Comments and Discussion Following Workgroup Reports

In our Workgroup, as in a number of other groups, we had difficulty with the term "elimination" and discussed this at some length. Fortunately, we owe a great debt to the Dahlem Workshop in eradicating the phrase "elimination of a disease as a public health problem". A number of us would like to eradicate the word "elimination". I think control is a respectable term. I hope we would see ourselves as being sufficiently imaginative and creative to be able to frame progress in terms of control as being an exciting and saleable entity. If we are going to use "elimination", we need to use it as carefully as we use "eradication". It has to be a feasible goal, and we ought to be able to demonstrate that it is a feasible goal. I was a little concerned, particularly with the noninfectious disease group, when we talked about eliminating iron, iodine and vitamin A deficiencies and eliminating lead poisoning. I think we all have to agree that none of these are feasible goals. It would be helpful in their report if they were to redefine "elimination" as being low incidence; it is not a goal to eliminate these conditions. This only illustrates our problem with the word "elimination" and what we mean by it and what we are trying to mean by it. In our dictionary, "elimination" and "eradication" have identical meanings. In other languages, as I am told, it creates no end of confusion. There is no way of differentiating between the two.

I have a question that is related to terminology but is perhaps more practical, bearing on the next-to-last recommendation for measles. The point was that efforts to address measles should not jeopardize programmes or efforts to eradicate poliomyelitis. That is the general recommendation. I wondered whether the group had considered giving some concrete examples to show how embarking on a more ambitious measles programme would not interfere with or jeopardize poliomyelitis eradication efforts. I ask for examples because one of the benefits of this meeting has been the juxtaposition of thinking about synergies in sustainable health development and a variety of different elimination or eradication programmes. Can we hear some creative thinking about concrete ways, operationally and conceptually, and how these programmes would harmonize, synergize, or potentiate one another's efforts?

I see the theoretical concern. I can give no example where a measles elimination programme has adversely affected poliomyelitis. In fact, I think they are mutually complementary. That has been my experience in Mexico. What we learned in poliomyelitis is now being applied to measles but without undoing our efforts to continue with poliomyelitis. These are synergistic efforts.

I would like to address a point that was brought out by one workgroup about special situations or special circumstances that make eradication particularly difficult in certain countries. Guinea-worm and poliomyelitis eradication efforts demonstrate that successful eradication efforts can be carried out in spite of war and conflict. What characterizes these countries is that a number of prerequisites for eradication are not present. The strategies for these situations (often without governments and without resources) are different from the strategies we advocate in the majority of countries. My suggestion is that the conference recognizes that the eradication prerequisites for these countries are different, strategies must be different, and funding needs are different. Special financing mechanisms must be created for eradication efforts in these countries.

I should like to respond to the question of competition between the measles and poliomyelitis eradication initiatives. The key issue here is planning and resources. In a number of instances, the country or an organization wanted to have what we would categorize as a multi-entity campaign -- the idea being that since the poliomyelitis campaigns were already being conducted, additional entities could simply be added. The need for additional health personnel, trained administrators, or trained vaccinators who know how to handle syringes and needles safely without transmitting bloodborne diseases was not considered. Programmes can work together, but the key issues are proper planning and proper resources. An area where different programmes can work well together is surveillance. We feel strongly that measles surveillance is needed to keep good poliomyelitis surveillance in place through the period of certification. Without enthusiasm, without a particular goal, surveillance tends to deteriorate over time. Poliomyelitis and measles eradication efforts can work very closely together, very cooperatively, so let's focus on making sure we have the resources to do it.

My comment is in relation to rubella vaccine and the inclusion of it in measles eradication. There was one bullet in the Workgroup Report that referred to vaccinating women of childbearing age with rubella vaccine to accelerate rubella elimination. There is a view that you need to include both men and women in relation to rubella vaccination if you really want to eliminate rubella. The rubella virus continues to circulate in the population, and some women who are pregnant may still be affected, and you may get cases of CRS.

The terms "eradication" and "elimination" have other problems that don't have to do with science, but have to do with communication. In my work with the spina bifida community, some people are vastly offended when I talk about elimination or eradication, because either they or their children have spina bifida, and they see this as in some way ending their lives. It is amazing that this hasn't been mentioned by the poliomyelitis and other communities, but it certainly has come out of the chronic disability communities in this country. This is another reason to think about terms like "complete prevention" or "80% control", rather than eradication and elimination.

My comment concerns a suggestion made in both Group 1 (disease elimination/eradication) and Group 3 (bacterial diseases). In Group 3, for example, one of their recommendations for each condition was that control be tightly related to general health-delivery systems or sustainable health development. We're all talking about sustainable health development. The phrase "general health-delivery systems" is a little passive. It suggests that people are being passive beneficiaries in the transfer of resources and efforts. These statements should be strengthened to recognize that probably many of our efforts in control and eradication would be of lower cost and more effective if we were able to work with communities that are more aggressive in demanding health care and that are able to recognize their rights to good health care. These diseases ought not to exist in communities that are well structured, well organized, and well mobilized. Community mobilization and organization in some peoples' terminology is part of sustainable health development and part of health-delivery systems, but I fear in some people's terminology, it isn't. I would like to strengthen the role of community participation.

I represent the Dutch government and I have to advise my government where to put our money. At this conference we have seen fantastic presentations, a contest of all the diseases we want to eradicate. We need financing for that. What is not clear from this conference is where do we put our money. I would like to compare certain diseases, certain interventions with others. Resources are limited -- not only limited financially, but also limited in human capital. I would like to see cost-effectiveness data for these diseases. Which of the interventions is most cost-effective? We have a universal unit of measurement, the DALY, although it has many critics. One of the problems with DALYs is that they do not exactly apply to what we want here because of the need to include transmission. The only disease that is included is tuberculosis. We're definitely looking at what is the effect of intervention on the cost-effectiveness ratio. That's one of the good examples. The whole global burden of disease studies and cost-effectiveness for many other diseases is not clear at all. My recommendation is to look into these issues more specifically so we could compare one intervention with the other.

As a number of speakers have already expressed, there is a concern that as we go from eradication to elimination to control, this list has become very, very long and somewhat cumbersome and has now become the battle of diseases as just described. One of the things we have failed to do in this meeting is to discuss any approaches to prioritization. There is a science to this. It is well described in the literature. There are approaches to public health problem prioritization that lend themselves to some of this discussion. We haven't had time in any of the groups to really focus on it. Another way to look at this issue is to take examples of poliomyelitis and guinea-worm disease and ask why they are currently at the top of the list. What is the logical framework that has led them to move to that level in contrast to some of the other issues? Of the issues that we've talked about, certainly feasibility and effectiveness are the two major parameters. There may be others, but those certainly are the most important. If you constructed a 2 X 2 table, those things that ended up in cell A -- highly feasible with a highly effective intervention available -- would be very top candidates for elimination. This would maybe address the concern about where to put the money. We need to be clear about describing what we mean by effectiveness. Much of the debate of the disease groups has focused on the question of efficacy, in addition to acceptability. Those two combined add up to effectiveness. The classic example of that is that you can use efficacious interventions such as condoms for HIV; and if it is unacceptable, you don't have a very effective intervention.

Feasibility is much more difficult to discuss. We've touched on some key issues of this, not the least of which is infrastructure concerns. Some of the groups tried to deal with that -- infrastructure concerns for both the service delivery, the ability to deliver whatever the intervention is, and surveillance to detect and monitor. Those two key factors are extremely important.

Resource constraints: we mentioned that, but if the resources are available and the political will is not there, that is a major consideration. What factors affect political will? Certainly the size of the problem in terms of prevalence, but also severe DALY measures, case-fatality rates, and other issues.

And last but not least, urgency. We've heard that issue come up again and again, which includes economic impact, infectious spread, and other issues that relate to that. So those are just some of the issues we can begin to discuss at some point. Perhaps not at this meeting, but in future ones. How to prioritize these? How to figure the appropriate weights of those elements? Where is the sensitivity analysis to guide where to put our emphasis? These might help us prioritize this very lengthy list of diseases and steer us in some of the right directions to help us spend our resources, time, and energy wisely.

My major concern is what will be next after this conference. I see that Dr Foege, after the break, will talk about "Vision for the future." But we have a very short list of diseases that are eradicable or can be eliminated. Probably this short list is a reflection more of our ignorance at the present time than actually the limits of science and technology and whatever the people can do. And I would like to recommend two things: that as an outcome of the conference, we actually make a proposal, and each organization and all the people involved are to allocate more resources in terms of research, including operational research (i.e. how to involve the communities) so we can actually move forward.

The second proposal I would like to make is that we bring the recommendations of this conference to other forums, particularly public health forums, so that efforts we have made can be put into action.

I'm really picking up some of the comments from the last couple of speakers. We don't have a lot of time and ability to try to refine further the work that has been done by the workgroups who have done enormous amounts under enormous pressure. Further work needs to be done, and I hope the conference is going to be giving a fairly broad mandate to the further editorial work of sifting down and clarifying, where we can, what seems to be a consensus. I think that the report should be as clear as it can in whatever can be distilled from what we said.

I certainly agree that we should do better with our priorities, better with our analysis, and better with our DALYs, but international development still remains far more of an art than a science. I hate to say it to our colleagues who are having a terrible problem of allocating resources from international development agencies, but you are not going to get a menu that's going to solve your problems. It's going to remain extremely difficult, although we need to do a better job than we're doing now in helping that process. We have that same problem also in WHO.

The definition problem has been raised by many. I don't see exactly a consensus. I see uncomfortableness expressed with how our current usage goes, not total comfortableness with the Dahlem recommendations. I wonder if the conference organizers or the secretariat who will be working on this further might consider if they can distil what they really feel is consensus from the conference, or even convene a small informal working group and put this as an annex to the conference report which would say, "Look, this seems to us . . . " -- because we are not ready to express the consensus of this conference, we haven't had the chance to endorse it. We need some further work so that we have something concrete to work on, so we can take that into other forums and see what to do with it. As I said, one way of doing this is to have a small working group and publish their report in an annex.

Other things about other forums: I hope my colleagues in WHO will work with me in trying to take some of the specific recommendations on tuberculosis and perhaps Chagas disease, certainly for the global programme on vaccines and immunizations on rubella and measles and feed those into our current expert advisory groups so we can look at them in more detail. Maybe they will give us some new insights; maybe there are ways that we can use those. Recommendations from those technical advisory groups can be published in the WHO Weekly epidemiological record and in other forums -- and maybe in a World Health Assembly resolution. As you know, this conference report will be published as a special supplement to the Bulletin of the World Health Organization. So that is another way of bringing it into international visibility.

My last comment is about too many diseases being candidates for eradication. WHO should be doing a better job in its role as a gate-keeper. I can speak from my own experience: when one enthusiastic programme manager says, "Let's do this, let's go for an elimination programme. I've got some wonderful NGOs. They're enthusiastic. We've got resources, let's go for it," I say, "Sure, let's do it." But we have not yet had in WHO really an upper, senior level management where we can debate with all the programmes and say, "Okay, how many of these things should go to the World Health Assembly?" This is not something that I can do inside WHO. You who will be coming to our Executive Board and will be attending the World Health Assembly can help with that process.

Fundamental to what we're trying to do here is reaching agreement on the basic framework -- that is, whether to include eradication, elimination, and control, or just eradication and control. It's very tempting for each of us to address that issue on the basis of political or personal commitment to our pet diseases, and there are obviously dangers involved in doing that. It makes much more sense for us to be asking a question of whether the strategies involved with control -- e.g. for infectious diseases in hyperendemic phases, or even decline phases -- are the same as the strategies that are necessary for elimination. And are those the same as strategies necessary for eradication? There is a growing volume of work in the literature, at least for infectious or communicable diseases, that say specific strategies or combinations of strategies do differ, and that we ought to be looking at this in a more sophisticated way. My personal bias is that the strategies do differ for at least the communicable diseases, and therefore it is important for us to agree on retaining elimination as a category.

Two comments and a question. First of all, much of this meeting has been talking about making possible what to others would seem impossible, and accomplishing what many would say is impossible. And that is a wonderful setting for heroes and stories. Second, the future of health, the world, etc. is in the hands of our youth. The question: Are we doing enough in taking these stories and examples of heroes -- many are in this room, and also the local community level -- and using them to develop and grow the leaders of the future?

With regard to the price of some new products being a perceived barrier to their wider use, I would like to comment on the pricing of products and the value of prevention. DPT vaccines were licensed at least 25-50 years ago, and it took us a long time to get these into wide use. Smallpox vaccine took even longer. Those vaccines that are now used at prices well under US$ 1 a dose have come to that pricing because of economies of scale and the learning curve that was 25-50 years long. What we are trying to do now in many cases is put products into wide use much earlier in their life-cycle, without the benefit of experience in increasing the efficiency of production. If you do cost-effectiveness analysis on hepatitis B vaccine at under US$ 1 a dose, perhaps down to US$ 0.50, and hepatitis A vaccine at US$ 3 per dose or perhaps slightly less, these vaccines in many developing countries are still cost-saving. In poorer countries, where they spend less on treatment, they still buy a unit of health benefit, whether a life saved or a DALY saved, at a value that the World Bank represents as a very good investment.

Clearly, we need to try to make vaccines more affordable. To get the price down, we have to get the number of doses up, and we need to target external assistance to those countries that are most in need of it. But the reality is that prices in the manufacture of many new products will never fall to the level we currently experience for poliomyelitis or measles vaccines. So we have to address the reality that many new products in their early life-cycle will be more expensive. We have to convince governments that investing in the use of these vaccines, in investing in prevention, is a good health investment.

Dean Jamison said very early in the conference that there was increasing evidence that investing in health is good for the overall economy of the country. We have to get this message out. Advocacy for investing in health must be a much bigger part of the overall strategy. We must use more sophisticated techniques for advocacy and the decision-making process. Many scientific advances are accumulating at the moment, many new vaccines that are in the pipeline will be licensed in the next few years, and there are probably many other technologies for drugs. These new products are not going to get to most developing countries in an acceptable time frame. We need to regard advocacy and changing the behaviour of government resource providers as a very significant part of the overall health strategy.

One thing I was hoping to hear from the meeting is what is the overall goal of eradication/elimination. We need to revisit that. Lastly, let us remember that knowledge also comes through practice. It is sometimes disheartening if we think that knowledge only comes through science and do not remember that there are people out there who have knowledge gathered through practice which could be shared in terms of strategy development. Many people out there will spend a lot of their time working with communities and working in districts -- developing strategies that could be part of this process of sharing.

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