Social representation of Hansen s disease thirty years after the term leprosy was replaced in Brazil

Psychologist, professor of Universidade Federal do Rio de Janeiro (UFRJ), Rua Francisco Sá, 38/806 22080-010 Rio de Janeiro  RJ Brasil OLIVEIRA, M. L. W.-del-R. de; MENDES, C. M.; TARDIN, R. T. and CUNHA, M. D.; ARRUDA, A: Social representation of Hansens disease thirty years after the term leprosy was replaced in Brazil. História, Ciências, Saúde  Manguinhos, vol. 10 (supplement 1): 41-8, 2003.


Historical references
R egarding the images and representations involving AIDS and leprosy, Tronca (2000) points out the idea that disease is a linguistic invention to refer to a biological phenomenon, influenced not only by the technology available but also by the historical contexts of all susceptible populations.Although the term leprosy was legally banned (Brasil, 1995) under pressure from the Movement for the Reintegration of Hansens Disease Patients (Morhan), it had been in use since the beginning of the 1970s in Brazil (Rotberg, 1972(Rotberg, , 1969)).This initiative was taken due to strong pressure from Brazilian leprologists, pursuant to recommendations of International Leprosy Congresses (Havana, 1948, andRio de Janeiro, 1963) concerning minimization of the leprosy stigma (Rotberg, 1975(Rotberg, , 1973)).For Brazils Ministry of Health (MoH), leprosy and all correlate adjectives were replaced by the term Hansens disease (HD) in 1976 (Brasil, 1975), even though the first and only mass media campaign in which the MoH introduced HD concepts and images only took place in the late 1980s (Oliveira et alii, 1989).
In general, all information materials from the health sector refer to HD and make no mention of leprosy.The term Hansens disease is willingly accepted by dermatologists, patients, and the media, despite some controversy still existing among general health workers (Del Fávero, 1973;Andrade, 2001) and, indeed, it is quite unknown to the susceptible population (Feliciano et al., 1977;Maia et al., 2000).It may have started changing after the notable fact that a famous Brazilian singer sponsored a Patients Movement and, in the past two years, has been playing a major role in introducing HD information on the agenda of different media, which reach more than 80% of the Brazilian population.

Methodology and theoretical references
This qualitative study also employed a quantitative method for structural analysis.It was conducted among the population from four areas of the Rio de Janeiro metropolitan region during 2001, encompassing the municipalities of Rio de Janeiro and Duque de Caxias, in order to understand whether the popularization of scientific notions of HD have incorporated the traditional stigmatizing knowledge about the category leprosy.A theoretical model considered adequate to explain this question was based on Moscovici (1998), a social psychologist who created social representation theory (SRT).The study endeavors to elucidate how new knowledge is incorporated into pre-existent knowledge, so that scientific issues are transferred to common thinking.To better understand the structural analyses of social representation, a complementary Central Core SOCIAL REPRESENTATION OF HANSENS DISEASE (CC) theory was applied (Abric, 1998).This model tries to identify the social-cognitive contents of social representation (SR), identifying two systems of representation: a more stable, consensual, and strict central system, and a more flexible, individual, peripheral system (Sá, 1998(Sá, , 1995)).The CC is responsible for SR command and articulation.Both these theories have been used in Brazil to study AIDS, epilepsy, and similar phenomena in other areas (Jodelet et al., 1998;Tura, 1998) but not in leprosy or HD as yet.
A free-word-association test was used with eight hundred women, mostly housewives, invited to promptly express their associations with the word hanseníase.In cases where they said nothing, the word leprosy was proposed.Coded as short one-or two-word phrases, their answers were arranged by EVOC software (Vergés, 1992) in spatial form, which allows us to understand the structural organization of this SR.The word distribution not only takes into account frequency but also the order in which they were evoked and their co-occurrence.The Average Order of Evocations (AOE) is obtained by dividing the word frequencies in each position (the first receiving value 1; the second, value 2; and so on) by the total word frequencies in all positions.
The results can be interpreted by the distribution shown in figures 1 and 2, where each cell has a specific meaning within this representation: Upper-left cell: allocation of the most frequent and prompt evocations, meaning CC of SR.Upper-right cell: prompt evocations with variable frequencies, meaning close to CC of SR.Lower-right cell: allocation of evocations with variable frequencies and order, meaning peripheral system of SR.Lower-left cell: allocation of less frequent evocations and variable order, meaning personal attribute with some intermediation with peripheral system.

Results and discussion
Of eight hundred women1 (average age of 42; 62% housewives; only 1.8% working in a college-education profession), 436 (54%) promptly expressed their associations with the word hanseníase (H group) while 358 (45.1%) expressed associations only when the word leprosy (L group) was offered as a second choice.The magnitude of this relation seems to be modified by education.According to the word distribution in the upper-left cell of square 1, which comes from the H group, here the CC is formed of three terms (disease, leprosy, skin) that are related to both the HD and leprosy categories.Therefore, leprosy reached the CC of hanseníase.Nevertheless, the word patch, occupying the upper-right-cell, close to the CC, is more related to HD and is a result of frequent but not prompt evocation.The lower-right cell is formed of many words, related to both categories studied and probably representing a popularization of some scientific notions of HD, co-existing with traditional knowledge of leprosy.It is important to stress the presence of cure, treatment, and numbness, always present in HD learning materials, while the expressions pieces fall off, dreadful, and fear historically remind one of leprosy.The word rat could be related to leprosy since in the peripheral area of Rio de Janeiro leprosy is mainly an animal disease, or it might result from some confusion between leptospirose (leptospirosis) and hanseníase (leprosy), both words that present some pronunciation problems for many Brazilians.

Structure of SR of leprosy in population group
Freq. = frequency.
In the upper-left cell of group L, the words dog, disease, and skin in the CC also link to HD and leprosy categories.The words itching and wound, occupying the upper-right cell, may cause some discussion concerning their relationship only to leprosy or also to HD.Both are present at the peripheral system of the H group.As in the H group, the lower-right cell of the L group is formed of many words, related to both categories studied.On the other hand, cure is not present, which is reinforced by the word incurable.
In the absence of official information linking HD to leprosy, even in the media (Reis, 2000), the relationship of signs, symptoms, and treatment in both categories is seen differently by many people.The collective memory of leprosy is mostly oral and mainly influenced by the individuals social network.An old woman, living in Duque de Caxias, said: In my state of Minas Gerais, leprosy was a human disease but here it is a dog disease.It must be pointed out that the population of these peripheral areas of metropolitan cities is mainly formed of migrants from different states of Brazil.
Based on the theory of SR, we may conclude that HD is part of a process of modernization of common thinking, anchored in the traditional representation of leprosy.The results of research on social representation carried out in HD patients at a basic health unit in Rio de Janeiro despite referring to both categories with no distinction showed that many of such patients, even under treatment, were really in doubt if their illness was leprosy or not (Claro, 1995).It may be that thirty years is not time enough to consolidate a SR of HD.Furthermore, there has not been an ongoing investment in social marketing to make the new terminology better known.
It is possible to infer that the results presented here can illustrate both the SR theory and the concept of the history of mentalities.As Moscovici (2001) puts it, the notion of collective representation owes much to the research done by historians about mentalities: The co-existence of various mentalities in the same person in the same époque is essential in the history of mentalities as well as its transformation (Le Goff, 1976).One mentality begins to disappear when another slowly takes hold.
According to Abric (1998), among the differences of the double system of SR, the most important one is that the central system is independent of the immediate context as its origin is socially and historically determined, thus being stable and resistant to changes in the short term.On the other hand, the peripheral system allows adaptation to and integration into ordinary experiences, and it is possible to be changed.Thus it can also reach the CC, influencing long-term changes.So the peripheral system is the target for health education and therefore the contents of this system must be considered in comprehensive educational processes (Wagner, 1999;Wagner et al., 1999;Spink, 1995).
As already mentioned, the ability for evocation after hearing hanseníase was associated with higher educational levels on the part of interviewed women, even among aged ones.As the new terminology is official and definitive in Brazil, besides being very well accepted by the patients, adequate communication with the susceptible population is a valid strategy for dealing with this social context.Le Goff (1996) reminds us that we should work in such a way that a collective memory is useful to freedom and not to human servitude.
Structure of SR of Hansens disease in sample