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Polio and the Politics of Policy Diffusion in Latin America

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Polio and the Politics of Policy Diffusion in Latin America © COPYRIGHT by Marguerite Rose Jiménez 2013 ALL RIGHTS RESERVED “A scientist who is also a human being cannot rest while knowledge which might reduce suffering rests on the shelf.” --Dr. Albert B. Sabin POLIO AND THE POLITICS OF POLICY DIFFUSION IN LATIN AMERICA BY Marguerite Rose Jiménez ABSTRACT The world’s health ministers convened in Geneva for the World Health Assembly from May 21- 26, 2012, and declared a global public health emergency, appealing to the countries of the world to respond to the threat of resurgent polio. Coincidentally, this historic declaration came fifty years to the day after the last case of polio was reported in Cuba on May 26, 1962, making Cuba only the second country in the world and the first in the Americas to successfully eradicate the dreaded disease. The Cuban strategy in 1962 was to mobilize volunteer armies to give the live oral polio vaccine (OPV) to children throughout the entire country twice a year on national immunization days (NIDs). Over the course of the next thirty years every country in Latin America adopted and implemented some variation of the original Cuban policy model, and in 1994 the Americas became the first region in the world to completely eliminate polio. The highly successful experience in Latin America was used as evidence to rally support for the Global Polio Eradication Initiative (GPEI) launched by the World Health Organization in 1988. The Americas seemed to have provided a simple blueprint for polio eradication that the rest of the world had only to follow in order to achieve the same dramatic results. However, as evidenced by the recent World Health Assembly declaration, the policy innovations that were adopted and implemented so successfully in the Region of the Americas have been far less effective when simply exported to other countries and other regions of the world. The persistent failure of both domestic governments and the GPEI itself has highlighted longstanding problems linked to the dissemination and diffusion of evidence and new public health innovations, and the “translation ii gaps” that prevent existing evidence-based interventions from being effectively implemented in different countries and sustained over time. This dissertation, Polio and the Politics of Policy Diffusion in Latin America, contributes to global health policy scholarship by providing the first comprehensive history of the domestic Latin American initiatives that preceded the regional polio eradication campaign in the Americas, after which both regional and global campaigns were modeled. In addition, my dissertation contributes to policy diffusion and implementation research. At its core, the history of polio eradication in the Americas is a history of how new ideas and innovations linked to polio and immunization strategies were circulated among actors in different countries, and what different actors did with new information and innovations once they became available. This history provides an opportunity to examine why new innovations and ideas were more effectively implemented in some countries than others and how interactions between domestic and external factors made it possible to overcome “translations gaps” hindering effective policy implementation at different points in time. iii ACKNOWLEDGMENTS Writing a dissertation is not for the faint of heart. It is also not something I could have done without the incredible team I was fortunate to have supporting me throughout the process. My family, both the one I was born into and the one I was lucky to become part of during graduate school, made my doctoral studies, and even writing my dissertation, a fantastic experience. I hold my father, Mike Jimenez, directly responsible for my interest in examining the role of key actors in the policy process, along with my stubborn sense of certainty that these individuals can make a positive difference and help bring about enduring changes in policies and institutions. Thank you for always reminding me that “It’s supposed to be hard! If it wasn’t hard, everyone would do it. The hard... is what makes it great!” My dad has been an endless source of support and inspiration, and I truly don’t think I would have done this without him. A special thank you to my amazing mom, Dr. Nancy Seldin who is, without a doubt, one of the smartest, most creative, generous, and capable women I know. My mom wrote her dissertation when my brother and I were little kids. To this day I have no idea how she did it! She gives me hope (and a wonderful example) that work-life balance is possible and that one can be an accomplished academic, excellent human being, and even more excellent mom. In addition to my parents, thanks go to my brother (and best friend), my step-pop and step-mom, aunt and uncle, and Kelsey, for feeding and sheltering me throughout “dissertation boot-camp” over the past nine-months, and for tolerating regular dinnertime conversations involving infectious disease trivia and “new fun facts about polio.” My family helped me talk through issues of research design, read drafts, saved me from embarrassing typos, made me laugh when I needed it, reminded me to exhale, knew just when to show up with a glass of wine or drag me away from the computer, and kept me sane throughout the writing process. iv Beyond my immediate family, my extended family and community at the School of Public Affairs helped make everything possible in different ways. My adopted PhD family – especially Bill, Korneliya, Nikki, Maria (honorary) and Mike D. – provided constant support, friendship, and rescue when needed. There is nothing quite as humbling as realizing your best friends are also some of the smartest people you know. They made this process more fun than I ever imagined possible. In addition to the PhD cohort I am hugely grateful for the support, kindness, patience, intelligence, and good humor of the amazing people who work at the School of Public Affairs at American University. Some of my biggest debts are to Meg Weekes, Gamze Zeytinci, and Bob Briggs. They always knew the right answers, helped me find creative solutions, and made time for me and anyone else who needed their counsel over the years. I can’t imagine this process without their institutional knowledge, patience, energy, and support. Additional thanks to the Provost’s Office for providing funding for the final semester that got me over the finish line. I owe another huge debt of gratitude to the members of my dissertation committee. Enormous thanks go to Bob Durant, who opened my eyes to the “wonderful world of policy implementation” in the first place and who, after receiving a “top 10 reasons why you should be on my dissertation committee list”, agreed to mentor me through this process. One course with Dr. Durant changed the entire trajectory of my research. To Bob Pastor who cannot have known what he was getting himself into when he asked to be on my dissertation committee, and who has always looked out for me and believed that I would do something useful (even if I didn’t succeed in writing my dissertation in a month as he suggested I should). Bob continues to be one of my heroes and has always kept me grounded and focused on the “so what” question. Jeremy Shiffman made me challenge my own assumptions and encouraged me to ask broad questions. v Thanks also to the unofficial but hugely important members of my dissertation team, especially Dick and Sandy Bennett, my dissertation coaches, who reminded me that I am “just a poodle jumping through a ring of fire trying to not get singed.” Everyone should be so fortunate to have such an amazing team of allies and models of public scholarship. Beyond the AU community there was a broad range of people who helped me and guided my research over the years. Thanks to Mrs. Heloisa Sabin who shared stories of her husband, “the uncompromising Dr. Albert Sabin”, with me. To Dr. Ciro de Quadros who spent hours answering my questions and who is one of the most inspiring individuals I’ve ever been fortunate enough to meet. To Dr. Samuel L. Katz who provided invaluable information and reminded me to include the human stories behind the medical breakthroughs, and who always took time to talk with me. To Dean Julio Frenk who reminded me of the “power of ideas to help shape the ideas of power”, and who gave me motivation to finish when I needed it. To Dr. Mike McQuestion who inspired me to think about public health as the ultimate form of collective action. Thanks also to others - such as Mrs. Andrea Gaye, Dr. Jaime Sepúlveda, and Dr. D.A. Henderson - who have been involved in this work and who have helped me think about this project in different ways. My gratitude also goes out to the team at the Albert Sabin Archives at the University of Cincinnati for helping make this research possible and for providing an endless supply of research support both at the Archives and from a distance. Special thanks to the Sabin Archivist, Stephanie Bricking. Stephanie introduced me to the Sabin Archives, helped me find much-needed resources, and always went above and beyond to support this project. The last and most profound thank you goes to my dissertation committee chair, Bill LeoGrande. Bill (who will forever be “the Dean” in my mind) became an expert in his own right on the history of public health in Latin America. Bill has been not only the best mentor vi imaginable, but also my intellectual sparring partner, the voice of reason during moments of academic mania, my biggest champion and toughest and most supportive reviewer, my role model for what public scholarship looks like, and more than anything, someone whom I would choose to have on my team no matter what.
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