BOX 3-18 Lost Windows of Opportunity

Emerging infectious diseases are closing, or have the potential to close, windows of opportunity for infectious disease eradication or elimination. The eradication of smallpox stands as one of the outstanding achievements in the history of public health. Eradication was achieved because of a worldwide effort that was supported by the necessary political will and human and technical resources. The world was able to take advantage of the window of opportunity for smallpox eradication because a safe vaccine was available.

In the year that smallpox was declared eradicated (1980), HIV appeared and rapidly colonized Africa and the world. Today the prevalence of HIV is greater than 25 percent in some adult populations, such as that of the Democratic Republic of Congo (formerly Zaire). In the United States, a military recruit who was immunized against smallpox developed generalized vaccinia because he was HIV-seropositive and died (Redfield et al., 1987). That tragic event highlights the fact that if the global smallpox eradication campaign had been postponed, the world would not have been able to eradicate smallpox as easily as was the case before 1980.

Many windows of opportunity have been lost. In the 1950s and 1960s, gonorrhea was highly prevalent throughout African countries. Governments did not attempt to change people’s behavior to prevent its transmission. Treatment was offered either infrequently or not at all. When available, treatment for sexually transmitted diseases was many times more expensive than treatment for other diseases, especially in the private mission hospitals throughout Africa. Therefore, gonorrhea went largely untreated, and its prevalence increased to a less manageable level. Today, gonorrhea is present throughout Africa, where it causes infertility in women and is one of the major driving forces in the HIV epidemic, facilitating the transmission of the virus. Had effective public health education been in place in the 1960s to help change sexual behavior and had antibiotic treatment been used effectively, there would not be such a great problem with gonorrhea today. In this case, a window of opportunity to control one disease and reduce the rate of transmission and impact of a far more serious disease has been lost.

The prevalence of tuberculosis (TB) and multidrug-resistant TB is increasing globally. The emergence of HIV facilitated the resurgence of TB, another example of a case in which a window of opportunity has been lost. Global surveys show that there is a 1 percent prevalence of resistance to at least one TB drug. Multidrug treatment for TB costs between US$20 and US$30 for a complete cure, but treatment costs are approximately US$3,000 for multidrug-resistant TB. In many places, a window of opportunity to achieve a manageable level of TB by the proper use of drugs has been lost.

The global effort in the 1960s and 1970s to eradicate malaria succeeded in eradicating malariologists, but not the disease. Today, the malaria parasite is resistant to the

tients and civil society—to the necessity of collective action. These groups are quite interdependent in their commitments. To secure the participation of patients and community members (for example, in undergoing testing for TB or HIV), it is often necessary to convince them that treatment will be available, and then to structure their active participation through grassroots-



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