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The Fight against Yaws in Brazil: Scope and Limitations of an Eradication Program

Amid the sanitary optimism and the biomedical discoveries of the post-World War II era, public health policies in Brazil in the 1950s were strongly marked by actions to control and eradicate diseases of the countryside. In 1956, President Juscelino Kubitschek (JK), to defend the importance of combating so-called rural endemic diseases — which he called “diseases of the masses” — affirmed that eradicating them could overcome the social backwardness and economic underdevelopment of Brazil. Among those mass ills of the countryside was a skin disease called yaws — a non-venereal treponematosis similar to syphilis in its initial symptoms. This disease, which can be highly debilitating to tissues and bones if left untreated, was targeted in an eradication campaign that took shape in Brazil between 1956 and 1961. The work carried out across the territory was inserted into the Brazilian state’s development plans. The campaign can also be understood in terms of long-standing discussions about endemic disease, and reveals some of the conceptions of disease, health and development during the period.

Campaigns for the eradication and control of diseases were launched in Brazil with the creation in 1956 of the National Department for Endemic Rural Disease. One of them was the Yaws Eradication Program, a little-known episode in the history of public health. Structured around the “magic bullet” of injectible penicillin, the campaign hadto confront the complex of hunger and malnutrition in the country’s interior, problems that were initially outside its mandate. The disease was common in the North-east of Brazil, in parts of Minas Gerais and in the Baixada Fluminense (in the state of Rio de Janeiro), and the Yaws Program worked these states with an itinerant campaign during its first five years – the length of time that it would take to eradicate the disease, according to the health authorities of the new administration. This was the “sanitary optimism” of the Kubitschek government in action.

Yaws was a disease that weakened the strength and the ability to work among poor men and women in the interior. It had a long history of different interpretative frameworks that had led to distinct prophylactic and therapeutic approaches. At the beginning of the 19th century it had been considered an incurable disease of African origin. Until the middle of the 20th century, isolation in barracks of those with the disease was the method usedfor avoiding the spread of infection. The identification, during World War II, of a single dose of penicillin as the antibiotic capable of curing yaws created the bases for the campaign.

Expectations of greater control of diseases had emerged along with new treatments and remedies like antibiotics, and DDT for insect vectors, in each case favouring the creation of campaigns against endemic rural diseases like malaria, smallpox, yellow fever, yaws and goiters. On top of this, yaws was the subject of the first eradication program undertaken on a global scale, with technical assistance provided by the World Health Organization (WHO).

At the beginning of the 1950s yaws was recognized as a public health problem in various countries of Latin America, Africa and Asia. Starting in 1951 the first campaigns to eradicate the disease were begun in these areas, supported by the WHO and the United Nations International Children’s Emergency Fund (UNICEF). UNICEF would provide the technical apparatus and the penicillin and the countries would supply the workers and the infrastructure. These programs were in short order responsible for the reduction of the incidence of yaws in a number of countries. The Pan-American Sanitary Bureau (the Secretariat of the Pan-American Health Organization [PAHO]) was responsible, in 1952, for the development of a method to carry out yaws eradication that would be provided to all countries of Latin America and the Caribbean in conjunction with the ministries of health of each country. The disease, known as “frambesia” and “pian” in Spanish-speaking countries, was a grave public health problem in Brazil, Colombia, Ecuador, Haiti, Peru, Santa Lucia, Guyana and Surinam. The illness had been known in Brazil since the early years of the institutionalization of public health, and Brazil had the largest number of registered cases, even though in other countries, like Haiti, it was considered a greater public health problem.

Photograph from the Campaign in Haiti (Bol. de la Oficina Sanitária Panamericana)

The Haitian campaign was one of the first to implement the single-injection-of-penicillin method combined with keeping the population in their houses rather than isolated or in hospices. More than half the people had yaws in Haiti in 1950, which made it one of the most serious diseases to confront. The campaign was the result of an agreement between the government of Haiti, PAHO, WHO and UNICEF, and was based on home visits and the application of penicillin in high dosages. The method devised in Haiti envisioned work divided into stages: creation of an epidemiological map, division of the country into zones and districts, the mounting of teams and periodical completion of reports. And this method, with necessary adaptations, was the modelfor the Brazilian campaign.

Training of personnel involved in the campaign was of short duration and had as its objective transmitting notions of hygiene and protection against infectious diseases. The sanitary guards who applied the injections and did the reinspections in the homes were also expected to act as propagandists of good daily habits that would avoid the transmission of yaws. To do this, materials like posters and printed matter were used as instruments in the training of professionals who would engage in fieldwork.

Among the material specially prepared for the Yaws Program a pamphlet for training sanitary inspectors stands out. Entitled Let’s Finish Off Yaws in Brazil, the slim booklet had illustrations and photos explaining to the sanitary inspectors who worked in the flying squads clinical definitions of yaws and the care that had to be given in each of the stages for a successful campaign. Regional vernacular terms for describing the disease (for example, mofina, catita and alueira) were used, showing how important were the close contact between inspectors and the sanitary habits and customs of poor populations in the interior of Brazil who were the main victims of yaws.

Yaws Pamphlet (Courtesy of the Library of the Ministério da Saúde – Brasília)

Also indicative are references to the good hygienic habits that should be transmitted to the the populations of the interior — the so-called backlanders. In the pamphlet for training sanitary inspectors for the yaws program, hygiene was given a fundamental role in the control of the disease. The focus on preventing the wounds of those suffering yaws, therefore, had to be via intervention in the daily customs of the men and women of the interior. For the government it was new habits of hygiene and newliving conditions that seemed to offer the definitive solution to the yaws problem. In this way, despite the fact that it was not a core part of the program, the environment, hygiene conditions, disease transmission and nutrition among the backlanders revealed themselves to be the real obstacles to the success of the work and the flying squads.

Articles on the disease in medical periodicals, in pamphlets and in other material disseminated by the program contained clinical descriptions of cases. The sick were exhibited in photographs and the evolution of cases were described in rigorous detail – expressions of the optimistic conception of health in an era prior to debates on patients rights. The classic “before and after treatment” clinical shot was also used in promotional material for the public to show that the shot of penicillin — or “Boubacillina” (Yawsicillin) — was capable of producing medical miracles.

“Today Yawsicillin is working miracles….” (Courtesy of the Library of the Ministério da Saúde – Brasília)

In the conceptions of hygiene and health characteristic of the yaws program, the treponematosis was directly related to extreme poverty, framed as an illness of the backlander that would never attack the rich. It could be eradicated from the lives of the rural populations by means of small changes in daily habits of hygiene, without necessity for structural changes in living conditions. This conception can be seen in one of the mottos of the campaign disseminated in pamphlets (see below): “Being poor does not mean being dirty. Teach them to be horrified of filth, fliesand other plagues that invade people’s houses. Constantly repeat to them the rhyme: God is good and loves the poor,but only if they’re clean for sure.”

“Being poor does not mean being dirty…” (Courtesy of the Library of the Ministério da Saúde – Brasília)

In the years between 1956 and 1961, the use of sanitary education in disease eradication campaigns was part of the practice of Brazilian public health. The participation of the social sciences directly in the training courses of health professionals, and the making of graphic and audiovisual materials and newspapers reveals the importance that the theme had acquired alongside more relevant issues in public health. Social scientists, by way of so-called community studies, tried to comprehend the mentality of the rural population in order to design an effective intervention in the way of life of those communities, and so create a “sanitary awareness”.

The spirit of the campaign for the eradication of yaws was the same that predominated in other campaigns of the 1950s – temporary actions oriented toward the elimination of a specific disease, using a given technology, without seeking to alter the living conditions of the populations in question. The history of the yaws campaign indicates the conditions, possibility and limits of eradication programs associated with development projects.

The use of the “magic bullet” did effect a substantial decrease in the cases of the disease in Brazil, and it was finally declared eradicated in the mid 1960s. The ‘plague’ of yaws is now all but forgotten by sanitary authorities, physicians and governments. There is no memory of yaws as a disease. Already by the 1970s the number of yaws sufferers had begun to grow again in rural communities in Africa,while little is known about the situation in the Americas. Without control programs, monitoring and follow-up by health officials, and given the difficulties with diagnosing it due to lack of health teams trained to pick it up, the affliction classified today as “a neglected tropical disease” appears to be returning to victimize, as always, the most needy in the poorest parts of Africa, Asia and the Americas.

References

Asieudu, Kinsley et alli. “Yaws eradication: past efforts and future perspective”. In: Bulletin of the World Health Organization. 2008, 86 (7). p. 499.

Cueto, Marcos. O Valor da Saúde: História da Organização Pan-Americana da Saúde. Rio de Janeiro, Editora Fiocruz, 2007

Hochman, Gilberto. Título: “O Brasil não é só doença”: o programa de saúde pública de Juscelino Kubitschek. Hist. ciênc. saúde-Manguinhos;16(supl.1):313-331, jul.

Kropf, Simone. Doença de Chagas, Doença do Brasil. Ciência, saúde e nação, 1909-1962. Rio de Janeiro: Editora Fiocruz, 2009

Organización Panamericana de la Salud. “Combatiendo la Frambesia em Haití”. In: Pro Salute Novi Mundi: historia de la Organization Panamericana de la Salud. Washington, D.C: OPS, 1992. p. 50

Porter, Roy. “From Pasteur to penicillin”. In: The greatest benefit to mankind: A Medical History of Humanity. New York/London: W. W. Norton & Company, 1999.

WORLD HEALTH ORGANIZATION (WHO). “The return of yaws”. In: Bulletin of the World Health Organization. 2008, 86 (7). pp. 507-8.

Érico Silva Muniz is a Doctoral Candidate in History of Sciences and Health at the Casa de Oswaldo Cruz/Fiocruz (COC). The preceding synthesizes ideas presented in his Master’s thesis,

Thanks to Steven Palmer for the translation and revision of this article/research note.

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