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Eliminating River Blindness: Clear and Bold Vision Required

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In 1974, onchocerciasis -- a parasitic disease that causes blindness and is transmitted by black flies --  was raging in many parts of West Africa.  The disease, also known as river blindness, was concentrated in the villages lying close to the rivers where the black fly breeds. In such villages, the spectre of young children leading blind adults with a stick was a common sight. Indeed, the high levels of blindness and the weight of parasitic burden on the population led to the abandonment of many villages and the cultivation of land in otherwise fertile river valleys.  

This plight was brought to the attention of Robert McNamara, President of the World Bank, in 1972, by a French epidemiologist named Rene Leberre. Leberre led McNamara and his wife to witness first-hand the devastating socio-economic impact of this disease along the banks of the Volta Rouge in Haute Volta.  McNamara decided that action against this disabling disease was imperative and urgent if rural development was to stand a chance. But what action was he to take? 

Fortunately, Leberre and other colleagues had been piloting efforts to kill the black fly larvae with a chemical larvicide placed in rivers. They observed in a few pilot treatment sites that, with decreases in the number of black flies, transmission of the parasite to humans was reduced. However, Leberre's recommendation to McNamara was far more grand.  He argued that the only way to make a major dent in transmission was to spray all of the breeding sites in all of the rivers across seven countries of West Africa.....using helicopters!   

Despite the incredible logistic challenge of doing this, McNamara bought into the idea and convinced three other key U.N. agencies - UNDP, FAO and WHO -- to join together and launch the Onchocerciasis Control Program (OCP) in 1974.  This commitment to "scale from the start" has characterized the evolution of the program:  In the mid-1980s, it expanded to four other countries in West Africa and in the mid-1990s it expanded to the continent as a whole under the name the African Program on Onchocerciasis.

In the last 4 decades, more than 600,000 people have been saved from blindness and millions spared its impoverishing consequences.  

What were the keys to this success? Not only blind ambition but a dedication to bringing science to bear on onchocerciasis control from the “bench to the bush.” The program drew on an incredibly diverse array of disciplinary experts, including hydrologists, vector biologists, epidemiologists, ophthalmologists, parasitologists, anthropologists and even economists. Their expertise found expression not only in the headquarters and planning offices but in the rivers and front-line villages of hyper-endemic disease.  

The initiative’s success has been reinforced by a willingness to learn and adapt control strategy over time.  

In the late 1980s, it became apparent that a "de-worming" pill for dogs was very effective at killing the micro-worms that caused so much damage to the eyes and skin of infected persons. The pill - Ivermectin – underwent clinical trials as part of the OCP and was found to be effective in controlling the disease with community mass distribution twice a year.

These encouraging results led Merck not only to provide the drug free of charge to the OCP but to do so in perpetuity!   This unparalleled donation has triggered a transformation in pharmaceutical donations for neglected tropical diseases (NTDs):  In 2012, a London Declaration on neglected tropical diseases (NTDs) brought commitments of close to $20 billion in drugs from the pharmaceutical industry, for a wide range of NTDs.

With Ivermectin available free-of-charge, the strategy for control shifted to community-based distribution using community health workers.   Over time, we’ve seen an "integration" of other disease control programs requiring similar community-based delivery. This integration has been studied and found to deliver better results at lower costs than for stand-alone programs. This evidence on the efficacy and efficiency of community-based delivery systems points to the importance and the imperative of credible front-line services, not only in Africa, but anywhere in the world

In 1986, when undertaking field research on the socio-economic impact of blinding onchocerciasis as part of my doctoral research, the leader of the OCP at that time, Dr. Ibrahim Samba paid a visit to Bamako, Mali, where more than 300 staff were preparing the Western Extension of the OCP.  

Dr. Samba came with presents to all staff: blue, polyester ties that had a small map of Africa with the OCP in West Africa highlighted in red alongside a symbolic blackfly.   After distributing the ties, Dr. Samba gathered the entire staff in the courtyard and delivered an impassioned impromptu speech that lasted almost 2 hours, in which he made clear to everyone their importance to the success of the program.
I still have that tie and wear it proudly this week as we mark the 40th anniversary of this program. Success against all odds is indeed possible.  The efforts against onchocerciasis provide a rich bounty of learning, including the importance of:  scaling-up from the start; bringing science from the “bench to the bush;” continuously adapting strategies for improved performance; and creating an unbreakable solidarity between the needs of the poorest with the means of the richest. 
Follow the World Bank health team on Twitter: @worldbankhealth

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