data from the influenza pandemic of 1918-1920: evaluating the effectiveness of nonpharmaceutical interventions to reduce the transmission and impact of infectious disease. While Markel’s research indicates that such efforts may have contained influenza in some U.S. communities, he acknowledges that implementing similar strategies in the future would be far from straightforward, given the increased mobility of populations, as well as the influence of civil liberties on public health policy.

Heymann’s and Markel’s workshop presentations were complemented by remarks from D.A. Henderson of the University of Pittsburgh Medical Center, leader of the quarter-century campaign by the World Health Organization to eradicate smallpox (Henderson, 1999). He noted that several factors made smallpox a uniquely favorable target for elimination: the virus infects only humans; it is not infectious until a rash appears; it spreads primarily through face-to-face contact; those who recover from the disease have permanent immunity; and its vaccine, which provides long-lasting protection, does not require refrigeration. Beyond these advantages, Henderson attributed the success of the smallpox eradication campaign—the first and only successful attempt to eliminate a human infectious disease from the planet—to its judicious use of available resources in host countries, its broad goals that could be achieved in multiple ways, and its support of a wide range of clinical, epidemiological, and operational research.

Henderson also explored the ethical implications of the smallpox campaign’s central strategy, the vaccination of 80 percent of the world’s population—which, he reported, proved a far more viable means of disease control than either quarantine or isolation. He noted that advocates of disease eradication consider immunization to be an important element of distributive justice, since the benefits of vaccination extend to all members of a community; however, eradication also raises the possibility that individual rights will be compromised if mandatory vaccination becomes necessary.

Acknowledging that top-down disease eradication programs often compete for resources with bottom-up basic health initiatives, Henderson argued that providing community-wide smallpox vaccination did serve the needs of basic health services—particularly since it provided a model for vaccinating against other important diseases. Indeed, the eradication of smallpox gave birth to an infectious-disease-management paradigm for immunization programs that, by 1990, had achieved its goal of vaccinating 80 percent of the world’s children against six major diseases: tuberculosis, diphtheria, pertussis, tetanus, measles, and polio.



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