Eradication

Introduction

Nancy Leys Stepan's "Eradication" delves into the complex world of disease eradication, a concept that has captivated scientists, policymakers, and philanthropists for over a century. This book takes readers on a journey through the history, science, and politics of attempts to rid the world of deadly diseases. From the early days of imperialism to modern global health initiatives, Stepan explores the successes, failures, and ethical dilemmas surrounding disease eradication campaigns.

The Possibility of Eradication

The idea of eradicating diseases entirely is a relatively recent development in human history. Less than a hundred years ago, people were dying in large numbers from illnesses that many of us today never have to worry about or that have been completely wiped out.

The turning point came in the 18th century with the advent of vaccines, which marked a significant triumph in public health. As our understanding of diseases and their spread has grown, we now have the theoretical possibility of eradicating many of them. However, this raises an important question: should we pursue total eradication?

Surprisingly, many people argue against the concept of complete eradication. This isn't because they want people to suffer from diseases, but because they believe the costs of these projects often outweigh their benefits and divert resources from other crucial health initiatives.

The Science Behind Eradication

The possibility of disease eradication became a reality in the 19th century when scientists began to understand the causes of various illnesses. For example, in 1882, Robert Koch discovered that tuberculosis was caused by bacteria called tubercle bacillus. This newfound knowledge about tiny organisms like bacteria, viruses, and parasites being responsible for diseases opened up new avenues for prevention and treatment.

Another crucial discovery was the role of insects in spreading diseases. At the end of the 19th century, Ronald Ross and Giovanni Batista Grassi found that malaria was transmitted by female mosquitoes of the anopheline genus. These scientific breakthroughs paved the way for the development of new technologies like vaccines, making eradication a tangible goal.

The Complexities of Eradication

While the idea of eradicating diseases seems inherently positive, the reality is far more complex. After World War II, when scientists launched eradication campaigns against smallpox and malaria, it became clear that the process raised numerous questions and challenges.

Some of the key issues that arise when considering disease eradication include:

1. How do we choose which diseases to eradicate?
2. How do we allocate funding for eradication efforts?
3. What are the biological, political, and logistical challenges involved?

Take malaria as an example. Despite massive eradication campaigns, the World Health Organization reports that it still affects 250 million people annually. This raises questions about the effectiveness of these efforts and whether the resources could be better spent elsewhere.

The Imperial Roots of Disease Eradication

The concept of disease eradication has its roots in imperialism, particularly in the United States' rise to imperial power at the end of the 19th century. As the U.S. intervened in Cuba and the Philippines, it faced new health challenges, such as an increase in yellow fever cases.

In 1900, U.S. physicians in Havana discovered that mosquitoes transmitted yellow fever, leading to the country's first attempt at disease eradication through a campaign to eliminate these insects. While successful in nearly wiping out yellow fever, this effort was not without its problems:

1. The primary motivation was to protect American interests rather than help the Cuban people.
2. The eradication of mosquitoes made it easier for colonial powers to expand into tropical regions.
3. The Cuban government couldn't maintain the expensive mosquito spraying program after the U.S. army left, leading to the disease's return.
4. The use of paraffin oil to kill mosquitoes had harmful environmental effects, such as poisoning water supplies in the Panama Canal area.

The Role of Philanthropic Organizations

After World War I, philanthropic organizations took over where government efforts left off. The Rockefeller Foundation, founded in 1913, was one of the earliest proponents of disease eradication. Their belief was that diseases were the root cause of societal problems like poverty and crime, and that fighting disease was essential for building an advanced society.

The Rockefeller Foundation achieved significant success, investing unprecedented amounts of money in healthcare infrastructure in countries with previously weak public health systems. They also led the way in disease research and prevention, resulting in sharp reductions of illnesses like malaria and yellow fever in many parts of Latin America.

However, the Foundation's eradication efforts were not without flaws:

1. They often lacked complete information about the diseases they were targeting.
2. They sometimes ignored local expertise, as in the case of rural yellow fever.
3. Their focus on eradication rather than control sometimes led to less effective outcomes.

Post-World War II Eradication Efforts

After World War II, eradication became a key component of international public health efforts. The newly founded World Health Organization (WHO) and its regional office, the Pan-American Health Organization (PAHO), took up the mantle of disease eradication.

The PAHO launched campaigns in the Americas against:

1. Yellow fever mosquitoes in 1947
2. Smallpox in 1950
3. Malaria in 1954

These efforts were partly motivated by Cold War concerns, as Western powers feared that diseased and impoverished populations might turn to communism. However, not all Western powers supported these eradication campaigns, with Britain and France resisting WHO efforts in their colonies.

The post-war eradication campaigns faced several challenges:

1. They often focused on single diseases without considering broader health contexts.
2. Solutions were sometimes implemented without thorough testing, leading to unintended consequences.
3. The widespread use of DDT for mosquito eradication had devastating effects on local ecosystems, as revealed in Rachel Carson's 1962 book "Silent Spring."

The Failure of Malaria Eradication

One of the most significant eradication campaigns that ultimately failed was the effort to eliminate malaria. After observing the high death toll from malaria during World War II, the WHO decided to take action to eradicate it completely.

The campaign faced several challenges:

1. Malaria can be spread by different species of mosquitoes, unlike yellow fever.
2. It was widespread throughout the tropics, making it more difficult to contain.
3. The massive use of DDT led to environmental destruction and the development of DDT-resistant insect populations.
4. The campaign neglected large parts of sub-Saharan Africa, considering them too difficult to access.
5. Administrative problems, misunderstanding of the disease's nature, and inadequate finances and supplies hindered progress.

By 1968, the WHO had to rebrand the eradication program as a "control" program, admitting the seeming impossibility of global eradication. Despite this setback, the program did achieve significant reductions in malaria rates and continues to save many lives.

The Success Story of Smallpox Eradication

In contrast to the challenges faced by other eradication campaigns, the fight against smallpox stands out as the only successful global disease eradication in history. The journey began in 1796 with the development of the smallpox vaccine, the first vaccine ever created.

The vaccine's discovery is credited to Edward Jenner, a surgeon who noticed that milkmaids who contracted cowpox, a milder form of smallpox, never suffered from smallpox itself. His experiments led to the creation of the vaccine, though it took years to understand how it worked and how to administer it safely on a global scale.

The global eradication effort gained momentum in the 1950s, with the WHO throwing its full support behind the campaign in 1966. The last recorded case of smallpox occurred in 1977, and in 1980, the WHO officially declared the disease eradicated.

However, the success of the smallpox eradication campaign raised important questions about the pros and cons of eradication:

1. How do we balance individual risks with national or global benefits?
2. Is containment and control safer than complete elimination?
3. How do we justify forcing poorer countries to focus resources on one disease when others might pose a greater threat?

The Evolution of Eradication Techniques

Since the late 1970s, the concept of primary health care – the belief that everyone should have access to basic medical treatment – has dominated global health discussions. This has led to debates about whether eradication should be considered part of primary health care or if it's an inefficient use of resources.

Some argue that focusing on eradicating specific diseases takes away from broader health issues like sanitation or general healthcare. Others believe that, given limited resources, we should focus on selective primary health care by eliminating one disease at a time.

Modern eradication campaigns have evolved from their predecessors:

1. The 1988 polio campaign focused on mass immunization, surveillance, and quick responses to new cases, more closely resembling selective primary care.
2. The campaign against guinea worm disease took a different approach, focusing on cleaning water supplies and educating local populations about water safety.

These newer approaches demonstrate a shift towards more holistic and sustainable methods of disease control and eradication.

The Ongoing Debate

The debate over disease eradication continues to this day. In 2007, the Bill and Melinda Gates Foundation declared its commitment to eradicating malaria, a goal that was met with mixed reactions from the medical community. Some praised the ambitious target, while others questioned whether it was the right goal to pursue.

This ongoing discussion highlights the complex nature of disease eradication and the need to consider various factors:

1. The cost-effectiveness of eradication campaigns versus other health interventions
2. The potential unintended consequences of eradication efforts
3. The ethical implications of focusing resources on specific diseases
4. The long-term sustainability of eradication programs

Conclusion

Nancy Leys Stepan's "Eradication" provides a comprehensive look at the history, science, and politics of disease eradication. While the idea of a disease-free world is appealing, the reality is far more complex. Eradication campaigns are challenging to manage and carry out, and they often involve political considerations that may not always benefit the people they aim to help.

The book highlights several key takeaways:

1. Disease eradication is theoretically possible but fraught with complications.
2. The history of eradication efforts is closely tied to imperialism and global politics.
3. Successful eradication, as in the case of smallpox, is possible but rare.
4. Modern approaches to disease control are evolving, incorporating elements of primary health care and selective interventions.
5. The debate over the merits of eradication versus control continues in the global health community.

While the elimination of smallpox was a remarkable achievement and other diseases have been significantly reduced, Stepan suggests that the main focus of global public health should not be eradication. Instead, a more balanced approach that considers the broader context of healthcare, resource allocation, and long-term sustainability may be more effective in improving global health outcomes.

As we continue to face new and evolving health challenges, the lessons learned from past eradication efforts will be crucial in shaping future strategies. The ongoing COVID-19 pandemic serves as a stark reminder of the importance of global cooperation, scientific research, and adaptable public health measures in addressing widespread diseases.

Ultimately, "Eradication" encourages readers to think critically about the complex interplay between science, politics, and ethics in the pursuit of global health. It reminds us that while the goal of eliminating deadly diseases is noble, the path to achieving it is rarely straightforward and requires careful consideration of multiple factors to ensure the best outcomes for all.