Cancer in Ceará: shaping a medical and social problem, 1940-1954

Abstract

This article addresses the shaping of cancer as a relevant medical and social problem in the Brazilian state of Ceará from 1940 to 1954. While this disease initially garnered little importance on the local medical and health agenda, and was considered a problem for philanthropy, a group of physicians and allies brought cancer to the public health agenda and led to the Campaign Against Cancer in 1954. This group's ability to unite internal and external allies with a broader reach portrayed cancer as a relevant medical and social problem in Ceará. We demonstrate this new portrayal in medical articles, institutional documents, biographies, newspapers, and other documents produced on and by the characters involved with anticancer activities in Ceará.

Keywords
cancer; Ceará; allies; anti-cancer actions

Resumo

Analisa a conformação do câncer em problema médico-social relevante no Ceará, entre 1940 e 1954. Nos anos 1940, a doença possuía pouca importância na agenda médica e sanitária local, sendo considerada um problema de filantropia. A partir da ação de um grupo de médicos e seus aliados, o câncer foi posto na pauta dos médicos e da saúde pública, levando à Campanha Contra o Câncer, em 1954. Argumentamos que o enquadramento do câncer como um problema médico-social relevante no Ceará esteve ligado à capacidade desses médicos em agregar aliados internos e externos para ampliar o alcance de suas agendas. Utilizamos artigos médicos, documentos institucionais, biografias, jornais e outros documentos produzidos sobre/pelos personagens envolvidos com as ações anticâncer no Ceará.

Palavras-chave
câncer; Ceará; aliados; ações anticâncer

In the early 1940s, medicine and public health underwent significant changes in Brazil, and more specifically in the state of Ceará. Within the context of Vargas’ New State, a political scenario took shape which involved the central power acting in the states within an interventionist regime (Souza, 1989). In the field of public health, the main changes observed during this period relate to the structuring of the state, with the creation of public health services and institutions based on a model of administrative centralization and verticalized actions which were typical of the public management model during this period (Fonseca, 2007). This was when the National Services were created to address diseases which were considered priorities for the reorganization of the country. The highlights of the health agenda were rural endemics and some highly prevalent communicable diseases such as tuberculosis and malaria, both of which received their own specific national services (Fonseca, 2007). An exception to this model was cancer, which at that time was considered a problem far from the Brazilian reality which represented a nebulous threat to the health of the population; later, however, this disease received its own specific national service because of the strong connections made by physicians involved with the control of this disease in the Federal District and in São Paulo (Teixeira, Fonseca, 2007).

At the local level, one element resulted in important changes for doctors in Ceará: the Pelón Reform, led by the sanitarian Amilcar Pelón starting in 1933, was an effort to create a network of health posts and centers in Ceará according to a care model resembling one proposed by the Rockefeller Foundation and launched in São Paulo in the 1920s (Faria, 2007). Although this reform was not implemented in its entirety, it did permit the creation of new spaces for medical practice in the state and particularly in Fortaleza, expanding the demand for professionals. In addition, the installation of national services and the division of the country into federal health bureaus also led to the creation of new jobs for physicians and sanitarians, requiring greater management capacity and more trained professionals in Ceará (Araújo Neto, 2016).

Within this scenario, the medical field in the state faced new demands such as the need for professionalization among sanitarian physicians, the shaping of medical specialties within the context of health services, initiatives to establish a medical school, and the emergence of new diseases on the health agenda. With regard to this last aspect, the 1940s and 1950s witnessed the organization of the first anti-cancer actions in the state, with the creation of institutions to assist cancer patients and the beginning of an anti-cancer campaign in Ceará in 1954. During this entire process of structuring of cancer control (Cantor, 2008), the disease took on a new meaning in the state, and was characterized as a medical and social problem, in other words, a relevant topic for medical practice and other dimensions of social life.

This article analyzes the process which affirmed cancer as a relevant medical and social problem in Ceará during the 1940s and 1950s. In the early 1940s, neoplasms were not a topic of interest for medicine and public health in the state, which mainly were dedicated to rural endemic diseases, urban epidemics, and "class problems” (Lima, 1940; Preenchimento…, 1940). Until that time, only one medical article had examined subjects related to malignant tumors in the territory of Ceará, and focused on clinical aspects of the disease (Aguiar, 1932). Other than this, care for the sick was essentially palliative care provided within the framework of Fortaleza's Santa Casa de Misericórdia Hospital. This scenario gradually changed throughout the 1940s after some doctors, philanthropists, politicians, and intellectuals mobilized to create a specific institution for cancer care in Fortaleza, the Cancer Institute of Ceará (Instituto do Câncer do Ceará, ICC).

We argue that the process of "positioning” cancer as a relevant medical and social problem was the result of actions on the part of a group of physicians from Ceará who had a strong presence in professional circles and were able to connect with local and national projects and initiatives to situate topic of cancer among the major interests of Ceará's population, or at least of the elites. Cancer was framed as a medical problem in the state of Ceará by transforming its meanings in Brazilian society, both in the dimension of public policies (with the creation of the National Cancer Service in 1942) and within the context of medical knowledge and actions focused on this disease. We believe that it is essential to analyze the association between these different levels of ongoing processes to understand how cancer was mobilized by certain characters in Ceará.

This work is built from a dialog with the "social studies of science,” especially the reflections of the sociologist Bruno Latour (2000). For this author, the study of scientific activity consists of discussing the process of constructing scientific facts and technical artifacts through enlisting allies and composing networks through which people, tools, knowledge and practices circulate, and which correspond with ways of "doing science.” In this article, we use Latour's concepts, especially the concept of "allies,” to analyze the connections made by the physicians who were involved in anti-cancer actions in Ceará. We will discuss how certain characters, mainly doctors, mobilized to affirm the importance of cancer within the state. This utilizes documentation related to the history of medicine and public health in the state of Ceará (particularly the publication Ceará Médico), biographical and bibliographical material produced by these characters on and in the period studied, and other sources related to the trajectory of anti-cancer activities such as legal decrees, institutional reports, minutes from meetings, speeches given by the physicians, and dissertations defended at the Ceará School of Medicine (Faculdade de Medicina do Ceará).

Constructing a place: cancerology in Ceará

In the early 1940s, Ceará had just over two million inhabitants, with nearly two hundred thousand people living in the state capital, Fortaleza (IBGE, 1946). At this time, the prevailing health concerns in the state were diseases like trachoma, yaws, cholera, leprosy, tuberculosis, and malaria (the first four generally in the interior of the state) (Lima, 1940). Fortaleza faced the problem of tuberculosis and the arrival of sick migrants seeking medical care at the Santa Casa de Misericórdia Hospital. In this scenario, cancer was given little importance in discussions related to public health, because of the difficulty obtaining mortality rates for this disease and also because it did not fit into the health priorities of the state and federal governments.

During the same period, the medical profession in Ceará underwent a series of changes, particularly with regard to specialization when a group of young doctors trained at schools in Bahia, Pernambuco, and Rio de Janeiro and specialized abroad arrived in Fortaleza.¹ At the time, medical activities and priorities for public health emerged from the only body in the capital dedicated to medical matters, the Ceará Medical Center (Centro Médico Cearense, CMC).

The CMC was created in 1913 to represent the interests of local medical class, especially against practices characterized by the physicians as "healing” and "quackery.” At the time the CMC was established, its founders wanted this mobilization to be a reference for neighboring states, which led to the creation of the medical journal Norte Médico, which was later renamed Ceará Médico. Starting in the 1930s, this center took on new functions such as appointing doctors and health workers for the regional division of the federal health bureau (Prenchimento…, 1940), which represented the extension of its professional authority into the field of public health. Amid the demand for new doctors, the CMC earned its status as a regulator of the profession and a voice for the agendas of one portion of local medicine, the "medical elite” (Garcia, 2011; Gadelha, 2012). From its quarterly magazine and sessions held at its physical location, the center became a space where diverse agendas of the elite were discussed, combining politics, medicine, public health, and religion.

Although the creation of a space for cancer care was in the statutes of the organization (Estatutos…, 1944), during its first three decades cancer was not the subject of discussions at the regular meetings. As a result, the initiative to create an anti-cancer institute in Fortaleza took shape in other circles of the local elite, involving a small group of doctors interested in organizing actions to combat this disease in the state. This led to the November 1944 creation of a society by physicians and representatives of the economic elite of Ceará to support a future cancer institute.²

Because of the creation of this society, the medical chronicles of Ceará refer to the 1940s as a milestone for anti-cancer activities in the state (ICC, 2004; Juaçaba et al., 1994; Silva, 2011). However, it is important to problematize these visions, since in reality no specific space was created for cancer care, teaching, or research about the disease. What came to exist in 1945 was an outpatient clinic and an office to provide care for cancer patients at the Santa Casa de Misericórdia Hospital in Fortaleza. This does not detract from the importance of the meeting which founded this supporting society, but only indicates the formalization of an agenda linked to specific characters; in other words, cancer was formally of interest to some doctors, politicians, and intellectuals in Ceará.

This leads to the second important point around the creation of the ICC, considering the collective nature of medical activity. Cancer was not the object of public health concerns, and may be characterized as an agenda of professional groups who saw professional and social demand in this disease. This character of cancer as a disease of groups has been noted in other regions of the country, such as Rio de Janeiro (Teixeira, 2009, 2010), for example, portraying it as a topic restricted to the universe of leagues, societies, and philanthropic associations to assist cancer patients.

The meeting to found the ICC in 1944 did not have great repercussions in the press or even in the Ceará Médico journal, where only a brief note was dedicated to the episode in the first edition of 1945 (Noticiário, 1945). The overarching project for an institution to bring together teaching, research, and care for the sick was initially restricted to the corridors of Santa Casa de Fortaleza. To achieve its objectives, the doctors involved with the institute project sought new alliances with philanthropists, other physicians, and important politicians to bring the disease to the public arena through lectures, educational campaigns, and the press.

For a real anti-cancer organization to get off the ground, this concern with care for the sick had to be based on the existence of a specific professional. This would be the foundation to develop a network of actions and practices directed at the disease. The characters involved in the creation of the ICC had very different backgrounds, but none of them had a specific connection to cancer. At that time in Brazil, there was no medical specialty focused on tumors; on the contrary, cancer care was provided by physicians who faced the disease in their daily practices, such as surgeons, dermatologists, and gynecologists. However, this does not mean that there was no set of techniques and knowledge directed at cancer, defined by doctors who focused on this disease and gathered under the term cancerology. In general, it can be said that Brazil in the mid-twentieth century had cancer, but did not have cancerologists. The fact that there were specific practices for cancer allowed some doctors, especially surgeons, to ascend to the stature of specialists and sometimes be called cancerologists (as in the cases of Mario Kroeff in Rio de Janeiro and Antonio Prudente in São Paulo).³

In Ceará, Haroldo Juaçaba was considered a specialist in cancer. Born in 1919, Juaçaba graduated in medicine from the Universidade do Brasil in Rio de Janeiro, and returned to Fortaleza, where he worked as a professor at the Nursing College and in the Casa de Saúde São Raimundo. In 1944, he worked in the Special Service to Mobilize Workers for the Amazon (Serviço Especial de Mobilização de Trabalhadores para a Amazônia, Semta), which was part of the effort to recruit "rubber soldiers” to obtain this resource from the Amazon during World War II (Campos, 2006; Ferreira, 2011). As a result of contacts he made with American doctors during this period, Juaçaba was invited to obtain his specialization in surgery at Riverside Hospital, in the state of Kentucky, USA (Silva, 2011). He also devoted himself to a period of study at the Mayo Clinic in Minnesota, in both cases focusing on cancer.

When he returned to Brazil, Juaçaba began to assume a central role in anti-cancer actions in Ceará, acting as a specialist in the disease and holding considerable scientific credibility because of his specialization in the US. In addition to producing studies on cancer in the following years, Juaçaba served as a spokesperson for the ICC and cancerology in newspapers and in the CMC, expressing its positions and those of its allies. Other doctors also directed their specializations toward important areas for cancer control, such as Livino Pinheiro, who specialized in pathology, and Walter Porto, who focused on radiation applied to cancer (ICC, 2004).

This specialized training gave the doctors involved with the ICC greater authority to talk about the disease and position it as a medical and socially relevant problem, which made it a "place” for speech specific to cancerology. However, these characters were not able to defend their ideas, or even to care for the patients based on the knowledge and specific practices of cancerology. Activities in other arenas were necessary to create spaces for practice and to develop an argument which portrayed cancer as a socially relevant medical problem.

Adding allies: the structuring of cancerology in Ceará

As in other locations, structuring the medical practice to combat cancer took place outside the scope of state institutions in Ceará. After the foundation of the ICC, the difficulties its founders faced in creating an autonomous space for the institution led them to establish other ways of facilitating the practice of cancerology in Fortaleza; this included linking into the process of creating the Ceará School of Medicine.

Since the 1910s, when the School of Law was created in Fortaleza, several doctors had intended to found a medical school there, in the belief that it was necessary for Ceará to train its own physicians (Alencar, 2012). During the 1940s, these intentions took shape as a plan defended by doctors involved in the institutionalization of medical practice and the establishment of "scientific medicine” in the state (Leal, 1978; Magalhães, 1945). The mobilization for local medical science especially gained strength after the first Brazilian Congress of Catholic Doctors (Congresso Brasileiro de Médicos Católicos) was held in 1946, where the proposition to create a medical school in Fortaleza was more explicitly stated by Jurandir Picanço, the main booster of the school project, founder of the ICC, and official spokesperson for the CMC (Primeiro Congresso…, 2010).

Despite raising questions among the physicians (Magalhães, 1945), especially among those who believed that resolving the main health problems such as leprosy, yaws, and trachoma should be the priority in Ceará, the faculty mobilization managed to gather allies among the local elite. In 1947, Jurandir Picanço and other doctors, politicians, and intellectuals of Fortaleza created the Institute for Medical Education (Instituto de Ensino Médico, IEM). Despite being called an institute, the IEM consisted of an association formed to financially and legally bring about the creation of a medical school in Ceará. The plan proposed by Jurandir Picanço, the president of the institute, was to found the college as a private entity, with recognition from public authorities⁴ (Livro de atas…, 1947). In weekly meetings held at the Medical Center or Picanço's home, agendas were established to deploy the faculty and a "golden book” was created, in which people could pledge funds (Livro de atas…, 1947).

The presence of the founders of the Cancer Institute in the process of creating the medical school is crucial in considering the organization of anti-cancer actions in the state. Jurandir Picanço, Waldemar Alcântara, Walter Cantídio, Livino Pinheiro, and Newton Gonçalves were active participants in the meetings of the IEM, with Picanço acting as president. In 1947, Waldemar Alcântara proposed that the ICC, which he led at that time, become a division within the future medical school (Livro de atas…, 1947, p.20).

Although it was well accepted by the majority of the IEM's board of directors, this proposal led to some divisions between members and questions about how the university would incorporate an institution that would require a considerable amount of funds to operate. Despite this discrepancy, it was decided that the merger would proceed and that a study would be presented on this subject at the next meeting.

At the meeting held on October 14, 1947, the needs of the Cancer Institute for its operations and the details of its annexation into the medical school were presented. Linking the ICC to the medical school was considered essential by the president of the ICC, because this would open the way for more government resources aimed at the initiative of controlling cancer. From this same perspective, it was decided that measures would be taken together with the National Cancer Service for this agency to "provide radium and provide technical and financial assistance to the Institute” (Livro de atas…, 1947, p.23).⁵ In accordance with the concept of health legislation at the time, both the Ceará School of Medicine and the Institute of Cancer were private initiatives, partly funded by the government. The doctors sought authorization from the public agencies to operate the medical school, along with funds to maintain the ICC, which would allow continuity of services directed toward sick patients while simultaneously contributing to its credibility in the medical field.

On May 12, 1948, the Ceará School of Medicine was inaugurated; the college was located in a building on José de Alencar Square, in the center of Fortaleza. In this space two sections were created to treat patients with cancer: the Radiation Therapy Service and a clinic equipped to perform electrosurgery. Another very important service for cancerology was the pathological anatomy division, which was led by Livino Virginio Pinheiro, one of the founders of the Cancer Institute. This division, which was created in 1949, produced data from anatomical studies of lesions and inflammatory processes in patients treated at private clinics and at the Cancer Institute of Ceará. These data were used to generate studies on the problem of cancer in the capital.

In addition to their connections with the School of Medicine, the doctors involved in building cancerology in Ceará attempted to enlist alliances with the local economic elite to undertake philanthropic activities. Such characters as Fernando Pinto, the chairman of the Companhia Importadora de Máquinas e Acessórios Irmãos Pinto (Cimaipinto) and Maria José Weyne, wife of former Fortaleza mayor Álvaro Weyne, were fundamental to structuring assistance to cancer patients in the city. As directors of two charities, the Julio Pinto Foundation and the Ceará Association for Cancer Assistance (Associação Cearense de Assistência aos Cancerosos), both Pinto and Weyne were important in organizing the main service attending cancer patients in Ceará at that time, the Fernando Pinto Cancerology Service. This service, which operated on the premises of Santa Casa (Juaçaba, Haroldo, 1994, p.118), was created in 1949 with funding from the businessman Fernando Pinto, a significant local philanthropist.

Sick patients from outside the state capital also received care in Fortaleza, and the Cancerology Service played a critical role in serving these patients who traveled from the interior to the administrative center of the state; it also dealt with patients who could not afford private medical care and were not able to obtain care at the Cancer Institute, which was now located within the university.

In addition to financing the establishment of the Cancerology Service, Fernando Pinto also acted as a patron for some doctors at the Cancer Institute such as Livino Pinheiro, for example. After a request from the ICC and the School of Medicine to create the pathological anatomy division, Pinheiro received a scholarship from the Julio Pinto Foundation to become the state's first specialist in pathology in 1948. Specialization was a fundamental aspect in the trajectory of this doctor, who came to occupy a central role at both the ICC and the School of Medicine, directing one of the most important departments at the medical school and acting as the chair of anatomy and pathological physiology.

Another fundamental aspect in the network of philanthropists created around cancer control in Ceará relates to actions undertaken by of women, specifically the ladies of Fortaleza's elites who were associated with the Women's Network of the Ceará Institute of Cancer (Rede Feminina do Instituto do Câncer do Ceará). This network was essential in publicizing the institute's anti-cancer actions among the population of Fortaleza, since it promoted campaigns for health education and support for sick people without being limited to the specialized language of medicine. According to the coordinator of the network, Heloísa Juaçaba, the service served four functions: (1) to disseminate information about the incidence of the disease and possible ways of avoiding it; (2) to initiate campaigns related to cancer care, or to participate in campaigns in this area promoted by other governmental or philanthropic organizations; (3) to raise funds to maintain or help maintain services and entities for prevention, early detection, treatment and patient rehabilitation; and (4) to collaborate with professionals in the area in order to improve and expand the services provided, as well as to refine the skills of these professionals in the use of new technologies (Juaçaba, Heloísa, 1994, p.57).

As in other states, the ICC Women's Network played an important role in the efforts to build the Ceará Cancer Hospital, which began in the same year the association was created. One important point in the trajectory of the network was the liaisons it made to purchase materials which were essential for medical practice; for example, as early as 1954, it acquired 240 milligrams of radium for use in the treatment for cervical cancer (Juaçaba, Heloísa, 1994, p.56).

The connections between physicians and members of the local elite who were interested in anti-cancer activities are of great analytical value in understanding the process of organizing cancerology and cancer control in Ceará. First, as already mentioned in this section, the process of structuring the practice of medicine, with specific spaces, instruments, knowledge, and techniques, is not restricted to the everyday work of doctors or other health professionals but rather involves a variety of characters from social life, operating from specific agendas and worldviews while converging to pursue common goals (Latour, 2000). This demonstrates that medical work occurred both inside and outside the clinic or laboratory, and was not limited to actions by the physician alone, but also relied on a series of relationships involving financial conditions, social legitimacy etc. Figures such as Fernando Pinto, Maria Weyne, Heloísa Juaçaba, Paulo Sarasate, and others mentioned above played a decisive role in anti-cancer actions in Ceará, whether these were successful or not. They were in the center of the process, and had "resources” to define directions and to allow or discourage certain types of actions by the doctors. In other words, the structuring of cancerology arose from connections between physicians and their "allies,” not from the mere imposition of professional knowledge (Juaçaba, Haroldo, 1994, p.56).

The second point which merits attention is how a specific group's agenda can gain evidence from connections made between the involved parties and new allies. As mentioned in the previous section, cancer as a topic received little attention in Ceará in the 1940s, even after the creation of the ICC, and had very few social repercussions. In the 1950s, the conscription of the members of Ceará's elites was followed by a greater presence for cancer in forums with a broader reach than the Ceará Medical Center and its journal, leading to a new scenario for the work of the physicians involved with cancerology.

The connection between the anti-cancer initiative in Ceará and other experiences inside and outside Brazil is no less important. From the beginning of the twentieth century, various initiatives were conducted in a similar way in Europe and in the US (Pinell, 2002; Patterson, 1987; Gardner, 2006; Carrillo, 2010). The format of educational activities, the mobilization of specific elite groups for fundraising, and the very insertion of the ICC into a national anti-cancer campaign all indicate an important movement of ideas and practices in the development of anti-cancer actions, with a strong convergence between the initiatives in Ceará and others in different regional, national, and international spheres. If cancer had no place in medical practice in Ceará between 1940 and 1947 (Os grandes problemas…, 1947), from 1947 a new space was created for these physicians, this time with more resources to connect their agendas to society. The construction of this new space for cancerology took place alongside the development of arguments to create an anti-cancer campaign in Ceará, which began in the meetings of the Ceará Medical Center and were brought to the elite circles of Fortaleza through exhibitions, lectures and publications in the press.

Framing cancer as a relevant medical and social problem: the Campaign Against Cancer in Ceará

The doctors involved with cancerology mobilized arguments and allies in order to make the disease more than just the interest of one limited group. Construing the idea that cancer represented an important medical and social problem was the fruit of a number of elements which extrapolated the local dimension, constituting what Teixeira and Fonseca (2007) characterized as the transformation of cancer into a public health problem. For these authors, this process was based on the emergence of institutions, professional associations, and journals in the 1940s, and culminated with the strengthening of the National Cancer Campaign in 1950. Furthermore, the growth of the developmentalist ideal within the fields of Brazilian politics and economics catalyzed the notion that cancer, which until this point had been seen as a disease of developed countries, was a problem that needed to be combated.

Another important aspect at this time was the change in the national and state political spheres, which was marked by the end of the Vargas dictatorship and interventionist regime. With the return to democracy, important members of the local medical class who were directly linked to the New State distanced themselves from executive positions in medicine, some due to their previous defense of the regime and its involvement with authoritarianism. For example, the exit of César Cals from the directorship of the Medical Center created a chance for other professionals take up leading positions in the organization. It was in this context that the physicians involved with cancerology were able to enter the directorships of the local medical institutions, which was the case for Waldemar Alcântara, Walter Cantídio, Haroldo Juaçaba, Newton Gonçalves, and Jurandir Picanço.

The new positioning of these characters in the medical class expanded their capacity to mobilize cancer as a topic on the institutional agendas, which created a resource defending the argument that the disease was important in Ceará. This affirmation of cancer among these physicians was directly associated with the holding of annual meetings of the Ceará Medical Center, for example. These meetings, which were proposed in 1946 by the president of the association at that time, Newton Teófilo Gonçalves, began in the following year; the goal was to create an "intellectual environment” capable of promoting advances in medicine, public health, and assistance to sick people in the state (Atividades…, 1947, p.2). In practice, the main goals of the meetings, which began as internal meetings and reached the level of regional congress, were to discuss a health agenda for local medicine and to promote debates about specific medical practices and medical specialties.

The first meeting, in 1947, sought to develop a more general framework of the problems relevant to medicine and public health in the state, with the aim of exploring them in the following years. Aspects related to health care, the exercise of the medical profession, and the main diseases occurring in Ceará were discussed. At the second meeting, a roundtable discussion entitled "The major health problems of Ceará” was held, which indicated the priorities for state medicine and public health. This session, which involved six panelists including Waldemar Alcântara (physician and president of the ICC) and a moderator, Newton Gonçalves, stirred interest in a number of participants and became a forum for discussions on health and disease.

In his first statement, Alcântara broadly stated the main public health concerns in the state. Alcântara, who was also the former director of the Ceará State Department of Health (Departamento Estadual de Saúde do Ceará, Desce), presented tuberculosis, childhood ailments, venereal diseases, and other communicable diseases (parasitic as well as acute infectious ailments) as the core medical concerns. In close, he added quackery and faith healing as problems to be faced by medicine in Ceará (Os grandes problemas…, 1947, p.26). His statement sparked participation by the other roundtable participants. The sanitarian Hider Correia Lima stated that priorities should be defined epidemiologically, especially by mortality, following the standards indicated by the federal agencies (Os grandes problemas…, 1947, p.31). Haroldo Juaçaba, who was directly associated with cancer, then intervened in the discussion, asking if the participants did not also consider cancer to be a public health problem. Waldemar Alcântara quickly responded that although the disease had not been mentioned, it was also considered a public health problem.

Juaçaba's intervention at that moment was an attempt by the spokesman for local cancerology to demarcate cancer as a public health problem. Although at that time specialists were gaining strength and the ICC was being incorporated into the School of Medicine, it was also important to convince these esteemed peers of the importance of dealing with cancer as an issue of great magnitude. This process of forming a consensus around cancer was quite complex, and involved characters from various arenas of society. While doctors involved with cancerology enlisted allies and resources in order to practice, there was a predominant vision that medicine and public health in Ceará should focus on rural endemics and the organization of a network of local services. For example, the conclusions of the first Annual Meeting of the Medical Center listed six priorities for local health, and cancer was not among them.

The following years were nevertheless marked by a greater concern with cancer among the members of the Ceará Medical Center, following the discussions on specialties and the medical school. At the end of 1947, Haroldo Juaçaba took over as director of the Ceará Médico journal, where he stayed until 1950, when he became president of the medical center. This new position for Juaçaba, alongside Gonçalves as chair of the CMC, Livino Pinheiro (official spokesperson), Waldemar Alcântara (vice president), Jurandir Picanço (director of the financial committee), Antônio Jucá (director of the clinic committee), and Luiz Gonzaga da Silveira (director of the general surgery committee), was fundamental for this topic to become central to the agenda for the group. Between 1948 and 1952, the annual meetings of the CMC were very productive spaces for discussion about the disease, and were able to create an argument defending cancer control in Ceará, as well as gain allies and partners to organize cancerology, such as the radiologist Raimundo Vieira Cunha and gastroentereologist Alber Vasconcelos, who became interested in studies on cancer.

At the second Annual Meeting of the CMC in 1948, the discussions focused on specific medical practices to diagnose and treat tumors of the digestive tract. One concern in the arguments contained in nine works on neoplasms revealed an essential aspect of framing this disease to the defenders of an anti-cancer campaign: an attempt to define it as a social evil, even though there was not yet a statistical foundation to justify this argument. For example, in the study by the gastroenterologist Alber Vasconcelos (1948, p.64) one can perceive a rhetorical attempt to construct a framework for the disease among the realities of Ceará, using data related to the US:

Gastric cancer is highlighted by order of importance, not only for its maximum severity and extraordinary frequency, but above all for the fact that not a single case has been known to be cured without surgical intervention throughout the entire history of medicine. The extension of this significance can be well assessed when one analyzes the rich material from the United States, and realizes that its annual mortality is approximately 40,000.

Vasconcelos's argument used a rhetorical appeal which was quite common in papers published in Brazil on the "problem of cancer”: it raised warnings about the statistical significance of the disease, but presented data from other countries and drew the problem towards the author's own area of specialty. This form of constructing the argument was partially related to the limitations of statistical studies on the disease as well as the notion that numbers from developed countries served as a basis for what was expected to happen in Brazil in the coming years (Araújo Neto, 2016). This conception is directly linked to the notion that cancer was a disease associated with socioeconomic development.

In another study published during this period, Luiz Gonzaga da Silveira, one of the founders of the ICC, established a relationship between a country's degree of development and the rates of mortality from cancer. In the arguments by Silveira (1949), cancer appears as a typical problem of "civilized areas,” which Brazil was becoming, and Ceará should prepare to deal with the disease. In summary, the author pointed out that it was necessary to discuss cancer in the state, since this was already underway in other places which were preparing to "combat” this "terrible evil” (p.23).

Again, the affirmation of the epidemiological relevance of cancer was part of the author's rhetoric, stating at the beginning of the article that the text will discuss 2,623 cases of diseases related to the cervix and begins with an explanation of cancer's status in the "civilized” world. Later, the author reveals that only 18 cases of malignant tumors were addressed, which transforms the initial number into a narrative strategy. The objective of the gynecologist from the Cancer Institute was to point out the importance of creating a campaign against this disease in Ceará, referring to other experiments conducted to this end in Brazil, especially in Rio de Janeiro and São Paulo. In his opinion, this subject needed to be officially brought into the association's debates, placing the ICC on the agenda for discussions at the state's hospitals. Silveira (1949, p.21) also indicated another interest for physicians involved with cancerology that would shape control of the disease, the creation of a "cancer service:”

In our land, the good news of interest in this subject is beginning to be reported, with the foundation of the Cancer Institute, under the auspices of the Institute of Medical Education, also signaling efforts by many [people] in different fields to contribute to the fight against deadly cancer. However, there is no service organized in the suggested manners, nor have we even heard the cry of alarm yet, calling the main warriors to this praiseworthy crusade, which must be all the doctors of Ceará. … We therefore wish to launch a vigorous and ardent appeal to all of our colleagues who carry out their professional activities here to organize our campaign, suggesting that the main theme of the 4th Annual Meeting of the Medical Center, to be held in 1950, address the foundations of a campaign against cancer in this State.

In 1950, the fourth Annual Meeting of the Ceará Medical Center was organized, with emphasis placed on cancer and a proposal to create a campaign against this disease. The main work presented on the occasion was by Juaçaba, "The problem of cancer in Ceará,” which assessed the organization of cancerology and anti-cancer actions in Ceará up to that time, pointing out improvements which had been achieved since 1944 and the main problems which still existed in local medical practice. According to Juaçaba, the creation of the ICC and the actions by its members drove a series of improvements in the clinical dimension of the disease, mainly by implementing specific surgical methods for each type of tumor, such as hysterectomy and gastrectomy, and the inclusion of new tools such as radiation therapy into the daily routine of cancerology. Furthermore, he credited improvements in the disease in the state to "greater dissemination among the lay public of the basics of this disease and consequent demand for specialists to clarify a greater number of cases” (Juaçaba, 1950, p.6).

For Juaçaba (1950), the campaign against cancer was a reality, which was shaped every day by the creation of new institutional devices and actions by the doctors at the ICC. Unlike in previous works, the author did not attempt to justify actions against the disease from the argument that the disease was a social evil. In his opinion, this idea had already been established.

During this period of five years (1947-1952), the disease had been placed on the CMC's agenda by doctors from the ICC, and important institutional changes had been mobilized, expanding the possibilities of medical practice and shaping a framework for the disease which maintained a dialog with other national and international experiences. However, it is necessary to question the effectiveness of the efforts by these characters to defend cancer control, mainly due to the scenario that formed over the following years within the CMC.

In 1953, Fortaleza hosted the second Medical Congress of the Brazilian Northeast, an event organized by the Ceará Medical Center in partnership with other state bodies, more specifically the medical associations of Paraíba, Rio Grande do Norte, and Piauí, and the medical societies of Pernambuco and Alagoas, with support from the Brazilian Medical Association (Anais…, 1953, p.IV). For the Ceará organization, this joint production of the regional congress and the annual meeting of the CMC represented a broadening of the scope of the annual meetings, which were now seen as a regional medical congress. That same year, the governing body of the CMC had undergone major changes, with the group of physicians tied to the university and to the ICC leaving nearly all the rosters, with the exception of Newton Gonçalves, who was a member of the Committee on Union and Defense of Class.

The panorama depicted in the program defined for the congress differed greatly from previous years. One-third of the programming was dedicated to themes considered "beneficial” for regional public health ("Endemic illnesses of the Brazilian Northeast,” "Chagas disease in the Brazilian Northeast,” "Helminthiases in the Northeast”), another third focused on the problems of the hospital structure in the region, and the last third was devoted to medical education, targeting the specialties (Anais…, 1953, p.X). In none of the 172 pages of the annals of the event was cancer portrayed or discussed, and all of the arguments about disease control and an anti-cancer campaign were silent.

This silence regarding cancer suggests that the disease was far from the largest public health concern for the national and regional health agenda. On the other hand, in local terms, although the doctors had lined up allies involved with cancerology, they were unable to produce a consensus on the importance of cancer in the state. With the exit of the founders of the ICC from the leadership of the Medical Center and Ceará Médico, and the new presence of physicians linked to other projects on the board of directors (projects including the creation of the Maternity Teaching Hospital [Maternidade Escola] and the review of the Pelón Reform), cancer was no longer the focus of the association, and only occupied the conferences which were not published in the journal. As a group agenda, the disease lost prominence in the state's main medical arena, to the same extent that the characters associated with cancer also lost prominence. The path that the physicians found was to rally more allies outside medicine, among the elites of Fortaleza.

In 1954, efforts to implement the anti-cancer campaign in the state intensified, and involved important figures in politics (such as the general Humberto Castelo Branco, who was later president of the Brazilian military regime, and state governor Raul Barbosa) and philanthropy (such as Maria José Weyne, president of the Ceará Cancer Assistance Association). On May 11 of this year, the first educational exhibit on cancer was launched in Fortaleza, in a building belonging to the Cimaipinto company on Major Facundo Street in the city center, with an inauguration speech by Haroldo Juaçaba. Next, the exhibition was taken to the interior of the state by Walter Cantídio (one of the main boosters of the campaign) and Haroldo Juaçaba, in order to convince the local elites about the importance of controlling this disease.

The initiative was reported in the Fortaleza press over the following days as part of a strategy to publicize the campaign's objectives. In the articles covering the event, Haroldo Juaçaba appeared as the personification of cancerology and the spokesman for the exhibit, and speeches by Waldemar Alcântara and Walter Cantídio were also highlighted. In the May 12, 1954 edition of Correio do Ceará newspaper (Terá início hoje…, 12 maio 1954, p.20), readers were invited to attend the exhibition, which was described as:

A popular education campaign on this terrible disease that cuts down thousands of lives in Brazil, consisting of an exhibition of photographs and brochures, in the Cimaipinto Room starting at 5:30 p.m. today. The achievements of the Cancer Institute of Ceará and the Santa Casa Cancer Service toward combating this evil will also be presented to the public. Lectures on cancer will also be featured by local broadcasters and various organizations.

Other newspapers like the Unitário and O Povo featured the exhibit on the day following the exhibition, mentioning "an extraordinary influx of people interested in the campaign which this exhibition initiates” (Instalada ontem…, 12 maio 1954, s.p.). The May 13 edition of O Povo included a portion of the speech by Haroldo Juaçaba, "distinguished fellow countryman [and] cancerologist” (Objetivo maior…, 13 maio 1954, p.12). In his explanation, Juaçaba sought to associate the exhibition in question with the National Cancer Service and with the efforts of doctors at the ICC, stating that it was necessary "to educate the people about this evil that today cuts down more than 100 lives per day” (p.12).

The work of the National Cancer Service at that time also was fundamental in lending authority to the messages from Juaçaba and his allies in the campaign against cancer. After its director Antonio Prudente, and his wife Carmen Prudente, journalist and president of the National Women's Anti-Cancer Network (Rede Nacional Feminina de Combate ao Câncer) visited Ceará, the mobilization of doctors from the state was recognized by the federal service and gained greater visibility in the press. In a talk held by the Ceará Radio Clube radio station, Prudente underscored the importance of the ICC's initiative, returning to the portrayal of the disease as a major social scourge, and fatalistically stated that "every 10 minutes, a life destroyed by cancer disappears in Brazil!” (Em cada dez minutos…, 30 maio 1954, s.p.).

The campaign efforts moved to the interior of Ceará, where the exhibition held at Cimaipinto was shown again. Malignant tumors gradually transformed from one group's agenda to a relevant medical and social problem, with recognition by various social segments with regard to the status of this disease within the health panorama in Ceará. However, this process took much longer and stalled many times in the following decades; for example, the Cancer Hospital itself, which suffered from a frequent lack of resources to build the wings of the institution, was only inaugurated in 1999.

Final considerations

Epidemiologically, Ceará during the 1940s was dominated by communicable diseases with high prevalence rates, specifically rural endemic diseases with high mortality, and cancer was not seen as a public health problem. Within this scenario, despite the creation of a federal service to control this illness, public investment in actions directed at tumors was negligible and the disease was characterized as a "problem related to philanthropy.”

The ICC, which was created by ten doctors and a priest, did not represent a clamor from society for a medical response to an alarming problem. The group's agenda at that time was restricted to the collective, with the participation of individual allies such as the lawyer Antônio Martins Filho and the senator Paul Sarasate. At the Ceará Medical Center, there was also no great concern with cancer in the first half of the 1940s, much less with the organization of a campaign against the disease. The exception was the status of the association, which, in 1944, indicated its plan to create an anti-cancer institution in the capital of Ceará.

The collective dynamics of medicine, based on connections and negotiations between doctors and their peers and allies, were essential to create a "place” for cancer in the state, allowing doctors to openly share this agenda with other doctors and society (or, at least, part of society). Haroldo Juaçaba's 1947 quest to have cancer recognized as a public health problem represented a scenario in which the disease was not a priority among medical and health authorities, but simultaneously demonstrated efforts by the characters involved with cancerology to broaden the group's agenda into something that could be converted into actions and investments to control cancer in Ceará.

This expanded agenda required allies that could take this agenda from doctors into everyday local health. To do this, the transversal connections between actors and institutions brought philanthropists, politicians, journalists, and other physicians (from Ceará and from "outside”) into the initiatives surrounding the construction of cancerology. An important point among these alliances was the incorporation of the ICC into the Ceará School of Medicine, a process engineered during the meetings of the Institute for Medical Education in 1947. With the incorporation into medical school, the ICC not only gained a space to operate fully, but was also strongly associated with the plan to develop current medical practice in the university, expanding the "credibility” of anti-cancer initiatives.

A remarkable change can be seen when comparing the scenario in the early 1940s with the time when the Campaign Against Cancer was created. If little or almost nothing addressed cancer in 1940, by the mid-1950s the disease had gained attention in various arenas of society. In 1954 it addressed a medical and social problem in the process of affirming that, even though it was far from a priority among physicians and the public administration, cancer control efforts had mobilized a significant portion of people, including figures from outside Ceará such as the director of the National Cancer Service at that time, Antônio Prudente.

Clearly, the process of transforming cancer's status did not begin in 1940 and did not end in 1954: it was and still is situated in a broad and continuous time frame and underwent changes that extend to the present, such as the notion that high mortality from this disease is not a sign of civilization and development, but rather indicates that health care for the population is compromised. Between 1940 and 1954, the turning point was the transformation of cancerology and cancer control from a group agenda to a relevant medical and social problem.

• Translated by Tracy Miyake.
• 1
  These young doctors were addressed with terms of praise by Ceará's medical chroniclers as the "1941 generation." Some authors (Gonçalves, 1966; Alencar, 2012; Leal, 1978) considered the members of this "generation" to be responsible for creating numerous medical institutions in Fortaleza, especially the School of Medicine. Elements of this discussion can be seen in Araújo Neto (2016).
• 2
  This foundation of the Society to Support the Cancer Institute of Ceará (Sociedade Mantenedora do Instituto de Câncer do Ceará) involved the physicians Antônio Jucá, Haroldo Juaçaba, Jurandir Picanço Livino Pinheiro, Luiz Gonzaga da Silveira, Saraiva Leão, Waldemar Alcântara, and Walter Cantídio, the priest Archimedes Bruno, the assemblyman Paulo Sarasate, the attorney Antonio Martins Filho, and the writer Fran Martins.
• 3
  Until the 1940s, the term cancerology generally designated spaces where cancer patients would be treated, such as the Center of Cancerology (Centro de Cancerologia) created in Rio de Janeiro in 1937. Starting with the creation of the Brazilian Society of Cancerology (Sociedade Brasileira de Cancerologia, SBC) in 1946, the term gradually became linked to medical practice, and in 1960, the discussion about the creation of a specialty gained strength in the context of the SBC, particularly with the creation of courses which were among the requirements for doctors to enter the National Cancer Institute.
• 4
  The Ceará School of Medicine was created in 1948, and became public in 1954, when the University of Ceará was established and the medical school was incorporated into its structure. There is evidence to believe that the creation of the medical school was part of a project by the local elite to establish a university as an equally symbolic and practical element in the formation of this very same group. A key element in this analysis can be found in Martins Filho (1949).
• 5
  In this and other citations of texts from non-English languages, a freetranslation has been provided.

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Publication Dates

• Publication in this collection
  Jan-Mar 2018

History

• Received
  06 Aug 2016
• Accepted
  01 Oct 2016