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Doctors, social scientists, and backlands peoples: continuity and change in representations of Brazil's rural world.

Studies on the history of public health in Brazil have intensified in the past two decades, illuminating important aspects of the creation of professional groups, social representations of endemic and epidemic diseases, and the history of public health research and teaching institutions.1 One topic analyzed and still a challenge for these new studies is the role of intellectual traditions related to medical thinking and their importance in the development of the country's social and political imagination. Focusing on these traditions makes it possible to contribute simultaneously to the history of public health and the intellectual history of Latin America. This article is motivated by just such an approach. It proposes to assess changes and continuities in the construction of images of Brazil's rural population groups.

In order to do this I analyze texts composed in three distinct moments. The first group of texts was generated in the context of the movement for rural sanitation, which had a high profile in the 1910s. The second were composed during the 1930s as a part of the fieldwork promoted by the Yellow Fever Service of the Rockefeller Foundation. Finally, I look at the relationship of medical thought to one of the most recurring debates among social scientists during the 1940s and 1950s, revolving around the question of social change and development, and cultural resistance to such change. In examining key texts in Brazilian social thought, I try to reconstruct the route by which the medical representation of rural Brazil influenced subsequent texts written by social scientists that concentrated on studies of social change and the so-called "folk culture of the Brazilian backlander."

The article begins with the travel accounts by two medical doctors, Arthur Neiva and Belisario Penna, of a 1912 journey through locales in the North-east and Centre-west of Brazil. Studies of public health in the First Republic have underlined the repercussions of the ideas mobilized in these texts, especially in terms of their references to sanitation and its relevance to the process of building the nationstate (Castro Santos 1987, 2004; Hochman 1998; Lima and Hochman 1996; Lima 2007).2 The photographic images that illustrated the publications have also received the attention of historians, who have shown that they contain possibilities for multiple readings (Mello and Pires-Alves 2009; Stepan 2001; Thielen et al. 2002). Nevertheless, no systematic reading has been done of the textual contents, the nature of this source, or the style adopted by the scientists, and these are the questions I will focus on here. In terms of the perspective adopted, I relate the cognitive universe of tropical medicine to ideas of the nation--two domains generally considered in the historical literature to be unconnected. I seek to contribute in this way to a line of research oriented by similar concerns: the connections between the history of science and the history of social and political thought (Kropf 2009; Lima 1999, 2009).

As for the trips promoted by the Rockefeller Foundation, the article analyzes Julio Paternostro's book, Viagem ao Tocantins (A Trip to Tocantins; 1945). Few works mention the book, with the important exception of a 1940 analysis by sociologist Florestan Fernandes, Mudancas Sociais no Brasil (Social Change in Brazil; 1960). It is fair to say that Paternostro's text is practically unknown today, yet the ideas put forth in the book were a key element in Fernandes's first analyses of social change and what he called "cultural backwardness." Finally, I look at the theme of representations of the rural world among social scientists during the 1940s and 1950s, with an emphasis on the texts of Florestan Fernandes and Emilio Willems. This way of approaching their work reveals the constitution of a field of research characterized by the persistence of many of the same representations of rural populations that had informed the medical thinking of earlier decades. Images whose resemblance is sometimes surprising were constructed by medical doctors and social scientists from different eras, formed according to distinct academic canons, yet apparently sharing the same sentiments of estrangement in the way they situate their place as intellectuals in relation to Brazil's rural populations--represented as "other" and seen as isolated, abandoned, suffering, backward, or resistant to change.

A Scientific Journey to the Heart of Brazil: Account of the Expedition of Arthur Neiva and Belisario Penna to Bahia, Pernambuco, Piaui, and Goias (1912)

The Instituto Oswaldo Cruz was created in 1900 as the Federal Serotherapy Institute with the objective of producing serum for bubonic plague. The institute never limited itself to that end, instead taking on research and teaching activities, especially after 1902 when it came under the direction of Oswaldo Cruz. Cruz, a medical doctor, would win international recognition following his successful campaign against yellow fever, and in 1908 the institute was renamed in his honour. Its actions were initially oriented toward the sanitation of the city of Rio de Janeiro, then the capital of the republic (Benchimol 1990; Benchimol and Teixeira 1993; Carvalho 1987; Needell 1983). Soon, however, it became involved in sanitation activities in other cities, particularly in other state capitals and in coastal ports and cities of the interior. This intervention in urban spaces, accompanied by battles against epidemics of diseases like yellow fever, bubonic plague, and smallpox, was followed by an intense public campaign for rural sanitation and the centralization of health services under a single, dedicated ministry (Castro Santos 1987, 2004; Hochman 1998). An increase in the number of scientific expeditions promoted by the Instituto Oswaldo Cruz started in 1907 (Lima 1999, 2009).

The first trips were devoted to prophylactic work for infrastructure projects associated with the emerging export economy: railroad building, port construction, and studies on how to improve rubber extraction from the Amazon (Lima 1999; Thielen et al. 2002). It was also in this context that Carlos Chagas and Belisario Penna set out in 1907 for Lassance, in the north of Minas Gerais, at the request of the Estrada de Ferro Central do Brasil (Brazilian Central Railroad). Their basic goal was to carry out prophylactic measures against the malaria that was decimating the workers contracted by the company. While they carried out their mission, Chagas made a number of observations on a haematophagous (blood-feeding) insect common to the area and popularly known as barbeiro (barber). He verified that the insect, Triatominae (in popular English, assassin or kissing bug), was the vector of a hitherto unknown disease associated with a series of clinical manifestations, especially cardiopathy, cretinism, and hyper thyroidism. Caused by protozoa that Chagas named Trypanosoma cruzi, the disease initially received the scientific name "American trypanosomiasis" and later "Chagas disease." In the context of an intense controversy over this scientific discovery in 1909, the disease became a symbol of Brazilian medicine and indeed of the high quality of national medicine (Kropf 2009).

In the 1910s the scientific field trips sponsored by the Instituto Oswaldo Cruz to aid the activities of the Office of Works for Drought Prevention stand out. These missions had as their goal an inventory of the epidemiological and socio-economic conditions of the regions bordered by the Rio Sao Francisco and other areas in the Brazilian North-east and Centre-west. Among the field trips, the one that would become best known was that of Arthur Neiva and Belisario Penna, which visited locales in the states of Bahia, Piaui, and Goias. In the space of seven months, from March to October 1912, the two doctors were responsible for improving the living conditions of the local populations, for compiling an expressive photographic registry, and for the account that became a point of reference for the movement for rural sanitation during the First Republic (Castro Santos 1987, 2004; Hochman 1998; Lima 1999). The "discovery" of this unknown and diseased Brazil in the medical expeditions of the Instituto Oswaldo Cruz--especially the discoveries by Carlos Chagas--generated one of the phrases that would become emblematic of the movement for rural sanitation of the backlands and of the creation of the Pro-Sanitation League of Brazil: Brasil imenso hospital ("Brazil--an immense hospital"), a powerful expression first coined by the physician Miguel Pereira in 1916 (Sa 2009).

How can we explain that a medical travel account brought to light so many diverse aspects, ranging from the nosology of the regions traversed to the habits, language, and economic activities of the populations with whom the scientist-travellers came in contact? I think this great breadth of topics and viewpoints can be understood as coming from an elective affinity between knowledge of tropical medicine and the ideas thematized in currents of social and political thought that were common during the First Republic. The search for knowledge coming from geography, culture, and history--fundamental for an understanding of the incidence of certain diseases and their distribution in time and space--favoured a wider perspective on the population groups with whom the doctors came in touch, often as an unanticipated effect of their activities. This hypothesis, if accurate, would require that we revise the argument that sees the consolidation of microbiology, especially under the influence of the work of Louis Pasteur, as a linear process, one that progressively displaced attention to the environment with a focus exclusive to the laboratory (Rosen 1994).

This linear interpretation has been reconsidered by a number of authors who, from a variety of theoretical perspectives, underline the fact that medical researchers' attention to environmental and social questions was not exactly abandoned during the so-called "bacteriological revolution," but rather underwent redefinition with respect to the understanding of social relations (Latour 1984; Murard and Zylberman 1985). Anne Marie Moulin (1996) and Nancy Stepan (2001), among other scholars of tropical medicine, have identified a contemporary perspective on processes of health and disease that had a strong emphasis on environmental variables. According to these authors, "tropical medicine," whose origins and name can be attributed to Patrick Manson, defined itself in terms of two scientific traditions: on the one hand, the model of experimental laboratory research characteristic of microbiology; and on the other hand, field studies on disease-transmitting vectors and the notion of natural cycles, suggesting the need to understand the complexity of environmental interactions. National contexts in which scientific knowledge related to microbiology was institutionalized also need to be considered.

According to Sandra Caponi's (2003) comparison of Brazil and Argentina, a more environmentalist vision emerged in Brazilian microbiology due to the intersection of two types of knowledge and two programs of research that did not always get along easily: microbiological laboratory studies and entomological field work based on the model of naturalist classification (Caponi 2003, 122). The scientific expeditions of the Instituto Oswaldo Cruz--and none more than the scientific journey of Neiva and Penna--offer very suggestive elements for evaluating the explanatory power of this hypothesis. For these scientists, not only ecological variations but also the historical register were crucial for understanding the complex of diseases and their relationship to the living conditions of the population. References to accounts written by naturalists on the populations and the diseases encountered should not be seen as mere illustrative citations; rather, they were intended to attribute explanatory importance to prior registries of the regions visited. Not only static aspects of the environment merited attention, but also the impact of their transformation.

In the same vein, popular terms for diseases, their synonyms, and their possible causes and treatments were considered by Neiva and Penna in the elaboration of scientific texts. The ambivalent feelings that the doctors expressed about how they related with the population, oscillating between negativity and admiration, did not impede their evident interest in learning local habits, culture, and language. The affinity between this knowledge and currents of social thought links to the role of doctors, among them Neiva and Penna, in the intellectual and political debate on the national question during the First Republic. As previous studies have observed, intellectuals actively participated in this debate that started at the time of World War I, and put on the public agenda a critique of deterministic views that stressed the unviability of the country as a nation due to the alleged racial inferiority of its population (Castro Santos 1987, 2004; Lima 1999; Lima and Hochman 1996; Oliveira 1990; Skidmore 1974).

At the same time and in large measure due to the impact of the Canudos War (a fin-de-siecle conflict pitting the backlanders of the Northeast against the federal government), an idea of constructing an authentic nation gained currency as the main axis for the incorporation of the populations of the interior. For this, Euclides da Cunha's book Os sertoes (Rebellion in the Backlands; 1966 [1902]), which interpreted the massacre of the backlanders of Canudos as a crime against a nationality in formation, was particularly influential.3 The travelling doctors of the Instituto Oswaldo Cruz were not hugely influenced by this climate of ideas, but they participated in its creation, and the scientific journey of Neiva and Penna can be inserted in this context of the movement for the rediscovery and invention of Brazil. Their positions reveal points in common with the contemporary debate on nationality and national cultures. At the same time, beyond the aforementioned ambivalence about approaching the rural populations, their proposition for including backlanders in the national project had a conservative bias and was quite distant from a defense of democratic values.

Finally, I wish to comment more generally with respect to the way the authors make explicit the tension inherent in the text, one that oscillates between scientific objectivity and literary subjectivity. They seem to have been unclear whether they were writing an article based on an account of a journey and marked by neutrality, or a "tragic poem," the term they used. Understanding this piece of writing and this tension requires a consideration of the scientific knowledge and style of the era. On this point, it is important to take into account Neiva's erudition. In the years following the voyage, he would publish books and articles on themes as varied as entomology, the therapeutic properties of plants, phytopathology, and indigenous vocabulary. At the same time, one cannot consider this profile singular, given that Brazil in the first decades of the 20th century was experiencing the beginning of a process of professional specialization of the scientist that was not yet characterized by a clean separation between men of science and men of letters, or by strict disciplinary specialization (Sa 2006). The travel account of Neiva and Penna (1916) is exemplary of this variation in language, bringing together descriptions of fauna, flora, and nosological profiles, commentaries of a political and social nature, and strong images of literary inspiration.

Throughout the account it is clear that one of the principal objectives of the trip was to find evidence that would corroborate the epidemiological importance of Chagas disease (Kropf 2009; Lima 2009). Beyond this, the concern with diseases of unfamiliar etiology that were noticeable for their high incidence in the state of Piaui justified the large number of pages dedicated to spasmodic dysfasia (difficulty in swallowing)4 and to the cardiac condition called vexame do coracao (literally, "scandal of the heart").5 One of the principal contributions of Neiva and Penna, despite being rarely noticed by scholars and teachers, is worth noting, however: their observations on the depletion of water, which was a priority issue for the Office of Works for Drought Prevention. The theme most emphasized was desertification as a result of deforestation.

With respect to human types, they described ethnic characteristics, differentiating the areas of greatest indigenous influence from those where the population of African descent predominated. Nevertheless, rather than stressing racial questions, the commentaries categorized human types in terms of economic occupations, like those of the cow herds and manicobeiros (workers who extract a kind of rubber from manicoba, a plant found in the Northeast). Neiva and Penna showed their sensitivity to the social picture, observing the great problems stemming from the concentration of land ownership. Their critical discussion of the debt bondage system of the barracoes,6 which can also be found in other contemporary travel texts, became particularly pointed in the authors' commentaries on manicoba exploration, which almost always co-existed with semi-slavery. They also noted the way that public authorities protected the interest of the bosses, or barraquistas:

The authorities pay closer attention to the manicobeiro who tries to flee his debt, and in the town of Parnagua, we had the displeasure of witnessing the arrest of 4 manicobeiros brought by force to the store of a boss known for the crimes he committed throughout this zone we were crossing. (Neiva and Penna 1916, 180)

The abandonment by public authority--its absence--is another theme highlighted by Neiva and Penna, which they called a "spirit of routine" that can only be broken when isolation ends. They stressed that in travelling more than 3,500 kilometres after leaving Petrolina they encountered only one railroad in Anhanguera (Goias) and scarcely three locales that had newspapers published locally. The spirit of routine manifested itself in the absence of money, use of the manual loom, the systems of measures, and the language. With the exception of the planters and a few well-travelled individuals, nobody placed any importance on money, and according to the doctors one could offer relatively large quantities of money for a dozen eggs without success.

Information on living conditions in Brazil in the early 20th century can also be discovered in the account, especially in descriptions of the towns of Sao Raimundo Nonato, Caracol, Parnagua, Piaui, and Porto Nacional, all in Goias, which are also the textual passages of greatest literary expression. Notable is the emphasis on the difficulties encountered in their long trajectory, especially the lack of water resources in the drought-hit regions, and the misery and abandonment of the populations all along the road, but principally in the north of

Goias. An image of generalized illness was accentuated at the end of the account, but what most stands out is the backwardness of the populations--a backwardness of three centuries, as they put it in one of many implicit references to images in Rebellion in the Backlands. Endemic diseases in the northern part of Goias were described more intensely, especially Chagas disease, whereas in areas of Bahia and Piaui the most recorded diseases were asthma and spasmodic dysphasia (see note 5) and, in some regions, malaria, particularly after the winter rainy season.

In this descriptive part of the account, contradictory information and observations like those referring to the indolence of the population can be found. In Parnagua, on the outer limits of the drought-stricken region, where they spent 20 days, the representation of the people as indolent is quite pointed. Nevertheless, in spite of this unfavourable portrait, the authors referred to a raca aproveitavel ("potentially useful race"), recalling once again numerous passages of Rebellion in the Backlands, especially those describing the cowherd as conjured by Euclides da Cunha. It is important to remember that for da Cunha the backlander was not always portrayed as strong; most representations oscillated between characteristics of Hercules and those of Quasimodo (the famous character of Victor Hugo, an author with a strong presence in da Cunha's works). The negative vision of the common people was, in part, undercut by an emphasis on the lack of public authority in terms of guarantees of elementary civil and social rights, as can be seen in the following passage:

It is a region that, though inhabited for centuries, still remains impervious to progress, its inhabitants living like primitive peoples. They live devoid of whatever assistance--without roads, without police, without schools, without medical and hygienic care--relying exclusively on their meagre resources, defending their lives and properties with antique weapons, without protection of any kind, knowing of the existence of governments because they impose taxes on them in cattle, in wood, in horses, and in burros. (Neiva and Penna 1916, 199) The portrait of the country sketched in the Neiva-Penna account pointed to disease and not to climate or race as the principal problem for progress in the regions. The backwardness could only be explained by the abandonment that the populations of the interior of Brazil experienced--a subtle but significant change in the well-known theme of isolation of the backlander proposed earlier by Euclides da Cunha.

For the diffusion of these ideas, they relied heavily on the publication of articles in the press: by Belisario Penna in the daily Correio da Manha' and by Monteiro Lobato in the newspaper O Estado de Sao Paulo. Penna's texts were reprinted in 1918 in a book, Saneamento do Brasil (Penna 1918). Their representations spread most widely, however, through the writings of Lobato, collected in Problema Vital (1957 [1918]). The book included a text on the rebirth of Jeca Tatu, one of his best-known characters, a classic literary representation of the Brazilian poor, especially peons and other rural workers. In the decades that followed, these powerful images were continually mobilized in intellectual and political debates on the state of Brazil, so well synthesized in the "immense hospital" metaphor of Miguel Pereira. The registry of the backlands populations' living and health conditions would acquire new contours and shades two decades later in a text by Julio Paternostro that narrated his journey to Tocantins.

A Trip to Tocantins: Central Brazil in the Eyes of a Physician

From 1934 to 1938, Julio Paternostro made two trips as a Yellow Fever Service (YFS) physician to regions on either side of the Rio Tocantins. The YFS was created through an agreement between the government of Brazil and the Rockefeller Foundation, and during this period the Rockefeller Foundation's activities around the world gave priority to malaria and yellow fever research and control (Cueto 1994; Marinho 2001; Faria 2007).7 Although the hypothesis that the transmission of yellow fever by vectors other than the Aedes aegypti mosquito and in non-urban environments had been proposed as early as 1914, it was in the 1930s that studies on jungle yellow fever intensified (Benchimol 2001; Lowy 1998, 2006). Paternostro's journey was part of this research effort that started in 1932 following an epidemic of yellow fever in the Canaa valley in the state of Espirito Santo. From November 1934 to March 1935 he travelled in the southwest and the centre of Goias and, later, from May to September 1935, he made a second journey with the official objective of discovering the distribution of yellow fever immunity in the region. His results would become one of the principal sources for the important publication in which Fred Soper (1937) analyzed data for Brazil, Colombia, Ecuador, Peru, Bolivia, the Guyanas, Venezuela, and the north of Chile (collected by doctors of different nationalities) with the aim of identifying cases of yellow fever in areas where the Aedes aegypti mosquito--to that point the only known vector of yellow fever, responsible for its transmission in urban areas--was not present.

It was this institutional and scientific complex that made Julio Paternostro's excursion to Central Brazil possible. In Viagem ao Tocantins ("A Trip to Tocantins"), the Brazilian physician discussed the role of his trip in the research carried out by the Rockefeller Foundation, and mentioned his field experience and a case of autopsy that constituted the first anatomo-clinical diagnosis of yellow fever in Central Brazil (Paternostro 1945, 331). Paternostro tells us that his assignment to traverse through areas of the state of Goias came from Soper's suspicion that the disease was present in the region. Paternostro was returning to Rio de Janeiro without having encountered any evidence to confirm the hypothesis when he heard rumours about the existence of cases showing clinical signs on the margins of the southern tributaries of the Tocantins. He resolved to investigate, altering the itinerary established by the Yellow Fever Service.

Leaving the automobile, I went on horseback into these woods where the locals had told me clinical stories of fatal cases and shown me individuals who had recuperated from a "fever" that, from the symptoms described, seemed like yellow fever. Thus I arrived in Jaragua, where I encountered Dr. Paulo Alves. ... We learned then that in a place called fazenda Candongas, four leagues to the northeast of Jaragua, there was a woman who had come down with yellow fever. (Paternostro 1945, 330)

Upon attending with the local doctor this woman gravely ill with yellow fever (referred to in the text as cabocla Vicenca), and in the face of resistance from the local population to performing autopsies, they had to deploy more than a few strategems. "Dr. Paulo" announced to the victim's parents that they would have to trust her with the doctors:

At midnight, I came upon Dr. Paulo, whose jacket sleeve had received a spew of black vomit from the woman in her death agony. The patient was dead. With the greatest care, avoiding making any noise, using an apparatus, the viscerotome,8 we extracted samples of the cadaver's organ that allowed for the first anatomo-pathological diagnosis of yellow fever in Central Brazil. (Paternostro 1945, 331)

The role of this scientific excursion in research on jungle yellow fever was not, however, the aspect given the most value in A Trip to Tocantins. Understanding the book and the ideas it advanced requires a brief commentary on the author's biography. At the time of the trip, on top of his job as a doctor in the Yellow Fever Service, Paternostro was politically involved as a militant in the Brazilian Communist Party. That influence revealed itself in the book in different ways, particularly in a defense of socialism, strongly mixed with nationalist ideas. Among other things, the author's interest in collecting signs of the passage through the area of the Prestes Column is evident. (9)

It could be said that a general thesis orients the book, according to which the country's geography does not simply influence the activities of its inhabitants, but their mentality as well. Many passages seem to show an intent to identify the characteristics of different regional types, so present in literature and social essays published in Brazil from the 19th century onwards. It is interesting to observe that the author tried to sketch out a sociological analysis of these national types on the basis of the social relations encountered. Beyond the reiteration of the idea of isolation and abandonment, Paternostro's characterization of the backlands relied on an image of the backlander as a "pariah of civilization." He also underscored the short distance between the social classes in many locales, in particular in cattle-raising areas, something demonstrated in the habit of the collective river bath. Paternostro observed that it establishes "local judge, planter, merchant, and ranch hand completely as one, levelled in the collective bath, which is also good for the body and the spirit" (Paternostro 1945, 191). In terms of health conditions, the greatest emphasis of the work is placed on pointing out a lack of medical attention and social backwardness as the population's principal problems.

The book even made observations about the local people's perceptions of the activities of the Rockefeller Foundation, signalling, for example, the greater acceptance of collecting blood samples on the part of indigenous societies like the Apinages, compared to some groups of backlanders:

When they seek out or are visited by a person they judge important, the Apinages paint themselves with urucu [achiote] and genipapo: this was the response I got when I asked them why the men and women disappeared from my view and returned with their faces and bodies covered in black and yellow. As my job was to collect blood for biological proof of yellow fever, I easily punctured the veins of 18 Apinages; the only condition that they gave me was that I first had to wait for them to paint themselves with urucu and genipapo. (Paternostro 1945, 145)

The third part of the book, chapter XI on the Middle Tocantins, was dedicated to the indigenous societies of the region and the interethnic contact of the Acuiris, Gavioes, Apinages, and Cherentes. In his conclusion, Paternostro stressed the precarious health conditions of these indigenous societies, their infectious diseases, the venereal diseases they contract from the backlanders with whom they interact, and the lack of attention from an efficient Protection Service (Paternostro 1945, 150). Cultural resistance to the journey's objectives--capturing mosquitoes and principally collecting blood from the inhabitants--was duly registered in the text. In the city of Piabanha, for example, the populations opposed the collection of samples, saying they were before an emissary of the Anti-Christ (Paternostro 1945, 217). In the same vein, he referred to resistance to exhumation, a significant fact in autopsies for the anatomo-clinical diagnosis of yellow fever (Paternostro 1945, 217). On the other side of things, he noted in those who responded positively to the doctor's work a great distance between the objectives of the journey and the expectations of the populace about its possible impact on the improvement of public health and medical services. Paternostro even mentioned that posts for malaria prophy laxis were set up in many settlements in the regions of the Tocantins valley and doctors were assigned following his visit.

Paternostro mentioned in more than one passage of the book this disconnect between the specific aims of the Yellow Fever Service and the demands formulated by political leaders in the towns visited. According to the author, in the north of Goias in 1935 only one city--Porto Nacional--had a doctor. The more advanced municipalities received medical care from the classic Santas Casas, crude hospitals that had irregular resources from endowments and small popular contributions made in the context of the traditional Church festivals. The precariousness of the help they provided was summed up in a phrase commonly used by the population: "I will die in the Santa Casa." As for public health, Paternostro observed that many state health posts installed in municipalities to take care of endemic diseases (malaria, hookworm disease, leishmaniasis, tracoma, etc.) had been built to guarantee the prestige of the jefes politicos (district adminstrators). This ensured that they were totally inoperative due to the great distances that the residents had to travel to reach them. The inhabitants of towns, small settlements, plantations, and unexplored territories of the 1574 Brazilian municipal districts could only count on the services of druggists, empirics, and curanderos. Paternostro proposed that official status be given these practitioners who provided care to rural workers, institutionalizing and expanding a practice that was already widespread: the use of some curanderos by municipally employed doctors to attend to the most isolated rural areas (Paternostro 1945, 240).

References to the expeditions of Arthur Neiva and Belisario Penna can also be found in the book. Paternostro pointed out that 26 years earlier they had travelled the area he visited in the north of Goias, especially Porto Nacional and locales close by. He compared his observations with those made by the Instituto Oswaldo Cruz scientists, especially in relation to cases of goitres and the presence of the kissing bug. He reiterated that when he observed families beset by goitres he did not find specimens of these triatomines. According to Paternostro, the notion that the insects were responsible for the transmission of Chagas disease was so widespread that the residents themselves had undertaken to eliminate them, to the point that they were now difficult to find in the principal cities of Goias.

Despite his interest in the history of health, the strong point of the book is its description of the economic activities, working conditions, and problems of communication among the populations encountered, with extensive descriptions of the extraction of Brazil nuts in Para, fishing, and the labours of boatmen and other typical figures.

Social Scientists and the Theme of Rustic Culture

In 1946 Florestan Fernandes, a sociologist who at the time already enjoyed considerable intellectual prestige, published a series of newspaper articles in the Jornal de Sao Paulo under the title Um retrato do Brasil (Portrait of Brazil) in which he commented on Julio Paternostro's Trip to Tocantins. The author, in dialogue with his public, makes clear the reasons for the title, as well as his motivations:

The reader, naturally, would like to know why I chose the title "Portrait of Brazil" for the studies in this series. Its curiosity must be greater in that it does not treat Brazil in general, but only comments on the data presented in Julio Paternostro's Trip to Tocantins. The answer is simple: taken together, the various aspects that will be successively analyzed ... give us a de facto portrait of Brazil. It is a Brazil that is distant from our eyes, remote from our daily preoccupations, but it is, nevertheless, a Brazil that still exists. (Fernandes 1979, 161)

Fernandes relied on Paternostro's text to discuss the meaning of the opposition between littoral and backlands and to point to the necessity for research carried out by specialists on population groups and their social relations in the interior of the country. He underlined the fact that Paternostro's book was a "biased" work, motivated by the doctor's socialist convictions, which gave it its accusatory character, but Fernandes saw this as positive, despite its simplifications, omissions, and superficial treatment of some issues. The sociologist noted the lack of geographical precision in the terms "littoral" and "backlands," which in reality appeared more as an expression of a certain type of social and cultural formation in which time--more precisely the contrasts between the various historical phases of a civilization--would be a more significant variable than space. It was not a question of geographical distance, but rather of the cultural distance that was manifest in the contrasts, or in the limits, the antagonisms and conflict, between civilization and "folk cultures" (Fernandes 1979, 123). For Fernandes, this opposition indicated a degree of civilization:

The socio-cultural development of Brazil was not uniform or organic. Some cities will accompany the "progress" of civilization, though in retarded fashion; they will transform themselves today like Sao Paulo into metropolises. Others, when not regressing, will immobilize themselves, stagnate in their socio-cultural process like the so-called "dead cities." ... These make up the "folk cultures." (Fernandes 1979, 124) Conforming to tradition, millions of individuals lived a life from the 18th or 19th centuries and, in the contact between the civilized man of the littoral and the man of the backlands--the "pariah of civilization," as Paternostro had called them--the attitudes varied from sympathy to rejection, but were marked by an undeniable ethnocentrism. In words with strong symbolic resonance, Fernandes affirmed that "the cultural reality of Brazil is and will be for some years to come that described by Euclides da Cunha in Rebellion in the Backlands" (Fernandes 1979, 125).

Fernandes opposed the excessive optimism of those who think that solutions to problems of education and health were the keys to overcoming obstacles to modernizing the country. In terms of the health conditions described by Paternostro, which called attention to the principal diseases and especially the omnipresence of malaria, the sociologist invited the reader to reflect on what he considered valuable from the medical and sociocultural points of view: the relationship between popular or (the term he used) "empirical" medicine and scientific medicine. This would be particularly important "in the study of the patterns of behaviour of a folk culture and also of certain aspects of social organization ... and useful in the analysis of the motivations for acceptance or rejection of the known forms of cure and treatment of diseases--those of 'scientific medicine' represented by doctors" (Fernandes 1979, 140).

In considering cultural changes, Fernandes observed that even local doctors resented the "cultural lag" due to the isolated conditions in which they remained, and noted that they were also vulnerable to the effects of folk culture. Finally, he underlined Paternostro's defense of the systematic use of curanderos and empirics, following some training by doctors, to transmit messages and administer medicines. This would reveal that the doctor had a good comprehension of the cultural complex that surrounded medical practice and that required the development of an "ethnological policy" (Fernandes 1979, 146).

For the sociologist, Paternostro's text brings together important facts about the conditions of life and work, and identifies the various types of backlands workers: "the rubber tappers, the cowherds, the boatmen, the transport workers, the Brazil nut workers, the mule drivers" (Fernandes 1979, 148). He observed that mobility existed among some of these categories of worker, one that is expressed even in the mixed language of the cowherd-boatmen. He emphasized verbal contracts, the absence of labour legislation to cover the rural workers in Brazil, and their low salaries. The demographic instability of some villages and the nomadism of the residents were likewise underlined.

Modernization required rational resources of thought and action, and this came up against obstacles of a cultural nature. In Fernandes's way of understanding, the conditions under which the country's demographic, economic, and political development took place meant that certain specific problems were located in the possibilities of promoting "directed change." Above all, the degree of economic and cultural discontinuity that existed between cities of the coastal strip and those of the backlands had created obstacles to administrative and political rationalization that the government was not prepared to tackle. For this reason, and within the optic of resistance to change, Paternostro's book ignited Fernandes's interest; this theme is also present in various other writings by Fernandes.

In his conclusions, Fernandes noted that all his commentaries on the doctor's work refer to "maladjustments and conflicts provoked by the diffusion of medicine, medico-sanitary and hospital care, primary education, etc." (Fernandes 1979, 163)--that is, those related to the introduction of cultural elements of "civilization" in those "folk" societies of the Tocantins valley. According to Fernandes, Paternostro's book revealed "the difference that exists between the process oriented or directed in some way through social techniques, and spontaneous sociocultural change" (Fernandes 1979, 163). In sum, the issue was to defend the adoption by the government and by local administrations of social techniques, informed by specialist workers in the area of social sciences, capable of sustaining a "policy of control and orientation, to the extent possible, of social processes" (Fernandes 1979, 164). The sociologist affirmed that the problem of intervention in the control over social processes was constitutive of the social sciences that, in his words, "were born and developed under the sign of Auguste Comte or under the sign of Karl Marx--with the double aim of exact knowledge of social reality; and of their dominion over man" (Fernandes 1979, 161).

Portrait of Brazil was later republished in Social Change in Brazil, a book that brought together for the first time texts written between 1943 and 1959. In the preface, Fernandes recalled the importance of the work of Emilio Willems, which made it evident that "diverse cultures coexist in Brazilian society, within the same political borders" (Fernandes 1979, 11). He cites one of Willems' texts in particular, "The Rural Problem in Brazil from an Anthropological Point of View," published in 1944 by the Secretary of Agriculture, Industry, and Commerce of the State of Sao Paulo. His interest in the text was awakened by the clear way in which Willems defended a program of political intervention in the "backlands cultures," relying on specialists in different areas and with a big presence from the social sciences. Over the course of the argument, there is an undeniable defense of the political significance of studies of rural communities--whether of immigrants, or of communities of caboclos10 or "backlanders."

For Willems the idea of backlands culture, cabocla culture, or rustic culture--terms used interchangeably--is something different than so-called "folk cultures" (this differs from the perspective adopted by Fernandes that, it would seem, did not attribute special meaning to that distinction). For the concept of cabocla culture, inter-ethnic contact played an important role, as we can see in the following passage: "Almost all Latin American countries have their cabocla cultures. In Africa and Oceania one can find primitive or semi-primitive cultures and the contacts that are established among them and the white civilizers can be compared--mutatis mutandis--to the contacts that linked littoral civilization in Brazil to the backlands cultures" (Willems 1944, 18).

The problem with the backlands populations was located in the pre-capitalist stage in which they lived, one of a "vegetative self-sufficient existence," in the words of Willems. What was needed was intervention in their forms of life that would inspire new necessities and integrate them into the market economy. Only knowledge coming from the social sciences would permit action oriented to altering cultural practices in a manner congruent with the milieu in which they found themselves. Even though this larger cultural universe might, at its limits, generate some situations of misery, these would be "a thousand times preferable" to the "vegetative existence" of the backlands populations, for they would be coming into contact with the "capitalist spirit" (Willems 1944, 12).11

The backlands figured as the locus of the disintegration of indigenous cultures and their substitution by "cabocla cultures." Willems' observation is emphatic:

Certainly no one will be surprised to observe that European peasant cultures present a richer and more varied content than the Brazilian backlands cultures. For many people, nevertheless, the fact that also the maj ority of indigenous tribal cultures from central Brazil and overseas are in relatively more favourable shape than their caboclo neighbours is a reason for grave concern. (Willems 1944, 35)

Many of the errors commited in the attempt to develop pedagogical programs jointly with backlands populations were attributed to measures that inadequately considered their cultural context. Willems picks up the theme of the "school of literacy" as an example of an approach that should not be followed, as its introduction would contribute little to integrate backlands culture into a competitive economy based on models of consumption and living that were considered civilized.

The reformer would always be faced with extremely complex problems, and specialists normally developed programs together with these populations, focusing on a cultural path or the introduction of an innovation, not seeing that success would depend on the proportion in which other cultural elements could be substituted (Willems 1944, 17). For example, Willems considered that one of the basic elements, the work regime, was almost always associated with conceptions of time, diet, family organization, religion, and recreational activities (Willems 1944, 13). He ultimately defends the presence of social scientists in processes of directed social change alongside traditional specialists involved in projects for caboclo populations--sanitary doctors, agronomists, educators, and economists: "[O]bservers are almost always specialists interested in, for example, curing maleita [tertian fever, associated with malaria], teaching potato cultivation, implanting preventive habits against hookworm disease, or studying the possibilities of credit or of cooperative organizations, while basic processes go unnoticed" (Willems 1944, 15).

In another passage, he writes that "for medical doctors, the caboclo is a sufferer and a malnourished being; for the teacher everything 'bad' stems from illiteracy; the agronomist verifies the absence of 'rational' agricultural knowledge; the economists see the absence of credit, of markets, and of means of communication; the moralists want to eradicate certain vices and so on" (Willems 1944, 21). These specialists cannot ignore the role of the social scientists, especially those in sociology and anthropology, who can connect ecology, demography, and social psychology in the elaboration of scientific plans based on cultural analysis and the organization of the process of transition for a modern society.

Anthropological and sociological studies would fulfil in this manner an important role, and it would be possible to follow the example of the United States, where specialists in rural sociology cooperated with the technical and administrative departments of the federal and state governments in the search for solutions to rural problems (Willems 1944, 29). This principle of intervention would have to orient a program of research in the social sciences in which monographic investigations were combined with comparative studies. In truth, the first would have to be subordinated to carrying out the second since, according to Willems, these were the ones that permitted the formulation of scientific laws. This understanding appeared in more or less explicit form in other works by Willems, especially in those dedicated to acculturation and assimilation of immigrants and backlanders, where the author's concern with assuring the greatest cultural uniformity and the development of mentalities congruent with the economy and life of modern societies is evident throughout.

The debate on processes of sociocultural change and the focus on the possible manifestations of anomie among the backlands populations were central in other studies that developed, at least in part, under the influence of Willems. Elsewhere I have looked at recourse to the concept of rustic culture in important lines of research like those of Maria Isaura Pereira de Queiroz on the peasantry and messianic movements in Brazil (Lima, 1999). One of the most suggestive approaches to the concept consists in the postulation of a medicina rustica (rustic medicine), made by Alceu Maynard Araujo, a professor at the Escola Livre de Sociologia e Politica who participated with Donald Pierson in a research project on the Sao Francisco valley. Winner in 1959 of the Premio Brasiliana, Medicina Rustica (19779) documents and analyzes healing practices and the vision of medicine among the populations of the northeast. According to Araujo, the hierarchy established by the people gave the highest place, among those who practice medicine, to the curanderos. Afterwards came benzedores (male and female folk healers) and benzinheiras (healers specializing in children); root doctors; pharmacists; and finally--lowest in the hierarchy--medical doctors. Moreover, according to Araujo, few inhabitants sought medical assistance, criticizing doctors who prescribe penicillin but will not go to the home of a poor person. Analyzing problems of great diversity and complexity, such as the relationship between religion and healing practices, Medicina Rustica's many merits include a displacement of attention on "cultural resistance and change" with a reconstruction of the actual problems in the relationship between doctors, as representatives of Western medicine, and the local populations.

Final Considerations

This article has tried to contribute to the historical analysis of representations of Brazil's rural world, considering the relations between the formation of the field of public health and the development of sociological and anthropological studies. The debates in the decades of the 1910s and 1920s on the possibility of transforming "Hospital

Brazil" and on modernization and cultural resistance to change from 1930 onward, were strongly sustained by a dialogue with the proposals articulated by medical doctors acting in the field of public health. We have also observed the role of these doctors in the interpretation of society and in the discussion of a national question that, in the case of Brazil, was marked historically by the contrast between littoral and backlands.

It was frequently in dialogue with this strong tradition of medical thought that influential social scientists, among them Emilio Willems and Florestan Fernandes, presented their reflections on cultural contrasts identified in Brazil. As other studies have already shown, the central problematic that accompanied the formation of the social sciences in Brazil was the same one that motivated important social actors in the area of health, and can be summed up in the question: What country is this? (Lima 1999; Peirano 1981; Queiroz 1973). To respond, social scientists returned to ideas originating in public health and looked at sources like medical theses, studies of rural hygiene, and accounts of medical doctors' travels in the interior of Brazil. As I have tried to show, Willems' appeal for the presence of social scientists at the side of agronomists and doctors in order to offer something distinct from technical advice on farming and disease, and permit a more complex comprehension of the cultural contexts of these populations, was not made in isolation. From the 1940s to the 1960s many community studies done by social scientists covered issues relating to the health and living conditions of rural populations (Maio and Lima 2009).

Recent historical studies have demonstrated the limits to the medicalization of society, the extreme complexity and pluralism of medical practices--the scientific ones as well as the popular ones--and the restricted reach of public health programs until the most recent period, in Brazil just as in other countries in Latin America (Hochman and Armus 2004). In the case of Brazil, it is possible to affirm that the authors who constructed the field of public health also filled the roles, among others, of interpreters of society, creating enduring images about the populations with whom they established contact and influencing in the process the formation of a sociological knowledge of the country.


I thank participants in the seminar Practicas, objetos y actores de salud en America Latina durante el siglo XX. Continuidades, cambios e innovaciones at the Universidad Nacional Autonoma de Mexico, for their comments on an earlier version of this text. I also thank Simone Kropf and Joffre Marcondes de Rezende, respectively, for the suggestions and assistance in the elaboration of notes on the "diseases of the backlands," and Steven Palmer for his careful translation of this article.

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(1) These are themes evident in articles that have appeared in the journal Historia Ciencias Saude--Manguinhos. For a general vision and a summary of some tendencies in historiographical production in Brazil and Latin America, see Hochman and Armus (2004).

(2) The First Republic is the period between 1889, when Brazil was declared a republic, and 1930, when the anti-oligarchic and revolutionary movement led by Getulio Vargas came to power.

(3) The book Os sertoes was published in English as Rebellion in the Backlands (Chicago: University of Chicago Press, 1944).

(4) A disease endemic among rural populations in some regions of Brazil, characterized by difficulty in digesting food. In 1916 Chagas formulated the hypothesis that the choking could be a clinical manifestation of American tryponasomiasis but did not persist in research on this aspect. In their account of the 1912 trip, Neiva and Penna (1916) dedicated particular attention to spasmodic dysphasia, known as mal de engasgo (literally, "choking disease") and entalacao, although without making explicit any connection with the hypothesis of the parasitic etiology of Chagas disease. From the 1950s onward, the physician Joffre Marcondes de Rezende, who saw in the descriptions of Neiva and Penna a reinforcement of his conviction about a correlation between mal de engasgo and Chagas disease (Rezende 2009), furnished convincing clinical, epidemiological and serological data that the symptoms of "megaesophagus" and "megacolon" were caused by infection by T. cruzi in its chronic phase.

(5) The term vexame do coracao was used by the rural population to describe subjective sensations of discomfort related to the functioning of the heart, such as palpitations and alterations in the rhythm of the heartbeat. Carlos Chagas, in a work written with Eurico Villela in 1922, affirmed that these phenomena--that could have diverse causes--were also part of the semi ological complex of American trypanosomiasis, constituting clinical signs of myocarditis caused by the pathogenic action of T. cruzi (Chagas & Vil lela, 1922).

(6) The barracao system refers to a specific form of debt peonage in which the workers or small independent farmers are remunerated with goods or credit in a store (barracao) owned by the boss.

(7) This changed after 1940 when the institution stopped projects like those stemming from the agreement that had established Brazil's Yellow Fever Service, a change of direction that would culminate, at the end of World War II, with a focus on medical instruction, physical and biological sciences, and agriculture.

(8) During the 1930s, on top of serological analyses, the extensive use of viscerotomies--the extraction of samples of organs, particularly the liver--emerged as an important means of carrying out research on yellow fever and of positively identifying cases.

(9) The Prestes Column was a military-political movement led by Miguel Costa and Luiz Carlos Prestes that covered almost 25,000 kilometres in the interior of Brazil between 1925 and 1927. Its leaders proposed different social and political reforms--the secret vote and free public education among them. Many of its followers would later participate in the movement that came to be known as tenentismo, a current formed of young junior military officers who would have an important role in the Revolution of 1930. Prestes later joined the Brazilian Communist Party, becoming one of its principal leaders (on this, see Prestes 1997).

(10) Caboclo was a term used to describe a poor, rustic person of mixed race.

(11) According to Willems, the condition of the backlands people was preferable "to real misery, for example, that of the 300,000 labourers in the United States whose fate is described by John Steinbeck in The Grapes of Wrath" (1944, 13).


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Author:Lima, Nisia Trindade
Publication:Canadian Journal of Latin American and Caribbean Studies
Date:Jan 1, 2010
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