I Blame Smallpox



Could the superb victory of global international development over the vicious Smallpox disease have sown the seeds of the serious struggles that we have experienced in countering other major health and development issues - particularly HIV/AIDS, malaria, Tuberculosis and the full range of child health issues? Of course no one wishes that we still had Smallpox in our lives and communities. The world is a much better place without it. And there should be no diminishing of the superb work and accomplishments of everyone - from local to international leaders, citizens and specialists responsible for the eradication of Smallpox. They achieved something truly remarkable.



The problem comes in the international development communities adoption of the Smallpox strategy and programming model - irrespective of the characteristics of the health issue being addressed and often blind to significantly changed circumstances and contexts. Though "indigenous" local and national groups have pointed the way to new intervention principles and action forms, the international community has basically stuck to the Smallpox model, with at best disappointing and at worst disastrous results.


From my reading of what happened on Smallpox the approach had the following basic elements:


  1. Treat Smallpox only - our only concern is Smallpox.
  2. Mobilise a proven and effective intervention - in the case of Smallpox it was the vaccine, of course - as a combination of the center and fulcrum points of the programming interventions.
  3. Utilise sophisticated epidemiology as the main source of decision-making information.
  4. Globally manage [maybe "direct" is a better word] the eradication programme - for example, the identification of priority areas and specific resource allocation. Do this as a parallel system to existing national and local systems.
  5. Take what ever steps are necessary to persuade, cajole, influence [fill other verbs from your knowledge] people to get the vaccine.
  6. Work with, do not challenge or even consider, the political systems available - in many ways the more authoritarian the system, the better the chances of 100% vaccination and eradication.
  7. Provide specific, high-cost support to technical experts on the issues in question.



In so many ways those strategic and planning principles describe so many of the health and development initiatives that followed the eradication of Smallpox. They were almost all discreet, vertical programmes - TB, HIV/AIDS, Malaria etc. For global agencies at the heart of these initiatives there was/is an overwhelming focus on either a proven intervention to mobilise [eg condoms, ORS, OPV, bednets] or a new intervention to find [eg Malaria and AIDS vaccines]. The epidemiologists rule and their data guides global decision making. Outsiders seeking to persuade, cajole and influence the locals dominate the development landscape. Little connection is made between the issues being addressed and the broader political and rights landscape.


Just before there are a flood of emails saying that, in Margaret Thatcher's infamous phrase: TINA [There Is No Alternative]; is it not worth considering the inverse of If It Is Not Broke Don't Fix It - which would of course be If It Is Broke We Need To Find Another Way!? The Smallpox approach, when applied to other health and development issues, does seem to be Broke. As best as I can discern from the data, there is little good news on health and development issues. HIV/AIDS, Malaria, TB, child immunisation rates and a bunch of other data are all heading South, as they say in the USA [which as a New Zealander I find a particularly ill-considered phrase!]. They are getting much, much worse, particularly in the economically poorest countries. There Has To Be Another Way.


That new way will not involve tinkering with the existing model. It needs a new set of principles with those principles being reflected in the policies and funding of the major agencies. I would suggest:



  1. Look at the commonalities across a range of health issues and address those commonalities.
  2. Focus on supporting communities, districts/provinces/states and countries to debate and decide their heath priorities, making the "proven intervention" [should it be available] part of the support package available should they decide to choose such support.
  3. Ensure that the perspectives of the people most affected by poor health conditions and status have influence equal to the data produced by epidemiologists in strategic decision making and monitoring.
  4. Decentralise control over financial resources and technical expertise to the most local level possible, ensuring that they are integrated into - as opposed to parallel to - national and local systems.
  5. Respond to and take the lead from the local populations about what will work best in their context.
  6. Recognise and explore the connections between the issues in question - for example, HIV/AIDS, child health, malaria - and the broader social and political issues in the community or country - from discrimination and prejudice to engagement in the local and national political processes.
  7. Provide as much support [preferably more] to the locally-initiated and -run movements on health as is provided to global researchers and scientists.



I can see many people within the international development community vigorously disagreeing with the notions above. Arguments such as - why do this "soft" stuff when we have the possibility of a vaccine that will "solve" all these problems? If only it was as simple as the days of Smallpox eradication. But as argued above, it is not and never will be again. Just as the world has changed, we also need to change - and quick!


Warren Feek