Reflections on how Latin America and the Caribbean defeated polio and sustained immunization programs

By Grace Virtue, Senior Advisor – Communications

There is one tool that stands out in the fight against disease: vaccines. Every child, no matter where he or she is born, has a fundamental right to vaccines.

— Ciro de Quadros, Brazillian Epidemiologist and EPI Founder

The last case of wild polio in the United States was recorded in 1979. Latin America and the Caribbean (LAC) celebrated its victory over the lethal childhood infection more than 26 years ago, making the Americas the first region of the world to eliminate the disease. According to the World Health Organization (WHO), the last case was detected in Peru on August 23, 1991. Fewer than two decades prior, there were nearly 6,000 reported cases in the LAC region. Three years later, the region was formally declared polio free.

The Pan American Health Organization (PAHO) coordinated the immunization and “mop-up” programs in the region. Retired director of PAHO, Sir George Alleyne, describes the story of how the region became the first to defeat the once lethal childhood infection and how it has sustained its infectious disease control programs since as one filled with good fortune, intrigue, political will, the value of effective public policy and planning, and value of stakeholder buy-in.

The value of smart leadership

The good fortune, Alleyne said in an interview with ACTION, was having native born Ciro de Quadros, a Brazilian epidemiologist leading the polio eradication program in the region during the 1970s and ‘80s. According to the New York Times, de Quadros “navigated war zones and reimagined outmoded public health practices” to lead the polio eradication campaign in Latin America and the Caribbean.

De Quadros organized health workers to vaccinate children in remote regions of Latin America. He gained renown for negotiating a 24-hour ceasefire between government and rebel forces in Guatemala and El Salvador, so he could carry out his immunization programs. For him, vaccines were not merely essential for good health but for productivity and peace within nations.

“He believed in the concept of health as a bridge for peace, and he was such a passionate advocate, he was able to convince even the guerrillas to hold fire so that children could get their vaccines. On declared national immunization days, even during civil wars, there was not a single shot fired,” Alleyne said. In fact, some rebels participated in the vaccine programs.

“We were extremely fortunate to have him leading that charge. He set the expectations, and that leadership carried straight down the chain of command. He did not just have the technical knowledge; he was passionate and inspirational and people followed his lead.”

Implementing effective systems

Alleyne, who headed PAHO from 1995 to 2003, said he inherited the systems and ideas espoused by de Quadros, including models of how programs were organized all the way to the community level—the interagency committees—led by the ministry of health and including local representatives, USAID, and Rotary.

The program’s success also relied on crucial availability of funding and stakeholder buy-in. “The countries of the region accepted the need to eliminate polio and infectious diseases in general and there was commitment to a regional (Pan-American) approach to solving the problem,” Alleyne said.

PAHO’s polio eradication program in LAC began in 1985 to complement the Expanded Programme on Immunization (EPI), founded by de Quadros in 1974 to vaccinate children worldwide. PAHO’s ancillary program included twice-yearly national vaccine days to immunize every child under five. Operation Mop-Up, the last stage of the campaign, included house-to-house vaccinations in areas with low coverage and a surveillance system implemented to track outbreaks.

Pooling resources to fund immunization

Post-polio eradication, there was no serious shock to the region’s health system, Alleyne said, in large part because regional governments had contributed the bulk of the resources from their own budgets in the first place. Of the $120 million for the first five years of the polio eradication program, $74 million came from national sources and $46 million from international donors.

More than that, the existence of the PAHO Revolving Fund, which de Quadros established, has been a key resource for more than 35 years to pay for programs against polio, measles, yellow fever, rotavirus, and HPV. The fund is a pool of resources contributed by member states to “procure high-quality life-saving vaccines and related products at the lowest price.”

“All the countries that needed the vaccines could get them at an affordable price. No country lacked the vaccine, and no country ever defaulted on a payment. All the countries pay the same price,” Alleyne said.

A model for transition?

With only eight reported cases of polio in the world in 2017, optimism abounds among stakeholders that the world will see the end of the disease in 2018. This will be a major victory in human development and for vaccine advocates, who have championed immunization programs for more than 30 years.

For some stakeholders, anticipation of the end of polio is tempered by the reality that withdrawal of funding earmarked for immunization by multilateral agencies—such as Gavi, the Vaccine Alliance, and the International Development Association (IDA)—will leave 24 low- and middle-income countries without budgets for key component of infectious diseases programs such as surveillance and laboratory infrastructure. ACTION’s research of this conundrum, Progress in Peril: The Changing Landscape of Global Health Financing, explores the problem known as “simultaneous transition” and challenges stakeholders to explore a planned and coordinated process and alternative financing that will not leave poor populations vulnerable to infectious disease and weak health systems.

Lessons learned from the LAC experience, particularly the PAHO Revolving Fund, is worth exploring among donors and stakeholders in the current debate on simultaneous transition.