Disease Eradication vs. Strengthening Health Systems

I’ve always been enamored of the power of modern medicine to stamp out diseases from the face of the earth. But when you think of it, we’ve only done that with one disease: smallpox. And therein lies a great puzzle: Why didn’t we succeed with the others. Can we? Should we? (ChatGPT informed me that Rinderpest is the second to have been eradicated but it affects only animals.)

Randall Packard’s ‘A History of Global Health – Interventions into the lives of other peoples’ has a take on this question. Despite a Marxian approach, it gave me a framework to think about public health. According to Packard, the genesis of Public Health lay in the efforts of colonialists to weed out dreaded diseases in the colonies. One of the pioneers of this movement was William Gorgas who led American efforts to manage yellow fever in Havana and later in Panama when the canal was being dug. The methods adopted were typically colonial – diseases surveillance, house to house campaigns, forced compliance – which eventually led to a fall in mortality. Setting up hospitals to address larger health requirements of the public were left to Christian Missionaries.  In such approaches, the methods are always top-down with no intent to strengthen health systems and have a very disease-specific focus.

Building health systems call for massive state capacities, investments in infrastructure, resource allocations, a dense network of Primary Health Centers and a medical training establishment geared to this philosophy. Without this, disease eradication campaigns end up being sub optimal and a colossal drain of resources. Packard’s grouse is that this is exactly the path that global institutions and consequently countries decided to embark on.

The post World War II era was marked by an increasing availability of diagnostic tools, X-ray technologies, antibiotics and vaccines. Epidemics of typhus and tuberculosis threatened post war populations and underlined the need to push forward disease-control campaigns. With communism rearing its head in different parts of the world, global health emerged as one of the battlegrounds in which the Cold War rivalries played out. Investments in large-scale, state-led programmes around health system strengthening were seen as Soviet-style Command and Control programmes. (The American PL-480 scheme of providing surplus food grains to countries in distress was also fueled by American fears of hunger and poverty transforming as fertile grounds for the spread of communism.)

In this backdrop, the possibilities of a global consensus around building health systems failed to materialize. Instead, what we got were global concerted efforts aimed at disease eradication. Two of the largest global programmes launched during the 50s were towards the eradication of smallpox and malaria. Smallpox got vanquished. But malaria is still very much a dreaded disease. The reasons for this variance of outcomes are not hard to explain. Malaria calls for a complex system of blood work, diagnostic facilities and treatment protocols which in turn call for some form of a health system to be put in place. Randall also argues that on top of this, the whole ancillary campaign to destroy mosquito populations also had in play chemical companies with vested interests. Smallpox on the other hand is highly symptomatic which makes it easier to ring fence primary contacts, it had a vaccine which was easy to transport and was circulating in just a few countries when the campaign began.

The success of the smallpox campaign pushed disease eradication further up the agenda. Polio, Guinea Worm. Measles, Mumps, Filariasis, all ended up getting dedicated eradication programmes. With mortality rates plummeting around the world, population growth became the next bogey for fearmongers. Today, it is well established that improving female literacy, higher GDP growth and increased mobility within the labor pool drive down fertility rates. But in the 60s, the prescription was for technological interventions – IUDs, contraceptives and family planning campaigns became the flavor of the day. International donors preferred family planning campaigns to traditional health interventions as the latter was seen to result in lower mortality which could be more dangerous to the planet in the long run (eerily similar to some of the arguments made against fossil fuels by climate activists today) .  In India, the Emergency today is remembered for its brutal excesses around family planning.

The last three decades has also seen a massive shift in global health policy with the AIDS pandemic, Respiratory epidemics, and the rise of philanthropy thanks to one gentleman – Bill Gates. Today, the BMGF is among the largest donors to the WHO and plays a highly influential role in shaping global policy. (An earlier piece on philanthropy).

Randall’s work has killed my excitement around disease eradication. Having a robust Primary Health Center-driven network of hospitals, increasing state capacities and building credible institutions can be far more effective than ‘glamorous’ disease-eradication programmes. One such glamorous programme was the Global Polio Eradication Initiative launched by the WHO in 1988. When launched, the estimated budget for achieving the goal was around $150 million. By 2011, close to $9 billion was spent with the disease still prevalent in Pakistan and Afghanistan. Running a fake polio-surveillance camp to track down Osama bin Laden also made matters worse. Should we chase the final few cases of polio or move the resources to more meaningful development pursuits?

PS: Our World in Data’s page on Disease-Eradication has some interesting stats and bacgkround info.