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CSU 117/2010: HISTORY OF THE WORLD HEALTH ORGANIZATION

Saturday, 20th of November 2010 Print

CSU 117/2010: HISTORY OF THE WORLD HEALTH ORGANIZATION

 
In 2004, WHO authorized the issuance of a series of volumes summarizing, by decades, the history of the organization.

The first three volumes of this historical  series are available online at http://www.who.int/global_health_histories/who_history/en/; volume 3 is at http://www.who.int/global_health_histories/who-3rd10years.pdf

  
Volume 3 covers the third decade of WHO, which saw the end of naturally occurring smallpox (last case in Somalia, 1977), the shift from malaria eradication to malaria control, the set-up of the Special Programme on Tropical Disease Research, and the creation of the Expanded Programme on Immunization, without which neither polio eradication nor the GAVI Alliance could have seen the light of day.
  
In its third decade, WHO hosted the Alma Ata Conference on Primary Health Care and launched the ambitious goal of “Health for All by the Year 2000."

 

The decade also saw the rise, outside WHO, of the ‘selective primary health care’ approach, memorably summarized by Walsh and Warren in their article of that name. Those unfamiliar with the debate between PHC and SPHC approaches should read on the subject from such sources as

 http://iph-partnership.org/index.php?title=Overview_Primary_Health_Care_and_Selective_Primary_Health_Care

 

 

For those born too late to work on smallpox eradication or the initial effort at global malaria eradication, the excerpts below from Volume 3 will be especially informative.

 

Good reading.

 

BD

 

  

ERADICATION OF SMALLPOX

 

It was the delegate of the USSR to the Eleventh World Health Assembly, in 1958, who proposed that WHO should undertake the global eradication of smallpox. This proposal was agreed to the next year, when the Twelfth World Health Assembly adopted resolution WHA12.54, which emphasized the “urgency of achieving world-wide eradication” and recommended that the health administrations of those countries where smallpox was still present organize and conduct eradication programmes “as soon as possible.”

 

Progress in the first years was patchy. Although several countries initiated mass vaccination programmes, most were handicapped by factors such as insufficient supplies of potent and stable freeze-dried vaccine, inadequate transport and the lack of a suitably designed plan and strategy. The Organization was limited to providing technical assistance and guidance, with no increase in resources under the regular budget. Furthermore, not all the regional offices were ready to promote the campaign fully; only the Pan American Sanitary Organization had an established programme, which dated back to 1950. Several countries where the disease occurred were not yet Members of the Organization, e.g. China and Viet Nam. More importantly, there were four large smallpox-endemic territories in Africa that either no longer participated in WHO (South Africa) or were represented by colonial powers (Mozambique and Southern Rhodesia).

 

In 1966, new impetus was given to the programme by the decision of the Nineteenth World Health Assembly (resolution WHA19.16) to intensify the global effort and to increase the Organization’s participation. Nevertheless, this decision was made with “grave reservations” (5). The Director-General did not consider that smallpox eradication was possible. Rather than risk an eradication campaign that might suffer the same fate as that for malaria (see below), the highest priority was given to “the establishment of permanent basic health services” (5). Dr Candau had previously stressed the importance of the basic health services (see Chapter 6), which might explain the slowness with which some regions initially gave their full support to the eradication campaign.

 

Four sources of funding were envisioned in the original plan: the WHO regular budget, which in the first year allocated US$ 2.4 million; contributions to the WHO Voluntary Fund for Health Promotion, Special Account for Smallpox Eradication; bilateral contributions; and contributions from other international agencies. It was originally estimated that US$ 48.5 million would be needed for a 10-year programme (1967–1976). Voluntary contributions were sought through mailings and visits to governments and other potential donors. Ultimately, international assistance between 1967 and 1979, when eradication was certified, amounted to some US$ 98 million, of which US$ 34 million came from the WHO regular budget.

 

The strategic plan for eradication was two-pronged: mass vaccination with freeze-dried vaccine of assured quality assessed by special teams, and a surveillance system for the detection and investigation of cases and the containment of outbreaks. The surveillance was to be based on a reporting system in which all existing medical and health units participated. This being a new concept, which might be difficult to implement in highly endemic countries, a three-phased programme for its development was proposed, during which reporting, field investigation, control procedures and laboratory study of cases were steadily improved.
  

The WHO Scientific Group on Smallpox Eradication, meeting at the end of 1967, defined smallpox eradication as “the elimination of clinical infection by variola virus” (6). Proof that smallpox had been eradicated presupposed the presence of a case detection system sufficiently effective to reveal the presence of the disease in an area before more than two or three generations of cases had occurred. When, within an arbitrary period of 2 years, no endemic case of smallpox had been detected and outbreaks due to imported infection had been promptly controlled, the country could be said to be ‘smallpox-free’. The word ‘eradicated’ could be used only when the disease was absent from an entire continent. At this time, smallpox was no longer present in Europe, North America or Australia including Oceania.

 

At the beginning of 1967, an estimated 10–15 million cases were occurring annually in 31 endemic countries or territories with a total population of more than 1 billion. Despite budgetary constraints, which forced the programme initially to expand operations with consultants rather than full-time staff, activities steadily increased during the first year. In 1968, the number of endemic countries with special eradication programmes increased from 12 to 19, and agreements for the commencement of programmes was reached in eight others. In 1969, 23 countries reported transmission, eight fewer than in 1968, and in five of them transmission was interrupted. By 1970, only 18 countries recorded endemic cases, and in six of these transmission was interrupted.

 

Progress was reported in surveillance reports in the Weekly epidemiological report every 2–3 weeks; more extensive summary reports were prepared twice a year. Each year, one or two international meetings were arranged for senior smallpox eradication programme staff from regional offices and endemic countries, annual conferences were held for WHO’s regional smallpox advisers, and biennial meetings were held of the research group concerned with monkeypox and related problems.

 

The WHO Expert Committee on Smallpox Eradication that met in November 1971 was asked to assess the present situation and to consider the strategy and method to be used in the years to come (7). Experience had shown that surveillance was the essential element of eradication, and WHO was called upon to intensify its efforts to support and coordinate programmes. When the incidence of smallpox decreased to zero in all countries and the absence of the disease was beyond doubt, it was hoped that the surveillance programmes could take on increasing responsibility for other communicable diseases.

 

By 1973, smallpox had been confined to five endemic countries: Bangladesh, Ethiopia, India, Nepal and Pakistan. A brief account of the efforts made to bring about successful conclusion of the campaign is given for India and Ethiopia.

 

In India, the national campaign, which had been in operation since 1962, was intensified in 1967. Progress was, however, less than had been anticipated, as outbreaks were not being detected early enough. In the summer of 1973, WHO staff and Indian national and state health personnel agreed on a strategy to detect outbreaks more quickly and to contain them promptly. The plan was for some 100 000 health staff to undertake 10-day village-by-village searches to detect cases, with containment teams following rapidly to stop outbreaks. Surprisingly, the initial search in several northern states revealed thousands of cases in areas where only a few hundred had been reported routinely. Case searches were repeated in heavily endemic areas every 1–2 months and less frequently in low-incidence areas. So great were the numbers reported that state and national health authorities were tempted to replace the surveillance and containment policy with one of mass vaccination, but this was resisted. Gradually, the searches were transformed into house-to-house searches, and the number of smallpox cases steadily decreased. With the mobilization of additional staff and the provision of emergency funds, ‘Operation Smallpox Zero’ was begun in January 1975.

 

New instructions were issued. As there were so few outbreaks, it was decided that each should be dealt with as an “absolute emergency, with maximum mobilization of staff and volunteers”. Whereas previously the containment teams had consisted of three or four persons, they would now consist of “15 or 20 workers or more, headed by the District Medical Officer of Health assisted by a national or WHO epidemiologist” (6). Operation Smallpox Zero was successful. In all, only 308 outbreaks and 1436 cases were detected in India after 1 January. In April, some 115 000 health workers undertook week-long, house-to-house searches throughout India. The last case was recorded in May 1975, and India celebrated ‘freedom from smallpox’ in August of that year.

 

Field operations did not begin in Ethiopia until early 1971. The challenges were formidable: most of the population was widely scattered over this vast country, where roads were few and health services sparse; people suffering from the mild variola form of smallpox travelled and spread the disease; several ethnic groups resisted vaccination. With only 67 available staff, resources were initially concentrated in four southwestern provinces, where the health service structure was better, although one or two staff in each of the other nine provinces began surveillance. By the end of the year, more than 26 000 cases had been found, an unexpectedly high number, as Ethiopia had been reporting only a few hundred cases each year for the entire country.

 

Steady progress was made during 1973 and 1974, and the number of cases decreased to 17 000 in 1973 and to less than 6000 in 1974. A severe drought in late 1974, however, resulted in an estimated 200 000 deaths and extensive refugee movement. Working conditions became increasingly difficult, particularly in areas where there was armed conflict.

 

At the end of the year, a major revolution took place, the Emperor was deposed and a new Government took charge. In some areas, smallpox eradication teams were attacked; several were kidnapped, and on one occasion two Ethiopian vaccinators were killed. Despite these obstacles, the programme continued and was strengthened by the donation of the services of three helicopters, which proved invaluable by permitting investigations in even the most remote areas. By the end of July 1975, only 131 known active outbreaks occurred in 13 clusters spread over a little more than 1% of the country’s total area.

 

As Ethiopia was by then the only known endemic country, WHO was able to make additional resources available, and the number of personnel grew to somewhat more than 1000. The revolutionary Government declared the programme to be of the highest priority. Activity intensified, and, in July 1976, an outbreak was found in the Ogaden Desert, which proved to be the last in the country. Unfortunately, smallpox had by then spread to neighbouring Somalia; emergency control programmes were instituted there, but it was not until 26 October 1977 that the world’s last case was found and isolated in the town of Merka and all his contacts were vaccinated.

 

From 1973, international commissions were constituted to visit previously endemic countries to determine, on the basis of reports and field visits, whether the surveillance conducted over at least the past 2 years had been adequate to detect cases of smallpox.
  

Eradication in South America was certified in 1973 and in Indonesia in 1974. Between 1975 and 1979, 15 international commissions visited 11 countries in Asia and 34 countries in Africa. In December 1979, the Global Commission agreed that eradication had been achieved and recommended that routine vaccination throughout the world be stopped.

 

Applied research contributed greatly to the rapidity with which smallpox was eradicated. Initial research showed that the new bifurcated needle was effective and that the technique of multiple-puncture vaccination could be learnt easily even by persons with little education. This needle permitted the vaccination of 100 persons from a standard vaccine vial, while conventional methods permitted vaccination of only 25. Moreover, the vaccination ‘take’ rates were generally higher. The methods for producing and testing smallpox vaccine were perfected by collaborating laboratories.

 

WHO encouraged field staff to undertake epidemiological studies, the results of which were widely distributed. Of particular importance was the early finding in western and central Africa and in Madras State, India, that smallpox spread less rapidly and less easily than was thought and that prompt detection and immediate containment of outbreaks was the most cost–effective means of pursuing the goal of eradication. Studies also showed that cases seldom occurred among adults in endemic areas, and few cases occurred among people who had previously been vaccinated. Vaccination campaigns therefore focused on children and on ensuring that all individuals had a vaccination mark. New approaches were used for surveillance, in schools and markets; sampling techniques applicable to developing countries were designed for use in quality-control studies; and, in meticulous studies of smallpox transmission, it was possible to demonstrate that essentially all cases resulted from face-to-face contacts between affected and susceptible persons. No less important were the studies of monkeypox, which showed that human-to-human transmission of the disease was sufficiently difficult that it was highly unlikely that infection with the monkeypox virus could become endemic.

 

Intensive efforts were made to identify all laboratories that might have smallpox virus and to persuade them to destroy the virus or to transfer their specimens to the WHO collaborating laboratories in Moscow, USSR, or Atlanta, Georgia, United States. A smallpox vaccine reserve of 200 million doses was set up in Geneva in 1976, which was later reduced to 5 million doses. The two collaborating centres continued to study smallpox virology and the potential for an effective antiviral agent, should one ever be needed for therapy.

 

MALARIA: FROM ERADICATION TO CONTROL
  

The global eradication campaign was launched in 1955. The resolution adopted by the Eighth World Health Assembly, in that year (WHA8.30), called for a programme for the worldwide eradication of malaria. The Malaria Eradication Special Account, which had been established to help finance the Organization’s expanded activities, proved of critical importance in financing the early years of the campaign. When this source of funding dramatically decreased in 1965, the Organization was obliged to allocate regular budget funds to meet programme operating costs. As a consequence, the Health Assembly began to scrutinize the programme more closely, which led to growing pressure on the Organization to re-examine its strategy. Furthermore, other priorities, particularly family planning and smallpox eradication, began to receive greater attention. Of even greater importance was the call (8) to integrate the malaria programme into basic health services, especially in countries where eradication was not foreseeable in the near or medium-term future.

After 2 years of study, the Twenty-second World Health Assembly, in 1969, adopted resolution WHA22.39, which continued to call for eradication of the disease but recognized the many problems that had blocked progress. Furthermore, WHO was asked to continue to provide assistance in studying the socioeconomic impact of malaria and of its eradication and to find a method for socioeconomic evaluation of the programmes under way. The review carried out during the previous 2 years had attempted to evaluate the impact but had been thwarted by lack of adequate reliable data.

For more than two decades, the malaria programme had been run as an independent, ‘vertical’ programme. The 1969 Health Assembly resolution now identified the role of  the basic health services as “crucial” in malaria eradication and thus “increased attention to their development” was needed. WHO called upon the Expert Committee on Malaria to review the principles of malaria eradication and to recommend a strategy more suitable to the current situation. At its fifteenth meeting, in October 1970, the Committee reviewed the practices of malaria eradication, emphasizing their “time-limited” nature (9). Where eradication could not be envisaged within a predetermined time, a malaria control programme was called for, control being defined as “an organized effort to carry out those anti-malaria measures that are possible with the available resources and suitable under the prevailing epidemiological conditions, with the objective of achieving the greatest possible reduction of mortality and morbidity.”

 

The Committee acknowledged that training had always been given high priority by WHO. More than 100 courses had been organized over the previous decade, at various training centres around the world. National training centres, assisted by WHO, had provided programmes for some 8500 staff in more than 280 courses. The new strategy of malaria eradication, however, called for more comprehensive training of malariologists.

A large international conference was organized by WHO in late 1972 on the subject Malaria control in countries where time-limited eradication is impracticable at present (10). The organization of malaria control activities was seen to require activities at three levels: central, intermediate and peripheral. At the central level, a team should be integrated into a communicable disease control unit, consisting of a malariologist and a sanitary engineer or ‘sanitarian’. They would be responsible for overall policy-making, conducting feasibility studies and the overall planning and management of the programme. The intermediate level was seen as the backbone of activities, consisting of a medical officer with a solid grounding in public health administration and epidemiology, assisted by a trained, experienced senior malaria health inspector. At the peripheral level, there would be supervisors and small teams to perform activities such as the conduct and updating of geographical reconnaissance or delimitation of vector-breeding places, training and supervision of spraymen and drug administrators, collection and microscopic examination of blood slides from fever patients and suspected malaria cases, treatment of malaria, regular reporting of results, feedback of data to the intermediate level and health education of the public.

Particular attention was given to research. Many questions remained: Why are certain anophelines, or strains of them, efficient vectors whereas others are not? What is the course of the disease in semi-immune populations and its effect on their working capacity during periods when the disease is quiescent? How can different staining or concentration techniques improve the diagnosis of malaria? How is the biochemistry of malaria parasites related to their biological cycles in the body of the host?

 

At its sixteenth meeting, in November 1973, the Expert Committee continued to refine issues raised at its earlier sessions. The importance of integrating antimalaria programmes into the health and socioeconomic context was discussed extensively. In order to determine which socioeconomic targets were feasible, these aspects had to be an important component of the feasibility survey carried out in the early stages of programme planning.

Studies of the cost–benefit type based on purely economic criteria fell short of what was needed. The interrelations between malaria and certain features of underdevelopment (e.g. primitive agricultural methods and human ecology conducive to contact between man and mosquito) were so close as to require not only a complete study of the effect of the campaigns on socioeconomic conditions but also a study of the effect of the latter on the malaria situation (11). Special attention was given to the impact of large-scale development projects on malaria and on the importance of including appropriate antimalaria measures in such projects from their inception.

 

The massive epidemics in the Indian subcontinent resulted in more than a tripling of reported cases from that area between 1972 (nearly 2 million cases) and 1976 (6.5 million cases). Particularly disturbing were the appearance of major epidemics in countries that in the 1960s were judged to be on the way to eradicating malaria. Against the background of meetings and studies to find new approaches to the problem and in light of the rapid deterioration of the malaria situation in a number of countries, WHO continued to promote, organize and coordinate antimalaria activities at national and international levels. Efforts were made to obtain international and bilateral assistance for malarious countries. WHO organized regional meetings on specific malaria problems and border meetings in several regions. New training programmes were set up, which were more comprehensive, as called for in the strategy adopted in 1969.

 

In an “analytic summary” of WHO’s work, prepared at the end of 1973 (12), the “solution” to the problem of malaria was found to be “inseparable from the solution of that of socioeconomic advance in the developing countries”. The use of all technical methods “must go hand in hand with the expansion of basic health services in rural areas, with the provision of more trained personnel, with better health education, and above all with an improvement in the economic conditions of underprivileged communities in tropical areas.”

The deteriorating situation led the Executive Board at its fifty-fifth session, in January 1975 (resolution EB55.R37), to establish an ad hoc committee on malaria to identify all aspects of the problem that required attention, with emphasis on the formulation of regional strategies, reorientation of national programmes and the design, production and adequate supply of antimalarials and insecticides.

 

A paper prepared by the secretariat for consideration by the ad hoc committee (13) described various issues, including WHO’s role as perceived by the Director-General. Reference was made to the unfavourable turn taken by the programme since 1969: while the strategy outlined in 1969 was considered to be sound, it was admitted that the Organization has been unable to implement it. This was judged to be due to the fact that no one—governments, national or international institutions or individuals—connected with the programme was psychologically prepared to admit even partial failure and to break away from the past, leading to the conclusion that “it was probably a mistake to stipulate that ‘global eradication’ remained the objective when it was obviously out of reach for decades to come, with the means at our disposal.” The views of the ad hoc Committee were requested in the hope that it would lead the Board to make a “strong statement” that would help to promote the radical change in attitude without which no fresh impulse could be given to the programme.

The ad hoc committee limited itself to proposing a role for WHO consisting of six points:

• recognition of WHO’s leadership role as mandated by the Constitution;

• WHO’s role in attracting international contributions to technically and economically sound programmes;

• a greater role for the WHO regional committees and regional offices in formulating regional approaches;

• close coordination among WHO secretariat at all operational levels, with the proviso that permanent WHO malaria teams would be required only exceptionally, while WHO could remain involved in field research “particularly to develop operational models and/or test various methods (drug regimes, insecticides) in the field”;

• the continuing need for an active role of WHO in antimalarial activities that involved several countries; and

• a role for WHO in initiating plans for the design, production and distribution of antimalarials and insecticides in liaison with other international institutions and with industry, while recognizing that its own resources could be used only for emergency cases and in limited amounts.

The Executive Board at its fifty-seventh session, in January 1976, endorsed the report of its ad hoc committee and outlined the role of WHO as follows:

• assist countries in taking more realistic, flexible approaches in antimalaria programmes;

• intensify coordination with other international organizations and bilateral agencies;

• emphasize and assist in the extension of training in malariology at both national and international training institutions, including formulation of training courses in this field suitable for all public health workers in malarious countries; and

• assert the Organization’s leading role in making overall plans for the design, production and distribution of antimalarials and insecticides.

When the Twenty-ninth World Health Assembly addressed the same subject, it added two further lines of action for the Organization to pursue:

• assist countries in conducting operational studies and setting up research facilities for various aspects of malaria, particularly for immunizing agents, new chemotherapeutic substances and biological methods of control; and

• promote the use of bioenvironmental methods of malaria control whenever feasible.

The first point, concerning research, became an essential feature of TDR, which was launched in 1975 (see Chapter 5 and below), while the second point was incorporated in later programmes.

The TDR programme for malaria started along four lines: chemotherapy, immunology, parasite biology and cultivation in vitro, and applied research. The work of the chemotherapy group included research on the mechanism of action of antimalarial drugs, improvement of drugs in clinical use, improvement of existing and new drug screening procedures, design of new drugs and clinical studies.

Immunological research in malaria had seen a “major renaissance” in 1976–1977 owing in part to the successful establishment of continuous cultivation of Plasmodium falciparum in vitro (14). The programme was oriented mainly towards research on malaria antigens, mechanisms of immunity and immune evasion, immunodiagnostic tests, immunopathological phenomena, development of blood state, sporozoite and gamete vaccines in animal models and, eventually, vaccination against malaria in humans.

 

The priorities for field research emerged from regional advisory committees on medical research and included baseline assessment and monitoring of drug sensitivity in P. falciparum, evaluation of community participation in antimalaria activities, chemoprophylaxis for children in malaria endemic areas, approaches to malaria control in problem areas and the strain distribution of P. falciparum.

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