Volume_101-2_page

HISTORY OF PUBLIC HEALTH
A Canada-Brazil Network in the Global Eradication of Smallpox Steven Palmer, PhD,1 Gilberto Hochman, PhD2 The year 2010 marks the 30thanniversary of the global eradi- study Medicine at Queen’s University was thwarted by admissions cation of smallpox, the only public health effort in history to policies favouring returning veterans. Instead he took his MD at eradicate a disease from the human species. The Smallpox the University of Rochester before joining CDC.5 Eradication Program (SEP) of the World Health Organization Hopes for disease eradication had waned following setbacks in (WHO) was an assemblage of state, bilateral and multilateral agen- the malaria eradication program launched in the 1950s and this cies and resources, deftly brought together and coordinated by was reflected in the SEP’s meagre budget. Henderson created a net- Donald A. Henderson, SEP director from 1966 to 1977. Less visible work of allies who could provide resources outside WHO institu- but equally crucial to the success of the SEP, especially at the level tional structures. The strategy led him to Robert Wilson, then the of vaccine research and production, were informal networks of pub- second-in-command at Connaught Laboratories. A professor of Hygiene and Preventive Medicine at the University of Toronto and These “epistemic communities” were made up of knowledge- a senior researcher at Connaught prior to becoming Assistant Direc- based experts with authoritative claim to policy-relevant knowl- tor in 1957, Wilson’s research interests had been concentrated on edge within their field of expertise.1 Circulating among and the development and production of combined vaccines such as transecting different levels of international cooperation, their mem- DPT and DPT-Polio.6 Henderson had become good friends with Wil- bers shared similar academic backgrounds and scientific values, fre- son from his days at CDC when both were closely involved with quented the same seminars and specialist committee meetings, and the introduction of the oral polio vaccine and attended many of the understood the challenges involved in the production of vaccines.
same meetings.7 Henderson asked Wilson if Connaught could test Often rooted in well-established research and production facilities, batches of vaccine produced by laboratories in Latin America, and these networks could operate without official nation-state sanction carry out site visits and oversee training to ensure that vaccines pro- or involvement by working through organizations with authority duced in the region met an SEP standard. This would allow local in international health like WHO and the Pan-American Health production to cover demand in populous areas like Brazil and let the SEP use donated vaccine in key sites like Indonesia that were One such epistemic community linked Canada’s Connaught Lab- without a domestic vaccine production capability.
oratories to the SEP and to Latin American – and particularly Brazil- In 1966, Connaught was an autonomous, non-profit laboratory ian – vaccine production. Its principal members were Henderson, affiliated with the University of Toronto and regularly working with José Fonseca da Cunha (1914-2005), who was responsible for vac- the provincial and federal departments of health to develop a vari- cine and serum production at Brazil’s Oswaldo Cruz Institute, and ety of vaccines. A world leader in the development of freeze-dried Connaught scientists Robert J. Wilson (1915-1989) and Paul Fenje.
smallpox vaccine, unencumbered by corporate or governmental Officially, Canada played only an indirect part in the SEP through oversight but interested in possible export markets, Connaught was its role as a WHO member state, and at the outset of the global ideally suited to take on the role that Henderson had in mind.8 Wil- eradication initiative had no bilateral ventures of any kind in Latin son, a well-connected public health scientist in a directorial post, America. The Canada-Brazil network linking Henderson, Wilson, was in a good position to accept Henderson’s appeal. His decision Fenje, Fonseca da Cunha and others, however, allowed Connaught to do so should also be understood in terms of its domestic back- and Canadian scientists to become significant players in the glob- drop. Canada was gearing up for its Centennial Year celebrations, al eradication effort2 while simultaneously pressing the Canadian and though the government remained ambivalent about playing government to be less of a “reluctant partner” in health coopera- any foreign policy or development role in the Americas, there was a new internationalism brimming in the country’s professionalelites, one fostered by Lester Pearson’s profile and vision.9 In more The SEP Link with Connaught
immediate public health terms, Latin America and Canada had In 1965, the World Health Assembly voted to move ahead with a been linked by smallpox only four years earlier, in 1962, when a global smallpox eradication program, an idea first proposed by the Canadian boy had provoked a bad “smallpox scare” and emergency Soviet delegation in 1958. Donald Henderson, an epidemiologist response after returning to Toronto via New York City suffering from the United States Centers for Disease Control (CDC) was appointed to direct the operation.4 Descended on both sides from Author Affiliations
southwestern Ontario farmers, Henderson had strong Canadian 1. Canada Research Chair in History of International Health; Associate Professor, medical roots. His mother, Eleanor McMillan, was a graduate of Department of History, University of Windsor, Windsor, ON Chatham Hospital School of Nursing and worked on the smallpox 2. Senior Researcher and Professor, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
Correspondence: spalmer@uwindsor.ca and hochman@coc.fiocruz.br
wards at Henry Ford Hospital during North America’s last outbreak Acknowledgements: The authors thank Luis Barreto, Christopher Rutty and Hugh
of variola major in Detroit and Windsor in 1924; his uncle, William McNaught of Sanofi pasteur for their help in consulting the Connaught Archives, andDanieli Arbex for research assistance. We owe special thanks to Donald Henderson for McMillan, a physician, would become the ranking Liberal Member an engaging interview. The research for this article was supported by a grant from of Parliament in the 1960s. Born in 1926 and raised in the United FIOCRUZ and the National Council for Scientific Development-CNPq, Brazil, and bythe Canada Research Chair in History of International Health at the University of States, Henderson’s 1946 attempt to follow family tradition and Canadian Public Health Association, 2010. All rights reserved.
CANADIAN JOURNAL OF PUBLIC HEALTH • MARCH/APRIL 2010 113
HISTORY OF PUBLIC HEALTH
Brazil and Smallpox
labs (working somewhat in the shadow of the Oswaldo Cruz Insti- Brazil was one of the most significant countries in the global small- tute) made with Connaught gave them tremendous technical, tech- pox eradication program, and it was the key country in South nological and morale boosts. In a 1970 letter to Henderson, he America. Aside from its great size and the fact that it bordered on commented that he was “vastly pleased” to see that “both Insti- every state in the region, in the middle of the 1960s it was the only tutes have taken the challenge, as have the young scientists and country with endemic smallpox, for the most part variola minor.
nothing is going to hold them back now.”21 Fonseca da Cunha Brazil had a long history of combating smallpox dating from the recalled the relationship between Oswaldo Cruz and Connaught as 19th century, though the disease had dropped off the public health a smoothly functioning one. “We sent vaccine samples to Toronto, agenda by the 1930s. Smallpox programs were revived by the they tested them and determined, ‘This one’s good, this one’s no Kubitschek administration in 1958 due to the international atten- good’. And from time to time we welcomed the consultants to the tion given to the Soviet eradication proposal to the World Health Assembly. A military government took power in Brazil in 1964, and A number of Brazilian scientists from all three facilities trained at began looking for national and international legitimacy. Despite Connaught. Among them was Fonseca da Cunha, whose 1968 res- formidable limitations in national infrastructure and fiscal capaci- idency to study production and testing of sterile freeze-dried vac- ty, and with most available epidemiological resources invested in cine cemented strong personal and professional relations with malaria eradication, in November 1966 the regime began a Small- Wilson and Fenje.23 Between 1969 and 1972, crucial years for pox Eradication Campaign (CEV) associated with the WHO project.
Brazil’s CEV, Fonseca da Cunha served as cabinet secretary at the Even though some material resources and technical assistance came Ministry of Health. Wilson himself took over as Chairman and from abroad, the eradication of smallpox in Brazil was led and Director of Connaught in 1972, allowing him to lobby the Cana- attained principally through national, Brazilian financial and dian government to make additional donations of vaccine ear- human resources.11 Vaccine science and production was concen- marked for the global eradication program. In August 1973, he trated at Oswaldo Cruz, a laboratory with a long history of sero- served as a member and Vice-Chairman of the commission that logical and tropical medical research excellence.12 certified the eradication of smallpox in Brazil, and, consequently – The vaccine science network linking Canada to Brazil actually Brazil being the last Latin American country with endemic cases – pre-dated the creation of the SEP and the Brazilian CEV. Sponsored by a Rockefeller fellowship, Fonseca da Cunha had visited Con-naught Laboratories in 1959, the same year that he became chief of Conclusion
vaccine production at Oswaldo Cruz.13 As early as 1960, he initiat- Wilson’s decision to make a deep commitment of Connaught’s ed correspondence with Cleve Russell Amies, the scientist leading energies to WHO, PAHO and the Brazilian CEV is a good example the research on freeze-dried vaccine at Connaught.14 Fonseca da of the willingness among leaders of the Canadian public health Cunha felt that a freeze-dried vaccine, whose development was sub- community to anticipate and promote the reorientation of Cana- sequently undertaken at Oswaldo Cruz, was “the true solution to dian foreign assistance, officially codified in a 1970 report initiat- the Smallpox problem in Brazil … [which was a] big country.”15 He ed by the Trudeau government that embraced greater hemispheric still held the conviction seven years later when stepped-up assis- involvement.25 In a fraught political and ideological Cold War con- tance from Connaught in the stabilization and quality control of text, Brazilian public health laboratories were able to engage a ‘neu- freeze-dried vaccine would prove crucial to overcoming challenges tral’ network for additional technical assistance in carrying out a stemming from the extension of the country’s territory and popu- national eradication campaign, in so doing dove-tailing with the objectives of WHO’s global eradication initiative. The history ofthis Canada-Brazil network reveals the importance of epistemic The Canada-Brazil SEP Collaboration
communities and non-governmental forms of engagement in the Mobilizing Connaught’s resources, Wilson was joined by Yugoslavian- global eradication of smallpox, and in Canada-Brazil scientific col- born Paul Fenje, internationally recognized for his improvement of smallpox vaccine quality.16 Between their first trip in 1967 andthe certification of smallpox eradication in Brazil in 1973, Con- REFERENCES
naught consultants made nine trips to Latin American countries, Peter M. Haas, “Introduction: Epistemic Communities and International Pol- with an increasing concentration on Brazil where 62% of their 310 icy Coordination,” International Organizations, 46:1, pp. 1-35 Winter 1992.
The Connaught venture with WHO is explored in depth by Luis Barreto and total person-days were spent.17 Between 1967 and 1969 in particu- Christopher Rutty, “The Speckled Monster: Canada, Smallpox and Its Eradi- lar Wilson and Fenje were applied-scientist road warriors of the late cation,” Can J Public Health 2002;93(4):I1-I20.
Dmitrienko Klaudia. Reluctant Partner: Canada’s Relationship with the Pan Pan-American age, taking on grueling itineraries with significant American Health Organization (PAHO). Hist. cienc. saude-Manguinhos [serial international health responsibility and the risk of professional and on the Internet]. 2006 Sep [cited 2010 Feb 12] ; 13(3): 717-732. Available from:h t t p : / / w w w. s c i e l o . b r / s c i e l o . p h p ? s c r i p t = s c i _ a r t t e x t & p i d = S 0 1 0 4 - political embarrassment should something go wrong.18 59702006000300009&lng=en (Accessed February 22, 2010).
The Connaught collaboration was considered a success by all Frank Fenner, Donald A Henderson, I. Arita, I, Zdenek Jezek, I. D. Ladnyi, three parties in the network.19 Although Wilson and Fenje’s efforts Smallpox and its Eradication (Geneva: WHO, 1988); Donald A. Henderson,Smallpox: the Death of a Disease: The Inside Story of Eradicating a Worldwide in Brazil were concentrated on stabilizing freeze-dried production Killer (Amherst, NY: Prometheus Books, 2009).
methods at Oswaldo Cruz – by far the most important producer in Gilberto Hochman and Steven Palmer, An Interview with Donald A. Hen-derson on the 30th Anniversary of the Eradication of Smallpox,” Hist. cien. South America – over half of their time in the country was spent on saúde-Manguinhos, forthcoming; Henderson, Smallpox, 7-8.
technical and training upgrades at serological laboratories in SaoPaolo and Porto Alegre.20 Wilson felt that the link these ‘secondary’ 114 REVUE CANADIENNE DE SANTÉ PUBLIQUE • VOL. 101, NO. 2
CELEBRITY INJURY AND CHILDREN’S ER VISITS
Howe A, Owen-Smith V, Richardson J. The impact of a television soap opera RÉSUMÉ
on the NHS Cervical Screening Programme in the Northwest of England.
J Public Health 2002;24(4):299.
Cram P, Fendrick AM, Inadomi J, Cowen ME, Carpenter D, Vijan S. The Objectifs : Déterminer si une forte augmentation des visites à la salle
impact of a celebrity promotional campaign on the use of colon cancer d’urgence de l’Hôpital de Montréal pour Enfants (HME) au cours de la screening: The Katie Couric effect. Arch Intern Med 2003;14;163(13):1601-5.
semaine suivant le décès de Natasha Richardson, morte d’une blessure à Larson R, Woloshin S, Schwartz L, Welch H. Celebrity endorsements of can- la tête suite à une chute en ski, était a) statistiquement significative et cer screening. JNCI Cancer Spectrum 2005;97(9):693.
b) liée à la couverture médiatique de l’événement. Nous avons postulé 10. Gould MS. Suicide and the media. Ann NY Acad Sci 2001;932:200-21.
que la couverture serait moindre dans les médias francophones ainsi que 11. Frey C, Michel K, Valach L. Suicide reporting in Swiss print media: Responsi- ble or irresponsible? Eur J Public Health 1997;7(1):15.
dans les centres à l’ouest du Québec.
12. Fekete S, Macsai E. Hungarian suicide models, past and present. In: Ferrari G Méthode : Nous avons comparé le nombre de visites à l’urgence de
(Ed.), Suicidal Behavior and Risk Factors. Bologna, Italy: Monduzzi Editore,1990.
l’HME pendant 10 semaines à compter du 5 mars et enregistré le nombre 13. Takahashi Y. Suicide in Japan. What are the problems? In: Kosly RJ, Eshkevari de blessures à la tête. Ces données ont également été comparées avec les SH, Goldney RD, Hassan R (Eds.), Suicide Prevention. New York, NY: Plenum moyennes du HME pour les mêmes semaines au cours des 16 années précédentes, avec le nombre de visites à l’Hôpital Sainte-Justine (HSJ), et 14. Tousignant M, Mishara B, Caillaud A, Fortin V, St-Laurent D. The impact of avec celles de 3 autres hôpitaux pédiatriques de provinces à l’ouest du media coverage of the suicide of a well-known Quebec reporter: The case ofGaetan Girouard. Soc Sci Med 2005;60(9):1919-26.
15. CHIRPP. Canadian Hospitals Injury Reporting and Prevention Program Résultats : Nous avons constaté une augmentation de 60 % des visites
(CHIRPP) Ottawa, ON: Public Health Agency of Canada, 2009. Available from: http://www.phac-aspc.gc.ca/injury-bles/chirpp/index-eng.php pour blessure à l’urgence de l’HME par rapport à la semaine de référence (p<0,001) et une différence de 66 % par rapport à la moyenne des 16. Mackenzie S, Pless I. CHIRPP: Canada’s principal injury surveillance program.
16 années précédentes. L’HSJ a également enregistré une forte hausse durant la même semaine, mais l’augmentation ne dura que quelques 17. Macarthur C, Pless I. Sensitivity and representativeness of a childhood injury jours. Des augmentations moins importantes ont été observées dans les surveillance system. Inj Prev 1999;5(3):214-16.
3 autres hôpitaux pédiatriques. À l’HME, près de la moitié des visites ont 18. Campo C, Walsh B, Cochrane D, Allegra J. Large increase in Emergency Department visits for head trauma after Natasha Richardson’s death. Ann été pour des blessures à la tête sans qu’il n’y ait aucun changement dans Emerg Med 2009;54(3 Supp 1):S48.
le nombre de celles jugées sévères.
19. Seguin R. Helicopter ambulance not a priority for Quebec. The Globe and Mail. Conclusions : Ces données suggèrent que la couverture médiatique de
20. Franklin C. Canada care may have killed Natasha. The New York Post. March la mort de cette célébrité a suscité de l’inquiétude chez les parents, les incitant à venir à l’urgence avec leurs enfants et qui, autrement, 21. Fallik D. Richardson tragedy promotes awareness of head trauma-when to n’auraient pas cherché à consulter pour des soins médicaux.
seek treatment, what to look for. Neurology Today 2009;9(9):1.
22. Wood-Black F. It’s raining, it’s pouring, the old man is snoring. J Chem Health Mots clés : personnes célèbres; mass-médias; blessures/[Épidémiologie];
service urgences/statistiques et données numériques 23. Lovell M, Pardini J. Neuropsychological assessment and sports-related trau- matic brain injury. In: Marcotte T, Neuropsychology of Everyday Functioning.
New York, NY: The Gilford Press, 2009.
24. Bergquist TF, Nehl C. Mild traumatic brain injury: Continued investigation and controversy. J Clin Ex Neuropsych 2008;30(7):850-52.
25. Grumbach K, Keane D, Bindman A. Primary care and public emergency department overcrowding. Am J Public Health 1993;83(3):372-78.
26. Burnett MG, Grover S. Use of the emergency department for nonurgent care during regular business hours. CMAJ 1996;154(9):1345.
Received: July 30, 2009Accepted: December 23, 2009 Smallpox, from page 114.
ogy, eds. Kenton Kroker, Jennifer Kealan and Pauline Mazumdar (Aldershotand Burlington: Ashgate, 2008), 280-89.
Robert J. Wilson biographical file, Sanofi Pasteur Limited (Connaught Cam- 17. Wilson’s hand-written calculations for DA Henderson, WHO correspondence with D. A. Henderson, SP-CA, 88-001-11.
Hochman and Palmer, Interview with Henderson.
18. Steven Palmer, Danieli Arbex and Gilberto Hochman, “Smallpox Eradication Barreto and Rutty, “Speckled Monster,” I11.
and a Good Place to Eat: A Canadian Scientist’s 1967 Brazil Travelogue,” Cul- Peter Stockdale, “Pearsonian Internationalism in Practice: The International tures of Health: A Historical Anthology, http://hih.uwindsor.ca/wordpress/ Development Research Centre,” unpublished Ph.D. thesis, McGill Universi- index.php/2009/03/02/smallpox-eradication-national-monuments-and- 10. Eric Jarvis, “A Contagious Journey within a Culture of Complacency. The 19. For Henderson’s views, Barreto and Rutty, “Speckled Monster”, I14-I15; Smallpox Scare of 1962 in New York and Toronto,” CBMH/BCHM, Hochman and Palmer, Interview with Henderson; Fenje and Wilson’s feel- ings that the mission was accomplished can be found in their personal cor- 11. Gilberto Hochman, “Priority, Invisibility and Eradication: The History of respondence, Smallpox, 88-001-36, SP-CA.
Smallpox and the Brazilian Public Health Agenda,” Med Hist. 2009;53(2):229- 20. Wilson’s hand-written calculations.
21. Wilson to Henderson, September 8, 1970, Smallpox, WHO correspondence, 12. Jaime L. Benchimol, ed., Manguinhos do sonho á vida. A ciencia na Belle Époque (Rio de Janeiro: Casa de Oswaldo Cruz – Fiocruz, 1990); Nancy Stepan, Begin- 22. José Fonseca da Cunha. Depoimento. Rio de Janeiro, FIOCRUZ/Casa Oswal- nings of Brazilian Science: Oswaldo Cruz, Medical Research and Policy, 1890-1920 (New York: Science History Publications, 1976).
23. The friendship is evident in the details of the correspondence between Fon- 13. Jaime L. Benchimol, ed., Febre amarela: a doença e a vacina, uma história seca da Cunha and Wilson in the early 1970s: Smallpox PAHO, Zone 5, Brazil, inacabada (Rio de Janeiro: Editora Fiocruz, 2001); Robert J. Wilson, Trave- Rio de Janeiro, correspondence, 88-001-27, SP-CA.
24. PAHO/WHO, “Final report of The Special Commission for the Assessment of 14. On Amies and freeze-dried vaccine, see Barreto and Rutty, “Speckled Mon- the Smallpox Eradication Program in South America”, CD22/19, Annex III.
Presented at XXII Meeting of the Directing Council Washington, D.C, Oct. 8- 15. José Fonseca da Cunha to C. R. Amies, January 24, 1960, SP-CA.
18, 1973. Available http://hist.library.paho.org/English/GOV/CD/49261.pdf 16. On Fenje, see Christopher Rutty, “Canadian Vaccine Research, Production 25. Klaudia A. Dmitrienko and Anne-Emanuelle Birn, “Juggling Demands: Cana- and International Regulation: Connaught Laboratories and Smallpox Vac- dian Health Aid to Latin America since World War II,” Can J Public Health cines, 1962-1980,” in Crafting Immunity: Working Histories of Clinical Immunol- 118 REVUE CANADIENNE DE SANTÉ PUBLIQUE • VOL. 101, NO. 2

Source: http://www.agendasdepoliticaexterna.com.br/img_db/prod/documentos/4_A%20Canada-Brazil%20Network%20in%20the%20Global%20Eradication%20of%20Smallpox.pdf