I Blame Smallpox!
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Could the superb victory of global international development over the vicious Smallpox disease have sown the seeds of the serious struggles that we have experienced in countering other major health and development issues - particularly HIV/AIDS, malaria, Tuberculosis and the full range of child health issues? Of course no one wishes that we still had Smallpox in our lives and communities. The world is a much better place without it. And there should be no diminishing of the superb work and accomplishments of everyone - from local to international leaders, citizens and specialists responsible for the eradication of Smallpox. They achieved something truly remarkable. The problem comes in the international development communities adoption of the Smallpox strategy and programming model - irrespective of the characteristics of the health issue being addressed and often blind to significantly changed circumstances and contexts. Though "indigenous" local and national groups have pointed the way to new intervention principles and action forms, the international community has basically stuck to the Smallpox model, with at best disappointing and at worst disastrous results.
From my reading of what happened on Smallpox the approach had the following basic elements:
- Treat Smallpox only - our only concern is Smallpox.
- Mobilise a proven and effective intervention - in the case of Smallpox it was the vaccine, of course - as a combination of the center and fulcrum points of the programming interventions.
- Utilise sophisticated epidemiology as the main source of decision-making information.
- Globally manage [maybe "direct" is a better word] the eradication programme - for example, the identification of priority areas and specific resource allocation. Do this as a parallel system to existing national and local systems.
- Take what ever steps are necessary to persuade, cajole, influence [fill other verbs from your knowledge] people to get the vaccine.
- Work with, do not challenge or even consider, the political systems available - in many ways the more authoritarian the system, the better the chances of 100% vaccination and eradication.
- Provide specific, high-cost support to technical experts on the issues in question.
In so many ways those strategic and planning principles describe so many of the health and development initiatives that followed the eradication of Smallpox. They were almost all discreet, vertical programmes - TB, HIV/AIDS, Malaria etc. For global agencies at the heart of these initiatives there was/is an overwhelming focus on either a proven intervention to mobilise [eg condoms, ORS, OPV, bednets] or a new intervention to find [eg Malaria and AIDS vaccines]. The epidemiologists rule and their data guides global decision making. Outsiders seeking to persuade, cajole and influence the locals dominate the development landscape. Little connection is made between the issues being addressed and the broader political and rights landscape.
Just before there are a flood of emails saying that, in Margaret Thatcher's infamous phrase: TINA [There Is No Alternative]; is it not worth considering the inverse of If It Is Not Broke Don't Fix It - which would of course be If It Is Broke We Need To Find Another Way!? The Smallpox approach, when applied to other health and development issues, does seem to be Broke. As best as I can discern from the data, there is little good news on health and development issues. HIV/AIDS, Malaria, TB, child immunisation rates and a bunch of other data are all heading South, as they say in the USA [which as a New Zealander I find a particularly ill-considered phrase!]. They are getting much, much worse, particularly in the economically poorest countries. There Has To Be Another Way.
That new way will not involve tinkering with the existing model. It needs a new set of principles with those principles being reflected in the policies and funding of the major agencies. I would suggest:
- Look at the commonalities across a range of health issues and address those commonalities.
- Focus on supporting communities, districts/provinces/states and countries to debate and decide their heath priorities, making the "proven intervention" [should it be available] part of the support package available should they decide to choose such support.
- Ensure that the perspectives of the people most affected by poor health conditions and status have influence equal to the data produced by epidemiologists in strategic decision making and monitoring.
- Decentralise control over financial resources and technical expertise to the most local level possible, ensuring that they are integrated into - as opposed to parallel to - national and local systems.
- Respond to and take the lead from the local populations about what will work best in their context.
- Recognise and explore the connections between the issues in question - for example, HIV/AIDS, child health, malaria - and the broader social and political issues in the community or country - from discrimination and prejudice to engagement in the local and national political processes.
- Provide as much support [preferably more] to the locally-initiated and -run movements on health as is provided to global researchers and scientists.
I can see many people within the international development community vigorously disagreeing with the notions above. Arguments such as - why do this "soft" stuff when we have the possibility of a vaccine that will "solve" all these problems? If only it was as simple as the days of Smallpox eradication. But as argued above, it is not and never will be again. Just as the world has changed, we also need to change - and quick!
Warren Feek
wfeek@comminit.com
February 3 2005
Comments
Warren,
Your suggestions A-G are a fine practical example of the Integrative Improvement approach I have been advocating in development circles for some time, most recently in the article A NEW APPROACH TO DEVELOPMENT at:
http://topics.developmentgateway.org/ngo/rc/ItemDetail.do?itemId=1030221 .
The difficulty is that virtually all people with the power to make the overdue change we seek have been trained on the basis that we live in a world of parts that must be managed into a stable state or moved from one stable state to another by top-down managers trained to think unintegratively rather than integratively. This is an obsolete approach. Our current scientific understanding of the world is that it tends to be self-organising with human beings whose minds are naturally integrative.
The Integrative Improvement approach originated from my development experience some decades ago. It seemed to me then and even more so now that each individual involved needs to change the way they have been trained to think - hence my low-cost process for doing this.
Kind regards,
Graham Douglas
www.integrative-thinking.com
I agree with Warren Feek’s summary of the approach to eradicating small pox. This was essentially a military style action – ‘targeting’ at risk people -- those who were not immunized – undertaken by experts in the name of public health, a public good in economic terms.
I am sure that many will highlight the differences between addressing small pox, a highly infectious, commonly but not inevitably rapidly fatal infection with a highly effective preventative intervention (vaccination), and addressing HIV/AIDS a far less infective, fatal after only a long delay and commonly a chronic illness, that currently does not have an effective preventative vaccine.
As prevention of HIV infection needs sustained adoption of healthy behaviour – I would argue with social and political change to enable individual behaviour change – and economic change to sustain individual health behaviour – I suggest that the military style expert driven model is not appropriate. I believe that we should not target risk groups for prevention but should adopt an empowerment paradigm for our work in HIV. All people, including the most vulnerable, have strengths and are resourceful. We should be facilitating local responses that draw upon individuals, families and communities strengths and resourcefulness. The added benefit of this approach, which is essentially a human capacity development approach as defined at the Barcelona International AIDS Conference in 2002, is that people families and communities learn problem solving from each other and are empowered to address stigma and other barriers to accepting care and treatment. With the current unprecedented global mobilisation of resources for care and treatment in the most AIDS-affected countries, barriers to care and treatment have assumed huge significance. Thus the empowerment paradigm is important for the whole treatment to prevention spectrum, and some clinicians might say for ensuring concordance rather than compliance with antiretroviral therapy.
Yours, Ruth Hope
Social & Scientific Systems, Inc., an employee-owned company
Ruth Hope, Senior Technical Specialist
The Synergy Project (www.SynergyAIDS.com)
SSS/1101 Vermont Ave NW, Suite 900, Washington, DC 20005
I agree that an entirely new set of principles that address connections between the issues being addressed and the broader political/rights landscape is needed. In fact I would go so far as to suggest just such an approach, to each and every new set of circumstances needing to be addressed. We can not allow ourselves to think that one size and style fits all. There is and always will be, various componets to each need addressed, for the rest of time. Finding "What Works" and then keeping an eye out for what works better, should be the methodology of choice. Always taking into consideration the totality of the situation within "Reality", seems to be the most common sense way to organize for or against anything. Negating any portion of the total range, realm and scope of "Reality" seems to be nothing more than a recipe for "What Doesn't Work"!
Lawrence H. Robertson
nice piece. why did you NOT include polio on your list? or would you agree with me, that maybe the smallpox model is appropriate for polio eradication.
in any case, if we are to succeed, I'm afraid the smallpox model is the only one that will get us there. just musing, but might be interesting to do a comparative analysis of the polio eradication effort and the guinea worm effort: these are the only two initiatives that have any hope of succeeding, IMHO, and the former must (I think) continue to follow the smallpox model while the latter could succeed with the softer model (I think).
anyway, thanks for continuing to stimulate thinking and debate.
Carl Tinstman
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