Smallpox Eradication Policies in Brazil (1962-1973)

ArticlEs / ArtÍCULOS SALUD COLEC T IVA. 2019;15:e2167. doi: 10.18294/sc.2019.2167

Chronicle of a consolidated success: smallpox eradication policies in Brazil (1962-1973)

Crónica de un éxito consolidado: las políticas de erradicación de la viruela en Brasil (1962-1973)

Jonatan Sacramento1

1PhD Student, Social ABSTRACT The aim of this article is to understand actions taken towards smallpox eradica- Sciences Postgraduation Program, Philosophy and tion in Brazil, in the framework of the Smallpox Eradication campaign that took place in the Human Sciences Research 1960s and 1970s. The article argues that, in addition to the bifurcated needle and the lyo- Institute, Universidade philized vaccine, epidemiological surveillance – based on the construction of instruments Estadual de Campinas, São Paulo, Brazil. * and protocols for health surveillance – was the third key element that guaranteed the eradication of the disease. The hypothesis is that the actions taken towards the control and eradication of smallpox contributed to the construction of new health institutions within Brazil. As an exercise of socio-historical analysis, this research was based on documentary sources (reports, newsletters and legislation), interviews with professionals directly involved in the eradication of smallpox, and part of the intellectual production on the subject. KEY WORDS Smallpox; Eradication; Epidemiological Surveillance; Health Policy; Brazil.

resumen El objetivo de este artículo es comprender las acciones del combate contra la viruela en Brasil en el marco de la Campaña de Erradicación de la Viruela, que tuvo lugar entre las décadas de 1960 y 1970. A partir de la construcción de instrumentos y protocolos de vigilancia en salud, se intenta argumentar que, además de la aguja bifurcada y de la vacuna liofilizada, la vigilancia epidemiológica fue el tercer elemento clave que garantizó la erradicación de la enfermedad. La hipótesis que se pretende sustentar es que las acciones de control y erradicación de la viruela contribuyeron a la construcción de nuevas instituciones de salud en el interior de Brasil. Como un ejercicio de análisis sociohistórico, la investigación se basó en fuentes documentales (informes, boletines y legislaciones), en entrevistas con profesionales directamente involucrados con la erradicación de la viruela y en parte de la producción intelectual de estos respecto del tema. palabras claves Viruela; Erradicación; Vigilancia Epidemiológica; Políticas de Salud; Brasil.

Salud Colectiva | Universidad Nacional de Lanús | ISSN 1669-2381 | EISSN 1851-8265 | doi: 10.18294/sc.2019.2167 2 Sacramento J.

INTRODUCTION with power and as an object of knowledge through the control of smallpox in the 18th century.(9) As a chronicle of a consolidated success, If taking actions to combat smallpox in smallpox eradication occupies a unique place that century helped to constitute the new in the history of international public health. form of the State and the State power, in Bra- However, research studies on this subject zil, at the beginning of the 20th century, the seem to have a marginal place in the historiog- fight against smallpox had the same role in raphy of public health in Brazil, only dealing promoting the creation of scientific institu- with analyses that emphasize a major episode tions to produce the vaccine and generating known as the “The Vaccine Revolt,” which oc- the need to maintain a team of civil servants curred in the year 1904, when the population to fight epidemics. As shown by Hochman,(10) of Rio de Janeiro of the newly-born republic the “sanitation of Brazil” enabled not only S A LUD CO L ECT IV . 2019;15:e2167. doi: 10.18294/sc.2019.2167 rose in rebellion against the mandatory vac- the fight against the main diseases that dev- cination measures imposed by the municipal- astated the inner territories of Brazil, but also ity of Rio de Janeiro.(1,2,3) Interest in discussing the construction of the whole State public smallpox eradication is recent and, until now, health bureaucracy in the 1920s and 1930s, there have been few research studies seeking which would be consolidated in the insti- to recover the history of the Smallpox Eradica- tutions that even today, one hundred years tion Campaign in Brazil.(4,5,6,7,8) later, are still active in the country. Keeping However, observing smallpox and its in mind the relative importance and the his- eradication campaign helps us to understand torical context, something similar seemed to the relations between health, society, the have happened with smallpox eradication. State, and its institutions, as well as the actors As I will show throughout this article, the that were involved in such experiences. As fight against smallpox, starting in 1965, made shown by Foucault,(9) the response adopted possible the redefinition of health institutions by the State to smallpox epidemics in Europe at a national scale, the production of immu- in the 18th century led to one of the most sig- nological materials, and the creation of pub- nificant political and organizational changes lic health statistics, apart from organizing a in terms of the conception of power and its new public health routine for reporting and connection with the people. controlling diseases. The emergence of the idea of population, The Brazilian production on smallpox as an entity that should be managed through eradication has shown how this action was in- a security apparatus as a new technique of tegrated into a broader scenario of discussion power, brought along the need to combat within the international public health sphere smallpox in order to control death rates, as a regarding eradication of diseases,(4,5,6,7,8) in result of the disease outbreaks. Furthermore, which epidemiological surveillance became, this safety device enabled, after establishing at least in terms of smallpox eradication, a vital statistics records and probability calcu- methodology applied to control diseases.(4) In lations for life expectancy, not only a direct this sense, Gazeta(5) affirms that the Smallpox control of the population health, but also the Eradication Campaign in 1966 was used as a protection of health and a less dangerous public health policy in a context of interna- type of the disease. tional articulation and efforts to control and According to Foucault, smallpox started eradicate the disease, subject to the coordi- to be understood as a collective phenome- nation by the World Health Organization non, and as a result it was included in the (WHO). In this way, according to the author,(6) social dynamics of a safety device that was the structure within which the Campaign was born at that time, focused on the demogra- established was inversely proportional to the phy of the disease and its control. Hence, the seriousness of the disease in Brazil, where the concept of population was born as a correlate “benign” version was already predominant as Chronicle of a consolidated success: smallpox eradication policies in Brazil (1962-1973) 3 SALUD COLECTIVA. 2019;15:e2167. doi: 10.18294/sc.2019.2167

a consequence of the control measures im- process, the aim was to understand the intel- plemented in the 1962-1965 period. lectual trajectories of the participants in erad- It is along those lines that Hochman(7) icating the disease as well as the international shows how such changes within the national public health context in which such actions and international context of disease eradi- were taken. cation and control policy referred not only to public health, but also to issues linked to economic development and international re- METHODOLOGY lations between the main political and economic powers of that time, mainly the USA and the Soviet Union, and other countries. Using a qualitative approach, the research In the case of Brazil, even without a consen- was based on three procedures: a review sus between physicians and national author- of national and international literature deal- ities on the health significance of eradicating ing with smallpox eradication in Brazil and smallpox, control of the disease materialized worldwide; documentary analysis of epi- as an opportunity to create a good image of demiological newsletters published by the the military regime at that time, apart from Smallpox Eradication Campaign between having been a contribution to the construc- 1967 and 1974, of federal and state legis- tion of an “immunization culture” in Brazil.(8) lation relating to smallpox eradication, and In this context, this article seeks to under- of statements made by physicians and other stand the process of eradication of smallpox health care professionals working in the in Brazil, based on the construction of epide- Campaign; and an interview with one of the miological knowledge and the institutional- Campaign coordinators. ization of a public health apparatus within the policies to combat smallpox in the national territory. In order to discuss the dynamics of From center stage to backstage: the production of epidemiologic knowledge smallpox as a national public health and public health policies, the goal is to priority show how the combat against smallpox and, mainly, the rediscovery of smallpox as a pub- In the history of Brazilian public health, lic health problem enabled the consolidation smallpox followed a priority, invisibility and of the bureaucratic and intellectual apparatus eradication triad.(7,8) It was a priority at the of Brazilian public health, through the insti- beginning of the 20th century, along with tutionalization of protocols and public health yellow fever, as it was the target of the man- practices. The hypothesis presented here is datory vaccination campaign imposed by the that, in addition to the bifurcated needle and federal government in the actions directed by the lyophilized vaccine, indicated in the Bra- public health officer Oswaldo Cruz (1872- zilian literature as being essential for eradi- 1917), in the transformation process under- cation, epidemiological surveillance was the taken in the city of Rio de Janeiro during the third key element for its consolidation. year 1904. The goal of such action was not This article is a part of a master’s degree only to carry out sanitation policies in the research project entitled Knowledge, power capital city of the young republic, releasing and embodiment: the biopolitics of small- it from smallpox and yellow fever, but also to pox eradication [Saberes, poderes e corpo- provide a scenario for urban transformation ralidades: a biopolítica da erradicação da in the configuration of the city, a transforma- varíola], which was defended as a require- tion with clear marks of race and class.(2) ment of the Postgraduate Program in Social In that context of public intervention, of Anthropology at the Universidade Estadual de population displacement and imposition of Campinas in February 2018. In this research prophylactic measures, which were added project, apart from the smallpox eradication to the political atmosphere of the newly 4 Sacramento J.

established Republic,(1) the population of major, the most severe form of the disease, Rio de Janeiro bucked against the actions of existed along with variola minor, a benign the public power, through riots that lasted and non-lethal form of smallpox; however, for days and appeared on the pages of the unlike the beginning of the 20th century, sce- Brazilian historiography as the “ the Vaccine narios of disease outbreaks were no longer Revolt.” This revolt was a crucial moment in common. In that context, on the same wave- Brazilian politics at that time, and its conse- length with international debates, controlling quences were not only the abolition of the a communicable disease like smallpox was mandatory vaccination prerogative, but the seen as a sign of economic and social devel- restructuring of public health actions in the opment, and should therefore be included in Brazilian capital city, by laying out new pub- the agenda of the developmentalist process lic health goals and opening a new scenario undertaken by Goulart.(6) for public health measures regarding small- Four years after, in 1966, during the S A LUD CO L ECT IV . 2019;15:e2167. doi: 10.18294/sc.2019.2167 pox and yellow fever.(11) World Health Assembly of the World Health Although after mandatory vaccination Organization (WHO), when smallpox eradi- was interrupted, the practice of vaccination cation was approved as a goal to be achieved continued and contributed to stopping the by all member states, Brazil ordered the start growth of the number of cases of smallpox of Smallpox Eradication Campaign activities, in Brazil – at least in large urban centers, the as it was the only country in the Americas disease switched to an “invisibility” phase that had not eradicated the disease. in public health actions. The effectiveness The Smallpox Eradication Campaign ac- of the vaccine to fight smallpox allowed the complished its goals within the dynamics of Brazilian government to adopt, as a priority this social context in 1971, the year in which guideline of public health actions, the con- the last case of smallpox in Brazil was reported tinuity of the fight against yellow fever and in the city of Rio de Janeiro.(13,14) The smallpox the so-called “northeast diseases” [“enferme- eradication certificate in Brazil was officially dades del sertón”], such as hookworm infec- issued by the WHO in 1973. Seven years tion, diphtheria, the newly-discovered Chagas later, in 1980, the Ministry of Health released disease, and malaria.(10,12) Smallpox would Resolution No. 55, which put an end to small- only be included again in the national public pox vaccination.(15) Worldwide eradication of health agenda starting in the 1960s. the disease, possible in part thanks to the collaboration of Brazilian specialists and the successful experience developed in the country, From backstage to center stage: was declared in 1977, after the report in So- smallpox again in the national public malia the last known case of smallpox; and in health agenda 1980 the Smallpox Eradication Commission at the WHO issued the global certification of Eradication, the last phase of smallpox in smallpox eradication.(16) public health policies in Brazil, did not be- gin until 1962 with the National Campaign Against Smallpox. It was implemented by National Campaign Against Smallpox then president João Goulart (1961-1964), (1962-1965) whose objective was to expand the national coverage of vaccination against the disease, Created in 1962 during João Goulart’s ad- which was no longer considered serious.(4,6) ministration (1961-1964), the National Cam- However, in order for such actions to be ma- paign Against Smallpox was an initiative by terialized, smallpox had to be “rediscovered” the Federal Government aimed at controlling as a public health problem. Even without a re- the incidence of smallpox in the national ter- liable statistics system, it was known by Bra- ritory, and preventing the emergence of new zilian authorities that in the country variola epidemics of the disease.(17) At that time, the Chronicle of a consolidated success: smallpox eradication policies in Brazil (1962-1973) 5 SALUD COLECTIVA. 2019;15:e2167. doi: 10.18294/sc.2019.2167

variola major, the most severe form of the At an international level, the trajectory disease that could lead to death or cause of disease eradication dates back to the be- consequences such as blindness, still existed ginning of the 1950s, when Fred Soper along with variola minor, a benign form of (1893-1977), the then director of the PAHO the disease whose death rate is almost zero. (1947-1959) who had a major interest in dis- Although it was created in the federal ease eradication, proposed to the organiza- sphere, the implementation and the oper- tion the eradication of smallpox throughout ation of the activities of the National Cam- the Americas. The proposal was accepted and paign Against Smallpox took place in a some countries even implemented initiatives decentralized way within municipal and in that direction without receiving funds from state spheres, and the only tasks under the the PAHO for such actions. In 1966, the only responsibility of the Union were the plan- country in the Americas that had not eradi- ning of actions, harmonization of practices, cated smallpox was Brazil,(20) in contrast to and the control of epidemiological data re- Cuba, USA, Mexico, Peru, and Chile, which garding the actions themselves.(7) In that way, had eradicated the disease in 1923, 1949, as each state, municipality, and territory was 1952, 1957, and 1959, respectively, prior to responsible for organizing and implementing the initiative of the WHO, in a context of na- vaccination against smallpox, the control of tional efforts towards epidemic combat and the disease through the actions of the Na- control. According to Donald A. Henderson tional Campaign Against Smallpox was not (1928-2016), who was the director of the consistent. On the contrary, although the smallpox eradication program of the WHO, vaccination coverage rates contributed to the the reason that led the Union of Soviet So- control of the disease, they varied from re- cialist Republics (USSR) to propose eradica- gion to region, and they were subject to the tion of the disease during the World Health type of priority that smallpox was given in Assembly in 1958 – without being accepted the public health agenda within each local- by the organization – was the fact that the So- ity.(7) Such efforts contributed to reducing the viet countries in Asia had cases of smallpox rates infection and also reducing the major exported from neighboring countries.(20) Fur- form of smallpox, but they were not enough thermore, the USSR was, in those days, the to eradicate or even eliminate the disease.(18) country with the largest production of small- As a result, in the 1960s, Brazil was the only pox vaccine and one of the greatest authori- country in the Americas with smallpox cases. ties on the subject. In 1966, during the military Government At a global level, mainly regarding eradi- of General Castelo Branco, an executive or- cation measures adopted by African countries, der was issued that established the Small- the United States Agency for International pox Eradication Campaign (the Campaign), Development (USAID) would contribute lo- whose goal was to eradicate the disease in gistic resources to take necessary actions, and the country. The Campaign was integrated the Centers for Disease Control and Preven- into a context of broader international efforts tion (CDC) would provide the technical staff to eradicate the disease,(19) and it was imple- and epidemiological expertise. Each country mented with the administrative, intellectual, developing the program would be responsi- and financial support of the Pan-American ble for the acquisition of vaccines; however, Health Organization (PAHO), the regional although they cost less than one dollar, they office for the Americas of the World were not on the priority list – unlike yellow Health Organization (WHO), after the World fever – and so would be acquired through a Health Assembly in 1965 decided on the loan policy implemented by the US to help global eradication of smallpox. In that con- interested countries. text, it is necessary to clarify some viewpoints The strategy of the CDC for smallpox in the international public health and politi- was simple and based on two actions: pre- cal scenario prevailing in those days. ventive vaccination, to reduce the number of 6 Sacramento J.

individuals who could catch the disease, and paign was a public health action coordinated the creation of epidemiological surveillance by the Ministry of Health, through the Foun- systems, aimed at monitoring the cases of the dation Special Service of Public Health (SESP) disease.(20) In the places where the basic health [Servicio Especial de Salud Pública], a federal network was precarious, it was necessary to entity specializing in massive public health apply massive vaccination, in order to get at measures, which operated in Brazil during the very least 80% vaccination coverage. The the 1942-1990 period, alongside the Malaria adoption of the surveillance and control strat- Eradication Campaign and the international egy, in turn, relied on the need to gather data collaboration of the PAHO/WHO.(25) The on the epidemic, since in many countries the goal of the Campaign was to eradicate small- statistics on the disease were not available. pox in the national territory through vaccina- In 1967, Dr. William Bill Foege imple- tion of, at the very least, 90% of the popula- mented certain measures in Nigeria that be- tion. Structured in three stages (preparation, S A LUD CO L ECT IV . 2019;15:e2167. doi: 10.18294/sc.2019.2167 came the WHO’S official strategy in the fight attack, and maintenance), the Campaign had against smallpox: vaccination through epide- its own resources coming from the Ministry miological surveillance and barrier vaccina- of Health, and the financial and technical tion, no longer through mass vaccination as support of international organizations. had been done before, which was counter to The Executive Order instituted a super- the belief that it was necessary to vaccinate intendent in charge of the national coordi- the global entire population to put an end to nation of the Campaign. The professional, smallpox.(21) At the same time, despite the great appointed by the general manager of the Na- investment by the USA through USAID and tional Department of Health of the Ministry CDC, the USSR was the greatest enthusiast of of Health, was chosen for being an “expert of the campaign, backing Henderson’s actions well-recognized competence,”(25) and had the as a general coordinator and serving as one of tasks of guiding, coordinating, and supervis- the biggest donors of the lyophilized vaccine ing the work of the Campaign based on the used in the eradication procedures.(22,23,24) guidelines of the yearly plan elaborated by In Brazil, unlike the situation in coun- the superintendent himself. Furthermore, the tries of Africa and Asia and especially in In- resolutions linked to the admission and dis- dia,(4,5,6,7,8,20) the official strategy adopted for missal of staff working in the Campaign, and the Campaign was massive vaccination and the management of resources would fall un- not epidemiological surveillance. The Cam- der this person’s responsibility. It was also the paign coordinators, Oswaldo Silva and, later, responsibility of this professional to recom- Claudio Amaral, chose to use the lyophilized mend regional advisers and coordinators that vaccine, together with jet injectors (Ped-O-Jet), would have to act as intermediaries between and the tactic of mass vaccination in public state health secretariats and their respective spaces.(13,14) However, as I will show below, the campaigns as well as the national Campaign. way in which the Smallpox Eradication Cam- As to human resources, the Campaign paign was organized in Brazil made it possible would hire employees from the Ministry of to try other methods and techniques and en- Health that could be transferred to eradica- abled the creation of public health expertise, tion activities, as well as other federal em- which would be used for eradication and later ployees, or state and municipal staff, released exported and adapted to fight other diseases. from their duties for that purpose. Further- more, the Campaign had the prerogative of freedom to hire its own professionals for the Smallpox Eradication Campaign (1966- actions that would be developed, both for 1971) vaccination and for technical tasks.(25) In terms of legislation, the organizational Created under Executive Order No. 59153, structure of the Campaign seemed quite ane- dated 1966, the Smallpox Eradication Cam- mic, but regarding its everyday actions, the Chronicle of a consolidated success: smallpox eradication policies in Brazil (1962-1973) 7 SALUD COLECTIVA. 2019;15:e2167. doi: 10.18294/sc.2019.2167

reality was different. The Foundation SESP, as Once the attack phase was over, a unit of the entity specializing in public health and epidemiological surveillance was installed in with experience in fighting epidemics and en- each state, decentralized into municipal and/ demic diseases, provided the physicians and or regional reporting units, so that in some technicians necessary for the consolidation of municipalities, there could be more than one the Campaign actions. At the same time, with reporting unit. The function of the reporting resources coming from PAHO/WHO, the unit was the epidemiological surveillance Campaign could make use of national and of possible cases of smallpox, research of international consultants specialized in pub- suspected cases, establishment of necessary lic health and epidemic diseases, who shared diagnosis – including the collection of puru- their expertise and contributed to the Cam- lent material, referral to certified laboratories paign achieving its objectives. Furthermore, to carry out tests, and reporting these cases the states of the federation had autonomy to to the state division of epidemiological sur- organize their campaigns, provided that they veillance that, in turn, had to gather the data followed the basic guidelines imposed by the informed by all the units in the state and send national Campaign. That, in turn, led to the them to the national Campaign. creation of some strategies not previously es- The general strategy of the national Cam- tablished in the initial plans, such as the ex- paign was based on mass and house-to-house perience of epidemiological surveillance in vaccination by means of the bifurcated nee- the states of Parana, Rio Grande do Sul, and dle, easily transported and handled, which Bahia, for instance.(26,27) could be reused on the subsequent days. As The preparation phase took place before for mass vaccination actions, the strategy was the start of the vaccination activities, and to gather groups of people in public spaces was aimed at identifying the areas where the and events, like squares, bus terminals, or fes- Campaign would be conducted, in order to tivals. In these cases, the instrument used was elaborate action strategies, apart from train- the jet injector, which enabled vaccination of ing personnel in the field and offering health approximately 1,000 people per hour. That education activities to the population. The way, in a few hours, depending on the num- next phase was the attack, which started af- ber of city inhabitants, the Campaign man- ter defining the vaccination strategies. In that aged to achieve the goal of 90% vaccination. stage, there was certain flexibility within the However, the strategy of itinerant units national framework regarding the actions de- set up in busy points around the cities did not veloped locally, but there was a basic proto- always have the effect sought with respect to col to be followed that could only be adapted the target audience that quite often was just in exceptional cases. In that phase, two types passing by in the city and did not have time of assessment were stipulated: one daily and for vaccination.(14) To that effect, it was neces- one weekly, which evaluated not only the sary to visit schools, local radio stations, fairs, work done, but also the effectiveness and and churches, in order to spread the word the scope of vaccination. The last phase was about the vaccination actions. maintenance. Its objective was to organize The national Campaign, established in a system for reporting cases of smallpox, 1966, had a calendar defining the start of for epidemiological control purposes, a task activities in each state. Vaccination began that was the responsibility of local services in the northeast region and, once the attack (state and municipal), and that health pro- stage was completed in each state, the activi- fessionals and the community carried out, ties spread “downward” toward other regions mainly, in areas with precarious health ser- of Brazil. At the same time, given the flexible vices. Furthermore, that phase established nature of the Campaign, it was possible for vaccination of 90% of live births in a specific each state to organize their own actions out- year, and yearly revaccination of 20% of the side of the national calendar, as in the case of population. Sao Paulo and Bahia, where the campaigns 8 Sacramento J.

commenced in 1968 and with the state’s own Although the attack phase of the national resources. Campaign was the responsibility of the fed- In Sao Paulo, the Campaign was created eral government and the one that followed, in 1967,(28) and began to operate effectively the maintenance phase, was the responsi- in 1968. As with the national version, the bility of local governments, in Sao Paulo Campaign in Sao Paulo was also supervised the state government assumed responsibility by a superintendent and made up of three for all three phases. The attack phase in Sao types of activities: administrative activities, Paulo involved vaccinating 90% of the pop- which involved management, communica- ulation, with expected completion in June tion, human resources, logistics of materials, 1970. At that time, while the national Cam- financing, maintenance of transportations, paign had begun the consolidation phase, the and consultancies; technical activities, di- aim of the campaign in Sao Paulo was to pre- vided into epidemiology and statistics, health vent smallpox from spreading through barrier S A LUD CO L ECT IV . 2019;15:e2167. doi: 10.18294/sc.2019.2167 education, training and vaccination; and, fi- vaccination, in outbreaks or isolated cases. nally, field activities, carried out by directors, In order to organize the maintenance assistants, supervisors, and vaccinators. phase, which included epidemiological sur- As with the national Campaign, the Exec- veillance of smallpox, the Campaign in Sao utive Order issued in Sao Paulo established Paulo had not only reporting units, but also its own resources to support the Campaign received the help of civil register offices, actions. As justification for its creation, the which submitted data to allow the epidemi- executive order included twelve items, out ological surveillance division to elaborate of which the most important were the man- periodical reports on new births and those datory reporting of smallpox – highlighted as registered in institutions. By so doing, epide- a standard procedure adopted internationally miological surveillance of births and vaccina- – and the argument that Brazil, during the tions was possible in all the municipalities. 1963-1965 period, had the largest percent- In Sao Paulo, the epidemiological sur- age of cases reported, accounting for 85% of veillance team was composed of a physician all records in the Americas.(29) epidemiologist, a public health nurse, and a Another highlighted argument was that health educator. The physician’s duty was the routine smallpox vaccine proved inef- the general supervision of activities, apart fective as a prophylactic measure, not offer- from epidemiological surveillance and vacci- ing the expected protection. Furthermore, nation. The health educator was responsible according to the Executive Order, the state for the supervision of educational works, in of Sao Paulo received a great number of im- addition to the formulation and implemen- migrants from several parts of the country, tation of courses and training for physicians including people that could be carrying the and support staff at the reporting units.(30) The smallpox virus, a risk factor given that 39% of public health nurse monitored nursing activ- the state population was susceptible to catch- ities and worked with the health educator to ing the disease.(28) formulate and implement public health edu- It is important to highlight that for some cation programs and trainings.(19,24,31) time the state of Sao Paulo had been an ex- However, Sao Paulo was not only the ample regarding public health policies. From state that enjoyed prerogatives of autonomy the beginning of the 20th century, with the in the organization of Campaign actions. Pri- actions of rural sanitation that would then be marily the states of Parana, Rio Grande do imitated by the federal government,(10) the Sul, and Bahia were noteworthy in their epi- land of the “bandeirantes” [17th century set- demiological surveillance actions to fight the tlers] emerged as an example to be followed disease, and these experiences were crucial or considered in terms of the formulation and to adopting new directions to eradicate small- execution of prophylactic measures. pox in Brazil, and to consolidate a national system of epidemiological surveillance, the Chronicle of a consolidated success: smallpox eradication policies in Brazil (1962-1973) 9 SALUD COLECTIVA. 2019;15:e2167. doi: 10.18294/sc.2019.2167

eradication of poliomyelitis and, later, to ex- ication campaigns. However, as I will also port expertise of Brazilian epidemiologists for demonstrate, the Brazilian Campaign pre- actions in the eradication of smallpox in Af- ferred to adopt the mass vaccination method rica and Asia. and, at a later time, when the attack phase In Africa, smallpox eradication actions, was completed, to implement epidemio- promoted by the WHO and financed by the logical control and surveillance, whose aim USA, were framed in the Smallpox Eradica- was containing episodic cases of the disease. tion Program (SEP) launched by the US Gov- However, in the states of Parana, Rio Grande ernment in the context of the Global Great do Sul, and Bahia a team linked to the Foun- Society,(32,33) created by democratic president dation SESP would emerge that would struc- Lyndon B. Johnson (1908-1973) in 1964, ture the state Campaign by using a surveil- whose aim was to support the economic and lance strategy and barrier vaccination. social development of the poorest countries The idea of structuring eradication by by expanding a liberal agenda that included relying on epidemiological data to plan ac- the fight against hunger, diseases, and com- tions, goals, and assessments was long-stand- munism.(33) In this context of these actions, ing and had been used since the 1950s, but and amidst the crossfire of the Cold War and particularly in quarantine cases.(23) In 1964 the dispute between USA and the USSR, the that idea was set aside in order to cover a American SEP had several goals including the wider and more collective scale, thanks to the control of measles in Africa, by selling a new intellectual production of Czech epidemiolo- vaccine developed in the USA that would be gist Karel Raska (1909-1987). In the USA, the bought by the countries of central and west- CDC mostly disseminated this new concept, ern Africa through loans granted by USAID.(20) based on the production of Alexander Lang- In Asia, in turn, mainly in India, a coun- muir (1910-1993), an epidemiologist from try that in 1962 accounted for more than John Hopkins University and the creator of 60% of the cases of smallpox reported world- the Epidemic Intelligence Service at the CDC. wide,(34,35) the campaign of the WHO looked more complicated. For the eradication of the disease to be carried out, the WHO and its Experience in Gaul and Parana South East Asia Regional Office (SEARO) had regarding epidemiological surveillance to join efforts with the Indian government, of smallpox both at a federal level, negotiating with the Executive Branch and the Ministry of Health, In Brazil, smallpox eradication through sur- and at a local level, dealing with the states veillance and control was first tested in the and leaders and local health bureaucracies. state of Parana. In 1970, the Campaign had (12,34,36,37) At the same time, for the eradication no financial resources to undertake vaccina- tasks to be successful, the strategic action tion activities in the state, and this situation plan of the vaccinators and the team fighting led the Foundation SESP, in the context of smallpox had to be adapted to account for the the Smallpox Eradication Campaign, to test local reality, for example when resorting to surveillance and control methods instead of epidemiological surveillance instead of mass mass vaccination. At that time, Ciro de Quad- vaccination, as I will explain below.(13,14) ros (1940-2014), a physician from the Med- ical School of Santa Casa in Porto Alegre, assumed the duty of organizing the Center of Smallpox eradication and the Brazilian Epidemiological Research in the state based epidemiological surveillance strategy on the actions coordinated by the Campaign. In that context, instead of mass vaccination, As noted above, the vaccination strategy suspected smallpox cases reported by the through epidemiological surveillance was a state secretariat were investigated. Based on prerogative of the WHO for smallpox erad- these cases, the vaccination strategy involved 10 Sacramento J.

vaccinating the entire population of the re- area of health, even in epidemiology. In that gion in which a suspicious smallpox case has way, in addition to the formulation of detailed been confirmed.(36,37) standards for gathering and treating data so as The eradication experience in Parana, to guarantee technical quality, the Foundation through surveillance and control, enabled managed to modernize epidemiological statis- the decentralization of actions to fight the tics through computerized data records.(26,27) disease and, while the national coordination After the smallpox eradication experi- of the campaign was still centralized, the ac- ence, Rio Grande do Sul was able to insti- tions were structured consistently with the tutionalize the practice of epidemiological goal of the national Campaign. surveillance, mainly by hiring epidemiology In Rio Grande Do Sul, Airton Fischmann assistants who had been trained at Founda- (1941) and Claudio Marcos da Silveira (1936), tion SESP and by including other diseases also trained at Santa Casa in Porto Alegre, to be reported and fought, as was the case S A LUD CO L ECT IV . 2019;15:e2167. doi: 10.18294/sc.2019.2167 were hired by the state Secretariat of Health to of poliomyelitis. This experience would be work at the Epidemiological Surveillance Divi- later imitated, at a national level, through the sion within the state, under an agreement exe- circulation of professionals from Rio Grande cuted, in 1969, with the Foundation SESP. At do Sul between the Foundation SESP and the that time, as noted above, for the Campaign, Ministry of Health.(38) the concept of epidemiological surveillance was supplementary to mass vaccination. In Rio Grande do Sul, smallpox eradica- Split epidemiological surveillance: tion actions took place in a hybrid way, joining Boletim da Campanha de Erradicação mass vaccination and vaccination through epi- da Varíola demiological surveillance. In turn, it was characterized by the collection of data on possible As a way of strengthening smallpox eradica- smallpox cases, via a preliminary analysis and, tion, the Campaign established a mechanism upon confirmation, barrier vaccination in those for data control and collection of suspected people close to the sick person and the ones smallpox cases throughout the national ter- that were inside certain a radius. The Cam- ritory, not only in the states in which the paign of Rio Grande do Sul started in the city campaign had not been initiated, but also of Porto Alegre and the plan was to continue in those states that were already in the final towards the rest of the state upon completion stage of control and maintenance. Therefore, of mass vaccination in the capital. However, suspected cases would be communicated to Airton Fischmann and other employees at the the epidemiological surveillance of small- Epidemiological Surveillance Division were pox, so that such cases could be investigated already working on the implementation of sur- and barrier vaccination could be carried out veillance and reporting units and, based on the where necessary. This strategy also permitted data gathered by these entities, on barrier vac- a clearer panorama regarding the effective- cination in suspected cases.(26,27) ness of the Campaign actions so as to assess The model of epidemiological surveil- the program as a whole. lance of smallpox adopted in Rio Grande do To that effect, in 1967, the Boletim da Sul was conceived of by a group of physicians Campanha de Erradicação da Varíola(39) from the Foundation SESP whose main con- [Newsletter of the Smallpox Eradication cern was not only smallpox eradication, but Campaign] was created, which was a weekly also the organization of an epidemiologic sur- publication distributed until 1974, when it veillance system that could be used for other was replaced by the Boletim Epidemiológico diseases.(27) Apart from eradicating smallpox [Epidemiologic Newsletter]. The publication and implementing the divisions of epidemio- was divided into sections and contained not logical surveillance, the Foundation SESP was only epidemiological data on smallpox erad- interested in training human resources in the ication around the world (mainly in Latin Chronicle of a consolidated success: smallpox eradication policies in Brazil (1962-1973) 11 SALUD COLECTIVA. 2019;15:e2167. doi: 10.18294/sc.2019.2167

America), but also material and interviews sent PAHO/WHO the relevant information with specialists dealing with the subject, in on the epidemiological picture of the disease addition to the the section of weekly reports in the country. of the number of smallpox cases in Brazil, Furthermore, data was gathered regard- which were to be mandatorily reported, and ing the epidemiological profile in the Bra- epidemiological articles that included news zilian states with respect to other diseases and data on the eradication of the disease in because, at the beginning of the 1970s, the other parts of the world. Campaign was aligned with the Federal Gov- The newsletters also contained a de- ernment, within the purview of the Ministry scription of the main symptoms of smallpox, of Health, and with the state and municipal with the intention of making it easy for health governments, through state and municipal care professionals to identify a (potential) secretariats of health, with the aim of intro- sick individual. Symptoms included intense ducing other vaccines into the campaign, a headache, pain in the spine (rachialgia), dis- practice known as multi-vaccination, which comfort, shivers, and temperatures between consisted in applying more than one vac- 39°C and 40°C. Pus-filled pustules, a com- cine on the same day,(18) in contrast to the mon sign of smallpox, appeared from the combined vaccine, which included antigens sixth day and were principally displayed on for two or more diseases, like smallpox and the face, arms, and legs. Depending on the measles. Multi-vaccination was a common condition of the pustules and the symptoms procedure, adopted by most of the state Cam- displayed in each individual, smallpox could paigns. Given the often adverse conditions be confused with chickenpox – also known encountered by the municipal public health in Brazil as catapora – as well as syphilis or authorities, adding vaccines for measles, tet- herpes. As a result of these imprecise charac- anus, and other diseases to the mandatory teristics of smallpox, the definitive diagnosis smallpox vaccination increased the scope could only be accomplished by means of lab- of prophylactic actions, even for groups and oratory testing, and that is why it was neces- regions which had not been reached by stan- sary to make symptoms know to the public, dard health services before. so that suspicious cases could be recorded In 1974, when the Boletim da Cam- and necessary measures be taken. panha de Erradicação da Varíola was refor- “Epidemiologic Articles,” one of the sec- mulated and its new name became Boletim tions in the Boletim, was aimed at informing Epidemiológico, the publication began to the people of the numbers of cases by regional publish data relative to other diseases that health department, which were classified as had to be officially reported, such as measles “smallpox,” “not smallpox,” and “doubtful and poliomyelitis, the second disease to be diagnosis.” The confirmation tests were per- eradicated in Brazil and the target of inter- formed in three laboratories: in Sao Paulo, at national campaigns. A year later, in October the Instituto Butantan; in Rio de Janeiro, at the 1975, Act No. 6259 was published, which Instituto Oswaldo Cruz (IOC/FIOCRUZ); and governed the organization of epidemiolog- in Rio Grande do Sul, at the State Central Labo- ical surveillance at the national level, the ratory (LACEN) [Laboratório Central do Estado]. National Immunization Program, and the re- As it was a disease that had to be re- quired reporting of diseases.(40) ported officially, the systematization of the epidemiologic data of smallpox followed this trajectory: from the municipalities to the re- The third element: epidemiological gional departments of health; from the states surveillance as a key eradication to the state secretariats of health; from the technology Union to the Ministry of Health, especially, to the National Health Department. In turn, According to literature on this topic, the tech- the superintendent of the national Campaign nology of the bifurcated needle was essential 12 Sacramento J.

for smallpox eradication, since it was easy to years of the smallpox vaccine coexisting with handle, transport and reuse. The lyophilized the disease. vaccine was also essential due to its resis- In that same direction, Chagas(4) high- tance to warm weather conditions. Epidemi- lights that, although Brazil had not assumed ological surveillance is not indicated as one epidemiological surveillance as a central of the technologies responsible for the end of strategy of the fight against smallpox due smallpox, but rather as a product coming from to the commitments taken on with PAHO/ the eradication experience. However, as an WHO to accomplish the Campaign through analysis of the literature, the documents, and mass vaccination, surveillance made it pos- the interviews with Brazilian professionals of sible to eradicate the disease, something that the Campaign has shown, epidemiological had not happened with the National Cam- surveillance was the third key factor in the paign Against Smallpox, which only used eradication of the disease in Brazil. occasional vaccination campaigns, with no S A LUD CO L ECT IV . 2019;15:e2167. doi: 10.18294/sc.2019.2167 Based on the actions of reporting of mechanisms for controlling and assessing its cases, investigation, and barrier vaccination, actions. Therefore, the epidemiological sur- the epidemiological surveillance of small- veillance later implemented by the Smallpox pox – both as a stage of the Campaign and Eradication Campaign, by following the evo- as a strategy of vaccination to the detriment lution of the incidence rate of smallpox cases of mass vaccination – was consolidated and its clearly visible decrease, managed to through the collection and systematization assess the impact of the eradication program, of the epidemiological data of smallpox making sure that the disease would not reap- cases – confirmed or not by laboratory test- pear in the regions where it had already been ing – sent from epidemiological surveil- eliminated. lance divisions to state Campaigns. Thanks More than just a significant legacy from to these data, the team of physicians work- the activities of the Campaign, epidemiolog- ing in the Campaign was able to plan and ical surveillance was characterized as an es- execute barrier vaccination measures and sential tool in the eradication of the disease contain potential outbreaks. At the same itself. Moreover, although it was work strategy time, the epidemiology team accomplished proposed by the WHO, vaccination based on the tabulation and study of data, in order to surveillance was not adopted as a strategy by specify the rates of disease susceptibility in the national Campaign, which opted for mass the population, apart from controlling the vaccination. However, in the states where it effectiveness of the actions, including mass was applied (Parana, Bahia, and Rio Grande and barrier vaccination. do Sul), and in the surveillance phase of the Two of the professionals that worked in national plan of eradication, epidemiological the epidemiological surveillance of the Cam- surveillance proved just as highly essential in paign, one in Rio Grande do Sul, and the the fight against smallpox as the bifurcated other one in the Campaign of Bangladesh, an- needle and the lyophilized vaccine. alyzed their experiences in research for their Control actions after mass vaccination and master’s degree in public health.(41,42) In those use of the strategy of barrier vaccination were studies, both analyzed the methods and the possible only by applying the techniques of re- organization of epidemiological surveillance porting and investigation implemented by ep- of smallpox (and poliomyelitis), and showed idemiological surveillance. Furthermore, the how the procedure was essential for small- divisions of epidemiological surveillance de- pox eradication in Brazil and in countries manded action by highly-qualified profession- in Africa and Asia. Furthermore, according als in their operations, and the qualification of to Verani,(42) epidemiological investigation these professionals allowed these divisions to of smallpox, as an action strategy, replaced guarantee smallpox eradication. mass vaccination and allowed the eradica- The creation of the position of an ex- tion goal to be achieved, despite almost 200 pert in epidemiology and the formation of Chronicle of a consolidated success: smallpox eradication policies in Brazil (1962-1973) 13 SALUD COLECTIVA. 2019;15:e2167. doi: 10.18294/sc.2019.2167

reporting and surveillance units at a state formulate vaccines and other effective phar- level modernized and strengthened new ac- maceuticals.(11) tions in the public health field institutionally That way, with sparse statistics on the speaking. At the same time, new diseases control of cases of the disease, and with occa- were included in the agenda of the Ministry sional recorded epidemics, smallpox, as a pub- of Health, not as part of campaigns, as had lic health problem, had to be “rediscovered” been the case until then,(10,12) but as effective to be able to dispute a place within the public actions of control and implementation, such health actions ordered by public authorities. as national days of vaccination to fight polio- The National Campaign Against Smallpox, myelitis and measles. although planned at a national level, was the Furthermore, they generated training op- responsibility of the local powers and, for that portunities for well-established public health reason, did not have the expected effect to leaders, making it possible for some of them eliminate the disease in the national territory, to consolidate a national and international and its implementation became tied to local career in smallpox and poliomyelitis eradica- priorities that, many times, did not include tion. Therefore, smallpox eradication meant smallpox as a disease to be fought. not only the control and elimination of a mil- As Brazil was the only country in the lenarian disease, but also, the redesign of the Americas that had not eradicated the disease, Brazilian public health and its institutions at the international pressure for implementing a national level. the Smallpox Eradication Campaign and the financial and technical assistance PAHO/ WHO offered to the country conferred CONCLUSIONS greater legitimacy to the actions. The scarce epidemiological data available were also On the rediscovery of smallpox: public employed to this end, in addition to the epi- health officers, politicians, national and demic’s history and the frustrated attempt by international interests Oswaldo Cruz to eliminate the disease at the beginning of the 20th century. Even though smallpox eradication was gener- That way, when smallpox was “redis- ally justified due to the existence of an inef- covered” as a public health problem, even fective vaccine, the fact that the virus did not in an involuntary way, Brazilian health care have another reservoir aside from human be- authorities and professionals involved in ings, and the savings that the countries would the eradication campaign breathed fresh air have because they would not have to depend into health services, established new public any longer on their budgets for maintenance health protocols, created new areas of ac- vaccination, in Brazil, the disease was not in tion for health care professionals, and were the public health agenda of the time, and that reborn as experts in an area that was always is why it is necessary to include some addi- well-regarded within the sphere of national tional considerations. medicine: public health. In turn, these pro- After the prophylactic measures at the fessionals reinvented Brazilian medicine, beginning of the 20th century, and sanitation translating into systematized scientific knowl- actions,(10,12) smallpox became a secondary edge the concepts and practices of epidemi- interest when planning the national public ology and opening up an opportunity for the health agenda. The focus on yellow fever and emergence of a new health professional: the malaria, although it did not make the prac- epidemiologist. tice of smallpox vaccination disappear, led In retrospect, the fight against smallpox, at public health authorities to orient efforts and the beginning of the 20th century and from the plans of cooperation to try and eliminate the 1960s onwards, while surrounded by politi- mosquito transmitting those diseases, and to cal and scientific controversies, went beyond the prophylactic measures of control and 14 Sacramento J.

eradication of the disease. These measures state health agencies that had been scattered made it possible to construct and consoli- among different ministries and secretariats. date public health and scientific institutions, The chronicle of a consolidated success in addition to public health protocols, which allows us to examine the fight against small- were broadened at the beginning of the cen- pox and to see, apart from its eradication, the tury with the creation of the first research historic roots of the institutions, protocols institutions in Brazil and, in the 1960s, with and health care actions that still operate in the grouping together and consolidation of Brazil at present. S A LUD CO L ECT IV . 2019;15:e2167. doi: 10.18294/sc.2019.2167

Acknowledgements [Dissertação de Mestrado]. Rio de Janeiro: Casa de Oswaldo Cruz, Fundação Oswaldo Cruz; 2008. The author would like to thank Fundação de Amparo à Pesquisa do Estado de São Paulo for 5. Gazêta AAB. Uma contribuição à história do the fellowships granted (FAPESP 2015/21537-8 y combate à varíola no Brasil: do controle à erradi- 2016/19402-0), and professor and director Dr. He- cação. [Teses de Doutorado]. Rio de Janeiro: Casa loisa Pontes for her support. The opinions given in do Oswaldo Cruz, Fundação Oswaldo Cruz; 2006. this article are the whole responsibility of the author 6. Gazêta AAB. A campanha de erradicação da and do not represent the opinions of the financing varíola no Brasil. [Dissertação de Mestrado]. Rio agency. de Janeiro: Núcleo de Estudos de Saúde Coletiva, Universidade Federal do Rio de Janeiro; 2001.

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CITATIOn Sacramento J. Chronicle of a consolidated success: smallpox eradication policies in Brazil (1962-1973). Salud Colectiva. 2019;15:e2167. doi: 10.18294/sc.2019.2167.

Received: 7 February 2019 | Revised: 13 July 2019 | Accepted: 16 July 2019

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https://doi.org/10.18294/sc.2019.2167 This article was translated by Mariela Santoro, and reviewed by Vanessa Di Cecco.