Abstract

This study analyzes how São Paulo state government promoted public assistantships policies during the First Republic. During this time, the government aimed at controlling epidemies and endemics, leaving individual care to private institution. Through budget plans, reports from the Secretary of Interior, speeches at the Chamber of Deputies, and newspaper articles, we observed that there was a budget policy which allowed the government to spend money on institutions that assisted immigrants and poor people. Besides an annual expenditure, the government could also send extra budget during epidemics, and also developed periodic inspections to evaluate the sanitary conditions of the subsidized institutions. The document’s analysis showed that the resources spent were high in value, almost as much as the one available for Sanitary Service, a public organization created in order to fight infectious diseases. The state also used the same system to install its own structures used to fight diseases like trachoma and hookworm in 1906. However, in a time when the main discourses asked for public dispending reduction, the high costs to upkeep these institutions made them to be shut down. The government, thought, kept the old system, sending resources to philanthropic and private hospitals.

Keywords:
Public Health; Health Services; Delivery of Health Care; History; São Paulo

Introduction

The first republican constitution of Brazil created a federative system that decentralized the political and economic power, empowering the states with authority. São Paulo, which was at the time a leader in the coffee economy, argued for such decentralization, given that the proposal favored the São Paulo government to work detachedly from the federation, keeping and expanding projects in which it had economic interest, especially those related to the coffee-growing (Luna; Klein, 2019LUNA, F. V.; KLEIN, H. S. História econômica e social do estado de São Paulo: 1850-1950. São Paulo: Imprensa Oficial, 2019.).

The São Paulo’s elite, composed of the coffee lords and their allies, was a united group, experienced in business and agriculture, and holding a close relationship with the São Paulo Republican Party and city authorities. The ability to be granted credit due to the elite influence over the government enabled the São Paulo state to expand services and infrastructures, of which stood out the implementation and expansion of railroads, banks and traders, import and export trades, wholesale and retail businesses, industries and communications (Gunn, 1992GUNN, P. A importância histórica da fronteira cafeeira na ocupação territorial de São Paulo. Boletim Técnico São Paulo, São Paulo, n. 8, p. 59-72, 1992.; Luna; Klein, 2019LUNA, F. V.; KLEIN, H. S. História econômica e social do estado de São Paulo: 1850-1950. São Paulo: Imprensa Oficial, 2019.).

The credits and public investments expanded the rail network, enabling the expansion of farms and coffee plantations towards the West zone of the state (Losnak, 2017LOSNAK, C. J. Territorialidades do oeste de São Paulo: transformações e interpretações. História: São Paulo, São Paulo, v. 36, n. 13, p. 1-31, 2017.; Luna; Klein; Summerhill, 2014LUNA, F. V.; KLEIN, H. S.; SUMMERHILL, W. R. A agricultura paulista em 1905. Estudos Econômicos, São Paulo, v. 44, n. 1, p. 153-184, 2014.).²2According to Losnak (2017), the interests of the coffee farmers and of the state government had a close relation with the expansion of the rail networks into the state inlands, as they analyzed the economic viability of the region. Luna, Klein and Summerhill (2014) found that, among the 165 municipalities concentrating coffee farms in 1905, 87 of them had train stations inside the farms themselves. These also allowed the state to promote a migratory police, fostering strategies such as subsides to travel tickets, assistance and lodging,³3Udaeta (2013) states that São Paulo had three types of Immigrants Lodging: one for immigrants, one for the colonial group and one for internment, with each one having a specific scope. which would ensure enough workforce available during a scarcity time, post the abolitionist measures in place from the 1850s on⁴4The abolition of slavery in Brazil was a slow process initiated in 1831, with the attempt to prohibit the slave trade. Without practical results, a new bill passed in 1850 definitely prohibited the transportation of African people across the Atlantic. In spite of the trade prohibition, the slavery continued in Brazil, being gradually extinct: in 1866, slaves who served the army were released; in 1885, freedom was granted to the slaves older than 60 years old; and in 1888 all slaves were granted freedom. (Schwarcz; Starling, 2015). (Udaeta, 2013UDAETA, R. G. S. Nem Brás, nem Flores: hospedaria de imigrantes da cidade de São Paulo (1875-1886). 2013. Dissertação (Mestrado em História Econômica) - Universidade de São Paulo, São Paulo, 2013.).

These policies based on the subventions implemented post 1870 increased the demographic density in São Paulo, even tripling the inhabitants in the state from 1872 to 1900 (Ribeiro, 1993RIBEIRO, M. A. R. História sem fim: um inventário da saúde pública, São Paulo, 1880-1930. São Paulo: Unesp, 1993.).⁵5In 1872, the São Paulo’s population was of 837,354 inhabitants, reaching 2,282,279 in 1900 (Ribeiro, 1993). The immigrants arriving in Santos were, mostly, from the North of Italy, a region of agriculture tradition and with high poverty rates. Unable to provide for themselves, many immigrants would temporarily accept the labor conditions in the farms, quickly moving to the urban centers in the search for better life and work conditions (Lanna, 2012LANNA, A. L. D. Aquém e além-mar: imigrantes e cidades. Varia Historia, Belo Horizonte, v. 28, n. 48, p. 871-887, 2012.). The issue then is that the São Paulo government had no proper urban and sanitary planning to welcome the immigrants settling in the cities, leaving the population in an unhealthy environment, favorable to the spread of diseases, such as the yellow fever.

In this context of an ill workforce, the government moved on to implement stronger measures against epidemics. By the end of the 19^th century, the Sanitary Code was created and the old and simple Hygiene Inspectorate was restructured, installing a great apparatus composed of laboratories and research institutes that, along with the Immigrants Lodging, sought to manage the public healthcare programs in face of a growing immigration. The structure for individual assistance, however, was not a priority in the governmental projects since, according to Telarolli Junior (1996)TELAROLLI JUNIOR, R. Poder e saúde: as epidemias e a formação dos serviços de saúde em São Paulo. São Paulo: Editora Unesp, 1996., the government limited its work to controlling infectious diseases through its institutions. The reason for it, according to Sanglard (2008SANGLARD, G. A Primeira República e a constituição de uma rede hospitalar do Distrito Federal. In: PORTO, A.; FONSECA, M. R. F.; COSTA, R. G. (Org.). História da saúde no Rio de Janeiro: instituições e patrimônio arquitetônico (1808-1958). Rio de Janeiro: Fiocruz , 2008. p. 59-87.), is that the role of the state would be to intervene in calamitous situations only - what, in the field of assistance, meant to act during epidemics only. Thus, the state government transferred the responsibility for treating non-infectious diseases to the citizens, physicians and private institutions.⁶6The understanding of private institutions is institutions or associations classified by the end of the 19th century by the Notary’s Office under the stamp “Civil Societies” or of private initiative (Mott; Sanglard, 2011; São Paulo, 1906). Fall under these categories associations that provided free care and/or paid care, they could be secular or religious, philanthropic, charities, of mutual assistance and private; and with distinct purposes, such as the protection and promotion of care to the ill, orphans and the poor, and associations and institutions healthcare service providers and asylums. (Mott; Sanglard, 2011).

Under this management model, the state government financially supported certain institutions that providing services to the poor and the immigrants. This practice, which dated back to the Imperial period, increased after the Proclamation of the Republic, when the rates of medical services to the ill increased in the same proportion as the population rates (Silva, 2010SILVA, M. R. B. Santa Casa de Misericórdia de São Paulo: saúde e assistência se tornam públicas (1875-1910). Varia Historia , Belo Horizonte, v. 26, n. 44, p. 395-420, 2010.).⁷7Silva (2010, p. 405), for example, observed that the funds transferences to the Santa Casas de São Paulo increased until turning into regular “considerable amounts” transferred by the municipal and state governments, reaching, in the first years of the 20th century, 50% of the revenue figures of the Irmandade.

The relationship between the state and the private healthcare institutions was a subject for numerous researchers, especially in the past ten years. Among those, we emphasize the work of Sanglard and Ferreira (2018SANGLARD, G.; FERREIRA, L. O. Caridade e filantropia: elites, estado e assistência à saúde no Brasil. In: TEIXEIRA, L. O.; PIMENTA, T. S.; HOCHMAN, G. (Org.). História da saúde no Brasil. São Paulo: Hucitec, 2018. p. 145-181.), whose research projects were about Rio de Janeiro; the article by Souza (2011SOUZA, C. M. C. Saúde pública e assistência na Bahia da primeira metade do século XX. In: SIMPÓSIO NACIONAL DE HISTÓRIA, 26., 2011, São Paulo. Anais… São Paulo: Anphu, 2011. ), about the healthcare network in Bahia state and, in particular, the works by Silva (2010SILVA, M. R. B. Santa Casa de Misericórdia de São Paulo: saúde e assistência se tornam públicas (1875-1910). Varia Historia , Belo Horizonte, v. 26, n. 44, p. 395-420, 2010., 2011), who researched the Catholic healthcare providers in São Paulo and their relationship to the São Paulo government. In these works, we observe that the majority of care institutions, especially the philanthropic ones, had a public function, in spite of being private entities.

Despite this important and growing referential that marked the engagement of the state in the matters concerning individual healthcare, we see that the public policies of the São Paulo government concerning these institutions have yet to be approached in-depth.⁸8Luna and Klein (2019), who researched the economic history of São Paulo, analyzed the budget plans of the state in the turn of the 19th to the 20th century. In the third chapter of the work, the authors mention the budget amounts in the category “subsides and aids,” without, however, looking into it in detail. The bibliography about the São Paulo government suggested the allocation of financial resources to the philanthropic and charity institutions, yet it did not analyze the share of it forwarded to private institutions, what the subsidy represented for the state budget, which institutions were the receiving those funds, and how the partnership between the state and the private institutions occurred.

In this article, we seek to fill these blanks through the analysis of the São Paulo’s budget plans between 1891 and 1910, of the framework of laws and state decrees, of the Reports of the Secretary of the Interior and press articles, thus contributing to the historiography on public and private assistance in São Paulo. In conceptual terms, we will use the assumptions by Sanglard and Silva (2010SANGLARD, G.; SILVA, R. P. A organização da assistência hospitalar no Distrito Federal entre filantropia e a ação do Estado (década de 1920). In: MONTEIRO, Y. N. (Org.). História da saúde: olhares e veredas. São Paulo: Instituto de Saúde, 2010. p. 65-78.), which define the “public assistance” as the set of public and private institutions, secular and religious, who had founded hospitals, nursing homes, nurseries, orphanages, asylums, and polyclinics to treat the ill, the poor, the elderly and the mentally ill. In our analysis, we considered institutions for public assistance those listed in the plans as “Santa Casa,” “Hospital,” “Maternity Hospital,” “Dispensary,” “Sanatorium,” “Polyclinic,” “Charity,” “Nursery Home,” “Shelter,” “Casa Pia,” “Orphanages,” “Home,” and “Conferência S. V. de Paulo.”

In addition to the introduction and final considerations, we divided the article in three parts. The first seeks to briefly introduce how the government approached the private institutions, especially the philanthropic, to help them in the matter of public assistance. In the second part, we identify the private institutions who received governmental funding and the figures allocated to them. Also in this second part, in order to understand what the subsided funds represented in the budget plan of the state, we will use the figures allocated to the Sanitary Service as a comparative basis, as the Sanitary Service is the body responsible for the sanitation and for the fighting of infectious diseases. This body, created and managed by the public government, in addition to having a team directly connected to the board, also had several institutes under its management, such as the General Service of Disinfection, the Bacteriological Institute, the Clinic Analyses Laboratory, the Chemistry Analyses Laboratory, the Vaccination Institute, the Pharmaceutical Laboratory and the Isolation Hospitals. According to Ribeiro (1993RIBEIRO, M. A. R. História sem fim: um inventário da saúde pública, São Paulo, 1880-1930. São Paulo: Unesp, 1993.), Telarolli Junior (1996)TELAROLLI JUNIOR, R. Poder e saúde: as epidemias e a formação dos serviços de saúde em São Paulo. São Paulo: Editora Unesp, 1996., and Mota and Marinho (2013MOTA, A.; MARINHO, M. G. S. M. C. (Org.). Práticas médicas e de saúde nos municípios paulistas: a história e suas interfaces. São Paulo: FMUSP, 2013.), the Sanitary Service was an important governmental body that managed to control and fight some of the most serious diseases of the time, such as the yellow fever, the smallpox and the bubonic plague. In the third part, we analyze the governmental action in the campaign to fight the trachoma, an endemic infectious ophthalmological disease in São Paulo since the 1880s. In the first decades of the 20^th century, the state government tried to implement a state-owned network of medical care to service not only those with trachoma, but also to treat other diseases, such as ancylostomiasis, malaria and typhoid fever, in addition to vaccination. Through the trachoma history and the parliamentary speeches, we were able to analyze the governmental action to implement and maintain the healthcare facilities installed in several locations across the state and how the partnership between the state and the private institutions worked.

The poverty, the immigration, the disease and the healthcare

In February 1836, the São Paulo province approved the “Commitment of the Irmandade da Santa Casa de Misericórdia of the Imperial City of São Paulo,” under the Law no. 2, signed by the President of the Province, José Cesário de Miranda Ribeiro. According to the law, the Irmandade would be obligated to maintain the orphanages, the hospital for the poor and the leprosarium established by the organization (São Paulo, 1836SÃO PAULO (Estado). Lei nº 2, de 9 de fevereiro de 1836. Compromisso da Irmandade da Santa Casa de Misericórdia da Imperial cidade de S. Paulo. Assembleia Legislativa do Estado de São Paulo, São Paulo, 1836.).

Guided by the principles of this first Commitment, the Irmandade established, in little over half a century, hospitals in more than 35 municipalities, serving the port city of the state, the capital and several inland municipalities (Koury, 2004KOURY, Y. A. (Coord.). Guia dos arquivos das Santas Casas de Misericórdia do Brasil: fundadas entre 1500 e 1900. São Paulo: Cedic, 2004.). The process of establishing the first hospitals in Santos and in São Paulo is considered by Silva to be (2011SILVA, M. R. B. Concepção de saúde e doença nos debates parlamentares paulistas entre 1830 e 1900. In: MOTT, M. L.; SANGLARD, G. (Org.). História da saúde: São Paulo, instituições e patrimônio histórico e arquitetônico (1808-1958). Barueri: Minha Editora, 2011. v. 1, p. 63-92., p. 65) “one of the first forms of healthcare verified in São Paulo.”⁹9To Sanglard (2005) the Santa Casas managed to be hegemony in healthcare services because, even though it had Christian principles, the hospitals provided services to the population regardless of its religious option. Based on the author’s interpretation, we notice that the distinction between charity and philanthropic institutions are hard to verify, demanding documental sources that confront the speeches given and the actions taken by the institutions and their members.

With the expansion of the cities and a greater circulation of poor people on the streets, the concept of assistance started to acquire a new connotation. The “poor of God,” who should be assisted by the philanthropic and charity institutions, started to be seen as the hassling poor, who brings discomfort to the society and that should, therefore, be moralized, educated and treated (Sanglard; Ferreira, 2018SANGLARD, G.; FERREIRA, L. O. Caridade e filantropia: elites, estado e assistência à saúde no Brasil. In: TEIXEIRA, L. O.; PIMENTA, T. S.; HOCHMAN, G. (Org.). História da saúde no Brasil. São Paulo: Hucitec, 2018. p. 145-181.; Sanglard; Silva, 2010SANGLARD, G.; SILVA, R. P. A organização da assistência hospitalar no Distrito Federal entre filantropia e a ação do Estado (década de 1920). In: MONTEIRO, Y. N. (Org.). História da saúde: olhares e veredas. São Paulo: Instituto de Saúde, 2010. p. 65-78.). Thus, to care for the forgotten and treat the poor ill that were multiplying in the urban centers became a large project, demanding efforts beyond the philanthropic and charity institutions. In this context, the government started to suffer pressure to come up with alternatives to the assistance issues.

During several sessions in the São Paulo Legislative Assembly, the state representatives discussed forms of financially support the Irmandades. They discussed, voted and approved amendments, annexes, funding from lotteries and resources from the building renovation and maintenance (Silva, 2011SILVA, M. R. B. Concepção de saúde e doença nos debates parlamentares paulistas entre 1830 e 1900. In: MOTT, M. L.; SANGLARD, G. (Org.). História da saúde: São Paulo, instituições e patrimônio histórico e arquitetônico (1808-1958). Barueri: Minha Editora, 2011. v. 1, p. 63-92.). Just after past the second half of the 20^th century, these financial measures were palliatives, with the approval of some lotteries and the assignment of funds to the maintenance and renovation of few units of Santa Casa Hospitals.

From the 1874’s budget plan on, the resources for the Santa Casas and other charity and philanthropic hospitals increased and became regular. In the final years of the 19^th century, the resources started to be assigned to any institution that provided free care, regardless of being charity, philanthropic, associative or private institutions.

This new landscape, formed by the increase in resources and the expansion of scope of the subsidized institutions, was a consequence of two factors: first, the slave abolition that freed elderly people, children, men and women without sufficient structure to proper insert them into society. Second, the immigration policy that caused a loss of control in the population increase, causing poverty, and poor hygiene and assistance conditions (Risi Junior; Nogueira, 2002RISI JUNIOR, J. B.; NOGUEIRA, R. P. (Coord.). As condições de saúde no Brasil. In: FINKELMAN, J. (Org.). Caminhos da saúde pública no Brasil. Rio de Janeiro: Fiocruz, 2002. p. 118-234.). In regards to immigration, Luna and Klein (2019LUNA, F. V.; KLEIN, H. S. História econômica e social do estado de São Paulo: 1850-1950. São Paulo: Imprensa Oficial, 2019.) emphasize that the state also found itself forced to rethink the social issues when the strikes and immigrant-led conflicts started to demand better educational, health and social assistance conditions.

The governmental subsidies “sub1”

In 1909, the private institutions stood out in the annual report of the São Paulo governor, Albuquerque Lins. In his report, the governor emphasized the relevance of such institutions to the state and opened a debate over the need to review the figures and institutions that received public subsidies. As per his words,

The several charity associations subsidized by the state keep providing their best services.

The governor’s remarks mention a debate that had been occurring in the Legislative Assembly, where the state representatives discussed the revision of the budget subsidies transferred to 58 private institutions established in the São Paulo state. Out of the speeches given in several sessions, we notice that the politicians had a pro-active attitude in the defense of some institutions, such as the “Sociedade Beneficente de Itapetininga,” defended by Júlio Prestes, under the allegation that the aid given by the state was “minimal and insignificant, considering the great and real services that it provided to the entire zone it services.” The same is true for the resources to the Bananal, São José do Barreiro, Areias, Queluz, Pinheiros and Silveira municipalities, mentioned by the state representative Oscar de Almeida, who assured that the Irmandades had “scrupulously spent the aid voted on in the budget of our state, which can be attested by the illustrious sanitary inspectors, who had constantly visited said hospitals” (Câmara, 1909CÂMARA. Correio Paulistano, São Paulo, 7 dez. 1909, p. 2., p. 2).

By analyzing the budget plans of the São Paulo state since the beginning of Republic, we notice that the funds allocated under the nomenclature “subventions” and the list of favored institutions suffered adjustments throughout the years. In the first budget law of São Paulo, dated 1891, for example, the aids and subventions to hospitals amounted to 24:000$000.¹⁰10Brazil had several currencies overtime. For example, the “Réis” in the colonial time, the “Cruzeiro” from 1942 to 1964, the “Cruzado” from 1986 and 1989 e the “Real,” from 1994 to this day. In the next year’s budget, the funds increased to 250:000$000, destined to the Santa Casa, to the Hospital Samaritano de São Paulo and to a category of “orphanages and hospitals.” In 1900, the values reached 608:000$000 and, in 1910’s budget, the Santa Casas would receive 1.292:000$000 and other hospitals and leprosarium had an allocated funding amounting to 293:000$000 (São Paulo, 1891SÃO PAULO (Estado). Lei nº 15, de 11 de novembro de 1891. Orça a receita e despesa do Estado para o exercício de 1892. Assembleia Legislativa do Estado de São Paulo, São Paulo , 1891., ¹⁸⁹²SÃO PAULO (Estado). Lei nº 118, de 3 de outubro de 1892. Fixa a Despesa e Orça a receita para o exercício de 1893. Assembleia Legislativa do Estado de São Paulo, São Paulo , 1892., ¹⁸⁹⁹SÃO PAULO (Estado). Lei nº 686, de 16 de setembro de 1899. Fixa a Despesa e Orça a receita para o anno financeiro de 1º de janeiro a 31 de dezembro de 1900. Assembleia Legislativa do Estado de São Paulo, São Paulo , 1899., ^1909aSÃO PAULO (Estado). Lei nº 1.197, de 29 de dezembro de 1909. Orça a receita e despesa do Estado para o exercício de 1910. Assembleia Legislativa do Estado de São Paulo, São Paulo , 1909a.).

A representative year for us to analyze the discussions and criteria to the fund allocation for the institutions is 1906, when the Sanitary Service implemented a reform in its administrative structure, seeking to centralize the acts of public health in the state sphere, leaving to the municipalities a secondary role. This action caused all reports concerning “public health” and “public assistance” of the more than 170 municipalities of the São Paulo state to be centralized in the headquarters of the Sanitary Service in the capital, which allowed us to better understand the process of funds allocation.

This reorganization created 14 sanitary districts in São Paulo, managed by Sanitary Inspectors. Among the activities carried out by the inspectors were the supervision of the sanitation works executed by the municipalities, and the inspection of the public and private facilities, including hospital hygiene conditions. In the end of 1906, the State Affairs Secretary, the body responsible for the Sanitary Service, published a summary of the reports produced by the inspectors. The report of the conditions found in the Santa Casa operating in the Jaú municipality was among the documents, which, according to the inspector in charge of the region had infirmaries, rooms and operating rooms “worthy of compliments” (São Paulo, 1908bSÃO PAULO (Estado). Relatório da Secretaria do Interior, annos de 1907 e 1908. São Paulo: Duprat & Comp., 1908b., p.28). In the city of Amparo, the Beneficiência Portuguesa hospital was rated as “in good conditions” (p. 24). In the report of the inspector in charge for the Mogi-Mirim region, the Santa Casa was described as having spacious accommodations, but suffering with poor cleaning and lighting, in addition to having toilet equipment “poorly assembled” (p. 24) and, in Tatuí, the Hospital de Beneficiência was in regular conditions, in need of renovations in some of the wings (p. 19). In relation to the Isolation Hospitals (the only ones under public management), ¹¹11The Isolation Hospitals were part of the public equipment to combat infectious diseases. These institutions received the patients that needed to be isolated from society as a precautious measure to keep health individuals from being infected (Ribeiro, 1993). the maintenance status also varied according to the location. Those in Amparo and Brotas cities were well maintained, while the one in Jaú had “defective and useless toilet equipment (p. 28) and the one in Mogi Mirim was “poorly maintained […], the building has cracks from end to end […] in danger of collapsing (p. 24); and the hospital in Casa Branca was “abandoned, with cracking walls and the floor rotted by the rains” (p. 24).

Despite the appointed characteristics, not every inspector mentioned the sanitary and operating conditions of the institutions in their jurisdiction. The lack of data is justified by the inspectors under the allegation the Secretary of Agriculture already received a detailed report, being the body responsible for the distribution of government subsidies. This circumstance was appointed by the 8^th District inspector, in charge of the Itu region, who wrote that “all hospitals receiving subsidies were inspected, according to report” (São Paulo, 1908bSÃO PAULO (Estado). Relatório da Secretaria do Interior, annos de 1907 e 1908. São Paulo: Duprat & Comp., 1908b., p. 21). The 5^th District inspector, in charge of the Taubaté region, also reported it, stating that “the charity facilities were inspected […] according to the reports sent with the purpose of subsidy” (p. 17).

The Secretary of the Treasury compiled the information sent by the inspectors and had it sent to the state representatives to analyze and deliberate on the expansion, maintenance or inclusion of “public assistance” institutions in the governmental budget program, as we mentioned in the beginning of this session.

With the centralization of data in the Sanitary Service, the Secretary of the Interior exposed, for the first time in its report, the list of all charities and assistance institutions subsidized by the state government. It lists 53 Santa Casas established in São Paulo state and another 43 institutions composed by several charity societies, hospitals, asylums and sanatoriums, dispensariums and institutions associated to the São Vicente de Paulo Order. In this list, the secretary highlighted the funds allocated to each institution and the total budget amount for the category, allocated in the year of 1917, was of 1.455:200$000.

These figures seem to be expressive; however, we need a comparative basis to better understand what they represented in the budget plan at the time. To create an analysis parameter, we compared it with the financial resources allocated to the Sanitary Service, under public management, created specially to handle sanitary issues and to fight epidemics, and seen by several authors as one of the most important bodies of the São Paulo government (Mota; Marinho, 2013MOTA, A.; MARINHO, M. G. S. M. C. (Org.). Práticas médicas e de saúde nos municípios paulistas: a história e suas interfaces. São Paulo: FMUSP, 2013.; Ribeiro, 1993RIBEIRO, M. A. R. História sem fim: um inventário da saúde pública, São Paulo, 1880-1930. São Paulo: Unesp, 1993.; Telarolli Junior, 1996TELAROLLI JUNIOR, R. Poder e saúde: as epidemias e a formação dos serviços de saúde em São Paulo. São Paulo: Editora Unesp, 1996.). The funds allocated to this service were destined to the payroll, expenses with the laboratories, disinfection services; statistics services; maintenance of the Isolation Hospital and funding to maintain a few sanitary committees. For the year of 1907, these are the figures:

Comparing the funds allocated to the Sanitary Service with the funds destined to the assistance institutions, we see that, in that year, the resources destined to the Sanitary Service (1.395:220$000) were just below those destined to the assistances institutions (1.455:200$000). This budget similarity between the “public assistance” and the “public health” also appears in an expanded timeframe as shown in Chart 3.

Based on these data, we can conclude that, within the budget plans, the government tried to balance the funds between the Sanitary Service, responsible for the sanitation and the prophylaxis of infectious diseases, and the “public assistance” institutions, who offered the treatments. Thus, we conclude that the costs to aid the private institutions were high. In this scenario, we ask: if the funds for “prophylaxis” and “treatment” were so close, showing a budget balance between the “public health” and the “public assistance’, why does the government did not take managerial responsibility for the assistance institutions, as it did for the Sanitary Service?

The history of trachoma in São Paulo, which had government intervention both in the prophylactic and in the treatment measures, help us to clarify what caused the São Paulo government to split the measures against epidemics and healthcare actions. To fight and treat this disease, the São Paulo government set up an apparatus with great regional coverage to serve as points of service to trachoma and other diseases, such as malaria, ancylostomiasis, small pox and typhoid fever. The more than 30 urban units, installed in several municipalities in 1906 with a team of over 300 members, brought experience and reflections to the state government on the responsibility and the costs of maintaining a state-owned treatment structure.

The anti-trachoma government campaign: the combined implementation of prophylactic and treatment actions

After sending a medical committee to the inlands of São Paulo in 1904, the state government became aware that the inhabitants of areas far from the capital suffered from a highly contagious conjunctivitis, called trachoma or granular conjunctivitis. The disease, which landed in São Paulo’s territory coming with the Italian immigrants in the 1880s, concomitantly spread towards the new coffee plantations. The Northwestern part of the state, close to Ribeirão Preto, which sheltered a great share of the incoming workers, was one of the hardest hit regions. Physicians, Italian travelers and municipalities’ state representatives estimated that one in every three rural workers had trachoma or that the disease affected over 75% of the immigrant population. In absolute figures, they would risk estimating that the number of infected were over 120,000 in that area of the state (Ribeiro, 1993RIBEIRO, M. A. R. História sem fim: um inventário da saúde pública, São Paulo, 1880-1930. São Paulo: Unesp, 1993.).

In 1906, after confirming the high incidence of trachoma, the directors of the Emílio Ribas Sanitary Service started an intense work to fight the disease. With the support of physicians specialized in ophthalmology, Emilio Ribas structured a campaign and established, on September 3^rd, the creation of the “Trachoma Prophylaxis and Treatment Service.” Thus, the state government sought to implement with its own resources a healthcare project uniting the “public health” - by applying the prophylactic measures - and the “public assistance” - by taking the responsibilities and the expends treatments that were before offered through private hospitals (Luna, 1993LUNA, E. J. A epidemiologia do tracoma no Estado de São Paulo. 1993. Dissertação (Mestrado em Ciências Médicas) - Universidade Estadual de Campinas, Campinas, 1993.).

With prophylactic measures aimed to control the spread of the disease, the Sanitary Service implemented medical inspection in the ports for all the ships arriving from Europe. It also surveyed the schools to keep ill children out of the school environment; and diffused prevention measures to the population and to the farmers, such as washing hands and face frequently and the individual use of clothing, towels and linen (Luna, 1993LUNA, E. J. A epidemiologia do tracoma no Estado de São Paulo. 1993. Dissertação (Mestrado em Ciências Médicas) - Universidade Estadual de Campinas, Campinas, 1993.).

In parallel to the prophylactic measures, the government structured, established and managed several treatment units across the state. From September, when the decree was issued, by the year-end, the state already had 35 physicians and the triple of nurses and disinfectant officers to work in 25 units. By the end of 1908, the structure had reached 37 units located in the urban areas of the state and 255 treatment units in the rural areas. (Telarolli Junior, 1996TELAROLLI JUNIOR, R. Poder e saúde: as epidemias e a formação dos serviços de saúde em São Paulo. São Paulo: Editora Unesp, 1996.). In order to manage the implementation of a public treatment structure to service so many municipalities in such a short time, the São Paulo government had the help of the municipalities. In this project, the state would pay for the payroll and medication, and the municipalities would contribute with the physical structure and financial resource, when the municipal budget allowed it.

The units, first created for the trachoma treatment, moved on to providing other services, such as the prophylaxis of ancylostomiasis, malaria and typhoid fever and vaccination. Campos, Marinho and Lódola (2018CAMPOS, C.; MARINHO, M. G. S. M. C.; LÓDOLA, S. O serviço público de saúde no município de Araraquara: do Posto Sanitário ao Health Training Center: análise de uma trajetória. História Unisinos, São Leopoldo, v. 22, n. 4, p. 566-578, 2018.) argue that some of the units created with the purpose of fighting trachoma, as the one in Araraquara, moved on to be permanent, expanding its scope and operating in spite of epidemic campaigns.

To treat trachoma, the medical conduct were in accordance to the scientific knowledge at the time, which prescribed the cauterization of the granules that emerged in inside the eye-lid and changes of bandages for 15 consecutive days. The most critical cases would go under surgery. By employing these methods, the physicians of the units managed to perform 201,179 bandages in an universe of 14,967 patients in the first three months of operation (São Paulo, 1907bSÃO PAULO (Estado). Relatório da Secretaria do Interior, anno de 1906. São Paulo: Typographia do Estado de S. Paulo, 1907b.). By analyzing the balance of service in 1907, we can see the great action of these healthcare units funded and managed by the state:

Despite the lack of data providing information about the exact expense of the campaigns,¹²12The accounting reporting the costs related to the trachoma campaign was not found in the researched files (São Paulo Public Archive, Emilio Ribas Museum of Public Health and Center for Research Libraries, although the sources indicate that the funding was assigned through the “Public Aid” category. By analyzing this category in the government plans, we observe that small figures were allocated in the budgets and would only get a higher allocation in face of a general problem, not restricted to the “public health” problems. we understand, from the created structure and from the State Affairs Secretary Report - responsible for managing the funds and the services to control trachoma -, that costs were high. This justified the termination of the committees in 1908 under the allegation of lack of resources allocated especially to this purpose (São Paulo, 1908bSÃO PAULO (Estado). Relatório da Secretaria do Interior, annos de 1907 e 1908. São Paulo: Duprat & Comp., 1908b., ¹⁹¹²SÃO PAULO (Estado). Relatório da Secretaria do Interior de 1908-1909. São Paulo: Casa Garraux, 1912.).

With a team that amounted to 59 physicians and 362 assistants, this structure was terminated past two years of its creation, without a significant decrease in the infected rates (São Paulo, 1912SÃO PAULO (Estado). Relatório da Secretaria do Interior de 1908-1909. São Paulo: Casa Garraux, 1912.). From that moment on, the government decided to increase the government subside granted to certain assistance institutions, enabling them to offer the care to the infected that the state was unable to maintain.

In the 1908-1909 report of the Secretary of the Interior, the secretary, Carlos Augusto Guimarães, explained the intentions of the state government in choosing to use the private institutions, emphasizing that the decision taken had a direct relation to the economic issues:

With the transfer of trachoma-infected patients to the private institutions, the state representatives took to the plenary council the debate over the amounts that should be transferred from the government to the public care institutions. One of the debates addressed the funds destined to the Hospital Ophtálmico, a private hospital created in 1903 to provide care mostly to trachoma patients. During a session on December 1903, the state representative Francisco Sodré, when defending the hospital, argued that, given that the Trachoma Committee was terminated “overnight, due to its excessive costs and given that the government could not reinstate it in a simpler model, the expenses of the Hospital Ophtálmico naturally increased day after day” (Câmara, 1909CÂMARA. Correio Paulistano, São Paulo, 7 dez. 1909, p. 2., p. 2, our emphasis).

Thus, the state representative required an increase in the government funding to balance the expenses and keep the Hospital from “being forced, overnight, to refuse critical trachoma patients, who come from the state inlands” (Câmara, 1909CÂMARA. Correio Paulistano, São Paulo, 7 dez. 1909, p. 2., p. 2). By the end of his speech, Francisco Sodré emphasized that the Hospital was a fundamental institution to the state public health. In his words,

The Hospital, which received subsides since its foundation, in 1903, had its funds increased from 10:000$000 in 1904 to 25:000$000 in 1906, 1907, 1908, and to 40:000$000 in 1909, when the trachoma campaign was terminated. The state representative Fontes Junior also defended the constant increases, who recalled the services provided to the society, in the form of free care offered to a large number of patients after the termination of the campaign.

Even with the increase in the budget allocation to the Hospital Ophtálmico at the time of the termination of the trachoma committee, the government could not prevent the spread of the disease in the Westernmost regions of the state. In this landscape, a new “Provisional Committee Against Trachoma and Other Eye Diseases” was established in 1911. Unlike the first attempt, that accounted for 59 physicians, in the second campaign the team was quite smaller, with the allocation of 16 physicians divided into two zones that serviced the Ribeirão Preto and São Carlos regions. The restructured also included traveling medical teams, who visited farms and provided care in hospitals and in several locations within its jurisdiction.

With the opening of the new front of government services, the state representative João Sampaio, in a session hold in 1913, requested the decrease in the funds allocated to the Hospital Ophtálmico claiming that their services were not so essential anymore:

In the set of the highlighted speeches - the Secretary Carlos Augusto Guimarães and the state representatives Francisco Sodré and João Sampaio - the financial issues had relevance in the debates approaching the medical care provided to the trachoma patients by the government. To support a state-owned structure of service, installing units and allocating medical teams, would demand great resources from the public treasury. In face of such expense, the option was to terminate the majority of the units established in the inlands and allocate a smaller team, in the case of the second committee, or to adjust the figures transferred to the private hospital, as it was the case with the Hospital Ophtálmico. As we could see, the speeches of the state representatives brought a consensus that the state would save a great deal if the treatments were provided by the private institutions, even if, to do so, the government had to increase the funds granted.

Final remarks

The interests of the agricultural sector, the slavery and the social inequality that had printed their marks in the imperial period had left vestiges in the Republic was in formation. The São Paulo government assistance did not contemplate the social matters, so present and intense in the period, through a proper structure of service, leaving for the private institutions the history of support to individual health.

These entities, created by non-governmental initiative, received funds from the state for over a long time, especially the Santa Casa de Misericórdia, working in the country since the 16^th century. Some authors already researched the relation between the public and the private, as we mentioned throughout the article. Yet, historiography still had a gap concerning the weight of the funds transferred to these organizations over the budget. In this article, we seek to measure this public funding and to understand how the richest state of the country, presenting considerable a demographic explosion, approached the questions of individual medical assistance in the turn of the 19^th to the 20^th century.

We observed in this research that the government action in the public health field was attached to the idea of having government intervention only during epidemics. To fulfill this ideal, the São Paulo government implanted and structured the Service Sanitary and established the Isolations Hospitals to combat infectious diseases. However, the state, who depended on the health of the immigrant workforce to maintain the coffee farms, noticed a need to support, with increasingly financial resources, the entities willing to offer free healthcare. As we could verify, the amounts transferred to these institutions suffered exponential increases throughout the first years of the Republic, even exceeding the amounts destined to the Sanitary Service and its branches at times.

Without directly interfering in the management of these institutions, the government promoted inspections of their facilities, as a form to controlling them and, in a way, of demanding minimum conditions of service, under the penalty of either suspension or cancellation of the granted funds. Beyond the subsidies promoted for the Secretary of Agriculture and of the inspections conducted with the purpose of debating in the Assembly the subsides figures, the state developed understandings with the institutions to increase the transferring of funds during epidemics, just as it had done with the Hospital Ophtálmico.

The notes on the history of trachoma in São Paulo also showed us that the government sought to implant units of treatment to the trachoma patients that eventually also provided care to other diseases, such as ancylostomiasis, malaria, smallpox and the typhoid fever. With more than 30 units, the apparatus created, however, proved itself unsustainable due to the high maintenance costs, being dismantled shortly afterwards. By analyzing this campaign, we investigated that the extinction of the units was grounded on economic reasons, making more beneficial to the state finances to choose a subside policy, supporting an already existing care arrangement, in detriment to the creation of its own structure.

References

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