Why haven't we eradicated more diseases?: The Story

One disease in forty-six years

Smallpox killed roughly 300 million people in the twentieth century. In 1980, the WHO declared it eradicated. It remains the only human disease ever fully eliminated. Forty-six years later, the list hasn’t grown.

Polio was supposed to be next. The Global Polio Eradication Initiative launched in 1988 with a target of 2000. Then 2005. Then 2012. Then 2018. Wild poliovirus is now endemic in exactly two countries — Afghanistan and Pakistan — and the number of cases is in the low dozens. We are tantalizingly close and have been for twenty years. The last mile is not a science problem. It’s an access problem, a trust problem, a sovereignty problem, and — underneath all of those — an incentive problem.

What the money wants

Malaria kills over 600,000 people a year, almost all of them children under five in sub-Saharan Africa. A vaccine exists — RTS,S, approved in 2021. It reduces severe malaria by about 30 percent. Not great, but a start. The public health camp wants to scale it alongside bed nets and indoor spraying and close the gap. The pharma incentives camp asks why the vaccine took thirty years and reduces severity by only a third — and the answer involves what drug development money actually optimizes for.

The global pharmaceutical market is worth $1.6 trillion a year. Diseases that primarily kill poor children in poor countries attract a fraction of R&D investment. Malaria research funding totals about $800 million annually. Pfizer spent more than that on a single COVID vaccine trial. The market doesn’t fund eradication because eradication is a one-time sale. Treatment is a subscription.

The Global South watches this dynamic and sees something older than market failure — a pattern where the countries bearing the disease burden have the least control over the tools, the trials, and the priorities. The effective altruists run the numbers and find that the cost per life saved by scaling existing interventions is staggeringly low, and the gap between what we spend and what would work is not technical but political.

The bottleneck

Eradication requires sustained political will across decades, across borders, and across election cycles. Smallpox succeeded because the Cold War gave both superpowers a reason to cooperate. No equivalent incentive exists today. The WHO’s budget for all infectious disease is less than what the US spends on a single aircraft carrier. The people who die of preventable disease don’t vote in the countries that fund the research.

Perspectives:
- Public health
- Pharma incentives
- Global South sovereignty
- Effective altruists