A426 /f.30: Segre Refetas me peal <4 hy Ua 2 - f “'o ZL A “a i . | LB. fh. Mad : Crraferyomer & Srsot tut af Pome Art 4 g | ced F 4 Aah, Ut es : Zz f Kia 7 Teed a A ; Bf i, if ann spree lb by oe : z a “oP Tas ' Aer | Cxronardd nx: of OO Ake I aR nahbada dust Lo ad St Cab. mut ao p 7 Tog tees fe Cg igethe tied as 7 elden, Fic Ge aad, fi Aker £, e).- ow eek: g, /0, a. Se ~ LA Ere Cure ana Ce SO q- sg woes pons lage Mhugs Ogee | (oper Y 62. Gee 1430 1930. March 20th. Arrive Rio 8:30,PM and am met by Drs. Servulo Lima and Waldemar de S& Antunes in addition,to Drs. Connor, Tomaz Alves: Alfredo and Juan. See Paranhos on the ship. “ te Gerke j Af March 21. Friday. Conference with. orl’ Very optimkistic-suggests that survey be made of the Sao Francisco vi ley. Suggestion immediately agreed to by MEC who says that he can relieve Biao from Aracaji for the purpose. CF has had a good letter from Marchoux telling him how remarkable it is that Rio was cleaned of yellow fever in less than ‘two years the second time the task was undertaken whereas it took five under the famous Oswaldo Cruz! I tell CF that the season's g 0 or es material for the work. (CF insists that now is the time to undertake the job of eliminating yellow fever from all Brazil because he has the unique opportunity because the government is aroused on the problem at the present tim and is ready to back any measures proposed.) With MEC see two suspect convalescent cases at HSS. One cholangitis-one bronchopneumonia; both icterie-both have bradycardia; pneumonia case has pulse of 40! MEC comes out with direct question as to why of my return to Brazil; "What did you expect to do coming back to Brazil now?" My reply in as even voide as possible under the circumstances was that at the time of my arrival in New York, MEC's request for six months leave of absence beginning in April 1930 was in FFR's hands; that although FFR and I discussed the diffioulties of divided authority in Brazil, there seemed to be no urgency regarding the situation since I would return to Brazil in any case only shortly before the first of April; that the news of MEC's withdrawal of his request for leave had reached me only on the eve of my departure from NY for Rio and during the absence of FFR in Europe. I therefore returned to Brazil to reassume the position vacated in Nov. MEC then explained that the RF had granted his request but had informed him that he hadoverstayed his leave and actually owed the Foundation time; this time will be repaid by sometime in June of this year: MEC therefore suggests that I go North as soqn as possible and return to Rio after a somewhat rapid inspection of the yellow fever service so that he will be able to get away for NY before everyone goes on summer vacation from the New York office. MEC again reiterates that_he found control of his service difficult because of dual authority vested in MEC and FES. CIE Pai - MEC says that EP closed out diet kitchen at Arthur Bernardes Hosp. as a way out of her offer to put in air extractors at her own expense which offer had been accepted by Dr. E. Mattos. MEC believes that usefulness of EP in Brazil is past but that RF should not think of withdrawing from nursing service, Instead should carefully select successor to EP. that-ne has -a-total mon in the State of Rio and is also furnishing the March 22. MEC offers ARAGAO 12 monkeys for further work at oor/ It seems that government money for the purchawe of monkeys has run out. (MEC's readiness to accede to this suggestion as well as to CF's suggestion regarding the Sao Frangcisco mad¥e me stop and reflect!) March 234 Drive with Dawsons and Kinmonts to Tijuca. Dinner c MEC at Internation- al. March 24. M. Call on Fialho, Placido Barbosa, Lessa, Rangel and Magalhaes, Warch 25. Sail on Itenagé for Par&. (MEC's decision that I should leave immed-. Lately robbed me of the pleasure of showing something of leprosy in Brazil to one bf the granddaughters of Queen Victoria. However, I turned the task ofer to Dr. Arminio Frgga who tells me that that lady is somewhat elderly and nott too attractive. HCMitchell and femily on Itanagé- also Mr. Wilcox @f EBand S Co. March 26. At sea. §3 « rt ‘ ‘ . ee March 28. Wilson, Davis, Frobisher, Cardoso, Cunningham on docks. Spend AM at office; write FFR as follows: Bahia Brazil March 27th 1930, Dear Dr. Russell: I arrived in Rio on March 20th and tok the first boat for the North arriving here this morning. One of the first questions asked by Dr. Connor after my arrival in Rio was whether any change had been made in the division of authority in this field to which I replied that the matter had been discussed between us in December but that as fas as I knew no change had been made. Dr. Connor then asked what I expected to do in Brazil at this time; I replied that. &bt the present time the Foundation's programme in Brazil is largely bhimited to yellow fever control work and that at the time the question was discussed in New York, Dr. Connor's request for six month's leave of absence to begin in April was in your hands; his later withdrawal of this request cane to my lmowledge only on the eve of my departure from New York for Rio and at a time when you were in Burope; therefore, I assume that I had come back to Brazil to make myself as useful as possible in the yellow fever campaign. After due consideration of the situation, Dr. Connor recommended that I come north on the first boat and visit all the stations during the next two months, enabling him to leave for New York in June. I accepted this recommendation and am making this tour of inspection, leaving the direction of the work entirely in Dr. Connor's hands until my return to Rio about June lst. Very Sincerely Yours, Fred L. Soper. Fix up letter to New York regarding depreciation of Pontiac car; ie of Packard car on the basis éf Pontiac sedan. Call at both Davis and Wilson homes and dine with Wilsons when boat fails to leave at five PM as scheduled, See Dr. Magalhaes NotS-End suggest that our sailing to Rio coincide in late May or early Ju ne. Dr. Barros Barretto sends up word that he will receive me at 2:30 P.Mé Wilson Davis Cardoso and I present ourselves at the appointed hour. BB pretends to be deeply absorbed in offical papers and routine and curtly nods us to seats as we enter. After some delay he comes to converse with us and after a very chilly hand shake, “De que se-trata?" I contain myself as well as possible and explain that I have just arrived in Brazil after an absence of some months in the United States during which time I was entirely out of touch with the work in Brazil; that my present trip to north Brazil is being made to again famil- larize myself with the situation, etc. etc. BB finally comes clean and says that he has been so nasty to me personmaly because I refused to import scales duty free for his service last year; that he is sure that no one has given better cooperation to the yellow fever service than has recently been had from his service in the state of Bahia ‘with no profit to him' but that he is not sure that others have been furinshing help disinterestedly! Fram this the discussion is turned by BB to his losses on the importation of monkeys; I assure him that the RF is anxious that he shall personmaly sustain no loss through cooperation with us just as we are anxious that he shall have no profit; In other words the RF believes that the cooperation should be a disinterestedgone. We part more or less friends, ie to say at least on speaking terms. Wilson seems to feel that inadequate personnel is available for the work in the vapant lots and the jungle; I assure him that I have no authority to change anything at the present time and that all of his troubles should be re- ferred to MEC. Cunninghem is at work on a map of the city; I do not quite understand this detailing of a physician to a mapping of the city but suspect that DBW has not found him suitable for the work in hand. C is supposed to. go to the laboratory in the near future. Shannon will arrive tomorrow from Recife. ¢ fe DBW says that he does not desire a second assignment in yf work; also of ‘plainly Indicates that he does not believe in the efficacy of ee ony con~ trol (Bahia is a State of Four Million whereas the capital con 8 Only some 200 000) Suggests he has been almost long enough on maximum salary! Knows that Barnes was voted increase of salary before resignation. (How?) ARCS hed fond Be dare ce Wo on Woh 13 Jeotwuss) ow Hara fora. traded Dhdonuny mck 4 Ck AR ow Poway, RECIFE/. March 50. Sunday. Met at dock by Dr. Gouweia and ERR/ Doyle and Waldemar da Rocha come from Parahya and are seen at the office. ERR has a man by the name of Furtado working with him who speaks osme English. ERR and family appear quite happy in RF work at present. Uncle is retiring immediately byt ERR is giving this chance the go-by and is considering writing in to FFR withdrawing his potential resignation at the end of his present period of service. ERR in answer to direct question from me says that bt suits him personally much better to remain than to return to take up Uncle's practice at the present time. Coam- plains that MEC forced him to withdrew salary increases granted by him in accord with authorization given by MEC to DBW and entered in DBW's station journ- al. Has a good opinion of WHD's intelligence and ability but notes abuse of authority and lack of sociability. MEC requested DBW to recommend @§D for the reguaar staff but this DBW refused to do. Suspect cases have been reported from Bom Conselho and Dr. Amaral has been sent to investigate them. From available reports ERR believes that they will be proven positive. a : - March 31.Dr. Nellio Tavares meets the boat and togehter we call on the Govern- ‘or. From his reception of us and from his remarks I believe that we Should have advised him of my arrival in the city. In any case shall do sonon my return fram the NorthZ At Dr. Lamatine's suggestion, NI takes me to see the new Aero Club where a hangar with two planes for the training of amateurs is found, Tennis, deck tennis, bathing, dancing, billiard and pingpong facilities are also found, Call on Dr. Christovao Dantas at the newspaper office; CD leaves tomorrow to become part and parcel of the Federal House of Representatives on behalf of the State of Rio Grande do Norte ‘ FORTALEZA, —— (Coriwa ow ings) April 1. Dr. Samuel Uchoa comes on board and speaks of the need of a calha gang. e im that for the present all such questions must be referred to MEC. he. Ag. Sho LUIZ April 2. Arrive at midnight; Gchefe cames on board c compliments of Dr. Cassioy iirands. Sail at 7AM. April 3. Deck Golf all day. qpiné Belém PARA ——~— April 4th. Arrive in Belém at noon, Aspect of the river and the town unchanged since first visit in 1920. Met by Dr. Crawford, Muench and Silva. (Silva is a young medico from Rios; claims to be a cousin of CF). Call on Dr.“Aben caused MEC to suggest plague was not confined to the Corredor b as general gz (6b throughout the city whereas the suspect cases of yellow fever occurred only in the Corredor beginning at the upper part and gradually working down toward the bridge which separates the Copredor from the rest of the city. Suggest to AM that the distribution of cases and course of the epidemica are sufficiently in- teresting to justify the making of a detailed map giving location of houses, and cases as well as other important information, Some culex are still to be found in the infected zone but as far as could be noted the number of adult stegomyia is now very low. This is much different from the report of ERR as to the incidence of stegs just Biweeliays ago. It would seem that there is a high mortality in stegs and that the number which may be observed in a zone diminishes very rapidly as soon as the source of supply is cut off. This is in agreement with the experience of the Nurses School last year where the same rapid diminution was noted when producing foci were destroyed. I leave Bom Conselho with.he definite impression that the cases reported have been yfi on the other hand I am surprised that we received notice of the outbreak as early as we did if at all taking into consideration the very low mortality in- volved § five or six deaths in sgme sixty suspect cases)/. It should be noted that the only physician in the place, and many towns of this size are without physicians, after causing the local intendente to notify the cases as yellow fever, fled to Recife and has not since been available to give inform- ation regarding the later cases. It is probable that we can still count off getting reports of yellow fever in the sert&&o when invasion occurs there but difficulty will probably be experienced in setting reports from the zone of the litoral lying between Recife and the sertio. That is to say, reports may be expected to come in from the epidemic areas but not from the endemic areas. Cases will be reported in the cities when the infection exists and comes in contact with the non-immune foreign population; cases will be reported in the border zone between the serta&o and the literal, when the infection comes in contact with people who have moved in from the sertao and from the sert&o it- self in epidemic times. Reasoning from this, the zone to be attacked is not the sert&o, but is the immune gone lying along the litoral. I left Bom Conselho with the feeling that the situation is well under control and that there is no danger of an extension of the infection to other zones of the city. May Srd. Spend day on train returning to Recife. Meet Mr. and Mrs. George Taylor and Mr. and Mrs. Anderson. Also young agronomist by name of Bianchini. Arrive Recife too late for dinner at Lloyds. May 4th. Drive to S&éo Laurengo uad teke tea with the Bathams. Meet Mr. and Mrs. Miles also. 63. May 5th. Spend day largely at the office in Recife. Dr. Gouveia de Barros called with Dr. Cista Ribeiro, director of Hygiene for Recife, to return Dr. BRR's and my call of the other day. In afternoon visited ditching service with ERR. Plan adopted is for serviee to put through the madter ditches needed and torequire the residents of the zone to fill in o€ drain the mud holes in their back yards; this is important as then more care will be exercised in the duture in the digging of such pits for getting mud for the construction of mud huts. Most of land in these sections of Recife is owmed in large tracts and the owners of the tracts are willing to force residents to comply to avoid getting fines assessed against the property. Also visited first day's work of sang engaged in screening vent pipes of cess pools, Work done with copper screen already roughly formed in the office application being made with wire and pitch. Visit zone of Mansoni production and see pistia gangs at work. May 6th. Wire fram MEC advises WAS will arrive in Rio May 15th; suggests I re main Recife until local situation clears. ERR, AM, and I go to get piece of liver of case reported by guarda; case surely not yellow fever. May 7th. Classify larvae brought in by the guardas, 67 stegs out of total of 192. See Page 63 A for details of classification methods. Visited Medical School with Dr. Octavio de Freitas. May Sthe Muench aid Davis in Pert. Lunch of medical personnel with Dr. Gouweia dé Barros also present. Muench rgports that he knows nothing of sny campaign against the yellow fever service in Para report d to have been carried out by the Folha do Norte; says that certain ¢ iculties have been encountered there in seoy or bodies for sutopngs= es mo st of WolCSn WOULd seem O be gue O certa Ny OO e depa a emp lovees want= neo graft out ofthe Rockefeller Fimds. Davis wishes to return to Natal next week Prolonged conference of ERR and FlS and later HM and NCD with us on forms to be uged_ In control work, Dinner at Ryckards and confidential information comes out thet Crawford has developed three boils since my visit to the city. The Brasil Medico recently gave notes on a hospital association meeting in Recife in which the idoniedad of the Rockefeller Laboratory at Bahia was called in question "com elementos" by a Dr. Mariano im Recife. I called Dr. Gouveia's attent- ion to this note and he assured me that the man making the charge had no scientific standing in the commmity but that nevertheless he would take it upon himself to call the mean to aecount. This he did and the men has said thet it was all a mistake and has written a letter to that effect and has promised to make due correction at the next meeting of this association so that correction may be made in the Brasil Medico. May 9the Day mostly at office. Attention called to article of Sebastiao Barroso in Brazil Medico of March 29th. : ie Qe eee Notes on Visit to Medical School on May 7th. Funds State annually 50 contos Federal * 1oo)—Cl®* Students Fees 320 —Co&® Investment in plant 2075 " Capital on Hand 1000.)6—CU*”” Students on hend Medics 297 Dentics 22 Pharmmics 3 Professors receive forty milreis per lesson or four hundred iilreis per month for 9 months in the year. 63 A May 7th,1930. Spend morning at the office classifying the mosquitoes brought in by The pusrdas during the weekly collection. Of 192 foci classified, 67 or 34.9 % were egypti. Among others found were various kinds of culex, limatus and taeniorhynchus . Notes on classificagtion of local mosquitoes in Recife. Adults: Aedes egypti lyre on back which may be rubbed off in old specimens or sppcimens hatching in bottles in which case may be mistaken for taeniorhunchus. Aedes Bicwvinhijval{ tocni orhynchus) looks much like steg but has no lyre on back. Back of thorax is black. Mansoni titillans is a black mosquito,rather sluggish in movement and easily killed. Found only in zones where pista plant grows, Has marked white zone on upper side of proboscis. Aedes scapularis resembles other aedes mentioned above but has large white soot on back of thpoaax. Limatus durhemi is a very fragile moth like mosquiteo which seldom attacks humans. Cannot be mistaken for other commonv local varieties. SESSTSSTSS sere sssssesrsasss : e e eoeveroee Larvae=3 Aedes egypté-spines on middle and posterior tufts of thorax. One row of trident shaped spines on 8th segment. Gills . ratber long. Photophobic. as rudimentary spine on posterior thoracic tuft only. Triangular patch of simple spines off 8th segment. very short anal gills. Mansoni titillans- larvae are to be found attached to the roots of the pista a water plant the cells of which contain much air which enables these larvae to avoid the surface entirely. hedds scapularis-has rudimentary spine on posterior thoracic tuft only. Double row of simple spines on 8th segment. Long slender anal gills. Limatus durhami- longer and narrower than steg. Brownish yellow. Move- ment very sluggish. No spines on throacic tufts. No pecten. Very few simple spines on 8th segment. (Alive is more apt to ne mistaken for culex than for egypti.) Aedes 64. May 10. Saturday. Visits casas fechadas turma with Rickard. Attempt being made to render unoccupied houses mosquito proof for thirby days. Cow pasture pool in the afternoon; dinner party at Rickard's in the evening. Present Goodmen, Lloyd, Rawson, Hendrickson, Mottram, Tennant, Ingram. Callender, Van den Arnd, Italian Consul. May 11, Sunday. To Parahyba in sopa~ four hour trip as Monsenhor holds un the trip by ordering jantar at Goyanna. PARARYBA. May 12. 414 0-28. Angl@ Mexican furnishing o11 for Ford. Maritime visits are listed as house visits. Classification of foci not mark-d on guardas report, merely verbal report of g to ge each morning at office. WR finds no fault with 14B but admits that he had expected to ask permission to print oPher form on back of FA2C in order to get necessary information for 14B. Call on Dr. Guedes Pereirawho is still convinced that Jaceurau_cases were yellow_fever and who think “that yellow fevers che \insérior of his state althourh he does not know just where it is. Ho. 427 May 13th. Visit number of house in central zone with mosquito comrhaint; find many mosquitoes in several houses but stegs in only one house.It would appear t that the sudden appearamce of mosquitoes in quantity in this zone is due to the recent rains which either through actuel drainage of rain into the cess pools or through raising the level of the ground water have so diluted the contents as to make them suitable breeding places for culex; stegs found had probably come from an incompletely sealed abandoned well. Visit vacant lot gangs, and ditch conservation man. Discuss settas and numbering of houases with WR. PM spent working on reports. Return visit of Dr. Guedes at Hotel. Attend theater with WR end Mr. Vance and see A NMUlher do Trem. Taubatg, Received wire from ERR "Davis wires Liver Gaudencio Siva positive yellow fevere. Also had schisto- somiasis sto weveral more cases and 2 deaths Bom Conselho. Stop Rickard.” May 14 "Sopa" to Recife. Purchase suitcase; call on Bathem and on Goodman's; Again go over forms with ERR; receive letters regarding visit of WAS; FFR wishes wAS to visit YF service with MEC; MBC to go on leave Jume 27th; WAS to sail for 2 1 DS . Europe from Bahia Jame OO RI May 15. Telegram to GB‘from business men of Bom Conselho asks for aiid saying that the fever is spreading and is fJeginning to kill people and saying that Bp had epidemic of more than thousand cases in 1919; GB says this telegrams means that cases have begym to occur in gente boa and that people from surrounding © towns have learned of the sanitary condition of Bom Conselho and are not coming there to purchase. i tell GB that we think the service in BC is adequate but that to relieve all doubts on the local situation Dr. AM is going tomorrow with two more guardas to check up on everything, . ("Rockfound xecife. Davis reports tissues Gaudencio da Silva posttive stop suggest orgenizing service for all towns on railway system-stop think we must regard eastern third of state infected stop eeee.eee. stop Connor")Why oh why must we suddenly decide that the entire eastern third of the state is in- fected? One moment yellow fever does not exist, the only disease present being plague or psittacosis of cats and thenext minute the whole third of the state infectedi We have at the present time no more reason for thinking that the whole third of the state is infected than we had after Sanharo and Timabauba. in 28, after Bom Sorte and Pedra in 1929 when cases were also being reported for Aguas Bellas, Correntes and Garanhuns. Also why should service be opened in entire eastern third of the state of Pernambuco and nothing done in Alagoas which is equally if not more exposed to infection from BOM CONSELHO. Any pro- gram for the control of yf in the interior of Pernambuco cannot neglect the > neighboring states of Alagoas, Parahyba, Rio Grande dg Norte and probably Ceara.) Forward baggage with Capitan Shulze of the Itanage to Bahia wiring to DBW to receive same. Lloyds dine at Rickards. 650 May 16th. Friday. All day train trip to Maceid. Met by Dr. José de liendonga de Almeida. ALAGOAS. May 17th. Go to office to talk over service with MA before beginning inspections of zones. J1EC last visited service here June 1929. Mendonca discusses the Leopoldina cases of last year and leaves me with the impression that they were yf in spite of the positive blood for typhoid finally reported for a case from Vie that place. Tells me that suspect cases in Vigosa were re»vorted to the Governor EGOS by the prefeito iff letter of about April 19th; that he went with another doctor of the health service to WicOsa on April 2lst, seeing more than twenty sick and teking slides for malaria examinations all of hich proved to be negative; bloods for typhoid cultures were all negative. I suggest that we return to Vigosa today as his account of cages seen sounds remakksbly’ suspicious of yf. First call on Dre LeM. at his dairy, then lunch and leave &t 11:20 AM via Ford arriving at V at 3 PM. Spend afternoon seeing sick, convalescents, and getting histories of fatal cases. I believe there is no doubt that yf has existed in V since Feb. 17th at least. Two opposite zones of the city seem to have been the Most heavily hit by the epidemic, the center of the tem showing nothing so far as is knovm up to the present. (Steg index taken on MAs previous visit was '80 per cent for all zones: including certer.) Bloods taken for protection tests. Arrive in Maceio without jantar at 10 PM. ,"Bight cases febre mau character with black vomit and anuria reported in Quipapa two deaths stop Brito leaves Saturday to investigate stop Rickard." May 18th. SUNDAY. Wired MEC, "Spent Saturday at Vigosa with Dr. Mendonga stop No reasonable doubt yellow fever epidemic there stop suggest you authorize ser= vice Vicosa and other points stop Blood teken for tests. Soper." Hietory of some cases of Vigosa: Jose Ferreira da Cesta - 22- always resident in this county. Onset April 18th; sudden onset headache fever vomiting. Later dcanty dark colored urine. Noted eyes were yellow in convalescence but thinks they are now all right. ( AS matter of fact eyes are still markedly jaundiced) His sister, licria Candida de Jesus, 24, took sick in the same house on April 13th with similar symptoms; on the third day, M began to have bloody and dark colored stools and vomited black becoming very weak on the succeéding days, finally becoming jaundiced and dying on April 23rd. Blias Leite da Silva. 28. Onset May 9th with high fever, dhills headache and body pains. Vomiting reported during the entire course of the illInss at first yellow but on fifth day black. Died on May 14th. Jose Antonio dos Santos 15 Born in Municipio of Uniao but in Vicosa for one yeare Onset April 13th fever, headache, body pains, nausea. On day of death had numerous bloody stools. Died off April 18th. Other histories were-taken by MA which are not recorded here. ¢ * MEC wired that Serum from Luzia Amelia stop Edinor Lima Moura stop Edmil- son Lima Moura all of Mossoro failed to protect stop." May 19th. 255 O steg- 2 culex-lanopheles in 25 houses. Guarda worked well. Visited the previous palace of the government which has long under gound gallery which previously produced culex in quantity. Has been been correcééd by installation of syphos at very low cost. Visited places in Jaragua where the drains are giving clouds of mosquitées. O11 will not act and neither will the prefeito. Take up question of numbering city with MA; prefeito insists that R F is wealthy enough to furnish metal plates for houses to be numbered. I advise MA to go ahead and nunber the houses according to our system without consulting prefeito and await results. Call on Sampaio the local manager of the SOB. Dre MA has orders to close service in Penedo at end of June. I sug-M\\\ gest not doing so unless those orders are renewed. —— 65.74 May 19 continued. Called on Dr. Meneschal and secured the following informat ion of historical interest: ARAPIRACA. Dr. Meneschal saw typical case here in 1929 before our service was reopened in Maceio; notified this case and other suspeets to MEC who did not investigate the matter further. LEOPOLDINA. Before May i, date of opening of our ser- vice in Maceio, rumors were heard of cases of yf in Leopoldina close to Palmares « MA and other doctor were sent to investigate and saw more than ten cases “ith fever headache body pains and certain hemorrhagic phenomena. Slides all negative for malaria. People of Leondldina insisted that veople attacked either died in the first seven days or got well. Deaths in Leopoldina were, Jen 1929 6, Feb 9 Mar 9, Apr 14, May 16 up to 25th of month. Both MA and LM are convinved that these cases were yf although a positive blood culture was reported for a case there occurring toward the end of the epidemic. PALMETRA DOS INDIOS On June llth 1929 telegram wes re=- ceived stating that Burydice Martins had todaos symptomas febre amarella com grende perda albuminuria. Two local physicians who at first disagreed on diagnosis decided in favor of yellow fever after watching the course of the illness. Eurydice Martins onset suddenly June 4th at 11 AM, fever, headache, back pains.’ Vomiting at first bilious material later (3rd day) black. Black stools; scanty urine heavy with albumin. Jaundice. Afebrile on tenth day. MA found histories of four or five cases in Palmeira and others outside which had symptoms of yf with death on third or fourth day. Deuth rate trio in May over previous months; Our service organized én Avg 1 and discontinued Dee. el. Dre Meneschal also reports that there have been rumors reaching him of yf in Anadia, and I suggest to MA that we go there this afternoon although it is already 2:45 PH. Finally leave for Anadia via Ford at 3:30 arriving at 6:30 PM and returning at midnight after seeing cases of fever in Anadia and in Tavera. History and distribution of most of ceses does not soud like yf; cases seen did not look like yf. However, one case in Tapera gave the following history, Onset May Lllth at 8 AM, fever and body pains and headache. On the fourth day began to vomit, vomitang blood twice and black once. Stools black. Om the fifth day, he appeared to be paralyzed in the left arm end right leg, dying on this day» One other similar history was reported at an outlying inaccessible point, The result of our trip was that we were convinced that most of the cases of fever occurring in the neighborhood are not yellow fever although the exist- ence of the infection of this neigborhood cannot be ru@ed out in the Light of the two histories mentioned. Way 26. MEC wired “Authorize control measures for Vieosn and other points you may believe necessary. May 21. Wasted day waiting for plane expected hourly. 22. Worked all day while waiting for plane. 23. Worked in office all day. 24th Spent day on Lake in front of Maceio and flew to Bahia of Rio-de—daneire. Met at dock by Sawyer, Cgnnor, Wilson, Frobisher, Shannon, Cunningham. 25th MEC and WAS sail for Recife on Araraquara. Wilson, Cynningham and I play hillside pingpong by the sea in the afternoon. e6th Dre Mag alhaes Neto calls on me at the office and we discuss once more yellow fever; MN gives some interesting information regarding the rete of travel of the disease in the interior. YP apparently rarely svreads like wildfire but is a relatively slow moving disease. Dr. Wilson and I call on Dr. Barros Barreto end are well received. Discuss forms with DBW meking a few minor chenges in head ings; W would like to have percentage of tota& foci encotntered in each type of deposit but there seems to be no way of getting this information on one sheet of A aap af Mabeee Deaf De. Russell: I have received your letter of April fist regarding Dr. Sewyer's present visit te Brasil and Dr. Comor's leave beginning in June. As Dr. Sawyer 4e not returning to New York, I am submitting the following notes regarding yellow fever in North Brasil for your consideration; as through previous work end travel I em more farilier with the situation in the state of Pernambuco then eleehere, I shall limit the disoussion lergely te that state. 1 shall ef course discuss the situation thoroughly with Dr. Sauyer, but as a change of policy is being suggested, I shall forward a copy ef this letter to you by air mail. 5 Tn 1926, Dre Gouveia de Barros, now Direotér of the Health services in the state of Pernambuee, then Congressman, introduced a measure in the Brasil dan Congress providing fer a national campaign under the auspices of the National Health Department against yellow fever throughout north Brasil, the purpose being to eradicate the disease from the country. This measure, whieh wes probably a direct result of General Gorgas’ visit to Brasil, passed and federal comission were organised and sent to all the northern states from Espirite Sento to Amas enas. The funds and personnel evailable for this service were more than ample; when Drs Lyster and I visited Recife in Merch 1920, we found that nine doctors were working in Pernambuco with a very large staff of guardeas and serventes. Dr. Lyster's verdict efter an examination of the records of the service and after visiting « mumber of houses in different parts of the city was to the effect that the stogemyis index was probebly well below the eritioal index for the production of secondary cases. Y am not so familier with the resujts of the work in Bahia know that visible yellow fever disappeared from the capitals north of Bahia. once the work of these commissions was discontinued however cases began again to &e FLO to FFR May 16 1930s “Dy a E = the points ‘that I wish to emphasise regarding this national effort are that 1. The effort was conceived as a result of the visit of General Gorgas end was organired with the expectation of eliminating the disease from the country through control of the capital cities and such other places as might be reported to have the disease. 5 2. This effort, although amply supplied with funds and men, failed in t spite of its apparent ducoess in eliminating the disease from the capital cities. 3. Many of the Brazilian workers became convinced of the futility of attempting to eradicate yellow fever from North Brazil, through a control limited to the capital cities. I doubt if the later American workers in Brazil have ever appres dated the extent and seriousness of this first attempt to eliminate yellew fever from North Brasil! You ere familiar with the outbreaks of 1922 and 1923 and the history of the Foundation's intervention beginning toward the end of the latter year. The first Foundsetion attempt, if I may so designate the period of Dre Whitets ad ministration, promised well from the beginning and the end was believed to be in sight when the S& Francisce River and Parahyba epidemics of 1926 spoiled the picture. These epidemios were attributed to the seattoring of the otherwise dying embers of the infection by the exceptional movenent of non imrune troops through the interior of the north occurring in that year. The points I wich to emphasize regarding this first Foundation attempt are that 1. The effort was based on the idea that control of tkey centers! of infection would let the infection burn itself out in the interior and would thus automatically disappear. 3. FLS to PPR Lay 18 1950 2. This effort, although amply supplied with funds and men, _failod 4n spite of its apparent success in eliminating tho disease from the ‘gapital cities. 3. Certain Brazilian workers became more convinced than ever of the futility of attempting to control] yellow fever in North Brasil, through a control of the disease limited to the capital cities. The second Foundation attempt, by whieh I refer to the period from Nov. 1926 to March 1928, secured apperent control of the situation readily and from April 1927 to March 1928, a period of eleven months, no cases of yellow fever were confirmed in all Brazil. The happy prospect of the early elimination of the disease was spoiled however by an’isolated'case in the interior of Sergipe in March 1928, an ‘isolated? case in the interior of Pernambuco in April and the Rio de Janeiro epidemic which became apparent in lay. The points I wish to emphasise regarding this second Foundation attempt are that 1. The effort was based on the idea that control of key centers of infection would let the infection burn itself out in the interior and on the assumption that the previous efforts had failed through inefficiency and in ability to maintain such key centers free of infection. 2- This second Foundation effort, although organized on a less expensive basis than the first, was limited in funds ond personnel only by the judgement of the director in the fields apparently successful in the attempt to maintain the key centers free of infection, failure was registered in the larger attempt to eliminate the disease from the country. S. Certain American workers including myself befan to have serious doubts as to the feasibility of eradigating yellow fever from Brasil through control measures limited to the capital cities and to those interior points where the disease might be visible. The third Foundation attempt, by whioh I refer to the period from June 1928 to the present, has been characterized by an intensification of control 4. FLS to FFR Mey 18 1930 measures in those centers where services were still in operation in March 1928 ‘and a reorganization of services in the other capital cities of the north with the exception of Theresinha and Menatis; temporary services have been organized in a few interior points, generally only after confirmation of the presence of yellow fever in the area. Visible cases of yellow fever continued to occur from Maroh 1928 to July 1929 but from the first of August 1929 until after my return to Brazil in Maroh of this year, no confirmed cases were reported for all north Brasil. However, a positive autopsy was secured date in April in Bom Conselho, Pernambuco, and there is ample reason for believing that Vigosa, Alagoas, has been having an epidemic of the disease since the middle of Februcry. The points I wish to emphasise regarding this third Foundation attempt are that 1. The effort was based on the idea that the control of key centers would let the infection burn itself out in the interior and that previous efforts had failed through a failure to maintain such key centers "non infectible" over a sufficient period of time. The occurrence of local cases in the principal capital cities, Bahia and Recife, in spite of the intensification of the services in these points immediately after the declaration of yellow fever in the Federal ‘Cepitel, was taken to indicate that they had probably never been made“non infectible? 2. This third Foundation effort, though et first somewhat handicapped through the previous overeconomical reduction of medical personnel, haa had ample funds at its disposal; since ierch 1929 the federal goverment has been paying fifty percent of the field expenses and has complained at times that the money was not being spent fast enough to give the results desired. This effort has thus far failed to eliminate yellow fever from the country although the capitals have been kept free of visible infection since July 1929. (This statement i@ made ignorant of the result of examination of liver of child autopsied in Perdin Meareh 1930.) | 3. The few workers with whom I have talked since the outbreak in. Bom Conselho are all convinced of the futility of the key center programme. I an convinwed that the disease is capable of maintaining itself indefinitely in the 6 FLS to FYR lay 18 1980. interior of the country$ SERTLIIT ASST ST STE RS LAS AE SASL TACT ASSES ETE TER SAS ESS ets esses steers esac satan The discussion of the situation is made difficult by the impossibility of Slearly defining the word “non infectible"; of course it means when applied to a city or area that such oity or area may have introduced into it infective oases of yellow fever without the production of secondary cases. It has been long recognised that the infectibility of a place to yellow fever would depend on the muber and distribution of none immmes and on the number and distribution ' of insect vectors of the diseases; 4t has not been so well recognised that the probability of infection of a commmity will also vary with the mmber and distibution of imported infective cases. The introduation of a single infective case of yellow fever into a city with a stegomyis index of 100 end an entirely non immune population would almost certainly produce secondary cases; the introduct dion of hundreds of infective cases into a city having only one adult female stegomyia and one non imme inhabitant might well fail to produce a secondary ease, Those are however unusual cases. Suppose a city to have an evenly distrib uted adult stezonyie index of 10; a single infective case of yellow fever should have ordinarily only one chance in ten of infecting mosquitoes, whereas the introduction. of five such cases would make the chances even and the introduction of ten caseg would make the infection of mosquitoes almost certain. The actual number of oases occurring will of course vary with the distribution of the non immune popyiation. other examples might be given, but I prefer to let pr. Putnam work out the details for you at her leisure. The point thet I wish to make is that the infeot ibility of a plawe will vary with the infectivity of those places with which close contaot is maintained as well as with the number and distribution of mos quitoes end non immunes. This may help explain the apparent breakdown of the defenses of the capitale of north Brazil in 1928 and 1929 after Rio de Janeiro began to manufacture and export yellow fever virus on a largo scale; furthermore 6 FLS to FFR Lay 18 1930 it may be more than a coincidence that apparently complete control of these ' oapitels was seoured only in July of 1929 at which tine yellow fever greatly declined in the federal capital. The sudden occurrence of cases of yellow fever of lecal originin a eontrol erea does not then necessarily indicate that there has been eny letup in the local services neither need it indicate thet the disease has been maintaining itself invisible in the control area over a long period of time; either of these hypotheses may be true but the explanation of such occurrence may well be thet the eritial index hes been lowered by an 4n creased introduction of infeotive cases from outeide the control areas It is then entirely possible that the placos worked by the yellow fever service in Brazil since 1923 have had a sufficiently low index most of the time to have caused the complete disappearance of yellow fever long ago had each of then been isolated as was Guayaquil in 1918, free from reinfection from without and with very limited contiguous infoctible territory! after what may be oalled four serious well financed attempts to eliminate yellow fever from Brasil extending over a period of trelve years, all of which have failed, should we not begin to doubt the premise on which these attempts were based? Is it not probable that endemic regions exist which are cs dangerous to the capitals as the capitals were to other points before control measures were instituted? Can we really expect to control yellow fever in the state of Behia, for exemple,with its four million inhabitents, by reducing the insect vectors of the disease which have access to only some two hundred thousand of ite people? ( You will remember correcting my useg of the word "enormous" referring to the Anterior population of north Brasil in our discussion of this problem last Deo ember; it is true that the inhabitants per square kilometer are few, nt unfor tunately for yellow fever control, these are not evenly distributed over the total area of the northern states.) . POUSTESCT ATES ERTS STS TET LAE SEA TST T ATES T TES EST STOEL SEES EMTS TESTES EES ES TES t esate I believe certain important oonolusions can be (irawn from a study of the 7° FLS to FFR may 18 19%0 known distribution of yellow fever in relation to poph&ation distribution in ' Pernambuco during the past ten or twelve years. From such a study, I have divided the state into four sones, as follows, ‘Zone 1. Reoife and suburbs where occasional cases of yellow fever have cocurred, especially in 1929, in spite of control measures. Zone 2. The litoral, or relatively narrow, heavily populated strip, roughly parajjeling the coast where ocoagional tisolated! cases of vellow fever have occurred) e.g., Cabo, Timbatiba. fone S. Intermediate zone of transition from litoral to sertaso, relatively heavily populated and receiving newoomers constantly from both zones» This sone has produced epidemics during the period wuder discussion as folievs, 7 Bom Conselho 1919 Agues Bellas 1919 Sqnharé 1928 Boa Sorte 1929 Pedra 1929 Bom Conselho 1930 Zone 4. The sertéo or relatively arid sparsely populated sone comprising Youghly the western three fifths of the state: not imown to have had yellow fever during the period under discussion. Such a soneing of the state, based on admittedly incomplete date, may neverthelesa, help to visualize the problem of control. One of the great dif ficulties in orienting control campairns in Brazil has been the impossibility of knowing where the disease existed; the four zones mentioned above are believed to present different degrees of visibility of yallow fever when the infection exists. Yellow fever in Sono 1, voztrery to the opinion hold by some, should be readily visible; a rather large number of foreign non imaunes, a large number of practicing physicééns, a service for “vyerificagio do obitos" of the Health Depertwemttand an increasing mmber of youthful non imunes growing up under control conditions are important factors. Yellow fever in 6 FILS to FrR Hay 18 1930 zone 2 is such less visible than in Zone 1 because of the small number of "physicians and foreigners and coexisting widespread maleria which always furnishes a ready diagnosis for fever and deaths the absence of epidemics in zone 2 over « period of years when the infection is known to have been present at times within the sone and most certainly mst have been reintroduced repeatedly from Zone 3 and oocusionally from Zone 1 indicates that there is a high degree of adult immunity in this sone. Yellow fever in Zone 3 has been more visible than in other parte of the state because of epidemic conditions due to relatively little inmmity in adults of this region, both Boa Sorte and Bom Conselho epidemics giving cases in all age prowess in the absence of malaria, epidemics of yellow fever are generally easily diagnosables even the matuto, femilier as he is with the recurring outbreaks of plague in this zone, readily differentiates yellow fever and plague. The invisibility of yellow fever in Zone 4, may indioate only that we lack data from this region but in conjmotion with the epidemic history of Zone three probaly indicates that the infection has not been wide spread in this region. It is ontirely possible that with Zone 1 under control, with Zone 2 largely immmized and Zone 4 probably relatively non infectible, the infection will in time burn itself owt in Zone 3, on the other hand it is more probable that Zones 2 and 3 together with similar sones of Alagoas form en endemo epi demic area capable of maintaining the infection indefinitely. To control yellow fever in these sones I believe we must extend services on a permanent basis to the more important centers in the se areas. As the Pernambuco Alagoas sector is but a small part of the infect ible territory of north Brasil, an extension of services to the interior of these two states will not resolve the problem if similer conditions obtain eleexhere. I believe we should reconsider the entire situation and make plans 9 FLS to FFR my 16 1930 to extend to suspect areas in the interior as rapidly as possible. If such a proeramse is undertaken immediately, necessary extensions cen probably be com pleted before the end of the year for the entire territory, thus giving tine for one yeexr of such control before the termination of the present sontract. In determining suspect areas I would be inclined to be rather thorough than otherwise. Very sincerely yours, Frod Le Soper. 17 3e copy Originals by airmeil and common mail on vay 23rd. Maceio Alagoas May edrd. Dear Dr, Russell: In further reference to the proposed change of program advocated in my letter of May 18th, I would like to state that this change would have been recommended me in the absence of confirmed cases of yellow fever this year; in fact, a large part of the letter was drafted in Fortaleza before such confirmations were made. In addition to the arguments presented for increasing the scope of our program, there are certain other reasons of policy which make such a change advisable. When yellow fever was discovered in Rio two years ago, it soon became the question of greatest public interest of the moment. There were those who wildly accused the Foundation of permitting this national disgrace through its failure to listen to Sebastifo Barroso when he warned Dr. White personally end through the press that the disease in néth Brazil could not be controlled thor a contpol of the capital cities; Dr. Connor came to Rio and talked of the ’nsdad for a nation wide campaign from the north to the :south and from the Atlantic to the Andes!! to include all the infectible territo:ry of Brazil. Both Dr. Connor and Dr. Fraga agreed that there was need for a revision of the agreement existing between the government and the Foundation; Dr. Coimorts idea was that the governe ment should turn over the service throughout the :ontire country to the Foundation and pay fifty percent of the operating expenses whereas Dr. Fragats idea was that the Foundation program needed his personal svidence end direction. Dr. Fraga made plens as warly as August 1928 to come north end show the Foundation how to do the job end Dr. Comnor presented a proposed contract as late as September of the same year wiich would heve taken the entire direction of the yellow Sever services throughout Brazil out of Fragats hands. Strange as it may seom, it was only the gs eriousness of the situation in Rio and the difficulty encountered there in extin guishing the disease, that kppt Dr. Praga out of the north in 1928 and early in 1929.The greater the gmifficulty encountered in Rio and ithe longer the infection was eble to maintain itself there the greater became the prestige of the Foun dation through its abikity to keep the northern capitals almost free of the dis ease during the Rio epidemic. So great wes this prestige at the time the contra ct was signed in Jengary of 1929 that Dre Fragets position with the general youblic end probably with the government was strengthened, when it became known that the Foundation had sufficient confidence in him to sign a contract of this kind. To return to ancient history; on March 27th 1028, Rocha Lima gave a positive diagnosis on the Estancia case. Fraga asked me to insist with Dr. Connor that steps be taken to prevent the spread of the disease. Finally, Dr. Fraga went so far as to tell me that Rio de Janeiro was without control of any kind and that he feared what might happen should the disease be intro duced into the federel district. ( This was in April, af a time when yellow fever undoubtedly existed in the federal district; I have sometimes wondered whether Dr. Fraga may not have already heard of suspected cases in the city?) Tn any case, at Dr. Fragats requdst I telegraphed Dr. Connor, who came to Rio ansisted that the Estancia case @ould not be yellow fever, and that even if it were yellow fever, there was absolutely no danger of the intreduction of the disease. Had it not been more or less constantly present in the north during twenty years without having been successfully introduced into Rio? Although the extension of the service as requested &t the time would not have prevented the infection of Rio de Janeiro, our position was somewhat weaker when the infection was discovered some six weeks later. The present contract was signed and approved by the Brazilian euthorities because they felt that the 1928 outbreak had proven once again that yellow fever could not be controlled by controlling the capital cities alone. (As fer as T kmow the Brazilians never seriously doubted the efficiency of the Foundation service in those places where work had been carried out. “hen we insisted in carrying on the owrk on the seme plan as previously adopted, we were frankly admitting to the world that we discredited the results obteined locally by our ser services from 1923 to 1928. ) The government did not feel that the Foundation oe could be expected to bear the expense of an interior campaign in addition to control measures in the capitals and hence agreedt to pay fifty percent of the total expenses rather than organize a separate service for the interior. As -evidence of goo#faith and in the expectation of an enlarged program, the governemtnt opemsed a credit of five thougand contos, six hundred thousand dollars, to cover their portion of the 1939 expenses and Dr. Fraga compadined more than om once during the year thet the money was not being spent rapidly enough to bring the interior under control. The present conMact was signed during Dr. Connors absence from the countrys on his return from Europe in February of last year just a few days before the contract ves to become operetive, Dr. Connor and IT had a long conference with Dr. Fragae At this conference, which I believe occurred on the 22nd, Dre Fraga asked for a wide extension of the service to which Dr. Connor agreed, saying that he would study the situation and present a programme later. However, the programme adopted has been to control the capitel cities and points in the interior when positive ditgnpeies indicate the presence of yellow fever. This I believe is a gomewhat more limited programme than that adopted in the earlier years of the Foundation service. ; when I arrived in Rio from New York in March of this yesr, no gases of rad ystlow fever had been confirmed fof the entire country, with The possible exception of cases in the Minas in the month of Janaury, singe Septembey of last year. Dr. Connor and I called on Dr. Fraga, who was quite pleased with the — ituetion in the south but wished to discuss an enlarged progremme for the North. I avoided the issue, saying that I was leaving fn a few days to make a wo montgstrip in the northm efter which I would be better able to discuss fthe situation with him/ To teke his mind off the north, I told him that I was quite pleased with the results in the south and lmowing the way the work was being carried on in the federal district since last year that I was not surprifsed to learn that no further cases had been registered there but that it was almost miraculous to me that no cases had occurréd in the State of Rio. Dr. Comor has since reported cases in the south but. in the meantime we have had to declare cases in Pernambuco. Dr. Fraga considers that his position is unique; through the recant epidemic in Rio,, the government recognizes the gravity of the yellow fever problem for Brazil and is willing to go to any length to seture its eraffication. Neither efonce nor authority have been lacking for the service in Rio and Frage feels that the seme is and will be true for tie service in the north. te feels however that as time goes by without further ceases in the soubh, that such unlimited cooperation of the govern: ent may not be available and that now is the approved time for action. After all the governement has a fifty percent interest in the service in thie north and a one hundred per cent interest in the service in the south which is ‘of course only a complementary service. I believe we should face the situation squarely and either enter on ang ofientes campaign or frankly and openly refuse to do so and give the government chance to handle: its own problem. “— Sincerely yours, ° ~~ gL = Fred Le. Soper. May 17 As Drae Sawyer, Cormor and Seper will be at this post next week I hope to hear at least sane of the following points disoussed{ No thought of eritician ef the present campaign methods prempts the bringing up of these items at this tine, le ge Se 4. Se be Te Oe 10. Is the campaign atteupting to eradicate or eontrol yellow fever? Should the anti—larval measures be. eonfined to coastal er also to interior areas with a past history ef yellow fever? If werk is te be carried on in the interior ‘to-what extent should this be done? The present campaign in. Bahia is presumably building yp a uontamme population, and would {t ndt be better to give o our present eontrel werk and allow gradual Semmization being apented she IF there 4a a possibility of adiataia sod hovemme ef the high percentage of non-- femmes move difficult to eontrol, Campaign should be based on elimination of breeding in: a) Water oontainers in and about the puildings 3 Abandoned deposits within @ eertain radius of the buildings, @) Reof gutters, Suffieient personnel should be available to contre] efficlently prot in eash of these thede: groups of eontainers. Investigations should be earried out to determine the relative . Ko fens or hunches of varicus re of the field staff should be applied in the field os provicusly confirmed — wt a small experimental field: ‘stations The field services should have available the. services of an epidemiologist and a statistician, | Reg raenrOT, We should be pranmptly notified in writing frah Rio office ef advances made by the laboratory ob-edveneee mate Vy-te5 ‘emwahery. which are applicable in the field, A means of eheoking progress should be established. If no suitable yard stick is available studies should be made to establish one, This would wupplement the present predio index reeerd, Educational work should not be left entirely to the quavdas. Befero a medical man is detatled to field work he should have & preliminary short ceurse at the leboratery where the entenelogy, patholegy ete. of the disease should be taught, ll. We 13. 14. 15. : te the long hours ef werk and mental wear and involved in this campaign the medical men and if sible the subordinate personne] should receive two lecal leave, this is a Federal eanp the possibility ef building up @ logal organisation with full State basking te later over the werk is difficult. Ideally the campaign should be supported by Federal, State amd Re F, funds, HY et f Interior towns whewe yefs cocurred in for example 1926 should be investigated by the laboratory to see if children under 4 years of age ave imame or son immune. Malaria and Y6F, Work, Malaria in S80 Salvador is | reported a8 the second cause of death, In 1929 the speeific death rate for malaria in an estimated population - ef 330,000 was 147,6 per 100,000, IP malaria work is wadertaken here, a therough prelininary survey should be made and under no eondition should the malarial eampaign be carried out by a-lesal director who has not had sufficient training in this type of work, Dr. Cumingham has suggested the idea of a semiamual conferenee of tho yellow fever dectors and in Bahia a biweekly seminar of the combined laboratory and field docters. Was to Cr 8.3. Cap Norte, appreaching Bahia, May 22, 1930, WA Stusyen bo Discoter ef tie Tertenal Department Chere oats droga of Public Health, Rio de Janeiro, Brazil, Dear Dostor Fraga: I am taking this first opportunity to thank om tor the many courtesies you showed me during my short visit in Rio de Janeiro. Iwas greatly interested in seeing the serviee whieh you created for the purpose of suppressing the yellow fever epidemic, and I was impressed by the completeness of the organization and the enthusiasm of the dostors ddrootly din charge of the work, The fact that no case of yellow fever has been confirmed in the city of Rio de Janeiro sinee last September is strong evidence that your efforts have been rewarded by the disappearance of the | disease from the oity, but I am heartily in agreement with your thought that the work direoted against the mosquito should be continued without relaxation so that the city will remain non — infegtable, Soon I ghali be in northern Brasil with Dr, Connor making inspections ef the control work against yellow fever in which the International Health Division of the Rockefeller Fowndatia 2 has been participating. With regard to this endemic region I am 4n complete agreement with the opinion you expressed that the soientific studies accompanying the control work should be continued and extended, With the deve lopment of new methods Rar tnd Ais Kast pr bet ute 4% should be increasingly possible to determine the presenee or — s J Pangternn gg eto absence of yellow fever with precision doth on the coast and in the interior, and with this knowledge to decide where control work 4s most needed, It gave me great pleasure to hear from you that the govermasnt of the United States of Brasil had aceppted your thought that the control of yellow fever is a national problem, It is also most enoouraging to find that you are so strongly in fawar of the permanent methods of control, one of the most ? important of which is the installation of modern and adequate water supplies in all cities, especially the large ones, When all the houses in thesa sities are econmected with an adequate supply available at all hours, there will be no need for the nunerous water receptacles which now breed mosquitoes and require frequent inspection. The Direotor of the International H,alth Division, Dr, F, F, Russell, rogretted groatly thet he could not come te Brasil this year and confer with you. I shall, of course, make reports to him regarding our conforences and the inspections in the north. Permit me again to thank you for your kindness and agsaistance during my visits Sineerely yours, We Ae Sawyer 66. Prt, 1939 I coe May 26 combinued. ; ky, Visit laboratory in the afternoon. Find Cabral idle and , others workins. “ith Pavis absent he says there is vwerw little for him to do. buy I learn that three autopsies were made in Natal on the 9th, Jeth and 14th of h / J May end the tissues forwarded to the laboratory on the 15 hese cases were MALY witho ical attention and were never suspected of be yellow fever but aor, came in as part of the program just begun to ™ ave routine autopsies on all ae persons dying in Natal with fever of less than ten days duration who had not been definitely diagnosed something else by an ab'ending physician. Awe Severino Santos , 3, dying 9th, reported suspicious by Frovasteny Emilia Remos > LT, " 12th, reported positive ~ Jose Felippe Filho a0, " 14th, reported eoeitive. + a Lo “At the time I was in Natal arranging for these routine autopsies, I had hopes-——__ of picking up sonething In the course of weeks Or months if the infection were really present but I never had any idea that two ard’ possitfy three of the first three autopsies would disclose yellow fever in Natal where cases have not been reptetered for, many Nap RHE: (2H SL Na aa! Parag gue of mY letter of liay 18th. } oe aut’ Telegram received:" Inspeccionei hontem povoado Amnel constatando gras- sar molestia caracter epidemico com dous casos fataes mes Abril ponto Historia doenca contada mulher Eduardo Jeronymo morto terceiro dia suspeitissima potsto Visitei seis dgemtes cujas observagoes seguirao Rio ponto Collhi sangue para provar protecgao e inoc)agao que remetterei primeiro NYRBA ponto chamou minha attencao Eren de, Caan coincidindo apparecimento casos humanos pt Informa populagao daquella localidade que. felinos morrem vomitando em poucos dias ponto Consegui fazer autopsia um retirando figado gue enviarei nosso lab- oratorio para esclarecimentos histologicos ponto occasiao em que procurava colher sangue convalesventes rua Palhico visitei doente quinto dia dezeseis annos idade apresentando franca ictericia e intensa albuminuria mesma casa sua irma morreu oitavo dia vomitando preto e entererrhagia ponto Extrahi sangue sua mae Joaquina Maria mais trinta dias data inicio molestia pt ees: tt Telegram sent: Rockfound Maceio Telegram regarding investigations re= ceived stop Autopsia gato deve ser muito importante stop Peco mandar tambem sangue em venulas con e sem citrato para o laboratorio aqui Stop Ja: "(I hope he gets the idea that I want wilosd ose ) Rockfound e: e y. reports results of further investigations in small towns above Vicosa stop Epidemic with fatal cases presenting all characteristics of yellow fever associated with epidemic killing cats stop Cat autopsy material being forwarded to laboratory stop. Am requesting also cat blood stop Expect to sail for Rio Friday. Rockfound Recife: Frobisher reports two of three Ny -livers from Rio Grande do Norte p@@@re stop Third considered suspicious stop a These livers are from persons dying in Wah without medical attention and less SA than ten days illness stop Autopsies were performed because of recent agreement — for routine autopsies and not because of any suspicion of yellow fever stop Suggest Drs. Sawyer end Connor visit Natal and request that Dr. Connor reorganize il service if necessary. I believeguarda chefe inefficient stop Soper. e, The Wilsons and Cunningham to dinner. 67. May 27th. Bahia. Learn from Wilson that there were suspect cases of yf in the sertao of Pernambuco last year in the zone beyond Villa Bella. These . cases were never investigated although they were reported to MEU as suspects. Davis wires that there is a lot of malaria in Natal and that Tavares does not wish td accept trobisher's diagnosis o on the routine autopsies there. This is quite natural. MF replies to me that one of the three cases is ~~ absolutely typical and that another is surely yellow fever; he is willing to a admit: that there may be room for doubt on the third case but that thinking that Co they were all three from the same suspect epidemic he made the diagnosis of the e, three on the first two slides. . Visit with DBW turmas de matto, turma de calhas and turma de latas; NG visit ditching service, half abandoned factory where extensive repairs are under way to tender drains mosquito proof; suggest the use of syphons to avoid part of the expensive repair of the wnder floor drains. Visit also the now unworked zone along the railroad which goes to Plataforma and also make a bird's eye inspect ion of Plataforma. Wilson believes that these zones should be wnder control as for all practical purposes they are a part of the city. May 28th. Spent day at the office getting up correspondence and notes. Learn that Burke's Journal is missing and that the large wall map of yellow fever cases is no longer here. (Given to Beeuwkes by Burke in April 1929) May 29th. Spend morning at the laboratory; discuss Natal cases with MF and reexamine the three slides from there. Personally I beldieve there can be no dowbt of one of the three cases; one of the other two shows much pigment and the third some, Mr stands by his guns absolutely on one of the three beigg yf. Fick up lunch with the rrobishers at the Nova vintra. Dinner with C at the rens&o Edith. MF suggests that part of the difference in susceptibility of monkeys to yellow fever may be due to diet.He has noted that the monkeys in NY which had a more limited diet seemed to show much greater suspeptibility to the disease; I give him the details of Lamson's work with calcium deficiency and susceptitbility to intoxication with CC14. this was unknown to him; we agree that it should be worth while to starve his monkeys for a few days and them put them on a redused diet to see if any difference in resistance can be noted. “Mailing tissue from Edgar raria digsnoged suspicious yellow fever vr. Abenathar. Letter follows. Crawford" @.1...-~ sy Suth Spend morning visiting garbage dumps with Wilson; also slide dow the S ind the Bédau sejow’ to see breeding pools of taeniorhynchus on the water front. Bamboo problem also investigated. sail on Gelria for Rio. Conversi with vr. Estaocio Coimbra and with Mrs. Fw HAmner whose husband is the organizer of the Kondor syndicate: Mrs. Hammer came over in the Zeppelin last week; certificate of crossing the line very well done showing Acolus playing the usual role of Neptume and Neptune somewhat put out at the lost of prestige. ; SS Day at sea. « Sunday. Arrive Rio. Arrange with Mr. Hammer of the Condor to give 5u per cent on flights when pianes are going empty and ten per cent when passage would otherwise be lost, June 2. Visit Dr. Fraga and talk with Lefayette who cont'irms notice of’ cases in toe Lampos and in mmicipio of Magé. Li reports interesting oase of an elederly woman * - living in isolated house of diffioult access at st. Aleixo near Magé; this woman had heen ailing for some weeks, was u native born Brazilian and was seen by him and other physicians shortly before death. Nothing in the ugeested yell but_since he had given the order ror all deaths to be inyestigated he did not care to make an exception in this case. What was his surprise to learn that the case was positive) 68. ox [FLO June 3. see UF about invasion of school rights by the hospital construction which was brought to my attention by Miss rallen; according to the correspondence all this land belongs to the school, UF suggests that I see Thompson Motta. suggest to CF that we may hire one ur. Kerreira da Vosta to go north; he offers no objection but says that he will have h cooked up in his departmant. Notify Ur of all the suspects registered to date the north. June 4. Luncheon at Auto C)Gb to Merrill of ranAmerican union and of AMCABLE/ Supper with C Cox family. Drop cards on Morgan, Dawson, Linton and oall with Coxs on Ellis. June 5th. Practically hirelerreira aa vosta. To be ready for work within a week. Thompson Motta cames to office and assures me that we will have no difficulty ofer the ground of the Nurse's school. "Dr. Abenathar diagnoses liver Luoimar pagsos as suspicious stop Liver from kdgarriraria a routine autopsy case also diagnosed suspicious hence am sending liver to vavis Crawford." MEC to FFR JAN 13.“Muenoh reports rumours of an epidemic on one or two of the Croke d4slands in the amazon Basin about two days by water travel from raré, Local tC. authorities regard the epidemic aw malaria on the basis of history of these v places in past years. I have instructed Muench to encourage the local health authorities to investigate and failing this we will investigate." But on June 1 crawford reports that an engineer returning from the Ilha Mexiana reports a series of cases there with black vomit dying in two to four days after onset. (May 28th telegram) 7 when I ask for investigation of these cases receive the following under date > ¢ of June 4th “ Reported deaths in Ilha Mexiana were in Ilha Caviana stop vootor | Albino has had notice that oases were malatia and condition much improved stop S no boat for fourteen days yet stop two Crawford.*" June 5th Rockfound Par&. " Ilha Caviana should be investigated stop Take every precaution to protect yourself against malaria stop should carry with you mosquito net and quinine stop collect samples for protection tests especially from convalescent children Soper® | ‘ o mer Pe Lf ™ fp Received following wire from Rocha PARAHYBA ‘Tendo ur. Guedes recebido aenuncia caso fatal suspeito febre amarella cidade Pilar distante aproximadeamente trinta kilo metros capital averiguei caso naquella localidade pt voente branca feminina Brasileira dezenove annos apgocen vinteseis faleceu trinta um com alguns symptomas geraes febre amarella’“téndo sido retirado material para exame pt. voente esteve anterior ment itabayanna itambe pt todo quarteir&io onde se deu case foi inspecionado havendo doente algum ......eRkocha. ( Sent same telegram to Rookfound Recite) -\ INTERESTING EXTRACTS FROM MEC correspondence. uv MEC to FFR Apr 15 1930 " You will be interested to know that ano? calhas (roof gutters) probiem has been sélved in Mahia partly by an ofticient order requi requiring proper grades and partly by our puncturing water holding gutters when the interested party fails to comply with requirements ana partly by otfering a prem ium of $500 per meter to the squad securing the removal of gutters with the kmowledge and consent of the houseowner. Hy means of this iast measure nearly six kilometers of guttering were removed during two months.” MEC to #FR Jan 4 1950. ~ What I wish most tuo get across is the thought that the yellow rever infection still appemzrs to me to be not only controlable but eradicable in the americas but to secure this objective the problem must be attacked in all places at the same time.:-" MECto'PFR March 13 1930 ° but as the yellow fever infection periods of tine, it might well have boon among the gu ical form over long | Mew eriods of time, it might well have been among the guests at the Hotel Nova vintra,‘ 69. Jue 5 continued, ; O er MEU tu Fk® april Zoth ” ur. rraga is rather inclined to insist that we extend our services to the priroipal interior towns regardless of whether the infection has been confirmed in these particular small places. in principle I am opposed to this plan at this time preferring to continue our present polic 4 Litty there arg cleaver idlcations thin we Low hive Tor modpiying our present policy. The proposed commission would be encouraged to stu & particular phase of the problem. vr. Fraga hae offered no sound argument for the extension small commmities. i think we shall be able +o ‘present some definite data within a few weeks regarding the yellow fever infection in the interior of rernambuco, Alagoas and Rio Grande do Norte. wecses” Aoknowledged by FR as follows ‘Stating that ur. rraga would like to have roundation extend its work to the interior towns but that you see no reason for a change of policy at the present time.~ round in the files that ur. Uchoa had reported a suspect case of yf from Maranguape Ceara in May. Roberto Braquelais arrived from France on April 2u one night in rortaleza then to Maranguape where onset occurred on April 3u. Case presented typical signs of yf but recovered. Albuminuria of 4.5 per 1. on 6th day. Temp back to normal on 8th day. FROM ERR~ RECIFE 9p Fils “ MAY $0. ....ithe last few days have been extremely interesting. vue to lack of hotel space voctor sawyer stayed at the house thus giving me a good opportunity to get weal] acquainted, Having received your wire about the soft pedal I have made no effort to make any special sort of a campaign. There was no needwhatever, as ur. U now the strongest chempion of all your idees. He has completely given up the cartertheory and is expounding on your endemic and epidemic zone idea; he is also using as his wwm many of my phrases used in that section of my journal to which he took such marked exception some few weeks ago and which caused him to write me that letter (the one that worried me.) This morning in aflengthy but interesting conference attended by voctors sawyer, Connor, vavis and myself the whole situation was gone over, Vonnor seems to have convinced voctor sawyer that a greatly extended program is necessary and recomnended that all the states in our sector be supplied with North American directors, That seemed too expensive end hard to arrange to me; so I put in a word for A erican directors in the more important states as now, full time Brazilian doctors in the rest and two assistent general inspectors to have charge of a northern and sounthern division of our sector. ‘the job of the assistant general inspectors would be to supply the oft repeated fiscalizations and inspections necessary for the best functicning of B personnel. As yet nothing has been resolved. *I regret greatly that you oanmot be here as the discussions that are teking place spem to be of greatest importance and certainly the man who is going to direct the service should be in on them. I was very happy to hear from vr. sawyer that you are to be in full charge. Congratulations!! We shall have to throw a special party to celebrate when you came up again,®" re. oe Um June 6th. Elmendorf to HHH May 5th " YF broke out in Guayana in June 928 but Hod “came to the essertion of-the authorities only a year lajér. State of Rio. Learned fram confidential sourees that phe State of Rio YF control is not yet settled; that when cases were recently ¢ firmed for Campos that CF attempted to send in more men from his service and ugurate direct control the situation there but that his men were met in Nichteroy and advised not to Niccca as the governor of the state had ordered their arres if they should attempt . to work in Campos, Again CF was forced to bow to the needs of political opportunisml! However there surely must be a payday caning some timel! State of Minas information seems to be entirely lacking in Rio de Janeiro. since January cases close to Dismentina. Interviewed Dr. Guilherme Ferreira da Costa, recent graduate who desires to go to work in the yellow fever service. Shall look him up and probably hire him for Pernambuco. Dine with Ellis family. June 7th. Call on Insurance company and secure 25% rebate on fleet insurance of cars in North Brazil, All day at office. June 8th. Dine with YWCA secretaries after playing golf in AM with Nave and Ellis. Drive to Alto de Boa Vista and over to Paineiras along the new road, All Rio can be seen from this road. __ dune 9. Dr. HAragfio calls; has not yet received dozen monkeys promised him by MEC in March! I s doing nothing on yellow fever at the present time. Arrange for Texas company to sell us garage service for the two cars now in US6.6 Andrade advises that Lintz and Decio desire that my trip to the service in - Nichteroy should be an official one and that the best hour is two thirty in the PM; Acs this would mean that I would see nothing of the service, I have refused to go at this hour but insist on the, original schedule of the seven oclock ferry. June 10th. Go to Nichteroy accam»anied by Decio and Lintz at 7 AM. They give all possible details of their service in the least possible time; are quite proud of the medical vigilance service established for the travelling public who must buy tickets from the Leopoldina railway. I rather throw cold water on their enthusiasm for this particular form of spending money in yellow fever control and gleo on fumigation; show me seven livers that have arrived since yesterday for path- ological examination frog different enthusiastic and cannot find words enough to express my high appreciation of the mportance of wha ey are doing. tis seryice started 20 days ago has aarendy dem- onstrated one unknown foocug or che yellow fever infection in the baizada fl inse When I learn tha e service has only been going days I claim priorty of execut- ion for the routine oe plan is may force Decio to ge into print right away with his idea which shou @ of great value to all of us. the method of getting autopsies in the state of Rio is interesting and _shou e of value to us in the north. The state Health seryice called together =r of the escrivaes de paz fran the interior Specimen bottles containing formalin solution an with the promise of f milreis for eac Ver section forwarded fram persons dying in-seven days or less after onset of an acute illness. As it is the escrivéio de paz who controls the registration of burials for cemetaries of his respective district the method is working like a charm. Copies of instructions and report form were given me for future reference. Visit Andrade's. service and find the guardas working in groups which requires that one man have nothing else to do but indicate to the others which houses have been worked by the guardas which are ahead of them; this service de arrastéo does not seem practical to me as there is a great deal of wasted time. It does have the advantage however of having the entire personnel always under the eye of the guarda chefe. I believe the requirement however that the guarda chefe should gc into each and every house examined by the guardas is not practical as he would need as much time as the guarda to check accurately the work of the guarda. Found only the guarda chefe with a lantern and it an old type non-focussing one. ‘ Davis wires that Natal cases are vrobably all malaria. ‘Lucimar Passos > and Edgar Faria from Par& however are positive.!!I!t!l!! Wire Crawford to postp hg - trip to [Ilha Caviana jand thet I am sending him Dr. Ferreira Costa. 1 3 ae Nester (Leas) (096) Aout + Visenebion and gaye them practical demonstrations as to how liver fragments can be removed fron cadavers with the least trouble; They were then supplied with a Tew simple instruments, sent back to thej ows ~ 71. June 10th. continued. Lucimar Passos was discovered by P JC accidentally while out fidcalizing in the Val de Caes zone. Learning that a child had died after sev en days illness he was finallyable to convince the parents that an autopsy should be done in spite of the fact that the only indications were that the child had died after point of the epidemiology of yellow fever in Par&, The other case that of Edgar Faria is one of the routine autopsxes beigg done under the autopsies of the police depart- ment. June llth. Sail on Northern Prince for Bahia. Cabin mate by name of Warnau, French, temporarily to direct the Bahia Docas company. June 12. on Board with Dr. Torres and family. June 13th. Arrive Bahia. Canningham meets wm and together we go to the Flandria where we find Drs. Sawyer, Connor, Wilson, Frobisher, Davis. MEC sails for Rio. Long discussion with WAS. June 14th. AM calling on BB and Araujo both of whom are absent; purchase passage for WAS, change money and make arrangements for flying trip to Aragaju. Visit Dr. Ferreira Costa on board Santarem and give him letter to Dr. Crawford. SUNDAY June 15th. Meet Briggs, American Consul in Bahia. Spend AifVas scussing various problems with WAS¢ visit British cemetery. Golf in PM; dinner at Dewis home with Rockefeller family all present. June 16th To lab in AM and for lunch; learn that 100 monkeys are to be used in the Magé tests. Frobisher administers lst shot of OCI typhoid vaccine to me. Davis wishes to continue shipments of loo monkeys per month and will ship Aragiéio the 12 monkeys promised by MEC in March. Davis presents proposal for leave March lst 1931 but states that from now till then he expects to be almost continuou&sy in Bahia. Requests loo bloods from south Brazil from uninfected zone for control work Davis requests commercial carbon tetrachloride in place of c.p. _..uses for killing mosquitoes. Conference with WAS: outline my immediate plan of operations which is to extend control measures to the interior of Alagoas, Pernambuco, Parahyba, Rio Grande and Cear&. Bahia will be developed only after this central triangle or quadrangle is organized unless epidemic conditions force our hand earlier. The Amazon region is probably to be considered a separate field for investigation rather than inmed fate control. Conourrently with the developpent of interior stationsyfield and lab oratory studies are to be carried on; such studies should show wheré our programme has gone too far and where it has not gone far enough. WAS spontaneously suggested thet Alagoas and Parahyba should be under the same direction as Pernambuco; I agreed saying that I had already considered such a grouping which would probably also include Rio Grande do Norte because of railroad and auto road commmications with Recife; also that I expeoted to place Sergipe under direction of the American disector in Bahia and probably Maranh&o and Piauhy under the director of Cear& when that service is organized. TAS seid thet he had elready discussed the group rT Ang of these three states with MEC and ERR both of whom hed opposed 2+ _on the. lt grounds that it was not well to have services over lapping state lines. “DEW tells WAS that calhas are a big crobter geiil In Bahia and that only last week MEC authorized three more turmas for that work; WAS non-conmital on letter of MEC stating that calhas problem in Bahia had been solved. I discuss with DBW some of the plans for organiztion in the future and suggest to him that he get the looal situation in hand as well as possible so that it may be shifted eventyally to « sub director (Brasilian) thus making him free to superintend the work in the interior when extensions occur. T26 June 16th continued. Tell DBW that I expect to replace Doxye with Cunningham in ————"_ Sergipe, placing Sergipe immediately under DBW& supervision. NCD brings up again the question of reinburseing ALBB for monkey ex penses; I have already approved such payment in case proper receipts were present ed. RBraquelais Marenguape Ceara protects. Four bbloods VICOSA ALAGOAS protect. «<< DBW and I visit Magalhaes and Cia and settle for calhas illegally re moved by our galha gang. Original bill for 900$, cost proved to be 600$, SF to pay 300% which will be eventually deducted in monthly installments from the sal aries of the men doing the work. Acoompany WAS on visit to Instituto OC and Dr. Araujo. Ask DBW and Magalhaes Neto for population statistics of interior Bahia. WAS and I agree that Shannon is to be under NCD for field work from now One WAS believes that I should keep a station journal from now on submitting | same to New York. Fos Poe June 17th. Diner at Frobisher& apartment. June 18th. Visit new water works construction with ALBB; project looks very in adequate as the amount of water now running through the dam is very small. Future programme covering a period of five years is supposed to give available water for double the present population of the city. Show WAS change of contract and motion ploture etatement in YF annual report for last year. Advise Cunningham that he is to go to Aracaj&ii as soon as the map is finished; he asks WAS for laboratory or epidemiological assignment. NCD says RCS will go to Maceio June 22. June 19. DBW takes WAS and FLS to Jtapagipe to get the Condor plane leaving at 6 AM. ( Fare after 50% reduction 210$.) Arrive Araqajii 8:15. Met by Dr. Doyle and Dr. Tourinho of the State Health Department. Spend the morning with Doyle seeing some of the difficulties of the local flooded situatinn. ARACAUT. 40 000-flat and surrounded by water; ground level (water) high right now being about ten inches in most parts of the city. Streets are very regulerly laid out at right angles but unfortunately for the present oenpaign are at a higher level than are the surrowding lots so that Fin water cannot drain away. Backyards and unpaved streets with pools are now breeding sone culex and enormous quentities of taenlorhynchus. Even relatively dirty pools in the streets are found breeding. MDasks for more tien for the local service at least during the_ rainy season; all of the local people insist that the presen* rainy season has en the heaviest noted over a large nuisber of years. Persomel Present Desired 11 zone guerdas 13 zone guardas 2 revision " 2 mother food 1 casas fechades 1 casas fechadas ,tl3 servants -15 servants / (4 fishermen » 4 fishermen { « 4 roof gutters | | 2 roof gutters ~~~ 1 Caixas dtagua ~. }1 caixas dtagua / 1 office ‘\1 office / 2 ditches end lots 5 ditches end lots ‘.1 ofler 2 oilers ‘1 secretary 1 secretary 1 chauffeur 1 chavffeur 1 fish distributor 1 fish distributor 2 guardas chefes 3 guardas chefes 73.6 June 19th. continued. WJD§ request for increased personnel really means and in creased expense of 960$ per month; 2 guardas 420$, 1 guarda chefe 300%, two servants 2408/. (On June 20th after becoming more familier with the local situation and discussing with WAS the relationship of our service to genera 1 mosquito control, the following was authorized, increase service by two guardas and one guarda chefe and one practicante. Seeing large number of dead fish in container, death undoubtedly being due to neglect, I suggest to WJD thet he pur chase fish by the thousand alive twenty four hours after delivery; ralsing the price per thousand to get fishers to work rather than putting them on the monthly payroll. Authorize Doyle to use petty cash funds for personal expenses if neo essary as it has been impossible for him to secure money on his letter of oredit here; however, expect to have Cunningham advance him money to be returned through the Bank of Brazile Also request Boyle to show on Form 24 Distribution of Advance MEC wires case confirued in June in Itaocera, E. do Rio. WID states that the local water supply is far from sufficient with oressure only between the hours of Gam and 4:30 pm; approximately one third of the houses sce connected; Aracaju Has a very good sewage disposal plant which serves only a very smell part of the city. WAS WJD and I spend the afternoon seeing the ground breeding problem; the city is lov and flat with wany of the streets hisher then the lots; this years flood coniitions have caused many houses to melt away from below end others have been flocded from stem to stern. Taeniorhynchus breeding has been and is a tremendous problem; culex breeding comes second just now. Visited nine houses finding two steg foci, one in a flower pot and one in a barrel. Backyards gave large colonial clustered foci of T. Dhas athempted control by fish, by oik and by drainage, Fish have siven remarkeble results in certain srassy pools which et first cslanee would apoear to favor the larvae; simall adjacent pocls without fish were found breeding in one home where the more favorable foci were fished und clean of larvae. Visit zone being drained by our service; there can be no doubt thet the zone needs draining as the flooded conditions render even regular house visits difficult; WAS and I discuss drainage in relation to our vrogremme and decide that it should be limited as much as possible. Although Davis secured transmission with the emulsion of infected T. he was never able to secure infection through the bite. Problem of locel drainage should be one to be settled by local authorities with local budgets. June 20, FLS 23 Istep, several T. and culex in vonds and pools. WAS 48 Osteg Call _on Dr. Tourinho at Health Department and make arrangement to visit governor with whom we discuss drainage eandfautopsies) All supvort on both programs promised. Call on Theophilo Dantas, iIntendente of Aragaju and brother of Lianoel Dencas the gorernor, TD promises to let Doyle know tomorrow what can be done ebout supplying additional men to work under Doyle's direction on emergency drainage. I do not somehow expect vory much. Visit Institrbo Arthur Bernardes and ineet the chemist, Dr. Bragenca, who wishes to know vhen he can have the fellowship so freely promised him by Dr. Connor “WAS ,WJID, FLS, Tourinho anu Brayanca go to Cabrito to see the waterworks. Installation is very modern with rapid sand filters, lacking only chhorination to give entirely satisfactory supply. B. insists that plenty of water is avoileble for twentyfour hour supply but that the comoany is forced to cut off the suoply at night because of the absence of water meters; feucets and hydrants are neglected and water runs in many homes throughout the full period of pressure, 8. insists that company would be glad to maintain twentyfour pressure if hydirometers were installed. Get stuck several times on the return trip of 18 kn. but are finally rescued by a band of assassins from the penitentiery where we take coffee before driving on into the city. Condy June cl. WAS and I arrive in Maceiorfrom Aracaju by the Porto esre in about two hours time at cost of 145g per capita. Met by Dr. Alméida;~talk with Dr. Meneschal and notify of confirmation of Vicosa cases by protection tests. WAS agrees with me that we should not be responsible for conservation of drainage and Dr. lieneschal also agrees that the respohsibility should be his but states 74. June 21. continued. that during the vresent year there are no funds available for this service. I then agree that we will maintain twenty men for this service as at vresent until the end of the current year but that after the first of January that these men will be taken off. Meneschal agrees to have funds for this service next year but says he would like to have our service continue to supervise the work, We agree thet this will be possible and probably better all around as thus there will not need to be two antimosquito services in Macelo. WAS and I make rounds of city rapidly to give him some idea of the topography of the place. At 3:30 leave for Vicosa arriving there at 7:30. WAS diagnoses stegs, culex and cimex in his bed. Bald heads do suffer. Almeida reports that he autopsied a small child here esbout four days ago. (Although in the known in- fected district the history does not sound very suspicious of yf although another child died recently in the family.) Jveyd. Davis REPoRTS MIR NEGATE. June 22. SUNDAY. Rather hectic day chasing around in the mud trying to find out how many mosquitoes there are and how many cases of yellow fever there have been in Vicosa. 21 houses in R. Palhico e¢ two steg foci. On house to house questioning find meny more suspeet cases in R. Palhico and find cases in R. do Cravo and R. da Compenia. The disease has apparently beenrather widespread except possibly right in the center of the city where only one case is thought to have occurred.Vicosa had yf epidemic about 1890 and since then at intervals has had suspicious cases. Is now a town of ¥700 houses and about 8000 popuhation. On June 6th the prefeito, one Villela wrote to the governor that yf had been confirmed by the laboratory fnot true) and that he estimated that he had lost "24 municipes" from the disease this year; however he still talks about the lost 24 fifteen days later end we know there have been deathe in the meantime; when pressed for the data for his statement he brings around a list of deaths by months diagnosed as "fever". Almeida is instructed to vet what mortality statistivs are available for study and analyze them. It is of course possible that this many deaths have occurred from the disease but the data so far presented are far from convincing. The intendente is emphasizing his losses in an attempt to secure from the governor an order for the prophylexia rural which is without budget for such an undertaking the establishment of a post in his county. During the day we picked up the history of one case who went to Agua Branca in the ebatby of Palmette dos Indios from the focus next to the school; took sick on second day after leaving Vicosa and remained in Agua Branca only four days returning &e soon as he was able to walk. This case was probably in Agua Branca during the entire infective stage of a mild attack of yellow fever. Boy working at hotel was only severe case in large family where all were ill. Take Almeida to task for failure to clean up hotel block, Discuss with him his relationshiv to the service; he states that he is willing to be transBerred to other state if necessary for the welfare of the service. June 23. Monday. Left Vicosa 6:20 am arriving Maceig 10:20, Long, conference with Meneschal; discuss drainage problem again and also the need f outine puboneiess good nromises of cooperation secured. (Discusses specificity of liver esion in yf; stateSthat Prof. Leoncio Pinto, pathologist in Bahia believes this lesion to be due to post mortem changesiJiii!, having produced it in both acute alcoholic and creolin poisoning cases by letting origimally negative liver stand for several hours before fixation.) WAS and I visit zones tere oilers have been at work and find it hard to believe that certain pools with large foci were oiled only three days ago. Almeida and guarda chefe both insist however that the oiling was done Friday but that the heavy rains carry oil off so rapidly that the larva® are not killed. Find one large backyard focus where the outlet is so arranged that oil would literally be skimmed off the top by the outflow. Authorize another oiler for this district and insist that the situation must be brought under control. The oiler is to be supplied from the men who were on drainage work. To. June 24th. Lv Maceio 7:50 am,arrive Recife 730 pm; see Sao Benedicto enroute. SB is rather a small compact town very easily controlled if by chance the disease has not already burned itself out, Receive letter from MEC enclosing co which he suggested i ! Newspapers report two cases in Belem; one of these an Englis by the name of Chandler. “ire from PJC says Chandler died June 21 clinically yellow fever. Telegram received from Uchoa asking for authority to open services in interior points such as Pompeu, Quizada and Oros. his 1928 letter to _FFR in June 25, PJC wires that Dr. Costa is doing vigilance work in the afternoons and that 21 primary foci were found on Sunday June 22nd, 15 of which were in roof gutters. Visit Gouveia with W d . Talk sutopsies and my need for a personal i in ; office rooAreadily promised. G greatly pleased with the new orientation which calls for extesions to the interior. G has always been one of our most loyal supporters even in the face of severe criticism although he himself has never believed that yellow fever could be eliminated through the control of the capitals alone. G pays a glowing tribute to the results of the service in Recife and is happy to know that we prpect to get the interior well under weight before he retires from office in October of this year. Call on Tete of general Motors and get promise of cars at rock bottom prices. Finel conference with WAS more or less summarizing plans for the future; notes on this conference taken by WAS who will prepare copies for NEW YORK office and for me. In brief the outline is a s follows; MINIMAL PERSONNEL REQUIREMENTS. AMERICAN BRAZILIAN General Inspector (Soper, Recife. Assistent Bailey, Rio. Lia&ieon (Alves, Rio) Bahia Wilson, SS. - Sergipe Pernambuco Rickard Recife Alagoas, Parahyba, R.G.do Norte. Ceara Doyle, Fortaleza) Piauhy and Maranhao. Para Crawford, Belem) (These are the principal key positions where men in charge will be located; in addition a number of Brazilian physicians will be amployed to help out in the larger capitals end in the interior.) Director of Laboratory. (Davis) Bacteriologist proviee! man) Bacteriologist (Frobisher) Epidentologist (field studies) Assistant epidemiologist. JOOS ICO ICICI IC OR ICO cago I OGG aC I ICICI CIO ACTOR IGOR ACC ACI A ACR For administration purposes the north of Brazil probably best dimkided into sections as follows; 1st. Bahia and Sereipes 2nd. Alagoas, Pernambuco, Parahyba and Rio Grande do Norte. 3rd. Ceara, Pisuhy and Maranhao, 4th, Para and Amazonas. Present plans call for immediate development of interior program instates of section 2 beginning with the state of Pernambuco and working both ways from the center; this to be accompanied by an almost simultaneous development in Ceara with the bringing of services in Natal and Sao Luiz directly under ovr control with full time directors, First section to be held as at present unless something pops in which cases development will be undertaken immediately; fourth section to be held as’ at present and to be subject to invest’ gationaas soon as possible, Prosram for Pernambuco calls for work in all towns of 2000 or over which should include practically all of the county seat towms in the gone as far west as Aguas Bellas and Rio Branco; work to begin on weekly cycle but to be lengthened and cheaper- ed as fast as field studies warrant; probable that supervision can never be maintained with cycle greater than four weeks, Places smaller than 2000 worked PRN 76. June 25th. continued. Investigations. The investigational side of the work should be stressed; it is quite probable that two cuite separate types of service will be needed, the one directly responsible to the control service for working out problems of local interest and running dowm local rumours and the other entirely independent of state and sectional boundaries with no direct respohsibility to the sectional directors but with freedom to go anywhere and study the problem in the north as a whole. Proposed studies; Distribution of immunity in age groups in typical towns of four zones previously described for Pernambuco. Distribution of immunity in Amazon valley. Distribution of immunity in small town immediately following epidemic. Mappféing of immunity distributions throughout north Brazil, ( All of which should keep us all busy for the rest of our natural lives if properly carried out.) June 26h. WAS sails Arlanza for Cherbourg. G_ furnishes office and again »romises “~~ help on securing autopsies in the interior. Decided to try out the matter in the county of Nazareth where there are nine districts with as many local escrivaes do paz; if resutts here are good the system then may be extended to the rest of the state; if results are poor =o else may be tried. Rocha comes to Recife from Paranya to discuss the service there and totalk about his leave; I am forced rather against my will to talk harshly to him about giving to Ceasar the things that pertain to Caesar;fhdally relent somewhat and promise to get him relief before the end of July but insist that he make up his m mind now whether he wishes to return to our service or not after his short leave in Sao Paulo. MEC sends copy of letter from lawyer representing the old employees of the Malaria Service in the state of Rio who did not get paid after the month of Sept; on the same mail comes the notice that the President of the state of Rio has approved the request that the malaria accounts be paid from a special draingge budget which is available this year. Advise Natal that Davis reports livers of IGOMEZ, MFRANCISCA and PFELIX negative. Juns 27th, Wire Rio to write ERR how cars should be billed for free importation into the port of Santos for the GMCs Dolye to remain with Cunningham week or ten days and then relieve Rocha in Parahyba. I get shot of local typhoidueccine by mistake. This is the second, Rickard says that shift of responsibility for the Recife service will be made to Machado on Monday of next week. NOTE (25 April 1968): For corresponience WAS to FFR, with translation to Fraga and Fraga's reply, see insert after last entry of August 1930 e June 28. Left Re@ife at 11:20 AM on NYRBA plane Sao and the new guarda chefe in Natal c nothing new there; malaria continues to be a sent up from the Rio office has been red - side breeding places, Arrived in Fortalg because of police visit. Dr. Samuel Uchoa, director of the State and Federal Health Services in Ceara, who has been directing the yellow fever service in Fortaleza since March, met me at the lending. We spent the following three hours discussing the local and national aspects of the yellow fever situation. Dr. Uchoa is and has been for a long time anxious for the service to be extended to the interior. On June 23 after receivbigg confirmation of the Braquelais case from Maranguape, Uchoa wired Connor asking for authorization to extend the campaign to include centers of population in the interior and mentioned especially Oros, Queixada and Senddor Pompeu and calling attention to the expected influx of foreigners with the re- opening of the Obras contra as Seceas of the Federal government. I explained to him in outline the programme for the immediate future upon whibh he himself suggested that no change should be made until after the arrival of Dr. Doyle. On learning that plans had been made to send in a full time man to take over the service, Uchoa showed me the draft of a telegram to MHC which he had expected to send in the near future asking to be relieved from the direction of the yf service because of the weight of other duties, The Maranguape case came in for considerable discussion; Uchoa finds it strange that a single case could appear in this town with no preceding nor posterior cases in spite of the heavy steg breeding encountered. I eite the Estancia and Timbauba cases of 1928 .as-exactly parallel cases in which the epi-+ demiological inquiry failed to reveal other cases and told Uchoa that this is z* Dr. Nellio Tavares to the plane and reported xOus problem. The Paris green d is being used on the river & PM but landing was delayed the type of thing that has apparently been going on for a “ong time in “7. "endemic" areas of north Brazil. I also cite the discovery in Belem of two cases \ in Vi children in widely separated zones of the city through routine autopsies and the failure to find any connection between these two cases or any indication of the occurrence of othercases in the imnediate surroundings. Uchoa brings up question of guarda chefe for discussion; he feels that there was no justification for the charges preferred against the guarda chefe to Dr. Connor and that the mam should not be-transferred as a punishment. I reply that anonymous letters never receive attention from me and that in any case the question of subordinate personnel and their punishment if necessary is to be left in the hands of the local director. No change will be made then before Doyle's arrival who should be able to choose his own guarda chefe if the present one does not suit, Uchoa insists that the service in Fortaleza is in good shape and that the service in Maranguape was very efficient and very rapid in its results; the cooperation in Maranguape was all that could be desired, a conto being voted by the municipality to help in the work and regulations for the restriction of raising pigs being immediately enforced. Loose hogs in the streets were actually shot down by the local police authority. Received telegrams before leaving Recife: from Rio stating that Rio papers are copying alarming information from papers in Para and that presence of yf there is due to insufficient personnel and material in our service and that Ambassador Morgen has asked the government for official information regarding the dieease in Belem; from Rio stating that a very suspect Portuguese has been removed to the SSebastiao Hospital from the Cattete district in Rio but that the medicos in charge have not made a definite diagnosis as yet; from Bahia stating that a very sus- picious Swiss has arrived in SSalvador from Jlheos:::::1 wired Wilson to investigate Ilheos with one of his doctors and to Rio that only three cases are known to have oceurred in Belem including those discovered by routine autopsies. Wilson also wires regarding the purchase of the projector from Burke; I reply that this purchase was authorized by Dr. Connor and that the projector should remain for the present in Bahia. FLS 1930 June 29,.Sunday. Up at 4 in the morning to get away at six. Iwo bassengers and about thirty gallons of gasoline had to be left at Fortaleza because of inability of the Sao Luis to rise from the water with a full load, From the air it would appear that Aracahu and Camocim, Ceara,and Parnehiba, Piauhy, are sufficiently important centers to merit consideration on any extensive vrogramme of yellow fever control in this area. Arrived at Maranhao about ten thirty and Para at 2 PM. We had a good tail wind all the way from Refife to Para and kept well ahead of schedule throughout the trip. Dr. Crawford reports rather optimistically regarding the local situation in spite of all the newspaper talk of yellow fever epidemic. Since July of 1929 only three cases of yellow fever are known to have been in Belen; one dying on the 16th of May and one dying on the 2lst of May, both picked up accidentally postmortem Dy routine autopsies, neitner having been suspected nor reported; the third, an Englishmen by the name of Chandler died June 2lst. the liver examination report on this last case has not yet been received but from history of illness duration of the disease and the macroscopical exai ination of the body, yellow fever is believed to be the most probable cause of death. fhese cases occurred in three rather widely separated parts of the city and so far as could be learned have no connection one with either of the others. Two cases were in Brazilian children of six and seven years of age respectively; on inquiry the father and mother of one of these cases (Lucimar dos Passos from Val de Caes) both gave suspicious case histories for themselves but reported nothing for their other three children.(Dr. Crawford has already drawn blood for protection tests on the father end mother and I am suggesting that we get bloods from the three children to determine if possible whether the entire family has not been immunized with the appearance of on}y one serious case.) No report was secured for suspicious illnesses in the families nor associates of Edgar Faria and Chandler. In checking over the two cases which ovcurred in May, Hothing striking was discovered in the nature of stegomyia breeding in and around the houses where the cases occurred; fourteen pup&A foci in roof gutters were found within one block of the house where Chandler died however. The regular routine service of the zone guarda was avparently in good shape. Crawford reports that the news items referring to lack of personnel and ewerwork of the guardas published here and copied in the Rio press were instigated by some disgruntled employees or rather ex-employees who desired to make trouble; insiste that there is apparently no ill will on the part of the local press and that no difficulty is encountered in getting any desired propaganda nut before the peole through the press. Crawford believes that the local stegomyia problem can be handled efficiently without any great increase in personnel; all but one of the servants on the ditching work have been taken off and assigned to the in- creased roof gutter squads or put on vacant lot clean ups. Roof gutters and vacant lot trash collections seem to be the special problems needing emphasis at tne present time. The roof gutter problem has been taken up with the govern- or who is quite ready to cooperate and adopt the same regulations as arennow in force in the Federal district; he suggests however that for legal reasons this measure should go on the books as a regulation of the city council of Belem. This regulation has been drawn up and submitted and should be passed during the coming week. Crawford reports good cooperation from both the state and the fed eral health authorities in Belen. June 30. Call on Dr. Albino Cordeiro off the State Health Service and Dr. Jayme Aben-Athab. Dr. Albino insists that the roof gutter reguaa&ation in now before the council and will surely be voted within the next three days. I ex- oress to him our thanks for his cooperation in getting the routine gubopsies which revealed the presence of yellow fever in Belem a full month before the Chandler case was announced and called his attention to the fact that this latter case mignt well be entirely accidental and the only one of its class and that we might have gone on for months without knowing of the infection wibhout the autopsies which he has enabled us to secute. I then discussed the importance of securing routing’ autopsies from the interior of the state and exvhadined to him the system now in use in the syate of Rio de Janeiro through which the township clerks send in liver specimens from fewpectases dying alter less than eee el FLS 1950 June 30. continued. eight days bllness, As amy innovation in any service here ; “will at first meet with opposition, I suggested thet Albino and I disevss the matter with the President of the state. Ur. Albino promised to find out who is resvonsible for the cemeteries in the interior of this state and through which nel_we could bests re liver svecimens and arrange for a meet- ing with the governor on July end. Dr. Crawford and I thanked Dr. Aben-Athar of the Prophylaxia Rural for the fine cooperation he has been giving in the macter of fines and forcing the correction of roof gutters and in the examination of routine liver specimens in his laboratory. He assures us that he is vitally interested in tne whole problem of yellow fever and that anything he can do to aid the service will be done willingly. We discuss fully the yellow fever situation as we see it throughout brazil togay and call his attention to whet is being done with routine autopsies here anv in the states of Rio de Janeiro _and Rio Grande do Norte. He assures me that he will be able vo secure autopsies for us in the followiny points wnere he has services organ- ized: ALENQUER SAXTAREM CanwkitaA CACHUSIRA IGARAPE-ASSU BRAGANCA and BREVES, Our service will furnish necessary conteiners end will forward the specirens to the Bahia laboratory for examination as this routine would really work a hardship on Dr. AbenAthar who is his own enatomist. Somehow I havesmore faith in securing specimens from these various places than I would have in case someone else had Te de the promise. * hot 3 Discuss roof gutter problem with Crawforu and suggess tuat we had better set out and see what is happening in roof gutters where foci were found bdne two and three weeks ago as we have at present no infor:ation on which to base the interval for routine reinsyections. Crawford states that he is entirely satisfied with the work of Dr. Silva who is just now completing his first @ix months of service; I therefore authorise 9 two hundred milreis ver month increase in his selary. July 1. Visit roof gutters of one two ond three weeks ago; find some corrections —~ made, more not made. We tae ‘cm seven meters of gopoergutter in a "repeater", Crawford and I agree that it would probebly be well to have » special squad to visit all roof gutters where foci have been found fifteen days after the discovery of the first focus. Roof gutter breeding in Para will probably be a ereater problem in the dry months then in the rainy season as there is throughout the year some rain which will beep weter in the utters but which will seldom 2 te come down in sufficient quantity to flush them out. keceive wire from Kio asking authorization to advace one months salary to Dr. Kenoel Leal Ferreira who leaves on July 3rd for the USA; suthorise this as it had already been promised by Dr. Conmor. Advise Sad Luis, Fortaleza, hatal, Recife, Bahia, Behia Lab and Rio of my schedule till the 15th of July. Dr. Crawford and I visited the house where Edgar Faria, the six year old Brazilian child, living in the city of Belem, discovered to-have had through routine autonosy on May 21st, died, The nouse is one of the pporer type structures of one story but is outside of the heavy malaria zone. At first the family insisted that there had been no other cases of illness in the family but when they discovered that our intentions were of the best and that we were anterested in other than fatal or nigh unto fatal illnesses, they admitted that five of the twelve persons resideing in the house had suffered from attacks of fever, headache, bodypains and vomiting between January and June of this year; these attacks were sufficiently severe to cause confinement to bed for from four to thirty days. From the history given, I believe malaria can be ruled out in these cases and am conyinced that there were probably a series of cases in this family but that because of large number of immunes in surrounding housés or low of steromyia serving as vectors, there was apnarently no local ex- osion of the disease.A Tater visited the house of Lucimar Passos in Val de Caes but were able to obtain no further information than that already noted June 29. NeT CONFIRMED By PROfECTION TESTS, Vury 1933 - Retfanaimnalio, une) (AF 000 Quyrerd