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. 2017 Apr;107(4):517–524. doi: 10.2105/AJPH.2017.303652

Leaking Containers: Success and Failure in Controlling the Mosquito Aedes aegypti in Brazil

Ilana Löwy 1,✉
PMCID: PMC5343710  PMID: 28207332

Abstract

In 1958, the Pan American Health Organization declared that Brazil had successfully eradicated the mosquito Aedes aegypti, responsible for the transmission of yellow fever, dengue fever, chikungunya, and Zika virus. Yet in 2016 the Brazilian minister of health described the situation of dengue fever as “catastrophic.” Discussing the recent epidemic of Zika virus, which amplified the crisis produced by the persistence of dengue fever, Brazil’s president declared in January 2016 that “we are in the process of losing the war against the mosquito Aedes aegypti.” I discuss the reasons for the failure to contain Aedes in Brazil and the consequences of this failure. A longue durée perspective favors a view of the Zika epidemic that does not present it as a health crisis to be contained with a technical solution alone but as a pathology that has the persistence of deeply entrenched structural problems and vulnerabilities.

In 1958, the Pan American Health Organization (PAHO) officially declared that Brazil had successfully eradicated the mosquito Aedes aegypti, responsible for the transmission of yellow fever, dengue fever, chikungunya, and recently Zika virus.1 In early 2016, the Brazilian minister of health, Marcelo Castro, described the situation of dengue fever as “catastrophic.” He explained that “2015 was the year of the greatest number of cases of dengue in the history of Brazil.”2 Discussing the epidemic of Zika virus, which amplified the crisis produced by the persistence of dengue fever, Brazil’s president, Dilma Russeff, declared in January 2016 that “we are in the process of losing the war against the mosquito Aedes aegypti.”3 Such pessimistic statements—followed by affirmations that the current severe setbacks can be overcome—contrast dramatically with the optimism of the 1960s. In 1964, Fred Lowe Soper, who directed the Pan American Sanitary Organization between 1947 and 1959, claimed that there could be no doubt about the success of the continent-wide campaign to eradicate the Aedes mosquito.4 The impressive progress toward the eradication of Aedes in Latin America gave hope that its eradication in Asia was feasible as well.5

I discuss the reasons for the failure to contain Aedes in Brazil and the consequences of this failure. I had no ambition to tell the complete story of Brazilian effort to control disease-transmitting mosquitoes, only to put these efforts in a historical context. Recent debates on Zika epidemics in Brazil rarely evoked a longue durée perspective. This is regrettable, because such a perspective favors a better understanding of a complex and “recalcitrant” public health problem. This perspective also favors a view of the Zika epidemic that does not present it as a health crisis that has to contained with the “right” technical solution but as a pathology that has the persistence of deeply entrenched structural problems and vulnerabilities.6

1930–1939: ELIMINATING AEDES FROM BRAZIL

Fred Soper was one of the main advocates of the vector and disease eradication doctrine.7 He elaborated this doctrine in the 1930s, when he was the director of the Brazilian branch of the International Health Division of the Rockefeller Foundation.8 In Brazil, the International Health Division had chosen yellow fever as a “demonstrative disease” that would show the efficacy of North American approaches to public health.9 In the 1920s, the International Health Division intervention in Brazil was grounded in the “key focus” theory, which assumed that lowering the density of Aedes mosquitoes in coastal cities would break the chain of transmission of the yellow fever virus and lead to the disappearance of the disease. This approach seemed to be effective. Between 1923 and 1928, the prevalence of yellow fever in Brazil decreased steadily. However, in 1929, a major outbreak of yellow fever in Rio de Janeiro, Brazil, radically upset the ways Rockefeller Foundation experts such as Henry Rose Carter, Joseph White, Lucien Smith, and Michael Connor understood yellow fever epidemiology.10

The subsequent reorganization of the Brazilian Yellow Fever Service under Soper’s direction, and the enlargement of the scope of anti-Aedes campaigns, reflected the new understanding that urban yellow fever originated in the countryside. In 1932, the finding that the yellow fever virus had a reservoir in jungle animals and was transmitted by jungle mosquitoes put an end to the attempt to eliminate this virus from Brazil.11 The Rockefeller Foundation specialists’ goal then shifted to prevention of urban outbreaks of yellow fever through the eradication of their vector, A. aegypti, especially in urban areas, combined, from 1938 on, with the diffusion of an efficient anti–yellow fever vaccine, with control of sporadic rural outbreaks as a result of vaccination.12

In the early 1930s, the goal of the Brazilian cooperative Yellow Fever Service was to decrease drastically the density of Aedes. The eradication of this mosquito from selected Brazilian cities, first observed in spring 1933, was an unintended effect of carefully planned and meticulously organized programs to eliminate Aedes larvae. It then became the official goal of the Yellow Fever Service.13 The successful eradication by Soper and his coworkers of Anopheles gambiae from northern Brazil in 1937 to 1939 might have reinforced Soper’s faith in the validity of the eradication concept.14

The anti-Aedes campaigns in Brazil were grounded in a multilevel system of surveillance: (1) surveillance of the territory through identification of “yellow fever landscapes,” sites where the proximity of the jungle and human habitations produced favorable conditions for the spread of the yellow fever virus; (2) epidemiological surveillance of populations through collection of sera and autopsies of people who had died from a suspicious “fever”; and (3) rigorously codified surveillance of habitants in Aedes-infected areas. Sanitary inspectors made weekly visits to every house in such an area and eliminated containers with stagnant water where Aedes larvae bred; repeated offenders were fined. The quality of the work of rank and file inspectors was systematically checked by their hierarchical superiors through verification of their written records, spot checks of inspected houses, and “adult mosquito capture”—an independent measure of the progress of the antimosquito campaign. Almost a third of the Yellow Fever Service budget was devoted to the supervision of the sanitary inspectors’ work. Such tight supervision, Soper stressed, was essential for the success of eradication efforts.15

1940–1973: DECLARING BRAZIL FREE OF AEDES

In the 1940s, Aedes was eradicated, or was close to being eradicated, in many regions of Brazil, but the attempt to eliminate the yellow fever threat was endangered by the presence of this mosquito in neighboring countries. In 1942, at the 11th meeting of the Pan American Sanitary Conference, Soper proposed to organize national services for the eradication of disease vectors.16 The efforts to eradicate Aedes conducted by these services were intensified after the Second World War. At that time, the availability of DDT made the eradication work less labor-intensive.17 Weekly inspections, repeated for many months, were replaced by one to three DDT-spraying sessions per year.18 The 1947 meeting of the Pan American Sanitary Bureau, the executive organ of the Pan American Sanitary Organization directed by Soper, adopted the vector eradication doctrine.19 The 1947 resolution promoted continent-wide campaigns against Aedes and secured the Pan American Sanitary Bureau’s financial support for these campaigns.20

Soper was aware of the difficulty of scaling up the efforts to eliminate A. aegypti. Continental eradication of this mosquito was more difficult than the organization of local or national campaigns. It implied the efficient cooperation of sanitary authorities in all the infested countries and a reliable monitoring of the progress of the eradication work on a very large scale.21 Efforts to eradicate Aedes from the Americas also were hampered by US sanitary authorities’ reluctance to engage in eradication programs. The United States supported the 1947 program for continental eradication of Aedes. In 1957, the US Public Health Service started a pilot program to test the feasibility of Aedes eradication in Pensacola, Florida. The program was successful and served as the basis for a countrywide eradication program proposed in 1962–1963. The United States officially abandoned its Aedes eradication efforts in 1969. Soper believed that the low enthusiasm for these efforts in the United States reflected the absence of a yellow fever threat to US citizens, the low priority attributed to the risk that mosquitoes from the United States would infest other countries, and the high cost of antimosquito campaigns. Additional issues were the difficulty in imposing antimosquito spraying and search for larvae human habitations, obstacles in delegating the conduct of antimosquito campaigns to local authorities, lack of a reliable system of supervision of the progress of elimination of Aedes, and US entomologists’ objections to eradication programs.22 An additional obstacle was growing opposition to DDT use and the rise of insecticide-resistant strains of Aedes. In the mid-1950s, entomologists had already reported that selected strains of Aedes had become resistant to DDT. This problem became especially acute in the Caribbean region.23 Soper acknowledged in 1964 that the progress of eradication of Aedes in the Americas was slower than expected, but he had no doubt about its final success.24

In the mid-1970s, the continental eradication of Aedes could have been presented as partial success. The following countries were declared free of Aedes: Argentina, Belize, Bermuda, Bolivia, Chile, Equator, the Panama Canal zone, Paraguay, Peru, and Uruguay. On the other hand, the United States, Colombia, Cuba, the Dominican Republic, Guyana, the Caribbean islands, and Venezuela never eliminated this mosquito. The continued presence of Aedes in these countries favored in the late 1960s the infestation of countries previously certified Aedes-free.25 Such reinfestation also was attributed to the growing density of population, degradation of sanitary conditions in the cities, increase in migration movements and tourism, existence of zones of intensive illegal traffic, uncontrolled circulation of small airplanes, continental trade in old automobile tires, and a gradual abandon of mosquito control efforts.26 The difficulty to control Aedes was probably aggravated by the inaccuracy of reports about the progress of eradication work. In the early 1960s, many of PAHO’s experts were unaware of the extent of infestation of the Caribbean region by A. aegypti. At that time, the focus on risks linked with the presence of Aedes started to shift from yellow fever to dengue. A dengue-like disease persisted in the Caribbean region. A year later, in 1963, the situation exploded, and dengue fever nearly blanketed the Caribbean and coastal Venezuela.27

The status of elimination of A. aegypti from Brazil illustrates the shifting fate of the continental eradication program. The Rockefeller Foundation officially left Brazil in 1939, although its experts—virologists, entomologists, and epidemiologists—continued to work with their Brazilian colleagues from the Yellow Fever Service. In the 1950s and 1960s, the elimination of Aedes from Brazil was conducted by a series of organizations affiliated with the Ministry of Health’s first Departamento Nacional de Saúde (National Department of Health), later Departamento Nacional de Endemias Rurais (DNERu; National Department of Rural Endemic Diseases) created in 1953, and then Superintendência de Campanhas (SUCAM; Superintendency of Sanitation Campaigns) created in 1967. SUCAM was replaced in 1988 by Fundação Nacional de Saúde (National Foundation of Health), affiliated with the newly created Brazilian National Health Service (Sistema Único de Saúde).28 Representatives of DNERu and SUCAM often were well received by inhabitants of remote regions of Brazil, who appreciated their multilevel contribution to health care. The declaration of Brazil as an Aedes-free country in 1958 was perceived as a triumph of the patient efforts of sanitary agents who often worked in very difficult conditions.29

Dedicated fieldworkers were, however, unable to prevent the return of Aedes to Brazil. In July 1967, a physician in Belém, Pará, captured a mosquito identified as A. aegypti. In August 1967, when technicians of DNERu arrived in Belém, they found a significant presence of Aedes in the city and several inland localities. DNERu’s inspectors immediately started an energetic eradication campaign. At first, this campaign was hampered by a reduction in the number of the agency’s technicians and difficulties in obtaining sufficient quantities of insecticide, but later it was presented as a success.30 In 1973, PAHO again declared that Brazil was Aedes-free. The second official eradication period did not last long. In 1976 and 1977, A. aegypti was found in Rio de Janeiro and Salvador, Bahia, and then in nearly all the Brazilian states.31

1974–PRESENT: AEDES AND DENGUE EPIDEMICS

The reappearance of A. aegypti in Brazil in the 1970s was followed by outbreaks of dengue fever, absent from Brazil for 50 years. The first outbreak, the 1981–1982 epidemic in the state of Roraima (Amazônia Region), was followed by numerous other outbreaks, among them a major epidemic in Rio de Janeiro in 1986. These epidemics dampened the hopes to rid Brazil of Aedes.32

The widespread presence of dengue fever in Brazil was interpreted as an indicator of the persistence of serious social problems. A survey in the late 1980s found that 33.8% of Brazilian homes lacked a clean water supply, and 39.8% had no garbage collection. The catastrophic sanitary situation in the rapidly growing poor urban and periurban neighborhoods (favelas), coupled with the degradation of security conditions in these neighborhoods, facilitated the spread of Aedes.33 Additional elements that favored it were an increase in the volume of air travel, the mosquitoes’ growing resistance to insecticides, and the low priority attached to costly mosquito eradication programs.34 In the mid-20th century, favelas were seen as relatively safe places, less plagued by crime than the more affluent neighborhoods. The security situation in the favelas deteriorated dramatically, however, in the last quarter of the 20th century with the rise of the favela-based drug traffic.35

In the 1990s, Brazilian public health experts believed that the spread of dengue could be halted through the intensification of educational efforts about importance of anti-Aedes measures and the enrollment of leaders of the affected communities in these efforts. At the same time, public health specialists recognized that targeted campaigns to reduce the density of mosquitoes in a given locality provided only a short-term solution. Long-lasting prevention of dengue fever required a dramatic improvement of the sanitation in poor neighborhoods, an ambitious and expensive endeavor that was not seen as a high priority by Brazilian authorities.36

At the 1978 PAHO meeting, participants discussed the epidemic of dengue fever of 1977, the serious threat of hemorrhaging dengue fever in Caribbean countries, and the recent infestation of many Latin American countries by Aedes. The PAHO’s leaders again affirmed that the organization’s goal was the eradication of the Aedes mosquito from the Americas. All the countries were asked to allocate appropriate resources to emergency mosquito eradication programs, “which, if effectively carried out, will prevent epidemics of dengue and yellow fever and alleviate the need for expensive emergency measures.” The PAHO’s leaders voted the allocation of special funds to support national eradication programs; they also recommended epidemiological surveillance of dengue and yellow fever and elaborated guidelines for emergency interventions such as ground and aerial application of insecticides.37

Seven years later, in 1985, the PAHO’s leaders declared that the 1947 goal of eradication of Aedes was no longer realistic. They proposed to replace it with efforts to maintain the vector populations at a level that did not present a significant public health threat. This aim would be achieved through the integration of chemical, biological, and physical methods of Aedes control with education of the public and the participation of affected communities.38

The new policy did not slow Aedes proliferation in the Americas. In 1995, Brazilian representatives in PAHO proposed to return to a strategy of continental eradication of Aedes.39 PAHO’s Directing Council, which investigated the feasibility of this proposal in 1996, recommended preparing a detailed eradication program. Such a program was formulated in 1997, but it was never implemented. The Brazilian health ministry elaborated in 1996 an ambitious project of nationwide eradication of A. aegypti. This project also was never implemented.40 Just the opposite occurred. Brazilian sanitary services that dealt with mosquito control, seen as too costly, were drastically reduced in the 1990s, a development linked to the reduction of public spending under the neo-liberal presidents Fernando Collor, Itamer Franco, and Fernando Hernriquez Cardoso.41 Soper had insisted on the crucial role of money in sanitary work. “Continuing Aedes aegypti control,” he wrote in 1967, “is difficult and expensive: it is not an easy task to get the money to keep this mosquito under control.”42 Securing funds for public health work was, however, an absolutely essential task: “the point is too often missed by public health administrators that theirs is a selling as well as administrative job.”43 Brazilian public health administrators probably failed in their task as “salesmen/saleswomen.”

In 1999, Rio de Janeiro fired approximately two thirds of the sanitary agents responsible for mosquito control in the city. In 2002, Rio experienced the worst dengue epidemic in its history. The crisis was aggravated by the presence of a different strain of the dengue virus, DEN-2, which produced more severe syndromes in people previously infected by the DEN-1 strain.44

In the early 21st century, eradication of Aedes from Brazil was no longer on the public health agenda. In 2001, the Brazilian government officially abandoned the 1996 project to eradicate Aedes and proposed instead a Plan of Intensification of Actions of Control of Dengue. In 2002, this plan was replaced by the National Plan of Control of Dengue. Its goals were the development of permanent programs of mosquito control, elaboration of large-scale information and education campaigns to stimulate community-based antimosquito measures, integration of the control of mosquitoes with other programs of basic public health such as the popular Program of Family Health, and perfection of tools of epidemiological surveillance.45 The National Plan of Control of Dengue did not promote, however, large investments in sanitation in poor neighborhoods.46 In the late 20th and early 21st century, Brazil made important advances in the reduction of extreme misery and greatly improved the access of the poor to primary health care and education. It did not make similar advances in providing clean water and sewage and trash collection to destitute neighborhoods.

Hopes that new scientific developments, such as the massive use of genetically modified mosquitoes, would stop the progress of dengue fever did not materialize either. Between 1997 and 2002, Brazil reported more than 2 million cases of dengue, 70% of the cases of this disease recorded in Latin America. Dengue fever was no longer located in specific Brazilian states but was distributed all over the country’s territory. The large-scale diffusion of dengue was accompanied by an increase in the number of cases of hemorrhagic dengue fever and of deaths attributed to this pathology.47

In the first years of the 21st century, the effective control of mosquitoes in Brazil was frequently presented as an impossible task: “Aedes has a million incubators ( . . . ), potholes and potted plants, plastic scrap and rubber tires, a ditch or a muddy footprint.”48 Dengue fever epidemics, epidemiologists stressed in 2009, “have their deepest roots in the explosive expansion of the urban environment, with a major portion of the urban population lacking basic environmental infrastructure.” If these problems are not addressed, the situation will probably become worse.49 Moreover, efforts to control Aedes proliferation were hampered by the consequences of global warming. In 2010, Rio de Janeiro had the worst dengue epidemic in the city’s history since 2002, and the disease has become hyperendemic in most Brazilian states.50

A 2011 survey of the state of control of infectious diseases in Brazil presented the unstoppable progress of dengue fever as a major failure of public health efforts. The Brazilian government had invested every year R$900 000 in anti-Aedes campaigns, but these campaigns failed to halt the spread of dengue fever. The prospects for the future, the authors of the survey concluded, were not encouraging.51 They were right. The prevalence of dengue fever in Brazil has not diminished.52 Moreover, in 2014, this country was infested by another pathogen, transmitted (mainly) by Aedes, the Zika virus.

ZIKA IN BRAZIL: BACK TO THE STARTING POINT?

The Zika virus was first described in central Africa. It reached Brazil in summer 2014 and spread rapidly, especially in the northern part of the country.53 At first, Zika was associated with only a mild febrile condition accompanied by a rash. In fall 2015, Brazilian authorities noted, however, an excess of cases of microcephaly in newborns in Pernambuco State. Many of the women who had children with this condition reported having had fever and a typical rash during pregnancy. The introduction of a more restrictive definition of microcephaly in March 2016 reduced the number of reported cases.54 Experts gradually shifted from a focus on brain size to an investigation of a wide range of Zika-induced brain anomalies produced by infection with Zika virus early in pregnancy.55 In addition, this virus was linked with placental anomalies, spontaneous abortions, in utero deaths, and, separately, with the Guillain–Barré syndrome.56

The Zika epidemic presents a serious challenge to public health in Brazil.57 The rapid spread of Zika, like the spread of the dengue and recently also of chikungunya viruses, is seen as the result of uncontrolled proliferation of Aedes mosquitoes. Zika epidemics were framed, especially by US experts, as a global health emergency and a problem that awaits a technological, pharmacological, or organizational solution—a point of view that resonates strongly with the legitimation of anti-Aedes campaigns from the 1920s onward. An exclusive focus on the elimination of mosquitoes deflects attention from structural problems of chaotic urbanization and the fate of vulnerable populations.58

The challenges posed by fetal anomalies induced by Zika are also directly related to severe restrictions on women’s reproductive rights in Latin America.59 Contraception is legal in Brazil, but poor women have difficulty in gaining access to reliable and well-adapted contraceptive means; abortion for a fetal indication is criminalized, with the sole exception of anencephaly. Brazilian women from the lower social classes may have more difficulty in controlling their fertility and, when diagnosed with a severe fetal anomaly, cannot choose to terminate the pregnancy. Despite the official discourse of Brazilian health authorities, mothers of children with Zika-induced neurological impairments often receive inadequate, if any, help.60 Class differences with respect to the possibility of reacting to the consequences of infection with Zika show the biological effects of gender, or rather gender-related discrimination, because poor women have limited access to efficient contraception and no possibility to undergo a safe interruption of pregnancy.61

In January 2016, the Brazilian government sent more than 200 000 soldiers to Aedes-infested areas in the northeast of Brazil. The soldiers went from house to house, sprayed insecticides, and attempted to eliminate potential sources of Aedes breeding in a massive effort to halt the propagation of this mosquito and to demonstrate the government’s intervention in the Zika crisis—even though such an intervention probably had limited practical consequences.62 Brazilian researchers have warned that the country may be facing more pain before a solution to the Zika crisis is found.63 The best-case scenario for the Zika epidemic would be the discovery that a single infection with this virus produces lasting immunity, the transformation of Zika into a (mainly) childhood disease, the elaboration of better tools to control Aedes, and, above all, the production of an effective anti-Zika vaccine.64 The experts’ main hope is thus a rapid development of new technologies, coupled with biological luck.65

The best-case scenario, although far from being certain, offers a genuine possibility of reduction of Zika-induced harm.66 However, the Zika epidemic, like that of dengue and chikungunya, does not stem exclusively from the proliferation of mosquitoes and viruses. It is also driven by the persistence of severe inequality, which limits political interest in improving the sanitary conditions in poor areas. Epidemics of arboviruses are collective problems that stem from specific forms of interactions of humans with their environment.67 Sanitary campaigns that focused on mosquitoes and “forgot” the people who lived in the mosquito-filled area were problematic in Soper’s time.68 They were even more problematic in the first 15 years of the 21st century, when the transmission of diseases by mosquitoes was strongly favored by indirect mechanisms: rapid urban growth, migration, and the deterioration of access to health care.69 Containment may be illusory when the containers are leaking—physically and metaphorically. In the absence of solutions to the social problems that have favored a rapid spread of Zika virus in Brazil, even a best-case scenario may be effective only until the next public health crisis. Wilbur Sawyer—International Health Division’s director between 1935 and 1941 and Soper’s supervisor during the decisive years of elaboration of the vector eradication doctrine—might have agreed. Summing up the International Health Division’s achievements in 1951, Sawyer concluded that the early hopes of finding effective technical solutions to public health issues might have been misguided: “the problem is much broader than health, which cannot flourish in an adverse socioeconomic environment.”70

ACKNOWLEDGMENTS

I am grateful for colleagues who expanded my understanding of control of mosquitoes in Brazil: Jaime Benchimol, Marcos Cueto, and Denise Nacif Pimenta, and to AJPH’s anonymous reviewers for their important contributions to the improvement of this article.

ENDNOTES

  • 1. The expression “leaking containers” is borrowed from Lynn Morgan’s description of storage of dead fetuses. Lynn Morgan, Icons of Life: A Cultural History of Human Embryos (Berkeley, CA: California University Press, 2009).
  • 2. “El Ministro de Salud Pública de Brasil Calificó de Catastrófica la Situación Que Vive el País,” Telemundo, January 26, 2016, http://www.teledoce.com/telemundo/internacionales/brasil-esta-perdiendo-la-batalla-contra-el-dengue (accessed January 26, 2017)
  • 3. Dilma Roussef, “Estamos Perdiendo la Lucha Contra el Mosquito Aedes aegypti,” Infobae América, January 29, 2016, http://www.infobae.com/2016/01/29/1786411-dilma-rousseff-estamos-perdiendo-la-lucha-contra-el-mosquito-aedes-aegypti (accessed January 26, 2017)
  • 4. Fred Soper, “The 1964 Status of Aedes aegypti Eradication and Yellow Fever in the Americas,” American Journal of Tropical Medicine and Hygiene 14, no. 6 (1964): 887–891. Pan American Sanitary Organization changed its name to PAHO (Pan American Health Organization) in 1958. [DOI] [PubMed]
  • 5. Fred L. Soper, “The Prospects for Aedes aegypti Eradication in Asia in the Light of Its Eradication in Brazil,” Bulletin of the World Health Organization 36, no. 4 (1967): 645–647. [PMC free article] [PubMed]
  • 6. João Nunes and Denise Nacif Pimenta, “A Epidemia de Zika e os Limites de Saúde Global,” Lua Nova 98 (2016): 21–46.
  • 7. N. L. Stepan, Eradication: Ridding the World of Diseases Forever? (London, UK: Reaktion Books, 2011).
  • 8. M. Cueto, ed., Missionaries of Science: The Rockefeller Foundation and Latin America (Bloomington, IN: Indiana University Press, 1994).
  • 9. On the Rockefeller Foundation campaigns against yellow fever in Brazil, see Ilana Löwy, Virus, Moustiques et Modernite: La Fièvre Jaune au Brésil Entre Science et Politique (Paris, France: Editions des Archives Contemporaines, 2001); Jaime Benchimol, coordinator, Febre Amarela: A Doença e a Vacina, Uma História Inacabada (Rio de Janeiro, Brazil: Editora Fiocruz, 2001).
  • 10. Löwy, Virus, Moustiques et Modernite.
  • 11. F. Soper et al., “Yellow Fever Without Aedes aegypti: Study of a Rural Epidemic in the Valle do Chanaan, Esprito Santo, Brazil,” American Journal of Hygiene 18 (1933): 555–587.
  • 12. Soper, “1964 Status of Aedes aegypti Eradication,” 887. On the role of yellow fever vaccine in Rockefeller Foundation’s strategies, see Benchimol, Febre Amarela. Löwy, Virus, Moustiques et Modernite, chap. 6.
  • 13. Soper, “Prospects for Aedes aegypti Eradication,” 646. [PMC free article] [PubMed]
  • 14. F. Soper and W. Bruce, Anopheles gambiae in Brazil, 1930-1940 (New York, NY: Rockefeller Foundation, 1943).
  • 15. Fred Soper et al., The Organization of Nation-Wide Anti Aedes Aegypti Measures in Brazil (New York, NY: Rockefeller Foundation, 1942); Fred Soper, “Rehabilitation of the Eradication Concept in Prevention of Communicable Diseases,” Public Health Report 80 (1965): 855–869. [PMC free article] [PubMed]
  • 16. On the role of Soper’s campaigns against malaria during the Second World War in establishing the eradication doctrine, see Stepan, Eradication, 105–108; Rodrigo Cesar da Silva Magalhães, A Erradicação do Aedes aegypti Febre Amarela: Fred Soper e Saúde Pública nas Américas (1918-1968) (Rio de Janeiro, Brazil: Editora Fiocruz, 2016), 148–167.
  • 17. Soper’s aspiration to eradicate Aedes from the Americas dates from the 1930s. Löwy, Virus, Moustiques et Modernite; Magalhães, Erradicação do Aedes aegypti.
  • 18. Zouraide Guerra Antunes Costa et al., “Evolução Histórica da Vigilância Epidemiológica e do Controle da Febre Amarela no Brasil,” Revista Pan-Amazônica de Saúde 2, no. 1 (2011): 11–26.
  • 19. On the history of the Pan American Health Organization (PAHO), see Marcos Cueto, The Value of Health: A History of the Pan American Health Organization (Washington, DC: Pan American Health Organization, 2007); Marcos Cueto and Steven Palmer, Medicine and Public Health in Latin America: A History (New York, NY: Cambridge University Press, 2015).
  • 20. F. L. Soper, Ventures in World Health: The Memoirs of Fred Lowe Soper, ed. John Duffy (Washington, DC: Pan American Health Organization, 1977), 326–330; Magalhães, Erradicação do Aedes aegypti, 213–221. Magalhães studied the role of Office of Inter-American Affairs (OIAA) in shaping Pan American Health Organization’s eradication policy.
  • 21. Soper, Ventures, 343; Magalhães, Erradicação do Aedes aegypti, chap. 7.
  • 22. Soper, Ventures, 351–357; Magalhães, Erradicação do Aedes aegypti, 292–315.
  • 23. George Shidrawi, “Laboratory Tests on Mosquito Tolerance to Insecticides and Development of Resistance by Aedes aegypti,” Bulletin of the World Health Organization 17 (1957): 377–411; Soper, Ventures, 340–343. [PMC free article] [PubMed]
  • 24. Soper, “1964 Status of Aedes aegypti Eradication,” 888; Soper, Ventures, 342–343.
  • 25. Magalhães, Erradicação do Aedes aegypti, 276–286.
  • 26. Soper, Ventures, 342–343; Francisco Pinheiro and Michael Nelson, “Re-Emergence of Dengue and Emergence of Dengue Haemorrhagic Fever in the Americas,” Dengue Bulletin 21 (1997): 16–24. Fears of return of yellow fever did not materialize because local outbreaks of jungle yellow fever were contained through vaccination.
  • 27. Vector Control and the Recrudescence of Vector-Borne Diseases: Proceedings of a Symposium Held During the Tenth Meeting of the PAHO Advisory Committee on Medical Research, 15 June 1971 (Washington, DC: Pan American Health Organization, Pan American Sanitary Bureau, 1972), Contributions of William Reeves and J. Ralph Audy, 7–8, 78–79.
  • 28. C. O. Fonseca, “Interlúdio: As Campanhas Sanitárias e o Ministério da Saúde, 1953-1990,” in Febre Amarela: A Doença e a Vacina, Uma História Inacabada, coordinator Jaime Benchimol (Rio de Janeiro, Brazil: Editora Fiocruz, 2001), 299–305.
  • 29. Memoirs of Superintendência de Campanhas (SUCAM) agents are reproduced in Hélbio Fernandes Moraes, coordinator, vol. II of SUCAM, sua Origem, sua História (Brasília: Ministério da Saúde, 1988), 23–76.
  • 30. Odair Franco, ed., “A Erradicação do ‘Aedes aegypti,’” in História da Febre Amarela no Brasil (Rio de Janeiro, Brazil: Ministério da Saúde Departamento Nacional de Endemias Rurais, 1969), 135–156.
  • 31. Fonseca, “Interlúdio.”.
  • 32. J. C. Serufo et al., “Dengue in the South-eastern Region of Brazil: Historical Analysis and Epidemiology,” Revista de Saude Publica 27, no. 3 (1993): 157–167. [DOI] [PubMed]
  • 33. D. N. Pimenta, “Determinação Social, Determinantes Sociais da Saúde e a Dengue: Caminhos Possíveis?,” in Dengue: Teorias e Práticas, coordinators Denise Valle et al. (Rio de Janeiro, Brazil: Editora Fiocruz, 2015), 407–447.
  • 34. K. B. Marzochi, “Dengue in Brazil–Situation, Transmission and Control—A Proposal for Ecological Control,” Memorias do Instituto Oswaldo Cruz 89, no. 2 (1994): 235–245. [DOI] [PubMed]
  • 35. J. Perelman, Favela: Four Decades of Living on the Edge in Rio de Janeiro (New York, NY: Oxford University Press, 2010).
  • 36. Serufo et al., “Dengue in the South-eastern Region of Brazil,” 165; Marzochi, “Dengue in Brazil,” 239–241.
  • 37. Pan American Health Organization (PAHO), Report of 30th Meeting of the Regional Committee of WHO for the Americas (St. Georges, Grenada, September 25, 1977) (Washington, DC: PAHO, Document n° 164), 275–276.
  • 38. Pinheiro and Nelson, “Re-emergence of Dengue,” 22. The new strategy was summarized in the 1994 Washington, DC, Pan American Health Organization (PAHO) document, “Dengue and Dengue Hemorrhagic Fever in the Americas: Guidelines for Prevention and Control,” (accessed January 26, 2017).
  • 39. On the international context of nonimplementation of eradication programs at that time, see T. M. Brown, M. Cueto, and E. Fee, “The World Health Organization and the Transition From ‘International’ to ‘Global’ Public Health,” American Journal of Public Health 96, no. 1 (2006): 62–72. [DOI] [PMC free article] [PubMed]
  • 40. Pinheiro and Nelson, “Re-emergence of Dengue”; Ima Aparecida Braga and Denise Valle, “Aedes aegypti: Historico do Controle no Brasil,” Epidemiologia e Servicos de Saude: Revista do Sistema Unico de Saude do Brasil 16 (2007): 113–118.
  • 41. M. Margolis, “The Bug Is Back,” Newsweek International, June 17, 2002, 60. The cuts in health budgets in the 1990s reflected Brazil’s shift to neo-liberal policies. The reversal of these policies under the presidency of Luiz Inácio Lula da Silva did not reduce, however, the prevalence of dengue fever.
  • 42. Soper, “Prospects for Aedes aegypti Eradication,” 645. [PMC free article] [PubMed]
  • 43. Soper, “Rehabilitation of the Eradication Concept,” 858. [PMC free article] [PubMed]
  • 44. T. M. F. Luiz, “Dengue in Brazil: Past, Present and Future Perspectives,” Dengue Bulletin 27 (2003): 25–33.
  • 45. Braga and Valle, “Aedes aegypti.”.
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  • 48. Margolis, “The Bug Is Back.”.
  • 49. Maria Glória Teixeira et al., “Dengue: Vinte e Cinco Anos da Reemergência no Brasil,” Cadernos de Saúde Pública 25, suppl. 1 (2009): S7–S18, quotation S15. Dengue outbreaks were related to the degradation of sanitation in cities. Denise Nacif Pimento, “Determinaçao Social, Determinantes Sociais da Saude,” in Dengue: Teorias e Práticas, eds. Denise Valle, et al. (Rio de Janeiro, Brazil: Editora Manguinhos, 2016), 407–448.
  • 50. I. Rodriguez-Barraquer et al., “From Re-emergence to Hyperendemicity: The Natural History of the Dengue Epidemic in Brazil,” PLoS Neglected Tropical Diseases 5, no. 1 (2011): e935. [DOI] [PMC free article] [PubMed]
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  • 52. Specialists predict that the prevalence of dengue and chikungunya in Brazil will increase in winter 2016/2017.
  • 53. D. Musso, “Zika Virus Transmission From French Polynesia to Brazil,” Emerging Infectious Diseases 21, no. 10 (2015): 1887. [DOI] [PMC free article] [PubMed]
  • 54. Portal da Saúde, http://portalsaude.saude.gov.br/index.php/o-ministerio/principal/secretarias/svs/noticias-svs (accessed January 26, 2017). Reporting on fetal malformation in Brazil is often incomplete.
  • 55. G. V. França et al., “Congenital Zika Virus Syndrome in Brazil: A Case Series of the First 1501 Livebirths With Complete Investigation,” Lancet 388, no. 10047 (2016): 891–897. [DOI] [PubMed]
  • 56. E. J. Rubin, M. F. Greene, and L. R. Baden, “Zika Virus and Microcephaly,” The New England Journal of Medicine 374, no. 10 (2016): 984–985. [DOI] [PubMed]
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  • 58. Some researchers have argued that people who live in poor, mosquito-infested neighborhoods are at an increased risk for contracting Zika; for example, Paula Andrade Lotufo, “Zika Epidemic and Social Inequalities: Brazil and Its Fate,” Sao Paulo Medical Journal 134 (2016): 95–96; Jeffrey Lesser and Uriel Kitron, “The Social Geography of Zika in Brazil,” NACLA Report on the Americas 48(2016): 123–129. The putative link between poverty and Zika is, however (as for now), an unproven hypothesis. [DOI] [PMC free article] [PubMed]
  • 59. Mónica Roa, “Zika Virus Outbreak: Reproductive Health and Rights in Latin America,” Lancet 387, no. 10021 (2016): 843. [DOI] [PubMed]
  • 60. S. J. Dos Santos Oliveira, et al., “Anxiety, Depression, and Quality of Life in Mothers of Newborns With Microcephaly and Presumed Congenital Zika Virus Infection,” Archives of Women’s Mental Health 19, no. 6 (2016): 1149–1151. [DOI] [PubMed]
  • 61. D. Diniz, “Zika Virus and Women,” Cadernos de Saúde Pública 32, no. 5 (2016): e00046316 Alexandra M. Stern, “Zika and Reproductive Justice,” Cadernos de Saúde Pública 32, no. 5(2016): e00081516. [DOI] [PMC free article] [PubMed]
  • 62. Soper and his colleagues might have questioned the efficacy of such a campaign, as do some experts today. Dr. Marie-Paule Kieny, assistant director general at the World Health Organization, explained in a press conference held March 9, 2016, that “spraying insecticides to kill mosquitoes has had no evident effect on halting the spread of dengue fever, raising concerns that it may be equally ineffectual in checking the spread of the Zika virus.” Nick Cumming-Bruce, “Zika Vaccine Still Years Away, W.H.O. Says,” New York Times, March 3, 2016, https://www.nytimes.com/2016/03/10/world/americas/zika-vaccine-still-years-away-who-says.html?_r=0 (accessed January 26, 2017).
  • 63. G. Vogel, “Experts Fear Zika’s Effects May Be Even Worse Than Thought,” Science 352 (2016): 1375–1376; Margaret A. Honein and Denise J. Jamieson, “Monitoring and Preventing Congenital Zika Syndrome,” The New England Journal of Medicine 375, no. 24(2016): 2393–2394. [DOI] [PubMed]
  • 64. However, a vaccine, even an effective one, may not be sufficient to eliminate the Zika epidemics. Tom Solomon, Matthew Baylis, and David Brown, “Zika Virus and Neurological Disease—Approaches to the Unknown,” Lancet Infectious Diseases 16, no. 4 (2016): 402–404. [DOI] [PMC free article] [PubMed]
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  • 66. Cumming-Bruce, “Zika Vaccine Still Years Away.”.
  • 67. D. Valle, D. N. Pimenta, and R. Aguiar, [“Zika, Dengue and Chikungunya: Challenges and Issues,”] [in Portuguese] Epidemiologia e Servicos de Saude: Revista do Sistema Unico de Saude do Brasil 25, no. 2 (2016): 419–422. [DOI] [PubMed]
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  • 69. A. Castro, Y. Khawja, and J. Johnston, “Social Inequalities and Dengue Transmission in Latin America,” in Plagues and Epidemics: Infected Spaces Past and Present, eds. D. Ann Herring and Alan C. Swedlund (New York, NY: Berg, 2010), 231–250; Nunes and Pimenta, “Epidemia de Zika.”.
  • 70. Wilbur Sawyer, “Medicine as a Social Instrument: Tropical Medicine,” The New England Journal of Medicine 244 (1951): 217–224. On the context of Sawyer’s statement, see Magalhães, Erradicação do Aedes aegypti, 233. [DOI] [PubMed]

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