What does it take to eradicate neglected tropical diseases?

LW

By Linda Waldman, Institute of Development Studies, UK

The term Neglected Tropical Diseases, or NTDs, refers to a diverse collection of tropical infections that primarily affect people living in poverty, sometimes in high-income countries, but more frequently in low- and middle-income countries. They are caused by a variety of pathogens, including viruses, bacteria, protozoa and helminths (or worms). Not many neglected tropical diseases (NTD) can be successfully eliminated. Strategies to tackle these diseases include, in addition to elimination, seeking to control NTDs. Control does not eradicate the disease, but it does ensure that it no longer constitutes a major public health burden.

Another strategy is to eliminate the disease in a particular part of the country, rather than seeking country-wide eradication. This involves reducing disease transmission to less than 1% within the specific area and managing the area to prevent re-infection. Ghana’s management of NTDs has involved all three strategies: eradication, control and elimination. Development partners such as donors, NGOs, religious groups, local leaders, missions, private companies, community organisations, local volunteers and others all play crucial roles in tackling NTDs.

This blog, and the following two posts, explore Ghana’s experiences of dealing with three NTDs through the eyes of Mr Stephen Sarkodie, a voluntary Community Drug Distributer who lives at Obo, in the Ga West South sub municipal, close to Accra. He has helped Ghana to tackle NTDs for the past 27 years. Part one looks at the eradication of Guinea worm, Part Two at the control of Buruli Ulcer and Part Three at the elimination of Lymphatic filariasis.

Part One: Eradicating Guinea Worm

In 2014, the World Health Organization confirmed that Ghana had successfully eradicated Guinea worm disease. Guinea worm is one Neglected Tropical Disease (NTD) that no longer plagues Ghana. The disease is caused by a parasitic worm and is transmitted through drinking contaminated water. Like all other NTDs, it is endemic, disproportionately affects rural communities who live in poverty and causes significant health and economic burdens. Neglected diseases seldom kill people, but they can be severely disabling.

Imagine the scene: Adwoa a perfectly healthy woman, drinks water from a pond close by to her home. About a year later, she discovers a painful, burning blister on her ankle. This hinders her work, her ability to fetch water, cook or continue daily activities. To ease the burning, Kudjoe soaks her foot in water. While doing so, the worm protrudes from the blister, releases larvae into the water and then retreats back into her leg. The larvae are consumed by tiny water fleas, and these in turn, are swallowed by other oblivious members of Kudjoe’s community who drink from the same water sources.

To achieve certification of national level eradication, Ghana had to have zero reported cases of Guinea worm transmission, and needed to confirm this through active surveillance and investigation for at least three years. The challenges associated with doing this must, at one point in time, have appeared insurmountable. All these challenges are generic to many NTDs, as colleagues reminded us in the recent COUNTDOWN workshop in Accra.

First, these diseases are neglected; neglected by academics, neglected by donors, neglected by Ministers of Finance, neglected by health providers, and neglected by the international community. Second, national health services are constrained by funding and staff are often overworked, underpaid and inadequately trained. Third, in-country travel is difficult – or to be more accurate – very, very DIFFICULT and easily underestimated. Fourth, language is an issue. Although English is Ghana’s official language, it is not always spoken in remote rural communities where over 80 local languages are used. This too is underestimated.

Given these challenges, eradicating Guinea worm involved the work of many different actors. At international level, the World Health Assembly’s Declaration in 1986 encouraged global eradication of the disease. At national level, Ghana, having recorded 180,000 Guinea worm cases in 1988, established the Ghana Guinea Worm Eradication Program (GGWEP).

Close to the Obom Health Centre, is the home of Mr Stephen Sarkodie, a farmer in Obom and a volunteer Community Drug Distributor. His story reveals the challenges of dealing with NTDs in Ghana. Stephen became a community health worker in 1989, just as the Guinea worm eradication programme was beginning. He explains: “I was living in the community and I could see the people being infected. They can’t work or do anything for themselves. I feel (sic) for them, so I gave myself up to volunteering”.

Findings were reported to the District Health Director who then needed to ensure that the water source was treated with ABATE, a chemical that kills the Guinea work larvae.   When GGWEP was initiated in 1989, it was hoped that the worm would be eradicated by March 2007.

But eradicating a NTD like Guinea worm was never going to be easy. In 1999-2000, frustrated by the lack of progress in tackling Guinea worm, the Government created an Inter-Agency Co-ordinating Committee, and emphasised the need to provide potable water. Development partners were further mobilised to support the eradication programme in 2004.

In 2005, a major Guinea worm outbreak occurred in Ghana. In 2006, despite the work of community health workers like Stephen Sarkodie, Guinea worm was still endemic and Ghana was ranked as the world’s second worst country for the disease. Despite all the work, problems persisted. Stephen explained that some communities refused treated water. Village elders were worried that applying the ABATE would weaken the ancestral spirits and, as they had been using the water for years, didn’t make the link between the painful blisters and the water.

However, there was progress. From the mid-2000s, the numbers of Guinea worm cases began to decline: in 2008, 501 cases were reported; in 2009, 242 cases and, in the first half of 2010, only eight cases. On 11th May 2010, the last Guinea worm case was diagnosed in Ghana. Then came the period of waiting, of hoping and of investigating, making sure that Ghana could ensure zero reporting of Guinea worm transmission for three years. Guinea worm was declared eradicated in 2014 in Ghana and was, says Stephen, “Our first success”.

Throughout the time that he was dealing with Guinea worm, Stephen was also working hard to tackle other NTDs, which we will report on in our next blog post soon.

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