Abstract

A brief review of the career of the public health physician Walter Sidney Pereira Leser, who died in 2004 aged 94. Self-taught, from his 1933 doctoral thesis he became a country reference in the field of statistics and epidemiology, with dozens of studies and supervisions. In the clinical field he is one of the founders of Fleury Laboratory, and participates in the creation of CREMESP. As an academic, Leser was a professor at the Escola de Sociologia e Política de São Paulo, Escola Paulista de Medicina e Faculdade de Farmácia e Odontologia da USP. Also, Leser introduced objective tests in the college entrance examination, and led the creation of CESCEM and Carlos Chagas Foundation. In the Escola Paulista de Medicina he created the first Preventive Medicine Department of the country. As a public official, he was secretary of the State Department of Health of São Paulo between 1967 and 1971 and between 1975 and 1979, responsible for extensive reforms and innovations. Among the most remembered, the creation of sanitary medical career. Throughout this legacy, he lent his name to the “Medal of Honor and Merit Public Health Management” of the State of São Paulo.

Key words
Public Health/history; Health care reform; Preventive medicine; Health centers; Medical Education

Professional history of Walter Sidney Pereira Leser (1909-2004) begins in the approval to attend the Faculty of Medicine and Surgery of São Paulo in 1928. He had used rhetorical ploys to impress the evaluators in an attempt to reverse his disadvantage in matters he was not well prepared. Never more he would forget - and, somewhat embarrassed, accept – that entrance examination inconsistencies could be responsible for his approval¹1 Leser WSP. Porque estou escrevendo? In: Bonfim JRA, Bastos S, organizadores. Walter Sidney Pereira Leser: das análises clínicas à medicina preventiva e à saúde pública. São Paulo: Editora Hucitec; 2009. p. 13-113.. Apparently it never crossed his mind that, together with the method itself disabilities, his performance could be considered from another perspective as a good candidate proof of ability and intelligence -as definitely he proved he was. The fact is that the idea of 'subjectivity’ would never deserve any prominence in his dictionary.

With ability in exact sciences and admittance permitted to attend Polytechnic School by having coursed the State Gym, he never found objective explanation for his choice of medicine. In medical school, early on he realized that he could not handle the diagnostic uncertainty regarding the lack of objective tests, leading him to rule out the possibility of a clinical career. Surgery, a more categorical field that he came to dedicate as an intern, was ruled out by the need for a longer training time to the financial equilibrium, which he could not afford to. So that near the end of the course he still saw no major prospects profissionais¹1 Leser WSP. Porque estou escrevendo? In: Bonfim JRA, Bastos S, organizadores. Walter Sidney Pereira Leser: das análises clínicas à medicina preventiva e à saúde pública. São Paulo: Editora Hucitec; 2009. p. 13-113..

Seeking help for a doctoral thesis - obligatory for graduating – he sought Geraldo de Paula Souza in the Hygiene Institute of São Paulo, being encouraged to write about ‘medical statistics’, until then an unprecedented discipline in the country. Forging so the final mold of the self-taught Leser. With no specific intellectual support, he could only rely on his practical advisor's advice: when in doubt, “lie down, pray, and think”¹1 Leser WSP. Porque estou escrevendo? In: Bonfim JRA, Bastos S, organizadores. Walter Sidney Pereira Leser: das análises clínicas à medicina preventiva e à saúde pública. São Paulo: Editora Hucitec; 2009. p. 13-113.. It worked, and in 1933 he formed with the pioneering ‘thesis’: “Contribution to the study of statistical methods applied to medicine and hygiene”²2 Leser WSP. Contribuição para o estudo dos métodos estatísticos aplicáveis à medicina e à higiene [tese]. São Paulo: Instituto de hygiene; 1933.. From then Leser's path can be counted in the three main fields of activities in which he got involved: the clinical laboratory; teaching; and health administrator career.

The clinic career

On the recommendation of Paula Souza, the newly formed Leser is hired as an assistant in the Department of Chemical-Biological of medical school, where he began to work with the preparation of blood chemistry standards and has his early studies edited³3 Leser WSP, Germek O. Notas sobre o méthodo de Kuttner-Lichtenstein-Bodansky, para determinação do phosphoro inorganico no sangue. Annaes da Faculdade de Medicina da Universidade de São Paulo 1936; XII(Fasc. 3°):337-366.. In mid next year he is surprised with the doctor Gaston Fleury invitation to join his clinical laboratory. In a painful decision, narrates, he exchange the assistance in the Faculty of Medicine by the private sector, where an extensive professional network would be created - without ever being able to imagine that the little Laboratory Fleury would become one of the greatest medical achievements of the country. In the 1970s, when left the first administration as Secretary of Health, and had just retired from the USP Faculty of Pharmacy and Dentistry, Leser turned off his participation on the laboratory, reducing the work to just keeping it in the Escola Paulista de Medicina (EPM).

Also in the clinical field, at the end of 1955 he participates in the creation of the Regional Council of Medicine (CREMESP), which is inscribed with the number 0004. Invited by Flaminio Fávero, candidate for director who had took part in his doctoral degree banking, Leser integrated the victorious plate ‘Class and Defence Union’, exerting an single seat of four years⁴4 Conselho Regional de Medicina do Estado de São Paulo (CREMESP). CREMESP: uma trajetória. São Paulo: CREMESP; 2004..

The professor career

In 1934, at the first year of life of the new Es-cola Livre de Sociologia e Política of São Paulo, Leser received new indication from Paula Souza - who participated in the School foundation – and gave course for the first class as a substitute teacher of statistics, soon being effected. As he said about that start: “I went in a few months from the situation of an unemployed person with no future to one where I was professor of a faculty and hired assistant in another”¹1 Leser WSP. Porque estou escrevendo? In: Bonfim JRA, Bastos S, organizadores. Walter Sidney Pereira Leser: das análises clínicas à medicina preventiva e à saúde pública. São Paulo: Editora Hucitec; 2009. p. 13-113.. In 1936 he writes with the colleague Peter Egydio de Carvalho -neurologist who by his statement assumed vacancy statistics at the Institute of Hygiene - a statistical book in two volumes, published by the São Paulo Hall Department of Culture⁵5 Carvalho PE, Leser WSP. Metodologia estatística. São Paulo: Departamento de Cultura; 1936.. Later, in 1946, he would leave the School of Sociology and Politics to devote to the EPM and USP (University of São Paulo).

At the turn of the 1940s once again Paula Souza remembers Leser and point him out to the EPM Hygiene Chair, which had become vacant. It was not by chance the withdrawal of the two previous candidates. The teaching effectiveness required a thorough preparation for various stages of a contest and a chair thesis defense at the end of two years. Even without the prestige of clinical chairs, low wages, and increased work in Laboratory Fleury, Leser just capitulating to the temptation to become professor of an important medical school “at thirty”¹1 Leser WSP. Porque estou escrevendo? In: Bonfim JRA, Bastos S, organizadores. Walter Sidney Pereira Leser: das análises clínicas à medicina preventiva e à saúde pública. São Paulo: Editora Hucitec; 2009. p. 13-113.. At the end of two years he was approved in the contest with a thesis on food hygiene on bananas as a source of vitamin C⁶6 Leser WSP. Da importância na higiene alimentar em nossa população, do suprimento de vitamina C pela Musa chinensis, Sweet, (banana nanica), e Musa paradisiaca, L., (subespécie sapientum, Schum.), variedade maçã, (banana maçã), e da exigência de se praticar o doseamento da vitamina C, com redução pelo gás sulfídrico e oxidação pela ascorbinase [tese]. São Paulo: Escola Paulista de Medicina; 1941.. In his thesis banking were names that would become major references in their fields: Geraldo de Paula Souza, Francisco Borges Vieira, Samuel Pessoa, Marcos Lindenberg and Pedro of Alcantara Machado. In 1942 he is inaugurated professor of Hygiene at EPM.

New unexpected invitation comes in 1946, interceded for an important group of teachers, including Zeferino Vaz. They requested Leser to run for the Faculty of Pharmacy and Dentistry, University of São Paulo. Among the purposes, they predicted that he would help in it academic structure modification, facing strong personal interests, which included, in the lead, the very rector of university¹1 Leser WSP. Porque estou escrevendo? In: Bonfim JRA, Bastos S, organizadores. Walter Sidney Pereira Leser: das análises clínicas à medicina preventiva e à saúde pública. São Paulo: Editora Hucitec; 2009. p. 13-113.. Overcoming the vices of the contest, it was approved with new defense of professorship thesis on vitamin A⁷7 Leser WSP. Demonstração da existência de hipovitaminose A em certos grupos da população da cidade de São Paulo, por meio da biofotometria, expressos os resultados por uma nova forma - o índice biofotométrico, necessidade da determinação desse índice nos candidatos a carteira de motorista e seus portadores [tese]. São Paulo: Universidade de São Paulo; 1946.. He remained at USP until retire.

Years of Escola Paulista de Medicina (EPM)

Facing the field of statistics and epidemiology, at EPM Leser had been at the forefront of new curriculum for graduation, as well as guidance and support to dozens of studies. Among his epidemiological studies, it caused sensitive impact the relationship between infant mortality in São Paulo, purchasing power and water supply between 1950-1970⁸8 Leser WSP. Crescimento da população da cidade de São Paulo, entre 1950 e 1970, e seu reflexo nas condições de saúde pública In: Bonfim JR A, Bastos S, organizadores. Walter Sidney Pereira Leser: das análises clínicas à medicina preventiva e à saúde pública. São Paulo: Editora Hucitec; 2009. p. 313-33.. Also an epidemiology book was published based on two statistical handouts organized in 1973⁹9 Leser WSP, Barbosa V, Baruzzi RG, Ribeiro MBD, Franco LJ. Elementos de epidemiologia geral. Rio de Janeiro, São Paulo: Livraria Atheneu; 1988.. But undoubtedly his work on the EPM is mainly remembered for the creation of the Department of Preventive Medicine, and the proposed changes in the entrance examination for medicine.

The Department of Preventive Medicine (DMP)

The creation of the DMP was a direct consequence of medical education seminar organized in 1955 by the Pan American Health Organization (PAHO) in Viña Del Mar, Chile. Only two courses sent the commissioned study on its activities in the field of hygiene, which provided motive to put that one produced by Jairo Ramos, Walter Leser and Felicio Prado in the center of the South American debate. The new premises disseminated by PAHO included the defense of general medicine teaching; individual, family and community care; introducing the vision of health instead of only disease in the medical reference system; and guidance of practical community activities¹⁰10 Mascarenhas RS, Wilson D, Bourroul G. O ensino da medicina preventiva em escolas de medicina. Arquivos da Faculdade de Higiene 1961/62; 15/16:17-24.. After the seminar, DMP had extended its classes to several years of the curriculum, developing its activities through lectures, field visits, seminars with guests, and assistance in the new general medical outpatient clinic, focused on teaching clinical prevention, natural history of disease and multicausality.

In 1962 Leser is carried by the Rockefeller Foundation's to an extensive schedule of visits to preventive medicine departments of major centers in the US, including Columbia, Harvard and Cornell, without accuse marked differences compared to EPM. He particularly enjoyed the visit to the Western Reserve University, which developed the ‘vertical comprehensive curriculum’ that both defended in EPM, in the Brazilian Association of Medical Education (ABEM), and as consultant of Faculty of Medicine, University of Brasília¹¹11 Rotberg A, Carvalho AA, Lindenberg M, Iunes M, Lemmi O, Castro NM, Toledo R, Ratto OR, Leser WSP. Sugestões para a reforma de ensino médico. Documenta 1962; 9(novembro):95-104..

But as always relentless, time would bring criticism of those new standards. And precisely these discursive bodies of preventive medicine - shaping the field of medical education - cause the epistemological rupture of the new field of ‘collective health’ um Brazil, instigated by its ‘preventive dilemma’.

The entrance examination for medicine (vestibular)

Since the beginning Leser was concerned about the objective assessment of students in EPM. As a penitent carrying the burden of the personal benefit of a failure selection, he agreed to chair the oral vestibular banking in 1952. Disappointed with the model, took the problem to the Faculty Congregation, which has consented in carrying out an intelligence test in the following year, without that was worth note. Performed the exam, an adapted test of US military allowed Leser to conclude that part of the approved students had no degree of intelligence necessary to study medicine. It was enough to permit him a complete refurbishment of the admissions process, which now has specific objective tests of disciplines, intelligence test and a writing text (‘semi-objective’ correction of dissertations became a particular challenge)¹²12 Leser WSP. As origens do Vestibular Unificado. Educação e Seleção 1985; 11(janeiro-junho):3-7.. In 1962 he was invited to work with Isaías Raw for restructuring the USP entrance examination for medicine. Increased demand of others courses and workload led them to found the Candidate Selection Center at Medical Schools - CESCEM; and, to be insufficient, the creation of the Carlos Chagas Foundation (also influencing the emergence of CESGRANRIO and FUVEST)¹²12 Leser WSP. As origens do Vestibular Unificado. Educação e Seleção 1985; 11(janeiro-junho):3-7..

Health administrator's career

The performance of Leser as secretary of the State Department of Health of São Paulo (SESSP) would definitely enhance his name in the history of public health. Without experience in public administration, is taken for granted that Jairo Ramos, an influential professor at EPM, pointed him out to the Governor Abreu Sodré.

Certainly he had the qualifications for the most pretentious bureaucratic reform of the state administration envisioned: professional merit, competence, rationality and firmness of positions among them. But in times of political radicalism undoubtedly his ancestries to the lineage Paula Souza, strong presence in liberal medicine, and distance from politics parties were inalienable traits of acceptance.

The reorganization of SES-SP was no simple task. The high rate of rotation of secretaries and directors maintained their acting always in the contingency plan, permeated by structural deficiency, centralism, technical deficiency, lack of coordination, and of course, political patronage. In 1947 the area of Health is dismembered of the Education in the Public Health Affairs and Social Assistance State Department, but without such reorganization would translate in the expected efficiency. On the contrary, the various reform commissions led to few practical results, “Only the author of this work participated in seven commissions from the first created by the first Secretary of Public Health and Social Assistance”¹³13 Mascarenhas RS. História da saúde pública no Estado de São Paulo. Rev Saude Publica 1973; 7(4):433-446.. The reality of the services that reaches Leser administration is described by Yunes & Bromberg¹⁴14 Yunes J, Bromberg R. Situação da rêde pública de assistência médico-sanitária na área metropolitana da Grande São Paulo. Rev Saude Publica 1971; 5(2):221-236.: “lack of rational location criteria” for equipment, professional failure and complete “lack of coordination between the public authorities responsible for units health, leading to plentiful resources of some areas and the total abandonment of others”.

The Health Department reform was induced by the well known 200 Federal Decree-Law of 25.02.1967, an ambitious project of public administration renovation. Its version in São Paulo, the 48,040 Decree-Law of 06/01/1967, mirrored the Federal guidelines: operational efficiency; administrative efficiency; and enhancement of public servant - a prospect that was opposed to patrimonial culture and changed the established political forces relationship.

The State Decree defined the creation of a ‘Study Group for Administrative Reform’ (GERA) in the Department of Finance in order to analyze, prepare, start running, track and assist the State secretariats in the reform process. For the reform of public health, GERA was reinforced by a select roster of experts linked to SES-SP and FSP-USP, responsible for drafting the project that would become known as ‘Leser Reform’.

First administration (1967-1971): the ‘Leser Reform’

It is not the case to scrutinize the details of the reform, easily accessible from the State legislation and other documentos¹³13 Mascarenhas RS. História da saúde pública no Estado de São Paulo. Rev Saude Publica 1973; 7(4):433-446.. Redefined just as State Department of Health, that was opportunity to make the health center the real “axis of health-care organization”, as assumed in the decrees. As principle, the Community Health Coordination is planned as the largest among the four planned (Leser's friend Rodolfo Mascarenhas, who accepted this direction, never assumed in fact, prevented by the illness that would victimize him).

A more than three decades aspiration was achieved by the reform: the expected sanitarian medical career, with the forecast of 622 specific posts. The Health Institute of São Paulo was also created as an aid in assisting and assessing the services performance.

Epidemiologist, Leser bring the prevention vision to the forefront, especially based on vaccine campaigns, immunization and sanitation program. As the first challenge, the eradication of smallpox stimulated by the World Health Organization triggered mass vaccination of 90% of the state's population from 1968 to 70; in addition to establishing a vaccination schedule, technical reference standards and - so common nowadays -a vaccination booklet. He also worked on the renovation of the Health Code, part of which dated back to 1918 Sanitary Code; building installations; definition of drug purchasing policies; mental health policy; endemic diseases combating, particularly schistosomiasis; creation of school health centers, among others. The fight to a typhoid fever epidemic in Igaraçu do Tiete earned him the name of a street as tribute¹⁵15 Bonfim JRA, Bastos S, Postigo VRM, Leser WSP, organizadores. Walter Sidney Pereira Leser: das análises clínicas à medicina preventiva e à saúde pública. São Paulo: Editora Hucitec; 2009..

The leprosy problem was at the center of the action. Coordinated by his classmate Abrahão Rotberg, the reform sought to options to the compulsory isolation of patients. Although Leser had some scientific papers in the field, his greatest impact partnership was due to the successful proposal to replace the term ‘leprosy’ with ‘hanseníase’, made State and Federal law and therefore observed in the Brazilian translation of the International Classification of Disease¹⁶16 Rotberg A. Do “Fator N” [1937] ao “leprostigma”. In: Bonfim JRA, Bastos S, organizadores. Walter Sidney Pereira Leser: das análises clínicas à medicina preventiva e à saúde pública. São Paulo: Editora Hucitec; 2009. p.379-387..

Politically Leser had a particularly serious situation to deal with: the compulsory retirement of the USP professors by the military government. Although belonged to a conservative social environment and express reservation to the political intricacies, he has engaged in defending the sanitarian medical group that started working in SES-SP. Several of them with left filiations, among the most cited, David Capistrano da Costa Filho and Pedro Dimitrov. Not that it was a reversal to a progressive filiation nor that it was professed as virtuous attitude. But something simpler, as seems to have been their walk in life, integrity about what seemed correct or not.

Second administration (1975-1979)

In 1975 Leser, then aged 65, received an invitation to return to the Health Department by the future governor Paulo Egydio Martins. The challenges were wide open from in welcoming: a literal war operation against meningitis epidemic in the very first week of work - hitherto censored by the dictatorship. It has been established a impressive mark of 10 million people vaccinated in four days in São Paulo, followed by about 95% vaccination coverage in the rest of the state. The end of the epidemic was enacted. Not enough, the same year had to deal with a second hatched epidemic on the south coast of São Paulo, characterized by a severe and unknown neurological condition; which was finally controlled without establishing clearly the nosology¹⁵15 Bonfim JRA, Bastos S, Postigo VRM, Leser WSP, organizadores. Walter Sidney Pereira Leser: das análises clínicas à medicina preventiva e à saúde pública. São Paulo: Editora Hucitec; 2009.. Leser's name inevitably wins mythical contours.

Following the administration he gave priority to what was expected: focus on basic services; implementation of the modern ‘programming model in Health’ in the health centers; strengthening the vaccination program; new units construction; plus new revision of the State Sanitary Code.

But the collective public health memories of São Paulo guard the consolidation of sanitarian medical career as the central representation of this period. After all those years, only two hundred of the 622 positions created in the reform were filled. One problem was that after an open initial period of three years, the Public Health specialty became requirement for the medical sanitarian career. To reverse the situation, at a personal cost, Leser induces the old course reorganization in half-yearly classes, with the increase to 60 vacancies and also the revocation of the applicant's need link with the state public service¹⁷17 Souza JMP, Mercadante OA, Arantes GR, Ferreira SA, Vasconcelos TP. Curso de Saúde Pública em um semestre: algumas considerações. Rev Saude Publica 1975; 9(1):87-92.. Six classes were offered between 1976 and 1978, allowing the realization of over 300 medical sanitarians in the state. Basically the currently most recognized names in the collective health field were there. Apparently, the progressive force printed by that sanitary youth would have been the real reason for career extinction sanitarian in 1987.

Final considerations

Human all too human. Leser cultivated many friendships, reserving special appreciation for his long walk companion, Ms. Helena - he died at 94 and her 100 years. Chess and football were another of his passions, if his rationality would allow such license. Austerity, sobriety and intelligence are personality traits commonly remembered. The sense of refined mood is revealed in the question about if he considered subversives the “students” in a written interview: “What would you think of a question like this: Are students vegetarians?”¹⁵15 Bonfim JRA, Bastos S, Postigo VRM, Leser WSP, organizadores. Walter Sidney Pereira Leser: das análises clínicas à medicina preventiva e à saúde pública. São Paulo: Editora Hucitec; 2009..

Walter Leser was a modern man at the forefront of his midst. However, it was not among his attitudes manifestation of raptures visionaries or higher intelligence claims. On the contrary, he never failed to point out that he believed he had passed the medical entrance exam for deficiency of the method. His writings often praise the ability and peer intelligence. Biostatistics pioneer? No, “just play by ear”¹⁵15 Bonfim JRA, Bastos S, Postigo VRM, Leser WSP, organizadores. Walter Sidney Pereira Leser: das análises clínicas à medicina preventiva e à saúde pública. São Paulo: Editora Hucitec; 2009.. Neither showed self-centered personality. Notice that when reviewing the history of public health, Rodolfo Mascarenhas focuses the ‘master’ Paula Souza achievements at the individual level - as is usual in the writings related to his figure. Speaking about the friend, the tables are turned: “The Department restructuring is the result of the efforts of a team led by Walter Leser. Although it is the work of a group and not of a person, it is nevertheless to have opponents’¹⁵15 Bonfim JRA, Bastos S, Postigo VRM, Leser WSP, organizadores. Walter Sidney Pereira Leser: das análises clínicas à medicina preventiva e à saúde pública. São Paulo: Editora Hucitec; 2009.. From a close interaction, Zilah Abramo summarizes: “austerity in treating public matters, was the characteristic feature of the Secretary Leser”¹⁷17 Souza JMP, Mercadante OA, Arantes GR, Ferreira SA, Vasconcelos TP. Curso de Saúde Pública em um semestre: algumas considerações. Rev Saude Publica 1975; 9(1):87-92.. The practical translation of what is conceptually difficult to translate to Portuguese: accountability. He was eminently a man of his time, but as a man of his time seemed unbeatable.

After all, in his retreat, what would he say about his primacy of action: physician, statistician, professor or sanitarian? Witness of his final moments in the hospital, Ausonia Donato²⁰20 Donato AF. Educação em Saúde e interdisciplinaridade na APSP. In: Paula SHB, Bonfim JRA, Louvison M, Martins CL, Capucci PF, organizadores. Associação Paulista de Saúde Pública: 40 anos de atuação no movimento sanitário paulista. São Paulo: Instituto de Saúde; 2014. p. 135-140. states: “he was keen to talk things from the smallpox eradication campaign where I worked, and one thing struck me… He said thus: ‘The worst nonsense, my daughter, was the career extinction of sanitary doctors’”.

Too bad no one had remembered to ask him when he still had health if finally at ninety he agreed that the entrance selection of 1928 lived up to one of their best candidates: Walter Sidney Pereira Leser.

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