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Roundtable discussion: Ethics and equity of eradication and routine programs

Olakunle Alonge & Svea Closser discuss the ethics and equity of an eradication vs. routine program. (Step 5.8)
ANNA KALBARCZYK: Hi everyone, and welcome to our roundtable discussion. I’m Anna Kalbarczyk, and today I’m joined by Svea Closser and Kunle Alonge. And we’re all faculty members at the Bloomberg School of Public Health. The topic we’re discussing today was originally designed as a debate– eradication programs versus routine immunization programs, and where we should be putting our investments. But we know that in global health, it’s rarely just one approach versus another. Things are rarely that straightforward. So today, I’d like to ask Svea and Kunle to discuss some of the ethical and equity implications of these two approaches, and describe their complexities.
SVEA CLOSSER: Yeah. So maybe we can start by describing what a polio eradicator would say was great about their program in terms of equity. So rather than actually having the debate, I’ll voice what that side would say for a moment. So polio eradication, leadership from the very beginning of the program, have sold the program quite vocally as what one of them called the ultimate in equity in public health. And the reason they say this is that eradication programs are forced, because they have to eliminate every last case of the disease to reach every last person on earth.
So it’s definitely true that the polio program has reached populations that were neglected for a variety of reasons and were not getting health services from any other program. Nomadic populations very, very far away from population centers. Populations that were marginalized politically. All kinds of groups of people that were not being served by any health system– of course, there were indigenous health systems, but from any government health system– were reached and vaccinated by polio eradication. So that’s one side of what they would say is the equity piece of eradication. That you really reach people that are not reached by any other program.
And the other piece of why they say eradication is the ultimate in equity is that everybody receives the same benefits once the disease is eradicated. So once the disease is eradicated, it doesn’t matter whether you’re the richest person in the world or the poorest, everybody now has a 0% chance of getting this disease. So whereas most infectious diseases tend to affect the poor the most, in an eradication program the benefits, if eradication is achieved– we’ll talk more about that in a moment. But if eradication is achieved, the benefits flow to everyone equally. So that’s the pro eradication stance.
OLAKUNLE ALONGE: And I mean, very well said, Svea. And I would just like to pick it up from there. Without any doubt, there is a lot of equity benefits for eradication– that is, easily able to achieve eradication. And that’s the point for me. And I think the other side of the story is really the question of can you actually achieve eradication? And what are the ethical dilemmas to that? Because when we think about eradication in this very strict sense, we are saying that you have the capacity to be able to surveil every case of a particular disease in every part of the world.
You have the ability, you have an effective intervention, that is able to eliminate– that is to say make the incidence of the disease to be completely zero. And that is to say able to remove the organism from its lateral reservoir and so on. So there are real scientific criteria. You really want to consider whether this is truly achievable given the knowledge of the biology of the disease. The knowledge of the natural history and the way it’s transmitted within a population. And it is in this that we have some challenges. Because obviously you’re going to have to make some judgment call. So the question is, are you making a judgment call based on the best science? Based on the best information?
And are you being completely transparent in the principles and how you’ve adopted the principles, you know? Obviously the equity benefit is really clear But the question is before you get to the equitable future, you have to achieve the eradication. And if the eradication– if the principal upon the eradication is based is faulty, then there may be dilemma issues.
SVEA CLOSSER: And I just want to add to that, absolutely, that the decision making process about taking up an eradication program also raises questions about equity. Is it donors and wealthy countries that don’t want to spend money on vaccination anymore? And people like, for example, in the case of polio, Sabin, the developer of the oral polio vaccine who wanted to leave a legacy, are these people the ones whose voices are getting heard and the ones that are driving a decision to eradicate or not eradicate a disease? Or is it the people who are actually affected by that disease? Are they the ones saying, yes. This disease is the one we want eradicated. This is our priority.
And you know, to what extent are marginalized voices foregrounded in this decision making process versus very wealthy powerful voices? That’s an important consideration.
OLAKUNLE ALONGE: Yeah. And I think the other side to it is also– so we took the body biological criteria for eradication. The economic criteria– and this also creates another ethical dilemma. So if you have– if the decision has been made need to eradicate, are you going to be committing huge resources? There’s an opportunity cost to that. So the money that is being invested into eradication you could easily argue that they could go into routine management of diseases, routine immunization, and so on and so forth. But because of the decision that you made to pursue an eradication goal, there is an opportunity cost that is lost in terms of what other things those resources could go to.
And that’s why the decision is something that should not be taken lightly. And I think one [INAUDIBLE] in my mind, I think being true to the science. Since eradication is a scientific endeavour, rooted in science, to the science and the biology of the disease, to the science of the transmission of the disease, it’s really key. It’s really key. And of course the politics will influence the science in the long run. But for the fundamental decision on whether to eradicate or not, I think the science and the facts should really play a significant role.
SVEA CLOSSER: But I would also add to that that just because something is eradicable in theory, when we talk about the scientific facts, it also include the facts about things like conflicts, about things like inaccessible areas. We can’t just think of the science as something that exists outside of on the ground political realities. Because those are part of an eradication program, as well.
OLAKUNLE ALONGE: Absolutely. Absolutely. I couldn’t agree more. And I think really thinking through all of this consideration is really key. So it’s not just about– I mean, we don’t question the benefits. We don’t question the equity. We don’t question– and we’ve seen the polio program has done that in a tremendous way. The polio program has been to places where no other program has ever been. You know, the polio program is the health system in a lot of places. It’s actually the health system in a lot of places. So we have that equity gain.
But we’ve also seen that in the last 10 or 20 years, or there about, it has been so difficult to achieve the goal of eradication, because of the [INAUDIBLE],, and for some of the reasons Svea was mentioning– thinking through the politics, thinking through the political and the social cultural context, and whether eradication is feasible in this setting. Again, visiting the sites. Making sure that we are really using our best scientific information. And obviously we’re dealing with people, so engaging with people on a continuous basis is also important. So again, I don’t think that there’s like a clear cut yes or no answer. But obviously there are clear advantages, clear equity benefits.
And there are also ethical issues that need to be reviewed. And I think being open and having open conversation around some of these challenges means a more collaborating together with different actors is really key.
SVEA CLOSSER: Yeah. And I just want to add something– I couldn’t agree more, again. I think one of the things you mentioned was that in certain areas the polio program has become the health system. And that raises particular ethical equity issues if all that’s being provided is just oral polio vaccine. So when you have a health system that’s been created to serve you, and yet only provides you with one vaccine, is that equity? And the answer to that question depends on who you ask, for sure.
SVEA CLOSSER: So that comes back to Kunle’s concluding point, I think, about the importance of thinking collaboratively, working with communities. And even if you’re focused on an eradication goal, perhaps thinking a bit more broadly than just that narrow goal can help it serve equity maybe a little better.
ANNA KALBARCZYK: I think not only does that tie back to Kunle’s point, but also one of your original points about prioritization. And who is setting some of those priorities? And so what does that look like if you’ve got the polio program as your health system if it’s not your priority? So I’ll stop us there. Thank you for a lively not debate, but discussion, on this very interesting topic. Thanks, everyone, for joining us.

Experts discuss the ethics and equity of an eradication vs. routine program.

Presenter 1: Olakunle Alonge, MD, MPH, PhD Bloomberg School of Public Health, Johns Hopkins University, USA

Presenter 2: Svea Closser, MPH, PhD, Bloomberg School of Public Health, Johns Hopkins University, USA

Moderator: Anna Kalbarczyk, DrPH, MPH Bloomberg School of Public Health, Johns Hopkins University, USA

In the roundtable discussion, Svea Closser states:

“In certain areas the polio program has become the health system. And that raises particular ethical and equity issues if all that’s being provided is just an oral polio vaccine. So when you have a health system that’s been created to serve you, and yet only provides you with one vaccine, is that equity?”

Reflect on this and the content we have covered so far this week. Then consider the following questions:

What do you think? Is it valuable that polio programs have reached regions that haven’t been reached by any other aspect of modern health systems? If you think yes, why? If not, why not? What, if anything, should be done instead?

Post your thoughts in the discussion.

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Planning and Managing Global Health Programmes: Promoting Quality, Accountability and Equity

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