By Linda Waldman
Lymphatic filariasis or LF is, like Guinea worm, caused by a worm and transmitted by mosquitoes. The disease leads to massive swelling of the legs, other limbs, breasts, women’s vulva and men’s genitals, hence its common name elephantiasis. It causes considerable pain, severe disability, stigma and mental distress. Add financial loss to this and the disease contributes significantly to poor quality of life and poverty.
Here’s an example of how it can affect someone’s life. Kofi, a strong man, living and working in Obom is in the prime of his life and hopes to have many more children with his young wife. As a child, Kofi was bitten by mosquitoes carrying the parasite. The worms made their way to Kofi’s lymphatic system where they grew to adulthood and survived – undetected – for about eight years. During this time, they released larvae that began to circulate in Kofi’s blood, and eventually disrupted his immune system. All evidence of this damage to his lymphatic system remained hidden for many years.
Now, many years later, he experiences scrotal swelling and other signs of lymphoedema. Sitting outside his home, unable to work, Kofi continues to be bitten by mosquitoes. These mosquitoes then, in turn, suck blood from other villagers who live in Obom. As they do so, mature larvae are transferred from the mosquito and unnoticed make their way into the villagers’ bodies.
Government and community efforts
LF is endemic in 74 regions in Ghana. Ghana’s strategy for dealing with LF has focused on control and more recently elimination to ensure that the transmission of disease is stopped in particular areas. It also focuses on integrated programmes, which include treatment through mass drug administration (MDA).
The government started tackling LF in 2001 through an elimination programme. It involved MDA, using a combination of Invermectin and Albendazole/Mebendazole. These drugs have the advantage of simultaneously addressing other neglected tropical diseases such as Onchocerciasis. The programme also trained community health workers, teachers, environmental officers and others, conducted health promotion through mass and print media and held advocacy meetings to increase awareness and provide support.
By 2007-2008 some communities had reduced prevalence to less than 1%. Much of the work was done by Community Drug Distributors like Stephen Sarkodie. Stephen himself was actively involved as a key volunteer administering drugs in the elimination programme. He used charts and guidelines to determine dosages: “We measure people’s height with a colour marked stick to get the dosage… Green, red, blue provide categories for different height/dosage. If someone is categorised as blue, he or she receives a certain number of Ivermectin tablets. Everybody takes one tablet of Albendazole.”
As well as ensuring that all community residents received medication to halt transmission, Stephen and other community health workers would seek out people inflicted with LF and who may, as a result of the stigma, be isolated in their homes and be reluctant to appear in public. “We ask them to come to the clinic. We come across many men and women and we advise them to seek treatment. LF can’t be cured, so people have to know how to manage it.”
Human beings form the only natural reservoir for the worms, so eliminating it from humans could bring an end to LF. However, the drugs provided through MDA have only a limited effect on adult worms. They decrease the larvae density in the bloodstream and curb the parasites’ ability to be picked up by mosquitoes and transferred to other human hosts. It takes between four and six years of repeated drug administration to interrupt the transmission cycle.
This does not help people like Kofi who have already been infected with LF and have the severe form of the disease. The disease can, to a certain extent, be managed through a combination of skin care, hygiene, exercise and elevation of affected limbs and further progression can be prevented. In some extreme cases, surgical removal of excess tissue is a possibility, but this is not a World Health Organization recommendation. However, as Stephen points out, people are also sometimes too afraid of travelling long distances and being isolated in alien hospital environments, far from their family and friends, to undergo this operation.
Challenges along the way
Stephen’s work – and the success of the MDA program – was threatened by the fact that many of Obom’s residents did not wish to take the drugs. Ironically, given the effects of LF, men worried that they would become impotent and would die from the medication. Indeed, some people did suffer adverse reactions to the treatment, particularly headaches, stomach aches and itchy skin.
Stephen and his co-volunteers had to develop their own communication strategy, in parallel with the government’s official media broadcasts. They advised villagers of the side effects, recommending that anyone experiencing these symptoms should come to the clinic where they would receive free treatment from the Disease Control Officer. They were slowly able to convince people of the value of medication. “Now when we go to the village, people take the medication. Now if we go to a village, and people are not home, they later will come and find me at my home to receive the medication.”
Eliminating neglected tropical diseases
The good news is that transmission has been broken for LF in Obom. No longer do people contract this debilitating disease through mosquito bites. Today, only a couple of residents still live with the devastating swellings of LF and their conditions are carefully managed.
So, what does it take to eliminate neglected tropical diseases in Ghana? It takes commitment from a wide range of development partners – donors, NGOs, religious groups, local leaders, missions, private companies, community organisations, local volunteers and others – and an approach which focuses on control, then elimination and finally eradication. It takes many years of dedicated effort, communication and persuasion.
It takes constant vigilance, as Stephen explains, to ensure that these diseases don’t get re-introduced as people travel to other areas in Ghana and elsewhere. But most of all, it takes people like Stephen. People who derive their ‘most satisfaction’ from hearing that they have eradicated Guinea worm, who selflessly serve their communities volunteering their knowledge, time and skills.
As Stephen says ‘I became used to the work, it was a service to my people. From today, to tomorrow, then the next day, I go to the villages. There is no village in the area where people do not know me’.
Thank you Stephen for your tremendous gift to Ghana and for the legacy you have left the people of Obom.