Since the early 20th century, Brazilian public health has focused on rural areas, the people living there, and the so-called endemic rural diseases that plague them. These diseases—particularly malaria, hookworm, and Chagas disease—were blamed for negatively affecting Brazilian identity (“a vast hospital”) and for impeding territorial integration and national progress. For reformist medical and intellectual elites, health and educational public policies could “save” the diseased, starving, and illiterate rural populations and also ensure Brazil’s entry into the “civilized world.” In the mid-20th century, public health once again secured a place on the Brazilian political agenda, which was associated with the intense debates about development in Brazil in conjunction with democratization following World War II (1945–1964). In particular, debate centered on the paths to be followed (state or market; nationalization or internationalization) and on the obstacles to overcoming underdevelopment. A basic consensus emerged that development was urgent and should be pursued through modernization and industrialization. In 1945, Brazil remained an agrarian country, with 70 percent of the rural population and a significant part of the economy still dependent on agricultural production. However, associated with urbanization, beginning in the 1930s, the Brazilian government implemented policies aimed at industrialization and the social protection of organized urban workers, with the latter entailing a stratified system of social security and health and social assistance. Public health policies and professionals continued to address the rural population, which had been excluded from social protection laws. The political and social exclusion of this population did not change significantly under the Oligarchic Republic (1889–1930) or during Getúlio Vargas’s first period in office (1930–1945). The overall challenge remained similar to the one confronting the government at the beginning of the century—but it now fell under the umbrella of developmentalism, both as an ideology and as a modernization program. Economic development was perceived, on the one hand, as driving improvements in living conditions and income in the rural areas. This entailed stopping migration to large urban centers, which was considered one of the great national problems in the 1950s. On the other hand, disease control and even campaigns to eradicate “endemic rural diseases” aimed to facilitate the incorporation of sanitized areas in agricultural modernization projects and to support the building of infrastructure for development. Development also aimed to transform the inhabitants of rural Brazil into agricultural workers or small farmers. During the Cold War and the anti-Communism campaign, the government sought to mitigate the revolutionary potential of the Brazilian countryside through social assistance and public health programs. Health constituted an important part of the development project and was integrated into Brazil’s international health and international relations policies. In the Juscelino Kubitschek administration (1956–1961) a national program to control endemic rural diseases was created as part of a broader development project, including national integration efforts and the construction of a new federal capital in central Brazil (Brasilia). The country waged its malaria control campaign in conjunction with the Global Malaria Eradication Program of the World Health Organization (WHO) and, to receive financial resources, an agreement was signed with the International Cooperation Agency (ICA). In 1957 malaria eradication became part of US foreign policy aimed at containing Communism. The Malaria Eradication Campaign (CEM, 1958–1970) marked the largest endeavor undertaken by Brazilian public health in this period and can be considered a synthesis of this linkage between development and health. Given its centralized, vertical, and technobureaucratic model, this project failed to take into account structural obstacles to development, a fact denounced by progressive doctors and intellectuals. Despite national and international efforts and advances in terms of decreasing number of cases and a decline in morbidity and mortality since the 1990s, malaria remains a major public health problem in the Amazon region.
When crises collide—Policing a pandemic during social unrest