No. 5.889). Regulamentation of this federal agency became official under Decree No. 15.971, dated July 4, 1944, which approved by-laws detailing its structure, goals, and forms of action. But that same year, the São Paulo association's action plans once again came to irritate the director of the SNC, who, upon learning of the APCC program and statutes, sent a private communiqué to Gustavo Capanema, suggesting that its draft by-laws be restricted.

[Honorable Minister], I would kindly suggest that restrictions, which I consider pertinent, be made to the draft Statutes of the "São Paulo Association to Fight Cancer," which have been submitted to the government for appreciation ... . I am approaching you about this privately, as requested of me. ... However, this ought to be done so officially, because the National Cancer Service, being the agency that controls the campaign against cancer nationwide, pursuant to the very decree that created it, should be received in a meeting.

In Article 1 of the "São Paulo Association to Fight Cancer," where it reads "acting nationwide," it should read "subordinated to the National Cancer Service."

In Article 4, letter b, where it reads [creation of a] Cancer Institute, it should read "São Paulo Cancer Institute" or "São Paulo Regional Institute" (Kroeff, n.d., phot.947).

Kroeff's last reservation concerning the Association's statutes derived from the similarity he noticed with an article in Chapter 2 of the SNC by-laws ("On organization"), which stated that the Cancer Institute would be a constituent part of the organization of the federal agency. The director argued that the APCC's use of the name Cancer Institute could lead to future confusion over nomenclature and to a duplication of duties. For Kroeff (n.d., phot.947), "it is up to the National Cancer Service to execute and control the fight against cancer nationwide".

Significantly, the SNC's proposed organizational structure proved inadequate, given insufficient funding and attention right from the start of the agency. Its reports from 1942 through 1945 reflect little activity as well as a scarcity of funds, as compared with other national services. Although the agency had been assigned countless responsibilities, its activities were in fact limited to clinical treatment and sanitary education, and to extolling early diagnosis as the main weapon in the fight against cancer, while reiterating the maxim that cancer was curable. Its institutional frailty impacted the diversity of projects for combating the illness, in dissonance with the regulatory centralization typical of public health efforts at that time.

In 1945, following the troubles over submission of the APCC and SNC work plans, Antônio Prudente Meireles de Morais went to the United States under arrangements with the federal sanitary authorities of that country. Gustavo Capanema requested that he conduct research and studies on the problem of cancer in the United States. According to the minister, Antônio Prudente was sent because the APCC had been brought into the National Campaign Against Cancer in 1943 (Capanema, July 2, 1945). Writing to Prudente, Gustavo Capanema praised the doctor's mission to the United States and its purposes. He underscored the campaign against cancer in Brazil and pointed out how the mobilization of both government agencies and private initiative in scientific investigations had brought reliable, satisfactory results. He closed by mentioning his interest in and expectations regarding the doctor's trip: "Knowing of your approaching trip to the United States, I would like to ask you to gather the greatest possible amount of scientific data, information, and studies while there, in order to enable us to ever more accurately guide our preventive and assistance efforts" (Capanema, Aug. 3, 1945).

To help assure that Antônio Prudente's stay would go smoothly, Capanema sent a communiqué to José Roberto de Macedo Soares, then Minister of Foreign Relations, asking his ministry to provide all possible assistance to the physician during his visit to the United States. While Antônio Prudente was actually there, the Minister of Education and Health received no report or any correspondence from him. One reasonable hypothesis is that the trip coincided with the final period of the Getulio Vargas administration, which was rocked by the internal political crises that culminated with the Armed Forces seizing control of the government, on October 29, 1945, and subsequently saw Gustavo Capanema's departure from the ministry. Be that as it may, the APCC director's trip to the United States merits note as yet another element in analyzing this period, which was marked by the definitive placement of cancer on the government's agenda, with an integral role being played by scientific exchange between Brazil and the United States.

Final considerations

This article has discussed the institutionalization of initiatives to fight cancer in Brazil in the 1940s, looking at two intersecting historical paths. It first explored the international context, where events like World War II and disputes between world powers led to the Good Neighbor Policy. If, on the one hand, this intensified cultural exchange, on the other, it redounded in major changes to the local structure of healthcare services and scientific research, during a historical period when U.S. influence was gaining ground in different sectors of the country. These transformations had a direct influence on cancer research and on services aimed at fighting the disease, as they fueled study trips by professionals who used the opportunity to help bring their projects to life at both a local and national level.

Far from representing the mere imposition of one country's will over another's, the process was about assimilating international precepts on how to organize cancerology services and adapt them to local needs. This has been explored here in terms of two dimensions: the public dimension, represented by the SNC and its director Mário Kroeff; and the private dimension, represented by the actions taken in São Paulo and Rio Grande do Sul. We have shown that these initiatives were not mutually exclusive but rather complementary in the institutionalization of cancerology in Brazil. The clashes between government and private initiative, as exemplified by the National Network Against Cancer and the National Plan to Fight Cancer, reflect a dispute for ascendancy in organizing the fight against the disease rather than a particular disagreement between institutions. What was actually at stake was who would be the protagonist in proposing actions and initiatives to fight cancer, in a conjuncture where the nation's healthcare services were being re-structured.

NOTES

REFERENCES

• ANAIS... Anais da Sociedade Médica de Combate ao Câncer no Rio Grande do Sul Rio Grande do Sul: s.n. 1943.
• ARANHA, Osvaldo. Correspondência a Nelson Aidrich Rockefeller. Arquivo Osvaldo Aranha, fot.191 (Centro de Pesquisa e Documentação de História Contemporânea do Brasil - CPDOC). s.d.
• AZEVEDO, Sérgio. Correspondência a João de Barros Barreto. Arquivo Gustavo Capanema, série Correspondência, rolo 66, fot. 927. (CPDOC). 3 mar. 1943.
• BARRETO, João de Barros. Correspondência a Gustavo Capanema. Arquivo Gustavo Capanema, série Correspondência, GC38.02.05-H (CPDOC). 4 mar. 1943.
• BARRETO, João de Barros. Projeto de luta anticancerosa no Brasil. In: Primeiro Congresso Brasileiro de Câncer, 1935. Rio de Janeiro. Actas e trabalhos.. . Rio de Janeiro: Sociedade de Medicina e Cirurgia do Rio de Janeiro; Ministério da Educação e Saúde Pública. p.83-204. 1936.
• BRASIL. Ministério da Saúde. Instituto Nacional de Câncer. Resenha da luta contra o câncer no Brasil: documentário do Serviço Nacional de Câncer. Brasília: Ministério da Saúde. (História da Saúde no Brasil, 1). 2007.
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1

In a critical review of

Imperialismo sedutor, André Luiz Vieira de Campos (2001) points out that the book's author, Antônio Pedro Tota, limited himself to the field of cultural relations between Americans and Brazilians during the days of the Good Neighbor Policy. As Campos shows, the Office of Coordinator of Inter-American Affairs (OCIIA) was active in a number of arenas, like agriculture, the healthcare system, public administration, transportation, and education.

2

The method involved use of a scalpel to transmit intense heat to tissues using high-frequency electrical energy; this allowed for larger cuts and, because it clotted the tissue near the scalpel, decreased bleeding during operations.

3

The institutions that were incorporated into the National Campaign Against Cancer were: Medical Society to Fight Cancer in Rio Grande do Sul (Decree-Law No. 4.975, dated Nov. 19, 1942); São Paulo Association to Fight Cancer, or APCC (Decree-Law No. 5.889, dated Oct. 19, 1943); Minas Gerais Radium Institute (Instituto de Radium de Minas Gerais; Decree-Law No. 6.829, dated Aug. 26, 1944); and Bahian League Against Cancer (Liga Bahiana Contra o Câncer; Decree-Law No. 6.525, dated May 24, 1944).

4

Created in 1940 as the Office for the Coordination of Commerce and Cultural Relations between the American Republics, the agency changed its name in 1941 to the Office of the Coordinator of Inter-american Affairs; in 1944, it became known as the Office of Inter-american Affairs.

5

All quotations in this article have been freely translated from the original Portuguese.

6

In a 1941 address to the U.S. Congress, Franklin Roosevelt named the four freedoms to which all human beings had a right: freedom of speech and expression, freedom of worship, freedom from want, and freedom from fear.

Publication Dates

• Publication in this collection
  05 Aug 2010
• Date of issue
  July 2010

History

• Accepted
  Feb 2010
• Received
  Apr 2009