Woman and baby exiting a ferry.

Death by Proxy: What Twentieth-Century Infant Mortality Discourses in Brazil Can Tell Us About COVID-19

When the global death toll of the ongoing COVID-19 pandemic surpassed one million in late September, the United States and Brazil registered the world’s two highest death counts. In the wake of this grim milestone, media outlets in both countries circulated various analogies to make sense of the scale of human loss. In Brazil, one major news site published a table comparing the number of pandemic fatalities to a series of historical events and national tragedies, like the 2013 Kiss nightclub fire and the 2019 dam collapse. The table also invoked the familiar image of Brazil’s largest soccer stadium and noted that, globally, COVID-19 had claimed thirteen times the venue’s maximum capacity. Elsewhere in the global media, commentators and journalists expressed the magnitude of COVID-19 mortality in terms of airplane crashes, city populations, natural disasters, and wars.

As the saying goes,“a single death is a tragedy; a million deaths is a statistic.”[1] Death on a mass scale seems to confound humankind and evades our understanding. Inherently, when we quantify death, we depersonalize it. And, the higher the death count climbs, the more abstract the scale of mortality becomes. Some researchers suggest that, on a basic cognitive level, humans struggle to comprehend exponential figures, like the rapidly-rising COVID-19 case counts and fatalities that flash across our screens every day. Others argue that, over time, mass death events induce “compassion fatigue,” leading the public to disassociate with the painful reality of human loss. Mark Honigsbaum, author of The Pandemic Century: One Hundred Years of Panic, Hysteria, and Hubris, argues that COVID-19 numbers are losing their power to “shock” us.

graph showing the COVID-19 cases in Brazil
COVID-19 cases in Brazil in 2020. (Wikimedia Commons)

When statistics surpass the threshold of significance, analogies and proxy metrics often take up the explanatory slack, so to speak. They provide us with a shorthand, a more relatable framework that translates incomprehensible quantities into more manageable proportions.[2] Allusions to packed stadiums and other mass-casualty events contextualize and ground abstract statistics in more familiar terms. Drawing equivalency between historical events and the impalpable scale of pandemic deaths in the present also provides a sense of precedence. It serves as a reminder that human populations have successfully overcome episodes of mass death in the past and could do so again in the present.

Several decades before the COVID-19 pandemic, Brazilian health officials and statisticians turned to analogies and proxy metrics to make sense of another public health crisis: high infant mortality. In the first half of the twentieth century, Brazil’s national infant mortality rate ranged between 150 to 200, meaning that close to one of five infants died before reaching their first birthday.[3] When the country celebrated its Independence Centennial in 1922, its most renowned pediatrician lamented that Brazil’s high rate of infant mortality placed it in a “humiliating condition of inferiority” within the Americas.[4] While neighboring countries saw rates begin to decline after 1940, Brazil’s infant death rate remained static. A 1945 study revealed that only Bolivia had a higher rate of infant mortality. The study also underscored the stark regional variations in infant mortality rates, noting that in some parts of the country’s poor northeastern and rural interior regions “it would not be unusual for people to lose half of their children” before age one.[5] By the early 1940s, public health officials had identified infant mortality as “public enemy number one” and a major obstacle to Brazil’s development.[6]

Brazil’s enormous territorial size and a general paucity of accurate birth and death records meant that statistical measurement of infant mortality remained scarce and imprecise.[7] As a result, public health officials and other policymakers relied heavily on a set of analogies to bring awareness to the crisis. Like their present-day counterparts facing rising mortality from COVID-19, mid-twentieth-century Brazilian health experts also hoped that more relatable comparisons might bring the infant mortality epidemic into sharper relief and elicit a more robust response from both the state and the general public.

Like some COVID-19 analogies circulating today, Brazilian health officials drew comparisons to war casualties and referenced city populations to capture the scale of infant mortality. One health official argued that the “culling” of infants claimed more lives in a year than the total death toll from all the German bombings of England.[8] A striking 1949 infographic calculated the deleterious impacts of high infant mortality in terms of “disappearing” cities and states across Brazil. The author asked readers to imagine annual rates of infant death as equivalent to “wiping the city of Recife off the map” and, over three years, “losing the entire population of the country’s federal district [Rio de Janeiro].”[9]

Some of the most frequently circulated proxy metrics invoked the spatial scale of mass infant death. Brazilian health officials and others in the media expressed infant mortality in terms of the territorial space required to bury the dead. In one such analogy, a statistician asserted that the number of coffins needed to bury the country’s daily infant death count “would stretch the 42 kilometers from Copacabana to Petropolis.”[10] Similarly, a 1953 print source conjured the image of a cemetery spanning “120 leagues” filled with the coffins of the more than 2,000 infants who died each day across Brazil. These macabre metaphors, quite literally, ground the scale of infant loss in various local landscapes. Intriguingly, when Brazil surpassed 100,000 COVID-19 deaths last August, a Brazilian journalist likewise mapped how many square meters of urban space would be covered by the total number of graves needed to bury the dead. Her visualizations referenced iconic landmarks like Rio de Janeiro’s Ipanema Beach and a central commercial zone in São Paulo. Such spatial representations, like those used decades earlier, reclaim mortality from statistical oblivion by materializing the scale of death in a familiar context.

While proxy metrics acted as useful substitutes for mortality data in mid-twentieth-century Brazil and certainly drew attention to the crisis, they ultimately did little to stem the tide of mass infant loss. Significant declines in Brazilian infant mortality came much later, owing largely to the expansion of primary health care and mass vaccination campaigns in the 1970s.[11] However, the existence of these analogs reveals a shared impulse among public officials and others to humanize death and not surrender to apathy in the face of a health crisis.

This lesson remains vitally important as we face the current pandemic. We are reminded that, despite our best measurement efforts, the impact of death on the living remains incalculable, whether it claims one, or more than one million lives. As the numbers continue to rise and move further into abstraction, we should focus our attention on the faces, names, and stories behind the statistics. The organizers of Brazil’s crowdsourced online memorial, Inumeráveis (Innumerables), aim to transform numbers into stories, arguing that “no one wants to be just a number; people deserve to exist in prose.” Personalized blessings, jokes, and memories shared on the site not only record the stories of the country’s COVID-19 victims – from the 109-year-old dance-loving grandmother to the newborn baby lovingly named for an angel – but offer a space for collective grieving and healing.

Notes

    1. The origins of this statement are disputed. It is most commonly attributed to Joseph Stalin, while other scholars trace it to an essay by German satirist Kurt Tucholsky.
    2. Gary Baines, “Vietnam Analogies and Metaphors: The Cultural Codification of South Africa’s Border War,” Safundi: The Journal of South African and American Studies 13, nos. 1–2 (2012), 74.
    3. Instituto Brasileiro de Geografia e Estatística (IBGE), “Evolução e perspectivas da mortalidade infantil no Brasil,” (1999), 20. Infant mortality coefficients express the number of deaths before age one out of 1,000 live births. Most infants died from preventable illnesses, such as malnutrition and gastrointestinal disease. Structural inequalities, including the lack of access to health services and basic sanitation, put the country’s impoverished rural and urban populations at a disproportionate risk for high rates of infant death.
    4. Assistência pública e privada no Rio de JaneiroHistória e estatísticaComemoração do Centenário da Independência Nacional (Rio de Janeiro: Typographia do Annuário do Brasil, 1922), 14. On early twentieth-century reforms aimed at reducing high infant mortality, see Okezi Otovo, Progressive Mothers, Better Babies: Race, Public Health, and the State in Brazil, 1850-1945 (University of Texas Press, 2016).
    5. E.H. Christopherson, “Child Welfare Work in Brazil,” Journal of Pediatrics 28, no. 3, (1946): 334. This estimation is corroborated by earlier studies showing localized rates in Brazil’s northeast, in particular. See Antonio Barros de Ulhôa Cintra e Mário Mesquita, “Mortalidade infantil na capital,” São Paulo na Conferência Nacional de Proteção à Infância-setembro 1933, (1934), 213. A fifteen-city study covering the years 1942 to 1948 also revealed similar statistics, see Departamento Nacional da Criança “A mortalidade infantil no Brasil,” Boletim do Departamento Nacional da Criança (Rio de Janeiro: DNCr, 1951), 18.
    6. Martagão Gesteira, “Discurso sobre as realizações do governo federal de proteção à maternidade e à infância,” (Rio de Janeiro: DIP, 1941); Odilon de Andrade Filho, “Despertar pelo Brasil,” Boletim Trimensal do Departamento Nacional da Criança 4, no. 19 (December 1944): 39.
    7. On the challenges to collecting vital statistics related to birth and death in the first half of the twentieth century, see Cassia Roth, A Miscarriage of Justice: Women’s Reproductive Lives and the Law in Early Twentieth-Century Brazil (Stanford University Press, 2020); Gilberto Hochman, The Sanitation of Brazil: Nation, State, and Public Health, 1889-1930 (University of Illinois Press, 2016) and Brodwyn Fischer, A Poverty of Rights: Citizenship and Inequality in Twentieth-Century Rio de Janeiro (Stanford University Press, 2008).
    8. This comparison also appeared in “Salvemos nossas crianças,” O Momento Feminino (October 1950), 10.
    9. “Mortalidade infantil: inimigo público N°1 do Brasil,” Diário de Notícias (April 24, 1949), suplemento de puericultura.
    10. “Exposição ao Ministério de Educação e Saúde,” Relatório de 1947: Departamento Nacional da Criança (Imprensa Nacional 1947), 24.
    11. On public health responses to infant mortality in the latter twentieth century, see Nancy Scheper-Hughes, Death Without Weeping: The Violence of Everyday Life in Brazil (University of California Press, 1992).

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