In São Paulo and in other parts of Brazil, smallpox epidemics increased in frequency after 1850.  In the table below, we see outbreaks as they were reported by the annual São Paulo President’s and Governor’s Reports.  Some years, São Paulo’s provincial president vaguely described smallpox as occurring “throughout the state,” but it is unlikely that every or even most township had outbreaks those years.  in the 14 years between 1837 and 1850, there were four epidemics.  In the 14 years that followed, there were nine.

In some places, such as Santos, smallpox mortality rose until the 1880s, before declining (see figure below).  Epidemics, however, became more virulent until the 1890s, before they largely vanished due to far more effective and financed public health efforts under the new Republican government.   Similarly, in Rio de Janeiro, smallpox epidemics became more frequent and general mortality increased until the 1880s, before declining.  Rio de Janeiro experienced two terrible outbreaks of smallpox in 1904 and 1908 during a decade when São Paulo suffered no major epidemics.  This was an eradicable disease:  European governments had begun greatly reducing the threat of smallpox as early as the 1830s.

I plan to discuss how railroads facilitated the spread of smallpox.  In the map below, we can see various township centers connected by the railroad (grey line).  The red circles indicate epidemics that occurred between October and December, 1892.   Township centers without railroad states, including Tieté, Porto Feliz, Cajurú, Riberão Bonito, Socorro, Serra Negra, Caconde, Nazare Paulista (Nazareth), Maripora (Jaquery) and others, avoided this disease.

Other factors that may have prompted the spread of smallpox include large populations, large population growth (between 1872 and 1890), or proximity to navigable rivers.   In the final table we can see that the size of the population mattered, but there was a larger correlation between railroad stations and smallpox epidemics.  

Contemporaries were not blind to the fact that trains carried smallpox and, in fact, stations were closed when epidemics occurred.  Three local outbreaks reported by the Diário Official do Estado de São Paulo in 1891 occurred within walking distance of the train stations in São Paulo, Bocaina, and Conchas.

This is not the only disease that railroads helped make into a worse problem.  In 1889, yellow fever appears to have been greatly aided in spreading to “virgin soil” populations in interior São Paulo, devastating towns such as Campinas (see my previous post).   Railroads may have accelerated growth in Brazil, but historians who have estimated savings brought by railroad building have not yet included the enormous costs of these two contagious diseases. 

Considering its importance for day-to-day life in Brazil, it is remarkable that we know so little about it.  Were people helpless? Did the Emperor, provincial presidents and town mayors not fight back?  Remember that this was the only major disease that European governments and charitable organizations had successfully resisted through public health programs and stringent laws as early as the 1820s.  Did Brazilians organize and finance institutions to provide vaccination for those who needed them?  Historians have guesses (i.e., the imperial government was too weak and poor), but few firm answers. 

I'll be putting more up as things develop. For the full series of maps, please click here.  



Smallpox in São Paulo, 1863

Figure 1.

Figure 2.

Figure 3.

Because tetanus mostly strikes newborn babies whose umbilical stumps become infected through unhygenic post-natal care, this disease is a unque indicator of medical treatment and life conditions.

These three graphs demonstrate that tetanus, a frequent killer in the 1850s, become a rare disease by the 1890s in the large southern Brazilian city of Porto Alegre.  For a description of tetanus and this current project, see my earlier post.  As seen in Figure 1, infant mortality also declined (at least in relation to deaths of other age groups).  This gives us strong evidence that as tetanus disappeared, newborns had a greater chance of living.  Interestingly, tetanus among slaves showed an opposite trend, as we can see in Figure 2.  Between 1850 and 1870, tetanus increased as a cause of about 3 percent of total slave deaths to 5.5 percent.  This may have been a consequence of the end of the international slave trade in 1850 because after this point, the male to female sex ratio fell and, possibly, more slaves had chidren.  But as an aging population, I would expect to see a falling percentage of tetanus deaths since this group was much older on average and less prone to infantile afflictions.  Data from Santos shows tetanus rates falling even among slaves during this same period so it may be simply that conditions and treatment of slaves in Porto Alegre worsened despite their rising price.  I excluded data after 1871 since all babies born to slaves were legally free in Brazil when the Imperial government passed the "Free Womb Law" in 1872. Figure 3 demonstrates that even though relative rates of tetanus may have been on the rise among slaves, by the 1890s -- after slavery was abolished -- the gap between the (wealthier) white population and the (poorer) "people of color " (i.e., pretos, pardos, morenos, etc.) vanished.  This is another surprising finding since most historians assume that whites continued to recieve superior medical treatment compared to non-whites.

Data is taken from 46,254 free people and 6,739 slaves who were buried in the cemetery of the Santa Casa de Misericordia in Porto Alegre between 1850 and 1898.

For a short discussion of possible bias in the obit data of tetanus deaths, view this.

"One way to address and analyze the impact of Brazil's Era of Epidemics on public policy, overall population welfare, changes in treatments, and other areas of interest is to compare the Brazilian context with the epidemic context of another large country in the Western Hemisphere: the United States. This blog post will summarize existing historiography of U.S. health related to infectious diseases in the second half of the nineteenth century. Since the focus is on infectious diseases with epidemic potential, this review has a more narrow scope than U.S. health historiography generally for the period. Many studies exist on mental health, chronic disease, cancer, heart disease, and other health concerns in the nineteenth century; their exclusion here does not necessarily reflect a small place in the literature. Studies conducted by demographers, geographers, and economic historians also have a big presence in this review because their methodologies often analyze mortality.

Existing research, as may be expected, generally follows the existing sources. Census data years, military records, especially concerning Civil War soldiers, surveys of cities like Philadelphia with early vital statistics record-keeping, and hospital data all dominate the literature on non-slave populations. Slaves welfare has a large place in the historiography which is discussed in detail below. I will begin with a summary of..."

Click here for the rest of this excellent historiography by Glynnis Kirchmeier.

Opisthotonus, Charles Bell

Tetanus has become the latest focus of the EE project.  This disease is usually the result of a wound infected by the Clostridum tetani bacteria.  As this microbe multiples it release a neurotoxin that can quickly become fatal if untreated.  Poisoning is accidental, since the nuerotoxin is a natural byproduct of its life cycle.  It is a terrible accident, though, since it causes spasms and tightened muscles, especially around the jaw (hence its older popular name "lock-jaw") and  back (called opisthotonos, see image).  One of its most tragic manifestations is neonatal tetanus, usually due to an infection at the umbilical stump caused by a dirty cut or contaminated poultice.  In some parts of Brazil as many as one out of three infants died from neonatal tetanus.   Millions of mothers and fathers watched their newborns stop feeding and arch in pain for days before dying.   

I have only just begun to look at the data, but so far I have found a large drop in in the incidence of neonatal tetanus around 1890 in some parts of Brazil, right around the time that European and Japanese doctors discovered and isolated the tetanus bacteria.  As the same time, there are still a sufficient cases of neonatal tetanus in the early 1900s, indicating that asceptic practices were uneven.  What fascinates me about this disease is how connected it is to medical practice and belief.  By understanding the history of tetanus, we will have a much better idea of how foreign medical knowledge disseminated in Brazil and how quickly medical and midwifery practice changed.  A fuller description of this research can be found here.

I hope this video, shown recently at BRASA, gives support to several arguments.  The first is that yellow fever most likely appeared in Brazil in 1849 (for the first time in 157 years) because it was transported on ships carrying migrants on route to mine gold or settle in California.  Contemporaries blamed a ship arriving with 49ers as the cause of the outbreak in Bahia, but this is not widely known or discussed by historians today.  In fact, historians more commonly connect the slave trade with the outbreak of yellow fever, although this seems improbable for reasons that I'll save for another post.

Second, yellow fever moved inland both in the United States and Brazil with the help of steam propelled riverboats and locomotives.  See my previous post for evidence that it also followed railroad routes.  

There is an important implication to the disease's dramatic movement.  Yellow fever, cholera and bubonic plague were all absent in Brazil during the first half of the 19th century, but caused hundreds of thousands of deaths during the second half.  Smallpox also worsened in mortality, killing millions.  For the United States, all of these diseases except bubonic plague were present, but were worse during the first half of the century.  Therefore, we should include the changing epidemiological environment with geography and institutions as the main reasons why the development gap between these two countries widened between 1850 and 1900. 

The last argument was methodological, and I hope it became apparent in the video/slide show.  I believe that visually representing spatial data not only gives us the tools to make connections we might not have made otherwise, but it helps build support for our arguments.  It is one thing to say that steamboats preceded outbreaks of yellow fever on the Mississippi, São Francisco and Amazon Rivers, but another thing to show the arrival of the steamboats and outbreaks on a geocoded map changes over a set time period.

Many of the day-to-day affairs of the Brazilian Empire (1822-1889) were overseen by the Ministerio do Imperio (Ministry of the Empire).  Once or twice a year this Ministry published an update of the Empire's state of affairs, including reports on schools, municipal elections, and the imperial family. These reports are valuable for this project because they became increasingly detailed in their discussion of public health following the outbreaks of yellow fever and cholera in the 1850s. By the 1860s, they included special reports written by Brazil's top health authorities.  Beyond health, historians studying education or searching for details on some of the smaller provinces will also find them to be a rich primary source.

Ministerial Reports are one of the most accessible primary sources for the imperial period because they can be read online though the Center for Research Libraries (CRL) website.  The CRL does an invaluable service making these available without any special licence or access.  Historians are limited by this source, however, by their length  (as many as 1000 pages for some in the 1870s) and the lack of detailed index.  Furthermore, the CRL only holds page images that have not, until now, been OCR processed.  Without machine readable text, they cannot be searched, making the task of finding answers to specific questions much like finding a needle in a haystack.

I've been working with my father for more than a year now to make part of the enormous collection of government documents at the CRL searchable.  My father created a web-based program that runs on a Linux server and uses MySQL to store and retrieve text records. A separate Python program processes the OCR text information and organizes it in the MySQL database. This technology allows anyone with an internet connection to be able to search the Ministry of the Empire reports by keyword or character combination here.  In total, there are 19,640 pages from 60 reports covering the period 1832-1888.

One caveat:  Often the image or text quality is so poor that our OCR program (AABBY) couldn't read the text correctly.  This means that there are many misspelled words or misidentified characters.   Working around this problem, we included regular expressions searches, a powerful way to find words using wildcard characters or other expressions.  We've also included a quick link to a specially created .pdf page and the CRL's page image for each returned search hit, and these are often easier to read.

Eventually we would like to expand to include more reports.  Even though this could be done for a relatively small price, the cost for us at this point is prohibitive.   We are looking for sources of funds that could make this possible and are open to any ideas.  Potentially, the program's use could be greatly broadened because it could provide a search engine for other primary sources that have been OCR processed. 

Yellow fever outbreaks in the US from 1790 to 1909 from Ian Read on Vimeo.

A few things stand out in this map.  First, yellow fever left its greatest mark on the eastern seaboard and, especially, in the northeastern ports between 1790 and 1820.  After this period, it lingered in this area, but also expanded southward, mostly in the Gulf Coast region. During the 1810s, it took root in and near the Mississippi delta.  Yellow fever appears to become endemic in New Orleans.  By the 1820s, it slowly but erratically spread up the Mississippi River.  The Texan Gulf also had a first outbreak.  By 1854, yellow fever was now a “southern” disease, with periodic outbreaks in the gulf and delta areas especially.  The 1878 epidemic was memorably severe in how far it spread inland (more on that in a minute) and high levels of mortality.  There were fewer epidemics during the 1880s, but yellow fever returned with virulence in the south in the 90s.  After 1901, health officials learned that yellow fever was transmitted by the (aedis aegypti) mosquito and in the next few years health boards attempted mosquito larva eradication programs.  Such programs diminished but did not halt the last major epidemic, in 1905.

I'm building a similarly detailed map for Brazil, but this is a more difficult task because far fewer historians have collected yellow fever statistics.  But from what we know, yellow fever and its mosquito vector shifted considerably in its range.  For instance, in São Paulo during the 1850s, the disease was almost entirely confined to the coast and only took its victims from an area not far from the international port at Santos.  Even though the coffee boom in the following decade brought many more ships, non-immune European sailors and immigrants, yellow fever had largely vanished.  It returned in 1870 and began to spread inland.  By 1889, yellow fever mosquitoes had crossed the tall mountain range and entered the Paulista highlands, where thousands of coffee trees were producing most of the world’s coffee, bringing new wealth to Brazil.  Epidemics occurred in coffee towns previously thought to be immune to the fever until 1903 when the last major outbreak occurred in Riberirão Preto.

This changing distribution of the disease in inland US and Brazil was largely caused by railroad cars that transported infected insects and people into areas with low levels of immunity.  In the two maps below, we can see that the outbreaks in Texas (1862-73) and São Paulo (1889-1903) usually occurred near the railroads.  In fact, Houston and Campinas were both hubs of two strikingly similar disease networks.  Residents were well aware of the threat that this new technology brought, and in both instances, the railroads were closed during (but not before) some of the worst epidemics.

Although there is little doubt that transportation technology like railroads and riverboats contributed greatly to the expanding and changing distribution of yellow fever outbreaks, it is much harder to explain why yellow fever shifted from the American east coast to the south and why yellow fever was not even present in Brazil between 1693 and 1849.  Furthermore, yellow fever epidemics were less common in both countries during the 1860s and 1880s than the 1850s, 1870s and 1890s.  I believe that these changes were caused not by something that people did, but by naturally shifting boundaries of the mosquito host.  

When the Brazilian congress approved the Mandatory Vaccination Law in 1904, public health officials and police were given the power to enter homes and vaccinate for smallpox by force.  Many Brazilians at this time, especially among the poorer classes, saw vaccine as either ineffective at best or deadly at worse.  In fact, smallpox vaccination still carries a small risk of illness or even death, so this worry was not entirely displaced. To many, the main problem was the intrusion by the state into homes and control over bodies, including those of wives and daughters.  During the second week of November, Rio de Janeiro spiraled into revolt over the compulsory vaccinations.  Cariocas (residents of Rio) overturned trams, barricaded streets, and fought police with sticks and rocks.  The revolt succeeded in the short run; the government was forced to temporarily suspend the vaccination program.  Despite this public upheaval, the program resumed and within a few years was showing successful results in lowering the incidence of smallpox in the Republican capital and other urban areas of Brazil.

Many Brazilians learn about the “Revolta da Vacina” as school children, but few know that similar events occurred elsewhere, including in Boston.  For example, when smallpox became epidemic in Boston in 1901, taking hundreds of lives, the Boston Board of Health sent “virus squads” that targeted mostly poor men living in tenement housing.  The Board met considerable resistance, like in Rio de Janeiro.  A reporter to the Boston Globe who accompanied one of these squads described a “fighting tramp,” who “went down in a heap on the floor” from the blow of a policeman's club.  This poor man received both vaccination and suturing of his scalp, according to this wonderful short article on the episode.  The resistance in Boston did not turn into violent mobs like in Rio de Janeiro, but vaccination opponents fought the efforts of the state on multiple levels, including in court.  One case went as far as the Supreme Court, which ruled in support of a state’s right to force vaccinations in order to protect the public during dangerous epidemics.   Today, it may be not unconstitutional for the U.S. government to force vaccinations in the face of an outbreak of a deadly and contagious disease.

The top illustration, published in the Revista da Semana in 1904, shows the Brazilian povo (people) begging mercy from the stern congresso (congress) wearing a Roman tunic.  Below, we see a various scenes from Boston's obligatory vaccination campaign published in the Boston Globe in 1902.  This includes a child “protecting mama” and a man who “strenuously objected.”