Women, cancer and public health in Brazil
Oswaldo Cruz Foundation – by Luiz Antônio Teixeira
The first responses to gynaecologic cancer in Brazil date from the beginning of the 1940s, with the development of gynaecology as an autonomous course separated from obstetrics, and the appearance of the first gynaecological care centres linked to medical schools that included cervical cancer prevention and treatment among their activities. From 1936, the gynaecology professor Arnaldo de Moraes implemented at the Rio de Janeiro Medical School a renovation of gynaecological practices based on recently developed knowledge. This led him to create the Instituto de Ginecologia (IG), where he encouraged research into the prevention of cervical cancer. The IG would rapidly become a centre for diffusion of preventative techniques; its model would be followed by other institutions in big cities, which in the 1950s began to develop clinics for cervical cancer prevention.
Recent work by Ilana Lowy at the Oswaldo Cruz Foundation and Yolanda Eraso at Oxford Brookes University have revealed the impact of German scientific work on Brazilian gynaecology; they have also described the scientific networks created by the IG and how this fostered a cervical cancer prevention model based on the combined use of colposcopic examination and exfoliative cytology (Pap smear).
By the end of the 1960s, the Pan American Health Organization (PAHO) started to consider cervical cancer as an important public health issue in Latin American countries, and suggested an expansion of screening programmes aimed at controlling the illness across the region. Prevention campaigns started to appear in response, and followed the US and European models that used cytology as first exam and colposcopy in cases where the slide analysis showed anomalies (which enabled greater coverage). The Cervical Cancer Control Program in Campinas, São Paulo, was the first large-scale effort in Brazil. Implemented in 1965, with technical support from PAHO, it worked in collaboration with municipal and state health centres, hospitals and other philanthropic medical institutions, and achieved unprecedented population coverage. At the end of the 1960s other institutions in São Paulo State started to elaborate campaigns for the control of cervical cancer, and used the Campinas methodology as a blueprint. From 1973 onwards, with the creation of the National Program for Cancer Control, these campaigns began to receive a high level of support from the Ministry of Health. However, gaps remained in these initiatives.
The late 1980s marked a turning point. Further health reforms culminated in the creation of the National Health System (Sistema Único de Saúde), which was able to ensure that the profile of cervical cancer control programmes started to change. From 1995, as consequence of the demands of the feminist movement, the Ministry of Health organised a project for wide-ranging community screening for cervical cancer based on cytological examinations. The project was carried out by the National Cancer Institute (Instituto Nacional de Câncer) and developed the basis for the creation of the national cervical screening programme in place today. Such developments illustrate how seriously Brazilian government and civil society organisations now view cervical cancer as a public health problem.
Luiz Antônio Teixeira is a Researcher and Professor in the Postgraduate Programme in the History of Sciences and Health, Oswaldo Cruz Foundation.