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The fight to achieve global eradication of poliomyelitis continues. Although native transmission of
We examined a portion of this
poliovirus was halted in the Western Hemisphere by the early 1990s, and only a few cases have been
campaign that many experts
imported in the past few years, much of Latin Americas story remains to be told. Peru conducted a
successful flexible, or flattened, vertical campaign in 1991. The initial disease-oriented programs consider a success: the elimina-
began to collaborate with community-oriented primary health care systems, thus strengthening pub- tion of poliomyelitis from Peru,
licprivate partnerships and enabling the common goal of poliomyelitis eradication to prevail despite despite adverse conditions,
rampant terrorism, economic instability, and political turmoil. Committed leaders in Perus Ministry of through national immunization
Health, the Pan American Health Organization, and Rotary International, as well as dedicated health days and a house-to-house vac-
workers who acted with missionary zeal, facilitated acquisition of adequate technologies, coordinated cination strategy. The events
work at the local level, and increased community engagement, despite sometimes being unable surrounding the discovery of
to institutionalize public health improvements. (Am J Public Health. 2014;104:22982305. three-year-old Luis Fermn Teno-
doi:10.2105/AJPH.2014.301995.)
rio Cortez, the last polio victim
in the Americas, embodied the
DURING THE PAST FEW initiatives.2 The international heart of the eradication achieve-
decades, immunization has campaign against poliomyelitis ment. He was found by Roger
evolved into a crucial health inter- (also known as infantile paralysis) Zapata in Pichanaki, a remote
vention in developing countries, launched in the late 1980s by the Andean town in the Central
and advocates of both vertical, World Health Organization Andes, in August 1991. Follow-
disease-oriented programs and (WHO) continues to be a major ing this discovery, an energetic
horizontal, community-oriented undertaking of international campaign supported by the
primary health care (PHC) defend health. Although historians of Peruvian Ministry of Health, the
its relevance.1 In addition, immu- medicine have described the his- Pan American Health Organiza-
nization campaigns have been tory of polio eradication in devel- tion (PAHO), and Rotary Inter-
viewed recently as tests for cov- oped countries, mainly achieved national (RI), among other
eted publicprivate partnerships, before the WHO initiative,3,4 only agencies, mopped up the 890
the integration of health relief a few studies have analyzed in districts surrounding Pichanaki,
efforts into permanent health detail how the fight against polio vaccinating more than two mil-
institutions, and community proceeded in less-developed coun- lion children in two weeks.8 For
engagement in public health tries in the late 20th century.57 several years, poliomyelitis
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PUBLIC HEALTH THEN AND NOW
December 2014, Vol 104, No. 12 | American Journal of Public Health Sobti et al. | Peer Reviewed | Public Health Then and Now | 2299
PUBLIC HEALTH THEN AND NOW
Care in Alma-Ata, Soviet Union. (Shining Path). Belandes lack marginalized the rural popula-
The conference was consonant of organization, inability to focus tion, which, by the 1970s, repre-
with the medical tradition in Peru on and solve the mounting chal- sented approximately 40% of the
that before the 1970s and under lenges of the failing economy, populace. With few monetary
different names, such as social and ineffectual social policies resources, the Peruvian Ministry
medicine, promoted popular allowed violence and terrorism of Health was unable to carry
health education and community to spread throughout the out important PHC interventions,
country. such as promotion of breastfeed-
Beginning in 1974, and acting ing and improving childrens
on World Health Assembly Reso- nutrition, growth monitoring,
lut
lution 27.57, the WHO; its and immunization. Neverthe-
reg
regional arm, the Pan American less, segments of the PHC strat-
He
Health Organization; and the egy, such as oral rehydration
Pe
Peruvian Ministry of Health coor- techniques for diarrheal dis-
din
dinated various immunization eases, were enthusiastically pro-
pro
programs. Over the next few moted by Belandes minister
ye
years, immunization became of health, Uriel Garcia, in the
en
enshrined as one of the principal major urban shantytowns dur-
PH
PHC interventions after the suc- ing the 1980s.
ces
cessful experience of smallpox Without a budget for specific
era
eradication (begun in the 1960s health programs, the ministrys
an
and achieved in 1980) and the already inadequate funding was
lan
landmark conference at Alma- not enough for a full PHC reform
At
Ata in 1978. Initially, immuniza- as called for in the Alma-Ata
tio
tion programs were small, local- Declaration. The absence of
ize
ized, and underfunded, and they expert, full-time personnel was
ac
accorded little importance to sur- another logistical obstacle. Public
veillance.14 Although the Peru-
ve health infrastructure was frag-
via government was in a state
vian mented: the public, social secu-
of transition, the military regime rity, private, military, and
ba
backed these public health initia- indigenous sectors had little coor-
ti
tives and in 1977 adopted the dination.18 The country lacked a
E
Expanded Program on Immuni- comprehensive national surveil-
z
zations, the WHOs smallpox lance system, another crucial
eradication model, which public health component, because
emphasized containment and the Peruvian National Institutes
surveillance. This interna- of Health (created in the late
tional WHO program 1930s by a former Rockefeller
administered the Sabin oral fellow) had been losing resources
vaccination for poliomyelitis and power. Prior to 1982, only 1
an collaboratively promoted
and physician and 1 nurse in the Min-
programs that often aimed to va
vaccinations for diphtheria, istry of Health had responsibility
counter official health policies.12,13 whooping cough, tetanus, mea- for national immunizationa step
Boy showing his painted finger, rep- The 12-year military reign, sles, and tuberculosis.1517 backward from the situation in
resenting a vaccinated child. Date with its unsuccessful attempts to During the late 1970s and the 1960s and 1970s, when a
unknown. Courtesy of Roger Zapata.
institute social reforms from early 1980s, political turmoil more adequate force of health
above, was followed by the and public healths low priority personnel worked on smallpox
socially passive administration of in the government precluded eradication. In the early 1980s,
democratically reelected Presi- major advances. Furthermore, provincial responsibility was dele-
dent Belande (19801985). most immunization program- gated to epidemiologists at the
His five-year term saw the for- ming was limited to the capital department level (the subnational
mation and growth of the Maoist city of Lima and the countrys political division of the country)
organization Sendero Luminoso other major urban centers. This and nurses at the hospitalclinic
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PUBLIC HEALTH THEN AND NOW
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PUBLIC HEALTH THEN AND NOW
Garcia made no attempt to containment that were successful national organization, in part
intervene in the public health in the WHO smallpox eradication because of partnerships with out-
system. Instead, he relied on the program. The emphasis was not side organizations.
sanitation leaders of his party, only on the number of people One private participant in the
some of whom had sound inter- receiving the vaccine, but also on fight against poliomyelitis was the
national experience and were the identification of outbreaks nonprofit RI, which maintained a
open to PHC perspectives. One and individual cases that national network of offices and
of these was the newly appointed appeared after initial vaccination nonmedical volunteers that
minister of health, David Tejada campaigns, as well as the vaccina- became an asset to the eradica-
de Rivero, an experienced inter- tion of everyone within a radius tion effort. They were known
national health official who had of a few miles of such outbreaks locally in their towns and neigh-
played a crucial role in the orga- and cases.21 borhoods and could provide the
nization of the landmark 1978 Also in 1985, Dr Carlyle necessary support. In addition, in
Alma-Ata conference as one of Guerra de Macedo, PAHOs 1985 RI initiated PolioPlus, a
the assistant directors under director of the Pan American global program to immunize all
Halfdan Mahler, director general Sanitary Bureau, proposed a plan children younger than five years
of the WHO.20 The combined for eradicating polio from the against poliomyelitis, diphtheria,
A typical poster used in Peru to gar-
impact of this conference and Americas by 1990, primarily as tetanus, pertussis, and measles.
ner community support for the vacci-
nation campaign circa June 1991. Tejadas experienced and charis- a platform to strengthen health RI raised more than US $247
Courtesy of Roger Zapata/Pan matic leadership opened the infrastructure.22 A Brazilian doc- million in the first year alone to
American Health Organization. door for greater collaboration tor, Ciro de Quadros, who had support this ambitious endeavor.
among the WHO, PAHO, and played an important role in the RIs president, M. A. T. Caparas,
UNICEF, as well as other agen- WHOs smallpox eradication pro- wrote to President Garcia offer-
cies. Together they organized gram in Africa, led these efforts ing his support in September of
vaccination programming as PAHOs director of the Divi- 1986 (M. A. T. Caparas to Presi-
throughout Peru, starting with sion of Vaccines and Immuniza- dent Alan Garcia, written com-
the first official national immuni- tion.23 Meanwhile, the Ministry munication, September 1986).
zation days in 1985, a major of Health began an internal Subsequently, Gustavo Gross, a
effort to involve the community, restructuring, replicating the Lima-based Rotarian, managed
the private sector, and institu- WHO structure with the creation RI involvement in Peru and
tions, personalities, and leaders of a Peruvian Technical Advisory Ecuador.
from outside the health system in Group to collaborate with With the support of local
a public health intervention. PAHOs Expanded Program on health workers from the Ministry
Even at the lowest political lev- Immunization and with other of Health and many local volun-
els, routine immunization rates experts.14 The advisory group teers from RI, the Technical Advi-
began to increase.17 had six physicians: one for each sory Group was responsible for
Most health workers were of the five major regions in Peru vaccinating children younger
aware that Perus social and politi- and one international correspon- than five years in a specific area
cal conditions were not ripe for dent, who facilitated fluent and within its region. In addition, the
the implementation of a holistic secure communication with inter- formation of the Peruvian Inter-
version of PHC. They could, how- national agencies and laborato- agency Coordinating Committee,
ever, organize effective mobile ries. These developments with representatives from the
teams for the task of immuniza- stimulated the training of local Peruvian Ministry of Health,
tion. This response was similar to personnel and the establishment PAHO, RI, UNICEF, the US
the more reductionist selective of a more comprehensive surveil- Agency for International Devel-
PHC, which was promoted in lance system. opment, and the Inter-American
many developing countries by Between 1985 and 1987, ini- Development Bank, was integral
agencies such as UNICEF and tial coverage rates remained low: to securing essential funds and
the World Bank as a realistic approximately 50% for the fostering efficient communication.
implementation of the Alma-Ata national immunization days.24 However, it is important to
goals. This context allowed for Even so, polio eradication efforts underscore that despite the active
the adaptation of epidemiological slowly began to overcome the participation of nongovernmental
methods of surveillance and lack of funding and inadequate institutions, the government
2302 | Public Health Then and Now | Peer Reviewed | Sobti et al. American Journal of Public Health | December 2014, Vol 104, No. 12
PUBLIC HEALTH THEN AND NOW
(through the Ministry of Health for the task force personnel who regime. Therefore, in a remark-
and PAHO) always maintained orchestrated the national surveil- able case of inter-American soli-
leadership.20 At an international lance system. In all, PAHO darity, PAHO bypassed Peruvian
and a local (subnational) level, administered approximately laboratories and sent fecal sam-
the existence of a specific target $2.5 million for these efforts.24 ples of suspect cases, essential for
the eradication of poliomyelitis The advisory group physicians measuring the progress of the
gave agencies and local health oversaw a force of devoted and campaign, to the Oswaldo Cruz
workers a consensus and a com- highly skilled personnel, most of Foundation in Rio de Janeiro,
mitment to achieve success in a them Peruvians, who worked Brazil, the main biomedical cen-
specific public health initiative. full time on the eradication ter of South America (M. A. T.
This focus on polio exemplifies campaign. Caparas to President Alan Gar-
the dilemma frequently faced by In addition to funding, RI pro- cia, written communication, Sep-
health workers in developing vided a social network that mobi- tember 1986). The Technical
countries: how to choose lized rural human resources and Advisory Group also developed a
between saving lives with the provided volunteers. Between system to rapidly and effectively
resources available and promot- 1986 and 1992, approximately
ing major reforms of the health four million Rotarians from all
and social systems that tolerate parts of Peru volunteered during
the vicious cycle of poverty and the national immunization days. The formation of the Technical Advisory
disease. In addition, the local Rotary Group in Peru finally brought about a unified
The political climate became a clubs contributed nearly plan for national vaccination that could be
major challenge for eradication $900 000, a significant amount
efforts. The Shining Paths attacks for the Ministry of Health, implemented consistently.
on the government escalated toward food for the volunteers
from 1985 until the capture of its and publicity.24
leader, Abimael Guzman, in The formation of the Technical attack endemic regions with con-
1992. This terrorist activity Advisory Group in Peru finally firmed polio cases through so-
affected both rural areas and brought about a unified plan for called mopping-up operations, or
many urban shantytowns and national vaccination that could barridos, which entailed the
middle-class neighborhoods, cre- be implemented consistently. The indiscriminate, house-to-house
ating yet another obstacle to vac- group agreed to inoculate chil- immunization of children
cinating a large portion of Perus dren with the Sabin vaccine at younger than five years within
population. Indeed, the destruc- ages two, three, and four specific areas.26 This represented
tion of a rural health clinic months.17 According to interna- a different and more effective
caused Luis Fermn Tenorio Cor- tional experts, this method was intervention than was used in
tez, the last reported victim of more economical than alterna- previous eradication efforts; for
poliomyelitis in the Americas, to tives, easier, and more likely to example, during the campaign to
miss his final two vaccine doses.25 be accepted by the population, eradicate malaria, workers spray-
Social networking and finan- who tended to prefer oral admin- ing DDT tried to cover the entire
cial aid became available in istration to injections. A network nation instead of concentrating
Peru with the involvement of RI of health posts also developed, on critical areas and paid little
and other multilateral and bilat- increasing from 420 in 1986 to attention to surveillance. It is
eral agencies. RI purchased 947 in 1993.5-7 Each submitted plausible that the difference
many of the necessary polio weekly reports, and the manda- between the WHO malaria eradi-
vaccines, likely supplied by the tory objective was to achieve cation program of the 1950s and
Oswaldo Cruz Foundation, a zero confirmed cases. the later smallpox and polio
leading public health research Because of poor funding and eradication campaigns was one
institution in Rio de Janeiro, the crumbling surveillance sys- of type, not of degree.
Brazil. According to Gustavo Gross tem of the National Institutes of National and international sup-
(oral communication, November Health, Perus national laboratory port, the availability of effective
16, 2004) and Miriam Strull system could not support the techniques, and the mobilization
(oral communication, March 23, polio eradication campaign dur- of community resources and sup-
2004), RI also provided funding ing the trying times of the Garcia port that occurred after 1985
December 2014, Vol 104, No. 12 | American Journal of Public Health Sobti et al. | Peer Reviewed | Public Health Then and Now | 2303
PUBLIC HEALTH THEN AND NOW
reinforced a change in public per- trying to institute holistic PHC agencies disputed with one
ception of immunization, which was unrealistic, immunization another over leadership and how
had been skeptical. New educa- became an important health best to allocate resources.27
tional programs fostered commu- intervention. Although this inter- These different viewpoints sug-
nity involvement and awareness ventions accomplishments in gest an important fragility within
of the committed health workers Peru never paralleled the cease- the publicprivate relationship
working to protect the popula- fire it orchestrated in a Central and the need to institutionalize
tion. For example, collaboration American civil war during the coherent immunization efforts in
between other municipal pro- same period, nonmedical leaders conjunction with preexisting
grams, such as the Vaso de Leche and institutions, grassroots orga- activities of the Ministry of Health
(glass of milk) program, which nizations, and even at times an and general reform throughout
promoted nutrition among chil- antigovernment terrorist organi- the public health systema topic
dren in shantytowns and under- zation eventually perceived its that warrants further study.
served areas, and the Ministry of value. The desire to eradicate In acknowledgment of the
Education ignited community poliomyelitis overcame national importance of historical analysis,
involvement beginning in 1984. turmoil and created a temporary we aimed to provide a balanced
By the late 1980s, a significant shelter for the public health sec- perspective that will serve not to
number of nonmedical health tor, thereby helping to prevent its celebrate a specific health
leaders and community institu- collapse. Immunization, as car- achievement, but rather to invite
tions participated in and sup- ried out in Peru, transcended the reflection on the proper balance
ported immunization efforts. rigid and contentious division between the medical and non-
Local communities were between vertical, disease-oriented medical factors that account for
involved in the actual act of vac- programs and horizontal, a public health achievement
cinating during national immuni- community-oriented PHC mod- under adverse conditions. These
zation days. For example, church els. The initial vertical program factors include sustained politi-
groups or local Rotary clubs became flexiblesometimes cal commitment; community
organized local volunteers or focused and sometimes flattened engagement; strong leadership
additional transportation needed to allow for successful disease at the international, national,
for successfully immunizing a eradication. and local levels; adequate tech-
region in only a few days. Local This campaign set an impor- nology; and a fluent and open
brigades were organized for tant precedent for future immuni- collaboration between public
hard-to-vaccinate areas, which zation programs and a national and private partners. The les-
included not only rural settings surveillance system, as well as for sons learned might be useful for
but also terrorist-occupied areas, publicprivate partnerships that the crucial work being carried
where community involvement would become important and out by PAHO to verify the polio-
proved essential, because govern- more common. These partner- free status of the Americas
ment-sponsored personnel would ships should not be viewed as region and to control the impor-
have been at great risk traveling faultless, however. Our investiga- tation of wild poliovirus from
alone. Medical personnel who tion revealed that much endemic areas.28
vaccinated in areas controlled by depended on experts who knew We have seen a dramatic
the Shining Path attested that the what to do in a moment of politi- decline in polio cases around
perception that vaccination was a cal and economic crisis, but the world, to as few as 223 at
goal outside the political conflict whose work in the long run was the end of 2012.29 The WHOs
moved the group to allow health undermined by the lack of insti- Global Polio Eradication Initia-
workers to carry out their life- tutionalization of broader PHC tive, created in 1988, is on track
saving work.18,24 efforts. In addition, we found a to eradicate polio by 2018.
tendency to overemphasize any Despite these successes, there
CONCLUSIONS success, obscuring other health have also been troubling devel-
needs of the population. More- opments in the polio eradication
In a country with a chaotic over, participants had opposing campaign, most notably the tar-
political climate, a depressed viewpoints about the role played geted attacks against polio
economy, and public health by each agency and the recogni- health workers in Afghanistan
experts who were convinced that tion received thereafter, and and Pakistan30,31 and recent
2304 | Public Health Then and Now | Peer Reviewed | Sobti et al. American Journal of Public Health | December 2014, Vol 104, No. 12
PUBLIC HEALTH THEN AND NOW
outbreaks of mutated oral vac- Alliance for Vaccines and Immunization. the Americas: acute flaccid paralysis
Acknowledgments
Los Angeles, CA: University of Southern surveillance, 19881995. J Infect Dis.
cine, or vaccine-derived, polio We thank the interviewees, Lucia Hel-
California, Marshall Global BioBusiness 1997;175(suppl 1):S37S42.
ena Oliveira, Roger Zapata, Gustavo
cases.32 Although polio eradica- Gross, Jorge Medrano, David Tejada de Initiative; 2005. 22. Levine R. Eliminating polio in Latin
tion campaigns in each country Rivero, Washington Toledo, and Miriam 10. Moulin AM. A hiptese vacinal: por America and the Caribbean. In: Levine
face their own unique chal- Strull; PAHO information and documen- uma abordagem crtica e antropolgica R; What Works Working Group, eds.
tation officer Gaby Caro; and Brazilian de um fenmeno histrico [The vaccinal Millions Saved: Proven Successes in
lenges and require adaptation to collaborators Dilene Raimundo do Nas- Global Health. Sudbury, MA: Jones and
hypothesis: towards a critical and an-
specific contexts, certain paral- cimento and Eduardo Ponce Maranho. thropological approach to a historical Bartlett Publishers; 2007:3946.
lels can be drawn from the Peru- phenomenon]. Hist Cienc Saude-Man- 23. Fujimura SF. The man who made
guinhos. 2003;10(suppl 2:)499517. polio history. Perspect Health.
vian story, which illuminates Human Participant Protection
No protocol approval was required be- 11. Campos AL, Nascimento DR, Mara- 2005;10(2):1016.
how the shared goal of polio
cause no human participants were in- nho E. A histria da poliomielite no 24. Peru: Statistics Compendium 1989
eradication can result in impor- volved. Brasil e seu controle por imunizao 1990. Lima, Peru: National Institute of
tant collaborations that super- [The history of polio in Brazil and its Statistics and Information; 1990.
sede local conflicts and turmoil. control through immunization]. Hist
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December 2014, Vol 104, No. 12 | American Journal of Public Health Sobti et al. | Peer Reviewed | Public Health Then and Now | 2305