Reflections on Smallpox and Disease Eradication in an Age of Individualism

This past weekend, we lost William Foege, a giant of public health whose work shaped an entire generation of thinking about what collective action can achieve. Dr. Foege is best remembered for his pivotal role in the eradication of Smallpox, a singular public-health triumph that remains unmatched more than four decades later.

I never met Dr. Foege, but his legacy has been present in nearly every lecture I have ever attended on disease eradication. Smallpox eradication was not simply a technical success; it was also a moral and political one. Anchored in the strategy of ring vaccination an approach Dr. Foege helped conceptualize and operationalize, the campaign abandoned the fantasy of blanket vaccination coverage and instead targeted outbreaks with precision, surrounding cases with rings of protection and deploying scarce vaccine resources where they mattered most.

When smallpox was declared eradicated in 1980, it demonstrated something profound: that public health, when understood as a collective project, could achieve outcomes that no individual action ever could. That success inspired generations of researchers and policymakers to imagine the elimination and even eradication of other infectious diseases such as polio and measles. But nearly half a century later, it is worth asking whether such a feat would be achievable today.

Smallpox was, by any measure, a uniquely eradicable pathogen. It had no animal reservoir. Infection and vaccination conferred long-lasting immunity. There was little asymptomatic transmission. And we had a highly effective, durable vaccine. These biological features were essential but biology alone does not explain why eradication succeeded then and remains elusive now.

What has changed most dramatically is not our science; it is our social contract. At the time of smallpox eradication, vaccination was widely understood as a public good. It was not framed primarily as a personal consumer choice or an individualized risk–benefit calculation, but as a shared obligation to protect communities especially the most vulnerable. Dr. Foege articulated this ethos plainly when he said, “Public health might be the greatest measure of kindness, the greatest measure of how to treat each other.” That understanding of public health as an expression of collective responsibility has steadily eroded, replaced by a discourse that elevates individual preference above communal protection.

Public health continues to pursue eradication and elimination goals, but only a small number of human pathogens are even theoretically amenable to eradication. Disease elimination; defined as the interruption of transmission within defined geographic regions, has been achieved for several vaccine-preventable infections. Yet even these hard-won gains are now slipping away as vaccination is increasingly justified, defended, or rejected on the basis of individual preference rather than collective responsibility.

Poliomyelitis illustrates this tension clearly. Before vaccines, poliomyelitis was a devastating disease that paralyzed and disabled children worldwide. Biologically, polio remains a plausible eradication target: humans are the only reservoir, and effective vaccines exist. But unlike smallpox, polio is often transmitted silently through asymptomatic shedding, and vaccine-derived poliovirus strains complicate eradication efforts. Add to this the realities of conflict, fragile health systems, and deepening mistrust of vaccination campaigns, and the challenge becomes not just technical but political. The erosion of commitment to individual action for collective benefit has materially slowed progress. Recent suggestions by senior policy figures in the United States that polio vaccination could be made “optional” triggered predictable alarm and underscored how deeply individualism has polluted vaccine discourse.

Measles offers an even starker warning. Measles is a human-only pathogen with an excellent vaccine. Yet it is also among the most contagious viruses known: one infected person can transmit measles to 12–18 others. Preventing outbreaks requires sustained vaccination coverage above 95%. For measles, perhaps more than for any other vaccine-preventable disease, community protection is the intervention. Individual protection alone is insufficient. And yet, measles has returned rapidly and predictably in settings where it had previously been eliminated. The reasons are not mysterious. Decades of disinformation falsely linking vaccines to autism, combined with the ongoing politicization of vaccine policy and the reframing of vaccination as a matter of personal choice, have undone elimination gains that took years to achieve.

As we reflect on the legacy of William Foege and the thousands who made smallpox eradication possible, we should resist the temptation to treat that achievement as a relic of a simpler time. The lesson is not that eradication is no longer possible because science has failed us. It is that eradication depends on a vision of public health that we have steadily abandoned. Yes, we vaccinate to protect ourselves and our children from disease. But in doing so, we also protect our communities and, in the case of smallpox, eliminated an entire human pathogen from existence.

If we wish to eliminate or even control infectious diseases in the modern era, we must reckon honestly with the shift from community good to personal choice alone. Public health cannot succeed when collective protection is optional, solidarity is negotiable, and community benefit is subordinated to individual preference. Science can take us only so far. What ultimately determines whether we eliminate or eradicate disease is how we treat one another and whether we are willing to accept that the choices we make about vaccination shape not just our own risk, but the health of our communities.

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