Cover: For ten years the world has been spared such a sight~a baby suffering from smallpox. Photo WHO

IX ISSN 0043-8502 World Health is the officia l il lu strated magazine of the World Hea lth Organization

Editor: John Bland

Deputy Editor: Christiane Viedma

Art Editor: Peter Davies

News Page Editor: Peter Ozorio

World Health appears ten trmes a year in English, French, Portuguese, Russian and Spanish, and four times a year in Arabic and Farsi. The German edition is obtainable from · German Green Cross, Schuhmarkt 4, 3550 Marburg, FRG. Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necess­ arily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland.

Contents Ten years of freedom from an ancient scourge Smallpox: never again ! by Halfdan Mahler . 3 In the aftermath of "target zero" byZdenekJezek ...... 4 The lessons learnt by Donald A. Henderson . . . . 8 Progress in the right direction by lsao Arita...... 12 The poorest had most to gain by Jarl Tranaeus. . 14 A world freed the threat of smallpox. 16-17 Can smallpox return? by Frank Fenner. 18 Surveillance and research by Svetlana Marennikova . . . 22 Getting your money's worth by John F. Wickett ...... 24 Spin-off from space travel by Silvia Michanie and Frank L. Bryan ...... 26 • Department Health Manpower Development Meeting health needs by Abdul Rahman AI-Awadi 28 News Page ... 30-31

2 ·rEN YEARS OF FREEDOM FROM AN ANCIENT SCOURGE Smallpox: never agai1n! by Dr 'Halfdan Mahler Director-General of the World Health Organization

en years have now elapsed since pull together in a venture that will the world's last case of endemic benefit not only our generation but that Usmallpox was detected, in of our children and our children's chil­ Somalia. Ten years are surely enough dren. When the history of the twentieth to convince even the most hardened century comes to be written from the sceptics-and there were many-who standpoint of the twenty-first, this said that smallpox was too insidious a achievement will undoubtedly rank disease to oe really eradicated .from the. alongside such wonders as the mastery planet. Surely it would turn up again to of flight and the landing of men upon plague mankind as it has done since the moon. time immemorial? We at WHO are proud of the part we Nevertheless smallpox has gone from played in this achievement-but we are the world. Throughout the past decade, not resting on our laurels either. The the alarm bells have rung many times. next step is to harness the same inter­ Smallpox has been "definitely diag­ national will and energy to bring about nosed" inthis country or that.. But the whole package of educational, en­ WHO's meticulously kept "international vironmental,social, behavioural, medi­ rumour register" proves the value of cal, organizational and managerial ac­ unremitting surveillance: every alarm tions that we call Health for all by the has turned out on investigation to be a year 2000. And in so doing, we shall false one-the result of chickenpox or make good use of the lessons we learnt I measles or skin disease or erroneous in those stirring years when the pock­ press reporting. marked map of the globe was gradually The eradication of smallpox is a truly cleansed until the last vestige of small­ sensational example of what can be pox was wipe9 away for ever. done when all the nations of the world

W oR LD HEALTH, Aug ./Sept. 1987 3 n October 1977, health staff their Organization to ensure that several countries of North America, working in the small port of this situation remained permanent. Europe and the Western Pacific. UMerka, in southern Somalia, Recommendations formulated by Even so, 133 countries were still diagnosed a case of smallpox in a the Global Commission for the Cer­ continuing routine vaccination 23-year-old hospital cook named tification of Smallpox Eradication programmes. Ali Maow Maalin. He was isolated, and the newly-established special With the certification of the eradi­ and his friends and eo-workers who WHO Committee on Orthopoxvirus cation of smallpox in May 1980, the had been in close contact with him Infections assisted WHO to map out representatives of WHO's Member were located, examined and vacci­ a post -eradication "insurance pol­ States endorsed the recommenda­ nated. Health teams then fanned icy " focusing on the main goal : tion that routine vaccination against out in search of every case of chick­ public safety by maintaining the smallpox was no longer justified enpox and skin rash they could find. world permanently free from and should be discontinued in every No more smallpox was discovered. smallpox. country. By the end of 1984, all Mankind had seen its last case of countries had ceased smallpox vac­ this endemic disease. Smallpox ••••••••••••••••••••••••••• cination of the general public . " target zero" had now indeed been • • Routine vaccination did not cease • Dr Zdenek JEZEK heads • achieved. The ancient scourge, . . . . instantly, as appropriate instruc­ which had killed millions since the : WHO's Smallpox Erad1cat1on : tions were not always transmitted dawn of civilization, was finally : Programme. : throughout the health services. In eradicated. This fact was certified, •••••••••••••••••••••••••••• • some places, smallpox vaccine con­ in a historical session, by the Thirty­ tinued to be made available on third World Health Assembly of the Vaccination policy: The modern request. Health staff in these coun­ WHO in May 1980. world had built up an elaborate tries had to explain to anxious pa­ But the job was not yet finished. system of defence against smallpox rents that the risks posed by vacci­ It was necessary to convince the which included compulsory vacci­ nation for their children stood world community that the disease nation and constant checks on in­ against "zero" benefits. There was had gone forever, to ensure that ternational travellers. Already part no disease to be feared. Some phy­ advantage was rapidly taken of the of that system was being dismantled sicians had to be persuaded that benefits of this achievement. De­ by 1977, when worldwide eradi­ smallpox vaccination has no value spite the overwhelming evidence cation became imminent. By that in treating or preventing recurrent that the world had been freed from time, routine vaccination, which herpes infections, warts and so smallpox, measures needed to be had been in existence for over 175 forth, and that, furthermore, misuse taken by the Member States and years, was no longer required in of smallpox vaccine for such treat-

4 W oRLD HEALTH . Aug ./Sept. 1987 ment is associated with the risk of Facing page: Helicopters helped to severe complications. close the net on smallpox in Somalia. WHO In 1983, contacted govern­ Photo W HO/E. Shafa ments and vaccine producers and urged them not to distribute vaccine Right : Health workers summoned peo­ to civilians. Nevertheless, military ple to come forward for vaccination, personnel have continued to be vac­ offered cash rewards for anyone report­ cinated in some countries, resulting ing a smallpox case, and stuck up post­ in the accidental vaccinal infection ers to explain the campaign. Eradication of their civilian contacts. In 1983 , in meant savings in time and money for order to prevent such incidents, the everyone at airport health control Committee on Orthopoxvirus In­ points. Photos WHO/P. Almasy. WHO/E. Shafa. fections recommended that " milit­ WHO/P. Almasy and W HO/Novosti ary personnel who have been vacci­ nated be confined to their bases and prevented from contacting unvacci­ could reach any country m the nated persons for a period of two world within 24 hours. weeks following vaccination". And At the end of last year the stock in 1986 the Committee proposed amounted to more than five million that smallpox vaccination of milit­ ampoules which, with the use of ary personnel be terminated. Small­ bifurcated needles, would be suffi­ pox vaccination is now only re­ cient to vaccinate about 250 million quired for the small number of lab­ persons. Considering that nearly oratory workers who handle variola ten years had elapsed since the last virus or closely related orthopox­ endemic case of smallpox and that viruses in their laboratories. Vast human monkeypox had not proved sums taken from scarce health to be a significant health problem, resources and spent on smallpox the Committee on Orthopoxvirus vaccination in the past are now Infections considered iri March diverted to other pressing public 1986 that there was no further need health problems. for WHO to maintain the global Checks on international travel­ vaccine reserve. lers: In May 1980, the Member Reports on smallpox prove false: States agreed to withdraw require­ We had no doubt that reports of ments for valid smallpox vacci­ suspected cases of smallpox would nation certificates for international reach WHO for several years after travellers, and the following year the declaration of its eradication. smallpox was formally struck from The thorough and prompt investi­ the International Health Regu­ gation of such reports, backed up lations. Despite health administra­ by laboratory examination and sub­ tions withdrawing such require­ sequent disclosure of results, would ments, international travellers and be a very important element of crews of ships and aeroplanes were post-eradication surveillance. Any occasionally asked for such certifi­ report of a suspected case is re­ cates at ports and airports, when garded as a public health emergen­ applying for visas, or simply by cy and has to be promptly investi­ travel agencies. WHO cooperated gated. Since 1980, WHO has coordi­ with national health authorities to nated the investigation of 131 clarify reports of such incidents, rumours of suspected cases, re­ which had virtually ceased by 1986. corded in an International Rumour Reserve stock of smallpox vac­ Register. The key role in confirm­ cine: In order to free the world ing a correct or incorrect diagnosis from vaccination regulations, na­ lies with two WHO Collaborating tional health authorities had to be Centres, at the Centers for Disease absolutely sure that smallpox was Control, Atlanta, USA, and at the gone and that a smallpox vaccine Research Institute for Viral Prepa­ reserve is kept in case of unex­ rations, Moscow, Soviet Union, pected emergencies. A reserve who provide laboratory diagnostic stock was established by WHO in services. No single case of smallpox 1980 , and its existence made it has been proven. much easier for Member States to Variola virus after eradication: decide to discontinue both smallpox Once the transmission of endemic vaccination and vaccine production. smallpox had ended, the only It has been widely publicised that known source of variola virus-and vaccine from this stock can be made a potential danger for the available and, in an emergency, future-resided m laboratories

W oRLD HEALTH, Aug./Sept 1987 holding stocks of variola virus. WHO 1980 provided a strong incentive Braving the needle in Africa. Smallpox began trying to reduce their number for them to destroy or transfer their vaccination was soon to become a thing even before smallpox-free status stocks. Since 1984, variola virus has of the past. had been reached. been confined to glass-vials kept Photo W HO In 1975 , WHO officials contacted under high security in the two WHO all those countries and individual Collaborating Centres, neither of laboratories known to have worked which now cultures the virus. by them. But one animal pox-dis­ with the virus in the past. By the ease known to affect monkeys kept end of 1976 , 75 laboratories were in captivity was looked upon with identified which held stocks of va­ For centuries, the word suspicion. riola virus. "smallpox" brought terror The suspicion turned into anxiety The following year, the Thirtieth to the civilised world as it . when in 1970 a nine-month-old World Health Assembly recom­ killed hundreds of millions of child from a village located in a mended that stocks be retained only people. Dramatic news it smallpox-free part of Zaire de­ in WHO Collaborating Centres and was therefore when the veloped a smallpox-like illness. Sur­ under conditions assuring the max­ World Health Assembly in prisingly, monkeypox virus was imum safety. WHO officials sought to May 1980 decl.ared the dis­ confirmed by laboratory testing to persuade the laboratories to destroy ease to have'been wiped out ' be the causative agent of the child's the virus held or transfer it to the from the Earth. This was the illness. Subsequently, similar cases WHO Collaborating Centres. first disease to be totally were detected in other countries of Lost or hidden vials with variola conquered by man. western Africa. virus remained a worldwide con­ It was learned that monkeypox cern at that time. There was no way virus, although a distinct species for WHO officials to go through Animal poxviruses-monkeypox: from variola virus, gave rise to an every deep-freeze in the world and One of the bases on which eradica­ extensive pustular rash, indistin­ look at each vial. tion of smallpox was attempted was guishable from smallpox. Human Only 18 laboratories were known the conviction that this specifically monkeypox was not a new disease, to have retained variola virus at the human disease had no intermediate but, being rare and so like smallpox, end of 1977. The laboratory associ­ host or reservoir of variola virus in it could never have been recognised ated outbreak of smallpox in Bir­ animals. until smallpox had been eliminated. mingham, United Kingdom, in Although a variety of animals In March 1986 the Committee on 1978 and the declaration of the suffered from " pox" diseases, man Orthopoxvirus Infections took note eradication of smallpox in May had not been significantly affected of the low incidence of human mon-

6 W o RLD HEALTH, Aug ./Sept. 1987 In the aftermath of" target zero" keypox and the growing conviction Documentation of the smallpox that the virus could not sustain itself eradication programme: Since the by man-to-man transmission, and eradication of smallpox was a stated that in its view human mon­ unique event in the history of man­ keypox does not pose a significant kind, it was important to document health problem. the operational and scientific Laboratory investigations and re­ achievements of the programme, its search: Both before and during the experiences and the lessons learned post-eradication period, WHO has in various corners of the globe. WHO ::2; actively helped to maintain suitable published monographs describing 0 laboratory expertise and laboratory eradication in four priority coun­ sI preparedness for unexpected prob­ tries: Bangladesh, Ethiopia, India 0 0 lems that might arise with smallpox and Somalia. WHO also helped to .£:a.. but also with other poxvirus dis­ prepare a monograph dealing with eases of man. Most of the labora­ management aspects of the largest Monkeypox in a Zairean child tory diagnostic work has been car­ national programme, India. A com­ -note her enlarged glands. ried out in the two WHO Collaborat­ prehensive reference work entitled ing Centres in the US and the " Smallpox and its Eradication", Human.monkeypox Soviet Union. Between 1980 and dealing with all scientific, oper­ Because of its close clinical 1986, these two centres alone ational and administrative aspects, resemblance to smallpox, mon­ tested about 22,000 human speci­ will be published by the WHO in late keypox became an important mens and about 3,000 animal speci­ 1987 , about the time of the lOth disease for post-eradication sur­ mens collected in 36 various, mostly anniversary of the occurrence of the veillance. Since 1970, 400 pa­ developing, countries. Several un­ last case of endemic smallpox. tients suffering from monkeypox solved virological and immunologi­ For centuries, the word "small­ have been recognised in seven cal problems relevant to orthopox­ pox " brought terror to the civilised countries of western and central viruses merited further research. world as it killed hundreds of mil­ Africa; Zaire alone accounted for 95 per cent of them. Most cases Assisted by WHO in the post-eradi­ lions of people. Dramatic news it occurred in small. remote vil­ cation era, research progressed along was therefore when the World lages close to or in the forest. two main lines: analysis ofthe DNA Health Assembly in May 1980 de­ where local people have multiple of variola and other orthopoxviruses, clared the disease to have been contacts with a variety of wild and development of reliable sensi­ wiped out from the Earth. This was animals and hunting is important tive serological tests specific for the first disease to be totally con­ to obtain daily food. Many vic­ various species of orthopoxvirus. quered by man. The main target of tims were young children, post-eradication surveillance, to among whom the case-fatality provide assurance to the world that was similar to that formerly Millions of phials of vaccine were pro­ it is permanently free from small­ caused by smallpox. duced and distributed around the world. Ecological studies in recent pox, has been successfully achieved Photo WHO/J. Mohr years suggest that squirrels are a by WHO and its Member States. • significant host or reservoir of monkeypox virus. Large num­ bers live in the oil-palms which grow between the village and the primary rainforest. Despite intensified surveil­ lance during the last six years. human monkeypox is viewed as an infrequent and sporadic zoonosis, that is, contracted only by close contact with infected wild animals. However. there have been episodes of transmis­ sion from one person to another. between siblings, children and parents, playmates, or patients lying in the same hospital ward. Generally, the transmission stop­ ped spontaneously at the first generation of the cases. Despite waning immunity in the local population in the absence of routine smallpox vaccination. the infrequent nature of human con­ tacts with monkeypox virus and the low transmissibility of the virus may be important factors in limiting its spread. •

7 The lessons learnt

by Donald A. Henderson

mall pox is the first disease to countries with a population of more missions visited and verified the have been eradicated through than 1,000 million persons. Given absence of smallpox. Finally, a WHO § a concerted global effort. Al­ that programmes would have to be Global Commission, through a var­ though this is a stupendous achieve­ conducted in most of the least de­ iety of studies, satisfied itself that ment in itself, it also has broader veloped countries, that disruptions eradication had been achieved, and implications for health policy in due to civil strife, famines and its conclusions were endorsed by demonstrating the impact which a floods were inevitable, and that the Thirty-third World Health As­ community-based programme can more than a century and a half sembly in May 1980. have in the field of prevention, the had already elapsed since Edward It is sometimes suggested that the considerable resources that can be Jenner's discovery of a vaccine, programme should serve as a tem­ mobilised for such an effort, the the goal was an optimistic one. plate for other disease control or value of setting measurable goals Nevertheless, the last known en­ eradication compaigns. This is not and monitoring the incidence of demic case occurred just 10 years, feasible , because each disease has disease, and the remarkable cost­ 9 months and 26 days after the its own epidemiological characteris­ benefit advantages of prevention programme began. tics and methods for control which programmes. It is in part because of require strategies and tactics unique smallpox eradication that increased ••••••••••••••••••••••••••• to that disease. But the rapid pro­ emphasis is now being given to • gress in eradicating smallpox after disease prevention and health Dr Donald A. HENDERSON • so many decades of persistent trans­ promotion programmes throughout is the Dean of the School of • mission provides principles and les­ the world. Specific, measurable Hygiene and Public Health at • sons which have implications for goals in national and local health the Johns Hopkins University, • other health initiatives . programmes are being more widely Baltimore. USA. • For a global programme to be identified and used in manage­ •••••••••••••••••••••••••••• undertaken, universal political ment, and health authorities are commitment is necessary and, for increasingly adopting surveillance The strategy of the programme this purpose, the World Health Or­ and sample survey techniques that was two-fold: to vaccinate at least ganization and the World Health were elaborated during smallpox 80 per cent of the population, and Assembly were essential. The As­ eradication. to establish systems for surveillance sembly uniquely provides the It was in 1958, that a Soviet (case detection) and containment of necessary forum for countries to delegate to the World Health As­ outbreaks. Between 1967 and agree on global health policies. sembly proposed that global small­ 1971 , WHO-supported national pro­ WHO, alone among the international pox eradication be undertaken by grammes began in all endemic organizations, has the requisite sci­ WHO, and this was unanimously ap­ countries and in others that were at entific expertise and channels of proved at the following year's As­ special risk of importations. All communication with national au­ sembly. At that time, 60 per cent of programmes functioned within the thorities for the monitoring and the world's population still lived in public health structure and each coordination of health programmes. areas where smallpox was endemic. differed from the others in order Smallpox eradication could not During the succeeding seven years, to cope best with different have been achieved were it not a some progress was made in improv­ epidemiological patterns of small­ targeted, time-limited special pro­ ing vaccine quality and a number of pox, national administrative prac­ gramme with funds specifically allo­ countries became free of smallpox, tices and socio-cultural conditions. cated for it, both in the WHO budget but the disease, often in epidemic After the occurrence of the last and in most national budgets, and form, continued to be widespread. known smallpox cases, health offi­ with full-time technical staff re­ Delegates at the Nineteenth cials in all countries had to be sponsible for its supervision. Yet World Health Assembly (1966) al­ sufficiently confident of eradication some argue, even today, that special located special funds for an inten­ that they could stop vaccination. So programmes are inherently poor sified programme starting in J anu­ surveillance programmes and spe­ policy, serving only to divert re­ ary 1967. They proposed a ten-year cial search activities were con­ sources and attention from the de­ goal for the achievement of eradica­ ducted for at least two years in velopment of primary health care tion. At that time, an estimated 10 every country after the last known systems. That such programmes can to 15 million cases of smallpox were case had occurred. At that time make important contributions to occurring annually in 31 endemic wHo-appointed International Corn- the development of national health

8 WoRLD HEALTH, Aug ./Sept. 1987 Dr D.A. Henderson, then chief of wHO's smallpox eradication unit, examining vaccination scars during casefinding operations in Ethiopia.

Right: Village children wait in the rain in an Indonesian village for the mysteri­ ous prick of a needle that would protect them. Photos WHO and WHO/C. Frucht services was demonstrated by the smallpox eradication programme. In part, this is because it functioned within the existing public health structure rather than as an entirely separate entity as was the case with the earlier (and unsuccessful) malaria eradication campaign. It was thus obliged to work with and through the existing administrat­ ive health structure and to coordi­ nate its activities with other programmes. In addition, a specially dedicated and trained professional smallpox eradication programme staff was necessary at all levels to design and coordinate the programme ; to de­ velop reporting and surveillance systems ; to undertake case-detec-

WoRLD HEALTH, Aug./Sept. 1987 The lessons learnt tion and containment measures, and to train local health staff. There was a need to seek the support of village leaders and, through them, the acceptance and participation of the population. The observations have important implications to the strategy for pro­ viding what is called primary health care. Such care is usually regarded as a closely related set of services, all delivered in a similar manner, but experience suggests that it would be better conceptualised as consisting of two different but com­ plementary components. One of these involves the traditional, primarily curative activities; the second involves those services intended to reach individuals throughout a community, including both preventive interventions (such as immunization or family plan­ ning) and curative ones (such as oral rehydration therapy). The traditional health care system may serve as the base for both functions but different types of programme, Surveillance teams tirelessly track~d dowr~; . every case, no matter how remote different personnel skills and differ­ the community, and asked everyone they riiet "Do you know anybody who is ent methods of assessment are re­ sick like this?" quired for each activity. Traditional, curative services can be provided in established health units by clinical­ ly-trained physicians and nurses, and are usually appraised in terms of the training of the practitioners, the quality and sophistication of facilities and the numbers treated. Community-wide programmes re­ quire active outreach by persons skilled in management and public education in order to ensure ac­ ceptance ; the provision of services at a site and time convenient to their clients; and methods such as surveillance to measure success in diminishing morbidity, mortality or fertility. Special purpose programmes identifying the achievement of cer­ tain objectives, usually within a fi ­ nite period of time, are generally better supported and financed than are programmes with less explicit goals. Experience shows that a pro­ gramme to eradicate smallpox or to prevent poliomyelitis, for example, has more popular appeal than one to develop the basic health services. Such special-purpose programmes are particularly important to public health because it is almost always more difficult to obtain support for public health programmes than for curative services. This reflects a

10 The lessons learnt reality that political leaders are usu­ other efforts in disease prevention ally more readily persuaded to pro­ More rapid progress might and health promotion. It is an or­ vide funds for the more tangible have been possible if. from ganization which can demonstrably curative services (hospitals and the beginning there had catalyse achievements far out of health centres) than for commu­ been special staff to han­ proportion to the resources it com­ nity-based programmes. dle .. . public information. mands. The extent to which it is A finite end-point-the nil inci­ Wide publicity was needed successful will depend upon the dence of smallpox-undoubtedly to encourage national pro­ confidence it merits from its was important in motivating staff grammes and to recruit sup­ Member States, on the effectiveness and sustaining interest. Though few port from donors but WHO's of its leadership in enunciating clear health programmes have such an public information office and measurable objectives and in end-point, comparable levels of was inadequately staffed mobilising support to attain them, achievement, interest and morale to ... stimulate coverage by on the number and competence of should be possible where specific the mass media, thereby in­ its professional staff, and on its goals are identified, where progress forming a broader public au­ ability to set aside extraneous pol­ is monitored and where programme dience. Not until 1977 was a itical agendas. WHO's ability to re­ staff are fully supported in their full-time public information spond appropriately will determine efforts. officer added to the small­ the degree to which it succeeds in Extraordinary achievements are pox eradication unit. His val­ the future in providing improved possible when countries throughout ue was immediately appa­ health and a better quality of life for the world pursue common goals rent. As a result of his ef­ all the world's people. • within the structure provided by an forts. it was eventually pos­ international organization. WHO sible to foster public confi­ Where there's a will, there's a way. played this role in the eradication dence that eradication had of smallpox. It now offers a Helping the surveillance team's vehicle been achieved so that vacci­ on its way in Thailand. unique-although only partially nation could be stopped. realised-potential in promoting Photo WHOfT. S. Sa tyan

W oRLD HEALTH , Aug ./Sept. 1987 11 Progress in the right direction

by lsao Arita

hilst I was travelling in west­ is that prevention is far better than gested that prevention would be the ern and eastern Africa dur­ treatment, and the second is that best method of coping with current ing the smallpox eradication international cooperation is of the medical problems and its import­ campaign in the 1970s, I often en­ utmost importance. These lessons ance would increase toward the end countered a patient with a malig­ -simple as they are-should be ap­ of this century. nant tumour of the jaw in the hospi­ plied to the control of chronic dis­ In order to further strengthen its tals which I visited. Later I realised eases in industrialised countries as aid programme, Japan's Interna­ that this was Burkitt's lymphoma, well as to the child survival pro­ tional Cooperation Agency last au­ a monoclonal tumour of B cells. gramme in developing countries. tumn dispatched a few teams to Denis Burkitt had travelled exten­ I retired from WHO in 1985 and South-East Asian countries, the sively in tropical Africa in the early now manage a national hospital of United States and Europe to study 1950s and had established the enti­ 550 beds in Japan. When I returned international health policy, espe­ ty of this special disease. to hospital work, I was astonished cially on a bilateral basis. I was a I have no intention of telling the by the tremendous progress made member of one of these teams and whole story of Burkitt's tumour observed as an outsider (not as a here, but it came to mind because I ••••••••••••••••••••••••••• WHO official) the latest trends in was once very much impressed by • • international health. I was surprised his brief essay entitled " Great pro­ i Dr lsao ARITA is Director of i to see the extensive and vigorous gress but in wrong direction" which : Kumamoto National Hospital : campaign called the Child Survival Lancet published in December : in Kumamoto City, Japan . : Programme. This programme is a 1984. •••••••••••••••••••••••••••• • joint effort of WHO , UNICEF, the In it he wrote: "Newspapers and World Bank, governments (bilat­ television have reported the inser­ in clinical medicine during the past eral assistance from the US and tion of a non-human primate's two decades with such processes as West European countries) and non­ heart into a baby and the implanta­ automatisation of diagnostic techni­ government organizations (Rotary tion of a plastic heart into an adult ques, imaging diagnostic methods, International, the Rockefeller man as if these were landmarks in hyperalimentation, anti-microbe Foundation and so forth) to reduce medical progress. But are they? treatment and organ transplants. the tragic mortality rate of children " All the really major advances in Yet these treatments, requiring ex­ in the Third World. health care have been in the realm pensive equipment, are being used It is heartening to see that, in this of prevention. Probably the greatest to manage the diseases of patients global programme, the main em­ health achievement in this century whose full recovery could not be phasis was placed on the Expanded has been the elimination of small­ expected because they are mostly of Programme on Immunization and pox. In 1967, there were an esti­ advanced age and suffering from all on Diarrhoea! Disease Control. As mated 10 to 15 million new cases sorts of complications. is quite well known, these two pro­ with an estimated two million In Japan, 600 ,000 persons die grammes have been initiated, deaths ; now the disease is non­ every year, 80 per cent of them strengthened and encouraged by existent. The cost of this achieve­ from cardiovascular diseases or the success of SME. Many staff ment, spread over ten years, was malignant tumours. As old persons members in those programmes around US $300 million. This is less form an ever-increasing proportion were among those who originally than the amount spent every two of the total population, these con­ worked for the smallpox eradi­ months in the United States on ditions will result in a substantial cation programme. coronary by-pass surgery or on re­ increase in medical costs. Under Let me cite one episode in rela­ moving gallbladders-both oper­ these circumstances, it is highly sig­ tion to this. During my trip to the ations for potentially preventable nificant that primary and secondary US I met the staff from WHO's diseases." preventive measures against these Office of the Americas who were As Denis Burkitt pointed out, diseases have been developing very carrying out the poliomyelitis elimi­ there are two principal lessons to be rapidly, as Sir Richard Doll noted in nation programme in the region. learnt from WHO's Smallpox Eradi­ an address to a learned London Many senior staff for this pro­ cation Programme (SME). The first society in October 1982. He sug- gramme, both at the WHO Regional

12 W oRLD HEALTH, Aug ./Sept. 1987 Right: Quality control of locally pro­ duced vaccines in Bangladesh. Interna­ tional cooperation was of the utmost importance in eradicating smallpox.

Below: Millions of vaccine doses from the Soviet Union contributed to the final success. Photos WHO/P. Claquin and WHO/Novosti

Office and at the country level were among those who once worked for SME. It was interesting to note that many important elements, such as programme management, surveil­ lance techniques and vaccine qual­ ity control, appeared to be derived from the experience gained from the eradication programme. The target was set, namely that 1990 would be the year when the last indigenous poliomyelitis case might occur in the Americas. Needless to say, Latin America will have to continue the polio vaccination pro­ gramme after the target is met. This was not the case with SME, where the vaccination programme could be stopped completely. In Latin America, it is important to develop primary health care systems in or­ der to maintain zero incidence once it is achieved.

H• lt is heartening to see that, in the vigorous global campaign known as the Child Survival Programme, the main em­ phasis was placed on immuni­ zation and diarrhoea! disease control-two programmes that have been initiated, strengthened and encouraged by the success of \/\,!HO's small­ pox eradication campaign. Many staff members in those programmes were among the thousands of helpers who worked for the eradication of smallpox.

The year 1987 marks the tenth anniversary of the occurrence of the world's last endemic case of small­ pox. During the last ten years, in­ numerable problems have arisen in carrying out various health pro­ grammes. But the success of the smallpox eradication programme will always give us grounds for op­ timism, and faith in the view that international public health efforts can and will eventually be crowned with success. •

W oRLD HEALTH, Aug ./Sept. 1987 13 The poorest had most to gain by Jarl Tranaeus

weden helped to fin ance WHO's countries which are today regul ar for efforts mmmg to improve life Smallpox Eradication Pro­ recipients of Swedish bilateral as­ for the poor, the vast majority of gramme because it was a ven­ sistance. In each country, an at­ whom live in the remote country­ ture that fell exceptionally well in tempt is made to arrive at a mix of side. Experiences over a quarter­ line with Swedish development as­ objective-oriented projects and century have shown, however, that sistance policies. Those policies programmes which take into ac- projects and programmes to pro­ were laid down by Parliament 25 mote economic and social equality years ago , and they were reaffirmed ••••••••••••••••••••••••••• are difficult to design and even and amplified in 1968 when the • • more difficult to implement suc­ decision was taken that one per cent : Dr Jarl TRANAEUS is Head : cessfully. Examples are manifold. of Sweden's gross national product : of Divi sion on special ass ign- : Typically, rural development or should be appropriated annually to • ment at the Swedish lnterna- • work projects may turn out to be of development assistance. : tional Development Authority : benefit not to the prime target The established aid objectives are • in Stockholm. • group but to those on a higher rung to promote economic growth, •••••••••••••••••••••••••••• • of the poverty ladder and having economic and social equality, access to the local power base. The economic and political independ­ count the direction of that country's poorest have no effective spokes­ ence and the development of demo­ own development plans. men and are at a disadvantage in cracy in society. No single objective As the 17 countries are all among community politics, where dispen­ takes precedence when it comes to the least developed in the Third sation of services or benefits hinge carrying out the policies in the 17 World, there is considerable scope on caste, tribe or land ownership.

14 W oRLD HEALTH, Aug ./Sept. 1987 programme was made available on The preservation of lives and the This was a unique achieve­ two occasions, and Sweden also relief of human suffering cannot be ment. No longer will smallpox contributed to the final effort in measured in monetary terms. But claim lives or deprive human Africa. the eradication of smallpox also beings of eyesight. And the The conduct of the campaign in brought very quantifiable benefits. principal beneficiaries of this India is well documented. Let me Sweden's contribution to the WHO achievement are the poorest just record that, on a field trip in component of the programme in and most disadvantaged in all early 1975, I saw what was prob­ India was of the order of US $8 countries, because it was ably one of the last cases of small­ million, which was small in com­ among them that smallpox pox in India. This was a young boy parison with the costs borne by the took its major toll. who had been hidden away by fam­ government of India and state gov­ ily elders when their household ernments. Once global eradication members were vaccinated. The only was confirmed vaccination was no Smallpox eradication offered a village inhabitant later to contract very different opportunity for a the disease, he was living testimony donor to become involved in an to the correctness of the contain­ The Swedish International undertaking of real benefit to the ment strategy. Development Authority, poorest. The vast majority of small­ Sweden's confidence in WHO and went into action in 1965. pox victims, actual as well as poten­ in that strategy was amply justified. About 40 per cent of Swe­ tial, were the truly poor and under­ In 1977 India was officially de­ den's annual appropriation privileged ; those with no access or clared free of smallpox and, not for development assistance limited access to health facilities, long afterwards, global eradication (now equivalent to $1,400 those weakened by malnutrition, was proclaimed. million) is allocated to bilat­ those most vulnerable in the battle This was a unique achievement. eral programmes on a grant for survival. This is why Sweden No longer will smallpox claim lives basis handled by SIDA. A responded positively when invited or deprive human beings of eye­ third of the aid budget is by WHO to help to finance the death sight; by the middle of the next earmarked for contributions of smallpox. century there will be very few, if to multilateral programmes, It all began at the end of 1973, any, disfigured survivors of the dis­ the principal recipients being when I was Head of Development ease to remind mankind that small­ the World Bank, UNDP and Cooperation at the Swedish Embas­ pox once existed. And the principal UNICEF. sy in New Delhi. I was approached beneficiaries of this achievement by members of the Smallpox Eradi­ are the poorest and most disadvan­ cation Project, working out of WHO's taged in all countries, because it was longer necessary and the resulting South-East Asia Regional Office in among them that smallpox took its annual saving in India exceeded the New Delhi. Would Sweden be will­ major toll. total cost of the 1973-1977 cam­ ing to provide finance for a pro­ paign. In the United States alone, gramme aiming to wipe out this Facing page: Checking a baby's vacci­ the annual expenditure associated killer disease? India was at the nation scar in Kenya. with vaccination requirements was focus of such a programme, for at $150 million. So by any cost/benefit that time the country accounted for Below: Pockmarked feet of a victim calculation, the global eradication some 80 per cent of all known during a 1972 smallpox outbreak in of smallpox stands out as a singu­ smallpox cases in the world. Yugoslavia. larly successful programme. The target Smallpox Zero stirred Photos WHO/C. Simayu and W HO/D. Egli This success gave encouragement our imagination : here was the pros­ to further programmes aiming at pect of eradicating a disease which disease control or eradication, and had plagued mankind for two also raised expectations about the thousand years. Equally impressive role to be played by WHO. Sweden was the conviction that the strategy has supported WHO-executed pro­ drawn up was right and that, given grammes in malaria, leprosy and the necessary finance, the job could tuberculosis in India, and has also be done. helped to fund international re­ I contacted the headquarters of search programmes on communi­ SIDA the Swedish International cable diseases under WHO auspices. Development Authority, endorsing The last few years have alerted the proposal, and their response the world community to the fright­ was equally positive. A formal re­ ening threat of AIDS, a disease for quest from the Government of which no cure is yet known and India was obtained with unpre­ which, if unchecked, may become a cedented swiftness, and the Swedish global plague even before the end Government made its decision of this century. This crisis calls for shortly thereafter. At the same both national and international ef­ time, Sweden provided funding forts on an unprecedented scale­ for the eradication programme and the Third World in particular in neighbouring Bangladesh. Ad­ will no doubt expect WHO to play a ditional finance to the India leading role in coping with it. •

W oRLD HEALTH, Aug ./Sept. 1987 15 a world Ire

Dr Jenner's legacy ::2 0 :;:I t was in 1796 that an English country 0 0 L doctor. Edward Jenner, discovered Q. Uthe principle of vaccination. By 1801 more than 100.000 persons had pro­ tected themselves with his vaccine, and he predicted that "the annihilation of the smallpox-the most dreadful scourge of the human species-must be the final result of this practice." In the end it took 183 years and a huge international effort. under the aegis of WHO . But Dr Jenner was proved right. Above: Search teams used every kind of vehicle, and offered cash rewa r.ds, to track down the last case in Bangladesh, three-year­ L. Sirman © old Rahima Banu, and-in Somalia in 1977-the world's last endemic case, Ali Maow Maalin . Below: Every rumour was checked on, but proved to be chickenpox or other diseases. Right: The Certificate of Global Above: Jenner demons­ Eradication. trates his vaccine, and a 16th century Mexican painting of smallpox victims.

Jenner (right) even left his "0 c mark on the moon, where :J c E 2 a crater bears his name. -"' N "'C: Above: In the 1870 Fran- Q) "'Q) 0 c the French were not-and Q) 0 L

W oRLD HEALTH , Aug ./Sept. 1987 ed from the threat of smallpox

sc 0' u"' cL 0 sI 0 0 £ 0..

ci 0 What next? I The USSR proposed ~ ifting the heavy yoke of small­ to the 11th World 2 0.. pox from a long-suffering world Health Assembly [b was probably the greatest that smallpox should health achievement of this century. be eradicated and Besides encouraging many advances this was approved in in producing and safeguarding vac­ 1959. The programme was greatly cines, it showed the impact that intensified in 1967, and in four community-based action can have on years had wiped out smallpox in preventive health, particularly when Latin America. Four more years backed by political will at the highest toppled the disease's last bastion level. The next step is to harness the in Asia . The multi-national teams same international will and energy to closed in on Somalia, scene of bring about the whole package of "the last stand". In December educational, environmental, be­ 1979, an independent commission Primary Health care and havioural, medical and managerial ac­ confirmed the eradication of immunization programmes tions that W HO calls Health for all by smallpox from the planet. learnt valuable lessons from the year 2000. smallpox eradication.

-~ ~- ~~~u.i.JI­ . .U· ;,~.;-.. ~ ,;•4•~

'"L...c... 'l._

•<~;.,;;..,;;, ... 4 • ..,_ ~ .. -

t ... - '" - .. j .... ~ '. c- ~-UL<..- ,;:;- ~ ... ~ ,, -· %-.;:: ~ Q) ""t: 0 sI 0 0 £ 0.. he last case of endemic small­ Concurrently with the need to eradicated worldwide, and included pox in the world occurred in explore the possibility of an animal a number of recommendations for UOctober 1977 and the last reservoir, from 1971, when the last the post-smallpox eradication era. case of smallpox (a laboratory­ case was reported in South Ameri­ This report and its conclusions and associated case) in August 1978. In ca, the Smallpox Eradication Unit recommendations were adopted by spite of careful scrutiny of all had to show convincing evidence the World Health Assembly on rumours of suspected smallpox, no that smallpox had indeed been 8 May 1980. Over seven years have case has been recognised since then. eliminated from countries, includ­ elapsed since that declaration, ten A review of all the sources from ing those with poorly developed years since the last case of endemic which infection could occur again health services, from regions, from smallpox (variola minor) occurred suggests that any such possibility is continents and finally from the in Somalia, and 12 years since the remote, but it is absolutely imposs­ world. last case of endemic variola major ible to exclude the unwitting sto­ occurred in Bangladesh. rage of variola virus in a deep­ •••••••••••••••••••••••••••• • Is there any evidence that small­ freeze cabinet, theft from a known •: Dr Frank FENNER, Emeritus •: pox has recurred after its supposed laboratory stock, or its deliberate : Professor in the John Curtin : elimination from a country? To secret storage for possible use as a • School of Medical Research, • investigate this, an International weapon of biological warfare. How­ •: Australian National University, •: Rumour Register was maintained at ever, even if an outbreak of small­ : Canberra. was Chairman of : WHO Headquarters in Geneva, and pox were to arise from any such : the Global Commission for : both wHo and national staff under­ source, it could be readily control­ : the Certification of Smallpox : took to make an accurate diagnosis led by surveillance and contain­ i Eradication, 1978-1980. i of every suspect case or rumour, ment, unless public health services • • supported by the diagnostic exper­ had completely broken down. ••••••••••••••••••••••••••• tise of the WHO Collaborating When the global smallpox eradi­ So it started a scheme for the Centres in Moscow, USSR, and cation programme was first pro­ certification of smallpox eradication Atlanta, USA. Since 1980, 131 posed in 1958, endemic smallpox which rapidly developed into a rumours have been investigated, had been eliminated from all the highly efficient system that coped excluding cases of monkeypox in countries of Europe and North successfully with the difficult prob­ western and central Africa. None America and from several countries lems of certification in the countries was smallpox. The commonest in other continents. There was of the Indian subcontinent and the clinical conditions that were con­ therefore a prima facie case that, Horn of Africa. Subsequently a fused with smallpox in the post­ once the cycle of human-to-human Global Commission for the Certifi­ eradication era (as indeed when transmission had been broken in all cation of Smallpox Eradication was smallpox was endemic) were chick­ countries of the world, the disease established, whose ultimate aim was enpox and measles. would not recur. However, from the to convince the World Health As­ However, two laboratory-associ­ outset of the Intensified Smallpox sembly that smallpox had indeed ated cases occurred in Birmingham, Eradication Programme the newly­ been eradicated worldwide, so that England, in 1978. On 27 August of created Smallpox Eradication Unit vaccination against the disease that year, the British health auth­ in WHO was acutely aware that there could be discontinued everywhere. orities reported that a medical might be an animal or other reser­ On 9 December 1979 the Global photographer in the University of voir of the virus, especially in the Commission formally adopted a Birmingham was suffering from highly endemic areas of tropical 122-page Final Report, which con­ variola major. Since she worked Africa and Asia. cluded that smallpox had been in rooms immediately above a

18 W oRLD HEALTH , Aug ./Sept. 1987 Death from smallpox was once commonplace. Could the virus sur­ vive in a long-burie(i corpse? Pox­ virus particles were indeed iden­ tified in a mummified child who died of smallpox in 16th century Italy, but careful testing showed the particles were not viable. Photo WHO

laboratory in which WHO-sponsored DNA are now available, which are smallpox, using material from an research with variola major virus safe to handle in open laboratories early case. With the elimination of was being carried out, it was clear and could be used in any emergency the endemic disease in 1976 the that the infection was laboratory­ for comparative studies of the na­ likelihood of continuing variolation associated, although the exact route ture of an orthopoxvirus. disappeared. In Afghanistan and of infection was never determined. Smallpox due to variolation­ China there were many professional The woman unfortunately died-the using material from a victim's scabs variolators and they used stored last ever victim of a disease that to confer " immunity" on others material which they regularly re­ used to kill millions. The only sec­ -caused outbreaks in China in the plenished with fresh scabs, since ondary case was a very mild attack early 1960s, and outbreaks associ­ they found it unreliable for more in the photographer's mother. This ated with variolation were a prob­ than a year. But outbreaks ceased incident alerted medical authorities lem in the eradication campaigns in once the activities of the variolators throughout the world to the poten­ Afghanistan and Ethiopia. In stopped. tial dangers of infection from Ethiopia, variolation was practised Five other possible sources for a laboratories in which variola virus only in the face of an outbreak of return of smallpox can be envis- was being used. Many laboratories used to carry stocks of variola virus as an aid for diagnosis. In response to enquiries by WHO in 1975 , no fewer than 75 The protected and the vulnerable laboratories confirmed that they then held stocks of the virus, but The little girl on the left, in Cote d' Iv.oire, was the following a recommendation that proud possessor of a vaccination certificate. But the little boy in Zaire was one of millions to be only WHO Collaborating Centres for afflicted with smallpox. Poxvirus Research should hold the virus, this number was reduced to Photos WHO/Gouvernement lvoirien and WHO/UN 18 by July 1977. The Birmingham outbreak led to a further reduction to seven laboratories at the end of 1979, and by 1983 only the WHO Collaborating Centres for Smallpox Diagnosis in Atlanta and Moscow held stocks of the virus. Both of these are high security laboratories and they are regularly inspected by WHO experts in microbiological safety. In spite of the very small risk of escape from such laboratories, a ' WHO committee that met in March 1986 suggested that WHO should recommend that these stocks should also be destroyed. This sug­ gestion was based on the fact that cloned preparations of variola virus ' W oRLD HEALTH , Aug ./Sept. 1987 19 aged: an animal reservoir, viral per­ collected, although it was unlikely sistance in the environment, trans­ Global capacity for vaccine production to have had sufficient strength to could be rapidly reactivated in the un­ formation of another orthopoxvirus infect humans. This belief is sup­ likely event of a deliberate release of into variola virus, reactivation and ported by interviews with vario­ variola virus. excretion in a human subject, and lators in Afghanistan, who reported Photo WHO/D. Henrioud deliberate release. that scabs which they had collected In 1959 a disease of monkeys had were seldom able to induce infec­ been reported that closely resem­ tion after one year, even when bled smallpox, and was caused by what was probably variola virus an orthopoxvirus. A group of ex­ have come to the notice of wHo pert virologists was called together since 1979: -one in Tanzania, one in 1969, and met biennially there­ in California and one in the United after, to discuss various technical Kingdom. In all cases the ampoules problems relating to orthopoxvi­ were immediately autoclaved. ruses and to consider especially the The excavation of the remains of disease monkeypox, and any evi­ persons who have died of smallpox, dence relating to an animal reser­ in towns in Europe, for example, is voir of variola virus. Their activities much more frequent than the likeli­ received a stimulus in 1970 when it hood of discovering a long-frozen was discovered that, in central and corpse of a smallpox victim , but this carries a negligible risk of surviving western Africa, monkeypox virus Mummified head of Ramses V caused a sporadic, smallpox-like shows that even a Pharoah was viable virus, since most such re­ disease in humans. But the new not immune from smallpox 3000 mains consist only of bones. In "genetic engineering" technology years ago. 1986, poxvirus particles were in­ has proved that variola virus could Photo WHO deed identified by electron micros­ not be derived from monkeypox copy in the skin lesions of a mum­ virus, and the conclusion among mified child who died of smallpox in virologists is that there is no animal stored at moderately low tempera­ Italy in the sixteenth century. But reservoir of variola virus­ tures. But could the virus survive .in careful testing showed that the pox­ smallpox was a specifically human vials stored in a deep freeze in a virus particles were not viable. disease. laboratory, or in the corpse of a In the early days of virology, it Variola virus is very resistant, fatal case of smallpox that has been was believed that variola virus and viable virus has been obtained deep frozen in an Arctic region? could be " transformed " into vac­ from scabs kept in a European Three instances of unwitting sto­ cinia virus by passage in cows, and laboratory 13 years after they were rage in a deep freeze cabinet of more recently some Soviet virolog-

20 W oRLD HEALTH, Aug ./Sept. 1987 Can smallpox return ? ists suggested that monkeypox virus Deliberate Release come increasingly difficult for any might have been " transformed " person or group contemplating the into variola virus. However, studies In 1973 many nations signed a release of variola virus to assure of the DNA of the accepted species convention outlawing the produc­ themselves and their colleagues of of the genus Orthopoxvirus show tion and use of biological weapons. protection against smallpox. Re­ that the differences between the Unfortunately, this does not com­ sumption of vaccination against DNA molecules of each species are pletely exclude the possibility that smallpox by a country could legiti­ too great for such a "transform­ variola virus might be deliberately mately be interpreted as a sign that ation" to occur. released as a means of warfare. But it might be considering the use Some viruses, such as the herpes the risk of the re-establishment of of variola virus for aggressive viruses, persist for life in infected endemic smallpox should not be purposes. persons and at intervals are reac­ exaggerated. Smallpox spreads Deliberate release or the threat tivated and cause the subject to comparatively slowly , by face-to­ of it by an individual or group, as an become infectious for others. Pox­ face contact. Unless the public act of sabotage or terrorism, cannot viruses, as a group, do not exhibit health services had completely bro­ be absolutely excluded, although this type of behaviour. If such reac­ ken down, the existence of reserve the possibility is remote because tivation were to occur, it would be stocks of vaccine and the capacity access to the virus is so restricted. most likely in patients subject to for production of vaccine to be The existence of such a possibility immuno-suppression, either by rapidly reactivated would ensure underlines the need for maintaining chemotherapy or because of a the containment of any outbreak "military" as well as microbiologi­ malignant disease of the lymphoid that followed a deliberate release of cal security in the two laboratories system. No such occurrence has variola virus. still holding variola virus stocks or, even been recognised, and this po­ With the cessation of vaccination better, the destruction of all such tential source can be excluded. and vaccine production, it will be- stocks. •

International Rumour Register In compil ing its International For example, a report from Kenya that rumours of smallpox in several Rumou r Reg ister. wHo recognised ca used some public hea lth concern countries of sub-Saharan Africa were that prompt reporting, investigation because the patient, who died three false. and diagnosis of all reports or days after developing a rash, had Rumours of small pox, especially rumours of suspected cases of been a trad itional hea ler, perhaps an those generated by the media, cou ld sma ll pox are essential tools for ex-va riolator who had used material spread rapid ly and cause inter­ maintaining the public confidence in from smallpox patients to immuni ze national concern. Iron ica ll y, one the fact of eradication. Assistance in others at a time when sma ll pox was "doctor-confirmed" rumour arose at this investigation and the collection sti ll endemic in hi s area. Prompt an international health seminar in of specimens for laboratory testing investigati on and co ll ection of spe­ lxtapa, Mexico, in 1985, w here 250 has come from state and reg iona l cimens by Kenyan hea lth officials delegates were warned to see their health departments, often staffed by and rap id laboratory investigation doctor upon returning home because veteran small pox fi ghters. proved w ithin a week that he had a delegate had been diagn osed by a The time requi red for national had ch ickenpox. hotel doctor as having smallpox. The health authorities to investigate the On the other hand, information rumour ci rcu lated ab road before a suspected cases va ried consider­ provided at a meeti ng of an interna­ diagnosis of chickenpox was con­ ably, pa rtly depending on the ap­ tiona l organization req uired nin e firmed by the WHO col laborati ng parent seriousness of the rumours. months of investigation to establish laboratory. •

Suspected cases of smallpox reported to wHo Headquarters, Geneva, 1980-1986 Ill Number of reports Results of investigation

Ski n 1 WHO Region 1980 81 82 83 84 85 86 Tota l Chi ckenpox Measle s disease Errors

Africa 9 11 5 5 6 5 6 47 18 7 8 14 Americas 3 6 0 4 5 0 1 19 11 1 3 4 South-East Asia 12 4 3 8 8 5 2 42 17 7 2 16 Europe 1 2 0 0 0 0 0 3 3 0 0 0 Eastern Mediterranean 4 3 2 1 2 0 0 12 2 1 2 7 Western Pacific 2 4 0 1 0 0 1 8 3 3 1 1

TOTAL 31 30 10 19 21 10 10 131 54 19 16 42 ' 1 In statistical reports, or by the news media. WoRLD HEALTH, Aug ./Sept. 1987 Surveillance and research by Svetlana Marennikova

nly two years after the world's which had been created by WHO , to involved in investigating rumours last case of endemic smallpox confirm that the whole planet was about smallpox, some of which (!] occurred in Somalia, in Oc­ "clean". In the Commission's re­ reached the press and thus aroused tober 1977, WHO was able to make port, recommendations for the the natural concern of the public. In the official declaration of global post-eradication era occupy a spe­ all these cases, WHO was eager to smallpox eradication. Throughout cial place, because of the need to obtain from the collaborating this period a continuous search was give the public evidence that small­ centres the results of laboratory undertaken for possible hidden pox will never reappear and that study of materials taken from the cases in the areas where the disease mankind is not endangered by other patients in question. To our general had previously been endemic. poxviruses. satisfaction, the rumours have This thorough and comprehen­ never been proved true. sive search relied heavily on ••••••••••••••••••••••••••• It is appropriate here to make a laboratory investigations of all sus­ • • small digression. During the cam­ : Dr Svetlana MARENNIKOVA : pect cases, since it was often only paign the laboratories performing •: is Chief. WHO Collaborating •: the laboratory that could show the diagnostic work that was : Centre on Smallpox and Re- : whether the disease was smallpox needed in order to identify new : lated Infections. Laboratory of : or not. Thousands of such investiga­ viral isolates used to use laboratory : Viral Vesicular Infections. : tions were carried out on smallpox strains of the variola virus. At our : Moscow Research Institute : suspects from dozens of countries at laboratory and elsewhere, the : for Viral Preparations. : the two institutions supremely qual­ • • peculiarities of variola virus strains ified in the laboratory diagnosis of ••••••••••••••••••••••••••• isolated in different geographical pox infections, namely, the WHO regions were studied. This work not Collaborating Centres in Moscow Laboratory work combining both only enlarged our knowledge of the (Moscow Research Institute for diagnosis and research formed a variola virus but also made it possi­ Viral Preparations) and in Atlanta, substantial element in this post­ ble to explain the difference in the USA (Centers for Disease Con­ eradication surveillance pro­ clinical course of the so-called trol) . These investigations gave gramme. The diagnostic part was in " Asian " smallpox and " African " negative results for all suspected effect a continuation of similar smallpox. The research undertaken cases: not a single case of smallpox work carried out during the closing in other laboratories involved a has been revealed. stages of the eradication campaign, comparative analysis of variola and The data obtained provided the when it related to patients sus­ other orthopox (especially monkey­ major premise that enabled the pected to be smallpox cases. pox) virus genomes. As a result of Global Commission for the Certifi­ In the past decade we at the this long-term work with variola cation of Smallpox Eradication, Moscow Collaborating Centre were virus, a vast collection of its strains was gathered in some laboratories. After smallpox transmission stop­ ped, the stocks of strains preserved in laboratories turned out to be a real potential hazard for the reap­ pearance of smallpox. The small number of laboratory­ acquired smallpox cases testify to the fact that work with variola virus without appropriate precautions al­ ways presents a danger for those who handle it as well as for other people. A threatening reminder was

Sealed refrigerator at the WHO Col­ laborating Centre in Moscow where variola virus strains are stored. Besides a lock and a seal, it is fitted with a sound alarm. Photo W HO/S. Marennikova

W oRLD HEALTH , Aug./Sept. 1987 the tragic episode that occurred in 1978 in Birmingham, England, when a woman working one floor above a laboratory where variola virus strains were being studied contracted smallpox and died. Her mother, too, was infected but recovered. The abandonment of vaccination after smallpox eradication naturally increases the risk of infection spreading if the virus ever escapes from a laboratory. That is why WHO has undertaken a complex of mea­ sures to exclude such a possibility. The first step in this direction was to reduce the number of laboratories maintaining variola virus strains. This process started even before the campaign was completed. In 1976 there were 76 such laboratories, but today there are only two, both act­ ing as WHO Collaborating Centres. The stocks in other laboratories work at the collaborating centres, it have either been destroyed (in most has been established that human Laboratory technicians in the Moscow cases) or transmitted to one of the monkeypox is a rare zoonotic dis­ centre which played a key role in eradicating smallpox. two centres. ease, but the geographical area Photo WHO/Novosti Besides this , in 1977 WHO began where it can be encountered is a to develop biological safety require­ large one and covers the tropical ments for laboratories dealing with rain forests of Equatorial Africa. periodical control of the properties or preserving variola virus. After Most patients (75.1 per cent) get of this virus in the future. some improvements, these require­ infected from animals-the natural Among other orthopoxviruses ments provided appropriate safe­ carriers of the virus. In 18.6 per (besides vaccinia virus), the cowpox guards both for people handling the cent of cases, the source of human virus is pathogenic for humans. virus and for those in the vicinity. monkeypox under conditions of During the years of post-eradica­ WHO inspection teams regularly close contact was the infected per­ tion surveillance, our knowledge of check that these requirements and son (second infection generation). the ecology of this virus was ex­ virus storage regulations are fulfil­ Transmission to the third genera­ tended. The most interesting thing led. It should be added that re­ tion was very rare (less than seven here is that we had to change our search into variola virus has actually per cent), and only once in 17 years opinion about the natural reservoir stopped within the last two years. was a fourth generation infection of this infection. It has been proved Now the question arises whether we found. Results obtained so far con­ that the carriers of the virus in must continue maintaining stocks of firm the initial data showing the nature are small rodents. It also variola virus or destroy them. small contagiousness and transmis­ appeared that the cowpox virus A no less important part of sibility of monkeypox in compari­ possesses a wide range of laboratory research in the post­ son with smallpox. pathogenicity and can affect indi­ eradication era was the study of An important step in the mon­ viduals of the majority of tax­ human monkeypox, a disease " dis­ keypox study was the detection of a onomic groups of animals. Recently covered" in Equatorial Africa in natural reservoir of this infection. the possibility of human cowpox 1970. Its striking feature is the For a number of years, efforts in infection caused by contact with similarity of the clinical picture to this direction failed to give any sick rodents was demonstrated. The that of smallpox. This very fact perceptible results. Only by the end feature of this infection and its accounts for the close attention paid of 1985 did the combined investi­ contagiousness has not changed to this disease and the need for it to gations carried out by WHO since Jenner's time, and it is only be investigated in the framework of epidemiologists and virologists harmful to human health in special a special WHO project. Some ques­ from the collaborating centres re­ cases, for instance, when it affects tions still remain to be answered sult in the discovery of the virus the eye. about the development of infection reservoir. It turned out to be some The overall conclusions of the in human beings, the ecology of the species of tropical squirrels. surveillance and research into virus and the potential danger of The long-term (17-year) study of orthopoxvirus infections conducted monkeypox under conditions of a monkeypox isolates obtained from during the post-eradication period steadily vanishing immunity to patients in various African coun­ are that smallpox itself has com­ smallpox. As a result of activities tries showed the pathogen to be pletely disappeared and that other organized and coordinated by WHO quite stable and not prone to any orthopoxviruses, including mon­ between surveillance teams in some substantial variability. However, it keypox, do not present a danger African countries and laboratory seems reasonable to maintain for public health. •

W oRLD HEALTH, Aug ./Sept. 1987 23 Gening your money's worth

by John F. Wickett

eople's eyes tend to glaze over would save them money. But they over a limited period on the eradi­ the minute they hear the also gained by no longer having to cation campaign. The amount lJ words "cost benefit analysis." treat complications, and maintain routinely spent on control, in real­ We all want to be convinced we are international controls. ity, counts as a saving ("the ben­ getting value for money, but in this efit") as a result of eradicating the case the benefit is more apparent disease. than the cost. •••••••••••••••••••••••••••• • The ratios of international to na­ Everyone knows that smallpox •: Mr John F. WICKETT, a for- •: tional input into smallpox eradica­ was a truly dreadful disease which • mer consultant with WHO's • tion were, in Bangladesh 1:1, in literally terrorised mankind for •: Smallpox Eradication unit, is •: Ethiopia 10:1, in India 1:3, and in thousands of years, and that, : now a consultant with the : Indonesia 1 :2. Let us assume for through international cooperation, : Special Programme on AIDS. : the other countries of Africa a ratio the disease has been totally elimi­ • • of international input to national nated. Everyone thinks, "Ah, yes. ••••••••••••••••••••••••••• input of 2:1, an equal share for This is a good thing. " The benefit is South America, and equal or two obvious. WHO calculates that the following times international spending per But then "everyone" did not costs for eradicating smallpox were national spending in the rest of have to pay for it; that was some­ incurred by the international com­ Asia, and we arrive at a total for thing to do with WHO, donor agen­ munity over the 13 years from 1967 national input that is at least equal cies and governments. Did we get to 1979: to the international input of $100 value for money? Estimated expenditure million. Even though Edward Jenner dis­ 1967-1979 Another way of looking at the covered vaccination back in 1796, International sources us$ problem is to note that India, na­ as recently as 1959 some 60 per WHO regular budget 33,565,248 tionally, spent $50 million to eradi­ cent of the world's population lived WHO voluntary fund 37,643,037 cate smallpox, money spent in this in areas endemic for smallpox. By Other agencies 2,492,328 field before 1973 considered as be­ 1967 and the start of WHO's inten­ Bilateral assistance 24,269,124 ing allocated to "control". In 1967, sified programme to eradicate India accounted for half the popu­ smallpox globally, fully 30 per cent 97 ,969,737 lation of the 31 smallpox-endemic still lived in endemic areas. Ten These figures are necessarily esti­ countries. Two times $50 million years later the disease had been mates, so let us say that interna­ equals $100 million, or the equiv­ wiped out and, by the end of 1979, tional input was $100 million, of alent of the international input. the Global Commission was able to which 70 per cent was channelled It is reasonable to conclude that certify that fact. Certification was through WHO. the total cost to the world of small­ an essential concomitant of the How much did countries spend pox eradication was as little as $200 actual eradication of the disease themselves? This is less easy to to $300 million. because the "pay-off" of the pro­ estimate, as we have to compare the The obvious basic saving re­ gramme was for countries to be amount a given country was spend­ sulting from eradicating smallpox absolutely convinced that it was ing each year on on-going smallpox comes from being able to stop vac­ safe to stop vaccinating. This alone control with the amount it spent cinating. A study performed in the

24 W oRLD HEALTH, Aug./Sept. 1987 History' ol eradication

~ ~~~rr~ ";~~ ;i~dpu 0~1is~i~ L.:.J 1,500-pag~ monograph which will be the definitive history ot. smallpox and of its eradication from the planet The publication coincides with the tenth anniversary of the finding-in Somalia_:of the world's last case of smallpox. lt includes chapterswritten by F. Fenner, D.A. Henderson, I. Arita, Z.Jezek and I .D. Lad­ nyi, who ·were · al[ intimately involved in the international effort to wipe out the disease af')d to prove to the worldthat it had.beeneradicated. Hie 31 and death that smallpox would have chapters of this monumental Case-finding in East Africa during the caused. work describe this now-ex­ closing stages of smallpox eradication. tinct di.sease, its virology, The costs of the programme were mod­ To estimate the value of not hav­ ing smallpox cases, we may look to pathology, immunology and est-the benefits incalculable. epidemiology, and its history Photo WHO/D. Henrioud a study in India based on 1971 prices. The cost associated with and the methods used to pre­ mortality was based on loss of pro­ vent it or mitigate its eJfect United States estimated that in ductivity at $900 per death, ad­ from ancient times to thevery 1968 it had cost $150,118,000 to justed for age, sex, life expectancy re:9er)t pa!?t . .:.lt e~pla ,ins .tlow vaccinate 7.2 per cent of the popu­ and distribution of cases. The cost the idea of. wipir'lQ Out small­ lation including producing and ad­ of morbidity was based on loss of p~x germinated, an? Qives a ministering the vaccine, treating productivity during 17 days. Treat­ step-by-step and country-by­ complications, indirect costs from ment costs are not considered here. country account of the usuc­ death, disability and loss of earnings The number of cases of smallpox cesses .and Occasional set­ from complications, and administ­ reported throughout the world in backs during wthe intensified ration of traffic and maritime clear­ 1967 is thought to be in the neigh­ programme for its eradication ances. Of the total, $92,800,000 bourhood of only one per cent of from 1967 to '1977. Finally, it was for vaccine and its administra­ those actually occurring. To be con­ explains the rigor9us system tion. In addition, there were indi­ servative, we shall assume two per of certiJicatjbn' instituted by rect costs equal to 46 per cent of cent reporting. Pro-rating other WHO:. .• which ensured :that,.one this figure. countries reporting cases of variola part of the globe after'another '" Let us leave out traffic clear­ major against India's per capita . coul.d be decl9r;ed a srqallpox­ ances. Let us assume all countries GNP and life expectancy, and then .free ~one uptil. i~ ·May were vaccinating to some extent adjusting to a 1979 dollar value, we 1980-some ;. 1~0 years after and calculate the cost based on each arrive at an estimated annual saving Epward .. J~nner. . forecast that country's per capita gross national of $1,500 million-give or take a hi~ n~wly-discovered vaccl~e product (GNP) relative to the few hundred million. must'result in the annihilatiOn . United States. Then we convert the To sum up-if you have managed of the 'disease- the World sum to 1979 dollars, since, if eradi­ to get this far-an investment of Health Assembly was ···· able cation had not been achieved, that some $200 million resulted in a sav­ formally to declare that small­ is the level at which money would ing-or rather, prevented a recur­ pox tlad been eradiq~tep. still have been being spent. It comes rent annual burden-of $1 ,000 mil­ Entitled ''Smallpox ghd its to $783,284,510. Add 46 per cent lion plus $1 ,500 million equals E:radication," the monograph for indirect costs in the indus­ $2,500 million. An annual return on is profus~ly il.l ustrated .. with trialised world (thus excluding de­ your investment of 1,250 per cent! c9lour plates ,, and" blaCIS-and­ veloping countries) and you arrive If putting a cash value on human yvhite pictures, and car) be at $1,000 million per year! suffering makes you uncomfortable, ordered from : DistribLtion This saving of $1,000 million per it still works out to an annual return a~d ·· s~ . les,w~ o . 1211 Geneva year is necessarily speculative, and of 500 per cent. Now that's what I 27, ~witzerland. · • it takes no account of the sickness call getting your money's worth! •

W oRLD HEALTH, Aug ./Sept. 1987 25 ...... I I I I I Spin-on lrom space travel I I I I Food associated diarrhoea! diseases are preventable and need I not occur. The concept of the hazard analysis critical control I I point (HACCP)· is the most viable means to this end yet devised I I I I I by Silvia Michanie and Frank L. Bryan I I I 1 [ t was in order to provide abso- A critical control point is an oper- During hazard analyses, sources 1 lutely safe foods for astronauts ation (practice, procedure, process and modes of contamination are I while travelling in space .in the or location) or a step of an opera- sought. Measurements establish I 1960s that the hazard analysis criti- tion at which a preventive or con- whether disease-causing microbes I cal control point (HACCP) con- trol measure can be exercised. This survive cooking or other processes, I cept evolved in the United States. measure will eliminate, prevent or and whether they multiply during I During the following decade, the minimise any hazard that has oc- intervals between preparation and HACCP approach was adopted by curred prior to this operation. ingestion. Certain foods may or I the US Food and Drug Adminis- The criteria that ensure control at may not lend themselves to sup- ~ tration in cooperation with the critical control points are specified parting the growth of microbes. 1 food-processing industry as a ••••••••••••••••••••••••••• Samples may be collected and ana- l means of providing safe low-acid ! lysed for the presence and quantity 1 canned foods. Dr Silvia MICHANIE is Food : of disease-causing and/or spoilage 1 Since then, many food proces- Protection Supervisor at the : microbes. Each step of the food I sors and some food-service Pan American Health Organi- : flow is considered and illustrated I operators have found that the zation/Pan American Zo- : on a diagram, with the hazards and I HACCP approach does not only onoses Center (CEPANZO), : critical control points highlighted. I provide a high degree of assurance Buenos Aires, Argentina, and ! Answers have to be found to a I of food safety and quality; it is also Dr Frank L. BRYAN is a Food : number of questions. For instance, economically advantageous. it is Safety and Training Consul- : what are the raw ingredients? I rational since it is based on histori- : tant based in Tucker, Georgia, : What is the pH (degree of acidity) I cal data about causes of illness and ! USA and works periodically as ! of the final product 7 What is the 1 spoilage; it is comprehensive in : a Consultant to the WHO/PAHO : time-temperature exposure of the 1 that it relates to ingredients and : Food Safety Programme. : product during processing of prep- 1 subsequent use of products as well : : a ration? Will the product be eaten I as to the process; it is continuous ••••••••••••••••••••••••••• immediately after preparation, or I in that problems are detected limits or characteristics. They may will it be stored hot, cold or at I when they occur and action is ta- be physical (time, perhaps, or tem- ambient temperature? I ken then to correct them; and it is perature), chemical (concentration This looks rather sophisticated I systematic in that it is a cam- of salt or acetic acid), or biological for use in homes, yet these anal­ ~ prehensive plan covering step-by- (sensorial or microbiological). yses have been conducted in 1 step procedures. And it offers grea- Monitoring means checking that homes in a capital city, an island I ter assurance than either testing a processing or handling procedure city, a suburban shanty town, a 1 final products or making periodic at each critical control point meets mountain pueblo and a rice-farming 1 inspections. the established criteria. it involves village. The variety of these set- 1 By hazard we mean the unac- systematic observation, measure- tings provides a stringent test of I ceptable contamination, growth or ment and recording of the signifi- the validity of the approach, and it I survival of micro-organisms that cant factors needed to prevent or has passed the test. I might cause illness or spoilage, control hazards. The monitoring In addition to contamination that I and/or the unacceptable produc- procedures chosen must enable may be specific to certain kinds of I tion (or persistence in foods) of action to be taken to rectify an out- raw food, such factors as tradi- ~ toxins of microbial metabolism. of-control situation or to bring the tions, education, economic re- I Severity is the magnitude of the product back within acceptable sources, sanitary facilities, personal 1 hazard or the degree of conse- limits either before start-up or dur- hygiene and environmental sanita- 1 quences that can result when a ing processing or preparation. So tion may further contribute to 1 hazard exists. Risk is an estimate of one great advantage of the HACCP hazards during preparation, when 1 the probability that a hazard will system is immediate response to food is kept after being cooked, or I occur. hazardous situations. while leftovers are handled . The L••••••••••••••••••••••••••••••••••••••••••••••••••••1 ••••••••••••••••••••••••••••••••••••••••••••••••••••• I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I giene to select or devise preventive able, and must also be communi- Hazard analysis involves finding out 1 whether disease-causing microbes sur­ and control measures and criteria. cated to the public either through 1 vive cooking or other processes. A hos­ These have to be both economical­ organized community action or na- I pital kitchen in Santiago, Chile. ly feasible and culturally accept- tional educational campaigns. I Photo WHO/P. Almasy As the diarrhoea! diseases are I studied in all their aspects more I intently than in the past it is be- I greatest hazard, however, is hold- coming clear that contaminated I ing cooked foods at ambient temp- and mishandled foods are the ma- erature for six hours or longer be- jar vehicles of transmission. So the I tween preparation and eating. This educational follow-up of HACCP 1 allows time for microbial contamin- evaluations may be the most valu- 1 ants to multiply to quantities large able function of the HACCP con- 1 enough to cause enteric illness or cept. This is particularly so in coun- 1 to generate toxins. Reheating of tries that lack foodborne disease I the leftover foods is often not surv.eillance activities. The infor- I enough to inactivate microbes that mation gathered can be used to in- I have grown during long holding form the health and social auth- I periods. orities, train public health personnel I All these observations reveal the and educate the adult public and I hazards and indicate the critical ,!, schoolchildren. control points of culture-associated ' (V.~[ify th~" syst~g:fi§ Food associated diarrhoea! dis- I food preparation procedures. The fung}joningas , pla~neg) · eases are preventable and need 1 next step of the HACCP approach not occur. The HACCP concept is 1 is for persons who are knowledge- the most viable means to this end 1 able of food microbiology and hy- yet devised. • I ~--·················································-~ Health Manpower Developtnent

Meeting health needs by Abdul Rahman AI-Awadi

ealth manpower is the key to developed countries alike. On the the present period of economic the whole health system other hand, a lack of other types of recession. mstructure, as this system de­ health manpower can be found in If the picture is already dark in pends mainly on service delivery. some countries such as Brazil, some developed countries, the de­ Since the key person in health care where physicians have even been veloping countries should learn delivery has traditionally been the doing the work of the nursing staff their lesson and be fully aware of physician, physicians have domi­ in certain areas of health care the great danger that may befall nated the health manpower picture delivery. their own health care systems if and have tried to build the pattern Such situations do not only cre­ proper thinking has not been ap­ of health care around themselves. ate an imbalance in manpower pro- plied to the issue of health man­ The result has sometimes been power development. very far removed from the actual •••••••••••••••••••••••••••• • What can they do? The answer health needs of communities. •: Dr Abdul Rahman AL-AWADI •: is to undertake appropriate health There have been other serious : is the Minister of Public Health : manpower planning. How can this consequences. Firstly, a great deal : of Kuwait. : be done? Firstly they must estab­ of emphasis has been put on train­ • • lish the country's health care deliv­ ing and developing physicians, and ••••••••••••••••••••••••••• ery requirements, taking into very little attention has been paid to duction, but also result in social consideration all the factors that other categories of health person­ unease and self-dissatisfaction. influence economic and social con­ nel. The training of medical person­ Thus in Mexico, the large numbers ditions. Of course, health care nel has always been hospital­ of unemployed physicians are delivery systems vary but if the centred, and hospital-oriented caus ing a problem for the govern­ guiding principle is the Alma-Ata health care has tended towards ment as they are very vocal in their Declaration on primary health care specialisation and sub-specialis­ demands and grievances because and the main goal is Health for all ation. As a result, community phys­ of their sophisticated education. In by the year 2000, the range of icians and general practitioners addition to this, the high cost of needs can easily be defined. have become "second class doc­ training of physicians poses a chal­ Next, they have to set down the tors" (the specialists being the lenge to many governments in proper objectives and goals in such "first class doctors"), and team a way that they can be quantifiably work by all medical personnel has defined and easily accepted by the not been recognised as lying at the policy makers. They should move core of health care delivery. Finally, to create a central health planning physicians have been left to them­ body working in close coordination selves to plan the health care deliv­ with the country's general plan, if ery system without involving such there is one. The central planning people as economists, paramedics, body should include represen­ statisticians, planners and sociolog­ tatives of all levels of health per­ ists, while the medical schools sonnel, besides specialists from have been dominated by phys­ other fields such as economists, icians and shaped around them to sociologists, statisticians, planners, the exclusion of other categories of health managers and education health manpower. experts. And let us not forget the These consequences have led Health workers in training in the East­ consumers- representatives from to the over-production of certain ern Mediterranean region. In the past, the general public. manpower in some countries, es­ too much emphasis was put on training lt is important that the health pecially the developed nations. And physicians, and very little on developing plan produced by this central plan­ other categories of health personnel. the surplus of physicians has be­ ning body should be built around come critical in developing and Photo WHO/D. Henrioud the health needs of the population

28 WoRL D HEALTH, Aug./Sept. 1987 and should be realistic in its objec­ tives and goals. A health plan docu­ ment is easier to prepare than to carry out. Now the problem will be to de­ velop the right health manpower mix. This mix is the real fuel and moving force in carrying out and expanding health care, so the health manpower training system has to be carefully designed. This is where the real challenge for health planners exists. An appropriate coordination mechanism between the production of health manpower and the use made of that man­ power is of utmost importance. Finally, it is vital to clarify the role of ministries involved in health care delivery and the role of training bodies involved in health man­ power production; proper links and coordination between these two bodies will require the utmost political backing. Without such backing the problems raised by an improper health manpower mix will seriously jeopardise the future of the developing countries.

Using the surplus In view of the above, the ques­ tion might be asked : How can we deploy a surplus of health man­ power in developed countries to benefit the developing ones? Much of this abundance of health manpower may on the face of it be unsuitable to the needs of the developing countries. But if it is truly intended to make use of this surplus, I believe that a real com­ mitment should be made by the countries with a surplus to transfer these health personnel to develop­ ing countries once they have been properly trained and reoriented . The developing countries them­ selves should be willing to incor­ porate this influx of manpower into their health system after making sure that they are properly trained for the type of health care they will Greater coordination and cooper­ A student nurse learns how to weigh a undertake. This programme could ation between these two organiz­ baby. An improper " mix" of all kinds be carried out under the sponsor­ of health worker can seriously jeopar­ ations to achieve a better and more ship of international organizations. dise the future of the developing coun­ effective system for health man­ wHo itself has a great deal of tries. power development will remain a influence and prestige among all Photo W HO/UN challenge that has to be met. If WHO countries as regards the delivery of and UNE SCO can accept such a chal­ health care to counter the health lenge and attempt to develop bet­ problems of the world. But unfortu­ other international organizations in­ ter models for health care delivery nately, its role in health manpower volved in manpower development systems and health manpower de­ development has not been effec­ globally, such as UNESCO, the UN velopment. the benefits for de­ tive and influential. This is in part Educational, Scientific and Cultural veloping countries can be of Im­ due to the lack of coordination with Organization . mense value. •

W oRLD HEALTH, Aug ./Sept. 1987 29 ...... Setting the Record ...••••••• ...... •••• ... ••• ...••• ...••• .• .....••••• ...... •...... •••••••••••••••••••••••••• ...... Biotechnology Era Straight About ...••• ...••• ....•••• ...••• ...••• ...••• • .....••••• .•...... ••••••••••••••••••••••••• . Of Vaccines Seen ...••• ...••• •••• ...••••••••••• ...... ••••••• ...... ••• .•...... ••••••••••••••••••• . I Monster Bugs I ...••• ...••• ....•••• ...... ••••••••••• ...... ••••••• ...••• .•...... •••••••••••••••••• . By Year 2000

A charge made during a re­ A new era of vaccines based cent meeting in Chicago of the on advances in biotechnological American Association for the Smoke-Free Work Sites techniques will be ushered in Advancement of Science that by the Year 2000, predicts a "strains of monster bugs" re­ Growing World-wide group of leading scientists who su lted from use of DDT during met recently in Geneva to malaria campaigns has been re­ Th e impetus to ban. or to • Australia. 1 March assess developments under butted by WHO. curb, smoking at work sites 1988 has been designated the theme "Immunization: Where resistance to insecti­ and public places. is picking as the target date for New Horizons". up momentum-in the smoke-free offices through­ cides developed "this was So much progress has been United States particularly, out the government. made says Dr Kenneth S. War­ mainly due to their widespread but elsewhere as well. • Belgium. King ren, Director of Health Sci­ use in agriculture-in areas Among recent develop­ Baudouin has signed into ences. Rockefeller Foundation, where there was intensive ag­ ments : law a ban on smoking in that these vaccines are likely to ricultural exploitation. involving • United States. Th e most enclosed public render antibiotics obsolete. aerial spraying of crops-and Federal Government, the places -such as schools. " lt is my belief." he adds not to the limited amount used employer of 2.3 million hospitals. rest homes. rail­ "that oral rehydration-that in malaria control operations", people, has ordered all de­ road stations and cu ltura l remarkable and relatively new says Dr Hakan Hellberg, until partments to provide a and sports centres- effec­ tool for the treatment of diar­ recently Director of WHO 's Divi­ "reasonably smoke-free en­ tive from 1 September rhoea! diseases-will also be sion of Public Information and vironment" on the job. in 1987. rarely used at the turn of the Education for Hea lth. essence decreeing that The law provides for fines century. Even family planning WHO launched a worldwide smoking is now forbidden of up to 18,000 Belgian will be aided by vaccines." everywhere except where it francs ($480) for violators. Among prospects are two malaria eradication programme is expressly permitted. • Peru. Th e country has vaccines against malaria, one in the mid-1950s on the basis New York State has pas­ banned smoking , as from genetica lly engineered. and the of successes achieved in sed laws-considered the December 1986, in all of­ other synthetic. as a result of Europe, the southern United toughest in the country fices of the Ministry of work in Australia and Sweden. States. and areas of a number - against public smoking in Hea lth . which are "about to undergo of tropical countries. such places as "indoor their first testing in man"; as By 1968 the number of arenas. schools and au­ • Singapore. The coun­ well as vaccines against schis­ people living in areas free of ditoriums. club houses and try has not only banned tosomiasis. or snai l fever; smoking in public places but malaria increased from an esti­ court houses. gymnasiums. aga in st leprosy, now being also in private offices that health clubs. rest rooms. tested in Venezuela; and mated 316 million to 997 mil­ share a common air-condi­ stores. banks. hospitals and against hepatitis B. lion, and mortality declined from tioning system with other movie theatres". according Although hepatitis B vac­ 2.5 million to under one million offices. to the New York Times . cines. based on techniques of yearly. In India alone. the death In banning smoking, the Now it has launched a genetic engineering, are being rate dropped from 75,000 to prestigious Mayo Clinic in campaign aimed at making produced by "at least seven Rochester. Minnesota has Singapore "a nation of non 16,000 -probably the single different manufacturers." he told its 14,000 workers that smokers" based on televi­ most significant indication of says, "a cheaper technique for the programme's success. "to permit smoking would sion spots aimed at over­ coming the public's shyness producing the vaccine from "Hopes were high that be inconsistent with ou r leadership role in health". about complaining about plasma has been developed malaria cou ld be conquered And, at a new community smoking, and on a campaign by the New York Blood Center. before resistance appeared," hospital opened recently in song that says: lt is being made in Korea at a Dr Hellberg says, "hopes Wentzville, Missouri, smok­ "Hey there. Singapore. cost of approximately $1 a which. with hindsight. are easy ers need not apply for em­ its time to clear the air. dose". to criticise". ployment. the management "Come on all you smok­ According to another par­ The criticism of WHO's malaria said. ers. show us that you care. ticipant, Dr Ralph Henderson. programme led to a story in the " We know that its a prob­ Director of WHO's Expanded Programme on Immunization: International Herald Tribune lem and quitting can be tough, "Progress in biotechnology headed. "Misuse of In sec­ "But we are sick of the makes it certain we will get ticides Creating 'Monster smoke and we think you've improved vaccines for six chil­ Bugs'." In a reference to a had enough." dren's diseases- measles. te­ statement that WHO had "given • United Nations. WHO tanus. whooping cough, polio. up" the programme in 1976, diphtheria, and tuberculosis." became the first of the UN Dr Hellberg said : specialized agencies to ban While saying that "we would "WHO has not abandoned its smoking, doing so begin­ certainly welcome vaccines malaria programme but its ap­ ning from 7 April, World that ca use fewer side effects. proach has changed. WHO sup­ Hea lth Day. UN IC EF is ex­ that are less sensitive to heat. ports a three-pronged ap­ pected to follow. The UN and that can be used with only proach : the judicious use of administration in New York one dose. and be given any suitable insecticides. biological is carrying out a staff survey time from birth," the task to­ day, he warned, " is to im­ control of disease-carrying in­ as a prerequisite to action. In the United Nations. as munize with the "old" vac­ sects. and general improve­ well as in the UN Develop­ cines and thus protect chi ldren . ment of the environment." ment Programme. smoking " We need to complete this lt also supports research to Photo WHO /Tibor Farkas is already prohibited in sma ll ta sk without delay," he states, find "new and better insecti­ At WHO headquarters : A conference rooms. and is "for each day that passes con­ cides and drugs, as well as a sign of changing times. discouraged in larger ones. • demns more than 9.000 chil­ malaria vaccine". • dren to needless death." •

30 W oRLD HEALTH , Aug ./Sept. 1987 wHo Found IUDs 'Safe, Effective, Newsbriefs And Reliable' • AIDS and a Smallpox Connection. Following a story carried 11 May in the Times of London stating that "the AIDS epidemic Intrauterine devices are may have been triggered by the mass vaccination campaign which "safe, effective and reliable" eradicated smallpox," this response from Or Jonathan Mann, as a method of contraception, Director of WHO's programme on AIDS: according to a group of experts "The only result we know of from the smallpox eradication from 13 countries. Meeting re­ programme was the eradication of smallpox itself. . cently under the auspices of "In Asia, where hundreds of millions of smallpox vaccinations WHO to evaluate that method of were given from 1967 to 1972, AIDS remains rare. Conversely,. the contraception, they add, how­ United States is experiencing a major AIDS epidemic, yet smallpox ever, that "careful patient was eradicated there many years ago (in the early 1950s). selection is essential for IUD "As many doses of smallpox vaccine were given in west Africa use. as in central Africa, yet AIDS is less common in west than in central Africa." Co pper T 220 - C • Calendar. Of more than usual noteworthiness, the 6th World Conference on Smoking and Health, from 9 to 12 November in Tokyo. Among items on the agenda: smoking and wom- • en, smoking and children, passive smoking, and the economics of smoking. ~ The Japan Heart Foundation, the Japan Anti­ Tuberculosis Association, the Japan Cancer Society, and the Japan Health Promotion and Fitness Foundation are represented on the conference's organizing committee. cm (For more information, w rite Japan Convention Services, Inc., Nippon Press Center Bldg ., 2-2-1 Uchisaiwai-c ho, Ch iyoda-ku, Tokyo, 100.) • "Inequity-a Sin". This excerpt from an address by Or Halfdan Photo WHO Mahler, WHO 's Director-General, delivered at the 1st International IUDs: The choice of 60 mil­ Conference on the Ethical and Moral Problems of Phar­ lion women. macotherapy held at the Vatican City: Developed about three de­ "The gap between 'health haves ' and 'health have-nots ' can cades ago, IUDs are estimated be summed up in one word-inequity. Need I remind you that the today to be the choice of con­ word closely resembles iniquity- a sin. Mere repentance by the traception for over 60 million world at large will not help. Action is required." women throughout the world. • Invitations to Research. WHO is seeking proposals for research However, lawsuits have in these two areas of human reproduction: (1) the regulation of been taken out against manu­ male fertility, and (2) the natural regulation of fertility. Being facturers, notably in the United offered for the former are initial grants up to $10,000, and for the States because IUD use has been linked to an increased risk latter, up to $20,000. of pelvic inflammatory disease, Submissions, including a provisional budget, should be a page and to infertility. in length and sent to WHO's Special Programme of Research, Two manufacturers have, as Development and Research Training in Human Reproduction, a result, discontinued produc­ Geneva. tion of IUDs, which in turn has • Like Father, Not Like Son. An heir to the fortune that tobacco "triggered off a worldwide built has divested himself of all stock in the family business while chain reaction of concern", the calling for a smoke-free US society by the Year 2000. experts say. "When my grandfather began manufacturing cigarettes at the However, "the risk of pelvic turn of the century, he did not know that smoking causes lung inflammatory diseases from disease, heart disease and cancer," Patrick Reynolds told an IUD use is much lower than interviewer from the New York Times. "Now that this has been that was previously thought", is "over-estimated," and "is absolutely proven, I want to help people wake up to how apparently limited to the first poisonous cigarettes are. " four months after the insertion Ironically, R.J. Reyno!ds, Sr.. founder of the tobacco company of the device," they add. that bears his name, shunned cigarettes- " He sold them, but While noting "with regret", would not smoke them," his grandson says- but his son, R.J. the withdrawal of the Lippes Reynolds, Jr., was a heavy smoker who developed emphysema, Loop, Copper 7, and Copper and died at age 58. T 200- despite approval of use Grandson Patrick quit after years of struggle. "it was a real by the US Food and Drug Ad­ battle, and I know how hard it is to stop", he says of the habit ministration- from the. US mar­ picked up as an unsuspecting teenager. ket, the experts point out that new copper devices-such as TCu220C, TCu380A Ag, and Nova T-are proving to be sig­ nificantly better in preventing pregnancy than the earlier cop­ In the next issue per devices. In addition, "the effective life The October issue of World Health will be devoted to of the new copper devices is at different aspects of the work of WHO and its collaborators least five years, and thus they in the health field throughout North, Central and South can be safely left in place," America - the Region of the Americas. they state. •

W oRLD HEALTH, Aug ./Sept. 1987