PUBLIC HEALTH THEN AND NOW

A Public Health Achievement

UNDER
ADVERSITY
The Eradication of Poliomyelitis From Peru, 1991

| Deepak Sobti, MD, Marcos Cueto, PhD, and Yuan He, BS

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

2298 | Public Health Then and Now | Sobti et al. American Journal of Public Health | December 2014, Vol 104, No. 12

joined smallpox as the only dis-
eases eliminated from the West-
ern 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 litera-
ture on the history of immuniza-
tion, particularly polio control
and eradication.911 It also illu-
minates some crucial issues in
Latin American public health,
such as the relationship between
vertical and horizontal programs
and immunization in underde-
veloped health care systems and
the possibility for broad alli-
ances between public and pri-
vate agencies for humanitarian
health goals.
The history of Perus fight to
eliminate polio falls into two peri-
ods: 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 polio-
myelitis 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, avail-
able technology, and public atti-
tudes toward immunization in
each of these periods.
December 2014, Vol 104, No. 12 | American Journal of Public Health
PUBLIC HEALTH THEN AND NOW
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 dur-
ing this period were fleeting,
and surveillance and epidemio-
logical studies were rare. During
the following 14 years, improved
information systems allowed for
a more accurate picture of the
diseases 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) inject-
able 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 Roger Zapata examines Luis Fermn
immunity and therefore break Tenorio Cortez in rural Pichanaki,
the transmission of wild poliovi- Peru. 1991. Courtesy of Roger
Zapata.
rus, and ease of use for massive
immunization campaigns. Still,
despite the vaccines 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
Belande. The resulting populist
military regime ruled Peru for the
next 12 years, including a term
under the more moderate Gen-
eral Francisco Morales Bermdez
(19781980). During this time,
sweeping social reforms were
unable to protect the country
from economic depression and
social unrest, but some high-rank-
ing public health officers were
aware of developments in interna-
tional health and sent representa-
tives to the 1978 International
Conference on Primary Health
Sobti et al. | Peer Reviewed | Public Health Then and Now | 2299

Boy showing his painted finger, rep-
resenting a vaccinated child. Date
unknown. Courtesy of Roger Zapata.
2300 | Public Health Then and Now | Peer Reviewed | Sobti et al.
PUBLIC HEALTH THEN AND NOW
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
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 Presi-
dent Belande (19801985).
His five-year term saw the for-
mation and growth of the Maoist
organization Sendero Luminoso
(Shining Path). Belandes lack
of organization, inability to focus
on and solve the mounting chal-
lenges 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 Reso-
lut
lution 27.57, the WHO; its
reg
regional arm, the Pan American
He
Health Organization; and the
Pe
Peruvian Ministry of Health coor-
din
dinated various immunization
pro
programs. Over the next few
ye
years, immunization became
en
enshrined as one of the principal
PH
PHC interventions after the suc-
ces
cessful experience of smallpox
era
eradication (begun in the 1960s
an
and achieved in 1980) and the
lan
landmark conference at Alma-
At
Ata in 1978. Initially, immuniza-
tio
tion programs were small, local-
ize
ized, and underfunded, and they
ac
accorded little importance to sur-
veillance.14 Although the Peru-
ve
via government was in a state
vian
of transition, the military regime
ba
backed these public health initia-
ti
tives and in 1977 adopted the
E
Expanded Program on Immuni-
z
zations, the WHOs smallpox
eradication model, which
emphasized containment and
surveillance. This interna-
tional WHO program
administered the Sabin oral
vaccination for poliomyelitis
an collaboratively promoted
and
va
vaccinations for diphtheria,
whooping cough, tetanus, mea-
sles, and tuberculosis.1517
During the late 1970s and
early 1980s, political turmoil
and public healths low priority
in the government precluded
major advances. Furthermore,
most immunization program-
ming was limited to the capital
city of Lima and the countrys
other major urban centers. This
American Journal of Public Health | December 2014, Vol 104, No. 12
marginalized the rural popula-
tion, which, by the 1970s, repre-
sented 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 breastfeed-
ing and improving childrens
nutrition, growth monitoring,
and immunization. Neverthe-
less, segments of the PHC strat-
egy, such as oral rehydration
techniques for diarrheal dis-
eases, were enthusiastically pro-
moted by Belandes minister
of health, Uriel Garcia, in the
major urban shantytowns dur-
ing the 1980s.
Without a budget for specific
health programs, the ministrys
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 frag-
mented: the public, social secu-
rity, private, military, and
indigenous sectors had little coor-
dination.18 The country lacked a
comprehensive national surveil-
lance 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 Min-
istry of Health had responsibility
for national immunizationa 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 dele-
gated to epidemiologists at the
department level (the subnational
political division of the country)
and nurses at the hospitalclinic

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 sanita-
tion leaders from PAHO, the Min-
istry of Health, UNICEF, and RI
to direct efforts.
These leaders confronted the
disorganization and lack of finan-
cial 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 refriger-
ated distribution system extend-
ing from the laboratory to the
child), viable laboratories, and
adequate information and diag-
nostic 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 neces-
sary to disseminate them, a prob-
lem exacerbated by the absence
of coordination among the vari-
ous health sectors. Some admin-
istered the Salk injectable polio
vaccine, others the Sabin oral
vaccine. Furthermore, vaccina-
tion schedules for children
changed often; some were vacci-
nated 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 sec-
tor maintained a separate infor-
mation system. This meant that
the number of polio cases was
not always shared among sectors,
and hence vaccination methods
December 2014, Vol 104, No. 12 | American Journal of Public Health
PUBLIC HEALTH THEN AND NOW
differed.16 Ultimately, a lack of
political commitment, a frag-
mented and disorganized system,
and insufficient funding yielded a
divided and inefficient public
health system that could not
eradicate poliomyelitis.
The governments indifference
to immunization engendered a
passive attitude among the pub-
lic. Even mothers who brought
their children for hospital visits
received little information on the
benefits of vaccination. Clinics in
rural areas and shantytowns rou-
tinely packed many sick children
into a single room for vaccina-
tions; as a result, mothers hesi-
tated to return and believed their
children were better off without
the vaccines (Roger Zapata, oral
communication, November 15,
2004). Little effort went into
increasing community participation
in vaccination programs, and
both the population and govern-
ment officials remained oblivious
to the extent of wild poliomyelitis
infections.
In 1980, only 15% of the in Peru, ultimately coming to frui- Letter from Peruvian Rotary
countrys eligible children tion six years later with the last President Gustavo Gross to Peruvian
received immunizations against native case of wild poliomyelitis in President M. A. T. Caparas offering
financial support. Lima, Peru. 1986.
poliomyelitis. Diphtheria, whoop- the Americas reported in 1991.14 Courtesy of Gustavo Gross.
ing cough, tetanus, measles, and
tuberculosis coverage also COLLABORATION AND
remained low.19 The original goal COMMITMENT
of the Expanded Program on
Immunizations in the late 1970s In 1985, a second democrati-
was to provide immunization ser- cally elected president took
vices for every child in the world office. Alan Garcia led a party
by 1990, and its main assumption that claimed to be the Peruvian
was that vertical programming version of European social
would help to strengthen public democracy, the centerleft
health care infrastructures. Later, Aprista Party (the acronym
in 1985, the PAHO Directing APRA stood for American Popu-
Council adopted the specific goal lar Revolutionary Alliance). Like
of eradicating wild poliovirus his predecessors, Garcia was
from the Western Hemisphere by unable to solve the economic
1990. This goal was a major and political problems of the
impetus for change in Peru as country, and a growing fear of
well as in neighboring Latin terrorism, a severe economic
American countries. The decision crisis, and governmental misman-
triggered significant developments agement led to hyperinflation.
Sobti et al. | Peer Reviewed | Public Health Then and Now | 2301

A typical poster used in Peru to gar-
ner community support for the vacci-
nation campaign circa June 1991.
Courtesy of Roger Zapata/Pan
American Health Organization.
2302 | Public Health Then and Now | Peer Reviewed | Sobti et al.
PUBLIC HEALTH THEN AND NOW
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 inter-
national experience and were
open to PHC perspectives. One
of these was the newly appointed
minister of health, David Tejada
de Rivero, an experienced inter-
national health official who had
played a crucial role in the orga-
nization 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
Tejadas experienced and charis-
matic leadership opened the
door for greater collaboration
among the WHO, PAHO, and
UNICEF, as well as other agen-
cies. Together they organized
vaccination programming
throughout Peru, starting with
the first official national immuni-
zation days in 1985, a major
effort to involve the community,
the private sector, and institu-
tions, personalities, and leaders
from outside the health system in
a public health intervention.
Even at the lowest political lev-
els, routine immunization rates
began to increase.17
Most health workers were
aware that Perus social and politi-
cal conditions were not ripe for
the implementation of a holistic
version of PHC. They could, how-
ever, organize effective mobile
teams for the task of immuniza-
tion. 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 vaccina-
tion of everyone within a radius
of a few miles of such outbreaks
and cases.21
Also in 1985, Dr Carlyle
Guerra de Macedo, PAHOs
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 doc-
tor, Ciro de Quadros, who had
played an important role in the
WHOs smallpox eradication pro-
gram in Africa, led these efforts
as PAHOs director of the Divi-
sion of Vaccines and Immuniza-
tion.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
PAHOs 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 correspon-
dent, who facilitated fluent and
secure communication with inter-
national agencies and laborato-
ries. These developments
stimulated the training of local
personnel and the establishment
of a more comprehensive surveil-
lance system.
Between 1985 and 1987, ini-
tial 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
American Journal of Public Health | December 2014, Vol 104, No. 12
national organization, in part
because of partnerships with out-
side 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 eradica-
tion effort. They were known
locally in their towns and neigh-
borhoods 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.
RIs president, M. A. T. Caparas,
wrote to President Garcia offer-
ing his support in September of
1986 (M. A. T. Caparas to Presi-
dent Alan Garcia, written com-
munication, 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 volun-
teers from RI, the Technical Advi-
sory Group was responsible for
vaccinating children younger
than five years in a specific area
within its region. In addition, the
formation of the Peruvian Inter-
agency Coordinating Committee,
with representatives from the
Peruvian Ministry of Health,
PAHO, RI, UNICEF, the US
Agency for International Devel-
opment, 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 com-
mitment 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 promot-
ing 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 Paths 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, cre-
ating yet another obstacle to vac-
cinating a large portion of Perus
population. Indeed, the destruc-
tion of a rural health clinic
caused Luis Fermn Tenorio Cor-
tez, the last reported victim of
poliomyelitis in the Americas, to
miss his final two vaccine doses.25
Social networking and finan-
cial aid became available in
Peru with the involvement of RI
and other multilateral and bilat-
eral 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
December 2014, Vol 104, No. 12 | American Journal of Public Health
PUBLIC HEALTH THEN AND NOW
for the task force personnel who
orchestrated the national surveil-
lance 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 pro-
vided a social network that mobi-
lized 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 chil-
dren with the Sabin vaccine at
ages two, three, and four
months.17 According to interna-
tional experts, this method was
more economical than alterna-
tives, easier, and more likely to
be accepted by the population,
who tended to prefer oral admin-
istration 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 manda-
tory objective was to achieve
zero confirmed cases.
Because of poor funding and
the crumbling surveillance sys-
tem of the National Institutes of
Health, Perus national laboratory
system could not support the
polio eradication campaign dur-
ing the trying times of the Garcia
regime. Therefore, in a remark-
able case of inter-American soli-
darity, PAHO bypassed Peruvian
laboratories and sent fecal sam-
ples of suspect cases, essential for
measuring the progress of the
campaign, to the Oswaldo Cruz
Foundation in Rio de Janeiro,
Brazil, the main biomedical cen-
ter of South America (M. A. T.
Caparas to President Alan Gar-
cia, written communication, Sep-
tember 1986). The Technical
Advisory Group also developed a
system to rapidly and effectively
The formation of the Technical Advisory
Group in Peru finally brought about a unified
plan for national vaccination that could be
implemented consistently.
attack endemic regions with con-
firmed 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 spray-
ing 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 eradi-
cation program of the 1950s and
the later smallpox and polio
eradication campaigns was one
of type, not of degree.
National and international sup-
port, the availability of effective
techniques, and the mobilization
of community resources and sup-
port that occurred after 1985
Sobti et al. | Peer Reviewed | Public Health Then and Now | 2303
 PUBLIC HEALTH THEN AND NOW
reinforced a change in public per-
ception of immunization, which
had been skeptical. New educa-
tional programs fostered commu-
nity involvement and awareness
of the committed health workers
working to protect the popula-
tion. For example, collaboration
between other municipal pro-
grams, such as the Vaso de Leche
(glass of milk) program, which
promoted nutrition among chil-
dren in shantytowns and under-
served 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 institu-
tions participated in and sup-
ported immunization efforts.
Local communities were
involved in the actual act of vac-
cinating during national immuni-
zation 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 govern-
ment-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
2304 | Public Health Then and Now | Peer Reviewed | Sobti et al.
trying to institute holistic PHC
was unrealistic, immunization
became an important health
intervention. Although this inter-
ventions accomplishments in
Peru never paralleled the cease-
fire it orchestrated in a Central
American civil war during the
same period, nonmedical leaders
and institutions, grassroots orga-
nizations, and even at times an
antigovernment terrorist organi-
zation eventually perceived its
value. The desire to eradicate
poliomyelitis overcame national
turmoil and created a temporary
shelter for the public health sec-
tor, thereby helping to prevent its
collapse. Immunization, as car-
ried out in Peru, transcended the
rigid and contentious division
between vertical, disease-oriented
programs and horizontal,
community-oriented PHC mod-
els. The initial vertical program
became flexiblesometimes
focused and sometimes flattened
to allow for successful disease
eradication.
This campaign set an impor-
tant precedent for future immuni-
zation programs and a national
surveillance system, as well as for
publicprivate partnerships that
would become important and
more common. These partner-
ships should not be viewed as
faultless, however. Our investiga-
tion revealed that much
depended on experts who knew
what to do in a moment of politi-
cal and economic crisis, but
whose work in the long run was
undermined by the lack of insti-
tutionalization of broader PHC
efforts. In addition, we found a
tendency to overemphasize any
success, obscuring other health
needs of the population. More-
over, participants had opposing
viewpoints about the role played
by each agency and the recogni-
tion received thereafter, and
American Journal of Public Health | December 2014, Vol 104, No. 12
agencies disputed with one
another over leadership and how
best to allocate resources.27
These different viewpoints sug-
gest an important fragility within
the publicprivate 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 systema 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 non-
medical factors that account for
a public health achievement
under adverse conditions. These
factors include sustained politi-
cal commitment; community
engagement; strong leadership
at the international, national,
and local levels; adequate tech-
nology; and a fluent and open
collaboration between public
and private partners. The les-
sons 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 impor-
tation 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 WHOs
Global Polio Eradication Initia-
tive, created in 1988, is on track
to eradicate polio by 2018.
Despite these successes, there
have also been troubling devel-
opments in the polio eradication
campaign, most notably the tar-
geted attacks against polio
health workers in Afghanistan
and Pakistan30,31 and recent

outbreaks of mutated oral vac-
cine, or vaccine-derived, polio
cases.32 Although polio eradica-
tion campaigns in each country
face their own unique chal-
lenges and require adaptation to
specific contexts, certain paral-
lels can be drawn from the Peru-
vian story, which illuminates
how the shared goal of polio
eradication can result in impor-
tant collaborations that super-
sede local conflicts and turmoil.
Furthermore, the study of polio
eradication campaigns can pro-
vide insight into how to deliver
other vaccines and PHC ser-
vices, reinforce public health
institutions, and overcome chal-
lenges faced by local health
workers.33 Q
About the Authors
At the time of the study, Deepak Sobti was
a chief resident and Yuan He was a medi-
cal and public health student at the Uni-
versity of Arizona, Tucson. Marcos
Cueto is with the Casa de Oswaldo Cruz,
Oswaldo Cruz Foundation (FIOCRUZ),
Rio de Janeiro, Brazil.
Correspondence should be sent to
Deepak Sobti, MD, UT Southwestern
Medical Center Dept. of Ophthalmology
5323 Harry Hines Blvd. MC 9057 Dal-
las, TX 75390-9057 (e-mail: deepak.
sobti.md@gmail.com). Reprints can be or-
dered at http://www.ajph.org by clicking
the Reprints link.
This article was accepted March 30,
2014.
Contributors
D. Sobti led the study conceptualization
and design; acquisition, analysis, and in-
terpretation of data; and initial drafting
and revision of the article. M. Cueto su-
pervised the research, analysis and inter-
pretation of data, and critical revision of
the article. Y. He substantially contrib-
uted to analysis and interpretation of
data and revision of the article.
December 2014, Vol 104, No. 12 | American Journal of Public Health
PUBLIC HEALTH THEN AND NOW
Acknowledgments
We thank the interviewees, Lucia Hel-
ena Oliveira, Roger Zapata, Gustavo
Gross, Jorge Medrano, David Tejada de
Rivero, Washington Toledo, and Miriam
Strull; PAHO information and documen-
tation officer Gaby Caro; and Brazilian
collaborators Dilene Raimundo do Nas-
cimento and Eduardo Ponce Maranho.
Human Participant Protection
No protocol approval was required be-
cause no human participants were in-
volved.
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