The lessons learnt

The lessons learnt by Donald A. Henderson § mall pox is the first disease to have been eradicated through a concerted global effort. Al- though this is a stupendous achieve- ment in itself, it also has broader implications for health policy in demonstrating the impact which a community-based programme can have in the field of prevention, the considerable resources that can be mobilised for such an effort, the value of setting measurable goals and monitoring the incidence of disease , and the remarkable cost- benefit advantages of prevention programmes. It is in part because of smallpox eradication that increased emphasis is now being given to disease prevention and health promotion programmes throughout the world. Specific, measurable goals in national and local health programmes are being more widely identified and used in manage- ment , and health authorities are increasingly adopting surveillance and sample survey techniques that were elaborated during smallpox eradication. It was in 1958, that a Soviet delegate to the World Health As- sembly proposed that global small- pox eradication be undertaken by WHO, and this was unanimously ap- proved at the following year's As- sembly. At that time , 60 per cent of the world's population still lived in areas where smallpox was endemic. During the succeeding seven years, some progress was made in improv- ing vaccine quality and a number of countries became free of smallpox, but the disease, often in epidemic form, continued to be widespread . Delegates at the Nineteenth World Health Assembly (1966) al- located special funds for an inten- sified programme starting in J anu- ary 1967. They proposed a ten-year goal for the achievement of eradica- tion. At that time, an estimated 10 to 15 million cases of smallpox were occurring annually in 31 endemic 8 countries with a population of more than 1,000 million persons. Given that programmes would have to be conducted in most of the least de- veloped countries, that disruptions due to civil strife , famines and floods were inevitable, and that more than a century and a half had already elapsed since Edward Jenner's discovery of a vaccine , the goal was an optimistic one. Nevertheless, the last known en- demic case occurred just 10 years, 9 months and 26 days after the programme began. ••••••••••••••••••••••••••• Dr Donald A. HENDERSON is the Dean of the School of Hygiene and Public Health at the Johns Hopkins University, Baltimore. USA. • • • • • • • • • • • • • ••••••••••••••••••••••••••• The strategy of the programme was two-fold: to vaccinate at least 80 per cent of the population , and to establish systems for surveillance (case detection) and containment of outbreaks. Between 1967 and 1971 , WHO-supported national pro- grammes began in all endemic countries and in others that were at special risk of importations. All programmes functioned within the public health structure and each differed from the others in order to cope best with different epidemiological patterns of small- pox, national administrative prac- tices and socio-cultural conditions . After the occurrence of the last known smallpox cases, health offi- cials in all countries had to be sufficiently confident of eradication that they could stop vaccination. So surveillance programmes and spe- cial search activities were con- ducted for at least two years in every country after the last known case had occurred. At that time wHo-appointed International Corn- missions visited and verified the absence of smallpox. Finally, a WHO Global Commission, through a var- iety of studies, satisfied itself that eradication had been achieved, and its conclusions were endorsed by the Thirty-third World Health As- sembly in May 1980. It is sometimes suggested that the programme should serve as a tem- plate for other disease control or eradication compaigns. This is not feasible , because each disease has its own epidemiological characteris- tics and methods for control which require strategies and tactics unique to that disease. But the rapid pro- gress in eradicating smallpox after so many decades of persistent trans- mission provides principles and les- sons which have implications for other health initiatives . For a global programme to be undertaken, universal political commitment is necessary and, for this purpose , the World Health Or- ganization and the World Health Assembly were essential. The As- sembly uniquely provides the necessary forum for countries to agree on global health policies . WHO, alone among the international organizations , has the requisite sci- entific expertise and channels of communication with national au- thorities for the monitoring and coordination of health programmes. Smallpox eradication could not have been achieved were it not a targeted , time-limited special pro- gramme with funds specifically allo- cated for it, both in the WHO budget and in most national budgets , and with full-time technical staff re- sponsible for its supervision. Yet some argue, even today, that special programmes are inherently poor policy, serving only to divert re- sources and attention from the de- velopment of primary health care systems. That such programmes can make important contributions to the development of national health WoRLD HEALTH, Aug ./Sept. 1987 Dr D.A. Henderson, then chief of wHO's smallpox eradication unit, examining vaccination scars during casefinding operations in Ethiopia. Right: Village children wait in the rain in an Indonesian village for the mysteri- ous prick of a needle that would protect them. Photos WHO and WHO/C. Frucht services was demonstrated by the smallpox eradication programme. In part, this is because it functioned within the existing public health structure rather than as an entirely separate entity as was the case with the earlier (and unsuccessful) malaria eradication campaign. It was thus obliged to work with and through the existing administrat- ive health structure and to coordi- nate its activities with other programmes. In addition, a specially dedicated and trained professional smallpox eradication programme staff was necessary at all levels to design and coordinate the programme ; to de- velop reporting and surveillance systems ; to undertake case-detec- WoRLD HEALTH, Aug./Sept. 1987 The lessons learnt tion and containment measures, and to train local health staff. There was a need to seek the support of village leaders and, through them, the acceptance and participation of the population. The observations have important implications to the strategy for pro- viding what is called primary health care. Such care is usually regarded as a closely related set of services, all delivered in a similar manner , but experience suggests that it would be better conceptualised as consisting of two different but com- plementary components. One of these involves the traditional, primarily curative activities; the second involves those services intended to reach individuals throughout a community, including both preventive interventions (such as immunization or family plan- ning) and curative ones (such as oral rehydration therapy). The traditional health care system may serve as the base for both functions but different types of programme, different personnel skills and differ- ent methods of assessment are re- quired for each activity. Traditional, curative services can be provided in established health units by clinical- ly-trained physicians and nurses , and are usually appraised in terms of the training of the practitioners, the quality and sophistication of facilities and the numbers treated. Community-wide programmes re- quire active outreach by persons skilled in management and public education in order to ensure ac- ceptance ; the provision of services at a site and time convenient to their clients; and methods such as surveillance to measure success in diminishing morbidity , mortality or fertility. Special purpose programmes identifying the achievement of cer- tain objectives, usually within a fi - nite period of time, are generally better supported and financed than are programmes with less explicit goals. Experience shows that a pro- gramme to eradicate smallpox or to prevent poliomyelitis, for example, has more popular appeal than one to develop the basic health services. Such special-purpose programmes are particularly important to public health because it is almost always more difficult to obtain support for public health programmes than for curative services. This reflects a 10 Surveillance teams tirelessly track~d dowr~;. every case, no matter how remote the community, and asked everyone they riiet "Do you know anybody who is sick like this?" reality that political leaders are usu- ally more readily persuaded to pro- vide funds for the more tangible curative services (hospitals and health centres) than for commu- nity-based programmes. A finite end-point-the nil inci- dence of smallpox-undoubtedly was important in motivating staff and sustaining interest. Though few health programmes have such an end-point , comparable levels of achievement , interest and morale should be possible where specific goals are identified , where progress is monitored and where programme staff are fully supported in their efforts. Extraordinary achievements are possible when countries throughout the world pursue common goals within the structure provided by an international organization. WHO played this role in the eradication of smallpox. It now offers a unique-although only partially realised-potential in promoting W oRLD HEALTH , Aug ./Sept. 1987 More rapid progress might have been possible if. from the beginning there had been special staff to han- dle .. . public information. Wide publicity was needed to encourage national pro- grammes and to recruit sup- port from donors but WHO's public information office was inadequately staffed to ... stimulate coverage by the mass media, thereby in- forming a broader public au- dience. Not until 1977 was a full-time public information officer added to the small- pox eradication unit. His val- ue was immediately appa- rent. As a result of his ef- forts. it was eventually pos- sible to foster public confi- dence that eradication had been achieved so that vacci- nation could be stopped. The lessons learnt other efforts in disease prevention and health promotion. It is an or- ganization which can demonstrably catalyse achievements far out of proportion to the resources it com- mands. The extent to which it is successful will depend upon the confidence it merits from its Member States, on the effectiveness of its leadership in enunciating clear and measurable objectives and in mobilising support to attain them, on the number and competence of its professional staff, and on its ability to set aside extraneous pol- itical agendas. WHO's ability to re- spond appropriately will determine the degree to which it succeeds in the future in providing improved health and a better quality of life for all the world 's people. • Where there's a will, there's a way. Helping the surveillance team's vehicle on its way in Thailand. Photo WHOfT. S. Satyan 11