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A HISTORY OF ERADICATION -- SUCCESSES, FAILURES, AND CONTROVERSIES

Sunday, 18th of March 2012

‘This book should be required reading for all who are concerned with global health development.’

A HISTORY OF ERADICATION—SUCCESSES, FAILURES, AND CONTROVERSIES

Book review published in The Lancet, Volume 379, Issue 9819, Pages 884 - 885, 10 March 2012

Donald A Henderson

Eradication: Ridding the World of Diseases Forever?

Nancy Leys Stepan

Reaktion Books, 2011

Pp 312. £25·00. ISBN-978186189 861 6

On May 8, 1980, the World Health Assembly endorsed a historic resolution, which declared “that the world and all its peoples have won freedom from smallpox”. Smallpox was the first and, so far, the only human disease to have been eradicated.

In 1967, the year the eradication programme began, there had been more than 10 million cases of smallpox in 43 countries. A 12-year all-out effort involved staff from 73 nations working with as many as 150 000 national staff. There had been countless problems: civil wars, floods, hundreds of thousands of refugees, continuing shortages of funds, and never-ending struggles with bureaucracies. On several occasions, the continuation of the eradication programme hung in the balance. But on Oct 26, 1977, the last patient was found and isolated—a 26-year-old Somali. For 2 years, extensive programmes of search for cases were undertaken worldwide. Thousands of suspect cases were investigated; none were smallpox. Vaccination could be stopped everywhere.

Not everyone was pleased. Soon after the Assembly, I was angrily confronted by a senior WHO official who spoke slowly and deliberately: “Let me assure you that in this organisation, there will never again be a vertical programme such as smallpox eradication.” A prevalent view was that categorical programmes like smallpox or malaria eradication were major impediments to the development of basic health-care systems, luring governments into extravagant, futile campaigns that compromised existing health programmes. Eradicationists, however, saw the initiatives as the only practical approach to achieve major advances in the prevention of some important diseases, especially in developing countries.

In Eradication: Ridding the World of Diseases Forever? noted medical historian Nancy Leys Stepan objectively explores the origin, development of, and controversy surrounding eradication programmes during the past century—warts and all. The campaigns at issue are few but they have been the largest international health initiatives so far undertaken. Each is a saga unto itself. Proposals for the eradication of other diseases are regularly under consideration and often debated. Thus, the need to better understand the history of eradication programmes and their evolution.

The belief that a disease might actually be eradicated dates only from the past century, although it is often attributed to Edward Jenner. He had discovered that cowpox inoculated into the skin prevented smallpox. Jenner wrote in 1800: “cowpox, an antidote that is capable of extirpating from the earth a disease which is every hour devouring its victims”. Clearly, Jenner's was the exuberant cry of an inventor, not a reasoned consideration that smallpox eradication might actually be achieved.

The first serious practical efforts to eradicate a disease began in 1909 with the support of John D Rockefeller. The disease was hookworm. The idea was for large-scale community programmes to systematically screen faecal specimens for hookworms, to treat people who were infected, and to promote the building of sanitary privies. Over 15 years, programmes were undertaken in 52 countries on six continents. The first evaluations took place a decade after the programme began and showed that infections among villagers were less severe but the proportion of people infected was unchanged.

Beginning in Latin America in 1918, interest shifted to the eradication of yellow fever with programmes supported by the Rockefeller Foundation. The strategy was to eliminate the breeding sites of the yellow fever mosquito vector, Aedes aegypti. Systematic, highly regimented, tightly supervised anti-mosquito workers moved from house to house destroying breeding sites. Yellow fever in the Americas all but disappeared within a decade, but then it was discovered that there was a monkey reservoir. The programme shifted to eradicating the vector itself.

One figure dominated the evolution of the eradication agenda almost until his death in 1977: Fred Lowe Soper. Stepan rightly characterises him as the “chief architect” of eradication and focuses on his career during the formative years of eradication programmes. A graduate in medicine, his only other training was a 3-week course in tropical medicine. Soper began work in the Rockefeller hookworm programme and later came to direct its yellow fever campaign. In 1947, he was elected Director of WHO's Office for the Americas (now the Pan-American Health Organization) and ultimately played a major part in the development of WHO's global malaria programme.

Soper was a tall, gruff, confident, autocratic administrator, and a relentless advocate for eradication. He insisted each national programme had to be an independent entity with its own employees and a leader that reported directly to the head of state. His programmes were masterpieces of military-style detailed organisation and management. Soper insisted that all was known that needed to be known; that the only problem was execution. Soper had little interest in research, writing “In practical life we observe that the best practical discoveries are obtained during the execution of practical work and that long academical discussions are apt to lead to nothing but academical profit.”

A WHO global malaria campaign began in 1955 that relied heavily on the use of the newly developed dichlorodiphenyltrichloroethane (DDT) to control mosquito transmission. Not surprisingly, health-service staff resented the large, usually better paid independent malaria operation. Much was accomplished but, with time, it became apparent that the programmes were far more costly than could be supported; resistance to DDT developed; and programmes were impossible in many of the densely populated, less-developed, tropical areas. By the late 1960s, programmes began to be curtailed, international support faded, and malaria resurged in many countries.

The idea of eradication was openly challenged. The scientist and writer Rene Debos asserted that it was untenable to believe that a single organism could be extracted from the complex ecological world in which it had evolved. Health officials openly condemned the programme that required so many resources and which contributed little to providing basic health services, as they saw it.

Meanwhile, the Soviet Union, in 1958, instigated another WHO effort—the eradication of smallpox. Few resources were provided and little progress was made. A proposal in 1966 to augment funding and to heighten the effort barely survived a World Health Assembly vote. The spectre of another malaria eradication effort overshadowed the realities that smallpox eradication was a far different problem. Far fewer resources were needed. There was a heat-stable vaccine that gave long-term protection with one inoculation; there was no vector involved in transmission; and a characteristic rash alone sufficed for diagnosis. The programme was provided with an augmented WHO budget—although one that was insufficient even to buy the needed vaccine—and a licence to seek other needed funds from donors. Contributions came with difficulty. Nevertheless, the programme target of 10 years was missed by only 9 months and 26 days.

For smallpox eradication, there had been lessons that could be drawn from the malaria experience. Most important was the extraordinary productivity of minimally educated staff that had been trained and whose performance was well supervised. The average African vaccinator in a team could inoculate 500 people per day and reach more than 90% of inhabitants. If vaccine was given only at a health centre, coverage seldom reached 60%. Continuing research both in the laboratory and the field was critical: current knowledge was needed to know where the disease was greatest and so where best to deploy staff. The programme laid the foundation for a global immunisation campaign that now includes polio, measles, hepatitis, and other vaccines.

The success of smallpox eradication stirred a moribund interest in eradication into a frenzy of ill-considered proposals that extended to tuberculosis, rabies, hunger, leprosy, and other diseases. Two programmes became operative: one for poliomyelitis and one for Guinea worm disease. Both programmes have been in progress for nearly 25 years and are more than 10 years beyond their target dates for completion. Both are nearing the eradication goal but are obstructed now by civil conflict. A third programme, malaria, is beginning but requires major developmental research and has a time horizon of perhaps 35 to 40 years.

Progress is now being made globally in developing needed health services; disease eradication campaigns are appropriately part of that agenda. They are increasingly being melded with other programmes for vaccination, the delivery of nutritional supplements such as vitamin A, and distribution of bednets for malaria control. A programme restricted solely to dealing with one disease is becoming as irrelevant as the antiquated concepts of a basic health service system built primarily on “doc-in-the-box” curative medicine units scattered across the country. This book should be required reading for all who are concerned with global health development; Stepan offers a uniquely knowledgeable insight into the evolution and controversies intrinsic to the important idea of eradication and its contributions to world health.

DAH led WHO's Global Smallpox Eradication Campaign in 1966.