Eradication: Ridding the World of Diseases Forever?

Public health, like any dynamic field filled with social reformers, scientists, and passionate believers, generates conflicting views, approaches, and goals. Thus, on domestic and global fronts, public health advocates compete for priority and resources for vertical (single-disease) versus horizontal (infrastructure or systems) programs; infectious diseases versus noncommunicable diseases; targeting diseases to improve health versus emphasizing the role of economic development or social determinants; and primary health care versus eradicating diseases. 
 
Eradication: Ridding the World of Diseases Forever? by Nancy Leys Stepan provides a rich context for the role of eradication historically and conceptually in public health and, along the way, touches on many of the fault lines that stress and enrich public health. The depth and breadth of the author’s approach also enrich her book and broaden its appeal to readers whose interests go beyond the topic of disease eradication and include public health history, governance, leadership, philosophy, and dependence on multiple disciplines. 
 
The book’s introduction and first chapter alone would provide a fine primer to begin the exploration of “what makes a population get healthier?” After this concise and clear context of eradication and its pursuit (eradicationism), the text then focuses specifically on eradication efforts and some key disease eradicators. Particular emphasis is given to a major 20th century public health leader and proponent of disease eradication, Fred Lowe Soper, and his role with the Rockefeller Foundation, his successful efforts in Brazil and other countries, and his global influence as director of the Pan American Health Organization. He targeted yellow fever and malaria, primarily through vector control (mosquito eradication), and became a champion for use of DDT. Stepan uses the colorful and compelling personality and strengths of Soper, the political complexities of international work, and the unforeseen conflict of insecticidal vector control with the advent of environmentalism to illustrate the considerable hurdles involved in any program of disease eradication, no matter how initially successful and promising. She continues with detailed examples of the successful program of smallpox eradication. 
 
After a description of the guinea worm eradication program, which has made extraordinary progress, the book seems to end a bit abruptly. Only a handful of pages are devoted to the world’s major current disease eradication program, polio, and there is little mention of measles. The book relies for information and opinion on distinguished leaders in eradication efforts, but almost all of them are American or live in the United States. Are European views different? What about having more insights from public health figures in the involved nations in Africa, southern Asia, and South America? The result feels somewhat parochial and incomplete. 
 
Nevertheless, this book provides an interesting and useful perspective on a major public health movement and is suitable for students beginning their public health studies as well as for their professors of epidemiology and public policy. Veterans of eradication efforts will enjoy reading it. Those currently involved in eradication campaigns and those considering joining them would be wise to read this book and absorb its lessons.


Reviewed by Stephen B Blount
The public health community will face moments of high drama in the next few months and years as the campaigns to eradicate polio and Guinea worm disease enter perhaps their final stages. After more than 20 years of global commitment and billions of dollars spent, the prospect of wiping these two scourges from the face of the earth has generated enormous excitement and enthusiasm, but the challenges of finishing the task have raised questions about the value of eradication efforts. As the world confronts the financial crisis that affects all public policy decision-making, the ultimate success or failure of these campaigns will substantially influence future global health priority setting and program implementation.
To help understand how we have reached this point and what the future may hold, Nancy Leys Stepan offers a useful prism through which to view this drama in her book, Eradication. A worthy contribution to the recently expanding literature on disease eradication, it wrestles with the thorniest questions confronting decision makers and public health practitioners. However limited and tentative some of her conclusions are, they prod us to think more carefully about what will be needed to reach success in eliminating or better controlling other conditions that have been targeted by countries, international organizations and donors, including measles, malaria and other neglected tropical diseases.
Stepan's stated goals are to identify the defining characteristics of the eradication enterprise as a model for public health action and to assess the histories of a number of eradication campaigns for what she calls their "useful ambiguities". She aims to answer the complex questions posed by both advocates and opponents of eradication, including whether establishing an absolute goal for an individual disease helps to focus efforts that lead to a reduction in its burden and what role eradication programs should have in today's radically altered global health terrain. Most of her conclusions are thoughtfully derived and compelling, but Stepan acknowledges that some of the answers she offers are less than completely satisfying.
The author's approach is most insightful when she uses the mixed experiences from the success of smallpox eradication and the failure of malaria eradication to consider broader issues, as well as their implications Disappearing disease for the immediate future. For example, Stepan describes the combination of hubris and insufficient scientific knowledge that led to the debacle of the malaria eradication program in the 1960s.
As a historian and professor emeritus at Columbia University, Stepan's method of inquiry is rigorous and she employs a range of approaches to explore the topic, including a careful reading of source documents and extensive interviews with current leaders in the field. Stepan's decision to use the life and work of Fred Soper, whose achievements include leading the effort that eradicated Anopheles gambiae in Brazil and whom she describes as an "arch-eradicationist", to provide the chronological structure and narrative arc of the book is creative. It has the mostly salutary effect of humanizing issues that too often have been reduced in other accounts to dry comparisons of cost-benefit ratios.
Stepan traces the evolution of views about eradication from its imperial origins in the early twentieth century, through the era in which the Rockefeller Foundation had a leadership role similar to that of the Gates Foundation today, to the post-war period and the founding of the World Health Organization. She also surveys the landscape of global health today, including the ongoing tension between advocates for provision of primary health care and proponents of campaigns against a small number of diseases whose eradication or elimination has been determined to be feasible. The globalization of the economy and its daunting realities, the enormous influence of what have been called 'philanthocapitalists' who consistently ignore the social determinants of health, and the diminished role of international organizations are all addressed. In combination, these have led to what the author characterizes as a "bewildering and overlapping array of health initiatives". The implications that she draws for decision-making at the highest level challenge the optimism of even the most determined public health practitioner.
Turning her eye to the current efforts to eradicate polio and Guinea worm disease, the author attributes their remarkable success to date to deliberate strategies to overcome the limitations of earlier campaigns and "incorporate some of the features of basic health services while nonetheless remaining focused on the removal of specific diseases". Despite dramatically reducing the disease burden, she concludes that the promise that polio eradication would help build health infrastructure has not always been achieved. Stepan views the Guinea worm eradication program, on the other hand, as an alternative model that is closer to the primary health care approach and whose network so lends itself to integrating other disease-specific interventions that it could, and should, become the organization through which basic health services can be extended to the poorest people in the most remote locations.
These critical, but positive and inspiring, conclusions round out this important contribution to the literature on eradication. Stepan is a talented historian and her accessible writing style brings to life the debate that she analyzes in depth. A minor criticism is that her decision to use the story of Fred Soper as a frequent point of reference may have led her to rely on his insights far beyond the time period of their greatest relevance. This is, overall, a highly readable and informative reflection on one of the most important issues in global health today and is heartily recommended.