A Public Health Achievement Under Adversity: The Eradication of Poliomyelitis From Peru, 1991

Abstract

The fight to achieve global eradication of poliomyelitis continues. Although native transmission of poliovirus was halted in the Western Hemisphere by the early 1990s, and only a few cases have been imported in the past few years, much of Latin America’s story remains to be told. Peru conducted a successful flexible, or flattened, vertical campaign in 1991. The initial disease-oriented programs began to collaborate with community-oriented primary health care systems, thus strengthening public–private partnerships and enabling the common goal of poliomyelitis eradication to prevail despite rampant terrorism, economic instability, and political turmoil. Committed leaders in Peru’s Ministry of Health, the Pan American Health Organization, and Rotary International, as well as dedicated health workers who acted with missionary zeal, facilitated acquisition of adequate technologies, coordinated work at the local level, and increased community engagement, despite sometimes being unable to institutionalize public health improvements.

During the past few decades, immunization has evolved into a crucial health intervention in developing countries, and advocates of both vertical, disease-oriented programs and horizontal, community-oriented primary health care (PHC) defend its relevance.¹ In addition, immunization campaigns have been viewed recently as tests for coveted public–private partnerships, the integration of health relief efforts into permanent health institutions, and community engagement in public health initiatives.² The international campaign against poliomyelitis (also known as infantile paralysis) launched in the late 1980s by the World Health Organization (WHO) continues to be a major undertaking of international health. Although historians of medicine have described the history of polio eradication in developed countries, mainly achieved before the WHO initiative,^3,4 only a few studies have analyzed in detail how the fight against polio proceeded in less-developed countries in the late 20th century.^5–7

We examined a portion of this campaign that many experts consider a success: the elimination of poliomyelitis from Peru, despite adverse conditions, through national immunization days and a house-to-house vaccination strategy. The events surrounding the discovery of three-year-old Luis Fermín Tenorio Cortez, the last polio victim in the Americas, embodied the heart of the eradication achievement. He was found by Roger Zapata in Pichanaki, a remote Andean town in the Central Andes, in August 1991. Following this discovery, an energetic campaign supported by the Peruvian Ministry of Health, the Pan American Health Organization (PAHO), and Rotary International (RI), among other agencies, “mopped up” the 890 districts surrounding Pichanaki, vaccinating more than two million children in two weeks.⁸ For several years, poliomyelitis joined smallpox as the only diseases eliminated from the Western Hemisphere.

The Peruvian campaign against wild poliomyelitis was remarkable for its success under adverse conditions. The late 1980s and early 1990s were years of economic hyperinflation and political violence in Peru. This turmoil encompassed the rise and fall of the Shining Path terrorist group, a crumbling democratic system, human rights violations perpetrated by the military and terrorists, and finally the emergence of an authoritarian regime under Alberto Fujimori.

Our investigation contributes to an emerging body of literature on the history of immunization, particularly polio control and eradication.^9–11 It also illuminates some crucial issues in Latin American public health, such as the relationship between vertical and horizontal programs and immunization in underdeveloped health care systems and the possibility for broad alliances between public and private agencies for humanitarian health goals.

The history of Peru’s fight to eliminate polio falls into two periods: the early 1960s until 1985, before the full implementation of an eradication campaign, and the design and enforcement of the campaign from 1985 to 1994, when eradication of wild poliomyelitis from the Americas became an official goal.^5-7 We searched library archives, unearthed rare publications, and conducted interviews in Lima between 2004 and 2005 to examine the Peruvian political context, human resources, available technology, and public attitudes toward immunization in each of these periods.

Roger Zapata examines Luis Fermín Tenorio Cortez in rural Pichanaki, Peru. 1991. Courtesy of Roger Zapata.

POLIO ERADICATION BEFORE 1985

The limited epidemiological records for Peru in existence for the pre-1985 period indicate that polio morbidity rates in the country averaged 0.7 cases per 100 000 inhabitants from 1939 to 1951. Vaccination efforts during this period were fleeting, and surveillance and epidemiological studies were rare. During the following 14 years, improved information systems allowed for a more accurate picture of the disease’s scope; the country averaged 3.8 cases per 100 000 population between 1952 and 1965, with peaks reaching 6.2 and 7.2 for a few years. The Salk inactivated (killed) injectable vaccine and the Sabin live (attenuated) oral vaccine were brought to Peru in 1963 and 1964, respectively, but the latter became more popular in all of Latin America after the mid-1980s because of its lower cost, ability to induce intestinal immunity and therefore break the transmission of wild poliovirus, and ease of use for massive immunization campaigns. Still, despite the vaccine’s availability, polio remained endemic and immunization rates low.^5-7

In 1968, mounting tensions over oil disputes and controversy led the former leftist general Juan Velasco Alvarado to lead a coup against President Fernando Belaúnde. The resulting populist military regime ruled Peru for the next 12 years, including a term under the more moderate General Francisco Morales Bermúdez (1978–1980). During this time, sweeping social reforms were unable to protect the country from economic depression and social unrest, but some high-ranking public health officers were aware of developments in international health and sent representatives to the 1978 International Conference on Primary Health Care in Alma-Ata, Soviet Union. The conference was consonant with the medical tradition in Peru that before the 1970s and under different names, such as social medicine, promoted popular health education and community programs that often aimed to counter official health policies.^12,13

Boy showing his painted finger, representing a vaccinated child. Date unknown. Courtesy of Roger Zapata.

The 12-year military reign, with its unsuccessful attempts to institute social reforms from above, was followed by the socially passive administration of democratically reelected President Belaúnde (1980–1985). His five-year term saw the formation and growth of the Maoist organization Sendero Luminoso (Shining Path). Belaúnde’s lack of organization, inability to focus on and solve the mounting challenges of the failing economy, and ineffectual social policies allowed violence and terrorism to spread throughout the country.

Beginning in 1974, and acting on World Health Assembly Resolution 27.57, the WHO; its regional arm, the Pan American Health Organization; and the Peruvian Ministry of Health coordinated various immunization programs. Over the next few years, immunization became enshrined as one of the principal PHC interventions after the successful experience of smallpox eradication (begun in the 1960s and achieved in 1980) and the landmark conference at Alma-Ata in 1978. Initially, immunization programs were small, localized, and underfunded, and they accorded little importance to surveillance.¹⁴ Although the Peruvian government was in a state of transition, the military regime backed these public health initiatives and in 1977 adopted the Expanded Program on Immunizations, the WHO’s smallpox eradication model, which emphasized containment and surveillance. This international WHO program administered the Sabin oral vaccination for poliomyelitis and collaboratively promoted vaccinations for diphtheria, whooping cough, tetanus, measles, and tuberculosis.^15–17

During the late 1970s and early 1980s, political turmoil and public health’s low priority in the government precluded major advances. Furthermore, most immunization programming was limited to the capital city of Lima and the country’s other major urban centers. This marginalized the rural population, which, by the 1970s, represented approximately 40% of the populace. With few monetary resources, the Peruvian Ministry of Health was unable to carry out important PHC interventions, such as promotion of breastfeeding and improving children’s nutrition, growth monitoring, and immunization. Nevertheless, segments of the PHC strategy, such as oral rehydration techniques for diarrheal diseases, were enthusiastically promoted by Belaúnde’s minister of health, Uriel Garcia, in the major urban shantytowns during the 1980s.

Without a budget for specific health programs, the ministry’s already inadequate funding was not enough for a full PHC reform as called for in the Alma-Ata Declaration. The absence of expert, full-time personnel was another logistical obstacle. Public health infrastructure was fragmented: the public, social security, private, military, and indigenous sectors had little coordination.¹⁸ The country lacked a comprehensive national surveillance system, another crucial public health component, because the Peruvian National Institutes of Health (created in the late 1930s by a former Rockefeller fellow) had been losing resources and power. Prior to 1982, only 1 physician and 1 nurse in the Ministry of Health had responsibility for national immunization—a step backward from the situation in the 1960s and 1970s, when a more adequate force of health personnel worked on smallpox eradication. In the early 1980s, provincial responsibility was delegated to epidemiologists at the department level (the subnational political division of the country) and nurses at the hospital–clinic level. Immunization was such a low priority that it was impossible to imagine the elimination or even effective control of some infectious diseases. Paradoxically, however, the organizational void allowed several committed sanitation leaders from PAHO, the Ministry of Health, UNICEF, and RI to direct efforts.

These leaders confronted the disorganization and lack of financial resources that characterized immunization services in Peru in the early 1980s. Many essential technologies were outdated or unavailable, such as a proper and extensive cold chain (a refrigerated distribution system extending from the laboratory to the child), viable laboratories, and adequate information and diagnostic systems. Peru lacked proper laboratory facilities; therefore, fecal samples were sent outside the country for testing.

Although polio vaccines had been available for more than a decade, Peru lacked the resources and equipment necessary to disseminate them, a problem exacerbated by the absence of coordination among the various health sectors. Some administered the Salk injectable polio vaccine, others the Sabin oral vaccine. Furthermore, vaccination schedules for children changed often; some were vaccinated at birth, two months, and four months, others at one, two, and three months of age (Jorge Medrano, oral communication, November 16, 2004). Without unification of the information system, efficient use of even the limited resources available was difficult. Before 1985, each sector maintained a separate information system. This meant that the number of polio cases was not always shared among sectors, and hence vaccination methods differed.¹⁶ Ultimately, a lack of political commitment, a fragmented and disorganized system, and insufficient funding yielded a divided and inefficient public health system that could not eradicate poliomyelitis.

The government’s indifference to immunization engendered a passive attitude among the public. Even mothers who brought their children for hospital visits received little information on the benefits of vaccination. Clinics in rural areas and shantytowns routinely packed many sick children into a single room for vaccinations; as a result, mothers hesitated to return and believed their children were better off without the vaccines (Roger Zapata, oral communication, November 15, 2004). Little effort went into in creasing community participation in vaccination programs, and both the population and government officials remained oblivious to the extent of wild poliomyelitis infections.

In 1980, only 15% of the country’s eligible children received immunizations against poliomyelitis. Diphtheria, whooping cough, tetanus, measles, and tuberculosis coverage also remained low.¹⁹ The original goal of the Expanded Program on Immunizations in the late 1970s was to provide immunization services for every child in the world by 1990, and its main assumption was that vertical programming would help to strengthen public health care infrastructures. Later, in 1985, the PAHO Directing Council adopted the specific goal of eradicating wild poliovirus from the Western Hemisphere by 1990. This goal was a major impetus for change in Peru as well as in neighboring Latin American countries. The decision triggered significant developments in Peru, ultimately coming to fruition six years later with the last native case of wild poliomyelitis in the Americas reported in 1991.¹⁴

Letter from Peruvian Rotary President Gustavo Gross to Peruvian President M. A. T. Caparas offering financial support. Lima, Peru. 1986. Courtesy of Gustavo Gross.

COLLABORATION AND COMMITMENT

In 1985, a second democratically elected president took office. Alan Garcia led a party that claimed to be the Peruvian version of European social democracy, the center–left Aprista Party (the acronym APRA stood for American Popular Revolutionary Alliance). Like his predecessors, Garcia was unable to solve the economic and political problems of the country, and a growing fear of terrorism, a severe economic crisis, and governmental mismanagement led to hyperinflation.

A typical poster used in Peru to garner community support for the vaccination campaign circa June 1991. Courtesy of Roger Zapata/Pan American Health Organization.

Garcia made no attempt to intervene in the public health system. Instead, he relied on the sanitation leaders of his party, some of whom had sound international experience and were open to PHC perspectives. One of these was the newly appointed minister of health, David Tejada de Rivero, an experienced international health official who had played a crucial role in the organization of the landmark 1978 Alma-Ata conference as one of the assistant directors under Halfdan Mahler, director general of the WHO.²⁰ The combined impact of this conference and Tejada’s experienced and charismatic leadership opened the door for greater collaboration among the WHO, PAHO, and UNICEF, as well as other agencies. Together they organized vaccination programming throughout Peru, starting with the first official national immunization days in 1985, a major effort to involve the community, the private sector, and institutions, personalities, and leaders from outside the health system in a public health intervention. Even at the lowest political levels, routine immunization rates began to increase.¹⁷

Most health workers were aware that Peru’s social and political conditions were not ripe for the implementation of a holistic version of PHC. They could, however, organize effective mobile teams for the task of immunization. This response was similar to the more reductionist selective PHC, which was promoted in many developing countries by agencies such as UNICEF and the World Bank as a realistic implementation of the Alma-Ata goals. This context allowed for the adaptation of epidemiological methods of surveillance and containment that were successful in the WHO smallpox eradication program. The emphasis was not only on the number of people receiving the vaccine, but also on the identification of outbreaks and individual cases that appeared after initial vaccination campaigns, as well as the vaccination of everyone within a radius of a few miles of such outbreaks and cases.²¹

Also in 1985, Dr Carlyle Guerra de Macedo, PAHO’s director of the Pan American Sanitary Bureau, proposed a plan for eradicating polio from the Americas by 1990, primarily as a platform to strengthen health infrastructure.²² A Brazilian doctor, Ciro de Quadros, who had played an important role in the WHO’s smallpox eradication program in Africa, led these efforts as PAHO’s director of the Division of Vaccines and Immunization.²³ Meanwhile, the Ministry of Health began an internal restructuring, replicating the WHO structure with the creation of a Peruvian Technical Advisory Group to collaborate with PAHO’s Expanded Program on Immunization and with other experts.¹⁴ The advisory group had six physicians: one for each of the five major regions in Peru and one international correspondent, who facilitated fluent and secure communication with international agencies and laboratories. These developments stimulated the training of local personnel and the establishment of a more comprehensive surveillance system.

Between 1985 and 1987, initial coverage rates remained low: approximately 50% for the national immunization days.²⁴ Even so, polio eradication efforts slowly began to overcome the lack of funding and inadequate national organization, in part because of partnerships with outside organizations.

One private participant in the fight against poliomyelitis was the nonprofit RI, which maintained a national network of offices and nonmedical volunteers that became an asset to the eradication effort. They were known locally in their towns and neighborhoods and could provide the necessary support. In addition, in 1985 RI initiated PolioPlus, a global program to immunize all children younger than five years against poliomyelitis, diphtheria, tetanus, pertussis, and measles. RI raised more than US $247 million in the first year alone to support this ambitious endeavor. RI’s president, M. A. T. Caparas, wrote to President Garcia offering his support in September of 1986 (M. A. T. Caparas to President Alan Garcia, written communication, September 1986). Subsequently, Gustavo Gross, a Lima-based Rotarian, managed RI involvement in Peru and Ecuador.

With the support of local health workers from the Ministry of Health and many local volunteers from RI, the Technical Advisory Group was responsible for vaccinating children younger than five years in a specific area within its region. In addition, the formation of the Peruvian Interagency Coordinating Committee, with representatives from the Peruvian Ministry of Health, PAHO, RI, UNICEF, the US Agency for International Development, and the Inter-American Development Bank, was integral to securing essential funds and fostering efficient communication. However, it is important to underscore that despite the active participation of nongovernmental institutions, the government (through the Ministry of Health and PAHO) always maintained leadership.²⁰ At an international and a local (subnational) level, the existence of a specific target—the eradication of poliomyelitis—gave agencies and local health workers a consensus and a commitment to achieve success in a specific public health initiative. This focus on polio exemplifies the dilemma frequently faced by health workers in developing countries: how to choose between saving lives with the resources available and promoting major reforms of the health and social systems that tolerate the vicious cycle of poverty and disease.

The political climate became a major challenge for eradication efforts. The Shining Path’s attacks on the government escalated from 1985 until the capture of its leader, Abimael Guzman, in 1992. This terrorist activity affected both rural areas and many urban shantytowns and middle-class neighborhoods, creating yet another obstacle to vaccinating a large portion of Peru’s population. Indeed, the destruction of a rural health clinic caused Luis Fermín Tenorio Cortez, the last reported victim of poliomyelitis in the Americas, to miss his final two vaccine doses.²⁵

Social networking and financial aid became available in Peru with the involvement of RI and other multilateral and bilateral agencies. RI purchased many of the necessary polio vaccines, likely supplied by the Oswaldo Cruz Foundation, a leading public health research institution in Rio de Janeiro, Brazil. According to Gustavo Gross (oral communication, November 16, 2004) and Miriam Strull (oral communication, March 23, 2004), RI also provided funding for the task force personnel who orchestrated the national surveillance system. In all, PAHO administered approximately $2.5 million for these efforts.²⁴ The advisory group physicians oversaw a force of devoted and highly skilled personnel, most of them Peruvians, who worked full time on the eradication campaign.

In addition to funding, RI provided a social network that mobilized rural human resources and provided volunteers. Between 1986 and 1992, approximately four million Rotarians from all parts of Peru volunteered during the national immunization days. In addition, the local Rotary clubs contributed nearly $900 000, a significant amount for the Ministry of Health, toward food for the volunteers and publicity.²⁴

The formation of the Technical Advisory Group in Peru finally brought about a unified plan for national vaccination that could be implemented consistently. The group agreed to inoculate children with the Sabin vaccine at ages two, three, and four months.¹⁷ According to international experts, this method was more economical than alternatives, easier, and more likely to be accepted by the population, who tended to prefer oral administration to injections. A network of health posts also developed, increasing from 420 in 1986 to 947 in 1993.^5-7 Each submitted weekly reports, and the mandatory objective was to achieve zero confirmed cases.

Because of poor funding and the crumbling surveillance system of the National Institutes of Health, Peru’s national laboratory system could not support the polio eradication campaign during the trying times of the Garcia regime. Therefore, in a remarkable case of inter-American solidarity, PAHO bypassed Peruvian laboratories and sent fecal samples of suspect cases, essential for measuring the progress of the campaign, to the Oswaldo Cruz Foundation in Rio de Janeiro, Brazil, the main biomedical center of South America (M. A. T. Caparas to President Alan Garcia, written communication, September 1986). The Technical Advisory Group also developed a system to rapidly and effectively attack endemic regions with confirmed polio cases through so-called mopping-up operations, or barridos, which entailed the indiscriminate, house-to-house immunization of children younger than five years within specific areas.²⁶ This represented a different and more effective intervention than was used in previous eradication efforts; for example, during the campaign to eradicate malaria, workers spraying DDT tried to cover the entire nation instead of concentrating on critical areas and paid little attention to surveillance. It is plausible that the difference between the WHO malaria eradication program of the 1950s and the later smallpox and polio eradication campaigns was one of type, not of degree.

National and international support, the availability of effective techniques, and the mobilization of community resources and support that occurred after 1985 reinforced a change in public perception of immunization, which had been skeptical. New educational programs fostered community involvement and awareness of the committed health workers working to protect the population. For example, collaboration between other municipal programs, such as the Vaso de Leche (glass of milk) program, which promoted nutrition among children in shantytowns and underserved areas, and the Ministry of Education ignited community involvement beginning in 1984. By the late 1980s, a significant number of nonmedical health leaders and community institutions participated in and supported immunization efforts.

Local communities were involved in the actual act of vaccinating during national immunization days. For example, church groups or local Rotary clubs organized local volunteers or additional transportation needed for successfully immunizing a region in only a few days. Local brigades were organized for hard-to-vaccinate areas, which included not only rural settings but also terrorist-occupied areas, where community involvement proved essential, because government-sponsored personnel would have been at great risk traveling alone. Medical personnel who vaccinated in areas controlled by the Shining Path attested that the perception that vaccination was a goal outside the political conflict moved the group to allow health workers to carry out their life-saving work.^18,24

CONCLUSIONS

In a country with a chaotic political climate, a depressed economy, and public health experts who were convinced that trying to institute holistic PHC was unrealistic, immunization became an important health intervention. Although this intervention’s accomplishments in Peru never paralleled the ceasefire it orchestrated in a Central American civil war during the same period, nonmedical leaders and institutions, grassroots organizations, and even at times an antigovernment terrorist organization eventually perceived its value. The desire to eradicate poliomyelitis overcame national turmoil and created a temporary shelter for the public health sector, thereby helping to prevent its collapse. Immunization, as carried out in Peru, transcended the rigid and contentious division between vertical, disease-oriented programs and horizontal, community-oriented PHC models. The initial vertical program became flexible—sometimes focused and sometimes flattened—to allow for successful disease eradication.

This campaign set an important precedent for future immunization programs and a national surveillance system, as well as for public–private partnerships that would become important and more common. These partnerships should not be viewed as faultless, however. Our investigation revealed that much depended on experts who knew what to do in a moment of political and economic crisis, but whose work in the long run was undermined by the lack of institutionalization of broader PHC efforts. In addition, we found a tendency to overemphasize any success, obscuring other health needs of the population. Moreover, participants had opposing viewpoints about the role played by each agency and the recognition received thereafter, and agencies disputed with one another over leadership and how best to allocate resources.²⁷ These different viewpoints suggest an important fragility within the public–private relationship and the need to institutionalize coherent immunization efforts in conjunction with preexisting activities of the Ministry of Health and general reform throughout the public health system—a topic that warrants further study.

In acknowledgment of the importance of historical analysis, we aimed to provide a balanced perspective that will serve not to celebrate a specific health achievement, but rather to invite reflection on the proper balance between the medical and nonmedical factors that account for a public health achievement under adverse conditions. These factors include sustained political commitment; community engagement; strong leadership at the international, national, and local levels; adequate technology; and a fluent and open collaboration between public and private partners. The lessons learned might be useful for the crucial work being carried out by PAHO to verify the polio-free status of the Americas region and to control the importation of wild poliovirus from endemic areas.²⁸

We have seen a dramatic decline in polio cases around the world, to as few as 223 at the end of 2012.²⁹ The WHO’s Global Polio Eradication Initiative, created in 1988, is on track to eradicate polio by 2018. Despite these successes, there have also been troubling developments in the polio eradication campaign, most notably the targeted attacks against polio health workers in Afghanistan and Pakistan^30,31 and recent outbreaks of mutated oral vaccine, or vaccine-derived, polio cases.³² Although polio eradication campaigns in each country face their own unique challenges and require adaptation to specific contexts, certain parallels can be drawn from the Peruvian story, which illuminates how the shared goal of polio eradication can result in important collaborations that supersede local conflicts and turmoil. Furthermore, the study of polio eradication campaigns can provide insight into how to deliver other vaccines and PHC services, reinforce public health institutions, and overcome challenges faced by local health workers.³³