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Vertical vs. Integrated Approaches

In this lecture, Daniela C. Rodríguez, outlines the debate between focusing on a disease eradication program vs. broader health services. (Step 2.13)
RODRIGUEZ: So the goal of eradication has been a controversial one since the beginning of the GPAI. If eradication succeeds, then all the effort we put into it was worth it. But eradication programs can fail. And in that case, the money and effort that has been poured into eradication could have been used better elsewhere. Also, there have been tensions between the ideals of community-based primary health care, which are focused on reaching large groups of people consistently, and vertical programs like eradication that focus on reaching every last person, as you see in examples like this one, where workers had to be quite literally helicoptered in for the smallpox eradication program in Nepal.
Let’s take a minute to understand the views of those that support eradication. Please watch this video on lessons from smallpox medication and then come back.
As the video you just saw mentioned, the success of smallpox eradication was something that was widely celebrated. Smallpox was the first human disease ever to be eradicated and it remains the only one. The only other disease to have been eradicated was rinderpest, a disease which affected cattle, an easier goal to reach than human eradication because it’s much easier to control and vaccinate animals. At the same time the smallpox eradication had been a stunning success, the WHO was not far away from an enormous failed eradication program. The effort to eradicate malaria had taken one third of the WHO’s operating budget for over 10 years, until the goal was finally abandoned without making significant impacts on malaria transmission in Africa.
This experience left many people wary of eradication programs. The Alma-Ata Declaration of Primary Health Care from 1978 was focused on equitable distribution, community participation, health workforce development, appropriate technologies, multi-sectoral approaches, and had goals of health for all by 2000. DA Henderson, a leader in the smallpox eradication campaign, talked about how Alma-Ata was calling for broad-based development of primary care services, rather than disease-specific vertical interventions. In fact, he said, quote, “At the present time, a single disease eradication effort runs against this tide of integration of programs and would not elicit the support enjoyed by the smallpox eradication program,” end quote. Others also had concerns about eradication.
In the 1980s, as Rotary and Saban were trying to gain support for the eradication initiative, the WHO was skeptical. In particular, they were concerned that pulling workers out of health centers and having them go door to door would pull resources out of the health system. Halfdan Mahler, then director general of the WHO, was very concerned it would detract from the broader goals of primary health care, and noted, “Any strategy that does not contribute to the strengthening of health infrastructure should be discouraged.” Eventually, Mahler would go on to support the eradication goal. The polio eradication also had early champions, including Ciro de Quadros, shown here. de Quadros had been a leader in the elimination effort in the Americas.
These champions won over Mahler and others by convincing them that polio eradication could help advance routine immunization and other goals of Alma-Ata. As he says here, “If we had a banner disease, something that would gain the public’s attention and rally support for the program, it could be a great success.” As this course will explore, the existence of that support has varied widely in different parts of the world and has been very complicated in practice. This debate continues still today, as you can see from these two publications shown here.
The one on the top argues that the global community should move from focusing on polio eradication to systematic sustained control of polio, with increased investments in routine vaccine delivery systems and linking it to universal health coverage. Whereas the publication on the bottom argues that abandoning eradication efforts now is going to lead to outbreaks of polio and children with permanent disabilities, and that the objective of eradication is still feasible. We’ll be hearing a lot more about the details of the pros and cons of an eradication program throughout this course, and we’d like you to continue to consider this debate throughout the course as a whole and to think critically about where you stand on this issue.
It may be more helpful to think in a more holistic way than this debate between eradication and integration suggests. What about a model in which these approaches were not seen as opposing, but as synergistic in a way that could benefit both? This has not been the way things have traditionally worked in polio eradication. However, there’s currently increasing understanding within the program that in order for polio to be eradicated, broader health goals must be considered, as well.
As you can see from this quotation from a global-level policymaker who says, “Some people would call them the blinders that polio often has, and others would say that it’s actually the extreme focus that the program has on a very specific goal and target so it can be phrased positively or negatively. You know, a day spent on strengthening routine immunization isn’t a day lost. It’s beneficial to the program.” The recent inclusion of Gavi, the vaccine alliance, to the GPI partnership aims to achieve the synergy for the polio program. This links back to our discussion on the global alliance in an earlier lecture. However, we like the model and theories to effectively achieve the synergy.
We’d like to acknowledge the contribution of these partners in mapping, synthesizing, framing, and preparing the content of the module. We would also like to acknowledge the contribution of these partners in providing information, data, and pictures for the module, as well as acknowledging the support of our funder.

Daniela C. Rodríguez, DrPH, MPH Bloomberg School of Public Health, Johns Hopkins University, USA

In the lecture, you are asked to watch the video Learning from smallpox: How to eradicate a disease.

Drawing from the lecture and the video, why do you think efforts for eradicating malaria were abandoned, whereas efforts to eradicate polio are still continuing even thirty years down the line? Do you think it has more to do with the nature and burden of disease or might this be due to other factors?

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