585-608 SSS-408380

Imperfect tools for a difficult job: Colposcopy, colpocytology and screening for cervical cancer in Brazil
Luiz Antonio Teixeira Ilana Lwy
Social Studies of Science 41(4) 585608 The Author(s) 2011 Reprints and permission: sagepub. co.uk/journalsPermissions.nav DOI: 10.1177/0306312711408380 sss.sagepub.com
Casa de Oswaldo Cruz, Fiocruz, Brazil
Centre de Recherche Medicine, Science Sant et Societ (CERMES), Paris
Abstract
The quasi-totality of social scientists who studied screening for cervical tumours identified such screening with a single method: the Pap smear (exfoliative cytology). This article explains that this method was not valid everywhere. The history of screening for cervical cancer in Brazil displays an alternative method for detecting cervical malignancies: a direct observation of the cervix with a specific instrument the colposcope. The development of this method in Brazil in the 1940s and 1950s reflected a complex mixture of professional interests, government policies, and regional, local and charitable initiatives. While the use of colposcopy for cervical tumour screening was phased out in the 1970s and 1980s, the long lifespan and widespread diffusion of this method illuminates the irreducible contingency of specific developments in science, technology and medicine. Seen from the vantage point of Brazil, the Western model for preventing cervical malignancies no longer appears self-evident. Alternative choices might have led to the development of different material and visual cultures of medicine, stimulated different patterns of medical specialization and division of medical labour, produced different links between malignancies, women, gynaecologists, epidemiologists and public health experts, and shaped different health policies.
Keywords
cervical cancer, colposcopy, health politics, medical practice, pap smear
Corresponding author: Luiz Antonio Teixeira, Casa de Oswaldo Cruz Fiocruz Av. Brasil 4365 sala 403, Rio de Janeiro, Brasil, Cep 21040-361. Email: teixeira@fiocruz.br
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Social Studies of Science 41(4)
In the 19th century, cancer of the uterine cervix (the lower, narrow part of the uterus) was the leading cause of cancer mortality among women (Moscucci, 2005). In the 21st century, it has become much less frequent among women who live in industrialized countries. Experts have often attributed this sharp reduction of mortality rate to the introduction of screening programmes that detect and eliminate cervical lesions before they become cancerous (Peto et al., 2004).1 Historians and sociologists have addressed numerous topics related to screening for cervical cancer, such as: stabilization of techniques, standardization and interpretation of results, training of specialists, practical organization of screening campaigns, educational and public health campaigns, controversies over cost-effectiveness and ethical issues. However, they implicitly take for granted that the history of the early detection of cervical malignancies involved the development and diffusion of a single approach the Pap smear (Papanicolau test, exfoliative cytology) (Armstrong and Murphy, 2008; Bryder, 2008; Casper and Clarke, 1998; Keating and Cambrosio, 2003; McKie, 1995; Singleton and Michael, 1993; Vayena, 1999).2 In this article, we argue that the identification of screening for cervical malignancies with the Pap smear was not the same everywhere. The history of screening for cervical cancer in Brazil displays alternative pathways and different solutions, and shows how knowledge about cervical cancer and precancerous lesions was locally produced through the alignment of heterogeneous elements. These local arrangements were later destabilized and replaced by approaches prevalent in Western Europe and North America. Before the introduction of exfoliative cytology, the only way to detect early cancerous changes in the cervix and catch the cancer at a curable stage was regular gynaecological examinations and visual inspection of the cervix. Doctors attempted to persuade women to undergo such examinations (Aronowitz, 2008; Gardner, 2006), but their campaigns reached only a small number of women. The introduction of exfoliative cytology led to a rapid increase of the number of women screened. It also produced new problems: uncertain diagnoses, false-negative and false-positive results, and overtreatment (Russell, 1994; Welch, 2004). Mass screening for cervical cancer was far from being an unmixed blessing (Bryder, 2009; Etzioni and Thomas, 2004). Initially, experts viewed the Pap smear as a definitive diagnostic test. In the 1950s and 1960s, however, persistent difficulty with homogenizing the classification of abnormal cells and defining uniform diagnostic criteria led to a change in the status of this test. The Pap smear became mainly a triage method a first screen that indicated a need for further investigation. In industrialized countries, women with positive Pap smears are invited to undergo colposcopy: a visual examination of the cervix with an optical instrument the colposcope. If suspicious lesions are observed, the patient undergoes a biopsy and the excised tissue is analysed by a pathologist. In some cases, direct observation of the cervix leads to a clean bill of health and a reclassification of a positive Pap smear as a false-positive result. In other cases, colposcopy and biopsy lead to a diagnosis of an already existing malignancy or dysplasia (an abnormal, potentially precancerous proliferation of cells). In still other cases, the patient receives a diagnosis of atypical squamous cells of unknown significance (ASCUS). Women with this diagnosis have frequent vaginal smears and gynaecological examinations, and, if the ambiguous results persist over time, they undergo a preventive treatment.
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In Western Europe and North America, this sequence a Pap smear for all women followed by a colposcopy only for those with positive vaginal smears was usually presented as the only rational approach for detecting cervical lesions. Latin American countries were different. In this continent, particularly in Argentina, Brazil and Chile, for a long time colposcopy was seen as a viable alternative to the Pap smear as the primary way to detect cervical lesions (Eraso, 2010).3 Some Latin American gynaecologists proposed the use of colposcopy as an initial screening tool, offering exfoliative cytology (the Pap smear) only to women with abnormal colposcopy findings. Others advocated simultaneous colposcopic and cytological examinations. From the late 1940s onwards, leading Brazilian gynaecologists implemented screening programmes that employed colposcopy as the initial screening tool. The rise of a distinct Latin American approach to screening for cervical tumours may be viewed as the result of contingent events. Colposcopy was invented in Germany in 1924, and was mainly diffused to German-speaking countries during the interwar years. At that time, numerous Latin American gynaecologists maintained close links with their German and Austrian colleagues. Moreover, these links were not interrupted or diminished by World War II. Colposcopy was introduced to Brazil in the early 1940s, a period unfavourable for the diffusion of German innovations in Western Europe and North America. Once established, colposcopy was able to successfully compete with the Pap test, a method originating in the US. However, ties between Brazilian and German gynaecologists are only part of the story. In Brazil, the rise of colposcopy a method that originated in a gynaecologists office and was grounded in regular visits to a specialist might have been favoured by health policies that promoted private or charity-sponsored healthcare and did not view malignant tumours as a public health problem. Systematic efforts to control cancer in Brazil started with the creation of the Servio Nacional do Cncer (SNC) in 1942 (Teixeira, 2009: 108). The SNC was formed by a central institute (today called the Instituto Nacional de Cncer (INCA) and the Campagne Nacional Contre le Cancer (CNCC), a network that included state-funded and philanthropic hospitals and charitable organizations.4 This alignment of institutions and organizations may seem impressive, but in fact the initial scale of SNCs interventions was very modest. It expanded somewhat in the 1950s. At that time, the Brazilian government increased the number of hospitals that had agreements with the CNCC and promoted the modernization of INCA, while private hospitals began to offer treatments to cancer patients covered by social security.5 Yet, these measures had only a limited scope. Most Brazilians did not have access to specialized treatment for malignancies (Teixeira and Fonseca, 2007). Low levels of public investment in cancer treatment reflected the priorities of a country still ravaged by lethal transmissible diseases such as malaria and tuberculosis. The prevention of cervical malignancies was similarly grounded in small-scale initiatives. In the 1940s and 1950s, there were a few university clinics and charity-sponsored cancer hospitals ambulatory centres dedicated to treatment of female breast and ovary cancers. Gynaecologists affiliated with these centres usually advocated colposcopy to screen for cervical tumours. Still a small enterprise in the 1960s, the prevention of cervical tumours remained the responsibility of individual doctors, charities, and selected academic centres; an approach that resonated with the liberal economic
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orientation vigorously promoted during the military dictatorship in Brazil (19641985).6 The strong institutional and political standing of some of the gynaecologists interested in colposcopy further helped to promote the technique. On the other hand, Brazilian politicians and public health specialists, including those who were active during the military dictatorship, were interested in international recognition and participation in transnational initiatives. In the early 1970s, the Pan American Health Organization (PAHO) highlighted the importance of cervical cancer as a major public health problem in Latin America and began encouraging prevention campaigns grounded in the use of the Pap smear, an approach already favoured by some Brazilian experts (Joly, 1977). PAHOs initiative favoured the establishment of a Brazilian National Program for the Control of Cancer (PNCC) in 1973, piloted by the Ministry of Healths Diviso Nacional do Cncer7 The PNCC-sponsored prevention campaigns intensified in the 1980s and consolidated the use of exfoliative cytology for cervical tumour screening (Lago, 2004). The alternative models of screening for cervical malignancies in Brazil persisted for nearly 40 years. Their long lifespan brings into question the presumed inevitability of the use of the Pap smear to detect malignant and premalignant lesions of the cervix. One of the key methodological innovations of Michel Foucault, his colleague Paul Veyne proposed, was to use history to make the familiar strange (Veyne, 1979). Seen from the vantage point of the history testing in Brazil, the use of exfoliative cytology as a first screening tool no longer appears self-evident. Alternative choices might have led to the development of different material and visual cultures in medicine, stimulated different patterns of medical specialization and divisions of medical labour, produced different links between malignancies, women, gynaecologists, epidemiologists and public health experts, and shaped different health policies. The tangled history of screening for cervical cancer in Brazil was produced by a complex mixture of governmental policies; regional, local and charitable initiatives; professional arrangements; and economic constraints. Locally determined, heterogeneous arrangements and spatial distribution of actors, resources and power produced divergent perceptions of womens bodies and shaped the complex trajectory of a new medical technology (Latour, 2005; Law and Bijker, 1992; Mol, 2002).
Colposcopy and colpocytology in Brazil:The beginnings

In the 19th century a diagnosis of cervical cancer was invariably a death sentence. The development of radical hysterectomy and radiotherapy (using radium, x-ray radiation or both) in the early 20th century made occasional cures of cervical cancers possible. Doctors noted, however, that only localized (stage I and II) tumours could be cured. Tumours extending beyond the cervix and invading other organs and tissues (stage III and IV), were, as a rule, incurable. Sadly, women who consulted gynaecologists for symptoms such as pain, vaginal discharge and irregular bleeding were often diagnosed with an advanced cancer. Doctors argued that the only way to decrease mortality from cervical malignancies was to promote early detection through regular visual examination of the cervix. In 1924, German gynaecologist Hans Hinselmann developed the colposcope a binocular microscope specially adapted for the observation of the cervix. This instrument
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facilitated the diagnosis of cervical malignancies and other gynaecological diseases (Hinselmann, 1952). In the early 1930s, an Austrian gynaecologist, Walter Schiller, found that when the cervix was stained with diluted iodine (lugol), normal tissue adsorbed this stain, while zones of abnormal cell proliferation remained white (Schiller, 1933). The combination of both methods colposcopy and lugol staining amplified the efficacy of each. Yet the identification of lugol-free zones of the cervix and colposcopical observations became accurate only after long periods of training of the experts eye. In the 1930s and 1940s, colposcopy was rarely used outside German-speaking countries, with one important exception: Latin America. The importance of colposcopy in Latin America is illustrated by the fact that Professor Wood from Chile, the keynote speaker at the First Brazilian Congress of Gynaecology and Obstetrics (September 1940), dedicated an important part of his discourse to uses of this technique (Wood, 1940). The organization in 1940 of a national congress of gynaecology was a sign of rapid growth of this discipline in Brazil. In 1936, the first chair of gynaecology was created at the Faculty of Medicine of Universidade do Brasil in Rio de Janeiro (today Universidade Federal do Rio de Janeiro). The incumbent of this chair, Arnaldo de Moraes, was a prominent figure in Brazilian gynaecology who received a Rockefeller Foundation scholarship to study pathology at John Hopkins University in 1927. De Moraes was a highly successful scientific entrepreneur. Upon his arrival in Rio, he founded the journal Anais Brasileiros de Ginecologia and the Sociedade Brasileira de Ginecologia. He also founded a gynaecology institute that attracted young researchers interested in new diagnostic and therapeutic approaches.8 In 1942, one of De Moraess collaborators, Joo Paulo Rieper, published a thesis on the uses of colposcopy for diagnosing gynaecological diseases (Rieper, 1942a). Rieper studied colposcopy with Hinselmann, and was recruited by De Moraes to introduce the new diagnostic technique to the Rio clinics.9 Rieper imported the instrument, but also Hinselmanns complicated terminology: transformation zones, pseudo erosion, green erosion, diffuse colpitis, base, mosaics, and so on. Rieper found that nearly every woman who underwent colposcopic examination (184 out of 200) had some kind of cervical anomaly. The complexity of Hinselmanns classification system probably accounted for some of the difficulties in adapting this technique for screening, an approach that aims above all to separate the normal from the pathological (Rieper, 1942b). Also in 1942, another assistant from the Gynaecological Clinics of the National Faculty of Medicine of University of Brazil, Vincente Ramos, published a thesis about the use of the cervical smear renamed colpocytology for early diagnosis of cervical malignancies (Ramos, 1942, 1943). Ramos faithfully applied the method, which had been described a year earlier by Papanicolau and Traut (1941). The rapidity with which the new technology was transferred to Brazil might have been facilitated by the fact that Brazilian gynaecologists were already familiar with vaginal smears and used this method to follow changes in hormonal activity in women (Quinet, 1940).10 The 1942 publication of a thesis on colposcopy, and another on exfoliative cytology by De Moraes students, were not chance events. De Moraes strongly advocated a combined use of these two techniques for early diagnosis of cervical malignancies (de Moraes and Lima, 1945). The choice of the term colpocytology might have reflected the wish to associate these two diagnostic approaches, but also to stress the priority of
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the older technique, colposcopy. Each method, de Moraes argued, produced erroneous diagnoses approximately 20% of the time, but the sources of error were not the same. A simultaneous use of both methods thus greatly increased the accuracy of diagnosis, especially when results were confirmed by an examination of biopsy material made by a trained histopathologist. The local culture of the Gynaecology Institute strongly favoured the triple model: a combination of colposcopy, colpocytology and histopathology (Rieper, 1945). De Moraes (1948a) energetically promoted colposcopy. The diffusion of this technique was, however, hampered, by difficulty with homogenizing colposcopic diagnoses. Terms used by colposcopists to describe changes in the cervix were complex and loosely defined, while the co-existence of several competing classifications of cervical lesions further complicated agreement on colposcopic diagnoses (Luz, 1954; Rieper and Maldonato, 1969).11 Since colposcopy required a tacit skill transmitted from master to pupil, Hinselmanns visits to Brazil played a central role in the diffusion of this method (Rieper, 1950a). After World War II, Hinselmann was sentenced for 3 years in prison for illegal racial sterilization of gypsy women, and was stripped of his academic privileges.12 Liberated from jail in 1949, he was invited to Latin America, and he described his enthusiastic reception in Brazil as a corner of blue sky (Rieper, 1959a). In the 1950s, Hinselmann made several visits to Brazil, the final one in 1958, a year before his death. During these visits, he organized practical courses on colposcopy in Belo Horizonte and Rio de Janeiro, and taught Brazilian gynaecologists how to recognize cancer and precancerous lesions (Rieper, 1950b; Rocha, 1955). The prophylactic destruction of the latter, Hinselmann stressed, completely eliminates the danger of cervical cancer. Sufferings induced by this malignancy were unnecessary, since they could be prevented by an efficient use of colposcopy (Hinselmann, 1951).
Ambulatrio Preventivo and the consolidation of the triple model

De Moraes rapidly expanded his Gynaecological Institute. In 1942, the Institute opened a consultation on sterility and a Roentgen therapy service. In 1945, it opened an experimental laboratory and a documentation service, and in 1948, the Ambulatrio Preventivo de Cncer Ginecolgico. In the same year, the Institute obtained legal status within the University of Brazil. The Ambulatrio Preventivo fully adopted the triple model for detecting cervical lesions. Joo Paulo Rieper was responsible for colposcopic examinations. Clarice do Amaral Ferreira, a gynaecologist trained in cytology in Argentina, took over the reading of Pap smears, and a German physician Hildegard Stoltz organized the data on diagnosis and treatment. De Moraes and his assistants claimed that the systematic combination of colposcopy, colpocytology and biopsy at the Ambulatorio greatly increased the efficacy of detecting cervical lesions (de Moraes, 1948b). The logic of the triple method was summed up in a title of a 1975 article: Better cytology with more colposcopy (Periera et al., 1975). During its first year, the Ambulatrio received 35 to 40 patients each morning, each of whom underwent a careful colposcopic examination. This was an intensive and difficult work, all the more so because Rieper and his colleagues used an old colposcope
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and had no technical help. Later the Ambulatrio hired technicians, reducing the number of patients examined in each session. The main task of the Ambulatrio was didactic: a demonstration of feasibility of a triple model and promotion of the diffusion of this approach in Brazil (Rieper, 1959b). Rieper wrote articles about colposcopy, taught colposcopy courses in several Brazilian universities, and was active in the 1958 foundation of the Sociedade Brasileira de Colposcopia. Similarly, do Amaral Ferreira promoted vaginal cytology, and co-founded the Sociedade Brasileira de Citologia in 1956. De Moraes and his colleagues strongly advocated the extension of colposcopic screening. He even toyed with the idea of compulsory screening for all the Brazilian women between 35 and 60 years old, or, at least, to introduce obligatory screening of selected categories of women such as civil servants (de Moraes, 1945). However, the diffusion of colposcopy in Brazil was hampered by a lack of resources.13 Brazils public hospitals were severely understaffed and colposcopists were obliged to work in sub-optimal conditions: without assistants and with inadequate light (ideally, colposcopic observations should be made in semi-darkness, but in a hot climate it was difficult to keep curtains and shades permanently closed without air-conditioning, a luxury unavailable in public facilities). They also were obliged to use less expensive, and consequently lower performing, instruments. Rieper argued, however, that a well-trained colposcopist could provide efficient services even under such difficult conditions (Rieper, 1955). The key element for advancing screening for cervical malignancies was training a sufficient number of experts. In order to meet Brazils needs, it was necessary to educate 10,000 colposcopists and several thousand cytologists and pathologists; a slow, costly but indispensable process (Rieper, 1971). The proposal to greatly increase the number of colposcopists received official support under the military dictatorship. In 1970, Rieper, together with Clovis Salgado, professor of gynaecology at Minas Gerais University in Belo Horizonte, and an enthusiastic supporter of the triple model, published a textbook of colposcopy for medical students (Salgado and Rieper, 1970). Salgado had a dual career as a gynaecologist and as a politician. He was twice elected vice-governor of the State of Minas Gerais in 1950 and 1956, governed that State in 1955, and was Minister of Education and Culture in 1956, under President Juscelino Kubitschek. Later Salgado supported the military regime and became the Health Secretary of Minas Gerais State and a member of the Federal Education Council (Fundao Getlio Vargas, 1984). Salgados political influence in all probability helped to secure government support for the teaching of colposcopy. Salgados and Riepers 1970 textbook was published by a government office, Fundao Nacional de Materiais Educacionais, and thousands of copies were distributed. The textbook stressed the importance of colposcopy as an initial screening technique, a key role for rapidly diffusing this method, and it also stressed the complementary nature of colposcopy and cytology (Salgado and Rieper, 1970).
From early detection to prevention: Colposcopy, cytology and stage zero cancer.
Between the 1940s and 1960s, the goal of screening for cervical cancer was to detect an already existing malignancy. The decision to name a clinic opened at the Univesidade
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do Brazil Ambulatrio Preventivo was made, mainly for psychological reasons (Rieper, 1959b). However, in the 1950s and 1960s, gynaecologists became increasingly interested in the detection and elimination of non-invasive precancerous lesions of the cervix: high-grade dysplasia and in situ carcinoma (cancer stage 0). At that time, the goal of screening gradually shifted from early diagnosis of an already present tumour to eliminating the danger of future cancer that is, to provide a truly preventive intervention. The Rio de Janeiro Ambulatrio reported that 10% of cervical malignancies diagnosed at this institution were stage 0 cancers. In the 1950s, the standard treatment for this lesion was ablation of the cervix for women under 40 years old and a surgical removal of the uterus for those over 40 years old. Some of the diagnosed women refused surgery, producing a natural experiment that revealed that many of these women did not develop cancer (Rieper, 1968; Stoltz, 1955). This observation initiated a debate on the status of precancerous lesions: very early cancer or cancer risk. Hinselmann claimed that it was absurd to speak about a carcinoma in situ or cancer stage 0, because a non-invasive cancer is a contradiction in terms. He elected to speak instead about carcinomateus epithelium, and advocated a conservative treatment of such abnormal epithelium: either excision biopsy or surveillance (Hinselmann, 1951). At first, Hinselmanns Brazilian followers did not adopt his position. They had chosen to use the term stage 0 cancer, which implied that these lesions were already cancerous, and promoted radical surgical treatment. However, in the 1960s, they switched to more conservative approaches such as conical biopsy (Maltez et al., 1965). With an increased focus on the diagnosis of precancerous lesions, debates on the relative efficacy of colposcopy and cytology focused on the capacity of each method to detect such lesions. Advocates of colposcopy reported important discrepancies between colposcopic and cytological findings, arguing that while the Pap smear was an efficient method for visualizing an invasive cancer, colposcopy, especially when coupled with biopsy was a more sensitive tool for the detection of premalignant lesions (Salvatore et al., 1976a; Stoltz, 1953). Supporters of cytology promoted the opposite view: cytology enabled the detection of premalignant changes even when the external aspect of the cervix was normal (Ferreira, 1952; Nestares et al., 1977). Finally, the promoters of the triple model argued that only a combination of colposcopy and Pap smear led to the detection of nearly all the precancerous lesions (de Moraes, 1953; Rieper, 1968).
The diffusion of the triple model of screening in Brazilian cities.

Even before the opening of the Ambulatorium in 1948, the Rio de Janeiro Gynaecological Clinic was seen as a model for detecting cervical malignancies. De Moraess approach directly inspired Salgados initiatives in Belo Horizonte. Salgado employed his considerable political influence to promote his views on screening for cervical tumours. In 1944, he inaugurated the Red Cross service for detecting cervical tumours in Belo Horizonte (Posto de Combate de Cancer de Cruz Vermelha) (de Moraes, 1944). The centre, which employed a colposcopist trained by Rieper, faithfully applied the triple method. Every woman underwent a colposcopic examination, a Pap smear, and, if necessary, a biopsy of detected cervical lesions (Rocha, 1955). The triple model was applied in two additional screening clinics later opened in Belo Horizonte. Hinselmanns 1949 course of colposcopy in Belo Horizonte further consolidated the status of this technique in Minas Gerais.
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The Gynaecology and Obstetrics Department of Medical Faculty Ribeiro Preto of So Paulo University (USP) started a screening programme for cervical malignancies grounded in the triple model in the 1950s. The simultaneous use of cytology and colposcopy was legitimated by the claim that a combined use of both techniques greatly reduced the danger of false-negative results. On the other hand, the triple method was labour-intensive. In the early 1960s, it became difficult to provide a colposcopic examination and Pap smear to all screened women. The solution chosen at Ribeiro Preto and in Hospital das Clnicas in So Paulo was to limit colposcopical examinations to women over 35 years old (Baruffi and Martinez, 1962). Doctors from the gynaecology and obstetric services of the Francisco Morato Hospital in So Paulo made the opposite choice. They simultaneously employed colposcopy and cytology, but believed that if one is obliged to choose only one technique, one should favour colposcopy coupled with biopsy, because a Pap smear alone was much less reliable (Lima et al., 1975). Gynaecologists from the preventive services (Instituto Nacional de Previdncia Social (INPS) of So Paulo, founded in 1969) shared this view. An optimal screening, they argued, should include colposcopy and cytology, but the central element of such screening was a colposcopic examination (Acuri, 1974). Specialists from another So Paulo centre, Gynaecological Clinics of Faculdade de Medicina da Universidade de So Paulo (FMUSP), stressed the importance of combining colposcopic and cytological testing for diagnosis of precancerous lesions. At their centre, cytology alone failed to detect 13.5% of such lesions, and colposcopy alone 6.3%. However, when employed together, the percentage of false negatives was reduced to 2.5% (Salvatore et al., 1976b). A similar argument was developed by gynaecologists from the Ambulatorio Preventivo of Rio Grande do Sul in Porto Alegre. All women screened at this clinic in the 1970s underwent a colposcopy, Schillers test and a Pap smear, an approach that favoured an optimal detection of premalignant lesions (Soldan et al., 1977). Ambulatrio Preventivo of Univesidade do Brazil was not the sole centre for screening cervical malignancies in Rio de Janeiro. INCA opened a screening centre in 1952. This centre, headed by a colposcopist trained by Hinselmann, employed the triple model, relying strongly on colposcopy (Servicio Nacional de Cncer, 1967). In the 1970s, Rio de Janeiro had nine centres, in addition to the Ambulatrio, specializing in screening for cervical lesions. All these centres employed the triple model, with a single exception: the screening centre of Legio Feminina de Educao e Combate ao Cncer, which relied exclusively on colposcopical examinations. The Rio de Janeiro centres employed 42 cytologists, 71 colposcopists and 17 pathologists. In spite of the multiplication of centres, in the 1970s only approximately 11% of women in Rio de Janeiro had access to screening for cervical tumours (Rieper et al., 1977). The triple model remained popular in Rio. As late as 1987, a pilot project funded by a private organization, Fundaao Bela Lopez de Olivera, employed a mobile colposcopy unit to examine 481 female workers at a factory in Rio de Janeiro state. Each colposcopic examination lasted about half an hour. The aim of this project was to demonstrate that it is technically possible to export methods employed in a private gynaecological practice to economically disadvantaged sites (Pasqualette et al., 1987). The demonstration, one may assume, was not very persuasive. In the 1980s, the main governmental body dealing
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with malignant tumours, the National Program of Cancer Control, exclusively promoted screening campaigns grounded in the use of the Pap smear.
The triple model in rural settings: Contrasting experiences

Some gynaecologists claimed that colposcopic examinations could be conducted only in big cities (Campos da Paz and Campos da Paz, 1966). Others gynaecologists believed, however, that women in the countryside were also entitled to high quality gynaecological care (Ferreira Filho, 1975). In the 1960s, social pressure to expand the coverage provided by the Brazilian social security health system to rural workers led to the founding of a new governmental agency, the rural assistance service, Fundo de Assistncia e Previdncia do Trabalhador Rural (FUNRURAL).14 Organizers of a pilot campaign conducted by Santa Maria Citys FUNRURAL, in collaboration with a private medical company Servio de Assistncia Mdica Particular (SAMPAR), claimed that this campaign had shown that it is possible to transport high-quality colposcopic equipment to the countryside (Souza, 1977). The organizers of a small screening campaign in a rural area of Minas Gerais similarly argued that it is perfectly possible to provide high-quality colposcopic screening in such a region, and that such screening is also cost-effective. It limited the number of false-negative and false-positive results, and unnecessary biopsies, and thus reduces the overall costs of detecting each cancer or precancerous lesion (Ferreira Filho, 1975). A screening campaign in rural zones of Parana State, proposed a mixed model of screening. This campaign employed mobile intervention units. In the first stage, three or four physicians were sent to a targeted municipality to prepare for the campaign. In the second stage, buses transported 50 to 60 people doctors, nurses, secretaries and social workers to that municipality. The mobile units organized screening, educational activities and standardized collection of data, and left once these tasks were accomplished. The organizers of the Parana campaign believed that, ideally, screening for cervical lesions should include cytology and colposcopy. They found out, however, that the exportation of the triple model outside big cities was a complicated endeavour, and settled for a compromise: Pap smear only for the majority of the screened women, and the addition of colposcopic examination in selected demonstration localities (Paciornik, 1976).
Alternative models: Health policy and cytology-based screening in the 1960s and 1970s
While some local and regional campaigns conducted in the 1960s and 1970s adopted the triple model, other campaigns adopted the Pap smear as a first screening tool. A cytology-based campaign was conducted in 1967 in the interior of the Bahia state. It was initiated in 1967 by gynaecologists from the Aristides Maltes Hospital in Salvador da Bahia and Liga Bahiana Contra o Cancer, and received financial help from state and federal authorities and from the national oil company, Petrobras (Barros, 1977; Galvao Filho and Monteiro, 1971). This programme was partly inspired by the campaign conducted in rural areas of Parana State, but with two important differences: colposcopy was reserved exclusively for women with abnormal Pap smears, and screening was
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performed by a fixed group of staff in order to promote regular screening. Directors of the Bahia campaign claimed that thanks to efficient organization, they were able to greatly reduce the costs of screening. An additional cost reduction could be achieved by simplifying the staining and fixation of slides and partially replacing skilled cytologists (often physicians) with cytotechnicians (Teixeira, 1970). In the states of Pernambuco and Paraiba in north-eastern Brazil, a Pap smear-based screening for cervical lesions was organized by Fundao Servio Especial de Sade Pblica (FSESP) with the collaboration of the Diviso Nacional do Cncer from the Ministry of Health. The FSESP was a unique structure: a public health service co-financed by the American and Brazilian governments, and endowed with an important degree of administrative and financial autonomy. FSESPs precursor, the Servio Especial de Sade Pblica (SESP), created in 1942, was a collaborative BrazilianAmerican endeavour. At that time, the US government aimed to promote the control of transmissible diseases in areas of Brazil seen as vital to the US economy, especially during wartime. Health centres managed by SESP (renamed FSESP in 1960) adopted North American approaches and technical standards (Campos, 2006). An earlier attempt to introduce Pap smear-based screening in seven cities within the interior of Pernambuco State was unable to secure adequate material and logistical support. The programme enrolled 5824 women in 1968, but only 1707 of them were tested between 1974 and 1975 (Galvao Filho and Monteiro, 1971). Physicians in the states of Pernambuco and Paraiba consequently asked the FSESP, which was known for its administrative efficacy, to organize a new, much larger, screening campaign (Galvao Filho, 1976). The FSESP campaign was seen as a demonstration project. It started in 1975, was conducted in ten middle-sized municipalities in the two states, and enrolled approximately 300,000 women. Each locality had a screening unit, with a physician, a nurse and a health visitor who collected vaginal smears. Slides were read in two reference laboratories, and women diagnosed with abnormal smears were directed to a central Cervical Pathology Clinic in Recife for colposcopic examination and biopsy. The campaigns goal was to provide regular screening at first, annual smears, and then biannual testsfor women who tested negative for two consecutive years. All the data on screening were centralized by FSESP (Ministrio da Sade, 1975). Probably the most successful among the screening campaigns for cervical cancer of the 1960s and early 1970s was conducted in the region of Campinas. Programa de Controle de Cncer Crvico-Uterino de Campinas (PCCUC), was founded in 1968 by Jos Aristodemo Pinotti from the Gynaecology and Obstetrics Department of the Medical Faculty of Campinas University, with technical help of PAHO. A Pap smear was used as a first screen, and only women with abnormal smears underwent colposcopy. At first the screening was limited to the city of Campinas (in the interior of So Paulo State), but later it was extended to the periphery. The campaign organizers linked testing to the systematic education of women about the importance of regular screening. The Campinas programme expanded steadily through the 1970s and 1980s. The important decrease in the prevalence of cervical malignancies in the Campinas region was attributed to the programmes success. In the 1970s, PCCUC became a model for screening campaigns initiated in other towns of So Paulo State (Pinotti and Zeferino, 1987; Zeferino et al., 2006).
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One of the main advocates Pap smear-based screening in So Paulo State was Joo Sampaio de Ges, Head of the Gynaecology Department at the So Camilo Philanthropic Hospital. In 1968, the Sampaio de Ges founded the Instituto Brasileiro de Estudos e Pesquisas em Obstetrcia e Ginecologia. This philanthropic institute, financed by the Government of So Paulo State, was later renamed Instituto Brasileiro de Controle do Cancer (IBCC). Sampaio de Ges, trained at Johns Hopkins Medical School, strongly promoted Pap smear-based screening for cervical tumours. IBCC organized the training of cytotechnicians, and started two pilot screening programmes grounded in the exclusive use of cytology. The first project was conducted in a low income zone of the city of So Paulo, and the second in two middle-sized cities in industrial areas of So Paulo State: So Caetano do Sul and So Bernardo do Campo (Ges Junior et al., 1977).15 These campaigns uncovered a high incidence of cervical cancers and precancerous lesions, especially among the poor and recent migrants to the area. Sampaio de Ges and his colleagues concluded that IBCCs pilot programmes demonstrated the feasibility of Pap smear-based screening for cervical cancer in Brazil (Ges Junior and Ges, 1982). Official reports of the screening campaigns of the 1960s and 1970s presented them as successful endeavours. The reality was more sobering. All the screening campaigns, those that privileged colposcopy, those that applied the triple model and those that favoured cervical smears, were woefully inadequate when measured against Brazils needs (Galvo Filho, 1976). Even at locales with multiple screening centres, such as Rio de Janeiro, morbidity and mortality rates indicated that preventive actions had only a modest effect if any at all on the incidence of cervical cancer, the proportion of women diagnosed with advanced, incurable tumours (stages III and IV), and the mortality from this disease.16 The situation was even worse outside the big cities. Created in a fragmented manner and working in a discontinuous fashion, programmes destined for Brazils interior generally reached only a small number of women. In the mid-1970s, the growing realization that some parts of Brazil had alarmingly high rates of mortality from cervical cancer, coupled with PAHOs pressures to promote Pap smear-based screening in Latin America, led to an increase of government interest in the prevention of this disease. In 1973, Sampaio de Ges was named Director of the National Division of Cancer of Health Ministry. One of his first interventions in this position was to create the PAHO-sponsored Programa Nacional de Controle do Cancer (PNCC), which promoted an early diagnosis of cervical cancer. PNCCs aim was to export the model elaborated by IBCC in So Paulo to other Brazilian states. PNCC also signed conventions with PAHO to promote the training of cytotechnicians and the standardization of cancer registries (Teixeira and Fonseca, 2007). Sampaio de Ges directed the PNCC for only 2 years, but his activities during his tenure probably played an important role in securing official support for alignment on the internationally accepted method and the adoption of cytology-based mass-screening campaigns. Such support was intensified in the late 1980s, during the transition from a military dictatorship to democracy. The growing adoption of the Pap smear as a first screen modified the meaning of colposcopic examinations. The focus in such examinations shifted from a specific diagnosis grounded in Hinselmanns terminology to the use of the colposcope to retrieve tissue samples that were then analysed by pathologists. A 1993 comparison of results from colposcopy and cytology illustrates this change. This study can be included
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in the long series of efforts to correlate results obtained with these two approaches, but with a twist. In earlier periods, gynaecologists attempted to correlate images observed through the colposcope with cytological data. The authors of the 1993 study equated colposcopical results with biopsy material, and compared two kinds of microscopic preparations: vaginal smears and cervical biopsies. The sophisticated diagnostic method developed by Hinselmann and his students was reduced to a search for suspicious regions of the cervix (Reis et al., 1992).
Transformation of cervical cancer into a public health problem

One of the main reasons for the increased interest in mass-screening for cervical tumours in the 1980s was a growing concern with gynaecological cancers as a public health problem. Programa de Ateno Integral Sade da Mulher (PAISM), created in 1984, and the Pro-Onco programme, created in 1987, listed the reduction of cervical tumours among their main goals (Lago, 2004). In the late 1980s, the two branches of Brazilian health services, the Social Security Medical Assistance branch and the Public Health branch, were reunited in Sistema nico de Sade (SUS).17 INCA absorbed the Pro-Onco programme, thus becoming responsible for the elaboration of national cancer policies. In 1995, Brazilian delegates to the VI International Womens Conference in Beijing stressed the importance of better control over gynaecological malignancies. That year, INCA started the Viva Mulher campaign for cervical cancer screening. Initially conceived as a pilot project, Viva Mulher was implemented in six state capitals. In 1998, the Ministry of Health transformed this project into a permanent programme for all Brazilian women (Instituto Nacional de Cncer, 2002a; Moraes, 1997). The limited success of campaigns by organizations such as FUNRURAL and INPS in the 1960s and 1970s may be related to the overall weakness of Brazilian state-sponsored health services at that time (Galvao Filho, 1976). Neither of the two branches of the national health service the individual-centred social security system, which focused on therapy, and the public health sector, which focused on prevention and control of transmissible diseases (vaccination, elimination of vectors) was interested in the prevention of cancer. The supportive rhetoric of screening campaigns was not translated into a consistent and effective commitment to interventions in the field. However, in the 1980s and 1990s, cervical cancer increasingly was perceived as a social problem in Brazil, as the disease was more prevalent among underprivileged women. The view of cervical cancer as a pathology linked to poverty was not entirely new. In 1967, Adonis de Caravalho noted that because cervical tumours were especially frequent in the north of Brazil, some doctors classified this pathology among tropical diseases. But, in fact, a high prevalence of cervical tumours in hot regions is not related to climate. Tropical frequently stands for poor, and poorer regions of Western countries also have higher rates of cervical cancer. The elevated incidence of this cancer in northern parts of Brazil reflected a combination of malnutrition, poor hygiene, early sexual relationships, lack of medical services and an elevated number of pregnancies. The high mortality rate from cervical malignancies in northern Brazil, de Caravalho concluded, was a drama of misery, ignorance and social suffering (de Caravalho, 1967: 86).
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From the 1960s on, Brazilian epidemiologists linked a higher prevalence of cervical cancer to smoking which, in the 1950s and 1960s, was independent of class and to the early onset of sexual activity, multiple sexual partners, early pregnancies, poor hygiene and inadequate nutrition (class-dependent variables) (Chaves, 1968; Salvatore, 1976). In the 1980s and 1990s, epidemiologists and public health experts proposed to direct preventive efforts to low-income women (de Caravalho, 2004; Lima et al., 2006). The view of cervical cancer as poverty-related disease competed, however, with the perception of the disease as a threat to all women. The latter view was implicitly incorporated into a new version of Viva Mulher programme. From 2001 onwards, this programme added to its goals screening for breast cancer, a disease that is more prevalent in women from higher socioeconomic status (Bicalho and Aleixo, 2002). The inclusion of screening for breast tumours in a campaign directed mainly at women who could not afford regular visits to a gynaecologist implicitly played down the role of poverty as a risk factor for cervical malignancies. In practice, two regimes of screening for cervical cancer co-exist in Brazil today. Middle-class, urban Brazilian women who have private health insurance often undergo regular (usually yearly) gynaecological check-ups, which include a Pap smear, but often also a colposcopic examination, since this instrument remains popular among Brazilian gynaecologists. These women follow a variant of the triple model: a cervical smear, a colposcopic examination and, if necessary, a cervical biopsy. They also can negotiate with their doctors over the frequency of vaginal smears and the age at which they wish to start and stop them (Zeferino et al., 1996). By contrast, Viva Mulher faithfully apply the PAHO guidelines: women with two consecutive negative Pap tests are tested every 3 years between the ages of 25 and 59 years (Instituto Nacional de Cncer, 2002b). The highest frequency and highest quality of screening are therefore found among women at the lowest risk of cervical cancer (Temes de Quadros et al., 2004). The history of screening for cervical malignancies in Brazil demonstrates the interplay between medical technologies and elements beyond the scope of medical intervention. Screening for cervical cancer in the more affluent parts of the globe is presented as an exemplary success story. The generalization of screening, epidemiologists proposed, led to a drastic decline in the prevalence and mortality from this disease (Peto et al., 2004).18 Brazilian public health experts hope to achieve similar results. The observation that the recent intensive efforts to promote screening for cervical cancer and the steep increase in the number of performed Pap smears did not lead to a decrease in mortality from this disease nationwide, and did not reduce its high incidence in north-east Brazil, is interpreted as an indication of the shortcomings of existing prevention programmes (Gamarra et al., 2010; Thuler, 2008).19 Brazilian specialists believe that a better organization of preventive services, coupled with well-targeted educational campaigns, will reduce the rate of cervical cancer in Brazil and bring it closer to Western standards (Bottari et al., 2008; Instituto Nacional de Cncer, 2002a). It is not certain, however, that this goal can be achieved without acting upon the conditions that favour the high frequency of cervical malignancies: poverty, discrimination against women, lack of adequate access to healthcare, and disrupted and chaotic lives (Gregg, 2003).20
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Conclusion
Efforts to control cervical malignancies in Brazil were shaped by the professional cultures of medicine, the availability of resources and their geographical distribution, and changing views of the entity cervical cancer. In other words, they were shaped by heterogeneous, dynamic networks (Law, 1987). Each configuration of the screening dispositif brought forth some elements of this pathology and masked others.21 In the 1940s and 1950s, an official discourse about the advantages of the triple model of screening disregarded life conditions of the majority of Brazilian women. It did not dwell on unequal geographical distribution of this disease, or its links with socio-cultural variables. Cervical cancer was seen above all as a disease that strikes blindly, putting every woman at an equal risk. In the 1960s and 1970s, this view was still prevalent among Brazilian gynaecologists. Experts such as Rieper and Salgado were aware of the fact that only a tiny proportion of Brazilian women had access to screening for cervical lesions. Their solution was to extend the triple model, grounded in voluntary visits to the gynaecology clinics, to the country as a whole. However, they did not provide realistic advice on how to achieve this goal. In retrospect, many of their writings looked more like wellintentioned wishful thinking than a public health programme. At the same time (the 1960s and 1970s) a few Brazilian experts developed a different discourse on the causes and epidemiology of cervical malignancies. They discussed the effects of poverty, early sexual activity, multiple sexual partners and early motherhood. Such a view of cervical cancer, rare at that time, became predominant in the 1980s. It may be connected to the aspiration, present in Brazil from early in the 20th century, to eliminate diseases indicating the backward status of the country (Hochman, 1998; Lima, 1999; Lwy, 2001; Stepan, 2001). It may also be linked with the description of the role of human papilloma virus (HPV) in the aetiology of cervical tumours.22 The transformation of cervical cancer into a transmissible disease strengthened the rationale of an epidemiological and social rather than purely medical approach to its prevention. Presently in Brazil, transmissible diseases are perceived above all as social issues and are seen as by-products of poverty and deprivation. Cervical cancer entered this category in the 1980s. The definition of cervical cancer as a social problem and a disease of women from lower socioeconomic strata might have contributed to the abandonment of colposcopy as an initial screen for the detection of cervical lesions. An approach that relies on expensive instruments and observations made by experts might have been perceived as less well-adapted to mass screening than the relatively simple Pap smear. On the other hand, the high cost of equipment and the need to rely on experts for the interpretation of data did not hamper the rapid spread of mammography screening for breast cancer in industrialized countries. The cost of instruments and scarcity of experts were not presented either as insurmountable obstacles to the planned extension of mammography to all Brazilian women in the framework of the Viva Mulher programme. Today, INCA experts promote the development of regional centres of mammography and mobile radiology clinics. It is not impossible to imagine similar arrangements for diffusing colposcopybased mass screening for cervical cancer. Costs and organizational problems are not sufficient to explain the demise of the Brazilian model of screening for cervical malignancies.
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The switch to an exclusive reliance on Pap smear, we propose, reflected changes in the organization of health services in Brazil during the transition from military dictatorships to democracy, the redefinition of cervical cancer as a public health problem, the long history of successful uses of Pap smear as a screening tool, and the influence of organizations such as the World Health Organization (WHO) and PAHO in promoting this tool. In the 1980s, the Pap smear was seen by experts who worked for international health organizations as the gold standard for screening for cervical malignancies. Testing and implementing an alternative screening approach in order to make it as reliable as the already validated Pap smear was probably viewed as a risky and costly enterprise (Caspar and Clarke, 1998: 274). In addition, reliance on an alternative model of screening would have made international comparisons difficult, and could have destabilized the ongoing efforts to standardize how gynaecologists, oncologists and public health specialists perceived the disease cervical cancer (Hogle, 2007: 848849). Therefore, it could have hampered efforts to better integrate Brazil into international health structures. Trajectories of scientific and medical innovation in developing or middle-income countries may be affected by important inequalities in the spatial and social distribution of resources, as well as by the existence of a large population of resource poor people. They may also be affected by broader political considerations. The development of public health in Latin America was shaped to an important extent by trans-national political variables, above all the relationships of Latin American countries with their powerful northern neighbour. The USA played a key role in health policies in Central and Latin America, either through direct intervention (Espinoza, 2009) or through the mediation of US-sponsored organizations and foundations (Birn, 2006; Cueto, 1994; Cueto and Zamora, 2006; Lwy, 2001). It is not surprising that relationships with PAHO in the 1980s played a central role in Brazil for establishing the Pap smear as the main tool for screening for cervical cancer. Between 1940s and 1970s, colposcopy-based screening for cervical cancer was a specific Brazilian development. The political status of Brazil favoured uninterrupted contacts between Brazilian and German gynaecologists in the late 1930s and early 1940s, and thus the rise of colposcopy. The use of this technique expanded in the 1950s and 1960s, thanks to the ability of key promoters to mobilize institutional support for it. During this period, colposcopic detection of cervical lesions was perceived as a do-able solution (Fujimura, 1987). This technique enabled the alignment of several levels of work organization and brought together interventions by distinct groups of actors: gynaecologists, cytologists and pathologists, nurses and health workers, hospital administrators and cancer charities. Moreover, the resonance between colposcopic screening and governmental visions of the organization of cancer care secured official support for this approach in the 1960s. However, the status of colposcopy changed in the 1980s. Important changes in Brazilian health policies and geo-political considerations and a shift in understanding of the natural history and epidemiology of cervical cancer favoured the abandonment of the unique Brazilian approach to screening for cervical malignancy and the adoption of methods favoured by international organizations. In spite of persisting difficulties to demonstrate the efficacy of the Pap smear in poorer regions of Brazil, this technique became widely perceived as the right tool for the job.
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1. The shorthand screening for cervical cancer (an actors term) often encompasses two different activities: the visualisation of suspicious cervical lesions and their destruction through surgical excision or other methods such as laser treatment. Only the latter activity can be called prevention. However, in Brazil the term prevencao became synonymous with Pap smear, a frequent source of misunderstandings and confusion (Gregg, 2000). 2. For example, a highly praised recent history of cancer states that the Pap smear had, in effect, pushed the clock of cancer detection forward for nearly two decades and changed the spectrum of cervical cancer from predominantly incurable to predominantly curable (Mukherjee, 2010: 290). 3. We are indebted to Yolanda Eraso for pointing out the specificity of Latin American screening for cervical malignancies. 4. Liga Paulista de Combate ao Cancer (So Paulo) and Liga Brasileira Contra o Cancer (Rio de Janeiro) were founded in 1934; Liga Baiana Contra o Cancer was founded in 1936 (Teixeira, 2010). 5. Between the early 1930s and late 1980s, Brazil had a social security system in which workers who held regular jobs, their employers, and the government jointly contributed to institutes that purchased health services from private suppliers. 6. The Brazilian state purchased the services of private hospitals to treat cancer patients covered by the national health insurance plan (Teixeira and Fonseca, 2007: 105). 7. The Diviso Nacional do Cncer, which replaced Servio Nacional do Cncer, was created in 1970 (Teixeira and Fonseca, 2007: 123). 8. Archives of the Academia Nacional de Medicina, Rio de Janeiro, Arnaldo de Moraes file. 9. In 1935, Moraes published a gynaecology textbook that discussed the uses of colposcopy (De Moraes, 1935). 10. Papanicolau developed the vaginal smear in 1917 to investigate the oestrus cycle in laboratory animals. This biological test was then employed to check the purity of oestrogen preparations (Oudshoorn, 1990). 11. Homogenization of Pap smear readings was also a difficult task, but the possibility of circulating microscope slides facilitated exchanges among professionals. In the 1950s, circulation of photographs of the cervix helped practitioners to compare diagnoses made by other colposcopists (Rieper, 1955). 12. Hinselmann was sentenced by a British Military tribunal for compulsory sterilization of Sinti and Romanies (source: Clauberg Verfahren, Bd. VI A, Bl. 9599). He was also suspected of collaboration with the Nazis in experiments on humans conducted in Auschwitzs (in)famous Block 10. His students, the brothers Helmut and Eduard Wirths the latter was Mengeles assistant in Auschwitz allegedly mediated the collaboration (Clauberg Verfahren, Bd. VI A, Bl. 171173). We are indebted to Martina Schlunder for this information. 13. In Western Europe and North America, one of the important obstacles for the diffusion of screening for cervical cancer was womens reluctance to undergo such screening because they found the sampling (using a speculum) painful or invasive. We did not encounter evidence of such reluctance in the Brazilian publications on screening for cervical cancer. It is possible that Brazilian women were less reluctant to undergo a gynaecological examination; it is also possible that health professionals in Brazil failed to notice such resistance to screening. 14. FUNRURAL was created in the framework of the law 4.214, ratified on 3 February 1963, on the status of rural workers. 15. The So Caetano campaign was accompanied by intensive education efforts, which its organizers reported led to a 275% increase in the uptake of tests (Oliveira Filho et al., 1977).
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16. For example, in 1941, 82.5% of cervical cancer patients seen at the Gynaecology Institute of University of Brazil, were diagnosed with advanced tumours (stages III and IV), a finding that prompted the Institutes doctors to promote an early diagnosis of cervical malignancies. Data from mid-1950s indicate that the percentage of women diagnosed with advanced tumours remained close to 80%. The rate diminished from 1959 to 1970 to approximately 65%, but the mortality rate from cervical cancer remained very high (Stehl Filho and Rieper, 1941; Stolz, 1955, 1959; Stoltz and Walty, 1970). 17. In 1988, a new Brazilian constitution established a universal and decentralized health system, Sistema Unico de Saude (SUS). 18. Some scholars strongly disagree. Linda Bryder summed up the positions of scientists who question the efficacy of screening for cervical tumours (Bryder, 2008, 2009: 8995). 19. In 2007, the estimated mortality from cervical cancer in Recife was 6.3 per 100,000, about four times higher than mortality from this disease in Western countries (1.52.5 per 100,000); the corrected mortality was even higher (Gamarra et al., 2010). 20. Gregg displays the indissociable links between coping strategies of women in Brazils northeast regions and risk of cervical cancer. A similar argument to the effect that the prevention of cervical cancer cannot be disentangled from social factors that favour the development of this disease was made by Manuel Galvao Filho (1976). 21. Michel Foucault (1994) defined dispositif as the network that links irreducibly heterogeneous elements: material entities, institutions, laws, scientific and philosophical concepts and spatial arrangements. Christiane Sinding (2007) imaginatively applied this concept in her research on technological change in medicine. 22. Some of the studies that established HPVs role in the genesis of cervical tumours followed cohorts of Brazilian women (Drst et al., 1983; Villa and Franco, 1989).
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Biographical notes Luiz Teixeira is a researcher at Casa de Oswaldo Cruz Fiocruz [House of Oswaldo Cruz Oswaldo Cruz Foundation, Brazil]. He is interested in the history of public health, particularly in the history of cancer control in Brazil. He has published (with Cristina Fonseca), From an Unknown Illness to a Public Health Problem: INCA and Cancer Control in Brazil (Ministrio da Sade, 2007) and Na Arena de Esculpio: a Sociedade de Medicina e Cirurgia de So Paulo 18951913 (Unesp, 2007)
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Ilana Lwy is a senior researcher at INSERM (Institut national de la sant et de la rcherche medicale, Paris). She is interested in the history of bacteriology, virology, immunology, oncology and tropical medicine, and in intersections between gender and biomedicine. She has published Virus, moustiques et modernit: Science, politique et la fivre jaune au Brsil (Archives dHistorie Contemporaine, 2001), LEmprise du Genre: masculinit, fminit, ingalit (La Dispute, 2006) and Preventive Strikes: Women, Precancer and Prophylactic Surgery (JHUP, 2010), and is now studying the history of prenatal diagnosis.

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Imperfect tools for a difficult job: Colposcopy, colpocytology and screening for cervical cancer in Brazil

Luiz Antonio Teixeira Ilana Lwy

Casa de Oswaldo Cruz, Fiocruz, Brazil

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

Social Studies of Science 41(4)

Teixeira and Lwy

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Colposcopy and colpocytology in Brazil:The beginnings

Teixeira and Lwy

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Ambulatrio Preventivo and the consolidation of the triple model

Teixeira and Lwy

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The diffusion of the triple model of screening in Brazilian cities.

Teixeira and Lwy

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The triple model in rural settings: Contrasting experiences

Teixeira and Lwy

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Teixeira and Lwy

Transformation of cervical cancer into a public health problem

Social Studies of Science 41(4)

Teixeira and Lwy

Social Studies of Science 41(4)

Teixeira and Lwy Notes

Social Studies of Science 41(4)

Teixeira and Lwy

Social Studies of Science 41(4)

Teixeira and Lwy

Social Studies of Science 41(4)

Teixeira and Lwy

Social Studies of Science 41(4)

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