Formation

Carlos Chagas: childhood, early studies and medical education

Simone Petraglia Kropf
Casa de Oswaldo Cruz/Fiocruz
Email: simonek@coc.fiocruz.br

Carlos Ribeiro Justiniano Chagas, the first of four children of José Justiniano Chagas and Mariana Cândida Ribeiro de Castro Chagas (Figure 1), was born on July 9, 1879, at the Bom Retiro Farm (Figure 2), near the small town of Oliveira, Minas Gerais. His ancestors, of Portuguese origin, had settled in the region for almost a century and a half. Orphaned at the age of four (Figure 3), Chagas spent his childhood on this and on another family farm where his mother ran the coffee crop. Although far from the illustrated centers of the country, living with maternal uncles (two lawyers and a doctor) made the boy express, early on, willingness to advance in studies, with particular interest in medicine.

At the age of eight, literate, he was enrolled in the College of St. Louis, boarding school run by Jesuits in Itu, interior of São Paulo. But it would not be there long. In May 1888, on hearing that the newly freed slaves were destroying farms, he fled the school to meet his mother. The indiscipline was punished with expulsion and the boy moved to the San Francisco College in São Joao del Rey, Minas Gerais. Having completed his studies, his mother decided that he should have a degree in engineering. In 1895, he entered the preparatory course of the Ouro Preto Mine School, a traditional center of higher education. However, the excesses of bohemian life cost him failed exams and return to Oliveira. With the help of his medical uncle, he overcame her mother’s resistance and moved to the federal capital to study medicine.

In Rio de Janeiro, he went to live with other students from Minas Gerais in a pension in the Tijuca neighborhood. In April 1897, he enrolled at the Faculty of Medicine on Santa Luzia Street, downtown. Chagas was strongly impressed by the political turmoil of the capital. The government of Prudente de Morais (1894-1898), the first civilian president of the Republic, sought to overcome the turmoil and conflicts that had been shaking the new regime, such as the Canudos revolt in the interior of Bahia. The Campos Sales government (1898-1902) would seal political and economic stabilization and lay the foundations for much-publicized republican modernization.

From the cultural point of view, the city also lived a moment of great effervescence. The young student, who had attended the creation of the Brazilian Academy of Letters, was enthusiastic about the new writers and styles that were projecting in the literary scene. In the various intellectual spaces, the belief was spreading that a new time was being lived, symbolically expressed in the coming new century, in which Brazil would enter the list of “civilized” nations. Under the values of positivism and other scientistic theories, science and technique were extolled by the so-called generation of 1870 as guiding elements of objective and effective knowledge capable of providing the moral and material well-being of society.

It was from this perspective that doctors and engineers engaged in thinking about solutions to the poor sanitary conditions of the federal capital, which were aggravated at the end of the century due to the very pace of urban modernization. The frequent epidemics, especially of yellow fever, that plagued the port area and the city center, brought severe damage to the economic activities that consisted of the exportation of coffee and other agricultural products and the importation of immigrants, manufactures and capital. Urban sanitation was seen as crucial to the country’s progress and, to that end, the city reform was to be carried out in the early years of the twentieth century.

It was in this context that microbiology spread in the country, in a process marked by controversy, debate and accommodation between those who adhered to the conceptions of Louis Pasteur and Robert Koch and those who defended the climatological theories of the hygienist tradition. The institutionalization of tropical medicine in Europe, in the context of the expansion of imperialist interests, generated new knowledge about the mode of transmission of infectious diseases such as malaria and yellow fever, especially about the role of insects as vectors.

In line with this renewal of the biomedical sciences, several professors of the Rio de Janeiro School of Medicine advocated, since the 1880s, the importance of incorporating into the teaching the precepts and practices of the so-called experimental medicine, that is, the scientific research carried out in the lab in search of new knowledge. This was the environment in which Chagas conducted his medical course between 1897 and 1903.

Two teachers decisively marked his formation. One of them was Miguel Couto, with whom Chagas learned to use the methods and principles of experimental medicine for the diagnosis and clinical study of the diseases that made up Brazilian nosology. Couto, of whom Chagas would become a personal friend, instilled in the young student the conception that the medical clinic should be renewed and subsidized by the new knowledge and techniques provided by scientific research. At his suggestion, Chagas learned about the works of Claude Bernard  e de Louis Pasteur.

Another decisive influence was that of Francisco Fajardo, one of the pioneers of microbiology in Brazil, who presented Chagas with the specific themes of tropical medicine. Deeply attuned to the studies and problems of this specialty, especially malaria, Fajardo collected blood-sucking insects and conducted experimental studies on the evolutionary cycle of the hematozoan discovered by Laveran, with whom he maintained personal contacts. In the Fajardo laboratory, at the Holy House of Mercy Hospital, Chagas assisted with hematological tests and the identification of different species of the malaria parasite, the basis for the differential diagnosis of the various clinical forms of the disease. Over time, he has accumulated material for his own experiences.

In order to elaborate his doctoral dissertation, a prerequisite for qualification for the practice of medicine, in 1902 he went to the Federal Serotherapeutic Institute in Manguinhos. He brought a letter of introduction from Fajardo to Oswaldo Cruz, the Institute’s technical director, created two years earlier to manufacture serum and vaccine against bubonic plague. This was the first contact with the one who would be his great teacher and with the institution in which he would carry out his professional life.

The Manguinhos Institute – which from 1908, under the name of Oswaldo Cruz Institute, would establish itself as a respected center for the production of immunobiologicals and of research and teaching in the field of experimental medicine, attracted interested students, such as Chagas, in the scientific study of tropical diseases. Accepted by Oswaldo Cruz, who became his advisor, Chagas then attended the Institute daily. In 1903, he defended his doctoral dissertation entitled Hematological Studies in Impaludism, analyzing the importance of knowing the evolutionary cycle of the plasmodium for the diagnosis and treatment of the various clinical forms of malaria.

Despite the invitation made by Oswaldo Cruzto to join the team of researchers from Manguinhos, Chagas preferred to dedicate himself to the clinic. In 1904, he was appointed physician of the General Directorate of Public Health (Figure 4), working for the isolation hospital of Jurujba, Niterói, intended to treat mainly plague patients. At the same time, he set up his private practice in downtown Rio. In July of that year, he married Iris Lobo, daughter of Senator Fernando Lobo Leite Pereira. From this union would be born Evandro Chagas in 1905 and Carlos Chagas Filho in 1910 (Figure 5). The following year, an invitation by Cruz to lead a malaria prophylaxis campaign would be the first step in a career reorientation that would take him back to the Manguinhos labs and to the discovery of the disease that bears his name.

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Carlos Chagas and the campaigns against malaria

Simone Petraglia Kropf
Casa de Oswaldo Cruz/Fiocruz.
Email: simonek@coc.fiocruz.br

In the early years of the twentieth century, in the context of the diffusion of the parasitic vector theory constitutive of the mansonian tropical medicine, the scientific world was marked by an intense search for winged transmitters for diseases, especially blood-sucking insects such as mosquitoes. To support medical research with expert knowledge of the biological characteristics of these insects, the British Museum has begun, for example, an ambitious survey of mosquitoes from around the world. The Royal Society has set up a commission to study malaria control in the colonies, and the British Museum of Natural History has set up a large collection of insects to support this endeavor. As Benchimol and Sá show, the debate on disease-arthropod vectors has made medical entomology an increasingly prominent area of ​​knowledge. Adolpho Lutz, then director of the Bacteriological Institute of São Paulo, was the main scientific authority in this area in Brazil. In constant exchange with researchers and international institutions, he would have a great influence on other scientists who would follow this path.

Oswaldo Cruz carried out works of insect collection and classification in Brazil, having identified in 1901 a new anopheline species on the shores of Rodrigo de Freitas Lagoon, naming it after Lutz. In 1906, the incorporation of Arthur Neiva reinforced the area at the Manguinhos Institute, of which Lutz would become a researcher in 1908. Having as reference the works of Lutz, Cruz and Neiva, Chagas published, in 1907, work on Brazilian culicids, with the description of new species.

The development of medical entomology in Manguinhos – and the insertion of Chagas in this process – were directly related to an important expansion front of the institution, triggered by Oswaldo Cruz especially due to the experience gained in the sanitary campaigns he commanded in the federal capital, between 1903 and 1909. Reproducing a common practice among European doctors and microbiologists who traveled to Africa and Asia to combat epidemics and study tropical diseases, the Manguinhos researchers engaged in scientific expeditions to various parts of the national territory. These missions served both to study the sanitary conditions of the different regions, as well as to counteract epidemic crises that undermined the works of public or private companies associated with the modernization of the country. Due to the demographic and economic expansion, the realization of these works, especially those that entered forests and inhospitable regions, was often accompanied by epidemic outbreaks, especially malaria. This was especially true at the time of the construction of the railways, whose lines and branches multiplied throughout the national territory with a view to a more efficient flow of agricultural production for export.

Requested by the health authorities, these trips reinforced the social identity of the Manguinhos Institute as an institution committed to solving public health issues of national interest. On the other hand, they also functioned as propelling occasions for their own research into the new issues of tropical medicine that arose in the medical-scientific environment. At these construction sites, the researchers collected materials, experiments and studies on various themes of Brazilian tropical pathology, related to both medical and health aspects, as well as biological issues concerning parasites and vectors. It was precisely through such journeys that Chagas remade his relationship with Manguinhos and the theme of malaria (studied by him in his doctoral thesis), developing specific skills and knowledge that would lead him to the discovery of a new tropical disease.

In 1905, the Santos Dock Company asked Oswaldo Cruz, who headed the General Directorate of Public Health, to take action to combat a malaria epidemic among workers who were building a hydroelectric dam in Itatinga to supply the port of Santos. Because of his knowledge of the disease, Chagas was tasked with the coordinatization of prophylaxis actions.

This was the first anti-malaria campaign conducted in Brazil. In February 1907, a similar mission was initiated by him, in partnership with Arthur Neiva, in Xerém, in the Baixada Fluminense, where the disease undermined the water catchment work for the federal capital, carried out by the General Inspectorate of Public Works.

In June of that year, also at Cruz’s request, Chagas went to northern Minas Gerais, in a new venture against malaria, along with Belisario Penna, who, like him, was also a doctor of the General Directorate of Public Health. In the Rio das Velhas region, between Corinth and Pirapora, an epidemic of the disease paralyzed the extension works of the Central Railway of Brazil, whose objective was to integrate the south to the north of the country by connecting Rio to Belém do Pará. In the municipality of Lassance, where a railway station was being built, Chagas set up a small laboratory in a train car which he also used as a dormitory. It was in the course of the activities of this campaign that the discovery of the disease was established that would consecrate it internationally.

Since English and Italian researchers unveiled in 1898/99 the mode of transmission of malaria by mosquitoes, scholars have devoted themselves in several countries to establishing measures to prevent and combat the disease, focusing on its two essential elements: the vectors and the individual carrying the parasite. In a 1906 paper, Chagas analyzed in detail the different strategies against malaria. “The prophylaxis of impaludism can be synthesized in two ways: to prevent the sick man from contaminating the transmitting culicid, to prevent the parasitic culicid from infecting the healthy man. (…) Prophylaxis will therefore be anti-culicidal when applied to the mosquito and germicidal when destroying the hematozoan in the endogenous phase of its evolution.”

The actions against the vectors contemplated offensive and defensive methods. The first was the direct combat against the anophelines, by means of campaigns, of military character, aiming at their elimination. The “mosquito brigades”, a term coined by the Englishman Ronald Ross, should attack them in their aquatic larval stage, either by applying toxic substances (such as oil) to water collections or by draining the wetlands that could serve as their habitat. The defensive measures consisted of individual and collective protection against mosquitoes through curtains on the beds and screens on the doors and windows of houses. The actions directed to the parasite were given by the administration of quinine (medicine extracted from the bark of the quina tree) to the patients, aiming to eliminate the hematozoan.

In his campaigns, Chagas sought to put these guidelines into practice by implementing preventive quininization and protecting individuals against mosquitoes. Expressing the articulation between the new theories of microbiology and tropical medicine and the interests of public health, he emphasized that studies on the different phases of the hematozoan evolutionary cycle and the typical vector habits in each region were fundamental to subsidize the measures against malaria. Clinical and epidemiological knowledge was also of great importance, emphasized, mainly because the patients constituted the parasite reservoir and, consequently, sources of mosquito contamination and disease spread.

From his first experience in Itatinga, Chagas has formulated the principle that direct attack on anophelines should not be restricted to antilarvary actions, either due to the difficulty in carrying them out in places where sanitation works were impracticable, and mainly because, in his conception, insects should be fought primarily in their winged, adult form within the dwellings. Observing the habits of anophelines, Chagas stated that malaria was an essentially household infection, that is, it was mainly in households that the mosquito was contaminated by the parasitized patient and the infection of healthy individual occurred. Thus, mosquitoes should be destroyed by spraying insecticidal substances such as sulfur and pyrethrum in these environments. Household purges with such substances had been made to fight yellow fever in the federal capital since 1903.

This method, which decades later would be used on a large scale with the advent of synthetic residual-action insecticides such as DDT, was applied in Itatinga, with a very favorable result, in Chagas’s appreciation, even though he pointed to the need for conjugation with other preventive measures, in particular the use of quinine. According to Carlos Chagas Filho, his father’s pioneering contribution to malaria studies and prophylaxis would only be fully recognized at the First International Congress of Malariology, held in Rome in 1925.

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Carlos Chagas and the discovery of a new human trypanosomiasis

Simone Petraglia Kropf
Casa de Oswaldo Cruz/Fiocruz
Email: simonek@coc.fiocruz.br

In June 1907, Carlos Chagas was appointed by Oswaldo Cruz, director of federal public health, to combat a malaria epidemic that paralyzed the extension works of the Central Railway of Brazil in Minas Gerais, in the Rio das Velhas region, between Corinth and Pirapora. In the municipality of Lassance, where a railway station was being built, he set up a small laboratory in a train car, which he also used as a dormitory. While coordinating the prophylaxis campaign, he collected species of Brazilian fauna, motivated by his growing interest in entomology and protozoology. In a context of international diffusion of theories of tropical medicine, these were areas of great importance in Oswaldo Cruz’s project to transform the Manguinhos Institute into a renowned center for experimental medicine. In 1908, when examining the blood of a marmoset, Chagas identified a protozoan of the genus Trypanosoma, which he named Trypanosoma minasense. The new species was a usual non-pathogenic monkey parasite.

At that time, the study of trypanosomes attracted the attention of researchers in the field of tropical medicine, especially since it was shown that, in addition to animal diseases, protozoans caused human diseases such as African trypanosomiasis. Traditionally known as sleeping sickness, this condition caused great concern among European countries that had colonies on that continent.

In addition to searching for new parasites, Chagas was alert to arthropods that could serve as vectors. On a trip to Pirapora, he and Belisario Penna (his fellow malaria counterpart) stayed overnight, along with the railroad engineers, on a ranch on the banks of Buriti Pequeno Creek. The head of the commission of engineers, Cornélio Homem Cantarino Mota, then showed them a very common hematophagous bed bug in the region, commonly known as a barber, for the habit of pricking their victims’ faces in their sleep. It was abundant in the region’s stick-to-shovel huts, hiding in the cracks and holes in the mud walls during the day and attacking its residents at night.

Knowing the importance of blood-sucking insects as transmitters of parasitic diseases to humans and animals, Chagas examined some barbers and found in their gut flagellated forms of a protozoan, with certain characteristics that made him think it might be a natural parasite insect or an evolutionary phase of a vertebrate trypanosome. In the case of this second hypothesis, it could be T. minasense itself, the barber being the vector that would transmit it to the marmosets.

Because he had no experimental conditions in Lassance to elucidate the issue, since the monkeys in the region were contaminated by the minasense, Chagas sent some of those insects to Manguinhos. Oswaldo Cruz fed them on laboratory-bred marmosets (and thus free of infection) and about a month later told Chagas that he had found trypanosome forms in the blood of one of the animals, which had fallen ill. Returning to the Institute, Chagas found that the protozoan was not T. minasense, but a new species of trypanosome, which he named Trypanosoma cruzi in honor of the master. The note announcing this discovery was written in Manguinhos on December 17, 1908 and published in the journal of the Hamburg Institute for Tropical Diseases.

In Manguinhos, Chagas began systematic studies on the evolutionary cycle of the new parasite which, in compliance with two of Koch’s postulates, proved to be able to experimentally infect dogs, guinea pigs and rabbits and to be cultured on blood agar. The barber, in turn, was thoroughly investigated by Arthur Neiva, also a researcher at the Oswaldo Cruz Institute. In search of other T. cruzi vertebrate hosts and suspecting that the man might be one of them – a hypothesis reinforced by his knowledge of malaria, also transmitted by a home-grown hematophagous insect and caused by a hematozoan – Chagas returned to Lassance. On the reasoning he undertook at that time, he said in one of his accounts of the episode:

“We had taken, as a guiding idea, the notion that human households constitute the favorite, if not exclusive, habitat of the hematophagous, as well as the fact, widely verified, that human blood is its quintessential food. It would be reasonable to think, therefore, of an infectious condition within the household and that the parasite’s host vertebrate was some domestic animal or man himself”.

This hypothesis would also explain certain morbid phenomena he had observed in the region that did not fit the known nosological picture.

In Lassance, Chagas undertook systematic blood tests on residents, and sought “the existence of characteristic morbid elements of trypanosomiasis”. Examining domestic animals, he verified the presence of T. cruzi in the blood of a cat. On April 14, 1909, he finally found the parasite in the blood of a feverish child. In a previous note sent to Brasil Médico, one of the country’s leading medical journals, he announced the discovery:

“In a feverish patient, deeply anemic and with edema, with engorged ganglionic Pleiades, we find trypanosomes, whose morphology is identical to that of Trypanosoma cruzi. In the absence of any other etiology for the observed morbid symptoms and according to previous animal experimentation, we believe it is a human trypanosomiasis, a disease caused by Trypanosoma cruzi, which transmitter is Conorrhinus sanguissuga.”

Berenice, a two-year-old girl, was the first case of what would henceforth be considered a new human disease. The fact was also disclosed through publications in the Archiff fur Schiffs-und Tropen-Hygiene and in the Bulletin de la Société of Pathologie Éxotique.

On April 22, at the same time that Medical Brazil was bringing in its pages the discovery made in the north of Minas, the fact was reported, in session of the National Academy of Medicine, by Oswaldo Cruz who read a work written by Chagas. The press also highlighted the episode, revered as one of the “Glories of Manguinhos”.

The discovery and early studies of the new morbid entity had a decisive impact on Chagas’ scientific career, which reached great prominence in the scientific world, with direct effects on its insertion in the institutional life of Manguinhos. In March 1910, Oswaldo Cruz launched a contest to fill the vacancy of “head of service” opened with the departure of Henrique da Rocha Lima. This was an event of great importance to the institution, as the occupant of the position was seen as the most likely candidate for succession of Oswaldo Cruz. Chagas got first place and the papers he had published on the new disease had a great weight in the process.

On October 26, 1910, Chagas was solemnly admitted as a full member of the National Academy of Medicine where he gave a lecture presenting his clinical studies and abundant material on the disease, including cinematographic images taken at Lassance. The following year, an event marked the dissemination of the discovery and the new disease in the international scientific scenario. At the Brazilian pavilion on the International Hygiene and Demography Exhibition held in Dresden, Germany, Chagas disease was featured prominently, arousing great public interest. This projection expressed the importance that the theme assumed as the flagship and showcase of research at the Oswaldo Cruz Institute. Another important milestone in the international repercussions of the discovery was Chagas’s conquest, in 1912, of the Schaudinn Prize, awarded every four years by the Hamburg Institute for Tropical Diseases for the best work in protozoology (Figure 1).

Thanks to the repercussions of the discovery and studies of Chagas, Oswaldo Cruz obtained from the federal government special funds to equip a small hospital in Lassance to host clinical studies on the new disease and to start building in Manguinhos a hospital for research and follow-up of clinical cases identified in northern Minas Gerais and other regions of the country. Under the leadership of Chagas and with the collaboration of several researchers from the Oswaldo Cruz Institute, the new trypanosomiasis began to be studied in its various aspects, such as the biological characteristics of the vector, the parasite and its evolutionary cycle, the clinical picture and the pathogenesis, epidemiological characteristics, transmission mechanisms and diagnostic techniques.

Assuming centrality in the institutional agenda of the Oswaldo Cruz Institute and in the very process of institutionalization of scientific activity in the country, the discovery of Chagas disease has been treated by contemporaries and medical memorialists, until the present, as a glorifying myth of Brazilian science. One of the considerations that would become more recurrent as to the importance of the discovery as “one-off” of national science was the unusual character of the sequence in which it occurred, since it started from the identification of the vector and the causal agent to then determine the associated disease. Another singular aspect was the fact that the same researcher discovered, in a short period of time, a new vector, a new parasite and a new morbid entity.

The historiography on the discovery of Chagas disease highlights its inscription in the context of the affirmation and institutionalization of European tropical medicine, both due to the theoretical references that made it possible, as well as by the contribution that the discovery itself had in consolidating the new specialty created by Patrick Manson in the last years of the nineteenth century. Another aspect highlighted by historians is the importance of discovery as a source of legitimation, visibility and resources – material and symbolic – for Oswaldo Cruz’s institutional project. Benchimol and Teixeira emphasize that the main effect of the discovery was the consolidation of protozoology as a focus area of ​​the Institute’s research, as well as the drive to recognize Manguinhos in the international scientific community as a center for research on tropical diseases. Kropf points out that if, on the one hand, the discovery contributed to make sense and reinforce Manguinhos’s institutional project, this discovery in itself gained particular meanings as a “great achievement of national science” due to the meanings associated with this project, which is it publicly presented as designed to link academic excellence and social commitment to identifying and solving the country’s health problems.

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Management

Carlos Chagas as director of the Oswaldo Cruz Institute and the National Department of Public Health

Simone Petraglia Kropf
Casa de Oswaldo Cruz/Fiocruz
Email: simonek@coc.fiocruz.br

On February 14, 1917, three days after the death of Oswaldo Cruz, Carlos Chagas was appointed by the President of the Republic, Venceslau Brás, to the direction of the Instituto Oswaldo Cruz (IOC), a position he would hold until his death on November 8. In line with the institutional model established by Cruz, research, teaching and production activities remained closely linked to the demands of public health, as an expression of the social commitment of Manguinhos science. This association was embodied in the figure of Chagas, who, since the discovery of the disease that bears his name, called for the expansion of health actions of the state, especially in the interior of the country. At the beginning of his tenure at the IOC, he participated directly in the discussions promoted by the so-called sanitation movement, led by Belisário Penna, about a reform of federal health services, especially with a view to the implementation of rural sanitation services.

During his administration, Chagas endeavored to expand the laboratory structure and the research team of Manguinhos, sending several of them abroad for further training courses. Aiming to give greater formality to the areas of work, he established, by means of regimental reform in 1926, six scientific sections: Bacteriology and Immunity, Medical Zoology, Mycology and Phytopathology, Pathological Anatomy, Hospitals, Applied Chemistry (created in 1919).

In order to follow the advances that were then being made in the biological sciences, particular attention was given to biochemistry and physiology, through the incorporation of José Carneiro Felipe and Miguel Osório de Almeida. In the areas of bacteriology and immunology, important expansion was provided by the works of José da Costa Cruz, Júlio Muniz, Genésio Pacheco, besides José Guilherme Lacorte and José de Castro Teixeira. The same was true in the fields of medical zoology, under the leadership of Lauro Travassos; of mycology, with research by Olympio da Fonseca Filho and Arêa-Leão; of entomology, projected internationally on the figures of Adolpho Lutz and Ângelo da Costa Lima and with the collaboration of Cezar Pinto and Arthur Neiva; and protozoology, led by Aristides Marques da Cunha. The scientific collections, formed since the time of Oswaldo Cruz, were expanded. Also, of particular interest was the theme of leprosy, whose research was carried out under the command of Heráclides César de Souza-Araújo.

One of the first achievements of the Chagas administration was the inauguration of the Manguinhos Hospital (later called the Evandro Chagas Hospital, later the Evandro Chagas Research Institute and the current Evandro Chagas National Institute of Infectious Diseases Evandro Chagas), designed in 1912 for the hospitalization of infectious diseases, especially for the American trypanosomiasis, on which researchers from the Institute were conducting studies (Figure 1) .The head of the hospital was Eurico Villlela, who gave major development to research in the field of pathology and was one of Chagas’ key contributors in the study of American trypanosomiasis. Large and well-equipped, the hospital was distinguished, among other things, by its pioneering use of electrocardiographic techniques under the supervision of Evandro Chagas, the eldest son of Carlos Chagas. The search for new medicines for tropical diseases, supported by the growing advances in the area of chemistry, was a field of particular prominence in investigations carried out within the hospital and in other sections of the IOC.

With regard to teaching, Chagas expanded the program of so-called Manguinhos Application Courses, offered since 1908 for the training of researchers in microbiology and medical zoology. The creation in 1925 of the Tropical Medicine chair at the Rio de Janeiro Medical School (of which Chagas was the first holder) opened an important interface between the IOC’s research program and professional training in the medical field (Figures 2, 3 and 4).

As for the production area, Chagas diversified the list of medicines and biological products manufactured in Manguinhos. He struggled to maintain its own income from patenting and selling vaccines against symptomatic carbuncle (or anthrax) and hematic carbuncle so as to ensure the financial flexibility that, from the early years of the IOC, was central to the development of the institution. In 1918, he organized the Service of Official Medicines, in the building that became known as the “Quinino Pavilion”, intended to manufacture and supply this product (used for malaria prevention and treatment), emetic tartar and other medicines, free of charge or at subsidized prices, to rural prophylaxis posts, state governments, the Armed Forces, and public and private companies. This measure expressed the active participation of Chagas, as director of Manguinhos, in the feasibility of measures recommended by the sanitary movement. The Institute also assumed responsibility for the quality control of immunobiologicals manufactured or imported by national laboratories, and incorporated the Municipal Vaccine Institute, responsible for the manufacture of the antiviral vaccine.

Besides the administration of the IOC, another field in which Chagas gained great projection and visibility was that of public health. In late 1918, he was hailed as a hero by the press for his dedication to fighting the Spanish flu epidemic, which devastating effects in the federal capital contributed to further amplifying the allegations that were being made about the weakness of public authorities in the health field. Summoned by the President of the Republic to command the assistance to the population, Chagas installed hospitals and emergency rooms in different parts of the city and called on the doctors to help the sick. In this context, he stressed the need for regional hospitals in the interior areas of the country affected by endemics, generally deprived of any medical and hospital care services. In accordance with the positions of the sanitary movement, Chagas emphasized that this should be a federal administration assignment.

The repercussions of his work in the fight against the Spanish flu weighed decisively in choosing his name to head the new federal health agency, the National Department of Public Health (DNSP), created after an intense parliamentary debate in December 1919. Similar to what Oswaldo Cruz had done in relation to the General Directorate of Public Health, Chagas accumulated the position with the direction of Manguinhos.

As Hochman points out, the new organization, embodying President Epitácio Pessoa’s intention to make health reform a priority of his government, largely met the demands of the health movement, broadening central government intervention and regulation in public health and counteracting the decentralized model based on the autonomy of states, in force until then.

Of the administration of Chagas in the DNSP, which would extend until 1926, stands out the creation of a complex and extensive Sanitary Code, which organized and modernized the Brazilian sanitary legislation. Another innovation was the extension of public health actions, hitherto concentrated in urban areas, to the interior of the country, aiming to promote, in particular, the fight against rural endemics. Belisário Penna, who had been the founder of the Pro-Sanitation League of Brazil in 1918, took over the then-created Directorate of Rural Sanitation and Prophylaxis. For these services, Chagas counted on the decisive performance of the Rockefeller Foundation’s International Health Board. Having sent a first commission to the country in 1915, it has since created hookworm and yellow fever prophylaxis posts in several Brazilian states and in 1923 would enter into a cooperation agreement with the DNSP to broaden the fight against this last disease. Maternity and childhood care, hospital care and the fight against tuberculosis, syphilis and leprosy were also contemplated with the creation of specialized organs and institutions.

Another important aspect of the Chagas administration was the investment in the training of specialized public health professionals, for which it also had the support of Rockefeller Foundation. In 1923, the first nursing school in the country was founded in the federal capital and a professionalized hospital nursing system was established at the then created São Francisco de Assis Hospital (Figure 5). In 1926, Chagas organized the Special Course on Hygiene and Public Health, as a specialization within the Faculty of Medicine of Rio de Janeiro. Taught by researchers from Manguinhos, the program and course regulations were responsibility of the IOC, and those approved would be guaranteed direct access to federal public health administration positions. As Fonseca shows, this course, the first of its kind in the country, was an important milestone in the institutionalization and professionalization of the sanitation career in Brazil.

Chagas’s ideas and projects in the field of public health had international repercussion through his performance, since 1922, as a member of the League of Nations Health Committee. In this regard, the creation of the International Center for Leprology, inaugurated in 1934 and which worked at the IOC until 1939, of which Chagas was founder and first director, deserves special mention.

Chagas’s appointment to these important positions in science and federal public health, while showing recognition and legitimacy, required greater susceptibility and exposure to criticism, controversy and tension. Thus, despite the prestige he gained as Oswaldo Cruz’s heir in Manguinhos and federal public health, Chagas faced challenges in both spheres of his public performance.

Throughout the 1920s, financial bottlenecks caused by competition with other immunobiological-producing laboratories, increasing budget shortfalls, and inflation led to the progressive erosion of the IOC’s physical and technological infrastructure, as well as the decline in wages of employees, with the consequent evasion of researchers and the widespread use of double job. All this caused damage to the yield and the quality of the research, which worsened in the early years of the government of Getúlio Vargas. Thus, between 1930 and 1934, Chagas ran an institution that suffered the effects of the transformations that the Brazilian state itself was undergoing, expressed, for example, in the creation of the Ministry of Education and Health in 1930. During this period, the IOC found itself faced with the need to redefine their bonds and attributions in face of the new demands and administrative structures of the sanitary field.

The conflicts he faced as part of his administration at the DNSP, especially during the presidency of Arthur Bernardes (1922-1926), contributed to Chagas’ political burnout. One of the reasons for criticism was, for example, the association with the Rockefeller Foundation in health campaigns, condemned by doctors who, in the nationalist context of the 1920s, bothered with the leading role of foreigners in a domain that Oswaldo Cruz had made the showcase of national competence in public health: the fight against yellow fever. In 1926, the year Chagas left DNSP, he was severely attacked in the press because of a smallpox outbreak in the city and the risk of a yellow fever epidemic. His frequent trips abroad were also the object of intense opposition.

These tensions, in addition to political and personal rivalries common to projection trajectories in the public scene, expressed the very tensions experienced by Brazilian society in the troubled 1920s, in a process that would lead to the so-called 1930 Revolution. They would be an important dimension of the challenges to Chagas’s disease discovered by Chagas, the subject of fierce controversy at the National Academy of Medicine between 1922 and 1923.

Despite these conflicts, Chagas’ professional work in public life expressed his consecration as a scientist who, since the discovery of the American trypanosomiasis in Lassance, had his professional life directed, with the explicit and systematic support of Oswaldo Cruz himself, to follow the path that It would make him not only heir of Manguinhos’ leadership, but of what this institution represented: a science project articulated with a national project, signed by its commitment to the health issues of the Brazilian population.

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Teaching

Carlos Chagas and medical education: the Tropical Medicine chair of Rio de Janeiro Medical School

Simone Petraglia Kropf
Casa de Oswaldo Cruz/Fiocruz.
Email: simonek@coc.fiocruz.br

Carlos Chagas’ performance as a teacher began at the Manguinhos Institute itself, since the early 1910s, he taught protozoology in the Application Course. In 1917, his appointment was considered to replace Miguel Pereira, then deceased, at the Faculty of Medicine of Rio de Janeiro (FMRJ). However, Chagas’s entry as a teacher at this school would not be until 1925, when he became a professor of tropical medicine, an activity that he would develop until his death in November 1934 (Figure 1).

The idea of establishing in the FMRJ a chair for the study of the so-called tropical diseases was an old aspiration of those who advocated the incorporation, in medical teaching, of new theories and practices of experimental medicine. In 1900, shortly after the foundation of the English schools of tropical medicine as modeled by Patrick Manson, the discipline of “tropical pathology and clinic” was proposed at the Brazilian Congress of Medicine and Surgery and was not approved. In addition to reservations about the concept of tropical medicine itself as a specialty, some faculty professors expressed resistance to researchers from Manguinhos, seen as critics of the lack of scientific research in official medical education. This would be one of the foci of the tensions experienced by Chagas himself, as director of Manguinhos, with the establishment of the Faculty.

In 1925, the chair of tropical medicine was created as part of the education reform promoted by the Ministry of Justice and Interior Business and conducted at FMRJ by its Juvenil da Rocha Vaz director. Decisions on the appointment of teachers, the regimental issues and the content of the discipline, which would become mandatory for the completion of the medical course, would be up to the IOC board. To minister it, Chagas was appointed professor in May 1925, by presidential decree which, according to the notorious criterion to know, exempted him from holding a competition. In September 1926, the inaugural class was given. To house the chair, at the back of the São Francisco de Assis Hospital (created by Chagas himself, as director of the National Department of Public Health in 1923), was built the Pavilion of Tropical Diseases, later renamed the Carlos Chagas Pavilion (Figure 2).

As Carlos Chagas Filho reports, Chagas’s classes always combined theoretical explanation and clinical observation of patients, and were subsidized by abundant expository material, brought from Manguinhos and composed of anatomical pieces, projections and films. At the end, the students would walk the pavilion wards, in the company of the teacher, to deepen the learning of the diseases presented in the course.

The chair of tropical medicine – a few years later called the Clinic of Tropical and Infectious Diseases – was an important space where Chagas defended his conviction that tropical diseases were topics that should attract the interest of Brazilian doctors, both from the strict point of view of scientific knowledge, as well as the legitimacy it lent to medical science in its public commitments to the nation. If, within the sanitary movement of the 1910s and at the head of the National Department of Public Health, the political dimension of Chagas’s work had been explicit, medical education became a space of great importance because it could mobilize future generations to the flags that have been unfurling since the discovery of American trypanosomiasis in favor of rural sanitation in the country.

In his inaugural class, Chagas defended the creation of that discipline at FMRJ not only as a specialty of medical knowledge, but for the importance it acquired in the national context, due to the nature of it related themes. Tropical diseases should be studied, he stressed, because they represented “the most relevant of our medical and social problems”. If tropical medicine had been created in Europe in the context of colonialist interests, in Brazil, he pointed out, “duties of the most exalted and foreseeable nationalism oblige us to study and research Brazilian nosology in order to promote the improvement of our race, from rare to native predicates, and to carry out, by the prophylactic method, the sanitary redemption of our vast territory.”

According to Chagas, although there are no exclusive diseases of the tropics, the demarcation of tropical medicine as a specialty was justified. Although climate was not a “direct etiopathogenic factor of any well-defined morbid entity”, he argued, “by it the disease transforms and modifies, and from it originate appreciable nosological variants in the various regions of the earth”. In short, climate would create regional variants in pathology by producing specific conditions for the occurrence of pathogens and vectors, as well as the susceptibility of the human organism to such microbial agents.

In defending the concept of tropical medicine as a path for the study of Brazilian nosology, Chagas undertook a cut that associated the specific features of this nosology with national identity: the tropical diseases of the country were, fundamentally, rural endemics, thus assuming to beyond its epidemiological expression, symbolic and political significance as the evils of Brazil. Under such a cut, the tropics assumed concreteness and were re-signified in the physical and social environment of the backlands, in reference to the political-social project of the sanitary movement of the 1910s, of which Chagas was protagonist. Under the theoretical arguments of the specialty, Chagas then explained a specific meaning linked to his own career as a scientist. American trypanosomiasis (discovered by him in 1909 in the interior of Minas Gerais) was, above all others, “an essentially Brazilian morbid entity”, not because it was exclusive to the country, but because it represented Brazil, in a juxtaposition of meanings: it had been discovered and studied here, it was an emblem of the health conditions of the interior country and a symbol of national medical and scientific competence. “It will be, therefore, the initial subject of this course”, he said.

The fundamental precept that governed the conception of teaching expressed in Chagas’s classes was that it should not be simply a vocational training for health care, but should embrace a broader meaning: the close association between teaching, clinical practice and scientific research. The specific terrain of tropical medicine, he claimed, was a clear example of this association: “If from the microscope they cannot (…) do without those who study and practice medicine in warm countries, because it is its management that the essential indications for the purpose of our work”, such as information on pathogenic parasites, for example. On the other hand, the laboratory could not replace the clinic. “The laboratory only prolongs the ward”, Chagas pointed out, “and continues or completes the etiopathogenic question, always guided by the initial clinical concept, which precedes all research”. In short, it was this articulation that should preside over learning and the study of the “nosological species peculiar to our country”.

This argument would again be emphasized at the conference he gave in 1928 at the opening of the FMRJ courses:

“It is from the past that this duality of tendencies, in the orientation of teaching, either to the hospital bed or to the research laboratories, thus defining a clinical school, which took longer to investigate the symptoms, and a scientific school that insisted more on experimental research. (…) The ward, the laboratory, and the anatomopathological institute today penetrate and complete each other, and constitute one technical unit, in which intelligence, insight, and understanding are applied to clarify the disease”.

The Pavilion of Tropical Diseases came to materialize this close association between teaching, research and health care, as it was equipped with research and analysis laboratories, wards and an amphitheater for lectures, and benefited from the autopsy service which, at Chagas’s initiative, the IOC had established it at the São Francisco de Assis Hospital. In addition to the chair of tropical medicine, Chagas was prominent in medical education as an elected member of the Faculty’s Technical-Scientific Council, along with Miguel Couto, Eduardo Rabello and Francisco Lafayette. In 1931, when the then Minister of Education and Health Francisco Campos began the university reform that would lead, in 1935, to the creation of the University of Brazil, Chagas formulated a project aimed at remodeling medical education, taking into account the precepts of the university system.

With his death in 1934, a contest was held to replace him in the chair. His son Evandro, who was already helping him in class and who had co-authored with his father a Manual of Tropical and Infectious Diseases, ran for the vacancy, but it was filled by Joaquim Moreira da Fonseca.

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Titles

Carlos Chagas: awards and titles

Danielle C. Barreto
Casa de Oswaldo Cruz/Fiocruz
E-mail: dbarreto@coc.fiocruz.br

With the discovery of American trypanosomiasis in the interior of Minas Gerais (1909), Carlos Chagas projected himself nationally and internationally as a great scientist, becoming a member of important societies and receiving numerous honorary titles and some awards. Already in the year following the discovery, on October 26, 1910, he became head of the National Academy of Medicine, which for the first time received a new member without a vacancy. The exceptionality of Chagas’s work was also quickly recognized by the international scientific community. On June 22, 1912, Chagas received from the Hamburg Institute for Tropical Diseases the Schaudinn Prize, which awarded the most important discovery in the field of protozoology every four years. Years later, in 1923, leading the Brazilian delegation at the commemorative conference of Louis Pasteur’s centenary of birth in Strasbourg, he would receive the hors-concours prize for his work on public health and tropical diseases presented at the exhibition that accompanied the congress. In 1925, the University of Hamburg awarded him the Kummel Prize (gold medal). In Brazil, the award given to Chagas for its work during the Spanish flu epidemic in the city of Rio de Janeiro in 1918, deserves special mention, he was responsible for the organization of emergency hospitals. Chagas presented the award to the Oswaldo Cruz Institute. In 1911 (to be nominated in 1913) and 1920 (to be nominated in 1921), he was nominated for a Nobel Prize in Medicine.

In 1921, Chagas made his first trip to the United States at the invitation of the Rockefeller Foundation, where he was honored with the title of Artium Magistrum, Honoris Causa by Harvard University, being the first Brazilian to receive such a distinction. To this were added others, such as the title of Knight of the Order of the Crown of Italy (1920); Commander of the Belgian Crown (1923); Knight of the National Order of the Legion of Honor of France (1923); Degree of Officer of the Order of Saint James (1924); Commander of the Order of Alfonso XIII (1925) and the Order of Elizabeth the Catholic (1926); Honorary Doctorate from the University of Paris (1926); Knight of the Order of the Romanian Crown (1929); PhD and Honoris Causa from the University of Lima (1929) and of the Faculty of Medicine of the Free University of Brussels (1934). Carlos Chagas Filho states that, of all the homages and honors received, his father would keep with great satisfaction those given to him by the kings of Belgium, Alberto and Elisabeth, who even visited the Oswaldo Cruz Institute in 1921 (Figure 1).

Carlos Chagas has joined numerous scientific associations. In addition to the National Academy of Medicine (1910), he was a member of the Société de Pathologie Exotique (1919); Honorary Member of the Physicians Club of Chicago (1921); of the Pan American Medical Association (1922); from Societas ed Artes Medicas in Indian Orientali Netherlands (1924); from the New York Academy of Medicine (1926); from the Kaiserlich Deutsch Akademie der Naturforscher zur Halle (1926); the Royal Society of Tropical Medicine and Hygiene of London (1928); of the Paris Academy of Medicine (1930); Honorary Member of the Biological Society of Buenos Aires (1930). He also received diplomas from the Academy of Medicine of the National University of Buenos Aires (1917), the Faculty of Medicine of the University of Hamburg (1925) and the German Red Cross (1932).

Nobel

Carlos Chagas and the Nobel Prize nomination

João Carlos Pinto Dias
Centro de Pesquisas René Rachou, Belo Horizonte
E-mail: jcpdias@cpqrr.fiocruz.br

José Rodrigues Coura
Instituto Oswaldo Cruz/Fiocruz
E-mail: coura@ioc.fiocruz.br

Marília Coutinho
Universidade de São Paulo
E-mail: marilia@ufl.edu

An unusual event with practically no publicity in Brazil, until 1999, Carlos Chagas’ nomination for the most laureate Medicine award could have been a political and historical event of great importance, especially for two reasons: it would increase the recognition of Chagas’ genius and unique work, and would consequently give greater visibility to American trypanosomiasis, with enormous medical and social impact on the Continent. In reality, there were four nominations, being two (1913 and 1921) the most formal and of an official nature, both registered at the Karolynska Academy. The first nomination fell to the Brazilian scientist Pirajá da Silva, who had been given the task of suggesting a name to the Nobel Commission in 1911. Pirajá had taken courses in Europe and had a relationship with Patrick Manson, a scientist of international fame, with whom he had discussed his unpublished observations. about Schistosoma mansoni since 1908, earning profound respect from the this scientist and his European colleagues. Pirajá knew Chagas’ work because he was an eminent and up-to-date parasitologist. In fact, he was also a pioneer in studies on schizotrypanosis in Bahia, already in 1910, when he detected and studied the occurrence of Trypanosoma cruzi and the vector Conorrhynus megistus in the vicinity of Salvador. His reasoning was firm and well grounded, contemplating the genius of Chagas’ discovery, who had described the parasite in a historical flash, starting from the vector, soon filling Koch’s four postulates in brilliant experimental sequence, to arrive – still he – at the first human case, a few months later. Apart from the scientific feat, correctly explored by Pirajá da Silva, perhaps the indication lacked, at the time, the necessary impact on the social and medical terrain of the new entity. In fact, Chagas had also brilliantly sensed it, already in publications of 1910 and 1911, based on two fundamental facts, of profound logic and consistency, which only posterity confirmed: a) through efforts induced by him and Oswaldo Cruz, the eminent entomologist Arthur Neiva, also from Manguinhos, started very early to map triatomines across the continent, including the species, the place of capture and their rates of natural infection by flagellates similar to T. cruzi. Since most of the specimens were domiciliary, from several countries, with probable human contact, Chagas was able to see (and proclaim) the enormous dispersion of his trypanosomiasis, which was restricted to the Americas; b) very early, also, Carlos Chagas realized that the great problem of human schizotrypanosis resided in a chronic heart disease, very common in the Lassance region and different, clinically and evolutionarily, from other well-known heart diseases at the time, mainly those of syphilitic and rheumatic origin. The few necropsies performed by him, by Vianna and by Crowell showed characteristics of cell loss and disseminated fibrosis, especially in the myocardium, in patients who in life had cardiomegaly, complex arrhythmias and lipotimo-syncopal pictures, in which they lack the well-known valvular lesions. and syphilitic gums. And in some cases, microscopically flagellated amastigotes were detected, close to the injured cells and to chronic inflammatory reactions. However, the blood parasite would be missing in these patients, which are so abundant in the acute phase. The tools for detecting the parasite or its presence in the chronic stage would only come to light from 1913, with the development of xenodiagnosis by Brumpt and serology by complement fixation by Guerreiro and Machado. Until 1912, only 14 works had been published on the entity, 12 of which were from Chagas himself. There was little information. The etiological nexus would only be established years later, in the 1940s, through systematic studies by Laranja and collaborators. In addition, with the fever of “microbes hunters” gradually cooling, medical interest was turning more to the new aspects of Immunology and Therapeutics. With all this, Carlos Chagas did not receive the award in 1913, and that year, Dr. C.R. Richet was awarded, for his original contributions to the study of anaphylaxis.

The second official nomination was in 1920, for the 1921 nomination, made by the eminent otorhinolaryngologist from Rio de Janeiro and a member of the National Academy of Medicine, Dr. Manoel Augusto Hilário de Govêa, in a document in French to the Nobel Prize Committee on Medicine and published in Memórias do Instituto Oswaldo Cruz in 1999. Between these two indications, Carlos Chagas had produced important works and the disease had been diagnosed in Central America, Venezuela, Bolivia and Argentina. Chagas’ publications would almost always be bilingual, Oswaldo’s primary orientation towards better international dissemination of the Institute’s works. In addition, Chagas had held numerous conferences on trypanosomiasis in Brazil and abroad, highlighting his participation in the Pan American Congress of Medicine in Buenos Aires, 1916, where he debated vehemently with R. Kraus, a renowned bacteriologist at the University of Vienna, convincing him fully of your his. With Eurico Villela, Chagas had taken up the theme of chronic heart disease, encouraging that this important line of work be implemented in hospitals and endemic areas in Minas Gerais. On the other hand, Neiva and his followers (especially Cezar Pinto) continued the triatomine mapping and a brilliant sequence of studies of new species, covering the whole continent. Step by step, there were other successes and new chapters in the history of the disease, such as the description of natural reservoirs, the first observations and experimental evidence on the congenital transmission of the parasite, Chagas’ first assumption about the chagasic etiology of the megaesophagus, detailed reviews of the parasite cycle, deepening on the pathogenic processes in human disease, etc. In the meantime, Carlos Chagas had also embarked on the social, political and prophylactic aspects of the endemic, in masterful conferences and publications where the rural poor ranch was situated as the main cause of the disease’s expansion, and in 1918 he even induced that Souza Araújo (also de Manguinhos) to study such aspects in Paraná and draft a law there on the construction of healthy homes on rural properties. Chagas had also gained enviable notoriety in the period, not only for receiving a series of awards and distinctions (especially the Schaudinn Award, from the Hamburg Institute of Tropical Medicine, in 1912), but also for assuming two positions of paramount importance, as were the board from Instituto Oswaldo Cruz in 1917 and the Directorate of the (National) Department of Public Health in 1920. Govêa’s indication was concise and based on Chagas’ scientific background, on details of the discovery of trypanosomiasis, clinical studies and pathological anatomy undertaken and some others on the ecology and medical-social expression of the disease. The document was accompanied by a brochure about the Oswaldo Cruz Institute and nine original works by Carlos Chagas. Once again, Chagas was not contemplated, despite having been the only scientist nominated this year, with the 1921 Nobel Prize for Medicine remaining vacant. Coincidence or not, Dr. Hilário de Gouvêa died the year after the refusal of his proposition. The two other nominations, as already mentioned, were informal and unofficially registered in the Swedish academy, one of which occurred after the scientist’s death. With all the merit, it is universally recognized today, Carlos Chagas should have received the highest award, especially in the 1921 nomination, when he had no competitor. The records in Stockholm are vague in this regard. According to researcher Rachel Lewinshon, who was there, there is a registered process, inaccessible to visitors, that leafed through by a friend who is a member of the Nobel Foundation only registers the nomination and contains nothing about the non-concession. Under current regulations, it is also not possible to open a review, nor to reinstall a post mortem process. Chagas would have been the first Nobel Prize in our country, until today, the only one.

Three considerations are pertinent, regarding these episodes that are gradually being studied.

First of all, there is no doubt about Chagas’ merit, taking into account the history, the essence of the feat and the real impact of the discovery. Today schizotrypanosis reaches eighteen countries and spreads across Europe and North America, through migrations, affecting more than fourteen million individuals, and is in the process of being controlled, through enormous efforts by the scientific community heir to Carlos Chagas. The discovery saga was decanted and recognized by the best scientists, in spite of jealousy and mistaken distortions, as recently, a French historian who superficially and lacking scientific ethics manipulates historical facts and makes value judgments about Chagas, calling him literally liar and opportunist. It is noteworthy, on the merit side, that when receiving the Schaudinn award in 1912, Chagas surpassed other competitors such as P. Erlich, E. Roux, E. Metchnikoff, C. Nicolle and A. Laveran, all renowned scientists Europeans who had already won or would receive the Swedish award.

A second reflection concerns the immense modesty and silence of Chagas, who, knowing the démarches, never gave knowledge to anyone, including his family and closest friends. None of his biographers refer to the nominations. Prof. Carlos Chagas Filho was totally unaware of them, mentioning nothing about it in his book “Meu Pai”, and also affirming it perfectly when questioned about it, shortly before his death, by Rachel Lewinshon and João Carlos Pinto Dias, among others. Modesty, ethical secrecy, care not to pressure the Academy, care not to hurt colleagues, disillusionment, here are some possible explanations, all of which are reasonable for a sensitive and ethical man, who refused to accumulate positions, who only admitted doing his science if it were grandiose and beautiful, “and in defense of life”. Chagas’ withdrawn and prudent posture also reveals a suffering man, matured in honorable and many battles and tasks, determined to preserve his Institute in line with Oswaldo’s ideals. A Chagas who wanted to offer the country – through patriotism and a vision of the future – a scientific conscience that was its own and of a high level, capable of solving problems and stimulating other sectors of nationality. His son portrays him with restraint and sadness in the years after the feud of the National Academy of Medicine, coincidentally the same after the second lost Nobel. Time to settle down, to manage difficult internal disputes in Manguinhos and to organize public health in the country. It was also a time to train new generations of researchers to carry out the immense task of recognizing and characterizing, once and for all, the issues that he deemed most relevant to the clinical characterization and treatment of the terrible disease, also its prevention. He started to live more with his children and students. It seems that he did not have time to enjoy regrettable sorrows, or to chase after an honorable prize that he deserved, that he knew, that one day, for sure, would arrive.

The third and necessary consideration is naturally related to the question that we all have: why not award the prize in 1921? It will be difficult to argue for the lack of scientific value of the researcher, or for the merit and medical significance of the discovery made. Govêa’s reasoning is consistent and well grounded, in addition, attaching a monograph on the excellence of the Institution where Chagas worked. Gradually, personalities such as Brumpt, Crowell, Krause, Noah, Gaminara, Segovia, Nathan Larrier and others were poring over the various aspects of the protozoosis. The triatomine chart was already very consistent and, gradually, acute cases were detected in other states and countries. Coutinho and collaborators point to a set of ancillary facts that could have diminished the importance and image of Chagas in the context of Stockholm’s time and interest: not only was the golden age of microbiology ending, but also as a result of new world political arrangements (first war, reduction of overseas colonies). Medicine also evolved at a fast pace, new horizons were opened in armed propaedeutics, new themes emerged in the fields of biophysics and genetics, among others. Furthermore, about Chagas some points could count against, such as not being a military doctor, not having studies abroad, because Brazil was not a colony managed by foreign doctors, etc. Nothing proven, Houssay would later receive the award in a similar situation. Perhaps the most probable is the hypothesis of Sierra Iglesias (1990), who described it like this (p. 225) “En 1921 era propuesto para Chagas el Premio Nobel de Medicina y cuando todo presumia que le sería otorgado, inconfesables influencias se interpusieron. El Instituto Sueco se había dirigido a organismos científicos del Brasil recabando datos sobre su personalidad, sobre su obra, pero algunos sus propios compatriotas (increíblemente, entre ellos algunos médicos, por lo tanto primariamente inhabilitados para juzgar el descubrimiento de la tripanosomiasis), lo desaconsejaron, siendo este año declarado desierto este codiciado lauro mundial”. Regarding this, two of us talked long and personally with Sierra Iglesias, who reiterated his version, giving as source the clear and illustrious Uruguayan researcher, Prof. Rodolfo Talice. Furthermore, Iglesias firmly believed that the Brazilian evasion had come from within the National Academy of Medicine itself, the stage at the time of the unfortunate campaign against Chagas. We were unable to speak to Talice, unfortunately deceased. A visit to the National Academy of Medicine was unsuccessful in terms of any record about the Nobel affair. Another to Stockholm, by Dr. Rachel Lewinshon, despite letters of recommendation from Fiocruz and of Organização Mundial da Saúde, was also frustrating, due to the impediment to examining the files and the probably correct information, from a member of Karolynska, that there is nothing about the refusal, only the indication and the curricular documents. Furthermore, the impression remains that things from the past are untouchable for that Academy, there is no greater interest in reviewing processes, much less reconsidering them. There would be complicated and endless problems, to be sure. After all, there are always risks in awarding the prize.

As an epilogue:

Carlos Chagas was the natural candidate for the Nobel Prize for a number of years due to a context constituted by the culture of medical research at that time, the impact of the discovery from a scientific and public health point of view, among others. The reasons why the award was denied when the nominations were made remains a mystery around which we all made our speculations.

The question at its heart concerns the role of public symbols of recognition of merit for the collectivities of the recognized: countries, institutions, communities, teams. The recognition itself has a profound impact, from a political and cultural point of view, on these collectivities. It is no accident that the Nobel Peace Prize is awarded to this or that – in general, is in mind a serious ongoing conflict, such as that of the Middle East, and the prize certainly has an interference “agenda” (positive). The scientific Nobel also follows agendas of interest. Nash was awarded for the economic impact of his theory and, being a winner, his content was doubly reinforced. Thus, Chagas’ “botched prize” certainly had a political development, only a “phantom impact”, inside out. We only know in hindsight: a disease that could, if given due visibility, have been controlled and thus saved the country a lot of suffering and even in finances, it could only be really dealt with in the 1980s (having been discovered in 1909). The “phantom” unfolding would represent a delay of several decades with a serious impact on national development and economic modernization.

Although this is totally speculative, the world of “if’s” (“if” Chagas had been awarded, so perhaps the resulting visibility would have allowed an early control of the disease), it can be believed that the rejection of the Nobel nominations had an undeniable consequence, and a large one. Countries need hero scientists when they are building or “negotiating” a role for their science. Communities struggling with complex social issues of disadvantage of all kinds can also profit from this. Dehumanizing individual achievements against certain conditions such as disease, drug addiction or various forms of human degradation may not be beneficial to anyone – in these cases, humanity and exposed conflicts may be more beneficial. For countries and communities, heroes do have a place, yes. Nobel prizes, Olympic medals and other symbols of recognition can make all the difference between a leap in quality that thousands of people can take together towards fundamental social achievements, or not. For this reason, the loss of the Nobel by Chagas was most regrettable. Whoever was responsible for it caused the country losses that we can never calculate.

A new Nobel nomination, post mortem, is unusual. It remains for everyone, on the occasion of the next centenary of the discovery of Chagas, the idea and the pride that our greatest scientist, to have been indeed awarded and with all honors, as an undisputed benefactor of humanity.

Carlos Chagas did not receive the Nobel Prize

Naftale Katz
Academia Mineira de Medicina, Instituto Mineiro de História da Medicina, Centro de Pesquisas René Rachou/Fiocruz
E-mail:

Carlos Chagas can be considered one of the most brilliant Brazilian scientists of all time. The fact that the same scientist discovered the etiologic agent, the vector insect, the reservoir animals and the disease, seems to have been unprecedented in the history of medicine. So, it should come as no surprise that Chagas was nominated twice for the Nobel Prize, unfortunately, each time (1913 and 1921) by a single Brazilian nominee. Based on information from Sierra Iglesias (1990), Brazilian researchers defend the idea that Chagas was not awarded the Nobel Prize due to criticisms made by his colleagues at the National Academy of Medicine. Based on data recently released by the Nobel Foundation, this fact is being discussed. A better explanation for the non-concession of the award to Carlos Chagas can perhaps be found in the credibility and respect among researchers from central countries in relation to those from peripheral ones.

In the history of medicine, the fact that the same scientist discovered the causative agent, the transmitting insect, reservoir animals and the anatomopathological description and the clinical picture of a disease seems to have been achieved only once, when the discovery of American trypanosomiasis was performed and called by Carlos Chagas. For these discoveries he would deserve any and all prizes that at the time (and even afterwards) could be awarded in recognition of a great discovery. Chagas disease, as it became known as the great clinician Miguel Couto’s baptism in 1910, was subsequently identified from the south of the American continent to the south of the United States in its different clinical forms, being the cause not only of morbidity, but of important mortality especially at the stage when man is most productive.

This work discusses and brings contributions to a specific problem which discussion started in Brazil in the late 1990s, regarding the reasons why Carlos Chagas was not awarded the 1921 Nobel Prize.

It all starts with a quote in the book by Sierra Iglesias (1990) about the life and work of Argentine researcher Salvador Mazza, who contributed greatly to the recognition of the importance of Chagas disease in Argentina. In this book, on page 225 you can read:

“En 1921 era propuesto para Chagas el Premio Nobel de Medicina, y cuando todo presumía que le sería otorgado, inconfesables influencias se interpusieron. El Instituto sueco se había dirigido a organismos científicos del Brasil recabando datos sobre su personalidad, sobre su obra, pero algunos de sus próprios compatriotas (increíblemente, entre ellos algunos no médicos, por lo tanto primariamente inhabilitados para juzgar el descubrimiento de la tripanosomiasis), lo desaconsejaron, siendo este año declarado desierto este codiciado lauro mundial”.

Based on this information, Coutinho and Dias start a series of articles where they defend as a highly plausible idea that it was due to the attitudes of Chagas’ colleagues, especially those from the National Academy of Medicine (ANM), that he was denied the Nobel Prize. Later, it is learned that the information contained in this founding paragraph was transmitted by Prof. Rodolf Talice, Uruguayan researcher, to Sierra Iglesias, who reported this to João Carlos Pinto Dias and José Rodrigues Coura. At the time, as Talice had passed away a few months ago, it was not possible to expand this information.

Several publications first appeared in 1999 called “Year of Carlos Chagas” by the World Health Organization and other world institutions in celebration of the 90 years since the discovery of American trypanosomiasis. Academia Mineira de Medicina joined these celebrations with various activities, one of which was the publication of a book about Carlos Chagas where there is a collection of articles about his life and work. Later, Lewinsohn in his book “Three Epidemics: Lessons from the Past”, in which Chagas disease is one of them, presents a chapter on the subject “Carlos Chagas and the Nobel Prize”.

It is necessary to note that these articles always follow the same line of argument and what would initially be evidence, over time they become statements, making the version become history.

Recently, the Nobel Foundation published information on Nobel prizes conceived from 1901 to 1951 on its website. It should be noted that for 50 years, all information regarding the choice of prize candidates, nominators and nominees was kept confidential. Now, with the data made public, it is possible to come up with different hypotheses to try to understand why Carlos Chagas did not receive the Nobel Prize for Medicine and Physiology in 1921.

It should first be noted that there was an intense controversy at the National Academy of Medicine that began in November 1922, going on until the following year, when the final report presented at the extraordinary meeting of December 6, 1923 was in favor of Carlos Chagas. If the Nobel Foundation (or Karolinska Institute, responsible for nominating the members who judge the prize, chosen by the Nobel for this purpose) had sent a request for clarification, it should have been sent in 1921. Having consulted the minutes of the ANM of that year, nothing finds regarding this subject. On the other hand, the consultation with the Academy, if done, should have been forwarded to its president, who at the time was Miguel Couto, a great admirer of Carlos Chagas. It is true that, especially three members of the ANM, Afrânio Peixoto, Figueiredo de Vasconcellos and Parreiras Horta, were in strong dispute with Chagas, either denying the importance of the disease or even the sole authorship of the discovery. However, the Academy recognized that Chagas was right and that he was the only discoverer of American trypanosomiasis. So there is neither in ANM nor in Carlos Chagas Filho’s detailed description of his father’s life any mention of this consultation by the Swedish institute.

The aforementioned authors claim that although there were no other nominees, and Chagas was the only one, due to the controversy (or rather, to the contrary opinions), the award was not granted that year. Consulting the information contained in the Nobel Foundation website, referring to the year 1921, it can be seen that 82 were those who nominated (nominator) and 42 those nominated (nominee). Carlos Chagas is 46^th in this list, having been nominated only once, by Hilário de Gouvêa, an ophthalmologist from Minas Gerais, exercising his profession in Rio de Janeiro. The Nobel Foundation’s record includes him as an otorhinolaryngologist, because at the time the two specialties were placed together in the Society of Otorhinolaryngology. Hilário de Gouvêa was invited by the Nobel Foundation to nominate a candidate. In this same year, the Brazilian surgeon C. S. de Magalhães, also an official nominator, nominated Patrick Manson to receive the award. Of the 42 nominees there were expressive names such as Gley (11 nominations), Roux (10 times), Sherrington (7 times), Duret (7 times) and 24 more nominees with a single nomination, as was the case with Chagas. However, the Nobel Prize for Medicine committee decided not to award the prize that year. It should be added that it was not only in 1921 that the award was not granted in the Medicine category, this fact was repeated in 1915, 1916, 1917, 1918, 1925, 1940, 1941 and 1942 for unknown reasons.

The important question to ask is why was Chagas not nominated by anyone else in 1921? It is known that his name was indicated in 1913 by Pirajá da Silva, the discoverer of schistosomiasis mansoni in Brazil, the year that Charles Richet was the winner of the award for his work on anaphylaxis. That year, 63 candidates were nominated by 118 nominators, and Carlos Chagas also had a single nomination at that time. For Lewinsohn, the 1913 candidacy was not yet mature. This statement does not seem to be in keeping with the recognition given to Carlos Chagas when receiving the Schaudinn Prize in Germany in 1912. This was an award given every four years by the Hamburg Institute for Tropical Diseases to a scientist of any nationality, author of the most important scientific discovery in the field of protozoology. Among the various personalities who made up the award committee were Koch, Von Hertwig, Buetschli, Manson, Ross, Blanchard, Roux, Metchnikoff and Oswaldo Cruz, to name just a few of the researchers’ representatives from Germany, France, England, Japan, Italy, Australia, Portugal, Russia, United States and Brazil.

For Pitella, who, like us, used the data from the Nobel Foundation files made available on the internet, the links between members of the Karolinska Institute and the Nobel Committee with the international scientific community, mainly with North American and European scientists, explain how the nominators, nominees and award winners were selected. In fact, for the United States of America, from 1901 to 1951, 732 nominators were selected, 1132 nominees and 14 winners; for Germany 763, 914 and 9, respectively and with similar numbers for England, 256, 464 and 9 awarded.

There were, therefore, two indications of Carlos Chagas made by two Brazilians with an eight-year interval between them. For information, Robert Koch was nominated 45 times, from 1901 to receiving the award in 1905; Metchnikoff 56 times and Ehrlich 58 times, to name but a few. On the other hand, it should be noted that the choice of the Nobel Prize is not based on the vote count that the nominees receive, although this should be important. Other nominees, for example, received the award with just one vote (Carrel) or two or three (Banting, Macleod and Meyerhof).

Based on the data collected by us, we agree with Pitella’s statement that the accountability for the controversy over Chagas’ disease and the blaming of Brazilian doctors for not indicating Chagas seems to be purely speculative, with no concrete evidence.

In fact, the non-awarding of the Nobel Prize to Carlos Chagas, one of our greatest scientists of all time, is much more due to the lack of indication of his name by dozens of nominators around the world than by the fault of Brazilian doctors who questioned his discovery. In fact, the lack of recognition of the important scientific contributions made by Brazilians by colleagues of other nationalities, especially by the so-called first world countries, is a fact to be discussed. This happened, for example, with Pirajá da Silva, the discoverer of schistosomiasis in Brazil. The relations of credibility and respect between researchers from central and peripheral countries, deserve further study. Perhaps there are clarifying explanations (Figures 1, 2, 3 and 4).

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