(13 May 196; original 22 April 1965) g ADMINISTRATION IS ESSENCE OF ERADICATION' DEFINITIONS Eradication Biological absolute LOCal Global No neglected minority Geographical, Cultural Defensible limits or continuing expansion People cry out for more research* for better tools. Aa eradica- tion involved the dscoverv and application of nothing new; & return to first simplified technique of Paris green application. t-++-*** Y He who rides the tiger may not dis- mount--so long as the tiger lives! Public Health Administration Total action applying scientific knowledge for benefit of public Includes housekeeping, bookkeeping Not blind application of pre- established measures Meticulous application of measures constantly adapted to changing conditions Administration itself an epidemio- logical tool. 2 Epidemiology Art and science of determining, on a continuous basis, where & when infectious diseases occur and how diseases spread from person to person, from home to home, and from community to community. Epidemiology is the intelligence service of man's war on disease; it is the detective service of public health. Public Health Administrator his own epidemiologist Current records Visualization Analysis Evaluation Flexible adaptation to phases of eradication--Epidemiology of a Disappearing Disease Y Administration not only essential in eradication but essential to determine feasibility of eradica- tion! Eradication--Modern concept awaiting Individual Disease Entity Demonstration Specific Cause Method of Prevention Smallpox Jenner, Jefferson . Parasitic Diseases Pasteur TBC, Chapin, 1888 Chapin, 1900 Bovine Pleuropneumonia, 1884 BAI, 1892 Texas Cattle Fever Yellow Fever Local, Havana, 1901 Panama Rio Etc. Malaria Mathematics, Ross USA, F. L. Hoffmann Hookworm Disease Rsc, 1909 RF, 1913 Yellow Fever RF/Gorgas, May 1915' First serious,international eradication effort General use of term Eradication when Control was meantJ attack on misapplication of term became attack on eradication concept itself Experience with Smallpox H!m TB, Chapin Bovine, l/2 per cent Malaria, RF, 1936 YF, Brazil, failure US PH workers settled for local health units; multivalent nurses and inspectors Rehabilitation (Cbnit further facts in Ag&ul- ture--pests and animal diseases) Species Eradication a. Aedes aegypti Brazilian cities, 1933 Nationwide planned 1934; official 1942 &267c, L/ 4 b. Anopheles gambiae Brazil, 1930-1942 QTPt, 1942-1945; Disease Eradication, International PAHO Urban Yellow Fever Aa eradication Bolivia, 1942 Brazil, 1947,a Yaws Haiti, 1949-195$ (Penicillin) Smallpox Costa Rica, 1950 (Dry Vaccine) Malaria Secretariat, 1950 Again 1954 (Residual DDT) UNICEF Malaria Mexico, 19% WHO Malaria Secretariat, 1955 Smallpox USSR, 1958 Significant Publications Species Eradication, FLS & DBW Aedes aegypti Anopheles gambiae Organization of Permanent Nation- wide Anti-Aedes Aegypti Measures -a in Brazil, FLS, DBW, SL, & WSA, 1943 Anopheles gambiae in Brazil, 1930-1940, FLS & DBW, 1943 Tuberculosis How Much Control of TB? W. Hampton Frost, 1937 (BEFORE specific drugs) Eradication of TB by Epidemio- logical Methods, J. Arthur Myers, 1947 (BEFORE specific dmgs) Arden House Conference, 1958 (AFTER specific drugs) Carroll Palmer James Perkins FIX (AFTE;? specific drugs) Plans 1963, Tennessee 1964, Texas 1964, California 1963, Textbook of Malaria Eradication by Emilio Pampana 1963, Evolution and Eradication of Infectious Diseases, by T. Aidan Cockburn 1965, World Eradication of Infec- tious Diseases, by E. H. Hinman As an almost fanatical eradicationist, I have welcomed the acceptance of the concept of eradication in the prevention of communicable diseases ;tbw &- &pJ but must lament the failure,,in many cases wt&& eradication is not easy; is not merely more of existing control effort. Eradication requires new standards of efficiency in local health ser- viees and coordination of operations 6 throughout entire range of infec- tion or vector under attack. This generation of PH workers faces Revolutionary Concept: Responsibility'to the totality of 'the population for the non-occur- rence'of any cases of specific disease under current attack rather than for generally low incidence of all diseases! Complacent disregard of minority, however small,'defeats eradica- tion effort. Complete coverage in depth of population served and service to,entire population. Specific vs. lity. . general responsibi- Pressure will build up increasingly as more and more diseases become eradicable: TB, polio, measles, leprosy, ,syphilisL-make your own list. I trust this introduction has gotten the attention of everyone here--stu- dents are notoriously loath to dig inte administrative problems when more interesting technical subjects are being taught. Importance of Eradication Concept 1930 A. gambiae, Local eradication, 1931 Interior infestation left A. gambiae, 1938 As& and Jaguaribe Valleys Total eradication Why the difference? 1930 & 1938? a. Recognition of threat 7 b. Eradication of Aa seen! Some species eradicable! c. Technique for Aa eradication learned while doing--why not possible with &? (Administration as Research Tool) Eradication of Aa had occurred through admin?%trative adaptation of known methods and not through development of new technical resources. Aedes aegypti Eradication May 1965: Golden Anniversary of RF decision to eradicate YF! ,,-,I \.,I ,.yQ 19&@uccess overshadowed by 1932 discovery of Jungle YF. Permanent source of reinfection. Problem partially solved ,by 1933 observation of Aa eradication. - Aedes aegypti problem in the Americas. Aa tree hole 'breeder in Africa, but strains which invaded Americas are adapted to artificial water con- tainers. Distribution: From Tennessee to Buenos Aires --all countries--all islands, in and about human habi- tation, not in forest areas. Distributes eggs over various containers --seeks container by instinct--travels as adult and as larva and pupa. Long lived egg. Long lived adult. 8 Effort to Eradicate YF by Aa Reduction - First local eradication human dis- ease-- YF Gorgas, Havana, 1901 Shot-gun anti-mosquito work also gave first control of,malaria 4 cb$ Local eradication in large cities led to area era&cation Key Center Plan based on weekly visits to all houses in Large Endemic Centers RF/Gorgas Program cY+ .;,...Jy YFAfollowed the rules everywhere except Brazil a. b. C. d. Federal Service, 1919-21, debacle RF--routine--special staff 1926--debacle; 192&-optimism 1928--debacle; 1929--kecife cases \ Attempted Aa eradication Curve flattened out Proposed decentralization "integration of Aa" - Were failures due to faulty adminis- tration or to failure of YF to obey the ground rules set up for it by Gorgas and the Rockefeller Founda- tion? Uncertainty regarding the efficacy of administration left the question unanswered! 9 IN 1930 FL5 as Administrative Head of RF Cooperative YF Service in North Brazil Came in at top without previous experience Rejection of proposal to decentra- lize--to integrate FIS education by guardas_ Mata mosquito gordo nao presta Learned to think like guarda Decided on certifiable results Manual of Operations Printed forms All topms mapped Blocks numbered Measured itineraries FA 52 Flag Responsible for being found Nichteroy explosio?-- Guarda in Maranhao Men in Uniform--Identified by numbered insignia; individual zone responsibility &&+p Detailed~lin& record each visit when made Supervisor made same report; Chief Inspector and Medical Chief also Records analyzed and bonuses established 10 Gave men legal support for neces- sary action All & foci found oiled Established independent check for low incidence and negative reports Capture of adults--costly but cheap Explained flattening of curve Most sensitive indicator of low level infestation--Example of needed flexibility of adminis- tration Expansion of responsibility to all Brazil in 2 steps (1932 story of Rio staff reduction-- administration valuable in public health as well as business--money saved in Rio carried program to interior --we should teach principles of administration to all public health administrators (MDS)) Good Administration in eradication refers to national as well as county and state machinery Aa eradication observed to have occurred in some cities in 1932 Aa eradication born of efficient -administration of a combination of known techniques First observed eradication of Aa 11 Eradication came through meticulous administration when it was not sought nor expected Obligatory expansion Soper's Law National Eradication proposed 1934 . Attempts in 1930's to get eradication of Aa in Paraguay, Bolivia, Peru, ColGbia, Venezuela, British Guiana, and the United States Only in Bolivia with direct adminis- w-ok g &&$ dJx tration by RF staff did eradication succeed before the introduction of DDT Back to A. gsmbiae eradication with confirmed concept and Aa administrative techniques - Problem radically different Ground breeding Anopheles in rural as well as village areas Mapping--marking zones Individual geographical responsibility Breakdown of jobs to simplest ele- ments --Paris green man never looked for mosquitoes, either adults or larva ' Success was due to simplification of Pg 0.L 3L Qt.- I9 - PA-- application--Learn by doing Few get so much credit for correcting past errors or omission as did we .for eradication of Acr 12 Story of & in Egypt With Manual of Instructions i"IY 3 150 tons of Pg 4600 men--1943 was a calamity Sending in 2 top administrators K f- ;'o : '4 ,L., yJ WY in 1944, problem was solved in 9 months Nothing altered for Egypt Administrative methods of Brazil worked perfectly well in spite of forebodings of other workers in Egypt International Eradication--RF, PAHO, WHO, and UNICEF sponsorship, already mentioned Special field for international agency But overshadowing of situation by philosophy of advanced nations, especially USA Malaria difficulties attributed to lack of rural health infrastructure 5, AJ (Brazil and Egypt), yaws in Haiti, and.smallpox in Latin America, in absence of health infrastructure General Health Service dedicated to control of all diseases, is not geared to eradication; direct specific geographical responsibility is essential Eradication'and the General Health Service Eradication is all-inclusive; inac- cessible population groups, whether isolated geographically or culturally must be served. The eradication concept by its very nature forces 13 new standards of public health administration. These new stand- ards involve both the efficiency of coverage of the entire population of a given area with respect to the infection or vector under attack and the concomitant coverage of periphe- ral areas from which reinfection or reinfestation may come. Eradication forces the consideration of the individual disease as a national, a regional, and a global problem; in eradication the policy of concentrating attack on the most obvious disease prob- lem in each local area must be subordi- nated at times to the over-all strategy of eradication. (PASC action against hold out countries, 1950.) The local health unit as developed in the United States is poorly adapted to eradication efforts. The multivalent nurse or inspector unavoidably becomes less active on individual pressures as these decrease in importance; it is dif- ficult to get the type of one-eyed-dog- in-the-butcher-shop type of fanaticism so essential to the final stages of eradication. The local health service, essentially a mechanism whereby heavily populated wealthy areas could look after themselves without consideration of isolated groups, is not effective in eradication programs. Economic eradication requires complete coverage of all population groups with concomitant operation over a progressively larger and larger area to obviate the threat of reinfection or reinfestation from the periphery.