Comments and discussion following workgroup reports

DISCUSSION AND SYNTHESIS Comments and discussion following Workgroup Reports Comment In our Workgroup, as in a number ot other groups. we had ditficulty with the term "elmination" and discussed this at some length. Fortunately, we owe a grcat debt to the Dahlem Workshop in eradicating the phrase "elimination of a dcsease as a public health problem". A number of us wvould like to cradicate the word "elimination". I think control is a respectable term. 1 hope we would see ourselves as bemg sufficiently imaginative and creative to be able to frame progtess in terms of control as being an exciting and saleable entity. If we are going to use "elimination", we nced to use it as carefully as we use -eradication". It bas to be a feasible goal. and we ought to be able to demonstrate that it is a feasible goal I was a little concerned, particularly with the noninfectious disease group. wlhen we talked about eliminating iron, iodine and vitamin A deficicncies and eliminating lead poisoning. I think we all have to agree that none of these are feasible goals. It would be helpful in their report if they were to redefine "elimination" as being low incidence; it is niot a goal to elinminate these conditions. This only illustiates our problcm vitlh the word "elimination" and what we mean by it and what we are trying to mcan by it. In our dictionanr. "'climination" and "eradication" have identical meanings. In other languages, as I am told. it creates no end of confusion. There is no way of differentiating between the two. Question I have a question that is related to terminology but is perhaps more practical, beanng on the next-to-last recommendation for measles. The point was that ef- forts to address measles should not jeopardize pro- grammes or efforts to eradicate poliomyelitis. That is the general recommendation. I wondered whether the group had considered giving some concrete ex- amples to show how embarking on a more ambiLious measles programme would not intertere with or jeopardize poliomyelitis eradication efforts. I ask ior examples because one of the benefits of this meeting has been the luxtaposition of thinkling about synergies in sustainable health development and a variety of different elimination or eradication pro- grammes. Can we hear some creative thinking about concrete ways. operationally and conceptually, and how these programmes would harmonize, synergize, or potentiate one another's efforts? Answer I see the theoretical concern. T can give no example wbere a measles elimination programme has ad- versely affected poliomyelitis. In fact, I think they are mutually complementary. That has been my ex- perience in Mexico What we learned in poliomyeli- tis is now being applied to measles but wvithout undoing our efforts to continue with polhonmyeliiis. These are synergistic efforts. Comment 1 would like to addrcss a point that was brought out by one workgroup about special situations or spccial circumstances that make eradication particularly difficult in certain countries. Guinea-worm and poliomyelitis eradication efforts demonstrate that successful eradication efforts can be carried out in spite of war and conflict. What characterizes these countries is that a number of prerequisites [or eradi- cation are not present. The strategies for these situa- tions (often without goveinmients and without resources) are different from the strategies we advo- cate Ln the majority of couLntnes. My suggestion is tLhat the conference recogniizes that the eradication prerequisites for these counttnes are different, strate- gies must be different. and tunding needs are differ- ent. Special financing mechanisms must be created for eradication elforts in these countries. Comment I should like to respond to the question of competi- tion between the measles and poliomyelitis eradica- tion initiatives. The key issue here is planning and resources. In a number of instances, the country or an organization wanted to have what we would cat- egorize as a multi-entity campaign- the idea being that since ihe poliomyclitis campaigns were already being conducted, additional entities could simply be added. The iieed for additional health personnel. trained adminisLrators, or trained vaccinators wvho know how to handle syringes and needles safcly without transmittino bloodborne diseases was not considered. Progranmmes can work together, but the key issues are proper planning and proper resources. An area where ditterent programmes can work well together is surveillaince. Wc (eel strongly that mea- sles surveillance is needed to keep good poliomy- elitis surveillance in place through the penod of Buletin of the WorAd Htealth Organization, 199B, 76 (Suppl 2) 104-108104 Comments and discussion certification. Without enthusiasm, without a particu- lar goal, surveillance tends to detenorate over time. Poliomyclitis and measles eradication efforts can work very closely together, very cooperativcly. so let's focus on making sure we have the resources to do it. Comment My coiunent is Ui relation to rubella vaccine and the inclusion of it in measles eradication. Thcre was one bullet in the Workgroup Rcport that referred to vac- cinating women of childbearing age with rubella vac- cme to accelerate rubella elimination. Thcre is a view that you need to include both men and women in relation to rubella vaccination if you really walit to eliminate rubella. The rubella virus continues to circulate in tlle population. and some women who are pregnant may still be affected, and you may get cases of CRS Comment The terms "eIadication" and "elimination" have other problems that don't have to do with science. but have to do with communication In my work with the spina bifida conmmunity. somne people are vastly offcnded when I talk about elimination or eradica- tion. because eithcr they or their children have spina bifida, and they see this as in somne way ending thielr lives. It is amazing that this hasn't been mentioned by the poliomyelitis and other communities. but it certainly has come out o1 the chronic disabilitv com- munities in this counltly. This is another reason to think about Lerms like ' complete prevention" or '80% control", rather than cradicationi and elimination. Comment My commnent conceins a sucgestion made in both Group l (discase elimination/eradication) and Group 3 (bacterial diseases). In Group 3. for exami- ple one of their recomminendations for each condi- tion was that control be tightly related to general hiealth-dclivcry systems or sustainable health devel- opment We're all talking about sustainable health developmnent. The phrasc "general health-delivery systems" is a little passive. It suggests that people are being passive beneficiaries in the transfer of re- sources and efforts. These statements should be strengtlhened to recognize that probably many of our efforts in control and eradication would be of lower cost and more effective if we were able to woik with communities that are morc agressive in demanding health care and that are able to recognize their rights to good health care. These diseases ougbt not to exist in communities that are well structured. well organ- ized, and well mobilized Community mobilization and organization in some peoplcs' terminology is part of sustainable bealth developmeent and part of health-delivery systems, but I fear in some people's terminology. it isn't I would like to strengtlhen the role of community participation. Comment I represent the Dutch government and I have to advLse my government wvhere to put our money. At this conference we hiave sccn fanitastic presentations, a coIntest of all the diseases we want to cradicate We need financing for that. Wlhat is not clear from this conference is where do wc put our money. I wouLld like to comparc certain diseases, certain interven- tions with others. Resources are limnited- not only limited financially, but also limited in hiuman capital. I would like to see cost-cffectiveness data for these diseases. Whicl) of the interv'entions is most cost- effective? We have a universal unit of measurement, the DALY. although it has many critics. One of the problems with DALYs is that they do not exactly apply to what wve want liere because of the need to include transmiissioni The only disease that is m- cluded is tuberculosis. We're definitclv looking at wlhat is the cffect of intervention on the cost- effectiveness ratio. That's one of the good examples. The wlholc global burden of disease studies anid cost- ettectiveness foi many other diseases is not cleai at all. MN, recommendation is to look into these issues more specifically so we could compare one interven- tion withl the other. Comment As a number of speakers have already expressed. there is a concern that as we go fiom eradication to elimination to conti ol. this list hias become very. very long anid somewvhat cunmbersomne and lhas now be- come the battle of diseases as just desci ibed One of the things we have faiilcd to do in this meeting is to discuss any approaches to prioritization. There is a science to this. It is wvell described in the literature. Tllere are approaches to public health problem prioritization that lcnd themselves to some of this discussion. We haven't had time in any of the groups to really locus on it. Aniother way to look at this issue is to take examplcs of poliomnyelitis and guinea- worm disease and ask why thley are currently at the top of the ltist WhIat is the logical lramework that bas led them to move to that level in contrast to sonme of the other issues? Of the issues tlhat we've talked about, certainly feasibility and effectiveness are the WHO Bulletin OMS Vo[ 76 Suppl 2,198 105 Comments and discussion two major parameters. There may bc others, but those certainly are the most important If you con- structed a 2 x 2 table, those things that ended up in cell A- highly feasible with a highly effective inter- vention available - would be very top candidates for ehnumation. This would maybe addrcss the con- cern about wvhere to put the monev. We need to be clear about describing what wc mean by effective- ness. Much of the debate of the disease groups has focused on the question of efficacy, in addition to acceptability Those two combined add up to effec- tiveness. The classic example ot that is that you can use cfficacious interventions such as condoms for HIVlY and if it is unacceptable. you don't have a very effective intervention. Feasibility is much more difficult to discuss. We've touched on some key issues of tis, not the least ot Nvhich is infrastructure concerns. Some of the groups tried to deal with that- infrastructure con- cerns for both the service delivery. the ability to deliver whatever the intervention is, aind surveillance to detect and monitor. Those two key factors are extremely important. Resource constraints: we mentioned that, buit if the rcsources are available and the political will is niot there, that is a major consideration. NX7That factors affect political will? Certainly the size of the problem in terms of prevalence, but also severe DALY mea- sures, case-fatality rates. and other issues. And last but not least, urgency. We've heard lhat issue come up again and again,. which includes economic impact. infectious spread. and other issues that relaLe to that. So those are just some of the issues we can begin to discuss at some point. Perhaps not at this meeting, but m future ones. How to prioritize these'?' How to figure the appropriate weights of those clcments? Where is the sensitivity analysis to guide where to put our emphasis? These might help us prioritize this very lengthy list of dis- eases and steer us in somc of the right directions to help us spend our resources. time. and energy wvisely. Comment My major concern is what will be next alter Lhis conference. I see that Dr Foege, after the break. wvill talk about "Vision for the future." But we have a very slhort list ol diseases that are eradicable or can be elinminated. Probably this short list is a reflection more of our ignorance at the prcsent timc than actually the limits ol science and technology and whatever the people can do And I would like to recommend two thilngs, that as an outcome ol Lhe conference, we actually make a proposal, and each organization and all the people involved are to allo- cate more resources m terms of research. includmg operational research (i.e. how to involve the commu- nities) so we cain actually move forward. The second proposal I would likc tomake is that we bring the recommelndations of this conference LO other forums, particularly public health foruims, so that efforts we have made can be put inito action. Comment I'm really picking up some of the commcnts from the last couple of speakers. We don't have a lot of time and ability to try to refine further the work thiat leas been donie by the workgroups who have done enor- mous amounts under enormous pressure Further work needs to be done, and I hope the conference is going to be giving a (airly broad mandate to the further editorial work ol sifting down and clarifying. where we can. what seems to be a consensus I think that the report slhould be as clear as it can in what- ever can be distilled trom what we said. I certaiinly agree that we should do better with our priorities, better with our analysis. and better with our DALYs. but intemational development still remains far more of an art than a science. I hate to say it to our colleagues wvho are having a terrible problem of allocating resources from international development agencies, but you are not going to get a menu that's going to solve your problems. It's going to remain extremely difficult, although we need to do a better job than we're doing now ini helping that process. We have that same problem also in WHO. The definition problemn bas been raiscd by many. I don't see exactly a consensus. I see uncom- tortableness expressed wlith how ouLr currcnt usage goes. not total comfortableness with the Dabl em rec- ommendations I wonder if the conference organiz- ers or the secretariat who wNill be working on this further might consider if they can distil what they really feel is consensus from the conferenice. or even convene a small infonnal working group and put this as an annex to the conference report which would say. 'Look. this seems to us. . . "- because we are not ready to express the consensus of this confer- ence. we haven't had the chance to endorse it. We need some further work so that we have something concrete to work on, so we can take that into otber forums and see what to do with it. As I said, one way of doing this is to have a sinall working group and publish their report in an anMnex. Other tlhings about other forums: I hope my colleagues in WHO will work with me in trying to take some of the specLfic recommendations on tuber- culosis and perhaps Chagas disease, certainly for the global programme on vaccines and immunizations on rubella and measles and feed those into our cur- rent expert advisory groups so we can look at them in WHO Bulletn OMS Vol 76, Suppl 2, 199B106 Comments and discussion more detail. Maybe they will give us some new insiohts; maybe there are ways that we can use those. Recommendations from those technical advisorv groups can be published in the WHO Weekl;) epide- miological record and in other forums- and maybe in a World Health Assembly resolution. As you know, this conference report will be published as a special supplement to the Butlletin of the World Health Organization. So that is another way of bring- ing it into international visibility. My last comment is about too many diseases being candidates for eradication. WHO slhould be doing a better job in its role as a gate-keeper I can speak from my own experience: whecn one entlhusias- tic programme manager says. "Let's do this, let's oo for an elimination programmc I've got some won- derful NGOs. They're enthusiastic. We've got re- sources, let's go for it." I say. "Sure. let's do it " But we have not yet had in WHOi eallv an upper, senior level management where we can debate with all tllc programmes and say. "Okay-, hiow many of these things should go to the World Health Assembly?' This is not something that I can do insidc WHO You who will be coming to our Executive Board and will be attendino the World Health Assembly can help wvith ithat process. Comment Fundamental to whlal we're trying to do here is reaching agreement on the basic framework - that is, whlether to include ei adication. elimination. and control. or Just eradication aind control. It's *'ery templing for eaclh of us to addresb that issue on the basis of political or personal cominitmcin lo our pet diseases. anid there are obviousIk dangers involved in doing that. It makes much more sense for us to be asking a question of whetlher the strateeies involved witlh control - c.g for inlectious diseascs in hypereiidernic phases. or even dccline phases - are the same as the strategies that are necessarv foi' elimination. And arc Lhose the same as straregics necessary for eradication? There is a growing Vol- ume o4f work in the literature, at least for infectious or commnnuicable diseases, that say spccific strategies or combinations of strategics do ditfer, and that we ought to be looking at this In a more soplhisLicated wav. My personal bias is that the stratcgics do differ for at least the communicable diseases, and therefoirc it is important for us to agree on retalIlIno climina- tion as a category. Comment Two commnents and a question. First of all, much of this meeting has been talking about making possibte wvhat to others would seem impossible. and accom- plishing what many would say is impossible. And that is a wonderftLil setting tor herocs and stories Second. tlle future ol health, the world. etc. is in the liailds of our youtlh. The question: Are we doing enough in taking these stories and examples of heroes- many are in this roomn. and also the local communitv lcvcl - and usiIIg them to develop and grow thc leaders ol the iuture? Comment With regard to thc price of some new products being a perceived barrier to their wider use, I would like to comnment on the pricing of produLcts and the valuc of pi evenlion. DPT vaccines were licensed at least 25- 50 years ago, and it took us a long timc lo get these into wide use. Smallpox vaccine took even longer. Those vaccines that are now used at prices well un- der US$ I a dose have come lo that pricing because of economies of scale and the learning curve that was 25-50 years long. What we are trying to do now in many cascs is put products into widc use much ear- lher in their life-cycle, witlhout the benefit of Cxperl- ence in iiicreasiii the efficiency of production. If you do cost-etfectiveness analysis on hepatitis B vaccine at under US$ I a dose, perhaps down to US$ 0.50. and hepatitis A vaccinc at US$ 3 per dose or perhaps slightly less, tlhcse vaccines in many developing coun- tIes are still cost-saving. In poorer countries, wlhere they spend less on treatment they still buti a unit of health benefit. vliethlei a life saved or a DALY saved. at a % alue that the World Baink represents as a vcrv good in'estment. Clcailv. we need to try to inake vaccines more affordable. To oet the pi;ice down. we lhave to get the number of doses up and we need to target cxteinal assistance to those countries that are most in need of it. But the reality is that prices in the manufacture of manv new products will never fall to the level we cunently experience for poliomyclitis or measles vaccines. So we have to addiess the reality that many new prodtucts in thlcii carly life- cyclc will be more expeiisive. We have to convince gcovernments that investing iIn the use of these vaccines. in investing in lrevenltion, is a good health investment. Dean Jamison said very eailv in the conterence that there was incrcasinig evidence that investing in healthl is good for- the overall economy of the coun- try. We lhave to_get this message out Advocacy for investina in health must be a much bigger part of tlhe overall strategy. We must use more soplhisticated techniques for advocacy and the decision-making process. Maily scientific advances aie accunmulating at thle momenit, many new vaccines that are in the WHO Bulilin OMS Vol 76. Suppi 2. 1998 107 Comments and discussion pipelne will be licensed in the next few yeais, and therc are probably many other technologies for drugs. These new products are not going to get to most developing countries in an acceptable time framc. We need to regard advocacy and changing the bebaviour of government resource providers as a very significant part of thc overall health strategy. Comment One thing I was hioping to hear fronm the meeting is what is the overall goal of cradication/elimination. We need to revisit that. Lastly, let us remember that knowledge also comes through practicc. It is some- Limcs disheartening if we think that knowledge only comes through science and do not remember that there are people out there whio have knowledge gathered through practice which could be shared in terms ot strategy development Many people out tlhcre will spend a lot of their time working with communities and working in districts - devel- oping strategies that could be part ot this process of sharinig. WHO Bulletin OMS Vol 76, SuppI 2 1998108