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From Africa Recovery, Vol.17 #1 (May 2003), page 6

Victory over river blindness

Success of "big dream" is a model for other African health campaigns

By Laolu Akande

Ms. Celestina Hiza, a 60-year-old grandmother in the village of Bombani, Tanzania, was suffering from uncontrollable itching and had developed skin lesions, clear signs of the progression of onchocerciasis, or river blindness. Fortunately for her, she was able to receive a free dose of the drug Mectizan, donated by the US pharmaceutical company Merck, in time to prevent the disease from reaching its mature stage, when irreversible blindness can occur.

Girl leads a man struck blind by onchocerciasis in Côte d'Ivoire.

Photo : ©WHO / Mark Edwards

Ms. Hiza, in fact, received the 250 millionth dose, a symbolic occasion marked by a ceremony of 2,000 Bombani villagers in September 2002 and attended by Tanzanian Vice-President Ali Mohamed Shein and Merck's chief executive. "This has been a relief to me," she later told reporters. "I am now able to go back to farming my land and looking after my family."

The Tanzanian grandmother is among a declining number of African villagers still requiring treatment for river blindness, mainly in East and Central Africa. Across the continent in West Africa, a 30-year campaign against river blindness, known as the Onchocerciasis Control Programme (OCP), formally concluded in December 2002. The World Health Organization (WHO) estimates that the effort has prevented 600,000 new cases of the disease. A total of 18 million villagers were freed from the threat of contracting river blindness. Thousands of farmers are moving to reclaim fertile river land in West Africa cleared of the danger, an area with the potential to grow enough food for 17 million people.

WHO Director-General Gro Harlem Brundtland, who is concluding her term in office this year, observed that the OCP's accomplishments "inspire all of us in public health to dream big dreams, because we can reach 'impossible' goals and lighten the burden of millions of the world's poorest people."

Ghana's Deputy Health Minister Moses Danyaba called the OCP one of the great success stories in the history of fighting disease. It is an "example for other disease elimination programmes around the world."

A debilitating scourge

In recent decades, onchocerciasis has struck some 18 million people worldwide, and accounts for nearly a tenth of all cases of blindness. The vast majority of river blindness cases have been in sub-Saharan Africa, where nearly 30 countries have been affected.

The disease is typically spread by the bite of a black fly, normally found near streams and rivers (giving the disease its common name). Sometimes the bite transmits parasitic worms into the body. As they spread, they cause terrible itching, muscle pains and weakness. Eventually, when the worms reach their adult stage, they attack the eyes, leading to permanent blindness. The entire process may take up to 30 years from the first bite.

Recently, some German scientists have maintained that a bacteria living inside the worms may actually cause river blindness. If future studies confirm this, then new cases of onchocerciasis may be more easily treatable with common antibiotics, helping reduce future infections even further. Such a breakthrough could help speed the work of the African Programme for Onchocerciasis Control, which was launched in 1996 to combat the disease in 14 less-severely affected countries in Central and East Africa, and hopes to complete its work by 2010.

The river blindness campaign's grassroots focus provides an example for other battles, including against HIV/AIDS, says Mr. Frank Richards of the Carter Center. "You have to involve the national authorities and local communities."

Onchocerciasis has been more than a health concern. Especially in West Africa, the black fly breeds along some of the most fertile riverbanks. As a result, at the peak of the disease in the 1970s, about 250,000 square kilometres of productive river valley were abandoned, causing estimated annual economic losses of some $30 mn. One of the most affected countries in West Africa, Burkina Faso, had 400,000 people infected by the parasite in the mid-1970s.

A coordinated campaign

In 1974, the Onchocerciasis Control Programme was formally launched. The OCP initially included seven countries, WHO, the World Bank, the UN Development Programme and the UN Food and Agriculture Organization, but participation eventually grew to more than a dozen countries in West Africa and more than 25 donors, some 40 non-governmental organizations (NGOs) and numerous rural community groups. In 1980 it came under the leadership of Dr. Ebrahim Samba, who 15 years later became the WHO's regional director for Africa.

At the peak of its campaign, the OCP involved some 800 scientists, physicians, field staff and other personnel. It operated on several fronts. Through air-borne spraying of insecticides, it reduced the black fly population in the most heavily infested areas. With donor assistance, it stimulated research into medicines and effective treatment programmes for those already infected with onchocerciasis.

As Dr. Samba and other observers have emphasized, one of the keys to the OCP's success was the participation of many different actors (see box). This made effective coordination especially important. Despite political conflicts within and among some of the affected countries, the OCP's reputation for honesty and efficiency enabled it to operate across borders.

One critical participant was Merck, a US-based multinational pharmaceutical firm, which in 1988 offered to donate the medicine Mectizan. If taken in annual doses over a period of 15 years -- the life of the adult parasite -- Mectizan has been demonstrated to be almost 100 per cent effective. By 2001, Merck had contributed up to 200 mn tablets free of charge (they usually cost $1.50 each). Hundreds of volunteers initially helped the OCP distribute the medicine, and eventually local communities themselves took over its distribution.

According to Merck Chief Executive Raymond Gilmartin, the company is "committed to continuing the supply of Mectizan free of charge to whoever needs it, wherever they are in the world."

Local involvement

One of the NGOs involved in monitoring the drug distribution programme and providing training has been Sight Savers International (SSI). The group has been active in combating river blindness for a half century, and has assisted more than 5.5 million people worldwide, according to Ms. Catherine Cross, SSI's programme manager.

One crucial method that SSI and other groups have used in the battle against the disease is to actively involve local people in different aspects of the campaign. They trained primary eye-health care workers, paramedics and specialists in the use of new technologies and techniques. They taught rehabilitation skills to local people, including the blind themselves. Communities and local government institutions were mobilized to help in drug distribution activities.

Mr. Frank Richards, a public health physician with the US-based Carter Center, which also has been active in the river blindness campaign, believes that the OCP's grassroots focus provides an example for other battles, including against HIV/AIDS. "The lesson for the international community," he says, "is that you have to involve the national authorities and local communities."

Dr. Ebrahim Samba
Photo : ©WHO

'You can tackle anything'

What the success of the campaign against river blindness in West Africa demonstrates is that with the right approach, "you can tackle anything" in Africa, including HIV/AIDS, says Dr. Ebrahim Samba, the Africa regional director of the World Health Organization (WHO). The fruitful outcome of the river blindness campaign, he told Africa Recovery, carries a number of lessons that are "applicable to any programme in Africa." These include:

-- A shared vision: "Among the elements that contributed to success were, number one, a real shared vision, by the beneficiary African countries at the highest level and the non-African partners."

-- Precise definition and realistic plan: The problem needs to be identified in scientific terms, followed by "a realistic, appropriate plan and strategy built for that problem."

-- Long-term approach: An effort of two, three, five years is a "waste of time." The campaign against river blindness was planned for 20 years, but went on for almost 30 years.

-- Good technical team: A team of technical experts and managers who can implement the broad vision, while also managing the human and financial resources of a complex, costly and lengthy programme. "Any abuse of resources, however small, could rupture the whole activity. So there has to be consistent, transparent management of the programme."

-- Enduring support: There must be ongoing political and financial support for the work of the team carrying out the programme. "The river blindness programme was lucky in that none of the partners bowed down, over the whole period. Some of them came in without being solicited as partners. I say 'partners' and not 'donors and recipients,' because everyone contributed -- the African contributed, the non-African contributed."

Similarly, for the current efforts to combat HIV/AIDS, Dr. Samba concluded, "There should be a shared vision. There should be a commitment over a long time -- it is much more complicated than river blindness, so it needs 30 years, minimum. There should be dedicated, good staff selected for their competence, not for political or other considerations. And there needs to be a corresponding commitment of funding over time."

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