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The 1950s: Era of the mass disease campaign

The inclusion in UNICEF's founding resolution of the phrase "for child health purposes generally" opened the way for UNICEF to become a permanent fixture in the UN system. And it also paved the way for UNICEF involvement not only in child feeding but in public health.

During World War II and its aftermath, disease rates had soared among weakened populations. In particular, forms of tuberculosis -- the 'white plague' -- had reached epidemic proportions. In Poland, for example, the child death rate from TB had multiplied four times during the war.

As a result, in 1947 the Scandinavian Red Cross societies sought assistance from UNICEF for an international tuberculosis campaign that aimed to immunize all uninfected European children. This was to be both the largest vaccination campaign ever undertaken and also the first one to use the BCG vaccine outside the controlled circumstances of the clinic.

Photo: Indonesia mounted the world's largest campaign against yaws -- curable through penicillin -- in the 1950s, employing large numbers of mobile male nurses working in the field. ©

There were some qualms that UNICEF would be treading on the territory of the fledgling World Health Organization (WHO), but it was argued that UNICEF would complement WHO's technical advisory role since it could offer material support in terms of vaccines, syringes and vehicles.

The international TB campaign set the tone for UNICEF's involvement in health care beyond emergency child feeding. Indeed, as the 1940s gave way to the 1950s, the predominant motif in international public health campaigns generally was the struggle to control or eradicate epidemic disease. These campaigns were among the first, and certainly the most spectacular, extensions of non-war-related international assistance. And they moved far beyond Europe, to Africa, Asia and Latin America. They also changed UNICEF's priorities -- extending its programme geographically to countries in the Middle East, the Indian subcontinent and the Far East, as well as shifting its focus from emergency first aid for children to long-term preventive health care.

This attack on ill health was prompted both by demand and supply. The demand came from the heavy case-load of infectious disease to be found among populations in the poverty-stricken 'underdeveloped' world. The supply came from the breakthroughs in medical technology of the previous half-century. New drugs and vaccines were becoming ever cheaper and, for the first time in history, offered a genuine prospect that age-old scourges could be swept away without waiting for the spread of doctors, hospitals and health centres. Used on a mass scale, and following a systematic geographical plan and timetable, the new techniques could -- theoretically -- force a specific disease to relinquish its hold over a whole population.

The disease that succumbed earliest and most dramatically to the mass campaign was yaws. This painful condition, spread by a micro-organism, could lead to total disability. It was found in tropical, poor and remote rural areas and was contracted through broken skin. In the early 1950s, there were thought to be around 20 million cases worldwide, over half of which were in Asia. The invention of penicillin transformed the prospects of cure. One shot cleared the ugly pink lesions, and a few more cleared the disease from the body.

The campaign against yaws with which UNICEF was most closely involved was in Indonesia. Mobile teams of lay health workers located the cases, and health professionals treated them. By 1955, these teams were treating over 100,000 yaws cases a month. Similarly in Thailand, nearly 1 million cases had been cured, and full eradication in Asia was becoming a distinct possibility.

The almost miraculous effect of the yaws cure also acted as a spur to other campaigns. One was tuberculosis: by the mid-1950s, 3.5 million children worldwide were being tested for TB every month and over 1 million vaccinated. Trachoma too was under attack. This eye infection, which then affected up to 400 million people worldwide, was treated on a mass scale with an antibiotic ointment. Malaria was another priority. At the mid-point of the century, this disease had the highest incidence in the world -- 200 million victims annually. The malarial frontier was rolled back by DDT spraying of people's homes.

Finally, leprosy sufferers could be offered a reprieve. As the first effective treatments for this stigmatizing condition came into use, they too were incorporated into the disease campaign machinery.

This enthusiasm for dealing with disease through technical interventions even extended to malnutrition. When in the early 1950s investigations among children on the African continent revealed widespread malnutrition, international public health experts were so attuned to the heroics of disease conquest that they behaved as if malnutrition, too, was an epidemic infection. They gave it medical labels -- kwashiorkor and marasmus -- and the medicine they prescribed was protein.

One of the most convenient forms of protein was milk. The alchemy that this particular blend of animal fat and protein could perform on child health was almost as sacrosanct a principle of nurture as motherhood. UNICEF was still heavily engaged with child feeding, and for the first two decades of its existence the heart of its efforts on behalf of child nutrition was the provision of milk.

This was greatly assisted by a reliable supply. In the early 1950s, the US had accumulated a vast reservoir of skim milk which, due to advances in dairy production, could be dried, preserved and later reconstituted. In 1954, the US Congress passed Public Law 480, through which the US offered aid organizations surplus farm produce free of charge. UNICEF was an important recipient; in 1957, it used this as part of its programme to provide milk via schools and health facilities to 4.5 million children and to pregnant and nursing mothers. In some countries, UNICEF also supported tropical dairying. In time, however, it was to replace milk-based interventions with sustainable solutions such as home-grown vegetables, fruits and poultry.

The mass disease campaigns certainly succeeded in reducing the levels of infection for both children and adults: in Ceylon, for example, between 1945 and 1960 the death rate from malaria dropped from 1,300 per million to zero. In fact, so successful were the campaigns that during the next decade they were blamed for igniting a population explosion. But, as experience was beginning to show, not everything about the campaigns was quite as perfect as their public image suggested.

The campaigns had been conceived as interim solutions -- a means of holding some forms of ill health at bay until such time as regular health services could be set up. However, it was precisely this lack of a health support network that made the operation very difficult and expensive to mount and sustain. In places where trained health professionals were few, administration weak, communications poor and transport intermittent, the sharp and decisive stroke the disease campaign was meant to deliver could dissolve into a long, repetitive and inconclusive enterprise.

The campaign managers had underestimated the operational difficulties and the human complexities. In the 1950s and 1960s, contemporary adulation for technology and the 'quick fix' encouraged the enthusiasts of international public health to believe that, with enough resources, better epidemiological surveillance and extra strategic refinements, they would finally reach their goal. Like their counterparts in other disciplines, the public health specialists were new to the challenges of development. They were bound to make mistakes.

For diseases like yaws, when people found painful sores disappearing as if by magic, they were happy to cooperate. And there were other notable successes, of which the greatest was the eventual eradication of smallpox. But for other diseases, people could not always see the cure work so directly and were therefore less likely to change their behaviour. One of the most difficult challenges was malaria.

The massive malaria campaign launched in 1955 by WHO and UNICEF finally failed because its chief architects misjudged the willingness of both humans and malarial mosquitoes to live, eat, sleep and generally behave according to technical assumptions. Eventually, the malaria warriors were forced to accept that without a basic service to back up and consolidate their gains, it was almost impossible to 'impose' health on a population unless it was geographically circumscribed -- as, for example, in a relief camp.

The most important lesson to be learned from the programmes of the 1950s was that the people of Africa, Asia and Latin America were not a blank sheet of paper on which experts from the industrialized world could write their own version of progress. However, another decade at least was to pass before this lesson was fully absorbed.

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