Eradication: Ethics, Autonomy, Priorities Alan R. Hinman, MD, MPH Task Force for Global Health May 3, 2011

Eradication Permanent reduction to zero of the worldwide incidence of infection caused by a specific agent as a result of deliberate efforts; intervention measures are no longer needed (Dahlem, 1997)

Eradication Permanent reduction to zero of the worldwide incidence of infection caused by a specific agent as a result of deliberate efforts; intervention measures are no longer needed (Dahlem, 1997) The absence of disease in a defined geographical area as a result of deliberate control efforts (Ernst Strungmann, 2010)

Criteria for assessing eradicability of diseases and conditions – ITFDE, 1993 Scientific feasibility –epidemiologic vulnerability –effective, practical intervention available –demonstrated feasibility of elimination Political will/popular support –perceived burden of disease –expected cost of eradication –synergy of eradication efforts with other interventions –necessity for eradication rather than control

Ethical Dilemmas in Current Planning for Polio Eradication “We consider it shortsighted for donors to use their considerable influence to promote polio eradication if this delays or diverts long-term investment by poor countries in sustainable health systems….Polio eradication will be a gift to the 21 st century only if donors and governments act in partnership to ensure long-term benefits for the least developed countries and poorest communities.” Taylor, Cutts,Taylor. AJPH 1997;87:

Conference on Global Disease Elimination and Eradication as Public Health Strategies Goal - assess the role of eradication or elimination in decreasing global burden of disease and more effectively utilizing health resources Atlanta, February 23-25, 1998

Actual and potential dangers of eradication for the health system and health development Diversion of resources from existing support to basic services Opportunities “forgone,” especially for countries for which the eradication effort is of low impact in terms of health outcomes Potential decrease in resources available for research Failure to accurately estimate the needs of the eradication efforts Enthusiasm for eradication could lead to many simultaneous eradication efforts and induce failure

Sustainable health services development - 1 Eradication programs should have two kinds of objectives: –reduction of the target disease to zero incidence which can be maintained even when all intervention is ceased –strengthening and further development of health systems, especially functions such as monitoring and surveillance, supervision, and program management

Sustainable health services development - 2 Potential benefits should be identified and delineated at the start of any eradication initiative As must be done for the disease eradication objective, measurable targets for achieving development benefits should be set and the program should be held accountable for their realization

Sustainable health services development - 3 Successful eradication programs are powerful examples of effective management. As such, they build program management capacities to be carried to other health programs Eradication initiatives should strive to demonstrate the principles of effective surveillance…which can be readily adapted to meet the needs of other national priority programs after eradication is achieved

Sustainable health services development - 4 Resources for eradication activities should be additional to those available for basic health care services and should not be provided at the detriment of existing services or those that are planned, without careful and explicit consideration of the consequences “Eradication programs should not be held responsible for curing the ills of existing health systems”

Candidates for eradication ITFDE, 2008 Dracunculiasis (Guinea worm) Lymphatic filariasis Measles Mumps Poliomyelitis Rubella Taeniasis/cysticercosis (pork tapeworm)

Disease eradication Eradication is for everyone, everywhere and forever. Eradication is the ultimate in equity.