Smallpox: Dispelling the Myths

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Dr Donald A Henderson is a resident scholar at the Center for Biosecurity, University of Pittsburgh Medical Center and a Distinguished Professor and Dean Emeritus at Johns Hopkins University. Chief of the World Health Organization's global smallpox eradication programme (1966-1977), he has been recognized for his work by many institutions and governments, having received 17 honorary degrees and awards such as the National Medal of Science and the National Academy of Sciences Public Welfare Medal. He was instrumental in initiating the WHO Expanded Programme on Immunization that is now providing six vaccines to children and saving tens of millions of lives throughout the world.

Twenty years ago Henderson and his colleagues published an exhaustive account of one of the World Health Organization's (WHO) most successful campaigns, Smallpox and its eradication. The 1500-page tome with its trademark red cover became known as 'the Big Red Book'. Next year, Henderson will publish his own reflections on the campaign in a new book Death of a disease.

Q: In 1966, the World Health Assembly voted to undertake a global eradication programme for smallpox. What was the immediate impact of this decision?

A: There was considerable debate as to whether that was a good idea or not. Several countries felt that it was impossible to do the job, and some were reluctant to provide more money to WHO to accomplish this. The Director-General (Marcolino Gomes Candau) was very much opposed to the programme, because the malaria eradication programme wasn't doing very well. His view was that if WHO were asked to undertake a second eradication programme, it would fail and that would reflect very badly on WHO and the public health community. He felt that the [United States of America] had played an important role in the debate in the assembly in persuading delegates to vote for this so he asked that an American--and specifically me--be assigned to the job, so when the eradication effort failed, the responsibility for it would be seen partly as that of the United States.

Q: What did you say when you were first approached about this?

A: I was reluctant to accept the challenge because in November 1965 the US government had decided to support a smallpox eradication--measles control programme in 18 countries of western and central Africa. I was asked to assume the responsibility for doing that. It was a big job and I was reluctant to leave the Centers for Disease Control and Prevention (CDC) barely a year later to work with a global programme. Second, only US$ 2.7 million was allocated by the World Health Assembly, not enough even to buy the vaccine we needed. So I could see some real difficulties in executing the programme.

Q: The eradication programme was originally conceived as a mass vaccination programme. Do you think that was the right approach?

A: The idea that this was conceived as a mass vaccination programme is a myth. It was not. Before 1966 special smallpox control efforts were primarily mass vaccination programmes. Little attention was paid to the reporting and control of cases and outbreaks, which we felt were the most important things. So when we worked to prepare a manual for the 18-country programme in western and central Africa--a manual that was printed in October 1966--we made a very strong point about the need for surveillance of cases and their containment. That manual was used in western Africa, but when I went to WHO we modified it so it would be appropriate for countries throughout the world.

Q: How did you get through all those initial challenges to a successful programme in the end?

A: To answer this requires an entire chapter in my new book! A host of problems had to be resolved--special measures were needed to persuade many governments to give the programme adequate support; vaccine production laboratories needed to be developed and improved in many countries; far more funds and personnel were needed than the budget would accommodate; the WHO bureaucracy was unaccustomed to dealing with a programme such as this; new strategies were needed; training programmes and teaching materials had to be developed. …