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Corresponding author:

Luiz Antonio Teixeira, Casa de Oswaldo Cruz Fiocruz Av. Brasil 4365 sala 403, Rio de Janeiro,

Brasil, Cep 21040-361.

Email: [email protected]

Imperfect tools for adifficult job: Colposcopy,colpocytology andscreening for cervicalcancer in Brazil

Luiz Antonio TeixeiraCasa de Oswaldo Cruz, Fiocruz, Brazil

Ilana LwyCentre de Recherche Medicine, Science Sant et Societ (CERMES), Paris

AbstractThe quasi-totality of social scientists who studied screening for cervical tumours identified such

screening with a single method: the Pap smear (exfoliative cytology). This article explains that

this method was not valid everywhere. The history of screening for cervical cancer in Brazil

displays an alternative method for detecting cervical malignancies: a direct observation of the

cervix with a specific instrument the colposcope. The development of this method in Brazil

in the 1940s and 1950s reflected a complex mixture of professional interests, government

policies, and regional, local and charitable initiatives. While the use of colposcopy for cervical

tumour screening was phased out in the 1970s and 1980s, the long lifespan and widespread

diffusion of this method illuminates the irreducible contingency of specific developments inscience, technology and medicine. Seen from the vantage point of Brazil, the Western model

for preventing cervical malignancies no longer appears self-evident. Alternative choices might

have led to the development of different material and visual cultures of medicine, stimulated

different patterns of medical specialization and division of medical labour, produced different

links between malignancies, women, gynaecologists, epidemiologists and public health experts,

and shaped different health policies.

Keywords

cervical cancer, colposcopy, health politics, medical practice, pap smear

Social Studies of Science

41(4) 585608 The Author(s) 2011

Reprints and permission: sagepub.

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586 Social Studies of Science 41(4)

In the 19th century, cancer of the uterine cervix (the lower, narrow part of the uterus)was the leading cause of cancer mortality among women (Moscucci, 2005). In the 21stcentury, it has become much less frequent among women who live in industrializedcountries. Experts have often attributed this sharp reduction of mortality rate to the

introduction of screening programmes that detect and eliminate cervical lesions beforethey become cancerous (Peto et al., 2004).1 Historians and sociologists have addressednumerous topics related to screening for cervical cancer, such as: stabilization of tech-niques, standardization and interpretation of results, training of specialists, practicalorganization of screening campaigns, educational and public health campaigns, contro-versies over cost-effectiveness and ethical issues. However, they implicitly take forgranted that the history of the early detection of cervical malignancies involved thedevelopment and diffusion of a single approach the Pap smear (Papanicolau test,exfoliative cytology) (Armstrong and Murphy, 2008; Bryder, 2008; Casper and Clarke,

1998; Keating and Cambrosio, 2003; McKie, 1995; Singleton and Michael, 1993;Vayena, 1999).2 In this article, we argue that the identification of screening for cervicalmalignancies with the Pap smear was not the same everywhere. The history of screen-ing for cervical cancer in Brazil displays alternative pathways and different solutions,and shows how knowledge about cervical cancer and precancerous lesions waslocally produced through the alignment of heterogeneous elements. These local arrange-ments were later destabilized and replaced by approaches prevalent in Western Europeand North America.

Before the introduction of exfoliative cytology, the only way to detect early cancerous

changes in the cervix and catch the cancer at a curable stage was regular gynaecologicalexaminations and visual inspection of the cervix. Doctors attempted to persuade womento undergo such examinations (Aronowitz, 2008; Gardner, 2006), but their campaignsreached only a small number of women. The introduction of exfoliative cytology led toa rapid increase of the number of women screened. It also produced new problems:uncertain diagnoses, false-negative and false-positive results, and overtreatment (Russell,1994; Welch, 2004). Mass screening for cervical cancer was far from being an unmixedblessing (Bryder, 2009; Etzioni and Thomas, 2004).

Initially, experts viewed the Pap smear as a definitive diagnostic test. In the 1950s

and 1960s, however, persistent difficulty with homogenizing the classification of abnor-mal cells and defining uniform diagnostic criteria led to a change in the status of thistest. The Pap smear became mainly a triage method a first screen that indicated aneed for further investigation. In industrialized countries, women with positive Papsmears are invited to undergo colposcopy: a visual examination of the cervix with anoptical instrument the colposcope. If suspicious lesions are observed, the patientundergoes a biopsy and the excised tissue is analysed by a pathologist. In some cases,direct observation of the cervix leads to a clean bill of health and a reclassification of apositive Pap smear as a false-positive result. In other cases, colposcopy and biopsy leadto a diagnosis of an already existing malignancy or dysplasia (an abnormal, potentiallyprecancerous proliferation of cells). In still other cases, the patient receives a diagnosisof atypical squamous cells of unknown significance (ASCUS). Women with this diag-nosis have frequent vaginal smears and gynaecological examinations, and, if the ambig-uous results persist over time, they undergo a preventive treatment.

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Teixeira and Lwy 587

In Western Europe and North America, this sequence a Pap smear for all womenfollowed by a colposcopy only for those with positive vaginal smears was usuallypresented as the only rational approach for detecting cervical lesions. Latin Americancountries were different. In this continent, particularly in Argentina, Brazil and Chile, for

a long time colposcopy was seen as a viable alternative to the Pap smear as the primaryway to detect cervical lesions (Eraso, 2010).3 Some Latin American gynaecologistsproposed the use of colposcopy as an initial screening tool, offering exfoliative cytology(the Pap smear) only to women with abnormal colposcopy findings. Others advocatedsimultaneous colposcopic and cytological examinations. From the late 1940s onwards,leading Brazilian gynaecologists implemented screening programmes that employedcolposcopy as the initial screening tool.

The rise of a distinct Latin American approach to screening for cervical tumours maybe viewed as the result of contingent events. Colposcopy was invented in Germany in

1924, and was mainly diffused to German-speaking countries during the interwar years.At that time, numerous Latin American gynaecologists maintained close links with theirGerman and Austrian colleagues. Moreover, these links were not interrupted or dimin-ished by World War II. Colposcopy was introduced to Brazil in the early 1940s, a periodunfavourable for the diffusion of German innovations in Western Europe and NorthAmerica. Once established, colposcopy was able to successfully compete with the Paptest, a method originating in the US. However, ties between Brazilian and Germangynaecologists are only part of the story. In Brazil, the rise of colposcopy a method thatoriginated in a gynaecologists office and was grounded in regular visits to a specialist

might have been favoured by health policies that promoted private or charity-sponsoredhealthcare and did not view malignant tumours as a public health problem.Systematic efforts to control cancer in Brazil started with the creation of the Servio

Nacional do Cncer (SNC) in 1942 (Teixeira, 2009: 108). The SNC was formed bya central institute (today called the Instituto Nacional de Cncer (INCA) and theCampagne Nacional Contre le Cancer (CNCC), a network that included state-fundedand philanthropic hospitals and charitable organizations.4 This alignment of institutionsand organizations may seem impressive, but in fact the initial scale of SNCs interven-tions was very modest. It expanded somewhat in the 1950s. At that time, the Brazilian

government increased the number of hospitals that had agreements with the CNCC andpromoted the modernization of INCA, while private hospitals began to offer treatmentsto cancer patients covered by social security.5 Yet, these measures had only a limitedscope. Most Brazilians did not have access to specialized treatment for malignancies(Teixeira and Fonseca, 2007). Low levels of public investment in cancer treatmentreflected the priorities of a country still ravaged by lethal transmissible diseases such asmalaria and tuberculosis.

The prevention of cervical malignancies was similarly grounded in small-scale initia-tives. In the 1940s and 1950s, there were a few university clinics and charity-sponsoredcancer hospitals ambulatory centres dedicated to treatment of female breast andovary cancers. Gynaecologists affiliated with these centres usually advocated colpos-copy to screen for cervical tumours. Still a small enterprise in the 1960s, the preventionof cervical tumours remained the responsibility of individual doctors, charities, andselected academic centres; an approach that resonated with the liberal economic

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orientation vigorously promoted during the military dictatorship in Brazil (19641985).6The strong institutional and political standing of some of the gynaecologists interestedin colposcopy further helped to promote the technique. On the other hand, Brazilian politicians and public health specialists, including those who were active during the

military dictatorship, were interested in international recognition and participation intransnational initiatives. In the early 1970s, the Pan American Health Organization(PAHO) highlighted the importance of cervical cancer as a major public health problemin Latin America and began encouraging prevention campaigns grounded in the use ofthe Pap smear, an approach already favoured by some Brazilian experts (Joly, 1977).PAHOs initiative favoured the establishment of a Brazilian National Program for theControl of Cancer (PNCC) in 1973, piloted by the Ministry of Healths Diviso Nacionaldo Cncer7 The PNCC-sponsored prevention campaigns intensified in the 1980s andconsolidated the use of exfoliative cytology for cervical tumour screening (Lago, 2004).

The alternative models of screening for cervical malignancies in Brazil persisted fornearly 40 years. Their long lifespan brings into question the presumed inevitability ofthe use of the Pap smear to detect malignant and premalignant lesions of the cervix. Oneof the key methodological innovations of Michel Foucault, his colleague Paul Veyneproposed, was to use history to make the familiar strange (Veyne, 1979). Seen from thevantage point of the history testing in Brazil, the use of exfoliative cytology as a firstscreening tool no longer appears self-evident. Alternative choices might have led to thedevelopment of different material and visual cultures in medicine, stimulated differentpatterns of medical specialization and divisions of medical labour, produced different

links between malignancies, women, gynaecologists, epidemiologists and public healthexperts, and shaped different health policies. The tangled history of screening for cervi-cal cancer in Brazil was produced by a complex mixture of governmental policies;regional, local and charitable initiatives; professional arrangements; and economic con-straints. Locally determined, heterogeneous arrangements and spatial distribution ofactors, resources and power produced divergent perceptions of womens bodies andshaped the complex trajectory of a new medical technology (Latour, 2005; Law andBijker, 1992; Mol, 2002).

Colposcopy and colpocytology in Brazil: The beginningsIn the 19th century a diagnosis of cervical cancer was invariably a death sentence. Thedevelopment of radical hysterectomy and radiotherapy (using radium, x-ray radiation or both) in the early 20th century made occasional cures of cervical cancers possible.Doctors noted, however, that only localized (stage I and II) tumours could be cured.Tumours extending beyond the cervix and invading other organs and tissues (stage IIIand IV), were, as a rule, incurable. Sadly, women who consulted gynaecologists forsymptoms such as pain, vaginal discharge and irregular bleeding were often diagnosedwith an advanced cancer. Doctors argued that the only way to decrease mortality from

cervical malignancies was to promote early detection through regular visual examinationof the cervix.

In 1924, German gynaecologist Hans Hinselmann developed the colposcope a bin-ocular microscope specially adapted for the observation of the cervix. This instrument

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facilitated the diagnosis of cervical malignancies and other gynaecological diseases(Hinselmann, 1952). In the early 1930s, an Austrian gynaecologist, Walter Schiller,found that when the cervix was stained with diluted iodine (lugol), normal tissue adsorbedthis stain, while zones of abnormal cell proliferation remained white (Schiller, 1933).

The combination of both methods colposcopy and lugol staining amplified the effi-cacy of each. Yet the identification of lugol-free zones of the cervix and colposcopicalobservations became accurate only after long periods of training of the experts eye. Inthe 1930s and 1940s, colposcopy was rarely used outside German-speaking countries,with one important exception: Latin America. The importance of colposcopy in LatinAmerica is illustrated by the fact that Professor Wood from Chile, the keynote speaker atthe First Brazilian Congress of Gynaecology and Obstetrics (September 1940), dedicatedan important part of his discourse to uses of this technique (Wood, 1940).

The organization in 1940 of a national congress of gynaecology was a sign of rapid

growth of this discipline in Brazil. In 1936, the first chair of gynaecology was created atthe Faculty of Medicine of Universidade do Brasil in Rio de Janeiro (today UniversidadeFederal do Rio de Janeiro). The incumbent of this chair, Arnaldo de Moraes, was a prominent figure in Brazilian gynaecology who received a Rockefeller Foundationscholarship to study pathology at John Hopkins University in 1927. De Moraes was ahighly successful scientific entrepreneur. Upon his arrival in Rio, he founded the journal

Anais Brasileiros de Ginecologia and the Sociedade Brasileira de Ginecologia. He alsofounded a gynaecology institute that attracted young researchers interested in new diag-nostic and therapeutic approaches.8

In 1942, one of De Moraess collaborators, Joo Paulo Rieper, published a thesis onthe uses of colposcopy for diagnosing gynaecological diseases (Rieper, 1942a). Rieperstudied colposcopy with Hinselmann, and was recruited by De Moraes to introduce thenew diagnostic technique to the Rio clinics.9 Rieper imported the instrument, but alsoHinselmanns complicated terminology: transformation zones, pseudo erosion, greenerosion, diffuse colpitis, base, mosaics, and so on. Rieper found that nearly everywoman who underwent colposcopic examination (184 out of 200) had some kind of cer-vical anomaly. The complexity of Hinselmanns classification system probably accountedfor some of the difficulties in adapting this technique for screening, an approach that aims

above all to separate the normal from the pathological (Rieper, 1942b).Also in 1942, another assistant from the Gynaecological Clinics of the NationalFaculty of Medicine of University of Brazil, Vincente Ramos, published a thesis aboutthe use of the cervical smear renamed colpocytology for early diagnosis of cervicalmalignancies (Ramos, 1942, 1943). Ramos faithfully applied the method, which hadbeen described a year earlier by Papanicolau and Traut (1941). The rapidity with whichthe new technology was transferred to Brazil might have been facilitated by the fact thatBrazilian gynaecologists were already familiar with vaginal smears and used this methodto follow changes in hormonal activity in women (Quinet, 1940).10

The 1942 publication of a thesis on colposcopy, and another on exfoliative cytology by De Moraes students, were not chance events. De Moraes strongly advocated acombined use of these two techniques for early diagnosis of cervical malignancies (deMoraes and Lima, 1945). The choice of the term colpocytology might have reflectedthe wish to associate these two diagnostic approaches, but also to stress the priority of

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the older technique, colposcopy. Each method, de Moraes argued, produced erroneousdiagnoses approximately 20% of the time, but the sources of error were not the same. Asimultaneous use of both methods thus greatly increased the accuracy of diagnosis,especially when results were confirmed by an examination of biopsy material made by

a trained histopathologist. The local culture of the Gynaecology Institute stronglyfavoured the triple model: a combination of colposcopy, colpocytology and histopa-thology (Rieper, 1945).

De Moraes (1948a) energetically promoted colposcopy. The diffusion of this tech-nique was, however, hampered, by difficulty with homogenizing colposcopic diag-noses. Terms used by colposcopists to describe changes in the cervix were complex andloosely defined, while the co-existence of several competing classifications of cervicallesions further complicated agreement on colposcopic diagnoses (Luz, 1954; Rieperand Maldonato, 1969).11 Since colposcopy required a tacit skill transmitted from master

to pupil, Hinselmanns visits to Brazil played a central role in the diffusion of thismethod (Rieper, 1950a). After World War II, Hinselmann was sentenced for 3 years inprison for illegal racial sterilization of gypsy women, and was stripped of his aca-demic privileges.12 Liberated from jail in 1949, he was invited to Latin America, and hedescribed his enthusiastic reception in Brazil as a corner of blue sky (Rieper, 1959a).In the 1950s, Hinselmann made several visits to Brazil, the final one in 1958, a yearbefore his death. During these visits, he organized practical courses on colposcopy inBelo Horizonte and Rio de Janeiro, and taught Brazilian gynaecologists how to recog-nize cancer and precancerous lesions (Rieper, 1950b; Rocha, 1955). The prophylactic

destruction of the latter, Hinselmann stressed, completely eliminates the danger ofcervical cancer. Sufferings induced by this malignancy were unnecessary, since theycould be prevented by an efficient use of colposcopy (Hinselmann, 1951).

Ambulatrio Preventivo and the consolidation

of the triple model

De Moraes rapidly expanded his Gynaecological Institute. In 1942, the Institute openeda consultation on sterility and a Roentgen therapy service. In 1945, it opened an experi-

mental laboratory and a documentation service, and in 1948, the Ambulatrio Preventivode Cncer Ginecolgico. In the same year, the Institute obtained legal status within theUniversity of Brazil. The Ambulatrio Preventivo fully adopted the triple model fordetecting cervical lesions. Joo Paulo Rieper was responsible for colposcopic examina-tions. Clarice do Amaral Ferreira, a gynaecologist trained in cytology in Argentina, tookover the reading of Pap smears, and a German physician Hildegard Stoltz organized thedata on diagnosis and treatment. De Moraes and his assistants claimed that the system-atic combination of colposcopy, colpocytology and biopsy at the Ambulatorio greatlyincreased the efficacy of detecting cervical lesions (de Moraes, 1948b). The logic ofthe triple method was summed up in a title of a 1975 article: Better cytology withmore colposcopy (Periera et al., 1975).

During its first year, the Ambulatrio received 35 to 40 patients each morning, eachof whom underwent a careful colposcopic examination. This was an intensive and dif-ficult work, all the more so because Rieper and his colleagues used an old colposcope

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and had no technical help. Later the Ambulatrio hired technicians, reducing the numberof patients examined in each session. The main task of the Ambulatrio was didactic: ademonstration of feasibility of a triple model and promotion of the diffusion of thisapproach in Brazil (Rieper, 1959b). Rieper wrote articles about colposcopy, taught col-

poscopy courses in several Brazilian universities, and was active in the 1958 foundationof the Sociedade Brasileira de Colposcopia. Similarly, do Amaral Ferreira promotedvaginal cytology, and co-founded the Sociedade Brasileira de Citologia in 1956.

De Moraes and his colleagues strongly advocated the extension of colposcopic screen-ing. He even toyed with the idea of compulsory screening for all the Brazilian womenbetween 35 and 60 years old, or, at least, to introduce obligatory screening of selectedcategories of women such as civil servants (de Moraes, 1945). However, the diffusion ofcolposcopy in Brazil was hampered by a lack of resources.13 Brazils public hospitalswere severely understaffed and colposcopists were obliged to work in sub-optimal con-

ditions: without assistants and with inadequate light (ideally, colposcopic observationsshould be made in semi-darkness, but in a hot climate it was difficult to keep curtains andshades permanently closed without air-conditioning, a luxury unavailable in public facil-ities).They also were obliged to use less expensive, and consequently lower performing,instruments. Rieper argued, however, that a well-trained colposcopist could provide effi-cient services even under such difficult conditions (Rieper, 1955). The key element foradvancing screening for cervical malignancies was training a sufficient number ofexperts. In order to meet Brazils needs, it was necessary to educate 10,000 colposcopistsand several thousand cytologists and pathologists; a slow, costly but indispensable proc-

ess (Rieper, 1971).The proposal to greatly increase the number of colposcopists received official supportunder the military dictatorship. In 1970, Rieper, together with Clovis Salgado, professorof gynaecology at Minas Gerais University in Belo Horizonte, and an enthusiastic sup-porter of the triple model, published a textbook of colposcopy for medical students(Salgado and Rieper, 1970). Salgado had a dual career as a gynaecologist and as a politi-cian. He was twice elected vice-governor of the State of Minas Gerais in 1950 and 1956,governed that State in 1955, and was Minister of Education and Culture in 1956, underPresident Juscelino Kubitschek. Later Salgado supported the military regime and became

the Health Secretary of Minas Gerais State and a member of the Federal EducationCouncil (Fundao Getlio Vargas, 1984). Salgados political influence in all probabilityhelped to secure government support for the teaching of colposcopy. Salgados andRiepers 1970 textbook was published by a government office, Fundao Nacional deMateriais Educacionais, and thousands of copies were distributed. The textbook stressedthe importance of colposcopy as an initial screening technique, a key role for rapidlydiffusing this method, and it also stressed the complementary nature of colposcopy andcytology (Salgado and Rieper, 1970).

From early detection to prevention: Colposcopy,cytology and stage zero cancer.

Between the 1940s and 1960s, the goal of screening for cervical cancer was to detect analready existing malignancy. The decision to name a clinic opened at the Univesidade

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do Brazil Ambulatrio Preventivo was made, mainly for psychological reasons (Rieper,1959b). However, in the 1950s and 1960s, gynaecologists became increasingly interestedin the detection and elimination of non-invasive precancerous lesions of the cervix:high-grade dysplasia and in situ carcinoma (cancer stage 0). At that time, the goal of

screening gradually shifted from early diagnosis of an already present tumour to elimi-nating the danger of future cancer that is, to provide a truly preventive intervention.

The Rio de Janeiro Ambulatrio reported that 10% of cervical malignancies diagnosed

at this institution were stage 0 cancers. In the 1950s, the standard treatment for this lesion

was ablation of the cervix for women under 40 years old and a surgical removal of the uterus

for those over 40 years old. Some of the diagnosed women refused surgery, producing a

natural experiment that revealed that many of these women did not develop cancer (Rieper,

1968; Stoltz, 1955). This observation initiated a debate on the status of precancerous

lesions: very early cancer or cancer risk. Hinselmann claimed that it was absurd to speak

about a carcinoma in situ or cancer stage 0, because a non-invasive cancer is a contradic-tion in terms. He elected to speak instead about carcinomateus epithelium, and advocated

a conservative treatment of such abnormal epithelium: either excision biopsy or surveil-

lance (Hinselmann, 1951). At first, Hinselmanns Brazilian followers did not adopt his

position. They had chosen to use the term stage 0 cancer, which implied that these lesions

were already cancerous, and promoted radical surgical treatment. However, in the 1960s,

they switched to more conservative approaches such as conical biopsy (Maltez et al., 1965).

With an increased focus on the diagnosis of precancerous lesions, debates on the rela-tive efficacy of colposcopy and cytology focused on the capacity of each method to

detect such lesions. Advocates of colposcopy reported important discrepancies betweencolposcopic and cytological findings, arguing that while the Pap smear was an efficientmethod for visualizing an invasive cancer, colposcopy, especially when coupled withbiopsy was a more sensitive tool for the detection of premalignant lesions (Salvatoreet al., 1976a; Stoltz, 1953). Supporters of cytology promoted the opposite view: cytologyenabled the detection of premalignant changes even when the external aspect of thecervix was normal (Ferreira, 1952; Nestares et al., 1977). Finally, the promoters ofthe triple model argued that only a combination of colposcopy and Pap smear led to thedetection of nearly all the precancerous lesions (de Moraes, 1953; Rieper, 1968).

The diffusion of the triple model of screening

in Brazilian cities.

Even before the opening of the Ambulatorium in 1948, the Rio de Janeiro GynaecologicalClinic was seen as a model for detecting cervical malignancies. De Moraess approachdirectly inspired Salgados initiatives in Belo Horizonte. Salgado employed his consider-able political influence to promote his views on screening for cervical tumours. In 1944,he inaugurated the Red Cross service for detecting cervical tumours in Belo Horizonte(Posto de Combate de Cancer de Cruz Vermelha) (de Moraes, 1944). The centre, whichemployed a colposcopist trained by Rieper, faithfully applied the triple method. Everywoman underwent a colposcopic examination, a Pap smear, and, if necessary, a biopsy ofdetected cervical lesions (Rocha, 1955). The triple model was applied in two additionalscreening clinics later opened in Belo Horizonte. Hinselmanns 1949 course of colpos-copy in Belo Horizonte further consolidated the status of this technique in Minas Gerais.

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The Gynaecology and Obstetrics Department of Medical Faculty Ribeiro Preto ofSo Paulo University (USP) started a screening programme for cervical malignanciesgrounded in the triple model in the 1950s. The simultaneous use of cytology and col-poscopy was legitimated by the claim that a combined use of both techniques greatly

reduced the danger of false-negative results. On the other hand, the triple method waslabour-intensive. In the early 1960s, it became difficult to provide a colposcopic exami-nation and Pap smear to all screened women. The solution chosen at Ribeiro Preto andin Hospital das Clnicas in So Paulo was to limit colposcopical examinations to womenover 35 years old(Baruffi and Martinez, 1962).

Doctors from the gynaecology and obstetric services of the Francisco Morato Hospitalin So Paulo made the opposite choice. They simultaneously employed colposcopy andcytology, but believed that if one is obliged to choose only one technique, one shouldfavour colposcopy coupled with biopsy, because a Pap smear alone was much less reli-

able (Lima et al., 1975). Gynaecologists from the preventive services (Instituto Nacionalde Previdncia Social (INPS) of So Paulo, founded in 1969) shared this view. Anoptimal screening, they argued, should include colposcopy and cytology, but the centralelement of such screening was a colposcopic examination (Acuri, 1974).

Specialists from another So Paulo centre, Gynaecological Clinics of Faculdade deMedicina da Universidade de So Paulo (FMUSP), stressed the importance of combin-ing colposcopic and cytological testing for diagnosis of precancerous lesions. At theircentre, cytology alone failed to detect 13.5% of such lesions, and colposcopy alone 6.3%.However, when employed together, the percentage of false negatives was reduced to

2.5% (Salvatore et al., 1976b). A similar argument was developed by gynaecologistsfrom the Ambulatorio Preventivo of Rio Grande do Sul in Porto Alegre. All womenscreened at this clinic in the 1970s underwent a colposcopy, Schillers test and a Papsmear, an approach that favoured an optimal detection of premalignant lesions (Soldanet al., 1977).

Ambulatrio Preventivo of Univesidade do Brazil was not the sole centre for screen-ing cervical malignancies in Rio de Janeiro. INCA opened a screening centre in 1952.This centre, headed by a colposcopist trained by Hinselmann, employed the triplemodel, relying strongly on colposcopy (Servicio Nacional de Cncer, 1967). In the

1970s, Rio de Janeiro had nine centres, in addition to the Ambulatrio, specializing inscreening for cervical lesions. All these centres employed the triple model, with a singleexception: the screening centre of Legio Feminina de Educao e Combate ao Cncer,which relied exclusively on colposcopical examinations. The Rio de Janeiro centresemployed 42 cytologists, 71 colposcopists and 17 pathologists. In spite of the multiplica-tion of centres, in the 1970s only approximately 11% of women in Rio de Janeiro hadaccess to screening for cervical tumours (Rieper et al., 1977).

The triple model remained popular in Rio. As late as 1987, a pilot project funded bya private organization, Fundaao Bela Lopez de Olivera, employed a mobile colposcopyunit to examine 481 female workers at a factory in Rio de Janeiro state. Each colposcopicexamination lasted about half an hour. The aim of this project was to demonstrate that itis technically possible to export methods employed in a private gynaecological practiceto economically disadvantaged sites (Pasqualette et al., 1987). The demonstration, onemay assume, was not very persuasive. In the 1980s, the main governmental body dealing

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with malignant tumours, the National Program of Cancer Control, exclusively promotedscreening campaigns grounded in the use of the Pap smear.

The triple model in rural settings: Contrasting experiencesSome gynaecologists claimed that colposcopic examinations could be conducted only inbig cities (Campos da Paz and Campos da Paz, 1966). Others gynaecologists believed,however, that women in the countryside were also entitled to high quality gynaecologi-cal care (Ferreira Filho, 1975). In the 1960s, social pressure to expand the coverageprovided by the Brazilian social security health system to rural workers led to the found-ing of a new governmental agency, the rural assistance service, Fundo de Assistncia ePrevidncia do Trabalhador Rural (FUNRURAL).14Organizers of a pilot campaign con-ducted by Santa Maria Citys FUNRURAL, in collaboration with a private medical

company Servio de Assistncia Mdica Particular (SAMPAR), claimed that this cam-paign had shown that it is possible to transport high-quality colposcopic equipment tothe countryside (Souza, 1977). The organizers of a small screening campaign in a ruralarea of Minas Gerais similarly argued that it is perfectly possible to provide high-qualitycolposcopic screening in such a region, and that such screening is also cost-effective. Itlimited the number of false-negative and false-positive results, and unnecessary biop-sies, and thus reduces theoverall costs of detecting each cancer or precancerous lesion(Ferreira Filho, 1975).

A screening campaign in rural zones of Parana State, proposed a mixed model of

screening. This campaign employed mobile intervention units. In the first stage, three orfour physicians were sent to a targeted municipality to prepare for the campaign. In thesecond stage, buses transported 50 to 60 people doctors, nurses, secretaries and socialworkers to that municipality. The mobile units organized screening, educational activi-ties and standardized collection of data, and left once these tasks were accomplished. Theorganizers of the Parana campaign believed that, ideally, screening for cervical lesionsshould include cytology and colposcopy. They found out, however, that the exportationof the triple model outside big cities was a complicated endeavour, and settled for acompromise: Pap smear only for the majority of the screened women, and the addition ofcolposcopic examination in selected demonstration localities (Paciornik, 1976).

Alternative models: Health policy and cytology-based

screening in the 1960s and 1970s

While some local and regional campaigns conducted in the 1960s and 1970s adopted thetriple model, other campaigns adopted the Pap smear as a first screening tool. Acytology-based campaign was conducted in 1967 in the interior of the Bahia state. It wasinitiated in 1967 by gynaecologists from the Aristides Maltes Hospital in Salvador daBahia and Liga Bahiana Contra o Cancer, and received financial help from state and

federal authorities and from the national oil company, Petrobras (Barros, 1977; GalvaoFilho and Monteiro, 1971). This programme was partly inspired by the campaign con-ducted in rural areas of Parana State, but with two important differences: colposcopywas reserved exclusively for women with abnormal Pap smears, and screening was

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performed by a fixed group of staff in order to promote regular screening. Directors ofthe Bahia campaign claimed that thanks to efficient organization, they were able togreatly reduce the costs of screening. An additional cost reduction could be achieved bysimplifying the staining and fixation of slides and partially replacing skilled cytolo-

gists (often physicians) with cytotechnicians (Teixeira, 1970).In the states of Pernambuco and Paraiba in north-eastern Brazil, a Pap smear-based

screening for cervical lesions was organized by Fundao Servio Especial de SadePblica (FSESP) with the collaboration of the Diviso Nacional do Cncer from theMinistry of Health. The FSESP was a unique structure: a public health service co-financedby the American and Brazilian governments, and endowed with an important degree ofadministrative and financial autonomy. FSESPs precursor, the Servio Especial de SadePblica (SESP), created in 1942, was a collaborative BrazilianAmerican endeavour. Atthat time, the US government aimed to promote the control of transmissible diseases in

areas of Brazil seen as vital to the US economy, especially during wartime. Health centresmanaged by SESP (renamed FSESP in 1960) adopted North American approaches andtechnical standards (Campos, 2006).

An earlier attempt to introduce Pap smear-based screening in seven cities within theinterior of Pernambuco State was unable to secure adequate material and logistical sup-port. The programme enrolled 5824 women in 1968, but only 1707 of them were testedbetween 1974 and 1975 (Galvao Filho and Monteiro, 1971). Physicians in the states ofPernambuco and Paraiba consequently asked the FSESP, which was known for itsadministrative efficacy, to organize a new, much larger, screening campaign (Galvao

Filho, 1976). The FSESP campaign was seen as a demonstration project. It started in1975, was conducted in ten middle-sized municipalities in the two states, and enrolledapproximately 300,000 women. Each locality had a screening unit, with a physician, anurse and a health visitor who collected vaginal smears. Slides were read in two refer-ence laboratories, and women diagnosed with abnormal smears were directed to a centralCervical Pathology Clinic in Recife for colposcopic examination and biopsy. The campaigns goal was to provide regular screening at first, annual smears, and then bi-annual testsfor women who tested negative for two consecutive years. All the data onscreening were centralized by FSESP (Ministrio da Sade, 1975).

Probably the most successful among the screening campaigns for cervical cancer ofthe 1960s and early 1970s was conducted in the region of Campinas. Programa deControle de Cncer Crvico-Uterino de Campinas (PCCUC), was founded in 1968 byJos Aristodemo Pinotti from the Gynaecology and Obstetrics Department of theMedical Faculty of Campinas University, with technical help of PAHO. A Pap smearwas used as a first screen, and only women with abnormal smears underwent colpos-copy. At first the screening was limited to the city of Campinas (in the interior of SoPaulo State), but later it was extended to the periphery. The campaign organizers linkedtesting to the systematic education of women about the importance of regular screening.The Campinas programme expanded steadily through the 1970s and 1980s. The impor-tant decrease in the prevalence of cervical malignancies in the Campinas region wasattributed to the programmes success. In the 1970s, PCCUC became a model for screen-ing campaigns initiated in other towns of So Paulo State (Pinotti and Zeferino, 1987;Zeferino et al., 2006).

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One of the main advocates Pap smear-based screening in So Paulo State was JooSampaio de Ges, Head of the Gynaecology Department at the So Camilo PhilanthropicHospital. In 1968, the Sampaio de Ges founded the Instituto Brasileiro de Estudos ePesquisas em Obstetrcia e Ginecologia. This philanthropic institute, financed by the

Government of So Paulo State, was later renamed Instituto Brasileiro de Controle doCancer (IBCC). Sampaio de Ges, trained at Johns Hopkins Medical School, stronglypromoted Pap smear-based screening for cervical tumours. IBCC organized the trainingof cytotechnicians, and started two pilot screening programmes grounded in the exclu-sive use of cytology. The first project was conducted in a low income zone of the city ofSo Paulo, and the second in two middle-sized cities in industrial areas of So PauloState: So Caetano do Sul and So Bernardo do Campo (Ges Junior et al., 1977). 15These campaigns uncovered a high incidence of cervical cancers and precancerouslesions, especially among the poor and recent migrants to the area. Sampaio de Ges and

his colleagues concluded that IBCCs pilot programmes demonstrated the feasibility ofPap smear-based screening for cervical cancer in Brazil (Ges Junior and Ges, 1982).

Official reports of the screening campaigns of the 1960s and 1970s presented themas successful endeavours. The reality was more sobering. All the screening campaigns,those that privileged colposcopy, those that applied the triple model and those thatfavoured cervical smears, were woefully inadequate when measured against Brazilsneeds (Galvo Filho, 1976). Even at locales with multiple screening centres, such asRio de Janeiro, morbidity and mortality rates indicated that preventive actions had onlya modest effect if any at all on the incidence of cervical cancer, the proportion of

women diagnosed with advanced, incurable tumours (stages III and IV), and the mor-tality from this disease.16 The situation was even worse outside the big cities. Createdin a fragmented manner and working in a discontinuous fashion, programmes destinedfor Brazils interior generally reached only a small number of women.

In the mid-1970s, the growing realization that some parts of Brazil had alarminglyhigh rates of mortality from cervical cancer, coupled with PAHOs pressures to promotePap smear-based screening in Latin America, led to an increase of government interest inthe prevention of this disease. In 1973, Sampaio de Ges was named Director of theNational Division of Cancer of Health Ministry. One of his first interventions in this

position was to create the PAHO-sponsored Programa Nacional de Controle do Cancer(PNCC), which promoted an early diagnosis of cervical cancer. PNCCs aim was toexport the model elaborated by IBCC in So Paulo to other Brazilian states. PNCC alsosigned conventions with PAHO to promote the training of cytotechnicians and the stand-ardization of cancer registries (Teixeira and Fonseca, 2007). Sampaio de Ges directedthe PNCC for only 2 years, but his activities during his tenure probably played an impor-tant role in securing official support for alignment on the internationally accepted methodand the adoption of cytology-based mass-screening campaigns. Such support was inten-sified in the late 1980s, during the transition from a military dictatorship to democracy.

The growing adoption of the Pap smear as a first screen modified the meaning ofcolposcopic examinations. The focus in such examinations shifted from a specificdiagnosis grounded in Hinselmanns terminology to the use of the colposcope toretrieve tissue samples that were then analysed by pathologists. A 1993 comparison ofresults from colposcopy and cytology illustrates this change. This study can be included

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in the long series of efforts to correlate results obtained with these two approaches, butwith a twist. In earlier periods, gynaecologists attempted to correlate images observedthrough the colposcope with cytological data. The authors of the 1993 study equatedcolposcopical results with biopsy material, and compared two kinds of microscopic

preparations: vaginal smears and cervical biopsies. The sophisticated diagnosticmethod developed by Hinselmann and his students was reduced to a search for suspi-cious regions of the cervix (Reis et al., 1992).

Transformation of cervical cancer into a public health problem

One of the main reasons for the increased interest in mass-screening for cervical tumoursin the 1980s was a growing concern with gynaecological cancers as a public healthproblem. Programa de Ateno Integral Sade da Mulher (PAISM), created in 1984,

and the Pro-Onco programme, created in 1987, listed the reduction of cervical tumoursamong their main goals (Lago, 2004). In the late 1980s, the two branches of Brazilianhealth services, the Social Security Medical Assistance branch and the Public Healthbranch, were reunited in Sistema nico de Sade (SUS).17 INCA absorbed the Pro-Oncoprogramme, thus becoming responsible for the elaboration of national cancer policies.In 1995, Brazilian delegates to the VI International Womens Conference in Beijingstressed the importance of better control over gynaecological malignancies. That year,INCA started the Viva Mulher campaign for cervical cancer screening. Initially con-ceived as a pilot project, Viva Mulher was implemented in six state capitals. In 1998, the

Ministry of Health transformed this project into a permanent programme for all Brazilianwomen (Instituto Nacional de Cncer, 2002a; Moraes, 1997).The limited success of campaigns by organizations such as FUNRURAL and INPS in

the 1960s and 1970s may be related to the overall weakness of Brazilian state-sponsoredhealth services at that time (Galvao Filho, 1976). Neither of the two branches of thenational health service the individual-centred social security system, which focused ontherapy, and the public health sector, which focused on prevention and control of trans-missible diseases (vaccination, elimination of vectors) was interested in the preventionof cancer. The supportive rhetoric of screening campaigns was not translated into a con-sistent and effective commitment to interventions in the field. However, in the 1980s and1990s, cervical cancer increasingly was perceived as a social problem in Brazil, as thedisease was more prevalent among underprivileged women.

The view of cervical cancer as a pathology linked to poverty was not entirely new. In1967, Adonis de Caravalho noted that because cervical tumours were especially frequentin the north of Brazil, some doctors classified this pathology among tropical diseases.But, in fact, a high prevalence of cervical tumours in hot regions is not related to climate.Tropical frequently stands for poor, and poorer regions of Western countries also havehigher rates of cervical cancer. The elevated incidence of this cancer in northern parts ofBrazil reflected a combination of malnutrition, poor hygiene, early sexual relationships,

lack of medical services and an elevated number of pregnancies. The high mortality ratefrom cervical malignancies in northern Brazil, de Caravalho concluded, was a drama ofmisery, ignorance and social suffering (de Caravalho, 1967: 86).

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From the 1960s on, Brazilian epidemiologists linked a higher prevalence of cervicalcancer to smoking which, in the 1950s and 1960s, was independent of class and tothe early onset of sexual activity, multiple sexual partners, early pregnancies, poorhygiene and inadequate nutrition (class-dependent variables) (Chaves, 1968; Salvatore,

1976). In the 1980s and 1990s, epidemiologists and public health experts proposed todirect preventive efforts to low-income women (de Caravalho, 2004; Lima et al., 2006).The view of cervical cancer as poverty-related disease competed, however, with theperception of the disease as a threat to all women. The latter view was implicitly incor-porated into a new version of Viva Mulher programme. From 2001 onwards, this pro-gramme added to its goals screening for breast cancer, a disease that is more prevalent inwomen from higher socioeconomic status (Bicalho and Aleixo, 2002). The inclusion ofscreening for breast tumours in a campaign directed mainly at women who could notafford regular visits to a gynaecologist implicitly played down the role of poverty as a

risk factor for cervical malignancies.In practice, two regimes of screening for cervical cancer co-exist in Brazil today.

Middle-class, urban Brazilian women who have private health insurance often undergoregular (usually yearly) gynaecological check-ups, which include a Pap smear, butoften also a colposcopic examination, since this instrument remains popular amongBrazilian gynaecologists. These women follow a variant of the triple model: a cervi-cal smear, a colposcopic examination and, if necessary, a cervical biopsy. They also cannegotiate with their doctors over the frequency of vaginal smears and the age at whichthey wish to start and stop them (Zeferino et al., 1996). By contrast, Viva Mulher faith-

fully apply the PAHO guidelines: women with two consecutive negative Pap tests aretested every 3 years between the ages of 25 and 59 years (Instituto Nacional de Cncer,2002b). The highest frequency and highest quality of screening are therefore foundamong women at the lowest risk of cervical cancer (Temes de Quadros et al., 2004).

The history of screening for cervical malignancies in Brazil demonstrates the inter-play between medical technologies and elements beyond the scope of medical inter-vention. Screening for cervical cancer in the more affluent parts of the globe ispresented as an exemplary success story. The generalization of screening, epidemiolo-gists proposed, led to a drastic decline in the prevalence and mortality from this disease

(Peto et al., 2004).

18

Brazilian public health experts hope to achieve similar results. Theobservation that the recent intensive efforts to promote screening for cervical cancerand the steep increase in the number of performed Pap smears did not lead to a decreasein mortality from this disease nationwide, and did not reduce its high incidence innorth-east Brazil, is interpreted as an indication of the shortcomings of existing preven-tion programmes (Gamarra et al., 2010; Thuler, 2008).19 Brazilian specialists believethat a better organization of preventive services, coupled with well-targeted educa-tional campaigns, will reduce the rate of cervical cancer in Brazil and bring it closer toWestern standards (Bottari et al., 2008; Instituto Nacional de Cncer, 2002a). It is notcertain, however, that this goal can be achieved without acting upon the conditions thatfavour the high frequency of cervical malignancies: poverty, discrimination againstwomen, lack of adequate access to healthcare, and disrupted and chaotic lives (Gregg,2003).20

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Conclusion

Efforts to control cervical malignancies in Brazil were shaped by the professional cul-tures of medicine, the availability of resources and their geographical distribution, and

changing views of the entity cervical cancer. In other words, they were shaped by het-erogeneous, dynamic networks (Law, 1987). Each configuration of the screening dis-positif brought forth some elements of this pathology and masked others.21 In the 1940sand 1950s, an official discourse about the advantages of the triple model of screeningdisregarded life conditions of the majority of Brazilian women. It did not dwell on une-qual geographical distribution of this disease, or its links with socio-cultural variables.Cervical cancer was seen above all as a disease that strikes blindly, putting every womanat an equal risk. In the 1960s and 1970s, this view was still prevalent among Braziliangynaecologists. Experts such as Rieper and Salgado were aware of the fact that only atiny proportion of Brazilian women had access to screening for cervical lesions. Theirsolution was to extend the triple model, grounded in voluntary visits to the gynaecol-ogy clinics, to the country as a whole. However, they did not provide realistic advice onhow to achieve this goal. In retrospect, many of their writings looked more like well-intentioned wishful thinking than a public health programme.

At the same time (the 1960s and 1970s) a few Brazilian experts developed a different

discourse on the causes and epidemiology of cervical malignancies. They discussed the

effects of poverty, early sexual activity, multiple sexual partners and early motherhood.

Such a view of cervical cancer, rare at that time, became predominant in the 1980s. It may

be connected to the aspiration, present in Brazil from early in the 20th century, to eliminate

diseases indicating the backward status of the country (Hochman, 1998; Lima, 1999;

Lwy, 2001; Stepan, 2001). It may also be linked with the description of the role of human

papilloma virus (HPV) in the aetiology of cervical tumours.22

The transformation of cervi-

cal cancer into a transmissible disease strengthened the rationale of an epidemiological and

social rather than purely medical approach to its prevention. Presently in Brazil, transmis-

sible diseases are perceived above all as social issues and are seen as by-products of pov-

erty and deprivation. Cervical cancer entered this category in the 1980s.

The definition of cervical cancer as a social problem and a disease of women fromlower socioeconomic strata might have contributed to the abandonment of colposcopy as

an initial screen for the detection of cervical lesions. An approach that relies on expen-sive instruments and observations made by experts might have been perceived as lesswell-adapted to mass screening than the relatively simple Pap smear. On the other hand,the high cost of equipment and the need to rely on experts for the interpretation of datadid not hamper the rapid spread of mammography screening for breast cancer in indus-trialized countries. The cost of instruments and scarcity of experts were not presentedeither as insurmountable obstacles to the planned extension of mammography to allBrazilian women in the framework of the Viva Mulher programme. Today, INCA expertspromote the development of regional centres of mammography and mobile radiology

clinics. It is not impossible to imagine similar arrangements for diffusing colposcopy- based mass screening for cervical cancer. Costs and organizational problems are notsufficient to explain the demise of the Brazilian model of screening for cervicalmalignancies.

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The switch to an exclusive reliance on Pap smear, we propose, reflected changes inthe organization of health services in Brazil during the transition from military dictator-ships to democracy, the redefinition of cervical cancer as a public health problem, thelong history of successful uses of Pap smear as a screening tool, and the influence of

organizations such as the World Health Organization (WHO) and PAHO in promotingthis tool. In the 1980s, the Pap smear was seen by experts who worked for internationalhealth organizations as the gold standard for screening for cervical malignancies.Testing and implementing an alternative screening approach in order to make it asreliable as the already validated Pap smear was probably viewed as a risky and costlyenterprise (Caspar and Clarke, 1998: 274). In addition, reliance on an alternative modelof screening would have made international comparisons difficult, and could havedestabilized the ongoing efforts to standardize how gynaecologists, oncologists andpublic health specialists perceived the disease cervical cancer (Hogle, 2007: 848849).

Therefore, it could have hampered efforts to better integrate Brazil into internationalhealth structures.

Trajectories of scientific and medical innovation in developing or middle-incomecountries may be affected by important inequalities in the spatial and social distributionof resources, as well as by the existence of a large population of resource poor people.They may also be affected by broader political considerations. The development of pub-lic health in Latin America was shaped to an important extent by trans-national politicalvariables, above all the relationships of Latin American countries with their powerfulnorthern neighbour. The USA played a key role in health policies in Central and Latin

America, either through direct intervention (Espinoza, 2009) or through the mediation ofUS-sponsored organizations and foundations (Birn, 2006; Cueto, 1994; Cueto andZamora, 2006; Lwy, 2001). It is not surprising that relationships with PAHO in the1980s played a central role in Brazil for establishing the Pap smear as the main tool forscreening for cervical cancer.

Between 1940s and 1970s, colposcopy-based screening for cervical cancer was aspecific Brazilian development. The political status of Brazil favoured uninterruptedcontacts between Brazilian and German gynaecologists in the late 1930s and early 1940s,and thus the rise of colposcopy. The use of this technique expanded in the 1950s and

1960s, thanks to the ability of key promoters to mobilize institutional support for it.During this period, colposcopic detection of cervical lesions was perceived as a do-ablesolution (Fujimura, 1987). This technique enabled the alignment of several levels ofwork organization and brought together interventions by distinct groups of actors: gynae-cologists, cytologists and pathologists, nurses and health workers, hospital administra-tors and cancer charities. Moreover, the resonance between colposcopic screening andgovernmental visions of the organization of cancer care secured official support for thisapproach in the 1960s. However, the status of colposcopy changed in the 1980s. Importantchanges in Brazilian health policies and geo-political considerations and a shift in under-standing of the natural history and epidemiology of cervical cancer favoured the aban-donment of the unique Brazilian approach to screening for cervical malignancy and theadoption of methods favoured by international organizations. In spite of persisting dif-ficulties to demonstrate the efficacy of the Pap smear in poorer regions of Brazil, thistechnique became widely perceived as the right tool for the job.

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Notes

1. The shorthand screening for cervical cancer (an actors term) often encompasses two dif-ferent activities: the visualisation of suspicious cervical lesions and their destruction throughsurgical excision or other methods such as laser treatment. Only the latter activity can be

called prevention. However, in Brazil the term prevencao became synonymous with Papsmear, a frequent source of misunderstandings and confusion (Gregg, 2000).

2. For example, a highly praised recent history of cancer states that the Pap smear had, in effect,pushed the clock of cancer detection forward for nearly two decades and changed the spec-trum of cervical cancer from predominantly incurable to predominantly curable (Mukherjee,2010: 290).

3. We are indebted to Yolanda Eraso for pointing out the specificity of Latin American screeningfor cervical malignancies.

4. Liga Paulista de Combate ao Cancer (So Paulo) and Liga Brasileira Contra o Cancer (Rio deJaneiro) were founded in 1934; Liga Baiana Contra o Cancer was founded in 1936 (Teixeira,

2010).5. Between the early 1930s and late 1980s, Brazil had a social security system in which workers

who held regular jobs, their employers, and the government jointly contributed to institutesthat purchased health services from private suppliers.

6. The Brazilian state purchased the services of private hospitals to treat cancer patients coveredby the national health insurance plan (Teixeira and Fonseca, 2007: 105).

7. The Diviso Nacional do Cncer, which replaced Servio Nacional do Cncer, was created in1970 (Teixeira and Fonseca, 2007: 123).

8. Archives of the Academia Nacional de Medicina, Rio de Janeiro, Arnaldo de Moraes file.9. In 1935, Moraes published a gynaecology textbook that discussed the uses of colposcopy (De

Moraes, 1935).10. Papanicolau developed the vaginal smear in 1917 to investigate the oestrus cycle in laboratory

animals. This biological test was then employed to check the purity of oestrogen preparations(Oudshoorn, 1990).

11. Homogenization of Pap smear readings was also a difficult task, but the possibility of circu-lating microscope slides facilitated exchanges among professionals. In the 1950s, circulationof photographs of the cervix helped practitioners to compare diagnoses made by other colpo-scopists (Rieper, 1955).

12. Hinselmann was sentenced by a British Military tribunal for compulsory sterilization of Sintiand Romanies (source: Clauberg Verfahren, Bd. VI A, Bl. 9599). He was also suspected of

collaboration with the Nazis in experiments on humans conducted in Auschwitzs (in)famousBlock 10. His students, the brothers Helmut and Eduard Wirths the latter was Mengelesassistant in Auschwitz allegedly mediated the collaboration (Clauberg Verfahren, Bd. VI A,Bl. 171173). We are indebted to Martina Schlunder for this information.

13. In Western Europe and North America, one of the important obstacles for the diffusion ofscreening for cervical cancer was womens reluctance to undergo such screening because theyfound the sampling (using a speculum) painful or invasive. We did not encounter evidence ofsuch reluctance in the Brazilian publications on screening for cervical cancer. It is possiblethat Brazilian women were less reluctant to undergo a gynaecological examination; it is also

possible that health professionals in Brazil failed to notice such resistance to screening.

14. FUNRURAL was created in the framework of the law 4.214, ratified on 3 February 1963, onthe status of rural workers.

15. The So Caetano campaign was accompanied by intensive education efforts, which its organ-izers reported led to a 275% increase in the uptake of tests (Oliveira Filho et al., 1977).

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16. For example, in 1941, 82.5% of cervical cancer patients seen at the Gynaecology Institute ofUniversity of Brazil, were diagnosed with advanced tumours (stages III and IV), a finding that

prompted the Institutes doctors to promote an early diagnosis of cervical malignancies. Datafrom mid-1950s indicate that the percentage of women diagnosed with advanced tumours

remained close to 80%. The rate diminished from 1959 to 1970 to approximately 65%, but themortality rate from cervical cancer remained very high (Stehl Filho and Rieper, 1941; Stolz,1955, 1959; Stoltz and Walty, 1970).

17. In 1988, a new Brazilian constitution established a universal and decentralized health system,Sistema Unico de Saude (SUS).

18. Some scholars strongly disagree. Linda Bryder summed up the positions of scientists whoquestion the efficacy of screening for cervical tumours (Bryder, 2008, 2009: 8995).

19. In 2007, the estimated mortality from cervical cancer in Recife was 6.3 per 100,000, aboutfour times higher than mortality from this disease in Western countries (1.52.5 per 100,000);the corrected mortality was even higher (Gamarra et al., 2010).

20. Gregg displays the indissociable links between coping strategies of women in Brazils north-east regions and risk of cervical cancer. A similar argument to the effect that the prevention ofcervical cancer cannot be disentangled from social factors that favour the development of thisdisease was made by Manuel Galvao Filho (1976).

21. Michel Foucault (1994) defined dispositifas the network that links irreducibly heterogeneouselements: material entities, institutions, laws, scientific and philosophical concepts and spatialarrangements. Christiane Sinding (2007) imaginatively applied this concept in her research ontechnological change in medicine.

22. Some of the studies that established HPVs role in the genesis of cervical tumours followedcohorts of Brazilian women (Drst et al., 1983; Villa and Franco, 1989).

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Biographical notes

Luiz Teixeira is a researcher at Casa de Oswaldo Cruz Fiocruz [House of Oswaldo

Cruz Oswaldo Cruz Foundation, Brazil]. He is interested in the history of publichealth, particularly in the history of cancer control in Brazil. He has published (withCristina Fonseca), From an Unknown Illness to a Public Health Problem: INCA andCancer Control in Brazil(Ministrio da Sade, 2007) and Na Arena de Esculpio: aSociedade de Medicina e Cirurgia de So Paulo 18951913(Unesp, 2007)

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Ilana Lwy is a senior researcher at INSERM (Institut national de la sant et de larcherche medicale, Paris). She is interested in the history of bacteriology, virology,immunology, oncology and tropical medicine, and in intersections between gender andbiomedicine. She has published Virus, moustiques et modernit: Science, politique et lafivre jaune au Brsil(Archives dHistorie Contemporaine, 2001),LEmprise du Genre:masculinit, fminit, ingalit (La Dispute, 2006) and Preventive Strikes: Women,

Precancer and Prophylactic Surgery (JHUP, 2010), and is now studying the history ofprenatal diagnosis.

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