June 18, 2014 The Pump Handle 0Comment

by Phyllis Freeman and Anthony Robbins, MD, MPA

One of our public health heroes, Ciro de Quadros, a public health physician from Brazil died on May 28, 2014. We need his attitude, skills, and persistence more than ever today. Ciro was a master of innovation, particularly in his efforts to prevent infectious diseases with vaccines. It seems especially timely today to review highlights of his career.

And why now? For one, because just now efforts to eliminate polio are foundering in the wake of the US CIA’s disastrous and hugely counterproductive scheme to identify Osama bin Laden’s children through a phony immunization program. The CIA’s ruse confirmed all the worst claims of vaccination opponents.

And why else? Because if we can assemble lessons from his career, they may benefit efforts to prepare public health workers to solve many other sorts of problems.

Ciro faced what seemed to most observers and colleagues to be insurmountable challenges as he tried to eliminate smallpox in Brazil and then Ethiopia.  But he always found an effective way forward. Later, when directing the Pan American Health Organization’s Division of Vaccines and Immunizations, he pioneered in broadening protection against many more vaccine-preventable diseases.  His career was one of problem solving – he never conceived of public health as a ‘discipline’ – to be defined in academic terms that might narrow his scope of activity.  Instead he learned on the go – any skill or information from any source available – redefining his role as he sized up challenge after challenge.

As we look to find a way forward after the CIA-initiated immunization reversal, and to increase commitment and urgency of public health workers – the newly arriving to public health work of any description and those continuing – we look at Ciro’s career for glimpses of what made him so effective, so relentlessly committed to solving problems, and so able to shape novel approaches and renew his own energy.

Ciro’s education and career

Ciro de Quadros lived in Brazil from his birth in 1940 until the early 1970s when his early successes caused his boss, WHO’s smallpox eradication program director, DA Henderson, to transfer Ciro to Ethiopia.  Just after medical school, Ciro had worked as chief medical officer of a public health center in the Amazon rainforest, in Altamira, a town of 5000. There he and his team (a nurse, a sanitarian, a lab technician, and a health educator) did every kind of task. Ciro, did more. He kept detailed records of everything—and by the end of that year the team knew they had vaccinated every man, woman, and child, even as they treated every sort of malady, performed surgery, dug latrines, etc. After that year he went back to school, also in Brazil, for an MPH. Then in 1969, Ciro headed back to the field, to the state of Paraná in southeastern Brazil, to be its smallpox surveillance officer.

He began earning respect for his ways of getting things done – ways that assure him a special place in public health history.  Although everyone was committed to mass vaccination against smallpox, there was no budget to do so in Paraná. Thus, Ciro tried a new and untested strategy–surveillance and containment. It was heretical, as at that time almost everyone believed that the only way to eradicate smallpox would be with mass immunization: vaccinate everyone. His experiment helped to topple ‘common wisdom’.  With a car and a nurse vaccinator, this little team chased reports of outbreaks or single cases – using local radio, a megaphone mounted on the car. They identified cases and vaccinated more than 38,000 people, anyone who may have had contact with a ‘case.’ When the mass campaign finally did go door to door later, they found not one case of smallpox.

DA Henderson lured Ciro to greater challenges in Ethiopia –where half the population lived more than a day’s walk from any road. Not only was the territory tough to traverse, but suspicions about vaccinators meant, as Ciro put it:

“You could go walking through those mountains for days and days to find a smallpox case but then you could not vaccinate anybody because nobody wanted the vaccination. They would throw stones. They would set dogs on you.”

After 6 years in Ethiopia, Ciro moved to Washington DC in 1977 – but only after having waited 6 months from when the last case of smallpox was reported in the country.

Working out of the Pan American Health Organization (PAHO) headquarters in Washington DC, but traveling throughout the Americas, Ciro used the smallpox successes to lead an immunization program to cover polio, measles, diphtheria, pertussis, tetanus, tuberculosis; adding additional vaccines as they became available. To make sure that vaccines were on hand when the programs organized in each country were ready to use them, he helped create PAHO’s Revolving Fund (a novel mechanism to assure a ready supply of international currency for purchasing qualified vaccines from reliable vendors anywhere in the world at the lowest prices he could help to negotiate for bulk purchase– allowing each country to replenish the Fund’s supply of US dollars using its local currency).  We have lasting memories of watching Ciro moving in and out of the ministries of health in the Americas – just ahead of the ‘detail men’ trying to cut special deals for direct vaccine sales – to remind everyone he had a better deal for their people – and that he and PAHO would be watching…. should evidence of ‘special deals’ mean higher purchase prices, possibly with ‘unaccounted for benefits’ to any ministry staff.

While at PAHO, Ciro led the successful program to eliminate polio from the Americas, then continued to strategize the global ‘endgame’ for measles from his final professional post at the Sabin Institute, becoming Vice President Emeritus there in 2003.

How did he work?

He defined the problems he aimed to fix—in the long term and all the steps along the way. He took on every issue that blocked his ability to solve the public health problems that needed fixing – making use of every role he could play, all knowledge he could glean, all the teamwork he could promote – with the immense energy he would characteristically muster.  He saw immunization – and immunization of the most vulnerable and hardest to reach children, in remote mountain villages, or caught in war zones during active conflict, or in urban slums that shared some debilitating characteristics of war zones – as the way to engage growing throngs of contributors in improving population health.

He worked from the bottom up; he worked across the top; and he wove through all the layers, following and creating glimpses of opportunity. When working in public health, we hope our colleagues, and our students will call on lessons we learned from Ciro’s education and career.  A quick Ciro list contains these elements:

  • He pursued his education in the setting where he hoped to contribute – for Ciro in Brazil. This meant he was drawing on his local knowledge and growing awareness of the needs of the population as he prepared himself with strategies to improve health – first of villagers, then in a region within his country, then in another country with even greater needs, then for the Americas, and for the world.
  • He went right to work in the field after medical school – where he could learn more about harsh realities undermining health from the perspectives of those living in problematic environments-and from others who had been working there before him.
  • He returned to school in public health – after his village medical officer immersion – to learn more technical skills and to improve his problem solving skills once he had experienced the limits and frustrations of working on the front lines.
  • He took on tough assignments and worked his tail off – all the while nurturing co-workers of every sort and community members.
  • He always looked to learn from everyone around him – in the field or workplace – people at every level because, as he said, the best ideas may not come from those you expect to offer them.
  • He valued his work based on what he actually got done.
  • He avoided becoming isolated in a narrow field of expertise – even while he grew to be so enormously knowledgeable about several aspects of health—for Ciro, infectious diseases, epidemiology, and immunization.
  • He left no assignment without succeeding or planning a logical transition to keep up the efforts to solve whatever the problem–with all the creativity, urgency, and persistence he felt the situation called for.
  • He took the lessons he learned with him everywhere he went.
  • He taught by doing, then articulating his observations and thoughts when he thought others could see their relevance and put them right to work.

He repeated this process throughout his career.

To remind ourselves of these lessons and to provoke strategic and energetic responses to the next public health problems, we who long observed Ciro’s way of working can now simply ask ourselves: What would Ciro do?

For those who did not get to watch him in action, we have offered a small window on years of incredibly effective action. That allows us to also put before readers of this post the question: What would Ciro do now?  Whether the challenge is re-establishing trust in vaccinators (in places where the CIA must have known it put their lives in peril) or charting national strategies to protect workers from avoidable harm – remembering Ciro’s educational and career choices and stunning successes gives us a way to honor his memory.

Phyllis Freeman and Anthony Robbins, MD, MPA are the co-editors of the Journal of Public Health Policy.


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