The concept of disease eradication, the reduction of cases from a single disease to ‘zero’, has a long history stretching back to the early part of the twentieth century. It is also a concept that has persisted despite the fact that the strategy has only been successful twice, and only once in eliminating a human disease – smallpox. Today, thanks to the Gates Foundation’s commitment to malaria eradication and continued efforts to eradicate polio and guinea worm, eradication remains a viable strategy for many global health leaders. For others, it is a costly and ultimately doomed quest for a public health chimera.
Nancy Stepan’s engaging new book attempts to trace the application of this concept from early attacks on yellow fever and hookworm at the beginning of the twentieth century to the current campaigns against polio and guinea worm. She charts the successes and failures of these eradication efforts and by doing so informs current debates about the usefulness of this strategy for improving the health of the world’s populations. The histories of the various eradication efforts she details have been examined by others and will be familiar to specialists in the history of international or global health. However, Stepan makes an important contribution by linking these eradication efforts together in a single historical narrative, highlighting the connections among them. In addition, she provides original case studies of eradication efforts in various parts of Latin America. Finally, Stepan is able to use the history of eradication to map out some of the major trends in the history of international and global health efforts. For all of these reasons the book is a welcome addition to the growing literature on the history of global health.
Stepan builds her narrative around the activities and vision of Frederick Soper, who might reasonably be considered the father of modern disease eradication efforts. There is value in this approach in that is provides a human face to this history. More importantly, Soper was the primary architect for the military style operations involving highly regulated forms of control, surveillance and evaluation that have characterised most eradication efforts. While Soper built his approach on that employed by William Gorgas to attack yellow fever and malaria in Cuba and Panama in the early decades of the twentieth century, Soper took the strategy to new levels and was a major force behind global eradication efforts through the 1970s. As we move to the post-World War Two era, Stepan acknowledges the expanding cast of characters who took up the eradication concept and played an important role in pushing it forward within the World Health Organisation (WHO) and other post-war international organisations. She thus refers to malaria eradication as having resulted in large measure from the formation of an ‘epistemic community’ of public health leaders dedicated to the implementation of eradication strategies.
If there is a weakness in this approach it is that it occasionally privileges the activities of individuals over the role of social and political forces. For example, while there is little doubt that men like Soper, Candau, Russell and Gabaldon played a key role in driving malaria eradication forward and in the World Health Assembly’s adoption of the Malaria Eradication Program in 1955, that decision was in some ways pre-determined by the earlier adoption of DDT as the sole weapon in the war against malaria by public health authorities around the globe beginning in the 1940s. This reliance together with the predictable emergence of vector resistance in the early 1950s made eradication an attractive strategy. In other words, eradication was a solution to a problem created by the world’s addiction to pesticides and the near cessation of research into alternative control methods. As the Director General of WHO stated in his presentation of the Malaria Eradication Programme resolution to the Eight World Health Assembly, ‘there was no other option’ than to push for eradication before resistance eliminated the effectiveness of DDT. Thus to understand WH0’s adoption of the eradication strategy in 1955, you need to explore the scientific, economic and political forces that led to the hegemony of pesticides in the war against malaria during World War Two and the immediate post-war years.
While Stepan’s epistemic community was instrumental in designing the eradication strategy, political interests played an important role in shaping the subsequent history of the eradication campaign. Stepan notes the importance of the Cold War in framing discussions of eradication, but does not discuss how Cold War concerns shaped the actual campaign. Cold War calculations not only led the US to support the eradication effort, as Stepan notes, but also shaped decisions as to where US bilateral funds would go, from the country level down to decisions about which villages would be sprayed in places like French Indo-China. More critically, Cold War calculations led the US to withdraw support from Ceylon at the point where malaria had nearly been eradicated in 1961, abetting the resurgence of malaria in the mid-sixties. This story was replayed in India in the early 1970s with the same result. Both decisions were driven by concerns that the two countries were flirting with socialism.
That said, Eradication provides historians and public health professionals with a much-needed historical perspective on a strategy that continues to be debated in public health circles.
