It is now more than 90 years since Dr. Oswaldo Cruz launched a public health revolution in Rio de Janeiro, and we have yet to see its like. When he started, in 1903, Rio was a plague and yellow fever pesthole that outsiders rightly shunned. When he finished six years later yellow fever had been banished, plague nearly so; Brazil had been acclaimed for its contributions to international medical research; the country had impressive control over its prevailing health problems; national self-esteem had risen; and Rio de Janeiro's remarkable transformation into a world tourist mecca had begun.

All this makes it worth recalling who Oswaldo Cruz was and what he did. In 1903, where we begin this story, Cruz was a 30-year-old medical unknown appointed Director of the Federal Department of Public Health by a newly elected president, Francisco Rodrigues Alves. Under Alves' predecessor the department was a peanut. Its entire staff consisted of a director, five aides, one sanitary inspector, five servants, and a coachman.

Public health programs in those days tended to fail, so public health was poorly regarded, ill funded, and mostly ignored. Also, the federal department had no jurisdiction over health in Brazil's states or even in the capital city of Rio itself; so aside from a few general measures mostly the establishment of quarantines at major ports its control was limited to parts of the federal district outside Rio.

With Alves' blessing, Cruz set out to breathe life into the Federal Department of Public Health.

The Rio Transformation

Cruz and Alves knew that yellow fever had been banished from Havana, Cuba, by eliminating Aedes aegypti, the mosquito recently found to carry the disease. Yellow fever posed no threat to most Rio residents, who typically acquired mild cases and a lifelong immunity during childhood. But non-immune adults visiting Rio in yellow fever season ran a high risk of quick and horrid death. Thus, as Cruz explained, yellow fever was like "an invisible stain that disgraces and humiliates us," a crippler of international commerce that blackened Brazil's name and scared away outsiders.

Within two months of Cruz's appointment, on 15 May 1903, the government sent the legislature a bill calling for a large and costly campaign against yellow fever in Rio, unification of the federal and municipal health services, imposition of a national sanitary code that included compulsory smallpox vaccination, and transformation of Cruz's federally funded serotherapy institute into a major research center modeled after the impressive Pasteur Institute in Paris.

These proposals cut into what congressmen felt was their cherished right to set state health policy and provoked long acrimonious debate. But Cruz didn't wait for all this: well before the bill was even presented and then laboriously scrutinized, his yellow fever campaign in Rio already had begun. He issued new yellow fever regulations, used previously authorized funds to create a Yellow Fever Prophylaxis Service, and by mid-April 1903 had set the service to work destroying mosquito foci in Rio and isolating yellow fever patients.

Bubonic plague, transmitted by fleas and spread by rats, was the city's other big communicable disease terror in those days. To combat it, Cruz undertook a campaign directed at identifying and treating plague cases and exterminating rats, in conjunction with a large government street-widening and sewerage program. He also went ahead with his plans for remaking the serotherapy institute, despite congressional refusal to fund the project.

Over time, these bold actions produced remarkable results. Yellow fever deaths in Rio declined from 548 in 1903 to none in 1909. Similarly, plague deaths in Rio fell from 360 in 1903 and 54 in 1908 to none in 1912. And the serum institute, formally funded by Congress in 1906 and renamed the Institute of Experimental Pathology, began turning out high-quality research, including work leading to the discovery of Chagas' disease by staff member Carlos Chagas in 1909.

By then Oswaldo Cruz was a national hero, the revered father of a newly empowered Brazilian public health. But the road to success was not always smooth, as we will see, and while Cruz had remarkable ability, he also had certain advantages worth noting. Together, this combination enabled him to advance Brazilian medical research and public health beyond his or anyone else's wildest dreams all in little more than a decade.

Optimizing Opportunities

The first advantage was that Cruz was born an insider. His father, Bento Gonçalves Cruz, had been Brazil's top public health officer under Emperor Dom Pedro II, and Oswaldo grew up closely acquainted with the Brazilian health fraternity. He was also precocious. Learning to read at age 5, he devoured 12 years of school in just 9, and at age 14 began his university training the equivalent of college plus medical school at Rio's National School of Medicine, where he finished his studies in 1892. Then, after a few years of clinical practice and having exhausted the training available to him in Brazil, he went off to Paris for three years to study at the Pasteur Institute, where he was exposed to some of the most original scientific minds in Europe. Cruz returned to Brazil a fully trained bacteriologist steeped in serotherapy, highly attuned to modern medical discoveries, and eager to promote medical research and public health at home.

He soon got a chance of sorts to promote research. Bubonic plague, an ancient scourge previously unknown in the Americas, struck Brazil in 1899 and Rio in 1900, killing at least 295 people in the capital. The government responded to the crisis by setting up the Federal Institute of Serotherapy in reality, nothing more than a small production laboratory at Manguinhos, a city-owned farm outside Rio, to make anti-plague immune sera and vaccines. Cruz, who had helped the government confirm the first suspected plague cases in Brazil and was recognized as one of the few available experts in this field, soon joined the Institute and became its manager. Then, in less than nine months, despite a green staff, scarce funds, and rudimentary equipment, Cruz turned the ramshackle physical plant at Manguinhos into a facility capable of supplying the government with plague vaccine and immune sera. In December 1902 he was named the Institute's director.

Thus, while Cruz was still a relative medical and political unknown when President Alves appointed him federal health director in early 1903, he was well-qualified for the post by his impeccable upbringing, education, and experience. Indeed, despite his youth, Cruz's unusual Pasteur Institute training and brief management of Manguinhos probably made him as qualified as anyone in the country at the time.

Another advantage: Rio's two most notorious afflictions, bubonic plague and yellow fever, were vulnerable to attack. "The extinction of yellow fever is a problem which has already found a practical solution," he informed J. J. Seabra, Alves' new Minister of Justice and Interior. "We can ... consider the question solved ... . Yellow fever will end in Rio de Janeiro when Congress gives us the means." Also, while control measures were not cheap at one point the yellow fever campaign was employing more than 2,500 men, some 1 percent of Rio's entire work force these diseases were such holy terrors that their conquest was justified at almost any price.

Still another advantage Cruz enjoyed was strong presidential support. As the former governor of São Paulo State, President Alves had intimate experience combating yellow fever and was aware of the Reed Commission's recent work in Havana confirming the Aedes aegypti mosquito as the disease's carrier. So when he campaigned for the presidency in 1902, he chose a health reform platform. He wanted Rio de Janeiro and its port of Guanabara to be cleaned up, and he wanted it done immediately. Therefore, Cruz rarely had to convince his chief of the need for strong measures; and while the legislature proved balky, it was much weaker than the president; so Cruz was repeatedly able to make end runs around congress with implied presidential backing.

The People vs. Oswaldo Cruz

What nearly upset Cruz's applecart was public clamor. Cruz usurped state and municipal powers. He funneled vast resources into an institute that he himself directed, thereby appearing self-serving. And he directed a yellow fever campaign that was expensive, controversial, and intrusive. So it is not surprising that many came to see him as a "mad scientist" squandering public money on a host of costly and questionable measures.

But what really drew public ire was smallpox vaccination. Cruz and Alves initially tried to make smallpox vaccination compulsory. In so doing, they roused the powerful Positivist Church in Rio, which opposed compulsory vaccination as limiting free choice. Political sentiments were so intense on this one issue that compulsory vaccination was dropped from the administration's proposed health legislation, and many Alves opponents began to see the health department's controversial actions as a means to discredit the government.

Then a major smallpox epidemic, causing some 130 deaths a week at its height in July 1904, prompted passage of a compulsory vaccination law. This evoked a thunderous response from the Positivists and other opposition groups that soon flared into an attempted coup against the government. The uprising was put down quickly, but the government got the message, and so the new law was not enforced.

All this explains why Cruz was unpopular at first, and why for several years he was pilloried in the press as a monster imposing scientific cruelties upon a cowering population. Eventually, however, mounting success against plague and yellow fever rescued Cruz's image, and international accolades won by research at Manguinhos completed the transformation.

The Tide Turns

In essence, what happened at Manguinhos was that the controversial attention and resources Cruz lavished on the facility produced the desired results. Under Cruz's leadership, the Institute became Brazil's first real center for research in tropical medicine and public health. Cruz did a masterful job of selecting, training, and personally guiding the center's staff. Then, as the yellow fever threat receded, he supplemented local staff members with Europeans, and the international health research community became aware of what was happening. As a result, in 1907 Brazil became the only Latin American country invited to attend the prestigious XII International Conference of Hygiene in Berlin; and during that event the meeting's judges were so impressed by a Cruz-directed presentation that they gave the Institute the conference's highest award, a gold medal, for its role in advancing the health sciences.

News of this unprecedented award excited Rio, and Cruz, who was practically mobbed by well-wishers on his return from Europe, quickly shed any lingering remnants of his "mad scientist" image. One political cartoon showed Cruz receiving a hero's garland over a caption reading "This is the way the country receives its sons that honor and love the nation; it crowns and blesses them." That year, the government gave the Institute the autonomy and authority of a major research center; and early the next year, Brazil's new president, Afonso Pena, issued an executive order renaming it the Oswaldo Cruz Institute, which is the name it bears today.

This has certain lessons for modern public health practitioners. To begin with, Cruz's experience underlines what we already know that major public health efforts require able, dedicated, well-educated leaders and strong political support; such efforts, which may require costly and controversial interventions to succeed, should be directed at surmountable problems; and they need to be supported by good public relations, for if they alienate the targeted community or the public at large, they do so at their own peril.

Cruz's work (notably Aedes and rat elimination) also relates to environmental issues. As Horst Otterstetter, who directs the Pan American Health Organization's Division of Health and the Environment, explains: "Cruz was one of the first people in the Americas to recognize the environment as a key factor affecting health and who acted accordingly. Furthermore, he left a legacy of environmental health consciousness in Brazil. Even today, largely as a result of the public health process that Cruz started, Brazilian health sector professionals have a strong awareness that human health depends upon creating and maintaining a healthy environment."

Cruz's story also has a bearing on the need for public support and participation. This is highly relevant in today's Brazil, where growing solid waste disposal problems have come to support large rodent populations, and where a national epidemic of Aedes-borne dengue fever has led to a major aegypti control program currently employing 47,000 people. As Otterstetter points out, "in the dengue case, just like the yellow fever case, if the community does not participate in destroying mosquito breeding grounds, one should not expect success. And if the community does not participate in sanitary disposal of solid wastes, thereby removing nutrients for the rodents, one should not expect any reduction in leptospirosis or hantavirus fever cases."

Perhaps complacence had something to do with emergence of the current picture. "I think," says Otterstetter, "that collectively we got very comfortable with past success; we relaxed too much, and we let the situation deteriorate to a point where today we need another Oswaldo Cruz."

Fortunately, Brazil has a good pool of potential health leaders because its public health establishment is strong. As Dr. Gabriel Schmunis, Coordinator of PAHO's Communicable Diseases Program, points out, "Oswaldo Cruz was able to build up a tremendous institution, the Oswaldo Cruz Institute. Today, it is part of an even larger entity, the Oswaldo Cruz Foundation, which has grown over the years because the Brazilian Government has had the wisdom to invest in it. The Foundation currently has several branches including a research hospital and a school of public health, and both it and the original Institute have provided models encouraging creation of other research-oriented public health institutions in Brazil."

The Cruz Legacy

Beyond this, elsewhere in the Americas and the world, Oswaldo Cruz's experiences provide a blueprint for those seeking to set up or strengthen public health establishments on their home soil. For experience to date suggests that the time and resources Cruz lavished on Manguinhos were not squandered, and that his vision was correct. In other words, if one is seeking to create a strong public health establishment, research is not a luxury but a necessity. As the world's universities have long demonstrated, effective research programs attract and hold bright scholars, who in turn attract and hold bright students. In the process, knowledge and motivation circulate, a foundation is laid for creating local leaders, and the seeds are planted from which a strong public health establishment can grow.

Clearly, neither Cruz's vision nor his actions provided any permanent health victories, even in Brazil. But just as clearly, his legacy is alive and well. The campaigns he led provide inspiration for those conducting similar campaigns today. The public health establishment he masterminded in Brazil is thriving. The approach he used to create this establishment provides a worthwhile model for other countries and locales. And while the health revolution he spearheaded was unique, in places where public health needs are great, there is good reason to think we could see his like again.

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Jonathan Leonard is a freelance scientific and medical writer based in Cape Cod, Massachussetts, U.S.A.