Interactive exercise companion to The Formula for Better Health teaching resources by Dr. Tom Frieden. This tool is designed to be used alongside the original teaching materials — visit formulateaching.theformulaforbetterhealth.net for the full instructor resources.
"Smallpox eradication remains humanity's greatest public health achievement. It has saved hundreds of millions of lives and hundreds of billions of dollars. Yet most people alive today — its direct beneficiaries — are unaware of the threat their parents faced or the effort that eliminated it. Public health success makes itself invisible."
— The Formula for Better Health
SEEBELIEVECREATE
What this exercise is for
The Smallpox Eradication case applies all three elements of the See/Believe/Create framework in a single narrative. This exercise works through each element in sequence — not as history, but as a series of decisions you would have faced. The goal is to encounter the strategic logic of eradication by making choices before the reasoning is explained, then examining what those choices reveal.
The case is also a demonstration that public health success makes itself invisible. Smallpox killed more than half a billion people. Its eradication — the only human disease ever eradicated — has saved hundreds of millions of lives and hundreds of billions of dollars. Most people alive today, its direct beneficiaries, have never considered it.
Graduate framing
This case integrates concepts from Chapters 1 through 5 of The Formula: surveillance as strategic resource (Chapter 1), technical packages (Chapter 3), cultivated optimism (Chapter 4), and management at scale (Chapter 5). As you work through each act, identify which chapter concept is doing the primary analytical work — and where the elements of the formula depend on each other rather than operating independently.
The 1967 baseline
In 1967, WHO set a goal of global smallpox eradication. The scale of the challenge was significant: outbreaks in 31 countries, approximately 10 million cases per year, and approximately 2 million deaths per year. The prevailing strategy was mass vaccination — vaccinate everyone, everywhere. A vaccine existed and had existed for nearly two centuries. What was missing was not the tool. What was missing was the strategy, the belief, and the operational system to deploy it globally.
31countries with outbreaks, 1967
~10Mcases per year
~2Mdeaths per year
Up to 30%case fatality rate
1979eradication certified by WHO
How it works: Three acts — SEE, BELIEVE, CREATE — each with one or two active decision moments before the reasoning is revealed. A fourth step applies the framework to today. Allow 20–25 minutes.
Learning objectives
1
Explain why surveillance and containment replaced mass vaccination — and identify the biological conditions that made targeted action possible.
2
Analyse the role of leadership in sustaining belief when success seemed impossible, distinguishing cultivated from misplaced optimism.
3
Evaluate why WHO multilateral leadership was essential — distinguishing between resources and legitimacy — and apply the biological feasibility criteria to current diseases.
Evaluate the conditions under which WHO multilateral legitimacy was operationally irreplaceable, assess what the Cold War cooperation tells us about multilateral institutions today, and apply the eradication feasibility framework to diseases that partially meet the biological criteria.
Act I of III — SEE
Act I · SEE
Nigeria, late 1960s. You have a vaccine shortage and a spreading outbreak.
Graduate framing
The shift from mass vaccination to surveillance and containment is framed as "surveillance required more information but less vaccine — a trade-off feasible only because smallpox biology permitted targeted action." Before choosing, identify the biological features of smallpox that would need to be true for a targeted approach to work. Then choose. Then see whether your reasoning matched Foege's.
You are a public health officer working on the Nigeria smallpox programme in the late 1960s. You are facing a severe vaccine shortage — not enough doses to vaccinate everyone in your coverage area. The outbreak is spreading. Two strategic options are on the table.
The prevailing global approach is to vaccinate as many people as possible, prioritising high-density areas and health facilities, accepting that coverage will be incomplete. Your colleague Bill Foege is proposing something different. He has been asking a question no one else has asked: if I were a smallpox virus, how would I move?
1
With limited vaccine, what is your strategy?
You cannot vaccinate everyone. How do you allocate what you have?
2
What features of smallpox made targeted action possible?
Foege's approach only worked because of specific biological properties of the Variola virus. Which combination of features was most decisive for making targeted action — rather than vaccinating everyone — the superior strategy?
Please make a selection above before continuing.
Act II of III — BELIEVE
Act II · BELIEVE
The campaign is years in. Some countries are resisting. Field workers are losing faith.
Graduate framing
The question of whether Foege's "Resident Con Man" role constitutes manipulation or leadership is worth holding explicitly. He knew the goal was achievable because the evidence supported it, and he protected his team from moments when evidence seemed to contradict it. As you choose, identify whether the response you select is grounded in evidence — or whether it is optimism applied beyond what the evidence supports.
It is the early 1970s. The global eradication campaign is several years old. Progress has been made — the number of countries with active outbreaks has declined. But in some regions, governments are resistant, community trust is low, and field workers who have been at this for years are beginning to doubt whether the goal is achievable. Several senior epidemiologists are arguing that eradication is impossible — that the virus will always find a pocket of unvaccinated people.
You are in Foege's position. He described himself as the programme's "Resident Con Man" — he knew the goal was achievable because the evidence supported it, and he protected his team from moments when the evidence seemed to contradict it. The scenario below represents the kind of challenge his leadership faced. How do you respond to your team?
B
How does Foege sustain his team's belief in the goal?
The sceptics are not irrational — eradication has never been achieved for any human disease before. Many assumed smallpox was inevitable. What is the basis of your response as programme leader?
Please make a selection above before continuing.
Act III of III — CREATE
Act III · CREATE
The strategy is proven. Now: how do you actually make it work at global scale?
Graduate framing
Two arguments are worth holding in tension here. First: the US provided critical resources, but resources and legitimacy are not the same thing — and the campaign required both. Second: the biological bar for eradication is genuinely high. As you work through both decisions, notice where the limiting factor is technical, political, or operational.
1
The campaign needs substantial vaccine supply from the Soviet Union. How should it be obtained?
It is the height of the Cold War. The US is the primary funder of the WHO eradication programme. The Soviet Union has vaccine manufacturing capacity that the campaign needs.
2
Which of these diseases could meet the biological conditions for eradication?
Smallpox was eradicable because of a specific biological profile: no animal reservoir, visible or easily detectable symptoms, effective vaccine with post-exposure efficacy, long-lasting immunity. For each disease below, assess whether it meets those conditions.
Disease
Key features
Your assessment
Polio
Faecal-oral transmission, mostly asymptomatic cases, effective vaccine, long-lasting immunity — polio shares several of the biological conditions that made smallpox eradicable
HIV
Spread from animals to humans, long asymptomatic period, no effective vaccine, lifelong infection — HIV does not share the properties that made smallpox eradicable
Animal reservoir (mosquitoes as vector), limited vaccine efficacy, no long-lasting natural immunity
Please make a selection for the WHO/US question and assess all four diseases before continuing.
Step 4 of 4 — Applying the framework today
Contemporary application
Could smallpox be eradicated today — if it had not already been?
Graduate framing
This exercise is about weighing technological progress against institutional erosion. The biological conditions that made eradication feasible in 1967 have not changed. What has changed — in both directions — are the institutional, political, and communication conditions. Your analysis should distinguish between the two categories clearly.
The smallpox eradication campaign ran from 1967 to 1980 — a period of Cold War tension, newly independent postcolonial states, limited laboratory capacity, and no internet. Many of those constraints no longer exist. But new ones have emerged. What would make eradication easier today, and what would make it harder?
Your overall assessment
Weighing what has improved against what has deteriorated since 1967, what is your overall judgement?
Please make a selection above before continuing.
Synthesis & debrief
See / Believe / Create — applied
The formula that eradicated smallpox
How the three elements worked together
This case integrates all three elements of the framework. Each was necessary; none was sufficient alone.
SEE
Surveillance as strategic resource
Foege's question — "if I were a smallpox virus, how would I move?" — transformed surveillance from data collection into strategic direction. Data substituted for vaccine when biology permitted targeted action.
BELIEVE
Cultivated optimism
Foege — "Resident Con Man" by his own description — kept health workers and governments believing eradication was achievable. Belief grounded in evidence, deliberately sustained through 13 years of a campaign that had never been done before.
CREATE
Operational excellence at scale
More than 200,000 health workers across more than 70 countries. More than 10 million contacts identified and vaccinated within 5 days of exposure. Clear objectives, delegated authority, simple scalable tools, regular performance review. The bifurcated needle required minutes of training. Simplicity is a design principle, not a compromise.
Public health success makes itself invisible
Smallpox eradication has saved hundreds of millions of lives and hundreds of billions of dollars. Most people alive today — its direct beneficiaries — are unaware of the threat their parents faced or the effort that eliminated it. Sustaining support for prevention requires making invisible success visible. This is a permanent obligation — and, as Foege urged, the charge to becoming better ancestors.
Interactive exercise design, scenario architecture, and tool format by Dr. Louisa Sun, National University Health System.
Licensed under CC BY-NC-SA 4.0.