Political epidemiology: Strengthening socio-political analysis for mass immunisation – lessons from the smallpox and polio programmes

Abstract

Control and reduction of infectious diseases is a key to attaining the Millennium Development Goals. An important element of this work is the successful immunisation, especially in resource-poor countries. Mass immunisation, most intensively in the case of eradication, depends on a combination of reliable demand (e.g. public willingness to comply with the vaccine protocol) and effective supply (e.g. robust, generally state-led, vaccine delivery). This balance of compliance and enforceability is, quintessentially, socio-political in nature – conditioned by popular perceptions of disease and risk, wider conditions of economic development and poverty, technical aspects of vaccine delivery, and the prevailing international norms regarding power relations between states and peoples.

In the past 100 years, three out of six disease eradication programmes have failed. The explanations for failure have focused on biotechnical and managerial or financial issues. Less attention is paid to socio-political aspects. Yet socio-political explanations are key. Eradication is neither inherently prone to failure, nor necessarily doomed in the case of polio. However, eradication, and similar mass immunisation initiatives, which fail to address social and political realities of intervention may be. A comparison of the smallpox and polio eradication programmes illustrates the importance of disease-specific socio-political analysis in programme conceptualisation, design, and management.

Keywords:

• socio-political analysis
• mass immunisation
• smallpox
• polio

Notes

1. All immunisation programmes deal with large cohorts within the population. ‘Mass immunisation programmes’ here refers primarily to large-scale, often time – and coverage target-bound actions which, whilst not precluding a role for clinic – or fixed post-vaccine delivery, include prominently house-to-house operations, and are, thus, distinct from routine immunisation services.

2. Seven, if you include the hookworm campaigns from 1909.

3. ‘Refractory’ behaviour of target populations (and vector) in the case of malaria; dependence on ‘behaviour change’ in target populations in the case of yaws; reduced political commitment, in the case of yellow fever, in the Americas region following significant reduction in the threat of urban epidemics and evidence suggesting negligible risk in that region of jungle-urban cross-transmission.

4. They are: ‘cooperation of those sovereign states with the disease’; adequate technical personnel; and adequate finance (Hinman 1999).

5. ‘An effective central and peripheral system of government is essential for the execution of an eradication programme. Political stability (not necessarily of a particular government, but of the overall political system) is a closely related requirement’ (Yekutiel 1980). There are cases that controvert this – Sudan, for example. But aside from cases where government has collapsed or fragmented through overt conflict, failure to take into account ostensibly peaceful, but fragile, states (fractured characteristically between centre and regions or central and local administrative levels) places programmes requiring a coherent national response (such as eradication) in some degree of jeopardy.

6. The size of effective resistance may be disputed; recent evidence from the UK with regard to the epidemiological impact of the refusal of extremely small groups of parents refusing Measles Mumps & Rubella (MMR) vaccination makes a strong case in favour of taking small group activism in this field seriously.

7. Over 100 years, thus, eventuating 35 million infections – a significant number in its own right, but still at or less than one-tenth of smallpox's toll.

8. Paradoxically, increasingly so as the programme's success reduces numbers of cases to virtual social invisibility, whilst simultaneously ramping up (highly publicly visible) vaccination campaigns (and their associated costs) in order to reach the final, inaccessible or unavailable, population sub-groups.

9. Although the ultimate selection of smallpox as the target for eradication conceals what are reported to have been bitter contests within the World Health Organisation, reflecting wider political and Cold War tensions, in particular with respect to the possible candidacy of malaria.

10. The author was a member of the Technical Advisory Group for Social Mobilisation and Communication, PEI, Abuja, 23–30 June, 2007.

11. Dr William Foege (former Chief of the CDC Smallpox Eradication Program) (2007) Personal communication. There is considerable debate around the length of immunity offered by smallpox vaccination at the time of the eradication campaign. The lowest estimates appear to be around 10 years, though other studies suggest a longer timeframe (see, e.g., Hammarlund et al. 2003).

12. See Henderson (1998b).

13. There is an increasingly rich historical literature on the relations – and contests – between states and populations over vaccination. From the smallpox riots in the early nineteenth century, through the experiences of criminalising vaccine refusal in the early part of the twentieth century, to the pertussis scare of 1974, and the much more recent, and ongoing, MMR ‘controversy’, there is persistent evidence of highly rational behaviour on the part of many vaccine ‘resistors’. Ignoring that rationality, especially as it gains increasing volume via traditional and new media, is something public health policy-makers and managers do at their peril. See, for example, Bhattacharya (2004), Durbach (2005) and Colgrove (2006).

14. For an excellent discussion of militarised enforcement in the latter stages of the SEP in India, see Greenough (1995).

15. It is interesting to compare this scale of intervention with comments from the Report of the Committee of Inquiry into the Smallpox Outbreak in London, March–April 1973: ‘Despite the formidable powers available to the Medical Officer of Health it seems that he … cannot compel vaccination … cannot always compel isolation … has not power to restrict the activity of a contact … and cannot compel a healthy contact to submit to daily surveillance’ (United Kingdom Parliament 1974).

16. Gwatkin et al. (2005) and others have demonstrated the correlation between lower socio-economic status and poorer access to health services. Perceptions and conditions of relative exclusion from such services are increasingly understood as underlying issues in non-compliance with polio vaccination. See, for example, Clements et al. (2006) How Vaccine Safety can Become Political – The Example of Polio in Nigeria, Current Drug Safety (2006). Yahya (2007) Polio Vaccines – ‘No Thank You!’: barriers to polio eradication in northern Nigeria, African Affairs, 106/423, 185–204. Also, UNICEF (n.d.). A revised PEI policy developed by UNICEF India after 2004, focusing explicitly on ‘the underserved’, also reflects the recognition of a relationship between vaccine resistance and social marginalisation, http://www.unicef.org/india/health_2876.htm