Neglected tropical diseases

Dr Margaret Chan, Director-General of the World Health Organization

08 December 2008 | Geneva
Address to 14th session of the Joint Action Forum of the African Programme for Onchocerciasis Control (APOC)

Your Excellency the President of Uganda;
Honourable Ministers of Health;
Friend and Colleagues;
Ladies and Gentlemen.

Thank you all for responding to the invitation to convene here in Kampala for this 14th session of the Joint Action Forum of the African Programme for Onchocerciasis Control (APOC). I would particularly like to express my sincere gratitude to the Government of Uganda for hosting the session.

The goal of Onchocerciasis Control Programme in West Africa (OCP) was to eliminate onchocerciasis as a public-health problem, and to mitigate its negative impact on the social and economic development of affected Countries. Today the strategic objective of APOC is to permanently protect the remaining 120 million people at risk of this debilitating and disfiguring disease in 19 countries in Africa through the establishment of community directed treatment with ivermectin (CDTI) which are capable of being sustained by the communities after APOC financing has ended.

Control efforts have had a significant impact on both public-health and development objectives in affected regions. The successes of onchocerciasis control in Africa has increased accessibility to fertile land and agricultural productivity, reduction of poverty, improved health status and has removed two significant public-health problems, namely onchocercal blindness and skin diseases.

Among the key factors contributing to this success are strong and sustained political will by affected Member States, excellent collaboration between the different levels of Government and the affected communities, the hard work and strong team spirit of health care workers and particularly of the affected communities and the steadfast and strong support of the donors to APOC.

The Non-Governmental Development Organizations (NGDOs) are a key partner in onchocerciasis control and other diseases; and we acknowledge their invaluable contribution. We are grateful to Merck and Co. Inc for their increasing generosity. Not only have they pledged to donate ivermectin free of charge for as long as needed for the treatment of onchocerciasis and also of lymphatic filariasis where the two diseases are co endemic, but they are also contributing financially to onchocerciasis control activities.

Africa needs to maintain the gains made in controlling onchocerciasis and to continue to reduce the impact of the disease as a pressing public-health problem and an impediment to social and economic advances. In just the past decade, health has achieved unprecedented prominence as a key driver of socioeconomic development. This prominence is formally expressed in the Millennium Development Goals, which recognize the two-way link between health and poverty, and give health development a central role to play. The international community, represented here by our distinguished guests, partners and donors and WHO, fully appreciate the efforts that have helped achieve these impressive results.

Onchocerciasis is one of the neglected tropical diseases. Conditions of poverty perpetuate these diseases, while the health impact of these diseases perpetuates poverty. This group of diseases of neglected populations expresses the link between health and development in an explicit, almost visual way – a way that is more compelling than statistics alone, as the itching, debilitation and blindness associated with onchocerciasis.

This geographical overlap means that people are often affected by more than one disease. It also means that strategies developed to deliver interventions for one disease can rationally be used to deliver interventions for others. This opens opportunities for integrated approaches, for simplification, cost-effectiveness, and streamlined efficiency.

We must not forget: we are dealing with neglected populations as well as neglected diseases. These people usually live in areas not covered by formal health services, and are notoriously difficult to reach.

For example, the dose pole was pioneered by the onchocerciasis control programme as a way to determine drug dosage, by height, for ivermectin. This innovation is now being used for schistosomiasis control, where praziquantel is administered in remote settings by non-specialized or medically trained staff. The benefit of onchocerciasis control to the countries has extended beyond the reduction in the burden of the disease and the associated social economic returns. The most important control operation is strengthening the health system in areas where it is currently weakest. The quality of life of communities will greatly improve and lead to enhanced performance and productivity and consequent economic benefits at household and national levels.

In 2005 WHO made a strategic move to view these diseases as a group with the establishment of the Control of Neglected Tropical Diseases Department. This made practical and operational sense. Strongly associated with poverty, these diseases frequently overlap geographically, with as many as six major diseases present in large parts of the world. Although medically very diverse, all of these diseases thrive under conditions of poverty and filth. They tend to cluster together in places where housing is substandard, drinking water is unsafe, sanitation is poor, access to heath care is limited or non-existent, and insect vectors are constant household and agricultural companions.

While maintaining clear focus on the Programme's original mandate – the elimination of onchocerciasis as a public health and socio-economic problem, APOC made a very welcoming paradigm shift in 2007 from single to multiple disease focus and the use of the strategy of community-directed treatment to bring multiple health interventions and commodities to onchocerciasis endemic hard-to-reach populations.

Disease-specific initiatives have and will continue to have their place. But a primary health care approach is essential to ensure that activities are better integrated. What we need to see is close interaction between programmes to bring multiple health benefits to people in need. In a welcome trend, we are seeing an increasing number of initiatives delivering a package of health promoting interventions, such as community-directed treatment interventions, school health programmes and campaigns targeting pre-school children.

When these tropical diseases are viewed together, we gain critical mass. We get a better grip on the scale of the economic and social as well as the health burdens. Arguments for giving these diseases higher priority become more powerful, more persuasive. As yet another advantage, grouping these diseases together creates opportunities for the sharing of innovative solutions, especially as most control programmes face similar operational constraints.

You will be discussing, in the coming days, issues that go beyond the spectrum of onchocerciasis control: among others integration, sustainability, strengthening of national health systems, human resources for health. Your conclusions and recommendations will no doubt come to enrich the current global debate on health and development.

May I express my most sincere and warm wishes of success to the 14th session of the JAF.