Recognising the role of community-directed treatment and of women in the fight against NTDs
Authors: Uche Amazigo, Andy Crump, Tore Godal
Journal: The Lancet Global Health (2017)

This year allows recognition and celebration of two key factors behind recent improvements in the health and wellbeing of marginalised people: the ivermectin donation programme for onchocerciasis and the role of women in the success of this and other strategies to combat neglected tropical diseases (NTDs). As societies evolve, demand for access to services and medicines increases. Since the 1978 Alma-Ata Declaration, which called for worldwide basic health care “at a cost that the community can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination”, there has been an increasing, yet largely unfulfilled, demand for community engagement in health service delivery. By the mid-1970s, disenchantment with health care was widespread. It had become obvious that the dynamics and context of demand had to be central to public health policy and decision-making. Health systems and interventions needed to be based on dependable evidence and provide what end-users expect.1WHOPrimary health care: joint report by the Director-General of the World Health Organization and the Executive Director of the United Nation's Children's Fund.http://apps.who.int/medicinedocs/documents/s21370en/s21370en.pdfGoogle Scholar The 2008 World Health Report confirmed that, since 1977, “health systems in developing countries have not responded adequately to people's needs”. WHO Director-General Margaret Chan stated that “The power of existing interventions is not matched by the power of health systems to deliver them to those in greatest need, in a comprehensive way, and on an adequate scale.”2WHOEverybody's business: strengthening health systems to improve health outcomes.http://apps.who.int/iris/handle/10665/43918Google Scholar The innovative concept of community-directed treatment (ComDT) is one means by which this misalignment can be addressed. Formulated 25 years ago, it originally empowered impoverished communities affected by onchocerciasis to take responsibility for distributing ivermectin3UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical DiseasesCommunity-directed treatment with ivermectin: report of a multi-country study. TDR, Geneva1996Google Scholar, 4CDI Study GroupCommunity-directed interventions for priority health problems in Africa: results of a multicountry study.Bull World Health Organ. 2010; 88: 509-518Crossref PubMed Scopus (126) Google Scholar within the world's longest-running drug donation programme, which itself began 30 years ago. The UN-based Special Programme for Research & Training in Tropical Diseases (TDR) recruited a team of predominantly African scientists who discovered that ivermectin delivery was feasible, cost-effective, and sustainable—if communities were enabled to take ownership. The African Programme for Onchocerciasis Control, established in 1995, adopted ComDT as its principal control strategy from 1997 (video). By 2002, other interventions—including similar drug donation programmes, malaria home management, and bednet and vitamin A distribution—had been incorporated into the ComDT mechanism. Health ministries, non-governmental development organisations, and donors switched to supporting and empowering rather than imposing solutions. ComDT demonstrated that therapy for NTDs, and other diseases and conditions that require non-sophisticated medical intervention, can be effectively managed at the community level by volunteers. If not for ComDT, many communities would still be marginalised, unable to benefit from essential health interventions. ComDT has revolutionised African health care, an example of “health for all” in practice, community-wide administration of ivermectin being labelled “an underutilized public health strategy”.5Speare R Durrheim D Mass treatment with ivermectin: an underutilized public health strategy.Bull World Health Organ. 2004; 82: 559-636Google Scholar An integrated ComDT system is the core undertaking in an expanded, multidisease elimination enterprise, the newly-established Expanded Special Programme for the Elimination of NTDs in Africa (ESPEN). Around the time it was developing ComDT, TDR also introduced a programme on gender issues, which demonstrated the crucial role of women, who bear the greatest NTD burden and who are the most resilient and often unrecognised combatants striving to overcome them.6Ogden S Women and NTDs: disproportionately affected, powerful champions.http://www.trachomacoalition.org/news-blogs/women-and-ntds-disproportionately-affected-powerful-championsGoogle Scholar Studies show that women are more committed, persuasive, and patient than men in ComDT, and underuse of female drug distributors has been identified as a causal factor behind instances of limited effectiveness, or sometimes failure.7Vouking MZ Tamo VC Tadenfok CN Contribution and performance of female community-directed distributors in the treatment of onchocerciasis with ivermectin in sub-Saharan Africa: a systematic review.Pan African Med J. 2015; 20: 188Crossref PubMed Scopus (9) Google Scholar At the NTD Summit in Geneva, Switzerland, April 19–22, the inaugural Women in Focus awards will commemorate the vital role that women play in conquering NTDs. Great progress has been made in tackling NTDs worldwide. In Africa, around 190 000 communities regularly receive ivermectin. Additionally, a network of trained volunteers, who supplement and reinforce the national health system in isolated areas, has been established, resulting in over 1 million disability-adjusted life years having been averted due to integrated ComDT. But much remains to be done. In 2015, worldwide, 991 million of the approximately 1·56 billion people needing treatment with donated drugs for NTDs received it. With respect to onchocerciasis, globally, of the 185·6 million people requiring ivermectin, 119 million were treated.8WHOUpdate on the global status of implementation of preventive chemotherapy.http://www.who.int/neglected_diseases/preventive_chemotherapy/PC_Update.pdfGoogle Scholar In 2016, Bill Gates declared “the best leaders have the ability to do both the urgent things that demand attention today and, at the same time, lay the groundwork for innovation that will pay dividends for decades”.9Gates B Accelerating innovation with leadership.https://www.gatesnotes.com/About-Bill-Gates/Accelerating-InnovationGoogle Scholar True agents of change, institutional or individual, should rightfully receive due recognition. TDR received the 2011 Gates Award for Global Health and ivermectin attracted a Nobel Prize in 2015. It is fitting that the immeasurably positive impact of women in accomplishing hitherto unimaginable advances in the health and wellbeing of resource-poor, remote populations is now being recognised too. We declare no competing interests. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3OTBhZDI4NjM0NTU3YzZhZTAxYTM4NjYxYzVjY2I3ZCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4Nzg2NjA3fQ.Jp_lvNzu5NfReOIvydH88G5DMKUWde8JPJyZZC4QtweF2OkRaEP5oZvHP1zgYMh1l_zXYQ7ncW3gjYSx3M6kk-FtO2OXqRG3LhzGRAl0h15o9SpLWfskngjT9cZ9QxG6UJv6cVhDx1-W3j7ZR53htiG2HrG6HU3iqIy2Odvy1Hzk9b5CvyTvWebs-UhPekC_hFfnrvv-rUpz67I3aRd8-tm8ZQJDDImg1QvkdwCMbVnEmvOrMPifVW5ULlv5SOEPO5je0KKI_qK7tFIPkg7MNsrZTfoXEfC6SPOphg5Ygch6Xe5aVv1bNLJl3q1QT06yX0X5XcYxNb8mMQoFwXv3Xw Download .mp4 (54.71 MB) Help with .mp4 files Supplementary videoCommunity-directed treatment for onchocerciasis in action in rural Uganda Vector control: time for a planetary health approachWhat is the world's most dangerous animal? According to Bill Gates, in an infographic that was memorable if not wholly fair, it is the mosquito. If we follow the logic that guns (or micro-organisms) don't kill, humans (or mosquitoes) do, the number of casualties caused by mosquitoes equates to around 725 000 per year. Ranked next in the top five are human beings (475 000), snakes (50 000), dogs (25 000), tsetse flies (10 000), triatomine bugs (10 000), and freshwater snails (10 000). The vast majority of these “killers” are therefore vectors (or intermediate hosts), dispensing death by means of malaria, dengue, yellow fever, Japanese encephalitis, rabies, human African trypanosomiasis, Chagas disease, schistosomiasis, and more. Full-Text PDF Open Access