The Sanitation of Brazil

Nation, State, and Public Health, 1889-1930

Gilberto Hochman, Diane Grosklaus Whitty, Diane Grosklaus Whitty

• Publisher: University of Illinois Press
• Year: 2016
• ISBN:
  9780252099052
• Topic: History
• Subtopic: World History
• Index: History

Celebrated as a major work since its original publication, The Sanitation of Brazil traces how rural health and sanitation policies influenced the formation of Brazil's national public health system. Gilberto Hochman's pioneering study examines the ideological, social and political forces that approached questions of health and government action. The era from 1910 to 1930 offered unique opportunities for public health reform, and Hochman examines its successes and failures. He looks at how health became a state concern, tying the emergence of public health policies to a nationalistic movement and to a convergence of the elites' social consciousness with their political and material interests. Politicians weighed the costs and benefits of state-run public health versus the burdens imposed by disease. Physicians and intellectuals, meanwhile, swayed them with warnings that endemic disease and official neglect might affect everyone--rich and poor, rural and urban, interior and coastal--if left unchecked. The book shows how disease and health were and are associated with nation-state building in Brazil.

CHAPTER 1

When Health Becomes Public

State Formation and Health Policies in Brazil

All human activity, political and religious, stems from an undivided root. As a rule, the first impulse for…social action comes from tangible interests, political or economic…. Ideal interests elevate and animate these tangible interests and lend them justification. Man does not live by bread alone; he wants to have a good conscience when he pursues his vital interests; and in pursuing them, he develops his powers fully only if he is conscious of simultaneously serving purposes higher than purely egotistical ones. Interests without such spiritual elevation are lame; on the other hand, ideas can succeed in history only when and to the extent that they attach themselves to tangible interests.

—Otto Hintze, 1931

I begin this analysis of the formation of public health policy in Brazil with the words of German historian Otto Hintze because his linkage of ideas and interests bears greatly on the topic at hand. The convergence of the two ultimately bolstered the decision to make health in Brazil not just a public matter but also a nationwide, state-led one. These pages explore how Brazil responded to its public health problems and examine the consequences of its decision to collectivize health nationwide, identifying the specific circumstances under which consciousness met interests, prompting relevant parties to act and permitting the genesis of state provision of public health.

I seek to construct a plausible interpretation of when, why, and how compulsory, nationwide, collective health care arrangements emerge within a given historical context and to examine the political consequences of this process. When does health become public? Or, to put it another way, why does health become a matter of public interest and the target of political initiatives? The second line of inquiry explores the circumstances under which public interests can be transformed into actual public policy—that is, what conditions prompt individuals to transfer responsibility for health to the state? A third question concerns the relations between the substance of the policies that are made public and the legal and institutional arrangements designed for policy enforcement. In other words: how do public policies reflect and/or alter relations among public power, political elites, and society at large? Finally, how does the process of collectivizing health nationwide relate to state building? Working within a particular historical and sociological framework that contextualizes and constrains choices and decisions, I answer these questions by analyzing the crucial decision-making processes that placed more power in the state sphere and the effects of these decisions on this framework.

Specifically, I explain why, at a given moment, individuals or groups collaborate in the creation of a public compulsory arrangement to address issues that do not necessarily affect them. This decision is in part connected with the rules governing how responsibilities are transferred to the state, or how public health authority takes shape. Furthermore, the decision to increase and expand state action affects both the framework of the initial decision and the decision makers themselves.

To this end, I present a formal logical argument that accounts for the decision to collectivize health care and connect that decision to the historical nature of the process of fashioning public authority. This interpretation is compatible with explanations for the emergence of social policy found in the vast literature on the topic. Combining logical and historical arguments allows us to observe both the conditions that induced a convergence of interests and ideas, thereby impelling actors to intervene, and the impact of this convergence. And by focusing on the collectivization of welfare within a given society at a given time, we can see why and how certain choices and decisions are made and subsequently produce laws, policies, institutions, bureaucracy, and so on. These choices and decisions not only are shaped by broad historical processes but also shape history. Historical processes thus form the backdrop and substance of my formal theoretical argument.

I also highlight the political backdrop, national context, and era when public health and rural sanitation policies emerged in Brazil under the so-called First Republic (1889–1930) because doing so permits me to evaluate two general interpretations that challenge some of the research as well as the conventional wisdom. First, the First Republic (also known as the República Velha [Old Republic]) was not an interregnum in the process of state building, running from the close of the empire through the post-1930 period, nor was the state fully formed at the end of the Brazilian Empire (1822–89). Second, the oligarchic domination characteristic of the First Republican period did not impede a process of mounting centralization and government intervention but was compatible with that process.¹ According to the alternative interpretations offered by Elisa Reis, the state-building process is not a discrete event with a firm endpoint and does not proceed solely in one direction. Further, the creation of public power is not necessarily incongruent with the strengthening of private interests.² To guarantee their interests, Brazil's oligarchies—especially the coffee sector—turned to public authority rather than the market to regulate economic activities, and this decision affected the construction of the state and the laying of its authoritarian foundations.³ This period indeed witnessed the effective creation of public power rather than a pure and simple freezing of the administrative and regulatory abilities of the nation-state under the might of coffee planters.

In his work, Luiz Antônio de Castro Santos takes up three main questions: the significance and impact of the movement for the sanitation of Brazil and public health policy under the First Republic, especially in the 1910s and 1920s; the construction of an ideology of nationality; and state building through the emergence of new public apparatuses charged with enforcing health and sanitation policy at both central and local levels.⁴ In his view, contrary to what a number of public health studies have claimed, the First Republic saw no straightforward causal relation between economic interests and health policymaking. Furthermore, according to this author, the period can be favorably assessed if the benchmark is the creation of public authority and corresponding health infrastructure rather than the short-term performance of public power in the provision of health, an approach that usually yields negative evaluations.

Throughout Brazil's First Republican period, in response to a number of decisions and initiatives to which the political elites acquiesced, government activism in health and sanitation grew in tandem with the government's capacity to implement policies nationwide. We observe the development of public consciousness and greater governmental responsibility for public health conditions and the health of the population in Brazil—any judgment about the performance of public power or about any seemingly preferable alternative aside. Yet we should not deem this a historically inevitable process, for such a perspective would shed little light on the form and content of subsequent government institutions and policies. The latter are unintended results shaped by the goals, conflicts, strategies, and choices of defined actors caught up in networks of institutions and mobilized by a social awareness enmeshed with material interests.

State, Power, and Public Health: On Theory and Methodology

This analysis of the transformation of health into a public good and the establishment of broad collective arrangements to produce this good draws associations between health issues on the one hand and the forging of public power and the associated emergence of public policies and government agencies on the other. Public power spread throughout the national territory in the form of newly created administrative structures, legal instruments, and personnel. The transformation of health into a public good interacted strongly with the shaping of a national community and state formation in Brazil.

Crucial choices and decisions transformed the approach to human deficiencies and adversity. According to Abram De Swaan, this process of collectivization of care can be analytically divided into three stages: care was first individual; became collective while preserving its voluntary, community, and local nature; and finally was shifted to the state.⁵ Yet this process was not as linear, evolutionary, or inexorable as this division into stages may seem to suggest.

In De Swaan's view, formal theory has ignored the collectivizing process of health just as it has neglected the process of collectivizing poor relief, education, and social security—in other words, it has neglected the historical nature of collective goods. Using as his point of departure Norbert Elias's analysis of the sociogenesis of the state, De Swaan offers an analytical frame of reference and an interpretation of the rise of welfare states that I employ, critique, and expand in conjunction with the contributions of other authors.⁶

Key to understanding the collectivization of welfare is Elias's idea of figuration. A figuration can be defined as a structured yet fluid pattern of reciprocal dependence between individuals, groups, and institutions. As a conceptual tool with an emphasis on interdependence, Elias's notion frees us from the antagonistic juxtaposition of individual versus society.⁷

In Elias's formulation, the transition from the traditional to the modern world brought the rise of nation-states and the development of capitalism along with its corollaries of industrialization, urbanization, and secularization. Concomitant chains of interdependence became so much more complex that they grew opaque and could not be controlled by any one individual or group, making it impossible to explain figurations through the properties of their individual components.⁸ In this interpretation, the development and historical dynamics of these chains of social interdependence wrought unplanned and even undesired social consequences independent of any component individual or group. Yet the chains also were the product of the interweaving of the motives and actions of these individuals and groups.⁹ In addition, complex figurations can be characterized and analyzed only by reference to their constituent bonds of interdependence.¹⁰

For De Swaan—still drawing from Elias—the analysis of the emergence of social policy is also an analysis of both the historical process by which human interdependence is generalized and the responses to the problems that accompany the ascent of nation-states and the development of capitalism.¹¹ The collectivization of welfare and state formation are more specific processes whereby the bonds of human interdependence change and lead to new arrangements as part of a broader, lengthier process. The collectivization of social provision thus breeds not only public power but also human collectivities. The formation of a national community is associated with the extension of chains of reciprocal dependence.

The bonds of interdependence that instill the need to collectivize care of the poor, destitute, malnourished, infirm, illiterate, and any other individuals suffering from temporary or permanent adversity are called external effects or externalities. They are, De Swaan tells us, “the indirect consequences of one person's deficiency or adversity for others not immediately afflicted themselves.”¹² For example, the poverty and destitution of some members of society brings the threat of illness, crime, unproductivity, or revolt for others.

De Swaan proposes to entwine formal theory on collective action—which he assigns to “welfare economics”—with historical sociology. Welfare economics endeavors to identify and analyze the circumstances requisite to state intervention and regulation in situations of human interaction and interdependence—that is, vis-à-vis public goods, negative externalities, and the dilemmas of collective action. Historical sociology, conversely, analyzes how interdependence affects the development of society. De Swaan introduces the idea of process to the analysis of individual interactions and choices.¹³ While following different routes, both approaches suggest that individual actions and choices yield unexpected aggregate results. I explore this idea of conjoining formal and historical arguments by discussing the negative effects of human interdependence and its possible remedies as part of a broader historical, sociological process.

Increased human interdependence expanded and intensified the external effects that the actions or existence of some (the poor) had on others (the established in society). By heightening problems of mutual dependence, the shift to an urban, industrial society compelled the gradual abandonment both of individual solutions (for example, fleeing contact with the destitute and/or leaving them to their own devices or the devices of the market) and of voluntary remedies (such as philanthropic, charity, or mutual aid associations) because neither approach could cope with the problem in its entirety. Contemporary welfare policies, like the state that produces them, are the unintended historical products of efforts by the elites (and of their internal conflicts) to exploit, administer, control, and remedy the progressive external effects of poverty in the face of the mounting failure of individual solutions and the fragility of voluntary solutions.

Based on the work of Mancur Olson Jr., De Swaan points out that in ever more complex societies, voluntary associations become unstable as a consequence not only of the challenges of coordination but also of the dilemmas of collective action—the problem of controlling the free riders who benefit from these arrangements or public goods without helping produce or maintain them.¹⁴ The issue is how to produce a collective good and distribute attendant costs when no member of the collectivity can be excluded from using or enjoying the good. The solution tends to be mandatory contribution and social provision through public authority. In the course of this process, a social consciousness of interdependence emerges. De Swaan defines this phenomenon, which is essential to the formation of a collective national identity, as an “awareness of the generalization of interdependence…coupled with an abstract sense of responsibility which does not impel to personal action, but requires the needy in general to be taken care of by the state and out of public tax funds.”¹⁵

This sense of responsibility did not end voluntary action but rather dictated ever greater reliance on state care and demanded ever greater resources, which are coercively extracted from society and benefit everyone, whether or not they contributed. Through the formation of this social consciousness, the state affirmed itself as a legitimate organization capable of regulating the negative effects of social interdependence, which, over time, tend to be reduced to legal, administrative solutions in the hands of a bureaucracy.¹⁶

According to De Swaan, this process of public collectivization of remedies for poverty, deficiency, and adversity has displayed three dimensions:

1. The scale of arrangements shifts from the level of some individuals to encompass groups of citizens or entire nations.
2. Arrangements grow more collective in nature as access to benefits grows more independent from the contributions of individual users.
3. The state becomes increasingly involved as there is greater agreement about allowing government to exercise authority and coercion and boost the level of bureaucratization.¹⁷

De Swaan says that the development of this process depends on three conditions. Two of these conditions promote collectivization but not necessarily the shift to government control: escalating “uncertainty as to the moment and the magnitude of the adversity [and] as to the efficacy of remedies against adversity or deficiency.” The third condition is a tendency for an increase in “the extent and reach of the external effects of adversit...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Dedication Page
• Contents
• Preface
• Translator's Note
• Chapter 1. When Health Becomes Public: State Formation and Health Policies in Brazil
• Chapter 2. The Microbe of Disease and Public Power: The Public Health Movement and a Growing Consciousness of Interdependence
• Chapter 3. Public Health Reform; or, Who Should Be Responsible for Communicable Diseases?
• Chapter 4. Consciousness Converges with Interests: A National Public Health Policy
• Chapter 5. São Paulo Exceptionalism? Political Autonomy and Public Health Interdependence
• Chapter 6. Final Thoughts
• Appendix 1. Institutions, Agencies, and Departments
• Appendix 2. States and Territories of Brazil under the First Republic (1889–1930)
• Notes
• Bibliography
• Index
• About the Authors