Copyright ( 1999 John Wiley & Sons, Ltd.

STATISTICS IN MEDICINE

Statist. Med. 18, 755—760 (1999)

BOOK REVIEWSEditor: Niels Keiding

1. ¼. R. Dowdle and D. R. Hopkins (eds), The Eradication of Infectious Diseases.

2. R. O. Mueller, Basic Principles of Structural Equation Modeling. An Introduction to LISREL and EQS.

3. Jim K. ¸indsey, Introductory Statistics: A Modelling Approach.

4. ¸esley Grayson, Scientific Deception: An Update.

1. THE ERADICATION OF INFECTIOUS DISEASES.W. R. Dowdle and D. R. Hopkins (eds.), Wiley,U.K., 1998. No. of pages: x#222. Price: £60. ISBN0-4719-8089-7

This is an extremely important book that deserveswidespread availability, discussion and debate bya broad range of individuals, from those concernedwith the details of infectious diseases, epidemi-ology, immunology and modelling, to those whosebusiness it is to protect mankind at the level ofpublic health management and control. One canonly regret that the purchase price is apparently£60: Can something be done about this?

The format of the book is presented as a ‘R eportof the Dahlem Workshop on the Eradication ofInfectious Diseases’, which took place in Berlin inMarch 1997, as organized by the well-known Dah-lem Konferenzen organization. It should also benoticed that the title page of the book explicitlydefines the ‘Goal of this Dahlem workshop’ asbeing ‘To identify the biological/epidemiological,cost/benefit, and societal/political criteria foreradication of infectious diseases’.

Although at first sight the list of contents appar-ently reveals only summaries of individual contri-butions, most of which have multiple authorshipand possibly divergent interests, this could be mis-leading. It is in fact clear that there has beenextensive collaboration, not only between multipleauthors of individual papers, but also betweenauthors involved in different papers. There are ofcourse many different points of view and somedisagreements, but the book as a whole reads asa concerted collaborative effort to deal with a ma-jor threat to the well-being of mankind.

It is important to appreciate that the book isprimarily concerned with the eradication level ofinfectious disease control, while at the same timedrawing on a wide range of relevant topics includ-ing basic epidemiology (Chapters 2 and 3), math-ematical modelling (Chapter 4), the role of generalhealth services (Chapter 6), broad economic per-spectives (Chapters 7 and 8), the estimation of costsand benefits (Chapter 9), and social and politicalaspects (Chapters 10—17).

At this point we need to be clear about defini-tions of the various levels of infectious diseasecontrol, and especially the term eradication empha-sized in the book title itself and mentioned ina general way in the above introductory remarks.While there is as yet no generally agreed set ofdefinitions, the Workshop was more or less unani-mous in accepting a list of well-defined terms thatcould be used in relation to given diseases orinfections (Chapter 5). A somewhat abbreviatedversion is given here as follows:

Control: continued intervention to maintainthe reduction of disease and related aspects.Elimination of a disease or infection: continuedintervention to maintain zero incidence ina given geographical area.Eradication (as relevant to the title of the bookreviewed): permanent reduction to zero ofworldwide incidence of an infection, interven-tion measures no longer being required.Extinction: the specific infectious agent no lon-ger exists in nature or a laboratory.

The last definition is a very strong statement: noexamples as yet exist. Smallpox has of course beeneradicated, and is in principle due for extinction inJune 1999. This is a highly debatable subject. For

the time being stocks of smallpox virus are held inhigh-security laboratories in the United States andthe Russian Federation.

Opinions differ as to what is desirable. If rel-evant stocks are totally destroyed the diseaseshould have gone for ever, but useful laboratoryresearch might well be disadvantaged. On theother hand, if some stocks are kept there is alwaysa danger of an infectious agent escaping throughhuman error or terrorist activity into a totallyunimmunized world. In this case a degree of labor-atory maintenance would be a safety measure. Thisis a highly sensitive matter and needs extensivediscussion at various national and internationallevels. This is mentioned in several places in thebook, although the latter is of course primarilyconcerned with the level of eradication.

Following the short introductory chapter thereis an extensive discussion of the general role oferadication and the lessons to be learned fromprevious eradication programmes (Chapters 2 and3). It is emphasized ‘that eradication of some dis-eases is possible, but it is not easy’. Apart fromsmallpox, further candidates underway for eradi-cation are poliomyelitis and Guinea worm(dracunculiasis), with measles and hepatitis Abeing perhaps potentially eradicable.

It is worth emphasizing that the technical dis-cussions, when on the level of biology, epidemi-ology, immunology, mathematical modelling, andother allied subjects, are clearly capable of beinghandled in a detailed scientific manner. This maynot be easy, but the problems of control and elim-ination, leading in a small number of cases to eradi-cation attempts, can be clearly set out and used forrational argument, planning and decision-making.

The situation becomes, however, more complic-ated as soon as one begins to review the possibili-ties of actual implementation in real life terms.This means dealing with practical problems ofgeneral health services (Chapter 6) and the broad,sometimes unexpected, consequences of certaindisease eradication initiatives. Some critics have inthe past claimed that disease eradication pro-grammes damage the establishment and strength-ening of other health services. However, theauthors in Chapter 6 believe that this view has notbeen confirmed. On the contrary, they maintainthat reliable evidence exists to indicate that recenteradication initiatives have played a major role infocusing more attention on the needs of generalhealth services. There is, however, a challenge toensure that both aspects are properly recognizedand are mutually supportive.

Further discussions in Chapters 7—9 look inmore detail at the economic aspects of the practicalproblems of eradication. While it is accepted thatquestions of cost-effectiveness and the detailed es-timation of costs and benefits are of fundamentalimportance in making judgements about any pro-posed eradication programme, it is evident thatthere are a great many important but only par-tially solved problems. The subject is reviewed herein considerable detail and many useful recommen-dations are made.

Next, Chapter 10 reviews the different, thoughclosely related, roles for public and private sectorsin eradication programmes. The following Chapter11 provides an interesting discussion of the politi-cal and cultural difficulties involved in diseaseeradication, while Chapter 12 deals with the ad-vantages and disadvantages of concurrent eradica-tion programmes.

The designing of eradication programmes tostrengthen Primary Health Care (PHC) is con-sidered in Chapter 13, while Chapter 14 examinesthe social and political criteria for disease eradica-tion. Next, the single author of Chapter 15 dis-cusses whether there are better global mechanismsfor implementing and evaluating eradicationprogrammes. Some general thoughts on the organ-ization required for disease eradication are pre-sented by a single author in Chapter 16. Finally, inChapter 17 we have a broad group report on thefundamental question of when and how shoulderadication programmes be implemented?

The material presented in the book should besufficient to give anyone, who is clearly aware ofthe major issues outlined above, a direct under-standing of the necessity to control in short orderthe massive threats from current infectious dis-eases, not to mention the continuous generation ofnew variants that we are unable to protect our-selves against.

As the biblical quotation (wrongly attributed toEcclesiastes) ‘Where there is no vision, the peopleperish. Proverbs 29:18’ warns at the head of thefinal Chapter 17, a serious understanding of theintricate problems reviewed above clearly indi-cates that there are massive medical, social andpolitical problems to be resolved in regard toa wide range of infectious diseases if mankind isnot to be subject to catastrophic infectious diseasedisasters in the very near future.

NORMAN BAILEY

Chalet Chrine, Fang3782 Lauenen, Switzerland

756 BOOK REVIEWS

Copyright ( 1999 John Wiley & Sons, Ltd. Statist. Med. 18, 755—760 (1999)