Successes Despite Weak Health Systems
Countries have implemented cost-effective interventions and accomplished major public health successes even under conditions of dire poverty, weak or nonexistent health care infrastructure, and civil unrest or war. Consider the worldwide eradication of smallpox. In 1980, the World Health Assembly declared that smallpox, which has been known since at least 1160 BC, was the first disease in history to have been eradicated. That eradication was accomplished through a global campaign that reached even the most distant rural parts of the world's poorest countries, war-torn countries, and countries whose health systems were barely functional.
Certain distinctive characteristics of smallpox shaped the strategy and influenced the success of the eradication. The disease was transmitted directly from person to person without any other hosts or vectors and was relatively easy to identify. Once an individual contracted smallpox, that person took 10 to 14 days to become infectious, but by then that individual was usually already bedridden, thereby reducing contact with others. People who survived the illness or were adequately vaccinated were immune for the rest of their lives. Thus features of the disease itself made its eradication feasible.
" smallpox, which has been known since at least 1160 BC, was the first disease in history to have been eradicated."
Essential technological breakthroughs for battling the disease included not only the actual smallpox vaccine but also the bifurcated needle, which reduced costs and made vaccinating people easier. Sustained leadership and funding were also crucial to the eradication campaign, but were not at first readily available. Initially proposed in 1958, the campaign to eradicate smallpox did not really begin until 1967 because of fortuitous changes in leadership and staffing at the World Health Organization (WHO) and decisions in the United States to commit substantial funding to the campaign.
Another important turning point involved shifting from a strategy of generalized vaccination of entire populations to a strategy of surveillance and containment. This so-called ring strategy involved highly refined epidemiological surveillance, selective containment, and vaccination of patients and communities in response to specific outbreaks. This strategy was crucial to eliminating the last remaining reservoirs of smallpox in five countries—Bangladesh, Ethiopia, India, Nepal, and Pakistan—even when one or more of these countries were in crisis, were suffering from war or civil unrest, or were facing massive refugee flows or extreme poverty.
The campaign against smallpox developed an intervention strategy independent of the existence or nonexistence of health systems and infrastructure in any of the countries, and it achieved its goal. A disease that at the start of the campaign had been responsible for millions of cases and 1.5 million to 2.0 million deaths a year, and that left many survivors deeply scarred or blind, had ceased to exist only three decades later.
