Authors: Heidi Larson, Ph.D. & Will Schulz, MSc, June 13 2017
- HL is an anthropologist and Director of The Vaccine Confidence Project (VCP); Associate Professor, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine (LSHTM); Associate Clinical Professor, Department of Global Health, University of Washington; and Chatham House Centre on Global Health Security Fellow. She previously headed Global Immunisation Communication at UNICEF, chaired GAVI’s Advocacy Task Force, and served on the World Health Organization (WHO) Strategic Advisory Group of Experts (SAGE) Working Group on Vaccine Hesitancy. A particular research interest is on risk and rumour management from clinical trials to delivery - and building public trust.
- WS studies vaccine hesitancy, as well as other issues of public engagement for public health, as a researcher with the Vaccine Confidence Project at the LSHTM. His interests include political psychology, international relations and development, public policy, medical anthropology, graphic design, and science communication.
In August 1980, just three months after the World Health Assembly declared smallpox to be officially eradicated, D.A. Henderson stood up to address a gathering at the Fogarty Center in Washington D.C. His audience, flushed with the successful defeat of smallpox, had one question at the forefront of their minds: What next? Which disease, after smallpox, shall we eliminate utterly from the earth? His answer, tempered by 15 years in the difficult struggle that had just been won: There is none.
According to D.A., who passed away last year at the age of 87, smallpox was uniquely suited to eradication, since it had no animal reservoir, its vaccine was heat-stable, and its cases were detectable at a glance. Even so, he said, they had succeeded only by virtue of extraordinary performances by field staff, and a considerable amount of luck. There was no other disease currently within reach, he told his audience.
Of course, the idea of eradication lived on, and poliomyelitis was soon chosen as the next target. And, with phenomenal effort and a little bit of luck, we may finally be close to achieving it. We cannot be certain how soon - the legacy of missed deadlines creates doubt, as does the vexing problem of outright violence against vaccinators by the likes of Boko Haram and the Pakistani Taliban – but with case counts lower than ever before, and breakthroughs in the last holdouts of the virus, there is a palpable sense of anticipation in the air. The time has come, therefore, to begin planning our answer when the question is asked again, as it surely will be: What next?
We hope that when the global health community answers this question again, we will draw on the experience we have accrued over the decades of the polio programme. Most of all, we hope that we will be honest with ourselves as to the challenges – including the practical as well as political hurdles we will encounter. It is this clear-eyed ambition, not vapid optimism, that makes eradication unique and audacious. Eradication is inspiring precisely because we go into it with full knowledge of its difficulties, and acceptance - not denial - of its inherent uncertainties.
Only by heeding the hard lessons of the past can we avoid repeating old mistakes. D.A. knew, for example, that polio eradication would encounter its greatest challenges "in those areas of Africa and south Asia which all but thwarted global smallpox eradication." (Henderson 1999, p. 21) Perhaps if his insights had been embraced early, rather than dismissed, polio would already be gone from the planet.
And yet, later in life, D.A. came to embrace polio eradication. He gave several reasons - Bill Gates' financial commitment to the effort, for example, and the appointment of PAHO's famed epidemiological miracle-worker, Dr. Ciro de Quadros, to lead it. However, there is also a deeper lesson we can learn from D.A.'s change of heart: The fact that a person so critical of eradication lent his support to it, in the end, should inspire us to always put forward our most constructive critiques, if we feel critiques are needed. Even the most sceptical people can contribute to the eradication effort, not dampening others' hope, but enriching it with our accrued wisdom and knowledge of past pitfalls.
We hope that we will remember not only the problems polio has presented, but also the solutions it spurred us to invent, notably the unprecedented advances in: disease surveillance, mapping of remote settlements, tracking technologies for managing vaccination teams, and adaptive models for delivering vaccines in difficult political environments. Although technological advances may render some of these outmoded in time, the deeper insights - that recruiting local vaccinators increases public trust, for example - can be expected to endure.
Finally, we also hope that we will not forget the sacrifices made by health workers and volunteers, especially those who gave their lives to deliver vaccines to children in the most dangerous corners of the world. The success of eradication depends on a highly choreographed coalition of national and local government, non-government organizations, international agencies, pharmaceutical companies and research institutions, and perhaps most importantly, the commitment of local vaccinators and social mobilizers working long days, weeks, months and years in difficult situations. Success depends not on a single leader, but on a chorus of local, national and global leaders - from houses of worship to the halls of power, and many others in between. When polio is defeated and laurels are bestowed in Geneva, let us not forget the real heroes. When we plan the eradication of the next disease, we must make their safety and welfare an inviolable priority.
Eradication is, by its very nature, an uncertain enterprise. If for some reason polio eradication fails, this does not necessarily mean we should abandon it as a strategy for fighting infectious disease. Yet by the same token, if polio eradication succeeds, it is no guarantee that we will find success eradicating the next disease, which is sure to have new characteristics and present new obstacles. What we can take with us, though, are the lessons we have learned from polio. We have a duty, whether or not we intend to participate in the next eradication effort, to catalogue our experiences for the benefit of posterity. If the next eradication programme comes along in ten years or a hundred, we will give it the best possible chance of success by being clear and honest about the challenges we've faced.
Henderson, D.A. 1999. "Global Disease Elimination and Eradication as Public Health Strategies." Centers for Disease Control and Prevention. MMWR. December 31, 1999, Vol. 48 Supplement.
McNeil, Donald G. 2016. "D.A. Henderson, Doctor Who Helped End Smallpox Scourge, Dies at 87." New York Times. Aug 21, 2016. [Accessed 13 June 2017].
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