Las epidemias en La Pampa (Argentina), en perspectiva histórica* / The epidemics in La Pampa (Argentina), from a historical perspective

Resumen Este artículo describe el inicio de las preocupaciones sanitarias vinculadas a las epidemias ocurridas durante el siglo XX en La Pampa, provincia argentina. Las epidemias, como las de la viruela, fueron un estímulo para estas políticas que frecuentemente tuvieron origen en Buenos Aires, la capital del país. El contagio de muchas epidemias dependía de carencias de infraestructura: agua, desagüe y desecho adecuado de basuras, de la ausencia de un número suficiente de trabajadores de salud, de la presencia de vectores transmisores de enfermedades como los mosquitos y, en última instancia, de la pobreza. La experiencia histórica descrita en este texto resalta la importancia de analizar el impacto del SARS-CoV-2 más allá de las grandes ciudades.

Abstract This article describes the emergence of health concerns relating to the epidemics that occurred during the twentieth century in La Pampa, a province in Argentina. Epidemics such as smallpox drove such policies, which frequently originated in Buenos Aires, the country's capital. The spread of many epidemics was due to shortages: water, sewage and adequate refuse disposal, an insufficient number of health care workers, the presence of disease transmission vectors such as mosquitos, and, ultimately, poverty. The historical experience described in this text highlights the importance of analyzing the impact of SARS-CoV-2 beyond the big cities.

Los orígenes de la vacuna / The origins of the vaccine

La medicina china y su cultura ancestral parecen tener los antecedentes más remotos de los intentos por prevenir o curar el azote epidemiológico de esa época: la viruela. Estos conocimientos empíricos llegaron al Asia Central y Europa, y algunos granjeros hicieron observaciones de la utilidad de la inoculación o variolización sin llegar a documentar sus ensayos en la comunidad científica. El mérito de Edward Jenner reconocido como el descubridor de la vacuna antivariólica, radica en haber demostrado con evidencia práctica la protección conferida frente a la enfermedad por la administración en un niño sano de un material proveniente de una persona con lesiones causadas por el cowpox, virus de la viruela vacuna. Desde Europa en el siglo XVIII y comienzos del siglo XIX, la inoculación primero y luego la vacunación llegan a Hispanoamérica por vías informales o por determinación de la corona como un servicio a las colonias. La vacunación antivariólica tuvo el valor agregado de motivar y convencer a las autoridades gubernamentales sobre la necesidad de implementar políticas de salud pública para responder a las necesidades sanitarias de la población. En Chile, Fray Pedro Manuel Chaparro fue el pionero en la aplicación y difusión de la vacuna, realizó la primera campaña nacional y se cuenta entre los padres de la salud pública nacional.

Chinese medicine and its ancestral culture seem to have the most remote history of attempts to prevent or cure the epidemiological scourge of that era: smallpox. This empirical knowledge reached Central Asia and Europe, and some farmers made observations of the usefulness of inoculation or variolization without documenting their trials to the scientific community. The merit of Edward Jenner, recognized as the discoverer of the smallpox vaccine, lies in having demonstrated with practical evidence the protection conferred against the disease by the administration in a healthy child of a material from a person with cowpox lesions. From Europe in the eighteenth and early nineteenth centuries, first inoculation and then vaccination arrive in Latin America by informal means or by determination of the crown as a service to the colonies. Smallpox vaccination had the added value of motivating and convincing government authorities about the need to implement public health policies to respond to the health needs of the population. In Chile, Fray Pedro Manuel Chaparro was the pioneer in the application and diffusion of the vaccine, conducted the first national campaign and is counted among the parents of national public health.

El niño con enfermedades infecciosas en las artes visuales: pintura / The child with infectious diseases in the visual arts: painting

Resumen: El impacto catastrófico de las enfermedades infecciosas sobre la salud infantil, como también el rol trascendental y benéfico aportado por la instauración y ejecución de medidas sanitarias y de inmuno- prevención ha sido un tema recurrente en la historia de la medicina, aunque una vez logrado el con trol de la enfermedad, estas pasan fácilmente al olvido. Ante esto, parece necesario rememorar aquel escenario social mediante un acercamiento a través de la pintura. Las obras pictóricas son testigo de aquello, pues las enfermedades son objeto de representación y a su vez se han convertido en un in valuable documento en la historia de la medicina. Patologías pediátricas como tuberculosis, difteria, poliomielitis, sarampión, viruela y sífilis como también el inicio de la vacunación, son analizadas en diversas pinturas con el objetivo de profundizar el conocimiento de la época histórica, el autor y su vínculo con dicha enfermedad.

Abstract: The catastrophic impact of infectious diseases on children's health, as well the transcendental and be neficial role played by the establishment and execution of health measures and immunoprevention, has been a recurrent subject in the history of medicine, although once the disease has been controlled, they are easily forgotten. In view of this, it seems necessary to recall that social scenario through an approach through painting. The pictorial works are witnesses of that since diseases are subject of representation, and at the same time, they have become an invaluable document in the history of me dicine. Pediatric pathologies such as tuberculosis, diphtheria, polio, measles, smallpox, and syphilis, as well as the initiation of vaccination, are analyzed in various paintings with the aim of deepening knowledge of the historical era, the author and his or her link to this disease.

Entre vacinas, doenças e resistências: os impactos de uma epidemia de varíola em Porto Alegre no século XIX / Between vaccines, diseases, and resistances: the impacts of a smallpox epidemic in nineteenth-century Porto Alegre

Resumo Uma epidemia de varíola que vitimou fatalmente 1% da população de Porto Alegre em 1874 é o tema deste artigo. Com base em ampla pesquisa documental e no cruzamento de informações produzidas por ocasião da morte dos indivíduos atingidos durante o evento, buscamos problematizar as razões pelas quais a varíola apresentou-se em formato epidêmico na cidade. De posse dos mapas de vacinados nos anos anteriores à eclosão da epidemia, pudemos constatar a baixa adesão da população de Porto Alegre ao preventivo, cujo benefício poderia ser ignorado pelos distintos grupos sociais que teciam relações dentro da cidade. Com a chegada de soldados doentes, oriundos de outras localidades, a moléstia se espalhou rapidamente pela cidade, causando a morte de centenas de pessoas.

Abstract This article examines a smallpox epidemic which killed 1% of the population of Porto Alegre in 1874. Through extensive documentary research and comparison with data from those who died, we problematize why smallpox manifested as an epidemic in the city. Maps showing vaccination in the years preceding the outbreak reveal that only low levels of the population of Porto Alegre participated in prevention efforts, and the benefits of these efforts were ignored by the different social groups which were interconnected within the city. As sick soldiers arrived from other places, the disease spread rapidly through the city and caused the death of hundreds of people.

Control, contención y educación higiénica en las campañas de vacunación contra la viruela en México durante la década de 1940 / Control, containment and health education in the smallpox-vaccination campaigns in Mexico in the 1940s

El artículo examina algunas transformaciones por las que atravesaron los programas mexicanos de vacunación, a partir de 1943, al establecerse la Campaña Nacional contra la Viruela. Se analiza por qué se procuró implementar un método uniforme y coordinado de vacunación para terminar con los brotes epidémicos de esa enfermedad endémica, sobre todo en la región central del país; se estudian las acciones de su amplio y heterogéneo personal y los argumentos por los que se consideró que la vacunación antivariolosa era central para consolidar una cultura de prevención. En suma, se estudia por qué se favoreció la vacunación selectiva, la persuasión y la extensión de los programas de educación higiénica, temáticas que han sido escasamente abordadas en la historiografía.

This article examines some of the changes that the Mexican vaccination programs underwent starting in 1943, the year when the National Smallpox Campaign (Campaña Nacional contra la Viruela) was established. It analyzes why a uniform and coordinated vaccination method was adopted to counter the outbreaks of this endemic disease, especially in central Mexico; the actions of its numerous and heterogeneous staff; and the reasons why smallpox vaccination was considered critical to establish a culture of prevention. In summary, the article examines why selective vaccination was chosen and the expansion of the health-education programs, topics that have been seldom addressed in historical research.

Commentory on “LIVE, ORALLY GIVEN POLIOVIRUS VACCINE - EFFECTS OF RAPID MASS IMMUNIZATION IN POPULATION UNDER CONDITIONS OF MASSIVE ENTERIC INFECTION WITH OTHER VIRUSES.

The following is a commentary on the article “Sabin AB, Ramos-Alvarez M, Alvarez-Amezquita J, Pelon W, Michaels RH, Spigland I, et al. Live, orally given poliovirus vaccine: effects of rapid mass immunization on population under conditions of massive enteric infection with other viruses. Jama. 1960;173(14):1521-6.” Abstract (of the original article): The phenomenon of viral interference must be taken into account in planning the use of live poliovirus vaccine in areas where conditions favor the extensive dissemination of naturally occurring polioviruses. Experience with feeding a trivalent vaccine to 26,033 children in a tropical city of 100, 000 population led to the conclusion that interference was overcome by mass feeding of vaccine to 86% of all children under 11 years within a period of about four days, and that, because dissemination of the poliovirus was self-limited, a second feeding of trivalent vaccine was necessary to achieve immunization of almost all children. Recom-mendations are here formulated for the eradication of poliomyelitis, but they apply only to subtropical and tropical regions with extensive dissemination of various enteric viruses and not to temperate zones with good sanitation and hygiene during certain periods of the year and under conditions of low or absent dis-semination of enteric viruses.

Defunciones en niños a principios de los siglos XX y XXI en Boyacá-Colombia / Deaths in children during the early twentieth and twenty-first century in Boyacá, Colombia

Objetivo Comparar y analizar las Tasas Brutas de Mortalidad (TBM), la Mortalidad en Menores (MN) de 5 años por mil Nacidos Vivos (NV) y la Mortalidad Infantil (MI) en el departamento de Boyacá-Colombia, a comienzos de los siglos XX y XXI. Métodos Estudio descriptivo comparativo con enfoque histórico epidemiológico. Se utilizaron dos fuentes de datos, para las defunciones: registros parroquiales de 1912-1927 y el Boletín epidemiológico de Boyacá 2007; para la población los censos DANE 1912-1918-1927 y 2005. Se almacenaron y analizaron en Mysql®. Se calcularon tasas brutas, específicas por edad e infantil, proporciones de mortalidad y mortalidad por causas. Resultados Entre 1912-1927 se registra una media de 7 958 muertes, en comparación con 5 813 en el siglo XXI; la TBM pasó de 150 muertes a 42 por 10 mil habitantes; la TMI se redujo considerablemente pasando de 231 a 17 por cada 1 000 NV; aunque se pueden comparar las tasas especificas en menores de 8 años con las de menores de 5, existe variabilidad en el rango y en la construcción de la TM especifica y la definida por OMS- UNICEF. Conclusiones Existe un impacto en la reducción de mortalidad, mayor en el siglo XXI, debido a las políticas nacionales e internacionales de control de enfermedades inmunoprevenibles y muerte materna. La pandemia de gripa de 1918-19 afectó considerablemente la mortalidad en todos los grupos de población; las causas violentas ocupan lugares importantes en la mortalidad infantil en el siglo XXI.

Objective Comparing and analysing crude death (CDR), child mortality (CMR) 5-year per thousand live births (LBR) and infant mortality rates (IMR) in the Boyacá department, Colombia, during the early 20th and 21st centuries. Methods A descriptive epidemiological comparative historical approach was adopted. Two data sources were used for deaths: parish registers 1912-1927 and the Boyacá Epidemiological Bulletin 2007 population census for 1912-1918-1927 and 2005 (Colombian Statistics Bureau - DANE); data was stored and analysed in Mysql. Crude rates, age-specific and child mortality ratios and mortality were calculated by cause. Results 7,958 deaths were recorded from 1912-1927 compared to 5,813 in the 21st century. CDR dropped from 150 to 42 deaths per 10,000 inhabitants; the IMR became significantly reduced from 231 to 17 for every 1,000 LB. Although specific rates for children under 8 years of age could be compared to children under 5, there was variability in the range and construction of the specific MR and that defined by WHO-UNICEF. Conclusions There was a higher reduction in mortality in the 21st century due to national and international policies for controlling preventable diseases and maternal death. The 1918-19 flu pandemic significantly affected mortality in all population groups; violent causes were prominent in infant mortality in the 21st century.

Francisco Xavier Balmis y las Juntas de Vacuna, un ejemplo pionero para implementar la vacunación / Francisco Xavier Balmis and the vaccine network, a pioneering example of vaccination implementation

La primera campaña mundial de vacunación organizada fue efectuada en América y las Filipinas por la Real Expedición Filantrópica de la Vacuna (1803-1810). La labor de Balmis como director y de Salvany, subdirector, no se limitó al mero transporte del fluido vacunal a través de los niños vacuníferos sino también al sistema organizativo que aplicaron. Las Juntas de Vacuna fueron una red de centros creados para preservar y transportar el fluido vacuno en buenas condiciones hasta los lugares de vacunación. Disponían de un Reglamento con instrucciones sobre las características del puesto de vacunación o cómo efectuar el censo de vacunados. Para mejorar la aceptabilidad vacunal integraron a los sanitarios locales y utilizaron la prensa para difundir noticias. La estrategia desarrollada constituye un antecedente que, transcurridos doscientos años, guarda una indudable similitud con modelos de planificación sanitaria como el de Pineault y Daveluy utilizados en los modernos programas de inmunización.

The first organised global immunization campaign was undertaken in America and the Philippines by the 'Royal Philanthropic Expedition of the Vaccine' (1803-1810). The work of Balmis as director of the Expedition and Salvany, his Assistant Director, not only included vaccinating children but also the development of an organised model for its application. The model was based on a network of centres created to protect and transport the vaccine fluids in good condition until they reached their vaccination sites and how to conduct a census of vaccinated people. In order to improve vaccine acceptability, local health workers were incorporated and the press was used to disseminate news. The strategy developed served as an antecedent that, two hundred years later, is unquestionably similar to health planning models such as Pineault and Daveluy, used in modern vaccination campaigns.

Another vaccine, another story: BCG vaccination against tuberculosis in India, 1948 to 1960 / Outra vacina, outra história: a vacinação de BCG contra tuberculose na Índia, 1948 a 1960

Através da observação da vacinação em massa de BCG contra a tuberculose na Índia durante os anos de 1948 a 1960, este artigo chama a atenção para a diversidade da história da vacinação. As características das campanhas de vacinação geralmente diferem daquelas celebradas nas campanhas para erradicação da varíola. Devido às diferenças entre a varíola e a turberculose, assim como entre as vacinas desenvolvidas para combater essas doenças, uma análise da vacinação em massa de BCG contra a turberculose parece especialmente bem situada para essa proposta. Três pontos de diferença foram identificados. O primeiro é que em contextos não ocidentais os procedimentos da vacinação de BCG foram modificados em uma extensão maior do que a vacinação contra a varíola. Em segundo lugar, a tuberculose não tinha o drama e a urgência da varíola, e as campanhas de vacinação de BCG sofreram mais com problemas de recrutamento do que a mais "heroica" campanha de erradicação da varíola. E por último, a vacina de BCG foi contestada em círculos médicos e foi muito mais bem adaptada do que a vacina contra varíola como um veículo para articulação de preocupações sobre a modernização pós-colonial.

Through an examination of mass BCG vaccination against tuberculosis in India between 1948 and 1960 this article draws attention to the diversity of the history of vaccination. The features of vaccination campaigns often differed from those of the celebrated campaign to eradicate smallpox. Due to differences between smallpox and tuberculosis as well as between the vaccines developed against them, an analysis of BCG mass vaccination against tuberculosis seems particularly well suited for this purpose. Three points of difference are identified. First, in non-Western contexts BCG vaccination procedures were modified to a greater extent than vaccination against smallpox. Second, tuberculosis lacked the drama and urgency of smallpox and BCG vaccination campaigns suffered more from recruitment problems than did the more "heroic" smallpox eradication campaign. Third, the BCG vaccine was contested in medical circles and was much better suited than the vaccine against smallpox as a vehicle for the articulation of concerns about post-colonial modernization.

Marcados en la piel: vacunación y viruela en Argentina (1870-1910) / Marked on the skin: vaccination and smallpox in Argentina (1870-1910)

Este artículo estudia la vacunación antivariólica en Argentina desde 1870, cuando se inician los debates al respecto, hasta la década de 1910, cuando se amplía al resto del país. Se analizan las prácticas de inmunización puestas en marcha con anterioridad a la Ley de vacunación obligatoria, aprobada en 1886 para la Capital y en 1904 para el resto del país. Tal medida fue resistida desde diferentes sectores. Su aprobación dependió de las consecuencias del proceso de modernización y urbanización acelerada, del peso de los higienistas en el escenario político y su extensión dependió de una concepción administrativa diferente, que incorporaba nuevas áreas y sectores al escenario nacional.

This paper studies the smallpox vaccination in Argentina since 1870, when these discussions were inittiaded until the 1910s, when they were extended to the rest of the country. We analyze immunization practices implemented prior to the compulsory vaccination law, passed in 1886 for the Capital and in 1904 for the rest of the country. Such a move found resistance from different sectors. Its approval depended on the consequences of modernization and urbanization, the weight of hygienists in the political arena, and its extension depended on a different administrative conception, incorporating new areas and sectors to the national scenario.

Estrategias, actores, promesas y temores en las campañas de vacunación antivariolosa en México: del Porfiriato a la Posrevolución (1880-1940) / Strategies, actors, promises and fears in the smallpox vaccinations campaigns in Mexico: from the Porfiriato to the Post-revolution (1880-1940)

El artículo estudia algunas de las estrategias a las que recurrieron las autoridades de salud durante la puesta en marcha de programas vacunación antivariolosa durante los años de 1880 a 1940, periodo que corresponde al gobierno encabezado por Porfirio Díaz (1877-1911), a la fase armada de la Revolución Mexicana (1910-1920), y a las dos primeras décadas del estado posrevolucionario (1920-1940). Por una parte se prestará atención a la preeminencia que tuvo la vacunación en los centros urbanos, notablemente en la ciudad de México; y por la otra, se destacará la gradual, pero decisiva, organización y reglamentación de la vacunación antivariolosa en los programas destinados para el heterogéneo y desigual ámbito rural. Asimismo, se analizará la importancia que adquirió la educación higiénica, y se prestará atención a las divergentes respuestas que la aplicación masiva y cotidiana de la vacuna suscitó en las ciudades principales y en pequeños pueblos y municipios rurales, respuestas que incluyeron la resistencia, el temor, la incredulidad y la franca aceptación.

The article examines some of the strategies employed by the Mexican health authorities that led to the organization of massive and obligatory smallpox vaccination campaigns from the late 1880s to the 1940s, a period of Mexican history that corresponds to the Porfirio Díaz regime (1877-1911), to the armed phase of the Mexican Revolution (1910-1920), and to the first two decades of the Post-revolutionary governments (1920-1940). Attention will be placed of the vaccination programs in the main urban settings, notably in Mexico City, as well as the gradual but decisive organization and regulation of vaccination campaigns in the heterogeneous rural milieu. Furthermore, the importance that hygienic education acquired will be explored, as well as the divergent and contested responses that emerged due to the obligatory vaccination campaigns, responses that included resistance, fear, uncertainty and widespread acceptance.

The discontinuation of routine smallpox vaccination in the United States, 1960-1976: an unlikely affirmation of biomedical hegemony / A descontinuação da vacinação de rotina contra a varíola nos Estados Unidos, 1960-1976: uma afirmação improvável da hegemonia biomédica

Este artigo procura entender o contexto discursivo da cessação da vacinação de rotina contra varíola nos Estados Unidos no início dos anos 70. Os Estados Unidos têm uma longa tradição na oposição à vacinação compulsória contra a varíola, geralmente expressa em relação ao que se refere à liberdade pessoal, à extensão da autoridade estadual e desafios à hegemonia da biomedicina ortodoxa. A rotina de vacinação contra varíola continuou nos Estados Unidos até a extinção da doença nos anos 70, seguida de uma recomendação em 1971 contra a prática emitida pelo Serviço de Saúde Pública dos Estados Unidos. Essa história investiga as maneiras pelas quais a oposição à vacinação compulsória contra a varíola nos anos 60 e 70 foi articulada e entendida por contemporâneos através da análise da retórica utilizada pelos principais periódicos médicos e jornais populares. Descobriu-se que esse movimento bem-sucedido de eliminar a rotina de vacinação contra a varíola explorou a linguagem da autoridade biomédica em vez de protesto político.

This article seeks to understand the discursive context of the cessation of routine smallpox vaccination in the United States in the early 1970s. The United States has a long tradition of opposition to compulsory smallpox vaccination, usually expressed in terms of concerns about personal liberties, the extent of state authority, and challenges to the hegemony of orthodox biomedicine. The practice of routine smallpox vaccination continued in the United States until its termination in the 1970s, following a 1971 recommendation against the practice issued by the United States Public Health Service. This history investigates the ways in which opposition to compulsory smallpox vaccination in the 1960s and 70s was articulated and understood by contemporaries through an analysis of the rhetoric used in leading medical journals and popular newspapers. It finds that this ultimately successful movement to end routine smallpox vaccination drew upon the language of biomedical authority rather than political protest.

As campanhas de vacinação contra a poliomielite no Brasil (1960-1990) / Vaccination campaigns against poliomyelitis in Brazil (1960-1990)

Este artigo pretende discutir as campanhas de vacinação contra a poliomielite no Brasil. Examina as questões que formataram a política de controle da doença, na interface com a história da ciência e da tecnologia, no que diz respeito à descoberta das vacinas, ao desenvolvimento de técnicas laboratoriais de diagnóstico e novos procedimentos de vigilância epidemiológica, e com a história das políticas de saúde pública, no que se refere à decisão e implementação do controle e posterior erradicação da doença. Pretende ainda demonstrar que, para além das tecnologias disponíveis, foram necessárias negociação e vontade política para se alcançar o controle e posterior erradicação da doença no país. As fontes utilizadas foram, principalmente, artigos científicos, depoimentos orais, documentos oficiais e matérias jornalísticas.

This article discusses the vaccination campaigns against poliomyelitis in Brazil. It examines issues that have shaped the politics of disease control at the interface with the history of science and technology with regard to the discovery of vaccines, the development of laboratory techniques for diagnosis and surveillance of new procedures, and history of public health policies in relation to decision making and implementation of control and eradication of disease. The aim is also to demonstrate that in addition to the technologies available, it was necessary some negotiation and political will to achieve the control and eradication of the disease in the country. The main sources used were scientific articles, oral testimonies, official documents and newspaper articles.

Smallpox eradication and Brazil: an interview with Donald A. Henderson / A erradicação da varíola e o Brasil: uma entrevista com Donald A. Henderson

Interview with Donald A. Henderson, the U.S. physician and epidemiologist who headed the World Health Organization's Smallpox Eradication Program from 1966 to 1977. The interviewer talks about the endemic nature of smallpox in Brazil; relations between WHO, the Pan American Health Organization, and the Brazilian government; the role of Connaught Laboratories in the quality of the Brazilian smallpox vaccine; the process that brought certification of smallpox eradication in Brazil; international cooperation in eradicating smallpox and the various strategies applied; the role played by Brazilians in eradicating smallpox in India, Bangladesh, and Africa; and the future of the notion of disease eradication.

Obligar a vivir o resignase a morir? Viruela y vacuna: el debate sobre una enfermedad y su prevención a comienzos del siglo XX en Chile / Forcing to live or resigning to die? Smallpox and vaccine: the debate about a disease and its prevention at the beginning of the twenty century in Chile

La vacunación obligatoria es el proceso coercitivo más emblemático del área de la salud. Sin embargo, en la actualidad, todos nos vacunamos cuando esdebido, sin cuestionar el ineludible procedimiento. Las voces desidentes son escasas, pero para la época en estudio esta situación era muy diferente. Para eceptar la vacuna con la tranquilidad que lo hacenos hoy, los médicos, el Estado y los ciudadanos debieron comprender y asumir la importancia de previnir enfermedades. Este interesante cambio de mentalidad, del cual daremos cuenta, se vivió con especial intensidad y dramatismo, constituyéndose en un momento histórico particularmente relevante en el contexto de la salud pública del país. Es pertinente recordar que la viruela, junto a otros males, ha sido un problema y por tanto, objeto de estudio, para diversos países del mundo.

Struggling to a monumental triumph: re-assessing the final phases of the smallpox eradication program in India, 1960-1980

The global smallpox program is generally presented as the brainchild of a handful of actors from the WHO headquarters in Geneva and at the agency's regional offices. This article attempts to present a more complex description of the drive to eradicate smallpox. Based on the example of India, a major focus of the campaign, it is argued that historians and public health officials should recognize the varying roles played by a much wider range of participants. Highlighting the significance of both Indian and international field officials, the author shows how bureaucrats and politicians at different levels of administration and society managed to strengthen-yet sometimes weaken-important program components. Centrally dictated strategies developed at WHO offices in Geneva and New Delhi, often in association with Indian federal authorities, were reinterpreted by many actors and sometimes changed beyond recognition.

O programa global de erradicação da varíola geralmente é apresentado como obra de um punhado de atores baseados no quartel-general da Organização Mundial da Saúde (OMS), em Genebra, Suíça, e em seus vários escritórios regionais. Este artigo apresenta descrição mais complexa do esforço para erradicar a varíola. Tomando como exemplo a Índia, um dos principais alvos da campanha, mostra que é importante reconhecer os variados papéis desempenhados por leque muito mais variado de participantes. Sem subestimar os funcionários que foram a campo, o autor analisa a atuação de burocratas e políticos em diferentes níveis da administração e da sociedade. Fica claro que foram capazes de fortalecer e, às vezes, também, solapar importantes componentes do programa. Desse modo, estratégias concebidas nos núcleos centrais da OMS, em Genebra e Nova Délhi, com freqüência envolvendo autoridades federais indianas, foram reinterpretadas por muitos atores e por vezes modificadas a ponto de se tornarem irreconhecíveis.