ORIGINAL ARTICLE
Syphilis on the big screen: an audiovisual representation of the health-disease process

INTRODUCTION

Syphilis is a sexually transmitted infection (STI) caused by the bacterium Treponema pallidum, which has different clinical manifestations and stages (primary, secondary, latent, and tertiary). In general, a disease is more likely to be transmitted in the primary and secondary stages. The main route of syphilis transmission is sexual intercourse without protection with an infected person, but it also happens during pregnancy or childbirth-the so-called congenital syphilis¹.

There are two theories for the origin of syphilis. The first reveals that the disease arose in the Americas and was taken to Europe by the crew of Christopher Columbus’ expeditions, between late 15th century and early 16th century. The second argues that it has existed for hundreds of years in the Old World, but only in the mid-sixteenth century it went through mutations that helped to expand its contagion capacity².

However, the first ever recorded epidemic of a disease that has the sexual act as its main form of transmission had syphilis as a protagonist, in the same period mentioned above. There are, however, records by Hippocrates of cases similar to what is now identified as tertiary syphilis, and also throughout Europe in the medieval period³.

The discovery of the etiological agent of syphilis would only happen in mid-1905, more than 500 years after the first records of the disease.

In the past, the disease has received various names: Gallic mal, mal venereum, coitus disease, venereal lues or simply lues, a term in Latin that means plague. This classification is also based on history: the first major syphilis epidemic emerged at some point in the decades of 1500 and 1510³.

Less than a century earlier, however, Europe experienced the epidemic cycle of bubonic plague, also called the Black Death, which took away about a third of the continent’s population at the time, with an estimated 75 to 200 million people dead. The name “syphilis” only appeared in the poem “Syphilis sive morbus gallicus”, by Girolamo Fracastoro de Verona, in 1530, and then became the definition of a pathological condition only in the middle of the 18th century⁴.

This historical rescue helps us understand the reasons that made the disease something that, in fact, frightened Europe at that time. The continent was in the Renaissance period, with man becoming an object of interest in the field of sciences. This period was marked by the emergence of Humanism and the appreciation of classical authors, especially the Greeks.

In the Health field, this logic could be observed in the maintenance of Hellenic concepts, with emphasis on the humoral theory, or humoralism, which supported the first efforts towards disease treatment methods adopted by physicians in the Renaissance era.

The search for a culprit for the spread of that disease helps to explain the different names given to syphilis. For the French of the 16th century, it was the illness of Naples, the city where the first medical records of the disease were made. In other parts of Europe, the term Gallic illness suggested the disease came from the region of Gaul, a territory that nowadays comprises France. At the time, there was a need to find a culprit, which helps to reinforce the theory that syphilis originated in the New World.

However, whatever its exact origin was, the syphilis epidemic has frightened the modern world with its aggressiveness. In its early years, the disease’s picture was severe skin lesions, with greater speed in clinical picture development and, consequently, in the number of deaths.

Soon, the disease was associated with sexual practice. And in an Old World where the Catholic Church was so strong, it did not take long for syphilis to gain the status of divine punishment. The sick would be removed from social life, and placed in facilities similar to those aimed for the lepers. There was no strategy or palliative treatment in the medical community.

In Brazil, syphilis has acquired local connotations, being linked to the tropical climate, the war in Paraguay (which increased the number of cases) or even the need for a medical intervention program. In 1880, João Pizarro Gabizo and Antônio José Pereira da Silva Araújo brought the teaching of dermatosyphilography to Brazil. Despite medical advances, syphilis continued to be linked to some social stigmas³.

In 1920, the “Inspectorate of Leprosy and Venereal Diseases Prophylaxis” was established, the first national program to combat syphilis, under the direction of Eduardo Rabelo. The actions of the inspectorate and the antivenereal discourse assumed a eugenic character, since the syphilographers endorsed the discourse of Brazilian promiscuity to a large extent. Some of these physicians wanted the serological test (or Wassermann reaction) to be mandatory for the so-called risk groups, which were composed of immigrants, prostitutes, soldiers, housewives, among others. Syphilographers also fought for mandatory notification in case of contamination and attacked the mystical explanations of healers and charlatans³.

Currently, syphilis has a relatively simple treatment with penicillin by health professionals. However, even with low-cost treatment and easy access in health services, a study developed by the World Health Organization (WHO) showed that 6.3 million cases were registered worldwide in 2016, in addition to about 200,000 cases of stillborn babies due to syphilis. In that same year, the disease was also identified as one of the main causes of infant mortality worldwide⁵.

Syphilis is currently a public health problem with large-scale growth in developing and underdeveloped countries. In Brazil, according to data from the Ministry of Health, the numbers jumped from 1,249, in 2010, to 65,878, in 2015, an increase that exceeds 5,000%, putting the country in an epidemic situation⁶.

According to the Epidemiological Bulletin produced by the Ministry of Health, the highest body of Brazilian health management, in 2019 a total of 152,915 cases of acquired syphilis were reported in the Information System for Acquired Syphilis (detection rate of 72.8 cases/100,000 inhabitants); 61,127 cases of syphilis in pregnant women (detection rate of 20.8/1,000 live births); 24,130 cases of congenital syphilis (incidence rate of 8.2/1,000 live births); 173 deaths from congenital syphilis (mortality rate of 5.9/100,000 live births)⁷.

Given this scenario, policies to combat and prevent syphilis transmission are a priority for the Ministry of Health of Brazil and are aligned with both the Pan American Health Organization and the WHO to achieve the goal of congenital syphilis incidence rate less than or equal to 0.5 cases per 1,000 live births⁷.

It all suggests little effectiveness of the prevention policies developed and applied to fight the disease. Some topics on the subject should, therefore, be noted.

Between the 1980s and 1990s, Brazil developed a campaign to combat and prevent the HIV virus that became a model around the world, especially because of its effectiveness. Prevention actions, maximized by campaigns in the radio, television and print media, were essential so that the situation of HIV and AIDS could be controlled in the country.

In parallel with syphilis, it is important to point out that the methods to prevent Treponema pallidum infection are basically the same as those adopted for almost two decades against HIV. Why, then, is Brazil experiencing an epidemic of syphilis, but not anymore of HIV?

In outline, some problems with regard to prevention can be pointed out. The most likely is also the one that should be the greatest ally: the low cost of penicillin, which discourages the pharmaceutical market to manufacture it. In 2015, for example, the country registered a lack of medication both in public and private health services.

Another problem identified by the monitoring carried out by the Ministry of Health of Brazil refers to the application of the drug. Until mid-2015, the use of penicillin by nursing professionals was prohibited when the place where the procedure would take place did not have equipment to care for patients who could manifest anaphylactic shock in response to it. In practice, health professionals chose not to administer the drug, as they could be held responsible if they did and the patient had a condition of shock.

There is still a serious problem when it comes to syphilis in pregnant women. Sometimes a pregnant patient’s partner refuses to take the medication to treat the illness. Then, there is reinfection, with all the characteristic cycles of syphilis. According to the Ministry of Health, 62% of partners make up this statistic.

This is an important matter for us to understand how a disease with relatively simple treatment could unleash an epidemic recorded since mid-2010. The data exposed so far allows us to state that the lack of information about syphilis-given that, until the beginning of the “Syphilis, No” project, Brazil had never had a specific campaign aimed at the disease-, the few actions giving importance to it prevention, and the attention to risk behaviors ended up expanding the problem to the current situation.

Thus, we have two infection situations that require specific care: syphilis in pregnant women and congenital syphilis, when the mother who does not undergo the treatment transmits the disease to the newborn.

It is, then, necessary to think about specific prevention solutions for the target audience in question. And this is where the work of communication is needed, especially through a language that is easily understood by the general population, including audiovisual resources. At this point, cinema is a protagonist as it records the fears and anxieties of the society that makes and consumes it.

Cinema has its history based on documentary records. When Louis and Auguste Lumière made their first films, their objective was not the fictional representation of social portraits, but their cataloging. With the advent of fiction cinema, especially after Georges Méliès, the fantasy of storytelling, once adopted only in books and in oral tradition, began to sparkle in the seventh art.

It was then that cinema gained the characteristic of adapting narratives by telling stories, original or not. And with that, this type of visual resource gained immense possibilities to talk to the public over time. When the narrative became part of the process of disseminating ideas, the cinematographic field was given new possibilities.

Thus, over time, cinema began to discuss what was notable topics in society. In this way, important historical facts such as wars, technological development and pandemics have become recurrent themes, since they have a chain impact on various social groups.

The theme of STIs has been widely explored in the motion pictures context, telling the story of the origins of diseases, their impact on society and how the whole health-disease process takes place, as in the cases of biopics that portray patients with some type of IST.

Although AIDS is the most common theme-mainly because of what it caused during its emergence period, in the mid-1980s-other STIs, such as syphilis, were also given space in the cinema, being portrayed for centuries in other domains of art and having its etiology clarified and treatment carried out only a few decades ago.

OBJECTIVE

The aim of this work was to perform a critical analysis of cinematographic works with syphilis in their plot, to identify and discuss the health-disease process throughout history, as well as its representation from the cinematic perspective.

METHODS

This work uses descriptive analysis of audiovisual works. Descriptive research allows the understanding of the studied reality, since a description requires observation, registration and analysis, aiming to deepen a matter, accurately characterizing investigated facts and phenomena⁹.

Analysis of imagery resources was also performed through clippings of the movies mentioned. This alternative allows to present to the reader how the audiovisual resource impacts the viewer via the cinematic representation of the IST within a historical context, even though it is not the central theme of the works.

This paper brings adequate bibliographical research, using concepts presented by authors of the health and audiovisual areas, in a transdisciplinary way. This resource is important, as it allows a theoretical contribution of remarks and interpretations built throughout the analysis process of the films.

The corpus of the study consisted of four films: “La Pelle”, by Liliana Cavani; “Miss Evers’ Boys”, by Joseph Sargent; “Heleno: O Príncipe Maldito”, by José Henrique Fonseca; and “Dr. Ehrlich’s Magic Bullet”, by William Dieterle.

RESULTS

For analysis purposes, each film was approached separately because, although all stories addressed the syphilis panorama in a relatively similar time period (between the 1940s and 1960s), each film was produced in a different decade (“La Pelle” in 1981, “Miss Evers’ Boys” in 1997 and “Heleno: O Príncipe Maldito” in 2011 and “Dr. Ehrlich’s Magic Bullet” in 1940). Therefore, over a period of 30 years, the perception about the importance of the impacts of this IST is relatively different. There is also the cultural matter, as each film brings a spectrum of different cultures.

In “La Pelle”, director Liliana Cavani makes a representation of Italy after World War II, with the challenges of a country recently devastated by historical confrontation. Set in the city of Naples, the most prominent in the southern region of the country (and, historically, also the poorest), the film presents us a context in which services in general-health among them-are scarce, which leads the main characters to social chaos.

In “Miss Evers’ Boys”, we are transported to the United States of the early 1930s, where an initiative of the American government to fight syphilis-which by then was already worrisome because of its epidemic character-leads to a study that disregarded all ethical details of that time. The film navigates through different periods of American history (which the study also dove into), passing through the period in which the racial segregation movement against African Americans peaked in that country.

In “Heleno: O Príncipe Maldito”, we have Rio de Janeiro’s football in the mid-1940s as the background, when this sport was still in transition between amateurism and professionalism, in a mixed scenario with the golden era of radio in Brazil and the influence of both on the society of the Brazilian federal capital. The main character is a figure that symbolizes social success: an athlete considered a national idol, immersed in one of the main sporting entities of that time, but who succumbs to the medium and long-term effects of a neglected disease which, in the period covered, already had possibilities of treatment and cure.

In “Dr. Ehrlich’s Magic Bullet”, a very different time frame is presented, with the representation of the 1940s; in other words, there are about four decades between this period and that of the other cinematographic works. The film takes an approach that contemplates the beginning of the era of drug treatments for syphilis. The feature film had its script built on the basis of letters and notes from the German doctor Paul Ehrlich. The film is not quite a biography, but it is a historical cut that covers a crucial period, when the first medical discoveries for the treatment of syphilis began to emerge. This is important because at that time, syphilis was an almost completely neglected disease; that is, it did not stir the interest of the medical community.

It should be noted that the feature films take place in equivalent periods, but in different geographic spaces (Italy, United States and Brazil). Thus, one can see how the illness was dealt with in the first years of penicillin use, the main antibiotic for the treatment of this type of disease.

Throughout the discussion, we will be making some remarks about the main points of each feature film and how their themes converge to the approach to STIs and their impacts on society.

DISCUSSION

CONCLUSION

The approach to the representation of syphilis in four films was satisfactory, although each one presents the audience with a different perspective. In all films, a questioning about the existence of adequate treatment is addressed, although only in one of them (“Miss Evers’ Boys”) penicillin is presented as a possibility of treatment.

As history shows, the concept of health reflects the social, economic, political and cultural situation, that is: health does not represent the same thing for all people. It will depend on the time, place, social class. It depends on individual, scientific, religious and philosophical values. The same happens with illnesses. Hence the concept of the health-disease process, as it is firmly related to and conditioned by the same determinants.

The first three films show different perspectives on the same health problem in the same time period, but in different scenarios. The fourth film complements these perspectives, but brings a distinct historical reality. Reflecting on these scenarios as opposed to the real world helps us to understand and seek what each of these represented groups needs in order to face the disease more objectively and effectively.

Such analyses also enable a clearer understanding of health problems with a broader scope, favoring the construction of solutions that are not limited to a specific field of knowledge, that is, that require an articulation between the various sciences for an effective resolution and improvement of morbidity and mortality indicators.